Systematic Random Biopsies Research Articles

Identifying Optimal Prostate Biopsy Strategy for the Detection Rate of Clinically Significant Prostate Cancer: A Systematic Review and Meta-Analysis of Randomised Controlled Trials (RCTs) in Biopsy-Naïve Population

Background: The growing role of multiparametric MRI (mpMRI) and MRI-targeted biopsy (MRI-TBx) suggests they may replace random systematic biopsy (SBx), specifically detection and subsequent treatment of clinically significant prostate cancer (csPCa). Objectives: To perform a systematic review and meta-analysis of randomised controlled trials (RCTs) comparing the detection rates (DR) of csPCa using MRI-TBx alone, SBx alone, or their combination in biopsy naïve patients suspected of having prostate cancer (PCa). Methods: PubMed, MEDLINE, Embase, and the Cochrane Library were searched up to 23 March 2023, for RCTs comparing PCa DR between biopsy strategies in patients with suspected prostate cancer. Detection rates were pooled using random/fixed effect models, and the study quality was assessed using the Cochrane risk of bias revised tool. Results: Ten RCTs (involving 3646 patients) were analysed, revealing that the combined biopsy method achieved higher overall csPCa DR compared to the SBx method alone (RR = 1.40 [95% CI = 1.15–1.71] and 1.47 [95% CI = 1.13–1.92], respectively). However, there was no significant difference in DR for clinically insignificant prostate cancer (ciPCa) between the two methods. Conclusions: This review concludes that MRI-TBx and SBx detect overall and clinically significant prostate cancer (csPCa) better than SBx alone. The variety of factors requires cautious interpretation, yet these findings are the strongest evidence. The combination technique is recommended for biopsy-naïve groups, but more study is needed to optimise execution and overcome uncertainties.

Targeted multiparametric magnetic resonance imaging/transrectal ultrasound-guided (mpMRI/TRUS) fusion prostate biopsy versus systematic random prostate biopsy: A comparative real-life study.

Patients with suspected prostate cancer usually undergo transrectal ultrasound-guided (TRUS) systematic biopsy, which can miss relevant prostate cancers and lead to overtreatment. The aim of this study was to evaluate the detection rate for prostate cancer in MR-guided targeted biopsy (TB) and systematic biopsy (SB) in comparison with mpMRI of the prostate. Three hundred and eight men who underwent mpMRI due to elevated PSA values between 2015 and 2020 were studied at university hospital Aachen, Germany. MRI-images were divided into cohorts with suspicious findings (PI-RADS ≥ 3) and negative findings (PI-RADS < 3). In patients with PI-RADS ≥ 3 TB combined with SB was performed. A part of this group underwent RP subsequently. In patients with PI-RADS < 3 and clinical suspicion SB was performed. In the PI-RADS ≥ 3 group (n = 197), TB combined with SB was performed in 194 cases. Three cases were lost to follow-up. Biopsy yielded 143 positive biopsies and 51 cases without carcinoma. TB detected 71% (102/143) and SB 98% (140/143) of the overall 143 carcinoma. Overall, 102 carcinomas were detected by TB, hereof 66% (67/102) clinically significant (Gleason ≥ 3+4) and 34% (35/102) clinically insignificant carcinoma (Gleason 3+3). SB detected 140 carcinomas, hereof 64% (90/140) csPCA and 36% (50/140) nsPCA. Forty-one of the overall 143 detected carcinoma were only found by SB, hereof 46% (19/41) csPCA and 54% (22/41) nsPCA. Tumor locations overlapped in 44% (63/143) between TB and SB. In 25% (36/143), SB detected additional tumor foci outside the target lesions. 70/143 patients subsequently underwent RP. The detection of tumor foci was congruent between mpMRI and prostatectomy specimen in 79% (55/70) of cases. Tumor foci were mpMRI occult in 21% (15/70) of cases. In the group with negative mpMRI (n = 111), biopsy was performed in 81 cases. Gleason ≥ 3+4 carcinoma was detected in 7% and Gleason 3+3 in 24% cases. There was a notable number of cases in which SB detected tumor foci that were mpMRI occult and could have been missed by TB alone. Therefore, additional systematic random biopsy is still required. A supplemental random biopsy should be considered depending on the overall clinical suspicion in negative mpMRI.

Prostate Cancer Detection and Complications of Transperineal Versus Transrectal Magnetic Resonance Imaging-fusion Guided Prostate Biopsies

ObjectiveTo assess the rates of detection of clinically significant prostate cancer (csPCa) and complications associated with transperineal (TP) and transrectal (TR) biopsy approaches to magnetic resonance imaging (MRI)-fusion targeted biopsy. Materials and methodsWe retrospectively identified men who underwent TP or TR MRI-targeted biopsy with concurrent systematic random biopsy from August 2020 to August 2021. Primary outcomes were detection rates of csPCa and 30-day complication rates between the 2 MRI-biopsy groups. Data were additionally stratified by prior biopsy status. ResultsA total of 361 patients were included in the analysis. No demographic differences were observed. No significant differences were observed between TP and TR approaches on any of the outcomes of interest. TR MRI-targeted biopsies identified csPCa in 47.2% of patients, and TP MRI-targeted biopsies identified csPCa in 48.6% of patients (P = .78). No significant differences were observed in csPCa detection between the 2 approaches for patients on active surveillance (P = .59), patients with prior negative biopsy (P = .34), and patients who were biopsy naïve (P = .19). Complication rates did not vary by approach (P = .45). ConclusionNeither the identification of csPCa by MRI-targeted biopsy nor rates of complications differed significantly based on a TR or TP approach. No differences were seen between MRI-targeted approaches based on prior biopsy or active surveillance status.

PD39-10 THE ASSOCIATION BETWEEN PSA DENSITY AND THE DETECTION OF CLINICALLY SIGNIFICANT PROSTATE CANCER ACROSS ALL PIRADS SCORES IN MEN WITH POSITIVE MPMRI. WHEN PSA DENSITY CAN HELP AVOIDING PROSTATE BIOPSY?

PD39-10 THE ASSOCIATION BETWEEN PSA DENSITY AND THE DETECTION OF CLINICALLY SIGNIFICANT PROSTATE CANCER ACROSS ALL PIRADS SCORES IN MEN WITH POSITIVE MPMRI. WHEN PSA DENSITY CAN HELP AVOIDING PROSTATE BIOPSY?

PD39-09 IMPACT OF PROSTATE IMAGING QUALITY (PI-QUAL) SCORE ON THE DETECTION OF CLINICALLY SIGNIFICANT PROSTATE CANCER IN MEN UNDERGOING MRI-TARGETED BIOPSY

PD39-09 IMPACT OF PROSTATE IMAGING QUALITY (PI-QUAL) SCORE ON THE DETECTION OF CLINICALLY SIGNIFICANT PROSTATE CANCER IN MEN UNDERGOING MRI-TARGETED BIOPSY

Endoscopic surveillance with systematic random biopsy for the early diagnosis of hereditary diffuse gastric cancer: a prospective 16-year longitudinal cohort study

Hereditary diffuse gastric cancer, generally caused by germline pathogenic variants in CDH1, presents with early-onset signet ring cell carcinoma. Prophylactic total gastrectomy is the definitive treatment. Endoscopic surveillance can inform the timing of prophylactic total gastrectomy through detection of microscopic signet ring cell carcinoma foci. However, evidence is scarce about the optimal endoscopic sampling technique and characterisation of signet ring cell carcinoma foci in hereditary diffuse gastric cancer. We aimed to formally assess the diagnostic yield of different sampling strategies and to identify criteria for the characterisation of endoscopic lesions. For this prospective longitudinal cohort study, we included individuals aged 18 years or older at the Cambridge University Hospitals National Health Service (NHS) Foundation Trust who fulfilled testing criteria for hereditary diffuse gastric cancer between June 1, 2005, and July 31, 2021. The primary outcome was detection of intramucosal signet ring cell carcinoma foci. We assessed the detection rate and anatomical location of signet ring cell carcinoma in random biopsy samples taken according to a systematic protocol compared with biopsies targeted to endoscopic findings. Endoscopic lesions were examined with white-light and narrow band imaging with magnification to assess the likelihood of cancerous foci. 145 individuals were included, of whom 68 (47%) were male and 92 (63%) carried the CDH1 pathogenic variant. 58 (40%) patients were diagnosed with invasive signet ring cell carcinoma over a median follow-up time of 51 months (IQR 18-80). The first diagnosis of signet ring cell carcinoma was most commonly made from random biopsies (29 [50%] of 58 patients), rather than targeted biopsies (15 [26%] patients). The anatomical distribution of signet ring cell carcinoma foci detected by random biopsies more accurately reflected those identified in prophylactic total gastrectomy specimens than did targeted biopsies. Omitting random biopsies in our cohort would have led to an under-diagnosis rate of 42%. Using a novel panel of endoscopic criteria, gastric lesions containing signet ring cell carcinoma were predicted with a sensitivity of 67·3% and a specificity of 90·2%. Random biopsies enhance the early detection of signet ring cell carcinoma and are complementary to targeted biopsies in surveillance of hereditary diffuse gastric cancer. This sampling method should be the standard of care when performing all surveillance endoscopies for individuals with hereditary diffuse gastric cancer. UK Medical Research Council.

Pathological Accuracy in Prostate Cancer: Single-Center Outcomes of 3 Different Magnetic Resonance Imaging-Targeted Biopsy Techniques and Random Systematic Biopsy.

The aim of this study is to compare systematic, cognitive fusion, in-bore, and software fusion prostate biopsies regarding rates of and risk factors for pathological upgrading. Charts of 291 patients with systematic biopsy (n = 105), magnetic resonance imaging- targeted cognitive fusion (n = 58), in-bore (n = 68), and software fusion biopsy (n = 60), and who subsequently underwent radical prostatectomy were retrospectively evaluated. The degree of similarity between the grade groups reported in the biopsy and radical prostatectomy pathology results was recorded. Analyses of the associated factors for concordance and discordance were performed with univariate and multivariate methods. The concordance rates were as follows: systematic biopsy = 42.8%, cognitive fusion-targeted biopsy = 50%, in-bore fusion-targeted biopsy = 61.8, and software fusion biopsy = 58.4%. The upgrade rate of systematic biopsy (46.6%) was higher than cognitive fusion-targeted biopsy (27.6%), in-bore fusiontargeted biopsy (26.4%), and software fusion-targeted biopsy (18.3%). The number of positive cores was significantly associated with grade group concordance for the systematic biopsy group (P = .040). Within the cognitive fusion-targeted biopsy cohort, number of positive cores was the only parameter that exhibited a significant association with grade group concordance in multivariate analysis (P = .044). Considering the in-bore fusion-targeted biopsy group, maximum tumor length was statistically significant (P = .021). In the software fusion-targeted biopsy group, low prostate volume was found to be the only significant predictor for grade group accordance (P = .021). Magnetic resonance imaging-targeted biopsy techniques showed higher concordance and lower upgrade rates compared to systematic biopsy. For systematic biopsy and cognitive fusion-targeted biopsy, the number of positive cores was associated with grade group concordance, while maximum tumor length in in-bore fusion-targeted biopsy and low prostate volume for in-bore fusion-targeted biopsy were associated with grade group concordance. Among the MRI-targeted biopsy methods, in-bore fusion-targeted biopsy and software fusion-targeted biopsy were more accurate than cognitive fusion-targeted biopsy in terms of grade group.

Does previous prostate surgery affect multiparametric magnetic resonance imaging accuracy in detecting clinically significant prostate cancer? Results from a single institution series.

Multiparametric MRI (mpMRI) has demonstrated high diagnostic accuracy for clinically significant PCa (csPCa). However, the accuracy of this test in men that received a previous prostatic surgery is still controversial. We aimed at assessing the effect of previous prostatic surgery on the detection of csPCa in a tertiary referral center. We relied on a cohort of 311 men with a positive mpMRI (prostate imaging - reporting and data system [PI-RADS] ≥ 3) who underwent a targeted (TBx) plus concomitant systematic random biopsy (SBx) at a single tertiary referral center between 2017 and 2020. The study outcome was to compare the detection of csPCa (Gleason score ≥ 3 + 4) between the two groups (no previous prostate surgery [Group 1] vs. previous prostate surgery [Group 2]). Multivariable logistic regression analysis (MVA) was used to assess the relationship between previous prostate surgery and the detection of csPCa at TBx, after taking into account potential clinical confounders. Overall, 24 (8%) patients received a previous prostate surgery before undergoing mpMRI. Median prostate-specific antigen density was 0.15 versus 0.08 ng/ml/cc, in Group 1 versus 2, respectively. The most frequent finding at mpMRI was in Group 1 versus 2, PI-RADS 4 (55%) versus PI-RADS 3 and 4 (42% each). The majority of patients were biopsy naïve in both Groups 1 (66%) and 2 (71%). The overall detection of csPCa in Group 1 versus 2 was 83% versus 75%, respectively. Differently, the detection of csPCa at TBx in Groups 1 versus 2 was 76% versus 71%, respectively. At MVA, previous prostate surgery (odds ratio: 0.65; p = 0.02) was significantly associated with lower csPCa detection at TBx, after accounting for potential confounders. The presence of previous prostate surgery significantly decreases the accuracy of mpMRI in detecting csPCa. These results should be taken into account when assessing patients with a history of prostatic surgery and a suspicious lesion at mpMRI, to better select those who might avoid an unnecessary biopsy.

MP09-06 PROSTATE CANCER DETECTION AND COMPLICATIONS OF TRANSPERINEAL VERSUS TRANSRECTAL MRI-FUSION GUIDED PROSTATE BIOPSIES

You have accessJournal of UrologyCME1 May 2022MP09-06 PROSTATE CANCER DETECTION AND COMPLICATIONS OF TRANSPERINEAL VERSUS TRANSRECTAL MRI-FUSION GUIDED PROSTATE BIOPSIES Dylan Buller, Jessa Sahl, Ilene Staff, Joseph Tortora, Kevin Pinto, Tara McLaughlin, Laura OlivoValintin, and Joseph Wagner Dylan BullerDylan Buller More articles by this author , Jessa SahlJessa Sahl More articles by this author , Ilene StaffIlene Staff More articles by this author , Joseph TortoraJoseph Tortora More articles by this author , Kevin PintoKevin Pinto More articles by this author , Tara McLaughlinTara McLaughlin More articles by this author , Laura OlivoValintinLaura OlivoValintin More articles by this author , and Joseph WagnerJoseph Wagner More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002531.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Detection rates of clinically significant prostate cancer (csPCa) in transperineal (TP) and transrectal (TR) MRI-fusion targeted prostate biopsies (MRI-bx) remains in question. We compared TP and TR approaches on rates of detection of csPCa and complications when performing MRI-bx. METHODS: We retrospectively identified men ages 18-89 who underwent TP or TR MRI-bx with concurrent systematic random biopsy from August, 2020 to August, 2021. Patients undergoing systematic-only TR biopsies were also included. Analyses primarily focused on cancer detection rates between the two MRI-bx groups; comparisons were also made to the standard random biopsy group. Data were additionally stratified by prior biopsy status. Grade Group ≥2 was considered csPCa. Complications within 30 days of biopsy were also compared. RESULTS: 520 patients were included in the analysis. No demographic differences were observed (Table 1). When analyzing only MRI-bx approaches, no significant differences were observed between TP and TR on any of the outcomes of interest (Table 2). TR MRI-bx identified csPCA in 47.2% of patients, and TP MRI-bx identified csPCA in 48.6% of patients (p = 0.777); systematic-only TR biopsies identified csPCA in 34.0% of patients. 50.4% of TR MRI-bx and 54.1% of TP MRI-bx identified csPCa in patients on active surveillance (AS) (p = 0.589). 30.8% of TR MRI-bx and 41.0% of TP MRI-bx identified csPCa in patients with a prior negative biopsy (p = 0.345). 62.5% of TR MRI-bx and 43.8% of TP MRI-bx identified csPCa in biopsy-naïve patients (p = 0.194). Significant differences were observed in csPCa detection between all three approaches for AS (p = 0.013) and prior negative biopsy patients (p = 0.045), but not between MRI-TP and MRI-TR biopsies. CONCLUSIONS: Neither the identification of csPCa by MRI-bx nor rates of complications differed significantly based on a TR or TP approach. No differences were seen between MRI-guided approaches based on prior biopsy/AS status. Source of Funding: Unfunded © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e137 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Dylan Buller More articles by this author Jessa Sahl More articles by this author Ilene Staff More articles by this author Joseph Tortora More articles by this author Kevin Pinto More articles by this author Tara McLaughlin More articles by this author Laura OlivoValintin More articles by this author Joseph Wagner More articles by this author Expand All Advertisement PDF DownloadLoading ...

Predicting the Performance of Concurrent Systematic Random Biopsies during Image Fusion Targeted Sampling of Multi-Parametric MRI Detected Prostate Cancer. A Prospective Study (PRESET Study).

Simple SummaryThe study provides a predictive model by using clinical factors in selecting men who may benefit from the addition of systematic biopsies with an image fusion targeted approach. The approach is likely to improve the detection of csPCa and avoid unnecessary detection of indolent prostate cancers.The study was aimed to develop a predictive model to identify patients who may benefit from performing systematic random biopsies (SB) in addition to targeted biopsies (TB) in men suspected of having prostate cancer. A total of 198 patients with positive pre-biopsy MRI findings and who had undergone both TB and SB were prospectively recruited into this study. The primary outcome was detection rates of clinically significant prostate cancer (csPCa) in SB and TB approaches. The secondary outcome was net clinical benefits of SB in addition to TB. A logistic regression model and nomogram construction were used to perform a multivariate analysis. The detection rate of csPCa using SB was 51.0% (101/198) compared to a rate of 56.1% (111/198) for TB, using a patient-based biopsy approach. The detection rate of csPCa was higher using a combined biopsy (64.6%; 128/198) in comparison to TB (56.1%; 111/198) alone. This was statistically significant (p < 0.001). Age, PSA density and PIRADS score significantly predicted the detection of csPCa by SB in addition to TB. A nomogram based on the model showed good discriminative ability (C-index; 78%). The decision analysis curve confirmed a higher net clinical benefit at an acceptable threshold.

Impact of MRI/US fusion-guided prostate biopsy on biopsy-naïve patients: A single urologist's experience.

ObjectivesTo report our experience with imaging‐guided targeted prostate biopsy (IGTpBx) for patients undergoing initial prostate biopsy in a clinical setting.Materials and methodsFrom July 2014 to February 2020, 305 men who had IGTpBx performed as their first prostate biopsy were enrolled. Two dedicated magnetic resonance imaging (MRI) radiologists segmented at least 1 region of interest (ROI) for each of these men using screening 1.5T MRI images. A single urologist employed the robotic‐assisted Artemis MRI/ultrasonography (US) fusion platform to obtain 2‐3 targeted samples from each ROI and additional random samples from the zones of the prostate outside the ROIs (a total of 12 zonal samples). Biopsy outcomes were categorized based on the Gleason score (GS) grade group (GG) as no cancer, favorable (GG < 3 or GS < 4 + 3), or clinically significant (GG ≥ 3 or GS ≥ 4 + 3) cancer.ResultsThe overall cancer detection rate was 75%:31% clinically significant, 44% favorable, and 25% no cancer. These findings triggered active interventions in 176 (58%) patients. A prostate‐specific antigen (PSA) level of 0–4 ng/mL was detected in 39 (66%) of 59 patients (32 favorable, 7 significant), 4–10 ng/mL in 147 (77%) of 190 patients (85 favorable, 62 significant), and 10 ng/mL and over in 44 (80%) of 55 patients (17 favorable, 27 significant).ConclusionsThe tumor detection rate was 75% with IGTpBx in patients without a previous biopsy. In addition, about 42% of detected cancers were deemed clinically significant and led to active interventions. IGTpBx as a patient’s first prostate biopsy improves the detection of clinically significant prostate cancer when compared with historical data for random systematic prostate biopsy.

MRI-targeted or systematic random biopsies for prostate cancer diagnosis in biopsy naïve patients: follow-up of a PRECISION trial-like retrospective cohort.

To test clinically significant prostate cancer (csPCa) rates during follow-up in biopsy naïve patients that underwent two different diagnostic pathways: (1) SB GROUP (n = 354): systematic random biopsies (SB) vs. (2) TB GROUP (n = 264): multiparametric magnetic resonance imaging (mpMRI) and only targeted biopsies (TB) of PI-RADS ≥ 3 lesions. Patients with PI-RADS ≤ 2 score avoided prostate biopsies. Retrospective single centre study of 618 biopsy naive patients (2015-2018). Two different definitions of csPCa were used: (1) csPCa ISUP GG ≥ 2 (ISUP grade group [GG] ≥ 2) and (2) csPCa ISUP GG ≥ 3. Kaplan-Meier plots and univariable Cox regression models tested rates over time of csPCa ISUP GG ≥ 2 and caPCa ISUP GG ≥ 3 in SB GROUP vs. TB GROUP. At initial biopsy, TB achieved higher rates of csPCa ISUP GG ≥ 2 (35.3 vs. 18.9%; p < 0.001) and csPCa ISUP GG ≥ 3 (12.6 vs. 6.2%; p = 0.04), relative to SB. After a median time follow-up of 36 months, the rates of csPCa ISUP GG ≥ 2 (6.1 vs. 4.4%; p = 0.6) and csPCa ISUP GG ≥ 3 (3.3 vs. 1.1%; p = 0.2) were similar in SB GROUP vs. TB GROUP. Moreover, in TB GROUP patients that avoided prostate biopsies because of negative baseline mpMRI (n = 145), only 4.1% exhibited csPCa ISUP GG ≥ 2 during follow-up. Moreover, none of these patients (PI-RADS ≤ 2) had csPCa ISUP GG ≥ 3. In biopsy naïve setting, a diagnostic pathway including pre-biopsy mpMRI and TB of only PCa suspicious lesions is not associated with higher rates of csPCa during follow-up, relative to a diagnostic pathway of SB. Moreover, patients with negative baseline mpMRI could safely avoid prostate biopsies and could be followed with repeated PSA testing, since only a small proportion of them would harbor csPCa.

SC51 - MRI-Targeted or systematic random biopsies for prostate cancer diagnosis in biopsy naïve patients: Follow-up of a precision trial-like retrospective cohort

SC51 - MRI-Targeted or systematic random biopsies for prostate cancer diagnosis in biopsy naïve patients: Follow-up of a precision trial-like retrospective cohort

68Ga-PSMA-11 PET/mpMRI for local detection of primary prostate cancer in men with a negative prior biopsy

Multiparametric MRI (mpMRI) represents the current gold standard for the detection of primary prostate cancer (PC) after a negative biopsy. PSMA PET imaging has been introduced in the diagnostic work-up of PC with high accuracy, but is currently mainly utilised in the setting of biochemical recurrence. This study aimed to determine the efficacy of combined 68Ga-PSMA-11 PET/mpMRI imaging to detect PC in patients with previously negative prostate biopsies. A total of 57 patients who had undergone at least one prior negative prostate biopsy were included in this retrospective analysis. All patients underwent 68Ga-PSMA-11 PET/mpMRI imaging of the prostate. mpMRI was evaluated according to the PIRADS classification system and 68Ga-PSMA-11 PET was rated on a 5-point Likert scale (1: PC highly unlikely; 2: PC unlikely; 3: presence of PC is equivocal; 4: PC likely; 5: PC highly likely). All patients received a systematic random biopsy as well as a targeted transrectal biopsy of lesions suspicious on imaging. Imaging and histological biopsy outcomes were compared on a per-patient basis. In the histological analysis, 35/57 (61.4 %) patients harboured PC lesions. In patients with biopsy-proven PC, 21/35 (60.0 %) had a PI-RADS 4 or 5 lesion on mpMRI and 28 /35 (80.0 %) had a PET rating of 4 or 5. Combined 68Ga-PSMA-11 PET/mpMRI missed only one patient with a Gleason score (GS) 7a tumour (rating of 1 or 2 in both PET and mpMRI). Limitations include the retrospective analysis as well as possible false negative biopsy results even in a fusion biopsy setting. In this initial analysis, the combined 68Ga-PSMA-11 PET/mpMRI proved to be a valuable imaging tool to guide prostate biopsies for the detection of PC in patients with a negative prior biopsy. In this approach, 68Ga-PSMA-11 PET and mpMRI show partially complementary findings that enhance the detection of PC lesions.

58 - Adding random systematic biopsies to MRI-fusion targeted prostate biopsy procedures: Always, in selected cases, or never?

58 - Adding random systematic biopsies to MRI-fusion targeted prostate biopsy procedures: Always, in selected cases, or never?

TERT C228T mutation in non-malignant bladder urothelium is associated with intravesical recurrence for patients with non-muscle invasive bladder cancer.

Telomerase reverse transcriptase (TERT) promoter mutations are frequently found in tumors or urine from patients with urothelial carcinoma (UC). TERT promoter mutations are also detected in urine from patients with no evidence of cancer but are associated with subsequent UC development. Mutations in the TERT promoter are thought to be present in nonmalignant urothelium (NMU) during early stages of tumor formation prior to pathological change, but this has not been proven directly. In this proof‐of‐concept study, we investigated the clinical utility of TERT promoter mutation analysis in NMU of patients with non‐muscle‐invasive bladder cancer (NMIBC). This single‐institute study included 53 primary tumors and 428 systematic bladder biopsy specimens from 54 patients with NMIBC. All patients underwent systematic random biopsy and transurethral resection of the bladder tumor. Genomic DNA was analyzed for TERT C228T and C250T mutations using droplet digital PCR (ddPCR). The association between TERT promoter mutation of NMU and bladder recurrence was examined by the Kaplan–Meier method and Cox proportional hazards model. Of the 54 patients, 16 (29.6%) had a TERT C228T mutation and three (5.6%) had a TERT C250T mutation in NMU. Of 428 biopsy specimens, the TERT C228T mutation was detected in 9% (31/364) of normal urothelium, 27% (4/15) of urothelial dysplasia (UD), 50% (9/18) of UD suspicious for carcinoma in situ (CIS), and 58% (18/31) of CIS. During follow‐up (median: 3.7 years), 22 (40.7%) patients experienced bladder recurrence and five (9.3%) experienced disease progression. Cox proportional hazard analysis showed that TERT C228T mutation in NMU was significantly associated with bladder recurrence after adjustment for cofounding factors (P = 0.0128). Thus, TERT C228T mutation was detected in NMU, which was a reliable independent prognostic factor of bladder tumor recurrence.

Multiparametric magnetic resonance imaging and clinical variables: Which is the best combination to predict reclassification in active surveillance patients?

Introduction & objectivesWe tested the role of multiparametric magnetic resonance imaging (mpMRI) in disease reclassification and whether the combination of mpMRI and clinicopathological variables could represent the most accurate approach to predict the risk of reclassification during active surveillance.Materials & methodsThree-hundred eighty-nine patients (pts) underwent mpMRI and subsequent confirmatory or follow-up biopsy according to the Prostate Cancer Research International Active Surveillance (PRIAS) protocol. Pts with negative (−) mpMRI underwent systematic random biopsy. Pts with positive (+) mpMRI [Prostate Imaging Reporting and Data System, version 2 (PI-RADS-V2) score ≥3] underwent targeted + systematic random biopsies. Multivariate analyses were used to create three models predicting the probability of reclassification [International Society of Urological Pathology ≥ Grade Group 2 (GG2)]: a basic model including only clinical variables (age, prostate-specific antigen density, and number of positive cores at baseline), an Magnetic resonance imaging (MRI) model including only the PI-RADS score, and a full model including both the previous ones. The predictive accuracy (PA) of each model was quantified using the area under the curve.ResultsmpMRI negative (−) was recorded in 127 (32.6%) pts; mpMRI positive (+) was recorded in 262 pts: 72 (18.5%) had PI-RADS 3, 150 (38.6%) PI-RADS 4, and 40 (10.3%) PI-RADS 5 lesions. At a median follow-up of 12 months, 125 pts (32%) were reclassified to GG2 prostate cancer. The rate of reclassification to GG2 prostate cancer was 17%, 35%, 38%, and 52% for mpMRI (−), PI-RADS 3, 4, and 5, respectively (P < 0.001). The PA was 69% and 64% in the basic and MRI models, respectively. The full model had the best PA of 74%: older age (P = 0.023; Odds ratio (OR) = 1.040), prostate-specific antigen density (P = 0.037; OR = 1.324), number of positive cores at baseline (P = 0.001; OR = 1.441), and PI-RADS 3, 4, and 5 (overall P = 0.001; OR = 2.458, 3.007, and 3.898, respectively) were independent predictors of reclassification.ConclusionsDisease reclassification increased according to the PI-RADS score increase, at confirmatory or follow-up biopsy. However, a no-negligible rate of reclassification was found also in cases of mpMRI (−). The combination of mpMRI and clinicopathological variables still represents the most accurate approach to pts on active surveillance.

The Use of Multiparametric Magnetic Resonance Imaging for Follow-up of Patients Included in Active Surveillance Protocol. Can PSA Density Discriminate Patients at Different Risk of Reclassification?

The objective of this study was to test Prostate Imaging Reporting and Data System (PI-RADS) classification on multiparametric magnetic resonance imaging (mpMRI) and MRI-derived prostate-specific antigen density (PSAD) in predicting the risk of reclassification in men in active surveillance (AS), who underwent confirmatory or per-protocol follow-up biopsy. Three hundred eighty-nine patients in AS underwent mpMRI before confirmatory or follow-up biopsy. Patients with negative (-) mpMRI underwent systematic random biopsy. Patients with positive (+) mpMRI underwent targeted fusion prostate biopsies+ systematic random biopsies. Different PSAD cutoff values were tested (< 0.10, 0.10-0.20,≥ 0.20). Multivariable analyses assessed the risk of reclassification, defined as clinically significant prostate cancer of grade group 2 or more, during follow-up according to PSAD, after adjusting for covariates. One hundred twenty-seven (32.6%) patients had mpMRI(-); 72 (18.5%) had PI-RADS 3, 150 (38.6%) PI-RADS 4, and 40 (10.3%) PI-RADS 5 lesions. The rate of reclassification to grade group 2 PCa was 16%, 22%, 31%, and 39% for mpMRI(-) and PI-RADS 3, 4, and 5, respectively, in case of PSAD< 0.10 ng/mL2; 16%, 25%, 36%, and 44%, in case of PSAD 0.10 to 0.19 ng/mL2; and 25%, 42%, 55%, and 67% in case of PSAD≥0.20 ng/mL2. PSAD≥ 0.20 ng/mL2 (odds ratio [OR], 2.45; P= .007), PI-RADS 3 (OR, 2.47; P= .013), PI-RADS 4 (OR, 2.94; P< .001), and PI-RADS 5 (OR, 3.41; P= .004) were associated with a higher risk of reclassification. PSAD≥ 0.20 ng/mL2 may improve predictive accuracy of mpMRI results for reclassification of patients in AS, whereas PSAD< 0.10 ng/mL2 may help selection of patients at lower risk of harboring clinically significant prostate cancer. However, the risk of reclassification is not negligible at any PSAD cutoff value, also in the case of mpMRI(-).

MP13-15 68GA-PSMA-11 PET/MPMRI FOR DETECTION OF PRIMARY PROSTATE CANCER IN PREVIOUSLY NEGATIVE-BIOPSIED MEN

INTRODUCTION AND OBJECTIVE: Multiparametric MRI (mpMRI) represents the current gold standard for detection of primary prostate cancer (PCa) after negative biopsy. PSMA PET imaging has been introduced in the diagnostic work-up of PCa with high specificity, currently mainly utilized in biochemical recurrence. Therefore, the aim of this investigation was to determine the efficacy of combined 68Ga-PSMA-11 PET/mpMRI imaging to detect PCa in patients with previously negative prostate biopsy. METHODS: 57 patients (pts.) who underwent at least one prior negative prostate biopsy were included in this analysis. All pts. underwent 68Ga-PSMA-11 PET/mpMRI imaging of the prostate. Lesions on mpMRI were evaluated according to the PI-RADS classification system and lesions on 68Ga-PSMA-11 PET were rated according to a 5-point scale on a sextant basis (1: PCa highly unlikely; 2: PCa unlikely; 3: presence of PCa is equivocal; 4: PCa likely; 5: PCa highly likely). All pts. received a systematic random biopsy as well as a targeted transrectal biopsy of lesions suspicious on imaging. Results of imaging and histological analysis of prostate biopsies were compared per patient and per prostate sextant. RESULTS: On histological analysis 35/57 (61.4%) of pts. and 75/342 (21.9%) of sextants showed PCa lesions. In patients with biopsy confirmed PCa 21/35 (60.0%) showed a PI-RADS 4 or 5 lesion on mpMRI and 28/35 (80.0%) presented with a PET rating of 4 or 5. 20/75 (26.7%) of sextants with histological confirmed PCa showed a PI-RADS 4 or 5 lesion on mpMRI and 26/75 (34.7%) of sextants presented with a PET rating of 4 or 5. Combined 68Ga-PSMA-11 PET/mpMRI missed only one patient with a Gleason-Score (GS) 7a tumor (rating of 1 or 2 in both, PET and mpMRI). Limitations represent the retrospective analysis as well as possible false negative biopsy results even in a fusion biopsy setting. CONCLUSIONS: In this initial analysis, 68Ga-PSMA-11 PET/mpMRI proved to be a valuable imaging tool to guide prostate biopsies for detection of PCa in patients after prior negative biopsy. Hereby, 68Ga-PSMA-11 PET and mpMRI show complementary findings thus increasing detection of PCa lesions. Source of Funding: none

Combination of Multiparametric Magnetic Resonance Imaging With Elastic-fusion Biopsy Has a High Sensitivity in Detecting Clinically Significant Prostate Cancer in Daily Practice.

The index lesion (IL) is the largest cancer focus, usually harbors the highest grade, and might drive the history of prostate cancer (PCA). Multiparametric magnetic resonance imaging (mp-MRI) has a high negative predictive value in ruling out clinically significant (cs)PCA. We aimed evaluating the efficiency of mp-MRI and targeted biopsy in detecting csPCA and the concordance between the MRI index lesion (MRI-IL) and the presence of csPCA inside it. We retrospectively evaluated 158 men who underwent prostate biopsy after a positive pre-biopsy mp-MRI scan. All mp-MRI lesions were biopsied using a transrectal ultrasound elastic-fusion approach (2-4 targeted plus 10-12 random systematic biopsies). csPCA was defined as grading group≥ 2 or > 3 cores with cancer or≥ 50% of core involved by tumor. mp-MRI detected 158 ILs and 46 non-ILs. One hundred were Prostate Imaging-Reporting and Data System version 2 (PI-RADS v2) score 3, 84 score 4, and 20 score 5. csPCA was found in 63.9% of the MRI-ILs. Eighty percent of detected cancer using mp-MRI and targeted biopsy was clinically significant. Eighty-seven percent of the transitional zone lesions were clinically non-significant or negative for cancer. The probability of detecting csPCA increases with increasing size of MRI-IL, and every extra millimeter raises the odds of detecting csPCA of 12.2%. All PI-RADS v2 score lesions showed a strong association with csPCA. The risk of matching between MRI-IL and csPCA inside it increases by 36.2% as the total percentage of cancer in all cores increases. mp-MRI showed high sensitivity in detecting csPCA in the peripheral zone, with concordance between MRI-IL and csPCA.