Transperineal Template Mapping Biopsy Research Articles

The Role of Multiparametric MRI and MRI–targeted Biopsy in the Diagnosis of Radiorecurrent Prostate Cancer: An Analysis from the FORECAST Trial

BackgroundThe role of multiparametric magnetic resonance imaging (MRI) for detecting recurrent prostate cancer after radiotherapy is unclear. ObjectiveTo evaluate MRI and MRI-targeted biopsies for detecting intraprostatic cancer recurrence and planning for salvage focal ablation. Design, setting, and participantsFOcal RECurrent Assessment and Salvage Treatment (FORECAST; NCT01883128) was a prospective cohort diagnostic study that recruited 181 patients with suspected radiorecurrence at six UK centres (2014 to 2018); 144 were included here. InterventionAll patients underwent MRI with 5 mm transperineal template mapping biopsies; 84 had additional MRI-targeted biopsies. MRI scans with Likert scores of 3 to 5 were deemed suspicious. Outcome measurements and statistical analysisFirst, the diagnostic accuracy of MRI was calculated. Second, the pathological characteristics of MRI-detected and MRI-undetected tumours were compared using the Wilcoxon rank sum test and chi-square test for trend. Third, four biopsy strategies involving an MRI-targeted biopsy alone and with systematic biopsies of one to two other quadrants were studied. Fisher’s exact test was used to compare MRI-targeted biopsy alone with the best other strategy for the number of patients with missed cancer and the number of patients with cancer harbouring additional tumours in unsampled quadrants. Analyses focused primarily on detecting cancer of any grade or length. Last, eligibility for focal therapy was evaluated for men with localised (≤T3bN0M0) radiorecurrent disease. Results and limitationsOf 144 patients, 111 (77%) had cancer detected on biopsy. MRI sensitivity and specificity at the patient level were 0.95 (95% confidence interval [CI] 0.92 to 0.99) and 0.21 (95% CI 0.07 to 0.35), respectively. At the prostate quadrant level, 258/576 (45%) quadrants had cancer detected on biopsy. Sensitivity and specificity were 0.66 (95% CI 0.59 to 0.73) and 0.54 (95% CI 0.46 to 0.62), respectively. At the quadrant level, compared with MRI-undetected tumours, MRI-detected tumours had longer maximum cancer core length (median difference 3 mm [7 vs 4 mm]; 95% CI 1 to 4 mm, p < 0.001) and a higher grade group (p = 0.002). Of the 84 men who also underwent an MRI-targeted biopsy, 73 (87%) had recurrent cancer diagnosed. Performing an MRI-targeted biopsy alone missed cancer in 5/73 patients (7%; 95% CI 3 to 15%); with additional systematic sampling of the other ipsilateral and contralateral posterior quadrants (strategy 4), 2/73 patients (3%; 95% CI 0 to 10%) would have had cancer missed (difference 4%; 95% CI –3 to 11%, p = 0.4). If an MRI-targeted biopsy alone was performed, 43/73 (59%; 95% CI 47 to 69%) patients with cancer would have harboured undetected additional tumours in unsampled quadrants. This reduced but only to 7/73 patients (10%; 95% CI 4 to 19%) with strategy 4 (difference 49%; 95% CI 36 to 62%, p < 0.0001). Of 73 patients, 43 (59%; 95% CI 47 to 69%) had localised radiorecurrent cancer suitable for a form of focal ablation. ConclusionsFor patients with recurrent prostate cancer after radiotherapy, MRI and MRI-targeted biopsy, with or without perilesional sampling, will diagnose cancer in the majority where present. MRI-undetected cancers, defined as Likert scores of 1 to 2, were found to be smaller and of lower grade. However, if salvage focal ablation is planned, an MRI-targeted biopsy alone is insufficient for prostate mapping; approximately three of five patients with recurrent cancer found on an MRI-targeted biopsy alone harboured further tumours in unsampled quadrants. Systematic sampling of the whole gland should be considered in addition to an MRI-targeted biopsy to capture both MRI-detected and MRI-undetected disease. Patient summaryAfter radiotherapy, magnetic resonance imaging (MRI) is accurate for detecting recurrent prostate cancer, with missed cancer being smaller and of lower grade. Targeting a biopsy to suspicious areas on MRI results in a diagnosis of cancer in most patients. However, for every five men who have recurrent cancer, this targeted approach would miss cancers elsewhere in the prostate in three of these men. If further focal treatment of the prostate is planned, random biopsies covering the whole prostate in addition to targeted biopsies should be considered so that tumours are not missed.

A Prospective Comparison of Transrectal Standard, Cognitive, Transperineal Fusion, and Mapping Prostate Biopsy for Cancer Detection.

Purpose: The aim of this research was to compare the clinically significant prostate cancer (csPCa) detection rate (International Society of Urological Pathology [ISUP] ≥2) for the four biopsy methods: transrectal ultrasound-guided biopsy (TRUS-GB), cognitive transrectal biopsy (COG-TB), fusion transperineal biopsy (FUS-TB), and transperineal template mapping biopsy (TPMB). Materials and Methods: The inclusion criteria were as follows: prostate-specific antigen (PSA) >2 ng/mL, and/or positive digital rectal examination (DRE), and/or suspicious lesion on transrectal ultrasound (TRUS) and Prostate Imaging Reporting and Data System (Pi-RADS) v2.1 ≥ 3 score. In total, 102 patients were enrolled in the study. Biopsies were performed by two urologists. In a single procedure, the first urologist performed a FUS-TB and TPMB followed by second urologist who performed TRUS-GB and COG-TB. All specimens were obtained within a single procedure. Results: The csPCa detection rate and overall cancer detection rate (CDR) per patient were comparable among the respective biopsy methods (p > 0.05). Compared with other biopsy methods, a lower clinically insignificant prostate cancer (cisPCa) was detected using COG-TB (p = 0.004). The positive cores percentage ratio (p < 0.001) as well as positive cores containing csPCa percentage ratio (p < 0.001) significantly increased for the targeted biopsy methods. The median maximum cancer core length (MCCL; p = 0.52) as well the median for the MCCL of csPCa (p = 0.47) did not differ significantly among the respective biopsy methods. Concordance of the Gleason scores between biopsy and postprostatectomy pathology did not differ significantly among biopsy methods (p = 0.87). For TRUS-GB, FUS-TB, and TPMB, the common predictive factors for csPCa were positive DRE, suspicious lesion on ultrasound and Pi-RADS 5. As for COG-TB, the only predictor was Pi-RADS 5. Conclusion: The targeted methods did not show an increase in detection of csPCa and overall CDR over systematic ones in patients with Pi-RADS ≥3. A lower cisPCa was detected using COG-TB in comparison with the other methods. The sampling efficiency increased for the targeted biopsy methods, which used only a proportion of positive cores and cores containing csPCa. There was no statistical difference in histology concordance among the biopsies. One common predictive factor of increased csPCa detection for all biopsy methods was Pi-RADS 5.

MP44-02 SYSTEMATIC AND MRI-TARGETED BIOPSY STRATEGIES FOR THE DETECTION OF RADIORECURRENT PROSTATE CANCER: AN ANALYSIS FROM THE FOCAL RECURRENT ASSESSMENT AND SALVAGE TREATMENT (FORECAST) TRIAL

MP44-02 SYSTEMATIC AND MRI-TARGETED BIOPSY STRATEGIES FOR THE DETECTION OF RADIORECURRENT PROSTATE CANCER: AN ANALYSIS FROM THE FOCAL RECURRENT ASSESSMENT AND SALVAGE TREATMENT (FORECAST) TRIAL

MP73-04 EXTERNAL VALIDATION OF A RISK SCORE PREDICTING FAILURE AFTER SALVAGE FOCAL THERAPY FOR LOCALIZED RADIORECURRENT PROSTATE CANCER: AN ANALYSIS FROM THE FOCAL RECURRENT ASSESSMENT AND SALVAGE TREATMENT (FORECAST) TRIAL

MP73-04 EXTERNAL VALIDATION OF A RISK SCORE PREDICTING FAILURE AFTER SALVAGE FOCAL THERAPY FOR LOCALIZED RADIORECURRENT PROSTATE CANCER: AN ANALYSIS FROM THE FOCAL RECURRENT ASSESSMENT AND SALVAGE TREATMENT (FORECAST) TRIAL

MP44-06 TUMOR CHARACTERISTICS OF MULTIPARAMETRIC MRI-DETECTED AND -UNDETECTED LESIONS IN PATIENTS WITH SUSPECTED RADIORECURRENT PROSTATE CANCER: AN ANALYSIS FROM THE FOCAL RECURRENT ASSESSMENT AND SALVAGE TREATMENT (FORECAST) TRIAL

MP44-06 TUMOR CHARACTERISTICS OF MULTIPARAMETRIC MRI-DETECTED AND -UNDETECTED LESIONS IN PATIENTS WITH SUSPECTED RADIORECURRENT PROSTATE CANCER: AN ANALYSIS FROM THE FOCAL RECURRENT ASSESSMENT AND SALVAGE TREATMENT (FORECAST) TRIAL

Registration of trans-perineal template mapping biopsy cores to volumetric ultrasound.

Pathology from trans-perineal template mapping biopsy (TTMB) can be used as labels to train prostate cancer classifiers. In this work, we propose a framework to register TTMB cores to advanced volumetric ultrasound data such as multi-parametric transrectal ultrasound (mpTRUS). The framework has mainly two steps. First, needle trajectories are calculated with respect to the needle guiding template-considering deflections in their paths. In standard TTMB, a sparsely sampled ultrasound volume is taken prior to the procedure which contains the template overlaid on top of it. The position of this template is detected automatically, and the cores are mapped following the calculated needle trajectories. Second, the TTMB volume is aligned to the mpTRUS volume by a two-step registration method. Using the same transformations from the registration step, the cores are registered from the TTMB volume to the mpTRUS volume. TTMB and mpTRUS of 10 patients were available for this work. The target registration errors (TRE) of the volumes using landmarks picked by three research assistants (RA) and one radiation oncologist (RO) were on average 1.32 ± 0.7mm and 1.03 ± 0.6mm, respectively. Additionally, on average, our framework takes only 97s to register the cores. Our proposed framework allows a quick way to find the spatial location of the cores with respect to volumetric ultrasound. Furthermore, knowing the correct location of the pathology will facilitate focal treatment and will aid in training imaging-based cancer classifiers.

Magnetic Resonance Imaging and Targeted Biopsies Compared to Transperineal Mapping Biopsies Before Focal Ablation in Localised and Metastatic Recurrent Prostate Cancer After Radiotherapy

BackgroundRecurrent prostate cancer after radiotherapy occurs in one in five patients. The efficacy of prostate magnetic resonance imaging (MRI) in recurrent cancer has not been established. Furthermore, high-quality data on new minimally invasive salvage focal ablative treatments are needed. ObjectiveTo evaluate the role of prostate MRI in detection of prostate cancer recurring after radiotherapy and the role of salvage focal ablation in treating recurrent disease. Design, setting, and participantsThe FORECAST trial was both a paired-cohort diagnostic study evaluating prostate multiparametric MRI (mpMRI) and MRI-targeted biopsies in the detection of recurrent cancer and a cohort study evaluating focal ablation at six UK centres. A total of 181 patients were recruited, with 155 included in the MRI analysis and 93 in the focal ablation analysis. InterventionPatients underwent choline positron emission tomography/computed tomography and a bone scan, followed by prostate mpMRI and MRI-targeted and transperineal template-mapping (TTPM) biopsies. MRI was reported blind to other tests. Those eligible underwent subsequent focal ablation. An amendment in December 2014 permitted focal ablation in patients with metastases. Outcome measurements and statistical analysisPrimary outcomes were the sensitivity of MRI and MRI-targeted biopsies for cancer detection, and urinary incontinence after focal ablation. A key secondary outcome was progression-free survival (PFS). Results and limitationsStaging whole-body imaging revealed localised cancer in 128 patients (71%), with involvement of pelvic nodes only in 13 (7%) and metastases in 38 (21%). The sensitivity of MRI-targeted biopsy was 92% (95% confidence interval [CI] 83–97%). The specificity and positive and negative predictive values were 75% (95% CI 45–92%), 94% (95% CI 86–98%), and 65% (95% CI 38–86%), respectively. Four cancer (6%) were missed by TTPM biopsy and six (8%) were missed by MRI-targeted biopsy. The overall MRI sensitivity for detection of any cancer was 94% (95% CI 88–98%). The specificity and positive and negative predictive values were 18% (95% CI 7–35%), 80% (95% CI 73–87%), and 46% (95% CI 19–75%), respectively. Among 93 patients undergoing focal ablation, urinary incontinence occurred in 15 (16%) and five (5%) had a grade ≥3 adverse event, with no rectal injuries. Median follow-up was 27 mo (interquartile range 18–36); overall PFS was 66% (interquartile range 54–75%) at 24 mo. ConclusionsPatients should undergo prostate MRI with both systematic and targeted biopsies to optimise cancer detection. Focal ablation for areas of intraprostatic recurrence preserves continence in the majority, with good early cancer control. Patient summaryWe investigated the role of magnetic resonance imaging (MRI) scans of the prostate and MRI-targeted biopsies in outcomes after cancer-targeted high-intensity ultrasound or cryotherapy in patients with recurrent cancer after radiotherapy. Our findings show that these patients should undergo prostate MRI with both systematic and targeted biopsies and then ablative treatment focused on areas of recurrent cancer to preserve their quality of life.This trial is registered at ClinicalTrials.gov as NCT01883128.

Image-guided in-Vivo Needle-Based Confocal Laser Endomicroscopy in the Prostate: Safety and Feasibility Study in 2 Patients.

Purpose: To assess the safety and technical feasibility of in-vivo needle-based forward-looking confocal laser endomicroscopy in prostate tissue. Methods: For this feasibility study, 2 patients with a suspicion of prostate cancer underwent transperineal needle-based confocal laser endomicroscopy during ultrasound-guided transperineal template mapping biopsies. After intravenous administration of fluorescein, needle-based confocal laser endomicroscopy imaging was performed with a forward-looking probe (outer diameter 0.9 mm) in 2 trajectories during a manual push-forward and pullback motion. A biopsy was taken in a coregistered parallel adjacent trajectory to the confocal laser endomicroscopy trajectory for histopathologic comparison. Peri- and postprocedural adverse events, confocal laser endomicroscopy device malfunction and procedural failures were recorded. Needle-based confocal laser endomicroscopy image quality assessment, image interpretation, and histology were performed by an experienced confocal laser endomicroscopy rater and uro-pathologist, blinded to any additional information. Results: In both patients, no peri- and post-procedural adverse events were reported following needle-based confocal laser endomicroscopy. No confocal laser endomicroscopy device malfunction nor procedural failures were reported. Within 1.5 min after intravenous administration of fluorescein, needle-based confocal laser endomicroscopy image quality was sufficient for interpretation for at least 14 min, yielding more than 5000 confocal laser endomicroscopy frames per patient. The pullback confocal laser endomicroscopy recordings and most of the push-forward recordings almost only visualized erythrocytes, being classified as non-representative. During the push-forward recordings, prostate tissue was occasionally visualized in single frames, insufficient for histopathologic comparison. Prostate carcinoma was identified by biopsy in one patient (Gleason score 4 + 3 = 7, >50%), while the biopsy from the other patient showed no malignancy. Conclusion: Needle-based confocal laser endomicroscopy imaging of in-vivo prostate tissue with a forward-looking confocal laser endomicroscopy probe is safe without device malfunctions or procedural failures. Needle-based confocal laser endomicroscopy is technically feasible, but the acquired confocal laser endomicroscopy datasets are non-representative. The confocal laser endomicroscopy images’ non-representative nature is possibly caused by bleeding artifacts, movement artifacts and a lack of contact time with the tissue of interest. A different confocal laser endomicroscopy probe or procedure might yield representative images of prostatic tissue.

Recent Advances in Systematic and Targeted Prostate Biopsies.

Prostate biopsy is the definitive investigation to diagnose prostate cancer. The ideal procedure would be one that offers fast and efficient results safely as an outpatient procedure. Historically, transrectal ultrasound (TRUS) biopsy is considered the gold standard but transrectal biopsy can under-sample the anterior and apical regions of the prostate and is associated with a risk of prostate biopsy-related sepsis, which may require intensive care admission. Transperineal (TP) biopsy addresses the inefficient sampling of TRUS biopsy but historically has been done under general anaesthetic, which makes it difficult to incorporate into timed diagnostic pathways such as the National Health Service (NHS) 2-week cancer pathway. TRUS biopsy has remained the mainstay of clinical diagnosis because of its simplicity; however, the recent development of simpler local anaesthetic transperineal techniques has transformed outpatient biopsy practice. These techniques practically eliminate prostate biopsy-related sepsis, have a shallow learning curve and offer effective sampling of all areas of the prostate in an outpatient setting. The effectiveness of TP biopsy has been enhanced by the introduction of multiparametric MRI prior to biopsy, the use of PSA density for risk stratification in equivocal cases and combined with more efficient targeted and systematic biopsies techniques, such as the Ginsburg Protocol, has improved the tolerability and diagnostic yield of local anaesthetic TP biopsies, reducing the risk of complications from the oversampling associated with transperineal template mapping biopsies. Areas where the literature remains unclear is the optimum number of cores needed to detect clinically significant disease (CSD) in patients with a definable lesion on MRI, in particular, whether there is a need for systematic biopsy in the face of equivocal MRI findings to ensure no CSD is missed. The Covid-19 pandemic has had a profound impact on prostate cancer referrals and prostate biopsy techniques within the UK; prior to the pandemic 65% of all prostate biopsies were TRUS, since the pandemic the proportions have reversed such that now over 65% of all prostate biopsies in the NHS are transperineal.

MP26-07 WHICH PROSTATE CANCERS ARE UNDETECTED BY MULTIPARAMETRIC MAGNETIC RESONANCE IMAGING IN MEN WITH PRIOR PROSTATE BIOPSY? AN ANALYSIS FROM THE PICTURE STUDY

You have accessJournal of UrologyProstate Cancer: Detection & Screening II (MP26)1 Sep 2021MP26-07 WHICH PROSTATE CANCERS ARE UNDETECTED BY MULTIPARAMETRIC MAGNETIC RESONANCE IMAGING IN MEN WITH PRIOR PROSTATE BIOPSY? AN ANALYSIS FROM THE PICTURE STUDY Joseph Norris, Lucy Simmons, Abi Kanthabalan, Alex Freeman, Neil McCartan, Caroline Moore, Shonit Punwani, Hayley Whitaker, Mark Emberton, Bloomsbury, and Hashim Ahmed Joseph NorrisJoseph Norris More articles by this author , Lucy SimmonsLucy Simmons More articles by this author , Abi KanthabalanAbi Kanthabalan More articles by this author , Alex FreemanAlex Freeman More articles by this author , Neil McCartanNeil McCartan More articles by this author , Caroline MooreCaroline Moore More articles by this author , Shonit PunwaniShonit Punwani More articles by this author , Hayley WhitakerHayley Whitaker More articles by this author , Mark EmbertonMark Emberton More articles by this author , Bloomsbury Bloomsbury More articles by this author , and Hashim AhmedHashim Ahmed More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002023.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Not all significant cancers are detected by multiparametric magnetic resonance imaging (mpMRI), when risk stratifying for suspected prostate cancer in both biopsy-naïve men, and those with prior biopsy. In the PICTURE study (Prostate Imaging Compared to Transperineal Ultrasound-guided biopsy for significant prostate cancer Risk Evaluation) all men underwent validation using 5mm transperineal sampling, thus providing the ideal setting to investigate cancer undetected by mpMRI, in men requiring repeat biopsy. METHODS: PICTURE was a paired-cohort confirmatory study in which patients requiring repeat biopsy underwent mpMRI, followed by 5mm transperineal template mapping biopsy (TTPM biopsy). Outcomes were overall and maximum Gleason scores, maximum cancer core length (MCCL) and prostate specific antigen density (PSAD). Four definitions of cancer were considered. RESULTS: When non-suspicious mpMRI was defined as Likert 1–2, mpMRI overlooked 2.9% (3/103; 95%CI 0.6–8.3%) of PROMIS definition 1 disease (Gleason ≥4+3 of any amount or MCCL ≥6 mm of any grade), 6.5% (11/168; 95%CI 3.3–11%) of PROMIS definition 2 disease (Gleason ≥3+4 of any amount or MCCL ≥4mm of any grade), 4.8% (7/146; 95%CI 2.0–9.6%) with any Gleason ≥7, and 9.3% (20/215; 95%CI 5.8–14%) with any cancer. The most significant cancers undetected by mpMRI (i.e. definition 1) were significantly lower in overall (Table 1) and maximum Gleason grades than cancer that was detected (p=0.02 and p=0.01, respectively). Cancer undetected by mpMRI had significantly shorter MCCL than cancer that was detected, for every definition (p=0.02, p=0.04, p=0.03, and p=0.0009, respectively). Finally, using a PSAD threshold of 0.15ng/mL/mL with non-suspicious mpMRI lowered the proportion with undetected disease to 0% (0/105; 95% CI 0–3.5%) for definition 1, and to 0.58% (1/ 171; 95% CI 0.01–3.2%) for definition 2 cancer. CONCLUSIONS: Few clinically significant prostate cancers are undetected by mpMRI in men requiring repeat prostate biopsy. Undetected tumours are of lower overall and maximum Gleason grade and shorter cancer length, compared to those that are detected, reaffirming the role of mpMRI as a triage tool to determine who undergoes repeat biopsy. Source of Funding: Medical Research Council (MR/S00680X/1) © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e464-e465 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joseph Norris More articles by this author Lucy Simmons More articles by this author Abi Kanthabalan More articles by this author Alex Freeman More articles by this author Neil McCartan More articles by this author Caroline Moore More articles by this author Shonit Punwani More articles by this author Hayley Whitaker More articles by this author Mark Emberton More articles by this author Bloomsbury More articles by this author Hashim Ahmed More articles by this author Expand All Advertisement Loading ...

Which Prostate Cancers are Undetected by Multiparametric Magnetic Resonance Imaging in Men with Previous Prostate Biopsy? An Analysis from the PICTURE Study

BackgroundMultiparametric magnetic resonance imaging (mpMRI) has improved risk stratification for suspected prostate cancer in patients following prior biopsy. However, not all significant cancers are detected by mpMRI. The PICTURE study provides the ideal opportunity to investigate cancer undetected by mpMRI owing to the use of 5 mm transperineal template mapping (TTPM) biopsy. ObjectiveTo summarise attributes of cancers systematically undetected by mpMRI in patients with prior biopsy. Design, setting, and participantsPICTURE was a paired-cohort confirmatory study in which men requiring repeat biopsy underwent mpMRI followed by TTPM biopsy. Outcome measurements and statistical analysisAttributes were compared between cancers detected and undetected by mpMRI at the patient level. Four predefined histopathological thresholds were used as the target condition for TTPM biopsy. Application of prostate-specific antigen density (PSAD) was explored. Results and limitationsWhen nonsuspicious mpMRI was defined as Likert score 1–2, 2.9% of patients (3/103; 95% confidence interval [CI] 0.6–8.3%) with definition 1 disease (Gleason ≥ 4 + 3 of any length or maximum cancer core length [MCCL] ≥ 6 mm of any grade) had their cancer not detected by mpMRI. This proportion was 6.5% (11/168; 95% CI 3.3–11%) for definition 2 disease (Gleason ≥ 3 + 4 of any length or MCCL ≥ 4 mm of any grade), 4.8% (7/146; 95% CI 2.0–9.6%) for any amount of Gleason ≥ 3 + 4 cancer, and 9.3% (20/215; 95% CI 5.8–14%) for any cancer. Definition 1 cancers undetected by mpMRI had lower overall Gleason score (p = 0.02) and maximum Gleason score (p = 0.01) compared to cancers detected by mpMRI. Prostate cancers undetected by mpMRI had shorter MCCL than cancers detected by mpMRI for every cancer threshold: definition 1, 6 versus 8 mm (p = 0.02); definition 2, 5 versus 6 mm (p = 0.04); any Gleason ≥ 3 + 4, 5 versus 6 mm (p = 0.03); and any cancer, 3 versus 5 mm (p = 0.0009). A theoretical PSAD threshold of 0.15 ng/ml/ml reduced the proportion of patients with undetected disease on nonsuspicious mpMRI to 0% (0/105; 95% CI 0–3.5%) for definition 1, 0.58% (1/171; 95% CI 0.01–3.2%) for definition 2, and 0% (0/146) for any Gleason ≥ 3 + 4. ConclusionsFew significant cancers are undetected by mpMRI in patients requiring repeat prostate biopsy. Undetected tumours are of lower overall and maximum Gleason grade and shorter cancer length compared to cancers detected by mpMRI. Patient summaryIn patients with a previous prostate biopsy, magnetic resonance imaging (MRI) overlooks few prostate cancers, and these tend to be smaller and less aggressive than cancer that is detected.

P1165 - Effect of prostate biopsy technique on nerve sparing during radical prostatectomy: Do transperineal template mapping biopsies in combination with mpMRI translate into more nerve sparing?

P1165 - Effect of prostate biopsy technique on nerve sparing during radical prostatectomy: Do transperineal template mapping biopsies in combination with mpMRI translate into more nerve sparing?

Intraprostatic Cancer Recurrence following Radical Radiotherapy on Transperineal Template Mapping Biopsy: Implications for Focal Ablative Salvage Therapy.

Men in whom external beam radiotherapy fails are usually placed on delayed hormone therapy. Some of these men have localized recurrence that might be suitable for further local therapy. We describe patterns of recurrence and suitability for focal ablative therapy in those undergoing transperineal template prostate mapping biopsies. The study included 145 consecutive patients (December 2007 to May 2014) referred with suspicion of recurrence due to rising prostate specific antigen after external beam radiotherapy or brachytherapy who underwent transperineal template prostate mapping biopsies. Suitability for focal ablative therapy required the cancer to be unifocal or unilateral, or bilateral/multifocal with 1 dominant index lesion and secondary lesions with Gleason score 3+3=6 with no more than 3 mm cancer core involvement. Mean patient age was 70.7 (SD 5.8) years. Median prostate specific antigen at time of transperineal template prostate mapping biopsy was 4.5 ng/ml (IQR 2.5-7.7). Overall 75.9% (110) were suitable for a form of focal salvage treatment, 40.7% (59) were suitable for quadrant ablation, 14.5% (21) hemiablation, 14.5% (21) bilateral focal ablation and 6.2% (9) for index lesion ablation. Three-quarters of patients who have localized radiorecurrent prostate cancer may be suitable for focal ablative therapy to the prostate based on transperineal template prostate mapping biopsies.

Oncological and Quality-of-life Outcomes Following Focal Irreversible Electroporation as Primary Treatment for Localised Prostate Cancer: A Biopsy-monitored Prospective Cohort

BackgroundFocal irreversible electroporation (IRE) can be used to treat men with localised prostate cancer (PCa) with reduced impact on quality of life (QoL). ObjectiveTo assess oncological and functional outcomes. Design, setting, and participantsTo report on a prospective database of patients undergoing primary IRE between February 2013 and August 2018. A minimum of 12-mo follow-up was available for 123 patients. Median follow-up was 36 mo (interquartile range [IQR] 24–52 mo). A total of 112 (91%) patients had National Comprehensive Cancer Network intermediate risk and 11 (9%) had low risk. A total of 12 (9.8%) had International Society of Urological Pathology (ISUP) grade 1, 88 (71.5%) had ISUP 2, and 23 (18.7%) had ISUP 3. InterventionFocal IRE ablation of PCa lesions. Outcome measurements and statistical analysisFollow-up involved serial prostate-specific antigen (PSA), multiparametric magnetic resonance imaging (mpMRI), and transperineal template mapping biopsy (TTMB) at 12 mo. Failure-free survival (FFS) was defined as progression to whole-gland or systemic treatment or metastasis/death. Functional outcomes were assessed. Results and limitationsMedian age was 68yr (IQR 62–73yr). Median preoperative PSA was 5.7ng/ml (IQR 3.8–8.0ng/ml). On post-treatment TTMB, in-field recurrence was present in 2.7–9.8% of patients. FFS at 3yr was 96.75%, metastasis-free survival 99%, and overall survival 100%. A total of 18 patients required salvage treatment (12 had repeat IRE; six had whole-gland treatment). The negative predictive value of mpMRI was 94% and sensitivity 40% for detecting in-field residual disease 6 mo after treatment. Among patients who returned questionnaires, 80/81 (98.8%) remained pad free and 40/53 (76%) had no change in erectile function. ConclusionsFocal IRE in select patients with localised clinically significant PCa has satisfactory short-term oncological outcomes with a minimal impact on patient QoL. Patient summaryIn this study, 123 patients underwent focal therapy using irreversible electroporation. Follow-up biopsy was clear of residual disease in 90.2–97.3% of patients. Of patients, 96.75% avoided whole gland treatment at 3yr.

11 - The ability of different clinical-pathological criteria’s to detect insignificant prostate cancer after transperineal template mapping biopsies

11 - The ability of different clinical-pathological criteria’s to detect insignificant prostate cancer after transperineal template mapping biopsies

Factors influencing urinary retention after transperineal template biopsy of the prostate: outcomes from a regional cancer centre.

Multi-parametric MRI (MP-MRI) prior to prostate biopsy is the investigation of choice for an elevated age-related PSA and abnormal digital rectal examination. MP-MRI in combination with transperineal template mapping biopsy has facilitated the development of the concept of targeted biopsies, either cognitively or with software fusion. Urinary retention is a recognised complication of transperineal prostate biopsy, with reported incidence being 1.6-11.4%. We present patient and procedure-related factors, which influence occurrence of urinary retention after transperineal template biopsy. Retrospective data collection of 243 consecutive cases of transperineal template biopsies performed at a single institution were recorded and analysed. Biopsies were taken using a standard 5-mm template in 4-6 sectors, depending on the prostate volume. 31/243 (12.8%) patients developed urinary retention, defined as patient discomfort and inability to micturate and bladder scan of ≥ 600ml. Patients in the retention group were significantly older (mean 68.7 vs. 65.8years, P = 0.034). Prostate volume was significantly greater in comparison with the non-retention group (mean 75.4 vs. 57.2cc, P = 0.0016). The number of biopsies taken was positively correlated with urinary retention (median 35 vs. 32 biopsies, P = 0.045), and this was independent of prostate size (R2 = 0.2). Presenting PSA, pre-operative flow and histopathological outcome were independent of urinary retention. Factors resulting in an increased risk of urinary retention are advancing age (> 68.7years); a larger prostate volume (> 75cc); greater number of biopsies (> 35); greater severity of lower urinary tract symptoms prior to biopsy and diabetes. Targeted biopsies alone, instead of a full template, may avoid urinary retention in the high-risk groups identified.

Confocal Laser Endomicroscopy and Optical Coherence Tomography for the Diagnosis of Prostate Cancer: A Needle-Based, In Vivo Feasibility Study Protocol (IDEAL Phase 2A).

BackgroundFocal therapy for prostate cancer has been proposed as an alternative treatment to whole-gland therapies in selected men to diminish side effects in localized prostate cancer. As nowadays imaging cannot offer complete prostate cancer disease characterization, multicore systematic biopsies are recommended (transrectal or transperineal). Optical imaging techniques such as confocal laser endomicroscopy and optical coherence tomography allow in vivo, high-resolution imaging. Moreover, they can provide real-time visualization and analysis of tissue and have the potential to offer additive diagnostic information.ObjectiveThis study has 2 separate primary objectives. The first is to assess the technical feasibility and safety of in vivo focal imaging with confocal laser endomicroscopy and optical coherence tomography. The second is to identify and define characteristics of prostate cancer and normal prostate tissue in confocal laser endomicroscopy and optical coherence tomography imaging by comparing these images with the corresponding histopathology.MethodsIn this prospective, in vivo feasibility study, needle-based confocal laser endomicroscopy and optical coherence tomography imaging will be performed before transperineal template mapping biopsy or radical prostatectomy. First, confocal laser endomicroscopy and optical coherence tomography will be performed in 4 patients (2 for each imaging modality) undergoing transperineal template mapping biopsy to assess the feasibility and safety of confocal laser endomicroscopy and optical coherence tomography. If proven to be safe and feasible, confocal laser endomicroscopy and optical coherence tomography will be performed in 10 patients (5 for each imaging modality) undergoing radical prostatectomy. Confocal laser endomicroscopy and optical coherence tomography images will be analyzed by independent, blinded observers. Confocal laser endomicroscopy– and optical coherence tomography–based qualitative and quantitative characteristics and histopathology will be compared. The study complies with the IDEAL (Idea, Development, Exploration, Assessment, Long-term study) stage 2a recommendations.ResultsAt present, the study is enrolling patients and results and outcomes are expected in 2019.ConclusionsConfocal laser endomicroscopy and optical coherence tomography are promising optical imaging techniques that can visualize and analyze tissue structure, possible tumor grade, and architecture in real time. They can potentially provide real-time, high-resolution microscopic imaging and tissue characteristics of prostate cancer in conjunction with magnetic resonance imaging or transrectal ultrasound fusion-guided biopsy procedures. This study will provide insight into the feasibility and tissue-specific characteristics of confocal laser endomicroscopy and optical coherence tomography for real-time optical analysis of prostate cancer.Trial RegistrationClinicalTrials.gov NCT03253458; https://clinicaltrials.gov/ct2/show/NCT03253458 (Archived by WebCite at http://www.webcitation.org/6z9owM66B)Registered Report IdentifierRR1-10.2196/9813

New technologies and techniques for prostate cancer focal therapy.

The aim of this study was to review the oncological and functional outcomes of new and established primary focal treatments (FT) for localized prostate cancer (PCa). We performed a systematic search of published studies on FT for localized PCa using electronic databases (Medline and Embase). These studies included reports on hemi-ablation, focal ablation and target-ablation. We excluded salvage focal therapy studies and limited the search to those with a minimum of 12 months of follow-up. We selected 20 studies with a total of 2523 patients who were treated in the primary setting. The energy sources used were cryotherapy (8), high-intensity focused ultrasound (9), irreversible electroporation (1), photodynamic therapy (1) and focused laser ablation (1), with 65% hemiablation, 25% focal ablation and 10% target-ablation. The median follow-ups ranged from 6 to 44.4 months. Mean age was 60.4-70 years and mean prostate-specific antigen was 4.4-<10 ng/dL; 26-100% had a Gleason Score of 6, and 0-65% had a Gleason Score of 7. Patient selection was carried out by TRUS biopsy in 9 studies, while transperineal template mapping biopsy and mp-MRI were employed in six and 13 studies, respectively. The overall post-treatment positive biopsy rate was 1.2-51% with 1.6-32% patients having a residual disease in the treated area. The post-treatment continence rates were 90-100%, and the rates of erectile dysfunction ranged from 0-53.2%. Reliable evidence for the partial-gland treatment of PCa is increasing, and encouraging mid-term oncologic outcomes with the preservation of sexual and urinary functions have been reported. Accurate patient selection at the outset of treatment and careful follow-up seem key attributes to achieve excellent functional results and encouraging oncological outcomes.

MP26-07 IN-OFFICE FREEHAND TRANSPERINEAL TEMPLATE MAPPING BIOPSY PERFORMED UNDER LOCAL ANESTHESIA USING A NOVEL NEEDLE GUIDE: FEASIBLE, SAFE, AND EFFECTIVE FOR CANCER DETECTION

You have accessJournal of UrologySurgical Technology & Simulation: Instrumentation & Technology I1 Apr 2018MP26-07 IN-OFFICE FREEHAND TRANSPERINEAL TEMPLATE MAPPING BIOPSY PERFORMED UNDER LOCAL ANESTHESIA USING A NOVEL NEEDLE GUIDE: FEASIBLE, SAFE, AND EFFECTIVE FOR CANCER DETECTION Matthew Lee, Shaan Setia, Adam Cole, Michael Fenstermaker, Chandy Ellimoottil, Lindsey Herrel, John Wei, Srinivas Vourganti, and Arvin George Matthew LeeMatthew Lee More articles by this author , Shaan SetiaShaan Setia More articles by this author , Adam ColeAdam Cole More articles by this author , Michael FenstermakerMichael Fenstermaker More articles by this author , Chandy EllimoottilChandy Ellimoottil More articles by this author , Lindsey HerrelLindsey Herrel More articles by this author , John WeiJohn Wei More articles by this author , Srinivas VourgantiSrinivas Vourganti More articles by this author , and Arvin GeorgeArvin George More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.865AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Sepsis following transrectal ultrasound-guided (TRUS) biopsy is rising with numerous strategies aimed at curbing its incidence. Transperineal prostate biopsy has negligible rates of sepsis but has traditionally been reserved for saturation sampling, required general anesthesia, and use of a brachytherapy grid/stepper. Additionally, the adequacy of modified 12-core transperineal template mapping biopsy (TMB) is debated. Herein, we describe our initial experience with completely in-office free-hand transperineal prostate biopsy (TPBx) performed under local anesthesia. METHODS A retrospective review was performed of patients who underwent TPBx at 2 institutions. TPBx was performed in lithotomy under TRUS guidance using a BK8848 biplanar probe after oral cephalosporin prophylaxis. Local anesthesia was administered via transperineal puncture and bolus delivery of anesthetic at the pelvic floor and through the endopelvic fascia anterior to the prostatic apex, bilaterally. The PrecisionPointTM device was used to access the left and right prostatic lobes to complete a modified barzell 12-core TMB. Patient characteristics and pathologic outcomes were collected and analyzed. RESULTS A total of 87 biopsies were performed with data available for 30 biopsies performed on protocol. Patient characteristics and pathologic data are summarized in Table 1. Mean age and PSA of the cohort were 63.4 years and 6.9ng/ml. Six men had a prior prostate cancer diagnosis and underwent biopsy on surveillance. The overall cancer detection rate (CDR) was 57% and clinically significant CDR (Gleason ≥7) was 33%. There were no complications noted within 30 days of biopsy. CONCLUSIONS Transperineal freehand prostate biopsy is effective for detection of prostate cancer. It is safe and well tolerated under local anesthesia, and can be performed in an office setting. Larger studies are required to validate this early experience. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e338 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Matthew Lee More articles by this author Shaan Setia More articles by this author Adam Cole More articles by this author Michael Fenstermaker More articles by this author Chandy Ellimoottil More articles by this author Lindsey Herrel More articles by this author John Wei More articles by this author Srinivas Vourganti More articles by this author Arvin George More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Preliminary Diagnostic Accuracy of Multiparametric Magnetic Resonance Imaging to Detect Residual Prostate Cancer Following Focal Therapy with Irreversible Electroporation

BackgroundIt is recommended to perform multiparametric magnetic resonance imaging (mpMRI) in the follow-up following focal therapy of prostate cancer (PCa). ObjectiveTo determine the diagnostic accuracy of mpMRI to detect residual PCa following focal therapy with irreversible electroporation. Design, setting, and participantsSeventy-six patients with biopsy-proven localized PCa consented for primary irreversible electroporation between February 2013 and March 2016. Final analysis was performed on 50 patients that received follow-up mpMRI at 6 mo, serial prostate-specific antigen (PSA) testing, and transperineal template-mapping biopsies at 12 mo. Outcome measurements and statistical analysisOutfield regions of interest (ROI) were reported using PI-RADS version 2. A binary outcome (suspicious vs nonsuspicious) was given for the infield ablation zone. Sensitivity, specificity, positive predictive values, and negative predictive values were calculated for different definitions of significant PCa: (1) Gleason ≥4+3 or Gleason ≥3+3 with a maximum cancer core length ≥6mm, (2) Gleason ≥3+4 or Gleason ≥3+3 with a maximum cancer core length ≥4mm, for outfield and infield ROI. Multivariate linear regression analyses evaluated the additional value of nadir PSA. Results and limitationsSensitivity, specificity, positive predictive values, and negative predictive values of infield ROI was 43%, 86%, 33%, and 90% for definition 1 and 38%, 86%, 33%, and 88% for definition 2, respectively. For outfield ROI this was 33%, 82%, 20%, and 90% for definition 1 and 38%, 86%, 50%, and 80% for definition 2. PSA had no additional value in predicting residual significant PCa. Limitations include retrospective design, single reader, and low incidence of residual PCa. ConclusionsOur preliminary data suggest that mpMRI can rule out high-volume residual PCa. However, follow-up biopsies should still be performed to determine oncological control. Patient summaryMultiparametric magnetic resonance imaging is able to detect high-volume significant prostate cancer following focal therapy. Prostate biopsies are still required in the follow-up of focal therapy as (low-volume) significant prostate cancer is being missed by multiparametric magnetic resonance imaging.