12-core Transrectal Ultrasound-guided Biopsy Research Articles

Predictive Factors for Extracapsular Extension of Prostate Cancer to Select the Candidates for Nerve-sparing Radical Prostatectomy.

Nerve-sparing radical prostatectomy (NSRP) for prostate cancer (PC) enables better postoperative recovery of continence and potency but may increase the risk of positive surgical margins. This study aimed to investigate preoperative predictive factors for extracapsular extension (ECE) of PC to select patients for NSRP. We retrospectively evaluated 288 patients with PC (576 lobes) diagnosed with 12-core transrectal ultrasound-guided biopsy and magnetic resonance imaging (MRI) who underwent laparoscopic or robot-assisted radical prostatectomy at our institution. Surgical specimens and preoperative parameters (prostate-specific antigen, prostate volume, biopsy and MRI findings, preoperative therapy) were analyzed. Of 576 prostate lobes, the incidence Ipsilateral ECE was identified in 97 (16.8%) lobes. The higher number of unilateral positive biopsy cores, the highest Gleason score 8 or more and positive unilateral findings on MRI are significant higher in prostate sides with ECE in univariate analysis. In multivariate analysis, positive unilateral MRI findings (odds ratio [OR], 2.86; p < 0.001) and unilateral biopsy positive core ≥ 3 (OR, 3.73; p < 0.001) were independent predictors of unilateral ECE. The detection rate of unilateral ECE in those cases with two factors (side-specific positive biopsy core 2 or less and side-specific MRI findings negative) was 7.1% (19/269). Patients with fewer unilateral positive biopsy cores and negative unilateral MRI findings might be good candidates for NSRP.

Standard 12-Core Transrectal Ultrasound-Guided Prostate Biopsy, a Useful Tool in Screening for Prostate Cancer: A Prospective Study in Uyo, Akwa Ibom State, Nigeria

Introduction: Guided prostate biopsy is still relevant in confirming the diagnosis of suspected prostate cancer. Objective: This study evaluated the role of Transrectal Ultrasound (TRUS) guided biopsy along with histopathological evaluation in the detection of prostate cancer on the basis of abnormal digital rectal examination (DRE) findings and elevated prostate specific antigen levels (PSA). Participants and Methods: This prospective study was undertaken among consenting men aged 40 years and above screened for prostate cancer at the University of Uyo Teaching Hospital using targeted, stepwise protocol including DRE, PSA and standard 12-core transrectal ultrasound guided biopsy technique. Biopsy samples were sent for histopathological evaluation. Findings were documented, analyzed and presented in tables and figures. Results: Among 437 participants, abnormal DRE findings, elevated PSA level above 4.0 ng/ml and abnormal TRUS findings were 17.2%, 21.1%, and 17.3% respectively. Of 44 participants who had prostate biopsies with histopathologic assessment, benign prostatic diseases were 24 cases (54.5%), slightly outnumbering malignant prostatic diseases seen in 20 (45.5%).The prostate cancer detection and prevalence rates were 45.5% and 4.6% respectively. Prostatic adenocarcinoma (45.5%), nodular hyperplasia (45.5%), basal cell hyperplasia (6.8%) and high grade prostatic intraepithelial neoplasia (2.2%) were identified histologic subtypes. Nodular hyperplasia was commonly associated with chronic prostatitis (80.0%). A significant association between DRE findings, outline of prostate, and tumour subtype was ascertained. Conclusion: Targeted screening protocol encompassing TRUS guided 12- core biopsy is a final arbiter in the diagnosis of prostate cancer and has a fairly high prostate cancer detection rate of 45.5%.

Emerging role of multiparametric magnetic resonance imaging in identifying clinically relevant localized prostate cancer.

To explore the recent advances and utility of multiparametric magnetic resonance imaging (mpMRI) in the diagnosis and risk-stratification of prostate cancer. Low-risk, clinically insignificant prostate cancer has a decreased risk of morbidity or mortality. Meanwhile, patients with intermediate and high-risk prostate cancer may significantly benefit from interventions like radiation or surgery. To appropriately risk stratify these patients, MRI has emerged as the imaging modality in the last decade to assist in defining prostate cancer significance, location, and biologic aggressiveness. Traditional 12-core transrectal ultrasound-guided biopsy is associated with over-detection, and ultimately over-treatment of clinically insignificant disease, and the under-detection of clinically significant disease. Biopsy accuracy is improved with MRI-guided targeted biopsy and with the use of standardized risk stratification imaging score systems. Cancer detection accuracy is further improved with combined biopsy techniques that include both systematic and MRI-targeted biopsy that aid in detection of MRI-invisible lesions. mpMRI is an area of expanding innovation that continues to refine the diagnostic accuracy of prostate biopsies. As mpMRI-targeted biopsy in prostate cancer becomes more commonplace, advances like artificial intelligence and less invasive dynamic metabolic imaging will continue to improve the utility of MRI.

Solitary Fibrous Tumor of the Seminal Vesicle: A Systematic Literature Review and Case Presentation.

Solitary fibrous tumors (SFTs) are ubiquitous mesenchymal neoplasms that have an unpredictable biological behavior. Histological criteria for this type of malignancy are uncertain. Clinical characteristics, diagnostic and treatment options of SFTs originating in the seminal vesicle are presented in this review article. A systematic review including the following databases: Scopus, Embase and Medline from 1960 until the end of March 2021 was performed according to the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines. We found seven patients affected with SFTs of seminal vesicle, in which we added our own case, making a total of 8 patients. Mean age at presentation was 55±7 years. Mean size of the SFTs was 9±2 cm and the right seminal vesicle was preferentially involved. The majority of patients were symptomatic and presenting symptoms were hematuria, dysuria, hematospermia, urinary increased frequency and urgency. Abdominal ultrasonography, computed tomography (CT) scan, and magnetic resonance (MRI) were the diagnostic tools. Trans-rectal ultrasound-guided core biopsy was also used. Seven (87%) patients had open surgery. Adjuvant radiotherapy after R0 resection was used in 1 patient. The treatment of SFTs located in the seminal vesicle necessitates a radical surgical resection to obtain acceptable results in terms of local recurrence and distant metastases.

Establishment and prospective validation of an SUVmax cutoff value to discriminate clinically significant prostate cancer from benign prostate diseases in patients with suspected prostate cancer by 68Ga-PSMA PET/CT: a real-world study.

Background and Aims: The aims of this study were to establish a maximum standardized uptake value (SUVmax) cutoff to discriminate clinically significant prostate cancer (csPCa) from benign prostate disease (BPD) by 68Ga-labeled prostate-specific membrane antigen (68Ga-PSMA-11) positron emission tomography/computed tomography (PET/CT) in patients with suspected prostate cancer (PCa), and to perform a prospective real-world validation of this cutoff value.Methods: The study included a training cohort to identify an SUVmax cutoff value and a prospective real-world cohort to validate it. A retrospective analysis assessed 135 patients with suspected PCa in a large tertiary care hospital in China who underwent 68Ga-PSMA-11 PET/CT. All patients were suspected of having PCa based on symptoms, digital rectal examination (DRE), total prostate-specific antigen (tPSA) level, and multiparameter magnetic resonance imaging (mpMRI). The 68Ga-PSMA PET/CT results were evaluated using histopathological results from transrectal ultrasound-guided 12-core biopsy with necessary targeted biopsy as references. Patients with Gleason scores (GS) ≥7 from the biopsy results were diagnosed with csPCa, and patients with negative biopsy and follow-up results were diagnosed with BPD. Receiver operating characteristic (ROC) curve analysis was used to identify the optimal SUVmax cutoff value. The cutoff value was prospectively validated in 58 patients with suspected PCa. The diagnostic benefits of the cutoff value for clinical decision making were also evaluated.Results: According to ROC curve analysis, the most appropriate SUVmax cutoff value for discriminating csPCa from BPD was 5.30 (sensitivity, 85.85%; specificity, 86.21%; area under the curve [AUC], 0.893). The cutoff achieved a sensitivity of 83.33%, a specificity of 81.25%, a positive predictive value (PPV) of 92.11%, a negative predictive value (NPV) of 65.00%, and an accuracy of 82.76% in the prospective validation cohort. Metastases were used as an indicator to reduce false negative results in patients with SUVmax ≤ 5.30. In patients without metastases, an SUVmax value of 5.30 was also the best cutoff to diagnose localized csPCa (sensitivity, 80.43%; specificity, 86.21%; AUC, 0.852). The cutoff discriminated localized csPCa from BPD with a sensitivity of 76.19%, a specificity of 81.25%, a PPV of 84.21%, an NPV of 72.22%, and an accuracy of 78.38% in the prospective validation cohort. The cutoff, combined with metastases, achieved an accuracy of 89.12% in all patients, increasing accuracy by 8.29% and reducing equivocal results compared with manual reading. There was a strong correlation between SUVmax and PSMA expression (rs = 0.831, P < 0.001) and a moderate correlation between SUVmax and GS (rs = 0.509, P < 0.001). The PSMA expression and SUVmax values of patients with csPCa were significantly higher than those of patients with BPD (P < 0.001).Conclusion: We established and prospectively validated the best SUVmax cutoff value (5.30) for discriminating csPCa from BPD with high accuracy in patients with suspected PCa. 5.30 is an effective cutoff to discriminate csPCa patients with or without metastases. The cutoff may provide a potential tool for the precise identification of csPCa by 68Ga-PSMA PET/CT, ensuring high accuracy and reducing equivocal results.

Standardized Nomenclature and Surveillance Methodologies After Focal Therapy and Partial Gland Ablation for Localized Prostate Cancer: An International Multidisciplinary Consensus

BackgroundFocal therapy (FT) and partial gland ablation (PGA) are quickly adopted by urologists and radiologists as an option for the management of localized prostate cancer. ObjectiveTo find consensus on a standardized nomenclature and to define a follow-up guideline after FT and PGA for localized prostate cancer in clinical practice. Design, setting, and participantsA review of the literature identified controversial topics in the field of FT. Online questionnaires were distributed to experts during three rounds, with the goal to achieve consensus on debated topics. The consensus project was concluded with a face-to-face meeting in which final conclusions were formulated. Outcome measurements and statistical analysisControlled feedback of responses of previous rounds were summarized and returned to the participants allowing them to re-evaluate their decisions. The level of agreement to achieve consensus on a topic was set at 80%. Results and limitationsSixty-five experts participated in this interdisciplinary consensus study (72% urologists; 28% radiologists). The experts propose the use of the herein standardized nomenclature for ablative procedures. After FT/PGA, the following tests should be performed to assess treatment outcomes: prostate-specific antigen (PSA), imaging, biopsies, and functional outcome assessment. Although not a reliable marker for treatment failure, PSA should be measured every 3 mo in the 1st year and every 6 mo thereafter. Magnetic resonance imaging is the preferred image modality and should be performed at 6 and 18 mo after treatment. A systematic 12-core transrectal ultrasound-guided biopsy combined with a targeted biopsy of the treated area should be performed 6–12 mo after treatment. Functional outcomes should be obtained 3–6 mo after treatment for the first time and until stability is attained. ConclusionsThe panel recommends the use of the proposed nomenclature and follow-up protocols to generate reliable data supporting a broader implementation of FT as a standard of care for select patients with localized prostate cancer. Patient summaryIn this report, we present expert opinion on the use of a standardized nomenclature, and surveillance methodologies after focal therapy and partial gland ablation for localized prostate cancer.

Ultrasound elastography in characterization of prostatic lesions: correlation with histopathological findings.

Ultrasound elastography is increasingly used in the diagnosis of prostate cancer, however results are heterogeneous. We correlate in a large sample-size prospective study the accuracy of elastography, aiming to settle an accurate cut-off point for diagnosis and possibility of use as a screening tool. Prospective study that included 120 patients with mean age 59.5 ± 9.8 years, showing enlarged prostate by clinical examination with prostate-specific antigen >4 ng ml-1.The study was done using high frequency high resolution endorectal probe with real time tissue elastography.Grayscale ultrasound examination was done first with Doppler followed by elastography color-coded map and strain ratio measurement. Then, transrectal ultrasound-guided core biopsy was done from suspicious areas detected by elastography (totally or partly stiff by color-coded map or with relative increased strain ratio), besides standard six-quadrant core biopsy samples. There was statistically significant difference (p < 0.001) regarding strain ratio in benign and malignant lesions. Strain ratio showed significant proportionate correlation with prostate-specific antigen level and Gleason pathological score, while no significant correlation noted with the age or the prostatic volume. A strain ratio with a cut-off value of 1.9 showed a sensitivity of 100%, specificity 93.8%, positive predictive value of 79.3%, negative predictive value 100 and 95% accuracy in differentiating between malignant and benign lesions. Strain ratio improves the detection of prostatic cancer with high sensitivity (100%) and high negative predictive value (100%). Different prostatic lesions are mostly similar in grayscale ultrasound.Imaging plays an important role in differentiation of prostatic nodules.Ultrasound elastography may play an important role in distinguishing benign from malignant nodules.

Patient Experience of Systematic Versus Fusion Prostate Biopsies

BackgroundThe magnetic resonance imaging/ultrasound fusion-guided biopsy (FBx) technique has gained popularity in prostate cancer (PCa) diagnostics, but little is known about its effect on patient experience. ObjectiveTo evaluate pain, discomfort and other non-infectious complications in PCa patients undergoing either systematic 12-core transrectal ultrasound-guided biopsy (SBx) or FBx and patient willingness to undergo rebiopsy. Design, setting, and participantsA prospective trial of 262 male patients, 203 of whom underwent transrectal SBx and 59 FBx at Helsinki University Hospital in 2015–2016. Patients completed two questionnaires immediately after and at 30 d after biopsy. Outcome measurements and statistical analysesPatients reported pain and discomfort on a numeric rating scale (NRS; 0–10) immediately after biopsy. At 30 d, discomfort was measured on a scale ranging from 1 (no inconvenience) to 4 (maximal inconvenience). Other symptoms were reported dichotomously (yes/no) in both questionnaires. Mann-Whitney U, Pearson's χ2, and logistic regression tests were used. Results and limitationsFor the SBx and FBx groups the median number of cores per patient was 12 and three, respectively. At 30 d, a higher proportion of patients in the SBx group had experienced pain than in the FBx group (70/203 [34%] vs 12/59 [20%]; p=0.043), whereas there was no difference in the median discomfort scores. Hematuria was less common in the FBx group (26/59 [44%] vs 140/203 [69%]; p<0.001). Patients willing to undergo rebiopsy immediately post-biopsy reported lower median NRS (3.0 [interquartile range 2.0–5.0] vs 5.0 [4.3–6.0]; p<0.001) and discomfort scores (4.0 [2.0–6.0] vs 7.0 [5.0–8.0]; p<0.001) than those unwilling. At 30 d, less discomfort (2.0 [interquartile range 1.0–2.0] vs 2.0 [2.0–3.0]; p=0.008) and fever (6/195 [3.1%] vs 6/28 [22%]; p=0.001) were experienced by patients willing to undergo rebiopsy. The nonrandomized design was a limitation. ConclusionsFBx is associated with less pain and hematuria than SBx during the 30-d interval after biopsy. Patient summaryMagnetic resonance imaging (MRI)-targeted prostate biopsy is associated with less pain, discomfort, and blood in the urine compared to the standard ultrasound-guided procedure. Performing MRI-targeted procedures may reduce biopsy-related complications and promote adherence to recommended repeat biopsy for patients on active surveillance for prostate cancer.

A multicentre randomised controlled trial assessing whether MRI-targeted biopsy is non-inferior to standard transrectal ultrasound guided biopsy for the diagnosis of clinically significant prostate cancer in men without prior biopsy: a study protocol

IntroductionThe classical pathway for the diagnosis of prostate cancer is transrectal ultrasound-guided (TRUS) biopsy of the prostate initiated on the basis of a raised prostate-specific antigen (PSA). An alternative pathway...

IJU this issue

Have you ever noticed morphological variations in inferior vena cava thrombus associated with renal cell carcinoma (RCC)? Do you feel any difficulty in determining the T factor of RCC (T3a or T3b) because the invasion of the inferior vena cava wall by the cancer cannot be precisely evaluated in the preoperative computed tomography or magnetic resonance imaging (MRI)? Choi et al. (Seoul, Korea) have shown challenging data connecting morphological features and the prognosis of non-metastatic RCC with inferior vena cava thrombus. They classified two types, namely, spherical (type 1) and speculated (type 2). A total of 29 patients had type 1 (18.6%), and 127 patients had type 2 (81.4%). Type 1 had a better prognosis than type 2 in overall survival and cancer-specific survival. Here arises a fundamental question. What is the biological background that makes these differences? Conceivably, well-marginated, firm cancer with abundant connective tissues makes type 1, whereas friable and disintegrating cancer makes type 2. However, abundant connective tissue is occasionally observed in sarcomatoid RCC showing a poor prognosis.1 If consistency can be evaluated by imaging, that helps precise preoperative staging. Clinical implications are that this helps the indication of an umbrella stent that blocks pulmonary embolism. A preoperative umbrella stent should be considered in type 2, because friable cancer tissue is likely to break off. Concordantly, in this cohort, perioperative mortality was higher in type 2. Do you think that aged patients with testicular germ cell tumors have a poor prognosis in comparison with young patients? Our feelings are “yes,” because aged patients cannot tolerate the standard chemotherapeutic regimen because of morbidities. Kawai et al. (Tokyo, Japan) described a Japanese cohort of patients aged 50 years and older. Of the 1119 cases, 123 (11.0%) were diagnosed at age ≥50 years. They were frequently seminomas, and more frequently diagnosed in clinical stage 1 than younger patients. Regarding metastatic cases, aged patients are classified more as the better prognosis group; however, cancer-specific survival was not superior to younger patients. This is due to the fact that not enough chemotherapy was given to the aged patients. They suggested alternative regimens without bleomicin for aged patients with comorbidities. Adenocarcinoma (ADK) of the bladder is rare. We vaguely believe that ADK has a poorer prognosis than urothelial carcinoma of the bladder. Is it really so? Using the SEER database of 10 024 patients with non-metastatic bladder cancer, Zaffuto et al. (Milan, Italy) have shown that 215 (2.1%) had ADK. Interestingly, cancer-specific mortality rates did not defer from urothelial carcinoma. A higher cancer-specific mortality applies to the signet ring cell variant. Among ADK patients, 30.7% harbored the signet ring cell variant. The signet ring cell variant should be paid attention to when ADK is pathologically diagnosed. Classical 12-core transrectal ultrasound-guided biopsy is limited to detecting clinically significant prostate cancer. Multiparametric MRI (mpMRI) has been widely used to facilitate the accurate diagnosis of clinically significant cancer. Tsivian et al. (Durham, USA) analyzed the accuracy of mpMRI in a repeat biopsy cohort of 50 cases using comprehensive transperitoneal mapping biopsy as the reference. mpMRI had high specificity and a high negative predictive value for detecting clinically significant prostate cancer. However, in our daily practice, target biopsy is the standard procedure, which might miss a relevant number of clinically significant prostate cancers, as mentioned by Kesch et al. (Heidelberg, Germany). We published a paper evaluating the prognostic marker of mpMRI for predicting biological recurrence after radical prostatectomy.2 We took Prostate Imaging Reporting and Data System 4/5 as positive, and showed that mpMRI was an independent biomarker for biological recurrence. We believe mpMRI is an effective index for determining the therapeutic strategy, as well as a the follow-up strategy.

First report of robot-assisted transperineal fusion versus off-target biopsy in patients undergoing repeat prostate biopsy.

To clarify the value of targeted versus off-target biopsies in men with a suspicion of prostate cancer (PC) and a visible lesion in multi-parametric magnetic resonance imaging (mpMRI) using transperineal robot-assisted biopsy. Fifty-five consecutive men with one non-palpable suspicious lesion in mpMRI after negative 12-core transrectal ultrasound-guided biopsy were enrolled in 2014-2015. Lesions were scored using the Prostate Imaging Reporting and Data System. A robot-assisted system was utilized to collect four robot-assisted targeted transperineal biopsy cores (RA-TB) within the lesion using mpMRI-TRUS elastic fusion. Untargeted transperineal 14-core biopsy was performed only outside the lesion (RA-UB). Histological grade was compared in biopsies and available prostatectomy specimens. Overall, 34 of 55 patients (62%) were diagnosed with PC based on biopsy. 85% of cancers were clinically significant PC (csPC) defined as GS≥7. 85% of biopsy-proven cancers were detected with RA-TB alone. RA-UB identified only one additional patient with csPC and lead to upgrading in five biopsy cases (14.7%). Pathological evaluation of 14 prostatectomy specimens showed upgrading in 2 patients (14.3%), while all other patients were correctly classified by RA-TB without need of additional RA-UB. Mean procedure duration was 43 (±6) min, and only minor complications according to Clavien-Dindo were recorded during 30-day follow-up. This is the first report of transperineal robot-assisted elastic mpMRI-TRUS fusion biopsy. RA-TB of positive MR lesions enabled reliable detection of csPC, while RA-UB in MRI-negative regions is of minor importance.

Six Weeks of Fluoroquinolone Antibiotic Therapy for Patients With Elevated Serum Prostate-specific Antigen Is Not Clinically Beneficial: A Randomized Controlled Clinical Trial

To evaluate asymptomatic men with elevated serum prostate-specific antigen (PSA) to determine whether a 6-week course of fluoroquinolone antibiotics lowers serum PSA and affects recommendations for prostate biopsy. A randomized, single-center prospective trial of 150 men with an initial elevated PSA was conducted. Patients were randomized to 6 weeks of ciprofloxacin or observation. Those patients with persistently elevated PSA were recommended to proceed with transrectal ultrasound-guided 12-core biopsy. Those with reduced PSA were offered transrectal ultrasound-guided biopsy but could opt to continue serial digital rectal examination/PSA. Patients were followed an average of 4.6 years to assess trends in PSA and biopsy results. Of 136 men who completed the trial, 63 were in the treatment and 73 were in the observation group. The average PSA change from baseline was borderline statistically significant with a change of -0.68 ng/mL in the treatment arm and 0.01 ng/mL in the observation arm (P = .052). Of those who underwent biopsy, prostate cancer was diagnosed in the first biopsy in 24 (63%) of the treatment vs 27 (52%) of the observation group (P = .60) over follow-up. In a cohort of asymptomatic men with elevated PSA, there was only a borderline statistically significant change in serum PSA between patients randomized to a 6-week course of fluoroquinolones vs observation, and there was no difference in positive prostate biopsy results. Our clinical recommendation is one should not treat patients with elevated serum PSA with antibiotics in the absence of clinical symptoms of prostatitis.

Contemporary outcomes in the detection of prostate cancer using transrectal ultrasound-guided 12-core biopsy in Singaporean men with elevated prostate specific antigen and/or abnormal digital rectal examination

ObjectiveDespite being the third commonest cancer in Singaporean men, there is a dearth of basic data on the detection rate of prostate cancer and post-procedure complication rates locally using systematic 12-core biopsy. Our objective is to evaluate prostate cancer detection rates using 12-core prostate biopsy based on serum prostate specific antigen (PSA) levels and digital rectal examination (DRE) findings in Singaporean men presenting to a single tertiary centre. The secondary objective is to evaluate the complication rates of transrectal prostate biopsies. MethodsWe retrospectively examined 804 men who underwent first transrectal-ultrasound (TRUS) guided 12-core prostate biopsies from January 2012 to April 2014. Prostate biopsies were performed on men presenting to a tertiary institution when their PSA levels were ≥4.0 ng/mL and/or when they had suspicious DRE findings. ResultsOverall prostate cancer detection rate was 35.1%. Regardless of DRE findings, patients were divided into four subgroups based on their serum PSA levels: 0–3.99 ng/mL, 4.00–9.99 ng/mL, 10.00–19.99 ng/mL and ≥20.00 ng/mL and their detection rates were 9.5%, 20.9%, 38.4% and 72.3%, respectively. The detection rate of cancer based on suspicious DRE findings alone was 59.2% compared to 36.5% based on serum PSA cut-off of 4.0 ng/mL alone. The post-biopsy admission rate for sepsis was 1.5%. ConclusionIn conclusion, using contemporary 12-core biopsy methods, the local prostate cancer detection rate based on serum PSA and DRE findings has increased over the past decade presumably due to multiple genetic and environmental factors. Post-biopsy sepsis remains an important complication worldwide.

PD12-02 UTILIZATION AND OUTCOMES OF REPEAT PROSTATE BIOPSY IN A STATEWIDE QUALITY IMPROVEMENT COLLABORATIVE

INTRODUCTION AND OBJECTIVES: Systematic 12-core transrectal ultrasound-guided biopsy (TRUSGB) is the recommended approach to diagnose prostate cancer (PCa). Overdiagnosis and sampling errors leading to incorrect risk stratification and treatment allocation represent major limitations. Multiparametric MRI is able to accurately identify PCa lesions within the prostate. Compared to random TRUSGB, MRI-guided targeted biopsy (MRGTB) has been shown to detect significant PCa in a higher proportion of men, using 1e4 cores instead of 12, and to reduce the diagnosis of insignificant PCa and thus overtreatment. Costs and technical limitations still prevent this promising approach from becoming the new standard in PCa diagnosis. The goal of the present study was to assess whether the added initial costs related to MRI are balanced with the benefits of MRGTB in a cost-effectiveness model. METHODS: A Markov model was developed to estimate the incremental cost-effectiveness ratio (ICER) over 10-, 15and 20 yr period. Study population consisted of men >50yr with a life expectancy >15yr and clinical suspicion of PCa. Based on previously published data, a simulation model taking into account the probability of men harboring PCa, the diagnostic accuracy of both procedures and the probability of being assigned to the various treatment options was developed. Medical (physician fees) and hospital costs (procedure fee, admission fee, tests andprocedures) basedonCanadiandatawere included. In order to avoid bias favoring MRGTB intervention, possible advantages of this intervention, such as decreased number of biopsy and change of PCa management, were not considered as base case but were tested in sensitivity analysis. ICER <50,000 CAD/QALY was considered as cost-effective. RESULTS: Following the standard systematic 12-core TRUSGB pathway, the calculated cumulative effects at 10-, 15and 20-year were 9.55, 13.56 and 16.66 years, respectively. When the MRGTB pathway was considered, cumulative effects were 9.65, 13.80 and 17.65 years, respectively. Costs related to the TRUSGB strategy were 9,762, 18,903 and 24,757 CAD at 10, 15 and 20 years, respectively, as compared to 15,112, 21,890 and 28,720 CAD for the MRGTB strategy. The corresponding 10-, 15and 20-year ICERs values when quality of life was taken into consideration were 22,043, 5,832 and 2,444 CAD/QALY, respectively. CONCLUSIONS: The incorporation of MRI and MRGTB in PCa diagnosis and management represents a cost-effective measure at 10, 15 and 20 years after initial diagnosis.

PD12-01 COST-EFFECTIVENESS OF MRI TARGETED BIOPSY OF THE PROSTATE

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Practice Patterns, Cost Effectiveness II1 Apr 2015PD12-01 COST-EFFECTIVENESS OF MRI TARGETED BIOPSY OF THE PROSTATE yannick Cerantola, Alice Dragomir, Simon Tanguay, Franck Bladou, Armen Aprikian, and Wassim Kassouf yannick Cerantolayannick Cerantola More articles by this author , Alice DragomirAlice Dragomir More articles by this author , Simon TanguaySimon Tanguay More articles by this author , Franck BladouFranck Bladou More articles by this author , Armen AprikianArmen Aprikian More articles by this author , and Wassim KassoufWassim Kassouf More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1053AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Systematic 12-core transrectal ultrasound-guided biopsy (TRUSGB) is the recommended approach to diagnose prostate cancer (PCa). Overdiagnosis and sampling errors leading to incorrect risk stratification and treatment allocation represent major limitations. Multiparametric MRI is able to accurately identify PCa lesions within the prostate. Compared to random TRUSGB, MRI-guided targeted biopsy (MRGTB) has been shown to detect significant PCa in a higher proportion of men, using 1–4 cores instead of 12, and to reduce the diagnosis of insignificant PCa and thus overtreatment. Costs and technical limitations still prevent this promising approach from becoming the new standard in PCa diagnosis. The goal of the present study was to assess whether the added initial costs related to MRI are balanced with the benefits of MRGTB in a cost-effectiveness model. METHODS A Markov model was developed to estimate the incremental cost-effectiveness ratio (ICER) over 10-, 15- and 20 yr period. Study population consisted of men >50yr with a life expectancy >15yr and clinical suspicion of PCa. Based on previously published data, a simulation model taking into account the probability of men harboring PCa, the diagnostic accuracy of both procedures and the probability of being assigned to the various treatment options was developed. Medical (physician fees) and hospital costs (procedure fee, admission fee, tests and procedures) based on Canadian data were included. In order to avoid bias favoring MRGTB intervention, possible advantages of this intervention, such as decreased number of biopsy and change of PCa management, were not considered as base case but were tested in sensitivity analysis. ICER <50,000 CAD/QALY was considered as cost-effective. RESULTS Following the standard systematic 12-core TRUSGB pathway, the calculated cumulative effects at 10-, 15- and 20-year were 9.55, 13.56 and 16.66 years, respectively. When the MRGTB pathway was considered, cumulative effects were 9.65, 13.80 and 17.65 years, respectively. Costs related to the TRUSGB strategy were 9,762, 18,903 and 24,757 CAD at 10, 15 and 20 years, respectively, as compared to 15,112, 21,890 and 28,720 CAD for the MRGTB strategy. The corresponding 10-, 15- and 20-year ICERs values when quality of life was taken into consideration were 22,043, 5,832 and 2,444 CAD/QALY, respectively. CONCLUSIONS The incorporation of MRI and MRGTB in PCa diagnosis and management represents a cost-effective measure at 10, 15 and 20 years after initial diagnosis. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e256 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information yannick Cerantola More articles by this author Alice Dragomir More articles by this author Simon Tanguay More articles by this author Franck Bladou More articles by this author Armen Aprikian More articles by this author Wassim Kassouf More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Detection and tumour grading of prostate cancer in community hospitals

Several studies have examined the variations between community pathologists and urological pathologists with respect to the detection and Gleason grading of prostate cancer via transrectal ultrasound–guided core biopsies of the prostate gland.1 Most studies are based on American and European hospitals, thus I congratulate Newell and colleagues2 on their study examining these differences in the Canadian population. The authors found a significantly higher rate of categorical diagnosis of prostate cancer at prostate gland biopsy in community hospitals than in university hospitals (58% v. 33%). Detection secondary to case-finding can be more evident in a community where prostate cancer screening may have been delayed and can explain the higher detection rates of prostate cancer found in their study. Several other factors are known to influence the yield of prostatic biopsy in the detection of cancer, including serum prostate-specific antigen (PSA) levels, findings from digital rectal examinations (induration v. hard nodules) and age. We also know that the size of the prostate may be a factor influencing prostate cancer detection rates. In Canada, where health care is provided in a single-payer system with limited resources, community urologists may have a different threshold for biopsy compared with university urologists. Furthermore, Newell and colleagues found significant variations among community pathologists in the diagnosis and grading of prostate cancer at biopsy. Previous studies have also shown that community pathologists tend to “undergrade” prostate cancer found at biopsy.1 In the present study, the incidence of Gleason score 6 prostate cancer was 36% compared with 49% in the literature; however, without review of all prostate gland biopsies by a dedicated urological pathologist, it is not possible to determine whether community pathologists in Canada also “undergrade” prostate cancer. Factors such as the size of the prostate and the extent of prostatic biopsies have been recently shown to influence Gleason scores and the incidence of “upgrading” on prostatectomy specimens; these factors should be taken into account when evaluating this specific issue.3 In larger glands, elevated serum PSA levels (the driving factor for a biopsy) are commonly the result of benign prostatic hyperplasia that is concomitantly present when cancer is found. The cancers detected in this setting typically can be well differentiated and low in volume. I believe it is beneficial to obtain a second consultation with a urological pathologist — especially for patients with prostate cancer who are being considered for active surveillance — to ensure the absence of higher-grade disease.

Prostate gland biopsies and prostatectomies: an Ontario community hospital experience

Transrectal ultrasound-guided core biopsies of the prostate gland and prostatectomies have become common procedures at many community hospitals in Canada, especially in the era of serum prostate-specific antigen (PSA) screening for prostate cancer. The Gleason grading of prostate cancer in biopsies and prostatectomies is a major determinant used for treatment planning. There is evidence in the literature that suggests important discordance between community hospital pathologists and urological pathologists with respect to the Gleason grading of prostate cancer. Our objective was to determine the diagnostic rates and Gleason scoring patterns for prostate gland biopsies and prostatectomies at our institution compared with the literature. We conducted a retrospective review of all prostate gland biopsies and prostatectomies performed at the Grey Bruce Health Services from January 2005 to September 2005. We collected data from 194 biopsies and 44 prostatectomies. We obtained prebiopsy serum PSA levels and digital rectal exam results for all patients from urologists' office records. The average age for men having biopsies was 65.8 (standard deviation [SD] 8.6) years, and the average prebiopsy serum PSA level was 8.7 (median 7.1, SD 6.2) mug/L. The rates of diagnosis from prostate gland biopsies of benign (17.6%), high-grade prostatic intraepithelial neoplasia (11.0%), atypical small acinar proliferation suspicious for invasive malignancy (13.2%) and invasive prostatic adenocarcinoma (58.2%) at our institution were significantly different than those reported in the literature (p < 0.001). We observed a significant variation in the rates of these diagnoses among the community hospital pathologists in our study (p = 0.004). There was a strong correlation between the increasing number of positive core biopsy sites and increasing Gleason scores in biopsies (p < 0.001). There was also a strong correlation between increasing pre-biopsy serum PSA levels and increasing Gleason scores in biopsies (p < 0.001). A substantial proportion (21.9%) of the biopsies given the Gleason score of 6 had a Gleason score of 7 in the prostatectomy specimen. Our results showed a significant difference in prostate gland biopsy categorical diagnoses compared with the literature. There were also significant differences in categorical diagnoses of prostate gland biopsies among the community hospital pathologists in our study. The data identify a strong positive correlation between the increasing number of positive core biopsy sites and increasing Gleason scores in biopsies, as well as a strong positive correlation between increasing prebiopsy serum PSA levels and increasing Gleason scores in biopsies that revealed cancer. We would encourage other community hospital pathologists, in collaboration with their urologists, to review periodically their prostate gland pathology practices in an attempt to improve the uniformity of diagnoses.

Steroid 5-α reductase type 2 activity in biopsies from malignant and normal prostatic tissues

BackgroundThe conversion of testosterone (T) to the more potent metabolite dihydrotestosterone (DHT) by prostate-specific steroid 5 α-reductase isoenzymes is a key mechanism in the action of androgens in the prostate and it is important in the promotion and progression of prostate diseases. We described an adaptation of a sensitive method for evaluation of the 5 α-reductase type 2 (5 α-R2) activity using a small quantity of protein. MethodsWe used 29 human prostate transrectal ultrasound-guided core biopsies obtained from patients (median age 70, range 55–86 y) undergoing this procedure for diagnostic purposes. 4-[14C]testosterone and NADPH were incubated with biopsy homogenate. Reaction products were extracted, separated by thin layer chromatography and revealed by autoradiography. Areas correspondent to T and DHT were scraped into vials and their radioactivity determined. ResultsThe 5 α-R2 activity was expressed as ln (natural logarithm). The assay was validated according to the protein concentration and incubation time linearities. The 5 α-R2 activity showed a significant difference between normal and neoplastic tissues with significance level set at P<0.05, mainly in the left prostate lobe. This was independent from the PSA levels. ConclusionsDetermination of 5 α-R2 activity, using the conditions reported herein, could be utilized as an efficient biochemical parameter of prostate neoplastic processes.

Predictors of seminal vesicle invasion before radical prostatectomy

To predict whether or not seminal vesicle invasion is present before radical prostatectomy, the relationships between clinical parameters and seminal vesicle invasion were analyzed. A review was conducted of 187 patients who had been clinically diagnosed with stages A(2), B(0), B(1), B(2) or C prostate cancer and who had undergone radical prostatectomy without neoadjuvant therapy. The parameters analyzed for potential predictors of seminal vesicle invasion before radical prostatectomy included age, clinical stage, serum prostate-specific antigen (PSA) level at biopsy, tumor differentiation of biopsy specimens and percentage of cancer positive cores by biopsy. For percentage of cancer positive cores by biopsy, 143 of 187 patients who underwent transrectal sextant biopsy or more than six transrectal ultrasound guided core biopsies were evaluated. These parameters were subjected to univariate and multivariate logistic regression analyses to identify predictors for seminal vesicle invasion. The median age was 66.8 years (range 51-77 years). Of 187 patients, 27 (14.4%) had seminal vesicle invasion confirmed pathologically. There were significant differences in all parameters except for age between patients with positive and negative seminal vesicle invasion on univariate analysis. Multivariate analysis revealed that serum PSA level, tumor differentiation of biopsy specimens and percentage of cancer positive cores were significant independent predictors of seminal vesicle invasion. The results showed serum PSA level, tumor differentiation of biopsy specimens and percentage of cancer positive cores by biopsy before radical prostatectomy may be useful predictors for seminal vesicle invasion.

PROQUR: A tool for quality control, epidemiological surveillance, patient follow-up and clinical research activities related to prostate cancer

Prostate cancer is a leading cancer in Western Europe and epidemiological surveillance is essential to better understand the disease and its treatment. A database for quality control starting with the diagnostic procedure transrectal ultrasound guided core biopsy of the prostate was designed with the aim of monitoring side-events to the procedure, direct printing of reports and forms related to the diagnostic procedure, the National Cancer Registry and the National Prostate Cancer Quality Registry. The programme is flexible, and new folders related to specific research activities can be attached. The programme is easy to handle and aimed at facilitating the daily work of the urologist, epidemiological surveillance and disease progression. We suggest the programme should become a common tool and platform for a standardised approach in diagnostic, therapeutic, administrative reporting to the National Cancer Registry and National Prostate Cancer Quality Registry, and research on prostate diseases in the urologic community in Sweden and eventually abroad.