Transperineal Mapping Biopsy Research Articles

Multimodal image and mapping guided focal salvage high-dose-rate brachytherapy for local recurrent prostate cancer.

122 Background: Image guided brachytherapy and mapping biopsy could reduce the toxicity of the total salvage brachytherapy. This study evaluate the tumor control and the tolerance of a focal real time salvage high-dose-rate (HDR) brachytherapy to treat the local relapse as defined on transperineal mapping biopsy, multipara-metric MRI and Choline PETSCAN on the same treatment planning. Methods: Between October 2013 and June 2016, Twenty-nine patients with local relapse on Choline PET Scan after a primary irradiation had a salvage HDR Brachytherapy (2 fractions of 10 Gy within 4-6 hours in one implant) without hormone. One month before brachytherapy All patients had real time transperineal randomized European regions standardised magnetic resonance imaging (MRI) prostate biopsies and targeted biopsies with a fusion of T2 MRI sequence /CholinePETscan (50 % SUV) to intraoperative transrectal ultrasound one month before brachytherapy. We used Flex Focus 400 ultrasound machine BK, Vitesse 3.0 and 3 D navigation with EXII Stepper in order to use the result of mapping biopsy for real time HDR brachytherapy treatment planning study. Tumor control was measure with phoenix definition and Kaplan-Meier. The GU and GI toxicity were measure with CTCAE V 3. Results: 13 Low risk, 10 Intermediate risk, 8 High risk, initially treated with 3 Iodine brachytherapy ( 160 GY), 15 EBRT ≥ 78 Gy and 7 EBRT ≤ 70 gy were include. The number of biopsy (mean volume, 21 cm3; SD, 6.7). Prostate Volume (mean volume, 29.7 cm3; SD, 12.5). CTV Volume (mean volume, 13.3 cm3; SD, 6.7). Mean dose to 90% of the prostate was 11.4 Gy (SD, 1.45). Mean dose to 90% of the CTV was 21.1 Gy (SD, 1.45). Mean dose to 90% of the CTVmri was 27.6 Gy (SD, 3.4). The biologic disease free survival at 2 years is 65 % (Kaplan-Meier). Disease without hormone survival at 2 years is 86,5%. The chronic toxicity ( > 6 mois) was 6 Gu and 4 GI for grade ≤ 2 and 1 GU grade 3 (total incontinence). Conclusions: Focal, mapping and multimodal image guided salvage HDR brachytherapy for recurrent prostate cancer is a feasible therapy. This approach has to be evaluated in multicenter cohort.

18F-Choline Positron Emission Tomography/Computed Tomography and Multiparametric Magnetic Resonance Imaging for the Detection of Early Local Recurrence of Prostate Cancer Initially Treated by Radiation Therapy: Comparison With Systematic 3-Dimensional Transperineal Mapping Biopsy

To compare the diagnostic performance of 18F-fluorocholine positron emission tomography/computed tomography (FCH-PET/CT), multiparametric prostate magnetic resonance imaging (mpMRI), and a combination of both techniques for the detection of local recurrence of prostate cancer initially treated by radiation therapy. This was a retrospective, single-institution study of 32 patients with suspected prostate cancer recurrence who underwent both FCH-PET/CT and 3T mpMRI within 3months of one another for the detection of recurrence. All included patients had to be cleared for metastatic recurrence. The reference procedure was systematic 3-dimensional (3D)-transperineal prostate biopsy for the final assessment of local recurrence. Both imaging modalities were analyzed by 2 experienced readers blinded to clinical data. The analysis was made per-patient and per-segment using a 4-segment model. The median prostate-specific antigen value at the time of imaging was 2.92ng/mL. The mean prostate-specific antigen doubling time was 14months. Of the 32 patients, 31 had a positive 3D-transperineal mapping biopsy for a local relapse. On a patient-based analysis, the detection rate was 71% (22 of 31) for mpMRI and 74% (23 of 31) for FCH-PET/CT. On a segment-based analysis, the sensitivity and specificity were, respectively, 32% and 87% for mpMRI, 34% and 87% for FCH-PET/CT, and 43% and 83% for the combined analysis of both techniques. Accuracy was 64%, 65%, and 66%, respectively. The interobserver agreement was κ=0.92 for FCH-PET/CT and κ=0.74 for mpMRI. Both mpMRI and FCH-PET/CT show limited sensitivity but good specificity for the detection of local cancer recurrence after radiation therapy, when compared with 3D-transperineal mapping biopsy. Prostate biopsy still seems to be mandatory to diagnose local relapse and select patients who could benefit from local salvage therapy.

High intensity focused ultrasound with Focal-One® device: Prostate-specific antigen impact and morbidity evaluation during the initial experience

ObjectiveWe report our initial experience in the treatment of prostate cancer (PCa) with high-intensity focused ultrasound (HIFU) using the Focal-One® device. Material and methodsRetrospective review of the prospectively populated database. Between June 2014 and October 2015, 85 patients underwent HIFU (focal/whole-gland) treatment for localized PCa. Preoperative cancer localization was done with multiparametric magnetic resonance imaging (mpMRI) and transperineal mapping biopsies. Treatment was carried out using the Focal-One® device under general anesthesia. Oncological follow-up: PSA measurement and control biopsy with mpMRI according to protocol. Questionnaire-based functional outcome assessment was done. Complications were reported using Clavien classification. ResultsThe median PSA was 7.79ng/ml (IQR: 6.32–9.16), with a median prostate volume of 38cc (IQR: 33–49.75). Focal and whole-gland therapy was performed in 64 and 21 patients respectively. Ten patients received salvage HIFU. Complications were encountered in 15% of cases, all Clavien 2 graded. Mean hospital stay was 1.8 days (0–7) and bladder catheter was removed on day 2 (1–6). Mean percentage reduction of PSA was 54%. Median follow-up was 3 months (IQR: 2–8). Functional outcomes: All patients were continents at 3 months and potency was maintained in 83% of the preoperatively potent. ConclusionsFocal-One® HIFU treatment appears to be a safe procedure with few complications. Functional outcomes proved no urinary incontinence and sexual function were maintained in 83%.

Ultrasonido focalizado de alta intensidad con el dispositivo Focal-One®: impacto sobre el antígeno prostático específico y evaluación de la morbilidad durante la experiencia inicial

ObjectiveWe report our initial experience in the treatment of prostate cancer (PCa) with high-intensity focused ultrasound (HIFU) using the Focal-One® device. Material and methodsRetrospective review of the prospectively populated database. Between June 2014 to October 2015, 85 patients underwent HIFU (focal/whole-gland) treatment for localized PCa. Preoperative cancer localization was done with multiparametric magnetic resonance imaging (mpMRI) and transperineal mapping biopsies. Treatment was carried out using the Focal-One® device under general anesthesia. Oncological follow-up: PSA measurement and control biopsy with mpMRI according to protocol. Questionnaire-based functional outcome assessment was done. Complications were reported using Clavien classification. ResultsThe median PSA was 7.79ng/ml (IQR 6.32-9.16), with a median prostate volume of 38cc (IQR: 33-49.75). Focal and whole-gland therapy was performed in 64 and 21 patients respectively. Ten patients received salvage HIFU. Complications were encountered in 15% of cases, all Clavien 2 graded. Mean hospital stay was 1.8 days (0-7) and bladder catheter was removed on day 2 (1-6). Mean percentage reduction of PSA was 54%. Median follow-up was 3 months (IQR: 2-8). Functional outcomes: All patients were continents at 3 months and potency was maintained in 83% of the preoperatively potent. ConclusionsFocal-One® HIFU treatment appears to be a safe procedure with few complications. Functional outcomes proved no urinary incontinence and sexual function were maintained in 83%.

Hemiablative Focal Low Dose Rate Brachytherapy: A Phase II Trial Protocol.

BackgroundThe objective of focal brachytherapy (BT) is to provide effective prostate cancer control for low-risk disease but with reduced genitourinary, gastrointestinal and sexual side effects in a cost-effective way.ObjectiveThe aim of this study is to describe a phase II study examining technical and dosimetric feasibility and toxicity, quality of life changes, and local control with post-treatment biopsy outcomes in men with early stage low volume prostate cancer treated with focal iodine-125 seed BT.MethodsThe study design is a prospective, multicenter trial with a planned sample size of 20 patients including men with a minimum age of 60 years, a life expectancy estimated to be greater than 10 years, with low or low-tier intermediate risk prostate cancer, unilateral disease on the biopsy, and a Gleason score of ≤3+4 and <25% cores involved. The investigations specific for the study are multi-parametric magnetic resonance imaging (Mp-MRI) baseline, at 20 and 36 months to rule out high grade disease and a transperineal mapping biopsy (baseline and at 36 months) for more accurate patient selection. The hemigland region will receive 144 Gy. Standard normal tissue constraints will be considered as for a whole gland (WG) implant. Dosimetric parameters will be evaluated at day 30 after the implant. Toxicity and quality of life will be evaluated with international validated questionnaires focusing on urinary, rectal, sexual domain, and general health-related quality of life. The patients will complete this assessment at baseline and then approximately every 6 months after the implant up to 10 years.ResultsTo date, one patient is involved in the trial. He underwent the pre-implant investigations which found bilateral disease. Therefore, a standard seed implant was performed. If the results from this trial provide evidence that the treatment is safe, feasible, and improves toxicity, funding will be sought to conduct a large, multicenter, randomized controlled trial (RCT).ConclusionsThis protocol is designed to show feasibility in delivering hemigland focal therapy with seed BT. It may answer crucial questions and obtain data which will enable downstream decisions on focal low dose rate (LDR) prostate BT.ClinicalTrialClinicaltrial.gov NCT02643511; https://www.clinicaltrials.gov/ct2/show/NCT02643511 (Archived by Webcite at http://www.webcitation.org/6ghLCzIhY)

MP57-07 TRANSPERINEAL PROSTATE MAPPING BIOPSY CORRECTLY IDENTIFIES CANDIDATES FOR RADICAL PROSTATECTOMY

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy III1 Apr 2016MP57-07 TRANSPERINEAL PROSTATE MAPPING BIOPSY CORRECTLY IDENTIFIES CANDIDATES FOR RADICAL PROSTATECTOMY E. David Crawford, Vassilios Skouteris, Paul Arangua, and Nelson Stone E. David CrawfordE. David Crawford More articles by this author , Vassilios SkouterisVassilios Skouteris More articles by this author , Paul AranguaPaul Arangua More articles by this author , and Nelson StoneNelson Stone More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.661AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Intra-prostatic staging by transperineal mapping biopsy (TPMB) may improve identification of men with prostate cancer best suited for radical prostatectomy (RP). We investigated the results of TRUS biopsy positive men with minimal disease, biopsy negative and biopsy naive men who had TPMB followed by RP. METHODS 366 men being considered for focal therapy or active surveillance had TPMB of which 45/218 with prostate cancer (20.6%) had RP. 12 (26.7%) had a prior positive TRUS biopsy with minimal disease, 24 had negative biopsy (median 1.5) and 9 were biopsy naive. TPMB was performed through a template with biopsies taken at 5 mm intervals. Multiple in-line samples were taken if prostate length exceeded 2 cm. A proprietary software program was used to track biopsy locations. Men with prior TRUS had a median of 12 cores sampled while the 45 with TPMB had 50 cores. Associations between positive TRUS and TPMB were compared in men undergoing RP by ANOVA and chi-square analysis. The surgical pathology specimen was also compared to the results of TPMB. RESULTS Median Age, PSA and PSAD were 63 years, 6.3 mg/ml and 0.164. Of the 12 men with prior positive biopsy 6 had Gleason score (GS) 6 and 6 GS 7. TPMB in these 12 revealed GS 6 in 3 (25%), 7 in 7 (58.3%) and 8-10 in 2 (16.7%). The median number of positive cores was 12 and 14 (58.3%) had bilateral disease. RP specimens revealed GS 6 in 2, GS 7 in 7 with 3 pending. After RP, 8 had pT2c and I pT3. No patients were downgraded to low volume GS 6. 33 had negative TRUS biopsy or were biopsy naive and had TPMP then RP. Mapping pathology was GS 6 in 11 (33%), 7 in 17 (51.5%) and 8-10 in 5 (15.5%). 22 (66.7%) had bilateral disease. Surgical specimen data was available in 25 with GS 6 in 5 (20%), 7 in 16 (64%) and 8-10 in 4 (16%). RP stage was pT2a/b in 4 (16%), pT2c in 13 (52%) and pT3 in 8 (32%). The 2 patients with low volume disease on RP each had 1 core GS 6 with TPMB. CONCLUSIONS Intra-prostatic staging by TPMB can correctly identify appropriate candidates for RP. 43/45 (95.6%) had high volume or grade on surgical pathology which was determined by TPMB. The 2 RP patients who could have been managed by AS were also identified by mapping biopsy. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e755 Advertisement Copyright & Permissions© 2016MetricsAuthor Information E. David Crawford More articles by this author Vassilios Skouteris More articles by this author Paul Arangua More articles by this author Nelson Stone More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

PD26-12 COMPLICATIONS ASSOCIATED WITH TRANSRECTAL AND TRANSPERINEAL PROSTATE MAPPING BIOPSY

You have accessJournal of UrologyProstate Cancer: Detection & Screening VI1 Apr 2016PD26-12 COMPLICATIONS ASSOCIATED WITH TRANSRECTAL AND TRANSPERINEAL PROSTATE MAPPING BIOPSY Vassilios Skouteris, Nelson Stone, Paul Arangua, and E. David Crawford Vassilios SkouterisVassilios Skouteris More articles by this author , Nelson StoneNelson Stone More articles by this author , Paul AranguaPaul Arangua More articles by this author , and E. David CrawfordE. David Crawford More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.373AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To evaluate incidence of complications in men undergoing transrectal (TRUS) and transperineal mapping biopsy (TPMB). METHODS 366 men, of which 258 (70.5%), had a prior TRUS biopsy had TPMB performed through a template with biopsies taken at 5 mm intervals. Multiple in-line samples were taken if prostate length exceeded 2 cm. A proprietary software program was used to track biopsy locations. Men with prior TRUS had a median of 12 cores sampled while the 366 with TPMB had 51.5 cores. The number of cores taken was volume based. Associations between urinary infection and retention were compared in TRUS and TPMB with age, core number, prostate volume (PV), PSA, PSAD and prior TRUS biopsy number by ANOVA and chi-square. Multiple significant associations were compared by logistic regression. RESULTS Median Age, PSA and PSAD were 65 years, 5.5 mg/ml and 0.159. 218/366 (59.7%) were diagnosed with prostate cancer by TPMB with a median of 7.0 cores positive. 11/258 (4.3%) of the men who had TRUS biopsy developed urinary tract infections compared 3/336 (0.89%) of those with mapping biopsy. Age, number of TRUS biopsies (mean 1.5, range 1-9), or PV were not associated with TRUS infections. None of the 11 men with TRUS infections developed an infection after TPMB. Neither the number of cores taken by TPMB or a larger PV was associated with infection. 2 of the 3 men who developed infection after mapping also had post-TPMB urinary retention (OR 27.0, 95% CI 2.4-308.6, p<0.001). No TRUS biopsy men developed retention while 27/336 (7.4%) did following TPMB. Mean age, PV and core number was higher in retention patients (69.5 vs 64 years, p=0.001, 62.6 vs 46 cc, p<0.001 and 62.6 and 56.9 cores, p=0.011). PSA, PSAD, prior TRUS biopsy, number of prior TRUS biopsies and diagnosis of cancer was not associated with retention. Linear regression revealed age (p=0.001), PV (p=0.010) and number of cores (0.061) as significant. CONCLUSIONS Urinary tract infections are 5x more common in TRUS biopsy compared to TPMB. A TRUS biopsy followed by a mapping biopsy does not increase the risk of a urinary tract infection. Men who develop retention after TPMB are much more likely to develop an infection (7.4% vs 0.3%). Urinary retention occurred in 7.4% and was associated with older age and increased prostate size. These data should be helpful in counseling men who desire prostate biopsy by TPM. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e648-e649 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Vassilios Skouteris More articles by this author Nelson Stone More articles by this author Paul Arangua More articles by this author E. David Crawford More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Procedure for transperineal mapping biopsy in the diagnosis of prostate cancer

Procedure for transperineal mapping biopsy in the diagnosis of prostate cancer

What tumours should we treat with focal therapy based on risk category, grade, size and location?

Focal therapy aims to reduce side-effects of active whole-gland therapies with an acceptable or noninferior oncologic benefit for the patient. The definition of the lesion to treat using this tissue-preserving approach is central, and there is a recent shift in considering more aggressive disease than in the past. This article examines recent consensus reports, assessment of emerging techniques, histologic considerations as well as results of trials and their development. Accumulation of evidence reinforces the concept of clinically significant disease. Latest histologic assessment studies specify the index lesion characteristics. Index lesion localization was accurately evaluated by both multiparametric MRI (mpMRI)-targeted and transperineal mapping biopsy techniques against reference standard. mpMRI continues its development in accurate disease stratification. Development of new treatment modalities allows the clinician to investigate treatment of a lesion in various zonal anatomy locations. Consensus reports establish the intermediate risk population as the target for focal therapy, leaving very low risk disease to surveillance. Reviews of past clinical trials, including intermediate risk population, reveal encouraging oncologic follow-up. Ongoing trials will test focal therapy of index lesion with surveillance of insignificant secondary lesions. Focal therapy should be investigated for intermediate risk population, leaving very low risk to surveillance. Detection and stratification techniques, namely mpMRI-targeted and transperineal biopsies, have an evolving role in lesion selection to confirm encouraging oncologic benefit for the patient.

MP83-02 COMBINATION OF MULTI-PARAMETRIC MAGNETIC RESONANCE IMAGING (MP-MRI) AND TRANSPERINEAL TEMPLATE-GUIDED MAPPING BIOPSY (TTMB) OF THE PROSTATE TO IDENTIFY CANDIDATES FOR HEMI-ABLATIVE FOCAL THERAPY

You have accessJournal of UrologyProstate Cancer: Localized IX1 Apr 2015MP83-02 COMBINATION OF MULTI-PARAMETRIC MAGNETIC RESONANCE IMAGING (MP-MRI) AND TRANSPERINEAL TEMPLATE-GUIDED MAPPING BIOPSY (TTMB) OF THE PROSTATE TO IDENTIFY CANDIDATES FOR HEMI-ABLATIVE FOCAL THERAPY Minh Tran, James Thompson, Maret Boehm, Marley Pulbrook, Daniel Moses, Ron Shnier, Phillip Brenner, Warick Delprado, Anne-Maree Haynes, Richard Savdie, and Phillip Stricker Minh TranMinh Tran More articles by this author , James ThompsonJames Thompson More articles by this author , Maret BoehmMaret Boehm More articles by this author , Marley PulbrookMarley Pulbrook More articles by this author , Daniel MosesDaniel Moses More articles by this author , Ron ShnierRon Shnier More articles by this author , Phillip BrennerPhillip Brenner More articles by this author , Warick DelpradoWarick Delprado More articles by this author , Anne-Maree HaynesAnne-Maree Haynes More articles by this author , Richard SavdieRichard Savdie More articles by this author , and Phillip StrickerPhillip Stricker More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1877AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Focal therapy (FT) is an emerging treatment option for patients with localized prostate cancer (PCa) aiming to reduce the morbidity of whole-gland therapy. Successful patient selection requires accurate identification and localization of clinically significant lesions within the prostate. Transperineal mapping biopsy (TTMB) is considered the gold standard diagnostic tool to identify candidates for FT. Multi-parametric magnetic resonance imaging (mp-MRI) has recently been shown to have a high NPV in detecting clinically significant PCa. We evaluated the accuracy of combined mp-MRI and TTMB for identifying lobes with significant cancer for application of hemi-ablative FT. METHODS From January 2012–January 2014, 89 consecutive patients aged ≥40 with PSA ≤15 underwent in sequential order: mp-MRI, TTMB and radical prostatectomy (RP) at a single centre. Analysis was performed on 50 patients that met consensus guidelines for FT (clinical stage ≤T2a, Gleason ≤3+4 and no evidence of extracapsular extension or seminal vesicle invasion on mp-MRI or TTMB). Lobes were stratified into lobes with significant cancer (LSC), insignificant cancer (LIC) and no cancer (LNC). Using histopathology at RP, the predictive performance of combined mp-MRI and TTMB in identifying LSC was evaluated. RESULTS The sensitivity, specificity and PPV for combined mp-MRI+TTMB for LSC was 97%, 64% and 84% respectively. Due to the risk of undertreating significant lesions, NPV was considered the primary parameter of interest. The NPV for combined mp-MRI+TTMB for LSC was 91%. Of the 50 patients, 22 had significant unilateral disease on mp-MRI+TTMB and were thus potential candidates for hemi-ablative FT. Two (91%) of the 22 patients had a significant lesion crossing the sagittal midline with contralateral extension of 4mm and 6mm respectively. One of these two patients additionally had a separate small but moderate risk lesion (<0.1cc Gleason 3+4 with 10% Gleason pattern 4) undetected by mp-MRI+TTMB. CONCLUSIONS In candidates for focal therapy based on consensus guidelines, mp-MRI reported by expert radiologists and TTMB provide an excellent negative predictive value in the application for hemi-ablative focal therapy. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e1050 Peer Review Report Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Minh Tran More articles by this author James Thompson More articles by this author Maret Boehm More articles by this author Marley Pulbrook More articles by this author Daniel Moses More articles by this author Ron Shnier More articles by this author Phillip Brenner More articles by this author Warick Delprado More articles by this author Anne-Maree Haynes More articles by this author Richard Savdie More articles by this author Phillip Stricker More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Diagnosis and management of local recurrence after low-dose-rate brachytherapy.

To describe the diagnosis of local failure after prostate brachytherapy (BT) and treatment options when recurrence is present. Review of literature for local recurrence after prostate BT and salvage therapy was performed. A total of 6 patients with prostate-specific antigen increase were identified as local failures by transperineal mapping biopsy (TPMB) and treated with targeted focused therapy using cryoablation. Local recurrence after prostate BT occurs in 2-20% and is dose dependent. The biologic effective dose greater than 200 Gy(2) is associated with a less than 2% recurrence rate. Confirmatory biopsy should include both the prostate and seminal vesicles, as prostate cancer can be found in 20% of the latter. The pathologist should be experienced in evaluating post-irradiation tissue because of the difficulty in distinguishing benign irradiated prostate from residual or recurrent tumor. Whole gland salvage, whether by prostatectomy or cryoablation, is associated with high complication rates. Focal therapy has fewer complications but accurate targeting remains a concern. Newer diagnostic and targeting modalities such as multiparametric MRI and TPMB offer improved opportunity to increase lesion identification and ablation. A TPMB approach, which incorporates new biopsy needle design and interactive targeting software, may offer the best avenue to true focused therapy. Local recurrences after prostate BT are uncommon because of high delivered radiation dose. When present, improved lesion identification and targeting may be associated with better cancer control and lower morbidity.

A21 Session 6: Case studies in ablative therapy : Utilizing multiparametric mri and 3-D transperineal mapping biopsies to localize, target and ultimately destroy prostate cancer with cryosurgery

Prostate cancer screening trials have shown a 30% reduction of prostate cancer mortality. However, the USPSTF has recommended against PSA screening because the harms outweigh the benefits. Indeed, screening has increased over-diagnosis and subsequent over-treatment of indolent disease that might not benefit from primary therapy, particularly when treatment-related side effects have a considerable impact on a man’s quality of life. In this context, we have focused our efforts on improving patient selection by integrating multiparametric MRI [mpMRI], 3-dimensional transperineal prostate mapping biopsies and targeted MRI/TRUS fusion biopsy techniques to aid in disease characterization. In this fashion, we can better determine those cancers that may be followed under an active surveillance protocol compared to those that require treatment. Active surveillance has been developed with the aim of postponing therapy in lower-risk patients. Focal therapy, or targeted ablation, offers the benefits of eradicating the known area(s) of cancer with the ability to employ active surveillance for the untreated areas of the gland. Following such a path should decrease the chance of over-treatment while still preserving a man’s continence and potency. The aim of our clinical protocol is to evaluate men willing to participate in focal therapy/active surveillance trials using mpMRI, which has been shown to have excellent performance in identifying large and poorly differentiated tumors. Multi-parametric MRI findings have been combined with ultrasound images to perform targeted biopsies, showing an improved detection of clinically significant cancers that harbor greater tumor volumes and often display more aggressive biologic behavior. We utilize 3 dimensional transperineal mapping biopsies, mp-MRI and targeted biopsy findings to improve patient selection, treatment planning and ultimately physiologic and cancer outcomes with targeted cryosurgery.

Multi-parametric MRI findings of transitional zone prostate cancers: correlation with 3-dimensional transperineal mapping biopsy.

A preliminary project to correlate MR findings with mapping prostate biopsy to help differentiate malignant transitional zone lesions form benign prostatic hyperplasia (BPH) nodules. Institutional IRB approved retrospective study with 14 patients suspected of having prostate cancer who underwent both prostate 3T MRI using endorectal coil and 3D transperineal mapping prostate biopsy. MR exams were independently reviewed by two abdominal radiologists blinded to pathology with disagreement resolved by consensus. An MRI lesion was defined as having hypointense T2 signal subjectively without corresponding T1 high signal intensity and low signal on ADC maps in the central gland. Mapping biopsy consisted of systematic transperineal US guided biopsy with 55-108 cores per patient. Twenty-nine lesions were detected on MRI. Of these, 13 correlated with Gleason 6 or higher biopsy samples. 16 were biopsy negative. Among the various MRI characteristics assessed, lack of T2 hypointense rim demonstrated the highest specificity (93%) and positive predictive value (89%). Highest sensitivity (85%) and negative predictive value (78%) were seen with ill-defined nodules. When suspicious MR characteristics were combined, the specificity and PPV rose to 100% while sensitivity decreased to 45% and NPV decreased to 73%. Preliminary study indicates MR findings which can help differentiate a BPH nodule from transitional zone prostate cancers which could help direct biopsy in the large and growing number of people suspected of having prostate cancer. Further work will be needed for validation.

Finding Occult Prostatic Cancer: The Value of Transperineal Mapping Biopsies and Epigenetic Assays

A 63-year-old Caucasian male was admitted on November 2012 with history of persistently increased serum levels of prostate-specific antigen (PSA) over the past five years. During this time, his PSA increased from 5.20 ng/mL in 2007 up to 17.40 ng/mL in 2012. These values triggered five transrectal ultrasoundguided (TRUS) biopsies through the years, which were all negative for malignancy. Other relevant clinical and pathology results are presented in Table 1. Informed consent was given by the patient according to the Institution's protocol.

Combining Multi-Modality Imaging and Transperineal Mapping Biopsy to Guide the Focal Application of Low-Dose-Rate Brachytherapy for Prostate Cancer: An Ethics Approved Pilot Study

Combining Multi-Modality Imaging and Transperineal Mapping Biopsy to Guide the Focal Application of Low-Dose-Rate Brachytherapy for Prostate Cancer: An Ethics Approved Pilot Study

Comparison of transperineal mapping biopsy results with whole-mount radical prostatectomy pathology in patients with localized prostate cancer.

Objective. We sought to evaluate the accuracy of transperineal mapping biopsy (TMB) by comparing it to the pathology specimen of patients who underwent radical prostatectomy (RP) for localized prostate cancer. Methods. From March 2007 to September 2009, 78 men at a single center underwent TMB; 17 of 78 subsequently underwent RP. TMB cores were grouped into four quadrants and matched to data from RP whole-mount slides. Gleason score, tumor location and volume, cross-sectional area, and maximal diameter were measured; sensitivity and specificity were assessed. Results. For the 17 patients who underwent RP, TMB revealed 12 (71%) had biopsy Gleason grades ≥ 3 + 4 and 13 (76%) had bilateral disease. RP specimens showed 14 (82%) had Gleason scores ≥ 3 + 4 and 13 (76%) had bilateral disease. Sensitivity and specificity of TMB for prostate cancer detection were 86% (95% confidence interval [CI] 72%–94%) and 83% (95% CI 62%–95%), respectively. Four quadrants negative for cancer on TMB were positive on prostatectomy, and six positive on TMB were negative on prostatectomy. Conclusion. TMB is a highly invasive procedure that can accurately detect and localize prostate cancer. These findings help establish baseline performance characteristics for TMB and its utility for organ-sparing strategies.

Clinical‐Pathologic Correlation Between Transperineal Mapping Biopsies of the Prostate and Three‐Dimensional Reconstruction of Prostatectomy Specimens

Extended transrectal ultrasound guided biopsies (TRUSB) of the prostate may not accurately convey true morphometric information and Gleason score (GS) of prostate cancer (PCa) and the clinical use of template-guided (5-mm grid) transperineal mapping biopsies (TPMBs) remains controversial. We correlated the clinical-pathologic results of 1,403 TPMB cores obtained from 25 men diagnosed with PCa with 64 cancer lesions found in their corresponding radical prostatectomy (RP) specimens. Special computer models of three-dimensional, whole-mounted radical prostatectomy (3D-WMRP) specimens were generated and used as gold standard to determine tumor morphometric data. Between-sample rates of upgrade and downgrade (highest GS and a novel cumulative GS) and upstage and downstage (laterality) were determined. Lesions ≥ 0.5 cm(3) or GS ≥ 7 were considered clinically significant. From 64 separate 3D-WMRP lesions, 25 had significant volume (mean 1.13 cm(3)) and 39 were insignificant (mean 0.09 cm(3)) (P < 0.0001); 18/64 lesions were missed by TPMB, but only one was clinically significant with GS-8 (0.02 cm(3)). When comparing the cumulative GS of TPMB versus RP, 72% (n = 18) had identical scores, 12% (n = 3) were upgraded, and only 16% (n = 4) were downgraded. Laterality of TPMB and RP was strongly correlated, 80% same laterality, 4% were up-staged, and 16% down-staged. Our clinical-pathology correlation showed very high accuracy of TPMB with a 5-mm grid template to detect clinically significant PCa lesions as compared with 3D-WMRP, providing physicians and patients with a reliable assessment of grade and stage of disease and the opportunity to choose the most appropriate therapeutic options.

3T MRI of the prostate correlation to 3D reconstruction of transperineal mapping biopsies.

e15176 Background: MRI is new tool in the diagnosis and surveillance of localized prostate cancer. Studies have examined the sensitivity and specificity of MRI for detecting and localizing prostate cancer as compared to radical prostatectomy specimens. We have previously demonstrated excellent correlation between 3-dimensional transperineal mapping biopsies (3DMB) to radical prostatectomy specimens. We hypothesize that MRI does not perform as well detecting smaller lesions of the prostate as larger ones. In this study, we retrospectively compare the correlation of 3DMB to 3T MRI-positive lesions. Methods: Between 2010 and 2011, 34 men with histologically-proven prostate cancer underwent 3T endorectal coil MRI and subsequent template-guided (5-mm grid) 3DMB. Three-dimensional computer models of the mapping biopsies were created using Proview software to identify clusters of positive biopsies likely belonging to a single lesion. MRIs were read by two trained radiologists blinded to 3DMB results. Disagreement between radiologists was settled by consensus. MRI and 3DMB were then compared in a retrospective fashion. Results: Median age and PSA were 65 years (49-76) and 4.3 ng/mL (0.7-15.0). Median prostate volume was 40 cm3 (21-105 cm3). Median total biopsy cores on 3DMB was 60 (26-151), and mean positive cores was 3 (0-13). 3D reconstruction of patient biopsy sets resulted in 58 distinct foci of cancer. MRI identified 64 individual lesions suspicious for cancer. Of these, 66% (n=42) could be correlated to a positive area on 3DMB consisting of one or more positive biopsies, and 34% (n=22) corresponded to negative regions on 3DMB. When two or more biopsies represented a positive lesion on 3DMB, the positive-predictive value of MRI was 100% (n=24). Conversely, only 72% (n=42) of positive 3DMB areas could be correlated to a lesion on MRI, and 28% (n=16) were not seen on MRI.. Conclusions: MRI has vast potential as a less-invasive method in the detection and surveillance of prostate cancer. While MRI does appear to have excellent positive predictive value, the number of false negatives and relevance to clinically-significant lesions require further illumination.

Appropriate Patient Selection in the Focal Treatment of Prostate Cancer: The Role of Transperineal 3-Dimensional Pathologic Mapping of the Prostate—A 4-Year Experience

This study was undertaken to evaluate the usefulness of transperineal mapping biopsy of the prostate as a staging procedure in the appropriate selection of patients for treatment with focal cryoablation. Between October 2001 and January 2006, a total of 80 patients underwent extensive template-guided transperineal pathologic mapping of the prostate (3-DPM), in conjunction with repeat transrectal ultrasound (TRUS)-guided biopsies. Before 3-DPM was performed, the following clinical variables were recorded: age, prostate-specific antigen (PSA), percent free PSA, total prostate volume, transition zone volume, Gleason score, TNM stage, number of positive cores, and maximum percent of positive cores. Results of 3-DPM were compared with those of TRUS-guided biopsies to determine patient suitability for focal cryoablation; this served as the study end point. Of 80 study patients, 43 (54%) were deemed unsuitable for focal cryoablation. When compared with 3-DPM in assessing patient suitability for focal cryoablation repeat TRUS-guided biopsies yielded a false-negative rate of 47%, a sensitivity of 54%, and a negative predictive value of 49%. None of the pre-3-DPM variables correlated significantly with patient suitability for focal ablation. Treatment selected by the 80 study patients included total gland cryoablation (30%), expectant management (23%), radical prostatectomy (18%), focal cryoablation (11%), external irradiation (10%), brachytherapy (6%), and combined external irradiation and brachytherapy (1%); 1% were undecided about treatment selection. In this study, we demonstrated that 3-DPM (1) effectively excluded patients with clinically significant unsuspected cancer outside the area destined to be ablated, (2) appeared to do so more effectively than repeat TRUS-guided biopsies, and (3) was able to precisely locate the site of the cancer to be selectively ablated.

Target focal therapy in early prostate cancer: Initial single institution results

15574 Background: Currently the potential for over- and under-treatment using radical and watchful waiting options respectively constitutes a challenge in the management of patients with early organ-confined prostate cancer. Target focal therapy (TFT) is emerging as an intermediary alternative option for such men. The goal is to provide ablative treatment with minimal impact on morbidity. Methods: As part of an IRB approved study protocol a total of 24 patients initially underwent a 3 dimensional transperineal mapping biopsy under TRUS guidance to confirm the extent of tumor burden and localize the cancer foci within the prostate. Only 12 men qualified to undergo target focal cryotherapy. The remaining patients did not qualify due to upgrading or downgrading of their stage and opted for other treatment options. Follow- up consisted of serial PSA measurements at 3 months interval, disease specific QOL questionnaires, IPSS, and SHIM scores. Results: The mean age was 62.4 years. The mean (SD) prostate size at the time of mapping biopsy was 39 ±14.8g. After mapping biopsy all patients reported time limited hematuria and 2 patients developed urinary retention and were managed successfully with Foley’s catheter for 5 days. Mean PSA before treatment was 5.2 ± 4.1 ng/dl. 10/12 patients had Gleason score (GS) of 3+3, the remaining 2 patients had GS of 3+4. At 3 months follow-up. A median drop of PSA of 1.9 (0, 9.5) ng/dl. All patients reported full urinary continence post operatively. IPSS median drop of 0 (2, -16). Sexual health as assessed by SHIM score showed a median drop of 6 (1, -15) points. In general 4 patients reported a significant change in sexual performance. 2 of which opted for PDE inhibitor with successful regaining of erection at 6 months follow-up. Overall EPIC QOL scores showed no change in rectal, urinary and hormonal components. Sexual component registered a drop of 5 points. Conclusions: The current initial early results appear to be encouraging for future implementation of TFT on select patients with organ confined early stage cancer. Future larger randomized studies are needed to better understand the value of this alternative option in the management of prostate cancer. No significant financial relationships to disclose.