Transperineal Prostate Mapping Biopsy Research Articles

Transperineal prostate biopsy identifies locations of clinically significant prostate cancer in men considering focal therapy with PI-RADS 3-5 regions of interest.

ObjectivesTo determine the benefit of performing transperineal prostate mapping biopsy (TPMB) following multiparametric magnetic resonance imaging (mpMRI) to increase the identification of clinically significant prostate cancer (csPCa) with Gleason grade group (GG) ≥ 2 and their locations outside of the PI‐RADS v2 3–5 category lesions.MethodsmpMRI was performed in 80 men prior TPMB from two institutions. The mpMRI was considered clinically significant (csMRI) if it contained one or more PI‐RADS 3–5 category lesion. mpMRI findings were compared against csPCa diagnosed by TPMB, performed between 16 November 2010, and 13 September 2019, for the entire gland, both lobes and to the right and left anterior and right and left posterior quadrants (RA, LA, RP and LP). Sensitivity, specificity, positive and negative predictive values (PPV, NPV), accuracy and the area under curve (AUC) were determined. Thirteen men also underwent radical prostatectomy and had comparison of TPMB pathology to prostatectomy specimen grading.ResultsTPMB was positive in 60/80 (75%) of which 32 (53.3%) were csPCa. csPCa was present in the RA in 9 (11.3%), LA in 11 (13.8%), RP in 25 (31.3%) and LP in 27 (33.8%) and involved 1 quadrant in 7 (21.9%), 2 quadrants in 12 (37.5%), 3 quadrants in 11 (34.4%) and all 4 quadrants in 2 (6.3%) patients; 57/80 (71.3%) men had a mpMRIs with lesions designated as PI‐RADS 3 in 24 (30%), 4 in 25 (31.3%) and 5 in 8 (10%). A csMRI was present in the RA in 7 (8.8%), LA in 8 (10%), RP in 31 (38.8%) and in the LP in 29 (36.3%), which were limited to one quadrant in 39 (68.4%), 2 quadrants in 16 (28.1%), and 3 quadrants in 2 (3.5%). Sensitivity, specificity, PPV, and NPV were determined from the results of the TPMB and were for the entire gland 81.3%, 35.4%, 45.6% and 73.9%. There were 31 csMRIs involving the right posterior of the gland but only 25 csPCa by TPMB of which 12/31 (38.7%) were concordant for high grade disease. There were 29 men who have a csMRI in the left posterior quadrant, and 14 (48.3%) were concordant with csPCa from the TPMB.ConclusionsMpMRI should be supplemented with TPMB to correctly identify the regions of the prostate that would require ablation in men considering focal therapy.

Value of an online PI-RADS v2.1 score calculator for assessment of prostate MRI

PurposeTo evaluate the value of a browser-based PI-RADS Score Calculator (PCalc) compared to MRI reporting using the official PI-RADS v2.1 document (PDoc) for non-specialized radiologists in terms of reporting efficiency, interrater agreement and diagnostic accuracy for detection of clinically significant prostate cancer (PCa). MethodsBetween 09/2013 and 04/2015, 100 patients (median age, 64.8; range 47.5−78.2) who underwent prostate-MRI at a 3 T scanner and who received transperineal prostate mapping biopsy within <6 months were included in this retrospective study. Two non-specialized radiology residents (R1, R2) attributed a PI-RADS version 2.1 score for the most suspect (i. e. index) lesion (i) using the original PI-RADS v2.1 document only and after a 6-week interval (ii) using a browser-based PCalc. Reading time was measured. Reading time differences were assessed using Wilcoxon signed rank test. Intraclass-correlation Coefficient (ICC) was used to assess interrater agreement (IRA). Parameters of diagnostic accuracy and ROC curves were used for assessment of lesion-based diagnostic accuracy. ResultsCumulative reading time was 32:55 (mm:ss) faster when using the PCalc, the difference being statistically significant for both readers (p < 0.05). The difference in IRA between the image sets (ICC 0.55 [0.40, 0.68]) and 0.75 [0.65, 0.82] for the image set with PDoc and PCalc, respectively) was not statistically significant. There was no statistically significant difference in lesion-based diagnostic accuracy (AUC 0.83 [0.74, 0.92] and 0.82 [95 %CI: 0.74, 0.91]) for images assessed with PDoc as compared to PCalc (AUC 0.82 [0.74, 0.91] and 0.74 [95 %CI: 0.64, 0.83]) for R1 and R2, respectively. ConclusionNon-specialized radiologists may increase reading speed in prostate MRI with the help of a browser-based PI-RADS Score Calculator compared to reporting using the official PI-RADS v2.1 document without impairing interreader agreement or lesion-based diagnostic accuracy for detection of clinically significant PCa.

Additional Value of Dynamic Contrast-enhanced Sequences in Multiparametric Prostate Magnetic Resonance Imaging: Data from the PROMIS Study

BackgroundMultiparametric magnetic resonance imaging (MP-MRI) is established in the diagnosis of prostate cancer, but the need for enhanced sequences has recently been questioned. ObjectiveTo assess whether dynamic contrast-enhanced imaging (DCE) improves accuracy over T2 and diffusion sequences. Design, setting, and participantsPROMIS was a multicentre, multireader trial, with, in this part, 497 biopsy-naïve men undergoing standardised 1.5T MP-MRI using T2, diffusion, and DCE, followed by a detailed transperineal prostate mapping (TPM) biopsy at 5 mm intervals. Likert scores of 1–5 for the presence of a significant tumour were assigned in strict sequence, for (1) T2 + diffusion and then (2) T2 + diffusion + dynamic contrast-enhanced images. Outcome measurements and statistical analysisFor the primary analysis, the primary PROMIS outcome measure (Gleason score ≥4 + 3 or ≥6 mm maximum cancer length) on TPM was used, and an MRI score of ≥3 was considered positive. Results and limitationsSensitivity without and with DCE was 94% and 95%, specificity 37% and 38%, positive predictive value 51% and 51%, and negative predictive value 90% and 91%, respectively (p > 0.05 in each case). The number of patients avoiding biopsy (scoring 1–2) was similar (123/497 vs 121/497, p = 0.8). The number of equivocal scores (3/5) was slightly higher without DCE (32% vs 28% p = 0.031). The proportion of MRI equivocal (3/5) and positive (4–5) cases showing significant tumours were similar (23% and 71% vs 20% and 69%). No cases of dominant Gleason 4 or higher were missed with DCE, compared with a single case with T2 + diffusion-weighted imaging. No attempt was made to correlate lesion location on MRI and histology, which may be considered a limitation. Radiologists were aware of the patient’s prostate-specific antigen. ConclusionsContrast adds little when MP-MRI is used to exclude significant prostate cancer. Patient summaryAn intravenous injection of contrast may not be necessary when magnetic resonance imaging is used as a test to rule out significant tumours in the prostate.

The Ratio of the Number of Biopsy Specimens to Prostate Volume (Biopsy Density) Greater Than 1.5 Improves the Prostate Cancer Detection Rate in Men Undergoing Transperineal Biopsy of the Prostate.

We sought to determine the minimum number of transperineal prostate mapping biopsies needed to optimize the prostate cancer detection rate. A total of 436 men underwent transperineal prostate mapping biopsy at 2 institutions. Biopsy density was calculated as the ratio of the total number of specimens retrieved (mean 59.4) to prostate volume (mean 44.9 cc). Associations of biopsy density with prostate specific antigen, prostate specific antigen density, cancer diagnosis and the Gleason score were tested by ANOVA and the chi-square test. Regression analysis was done to determine factors associated with a positive transperineal prostate mapping biopsy and Gleason score 7 or higher cancer. Transperineal prostate mapping biopsy was positive in 299 of 436 men (68.6%). The mean number of positive cores was 7.1 (range 1 to 41) and mean biopsy density was 1.46 (range 0.39 to 3.67). The mean number of cores in positive vs negative transperineal prostate mapping biopsies was 1.61 vs 1.14 (p <0.001). Biopsy density cut points of 0.5 or less, greater than 0.5 to 1.0, greater than 1.0 to 1.5 and greater than 1.5 were associated with positive biopsy in 25%, 37.4%, 70.7% and 84.9% of patients (p <0.001). Dichotomizing biopsy density to 1.5 or less vs greater than 1.5 resulted in a positive biopsy rate of 56.4% vs 84.9% (OR 1.5, 95% CI 1.3-1.7, p <0.001). More Gleason score 6 cancers were diagnosed with higher biopsy density (94 of 158 or 59.5% vs 62 of 141 or 44.9%, p = 0.007). However, the number of positive cores with Gleason score 6 was greater in men with higher biopsy density at 4.9 vs 3.6 (p = 0.036). Prostate specific antigen (p = 0.053) and biopsy density (p = 0.012) were significant on regression analysis for positive transperineal prostate mapping biopsy and Gleason score 7+ disease. Biopsy density greater than 1.5 increases the diagnosis of prostate cancer by 1.5 times, detects higher volume Gleason score 6 disease and should be considered the optimal sampling approach when performing transperineal prostate mapping biopsy.

Transperineal Prostate Mapping Biopsy Improves Treatment Selection in Men Receiving Brachytherapy

Transperineal Prostate Mapping Biopsy Improves Treatment Selection in Men Receiving Brachytherapy

This Month in Adult Urology

No AccessJournal of UrologyThis Month in Adult Urology1 Aug 2018This Month in Adult Urology Joseph A. Smith Joseph A. SmithJoseph A. Smith More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.05.009AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail References 1 : Diagnostic accuracy of multiparametric magnetic resonance imaging and fusion guided targeted biopsy evaluated by transperineal template saturation prostate biopsy for the detection and characterization of prostate cancer. J Urol2018; 200: 309. Link, Google Scholar 2 : A single center evaluation of the diagnostic accuracy of multiparametric magnetic resonance imaging against transperineal prostate mapping biopsy: an analysis of men with benign histology and insignificant cancer following transrectal ultrasound biopsy. J Urol2018; 200: 302. Link, Google Scholar 3 : Prevalence and characteristics of urinary incontinence in a treatment seeking male prospective cohort: results from the LURN study. J Urol2018; 200: 397. Link, Google Scholar 4 : A phase II, randomized, multicenter study comparing 10 months versus 4 months of degarelix therapy in prolonging the off treatment interval in men with localized prostate cancer receiving intermittent androgen deprivation therapy for biochemical recurrence following radical local therapy. J Urol2018; 200: 335. Link, Google Scholar 5 : Anterior urethroplasty using a new tissue engineered oral mucosa graft: surgical techniques and outcomes. J Urol2018; 200: 448. Link, Google Scholar 6 : Targeted antimicrobial prophylaxis does not always prevent sepsis after transrectal prostate biopsy. J Urol2018; 200: 361. Link, Google Scholar 7 : Impact of androgen deprivation therapy on self-reported cognitive function in men with prostate cancer. J Urol2018; 200: 327. Link, Google Scholar 8 : Cystic renal cell carcinoma: a report on outcomes of surgery and active surveillance in patients retrospectively identified on pretreatment imaging. J Urol2018; 200: 275. Link, Google Scholar 9 : Testis sparing surgery for benign testicular masses: diagnostics and therapeutic approaches. J Urol2018; 200: 353. Link, Google Scholar 10 : Perioperative immunonutrition modulates inflammatory response after radical cystectomy: results of a pilot randomized controlled clinical trial. J Urol2018; 200: 292. Link, Google Scholar 11 : Three-year treatment outcomes of water vapor thermal therapy compared to doxazosin, finasteride and combination drug therapy in men with benign prostatic hyperplasia: cohort data from the MTOPS trial. J Urol2018; 200: 405. Link, Google Scholar © 2018 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 200Issue 2August 2018Page: 215-217 Advertisement Copyright & Permissions© 2018 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joseph A. Smith More articles by this author Expand All Advertisement PDF downloadLoading ...

A Single Center Evaluation of the Diagnostic Accuracy of Multiparametric Magnetic Resonance Imaging against Transperineal Prostate Mapping Biopsy: An Analysis of Men with Benign Histology and Insignificant Cancer following Transrectal Ultrasound Biopsy

In this study we evaluated the diagnostic performance of transrectal ultrasound guided biopsy and multiparametric magnetic resonance imaging to detect prostate cancer against transperineal prostate mapping biopsy as the reference test. Transrectal ultrasound guided biopsy, multiparametric magnetic resonance imaging and transperineal prostate mapping biopsy were performed in 426 patients between April 2012 and January 2016. Patients initially underwent systematic 12 core transrectal ultrasound guided biopsy followed 3months later by 1.5 Tesla, high resolution T2, diffusion-weighted, dynamic contrast enhanced multiparametric magnetic resonance imaging. Two specialist uroradiologists blinded to the results of transperineal prostate mapping biopsy allocated a PI-RADS™ (Prostate Imaging-Reporting and Data System) score to each multiparametric magnetic resonance imaging study. Transperineal prostate mapping biopsy with 5 mm interval sampling, which was performed within 6 months of multiparametric magnetic resonance imaging, served as the reference test. Transrectal ultrasound guided biopsy identified 247 of 426 patients with prostate cancer and 179 of 426 with benign histology. Transperineal prostate mapping biopsy detected prostate cancer in 321 of 426 patients. On transperineal prostate mapping biopsy 94 of 179 patients with benign transrectal ultrasound guided biopsy had prostate cancer and 95 of 247 with prostate cancer on transrectal ultrasound guided biopsy were identified with cancer of higher grade. Using a multiparametric magnetic resonance imaging PI-RADS score of 3 or greater to detect significant prostate cancer, defined as any core containing Gleason 4 + 3 or greater prostate cancer on transperineal prostate mapping biopsy, the ROC AUC was 0.754 (95% CI 0.677-0.819) with 87.0% sensitivity (95% CI 77.3-97.0), 55.3% specificity (95% CI 50.2-60.4) and 97.1% negative predictive value (95% CI 94.8-99.4). Multiparametric magnetic resonance imaging is a more accurate diagnostic test than transrectal ultrasound guided biopsy. However, a significant proportion of ISUP (International Society of Urological Pathology) Grade Group 2 prostate cancer remained undetected following multiparametric magnetic resonance imaging. Although multiparametric magnetic resonance imaging could avoid unnecessary biopsy in many patients with ISUP Grade Group 3 or greater prostate cancer, at less stringent definitions of significant cancer a substantial proportion of prostate cancer would remain undetected after multiparametric magnetic resonance imaging.

MP38-07 SHOULD WE AIM FOR THE CENTRE OF AN MRI PROSTATE LESION? CORRELATION BETWEEN MPMRI AND 3-DIMENSIONAL 5MM TRANSPERINEAL PROSTATE MAPPING BIOPSIES FROM THE PROMIS TRIAL

You have accessJournal of UrologyProstate Cancer: Detection & Screening IV1 Apr 2017MP38-07 SHOULD WE AIM FOR THE CENTRE OF AN MRI PROSTATE LESION? CORRELATION BETWEEN MPMRI AND 3-DIMENSIONAL 5MM TRANSPERINEAL PROSTATE MAPPING BIOPSIES FROM THE PROMIS TRIAL Clement Orczyk, Yi Peng Hu, Eli Gibson, Ahmed El-Shater Bosaily, Alex Kirkham, Shonit Punwani, Louise Brown, Esther Bonmati, Yolana Coraco-Moraes, Katie Ward, Rick Kaplan, Dean Barratt, Mark Emberton, and Hashim U Ahmed Clement OrczykClement Orczyk More articles by this author , Yi Peng HuYi Peng Hu More articles by this author , Eli GibsonEli Gibson More articles by this author , Ahmed El-Shater BosailyAhmed El-Shater Bosaily More articles by this author , Alex KirkhamAlex Kirkham More articles by this author , Shonit PunwaniShonit Punwani More articles by this author , Louise BrownLouise Brown More articles by this author , Esther BonmatiEsther Bonmati More articles by this author , Yolana Coraco-MoraesYolana Coraco-Moraes More articles by this author , Katie WardKatie Ward More articles by this author , Rick KaplanRick Kaplan More articles by this author , Dean BarrattDean Barratt More articles by this author , Mark EmbertonMark Emberton More articles by this author , and Hashim U AhmedHashim U Ahmed More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1160AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES mpMRI enables a new way to stratify prostate cancer patients through visualisation of a target to biopsy. However, prostate cancer is heterogeneous, even within the same focus. We aimed to determine deploying the needle to the centre of a mpMRI lesion would reflect the true risk of that lesion. Our study involved a unique cohort of men in whom a pre-biopsy mpMRI was carried out prior to Transperineal Prostate Mapping biopsies taken every 5mm within the PROMIS trial. METHODS 94 patients included in this analysis comprised the pilot phase of the Prostate MRI Imaging Study (NCT01292291) investigating accuracy of mpMRI against standard of care with 3D 5mm TPM-biopsies as the reference test. All patients were biopsy-naive with a PSA below 15ng/ml, referred for suspicion of prostate cancer. Prior to biopsy, all patient underwent 1.5T mpMRI with standardized protocol (T2W, DWI , DCE) which were reported on a Likert scale, blinded to subsequent histology results. Patients then underwent TPM-biopsies blinded to the mpMRI findings so that the whole prostate was sampled every 5mm. Cores were separately labelled and oriented in space. A 3D digital map of the gland was reconstructed from the TPM-biopsies using in-house software. Prostates and mpMRI lesions were contoured (blind to pathology results), registered to the digital map by aligning gland boundaries. We identified the MRI lesion centroid and the locations of biopsy cores containing the maximum Gleason score of the lesion. We considered two cores in particular. First, the one closest to the centroid and second, the one with the longest maximum cancer core length. We computed the distance from these two cores to the centroid of the MRI lesion. RESULTS 41 patients (median PSA 6.5ng/ml, median age 62) were found to harbour cancer at TPM-biopsies in this cohort, leading to 75 MRI lesions correlated with cancer. From the centroid, the mean distance to closest maximum Gleason core was 7.8mm (+/-6.6), and to core with the maximum cancer length was 13.8mm (+/-8.3). CONCLUSIONS The histological tissue that harbours the highest Gleason score within a prostate cancer lesion seen on mpMRI is not consistently located near the centre. MRI-lesion-based targeting should include sampling the entire lesion with a number of cores. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e486 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Clement Orczyk More articles by this author Yi Peng Hu More articles by this author Eli Gibson More articles by this author Ahmed El-Shater Bosaily More articles by this author Alex Kirkham More articles by this author Shonit Punwani More articles by this author Louise Brown More articles by this author Esther Bonmati More articles by this author Yolana Coraco-Moraes More articles by this author Katie Ward More articles by this author Rick Kaplan More articles by this author Dean Barratt More articles by this author Mark Emberton More articles by this author Hashim U Ahmed More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Transperineal Magnetic Resonance Imaging-targeted Biopsy versus Transperineal Template Prostate Mapping Biopsy in the Detection of Localised Radio-recurrent Prostate Cancer

AimsMulti-parametric magnetic resonance imaging (mpMRI) may identify radio-recurrent intra-prostatic cancer accurately. We aimed to compare visually directed MRI-targeted biopsies (MRI-TB) to an accurate reference standard – transperineal prostate mapping (TPM) biopsies with 5 mm sampling – in the detection of clinically significant cancer in men with biochemical failure after radiotherapy. Materials and methodsA retrospective registry analysis between 2006 and 2014 identified 77 men who had undergone mpMRI followed by MRI-TB and TPM. Clinical significance was set at two definitions of disease. Definition 1 was Gleason ≥ 4+3 and/or maximum cancer core length ≥ 6 mm. Definition 2 was Gleason ≥ 3+4 and/or maximum cancer core length ≥ 4 mm. ResultsOf the 77 patients included, the mean age was 70 years (range 61–82; standard deviation 5.03). The median prostate-specific antigen (PSA) at the time of external beam radiotherapy (EBRT) was 14 ng/ml (interquartile range 7.83–32.50). The most frequent EBRT dose given was 74 Gy over 37 fractions. Eight patients had iodine-seed implant brachytherapy or high dose rate brachytherapy. Neoadjuvant/adjuvant hormonal therapy use was reported in 38. The time from EBRT to biochemical recurrence was a median of 60 months (interquartile range 36.75–85.00). The median PSA at the time of mpMRI was 4.68 ng/ml (interquartile range 2.68–7.60). The median time between mpMRI and biopsy was 2.76 months (interquartile range 1.58–4.34). In total, 2392 TPM and 381 MRI-TB cores were taken with 18% and 50% cancer detection, respectively. Detection rates of definition 1 clinically significant cancer were 52/77 (68%) versus 55/77 (71%) for MRI-TB and TPM, respectively. MRI-TB was more efficient requiring 1 core versus 2.8 cores to detect definition 2 cancer. ConclusionMRI-TB seems to have encouraging detection rates for clinically significant cancer with fewer cores compared with TPM, although TPM had higher detection rates for smaller lower grade lesions.

MP16-14 DETECTION OF PROSTATE CANCER USING MAGNETIC RESONANCE IMAGING/ULTRASONOGRAPHY FUSION TARGETED BIOPSY IN AFRICAN-AMERICAN MEN

INTRODUCTION AND OBJECTIVES: Precise risk stratification is essential in times where alternative treatment options to radical prostatectomy (RP) such as active surveillance, brachytherapy, radiotherapy and focal treatment of prostate cancer (PC) are available. However, the current concordance of conventional transrectal prostate biopsy (PB) regarding Gleason score (GS) is low 53-69%, when compared to RP specimens. Multiparametric MRI (mpMRI) of the prostate and fusion transperineal prostate mapping (TPM) biopsy might allow increasing the concordance facilitate the decision making. METHODS: A total of 348 patients were included in this retrospective analysis. Pathological reports were analyzed from patients who underwent radical prostatectomy (RP) and compared to GS acquired by PB or TPM after mpMRI. MpMRI fusion TPM was performed by taking biopsy cores from 20 predefined regions of the prostate and from MRI suspicious lesions after fusion. RESULTS: Patients with PB before RP demonstrated an overall increase in GS of 30% and a significant increase of 2 GS steps was detectable in 15%. Patients with a mpMRI and TPM demonstrated an increase in GS only 16.6% with maximally one GS step. This difference is even more pronounced if GS 3+4 and 4+3 are not differentiated and summarized to GS 7 only. In this case the GS upgrade is 6.3% for TPM compared to 22.8% for PB. However, the amount of downgraded GS after RP is higher for TPM (TPM 31.2% vs. PB 14.0%). The detailed analysis of the TPM group showed that GS upgrades were limited to GS 6 and 7a. None of the >7b GS demonstrated a GS upgrade indicating the superior precision of the extended TPM. CONCLUSIONS: MpMRI with TPM allows for a more precise risk stratification by displaying the true GS more often. Optimal diagnosis with minimal risk of underestimating the disease burden is crucial to select patients for focal treatment and to prevent over-treatment by radical therapy options. This novel diagnostic strategy will help counselling patients before any treatment strategy.

MP16-13 MINIMIZING THE GLEASON SCORE UPGRADE FROM BIOPSY TO PROSTATECTOMY SPECIMEN THROUGH MPMRI AND TEMPLATE MAPPING FUSION BIOPSY

You have accessJournal of UrologyProstate Cancer: Detection & Screening I1 Apr 2016MP16-13 MINIMIZING THE GLEASON SCORE UPGRADE FROM BIOPSY TO PROSTATECTOMY SPECIMEN THROUGH MPMRI AND TEMPLATE MAPPING FUSION BIOPSY Oliver Gross, Ashkan Mortezavi, Lilian Neuhaus, Tullio Sulser, and Daniel Eberli Oliver GrossOliver Gross More articles by this author , Ashkan MortezaviAshkan Mortezavi More articles by this author , Lilian NeuhausLilian Neuhaus More articles by this author , Tullio SulserTullio Sulser More articles by this author , and Daniel EberliDaniel Eberli More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2578AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Precise risk stratification is essential in times where alternative treatment options to radical prostatectomy (RP) such as active surveillance, brachytherapy, radiotherapy and focal treatment of prostate cancer (PC) are available. However, the current concordance of conventional transrectal prostate biopsy (PB) regarding Gleason score (GS) is low 53-69%, when compared to RP specimens. Multiparametric MRI (mpMRI) of the prostate and fusion transperineal prostate mapping (TPM) biopsy might allow increasing the concordance facilitate the decision making. METHODS A total of 348 patients were included in this retrospective analysis. Pathological reports were analyzed from patients who underwent radical prostatectomy (RP) and compared to GS acquired by PB or TPM after mpMRI. MpMRI fusion TPM was performed by taking biopsy cores from 20 predefined regions of the prostate and from MRI suspicious lesions after fusion. RESULTS Patients with PB before RP demonstrated an overall increase in GS of 30% and a significant increase of 2 GS steps was detectable in 15%. Patients with a mpMRI and TPM demonstrated an increase in GS only 16.6% with maximally one GS step. This difference is even more pronounced if GS 3+4 and 4+3 are not differentiated and summarized to GS 7 only. In this case the GS upgrade is 6.3% for TPM compared to 22.8% for PB. However, the amount of downgraded GS after RP is higher for TPM (TPM 31.2% vs. PB 14.0%). The detailed analysis of the TPM group showed that GS upgrades were limited to GS 6 and 7a. None of the >7b GS demonstrated a GS upgrade indicating the superior precision of the extended TPM. CONCLUSIONS MpMRI with TPM allows for a more precise risk stratification by displaying the true GS more often. Optimal diagnosis with minimal risk of underestimating the disease burden is crucial to select patients for focal treatment and to prevent over-treatment by radical therapy options. This novel diagnostic strategy will help counselling patients before any treatment strategy. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e166 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Oliver Gross More articles by this author Ashkan Mortezavi More articles by this author Lilian Neuhaus More articles by this author Tullio Sulser More articles by this author Daniel Eberli More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

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 ...

780 Minimizing the Gleason score upgrade from biopsy to prostatectomy specimen through mpMRI and template mapping fusion biopsy

INTRODUCTION AND OBJECTIVES: Precise risk stratification is essential in times where alternative treatment options to radical prostatectomy (RP) such as active surveillance, brachytherapy, radiotherapy and focal treatment of prostate cancer (PC) are available. However, the current concordance of conventional transrectal prostate biopsy (PB) regarding Gleason score (GS) is low 53-69%, when compared to RP specimens. Multiparametric MRI (mpMRI) of the prostate and fusion transperineal prostate mapping (TPM) biopsy might allow increasing the concordance facilitate the decision making. METHODS: A total of 348 patients were included in this retrospective analysis. Pathological reports were analyzed from patients who underwent radical prostatectomy (RP) and compared to GS acquired by PB or TPM after mpMRI. MpMRI fusion TPM was performed by taking biopsy cores from 20 predefined regions of the prostate and from MRI suspicious lesions after fusion. RESULTS: Patients with PB before RP demonstrated an overall increase in GS of 30% and a significant increase of 2 GS steps was detectable in 15%. Patients with a mpMRI and TPM demonstrated an increase in GS only 16.6% with maximally one GS step. This difference is even more pronounced if GS 3+4 and 4+3 are not differentiated and summarized to GS 7 only. In this case the GS upgrade is 6.3% for TPM compared to 22.8% for PB. However, the amount of downgraded GS after RP is higher for TPM (TPM 31.2% vs. PB 14.0%). The detailed analysis of the TPM group showed that GS upgrades were limited to GS 6 and 7a. None of the >7b GS demonstrated a GS upgrade indicating the superior precision of the extended TPM. CONCLUSIONS: MpMRI with TPM allows for a more precise risk stratification by displaying the true GS more often. Optimal diagnosis with minimal risk of underestimating the disease burden is crucial to select patients for focal treatment and to prevent over-treatment by radical therapy options. This novel diagnostic strategy will help counselling patients before any treatment strategy.

MP83-01 TRANSPERINEAL MRI-TARGETED BIOPSY VERSUS TRANSPERINEAL TEMPLATE PROSTATE MAPPING BIOPSY IN THE DETECTION OF LOCALISED RADIO-RECURRENT PROSTATE CANCER

You have accessJournal of UrologyProstate Cancer: Localized IX1 Apr 2015MP83-01 TRANSPERINEAL MRI-TARGETED BIOPSY VERSUS TRANSPERINEAL TEMPLATE PROSTATE MAPPING BIOPSY IN THE DETECTION OF LOCALISED RADIO-RECURRENT PROSTATE CANCER Abi Kanthabalan, Mohammed Abl-Azzeez, Manit Arya, Alex Freeman, Clare Allen, Alex kirkham, Shonit Punwani, Mark Emberton, and Hashim Ahmed Abi KanthabalanAbi Kanthabalan More articles by this author , Mohammed Abl-AzzeezMohammed Abl-Azzeez More articles by this author , Manit AryaManit Arya More articles by this author , Alex FreemanAlex Freeman More articles by this author , Clare AllenClare Allen More articles by this author , Alex kirkhamAlex kirkham More articles by this author , Shonit PunwaniShonit Punwani More articles by this author , Mark EmbertonMark Emberton More articles by this author , and Hashim AhmedHashim Ahmed More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1876AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Local salvage therapy following biochemical failure after radiotherapy requires accurate detection of radiorecurrent cancer within the prostate. We aimed to compare whole-gland Transperineal Prostate Mapping (TPM) Biopsies with cognitive/visually-directed, MRI-targeted biopsies (MRI-TB) in the detection of clinically significant prostate cancer in this group of men. METHODS Our academic registry of transperineal biopsies had 147 men referred for consideration of salvage therapy (2007-2014). 81 underwent multi-parametric-MRI, TPM biopsy and MRI-TB. Accuracy to detect clinically significant disease was evaluated using two definitions: UCL1 (Gleason >/=4+3 and/or cancer core length >/=6mm) and UCL2 (Gleason >/=3+4 and/or cancer core length >/=4mm). RESULTS Mean age was 70.0 years (STD+/-8.0) and median PSA prior to biopsy was 3.98ng/ml (range 0.54-20). 4960 TPM cores were taken in total and mean 34 per patient. Total of 302 MRI-TB cores were taken and mean 4 per patient. 17% (867/4960) of TPM cores were positive for any cancer compared with 54% (164/302) of MRI-TB. Detection rates of UCL2 disease was 81% (70/81) for TPM and 69% (56/81) for MRI-TB; sensitivity of MRI-TB 80%. For UCL1 disease, detection was 72% (58/81) for TPM and 62% (50/81) for MRI-TB; sensitivity of MRI-TB 86%. The sensitivity of MRI-TB for any Gleason pattern 4 was 80% (56/70). CONCLUSIONS MRI-Targeted Biopsies have a high detection rate of clinically significant cancer and requiring one-tenth of the number of cores compared to TPM. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e1050 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Abi Kanthabalan More articles by this author Mohammed Abl-Azzeez More articles by this author Manit Arya More articles by this author Alex Freeman More articles by this author Clare Allen More articles by this author Alex kirkham More articles by this author Shonit Punwani More articles by this author Mark Emberton More articles by this author Hashim Ahmed More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

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.

Biopsy strategies for selecting patients for focal therapy for prostate cancer

Focal therapy for localised prostate cancer requires accurate disease localization and characterization. Standard trans-rectal ultrasound biopsy can miss significant cancer and cannot accurately localize prostate cancer to guide focal therapy. This article examines various biopsy and imaging strategies to determine which is the most useful in diagnosing prostate cancer suitable for treatment with focal therapy. Advances in MRI and ultrasound have been combined with different biopsy techniques such as transperineal and targeted biopsy versus transrectal and whole-gland sampling to see which method detects and localizes cancer while reducing the burden of biopsy on patients. Studies tended to report on overall cancer detection rates as opposed to clinically significant cancer detection rates. A standard definition of clinically significant cancer must first be defined and validated against an accurate sampling strategy such as radical prostatectomy or transperineal prostate mapping biopsy. Image-guided targeted biopsy has increased detection rates of clinically significant cancer rate with fewer number of cores compared with whole-gland sampling. Further prospective randomized controlled trials are needed to identify a combined image and biopsy technique that detects and localizes the highest rate of clinically significant cancer while decreasing the risk to patients, in order to guide focal therapy.

Is the free/total PSA ratio useful at predicting the presence of prostate cancer on transperineal prostate mapping biopsies?

ingly recognised as being integral to high quality urological care. However, little evidence exists for whether the understanding experience of patients reflects the perceptions of healthcare professionals. This study aimed to explore urology patients' experience of the urology MDT. Method: Focus groups were set up to explore qualitatively participants' experiences and opinions. Questions covered patients' experience of being treated by a urology-MDT, awareness of the MDT's role, information the MDT should consider, and patient representation at MDT meetings. Results: Three focus groups were attended by 21 participants. Awareness of the MDT was low, but participants found the idea reassuring. Participants felt that it was important for the MDT to consider psychosocial information and their preferences, although this was not always their experience. Participants felt that the urology specialist nurse should act as their advocate in the meeting and that case discussion should be delayed if no one who had seen and knew the patient was present. Discussion: The concept of the MDT is popular with patients and could be promoted to increase patient satisfaction and improve patient experience. Further research is needed to link patients' MDT views with patient outcome and experience measures.

Transatlantic Consensus Group on active surveillance and focal therapy for prostate cancer

What's known on the subject? and What does the study add? Active surveillance for prostate cancer is gaining increasing acceptance for low risk prostate cancer. Focal therapy is an emerging tissue preservation strategy that aims for treat only areas of cancer. Early phase trials have shown that side-effects can be significantly reduced using focal therapy. There is significant uncertainty in both active surveillance and focal therapy. This consensus group paper provides a road-map for clinical practice and research for both tissue-preserving strategies in the areas of patient population, tools for risk stratification and cancer localisation, treatment interventions as well as comparators and outcome measures in future comparative trials. To reach consensus on key issues for clinical practice and future research in active surveillance and focal therapy in managing localized prostate cancer. A group of expert urologists, oncologists, radiologists, pathologists and computer scientists from North America and Europe met to discuss issues in patient population, interventions, comparators and outcome measures to use in both tissue-preserving strategies of active surveillance and focal therapy. Break-out sessions were formed to provide agreement or highlight areas of disagreement on individual topics which were then collated by a writing group into statements that formed the basis of this report and agreed upon by the whole Transatlantic Consensus Group. The Transatlantic group propose that emerging diagnostic tools such as precision imaging and transperineal prostate mapping biopsy can improve prostate cancer care. These tools should be integrated into prostate cancer management and research so that better risk stratification and more effective treatment allocation can be applied. The group envisaged a process of care in which active surveillance, focal therapy, and radical treatments lie on a continuum of complementary therapies for men with a range of disease grades and burdens, rather than being applied in the mutually exclusive and competitive way they are now. The changing landscape of prostate cancer epidemiology requires the medical community to re-evaluate the entire prostate cancer diagnostic and treatment pathway in order to minimize harms resulting from over-diagnosis and over-treatment. Precise risk stratification at every point in this pathway is required alongside paradigm shifts in our thinking about what constitutes cancer in the prostate.

Characterizing Clinically Significant Prostate Cancer Using Template Prostate Mapping Biopsy

Definitions of prostate cancer risk are limited since accurate attribution of the cancer grade and burden is not possible due to the random and systematic errors associated with transrectal ultrasound guided biopsy. Transperineal prostate mapping biopsy may have a role in accurate risk stratification. We defined the transperineal prostate mapping biopsy characteristics of clinically significant disease. A 3-dimensional model of each gland and individual cancer was reconstructed using 107 radical whole mount specimens. We performed 500 transperineal prostate mapping simulations per case by varying needle targeting errors to calculate sensitivity, specificity, and negative and positive predictive value to detect lesions 0.2 ml or greater, or 0.5 ml or greater. Definitions of clinically significant cancer based on a combination of Gleason grade and cancer burden (cancer core length) were derived. Mean±SD patient age was 61±6.4 years (range 44 to 74) and mean prostate specific antigen was 9.7±5.9 ng/ml (range 0.8 to 36.2). We reconstructed 665 foci. The total cancer core length from all positive biopsies for a particular lesion that detected more than 95% of lesions 0.5 ml or greater and 0.2 ml or greater was 10 mm or greater and 6 mm or greater, respectively. The maximum cancer core length that detected more than 95% of lesions 0.5 ml or greater and 0.2 ml or greater was 6 mm or greater and 4 mm or greater, respectively. We combined these cancer burden thresholds with dominant and nondominant Gleason pattern 4 to derive 2 definitions of clinically significant disease. Transperineal prostate mapping may provide an effective method to risk stratify men with localized prostate cancer. The definitions that we present require prospective validation.