Transperineal Template Research Articles

Local versus general anesthesia transperineal prostate biopsy: Tolerability, cancer detection, and complications.

ObjectivesTo compare data on transperineal template biopsy (TPTB) under general anesthesia (GA) compared with local anesthesia (LA) procedures using the PrecisionPoint™ Transperineal Access System (PPTAS) in relation to tolerability, cancer detection rate, complications, and cost.MethodsA prospective pilot cohort study of patients undergoing transperineal biopsy was performed. Patients were excluded if they had concurrent flexible cystoscopy or language barriers. Patients had a choice of GA or LA. A prospective questionnaire on Days 0, 1, 7, and 30 was applied. The primary outcome was patient tolerability. Secondary outcomes were cancer detection rate, complication rate, and theater utilization.ResultsThis study included 80 patients (40 GA TPTB and 40 LA PPTAS). Baseline characteristics including age, prostate‐specific antigen (PSA), digital rectal examination (DRE), findings, and prostate volume were comparable between the groups (p = 0.3790, p = 0.9832, p = 0.444, p = 0.3939, respectively). Higher median prostate imaging‐reporting and data system (PI‐RADS) score of 4 (interquartile range [IQR] 2) versus 3 (IQR 1) was noted in the LA group (p = 0.0326). Pain was higher leaving recovery in the GA group however not significantly (p = 0.0555). Median pain score at LA infiltration was 5/10 (IQR 3), with no difference in pain at Days 1, 7, or 30 (p = 0.2722, 0.6465, and 0.8184, respectively). For GA versus LA, the overall cancer detection rate was 55% versus 55% (p = 1.000) with clinically significant cancer in 22.5% versus 35% (p = 0.217). Acute urinary retention (AUR) occurred in 5% of GA and 2.5% of LA patients (p = 1.000). The GA cohort spent longer in theater and in recovery with a median of 93.5 min versus 57 min for the LA group (p = <0.0001).ConclusionThis study demonstrates that transperineal biopsy is safely performed under LA with no difference between the cohorts in relation cancer detection or AUR. LA biopsy also consumed less theater and recovery resources. A further larger prospective randomized controlled trial is required to confirm the findings of this study.

MP26-02 ROLE OF ANTERIOR PROSTATE SAMPLING USING A NOVEL PHILADELPHIA HYBRID ANATOMIC TRANSPERINEAL (PHAT) TEMPLATE: A SINGLE CENTER EXPERIENCE

You have accessJournal of UrologyProstate Cancer: Detection & Screening II (MP26)1 Sep 2021MP26-02 ROLE OF ANTERIOR PROSTATE SAMPLING USING A NOVEL PHILADELPHIA HYBRID ANATOMIC TRANSPERINEAL (PHAT) TEMPLATE: A SINGLE CENTER EXPERIENCE Johnathan Drevik, Adams Ako, Jeffrey Ellis, Phillip Abbosh, Jay Simhan, Justin Friedlander, Steven Sterious, Joshua Cohn, Robert Uzzo, and Serge Ginzburg Johnathan DrevikJohnathan Drevik More articles by this author , Adams AkoAdams Ako More articles by this author , Jeffrey EllisJeffrey Ellis More articles by this author , Phillip AbboshPhillip Abbosh More articles by this author , Jay SimhanJay Simhan More articles by this author , Justin FriedlanderJustin Friedlander More articles by this author , Steven SteriousSteven Sterious More articles by this author , Joshua CohnJoshua Cohn More articles by this author , Robert UzzoRobert Uzzo More articles by this author , and Serge GinzburgSerge Ginzburg More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002023.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Transperineal prostate biopsy approach has become more widespread due to lower rate of post-biopsy infections and better anterior gland sampling. Despite its increasing adoption, no universal transperineal template exists and the role of routine anterior gland sampling remains undefined. Here we propose a simplified office-based transperineal biopsy template and describe cancer distribution and the relevance of anterior cores. METHODS: A retrospective chart review of patients that underwent PHAT template transperineal biopsy (Figure 1a) between November 2017 through November 2020 was performed and clinicopathologic data along with relevant multiparametric MRI (mpMRI) data were abstracted. In patients with multiple biopsies only the initial systematic biopsy was included. Clinically significant cancer (csCa) was defined as ≥ GG2. Descriptive statistics were utilized to evaluate cancer detection rate and location. RESULTS: 178 unique patients (median age 64.0, IQR 10, median PSA 9.2, IQR 4.7) comprised the cohort of interest. 148 (83%) were performed in the office under local analgesia. Overall, cancer detection rate (CDR) was 140/178 (79%), while csCa was present in 94/178 (52.8%) The distribution of detected cancer using the PHAT template can be seen in Figure 1b. Cancer in anterior cores only was observed in 21 (11.8%) men, with 57.1% being csCa. mpMRI was available for 13 of 21 (61.9%) patients with anterior-only prostate cancer, of which 8/13 (61.5%) had no anterior lesions detected on MRI. Morbidity of this remained remained low, without any episodes of sepsis. CONCLUSIONS: The PHAT prostate biopsy template provides a high CDR and allows for comprehensive anterior gland sampling with minimal morbidity. Importance of routine anterior gland sampling is underscored, as 2/3 of anterior-only cancers would be missed if mpMRI alone was used to triage anterior gland targeting. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e462-e462 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Johnathan Drevik More articles by this author Adams Ako More articles by this author Jeffrey Ellis More articles by this author Phillip Abbosh More articles by this author Jay Simhan More articles by this author Justin Friedlander More articles by this author Steven Sterious More articles by this author Joshua Cohn More articles by this author Robert Uzzo More articles by this author Serge Ginzburg More articles by this author Expand All Advertisement Loading ...

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

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

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

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

P0942 - Comparative analysis of a novel target saturation biopsy approach in Magnetic Resonance Imaging (MRI) TransrRectal UltraSound (TRUS) fusion biopsy versus transperineal template saturation biopsy for the detection of significant prostate cancer

P0942 - Comparative analysis of a novel target saturation biopsy approach in Magnetic Resonance Imaging (MRI) TransrRectal UltraSound (TRUS) fusion biopsy versus transperineal template saturation biopsy for the detection of significant prostate cancer

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

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

Can quantitative analysis of multi-parametric MRI independently predict failure of focal salvage HIFU therapy in men with radio-recurrent prostate cancer?

ObjectivesFocal salvage HIFU is a feasible therapeutic option in some men who have recurrence after primary radiotherapy for prostate cancer. We aimed to determine if multi-parametric quantitative parameters, in addition to clinical factors, might have a role in independently predicting focal salvage HIFU outcomes. MethodsA retrospective registry analysis included 150 consecutive men who underwent focal salvage HIFU (Sonablate500) (2006-2015); 89 had mpMRI available. Metastatic disease was excluded by nodal assessment on pelvic MRI, a radioisotope bone-scan and/or choline or FDG PET/CT scan. All men had mpMRI and either transperineal template prostate mapping biopsy or targeted and systematic TRUS-biopsy. mpMRI included T2‐weighted, diffusion‐weighted and dynamic contrast‐enhancement. Pre-HIFU quantitative mpMRI data was obtained using Horos DICOM Viewer v3.3.5 for general MRI parameters and IB DCE v2.0 plug-in. Progression-free survival (PFS) was defined by biochemical failure and/or positive localized or distant imaging results and/or positive biopsy and/or systemic therapy and/or metastases/prostate cancer‐specific death. Potential predictors of PFS were analyzed by univariable and multivariable Cox-regression. ResultsMedian age at focal salvage HIFU was 71 years (interquartile range [IQR] 65–74.5) and median PSA pre-focal salvage treatment was 5.8ng/ml (3.8-8). Median follow-up was 35 months (23-47) and median time to failure was 15 months (7.8–24.3). D-Amico low, intermediate and high-risk disease was present in 1% (1/89), 40% (36/89) and 43% (38/89) prior to focal salvage HIFU (16% missing data). 56% (50/89) failed by the composite outcome. A total of 22 factors were evaluated on univariable and 8 factors on multivariable analysis. The following quantitative parameters were included: Ktrans, Kep, Ve, Vp, IS, rTTP and TTP. On univariable analysis, PSA, prostate volume at time of radiotherapy failure and Ve (median) value were predictors for failure. Ve represents extracellular fraction of the whole tissue volume. On multivariable analysis, only Ve (median) value remained as an independent predictor. ConclusionsOne pharmacokinetic quantitative parameter based on DCE sequences seems to independently predict failure following focal salvage HIFU for radio-recurrent prostate cancer. This likely relates to the tumor microenvironment producing heat-sinks which counter the heating effect of HIFU. Further validation in larger datasets and evaluating mechanisms to reduce heat-sinks are required.

MRI and targeted biopsies compared to transperineal mapping biopsies for targeted ablation in recurrent prostate cancer after radiotherapy: Primary outcomes of the FORECAST trial.

5009 Background: Radiotherapy is a common and effective treatment for localised prostate cancer. However, recurrence of cancer can occur in 10-15% of men in the following 5 years. Most patients with recurrence are managed using hormonal therapy with associated systemic side-effects and subsequent development of castrate resistance. Salvage prostatectomy confers a high risk of urine incontinence and rectal injury. Accurately localising and ablating only areas of recurrence within the prostate might be effective with fewer side-effects. The FOcal RECurrent Assessment and Salvage Treatment (FORECAST) trial assessed this diagnostic and treatment pathway for men with radiorecurrent cancer (NCT01883128). Methods: We first compared the accuracy of multi-parametric MRI (mp-MRI) and MRI-targeted biopsy in identifying areas of recurrent cancer to a transperineal template prostate mapping (TTPM) biopsy (Apr/2014-Jan/2018) in 181 patients from 6 UK centres. We then assessed the functional and cancer control outcomes of focally ablating areas of intraprostatic recurrence in 93 patients with localised or metastatic cancer (using cryotherapy or HIFU). Primary outcomes were sensitivity of mpMRI and MRI-targeted biopsies and urinary continence after focal ablation. A key secondary outcome was progression free survival (PFS) defined as no new metastases or hormone use (localised group only), or chemotherapy or further local treatment. Results: Of 181 men with suspicion of recurrence following radiotherapy, re-staging whole-body imaging (Choline PET and Bone Scan) showed localised disease in 128 (71%), nodal disease only in 13 (7%) and 38 (21%) metastatic. The sensitivity of MRI-targeted biopsy was 92% (95%CI 83-97%). Specificity, and positive and negative predictive values, were 75% (95%CI 45-92%), 94% (95%CI 86-98%) and 65% (95%CI 38-86%). 4/72 (6%) cancers were missed on TTPM biopsies alone and 6/72 (8%) were missed on MRI-targeted biopsies alone. Overall sensitivity of mpMRI was 81% (95%CI 73-88%) using Likert score 4-5 to denote a positive test. Specificity, and positive and negative predictive values, were 88% (95%CI 73-98%), 96% (95%CI 90-99%) and 57% (95%CI 42-70%). In the 93 men undergoing focal ablation, urinary continence was preserved in 78/93 (84%); 5/93 (5%) had a CTCAE grade 3+ adverse events. There were no rectal injuries. With a median follow-up of 27.8 [SD 1.3] months, PFS was 66% [54-75] at 24-months. Metastases-free survival in the 73 men with localised disease was 80% [95%CI 68–88] at 24-months. There were no cancer specific deaths. Conclusions: Prostate mpMRI and MRI-targeted biopsies can accurately detect and localise recurrent prostate cancer following radiotherapy. Focal ablation to areas of intra-prostatic recurrence preserves continence in the majority of men with good cancer control. Clinical trial information: NCT01883128.

Initial phantom studies for an office-based low-field MR system for prostate biopsy

PurposeProstate cancer is the second most prevalent cancer in US men, with about 192,000 new cases and 33,000 deaths predicted for 2020. With only a 31% 5-year survival rate for patients with an initial diagnosis of stage-four prostate cancer, the necessity for early screening and diagnosis is clear. In this paper, we present navigation accuracy results for Promaxo’s MR system intended to be used in a physician’s office for image-guided transperineal prostate biopsy. MethodsThe office-based low-field MR system was used to acquire images of prostate phantoms with needles inserted through a transperineal template. Coordinates of the estimated sample core locations in the office-based MR system were compared to ground truth needle coordinates identified in a 1.5T external reference scan. The error was measured as the distance between the planned target and the ground truth core center and as the shortest perpendicular distance between the planned target and the ground truth trajectory of the whole core. ResultsThe average error between the planned target and the ground truth core center was 2.57 ± 1.02 mm, [1.93–3.21] 95% CI. The average error between the planned target to the actual core segment was 2.05 ± 1.24 mm, [1.53–2.56] 95% CI. ConclusionThe average navigation errors were below the clinically significant threshold of 5 mm. The initial phantom results demonstrate the feasibility of the office-based system for prostate biopsy.

Effect of transperineal template prostate biopsy on perioperative and functional outcomes following robotic-assisted radical prostatectomy

Objective: This study aimed to determine the effect of template transperineal (TTP) compared to transrectal (TR) biopsy on surgical and functional outcomes after robotic-assisted radical prostatectomy (RARP). Methods: From 2014 to 2018, 280 patients underwent RARP by a single surgeon. Of these, 184 had TR, and 96 had TTP biopsy. Primary outcomes were continence and erectile function recovery (EFR) rates up to 24 months postoperatively. Secondary outcomes comprised positive margin rates and markers of a difficult operation, including operative time, estimated blood loss (EBL), urethral preservation quality and ability to perform planned nerve-sparing surgery. Results: The median age was greater in the TTP group (64 vs. 62 years, p=0.028). The proportions of men with preoperative erectile dysfunction and men undergoing nerve-sparing surgery were not different between groups. Operative time, EBL, urethral preservation quality, proportion of men undergoing intended nerve-sparing procedure, positive margin rates and continence recovery rates were not different among the groups. At 24 months, men in the TR group had a higher EFR rate on univariate analysis ( p=0.036), and multivariate analysis ( p=0.03). Conclusion: TTP biopsy was not associated with markers of a more difficult RARP or worse oncological and continence recovery outcomes but did appear to impact upon long-term rates of EFR. Level of evidence: Level 4.

Combined Utility of 68Ga-Prostate-specific Membrane Antigen Positron Emission Tomography/Computed Tomography and Multiparametric Magnetic Resonance Imaging in Predicting Prostate Biopsy Pathology

Background68Gallium-labelled prostate-specific membrane antigen positron emission tomography (68Ga-PSMA-11 PET) is a valuable staging tool, but its utility in characterising primary prostate cancer remains unclear. The maximum standardised uptake value (SUVmax) is a quantification measure of highest radiotracer uptake within PET-avid lesions. ObjectiveTo assess the utility of SUVmax in detecting clinically significant prostate cancer (csPCa) on biopsy alone and in combination with multiparametric magnetic resonance imaging (mpMRI). Design, setting, and participantsThis was a retrospective analysis of 200 men who underwent 68Ga-PSMA-11 PET/CT, mpMRI, and transperineal template prostate biopsy between 2016 and 2018. Outcome measurements and statistical analysisThe primary and secondary outcomes were detection of grade group (GG) 3–5 and GG 2–5 prostate cancer, respectively. We used the Mann-Whitney U test to compare SUVmax by GG, and calculated sensitivity and specificity for csPCa detection via 68Ga-PSMA-11 PET/CT, mpMRI, and both. Multivariable logistic regression analyses were used to identify predictors of csPCa on biopsy. Results and limitationsThe median SUVmax was greater for GG 3–5 tumours (6.40, interquartile range [IQR] 4.47–11.0) than for benign and GG 1–2 tumours (3.14, IQR 2.55–3.91; p < 0.001). The median SUVmax was greater for GG 3 (5.70, IQR 3.68–8.67) than for GG 2 (3.47, IQR 2.70–4.74; p < 0.001). For GG 3–5 disease, sensitivity was 86.5%, 95.9%, and 98.6%, and the negative predictive value (NPV) was 88.4%, 88.5%, and 93.3% using SUVmax ≥4, a Prostate Imaging-Reporting and Data System (PI-RADS) score of 3–5, and both, respectively. This combined model detected more GG 3–5 disease than mpMRI alone (98.6% vs 95.9%; p = 0.04). SUVmax was an independent predictor of csPCa for GG 3–5 disease only (odds ratio 1.27 per unit, 95% confidence interval 1.13–1.45). Our results are limited by the retrospective study design. ConclusionsGreater SUVmax on 68Ga-PSMA-11 PET/CT is associated with detection of GG 3–5 cancer on biopsy. The combination of PI-RADS score and SUVmax provides higher sensitivity and NPV than either alone. 68Ga-PSMA-11 PET/CT may be useful alongside mpMRI in improving risk stratification for localised disease. Patient summaryThe amount of a radioactive tracer taken up in the prostate during a type of scan called PET (positron emission tomography) can predict whether aggressive prostate cancer is likely to be found on biopsy. This may complement the more usual type of scan, MRI (magnetic resonance imaging), used to detect prostate cancer.

Detection and staging of radio-recurrent prostate cancer using multiparametric MRI.

We determined the sensitivity and specificity of multiparametric magnetic resonance imaging (MP-MRI) in detection of locally recurrent prostate cancer and extra prostatic extension in the post-radical radiotherapy setting. Histopathological reference standard was whole-mount prostatectomy specimens. We also assessed for any added value of the dynamic contrast enhancement (DCE) sequence in detection and staging of local recurrence. This was a single centre retrospective study. Participants were selected from a database of males treated with salvage prostatectomy for locally recurrent prostate cancer following radiotherapy. All underwent pre-operative prostate-specific antigen assay, positron emission tomography CT, MP-MRI and transperineal template prostate mapping biopsy prior to salvage prostatectomy. MP-MRI performance was assessed using both Prostate Imaging-Reporting and Data System v. 2 and a modified scoring system for the post-treatment setting. 24 patients were enrolled. Using Prostate Imaging-Reporting and Data System v. 2, sensitivity, specificity, positive predictive value and negative predictive value was 64%, 94%, 98% and 36%. MP-MRI under staged recurrent cancer in 63%. A modified scoring system in which DCE was used as a co-dominant sequence resulted in improved diagnostic sensitivity (61%-76%) following subgroup analysis. Our results show MP-MRI has moderate sensitivity (64%) and high specificity (94%) in detecting radio-recurrent intraprostatic disease, though disease tends to be under quantified and under staged. Greater emphasis on dynamic contrast images in overall scoring can improve diagnostic sensitivity. MP-MRI tends to under quantify and under stage radio-recurrent prostate cancer. DCE has a potentially augmented role in detecting recurrent tumour compared with the de novo setting. This has relevance in the event of any future modified MP-MRI scoring system for the irradiated gland.

Predictors of erectile dysfunction after transperineal template prostate biopsy.

PurposeTo investigate the incidence and possible contributing factors of erectile dysfunction (ED) after transperineal template prostate biopsy (TTPB).Materials and MethodsMales undergoing TTPB were prospectively administered a Sexual Health Inventory for Men (SHIM) questionnaire before biopsy and one month after. SHIM questionnaires were repeated at 3- and 9-months for males not receiving interventional treatment. Sexually inactive males were excluded. Interval change in SHIM categories based upon baseline characteristics were evaluated. Multivariable logistic regression models were used to evaluate predictors of change in SHIM score category.ResultsA total of 576 males were included in our sample. Of these, 450 (78%) males underwent their first biopsy. A decline in SHIM category within the immediate 4-weeks post-biopsy was reported by 167 males (31% of total eligible sample). Age was the strongest predictor of decline in SHIM category, the predicted probability of a decline in SHIM at age 50 was 10% (95% confidence interval [CI], 1%–19%), 32% at age 60 (95% CI, 25%–40%) and 36% at age 70 (95% CI, 29%–44%). For new onset ED, the predicted probability of ED within 4-weeks post-TTPB were 6.7% at age 50 (95% CI, 0%–15%), 26% at age 60 (95% CI, 17%–34%) and 31% at age 70 (95% CI, 21%–40%).ConclusionsOlder age at biopsy is an independent predictor of immediate ED after TTPB in sexually active males. This association was observed in the subgroup with no pre-existing ED. These findings provide useful information when counselling males undergoing TTPB.

The 31-month experience of transperineal template prostate biopsy at a rural district general hospital

Introduction: Transperineal template prostate biopsies (TPTPB) have been offered for prostate adenocarcinoma diagnosis since Mar 2017 at Hereford County Hospital, in conjunction with the Prostate Imaging Reporting and Data System (PI-RADS). This assesses the likelihood of clinically-significant cancer based on MRI prostate characteristics. Our study will evaluate this unit’s experience of TPTPB efficacy and safety.

Evaluation Of MR Only Trans-Perineal Interstitial Gynecological HDR Brachytherapy Workflow Using MR-Line Marker And MR Template

There is a growing interest in using MR-only trans-perineal gynecological interstitial brachytherapy because it offers excellent soft-tissue contrast due to MR imaging while reducing the resources required for planning and uncertainty due to registration with CT. The purpose of this work is to evaluate the variation in MR-only workflow in comparison to CT guided approach in gynecological trans-perineal interstitial high dose rate (HDR) brachytherapy. An in-house MR-line marker was designed and created to provide positive contrast on T1W MR images for delineating 6F interstitial catheters (Elekta), replacing the need for CT. A marker plate filled with contrast was affixed to the trans-perineal template, providing a clear reference plane for planning on T1W MR images. Ten patients diagnosed with locally advanced cervical cancer treated with HDR brachytherapy were retrospectively evaluated. An MR-only workflow was developed that used the positive contrast from the MR-markers on T1W images in conjunction with negative contrast on T2W images, to robustly and accurately delineate the interstitial catheters. Inter-observer variability in delineated catheter paths and time required to delineate the catheters were evaluated for 3 therapists and 2 medical physicists. A dosimetric comparison of the plans in the MR-only workflow was made with those in CT based workflow. The contrast in the MR-line marker was stable over time. MR-line markers were visible on planning T1-3D MR images but the complementary information from co-registered T2-3D images were needed at some anatomical locations where the background signal was comparable to that of the markers. MR-template helped to make quality assurance of reconstructed catheter lengths and hence to locate the first dwell point reliably. More than about 97% of catheter reconstruction variations were within 2mm. There were no statistical differences in gross tumor volume (GTV) D98 and High-risk clinical target volume (HR-CTV) D90 and the organs at risk (Bladder, sigmoid, rectum and bowel) D2cc between MR-only and hybrid CT/MR workflow. The average catheter reconstruction time was 51 ± 10 minutes across all ten patients for all observers. The results of this study show that the MR-only workflow is feasible. The use of MR markers enabled accurate and reproducible delineation of the catheters. Furthermore, it was also demonstrated that an MR-only workflow is dosimetrically equivalent to a CT based approach.

Can the combination of biparametric magnetic resonance imaging and PSA-related indicators predict the prostate biopsy outcome?

To assess the value of biparametric magnetic resonance imaging (bpMRI) for detecting and ruling out prostate cancer in patients with elevated prostate-specific antigen (PSA). The basic information and bpMRI images of enrolled patients who took transperineal template saturate biopsy were retrospectively collected for analysis. Based on our results, we found that free/total PSA, and PI-RADS score were independent risk factors of PCa (p<.05), the PSA density, PI-RADS score were the independent risk factors of csPCa (p<.05). PI-RADS score threshold of 3 could achieve the highest Yonder index for predicting PCa, and PI-RADS score threshold of 4 could achieve the highest Yonder index for predicting csPCa. Therefore, we draw a conclusion that PI-RADSv2 score-based bpMRI could diminish the unnecessary prostate biopsies in patients with elevated PSA when combined with other PSA-related indicators.

PT436 - Transperineal template biopsy is both safer and more cost-effective than transrectal ultrasound-guided prostate biopsy in the Australian public hospital setting

PT436 - Transperineal template biopsy is both safer and more cost-effective than transrectal ultrasound-guided prostate biopsy in the Australian public hospital setting

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

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

Manual prostate cancer segmentation in MRI: interreader agreement and volumetric correlation with transperineal template core needle biopsy.

To assess interreader agreement of manual prostate cancer lesion segmentation on multiparametric MR images (mpMRI). The secondary aim was to compare tumor volume estimates between MRI segmentation and transperineal template saturation core needle biopsy (TTSB). We retrospectively reviewed patients who had undergone mpMRI of the prostate at our institution and who had received TTSB within 190days of the examination. Seventy-eight cancer lesions with Gleason score of at least 3 + 4 = 7 were manually segmented in T2-weighted images by 3 radiologists and 1 medical student. Twenty lesions were also segmented in apparent diffusion coefficient (ADC) and dynamic contrast enhanced (DCE) series. First, 20 volumetric similarity scores were computed to quantify interreader agreement. Second, manually segmented cancer lesion volumes were compared with TTSB-derived estimates by Bland-Altman analysis and Wilcoxon testing. Interreader agreement across all readers was only moderate with mean T2 Dice score of 0.57 (95%CI 0.39-0.70), volumetric similarity coefficient of 0.74 (0.48-0.89), and Hausdorff distance of 5.23mm (3.17-9.32mm). Discrepancy of volume estimate between MRI and TTSB was increasing with tumor size. Discrepancy was significantly different between tumors with a Gleason score 3 + 4 vs. higher grade tumors (0.66ml vs. 0.78ml; p = 0.007). There were no significant differences between T2, ADC, and DCE segmentations. We found at best moderate interreader agreement of manual prostate cancer segmentation in mpMRI. Additionally, our study suggests a systematic discrepancy between the tumor volume estimate by MRI segmentation and TTSB core length, especially for large and high-grade tumors. • Manual prostate cancer segmentation in mpMRI shows moderate interreader agreement. • There are no significant differences between T2, ADC, and DCE segmentation agreements. • There is a systematic difference between volume estimates derived from biopsy and MRI.

Review article: MRI-targeted biopsies for prostate cancer diagnosis and management.

Transrectal ultrasound (TRUS)-guided biopsy has been the traditional biopsy route in the detection of prostate cancer. However, due to concern regarding overdetection of low-risk cancer and missed clinically significant cancers as well as risk of sepsis, alternative approaches have been explored. Transperineal template biopsy-sampling the gland every 5m to 10mm-reduces error by sampling the whole prostate but increases risk of detecting clinically insignificant cancers as well as conferring risks of side effects such as urinary retention and bleeding. There are various targeted biopsy techniques, each with different cancer detection rates, costs and learning curves. Current research focuses on refining biopsy methodology to maximize detection of significant cancers, whilst minimising invasiveness and complications. In this article, the up-to-date research data about MRI-targeted prostate biopsy were reviewed to show its utilization in prostate cancer management and diagnosis. Prostate multiparametric MRI has become an effective tool in the detection of significant cancers and an essential component of the prostate cancer diagnostic pathway incorporating MRI-guided biopsy decisions.