TRUS-guided Biopsy Research Articles

Evaluating Prostate Cancer: The Diagnostic Impact of MRI and Its Relationship With Transrectal Ultrasound (TRUS)-Guided Biopsy.

Background Prostate disorders, including benign enlargement and malignancy, are commonly evaluated through imaging techniques. Historically, transrectal ultrasound (TRUS) has been used for prostate imaging and biopsy. However, multiparametric MRI (mpMRI), which integrates structural and functional imaging methods, offers enhanced diagnostic capabilities. This study evaluates the effectiveness of mpMRI, including its grading via Prostate Imaging - Reporting and Data System (PI-RADS) or Likert scoring, in distinguishing between benign and malignant prostatic conditionsand compares these findings with TRUS outcomes. Methodology This prospective study enrolled 30 male patients aged 45 to 75 years (mean age 60 years), selected based on prostatic abnormalities, elevated prostate-specific antigen (PSA) levels (>4 ng/dL), or palpable nodules detected via digital rectal examination. MRI, including PI-RADS or Likert scoring, was utilized to assess prostatic lesions, and results were compared with histopathological data obtained from TRUS-guided biopsies. Results Among the 30 patients, common symptoms included urinary retention (60%) and painful urination (53.3%). Malignant tumors were diagnosed in 12 patients (40%). MRI identified eight cases with enlarged transitional zones and irregular signals in peripheral zones (benign prostatic hyperplasia with tumor)and four cases with irregular signals in both zones (sarcoma). Concordance between MRI T2-weighted (T2W) observations and biopsy results showed 60% malignancy detection. Sensitivity assessments revealed MRI detected 15 true-positives (50%), TRUS detected six true positives (20%), and multivoxel spectroscopic analysis (MVS) identified 14 true-positives (46.7%). PI-RADS or Likert scoring of mpMRI was correlated with TRUS outcomes, highlighting its enhanced diagnostic accuracy compared to TRUS alone. Conclusion While TRUS remains a standard diagnostic tool, it is limited by significant sampling errors and complications. The integration of mpMRI, with its grading system, significantly improves diagnostic accuracy and treatment planning. Although mpMRI alone has limitations, its combination with contrast-enhanced MRI, diffusion-weighted imaging, and MR spectroscopy offers a comprehensive approach to enhanced prostate cancer detection.

The Diagnostic Value of Multiparametric-MRI in Locating Prostate Cancer in Comparison with Transrectal Ultrasound-Guided Biopsy

Purpose: The present study was designed to evaluate the potential efficacy of Multiparametric-Magnetic Resonance Imaging (MP-MRI) in the detection of prostate cancer locations compared to Transrectal Ultrasound (TRUS) guided biopsy, as the gold standard method.
 Materials and Methods: A total of 66 subjects participated in this cross-sectional study. All individuals underwent MP-MRI imaging before the prostate TRUS. The findings of either method have been investigated and the comparison had been made using the Chi-squared test.
 Results: The sensitivity and specificity of the MP-MRI in the diagnosis of prostate cancer were 81.8% and 93.9%, respectively. The positive and negative predictive values were 93.1% and 83.8%, respectively.
 Conclusion: The current study indicates that the MP-MRI imaging method has sufficient sensitivity and specificity for detecting the location of prostate cancer and can potentially be employed as a clue-providing method prior to the TRUS-guided biopsy.

Advanced strain elastography is a reliable approach for prostate cancer detection in patients with elevated PSA levels

This study aimed to examine the validity and reproducibility of strain elastography (SE) for detecting prostate cancer (PCa) in patients with elevated prostate-specific antigen (PSA) levels. The study included 107 patients with elevated PSA levels. All eligible patients underwent transrectal ultrasound (TRUS) with real-time elastography (RTE) to detect suspicious lesions. Two readers independently evaluated the lesions and assigned a strain ratio and elastography score to each lesion. Histopathology was used as a reference standard to estimate the validity of RTE in predicting malignant lesions. An intraclass correlation (ICC) was performed to detect reliability of the strain ratios and elastography scores. TRUS-guided biopsy detected malignancies in 64 (59.8%) patients. TRUS with RTE revealed 122 lesions. The strain ratio index (SRI) cut-off values to diagnose malignancy were 4.05 and 4.35, with sensitivity, specificity, and accuracy of 94.7%, 91.3%, and 93.4%, respectively. An elastography score > 3 was the best cut-off value for detecting malignancy. According to readers, the sensitivity, specificity, and accuracy were 91.3–94.7%, 89.5–93.4%, and 91.3–90.9%, respectively. Excellent inter-reader agreement was recorded for SRI and elastography scores, with ICC of 0.937 and 0.800, respectively. SE proves to be an efficient tool for detecting PCa with high accuracy in patients with elevated PSA levels.

Current Approach to Complications and Difficulties during Transrectal Ultrasound-Guided Prostate Biopsies.

Prostate cancer is one of the most common male malignancies worldwide. It affects middle-aged men (45-60 years) and is the leading cause of cancer-related mortality in Western countries. The TRUS (trans rectal ultrasound)-guided prostate biopsy has been a standard procedure in prostate cancer detection for more than thirty years, and it is recommended in male patients with an abnormal PSA (prostate-specific antigens) or abnormalities found during digital rectal examinations. During this procedure, urologists might encounter difficulties which may cause subsequent complications. This manuscript aims to present both the complications and the technical difficulties that may occur during TRUS-guided prostate biopsy, along with resolutions and solutions found in the specialized literature. The conclusions of this manuscript will note that the TRUS-guided prostate biopsy remains a solid, cost-efficient, and safe procedure with which to diagnose prostate cancer. The complications are usually self-limiting and do not require additional medical assistance. The difficulties posed by the procedure can be safely overcome if there are no other available alternatives. Open communication with the patients improves both pre- and post-procedure compliance.

The Rate of Phosphatase and Tensin (PTEN) Gene Expression Loss in Prostate Cancer and its Link to Tumor Upgrading.

Recent studies have provided reliable evidence for a relationship between loss of PTEN gene expression and prognosis in patients suffering from prostate cancer, although the results have been somewhat diverse in different populations. We aimed to assess PTEN gene expression loss by immunohistochemistry in prostate cancer and also its link to tumor upgrading in a group of affected patients undergoing radical prostatectomy. This cross-sectional study was performed on 58 tissue samples sourced from the patients with prostate cancer and undergoing radical prostatectomy. TRUS-guided needle biopsies of the cancer tissue samples with histological grade groups of I to IV (the Gleason scores of 6 to 8) were prepared as the study samples. 29 patients with Gleason score (6 to 8) whose tumors on needle biopsy upgraded to Gleason score 7, 8 or 9 at prostatectomy (cases) were compared with 29 patients with Gleason scores of 6, 7 or 8 on both biopsy and prostatectomy samples (controls). Immunohistochemistry (IHC) technique was employed to determine PTEN gene expression status. Loss of PTEN gene expression was found in 62.1% of upgraded cases compared with 27.6% of controls, indicating a statistically significant difference, revealing a meaningful association between the loss of PTEN gene expression and tumor upgrading. Furthermore, we demonstrated that deletions of PTEN gene expression and increased Gleason score in control and upgraded case groups, did not reach statistical significance. A high rate of PTEN gene expression loss can be detected in prostate cancer tumor tissue, and this loss of gene expression is associated with tumor upgrading.

Efficacy of fosfomycin compared to second generation cephalosporin flumarin as antimicrobial prophylaxis for transrectal ultrasound-guided prostate biopsy: a single center retrospective study

BackgroundFluoroquinolone has been the historic choice of antimicrobial prophylaxis for transrectal ultrasound (TRUS) guided prostate biopsy. However, increased fluoroquinolone resistance and recent restrictions of its use for antimicrobial prophylaxis has led to the emergence of alternative agents for antimicrobial prophylaxis for TRUS guided prostate biopsy including fosfomycin and cephalosporins. This study aimed to compare the efficacy of fosfomycin and a second-generation cephalosporin flumarin as alternative antimicrobials for TRUS-guided prostate biopsy in terms of the incidence of infectious complications after TRUS-guided prostate biopsy.MethodsA retrospective chart review of all patients who underwent TRUS-guided prostate biopsy between November 2009 to January 2023 was undertaken. Comparison of baseline characteristics and the incidence of infectious complications was done between those who received fosfomycin as antimicrobial prophylaxis for TRUS-guided prostate biopsy and those who received flumarin. Multivariate logistic regression analysis was conducted to identify risk factors for infectious complications after TRUS-guided prostate biopsy.ResultsOf 2,900 patients identified as eligible candidates for analysis, 333 (11.5%) received fosfomycin and 2,567 (88.5%) received flumarin. The overall rate of infectious complications was approximately 3% lower in patients who received fosfomycin, although such difference did not reach statistical significance (5.7% vs. 8.6%, p = 0.074). Multivariate logistic regression analysis showed that history of operation done under general anaesthesia within six months of the biopsy (odds ratio [OR]: 2.216; 95% confidence interval [CI]: 1.042–4.713; p = 0.039) and history of prior antimicrobial use within six months (OR: 1.457; 95% CI: 1.049–2.024; p = 0.025) were significant risk factors for infectious complications after TRUS-guided prostate biopsy.ConclusionFosfomycin was comparable to second-generation cephalosporin flumarin in preventing infectious complications after TRUS-guided prostate biopsy. Coupled with its properties such as ease of administration, low adverse effects, low resistance rate, and low collateral damage, fosfomycin might be an attractive alternative antimicrobial prophylaxis for TRUS-guided prostate biopsy.

Comparing the Diagnostic Performance of Micro- Ultrasound-Guided Biopsy Versus Multiparametric Magnetic Resonance Imaging-Targeted Biopsy in the Detection of Clinically Significant Prostate Cancer: A Systematic Review and Meta-Analysis

Background Micro-ultrasound is a novel, high-resolution imaging modality that aims to improve the accuracy of prostate cancer diagnosis compared with TRUS-guided biopsy. While traditional ultrasound systems operate at 8 to 12 MHz, micro-ultrasound operates at 29 MHz, allowing enhanced recognition of microstructures with 300% higher resolution. Micro-ultrasound can potentially identify and target in real-time suspicious lesions, improving sensitivity and the negative predictive value for clinically significant prostate cancer. It may be a low-cost alternative to multiparametric magnetic resonance imaging (mpMRI) in the detection of prostate cancer. Methods A systematic review and meta-analysis was performed comparing the diagnostic performance of microultrasound- guided prostate biopsies with mpMRI-targeted prostate biopsies in the detection of clinically significant prostate cancer. PubMed, EMBASE, SCOPUS, and Cochrane CENTRAL databases were searched to identify relevant studies published up to July 2022. Results A total of 15 studies were included for the systematic review, with 12 of those studies being included for the meta-analysis. The pooled sensitivity and specificity for micro-ultrasound-guided biopsies detecting clinically significant prostate cancer were 89% (95% CI 83 to 93) and 31% (95% CI 23 to 40) respectively (I2 = 0%). In comparison, the pooled sensitivity and specificity for mpMRI-targeted biopsies detecting clinically significant prostate cancer were 86% (95% CI 73 to 93) and 32% (95% CI 18 to 50) respectively (I2 = 16%). There was no statistically significant difference in the sensitivity or specificity between micro-ultrasound and mpMRI. Subgroup analysis found no difference in MRI subgroups based on blinding (P = 0.383). Conclusion Micro-ultrasound-guided biopsies are comparable to mpMRI targeted biopsies with no difference in the detection of clinically significant prostate cancer between the 2 modalities. Large, multicentre, prospective studies are required to further substantiate the use of micro-ultrasound as an alternative to or in conjunction with mpMRI in the detection of prostate cancer.

Follow-Up of Men Who Have Undergone Focal Therapy for Prostate Cancer with HIFU-A Real-World Experience.

To determine oncological and functional outcomes and side effects after focal therapy of prostate cancer (PCa) with high-intensity focused ultrasound (HIFU). This retrospective single-center study included 57 consecutive patients with localised PCa. Aged 18-80 with ≤2 suspicious lesions on mpMRI (PIRADS ≥ 3), PSA of ≤15 ng/mL, and an ISUP GG of ≤2. HIFU was performed between November 2014 and September 2018. All men had an MRI/US fusion-guided targeted biopsy (TB) combined with a TRUS-guided 10-core systematic biopsy (SB) prior to focal therapy. HIFU treatment was performed as focal, partial, or hemiablative, depending on the prior histopathology. Follow-up included Questionnaires (IIEF-5, ICIQ, and IPSS), prostate-specific antigen (PSA) measurement, follow-up mpMRI, and follow-up biopsies. The median age of the cohort was 72 years (IQR 64-76), and the median PSA value before HIFU was 7.3 ng/mL (IQR 5.75-10.39 ng/mL). The median follow-up was 27.5 (IQR 23-41) months. At the time of the follow-up, the median PSA value was 2.5 ng/mL (IQR 0.94-4.96 ng/mL), which shows a significant decrease (p < 0.001). In 17 (29.8%) men, mpMRI revealed a suspicious lesion, and 19 (33.3%) men had a positive biopsy result. Only IIEF values significantly decreased from 16 (IQR 10.75-20.25) to 11.5 (IQR 4.5-17) (p < 0.001). The rate of post-HIFU complications was low, at 19.3% (11 patients). The limitation of this study is the lack of long-term follow-up. HIFU as a therapy option for nonmetastatic, significant prostate cancer is effective in the short term for carefully selected patients and shows a low risk of adverse events and side effects.

Transperineal template saturation and conventional biopsy for stage prediction in prostate cancer.

To evaluate the performance of risk calculators (RCs) predicting lymph node invasion (LNI) and extraprostatic extension (EPE) in men undergoing transperineal magnetic resonance imaging/transrectal ultrasound (TRUS)-fusion template saturation biopsy (TTSB) and conventional systematic TRUS-guided biopsy (SB). The RCs were tested in a consecutive cohort of 645 men undergoing radical prostatectomy with extended pelvic LN dissection between 2005 and 2019. TTSB was performed in 230 (35.7%) and SB in 415 (64.3%) men. Risk of LNI and EPE was calculated using the available RCs. Discrimination, calibration, and clinical usefulness stratified by different biopsy techniques were assessed. Lymph node invasion was observed in 23 (10%) and EPE in 73 (31.8%) of cases with TTSB and 53 (12.8%) and 158 (38%) with SB, respectively. RCs showed an excellent discrimination and acceptable calibration for prediction of LNI based on TTSB (area under the curve [AUC]/risk estimation: Memorial Sloan Kettering Cancer Center [MSKCC]-RC 0.79/-4%, Briganti (2012)-RC 0.82/-4%, Gandaglia-RC 0.81/+6%). These were comparable in SB (MSKCC-RC 0.78/+2%; Briganti (2012)-RC 0.77/-3%). Decision curve analysis (DCA) revealed a net benefit at threshold probabilities between 3% and 6% when TTSB was used. For prediction of EPE based on TTSB an inferior discrimination and variable calibration were observed (AUC/risk estimation: MSKCC-RC 0.71/+8% and Martini (2018)-RC 0.69/+2%) achieving a net benefit on DCA only at risk thresholds of >17%. Performance of RCs for prediction of LNI and EPE based on SB showed comparable results with a better performance in the DCA for LNI (risk thresholds 1-2%) and poorer performance for EPE (risk threshold >20%). This study is limited by its retrospective single-institution design. The potentially more accurate grading ability of TTSB did not result in improved performance of preoperative RCs. Prediction tools for LNI proved clinical usefulness while RCs for EPE did not.

Delta radiomic patterns on serial bi-parametric MRI are associated with pathologic upgrading in prostate cancer patients on active surveillance: preliminary findings.

The aim of this study was to quantify radiomic changes in prostate cancer (PCa) progression on serial MRI among patients on active surveillance (AS) and evaluate their association with pathologic progression on biopsy. This retrospective study comprised N = 121 biopsy-proven PCa patients on AS at a single institution, of whom N = 50 at baseline conformed to the inclusion criteria. ISUP Gleason Grade Groups (GGG) were obtained from 12-core TRUS-guided systematic biopsies at baseline and follow-up. A biopsy upgrade (AS+) was defined as an increase in GGG (or in number of positive cores) and no upgrade (AS-) was defined when GGG remained the same during a median period of 18 months. Of N = 50 patients at baseline, N = 30 had MRI scans available at follow-up (median interval = 18 months) and were included for delta radiomic analysis. A total of 252 radiomic features were extracted from the PCa region of interest identified by board-certified radiologists on 3T bi-parametric MRI [T2-weighted (T2W) and apparent diffusion coefficient (ADC)]. Delta radiomic features were computed as the difference of radiomic feature between baseline and follow-up scans. The association of AS+ with age, prostate-specific antigen (PSA), Prostate Imaging Reporting and Data System (PIRADS v2.1) score, and tumor size was evaluated at baseline and follow-up. Various prediction models were built using random forest (RF) classifier within a threefold cross-validation framework leveraging baseline radiomics (Cbr), baseline radiomics + baseline clinical (Cbrbcl), delta radiomics (CΔr), delta radiomics + baseline clinical (CΔrbcl), and delta radiomics + delta clinical (CΔrΔcl). An AUC of 0.64 ± 0.09 was obtained for Cbr, which increased to 0.70 ± 0.18 with the integration of clinical variables (Cbrbcl). CΔr yielded an AUC of 0.74 ± 0.15. Integrating delta radiomics with baseline clinical variables yielded an AUC of 0.77 ± 0.23. CΔrΔclresulted in the best AUC of 0.84 ± 0.20 (p < 0.05) among all combinations. Our preliminary findings suggest that delta radiomics were more strongly associated with upgrade events compared to PIRADS and other clinical variables. Delta radiomics on serial MRI in combination with changes in clinical variables (PSA and tumor volume) between baseline and follow-up showed the strongest association with biopsy upgrade in PCa patients on AS. Further independent multi-site validation of these preliminary findings is warranted.

DWI CAPACITY IN PROSTATE CANCER DIAGNOSING

Relevance: Prostate cancer is one of the leading causes of cancer deaths in men worldwide. Transrectal ultrasound-guided (TRUS) prostate biopsy is the most important diagnostic step, without which a definitive diagnosis cannot be made. Despite this, TRUS-guided prostate biopsy has a high rate of false negatives and is often accompanied by various clinical complications. Multiparametric MRI (mpMRI) is now widely used in routine urological and oncological practice. An element of mpMRI is diffusion-weighted imaging (DWI), which is successfully used in detecting and localizing clinically significant prostate cancer.&#x0D; The study aimed to evaluate the DWI capacity in diagnosing prostate cancer.&#x0D; Methods: 52 patients, 48-86 years old, with suspected prostate cancer, underwent mpMRI. DWI sequences obtained using T2-weighted imaging (T2WI) were compared with each other and compared with the anatomical structure of the prostate. Suspicious prostate cancer sites were marked as regions of interest, for which an apparent diffusion coefficient (ADC) was calculated. A 12-point TRUS-guided biopsy confirmed the presence or absence of prostate cancer.&#x0D; Results: When analyzing quantitative measurements, ADC showed low values for cancer in the central gland (transitional zone and central zone) – 0.610±0.157×10-3 mm2/s, p=0.0001, and for cancer in the peripheral zone – 0.651±0.228×10-3 mm2/s, p=0.0004, compared to normal tissue. It was found that the highest sensitivity value (87.5%) is typical for ADC central gland, and the lower value for ADC peripheral zone is 75%. The highest specificity value (90.9%) was observed in ADC peripheral zone, and a lower value in ADC central gland – was 84.1%.&#x0D; Conclusion: DWI is an effective non-invasive method for detecting and localizing prostate cancer, providing a qualitative (visual) and quantitative assessment of prostate cancer.

DWI CAPACITY IN PROSTATE CANCER DIAGNOSING

Relevance: Prostate cancer is one of the leading causes of cancer deaths in men worldwide. Transrectal ultrasound-guided (TRUS) prostate biopsy is the most important diagnostic step, without which a definitive diagnosis cannot be made. Despite this, TRUS-guided prostate biopsy has a high rate of false negatives and is often accompanied by various clinical complications. Multiparametric MRI (mpMRI) is now widely used in routine urological and oncological practice. An element of mpMRI is diffusion-weighted imaging (DWI), which is successfully used in detecting and localizing clinically significant prostate cancer.&#x0D; The study aimed to evaluate the DWI capacity in diagnosing prostate cancer.&#x0D; Methods: 52 patients, 48-86 years old, with suspected prostate cancer, underwent mpMRI. DWI sequences obtained using T2-weighted imaging (T2WI) were compared with each other and compared with the anatomical structure of the prostate. Suspicious prostate cancer sites were marked as regions of interest, for which an apparent diffusion coefficient (ADC) was calculated. A 12-point TRUS-guided biopsy confirmed the presence or absence of prostate cancer.&#x0D; Results: When analyzing quantitative measurements, ADC showed low values for cancer in the central gland (transitional zone and central zone) – 0.610±0.157×10-3 mm2/s, p=0.0001, and for cancer in the peripheral zone – 0.651±0.228×10-3 mm2/s, p=0.0004, compared to normal tissue. It was found that the highest sensitivity value (87.5%) is typical for ADC central gland, and the lower value for ADC peripheral zone is 75%. The highest specificity value (90.9%) was observed in ADC peripheral zone, and a lower value in ADC central gland – was 84.1%.&#x0D; Conclusion: DWI is an effective non-invasive method for detecting and localizing prostate cancer, providing a qualitative (visual) and quantitative assessment of prostate cancer.

Value of transrectal ultrasound-guided biopsy in endoscopy negative biopsy patients with rectal lesions

ObjectiveTo evaluate the value of transrectal ultrasound (TRUS) guided biopsy in endoscopy negative biopsy patients with rectal lesions.Methods150 endoscopy negative biopsy result rectal lesions adopted the transrectal ultrasound-guided biopsy. Based on whether the patients received contrast-enhanced ultrasound examination or not before the biopsies, all enrolled cases were divided into TRUS guided group and contrast-enhanced TRUS (CE-TRUS) guided group, and the safety and diagnostic performances were analyzed retrospectively.ResultsWe obtained adequate specimens in the majority of cases (98.7%,148/150); There were no complications identified in our study. 126 patients received contrast-enhanced TRUS examination before biopsy to evaluate vascular perfusion and necrosis. The sensitivity, specificity, PPV, NPV, and overall accuracy of all biopsies were 89.1%, 100%,100%, 70.4%, and 91.3% respectively; The sensitivity, specificity, PPV, NPV, and accuracy for TRUS-guided biopsy and CE-TRUS guided biopsy were 73.7%, 100%,100%, 50%,79.2% and 92.1%,100%,100%,75%,93.6% separately; The increase in correct diagnoses was significant (p < 0.05) between TRUS guided biopsy and CE-TRUS guided biopsy.ConclusionTRUS-guided biopsy is a reliable procedure that can be augmented by endoscopic biopsy techniques if the biopsy yields negative results. CE-TRUS might assist in the location of the biopsy and decrease sampling errors.

Comparison of intrarectal heated lidocaine gel and periprostatic nerve block for pain control in transrectal ultrasound-guided prostate biopsy: A randomized controlled non-inferiority trial.

To investigate whether intrarectal local anesthesia with heated lidocaine gel (IRLAH) is non-inferior to periprostatic nerve block (PNB) for reducing pain in patients undergoing transrectal ultrasound (TRUS)-guided prostate biopsy. We performed a randomized controlled non-inferiority trial with 100 participants who underwent systematic TRUS-guided, 12-core prostate biopsy from August 2019 to July 2020. These participants were randomly assigned to a group receiving intrarectal local anesthesia with 20mL of heated (40°C) 2% lidocaine gel (n=50) or PNB (n=50). The primary outcome was a pain score on a 0-10 visual analogue scale (VAS) at four time points with the non-inferiority margin of 1; VAS-1: during local anesthesia application; VAS-2: during probe insertion; VAS-3: during biopsy; VAS-4: 30minutes after the procedure. The secondary outcome included complications during and after the procedure. The IRLAH group (0.1) met non-inferiority as well as superiority criteria for mean VAS-1 score vs. the PNB group (2.33) (P<0.001), as the difference (95% confidence interval [CI]) between the two groups was-2.23 (-2.66 to-1.79) and the upper bound of the 95% CI were both below the prespecified non-inferiority margin and below zero. For mean VAS-3 score, the difference (95% CI) was 0.3 (-0.38 to 0.98) and the upper bound of the 95% CI did not exceed the predefined non-inferiority margin indicating that IRLAH was non-inferior (IRLAH group, 3.44; PNB group, 3.14). Also, non-inferiority was shown for pain scores at VAS-2 and VAS-4. There were no significant differences in complications. IRLAH is a noninvasive and non-inferior alternative to PNB for pain control in TRUS-guided prostate biopsy without increased risk of complications.

Expression of ERG in Prostatic Acinar Adenocarcinoma Diagnosed on TRUS-guided Biopsy and its Association with WHO Grade Group- A Prospective Observational Study

Introduction: Prostate cancer is a common malignancy affecting men and the second leading cause of cancer related death in India. Numerous molecular biomarkers have been evaluated for their potential role in predicting disease progression, their response to therapy and survival. Erythroblast Transformation Specific (ETS) related Gene (ERG) is one of the newest addition in the existing list of biomarkers of prostate cancer. Aim: To analyse the expression of ERG in prostatic adenocarcinoma and to evaluate its association with World Health Organisation (WHO) grade group. Materials and Methods: This was a prospective observational study was conducted in the Department of Pathology in association with Department of Urology, IPGME&amp;R, SSKM Hospital, Kolkata, West Bengal, India. The duration of the study was 1.5 years, from January 2019 to June 2020. A total of 267 cases of Transrectal Ultrasound (TRUS) guided tru-cut biopsy was included. Clinical data including preoperative Prostate Specific Antigen (PSA) level, Digital Rectal Examination (DRE) were obtained. Histopathological reports were prepared by two pathologists along with Gleason scoring and WHO grading as per 2014 International Society of Urological Pathology (ISUP) consensus conference on gleason grading of prostatic carcinoma. Formalin Fixed Paraffin Embedded (FFPE) sections of representative blocks of each tumour was selected for Immunohistochemistry (IHC) study. Only the cases which had more than 10% nuclear staining were considered as positive. Statistical analysis was performed with help of Epi Info (TM) 7.2.2.2 and Chi-square test was used to test the association of different study variables. Results: The mean age of the study participants was 65.55 years, and the age range was 45-93 years. Among the 80 malignant cases where, ERG immunostaining was assessed, 28 cases (35%) showed positive expression. Among these positive cases, 50% cases were weakly positive, 28.57% showed moderate positivity and 21.43% had strong positive expression. Highest positivity was observed in WHO grade group V (44.83%). The intensity of ERG expression was also higher in high grade group (13) than low grade group cancer patients. Conclusion: ERG expression in the prostate cancer can be a prognostic factor as the expression and intensity of expression both increases with higher grade group of cancer.

Evaluacija kliničke primene PAMD skora u proceni pozitivnog ishoda TRUS-biopsije prostate kod pacijenata sa PSA 4-10 ng/ml lečenih u Srbiji

Introduction: Transrectal ultrasound-guided prostate biopsy (TRUS-biopsy) is the "gold standard" in the diagnosis of prostate cancer (PC). There is much divided opinion on the need for biopsy in patients with prostate-specific antigen (PSA) between 4 and 10 ng/ml. The positive biopsy outcome (PC) in these patients ranges from 20 to 39%. Low sensitivity and specificity of PSA in predicting positive biopsy outcome results in a large number of unnecessary biopsies and treatments. In order to better select candidates for biopsy, several risk stratification models for PC have been proposed in recent years, among them the PAMD score. Aim: The aim of this study was to examine the value of the PAMD score in the assessment of positive biopsy outcomes in our population of patients, as well as to examine individual risk factors for PC in patients with PSA values between 4 and 10 ng/ml treated in Serbia. Material and methods: The study involved 50 patients at the Clinic of Urology, University Clinical Centre of Serbia, whose PSA value were measured in the range from 4 to 10 ng/ml. In all the patients we measured PSA and %fPSA, and performed DRE, as well as magnetic resonance imaging (MRI) to evaluate prostate volume (PV) and PI-RADS score. All patients underwent TRUS-guided systemic prostate biopsy. In accordance with the data from literature, PAMD score was determined for all the patients. Results: A PAMD score &gt; 3 showed a high specificity in the prediction of PC, as well as an association with a higher frequency of highgrade PC. A positive finding on DRE, %fPSA&lt; 16, age above 69 years and PI-RADS &gt; 3 showed a statistically significant association with the existence of PC. A high individual predictive value in assessing the presence of PC was confirmed for DRE, %fPSA, PV, and PI-RADS score. Conclusion: The PAMD scoring system may be of importance for better selection of candidates for TRUS-biopsy, in the population of patients with PSA values 4-10 ng/ml.

Comparison of Transrectal Ultrasonography-Guided Prostate Biopsies Analgesia's; Rectal Lidocaine Gel Versus Sandwich Anesthesia (Transurethral Plus Transrectal Lidocaine Gel Administration): A Double-Blind, Randomized, Controlled and Prospective Study.

We aimed to evaluate the effectiveness of the additive transurethral anesthetic agent to transrectal anesthetic agent. Transrectal ultrasound-guided 12 core prostate biopsy planned, 237 patients included in our study. The patients randomly divided into two groups. Group 1 (n=113): Only transrectal 2% lidocaine, Group 2 (n=124): Transrectal + Transurethral(Sandwiches) lidocaine gel given to the patients 10 min before the procedure as anesthesia. Immediately after the biopsy, the patient questioned about the level of pain he felt during the needle entry. The evaluation measured by the VAS score. Immediately after biopsy satisfaction rate with the procedure and if rebiopsy was required, acceptance was scored between 1 and 4. The two groups compared statistically. The mean VAS score of Group 1 and Group 2 was 4.88±1.89 and 3.77±1.83, respectively. The pain level of Group 2 was lower than Group 1' pain level. The difference between the two groups was considered statistically significant (p<0.001). The patient satisfaction rates of Group 1 and Group 2 found to be 2.45±0.71 and 2.78±0.66, and the acceptance rate of rebiopsy was 2.81±0.69 and 3.02±0.51, respectively. The patient satisfaction rate and acceptance rate of the rebiopsy of Group 2 were higher than Group 1. Patient satisfaction level (p<0.001) and rebiopsy acceptance rate (p=0.014) between the two groups found to be statistically significant. In the TRUS-guided prostate biopsies, sandwich anesthesia is a cheap, convenient, tolerable, and effective method.

Retrospective analysis of prostate cancer detection using mpMR/US-fusion and cognitive biopsy

Introduction. Transrectal biopsy under US-control has been standard diagnostic method for prostate cancer (PCa) detection for over 30 years. However, TRUS-guided biopsy is not without well-known drawbacks. MR-targeted biopsy methods were proposed to eliminate the drawbacks and improve detection rate of clinically significant Pca. Cognitive and mpMR/US-fusion biopsies have become the most widely used MR-targeted biopsies. However, there are contradictory data on detection of clinically significant Pca when comparing mpMR/US-fusion and cognitive biopsies.Objective. To compare the detection rate of clinically significant prostate cancer performing cognitive and mpMR/US-fusion biopsies.Materials and methods. Inclusion criteria: PSA &gt; 2.0 ng/ml and/or a positive DRE, and/or a suspicious lesion on TRUS, and PI-RADSv2.1 score ≥ 3. The outcomes evaluated are the detection of clinically significant Pca (ISUP ≥ 2), the overall PСa detection, the detection of clinically insignificant Pca, histological yield (proportion of positive cores, maximum cancer core length).Results. Retrospective data analysis was performed: cognitive biopsy was performed in 102 patients and mpMR/US-fusion biopsy in 176 patients. The median age was 63 years, prostate volume 46 cc. The median PSA was 6.4 ng/ml in the mpMR/US-fusion and 6.7 ng/ml in the cognitive biopsy group. MpMR/US-fusion and cognitive biopsies were comparable about the detection rate of clinically significant (30.3% vs 25.0%; p=0.329) and overall Pca detection rate (50.5% and 42.1%; p = 0.176). It was detected to be less clinically insignificant Pca in the cognitive biopsy group (11.8% vs. 25.5%; p = 0.007). The proportion of positive cores (30.5% and 29.5% respectively; p = 0.754) and maximum cancer core length (6.6 mm vs 7.6 mm; p = 0.320) were equal when comparing cognitive and mpMR/US-fusion biopsies. The proportion of positive cores with clinically significant Pca was higher in the cognitive biopsy group (18.6% vs 13.1%; p = 0.029).Conclusion. Both cognitive and mpMR/US-fusion biopsies are equally accurate for clinically significant Pca detection. Therefore, cognitive biopsy may be an alternative to mpMR/US-fusion biopsy in hospitals where mpMR/US-fusion technology is not currently available.

Transrectal ultrasound examination of prostate cancer guided by fusion imaging of multiparametric MRI and TRUS: avoiding unnecessary mpMRI-guided targeted biopsy.

The purpose of this study was to explore transrectal ultrasound (TRUS) findings of prostate cancer (PCa) guided by multiparametric magnetic resonance imaging (mpMRI) and to improve the Prostate Imaging Reporting and Data System (PI-RADS) system for avoiding unnecessary mpMRI-guided targeted biopsy (TB). From January 2018 to October 2019, fusion mpMRI and TRUS-guided biopsies were performed in 162 consecutive patients. The study included 188 suspicious lesions on mpMRI in 156 patients, all of whom underwent mpMRI-TRUS fusion imaging-guided TB and 12-core transperineal systematic biopsy (SB). Univariate analyses were performed to investigate the relationship between TRUS features and PCa. Then, logistic regression analysis with generalized estimating equations was performed to determine the independent predictors of PCa and obtain the fitted probability of PCa. The detection rates of PCa based on TB alone, SB alone, and combined SB and TB were 55.9% (105 of 188), 52.6% (82 of 156), and 62.8% (98 of 156), respectively. The significant predictors of PCa on TRUS were hypoechogenicity (odds ratio [OR]: 9.595, P = 0.002), taller-than-wide shape (OR: 3.539, P = 0.022), asymmetric vascular structures (OR: 3.728, P = 0.031), close proximity to capsule (OR: 3.473, P = 0.040), and irregular margins (OR: 3.843, P = 0.041). We propose subgrouping PI-RADS score 3 into categories 3a, 3b, 3c, and 3d based on different numbers of TRUS predictors, as the creation of PI-RADS 3a (no suspicious ultrasound features) could avoid 16.7% of mpMRI-guided TBs. Risk stratification of PCa with mpMRI-TRUS fusion imaging-directed ultrasound features could avoid unnecessary mpMRI-TBs.

PO50 Presentation Time: 10:00 AM: Long-Term Results of Salvage High Dose-Rate Brachytherapy with or without Pelvic External Beam Radiotherapy in Patients with Palpable Local Recurrence of Prostate Cancer After Radical Prostatectomy

<h3>Purpose</h3> This study aims to evaluate the long term outcomes and toxicities in patients with clinically apparent, gross local recurrence of prostate cancer after radical prostatectomy, treated with salvage high dose-rate brachytherapy (HDR-BT) with or without pelvic external beam radiotherapy (EBRT). <h3>Materials and Methods</h3> Retrospective chart review was performed to identify patients with clinically apparent, gross local recurrence of prostate cancer after radical prostatectomy who underwent salvage HDR-BT at a single institution between 2002 and 2020. HDR-BT regimens included 950 cGy x 2 (N=4), 1500 cGy x 1 (N=2), 950 cGy x 4 (N=1), and 800 cGy x 2 (N=1). Pelvic EBRT was allowed at the discretion of the treating physician. Treatment and clinical characteristics were obtained for each patient, and outcome and toxicity data were collected. Toxicity was graded according to Common Toxicity criteria for Adverse Events Version 5.0. Descriptive analysis was performed. <h3>Results</h3> A total of 8 patients were included in analysis with a median follow-up of 49 months (range: 9 to 223 months). Five (63%) patients presented with a biochemical recurrence, and 3 patients (38%) presented with symptoms including hematuria and urinary obstruction. Seven patients underwent TRUS-guided biopsy which confirmed recurrent adenocarcinoma. The remaining patient underwent a PSMA PET/CT scan revealing a PET-avid soft tissue lesion in the prostate bed, but declined biopsy and proceeded with treatment without pathologic confirmation. Median age at time of salvage brachytherapy was 68 years (range: 59 to 85 years). Median time from prostatectomy to salvage HDR-BT was 95 months (range: 19 to 207 months). Median PSA at time of HDR brachytherapy was 2.32 ng/ml (range: undetectable on ADT to 13 ng/ml). Median lesion size was 2.5 cm (range: 1 to 3.6 cm). Six patients (75%) received adjuvant pelvic EBRT, 45-50 Gy in 25 fractions. Seven out of 8 patients received ADT after salvage brachytherapy for a median duration of 12 months (range: 8 to 24 months). The remaining patient did not receive ADT due to cardiac comorbidities. Seven out of 8 patients were alive at last follow-up. There have been no locoregional recurrences. Three patients developed distant metastatic disease. One patient, who had negative conventional staging scans 3 months prior to brachytherapy, was found to have distant metastatic disease only 2 months after salvage brachytherapy and died due to metastatic prostate cancer 9 months after HDR-BT. The other 2 patients developed distant metastases at 14 and 27 months after brachytherapy. One patient developed late grade 3 urinary incontinence requiring artificial urinary sphincter (AUS) placement 18 months after brachytherapy. This patient had the largest tumor size, 3.6 cm in longest dimension, and received pelvic EBRT in addition to HDR-BT. He is now more than 10 years out from HDR-BT with undetectable PSA and doing well with his AUS. There were no other grade 2 or higher genitourinary or gastrointestinal toxicities. <h3>Conclusions</h3> This study demonstrates the long-term safety and efficacy of salvage HDR brachytherapy in the setting of clinically apparent local recurrence of prostate cancer after radical prostatectomy, with durable locoregional control and acceptable rates of toxicity. HDR-BT should be further explored as an option for dose-escalated salvage radiotherapy in patients with gross local recurrences after radical prostatectomy.