Concordance of preoperative prostate endorectal MRI with subsequent prostatectomy specimen in high-risk prostate cancer patients

ObjectiveEndorectal MRI (ER-MRI) may identify areas suspicious for prostate cancer. We evaluated the accuracy of ER-MRI compared with subsequent pathology specimen from prostatectomy.Materials and methodsWe reviewed 309 open radical retropubic prostatectomy cases (RRP) from 2003 to 2008 to identify 94 men with a preoperative ER-MRI, which was obtained in patients with high-risk factors suspicious for local extension (Gleason grade ≥ 4+3, PSA ≥ 10 ng/ml, abnormal rectal exam, or extensive biopsy core involvement). Findings of extracapsular extension (ECE), seminal vesicle invasion (SVI), and lymphadenopathy (LAD) on ER-MRI were compared with subsequent findings on pathology specimens.ResultsNinety-four men underwent preoperative ER-MRI. No tumor was seen on ER-MRI in 9 men (10%). Of 94 ER-MRIs, 4% showed SVI, and 12% had ECE. At prostatectomy, lymph nodes were pathologically positive in 10 men, none of which were enlarged on ER-MRI. RRP was aborted in 3 of these 10 patients due to positive nodes confirmed on frozen section. Comparing ER-MRI results to subsequent prostatectomy specimen the results for accuracy, positive predictive value, negative predictive value, sensitivity, specificity were 70%, 27%, 76%, 14%, 88% for ECE and 93%, 75%, 94%, 38%, 99% for SVI. The accuracy of ECE prediction was 86% in abnormal rectal exam vs. 66% in normal exam (P < 0.05).ConclusionsEndorectal MRI in the evaluation of high-risk prostate cancer was moderately accurate for SV involvement but inaccurate for ECE and insensitive for metastatic lymph node involvement. The predictive accuracy of ER-MRI improved in patients with an abnormal rectal exam.     

Prediction of focal extracapsular extension at radical prostatectomy: Relative merit of transrectal ultrasound, endorectal magnetic resonance imaging, prostate specific antigen, prostate specific antigen density, and systematic biopsy

We conducted a study to compare the relative merits of prostate specific antigen (PSA), PSA density (PSAD), transrectal ultrasound (TRUS), endorectal magnetic resonance imaging (MRI), and systematic biopsy in the prediction of focal extracapsular extension (ECE) at radical prostatectomy. A retrospective review of patients who underwent TRUS, endorectal MRI, and radical prostatectomy at our institution was performed. Patients with a diagnosis of prostate cancer who were thought to be surgical candidates by digital rectal examination and TRUS underwent endorectal MRI prior to radical prostatectomy. Imaging, PSA, PSAD, and systematic biopsy results (tumor grade and fraction of positive systematic biopsies) were correlated with step-sectioned, radical prostatectomy pathologic data. Data was analyzed for the entire prostate and on each individual side. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and likelihood ratios were calculated for each modality, and receiver operating characteristic (ROC) curves were generated. Stepwise logistic regression analysis was used to weigh the relative contributions of preoperative parameters in predicting ECE.

Data was collected from 54 patients who had sextant systematic biopsy, imaging, and radical prostatectomy. A total of 24 sides demonstrated ECE (19 patients, 5 with bilateral ECE). When assessed for the dominant prostate side and on a side-for-side basis, MRI had the highest sensitivity and NPV for detecting focal ECE. MRI also had the highest PPV, and TRUS had the highest specificity for side-for-side analysis. For the dominant prostate side, PSA had the highest specificity and PPV for detecting focal ECE. Of note, significant overlap was demonstrated in the 95% confidence intervals of all modalities with each other for all analyses. ROC analyses found MRI and Gleason sum to be superior for the dominant prostate side assessment and MRI and the fraction of positive systematic biopsies to be superior for a side-for-side analysis. Optimal likelihood ratios for positive test results were seen for PSA (dominant prostate side) and MRI (side-for-side), and for negative test results for MRI. Logistic regression demonstrated MRI and Gleason sum to be powerful predictors of ECE. Thus, we would conclude that endorectal MRI and tumor grade provide unique information in the prediction of focal ECE in select patients.     

Extracapsular extension on multiparametric magnetic resonance imaging better predicts pT3 disease at radical prostatectomy compared to perineural invasion on biopsy

IntroductionRisk assessment for non-organ-confined prostate cancer (PCa) is important in the surgical planning for radical prostatectomy (RP). Perineural invasion (PNI) on prostate biopsy has been associated with adverse pathological outcomes at prostatectomy. Similarly, the identification of suspected extracapsular extension (ECE) on multiparametric magnetic resonance imaging (mpMRI) has been shown to predict non-organ-confined disease. However, no prior study has compared these factors in predicting adverse pathology at prostatectomy. We evaluated mpMRI ECE and prostate biopsy PNI on multivariable analysis to determine their ability to predict pathological stage at time of RP.MethodsWe retrospectively investigated the prostatectomy database at our institution to identify men who underwent prostate biopsy with pre-biopsy mpMRI and subsequent RP from 2013–2017. Multivariable regression analysis was performed to compare the association of mpMRI ECE (mECE) and PNI on prostate biopsy on the likelihood of finding pT3 disease on pathology post-prostatectomy.ResultsOf a total 454 RP between 2013 and 2017, 191 patients met our inclusion criteria. Stage pT2 and pT3+ were found in 120 (62.8%) and 71 (37.2%) patients, respectively. Patients with mECE had 4.84 cumulative odds of worse pathological stage on RP (p=0.045) compared to PNI on biopsy, which showed cumulative odds of 2.25 (p=0.048). When controlling only for those patients without PNI, mECE was still found to be a significant predictor of pT3 disease at RP (p=0.030); however, in patients without mECE, PNI was not significant (p=0.062).ConclusionsWhile mECE and biopsy PNI were both associated with worse pathological stage on RP, mECE had significantly higher cumulative odds compared to PNI. The significant predictive ability of mECE adds further clinical value to the use of mpMRI in PCa management. While validation in a larger cohort is required, these factors have important clinical implications with regards to early diagnosis of advanced disease and surgical planning.     

Validation of an MRI-based prostate cancer prebiopsy Gleason score predictive nomogram

Background:Gleason score grading is a cornerstone of risk stratification and management of patients with prostate cancer (PCa). In this work, we derive and validate a nomogram that uses prostate multiparametric magnetic resonance imaging (MP-MRI) and clinical patient characteristics to predict biopsy Gleason scores (bGS).Materials and methods:A predictive nomogram was derived from 143 men who underwent MP-MRI prior to any prostate biopsy and then validated on an independent cohort of 235 men from a different institution who underwent MP-MRI for PCa workup. Screen positive lesions were defined as lesions positive on T2W and DWI sequences on MP-MRI. Prostate specific antigen (PSA) density, number of screen positive lesions, and MRI suspicion were associated with PCa Gleason score on biopsy and were used to generate a predictive nomogram. The independent cohort was tested on the nomogram and the most likely bGS was noted.Results:The mean PSA in the validation cohort was 9.25ng/mL versus 6.8ng/mL in the original cohort (p = 0.001). The distribution of Gleason scores between the 2 cohorts were not significantly different (p = 0.7). In the original cohort of men, the most probable nomogram generated Gleason score agreed with actual pathologic bGS findings in 61% of the men. In the validation cohort, the most likely nomogram predicted bGS agreed with actual pathologic bGS 51% of the time. The nomogram correctly identified any PCa versus non-PCa 63% of the time and clinically significant (Gleason score ≥ 7) PCa 69% of the time. The negative predictive value for clinically significant PCa using this prebiopsy nomogram was 74% in the validation group.Conclusions:A preintervention nomogram based on PSA and MRI findings can help narrow down the likely pathologic finding on biopsy. Validation of the nomogram demonstrated a significant ability to correctly identify the most likely bGS. This feasibility study demonstrates the potential of a prebiopsy prediction of bGS and based on the high negative predictive value, identification of men who may not need biopsies, which could impact future risk stratification for PCa.     

External Validation of a Multiparametric Magnetic Resonance Imaging–based Nomogram for the Prediction of Extracapsular Extension and Seminal Vesicle Invasion in Prostate Cancer Patients Undergoing Radical Prostatectomy

The nomogram reported by Gandaglia et al (The key combined value of multiparametric magnetic resonance imaging, and magnetic resonance imaging-targeted and concomitant systematic biopsies for the prediction of adverse pathological features in prostate cancer patients undergoing radical prostatectomy. Eur Urol 2020;77:733–41) predicting extracapsular extension (ECE) or seminal vesicle invasion (SVI) has been developed using multiparametric magnetic resonance imaging (MRI) parameters and MRI-targeted biopsy. We aimed to validate this nomogram externally by analyzing 566 patients harboring prostate cancer diagnosed on MRI-targeted biopsy followed by radical prostatectomy. At final pathology, 37% and 12% patients had ECE and SVI, respectively. Performance of the nomogram, in comparison with the Memorial Sloan Kettering Cancer Center (MSKCC) model and Partin tables, was evaluated using discrimination, calibration, and decision curve analysis. Regarding ECE prediction, the nomogram showed higher discrimination (71.8% vs 69.8%, p = 0.3 and 71.8% vs 61.3%, p < 0.001), and similar miscalibration and net benefit for probability threshold above 30% when compared with MSKCC model and Partin tables, respectively. Performance of the nomogram with regard to SVI was comparable in terms of discrimination (68.5% vs 70.4% vs 67.8%, p ≥ 0.6), presenting a slight overestimation on calibration plots and a net benefit for probability threshold above 7.5%. This is the first multicentric study that externally validates a nomogram predicting ECE and SVI in patients diagnosed with MRI-targeted biopsy. Its performance was less optimistic than expected, and implementation of MRI in this setting was not associated with a clear improvement in patient selection and clinical usefulness when compared with available models. We proposed an updated version of the nomogram predicting ECE using the recalibration method, which leads to an improvement in its performance and needs to be validated in another external set.Patient summaryWe validate a prediction tool based on multiparametric magnetic resonance imaging (MRI) parameters and MRI-targeted biopsy predicting extracapsular extension and seminal vesicle invasion at radical prostatectomy. An improvement of patient selection was not clearly demonstrated when compared with available models based on clinical parameters, and implementation of MRI in this setting still needs to be clarified.     

Prediction of extracapsular extension of prostate cancer based on systematic core biopsies

OBJECTIVE: To evaluate the clinical utility of transrectal ultrasound-guided systematic sextant or octant biopsies for the prediction of extracapsular extension (ECE) at radical prostatectomy. MATERIAL AND METHODS: We performed a retrospective analysis of 84 patients who underwent preoperative staging and transrectal ultrasound-guided systematic sextant (n=60) or octant (n=24) biopsy. The presence of ECE was correlated with the number of positive biopsies on each side of the prostate by chi(2) analysis. Sensitivity, specificity and positive and negative predictive values were calculated for both positive (two or three positive biopsies per side) and negative (none or one positive biopsy per side) test results. The number of positive cores was thereafter combined with two other parameters: prostate-specific antigen (PSA) level and Gleason score. RESULTS: ECE was evidenced at radical prostatectomy in 24% of patients (20/84). chi(2) analysis demonstrated a significant correlation between the number of positive biopsies and the presence of ECE. Analysis of the 168 prostate sides and dominant sides revealed that systematic needle biopsies had positive predictive values of 46.7% and 37%, respectively and negative predictive values of 89% and 94%, respectively. Use of a combination of parameters (biopsy Gleason score > or =7 vs <7; PSA >10 vs < or = 10 ng/ml; and >1 positive core vs none or one positive cores) identified patients at high or low risk of ECE. At the extremes, none of the 10 patients in the low-risk group had ECE at radical prostatectomy, compared to 77% of those in the high-risk group. CONCLUSION: The probability of ECE at radical prostatectomy can be accurately predicted based on the number of positive sextant and octant biopsies, either alone or in combination with other parameters.     

Multiparametric MRI with in-bore targeted biopsy in the diagnostic pathway of prostate cancer: Data from a single institution experience

BackgroundAccuracy of multiparametric MRI (mpMRI) for the detection of significant prostate cancer (CaP) varies in the literature as only few studies use radical prostatectomy specimens as their gold standard. On another hand, MRI-targeted prostate biopsy is emerging as an alternative to the traditional randomized biopsy, with a higher detection rate of high-grade cancers. However, data on MRI guided in bore biopsy is lacking.Material and methodsWe reviewed every patient that had his mpMRI, MRI guided in bore biopsy and radical prostatectomy performed in our hospital between November 2015 and December 2020. The diagnostic performances of both mpMRI and MRI targeted biopsy in sampling PIRADS index lesions were studied, using radical prostatectomy specimens as the gold standard. Sensitivity, specificity, positive predictive value and negative predictive value of mpMRI for detecting T3 stage, extra-capsular extension, seminal vesicles involvement and lymph node disease were also evaluated.ResultsSixty-two met our inclusion criteria. For PIRADS≥3 lesions, sensitivity and positive predictive value for detecting clinically significant CaP were of 83.5% and 94.7%. A total of 32.2% prostate cancers on targeted biopsy were upgraded on final pathology, with an upgrading to ISUP≥2 in 3.2% and to ISUP≥3 in 14.5%. A total of 20.9% of cancers were downgraded but without any downgrading to ISUP 1. When final pathology is taken as a gold standard, sensitivity of mpMRI was 31.8% for T3 staging prediction, 30.0% for extra-capsular extension, 28.7% for seminal vesicles involvement and 66.7% for lymph node disease prediction. Specificity was 89.3%, 93.1%, 95.3%, and 92.7%, respectively.ConclusionmpMRI has an acceptable accuracy for the prediction of significant CaP and index lesion detection but is unreliable for CaP staging. Comparison between pathology and biopsy results revealed that the in-bore biopsy technique has an upgrading and downgrading rate comparable in the literature to fusion biopsy, but higher than the combined biopsy approach.     

The presence of extracapsular extension is associated with an increased risk of death from prostate cancer after radical prostatectomy for patients with seminal vesicle invasion and negative lymph nodes

ObjectivesDetermining clinicopathologic features that stratify the risk of disease progression in patients with seminal vesicle invasion at radical prostatectomy remains critical for patient counseling, clinical trial enrollment, and the judicious application of secondary therapies. Then, we evaluated the prognostic significance of concomitant extracapsular extension (ECE) in patients with seminal vesicle invasion and negative lymph nodes at radical prostatectomy.MethodsWe identified 1,132 patients who underwent prostatectomy between 1987 and 2009 and were found to have pT3bN0 disease. Median postoperative follow-up was 10.6 years (interquartile range, 5.9–15.3). Survival was estimated using the Kaplan-Meier method and compared for patients with and without ECE with the log-rank test. The association of ECE with outcome was evaluated using Cox proportional hazards regression models.ResultsA total of 693 (61%) patients were noted to have ECE. Compared with pT3bN0 patients without ECE, patients with pT3bN0 tumors and ECE had a significantly worse 15-year biochemical recurrence-free survival (29% vs. 39%; P<0.001), systemic progression-free survival (71% vs. 81%; P<0.001), cancer-specific survival (80% vs. 89%; P<0.001), and overall survival (50% vs. 63%; P<0.001). On multivariate analysis, the presence of ECE was associated with significantly increased risks of systemic progression (hazard ratio [HR], 1.56; P=0.006), death from prostate cancer (HR, 1.71; P=0.01), and all-cause mortality (HR, 1.35; P=0.007). Meanwhile, adjuvant hormonal therapy, which was received by 334 patients (29.5%), was associated with significantly decreased risks of systemic progression (HR, 0.50; P=0.0004) and cancer death (HR, 0.57; P=0.03), but not all-cause mortality (HR, 0.81; P=0.09). Limitations included retrospective design and nonstandardized application of secondary treatments.ConclusionsThe presence of ECE in patients with pT3bN0 prostate cancer is associated with increased risks of systemic progression and cancer death. Pending validation, ECE may be incorporated into risk stratification or staging classification or both. Meanwhile, these patients continue to represent ideal candidates for adjuvant therapy trials.     

Sex hormone-binding globulin is a significant predictor of extracapsular extension in men undergoing radical prostatectomy

Study Type – Therapy (case series)
Level of Evidence 4 What’s known on the subject? and What does the study add? Previous reports showed controversial evidence supporting the role of sex steroids, mainly testosterone, in the etiology and pathogenesis of prostate cancer (PCa). The bioavailability of sex steroids is significantly regulated by sex hormone–binding globulin (SHBG). In this context, SHBG levels have been shown to be significantly higher in PCa patients than in controls. Likewise, SHBG was reported to serve as an independent predictor for extra‐prostatic extension of tumour [defined as cancer (≥pT3) with capsular penetration, seminal vesicle involvement, or lymph node invasion (LNI)] in patients with clinically localized PCa. The presence of non–organ‐confined disease is significantly associated with higher biochemical recurrence rates. This study provides novel evidence that SHBG might serve as a significant multivariate predictor of extra capsular extension (ECE) in PCa patients submitted to radical prostatectomy, after accounting for preoperative clinically available variables such as patient’s age, total PSA, clinical stage, biopsy Gleason sum, and BMI. Moreover, a clinical cut‐off for circulating SHBG allows using this easily quantifiable molecule as a novel clinical parameter in PCa patients.

OBJECTIVE

? To examine the association between sex hormone‐binding globulin (SHBG) and extracapsular extension (ECE) in men treated with retropubic radical prostatectomy (RRP).

PATIENTS AND METHODS

? Preoperative serum SHBG levels were measured in a cohort of 629 consecutive European Caucasian men [mean (range) age of 64 (41–78) years] who underwent RRP. ? No patient received any hormonal neoadjuvant treatment. SHBG levels were measured the day before RRP (08:00–10:00 hours) in all cases at the same laboratory. ? Logistic regression models tested the association between predictors [including age, prostate‐specific antigen (PSA) level, clinical stage, biopsy Gleason sum, body mass index (BMI), and SHBG] and ECE. ? Combined accuracy of predictors was tested in regression‐based models predicting ECE at RRP. SHBG was included in the model both as a continuous and categorized variable (according to the most informative threshold level of 30 nmol/L).

RESULTS

? In all, 92 patients (14.6%) had ECE. The mean (standard deviation; median) serum SHBG levels were significantly higher in men with ECE compared with those with no ECE at 41.1 (14.7; 37.5) vs 36.4 (16.7; 34) nmol/L (P= 0.007; 95% confidence interval ?8.00, ?1.29). ? Univariate analyses indicated that continuously coded SHBG was significantly [odds ratio (OR) 1.01; P= 0.03] associated with ECE, with a predictive accuracy of 60.1%. ? At multivariate analyses, both continuous (OR 1.01; P= 0.03) and categorical SHBG (OR 3.22; P < 0.001) were significantly associated with ECE, after accounting for age, PSA level, clinical stage, biopsy Gleason sum, and BMI. ? Addition of continuously coded SHBG slightly increased the predictive accuracy of the base model based on clinically established predictors from 63.3% to 65.5% (2.0% gain; P= 0.48). ? In contrast, a model based on categorized‐SHBG showed bootstrap‐corrected predictive accuracy of 68.4% (5.1% gain; P= 0.044).

CONCLUSION

? This study shows that SHBG might serve as a significant multivariate predictor of ECE in men with prostate cancer that undergo RRP.     

Cancer-specific outcomes for prostate cancer patients who had prebiopsy prostate MRI

PurposeWe characterized population-level cancer-specific outcomes for prostate cancer patients based on use of prebiopsy prostate MRI.MethodsUsing SEER-Medicare claims, we identified men diagnosed with localized prostate cancer from 2010–2015 and prostate-specific antigen (PSA) < 20 ng/mL. Primary exposure was prebiopsy prostate MRI prior to diagnosis (i.e., CPT 72197 linked to urology-specific diagnosis). Outcomes included diagnosis of Grade Group 2+ disease on biopsy and proportion treated with prostatectomy. We assessed those treated with prostatectomy and evaluated association with prebiopsy MRI and grade concordance between biopsy and prostatectomy. We estimated adjusted odds ratios with multivariable regression after accounting for other factors (e.g., age, year, PSA, race/ethnicity).ResultsWe identified 48,574 patients, where 915 (1.9%) underwent prebiopsy MRI. Patients with prebiopsy MRI had more GG>2 cancer on biopsy (70.0% MRI vs. 62.8% no MRI) but lost significance after adjustment (OR 1.12, 95% CI 0.96–1.30). Patients with prebiopsy MRI were more likely to have prostatectomy (39.2% vs. 28.5%, adjusted OR 1.51, 95%CI 1.31–1.76). Downgrading from biopsy GG 3–5 to final GG 1–2 was less common after prebiopsy MRI (21.3% vs. 28.2% no MRI, P = 0.05) but not significant after adjustment (OR 0.74, 95% CI 0.51 – 1.08). Among 14,027 men with prostatectomy, accurate risk classification was not more likely with a prebiopsy MRI (48.0% no MRI vs. 49.6% prebiopsy MRI, P = 0.56).ConclusionDuring initial adoption, men with prebiopsy prostate MRI had marginally increased detection of significant cancer on biopsy and were more likely to be treated with prostatectomy. For those treated with prostatectomy, use of prebiopsy MRI was not associated with a greater likelihood of accurate risk classification or grade concordance between biopsy and final pathology results.     

Evaluación de la invasión extracapsular y otros parámetros de estadificación mediante resonancia nuclear magnética multiparamétrica en pacientes con cáncer de próstata candidatos a prostatectomía radical

Introductionthe proper evaluation of the extracapsular extension (ECE), the invasion of seminal vesicles and regional lymph nodes are necessary to plan the treatment of localized prostate cancer. A model that assesses the risk of ECE in the specimen considering the clinical, histological and imaging findings is defined.Material and methodsprospective study in 85 patients with prostate cancer treated with radical prostatectomy. Prostate biopsy was performed 4 weeks before multiparametric study (mpMRI). mpMRI included T2-weighted endorectal magnetic resonance imaging (T2W-MRI), diffusion-weighted magnetic resonance imaging (DW-MRI) and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). The apparent diffusion coefficient (ADC) was also measured. A study of consistency (k) was assessed comparing receiver operating characteristic (ROC) curve and area under the curve (AUC), which were obtained in each case (Z). Finally, a regression model was performed to predict ECE.Resultsthe mean age was 63.7 ± 6.9 years and the mean value of PSA 12.6 ± 13.8. In 31.7% of cases, digital rectal examination was suspicious for malignancy. Prostatectomy specimen showed pT2a in 12 cases (14%), pT2b in 3 (3%), pT2c in 37 (43%), pT3a in 19(22%) and pT3b 14 cases (17%). ECE was evidenced in 33 (39%) of the specimens, seminal vesicle invasion in 14 (16.5%) and pelvic node involvement in 5 patients (6%). The consistency in the evaluation of ECE (image and pathological studies) was .35 for MRI (sensitivity .33, specificity .96) and .62 for mpMRI (sensitivity .58, specificity .98). Mean value of ADC was .76 ± .2 in patients with ECE. This value was not associated with Gleason score (P = .2) or with PSA value (P = .6). AUC value as predictor of ECE was of 65% for MRI, 78% for mpMRI and 50% ADC (Z = .008). Univariate analysis demonstrated that ECE probability increases with each Gleason score point, whilst this probability increases 1.06 times with each PSA point, and decreases .3 times with each point of ADC. Multivariate analysis confirmed that ADC value is a slight protective factor against ECE (OR = .01; CI 95% .002-.14). The consistency in the evaluation of seminal vesicles was .43 for MRI and .67 for mpMRI. AUC was 69% and 82% respectively (Z = .02). The consistency in the evaluation of positive lymph nodes was .4 for MRI and .7 for mpMRI. AUC was 68% and 88% respectively (Z = .36).Conclusionsmultiparametric study allows to carry out a more proper preoperative evaluation of ECE than convectional MRI. The most reliable predictors of ECE are DW-MRI combined with DCE-MRI, ADC coefficient and Gleason score. The superiority of mpMRI is also demonstrated for detection of seminal vesicles invasion, but not for the evaluation of lymph nodes invasion.     

Unilateral lesion detected on preoperative multiparametric magnetic resonance imaging and MRI/US fusion-guided prostate biopsy is not an appropriate indication for focal therapy in prostate cancer

PurposeThis study aimed to investigate if preoperative assessments of multiparametric magnetic resonance imaging (mpMRI) and Magnetic resonance imaging /ultrasound (MRI/US) fusion-guided prostate biopsy could be used to guide focal therapy for prostate cancer.Materials and MethodsA total of 101 prostate cancer patients undergoing radical prostatectomy were included. Preoperative findings included mpMRI and MRI/US fusion-guided prostate biopsy, while postoperative whole mount pathology was based on surgical specimen.ResultsOf the 101 patients preoperatively diagnosed with a unilateral tumor, postoperative whole mount pathology showed 73.27% were bilateral tumors, and 71.62% of bilateral lesions were clinically significant. Comparison between preoperative and postoperative findings, the correct rate of preoperative mpMRI on the lesion side (left or right) was only 20.79%. As for the Gleason score, the correct rate of preoperative MRI/US fusion-guided prostate pathology was 67.33%. Judging from postoperative whole mount pathology, 47.52% of patients had a unilateral clinically significant tumor, which is an indication for focal therapy.ConclusionPreoperative examinations of mpMRI and MRI/US fusion-guided prostate biopsy cannot be used to guide focal therapy for prostate cancer.     

Prognostic significance of positive surgical margins after radical prostatectomy among pT2 and pT3a prostate cancer

ObjectiveTo investigate the prognostic significance of positive surgical margins (PSM)s among patients who underwent radical prostatectomy (RP) for pT2 and pT3a prostate cancer.Patients and methodsWe reviewed the records of 658 patients who were revealed to have pT2 and pT3a prostate cancer after undergoing RP without neoadjuvant or adjuvant treatment. For our analysis, patients were subgrouped as the following: group 1: 406 (61.7%) with negative surgical margins (NSM)s and no extracapsular extension of tumor (ECE); group 2: 99 (15.0%) with PSMs and no ECE; group 3: 63 (9.6%) with NSMs and ECE; and group 4: 90 (13.7%) with PSMs and ECE. The effects of various variables on biochemical recurrence (BCR)-free survival were assessed via uni- and multivariate analyses.ResultsDuring median follow-up of 36 months, group 1 had significantly higher BCR-free survival compared with the other 3 groups (P < 0.001). However, no significant differences in BCR-free survivals were observed among the group 2, 3, and 4 (all P > 0.05). In multivariate analysis, PSM (P = 0.009) was observed to be significantly associated with BCR-free survival among groups 1 and 2 combined. Among groups 3 and 4, pathologic Gleason score (P = 0.002), but not PSM (P = 0.668), was the only significant predictor for BCR-free survival in multivariate analysis.ConclusionsAccording to our results, PSM is significantly associated with biochemical outcome after RP in pT2 prostate cancer. Meanwhile, patients with pT2 tumor and PSM appear to have comparable biochemical outcome compared with those with stage pT3a tumor independent of their marginal status.     

Medium Term Outcomes of Focal Cryoablation for Intermediate and High Risk Prostate Cancer: MRI and PSA are Not Predictive of Residual or Recurrent Disease

ObjectiveTo understand oncologic outcomes of focal cryoablation for prostate cancer and efficacy MRI and PSA to predict residual disease and recurrence.MethodsWe retrospectively analyzed patients who underwent focal cryotherapy at a single institution. Inclusion criteria included clinically localized biopsy-proven cancer that was clearly visible on MRI or ultrasound. The primary outcomes were failure-free survival (FFS) defined as no transition to radical, whole-gland or systemic therapy and biochemical recurrence (Phoenix PSA nadir +2 increases), and secondary outcomes included changes in the Gleason grade group (GG) and MRI findings.Results75 patients completed post cryotherapy biopsy with a median follow-up of 1.89 [IQR 1.19-2.77] years. Failure free survival was met by 96.2% of patients at 2 year follow up and of those who did not meet this outcome, 3 had metastasis, 1 had a salvage prostatectomy and 5 underwent radiation. On the treated side of the prostate, 7 (9.5%) of patients had residual ≥GG2 disease compared to 7 (9.5%) patients on the untreated side. Out of the 12 patients who had residual ≥GG2 disease at follow up biopsy (either on treated or untreated side of the prostate), 11 (91.7%) had PI-RADS 1-3 on follow up MRI. Using a multivariate cox proportional hazards model, Phoenix criteria for recurrence (PSA nadir +2) was not predictive for FFS.ConclusionsFocal cryotherapy is effective for treating focal lesions of prostate cancer, but patients require continued surveillance. MRI and PSA are not reflective of residual disease on follow up biopsy.     

多参数磁共振成像联合四基因模型提高前列腺癌早期诊断效能的临床研究

目的探究多参数磁共振成像（MP-MRI）联合外周血四基因模型（ITGB5,ERG,TIMP1,TMEM176B）对前列腺癌（PCa）成像的早期诊断效能。 方法建立外周血四基因PCa诊断模型,对363例疑似PCa患者进行MP-MRI检查和外周血四基因检测（结果只判定阳性或阴性）,以前列腺穿刺活检或术后病理结果为金标准,计算MP-MRI、四基因模型、MP-MRI联合四基因模型诊断PCa的灵敏度、特异度、阳性预测值和阴性预测值。 结果四基因模型单独诊断PCa具有较高的灵敏度（99.0%）和阴性预测值（97.9%）。相比MP-MRI或四基因模型单独诊断PCa的效能,MP-MRI联合四基因模型能显著提高诊断PCa的特异度（86.4%）和阳性预测值（87.5%）。 结论四基因模型及MP-MRI联合四基因模型是诊断PCa的比较理想的方法,对PCa的早期诊断显示出良好的临床应用前景。     

The Key Combined Value of Multiparametric Magnetic Resonance Imaging,and Magnetic Resonance Imaging–targeted and Concomitant Systematic Biopsies for the Prediction of Adverse Pathological Features in Prostate Cancer Patients Undergoing Radical Prostatectomy

BackgroundThe combined role of multiparametric magnetic resonance imaging (mp-MRI), and magnetic resonance imaging (MRI)-targeted and concomitant systematic biopsies in the identification of prostate cancer (PCa) patients at a higher risk of adverse pathology at radical prostatectomy (RP) is still unclear.ObjectiveTo develop novel models to predict extracapsular extension (ECE), seminal vesicle invasion (SVI), or upgrading in patients diagnosed with MRI-targeted and concomitant systematic biopsies.Design, setting, and participantsWe included 614 men with clinical stage ≤ T2 at digital rectal examination who underwent MRI-targeted biopsy with concomitant systematic biopsy.Outcome measurements and statistical analysesLogistic regression analyses predicting ECE, SVI, and upgrading (ie, a shift from biopsy International Society of Urological Pathology grade group to any higher grade at RP) based on clinical variables with or without mp-MRI features and systematic biopsy information (the percentage of cores with grade group ≥2 PCa) were developed and internally validated. The area under the curve (AUC) was used to identify the models with the highest discrimination. Decision-curve analyses (DCAs) determined the net benefit associated with their use.Results and limitationsOverall, 333 (54%), 88 (14%), and 169 (27%) patients had ECE, SVI, and upgrading at RP, respectively. The inclusion of mp-MRI data improved the discrimination of clinical models for ECE (67% vs 70%) and SVI (74% vs 76%). Models including mp-MRI, and MRI-targeted and concomitant systematic biopsy information achieved the highest AUC at internal validation for ECE (73%), SVI (81%), and upgrading (73%) and represented the basis for three risk calculators that yield the highest net benefit at DCA.ConclusionsNot only mp-MRI and MRI-targeted sampling, but also concomitant systematic biopsies provide significant information to identify patients at a higher risk of adverse pathology. Although omitting systematic prostate sampling at the time of MRI-targeted biopsy might be associated with a reduced risk of detecting insignificant PCa and lower patient discomfort, it reduces the ability to accurately predict pathological features.Patient summaryThe combination of multiparametric magnetic resonance imaging (mp-MRI) with accurate biopsy information on MRI-targeted and systematic biopsies improves the accuracy of multivariable models based on clinical and mp-MRI data alone. Correct mp-MRI interpretation and proper extensive prostate sampling are both needed to predict adverse pathology accurately at radical prostatectomy.     

How does a prebiopsy mri approach for prostate cancer diagnosis affect prostatectomy upgrade rates?

BackgroundTo compare the pathologic upgrade and downgrade rates after radical prostatectomy (RP) between patients diagnosed by prebiopsy prostate MRI followed by a combination of systematic and fusion biopsy (ComBx) versus patients undergoing systematic biopsy only (SBx).MethodsA retrospective review of men undergoing RP at our institution between Jan 2014 and Mar 2020 was performed. These patients were separated into two independent cohorts based on two approaches: Patients receiving prebiopsy prostate MRI during initial evaluation and those who did not receive MRI. Patients with positive MRI findings underwent subsequent ComBx to confirm diagnosis while those without MRI underwent standard trans-rectal ultrasound (TRUS) guided systematic 12-core biopsy (SBx). Primary outcomes were rates of pathological upgrade (prostatectomy grade higher than grade determined at time of biopsy) and downgrade (prostatectomy grade lower than biopsy grade).ResultsA total of 213 patients undergoing radical prostatectomy, 91 diagnosed via a prebiopsy MRI and ComBx approach and 122 diagnosed by a traditional SBx approach, were included in the study. There was no significant difference between age, PSA, or positive family history between the two cohorts. Of the 91 patients who received prebiopsy MRI, 88 patients were determined to have a PIRADS 4 or 5 lesion. Patients who received MRI and subsequent ComBx had a lower rate of any pathological upgrade after RP (9.89% vs. 22.13%, P = 0.018) without a significant difference in pathologic downgrade rate (28.57% vs. 18.85%, P = 0.095). On multivariable logistic regression, receiving prebiopsy MRI during initial evaluation was the single negative independent predictor of pathologic upgrade (OR = 0.23, P = 0.017). A prebiopsy MRI approach was also the single predictor of pathologic downgrade (OR = 3.13, P = 0.041).ConclusionsPatients receiving prebiopsy MRI during prostate cancer evaluation were less likely to have their PCa upgraded. Furthermore, although diagnosis via MRI and subsequent ComBx was associated with an increased rate of downgrades after RP, relatively few resulted in a downgrade from clinically significant to clinically insignificant cancer.     

Correlation of endorectal coil magnetic resonance imaging of the prostate with pathologic stage

The aim was to evaluate the pretreatment efficacy of endorectal coil (ERC) MRI in accurately predicting extracapsular extension in a group of intermediate risk patients. A total of 40 intermediate risk patients were identified who underwent pretreatment ERC MRI and subsequent radical prostatectomy (RP). Imaging studies and pathologic analysis were compared with respect to presence of extracapsular extension (ECE), involvement of seminal vesicles, and appearance of regional nodes. Mean age was 62 years, PSA 14.8, and most common stage was cT2a/pT2c and Gleason 6. ERC MRI has a positive predictive value of 81%, specificity 89%, and odds ratio 6.47 in determining extracapsular extension. Conversely, its sensitivity is only 43%, with a negative predictive value of 59%. ERC MRI may be useful as an adjunctive study for intermediate risk patients due to its high specificity and positive predictive value, thereby adding information to the clinical decision-making process.     

Important preoperative prognostic factors for extracapsular extension,seminal vesicle invasion and lymph node involvement in cases with radical retropubic prostatectomy

Introduction: Initial diagnostic evaluation may provide information about the extent of disease after radical retropubic prostatectomy (RRP). The aim of this study was to investigate the predictive value of preoperative serum prostate specific antigen (PSA) level, local disease extension identified by transrectal ultrasound (TRUS), total number of positive biopsies and percentage of positive cores for cancer, as well as TRUS Biopsy Gleason score in determining the extent of disease in radical retropubic prostatectomy specimens. Materials and methods: A retrospective analysis was performed on 171 patients who underwent RRP from March 1993 to February 2003 for organ confined prostate cancer and whose follow-up data was accessible. The correlation of preoperative serum PSA level, local disease extension in TRUS, the total number of positive sextant biopsies and the percent of cores positive for cancer and Gleason score at TRUS biopsy specimen with the extent of disease at final pathology (Extra-capsular extension (ECE), seminal vesicle invasion (SVI), lymph node involvement (LNI) and surgical margin (SM) status on RRP specimens) were analyzed. Results: The median age of the patients was 65 years. The mean preoperative serum PSA level of all patients was 11.6 ± 1.2 (median 8.6) ng/ml. Histopathological evaluation of RRP specimens revealed 60 (35%) patients with ECE, 38 (22.2%) with SVI, 7 (0.04%) with LNI, and 58 (33.9%) had positive SM. Comparing the preoperative TRUS findings and postoperative evaluation of RRP specimens, the sensitivity of TRUS in predicting the ECE was 11.8% and specificity was 96%. Sensitivity of TRUS in predicting SVI was 9.8% and its specificity was 99%. With univariate analysis (sample t-test), Gleason score, percent of cores positive for cancer, and DRE were found to be predictive factors for extra-prostatic disease in RRP specimens. But with multivariate analysis (logistic regression test) Gleason score appears to be the most important and independent predictive factor for extra-prostatic disease in RRP specimens. Serum PSA levels and percentages of cores positive for cancer were also significant predictors of non organ-confined disease found at final pathology. Conclusion: Gleason score is the most important and independent predictive factor for extra-prostatic disease. Serum PSA levels and percentages of cores positive for cancer are the other important but non-independent predictive factors.     

Validation of the current eligibility criteria for focal therapy in men with localized prostate cancer and the role of MRI

Purpose

To validate current eligibility criteria for focal therapy (FT) in prostate cancer men undergoing radical prostatectomy (RP) and to assess the role of magnetic resonance imaging (MRI).

Methods

Retrospective analysis of 217 RP patients (2009–2016) with preoperative MRI (almost all in external institutions) and fulfillment of different FT eligibility criteria: unilateral tumor, clinical tumor stage ≤ cT2a, prostate volume ≤ 60 mL and either biopsy Gleason 3 + 3 or ≤ 3 + 4 and PSA ≤ 10 or ≤ 15 ng/mL. Multivariable logistic regression analyses (MVA) assessed the role of MRI to predict the presence of significant contralateral tumor or extracapsular extension (ECE), including seminal vesicle invasion. To quantify model accuracy, Receiver Operating Characteristics-derived area under the curve (AUC) was used.

Results

Of 217 patients fulfilling widest biopsy criteria and 113 fulfilling additional MRI criteria, 64 (29.7%) and 37 (32.7%) remained eligible for FT according to histopathological results. In MVA, fulfillment of MRI criteria reached independent predictor status for prediction of contralateral tumor but not for ECE. Addition of MRI resulted in AUC gain (57.5–64.6%). Sensitivity, specificity, PPV and NPV for MRI to predict contralateral tumor were: 41.8, 71.6, 70.9 and 42.6%, respectively. Virtually the same results were recorded for Gleason 3 + 3 and/or PSA ≤ 10 ng/mL.

Conclusions

Patient eligibility criteria for FT using biopsy criteria remained insufficient with respect to contralateral tumor disease. Although, MRI improves accuracy, it cannot safely exclude or minimize chance of significant cancer on contralateral prostate side. To date, stricter eligibility criteria are needed to provide more diagnostic reliability.