Introduction: A functional tool to optimize patient selection for magnetic resonance imaging (MRI)-guided prostate biopsy (MRGB) is an unmet clinical need. We sought to develop a prostate cancer risk calculator (PCRC-MRI) that combines MRI and clinical characteristics to aid decision-making for MRGB in North American men. Methods: Two prospective registries containing 2354 consecutive men undergoing MRGB (September 2009 to April 2019) were analyzed. Patients were randomized into five groups, with one group randomly assigned to be the validation cohort against the other four groups as the discovery cohort. The primary outcome was detection of clinically significant prostate cancer (csPCa) defined as Gleason grade group greater than or equal to 2. Variables included age, ethnicity, digital rectal exam (DRE), prior biopsy, prostate-specific antigen (PSA), prostate volume, PSA density, and MRI score. Odds ratios were calculated from multivariate logistic regression comparing two models: one with clinical variables only (clinical) against a second combining clinical variables with MRI data (clinical+MRI). Results: csPCa was present in 942 (40%) of the 2354 men available for study. The positive and negative predictive values for csPCa in the clinical+MRI model were 57% and 89%, respectively. The area under the curve of the clinical+MRI model was superior to the clinical model in discovery (0.843 vs. 0.707, p<0.0001) and validation (0.888 vs. 0.757, p<0.0001) cohorts. Use of PCRC-MRI would have avoided approximately 16 unnecessary biopsies in every 100 men. Of all variables examined, Asian ethnicity was the most protective factor (odds ratio [OR] 0.46 [0.29–0.75]) while MRI score 5 indicated greatest risk (OR15.8 [10.5–23.9]). Conclusions: A risk calculator (PCRC-MRI), based on a large North American cohort, is shown to improve patient selection for MRGB, especially in preventing unnecessary biopsies. This tool is available at https://www.uclahealth.org/urology/prostate-cancer-risk-calculator and may help rationalize biopsy decision-making.

Men diagnosed with low-risk prostate cancer (PC) are increasingly electing active surveillance (AS) as their initial management strategy. While this may reduce the side effects of treatment for prostate cancer, many men on AS eventually convert to active treatment. PC is one of the most heritable cancers, and genetic factors that predispose to aggressive tumors may help distinguish men who are more likely to discontinue AS. To investigate this, we undertook a multi-institutional genome-wide association study (GWAS) of 5,222 PC patients and 1,139 other patients from replication cohorts, all of whom initially elected AS and were followed over time for the potential outcome of conversion from AS to active treatment. In the GWAS we detected 18 variants associated with conversion, 15 of which were not previously associated with PC risk. With a transcriptome-wide association study (TWAS), we found two genes associated with conversion (MAST3, p = 6.9×10-7 and GAB2, p = 2.0×10-6). Moreover, increasing values of a previously validated 269-variant genetic risk score (GRS) for PC was positively associated with conversion (e.g., comparing the highest to the two middle deciles gave a hazard ratio [HR] = 1.13; 95% Confidence Interval [CI]= 0.94-1.36); whereas, decreasing values of a 36-variant GRS for prostate-specific antigen (PSA) levels were positively associated with conversion (e.g., comparing the lowest to the two middle deciles gave a HR = 1.25; 95% CI, 1.04-1.50). These results suggest that germline genetics may help inform and individualize the decision of AS-or the intensity of monitoring on AS-versus treatment for the initial management of patients with low-risk PC.

You have accessJournal of UrologyProstate Cancer: Localized: Active Surveillance I (PD17)1 Sep 2021PD17-02 MRI-GUIDED BIOPSY IN ACTIVE SURVEILLANCE OF PROSTATE CANCER Adam Kinnaird, Nitin Yerram, Luke O'Connor, Wayne Brisbane, Vidit Sharma, Ryan Chuang, Rajiv Jayadevan, Michael Ahdoot, Michael Daneshvar, Alan Priester, Merdin Delfin, Elizabeth Tran, Danielle Barsa, Anthony Sisk, Robert Reiter, Ely Felker, Steve Raman, Lorna Kwan, Peter Choyke, Maria Merino, Bradford Wood, Baris Turkbey, Peter Pinto, and Leonard Marks Adam KinnairdAdam Kinnaird More articles by this author , Nitin YerramNitin Yerram More articles by this author , Luke O'ConnorLuke O'Connor More articles by this author , Wayne BrisbaneWayne Brisbane More articles by this author , Vidit SharmaVidit Sharma More articles by this author , Ryan ChuangRyan Chuang More articles by this author , Rajiv JayadevanRajiv Jayadevan More articles by this author , Michael AhdootMichael Ahdoot More articles by this author , Michael DaneshvarMichael Daneshvar More articles by this author , Alan PriesterAlan Priester More articles by this author , Merdin DelfinMerdin Delfin More articles by this author , Elizabeth TranElizabeth Tran More articles by this author , Danielle BarsaDanielle Barsa More articles by this author , Anthony SiskAnthony Sisk More articles by this author , Robert ReiterRobert Reiter More articles by this author , Ely FelkerEly Felker More articles by this author , Steve RamanSteve Raman More articles by this author , Lorna KwanLorna Kwan More articles by this author , Peter ChoykePeter Choyke More articles by this author , Maria MerinoMaria Merino More articles by this author , Bradford WoodBradford Wood More articles by this author , Baris TurkbeyBaris Turkbey More articles by this author , Peter PintoPeter Pinto More articles by this author , and Leonard MarksLeonard Marks More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001999.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The promise of prostate Active Surveillance (AS) is that cancers likely to metastasize will be recognized and eliminated before cancer-related disease can ensue. The objective was to determine if prostate biopsy guided by magnetic resonance imaging (MRGB) may improve detection of high-grade cancers during AS. METHODS: From two prospective studies, a sub-cohort of 519 men with low-risk prostate cancer was selected for analysis. All men were diagnosed with Gleason Grade Group 1 (GG1) cancer and underwent confirmatory MRBG (targeted and systematic cores), followed by MRGB surveillance, typically every 12 to 24 months. The primary outcome was tumor upgrading ≥GG3. Secondary outcomes were upgrading ≥GG2 and biopsy type (targeted or systematic) identifying the upgrade. Cox proportional hazard regression was used. RESULTS: After a median follow-up of 4.8 years (IQR 3.1-6.5) after confirmatory MRGB, the primary outcome occurred in 92 men (18%). Upgrading-free probabilities at 2, 5, and 7 years were 0.95, 0.85, and 0.77, respectively. Cancer detected in a targeted core at confirmatory MRBG increased risk of tumor upgrading during AS (HR, 2.7; 95%C.I., 1.2-6.0), while cancer detected by systematic cores did not (Figure 1). In men who upgraded ≥GG3 during AS, upgrading was detected by targeted cores only in 27%, systematic cores only in 25%, and both in 47% (p=0.02). Upgrading ≥GG2 occurred in 164 men (37%). In 63 men undergoing prostatectomy, upgrading from MRGB was found in 5 (8%). CONCLUSIONS: In patients undergoing surveillance with MRI-guided and systematic biopsies, cancer detected in biopsies of MRI-visible lesions, but not systematic samples, indicated risk of subsequent upgrading. Source of Funding: This research was supported in part by R01CA218547, R01CA195505, the Intramural Research Program of the National Cancer Institute, the Center for Interventional Oncology, intramural NIH Grants Z1A CL040015, 1ZIDBC011242, and UL1TR000124 from University of California, Los Angeles Clinical and Translational Science Institute © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e284-e285 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Adam Kinnaird More articles by this author Nitin Yerram More articles by this author Luke O'Connor More articles by this author Wayne Brisbane More articles by this author Vidit Sharma More articles by this author Ryan Chuang More articles by this author Rajiv Jayadevan More articles by this author Michael Ahdoot More articles by this author Michael Daneshvar More articles by this author Alan Priester More articles by this author Merdin Delfin More articles by this author Elizabeth Tran More articles by this author Danielle Barsa More articles by this author Anthony Sisk More articles by this author Robert Reiter More articles by this author Ely Felker More articles by this author Steve Raman More articles by this author Lorna Kwan More articles by this author Peter Choyke More articles by this author Maria Merino More articles by this author Bradford Wood More articles by this author Baris Turkbey More articles by this author Peter Pinto More articles by this author Leonard Marks More articles by this author Expand All Advertisement PDF downloadLoading ...

You have accessJournal of UrologyProstate Cancer: Staging II (PD57)1 Apr 2020PD57-08 TRACKED BIOPSY DATA IMPROVES PREDICTION OF PROSTATE TUMOR SIZE AND STAGE Alan Priester*, Adam Kinnaird, Merdie Delfin, Danielle Barsa, Anthony Sisk, and Leonard Marks Alan Priester*Alan Priester* More articles by this author , Adam KinnairdAdam Kinnaird More articles by this author , Merdie DelfinMerdie Delfin More articles by this author , Danielle BarsaDanielle Barsa More articles by this author , Anthony SiskAnthony Sisk More articles by this author , and Leonard MarksLeonard Marks More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000967.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Pre-operative assessment of prostate cancer (PCa) volume and pathologic stage are critical for risk stratification and disease management. Herein, we report on improved techniques for estimating tumor size and stage through analysis of the spatial distribution of tracked biopsy cores. METHODS: Subjects were 209 consecutive, treatment-naïve patients who received MRI-US fusion biopsy followed by radical prostatectomy and whole mount (WM) slide preparation at UCLA. Final Gleason Group was 1 in 7% of patients, 2 in 59%, 3 in 23%, and 4-5 in 11%. For each case, the minimum (Tm) and maximum (TM) tumor volume was estimated from the coordinates of positive and negative cores recorded by a MRI-US fusion system (Fig 1A). The diameter and volume of Tmand TMwere recorded along with other metrics: number of positive cores, prostate specific antigen (PSA), and maximum cancer core length (MCCL). Logistic regressions were performed to predict maximum tumor diameter and extraprostatic extension (EPE) on WM. Wilcoxon signed rank tests were used to assess statistical significance. RESULTS: Biopsy-defined minimum tumor (Tm) volume was the feature most strongly correlated with WM tumor diameter (Spearman R = 0.40). Tm diameter had a median absolute error of 7 mm, significantly lower than the median MCCL error of 15 mm (p < 0.01). For prediction of tumor diameter, the first logistic regression model (Fig 1B) incorporated PSA, positive core number, Tm/ TM measures, and prostate volume. The model had Spearman R = 0.63 and median absolute error = 4.0 mm. It was more accurate than any individual feature and a control model which excluded features derived from fusion biopsy (p = 0.01). For prediction of EPE (78/209), the second logistic regression model (Fig 1C) included PSA, Gleason Grade, MCCL, and PCa-positive MR target diameter. In the second model, Spearman R = 0.47 and AUC = 0.78, predicting EPE more accurately than any individual feature and the control model (p = 0.01). CONCLUSIONS: Tracked biopsy features (i.e. the spatial coordinates of positive and negative cores), when used alongside other clinical parameters, improved prediction of PCa volume and stage. These metrics, once validated in prospective trials, may improve PCa risk classification and disease management. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1196-e1197 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alan Priester* More articles by this author Adam Kinnaird More articles by this author Merdie Delfin More articles by this author Danielle Barsa More articles by this author Anthony Sisk More articles by this author Leonard Marks More articles by this author Expand All Advertisement PDF downloadLoading ...

PURPOSE:Contemporary biopsy methods were used to determine the success rate of hemigland cryoablation as a primary treatment for prostate cancer. Previous studies, often including men at low risk, have used magnetic resonance imaging guided biopsy to a variable extent. Here, we uniformly used the new diagnostic modality to study all men, each with clinically significant cancer, at baseline and at short and intermediate-term followup. MATERIALS AND METHODS:In an open label trial (NCT03503643) 61 men with unilateral cancer (all clinically significant, ie Grade Group 2 or greater) underwent primary hemigland cryoablation. Subjects were 80% Caucasian, average age 69 years, prostate specific antigen 6.6 ng/ml and prostate volume 38 cc. Biopsy was performed using magnetic resonance imaging/ultrasound fusion prior to treatment and at the followup intervals of near-term (6 months, in 61) and intermediate-term (18 months, in 27). All utilities of fusion biopsy, ie targeting of magnetic resonance imaging visible lesions, template systematic sampling, and in followup, tracking of prior positive sites, were used throughout the study to detect clinically significant cancer, the primary end point. RESULTS:Following treatment 82% of men (50 of 61) had no biopsy detectable clinically significant prostate cancer at 6-month near-term followup and 82% of men (22 of 27) reaching the 18-month intermediate-term remained biopsy negative. Combination of the 3 sampling methods provided maximal cancer detection. During followup a new focus of cancer was found in the contralateral prostate in only 1 of 27 men. No adverse events above Clavien-Dindo grade 2 were encountered. CONCLUSIONS:Hemigland cryoablation, when rigorously evaluated by all utilities of magnetic resonance imaging guided biopsy, appears to eliminate clinically significant cancer in 82% of men, a success rate that endures for at least 18 months.

You have accessJournal of UrologyProstate Cancer: Detection & Screening IV (MP56)1 Apr 2020MP56-09 A RISK CALCULATOR INCORPORATING MRI-GUIDED BIOPSY DATA TO PREDICT CLINICALLY SIGNIFICANT PROSTATE CANCER Adam Kinnaird*, Alan Priester, Ryan Chuang, Danielle Barsa, Merdie Delfin, Anthony Sisk, Ely Felker, Lorna Kwan, and Leonard Marks Adam Kinnaird*Adam Kinnaird* More articles by this author , Alan PriesterAlan Priester More articles by this author , Ryan ChuangRyan Chuang More articles by this author , Danielle BarsaDanielle Barsa More articles by this author , Merdie DelfinMerdie Delfin More articles by this author , Anthony SiskAnthony Sisk More articles by this author , Ely FelkerEly Felker More articles by this author , Lorna KwanLorna Kwan More articles by this author , and Leonard MarksLeonard Marks More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000925.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: MRI guidance provides increased accuracy of prostate biopsy, and use of the PIRADS score helps determine cancer likelihood. However, when used alone the PIRADS score, especially in the mid-ranges, is only moderately predictive of clinically-significant prostate cancer (csPCa). Thus, we aimed to create a predictive index which combines MRI and clinical characteristics, potentially allowing a patient to rationally answer the question, “Do I Need a Biopsy?” METHODS: Subjects were all men undergoing MRI-guided biopsy to rule out csPCa at UCLA (9/09-4/19), excluding only men with previously diagnosed PCa. Mean (SD) age was 64.8 (7.7). 66% were Caucasian. Biopsy strategy combined targeted and systematic sampling (JAMA Surg online 6-12-19). csPCa was defined as Grade Group ≥2. A prediction tool was created from a logistic regression model that included age, race, family history, abnormality on rectal exam, PSA, prostate volume, PSA density, previous negative biopsy, MRI score, and longest diameter of region of interest (ROI) on MRI. Clinical characteristics were chosen a priori based on previous research. ROC curves were generated to display the relative ability of each variable to predict csPCa. RESULTS: Of the 2643 men undergoing biopsy, 1605 were eligible for the study. csPCa was detected in 683 (43%). Odds ratios of clinical and radiological variables included in the creation of the risk calculator are listed in Table 1. The overall AUC of the prediction tool (Figure 1) was superior to AUC of MRI score alone (0.874 vs. 0.792; p<0.0001). Inclusion of the MRI-visible lesion’s longest diameter into the model, regardless of MRI score, improved prediction of csPCa at MRI-guided biopsy. CONCLUSIONS: A risk calculator has been created for prediction of csPCa (AUC = 0.874), based on MRI and clinical data and confirmed by MRI-guided biopsy. The tool can help rationalize biopsy decisions, beyond other inputs currently available. Multi-site prospective testing of the tool is in progress. Source of Funding: R01CA218547, R01CA195505 © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e850-e851 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Adam Kinnaird* More articles by this author Alan Priester More articles by this author Ryan Chuang More articles by this author Danielle Barsa More articles by this author Merdie Delfin More articles by this author Anthony Sisk More articles by this author Ely Felker More articles by this author Lorna Kwan More articles by this author Leonard Marks More articles by this author Expand All Advertisement PDF downloadLoading ...

INTRODUCTION AND OBJECTIVE:Hemi-gland cryoablation (HGCryo) aims to eliminate clinically-significant disease (csCaP) while minimizing adverse after-effects. MRI-guided biopsy (MRGB) has been used t...

You have accessJournal of UrologyProstate Cancer: Epidemiology & Natural History II (MP64)1 Apr 2020MP64-10 MRI-GUIDED BIOPSY TO EVALUATE PROSTATE CANCER SEVERITY IN AFRICAN-AMERICAN MEN Jorge Ballon, Ryan Chuang*, Adam Kinnaird, Rajiv Jayadevan, Steve Zhou, Danielle Barsa, Lorna Kwan, and Leonard Marks Jorge BallonJorge Ballon More articles by this author , Ryan Chuang*Ryan Chuang* More articles by this author , Adam KinnairdAdam Kinnaird More articles by this author , Rajiv JayadevanRajiv Jayadevan More articles by this author , Steve ZhouSteve Zhou More articles by this author , Danielle BarsaDanielle Barsa More articles by this author , Lorna KwanLorna Kwan More articles by this author , and Leonard MarksLeonard Marks More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000939.010AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The mortality rate of prostate cancer has long been considered higher among African-American (AA) men. Most diagnostic information has been obtained by ultrasound-guided prostate biopsy. To study the possibility that MRI-guided biopsy might provide histologic clarification of the apparent disparity, we studied use of the new modality in AA and other men at three time points in prostate cancer care: 1) at diagnosis, 2) during active surveillance, and 3) at final pathology after radical prostatectomy. METHODS: Subjects were 1002 consecutive men who underwent MRI-guided biopsy combining both systematic and lesion-targeted sampling between 2009-2018. Pathologic upgrading was defined as an increase in Gleason Grade group (GG) at structured follow-up biopsy during active surveillance (AS) or at whole-mount sectioning (prostatectomy). Statistical significance (p<0.05) was assessed using the Mann-Whitney-U test for continuous data, the Chi-square test (or Fisher's exact if necessary) for categorical data, and the Kaplan-Meier estimator to calculate progression-free survival probabilities. RESULTS: AA men (N=57) had higher rates of prostate cancer at diagnostic biopsy than other men (N=945) (79% AA vs 66% others; p=0.05). GG was similar in both groups: AA vs Other: GG <2, 25% vs 20%; GG3, 12% vs 10%; GG >4, 9% vs 9% (p=0.76). Upgrading at prostatectomy was found in 3/29 (10%) AA men and 32/262 (12%) other men (p=0.45). Among low-risk men in AS, Gleason upgrading during a median follow up of 4 years was found in 5/16 (31%) AA men and 93/274 (34%) other men (p=0.80). CONCLUSIONS: In our cohort studied with contemporary MRI-guided biopsy, aggressiveness of prostate cancer (judged histologically) was the same for both groups at initial biopsy, at prostatectomy, and during AS. Unlike similar investigations that used only ultrasound-guided biopsy, a method little changed from the 1980s, we found with the improved technology, no significant histologic differences between AA and other men at three important points in prostate cancer care. This suggests that differences previously observe were not based on physiology alone. Furthermore, these data indicate that after MRI-guided biopsy, entry into AS programs for AA men with prostate cancer is appropriate when low-risk pathology is determined using MRI-guided biopsy. Source of Funding: R01CA218547, R01CA195505 © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e966-e967 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jorge Ballon More articles by this author Ryan Chuang* More articles by this author Adam Kinnaird More articles by this author Rajiv Jayadevan More articles by this author Steve Zhou More articles by this author Danielle Barsa More articles by this author Lorna Kwan More articles by this author Leonard Marks More articles by this author Expand All Advertisement PDF downloadLoading ...

Purpose: Magnetic resonance imaging guided biopsy which reveals no cancer may impart reassurance beyond that offered by ultrasound guided biopsy. However, followup of men after a negative magnetic resonance imaging guided biopsy has been mostly by prostate specific antigen testing and reports of followup tissue confirmation are few. We investigated the incidence of clinically significant prostate cancer in such men who, because of persistent cancer suspicion, subsequently underwent a repeat magnetic resonance imaging guided biopsy. Materials and Methods: Subjects were all men with a negative initial magnetic resonance imaging guided biopsy who underwent at least 1 further magnetic resonance imaging guided biopsy due to continued clinical suspicion of clinically significant prostate cancer (September 2009 to July 2019). Biopsies were magnetic resonance imaging-ultrasound fusion with targeted and systematic cores. Regions of interest from initial magnetic resonance imaging and any new regions of interest at followup magnetic resonance imaging guided biopsy were targeted. The primary end point was detection of clinically significant prostate cancer (Gleason Grade Group 2 or greater). Results: Of 2,716 men 733 had a negative initial magnetic resonance imaging guided biopsy. Study subjects were 73/733 who underwent followup magnetic resonance imaging guided biopsy. Median (IQR) age and prostate specific antigen density were 64 years (59-67) and 0.12 ng/ml/cc (0.08-0.17), respectively. Baseline PI-RADS (R) scores were 3 or greater in 74%. At followup magnetic resonance imaging guided biopsy (median 2.4 years, IQR 1.3e3.6), 17/73 (23%) were diagnosed with clinically significant prostate cancer. When followup magnetic resonance imaging revealed a lesion (PI-RADS 3 or greater), clinically significant prostate cancer was found in 17/53 (32%). When followup magnetic resonance imaging was negative (PI-RADS less than 3), cancer was not found (0/ 20) (p <0.01). Overall 54% of men with PI-RADS 5 at followup magnetic resonance imaging guided biopsy were found to have clinically significant prostate cancer. Conclusions: Men with negative magnetic resonance imaging following an initial negative magnetic resonance imaging guided biopsy are unlikely to harbor clinically significant prostate cancer and may avoid repeat biopsy. However, when lesions are seen on followup magnetic resonance imaging, repeat magnetic resonance imaging guided biopsy is warranted.

OBJECTIVE To investigate safety, efficacy, and quality of life impact of hemi-gland cryotherapy for clinically-significant prostate cancer (CaP), when patient selection and follow-up includes MRI-guided biopsy. METHODS Twenty-nine men with unilateral CaP (all clinically significant with prostate volume < 60 cc) were enrolled in a prospective observational trial of hemi-gland cryotherapy. Mean patient age was 68.7 years. Median prostate-specific antigen (PSA) was 6.6 ng/mL. MRI-guided biopsy (3T-MRI, Artemis US fusion) was used for diagnosis and repeated at 6-month follow-up in all men. Treatment was under general anesthesia using the BTG/Galil system. Validated questionnaires were used to determine effects of treatment on urinary and sexual function and quality of life. RESULTS Cryotherapy was completed satisfactorily in all 29 cases in < 60 minutes with no intraoperative complications. Significant decreases in PSA (median decrease 5.6 ng/mL) and PSA density (median decrease 0.14 ng/mL/cc) were observed (P <.01). At 6 months, 23 patients (79%) demonstrated no residual cancer on follow-up MRI-guided biopsy of the treated side. Three patients (10%) revealed micro-residual disease. Three patients (10%) had residual cancer and underwent further treatment. Ipsilateral MRI lesions were present before treatment in 26 patients and after treatment in only 2, reflecting the gross ablative effect; however, MRI showed disappearance of lesions in 4 patients with residual tumor on biopsy. The single complication was 1 case of transient urinary retention; 85% of men who were sexually active continued without change after treatment. Voiding function was unchanged. CONCLUSION Hemi-gland cryoablation for clinically-significant CaP is well-tolerated, and when patients are selected and followed by MRI/US fusion biopsy, cancer control appears promising at 6 months. (C) 2019 Elsevier Inc.

INTRODUCTION AND OBJECTIVES: High-intensity focused ultrasound (HIFU) can be used to ablate prostate cancer (CaP) focally, non-invasively, and with minimal side effects. In this video, we present a method for focal HIFU, employing (1) multiparametric magnetic resonance imaging (mpMRI), (2) fusion biopsy, (3) margin generation, and (4) treatment. METHODS: After mpMRI is performed, prostate regions suspicious for CaP (PIRADSv2) are identified and contoured by an experienced radiologist. Suspicious regions receive targeted biopsy with an MRI-ultrasound fusion system; 10-12 systematic cores are also obtained. Patients are potentially eligible for focal HIFU if they harbor a single focus of organ-confined, clinically significant disease with Gleason Score (GS) ⩽ 4+3 and prostate volume ⩽ 55 CC. To generate a treatment margin, the original MR target is expanded 1 to 2 cm; prior studies informed our use of asymmetrical margins that were largest along the base-apex axis (Priester, J.Urol. 2016). Next, the biopsy coordinates are imported, and the margin is refined by excluding CaP-negative cores with ≥ 1 cm of tissue. Lastly, anatomic regions can be excluded from treatment. The urethra is spared whenever possible, with the risk of side effects weighed against the possibility of positive margins. The plan (Fig 1) is visualized and reviewed using open source software (3D Slicer). All surfaces (prostate, MR target, biopsy cores, margin, and urethra) are then exported to the HIFU device and overlaid on real-time ultrasound. Patients receive follow-up mpMRI and biopsy at 6 months. RESULTS: To date, this method has been used for focal HIFU in 20 patients. Plan generation is semi-automated and takes about 30 minutes. On average, 9.4 CC (29% of prostate tissue) was treated using these margins, with reduced treatment time relative to hemi- or whole-gland HIFU. Of 7 patients with 6-month follow-up biopsy, none had residual pattern 4 disease, but 3 of 7 had small-volume GS = 3+3. CONCLUSIONS: Treatment margins can be created in a patient-specific manner, incorporating data from MRI, fusion biopsy, and prostate anatomy. This approach helps to ensure cancer control while minimizing procedure time and damage to healthy tissue. Figure. No caption available. Source of Funding: This work was funded in part by the Jean Perkins Foundation and by Award Number R01CA158627 from the National Cancer Institute.

You have accessJournal of UrologyProstate Cancer: Localized: Ablative Therapy (MP78)1 Apr 2019MP78-07 DO CONTEMPORARY IMAGING AND BIOPSY TECHNIQUES RELIABLY IDENTIFY UNILATERAL PROSTATE CANCER? IMPLICATIONS FOR HEMIABLATION PATIENT SELECTION David Johnson, Jason Yang*, Lorna Kwan, Danielle Barsa, Sohrab Mirak, Aydin Pooli, Taylor Sadun, Rajiv Jayadevan, Steve Zhou, Alan Priester, Shyam Natarajan, Anthony Sisk, Ely Felker, Steven Raman, Leonard Marks, and Robert Reiter David JohnsonDavid Johnson More articles by this author , Jason Yang*Jason Yang* More articles by this author , Lorna KwanLorna Kwan More articles by this author , Danielle BarsaDanielle Barsa More articles by this author , Sohrab MirakSohrab Mirak More articles by this author , Aydin PooliAydin Pooli More articles by this author , Taylor SadunTaylor Sadun More articles by this author , Rajiv JayadevanRajiv Jayadevan More articles by this author , Steve ZhouSteve Zhou More articles by this author , Alan PriesterAlan Priester More articles by this author , Shyam NatarajanShyam Natarajan More articles by this author , Anthony SiskAnthony Sisk More articles by this author , Ely FelkerEly Felker More articles by this author , Steven RamanSteven Raman More articles by this author , Leonard MarksLeonard Marks More articles by this author , and Robert ReiterRobert Reiter More articles by this author View All Author Informationhttps://doi.org/10.1097/01.JU.0000557339.24703.e5AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVES: Hemiablation is a less morbid treatment alternative for select patients with unilateral prostate cancer. The accuracy of contemporary diagnostic techniques to identify appropriate candidates is currently unknown. The authors quantify the proportion of incorrectly identified hemiablation candidates and identify predictors of discordant laterality. METHODS: Retrospective analysis of patients undergoing multiparametric magnetic resonance imaging (MRI) with MRI-fusion prostate biopsy prior to radical prostatectomy at a single tertiary institution between June 2010-November 2017. The authors identified theoretical hemiablation candidates and a range of inclusion criteria in sensitivity analyses. Primary outcome was the proportion of hemiablation candidates with contralateral clinically significant prostate cancer on whole mount prostatectomy pathology and/or ipsilateral high-risk disease. The authors evaluate pre-operative predictors of undetected contralateral disease using multivariable analysis. RESULTS: Of 665 patients, 92 met primary hemiablation criteria. 44/92 (47.8%) had undetected contralateral Grade Group 2 and above prostate cancer on final pathology. Undetected contralateral disease ranged from 40.8%-47.8% depending on inclusion criteria. On multivariable analysis, men with anterior index tumors were 2.4 times more likely to harbor undetected significant contralateral prostate cancer than men with posterior lesions (p<0.05). Limitations include unknown clinical significance of missed contralateral disease. CONCLUSIONS: A substantial proportion of patients with presumed unilateral prostate cancer, based on contemporary imaging and biopsy techniques, harbor undetected clinically significant contralateral disease. The risk of inadequate treatment due to undetected contralateral disease must be weighed against the functional benefits of hemiablation. Further investigation to improve patient selection for focal therapy is necessary. Source of Funding: Department of Radiology and Pathology Integrated Diagnostics (IDx) program and the specialized program of research excellence (SPORE) in prostate cancer Los Angeles, CA© 2019 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 201Issue Supplement 4April 2019Page: e1144-e1144 Advertisement Copyright & Permissions© 2019 by American Urological Association Education and Research, Inc.MetricsAuthor Information David Johnson More articles by this author Jason Yang* More articles by this author Lorna Kwan More articles by this author Danielle Barsa More articles by this author Sohrab Mirak More articles by this author Aydin Pooli More articles by this author Taylor Sadun More articles by this author Rajiv Jayadevan More articles by this author Steve Zhou More articles by this author Alan Priester More articles by this author Shyam Natarajan More articles by this author Anthony Sisk More articles by this author Ely Felker More articles by this author Steven Raman More articles by this author Leonard Marks More articles by this author Robert Reiter More articles by this author Expand All Advertisement PDF downloadLoading ...

BackgroundHemiablation is a less morbid treatment alternative for appropriately selected patients with unilateral prostate cancer (PCa). However, to the authors’ knowledge, traditional diagnostic techniques inadequately identify appropriate candidates. In the current study, the authors quantified the accuracy for identifying hemiablation candidates using contemporary diagnostic techniques, including multiparametric magnetic resonance imaging (mpMRI) and MRI‐fusion with complete systematic template biopsy.MethodsA retrospective analysis of patients undergoing MRI and MRI‐fusion prostate biopsy, including full systematic template biopsy, prior to radical prostatectomy in a single tertiary academic institution between June 2010 and February 2018 was performed. Hemiablation candidates had unilateral intermediate‐risk PCa (Gleason score [GS] of 3+4 or 4+3, clinical T classification ≤T2, and prostate‐specific antigen level <20 ng/dL) on MRI‐fusion biopsy and 2) no contralateral highly or very highly suspicious Prostate Imaging Reporting and Data System version 2 (PI‐RADSv2) MRI lesions. Hemiablation candidates were inappropriately selected if pathologists identified contralateral GS ≥3+4 or high‐risk ipsilateral PCa on prostatectomy. The authors tested a range of hemiablation inclusion criteria and performed multivariable analysis of preoperative predictors of undetected contralateral disease.ResultsOf 665 patients, 92 met primary hemiablation criteria. Of these 92 patients, 44 (48%) were incorrectly identified due to ipsilateral GS ≥3+4 tumors crossing the midline (21 patients), undetected distinct contralateral GS ≥3+4 tumors (20 patients), and/or ipsilateral high‐risk PCa (3 patients) on prostatectomy. The rate of undetected contralateral disease ranged from 41% to 48% depending on inclusion criteria. On multivariable analysis, men with anterior index tumors were found to be 2.4 times more likely to harbor undetected contralateral GS ≥3+4 PCa compared with men with posterior lesions (P < .05).ConclusionsClinicians and patients must weigh the risk of inadequate oncologic treatment against the functional benefits of hemiablation. Further investigation into methods for improving patient selection for hemiablation is necessary.

Importance:Transrectal, ultrasonography-guided prostate biopsy often fails to disclose the severity of underlying pathologic findings for prostate cancer. Magnetic resonance imaging (MRI)-guided biopsy may improve the characterization of prostate pathologic results, but few studies have examined its use for the decision to enter active surveillance. Objective:To evaluate whether confirmatory biopsy findings by MRI guidance are associated with the risk of pathologic disease upgrading among patients with prostate cancer during active surveillance. Design, Settings, and Participants:This retrospective cohort study used prospectively obtained registry data from 332 men with prostate cancer of Gleason grade group (GG) 2 or lower who were referred for active surveillance at a large academic medical center from January 1, 2009, through December 31, 2017. Exposures:All confirmatory and follow-up biopsies were performed using MRI guidance with an MRI-ultrasonography fusion device. Patients underwent repeated MRI-guided biopsies every 12 to 24 months. At follow-up sessions, in addition to obtaining systematic samples, lesions seen on MRI were targeted and foci of low-grade prostate cancer were obtained again using tracking technology. Active surveillance was terminated with detection of at least GG3 disease or receipt of treatment. Main Outcomes and Measures:The primary outcome was upgrading to at least GG3 disease during active surveillance. Secondary outcomes were the associations of MRI lesion grade, prostate-specific antigen (PSA) level, PSA density, and biopsy method (targeted, systematic, or tracked) with the primary outcome. Results:Of 332 patients (mean [SD] age, 62.8 [7.6] years), 39 (11.7%) upgraded to at least GG3 disease during follow-up. The incidence of upgrading was 7.9% (9 of 114) when the confirmatory biopsy finding was normal, 11.4% (20 of 175) when the finding showed GG1 disease, and 23.3% (10 of 43) when the finding was GG2 disease (P = .03). Men with GG2 disease were almost 8 times more likely to upgrade during surveillance compared with those with normal findings but only among those with low PSA density (hazard ratio [HR], 7.82; 95% CI, 2.29-26.68). A PSA density of at least 0.15 ng/mL/mL was associated with increased risk of upgrading among patients with normal findings (HR, 7.21; 95% CI, 1.98-26.24) or GG1 disease (HR, 2.86; 95% CI, 1.16 to 7.03) on confirmatory biopsy. A total of 46% of pathologic disease upgrades would have been missed if only the targeted biopsy was performed and 65% of disease upgrades were detected only with tracked biopsy. Conclusions and Relevance:The findings suggest that confirmatory biopsy with MRI guidance is significantly associated with future disease upgrading of prostate cancer, especially when combined with PSA density, and should be considered as an appropriate entry point for active surveillance. Systematic and targeted biopsies were additive in detection of clinically significant cancers. Repeated biopsy at sites at which findings were previously abnormal (tracking biopsy) facilitated detection of cancers not suitable for continued active surveillance.

You have accessJournal of UrologyProstate Cancer: Localized: Active Surveillance I (MP48)1 Apr 2019MP48-03 TRACKING, TARGETING, AND DE NOVO TUMOR DEVELOPMENT IN MEN UNDERGOING ACTIVE SURVEILLANCE Rajiv Jayadevan*, Danielle Barsa, Haoyue Zhang, Lorna Kwan, Steve Zhou, Alan Priester, Jorge Ballon, and Leonard Marks Rajiv Jayadevan*Rajiv Jayadevan* More articles by this author , Danielle BarsaDanielle Barsa More articles by this author , Haoyue ZhangHaoyue Zhang More articles by this author , Lorna KwanLorna Kwan More articles by this author , Steve ZhouSteve Zhou More articles by this author , Alan PriesterAlan Priester More articles by this author , Jorge BallonJorge Ballon More articles by this author , and Leonard MarksLeonard Marks More articles by this author View All Author Informationhttps://doi.org/10.1097/01.JU.0000556473.69506.25AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVES: Tracking biopsy is the resampling of previously-documented site(s) of intra-prostatic tumor (CaP). Precise resampling is enabled via electronic storage of specific biopsy sites during MRI-ultrasound fusion biopsy (FB) for future recall. Though tracking can aid in surveillance of specific biopsy sites, it is possible for de novo tumors to develop in other regions of the prostate during active surveillance (AS). We sought to determine the cancer upgrading rate in tracked and non-tracked biopsies, and also to ascertain the frequency of de novo tumor development in a large sample of men undergoing AS. METHODS: Men diagnosed with Gleason Grade Group (GG) 1 CaP between 2009 and 2017 were offered AS. Multiparametric MRI and FB were performed every 12-18 months. All confirmatory biopsies (CB) and follow-up biopsies were performed using a FB system (Artemis). Systematic biopsy was also performed during all biopsy sessions. Sites that were positive for cancer on prior biopsies were resampled via tracking biopsy (Fig 1). Pathologic upgrading was defined as change from GG1 to GG2 or greater. MRIs were reviewed for the development of new regions of interest (ROI). RESULTS: 168 men had GG1 CaP on both diagnostic and CB, underwent at least 1 follow-up biopsy, and had both tracked and non-tracked biopsies during the same biopsy session (mean age 62.1, prostate specific antigen 4.8 ng/mL, median follow-up time 4.1 years). Of this group, 38% (n=63) were found to have pathologic upgrading to at least GG2 disease. 46% (n=29) of upgrading was detected via tracked biopsy only, 41% (n=26) detected via non-tracked biopsy only, and 13% (n=8) detected via both biopsy types. Of men whose upgrades were detected via only non-tracked biopsy, 35% (n=9) were detected via systematic biopsy, 65% (n=15) via targeted FB, and 8% (n=2) via both. 35% (n=9) of these upgrades appear to be de novo tumors, as upgrading foci were either contralateral to sites of known GG1 tumors (n=3), or found within newly detected ROIs seen on subsequent MRI. Median time from start of AS to development of new ROI containing upgrade was 2.1 years. CONCLUSIONS: Tracking biopsy detects a large percentage of pathologic upgrading for men on AS. Serial MRI and systematic biopsy during AS may detect de novo tumors. Both tracked and non-tracked biopsies are additive in the detection of pathologic upgrading and de novo tumors. Source of Funding: Supported in part by R01 grants CA158627, CA218547, and CA195505 Los Angeles, CA© 2019 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 201Issue Supplement 4April 2019Page: e697-e697 Advertisement Copyright & Permissions© 2019 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rajiv Jayadevan* More articles by this author Danielle Barsa More articles by this author Haoyue Zhang More articles by this author Lorna Kwan More articles by this author Steve Zhou More articles by this author Alan Priester More articles by this author Jorge Ballon More articles by this author Leonard Marks More articles by this author Expand All Advertisement PDF downloadLoading ...