Background:Several reports are available regarding the treatment decision regret of patients receiving conventional treatments for localized prostate cancer (PCa); yet data on patients undergoing focal therapy (FT) are sparse. Objective:To evaluate the treatment decision satisfaction and regret among patients who underwent FT for PCa with high-intensity focused ultrasound (HIFU) or cryoablation (CRYO). Design setting and participants:We identified consecutive patients who underwent HIFU or CRYO FT as the primary treatment for localized PCa at three US institutions. A survey with validated questionnaires, including the five-question Decision Regret Scale (DRS), International Prostate Symptom Score (IPSS), and International Index of Erectile Function (IIEF-5), was mailed to the patients. The regret score was calculated based on the five items of the DRS, and regret was defined as a DRS score of >25. Outcome measurements and statistical analysis:Multivariable logistic regression models were applied to assess the predictors of treatment decision regret. Results and limitations:Of 236 patients, 143 (61%) responded to the survey. Baseline characteristics were similar between responders and nonresponders. During a median (interquartile range) follow-up of 43 (26-68) mo, the treatment decision regret rate was 19.6%. On a multivariable analysis, higher prostate-specific antigen (PSA) at nadir after FT (odds ratio [OR] 1.48, 95% confidence interval [CI] 1.1-2, p = 0.009), presence of PCa on follow-up biopsy (OR 3.98, 95% CI 1.5-10.6, p = 0.006), higher post-FT IPSS (OR 1.18, 95% CI 1.01-1.37, p = 0.03), and newly diagnosed impotence (OR 6.67, 95% CI 1.57-27, p = 0.03) were independent predictors of treatment regret. The type of energy treatment (HIFU/CRYO) was not a predictor of regret/satisfaction. Limitations include retrospective abstraction. Conclusions:FT for localized PCa is well accepted by the patients, with a low regret rate. Higher PSA at nadir, presence of cancer on follow-up biopsy, bothersome postoperative urinary symptoms, and impotence after FT were independent predictors of treatment decision regret. Patient summary:In this report, we looked at the factors affecting satisfaction and regret in patients with prostate cancer undergoing focal therapy. We found that focal therapy is well accepted by the patients, while presence of cancer on follow-up biopsy as well as bothersome urinary symptoms and sexual dysfunction can predict treatment decision regret.

INTRODUCTION AND OBJECTIVE: To evaluate oncologic and functional outcomes following High Intensity Focused Ultrasound (HIFU) and Cryoablation (CRYO) focal therapy (FT) for localized prostate cancer (PCa). METHODS: We identified consecutive patients who underwent hemi-gland HIFU (h-HIFU) or hemi-gland CRYO (h-CRYO) FT as primary treatment for D'Amico intermediate risk PCa (IRB# HS-1700749). Patients were selected by 12-core systematic and target biopsy and had unilateral index lesion. Follow up biopsy (FU-PBx) was performed from 6-12M and every 2Y thereafter. Primary endpoint was Treatment Failure (TF) defined as radical (any whole-gland) treatment, systemic therapy, metastases, or PCa-specific mortality. Secondary endpoints were survival-free from i) biochemical failure (BF, PSA nadirþ2 ng/mL); ii) Grade Group (GG) 2 on FU-PBx, iii) repeat FT, iv) radical treatment, and v) systemic therapy. KaplanMeier method was used for survival evaluation. International Prostate Symptom Score (IPSS), International Index of Erectile Function (IIEF5) and continence (zero pad) were also evaluated. Statistically significant if p <0.05. RESULTS: 184 patients met inclusion criteria: 121 (66%) hCRYO and 63 (34%) h-HIFU. The baseline characteristics were comparable among h-HIFU vs h-CRYO, respectively, as follows: median age (65 vs 67 Y, p [0.15), PSA (5.9 vs 6.7 ng/mL, p [ 0.081), PSA density (0.18 vs 0.17 ng/mL, p [ 0.61), number of positive cores (3 vs 3, p[0.14) and maximum PCa core % (50% vs 50%, p[0.59). hCRYO had higher rate of GG3, as follows: GG1 (2% vs 7%), GG2 (79% vs 50%) and GG3 (19% vs 42%); p <0.001. The median follow up was longer for h-CRYO (30 M) vs h-HIFU (24M); p[0.005. PSA nadir was 1.1 ng/mL for h-HIFU vs 0.91 ng/mL for h-CRYO, p[0.53. The 3-year TF-free survival was: 88% for h-HIFU and 95% for h-CRYO, p[0.32. The 3-year free survival was, for h-HIFU vs h-CRYO, respectively: BF (80% vs 70%, p[0.89); GG 2 on FU-PBx (63% vs 90%, p <0.001), repeat FT (93% vs 98%, p[0.40), radical treatment (87% vs 99%, p[0.04) and systemic therapy (100% vs 96%, p[0.23). One patient on h-CRYO developed bone metastases, but no patient died. Median difference from preto post-FT IPSS (0 vs 1.5; p[0.99) and IIEF-5 (0 vs 2; p[0.14) were similar for h-HIFU vs h-CRYO, respectively. Continence was maintained in 100% h-HIFU vs 98% h-CRYO, p[1.00. CONCLUSIONS: Hemi-gland HIFU or CRYO for intermediate risk PCa provide acceptable short-medium term oncologic outcomes with excellent function outcomes. Hemi-gland CRYO provided longer radical treatment-free survival than hemi-gland HIFU.

In this review, we evaluated literature regarding different modalities for multiparametric magnetic resonance imaging (mpMRI) and mpMRI-targeted biopsy (TB) for the detection of prostate cancer (PCa). We identified studies evaluating systematic biopsy (SB) and TB in the same patient, thereby allowing each patient to serve as their own control. Although the evidence supports the accuracy of TB, there is still a proportion of clinically significant PCa (csPCa) that is detected only in SB, indicating the importance of maintaining SB in the diagnostic pathway, albeit with additional cost and morbidity. There is a growing subset of data which supports the role of TB alone, which may allow for increased efficiency and decreased complications. We also compared the literature on transrectal (TR) vs. transperineal (TP) TB. Although further high-level evidence is necessary, current evidence supports similar csPCa detection rate for both approaches. We also evaluated various TB techniques such as cognitive fusion biopsy (COG-TB) and in-bore biopsy (IB-TB). COG-TB has comparable detection rates to software fusion, but is operator-dependent and may have reduced accuracy for smaller lesions. IB-TB may allow for greater precision as lesions are directly targeted; however, this is costly and time-consuming, and does not account for MRI-invisible lesions.

The goal of this study is to review recent findings and evaluate the utility of MRI transrectal ultrasound fusion biopsy (FBx) techniques and discuss future directions. FBx detects significantly higher rates of clinically significant prostate cancer (csPCa) than ultrasound-guided systematic prostate biopsy (SBx), particularly in repeat biopsy settings. FBx has also been shown to detect significantly lower rates of clinically insignificant prostate cancer. In addition, a dedicated prostate MRI can assist in more accurately predicting the Gleason score and provide further information regarding the index cancer location, prostate volume, and clinical stage. The ability to accurately evaluate specific lesions is vital to both focal therapy and active surveillance, for treatment selection, planning, and adequate follow-up. FBx has been demonstrated in multiple high-quality studies to have improved performance in diagnosis of csPCa compared to SBx. The combination of FBx with novel technologies including radiomics, prostate-specific membrane antigen positron emission tomography (PSMA PET), and high-resolution micro-ultrasound may have the potential to further enhance this performance.

Journal of EndourologyVol. 35, No. 9 Point/CounterpointFocal Therapy for Low-Risk Prostate Cancer Opinion: NoDordaneh Sugano, Andre Luis Abreu, Giovanni E. Cacciamani, Inderbir S. Gill, and Amir H. LebastchiDordaneh Suganohttps://orcid.org/0000-0002-5892-6469USC Institute of Urology and Catherine and Joseph Aresty Department of Urology, and University of Southern California, Los Angeles, California, USA.Search for more papers by this author, Andre Luis AbreuUSC Institute of Urology and Catherine and Joseph Aresty Department of Urology, and University of Southern California, Los Angeles, California, USA.Center for Image-Guided and Focal Therapy for Prostate Cancer, University of Southern California, Los Angeles, California, USA.Search for more papers by this author, Giovanni E. CacciamaniUSC Institute of Urology and Catherine and Joseph Aresty Department of Urology, and University of Southern California, Los Angeles, California, USA.Center for Image-Guided and Focal Therapy for Prostate Cancer, University of Southern California, Los Angeles, California, USA.Search for more papers by this author, Inderbir S. GillUSC Institute of Urology and Catherine and Joseph Aresty Department of Urology, and University of Southern California, Los Angeles, California, USA.Center for Image-Guided and Focal Therapy for Prostate Cancer, University of Southern California, Los Angeles, California, USA.Search for more papers by this author, and Amir H. LebastchiAddress correspondence to: Amir H. Lebastchi, MD, USC Institute of Urology and Catherine and Joseph Aresty Department of Urology, University of Southern California, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA 90089, USA E-mail Address: [email protected]USC Institute of Urology and Catherine and Joseph Aresty Department of Urology, and University of Southern California, Los Angeles, California, USA.Center for Image-Guided and Focal Therapy for Prostate Cancer, University of Southern California, Los Angeles, California, USA.Search for more papers by this authorPublished Online:14 Sep 2021https://doi.org/10.1089/end.2021.0226AboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View articleFiguresReferencesRelatedDetailsCited byAblation of Low-Risk Prostate Cancer: Both Sides of the Story Michael A. Daneshvar and Peter A. Pinto14 September 2021 | Journal of Endourology, Vol. 35, No. 9 Volume 35Issue 9Sep 2021 InformationCopyright 2021, Mary Ann Liebert, Inc., publishersTo cite this article:Dordaneh Sugano, Andre Luis Abreu, Giovanni E. Cacciamani, Inderbir S. Gill, and Amir H. Lebastchi.Focal Therapy for Low-Risk Prostate Cancer Opinion: No.Journal of Endourology.Sep 2021.1284-1287.http://doi.org/10.1089/end.2021.0226Published in Volume: 35 Issue 9: September 14, 2021Online Ahead of Editing: April 13, 2021Keywordsprostate cancermagnetic resonance imagingablation techniqueshigh-intensity focused ultrasound ablationcryotherapyPDF download

“My life is in your hands doctora, whatever you think is best.” What a phrase to hear as an urologist in training. It is, on one hand, exciting to accept the responsibility which we have trained so hard to prepare for. On the other hand, that phrase conveys the immense gravity of such responsibility. In this particular case, my patient was a middle-aged man, Spanish-speaking, with a new diagnosis of low-intermediate risk prostate cancer. I was trying to explain to him his diagnosis and his options, including androgen deprivation therapy/radiation and surgery. We talked about risks of incontinence, erectile dysfunction. We talked about short-term vs long-term risks, hospital stays, and catheters. We spoke through a phone interpreter, spending over 30 minutes in discussion. Even with the interpreter, it seemed like the information was not processing. The combination of a new cancer diagnosis and complex shared decision making, all through the filter of a third-party translator, complicated an already difficult conversation. Throughout our interaction, my patient simply kept saying, “it is in your hands.”

Purpose of review To systematically review the current literature to assess the role of radiomics in the detection and evaluation of prostate cancer (PCa). Recent findings Radiomics involves the high-throughput extraction of radiologic features from clinical imaging, using a panel of sophisticated data-characterization algorithms to make an objective and quantitative determination of diagnoses and clinical characteristics. Radiomics evaluation of existing clinical images would increase their clinical value in many cancer management pathways, including PCa. However, a consensus on the implementation of radiomics has not been established across different sites, delaying its implementation in clinical practice. There are many potential advantages to radiomics. The ability to extract features from existing clinical imaging is one such advantage. A second is the empiric nature of the analysis. The third lies in the application of new technologies, such as machine learning, to be able to evaluate large quantities of data to make clinical conclusions. In this systematic review, we identify publications regarding the role of radiomics in PCa detection and evaluation. Many of these studies noted that radiomics, when incorporated into predictive models, had an advantageous impact on detection of PCa, clinically significant PCa, and extracapsular extension. This may assist in individualized decision making not only for diagnosis of PCa, but also for surveillance and surgical planning. With additional validation in large sample sizes, and randomized, multicenter studies using a consensus driven methodology, radiomics has the potential to alter the landscape of PCa detection and management, necessitating further prospective randomized investigation. Summary Radiomics is a promising new field, allowing for high-throughput analysis of imaging features for PCa detection and evaluation. These features can be extracted from existing data; therefore, the potential for future study is immense.

Currently, there is a dearth of data concerning the impact of hypogonadism on prostate cancer detection by imaging. In this study, we evaluated the performance of multiparametric MRI (mpMRI) and mpMRI-TRUS fusion biopsy in hypogonadal patients.

43 Background: Tumor volume measured on postoperative pathology has been shown to be associated with adverse pathologic and oncologic outcomes. Advances in imaging technology may facilitate the prediction of these outcomes prior to surgery. In this study, we evaluated the predictive value of tumor volume of the index lesion (ILTV) calculated from prostate MRI in analyzing adverse pathologic outcomes following radical prostatectomy (RARP). Methods: Clinical and pathologic data from a prospectively maintained, single-institution database was analyzed for patients who underwent 3T MRI prior to RARP (without prior therapy) between 2007 and 2016. ILTV was calculated from T2W MRI by multiplying length by width by depth by 0.52. Adverse pathologic outcomes were determined on whole mount prostatectomy specimens, and defined as positive margins (PM), extracapsular extension (ECE), positive lymph nodes (LNI), and seminal vesicle invasion (SVI). Logistic regression was used to assess associations of clinical, imaging, and histopathological variables with adverse pathologic features. Results: From the 501 patients who underwent RARP, 490 received MRI prior to surgery. The median age of our cohort of was 60 years (IQR 10), and median PSA was 6.21 ng/ml (IQR 6). There were 74/480 patients (15.4%) with PM, 112/474 (23.6%) with ECE, 30/478 (6.4%) with LNI, and 32/482 (6.7%) with SVI. Patients with adverse outcomes had larger ILTV compared to those without (PM: 1.038cc vs 0.807cc, p=0.041; ECE: 1.388cc vs 0.765cc, p<0.001; LNI: 2.970cc vs 0.797cc, p<0.001; SVI: 2.269cc vs 0.798cc, p<0.001). On multivariate analysis, ILTV was found to be an independent predictor of PM (OR: 1.149, p=0.036), ECE (OR: 1.269, p=0.001), LNI (OR: 1.387, p<0.001), and SVI (OR: 1.341, p<0.001). Conclusions: We demonstrate that Index Lesion Tumor Volume measured on T2W MRI is an independent predictor of PM, ECE, LNI, and SVI following RARP, and serves as a preoperative marker that may facilitate and inform patient counseling and decision making.

INTRODUCTION AND OBJECTIVE:Focal therapy (FT) for localized prostate cancer (CaP) has been shown to have encouraging short-term oncological outcomes, excellent preservation of functional outcomes and is increasing in popularity in urologic community. We aim to evaluate the preferences and practice trends among urologists regarding this treatment strategy. METHODS:A 20 item online questionnaire was designed to collect information on urologists' views and use of FT. The survey was sent to the members of the Endourological Society and the American Urological Association. Multivariate logistic regression analysis was done to determine predictors for utilization of FT. RESULTS:A total of 425 responses were received [American Urological Association: 319, Endourological Society: 106]. Mean age of respondents was 53(SD: 11.3) years. Although half of the respondents (50.8%) believed FT to be moderate to extremely beneficial in the treatment of CaP, only 24.2% (103) of the respondents currently utilize FT in their practice. Respondents who were fellowship trained in urologic oncology were more likely to consider FT to be at least moderately beneficial (P < 0.001). Surgeon's experience (greater than 15 years in urology practice) (P = 0.025) and seeing more than 10 patients with new CaP diagnosis per month (P = 0.002) were independent predictors of FT utilization for localized CaP. While the most common setting for utilization of FT was in patients with unilateral intermediate-risk (72.8%) CaP, a small percentage of respondents also used FT for patients with unilateral high-risk CaP and bilateral intermediate risk (21.4% and 10.7%, respectively). Most common reasons for not using FT were the lack of belief in 'index lesion theory' (63.2%), lack of experience (41.3%), lack of belief in FT's efficacy (41.1%), lack of infrastructure (35.8%), difficult salvage treatment in cases of recurrence (22.7%) and high cost (21.8%). About 57.6% would use FT more often in an office or outpatient setting if they had access to reliable and cost-effective options. CONCLUSIONS:Only a quarter of our respondents utilize FT in their practice with surgeon's experience being the important independent predictor for using FT. Majority of respondents though consider FT to be beneficial in CaP management, would use it more often if provided more reliable and cost-effective options. Over time, experience and accessibility to reliable methods to perform FT may lead to further utilization of this novel treatment strategy.

BackgroundProstate Imaging‐Reporting and Data System v. 2 (PI‐RADSv2) provides standardized nomenclature for interpretation of prostate multiparametric MRI (mpMRI). Inclusion of additional features for categorization may provide benefit to stratification of disease.PurposeTo prospectively compare PI‐RADSv2 to a qualitative in‐house system for detecting prostate cancer on mpMRI.Study TypeProspective.PopulationIn all, 338 patients who underwent mpMRI May 2015–May 2016, with subsequent MRI/transrectal ultrasound fusion‐guided biopsy.Field Strength3T mpMRI (T2W, diffusion‐weighted [DW], apparent diffusion coefficient [ADC] map, b‐2000 DWI acquisition, and dynamic contrast‐enhanced [DCE] MRI).AssessmentOne genitourinary radiologist prospectively read mpMRIs using both in‐house and PI‐RADSv2 5‐category systems.Statistical TestIn lesion‐based analysis, overall and clinically significant (CS) tumor detection rates (TDR) were calculated for all PI‐RADSv2 and in‐house categories. The ability of each scoring system to detect cancer was assessed by area under receiver operator characteristic curve (AUC). Within each PI‐RADSv2 category, lesions were further stratified by their in‐house categories to determine if TDRs can be increased by combining features of both systems.ResultsIn 338 patients (median prostate‐specific antigen [PSA] 6.5 [0.6–113.6] ng/mL; age 64 [44–84] years), 733 lesions were identified (47% tumor‐positive). Predictive abilities of both systems were comparable for all (AUC 76–78%) and CS cancers (AUCs 79%). The in‐house system had higher overall and CS TDRs than PI‐RADSv2 for categories 3 and 4 (P < 0.01 for both), with the greatest difference between the scoring systems seen in lesions scored category 4 (CS TDRs: in‐house 65%, PI‐RADSv2 22.1%). For lesions categorized as PI‐RADSv2 = 4, characterization of suspicious/indeterminate extraprostatic extension (EPE) and equivocal findings across all mpMRI sequences contributed to significantly different TDRs for both systems (TDR range 19–75%, P < 0.05).Data ConclusionPI‐RADSv2 behaves similarly to an existing validated system that relies on the number of sequences on which a lesion is seen. This prospective evaluation suggests that sequence positivity and suspicion of EPE can enhance PI‐RADSv2 category 4 cancer detection.Level of Evidence: 1Technical Efficacy: Stage 3J. Magn. Reson. Imaging 2018;47:1326–1335.

PURPOSE:We sought to determine whether saturation of the index lesion during magnetic resonance imaging-transrectal ultrasound fusion guided biopsy would decrease the rate of pathological upgrading from biopsy to radical prostatectomy.MATERIALS AND METHODS:We analyzed a prospectively maintained, single institution database for patients who underwent fusion and systematic biopsy followed by radical prostatectomy in 2010 to 2016. Index lesion was defined as the lesion with largest diameter on T2-weighted magnetic resonance imaging. In patients with a saturated index lesion transrectal fusion biopsy targets were obtained at 6 mm intervals along the long axis of the index lesion. In patients with a nonsaturated index lesion only 1 target was obtained from the lesion. Gleason 6, 7 and 8-10 were defined as low, intermediate and high risk, respectively.RESULTS:Included in the study were 208 consecutive patients, including 86 with a saturated and 122 with a nonsaturated lesion. Median patient age was 62.0 years (IQR 10.0) and median prostate specific antigen was 7.1 ng/ml (IQR 8.0). The median number of biopsy cores per index lesion was higher in the saturated lesion group (4 vs 2, p <0.001). The risk category upgrade rate from systematic only, fusion only, and combined fusion and systematic biopsy results to prostatectomy was 40.9%, 23.6% and 13.8%, respectively. The risk category upgrade from combined fusion and systematic biopsy results was lower in the saturated than in the nonsaturated lesion group (7% vs 18%, p = 0.021). There was no difference in the upgrade rate based on systematic biopsy between the 2 groups. However, fusion biopsy results were significantly less upgraded in the saturated lesion group (Gleason upgrade 20.9% vs 36.9%, p = 0.014 and risk category upgrade 14% vs 30.3%, p = 0.006).CONCLUSIONS:Our results demonstrate that saturation of the index lesion significantly decreases the risk of upgrading on radical prostatectomy by minimizing the impact of tumor heterogeneity.

You have accessJournal of UrologySurgical Technology & Simulation: Instrumentation & Technology I1 Apr 2017MP52-13 TRANSPERINEAL MR-GUIDED PROSTATE NEEDLE INTERVENTIONS USING A PATIENT-SPECIFIC TEMPLATE Dordaneh Sugano, Sheng Xu, Reza Seifabadi, Ivane Bakhutashvili, Neil Glossop, Peter Choyke, Peter Pinto, and Reto Bale Dordaneh SuganoDordaneh Sugano More articles by this author , Sheng XuSheng Xu More articles by this author , Reza SeifabadiReza Seifabadi More articles by this author , Ivane BakhutashviliIvane Bakhutashvili More articles by this author , Neil GlossopNeil Glossop More articles by this author , Peter ChoykePeter Choyke More articles by this author , Peter PintoPeter Pinto More articles by this author , and Reto BaleReto Bale More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1643AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The aim of the study is to test the feasibility of a low cost, patient-specific template that allows for angulated insertion of needles during transperineal MR-guided biopsy and treatment for prostate cancer. Currently, transperineal MR-guided biopsy can be performed with a standard straight grid, or with a robotic device. The straight grid does not incorporate information on patient-specific anatomy or disease, and renders it difficult to avoid structures such as the pubic arch. Robotic devices are not currently in widespread use due to regulatory issues, and can be prohibitively expensive. We propose a two-plate template in which guide holes drilled mid-procedure, using an MR image registered with 3D imaging software, allow for accurate direction of biopsy needles to specific tumor locations. METHODS The two-plate template was attached to a platform in a fixed position relative to a prostate phantom. A 3T MR image of the template (with gadolinium fiducials) and the phantom was obtained, and the template and phantom were registered to MRI coordinates. The MR images were uploaded onto a custom-made module in 3D slicer. Four fiducials were localized in the image and registered to their physical locations on the template, allowing the user to plan needle trajectories and calculate insertion depths to the targets. These trajectories can be manually translocated as necessary in order to minimize contact with other trajectories and nearby structures. The disposable plates were placed into a portable milling machine, which then drilled the corresponding guide holes according to the plan. The plates were replaced into the template frame, and biopsy needles were inserted into the phantom at the angle constrained by the guide holes. The phantom, template, and needles were imaged via CT scan for confirmation of placement accuracy. RESULTS Three MRI-visible targets were identified in the image. Mean and standard deviation of error was 2.83mm ±1.42 for user 1 and 4.70mm ±3.66 for user 2. CONCLUSIONS It is feasible to use a patient-specific template for low-cost, angulated transperineal MR-guided prostate biopsy. The method has potential applications not only in prostate biopsy, but also in other forms of targeted therapy. Future studies will consider further tests of accuracy, efficiency, convenience, and applicability. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e708-e709 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Dordaneh Sugano More articles by this author Sheng Xu More articles by this author Reza Seifabadi More articles by this author Ivane Bakhutashvili More articles by this author Neil Glossop More articles by this author Peter Choyke More articles by this author Peter Pinto More articles by this author Reto Bale More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

You have accessJournal of UrologyProstate Cancer: Localized: Active Surveillance II1 Apr 2017MP43-17 MPMRI FOR PREDICTING PROSTATE CANCER PROGRESSION IN MEN ON ACTIVE SURVEILLANCE: A COMPARISON TO PSA KINETICS Mahir Maruf, Abhinav Sidana, Amit L Jain, Brian Calio, Dordaneh Sugano, Michael Kongnyuy, Arvin K. George, M Minhaj Siddiqui, Akhil Muthigi, Subin Valayil, Thomas P. Frye, Peter L. Choyke, Baris Turkbey, Bradford Wood, and Peter Pinto Mahir MarufMahir Maruf More articles by this author , Abhinav SidanaAbhinav Sidana More articles by this author , Amit L JainAmit L Jain More articles by this author , Brian CalioBrian Calio More articles by this author , Dordaneh SuganoDordaneh Sugano More articles by this author , Michael KongnyuyMichael Kongnyuy More articles by this author , Arvin K. GeorgeArvin K. George More articles by this author , M Minhaj SiddiquiM Minhaj Siddiqui More articles by this author , Akhil MuthigiAkhil Muthigi More articles by this author , Subin ValayilSubin Valayil More articles by this author , Thomas P. FryeThomas P. Frye More articles by this author , Peter L. ChoykePeter L. Choyke More articles by this author , Baris TurkbeyBaris Turkbey More articles by this author , Bradford WoodBradford Wood More articles by this author , and Peter PintoPeter Pinto More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1327AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Pathologic progression is identified in >25% of prostate cancer (CaP) patients on active surveillance (AS). Yet, the ability to identify which patients are at risk for progression is limited to PSA-based biomarkers with variable utility. Multiparametric MRI (mpMRI) with fusion-guided prostate biopsy (FBx) has demonstrated utility in risk stratification for patients considering AS. We compared mpMRI characteristics with PSA kinetics for the prediction of pathologic progression in patients on AS. METHODS A review of men on AS with serial mpMRI and 2 or more FBx sessions was performed. FBx sessions consisted of targeted biopsies and a 12-core systematic biopsy. Men who met NIH Expanded AS criteria included those with low and intermediate risk CaP, Gleason score = 3+4 with no restriction on percent core involvement. Progression was defined by patients with initial Gleason 3+3 to any Gleason 4, and Gleason 3+4 to a primary Gleason 4 or higher. MRI progression was defined as increase in lesion suspicion score, size, or new lesion on follow-up. PSA density (PSAD) > 0.15ng/ml2, velocity (PSAV) > 0.75ng/ml/year, doubling time (PSAdt) < 3 years, and imaging characteristics were examined for association with pathologic progression at surveillance biopsy. RESULTS A total of 178 men were included for analysis. Median follow-up was 19 months [IQR 14-29]. Median age, PSA, and prostate volume of our cohort were 63 years [IQR 58-68], 5.0ng/ml [IQR 3.4-7.4] and 47.8ml [IQR 36.4-59.7] at enrollment. The sensitivity and specificity of predicting pathologic progression by mpMRI, PSAD, PSAV and PSAdt were 46% and 65%, 16% and 88%, 20% and 87%, and 30% and 75% respectively. A combination of MRI with PSAD, PSAV, or PSAdt yielded a sensitivity and specificity of 53% and 44%, 57% and 57%, or 63% and 49% respectively. Using a decision curve analysis, mpMRI offers a small additional benefit for predicting CaP progression. CONCLUSIONS MpMRI alone marginally outperforms PSA kinetics for predicting pathologic progression in men on AS for CaP. The combination of mpMRI with PSA parameters increases the sensitivity of identifying progression in AS patients, but still fails to capture a significant proportion of progression. Further research in prostate imaging and other biomarkers will be needed to more accurately risk stratify AS patients. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e560-e561 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Mahir Maruf More articles by this author Abhinav Sidana More articles by this author Amit L Jain More articles by this author Brian Calio More articles by this author Dordaneh Sugano More articles by this author Michael Kongnyuy More articles by this author Arvin K. George More articles by this author M Minhaj Siddiqui More articles by this author Akhil Muthigi More articles by this author Subin Valayil More articles by this author Thomas P. Frye More articles by this author Peter L. Choyke More articles by this author Baris Turkbey More articles by this author Bradford Wood More articles by this author Peter Pinto More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

INTRODUCTIONAlthough prostate cancer is the most common non-cutaneous cancer in men, it is traditionally diagnosed with a non-targeted, systematic transrectal ultrasound prostate biopsy (TRUS-Bx). This technique has been demonstrated to both under-detect clinically significant (CS) cancer and over-detect clinically insignificant cancer, and performs poorly in patients with a prior negative biopsy. With recent advances in MRI technology, most prominently the advent of multiparametric MRI, MRI-targeted prostate biopsy (MRI-TB) has been gaining favor as a more accurate alternative to TRUS-Bx. In this review, we attempt to summarize the current literature on MRI-TB and to determine if there is evidence supporting the use of MRI-TB alone.MATERIALS AND METHODSThe literature was reviewed for articles pertaining to MRI-TB and its performance compared to systematic biopsy.RESULTSMost studies support the increased sensitivity of MRI-TB (0.90, 95% CI 0.85-0.94) compared to TRUS-Bx (0.79, 95% CI 0.68-0.87) for the detection of CS prostate cancer, as MRI-TB can detect up to 30% more high risk and 17% fewer low risk cancers. MRI-TB also tends to perform better than TRUS-Bx in patients with prior negative biopsy, as TRUS-Bx may miss up to half of CS cancers detected by MRI-TB, and in those with lesions at atypical locations. However, as the technology for imaging and image-guided biopsies continues to develop, there is still a role for TRUS-Bx in the management of patients with prostate cancer.CONCLUSIONSOur analysis of the literature suggests that although MRI-TB is superior to TRUS-Bx, there is still a role for traditional systematic biopsy.

31 Background: To determine the accuracy of multiparametric MRI (mpMRI) and fusion biopsy in predicting focal therapy candidates by correlating agreement between patients’ pre-prostatectomy MRI and biopsy findings with whole mount pathology. Methods: Patients who underwent mpMRI and biopsy followed by prostatectomy between 2010-2015 were included in the study. Patients were considered good candidates for focal therapy if they had intermediate risk cancer (max Gleason 3+4 or 4+3 on biopsy) in only one hemisphere of the prostate, and if they had an mpMRI visible lesion(s) on one hemisphere that did not cross midline. Patients were considered poor candidates for focal therapy if they had either low risk cancer (Gleason 6), high risk cancer (Gleason 8, 9 and 10), intermediate risk cancer bilaterally, MRI visible lesions that cross the midline, or contained extracapsular extension or seminal vesicle invasion. Whole mounts of patients considered good candidates were then examined histologically for maximum tumor involvement. Results: 501 patients who underwent prostatectomy between 2010 and 2015 were included in the study, with mean age 60.0 (±10.0) and PSA 6.21 (±6.0). 395 patients were considered poor focal candidates, and 106 were considered good focal candidates. Of these 106, 66 patients had whole mounts available for analysis (14 random biopsy, 52 fusion biopsy). 42/66 (63.6%) patients were confirmed as candidates (6/14 (42.9%) who had random biopsy and 36/52 (68.0%) who had fusion). Candidates failed prediction due to Gleason upgrade in final histopathology in 20/24 (83.3%), and for significant Gleason detection bilaterally in 4/24 (16.7%). Conclusions: Our results suggest that application of mpMRI and biopsy criteria to predict focal therapy candidates may result in undertreatment of a large portion of patients with significant cancer. Results from mpMRI guided targeted biopsy were shown to be a more accurate tool for predicting candidates for focal therapy than results from random biopsy alone. More accurate predictive capability is needed before focal therapy can be widely accepted.

You have accessJournal of UrologySurgical Technology & Simulation: Instrumentation & Technology I1 Apr 2017MP52-08 TECHNIQUE AND CASE SERIES OF MRI GUIDED IN-BORE BIOPSY FOR PATIENTS WITHOUT RECTUM Dordaneh Sugano, Abhinav Sidana, Collier Wright, Brian Calio, Mahir Maruf, Amit Jain, Maria Merino, Peter Choyke, Baris Turkbey, Bradford Wood, and Peter Pinto Dordaneh SuganoDordaneh Sugano More articles by this author , Abhinav SidanaAbhinav Sidana More articles by this author , Collier WrightCollier Wright More articles by this author , Brian CalioBrian Calio More articles by this author , Mahir MarufMahir Maruf More articles by this author , Amit JainAmit Jain More articles by this author , Maria MerinoMaria Merino More articles by this author , Peter ChoykePeter Choyke More articles by this author , Baris TurkbeyBaris Turkbey More articles by this author , Bradford WoodBradford Wood More articles by this author , and Peter PintoPeter Pinto More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1638AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES MRI targeted biopsy has changed the evaluation paradigm of patients with elevated PSA. However, in patients without a rectum, the fusion platforms to target suspicious lesions on MRI cannot be utilized due to inability to use transrectal ultrasound. In-bore MRI guided biopsy is a potential alternative for targeting specific lesions in these patients. This report outlines the techniques used in a series of five patients undergoing in-bore MRI guided prostate biopsy using registration with the Visualase® (Medtronic) MRI guided laser ablation platform. METHODS Patients without rectum with presence of suspicious lesions on prostate mpMRI were scheduled for biopsy in the MRI suite. Patients were placed under general anesthesia and prepped and draped on the MRI table in the frog-leg position. The biopsy grid was positioned to be flush with the perineum. T2W MR images of the prostate were obtained, transferred to the Visualase platform, and registered to the fiducials using the Visualase system. Serial T1W MR images were used to identify the location and depth of the lesion and then to confirm the location of the biopsy needles. A total of 2-8 cores were obtained from each patient. After completion of the procedure, patients were transferred to the recovery area in stable condition. RESULTS Four patients with suspicion of prostate cancer on prostate mpMRI and surgical absence of rectum underwent prostate biopsy by above technique. The median age was 72 (58-77) years and median PSA was 4.28ng/ml (3.6-6.73). Patient 1 had ileoanal anastomosis and Patients 2-4 had APR, due to UC in Patients 1-3 and rectal cancer in Patient 4. Patient 1 was found to have Gleason 8 and patient 4 had Gleason 7(3+4). Patient 2 and 3 had negative targeted biopsy. No complications from in-bore biopsy were noted. CONCLUSIONS ″In bore″ MRI guidance as a technique during prostate biopsy has been in use since 2002. We report the technique of MRI targeted biopsy using the Visualase MRI guided laser ablation platform, which has traditionally been used for focal laser ablation. Use of this platform allows for accurate registration and targeting of the lesions in patients not eligible for MRI-TRUS fusion. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e706 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Dordaneh Sugano More articles by this author Abhinav Sidana More articles by this author Collier Wright More articles by this author Brian Calio More articles by this author Mahir Maruf More articles by this author Amit Jain More articles by this author Maria Merino More articles by this author Peter Choyke More articles by this author Baris Turkbey More articles by this author Bradford Wood More articles by this author Peter Pinto More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

32 Background: Several studies have demonstrated an association in prostate cancer patients between the tumor volume of the index lesion calculated from whole mount pathology after radical prostatectomy and biochemical recurrence (BCR). We aimed to evaluate whether the index lesion tumor volume (ILTV) measured on MRI would have similar predictive ability. Methods: Clinical and pathologic data from a prospectively maintained, single-institution database was analyzed for 501 patients who underwent RARP (without prior therapy) between 2007 and 2016. Patients were excluded if they were found to have metastatic disease on pathology or if postoperative PSA ≥ 0.2ng/ml after RARP. ILTV was calculated from T2W MRI by multiplying length by width by depth by 0.52. Tumor volume was stratified into two categories based on the cutoff of 2cm3. BCR was defined as 2 PSA values ≥ 0.2 ng/ml, 1 PSA value ≥ 0.4 ng/ml, or receipt of radiation therapy/hormonal therapy after RARP. Cox proportional hazard regression was used to assess associations of clinical, imaging, and histopathological variables with BCR. Results: The median age of our cohort was 60 years (IQR 10) and median PSA was 6.20 ng/ml (IQR 6). Of the 493 patients who met our inclusion criteria, 55 (11.2%) experienced BCR. Patients with ILTV > 2cc had a higher incidence of BCR compared to those with ILTV < 2cc (18.0% vs 8.8%, p = 0.008). On univariate analysis, age (HR 0.96, p = 0.026), PSA (HR 1.04, p < 0.001), black race (HR 1.816, p = 0.047), Gleason 8-10 on biopsy (HR 3.725, p < 0.001), and ILTV (HR 2.496, p = 0.002) were significant for prediction of BCR. Although age (HR 0.955, p = 0.021), PSA (HR 1.029, p = 0.013), and Gleason 8-10 on biopsy (HR3.367, p < 0.001) were found to be independent predictors of BCR, tumor volume was not found to be an independent predictor (HR 0.960, p = 0.642). Conclusions: Although ILTV alone was predictive of BCR, ILTV was not found to be an independent predictor of BCR, indicating that at this time, MRI cannot yet measure ILTV with enough accuracy to predict oncologic outcomes. As imaging technology improves, ILVT may provide additional prognostic information.

e541 Background: Focal therapy (FT) for localized prostate cancer (PCa) has been shown to have encouraging short term oncological outcomes, excellent preservation of functional outcomes and is increasing in popularity in Urologic community. We aim to evaluate the preferences and practice trends among urologists regarding this upcoming treatment strategy. Methods: An anonymous online questionnaire was designed to collect information on urologists’ views and use of focal therapy. The survey was sent to members of the Endourological Society (ES) and American Urological Association (AUA). Multivariate logistic regression analysis was done to determine predictors for utilization of FT for localized prostate cancer. Results: A total of 383 responses were received [AUA: 342, ES: 41]. Mean age of respondents was 43(±11.2) years. Although about half of the respondents (51.4%) believed FT to be moderate to extremely beneficial in the treatment of PCa, only 23% (89) of the respondents currently utilize FT in their practice. While the most common setting for utilization of FT was in patients with unilateral intermediate risk (75.2%) PCa, a small percentage of respondents also used FT for patients with bilateral intermediate risk and unilateral high risk PCa (9% and 7% respectively). The most common FT modality was Cryoablation in 62% followed by High Intensity Focused Ultrasound in 44%. Most common reasons for not using focal therapy were the lack of belief in ‘index lesion theory’ (186) (63.2%) followed by the lack of experience (121) (41.1%). About 58.2% respondents would use FT often in an office or outpatient setting if they had access to reliable and cost effective options. Surgeon’s experience (practice for more than 15 years) (p = 0.035) was the only independent predictor for utilizing FT in localized PCa. Conclusions: Only a quarter of our respondents utilize FT in their practice with surgeon’s experience being the only independent predictor for utilizing FT. Majority of respondents though consider FT to be beneficial in prostate cancer management would use it more often if they provided more reliable and cost effective options. Over time experience and accessibility to reliable methods to perform FT may lead to further use of this novel treatment.

15 Background: To determine the effect of learning curves and changes in fusion platform during 9 years of NCI’s experience with multiparametric MRI (mpMRI)/TRUS fusion biopsy. Methods: A review was performed of a prospectively maintained database of patients undergoing mpMRI followed by fusion biopsy (Fbx) and systematic biopsy (Sbx) from 2007−2016. The patients were stratified based on the timing of first biopsy in 3 groups. Cohort 1 included patients biopsied between 7/2007−12/2010, accounting for learning curve at our institution. Cohort 2 included patients biopsied from 1/2011 up to the debut of UroNav (Invivo) platform in 5/2013. Cohort 3 included patients biopsied after 5/2013. Clinically significant (CS) disease was defined as Gleason 7 (3+4) or higher. Cancer detection rates (CDR) between Sbx and Fbx during different time periods were compared using McNemar’s test. Age and PSA standardized CDRs were calculated for comparison between 3 cohorts. Results: 1528 patients were included in the study with 219, 549 and 761 patients included in 3 respective cohorts. Mean age, PSA and race distribution were similar across 3 cohorts. In cohort 1 there was no significant difference between CDR of CS disease by Fbx (24.7%) vs Sbx (21.5%), p = 0.377. Fbx was significantly better than Sbx in detection of CS disease in cohort 2 and cohort 3 (31.5% vs 25.3%, p = 0.001; 36.5% vs 30.2%, p < 0.001, respectively). There was significant decline in detection of low risk disease by Fbx compared to Sbx in the same period (cohort 2: 14.2% vs 20.9%, p < 0.001; cohort 3: 12.5% vs 19.5%, p < 0.001). Age and PSA standardized CDR of CS cancer by Fbx increased significantly between each successive cohort (cohort 1 and 2: 5.2%, 95% CI [2.1-8.5]), 2 and 3 (5.2%, 95% CI [1.8-8.6]). Conclusions: Our results show that after an early learning period using Fbx, CS prostate cancer was detected at significantly higher rates with Fbx than with Sbx, and low risk disease was detected at lower rates. Advances in software allowed for even greater detection of CS disease in the last cohort. This study shows that accuracy of Fbx is dependent on multiple factors; surgeon/radiologist experience and software improvements together produce improved accuracy.