Performance of systematic, MRI-targeted biopsies alone or in combination for the prediction of unfavourable disease in MRI-positive low-risk prostate cancer patients eligible for active surveillance.

PURPOSE: To assess the upstaging/upgrading rates of low-risk prostate cancer (PCa) according to the biopsy scheme used (systematic (SB), targeted biopsies (TB), or both) in the setting of positive pre-biopsy MRI. PATIENTS AND METHODS: We included 143 consecutive men fulfilling the Toronto University active surveillance (AS) criteria who underwent a pre-biopsy positive MRI, a combination of SB and software-based fusion TB, and a radical prostatectomy, in two expert centres. The primary endpoints were the pathological upgrading and upstaging rates. Overall unfavourable disease (OUD) was defined by any pT3-4 and/or pN1 and/or ≥ GG 3. RESULTS: Using TB alone would have missed 21.7% of cancers including 16.7% of ≥ GG 3. The use of TB was significantly associated with a lower risk of ≥ Grade Group (GG) 3 disease (p < 0.006) in RP specimens. Combination of SB and TB lowered this risk by 39%, compared with TB alone. The biopsy scheme did not affect the upstaging rates which were substantial even in case of combination scheme (from 37 to 46%). OUD was detected in approximately 50% of cases. The presence of high grade on TB was the only independent predictive factor for both ≥ GG 2 (p = 0.015) and ≥ GG 3 (p = 0.023) in RP specimens. CONCLUSIONS: High grade on TB biopsies represented the major predictor of upgrading. Combination of SB and TB better defined the sub-group of patients having the lowest risk of reclassification, compared with TB or SB alone. The risk of non-organ-confined disease remained high, and could not be accurately predicted by MRI or systematic/targeted biopsy features.

Added Value of Concomitant Systematic and Fusion Targeted Biopsies for Grade Group Prediction Based on Radical Prostatectomy Final Pathology on Positive Magnetic Resonance Imaging.

PURPOSE: We assessed the added value of concomitant systematic biopsy for final grade group prediction in patients with positive magnetic resonance imaging who were undergoing targeted biopsy. MATERIALS AND METHODS: Included in study were 478 consecutive patients with prebiopsy positive multiparametric magnetic resonance imaging and a greater than 10-core systematic biopsy combined with fusion targeted biopsy who underwent radical prostatectomy. The primary end point was the grade group concordance between biopsy and radical prostatectomy pathology according to the biopsy technique. Clinical and biological factors associated with the performance of systematic biopsy were analyzed. RESULTS: Adding systematic biopsy to targeted biopsy modified the d'Amico risk classification toward more intermediate and high risk in 7.8% of cases, mainly from low to intermediate risk with low risk prostate cancer on targeted biopsy in 44.3%. This reclassification was significantly higher in patients with lower prostate specific antigen and with prostate specific antigen density less than 0.20 ng/ml/gm (11.7% vs 2.4%, p <0.001). The concordance rate between biopsy pathology and radical prostatectomy pathology significantly differed between targeted biopsy and targeted biopsy plus systematic biopsy (45.2% and 51.7%, respectively). The upgrading rate in radical prostatectomy specimens decreased by 22% when systematic biopsy was added to targeted biopsy. Patients in whom systematic biopsy did not modify grading were more likely to have pT3-4 and/or pN1 disease on final pathology (56.9% vs 38.3%, p=0.007). CONCLUSIONS: Grading concordance between biopsy pathology and radical prostatectomy pathology was improved by adding systematic biopsy in all patient subgroups. Patients with prostate specific antigen density less than 0.20 ng/ml/gm benefited the most from this combined biopsy strategy. Systematic biopsy reclassified a nonnegligible number of cases toward a higher risk category, mainly the low risk cases. Thus, systematic biopsy could modify treatment decision making.

First report of testis-sparing surgery for sertoliform cystadenoma: case presentation and review of literature.

INTRODUCTION: Sertoliform cystadenoma is a very rare, benign lesion of the rete-testis difficult to distinguish from other malignancies of the testicle. CASE PRESENTATION: We present the case of a 42-year-old male who presented with a right testicular mass, asymptomatic for 1 year. Clinical examination revealed a palpable, painless, and well-delimited right testicular superior pole nodule. Testicular ultrasound confirmed the nodule, whereas serum tumoral markers were normal. The patient underwent inguinal partial orchiectomy. Intraoperative excisional biopsy and frozen section pathology were performed, reporting undetermined tumoral origin with negative surgical margins. Ischemia time was 12 minutes. The final pathology report showed a Sertoliform cystadenoma of rete testis, with immunomorphology positive for AE1, CK7, and negative surgical margins. CONCLUSION: To our knowledge, this is the first report of testicular sparing surgery for Sertoliform cystadenoma, a very rare benign tumor of rete testis. All previously reported cases were managed by radical inguinal orchidectomy.

Impact of MRI and Targeted Biopsies on Eligibility and Disease Reclassification in MRI-positive Candidates for Active Surveillance on Systematic Biopsies.

OBJECTIVE: To assess the impact of concomitant targeted biopsies (TB) for predicting final disease reclassification in MRI-positive low-risk prostate cancer patients eligible for active surveillance (AS) on systematic biopsies (SB). MATERIALS AND METHODS: From a prospective database, we included all prebiopsy MRI-positive men fulfilling AS criteria at diagnosis (Toronto [n = 114], UCSF [n = 82], or PRIAS [n = 60] criteria) on SB. All patients underwent a combination of SB and software-based fusion TB, and an immediate radical prostatectomy. The primary endpoints were the pathologic upgrading and upstaging rates. RESULTS: Biopsy grade group was upgraded to grade group (GG) 2 and to GG≥3 on TB in 65.9%-76.7% and in 12.2-16.7%, respectively. The rate of GG ≥3 in radical prostatectomy specimens varied from 31.6% to 43.3% with no relation between strictest criteria and lower upgrading rates. The proportion of not organ-confined disease (35%-39%) was comparable among the AS cohorts. Negative TB was strongly associated with the absence of final GG ≥3. Tumor grade on TB was significantly correlated with the risk of final GG ≥3 in both Toronto and UCSF cohorts, not in the PRIAS cohort. In the PRIAS cohort, the only independent predictive factor for GG ≥3 disease was the maximal tumor length in any core (P = .034). CONCLUSION: In MRI-positive patients, the risk of disease reclassification was comparable whatever the SB-based AS criteria used. TB were predictive of final upgrading, with a varied impact according to the AS criteria. SB features remained relevant for reclassification prediction even in case of positive TB. The risk of upstaged disease remains important, approximately one third, and neither TB/SB parameters nor MRI findings could accurately predict it.

Improvement of the intermediate risk prostate cancer sub-classification by integrating MRI and fusion biopsy features.

INTRODUCTION: Treatment decision-making for intermediate-risk prostate cancer (CaP) is mainly based on grade and tumor involvement on systematic biopsy. We aimed to assess the added value of multi-parametric magnetic resonance imaging (mpMRI) and targeted biopsy (TB) features for predicting final pathology and for improving the well-established favourable/unfavourable systematic biopsy-based sub-classification. MATERIALS AND METHODS: From a prospective database of 377 intermediate risk CaP cases, we evaluated the performance of the standard intermediate risk classification (IRC), and the predictive factors for unfavourable disease on final pathology aiming to build a new model. Overall unfavourable disease (OUD) was defined by any pT3-4 and/or pN1 and/or grade group (GG) ≥ 3. RESULTS: The standard IRC was found to be predictive for unfavourable disease in this population. However, in multivariable analysis regression, ECE on mpMRI and GG ≥3 on TB remained the 2 independent predictive factors for OUD disease (HR = 2.7, P = 0.032, and HR = 2.41, P = 0.01, respectively). By using the new IRC in which unfavorable risk was defined by ECE on mpMRI and/or GG ≥3 on TB, the proportion of unfavorable cases decreased from 62.3% to 34.1% while better predicting unfavorable disease in RP speciments. The new model displayed a better accuracy than the standard IRC for predicting OUD (AUC: 0.66 vs. 0.55). CONCLUSIONS: The integration of imaging and TB features drastically improves the intermediate risk sub-classification performance and better discriminates the unfavourable risk group that could benefit from more aggressive therapy such as neo-adjuvant and/or adjuvant treatment, and the favourable group that could avoid over-treatment. External validation in other datasets is needed.