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OBJECTIVE: To compare prostate artery embolisation (PAE) to the combination of tamsulosin and dutasteride therapy as a potential first-line therapy for obstructive benign prostatic hyperplasia (BPH) in treatment-naïve patients in the 'Prostate Embolisation AS first-line therapY compAred to meDication in treatment naïVe men with prostAte eNlargement, a randomised ControllEd trial' (P-EASY ADVANCE). PATIENTS AND METHODS: A total of 39 men with enlarged prostates, moderate-severe lower urinary tract symptoms (LUTS) and obstructed/equivocal urodynamic studies (UDS), and who had no prior treatment for BPH, were randomised to receive either combined medical therapy with tamsulosin and dutasteride (medication) or PAE. Follow-up UDS, International Prostate Symptom Score (IPSS), uroflowmetry and ultrasound were performed at short- to medium-term intervals following interventions and compared to baseline. RESULTS: The medication and PAE treatment groups had similar baseline characteristics, including prostate volumes (87.8 and 85.4 mL respectively), maximum urinary flow rate (Qmax; 6.5 and 6.6 mL/s, respectively), IPSS (19.5 and 21, respectively) and obstructed UDS (79% and 74%, respectively). Both interventions improved voiding and bladder outflow obstruction from baseline, with more patients unobstructed after PAE (63%) compared to medication (28%) (P = 0.03). PAE patients had significantly greater reductions in prostate size (P < 0.001), incomplete emptying (P = 0.002), total IPSS (P = 0.032), Qmax (P = 0.006) and quality of life (P = 0.001). Altered ejaculation, erectile dysfunction and nausea were more common in the medication group. CONCLUSION: Prostate artery embolisation was more effective than combined medical therapy at reducing urinary obstruction, decreasing prostate volume and improving LUTS in patients with BPH who had not previously been treated. This is the first randomised control study to compare PAE and combined medical therapy in exclusively treatment-naïve patients and raises the potential of PAE as an alternative early treatment option for BPH. Further randomised comparative trials are planned to further validate the role of PAE in mitigating obstructive BPH.
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[This corrects the article DOI: 10.1016/j.euros.2023.05.007.].
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Objective: To review the risk of prostate cancer (PCa) in men with incidentally reported increased intraprostatic uptake at 2-deoxy-2-[18F]fluoro-d-glucose positron emission tomography/computed tomography (18F-FDG PET/CT) ordered at Department of Urology, The Wesley Hospital, Brisbane, QLD, Australia for non-PCa related pathology. Methods: Retrospective analysis of consecutive men between August 2014 and August 2019 presenting to a single institution for 18F-FDG PET/CT for non-prostate related conditions was conducted. Men were classified as benign, indeterminate, or malignant depending of the results of prostate-specific antigen (PSA), PSA velocity, biopsy histopathology, and three-Tesla (3 T) multiparametric MRI (mpMRI) Prostate Imaging Reporting and Data System score, or gallium-68-prostate-specific membrane antigen (68Ga-PSMA) PET/CT results. Results: Three percent (273/9122) of men demonstrated 18F-FDG avidity within the prostate. Eighty-five percent (231/273) were further investigated, including with PSA tests (227/231, 98.3%), 3 T mpMRI (68/231, 29.4%), 68Ga-PSMA PET/CT (33/231, 14.3%), and prostate biopsy (57/231, 24.7%). Results were considered benign in 130/231 (56.3%), indeterminate in 31/231 (13.4%), and malignant in 70/231 (30.3%). PCa was identified in 51/57 (89.5%) of the men who proceeded to biopsy, including 26/27 (96.3%) men with Prostate Imaging Reporting and Data System scores 4-5 mpMRI and six men with a positive 68Ga-PSMA PET/CT. The most common Gleason score on biopsy was greater than or equal to 4+5 (14/51, 27.5%). 68Ga-PSMA PET/CT was concordant with the 18F-FDG findings in 26/33 (78.8%). All 13 men with a positive concordant 18F-FDG, 3 T mpMRI, and 68Ga-PSMA PET/CT had PCa on biopsy. There was no statistically significant difference in the 18F-FDG maximum standardized uptake value between the benign or malignant groups (5.7 vs. 6.1; p=0.580). Conclusion: In this study, after an incidental finding of an avid intraprostatic lesion on 18F-FDG PET/CT, 70 of the 231 cases (30.3%; 0.8% of the entire cohort) had results consistent with PCa, most commonly as Gleason score greater than or equal to 4+5 disease. Unless there is limited life expectancy due to competing medical co-morbidity, men with an incidental finding of intraprostatic uptake on 18F-FDG should be further investigated using principles of PCa detection.
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The PRIMARY score is a 5-category scale developed to identify clinically significant intraprostate malignancy (csPCa) on 68Ga-prostate-specific membrane antigen (PSMA)-11 PET/CT (68Ga-PSMA PET) using a combination of anatomic site, pattern, and intensity. Developed within the PRIMARY trial, the score requires evaluation in external datasets. This study aimed to assess the reproducibility and diagnostic accuracy of the PRIMARY score in a cohort of patients who underwent multiparametric MRI (mpMRI) and 68Ga-PSMA PET before prostate biopsy for the diagnosis of prostate cancer. Methods: In total, data from 242 men who had undergone 68Ga-PSMA PET and mpMRI before transperineal prostate biopsy were available for this ethics-approved retrospective study. 68Ga-PSMA PET and mpMRI data were centrally collated in a cloud-based deidentified image database. Six experienced prostate-focused nuclear medicine specialists were trained (1 h) in applying the PRIMARY score with 30 sample images. Six radiologists experienced in prostate mpMRI read images as per the Prostate Imaging-Reporting and Data System (PI-RADS), version 2.1. All images were read (with masking of clinical information) at least twice, with discordant findings sent to a masked third (or fourth) reader as necessary. Cohen κ was determined for both imaging scales as 5 categories and then collapsed to binary (negative and positive) categories (score 1 or 2 vs. 3, 4, or 5). Diagnostic performance parameters were calculated, with an International Society of Urological Pathology grade group of at least 2 (csPCa) on biopsy defined as the gold standard. Combined-imaging-positive results were defined as any PI-RADS score of 4 or 5 or as a PI-RADS score of 1-3 with a PRIMARY score of 3-5. Results: In total, 227 patients with histopathology, 68Ga-PSMA PET, and mpMRI imaging before prostate biopsy were included; 33% had no csPCa, and 67% had csPCa. Overall interrater reliability was higher for the PRIMARY scale (κ = 0.70) than for PI-RADS (κ = 0.58) when assessed as a binary category (benign vs. malignant). This was similar for all 5 categories (κ = 0.65 vs. 0.48). Diagnostic performance to detect csPCa was comparable between PSMA PET and mpMRI (sensitivity, 86% vs. 89%; specificity, 76% vs. 74%; positive predictive value, 88% vs. 88%; negative predictive value, 72% vs. 76%). Using combined imaging, sensitivity was 94%, specificity was 68%, positive predictive value was 86%, and negative predictive value was 85%. Conclusion: The PRIMARY score applied by first-user nuclear medicine specialists showed substantial interrater reproducibility, exceeding that of PI-RADS applied by mpMRI-experienced radiologists. Diagnostic performance was similar between the 2 modalities. The PRIMARY score should be considered when interpreting intraprostatic PSMA PET images.
Subject(s)
Multiparametric Magnetic Resonance Imaging , Prostatic Neoplasms , Male , Humans , Prostatic Neoplasms/pathology , Prostate/pathology , Reproducibility of Results , Magnetic Resonance Imaging/methods , Positron Emission Tomography Computed Tomography/methods , Retrospective StudiesABSTRACT
OBJECTIVE: To report the incidence of the reoperation surgeries of nearly all the Rigicon Infla10 implants performed since device introduction in 1/2019. Inflatable penile prosthesis has some of the highest survival from revision surgery of any medical device implanted in humans [1]. We expand on previous Rigicon Infla10 research, adding more patients and increasing follow-up duration [2]. MATERIALS AND METHODS: 535 patients had Rigicon Infla10 devices implanted from 1/2019 to 8/2022. 103 surgeons from 26 centers in 15 countries participated in the study. Patient information forms were analyzed from virtually all implantations. Explantation or revision surgery for mechanical failure, infection, other medical reasons, and patient dissatisfaction were cataloged. SPSS 25.0 (IBM) was used for the statistical analysis of Kaplan Meier survival statistics. RESULTS: Mean follow-up was 24.2months (7-43months). Mean patient age was 56years. Reoperation was necessary for 3.5% of subjects. Revision for mechanical failure occurred in 2.24% (12/535). The rate of explant for patient dissatisfaction was 0.56% (3/535). Revision for component out of place was 0.37% (2/535) with an infection rate and unsuccessful Peyronie's correction being 0.19% (1/535). Survival from requiring another corrective surgery at 1, 2, and 3years was 96.4%, 95.0%, and 94.0%, respectively. These initial survival rates compare favorably to devices currently available, which have been repeatedly enhanced to improve reliability. CONCLUSION: In its first 2-3years of availability, The Rigicon Infla10 inflatable penile prosthesis shows freedom from revision comparable to existing enhanced devices that have been on the market for decades.
Subject(s)
Erectile Dysfunction , Penile Implantation , Penile Prosthesis , Humans , Middle Aged , Male , Penile Prosthesis/adverse effects , Reoperation , Reproducibility of Results , Penile Implantation/adverse effects , Erectile Dysfunction/etiology , Patient Satisfaction , Retrospective Studies , Prosthesis Design , Prosthesis FailureABSTRACT
Anterior prostate cancer (APC) has been considered an indolent tumor, most commonly arising in the transition zone (TZ). More recently, detection of APC has been facilitated through multiparametric magnetic resonance imaging and improved biopsy techniques, enabling earlier detection. The pathologic features and clinical significance of pure APC in a large contemporary series of well-characterized tumors have, to date, not been elucidated. Cases with APC defined as cancer present anterior to the urethra only were identified from 1761 consecutive radical prostatectomy specimens accessioned between January 2015 and August 2016. The clinicopathologic features of these cases were compared with those of pure posterior prostate cancer (PPC) and the features of anterior peripheral zone (APZ) cancers were compared with those of TZ cancers. In addition, the tumor series from 2015 to 2016 was compared with a cohort of 1054 patients accessioned before the utilization of multiparametric magnetic resonance imaging in the routine workup of patients with prostate cancer. In the 2015-2016 series, there were 188 (10.7%) patients with APC compared with 5.4% in the series from the pre-multiparametric magnetic resonance imaging era. No difference was observed between APC and PPC with regards to patient age or mean serum prostate-specific antigen at presentation. Mean tumor volume and positive surgical margin (PSM) rates were significantly higher in APC. In contrast, PPC was more commonly high grade with more frequent extraprostatic extension (EPE). None of the cases of APC had infiltration of the seminal vesicle or lymph node involvement, in contrast to PPC, with almost 14% of cases in each category. The 3- and 5-year biochemical recurrence-free survival was significantly higher in APC when compared with PPC, although this was not retained on multivariable analysis which included tumor location. On division of APCs according to anatomic zone of origin, 45% were APZ cancer and 37% TZ cancer. On comparison of APZ and TZ cancers, there were no significant differences in mean age and serum prostate-specific antigen at presentation as well as tumor volume, Gleason score, and PSM rate. High-grade malignancy (Gleason score >3 + 4=7) was seen in 26% of TZ cancers which compared with 44% of APZ cancers and 56% of PPC cancers. The rate of EPE was significantly higher in APZ when compared with TZ cancer ( P< 0.0005); however, the biochemical recurrence rate was not significantly different between the groups. The prevalence of APC in radical prostatectomy specimens has increased in recent times, in association with earlier detection at a stage amenable to curative surgical treatment. APC, when compared with PPC, is less commonly high grade with less frequent EPE, despite the APC group having larger tumors and a higher PSM rate at presentation. However, not all anterior cancers are indolent. Anterior cancers are more commonly seen in the APZ than the TZ and APZ cancers appear more locally aggressive than TZ cancers.
Subject(s)
Multiparametric Magnetic Resonance Imaging , Prostatic Neoplasms , Male , Humans , Prostate-Specific Antigen , Prostatic Neoplasms/diagnostic imaging , Prostatic Neoplasms/surgery , Prostate/pathology , Prostatectomy/methods , Magnetic Resonance ImagingABSTRACT
This corrects the article on p. 285 in vol. 63, PMID: 35534217.
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PURPOSE: Focal irreversible electroporation (IRE) for prostate cancer aims to reduce quality of life complications, however outcomes data remains limited. We aimed to evaluate histological in-field clearance of prostate cancer at ≥12 months post-IRE. MATERIALS AND METHODS: Retrospective review of prospectively acquired data of consecutive patients treated between August 2018 and August 2021. Significant recurrence was defined as a ≥6 mm core Gleason 3+3, or ≥Gleason 3+4 with ≥4 mm tumour length. A second definition of any focus of International Society of Urological Pathology (ISUP) ≥2 was also analysed. RESULTS: The median follow-up of the entire cohort is 23 months (range 3-39 mo). For 64 primary IRE procedures, surveillance biopsy was performed in 40/50 (80.0%) with ≥12 months follow-up. Significant in-field recurrence occurred in 3/40 (7.5%), or 4/40 (10.0%) with any focus of ISUP >2. Significant out-of-field recurrence occurred in 5/40 (12.5%). In salvage IRE, three patients (3/6, 50.0%) have undetectable prostate-specific antigen levels, two have no residual cancer on biopsy and one patient had out-of-field recurrence. For sexually active men, erectile function was maintained in 24/28 (85.7%) of primary IRE. No incontinence developed in primary IRE (0/64). CONCLUSIONS: Focal primary IRE for prostate cancer is associated with 90% infield ablation of any ISUP grade >2 cancer with a low risk of urinary incontinence or impotence. Surveillance prostate biopsies are required to exclude progression despite a normal post-IRE multiparametric magnetic resonance imaging (mpMRI). Salvage IRE is a promising option for localised recurrence after prostate radiotherapy with low morbidity.
Subject(s)
Ablation Techniques , Prostatic Neoplasms , Ablation Techniques/adverse effects , Ablation Techniques/methods , Electroporation/methods , Humans , Male , Prostatic Neoplasms/pathology , Quality of Life , Treatment OutcomeABSTRACT
PURPOSE: The prognostic value of PSMA intensity on PSMA PET/CT due to underlying biology and subsequent clinical implications is an emerging topic of interest. We sought to investigate whether primary tumour PSMA PET intensity contributes to pre- and post-operative prediction of oncological outcomes following radical prostatectomy. METHODS: We performed a retrospective cohort study of 848 men who underwent all of multiparametric MRI (mpMRI), transperineal prostate biopsy, and 68 Ga-PSMA PET/CT prior to radical prostatectomy. PSMA intensity, quantified as maximum standard uptake value (SUVmax), and other clinical variables were considered relative to post-operative biochemical recurrence-free survival (BRFS) using Cox regression and Kaplan-Meier analysis. RESULTS: After a median follow-up of 41 months, 219 events occurred; the estimated 3-year BRFS was 79% and the 5-year BRFS was 70%. Increasing PSMA intensity was associated with less favourable BRFS overall (Log rank p < 0.001), and within subgroups of Gleason score category (Log rank p < 0.03). PSMA intensity was significantly associated with shorter time to biochemical recurrence, after adjusting for pre-operative (HR per 5-unit SUVmax increase = 1.15) and post-operative (HR per 5-unit SUVmax increase = 1.10) parameters. CONCLUSION: These results in a large series of patients confirm PSMA intensity to be a novel, independent prognostic factor for BRFS.
Subject(s)
Prostate , Prostatic Neoplasms , Gallium Radioisotopes , Humans , Male , Positron Emission Tomography Computed Tomography/methods , Prognosis , Prostate/pathology , Prostate-Specific Antigen/analysis , Prostatectomy , Prostatic Neoplasms/diagnostic imaging , Prostatic Neoplasms/pathology , Prostatic Neoplasms/surgery , Retrospective StudiesABSTRACT
Small renal masses are commonly diagnosed with modern medical imaging. Renal tumour volume has been explored as a prognostic tool to help decide when intervention is needed and appears to provide additional prognostic information for smaller tumours compared with tumour diameter. However, the current method of calculating tumour volume in clinical practice uses the ellipsoid equation (π/6 × length × width × height) which is an oversimplified approach. Some research groups trace the contour of the tumour in every image slice which is impractical for clinical use. In this study, we demonstrate a method of using 3D segmentation software and the 3D interpolation method to rapidly calculate renal tumour volume in under a minute. Using this method in 27 patients that underwent radical or partial nephrectomy, we found a 10.07% mean absolute difference compared with the traditional ellipsoid method. Our segmentation volume was closer to the calculated histopathological tumour volume than the traditional method (p = 0.03) with higher Lin's concordance correlation coefficient (0.79 vs 0.72). 3D segmentation has many uses related to 3D printing and modelling and is becoming increasingly common. Calculation of tumour volume is one additional benefit it provides. Further studies on the association between segmented tumour volume and prognosis are needed.
Subject(s)
Kidney Neoplasms , Humans , Kidney/diagnostic imaging , Kidney Neoplasms/diagnostic imaging , Software , Tumor BurdenABSTRACT
OBJECTIVE: To evaluate the ability of preoperative multiparametric magnetic resonance imaging (mpMRI) and a gallium-68 prostate-specific membrane antigen positron emission tomography/computed tomography (68 Ga-PSMA PET/CT) scan to predict pathological outcomes and also identify a group of men with a <5% risk of histological pelvic lymph node metastasis (LNM) at pelvic lymph node dissection (PLND) performed during a robot-assisted laparoscopic radical prostatectomy (RALP) for prostate cancer. We then aimed to compare these results to known risk calculators for LNM, including the Cancer of the Prostate Risk Assessment (CAPRA) score, Memorial Sloan Kettering Cancer Centre (MSKCC) and Briganti nomograms. PATIENTS AND METHODS: Between July 2014 and September 2019 only men who had both a preoperative mpMRI and staging 68 Ga-PSMA PET/CT at our institution followed by a RALP with PLND referred to a single specialist uropathology laboratory were considered for inclusion. The data were collected retrospectively prior to February 2019 and in a prospective manner thereafter. A model was built to allocate probabilities of the men with a negative 68 Ga-PSMA PET/CT scan having a <5% risk of histologically LNM at RALP based on the preoperative radiological staging. RESULTS: A total of 233 consecutive men met the inclusion criteria of which 58 men (24.9%) had a LNM identified on PLND histology. The median (range) International Society of Urological Pathology (ISUP) Grade was 5 (1-5) and the median (range) prostate-specific antigen level was 7.4 (1.5-72) ng/mL. The median (range) number of resected lymph nodes was 16 (1-53) and the median (range) number of positive nodes identified on histology was 2 (1-22). Seminal vesicle invasion on mpMRI was more common in node-positive men than in the absence of LNM (31% vs 12%). The maximum standardised uptake value of the primary tumour on 68 Ga-PSMA PET/CT was higher in men with LNM (median 9.2 vs 7.2, P = 0.02). Suspected LNM were identified in 42/233 (18.0%) men with 68 Ga-PSMA PET/CT compared with 22/233 (9.4%) men with mpMRI (P = 0.023). The positive and negative predictive value for 68 Ga-PSMA PET/CT was 66.7% and 84.3% respectively, compared to 59.1% and 78.7% for mpMRI. A predictive model showed only two men (4.2%) with a negative preoperative 68 Ga-PSMA PET/CT would be positive for a histological LNM if they are ISUP Grade < 5 and Prostate Imaging-Reporting and Data System (PI-RADS) <5; or ISUP Grade 5 with PI-RADS < 4. An inspection of three additional variables: CAPRA score, MSKCC and Briganti nomograms did not improve the predictive probability for this group. However, of the 61 men with ISUP Grade 4-5 malignancy and also a PI-RADS 5 mpMRI, 20 (32.8%) men had a microscopic LNM despite a negative preoperative 68 Ga-PSMA PET/CT. CONCLUSION: Preoperative 68 Ga-PSMA/PET CT was more sensitive in identifying histological pelvic LNM than 3-T mpMRI. Men with a negative 68 Ga-PSMA PET/CT have a lower risk of LNM than predicted with CAPRA scores or MSKCC and Briganti nomograms. We identified that the combination of a negative preoperative 68 Ga-PSMA PET/CT, ISUP biopsy Grade <5 and PI-RADS <5 prostate mpMRI, or an ISUP Grade 5 with PI-RADS <4 on mpMRI was associated with a <5% risk of a LNM. The addition of CAPRA scores, MSKCC and Briganti nomograms did not improve the predictive probability within this model. Conversely, men with ISUP Grade 4-5 malignancy associated with a PI-RADS 5 prostate mpMRI had a >30% risk of microscopic LNM despite a negative preoperative 68 Ga-PSMA PET/CT and this high-risk group would appear suitable for an extended PLND at the time of a radical prostatectomy.
Subject(s)
Lymph Nodes/diagnostic imaging , Lymph Nodes/pathology , Multiparametric Magnetic Resonance Imaging , Positron Emission Tomography Computed Tomography/methods , Prostatic Neoplasms/diagnostic imaging , Prostatic Neoplasms/pathology , Aged , Aged, 80 and over , Edetic Acid/analogs & derivatives , Gallium Isotopes , Gallium Radioisotopes , Humans , Lymph Node Excision , Lymph Nodes/surgery , Lymphatic Metastasis/diagnostic imaging , Lymphatic Metastasis/pathology , Male , Middle Aged , Neoplasm Grading , Neoplasm Invasiveness , Nomograms , Oligopeptides , Predictive Value of Tests , Probability , Prospective Studies , Prostatectomy , Prostatic Neoplasms/surgery , Radiopharmaceuticals , Retrospective StudiesABSTRACT
BACKGROUND: Prostate multiparametric magnetic resonance imaging (mpMRI) has become a popular initial investigation of an elevated PSA and is being incorporated into active surveillance protocols. Decisions on prostate cancer investigation and management based solely on a normal mpMRI remains controversial. Histopathological findings of a totally embedded normal mpMRI lobe are rarely described. METHODS: A retrospective review of the histological findings of negative preoperative mpMRI lobes in men treated by robot assisted laparoscopic radical prostatectomy (RALP). Inclusion criteria included a preoperative low risk mpMRI for both lobes (Prostate Imaging-Reporting and Data System (PIRADS) ≤ 2) or one negative lobe (with a PIRADS 3-5 in the opposite lobe). RESULTS: A single normal mpMRI lobe was identified in 1018 men (PIRADS 3-5 group). Both lobes were normal in 179 men (PIRADS ≤ 2 group). Prostate cancer was identified in 47.6% (485/1018) of the normal mpMRI lobe opposite a PIRADS 3-5 lesion, including 13.2% (134/1018) with >0.5 cc of International Society of Urologic Pathologists (ISUP) grade 2, or a higher grade cancer. ISUP grade 4-5 was only identified in 2% (20/1018). Compared to RALP histology of the PIRADS 3-5 mpMRI tumour, a pathological ISUP upgrade in the normal mpMRI lobe was identified in 58/1018 men (5.7%). In the PIRADS ≤ 2 group extraprostatic extension occurred in 19% (34/179) and seminal vesicle invasion (pT3b) in 3.9% (7/179). There was no difference in margin status between the PIRADS 3-5 and ≤2 groups (p = 0.247). CONCLUSIONS: mpMRI underestimates tumour grade and volume compared to totally embedded histopathological analysis of RALP specimens, although ISUP grade 4-5 cancer is uncommon. Our analysis provides useful insight into the multifocality of prostate cancers, and highlights the utility of systematic biopsy, in addition to targeted biopsies. These results have ramifications for clinical decisions on prostate cancer management based solely on the mpMRI appearance, including active surveillance.
Subject(s)
Laparoscopy/methods , Multiparametric Magnetic Resonance Imaging/methods , Preoperative Care , Prostatectomy/methods , Prostatic Neoplasms/pathology , Robotic Surgical Procedures/methods , Follow-Up Studies , Humans , Male , Prognosis , Prostatic Neoplasms/surgery , Retrospective StudiesABSTRACT
OBJECTIVES: Staging of extra-prostatic prostate cancer has traditionally been assessed by computerised tomography (CT), bone scan, and where indicated, pelvic lymph node dissection at the time of surgery. The advent of the prostate-specific membrane antigen (PSMA) positron emission tomography (PET) scan shows promise in improving the accuracy of preoperative staging of this cancer. The role of pelvic lymph node dissection and its associated morbidity will be examined. This article will review current literature assessing the current role of PSMA PET and lymph node dissection in the staging and treatment of prostate cancer. DATA SOURCES: Peer-reviewed literature and databases, including Medline and PubMed. CONCLUSIONS: PSMA PET/CT appears to be a promising and superior staging investigation that may replace bone scan and CT scan in guiding treatment decision-making. It has high specificity and positive predictive value, thus in patients with low-risk prostate cancer, unnecessary extended pelvic lymph node dissection (ePLND) may be avoided. It would also help detect lymph nodes in patients with intermediate- or high-risk prostate cancer where ePLND may be required. ePLND remains the gold standard in staging high-risk patients because the PSMA PET/CT scan may under-stage the cancer. IMPLICATION FOR NURSING PRACTICE: Given the increased utilisation of PSMA PET/CT scan as a primary staging investigation in clinical practice for prostate cancer and as an alternative to bone scan and CT scan, it is timely for prostate cancer specialist nurses to understand and recognise the specificity and sensitivity of PSMA PET/CT scans in prostate cancer staging. Because ePLND is the gold standard for staging high-risk disease, prostate cancer specialist nurses should be aware of the complications associated with pelvic lymph node dissection to optimise supportive care for men affected by complications from ePLND.
Subject(s)
Lymph Node Excision/methods , Lymphatic Metastasis/diagnostic imaging , Positron Emission Tomography Computed Tomography/methods , Prostatic Neoplasms/diagnostic imaging , Humans , Male , Neoplasm Staging , Oncology Nursing , Positron Emission Tomography Computed Tomography/adverse effects , Prostatic Neoplasms/nursing , Prostatic Neoplasms/surgery , Sensitivity and SpecificityABSTRACT
OBJECTIVES: To determine the proportion of solitary rib lesions on pre-treatment 68 Gallium-labelled prostate-specific membrane antigen (PSMA)/computed tomography (CT) scans in men with prostate cancer that are malignant and examine any predictive factors. PATIENTS AND METHODS: This retrospective single tertiary referral institution cohort study of men reviewed the results of 68 Ga-PSMA-11 positron emission tomography (PET)/CT scans performed for primary staging prior to treatment of prostate cancer from July 2014 to September 2019. Men with PSMA uptake outside the prostate in only the rib lesion were included. A solitary rib lesion was considered to be malignant if it increased in size on follow-up imaging. A lesion was considered benign if the prostate-specific antigen (PSA) level remained <0.1 µg/L following a radical prostatectomy (RP), <2 µg/L above nadir following radiotherapy (RT) as per the Phoenix criteria, histology was benign on rib biopsy, or follow-up imaging showed no growth of the rib lesion. If a lesion did not meet these criteria it was considered indeterminate. RESULTS: A total of 62 men had PSMA uptake in a solitary rib lesion; 54 went on to have RPs and eight underwent RT. In all, 61 of the men (98.4%) met the criteria for a benign rib lesion. Only one man had a false-negative malignant lesion. This man had a rib lesion with a low maximum standardised uptake value (SUVmax ) of 2.21 reported as benign, but the postoperative PSA level was 0.67 µg/L and the rib lesion progressed on follow-up imaging, with development of widespread metastases. Of the benign rib lesions, there were four false positives reported as possible metastases. Three had percutaneous rib biopsies, two of which came back with benign histology and one was indeterminate. The indeterminate biopsy patient had a RP and his postoperative PSA level was <0.1 µg/L. A total of 43 (69.4%) men with benign rib lesions had a SUVmax greater than the SUVmax of the malignant lesion. CONCLUSION: To our knowledge, this is the first cohort study of men with PSMA-avid solitary rib lesions on pre-treatment 68 Ga-PSMA PET/CT staging scans for prostate cancer. Our results indicate that the vast majority of these lesions have low-intensity uptake and are benign. Intervention to confirm this is not usually required.
Subject(s)
Bone Diseases/diagnostic imaging , Bone Neoplasms/diagnostic imaging , Bone Neoplasms/secondary , Edetic Acid/analogs & derivatives , Oligopeptides , Positron Emission Tomography Computed Tomography , Prostatic Neoplasms/pathology , Ribs/diagnostic imaging , Aged , Bone Diseases/etiology , Cohort Studies , Gallium Isotopes , Gallium Radioisotopes , Humans , Male , Middle Aged , Positron Emission Tomography Computed Tomography/methods , Prostatic Neoplasms/complications , Retrospective StudiesABSTRACT
OBJECTIVES: To describe the use of a novel 'trizonal' biopsy schema in which 'near-target' biopsies are taken adjacent to the MRI lesion, in addition to target and systematic biopsies, to determine the accuracy of prostate MRI fusion systems. PARTICIPANTS AND METHODS: A trizonal biopsy technique was used to evaluate 75 men with small Prostate Imaging Reporting and Data System (PI-RADS) 3-5 MRI lesions (<15 mm) identified from a prospective cohort of 290 men undergoing multiparametric magnetic resonance imaging (MRI) for suspected prostate cancer at a single high-volume institution between September 2017 and May 2019. In addition to target and systematic biopsies, near-target biopsies were taken 4 mm from the apparent border of the MRI lesion. Comparisons were made between highest International Society of Urological Pathology grade and longest tumour length. RESULTS: Fifty-three men with significant prostate cancer in the same quadrant as the target were included in the final analysis. The percentages of positive cores from target, near-target and MRI-negative zones were 66%, 39% and 17%, respectively. Significant cancer was detected in the near-target zone in 77% of cases when the target zone was positive. A total of 17% of participants were upgraded by a median (range) of 1 (1-3) grades through the addition of near-target cores. Notably, 9% of men were diagnosed with clinically significant prostate cancer solely via the near-target biopsy cores when the target cores were negative. CONCLUSION: The use of near-target biopsies as part of a trizonal biopsy schema provides a novel methodology to optimize clinically significant prostate cancer detection.
Subject(s)
Image-Guided Biopsy/methods , Magnetic Resonance Imaging, Interventional/methods , Prostate/diagnostic imaging , Prostatic Neoplasms/diagnostic imaging , Adult , Aged , Aged, 80 and over , Humans , Male , Middle Aged , Prostate/pathology , Prostatic Neoplasms/pathologyABSTRACT
BACKGROUND: 68Ga-PET/CT PSMA scan is being increasingly used for the staging of biochemically recurrent disease. Early identification of recurrent disease after radiotherapy is important in considering suitability for early salvage therapy to improve prognosis. The aim is to identify patterns of suspected prostate cancer recurrence in relation to post-radiotherapy PSA levels, especially below the accepted Phoenix definition of PSA failure (PSA nadir + 2). METHODS: This was a retrospective single tertiary institution cohort study of consecutive men between July 2014 and June 2018 who received a 68Ga-PSMA PET/CT for elevated PSA levels following radiotherapy as primary treatment of prostate cancer. The primary outcome measure was to determine the relationship between pre-scan PSA and the probability of identifying PSMA-avid disease suggestive of recurrent prostate cancer. RESULTS: Two hundred and seventy-six patients met criteria for inclusion. The median PSA was 3.60 ng/mL. The overall detection rate for suspected recurrent prostate cancer was 86.3%. Local recurrence was the most common site, occurring in 56.9% (157/276) of men, with isolated local recurrence in 32.6% (90/276). A total of 75.3% (55/73) of men below Phoenix criteria had scans suggestive of recurrent disease, with 52.1% of men having salvageable disease. The regions surrounding the iliac arteries were the most common areas of nodal metastatic disease, with 55.6% of recurrence occurring in the iliac regions. CONCLUSIONS: 68Ga-PSMA PET/CT frequently identifies suspected recurrent disease prior to the accepted Phoenix definition of PSA nadir +2. Prospective outcome studies are required to determine if early identification of local recurrence improves outcomes by increasing the use of salvage local treatments and whether earlier identification of metastatic disease may improve outcomes with prompt initiation of multimodality therapies.
Subject(s)
Brachytherapy/methods , Neoplasm Recurrence, Local/diagnostic imaging , Positron Emission Tomography Computed Tomography/methods , Prostate/diagnostic imaging , Prostatic Neoplasms/therapy , Aged , Aged, 80 and over , Dose Fractionation, Radiation , Gallium Isotopes , Gallium Radioisotopes , Humans , Male , Membrane Glycoproteins/administration & dosage , Middle Aged , Neoplasm Recurrence, Local/blood , Neoplasm Recurrence, Local/pathology , Organometallic Compounds/administration & dosage , Patient Selection , Prostate/pathology , Prostate/radiation effects , Prostate-Specific Antigen/blood , Prostatic Neoplasms/blood , Prostatic Neoplasms/diagnostic imaging , Radiopharmaceuticals/administration & dosage , Retrospective Studies , Salvage Therapy/methods , Treatment FailureABSTRACT
OBJECTIVE: To determine the number of men with 68 gallium-prostate-specific membrane antigen positron emission tomography/computed tomography (68 Ga-PSMA PET/CT) avid metastasis at diagnosis, as most data on 68 Ga-PSMA PET/CT are for the evaluation of recurrent disease after primary treatment and to our knowledge this study is the largest series of primary prostate cancer staging with 68 Ga-PSMA PET/CT. PATIENTS AND METHODS: A retrospective review conducted on 1253 consecutive men referred by urologists or radiation oncologists to our tertiary referral centre for 68 Ga-PSMA PET/CT scan for staging at the initial diagnosis of prostate cancer between July 2014 and June 2018. The primary outcome measure was to determine the risk of metastasis based on 68 Ga-PSMA PET/CT. Patients were risk stratified based on histological biopsy International Society of Urological Pathology (ISUP) grade, prostate-specific antigen (PSA) level, and staging with pre-biopsy multiparametric magnetic resonance imaging (mpMRI). Univariate and multivariate logistic regression were used to analyse results. RESULTS: The median PSA level was 6.5 ng/mL and median ISUP grade was 3, with high-risk disease in 49.7%. The prostate primary was PSMA avid in 91.7% of men. Metastatic disease was identified in 12.1% of men, including 8.2% with a PSA level of <10 ng/mL and 43% with a PSA level of >20 ng/mL. Metastases were identified in 6.4% with ISUP grade 2-3 and 21% with ISUP grade 4-5. Pre-biopsy mpMRI identified metastasis in 8.1% of T2 disease, increasing to 42.4% of T3b. Lymph node metastases were suspected in 107 men, with 47.7% outside the boundaries of an extended pelvic lymph node dissection. Skeletal metastases were identified in 4.7%. In men with intermediate-risk prostate cancer, metastases were identified in 5.2%, compared to 19.9% with high-risk disease. CONCLUSIONS: These results support the use of 68 Ga-PSMA PET/CT for primary staging of prostate cancer. Increasing PSA level, ISUP grade and radiological staging with mpMRI were all statistically significant prognostic factors for metastasis on both univariate and multivariate analysis.
Subject(s)
Membrane Glycoproteins , Organometallic Compounds , Prostatic Neoplasms/diagnostic imaging , Prostatic Neoplasms/pathology , Cohort Studies , Gallium Isotopes , Gallium Radioisotopes , Humans , Kallikreins/blood , Lymphatic Metastasis , Male , Neoplasm Metastasis , Neoplasm Staging/methods , Positron Emission Tomography Computed Tomography/methods , Prostate/diagnostic imaging , Prostate/pathology , Prostate-Specific Antigen/blood , Prostatic Neoplasms/epidemiology , Radiopharmaceuticals , Retrospective StudiesABSTRACT
PURPOSE: To review our experience with MRI-guided in-bore prostate biopsy (MRGB) and present a review of the literature on MRGB. METHODS: A retrospective review of patients presenting for MRGB between 2013 and 2018. Diagnostic and biopsy MRI scans were reviewed to collect data on scan dates, procedure times, characteristics of MRI targets (PI-RADS™ score, target size, ADC value and location). A review of the literature on MRGB for the period 2013-2018 was performed. RESULTS: 607 targets in 554 men were biopsied. Overall and significant cancer detection rate were 80% and 55% at a patient level, and 76 and 59% at the target level, respectively. Prostate cancer (CaP) detection in men with prior negative biopsy was 60% while 50% of men on active surveillance were upgraded to clinically significant disease (CSD). Lesion location did not predict for presence of CaP or CSD. PI-RADS™ score, age and PSAD were predictors of CSD at biopsy on multivariate analysis. Literature review identified 23 reports reporting on MRGB cohorts (~ 4000 patients). Overall cancer detection ranged from 23 to 74% and CSD in 63% overall. CaP detection in PI-RADS™ 3 targets was substantially lower in our series and the literature than for PI-RADS™ 4-5 targets. CONCLUSIONS: MRGB in PI-RADS™ 3-5 targets yields high rates of cancer diagnosis. High detection rates are also seen in men with prior negative biopsy and AS cohorts. PI-RADS™ score, age and PSAD can reliably predict CSD detection. The number of published series is small and the role of MRGB in PI-RADS™ 3 targets needs further study.
Subject(s)
Prostate/pathology , Prostatic Neoplasms/pathology , Aged , Biopsy, Large-Core Needle , Humans , Image-Guided Biopsy , Magnetic Resonance Imaging , Male , Middle Aged , Multiparametric Magnetic Resonance Imaging , Prostate/diagnostic imaging , Prostatic Neoplasms/diagnostic imaging , Retrospective Studies , Watchful WaitingABSTRACT
AIMS: The aims of this study were to evaluate the impact of tumour-associated necrosis (TAN) on metastasis-free survival for clear cell renal cell carcinoma (RCC), and to determine whether TAN provides survival information additional to World Health Organization (WHO)/International Society of Urological Pathology (ISUP) grading. METHODS AND RESULTS: The study consisted of 376 cases of clear cell RCC treated by nephrectomy, for which follow-up was available. WHO/ISUP grade was assigned, and sections were assessed for the presence of TAN. American Joint Committee on Cancer (AJCC) pT staging category and tumour size were also recorded. The development of metastatic disease was taken as the clinical endpoint, and survival analyses, utilising univariate and multivariate models, were performed. WHO/ISUP grades were: grade 1, 35 cases (9.3%); grade 2, 188 cases (50.0%); grade 3, 91 cases (24.2%); and grade 4, 62 cases (16.5%). Staging categories were pT1-pT2 [234 tumours (62.2%)] and pT3-pT4 [139 tumours (37.0%)]. TAN was seen in 128 cases (34.0%). Neither TAN nor metastases were seen in grade 1 tumours. Among grade 2-4 tumours, those with TAN had a significantly worse prognosis than those without TAN (P = 0.017, P = 0.04, and P = 0.006, respectively). Multivariate analysis (WHO/ISUP grade, pT staging category, and TAN) showed all three variables to be independently associated with outcome (P = 0.009, P = 0.005, and P = 0.001, respectively). For all tumour grades and pT staging categories, it was found that the presence of TAN was associated with a 2.91-fold greater risk of metastatic disease. CONCLUSION: Tumour-associated necrosis is an important prognostic factor for clear cell RCC, independently of WHO/ISUP grade. This supports the suggestion that TAN could be incorporated into tumour grading criteria.
Subject(s)
Carcinoma, Renal Cell/pathology , Kidney Neoplasms/pathology , Kidney/pathology , Adult , Aged , Aged, 80 and over , Carcinoma, Renal Cell/surgery , Female , Humans , Kidney Neoplasms/surgery , Male , Middle Aged , Necrosis/pathology , Neoplasm Grading , Nephrectomy , Prognosis , Treatment Outcome , World Health OrganizationABSTRACT
OBJECTIVES: To assess the safety, short-term efficacy and early functional results of prostate artery embolisation (PAE), an emerging minimally invasive treatment for symptomatic benign prostate hyperplasia (BPH). PATIENTS AND METHODS: In all, 51 men with BPH (prostate size >40 mL) causing moderate-severe lower urinary tract symptoms, who had either failed or ceased medical therapy and had declined or were considered unsuitable for surgical intervention, were recruited to this study. All men underwent baseline clinical assessment, PAE, and 3-month follow-up. The primary endpoints of this study were safety and feasibility. Safety was measured by the incidence of post-PAE adverse events and feasibility was defined by technical success. Secondary endpoints were changes in the International Prostate Symptom Score (IPSS) and quality of life (QoL) score at 3 months after PAE. RESULTS: There were no serious adverse events and all procedures were technically successful. For non-catheterised patients, improvement in IPSS and QoL was reported in 95.1% of cases (P < 0.001). The mean reductions in IPSS and QoL were 18.8 points (80.7%) (P < 0.001) and 3.8 points (80.6%) (P < 0.001), respectively. Of the 30 non-indwelling-catheter-dependent men on medical therapy, 23 men were able to completely cease all medications, with all but one of the remaining men reporting significant improvements in IPSS and QoL score. CONCLUSION: PAE is a technically feasible and safe procedure, with excellent short-term efficacy. High rates of patient satisfaction were achieved in this study, along with significant reductions in prostate symptoms and improvements in QoL. PAE may be an alternative to long-term use of medical therapy for symptoms due to BPH.