Confirmatory biopsy of men under active surveillance: extended versus saturation versus multiparametric magnetic resonance imaging/transrectal ultrasound fusion prostate biopsy.

OBJECTIVE: The aim of this study was to evaluate the detection rate for clinically significant prostate cancer (PCa) after multiparametric magnetic resonance imaging (mpMRI)/transrectal ultrasound (TRUS) fusion biopsy versus extended biopsy or saturation prostate biopsy (SPBx) in men enrolled on active surveillance (AS). MATERIALS AND METHODS: From May 2013 to January 2016, 100 men with very low-risk PCa were enrolled on AS. Eligible criteria were: life expectancy greater than 10 years, cT1c, prostate-specific antigen (PSA) below 10 ng/ml, PSA density less than 0.20 ng/ml², three or fewer unilateral positive biopsy cores, Gleason score (GS) equal to 6 and greatest percentage of cancer in a core 50% or lower. All patients underwent 3.0 T pelvic mpMRI before confirmatory transperineal extended biopsy (20 cores) and SPBx (median 30 cores) combined with mpMRI/TRUS fusion targeted biopsy (median four cores) of suspicious lesions [Prostate Imaging Reporting and Data System (PI-RADS) 3-5]. Clinically significant PCa was defined as the presence of at least one core with a GS of 4 or higher. RESULTS: After confirmatory biopsy, 16 out of 60 (26.6%) patients showed significant PCa. Targeted biopsy of PI-RADS 4-5 versus PI-RADS 3-5 lesions diagnosed six out of 16 (37.5%) and 12 out of 16 (87.5%) significant PCa, respectively, with two false positives (5%). The detection rate for significant PCa was equal to 68.8% on mpMRI/TRUS fusion biopsy, 75% on extended biopsy and 100% on SPBx. mpMRI/TRUS targeted biopsy and extended biopsy missed five out of 16 (31.2%) and four out of 16 (25%) PCa, respectively. CONCLUSIONS: Although mpMRI may improve the diagnosis of significant PCa in men under AS, SPBx had a higher detection rate for clinically significant PCa.

Multiparametric MRI Apparent Diffusion Coefficient (ADC) Accuracy in Diagnosing Clinically Significant Prostate Cancer.

AIM: To evaluate the accuracy of multiparametric magnetic resonance imaging apparent diffusion coefficient (mpMRI ADC) in the diagnosis of clinically significant prostate cancer (PCa). PATIENTS AND METHODS: From January 2016 to December 2016, 44 patients who underwent radical prostatectomy for PCa and mpMRI lesions suggestive of cancer were retrospectively evaluated at definitive specimen. The accuracy of suspicious mpMRI prostate imaging reporting and data system (PI-RADS ≥3) vs. ADC values in the diagnosis of Gleason score ≥7 was evaluated. RESULTS: Receiver operating characteristics (ROC) curve analysis gave back an ADC threshold of 0.747×10-3 mm2/s to separate between Gleason Score 6 and ≥7. The diagnostic accuracy of ADC value (cut-off 0.747×10-3 mm2/s) vs. PI-RADS score ≥3 in diagnosing PCa with Gleason score ≥7 was equal to 84% vs. 63.6% with an area under the curve (AUC) ROC of 0.81 vs. 0.71, respectively. CONCLUSION: ADC evaluation could support clinicians in decision making of patients with PI-RADS score <3 at risk for PCa.

Transperineal Versus Transrectal MRI/TRUS Fusion Targeted Biopsy: Detection Rate of Clinically Significant Prostate Cancer.

INTRODUCTION: To evaluate the detection rate for clinically significant prostate cancer (PCa) of transperineal (TP) versus transrectal (TR) multiparametric (mp) magnetic resonance imaging (MRI)/transrectal ultrasound-guided (TRUS) fusion targeted biopsy. PATIENTS AND METHODS: From January 2015 to January 2016, a total of 200 men (median age, 61 years) with negative digital rectal examination findings underwent repeat saturation TP prostate biopsy (SPBx; median 30 cores) for increasing or persistent elevated prostate-specific antigen values. Ten day before SPBx, all patients underwent 3.0 T pelvic mpMRI (Achieva 3T; Philips Healthcare Best, Netherlands). In the presence of mpMRI lesions suggestive of cancer (Prostate Imaging-Reporting and Data System [PI-RADS] score 4/5), targeted mpMRI/TRUS TR fusion guided biopsies (4 cores) and TP cognitive biopsies (4 cores) were added to SPBx. RESULTS: Median prostate-specific antigen was 8.6 ng/mL, and mpMRI revealed a suspicious lesion in 95 (47.5%) of 200 cases. Overall, in 60 (30%) of 200 men, a clinically significant PCa was found, and in all cases, mpMRI was positive. SPBx, TR fusion, and mpMRI/TRUS TP cognitive targeted biopsy diagnosed 59 (98.3%), 40 (78.3%), and 56 (93.3%) clinically significant PCa, respectively. TR fusion versus TP targeted biopsy missed 12 versus 1 (P = .001) cancers of the anterior zone and 8 versus 3 (P = .12) cancers of the peripheric gland, respectively; moreover, PCa diagnosed by TR fusion versus TP targeted biopsy had a mpMRI lesion diameter and percentage of positive cores equal to 13 versus 10 mm and 33% versus 58% (P = .001), respectively. CONCLUSION: mpMRI/TRUS TP cognitive targeted biopsy found a greater percentage of clinically significant PCa of the anterior zone compared to the mpMRI/TRUS TR fusion approach (93.3% vs. 25%; P = .0001).

Accuracy of pelvic multiparametric MRI in diagnosing local recurrence following radical prostatectomy. Case report and revision of the literature.

A Caucasian man (73 years old) six years from radical prostatectomy for prostate cancer (PCa) showed biochemical recurrence (BCR); the follow up based on PSA evaluated every 6 months was negative (0.1 ng/ml) for 5 years, but in the last year PSA increased to 0.3 vs 0.5 ng/ml. The patient was asymptomatic and underwent 3.0 Tesla mpMRI equipped with surface 16 channels phased-array coil placed around the pelvic area; multiplanar turbo spin-echo T2-weighted (T2W), axial diffusion weighted imaging (DWI), axial dynamic contrast enhanced (DCE) and spectroscopy were performed. Pelvic mpMRI demonstrated the presence of a nodular tissue with a diameter of 10 mm. located on the left of the prostatic fossa near the rectum that was higly sospicious for local PCa recurrence. The patient underwent salvage RT (64 Gy); one year from RT PSA was 0.1 ng/ml suggesting that the patient was free from recurrence. In conclusion, mpMRI could be combined with PSA kinetics in the evaluation of men with BRC also in the presence of PSA values < 1 ng/ml.

Detection rate for significant cancer at confirmatory biopsy in men enrolled in Active Surveillance protocol: 20 cores vs 30 cores vs MRI/TRUS fusion prostate biopsy.

INTRODUCTION: The detection rate for significant prostate cancer of extended vs saturation vs mMRI/TRUS fusion biopsy was prospectively evaluated in men enrolled in active surveillance (AS) protocol. Mterials and methods: From May 2013 to September 2016 75 men aged 66 years (median) with very low risk PCa were enrolled in an AS protocol and elegible criteria were: life expectancy greater than 10 years, cT1C, PSA below 10 ng/ml, PSA density < 0.20, 2 < unilateral positive biopsy cores, Gleason score (GS) equal to 6, greatest percentage of cancer (GPC) in a core < 50%. All patients underwent 3.0 Tesla pelvic mpMRI before confirmatory transperineal extended (20 cores) or saturation biopsy (SPBx; 30 cores) combined with mpMRI/TRUS fusion targeted biopsy (4 cores) of suspicious lesions (PI-RADS 3-5). RESULTS: 21/75 (28%) patients were reclassified by SPBx based on upgraded GS ≥ 7; mpMRI lesions PI-RADS 4-5 vs PI-RADS 3-5 diagnosed 9/21 (42.8%) vs 16/21 (76.2%) significant PCa with 2 false positives (6.5%). The detection rate for significant PCa was equal to 76.2% (mpMRI/TRUS fusion biopsy) vs 81% (extended) vs 100% (SPBx) (p = 0.001); mpMRI/TRUS targeted biopsy and extended biopsy missed 5/21 (23.8%) and 4/21 (19%) significant PCa which were found by SPBx (p = 0.001) being characterised by the presence of a single positive core of GS ≥ 7 with GPC < 10%. CONCLUSIONS: Although mpMRI improve the diagnosis of clinically significant PCa, SPBx is provided of the best detection rate for PCa in men enrolled in AS protocols who underwent confirmatory biopsy.

Can MRI/TRUS fusion targeted biopsy replace saturation prostate biopsy in the re-evaluation of men in active surveillance?

PURPOSE: The detection rate for significant prostate cancer of mMRI/TRUS fusion targeted biopsy versus saturation prostate biopsy was prospectively evaluated in men enrolled in active surveillance (AS) protocol. METHODS: From May 2013 to January 2015, 40 men aged 66 years (median) with very low-risk PCa were enrolled in an AS protocol, and eligible criteria were: life expectancy greater than 10 years, cT1C, PSA below 10 ng/ml, PSA density <0.20, ≤2 unilateral positive biopsy cores, Gleason score (GS) equal to 6, greatest percentage of cancer (GPC) in a core ≤50 %. All patients underwent 3.0-Tesla pelvic mpMRI before confirmatory transperineal saturation biopsy (SPBx; median 30 cores) combined with mpMRI/TRUS fusion targeted biopsy (median 4 cores) of suspicious lesions (PI-RADS 4-5). RESULTS: Ten out of 40 (25 %) patients were reclassified by SPBx based on upgraded GS ≥ 7; mpMRI found all the lesions predictive of significant PCa showing a false-positive rate equal to 5 %; on the contrary, mpMRI/TRUS targeted biopsy missed 3/10 (30 %) significant PCa characterised by the presence of a single positive core of GS ≥ 7 and GPC ≤ 5 %, suggesting that reduced number of targeted biopsies could miss small but significant PCa. Diagnostic accuracy, sensitivity, specificity, and positive and negative predictive value of mpMRI in diagnosing significant PCa were 95.2, 100, 93.8, 83.4, 100 %, respectively. CONCLUSIONS: Although mpMRI provided high diagnostic accuracy (about 95 %) in diagnosing clinically significant PCa, mpMRI/TRUS fusion targeted biopsy cannot replace SPBx at confirmatory biopsy of men enrolled in AS protocols.

Multiparametric pelvic MRI accuracy in diagnosing clinically significant prostate cancer in the reevaluation of biopsy microfocal tumor.

AIM: To evaluate the accuracy of multi-parametric pelvic magnetic resonance imaging (mpMRI) in diagnosing prostate cancer (PCa) in men with initial biopsy microfocal cancer. PATIENTS AND METHODS: From January 2012 to July 2014, 40 patients before undergoing repeat transperineal saturation prostate biopsy (SPBx; median, 28 cores) for the presence of a microfocal PCa were submitted to 3.0-Tesla mpMRI. RESULTS: A T1c clinical stage PCa was found in 23 (57.5%) patients submitted to SPBx; mpMRI was positive in 16/40 (40%) cases and in 11 of them a clinically significant PCa was found. On the contrary, the 12 men with negative mpMRI had a quantitative histology suitable for clinically insignificant cancer. Diagnostic accuracy of mpMRI in diagnosing significant PCa was equal to 100%. CONCLUSION: Multi-parametric pMRI should be suggested in the re-evaluation of microfocal cancer as a selection approach of patients at risk for clinically significant PCa.

Can 3-Tesla pelvic phased-array multiparametric MRI avoid unnecessary repeat prostate biopsy in patients with PSA < 10 ng/mL?

INTRODUCTION: The aim of this study was to evaluate multiparametric pelvic magnetic resonance imaging (mpMRI) accuracy in prostate cancer (PCa) diagnosis. PATIENTS AND METHODS: From June 2011 to March 2014, 100 patients (median age, 64 years) with negative digital rectal examination underwent repeat transperineal saturation biopsy (SPBx; median, 29 cores) for persistent prostate-specific antigen (PSA) values between 4.1 and 10 ng/mL with free/total PSA ≤ 25%. All patients underwent mpMRI using a 3.0-Tesla scanner (ACHIEVA; Philips) equipped with surface 16 channels phased-array coil and lesions suspicious for PCa were submitted to additional targeted biopsies. RESULTS: A T1c PCa was found in 37 (37%) of cases; SPBx and mpMRI targeted biopsy diagnosed 34 (34%) and 29 (29%) cancers, missing 3 (all of the anterior zone) and 8 cancers (7 and 1 of the lateral margins and anterior zone, respectively); in detail, mpMRI missed 8 (21.7%) PCa characterized by minimal histological disease at risk for insignificant cancer. The diameter of the mpMRI suspicious lesion was significantly correlated with the diagnosis of PCa with poor Gleason score (P = .005). The detection rate of cancer for each mpMRI core was 40.7%; moreover, mpMRI would have spared 31 (31%) unnecessary SPBx. Diagnostic accuracy, sensitivity, specificity, and positive and negative predictive value of mpMRI in diagnosing overall cancer versus significant PCa was 82.6% versus 81.3%, 82.2% versus 100%, 77.8% versus 78.9%, 65.4% versus 55.8%, and 95.5% versus 100%, respectively. CONCLUSION: mpMRI targeted biopsy improved diagnosis of significant anterior zone PCa, missing cancers at risk for clinically insignificant disease; moreover, the diameter of the lesion on mpMRI was significantly predictive of aggressive PCa.

Accuracy of 3 Tesla pelvic phased-array multiparametric MRI in diagnosing prostate cancer at repeat biopsy.

INTRODUCTION: Multiparametric pelvic magnetic resonance imaging (mpMRI) accuracy in prostate cancer (PCa) diagnosis was evaluated. MATERIALS AND METHODS: From June 2011 to December 2013, 168 patients (median 65 years) with negative digital rectal examination underwent repeat transperineal saturation biopsy (SPBx; median 28 cores) for persistently high or increasing PSA values, PSA >10 ng/ml or PSA values between 4.1-10 o r 2.6-4 ng/ml with free/total PSA < 25% and < 20%, respectively. All patients underwent mpMRI using a 3.0 Tesla scanner equipped with surface 16 channels phased-array coil and lesions suspicious for PCa were submitted to additional targeted biopsies. RESULTS: A T1c PCa was found in 66 (39%) cases; SPBx and mpMRI-suspicious targeted biopsy diagnosed 60 (91%) and 52 (78.8%) cancers missing 6 (all of the anterior zone) and 14 cancers (12 and 2 of the lateral margins and anterior zone), respectively; in detail, mpMRI missed 12 (18.1%) PCa charaterized by microfocal (1 positive core with greatest percentage of cancer and Gleason score equal to 5% and 6, respectively) disease at risk for insignificant cancer. The diameter of the suspicious mpMRI lesion was directly correlated to the diagnosis of PCa with poor Gleason score (p < 0.05); detection rate of cancer for each suspicious mpMRI core was 35.3%. Diagnostic accuracy, sensitivity, specificity, positive and negative predictive value of mpMRI in diagnosing PCa was 75.7%, 82.5%, 71.8%, 78.9%, 87.9%, respectively. CONCLUSION: Multiparametric pMRI improved SPBx accuracy in diagnosing significant anterior PCa; the diameter of mpMRI suspicious lesion resulted significantly predictive of aggressive cancers.

Prostate cancer detection at repeat biopsy: can pelvic phased-array multiparametric MRI replace saturation biopsy?

AIM: Magnetic resonance imaging (MRI) accuracy in prostate cancer (PCa) diagnosis in men submitted to saturation prostate biopsy (SPBx) was evaluated. MATERIALS AND METHODS: From June 2011 to December 2012, 78 patients (median 63 years) underwent repeat SPBx (median 28 cores). Multiparametric MRI using a 3 Tesla pelvic phased-array coil was performed before SPBx and lesions suspicious for PCa were submitted to additional targeted biopsies. RESULTS: A T1c PCa was found in 32 (41%) cases. SPBx vs. MRI-suspicious targeted biopsy diagnosed 28 (87.5%) vs. 26 (81.2%) PCa missing four (12.5%) and six (18.8%) cancers localized in the anterior zone and in the lateral margin of the prostate, respectively; moreover, MRI diameter lesions correlated with PCa diagnosis and Gleason score (p<0.05). CONCLUSION: Multiparametric MRI improved SPBx accuracy in diagnosing PCa of the anterior zone; moreover, suspicious areas >10 mm resulted as highly predictive of cancer (about 70% of the cases).

Partial priapism secondary to idiophatic segmental thrombosis of corpora cavernosa.

A 51-year-old man presented at our department 2 days after the onset of a painful mass in the perineum and dysuria. Diagnosis of partial priapism secondary to proximal segmental corpora cavernosa thrombosis was made through colordoppler ultrasound (CDU) and magnetic resonance imaging (MRI). Treatment consisted of administration of systemic anticoagulation drugs (acenocumarol) and local injection of ethylephrine chloridrate. The thrombosis resolved after two months with incomplete restoration of erectile function (loss of rigidity). In conclusion, on the basis of previous reports (23 cases reported in literature) and our experience, in presence of painful mass in the perineum, CDU and MRI evaluation allows to make diagnosis of the rare proximal partial priapism that as first option should be treated conservatively.