A Case of Penile Metastasis from Prostate Cancer, Identified by 68Ga-PSMA PET/CT, Mimicking Peyronie's Disease: A Diagnostic Challenge.

A 70-year-old man with high-risk prostate cancer (PCa) received radiation therapy and androgen deprivation therapy (ADT). The patient developed penile tenderness, compatible with Peyronie's disease upon physical examination. An ultrasound revealed a matching hypoechoic plaque and a thrombus in the vena dorsalis profunda, which were treated with anticoagulants. A follow-up ultrasound showed no abnormalities. Despite the use of analgesics, the patient suffered from persistent pain, later accompanied by an increasing PSA level of up to 7.5 ng/mL, despite ADT. 68Ga-PSMA PET/CT showed a PSMA uptake consistent with PCa penile metastasis. Due to severe pain and the presence of metastatic PCa, the patient was referred for penectomy. Histopathological analysis confirmed metastases originating from the PCa. This case underscores the importance of 68Ga-PSMA PET/CT in diagnosing PCa metastases and vigilance towards urogenital symptoms as potential indicators of metastases, despite the rarity of penile metastases.

Active Surveillance Versus Radical Prostatectomy in Favorable-risk Localized Prostate Cancer.

BACKGROUND: Active surveillance (AS) and radical prostatectomy (RP) are both accepted treatments for men with favorable-risk localized prostate cancer (PCa) (ie, clinical tumor category 1-2b, Gleason Grade Group 1-2, and prostate-specific antigen < 20 ng/mL). However, head-to-head studies comparing oncologic outcomes and survival between these 2 treatment strategies are warranted. The objective of this study was to compare the use of prostate cancer treatments and PCa death in men managed on AS and men who underwent immediate RP. PATIENTS AND METHODS: This was an observational study including 647 men on AS and 647 men treated with RP propensity score matched. We examined the 10-year cumulative incidence of salvage radiotherapy, hormonal therapy, castration-resistant PCa, and PCa death. RESULTS: The 10-year curative treatment-free survival for men on AS was 61% (95% confidence interval [CI], 57%-65%). No differences in use of salvage radiotherapy (AS, 2.7%; 95% CI, 1.4%-4.1% vs. RP 5.4%; 95% CI, 3.4%-7.3%), hormonal therapy (AS, 6.9%; 95% CI, 4.4%-9.4% vs. RP, 4.1%; 95% CI, 2.5%-5.6%), developing castration-resistant PCa (AS, 1.7%; 95% CI, 0.5%-2.9% vs. RP, 2.0%; 95% CI, 0.7%-3.4%), or cumulative PCa mortality (AS, 0.4%; 95% CI, 0%-1.0% vs. RP, 0.5%; 95% CI, 0%-1.5%) were observed between the treatment strategies. The main limitation was the non-random allocation to treatment strategy. CONCLUSION: In this observational study on men with favorable-risk localized PCa, we found similar PCa mortality at 10 years between men on AS and men who underwent immediate RP. Moreover, there were no differences in the use of PCa therapies between the groups. Our study supports active surveillance as a treatment strategy for men with favorable-risk localized PCa.

Prostate zonal segmentation in 1.5T and 3T T2W MRI using a convolutional neural network.

Zonal segmentation of the prostate gland using magnetic resonance imaging (MRI) is clinically important for prostate cancer (PCa) diagnosis and image-guided treatments. A two-dimensional convolutional neural network (CNN) based on the U-net architecture was evaluated for segmentation of the central gland (CG) and peripheral zone (PZ) using a dataset of 40 patients (34 PCa positive and 6 PCa negative) scanned on two different MRI scanners (1.5T GE and 3T Siemens). Images were cropped around the prostate gland to exclude surrounding tissues, resampled to 0.5 × 0.5 × 0.5 mm voxels and z -score normalized before being propagated through the CNN. Performance was evaluated using the Dice similarity coefficient (DSC) and mean absolute distance (MAD) in a fivefold cross-validation setup. Overall performance showed DSC of 0.794 and 0.692, and MADs of 3.349 and 2.993 for CG and PZ, respectively. Dividing the gland into apex, mid, and base showed higher DSC for the midgland compared to apex and base for both CG and PZ. We found no significant difference in DSC between the two scanners. A larger dataset, preferably with multivendor scanners, is necessary for validation of the proposed algorithm; however, our results are promising and have clinical potential.

Assessment of prostate cancer prognostic Gleason grade group using zonal-specific features extracted from biparametric MRI using a KNN classifier.

PURPOSE: To automatically assess the aggressiveness of prostate cancer (PCa) lesions using zonal-specific image features extracted from diffusion weighted imaging (DWI) and T2W MRI. METHODS: Region of interest was extracted from DWI (peripheral zone) and T2W MRI (transitional zone and anterior fibromuscular stroma) around the center of 112 PCa lesions from 99 patients. Image histogram and texture features, 38 in total, were used together with a k-nearest neighbor classifier to classify lesions into their respective prognostic Grade Group (GG) (proposed by the International Society of Urological Pathology 2014 consensus conference). A semi-exhaustive feature search was performed (1-6 features in each feature set) and validated using threefold stratified cross validation in a one-versus-rest classification setup. RESULTS: Classifying PCa lesions into GGs resulted in AUC of 0.87, 0.88, 0.96, 0.98, and 0.91 for GG1, GG2, GG1 + 2, GG3, and GG4 + 5 for the peripheral zone, respectively. The results for transitional zone and anterior fibromuscular stroma were AUC of 0.85, 0.89, 0.83, 0.94, and 0.86 for GG1, GG2, GG1 + 2, GG3, and GG4 + 5, respectively. CONCLUSION: This study showed promising results with reasonable AUC values for classification of all GG indicating that zonal-specific imaging features from DWI and T2W MRI can be used to differentiate between PCa lesions of various aggressiveness.

Active Surveillance for Localized Prostate Cancer: Nationwide Observational Study.

PURPOSE: The objective of this study was to investigate nationwide survival outcomes in men with localized prostate cancer managed on active surveillance. MATERIALS AND METHODS: A total of 936 men with localized prostate cancer were initiated on active surveillance in Denmark in 2002 to 2012. Kaplan-Meier estimated curative treatment-free, hormonal therapy-free, castration resistant prostate cancer-free and cause specific survival was calculated. RESULTS: Prostate cancer was classified as very low risk in 223 men, low risk in 436, intermediate risk in 259 (87% were at favorable intermediate risk) and high risk in 18. Median followup was 7.5 years (IQR 6.1-9.1). Kaplan-Meier estimated 10-year curative treatment-free survival was 62.8% (95% CI 59.1-66.3), 10-year hormonal therapy-free survival was 92.2% (95% CI 89.2-94.4), 10-year castration resistant prostate cancer-free survival was 97.2% (95% CI 95.3-98.4) and 10-year cause specific survival was 99.6% (95% CI 98.6-99.9). Compared to men with low risk prostate cancer, those with intermediate risk prostate cancer had higher curative treatment-free survival (69% vs 56%, p = 0.008), lower hormonal therapy-free survival (88% vs 95%, p = 0.005) and similar castration resistant prostate cancer-free survival (95% vs 99%, p = 0.17). CONCLUSIONS: In this nationwide cohort 10-year cause specific survival was similar to that in prospective active surveillance cohorts. Our study supports the use of active surveillance in men with localized prostate cancer, including men with favorable intermediate risk characteristics.

Prospective comparative study of 18F-sodium fluoride PET/CT and planar bone scintigraphy for treatment response assessment of bone metastases in patients with prostate cancer.

AIM: To compare 18F-sodium fluoride positron emission tomography/computed tomography (NaF PET/CT) and 99mTc-labelled diphosphonate bone scan (BS) for the monitoring of bone metastases in patients with prostate cancer undergoing anti-cancer treatment. MATERIAL AND METHODS: Data from 64 patients with prostate cancer were included. The patients received androgen-deprivation therapy (ADT), next-generation hormonal therapy (NGH) or chemotherapy. The patients had a baseline scan and 1-3 subsequent scans during six months of treatment. Images were evaluated by experienced nuclear medicine physicians and classified for progressive disease (PD) or non-PD according to the Prostate Cancer Working Group 2 (PCWG-2) criteria. The patients were also classified as having PD/non-PD according to the clinical and prostate-specific antigen (PSA) responses. RESULTS: There was no difference between NaF PET/CT and BS in the detection of PD and non-PD during treatment (McNemar's test, p = .18). The agreement between BS and NaF PET/CT for PD/non-PD was moderate (Cohen's kappa 0.53, 95% confidence interval 0.26-0.79). Crude agreement between BS and NaF PET/CT for the assessment of PD/non-PD was 86% (89% for ADT, n = 28; 88% for NGH, n = 16, and 80% for chemotherapy, n = 20). In most discordant cases, BS found PD when NaF PET/CT did not, or BS detected PD on an earlier scan than NaF PET/CT. Biochemical progression (27%) occurred more frequently than progression on functional imaging (BS, 22% and NaF PET/CT, 14%). Clinical progression was rare (11%), and almost exclusively seen in patients receiving chemotherapy. CONCLUSION: There was no difference between NaF PET/CT and BS in the detection of PD and non-PD; however, BS seemingly detects PD by the PCWG-2 criteria earlier than NaF-PET, which might be explained by the fact that NaF-PET is more sensitive at the baseline scan.

Length of life gained with surgical treatment of prostate cancer: A population-based analysis.

OBJECTIVE: The aim of this study was to analyse relative survival, excess mortality and gain in life expectancy in men who underwent radical prostatectomy (RP) for localized prostate cancer (PCa) between 1995 and 2011 in Denmark. MATERIAL AND METHODS: The study population comprised the complete cohort of 6489 men who underwent RP between 1995 and 2011. Risk of mortality was calculated using a competing risk model. Relative survival, excess mortality rate (EMR) and gain in life expectancy in men undergoing RP were calculated using a matched cohort Danish population based on date of birth and date of surgery. RESULTS: During follow-up 328 patients died, 109 (33.2%) of PCa and 219 (66.8%) of other causes. The cumulative incidence of PCa mortality was 5.8% [95% confidence interval (CI) 4.4, 7.2] after 10 years. Relative survival was significantly above 1.0 for RP patients, except for high-risk patients. EMR was -9.34 (95% CI -10.56, -8.13) after 10 years, i.e. nine men would die in excess of the general population. Overall, the gain in life expectancy in men undergoing RP compared with the general population was 0.41 years. CONCLUSION: This population-based study demonstrated that the gain in life expectancy with RP compared with the general population in Denmark is minimal.

[Scrotal Paget's disease].

A patient with extramammary Paget's disease (EMPD) had a plaque of the scrotum surgically removed. Histology and immunohistochemistry was consistent with primary EMPD. EMPD is a rare intraepidermal neoplasia mostly confined to regions of the skin with apocrine sweat glands. Clinical features include red plaques, which often will be mistakenly diagnosed as an infection or a rash. The treatment is surgical.

[Prevention of skeletal related events in patients with bone metastases from solid tumours]. / Forebyggelse af skeletrelaterede hændelser hos patienter med knoglemetastaser ved solide tumorer.

This article is based on a systematic literature search and meta-analyses of clinical data regarding effects of bisphosphonates (BP) and denosumab (DS) on preventing skeletal related events (SRE) in patients with bone metastases from solid tumours. Although there are pharmacological differences between the different types of BP no major differences were observed between BP in preventing SRE or in adverse events. Treatment with DS has in three randomised trials showed a greater effect than BP in preventing SRE. The optimal choice of bone-anti-resorptive agent should depend on the patient's general condition, renal function and treatment logistics.

MRI target delineation may reduce long-term toxicity after prostate radiotherapy.

BACKGROUND AND PURPOSE: Aiming for minimal toxicity after radical prostate cancer (PC) radiotherapy (RT), magnetic resonance imaging (MRI) target delineation could be a possible benefit knowing that clinical target volumes (CTV) are up to 30% smaller, when CTV delineation on MRI is compared to standard computed tomography (CT). This study compares long-term toxicity using CT or MRI delineation before PC RT. MATERIAL AND METHODS: Urinary and rectal toxicity assessments 36 months after image-guided RT (78 Gy) using CTC-AE scores in two groups of PC patients. Peak symptom score values were registered. One group of patients (n=72) had standard CT target delineation and gold markers as fiducials. Another group of patients (n=73) had MRI target delineation and a nickel-titanium stent as fiducial. RESULTS: At 36 months no difference in overall survival (92% in both groups, p=0.29) or in PSA-relapse free survival was found between the groups (MRI=89% and CT=94%, p=0.67). A significantly smaller CTV was found in the MRI group (p=0.02). Urinary retention and frequency were significantly reduced in the MRI group (p=0.03 in the matter of both). The overall urinary and rectal toxicity did not differ between the two groups. CONCLUSION: MRI delineation leads to a significantly reduced CTV. Significantly lower urinary frequency and urinary retention toxicity scores were observed following MRI delineation. The study did not find significant differences in overall urinary or rectal toxicity between the two groups. PSA-relapse survival did not differ between the two groups at 36 months.

Changes in preoperative characteristics in patients undergoing radical prostatectomy--a 16-year nationwide analysis.

BACKGROUND: The Danish attitude for diagnosis and treatment of early localized prostate cancer (PCa) has historically been conservative. Denmark introduced radical prostatectomy (RP) as the last of the Nordic countries in 1995. However, a rapid increment in the Danish incidence of PCa is indicative of a shift in attitude with increasing opportunistic PSA testing. This had led to an increasing number of RPs being performed in Denmark. The objective of this study was to analyze changes in preoperative characteristics over time for the complete cohort of 6489 men who underwent RP between 1995 and 2011. Our hypothesis was that an increasing amount of men undergo RP for lower risk PCa. MATERIAL AND METHODS: All patients operated from 1995 to 2011 were identified via patient files and registries. Changes over time in age at surgery, preoperative PSA, clinical T-category, biopsy Gleason score (GS), and D'Amico classification are described. Tests for statistically significant changes were performed. RESULTS: Median age increased from 61.4 to 64.8 years (p < 0.0001) during the 16-year period. Median PSA declined from 11.5 to 7.9 ng/ml (p < 0.0001). Distribution of biopsy GS changed significantly, especially after 2005. Biopsy GS = 7 was found in 20.2% of the patients in 2005 compared to 57.1% in 2011. The proportion of T1 disease increased from 32% to 56%. Significant changes in percentage of patients according to the D'Amico classification were found. After 2005 the proportion of intermediate-risk patients increased significantly. The proportion of patients age 70 or above increased from 2% to 13% in the period studies. CONCLUSION: Significant preoperative stage- and Gleason grade migration was found in this complete Danish nationwide cohort of patients undergoing RP during the past 16 years. This effect is most likely attributed to an increasing use of PSA as marker for early prostate cancer diagnosis in Denmark and new international guidelines for Gleason grading and scoring.

Survival after radical prostatectomy for clinically localised prostate cancer: a population-based study.

OBJECTIVES: To describe survival and cause of death in a nationwide cohort of Danish patients with prostate cancer undergoing radical prostatectomy (RP). To describe risk factors associated with prostate cancer mortality. PATIENTS AND METHODS: Observational study of 6489 men with localised prostate cancer treated with RP at six different hospitals in Denmark between 1995 and 2011. Survival was described using Kaplan-Meier estimates. Causes of death were obtained from the national registry and cross-checked with patient files. Cumulative incidence of death, any cause and prostate cancer-specific, was described using Nelson-Aalen estimates. Risk for prostate cancer death was analysed in a Cox multivariate regression model using the covariates: age, cT-category, PSA level and biopsy Gleason score. RESULTS: The median follow-up was 4 years. During follow-up, 328 patients died, 109 (33.2%) from prostate cancer and 219 (66.8%) from other causes. Six patients (0.09%) died ≤30 days of RP. In multivariate analysis, cT-category was a predictor of prostate cancer death (P < 0.001). Compared with T1 disease, both cT2c (hazard ratio [HR] 2.2) and cT3 (HR 7.2) significantly increased the risk of prostate cancer death. For every doubling of PSA level the risk of prostate cancer death was increased by 34.8% (P < 0.001). Biopsy Gleason score 4 + 3 and ≥8 were associated with an increased risk of prostate cancer death compared with biopsy Gleason score ≤ 6 of 2.3 and 2.7 (P = 0.003), respectively. The cumulative hazard of all-cause and prostate cancer-specific mortality after 10 years was 15.4% (95% confide3nce interval [CI] 13.2-17.7) and 6.6% (95% CI 4.9-8.2) respectively. CONCLUSIONS: We present the first survival analysis of a complete, nationwide cohort of men undergoing RP for localised prostate cancer. The main limitation of the study was the relatively short follow-up. Interestingly, our national results are comparable to high-volume, single institution, single surgeon series.

[Penile cysts]. / Simpel praeputialcyste.

Penile cysts are rare. In the literature, epidermoid cysts of the penis are a well-described entity. Here we describe a 21-year-old male who presented with a simple cyst on the dorsal aspect of the prepuce.

Pseudosarcomatous fibromyxoid tumor of the prostate.

A very rare case of benign infravesical obstruction due to a pseudosarcomatous fibromyxoid tumor of the prostate is presented. This entity is clinically and histologically difficult to distinguish from a malignant lesion. A discussion of the histopathological features and a review of the literature is given.