Aquablation versus HoLEP in patients with benign prostatic hyperplasia: a comparative prospective non-randomized study.

PURPOSE: The question of best surgical treatment for lower urinary tract symptoms (LUTS) due to benign prostate hyperplasia (BPH) remains controversial. We compared the outcomes of aquablation and holmium laser enucleation of the prostate ("HoLEP") in a prospective cohort. METHODS: Patients with BPH underwent aquablation or HoLEP according to their preference between June 2020 and April 2022. Prostate volume ("PV"), laboratory results, postvoid residual volume, uroflowmetry, IPSS, ICIQ-SF, MSHQ-EjD, EES and IIEF were evaluated preoperatively and at three, six and 12 months postoperatively. We also analyzed perioperative characteristics and complications via the Clavien Dindo ("CD") classification. RESULTS: We included 40 patients, 16 of whom underwent aquablation and 24 HoLEP. Mean age was 67 years (SD 7.4). Baseline characteristics were balanced across groups, except the HoLEP patients' larger PV. IPSS fell from 20.3 (SD 7.1) at baseline to 6.3 (SD 4.2) at 12 months (p < 0.001) without differences between aquablation and HoLEP. HoLEP was associated with shorter operation time (59.5 (SD 18.6) vs. 87.2 (SD 14.8) minutes, p < 0.001) and led to better PV reduction over all timepoints. At three months, aquablation's results were better regarding ejaculatory (p = 0.02, MSHQ-EjD) and continence function (p < 0.001, ICIQ-SF). Beyond three months, erectile, ejaculatory, continence function and LUTS reduction did not differ significantly between aquablation and HoLEP. CD ≥ grade 3b complications were noted in six patients in aquablation group while only one in HoLEP group (p = < 0.01). CONCLUSIONS: While aquablation revealed temporary benefits regarding ejaculation and continence at three months, HoLEP was superior concerning operation time, the safety profile and volumetric results.

Primary results of patients with genitourinary malignancies presented at a Molecular Tumor Board.

PURPOSE: Personalized medicine poses great opportunities and challenges. While therapeutic landscape markedly expands, descriptions about status, clinical implementation and real-world benefits of precision oncology and molecular tumor boards (MTB) remain sparse, particularly in the field of genitourinary (GU) cancer. Hence, this study characterized urological MTB cases to better understand the potential role of MTB in uro-oncology. METHODS: We analyzed patients with complete data sets being reviewed at an MTB from January 2019 to October 2022, focusing on results of molecular analysis and treatment recommendations. RESULTS: We evaluated 102 patients with GU cancer with a mean patient age of 61.7 years. Prostate cancer (PCa) was the most frequent entity with 52.9% (54/102), followed by bladder cancer (18.6%, 19/102) and renal cell carcinoma (14.7%, 15/102). On average, case presentation at MTB took place 54.9 months after initial diagnosis and after 2.7 previous lines of therapy. During the study period 49.0% (50/102) of patients deceased. Additional MTB-based treatment recommendations were achieved in a majority of 68.6% (70/102) of patients, with a recommendation for targeted therapy in 64.3% (45/70) of these patients. Only 6.7% (3/45) of patients - due to different reasons - received the recommended MTB-based therapy tough, with 33% (1/3) of patients reaching disease control. Throughout the MTB study period, GU cancer case presentations and treatment recommendations increased, while the time interval between initial presentation and final therapy recommendation were decreasing over time. CONCLUSION: Presentation of uro-oncological patients at the MTB is a highly valuable measure for clinical decision-making. Prospectively, earlier presentation of patients at the MTB and changing legislative issues regarding comprehensive molecular testing and targeted treatment approval might further improve patients' benefits from comprehensive molecular diagnostics.

Prospective Multicenter Validation of the Stockholm3 Test in a Central European Cohort.

BACKGROUND: It has been shown that the Stockholm3 test decreases overdetection of prostate cancer (PCa) while retaining the ability to detect clinically significant PCa (csPCa) in a Swedish population. However, the test includes potentially population-specific testing of single-nucleotide polymorphisms and has yet not been validated outside Scandinavia. OBJECTIVE: To assess the performance of the Stockholm3 test in discriminating csPCa in a Central European cohort undergoing prostate biopsy (PBx). DESIGN, SETTING, AND PARTICIPANTS: This prospective multicenter validation study was conducted from August 2020 to September 2022 at two centers in Switzerland and one center in Germany. The study involved 342 men undiagnosed with PCa who were scheduled for PBx after prostate-specific antigen (PSA) testing and subsequent magnetic resonance imaging (MRI) of the prostate. Before PBx, participants had a blood sample taken for Stockholm3 testing. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome was the accuracy of the Stockholm3 test in detecting csPCa (International Society of Urological Pathology grade group [GG] ≥2) according to the area under the receiver operating characteristic curve (AUC), sensitivity, and specificity, and the clinical consequences of using the model. RESULTS AND LIMITATIONS: The Stockholm3 test with a cutoff of 11% for csPCa detection had sensitivity of 92.3% (95% confidence interval [CI] 86.9-95.9%), specificity of 32.6% (95% CI 26.0-39.8%), a positive predictive value of 53.2% (95% CI 47.0-59.2%), and a negative predictive value of 83.6% (95% CI 73-91.2%). It showed superior discrimination for csPCa (AUC 0.77, 95% CI 0.72-0.82) in comparison to PSA (AUC 0.66, 95% CI 0.61-0.72; p < 0.001). Using a Stockholm3 cutoff of 11%, PBx could have been omitted for 73 men (21.0%), and 12/154 (8%) csPCa and 2/72 (2.8%) GG >2 cases would have been missed. Limitations include population selection bias. CONCLUSIONS: Our results show favorable clinical outcomes for the blood-based Stockholm3 biomarker test in a Central European patient cohort. PATIENT SUMMARY: The Stockholm3 blood test shows better accuracy in predicting prostate cancer than the more common PSA (prostate-specific antigen) test.

A Machine Learning Framework Reduces the Manual Workload for Systematic Reviews of the Diagnostic Performance of Prostate Magnetic Resonance Imaging.

Prostate magnetic resonance imaging has become the imaging standard for prostate cancer in various clinical settings, with interpretation standardized according to the Prostate Imaging Reporting and Data System (PI-RADS). Each year, hundreds of scientific studies that report on the diagnostic performance of PI-RADS are published. To keep up with this ever-increasing evidence base, systematic reviews and meta-analyses are essential. As systematic reviews are highly resource-intensive, we investigated whether a machine learning framework can reduce the manual workload and speed up the screening process (title and abstract). We used search results from a living systematic review of the diagnostic performance of PI-RADS (1585 studies, of which 482 were potentially eligible after screening). A naïve Bayesian classifier was implemented in an active learning environment for classification of the titles and abstracts. Our outcome variable was the percentage of studies that can be excluded after 95% of relevant studies have been identified by the classifier (work saved over sampling: WSS@95%). In simulation runs of the entire screening process (controlling for classifier initiation and the frequency of classifier updating), we obtained a WSS@95% value of 28% (standard error of the mean ±0.1%). Applied prospectively, our classification framework would translate into a significant reduction in manual screening effort. Patient summary: Systematic reviews of scientific evidence are labor-intensive and take a lot of time. For example, many studies on prostate cancer diagnosis via MRI (magnetic resonance imaging) are published every year. We describe the use of machine learning to reduce the manual workload in screening search results. For a review of MRI for prostate cancer diagnosis, this approach reduced the screening workload by about 28%.

[Novel hormone treatment for advanced prostate cancer]. / Neuartige Hormontherapien beim fortgeschrittenen Prostatakarzinom.

The systemic treatment of advanced prostate cancer (PCa) has undergone an absolute revolution in the past decade. Numerous new substances have been approved for all stages of advanced disease and treatment has been increasingly intensified. The focus continues to be on substances with an effect on the androgen receptor axis. In this review, approved treatment options for metastatic hormone-sensitive PCa (mHSPC), non-metastatic castration-refractory PCa (nmCRPC) and metastatic castration-refractory PCa (mCRPC) are summarized. A special focus is on novel hormone therapeutic agents. Based on recent trial data, potential triple combinations for mHSPC as well as treatment sequence options and novel targeted agents for mCRPC are also highlighted.

Prediction of upgrade to clinically significant prostate cancer in patients under active surveillance: Performance of a fully automated AI-algorithm for lesion detection and classification.

BACKGROUND: Multiparametric MRI (mpMRI) improves the detection of aggressive prostate cancer (PCa) subtypes. As cases of active surveillance (AS) increase and tumor progression triggers definitive treatment, we evaluated whether an AI-driven algorithm can detect clinically significant PCa (csPCa) in patients under AS. METHODS: Consecutive patients under AS who received mpMRI (PI-RADSv2.1 protocol) and subsequent MR-guided ultrasound fusion (targeted and extensive systematic) biopsy between 2017 and 2020 were retrospectively analyzed. Diagnostic performance of an automated clinically certified AI-driven algorithm was evaluated on both lesion and patient level regarding the detection of csPCa. RESULTS: Analysis of 56 patients resulted in 93 target lesions. Patient level sensitivity and specificity of the AI algorithm was 92.5%/31% for the detection of ISUP ≥ 1 and 96.4%/25% for the detection of ISUP ≥ 2, respectively. The only case of csPCa missed by the AI harbored only 1/47 Gleason 7a core (systematic biopsy; previous and subsequent biopsies rendered non-csPCa). CONCLUSIONS: AI-augmented lesion detection and PI-RADS scoring is a robust tool to detect progression to csPCa in patients under AS. Integration in the clinical workflow can serve as reassurance for the reader and streamline reporting, hence improve efficiency and diagnostic confidence.

Prediction of Significant Prostate Cancer in Equivocal Magnetic Resonance Imaging Lesions: A High-volume International Multicenter Study.

BACKGROUND: Decision of performing prostate biopsy in men with Prostate Imaging Reporting and Data System (PI-RADS) 3 findings in prostate magnetic resonance imaging (MRI) is challenging as they have a low but still relevant risk of harboring significant prostate cancer (sPC). OBJECTIVE: To identify clinical predictors of sPC in men with PI-RADS 3 lesions in prostate MRI and to analyze the hypothetical effect of incorporating prostate-specific antigen density (PSAD) into biopsy decision. DESIGN, SETTING, AND PARTICIPANTS: We analyzed a retrospective multinational cohort from ten academic centers comprising 1476 men who underwent a combined prostate biopsy (MRI targeted plus systematic biopsy) between February 2012 and April 2021 due to a PI-RADS 3 lesion in prostate MRI. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome was the detection of sPC (ISUP ≥2) in a combined biopsy. Predictors were identified by a regression analysis. Descriptive statistics were applied to evaluate the hypothetical effect of involving PSAD into biopsy decision. RESULTS AND LIMITATIONS: Of all patients, 273/1476 (18.5%) were diagnosed with sPC. MRI-targeted biopsy diagnosed fewer sPC cases than combined strategy: 183/1476 (12.4%) versus 273/1476 (18.5%), p < 0.01. Age (odds ratio [OR] 1.10 [95% confidence interval {CI}: 1.05-1.15], p < 0.001), prior negative biopsy (OR 0.46 [0.24-0.89], p = 0.022), and PSAD (p < 0.001) were found to be independent predictors of sPC. Applying a PSAD cutoff of 0.15, 817/1398 (58.4%) biopsies would have been avoided at the cost of missing sPC in 91 (6.5%) men. Limitations were the retrospective design, heterogeneity of the study cohort due to the long inclusion period, and no central revision of MRI. CONCLUSIONS: Age, previous biopsy status, and PSAD were found to be independent predictors of sPC in men with equivocal prostate MRI. Implementation of PSAD into biopsy decision can avoid unnecessary biopsies. Clinical parameters such as PSAD need validation in a prospective setting. PATIENT SUMMARY: In this study, we looked for clinical predictors of significant prostate cancer in men with Prostate Imaging Reporting and Data System 3 lesions in prostate magnetic resonance imaging. We identified age, previous biopsy status, and especially prostate-specific antigen density as independent predictors.

Individualized Decision Making in Transperineal Prostate Biopsy: Should All Men Undergo an Additional Systematic Biopsy?

Background: In prostate cancer (PC) diagnosis, additional systematic biopsy (SB) is recommended to complement MRI-targeted biopsy (TB) to address the limited sensitivity of TB alone. The combination of TB+SB is beneficial for diagnosing additional significant PC (sPC) but harmful in terms of the additional diagnosis of indolent PC (iPC), morbidity, and resource expenditures. We aimed to investigate the benefit of additional SB and to identify predictors for this outcome. Methods: We analyzed the frequency of upgrading to sPC by additional SB in a retrospective single-center cohort of 1043 men. Regression analysis (RA) was performed to identify predictors for this outcome. Reclassification rates of ISUP grade groups between prostate biopsy and a subsequent radical prostatectomy were assessed. Results: Additional SB led to upgrading to sPC in 98/1043 men (9.4%) and to the additional diagnosis of iPC in 71/1043 (6.8%). In RA, men harboring a PI-RADS 2-4 lesion were more likely to have TB results upgraded by SB (p < 0.01) compared to PI-RADS 5 men. When analyzing reclassification rates, additional SB reduced the upgrading to sPC from 43/214 (20.1%) to 8/214 (3.7%). In the PI-RADS 5 subgroup, this difference decreased: 4/87 (4.7%) with TB only vs. 1/87 (1.2%) with TB+SB. Conclusion: Men with a PI-RADS 5 lesion may obviate additional SB.

Development and Implementation of an Advanced Program for Robotic Treatment of Prostate Cancer-Is Surgical Quality Transferable?

Introduction: Robot-assisted radical prostatectomy (RARP) is a surgical treatment option for prostate cancer (PC). Quality in RARP depends on the surgeon´s operative volume and expertise. When implementing RARP, it is standard practice to hire a pre-trained surgeon. The aim of our study was to investigate the transferability of quality in RARP. Patients and Methods: We analyzed two consecutive retrospective cohorts of 100 and 108 men, respectively, who underwent RARP at two different centers and on whom surgery was performed by the same surgeon. Results: There were more men with high-grade PC in Cohort 1: 25/100 (25.0%) vs. 9/108 (8.3%), p < 0.01, and infiltration of the seminal vesicles was more frequent (23/100 (23.0%) vs. 10/108 (9.2%), p < 0.01). In Cohort 2, the duration of surgery was shorter and blood loss was lower: 149 (134−174) vs. 172 min (150−196), p < 0.01 and 300 (200−400) vs. 131 (99−188) mL, p < 0.01. No difference was found in the proportion of positive surgical margins in the T2 cohort (8.8% vs. 8.2%, p = 1.00). Conclusion: The procedural and oncological outcome parameters of Cohort 2 do not appear to be inferior to the results obtained for the first cohort. The quality of RARP is transferable if a pre-trained surgeon is hired.

Living systematic review and meta-analysis of the prostate MRI diagnostic test with Prostate Imaging Reporting and Data System (PI-RADS) assessment for the detection of prostate cancer: study protocol.

INTRODUCTION: The Prostate Imaging Reporting and Data System (PI-RADS) standardises reporting of prostate MRI for the detection of clinically significant prostate cancer. We provide the protocol of a planned living systematic review and meta-analysis for (1) diagnostic accuracy (sensitivity and specificity), (2) cancer detection rates of assessment categories and (3) inter-reader agreement. METHODS AND ANALYSIS: Retrospective and prospective studies reporting on at least one of the outcomes of interest are included. Each step that requires literature evaluation and data extraction is performed by two independent reviewers. Since PI-RADS is intended as a living document itself, a 12-month update cycle of the systematic review and meta-analysis is planned.This protocol is in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Protocols statement. The search strategies including databases, study eligibility criteria, index and reference test definitions, outcome definitions and data analysis processes are detailed. A full list of extracted data items is provided.Summary estimates of sensitivity and specificity (for PI-RADS ≥3 and PI-RADS ≥4 considered positive) are derived with bivariate binomial models. Summary estimates of cancer detection rates are calculated with random intercept logistic regression models for single proportions. Summary estimates of inter-reader agreement are derived with random effects models. ETHICS AND DISSEMINATION: No original patient data are collected, ethical review board approval, therefore, is not necessary. Results are published in peer-reviewed, open-access scientific journals. We make the collected data accessible as supplemental material to guarantee transparency of results. PROSPERO REGISTRATION NUMBER: CRD42022343931.

Quantitative Analysis of Diffusion Weighted Imaging May Improve Risk Stratification of Prostatic Transition Zone Lesions.

BACKGROUND/AIM: To investigate whether quantitative analysis of diffusion weighted images allows for improved risk stratification of transition zone lesions in prostate magnetic resonance imaging (MRI) evaluated according to PI-RADSv2.1 [Prostate Imaging Reporting and Data System, target variable: clinically significant prostate cancer (csPCa)]. PATIENTS AND METHODS: Consecutive patients with transition zone lesions in 3T prostate MRI were enrolled in the study. All lesions on MRI were histopathologically verified by transperineal MRI-TRUS fusion biopsy. Two blinded radiologists re-evaluated all lesions according to PI-RADSv2.1. A consensus reading was performed after reading of all cases. Additionally, mean apparent diffusion coefficient values (mADC) were derived from blinded lesion segmentation. ROC analysis was performed for PI-RADS categories and PI-RADS categories with separate subcategories and diffusion coefficient values (ADC). Data were examined for optimal mADC cut-off values that improve stratification of csPCa and benign lesions. RESULTS: Among 85 patients (mean age=66.2 years), 98 transition zone lesions were detected. Biopsy confirmed csPCa in 24/98 cases. Area under the curve (AUC) was 0.89/0.90 for reader 1, 0.92/0.91 for reader 2 and 0.92/0.91 for the consensus reading (5 category analysis/analysis with subcategories separately). Inter-reader agreement was substantial, with lower PI-RADS categories assigned by the more experienced reader (p<0.05). AUC for mADC alone was 0.81. When a cut-off threshold of 950 µm2/s mADC is used to downgrade PI-RADS 3 lesions to PI-RADS 2, biopsy could be avoided in all benign PI-RADS 3 cases. CONCLUSION: Quantitative analysis of diffusion weighted images may help avoid unnecessary biopsies of transition zone PI-RADS 3 lesions.

[Image-guided biopsy of the prostate gland]. / Bildgesteuerte Biopsie der Prostata.

The recommendations on carrying out a multiparametric magnetic resonance imaging (mpMRI) for the primary diagnostics and during active surveillance of prostate cancer, include as a consequence an image-guided sampling from conspicuous areas. In doing so, the information on the localization provided by mpMRI is used for a targeted biopsy of the area suspected of being a tumor. The targeted sampling is mainly performed under sonographic control and after fusion of MRI and ultrasound but can also be (mostly in special cases) carried out directly in the MRI scanner. In an ultrasound-guided biopsy, it is vital to coregister the MR images with the ultrasound images (segmentation of the contour of the prostate and registration of suspect findings). This coregistration can either be carried out cognitively (transfer by the person performing the biopsy alone) or software based. Each method shows specific advantages and disadvantages in the prioritization between diagnostic accuracy and resource expenditure.

Tyrosine Kinase Inhibitors in the Treatment of Metastasised Renal Cell Carcinoma-Future or the Past?

BACKGROUND: To review and discuss the literature on applying tyrosine kinase inhibitors (TKIs) in the treatment of metastasised renal cell carcinoma (mRCC). MATERIALS AND METHODS: Medline, PubMed, the Cochrane database, and Embase were screened for randomised controlled trials, clinical trials, and reviews on treating renal cell carcinoma, and the role of TKI. Each substance's results were summarised descriptively. RESULTS: While TKI monotherapy is not currently recommended as a first-line treatment for metastasized renal cell carcinoma, TKIs are regularly applied to treat treatment-naïve patients in combination with immunotherapy. TKIs depict the first-choice alternative therapy if immunotherapy is not tolerated or inapplicable. Currently, seven different TKIs are available to treat mRCC. CONCLUSIONS: The importance of TKIs in a monotherapeutic approach has declined in the past few years. The current trend toward combination therapy for mRCC, however, includes TKIs as one significant component of treatment regimens. We found that to remain applicable to ongoing studies, both when including new substances and when testing novel combinations of established drugs. TKIs are of major importance for the treatment of renal cancer now, as well as for the foreseeable future.

The maximum standardized uptake value in patients with recurrent or persistent prostate cancer after radical prostatectomy and PSMA-PET-guided salvage radiotherapy-a multicenter retrospective analysis.

PURPOSE: This study aims to evaluate the association of the maximum standardized uptake value (SUVmax) in positron-emission tomography targeting prostate-specific membrane antigen (PSMA-PET) prior to salvage radiotherapy (sRT) on biochemical recurrence free survival (BRFS) in a large multicenter cohort. METHODS: Patients who underwent 68 Ga-PSMA11-PET prior to sRT were enrolled in four high-volume centers in this retrospective multicenter study. Only patients with PET-positive local recurrence (LR) and/or nodal recurrence (NR) within the pelvis were included. Patients were treated with intensity-modulated-sRT to the prostatic fossa and elective lymphatics in case of nodal disease. Dose escalation was delivered to PET-positive LR and NR. Androgen deprivation therapy was administered at the discretion of the treating physician. LR and NR were manually delineated and SUVmax was extracted for LR and NR. Cox-regression was performed to analyze the impact of clinical parameters and the SUVmax-derived values on BRFS. RESULTS: Two hundred thirty-five patients with a median follow-up (FU) of 24 months were included in the final cohort. Two-year and 4-year BRFS for all patients were 68% and 56%. The presence of LR was associated with favorable BRFS (p = 0.016). Presence of NR was associated with unfavorable BRFS (p = 0.007). While there was a trend for SUVmax values ≥ median (p = 0.071), SUVmax values ≥ 75% quartile in LR were significantly associated with unfavorable BRFS (p = 0.022, HR: 2.1, 95%CI 1.1-4.6). SUVmax value in NR was not significantly associated with BRFS. SUVmax in LR stayed significant in multivariate analysis (p = 0.030). Sensitivity analysis with patients for who had a FU of > 12 months (n = 197) confirmed these results. CONCLUSION: The non-invasive biomarker SUVmax can prognosticate outcome in patients undergoing sRT and recurrence confined to the prostatic fossa in PSMA-PET. Its addition might contribute to improve risk stratification of patients with recurrent PCa and to guide personalized treatment decisions in terms of treatment intensification or de-intensification. This article is part of the Topical Collection on Oncology-Genitourinary.

Intraindividual Comparison Between [18F] PSMA-1007 PET/CT and Multiparametric MRI for Radiotherapy Planning in Primary Prostate Cancer Patients.

Introduction: Accurate detection and segmentation of the intraprostatic gross tumor volume (GTV) is pivotal for radiotherapy (RT) in primary prostate cancer (PCa) since it influences focal therapy target volumes and the patients' cT stage. The study aimed to compare the performance of multiparametric resonance imaging (mpMRI) with [18F] PSMA-1007 positron emission tomography (PET) for intraprostatic GTV detection as well as delineation and to evaluate their respective influence on RT concepts. Materials and Methods: In total, 93 patients from two German University Hospitals with [18F] PSMA-1007-PET/CT and MRI (Freiburg) or [18F] PSMA-1007-PET/MRI (Dresden) were retrospectively enrolled. Validated contouring techniques were applied for GTV-PET and -MRI segmentation. Absolute tumor volume and cT status were determined for each imaging method. The PCa distribution from histopathological reports based on biopsy cores and surgery specimen was used as reference in terms of laterality (unilateral vs. bilateral). Results: In the Freiburg cohort (n = 84), mpMRI and PET detected in median 2 (range: 1-5) and 3 (range: 1-8) GTVs, respectively (p < 0.01). The median GTV-MRI was significantly smaller than the GTV-PET, measuring 2.05 vs. 3.65 ml (p = 0.0005). PET had a statistically significant higher concordance in laterality with surgery specimen compared to mpMRI (p = 0.04) and biopsy (p < 0.01), respectively. PSMA PET led to more cT2c and cT3b stages, whereas cT3a stage was more pronounced in mpMRI. Based on the cT stage derived from mpMRI and PET information, 21 and 23 as well as 59 and 60 patients, respectively, were intermediate- and high-risk according to the National Comprehensive Cancer Network (NCCN) v1.2022 criteria. In the Dresden cohort (n = 9), similar results were observed. Conclusion: Intraprostatic GTV segmentation based on [18F] PSMA-1007 PET results in more and larger GTVs compared to mpMRI. This influences focal RT target volumes and cT stage definition, but not the NCCN risk group.

Risk Factors for Biochemical Recurrence After PSMA-PET-Guided Definitive Radiotherapy in Patients With De Novo Lymph Node-Positive Prostate Cancer.

Introduction: The National Comprehensive Cancer Network recommends external beam radiotherapy (EBRT) combined with androgen deprivation therapy (ADT) as the preferred treatment option for newly diagnosed node-positive (cN1) prostate cancer (PCa) patients. However, implementation of positron emission tomography targeting prostate-specific membrane antigen (PSMA-PET) in the staging of primary PCa patients has a significant impact on RT treatment concepts. This study aims to evaluate outcomes and their respective risk factors on patients with PSMA-PET-based cN1 and/or cM1a PCa receiving primary RT and ADT. Methods: Forty-eight patients with cN0 and/or cM1a PCa staged by [18F]PSMA-1007-PET (n = 19) or [68Ga]PSMA-11-PET (n = 29) were retrospectively included. All patients received EBRT to the pelvis ± boost to positive nodes, followed by boost to the prostate. The impact of different PET-derived characteristics such as maximum standard uptake value (SUVmax) and number of PET-positive lymph nodes on biochemical recurrence-free survival (BRFS) (Phoenix criteria) and metastasis-free survival (MFS) was determined using Kaplan-Meier and Cox proportional hazard regression analyses. Results: Median follow-up was 24 months. Median initial serum prostate-specific antigen was 20.2 ng/ml (IQR 10.2-54.2). Most patients had cT stage ≥ 3 (63%) and ISUP grade ≥ 3 (85%). Median dose to the prostate, elective nodes, and PET-positive nodes was 75 Gy, 45 Gy, and 55 Gy, respectively. Ninety percent of patients received ADT with a median duration of 9 months (IQR 6-18). In univariate analysis, cM1a stage (p = 0.03), number of >2 pelvic nodes (p = 0.01), number of >1 abdominal node (p = 0.02), and SUVmax values ≥ median (8.1 g/ml for 68Ga-PSMA-11 and 7.9 g/ml for 18F-PSMA-1007) extracted from lymph nodes were significantly associated with unfavorable BRFS, but classical clinicopathological features were not. Number of >2 pelvic nodes (n = 0.03), number of >1 abdominal node (p = 0.03), and SUVmax values ≥ median extracted from lymph nodes were associated with unfavorable MFS. In multivariate analysis, number of >2 pelvic lymph nodes was significantly associated with unfavorable BRFS (HR 5.2, p = 0.01) and SUVmax values ≥ median extracted from lymph nodes had unfavorable MFS (HR 6.3, p = 0.02). Conclusion: More than 2 PET-positive pelvic lymph nodes are associated with unfavorable BRFS, and high SUVmax values are associated with unfavorable MFS. Thus, the number of PET-positive lymph nodes and the SUVmax value might be relevant prognosticators to identify patients with favorable outcomes.

Similarity of competing risks models with constant intensities in an application to clinical healthcare pathways involving prostate cancer surgery.

The recent availability of routine medical data, especially in a university-clinical context, may enable the discovery of typical healthcare pathways, that is, typical temporal sequences of clinical interventions or hospital readmissions. However, such pathways are heterogeneous in a large provider such as a university hospital, and it is important to identify similar care pathways that can still be considered typical pathways. We understand the pathway as a temporal process with possible transitions from a single initial treatment state to hospital readmission of different types, which constitutes a competing risks setting. In this article, we propose a multi-state model-based approach to uncover pathway similarity between two groups of individuals. We describe a new bootstrap procedure for testing the similarity of constant transition intensities from two competing risk models. In a large simulation study, we investigate the performance of our similarity approach with respect to different sample sizes and different similarity thresholds. The studies are motivated by an application from urological clinical routine and we show how the results can be transferred to the application example.

More Than Detection of Adenocarcinoma - Indications and Findings in Prostate MRI in Benign Prostatic Disorders.

BACKGROUND: Multiparametric MRI of the prostate has become a fundamental tool in the diagnostic pathway for prostate cancer and is recommended before (or after negative) biopsy to guide biopsy and increase accuracy, as a staging examination (high-risk setting), and prior to inclusion into active surveillance. Despite this main field of application, prostate MRI can be utilized to obtain information in a variety of benign disorders of the prostate. METHODS: Systematic bibliographical research with extraction of studies, national (German) as well as international guidelines (EAU, AUA), and consensus reports on MRI of benign disorders of the prostate was performed. Indications and imaging findings of prostate MRI were identified for a) imaging the enlarged prostate, b) prostate MRI in prostatic artery embolization, c) imaging in prostatitis and d) imaging in congenital anomalies. RESULTS AND CONCLUSIONS: Different phenotypes of the enlarged prostate that partly correlate with severity of symptoms are discussed. We provide an overview of the different types of prostatitis and possible imaging findings, highlighting abscesses as a severe complication. The most common congenital anomalies of the prostate are utricular cysts, whereas anomalies like aplasia, hypoplasia, and ectopia are rare disorders. Knowledge of indications for imaging and imaging appearance of these conditions may improve patient care and enhance differential diagnosis. KEY POINTS: · Current guidelines do not implement indications for mpMRI apart from prostate carcinoma.. · MRI can distinguish different anatomical phenotypes of prostatic enlargement.. · Prostatic artery embolization represents a valuable treatment option in cases of symptomatic benign prostatic enlargement.. · Different forms of prostatitis exist and may mimic prostate carcinoma in MRI.. · MRI can be used to evaluate anatomical prostate anomalies.. CITATION FORMAT: · Oerther B, Sigle A, Franiel T et al. More Than Detection of Adenocarcinoma - Indications and Findings in Prostate MRI in Benign Prostatic Disorders. Fortschr Röntgenstr 2022; 194: 481 - 490.

Experimental ex-vivo performance study comparing a novel, pulsed thulium solid-state laser, chopped thulium fibre laser, low and high-power holmium:YAG laser for endoscopic enucleation of the prostate.

PURPOSE: The aim of this study was to compare the enucleation performances of four different types of laser devices in an ex-vivo experiment: a novel, pulsed Tm:YAG solid-state laser evaluation model (p-Tm:YAG), chopped thulium fibre laser (TFL), low-power Ho:YAG laser (LP-Ho:YAG), and a high-power Ho:YAG laser (HP-Ho:YAG). METHODS: Our primary aim was to endoscopically separate the fascial layers of a porcine belly using laser fibres within a time period of 60 s. The size of a "tissue pocket" was assessed numerically. The enucleation characteristics reflecting the surgeon's experience were evaluated via the NASA Task Load Index (TLX) questionnaire and a questionnaire based on Likert scale. RESULTS: HP-Ho:YAG achieved with the available laser settings the largest overall "tissue pocket" (31.5 cm2) followed by p-Tm:YAG (15 cm2), TFL (12 cm2), and LP-Ho:YAG (6 cm2). The coagulation performances of p-Tm:YAG and TFL were rated the best. In the performance evaluation by the Likert questionnaire, HP-Ho:YAG (average score of 4.06) was rated highest, followed by p-Tm:YAG (3.94), TFL (3.38), and LP-Ho:YAG (3.25). The evaluation of the NASA-TLX performance questionnaire revealed average scores for HP-Ho:YAG, LP-Ho:YAG, TFL and p-Tm:YAG of 4.38, 4.09, 3.92 and 3.90, respectively. CONCLUSION: We are the first to compare different laser devices and settings in an ex-vivo study. We found that the surgeons were most satisfied with the HP-Ho:YAG laser device, followed by the p-Tm:YAG. These findings could be highly relevant for future research and for the practical utilisation of laser systems in endourology.

Cancer detection rates of the PI-RADSv2.1 assessment categories: systematic review and meta-analysis on lesion level and patient level.

BACKGROUND: The Prostate Imaging Reporting and Data System, version 2.1 (PI-RADSv2.1) standardizes reporting of multiparametric MRI of the prostate. Assigned assessment categories are a risk stratification algorithm, higher categories indicate a higher probability of clinically significant cancer compared to lower categories. PI-RADSv2.1 does not define these probabilities numerically. We conduct a systematic review and meta-analysis to determine the cancer detection rates (CDR) of the PI-RADSv2.1 assessment categories on lesion level and patient level. METHODS: Two independent reviewers screen a systematic PubMed and Cochrane CENTRAL search for relevant articles (primary outcome: clinically significant cancer, index test: prostate MRI reading according to PI-RADSv2.1, reference standard: histopathology). We perform meta-analyses of proportions with random-effects models for the CDR of the PI-RADSv2.1 assessment categories for clinically significant cancer. We perform subgroup analysis according to lesion localization to test for differences of CDR between peripheral zone lesions and transition zone lesions. RESULTS: A total of 17 articles meet the inclusion criteria and data is independently extracted by two reviewers. Lesion level analysis includes 1946 lesions, patient level analysis includes 1268 patients. On lesion level analysis, CDR are 2% (95% confidence interval: 0-8%) for PI-RADS 1, 4% (1-9%) for PI-RADS 2, 20% (13-27%) for PI-RADS 3, 52% (43-61%) for PI-RADS 4, 89% (76-97%) for PI-RADS 5. On patient level analysis, CDR are 6% (0-20%) for PI-RADS 1, 9% (5-13%) for PI-RADS 2, 16% (7-27%) for PI-RADS 3, 59% (39-78%) for PI-RADS 4, 85% (73-94%) for PI-RADS 5. Higher categories are significantly associated with higher CDR (P < 0.001, univariate meta-regression), no systematic difference of CDR between peripheral zone lesions and transition zone lesions is identified in subgroup analysis. CONCLUSIONS: Our estimates of CDR demonstrate that PI-RADSv2.1 stratifies lesions and patients as intended. Our results might serve as an initial evidence base to discuss management strategies linked to assessment categories.