Improved diagnostic accuracy of readout-segmented echo-planar imaging for peripheral zone clinically significant prostate cancer: a retrospective 3T MRI study.

This study compares the readout-segmented echo-planar imaging (rsEPI) from the conventional single-shot EPI (ssEPI) diffusion-weighted imaging (DWI) for the discrimination of patients with clinically significant prostate cancer (csPCa) within the peripheral zone (PZ) using apparent diffusion coefficient (ADC) maps and pathology report from magnetic resonance imaging (MRI)-targeted biopsy. We queried a retrospective monocentric database of patients with targeted biopsy. csPCa patients were defined as an International Society of Urological Pathology grade group ≥ 2. Group-level analyses and diagnostic accuracy of mean ADC values (ADCmean) within the tumor volume were assessed from Kruskal-Wallis tests and receiving operating characteristic curves, respectively. Areas under the curve (AUC) and optimal cut-off values were calculated. 159 patients (105 rsEPI, 54 ssEPI; mean age ± standard deviation: 65 ± 8 years) with 3T DWI, PZ lesions and targeted biopsy were selected. Both DWI sequences showed significantly lower ADCmean values for patients with csPCa. The rsEPI sequence better discriminates patients with csPCa (AUCrsEPI = 0.84, AUCssEPI = 0.68, p < 0.05) with an optimal cut-off value of 1232 µm2/s associated with a sensitivity-specificity of 97%-63%. Our study showed that the rsEPI DWI sequence enhances the discrimination of patients with csPCa.

Prognostic significance of PI-RADS 5 lesions in patients treated by radical prostatectomy.

PURPOSE: To analyse the pathological features and survival of patients with a PI-RADS 5 lesion on pre-biopsy MRI. METHODS: We extracted from a European multicentre prospectively gathered database the data of patients with a PI-RADS 5 lesion on pre-biopsy MRI, diagnosed using both systematic and targeted biopsies and subsequently treated by radical prostatectomy. The Kaplan-Meier model was used to assess the biochemical-free survival of the whole cohort and univariable and multivariable Cox models were set up to study factors associated with survival. RESULTS: Between 2013 and 2019, 539 consecutive patients with a PI-RADS 5 lesion on pre-biopsy MRI were treated by radical prostatectomy and included in the analysis. Follow-up data were available for 448 patients. Radical prostatectomy and lymph node dissection specimens showed non-organ confined disease in 297/539 (55%), (including 2 patients with a locally staged pT2 lesion and lymph node involvement (LNI)). With a median follow-up of 25 months (12-39), the median biochemical recurrence-free survival was 54% at 2 years (95% CI 45-61) and 28% at 5 years (95% CI 18-39). Among the factors studied, MRI T stage [T3a vs T2 HR 3.57 (95%CI 1.78-7.16); T3b vs T2 HR 6.17 (95% CI 2.99-12.72)] and PSA density (HR 4.47 95% CI 1.55-12.89) were significantly associated with a higher risk of biochemical recurrence in multivariable analysis. CONCLUSION: Patients with a PI-RADS 5 lesion on pre-biopsy MRI have a high risk of early biochemical recurrence after radical prostatectomy. MRI T stage and PSA density can be used to improve patient selection and counselling.

Radical Nephroureterectomy Tetrafecta: A Proposal Reporting Surgical Strategy Quality at Surgery.

Background: Standardized methods for reporting surgical quality have been described for all the major urological procedures apart from radical nephroureterectomy (RNU). Objective: To propose a tetrafecta criterion for assessing the quality of RNU based on a consensus panel within the Young Association of Urology (YAU) Urothelial Group, and to test the impact of this tetrafecta in a multicenter, large contemporary cohort of patients treated with RNU for upper tract urothelial carcinoma (UTUC). Design setting and participants: This was a retrospective analysis of 1765 patients with UTUC treated between 2000 and 2021. Outcome measurements and statistical analysis: We interviewed the YAU Urothelial Group to propose and score a list of items to be included in the "RNU-fecta." A ranking was generated for the criteria with the highest sum score. These criteria were applied to a large multicenter cohort of patients. Kaplan-Meier curves were built to evaluate differences in overall survival (OS) rates between groups, and a multivariable logistic regression model was used to find the predictors of achieving the RNU tetrafecta. Results and limitations: The criteria with the highest score included three surgical items such as negative soft tissue surgical margins, bladder cuff excision, lymph node dissection according to guideline recommendations, and one oncological item defined by the absence of any recurrence in ≤12 mo. These items formed the RNU tetrafecta. Within a median follow-up of 30 mo, 52.6% of patients achieved the RNU tetrafecta. The 5-yr OS rates were significantly higher for patients achieving tetrafecta than for their counterparts (76% vs 51%). Younger age, lower body mass index, and robotic approach were found to be independent predictors of tetrafecta achievement. Conversely, a higher Eastern Cooperative Oncology Group score, higher clinical stage, and bladder cancer history were inversely associated with tetrafecta. Conclusions: Herein, we present a "tetrafecta" composite endpoint that may serve as a potential tool to assess the overall quality of the RNU procedure. Pending external validation, this tool could allow a comparison between surgical series and may be useful for assessing the learning curve of the procedure as well as for evaluating the impact of new technologies in the field. Patient summary: In this study, a tetrafecta criterion was developed for assessing the surgical quality of radical nephroureterectomy in patients with upper tract urothelial carcinoma. Patients who achieved tetrafecta had higher 5-yr overall survival rates than those who did not.

Magnetic Resonance Imaging-Targeted Biopsy and Pretherapeutic Prostate Cancer Risk Assessment: a Systematic Review: Biopsie ciblée par Imagerie par résonance magnétique et évaluation pré-thérapeutique du risque de cancer de la prostate : revue systématique.

INTRODUCTION: Multiparametric magnetic resonance imaging (MRI) has been included in prostate cancer (PCa) diagnostic pathway and may improve disease characterization. The aim of this systematic review is to assess the added value of MRI-targeted biopsy (TB) in pre-therapeutic risk assessment models over existing tools based on systematic biopsy (SB) for localized PCa. EVIDENCE ACQUISITION: A systematic search was conducted using Pubmed (Medline), Scopus and ScienceDirect databases according to Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement. We included studies through October 2021 reporting on TB in pretherapeutic risk assessment models. EVIDENCE SYNTHESIS: We identified 24 eligible studies including 24'237 patients for the systematic review. All included studies were retrospective and conducted in patients undergoing radical prostatectomy. Nine studies reported on the risk of extraprostatic extension, seven on the risk of lymph node invasion, three on the risk of biochemical recurrence and nine on the improvement of PCa risk stratification. Overall, the combination of TB with imaging, clinical and biochemical parameters outperformed current pretherapeutic risk assessment models. External validation studies are lacking for certain endpoints and the absence of standardization among TB protocols, including number of TB cores and fusion systems, may limit the generalizability of the results. CONCLUSION: TB should be incorporated in pretherapeutic risk assessment models to improve clinical decision making. Further high-quality studies are required to determine models' generalizability while there is an urgent need to reach consensus on a standardized TB protocol. Long-term outcomes after treatment are also awaited to confirm the superiority of such models over classical risk classifications only based on SB. © 2022 Elsevier Masson SAS. All rights reserved.

68Ga-PSMA PET/CT-based metastasis-directed radiotherapy for oligometastatic prostate cancer recurrence after radical prostatectomy.

PURPOSE: The aim of this communication was to assess the efficacy of directed oligometastatic radiotherapy (RT) based on 68Ga-PSMA PET/CT in patients with prostate cancer (PCa) biochemical relapse (BCR) after primary treatment with curative intent. METHODS: This is a retrospective analysis of a monocentric cohort of PCa patients diagnosed with oligometastatic disease on 68Ga-PSMA PET/CT and treated with metastasis-directed RT. Inclusion criteria were: histologically proven PCa, BCR after primary treatment with curative intent, oligometastatic disease defined as ≤ 3 metastatic lesions. To evaluate the efficacy of the therapy, biochemical response defined as a decrease of > 50% of PSA (PSA50) was measured at 1 and 4 months. Patients were followed up until progression and start of androgen deprivation therapy (ADT). BCR-free survival and ADT-free survival were calculated. RESULTS: 20 patients met the inclusion criteria. Median PSA value: 1.4 ng/ml (IQR, 0.3-2.3 ng/ml). A total of 30 PSMA-positive lesions were treated: 18 lymph nodes (60%), nine bone (30%) and three visceral lesions (10%). Median follow-up was 15 months (range 4-33 months). Biochemical response at 1 and 4 months was found in 3/20 patients (15%) and 14/20 (70%), respectively. BCR-free survival rate at 1 year was 79% and 53% at 2 years. ADT-free survival at 2 years was 74%. CONCLUSION: This retrospective study suggests that metastasis-directed RT based on 68Ga-PSMA PET/CT may be a valuable treatment in patients with PCa oligometastatic disease, providing promising BCR-free survival rates and potentially postponing ADT for at least 2 years in 74% of the patients. Response assessment should not be measured before 4 months after treatment.

A systematic review of contemporary management of oligometastatic prostate cancer: fighting a challenge or tilting at windmills?

PURPOSE: Amongst the unanswered questions regarding prostate cancer (PCa), the optimal management of oligometastatic disease remains one of the major concerns of the scientific community. The very existence of this category is still subject to controversy. Aim of this systematic review is to summarize current available data on the most appropriate management of oligometastatic PCa. EVIDENCE ACQUISITION: All relevant studies published in English up to November the 1st were identified through systematic searches in PubMed, EMBASE, Cochrane Library, CINAHL, Google Scholar and Ovid database. A search was performed including the combination of following words: (prostate cancer) and (metastatic) and [(oligo) or (PSMA) or (cytoreductive) or (stereotaxic radiotherapy) or (prostatectomy)]. 3335 articles were reviewed. After title screening and abstract reading, 118 papers were considered for full reading, leaving a total of 36 articles for the systematic review. EVIDENCE SYNTHESIS: There is still no consensus on the definition of oligometastatic disease, nor on the imaging modalities used for its detection. While retrospective studies suggest an added benefit with the treatment the primitive tumor by cytoreductive prostatectomy (55% survival rate vs 21%, p < 0.001), prospective studies do not validate the same outcome. Nonetheless, most studies have reported a reduction in local complications after cytoreductive prostatectomy (< 10%) compared to the best systemic treatment (25-30%). Concerning radiotherapy, an overall survival benefit for patients with a low metastatic burden was found in STAMPEDE (HR 0.68, 95% CI 0.52-0.90; p = 0.007) and suggested in subgroup analysis of the HORRAD trial. Regarding the impact of metastases-directed therapy (MDT), the STOMP and ORIOLE trials suggested that metastatic disease control might improve androgen deprivation therapy-free survival (in STOMP: 21 vs 13 months for MDT vs standard of care). Nonetheless, the impact of MDT on long-term oncologic results remains unclear. Finally, oligometastatic disease appears to be a biologically different entity compared to high-burden metastatic disease. New findings on exosomes appear to make them intriguing biomarkers in the early phases of oligometastatic PCa. CONCLUSION: Oligometastatic PCa is today a poorly understood disease. The implementation of new imaging techniques as whole-body MRI and PSMA PET/CT has increased exponentially the number of oligometastatic patients detected. Data of available trials suggest a benefit from cytoreductive prostatectomy to reduce local complication, though its impact on survival remains unknown. Radiotherapy may be beneficial for patients with low-burden metastatic PCa, while MDT may delay the need for androgen deprivation therapy. Results from ongoing trials data are eagerly awaited to draw reliable recommendations.

A multicentric study on accurate grading of prostate cancer with systematic and MRI/US fusion targeted biopsies: comparison with final histopathology after radical prostatectomy.

OBJECTIVE: To evaluate the accuracy in histologic grading of MRI/US image fusion biopsy by comparing histopathology between systematic biopsies (SB), targeted biopsies (TB) and the combination of both (SB + TB) with the final histopathologic outcomes of radical prostatectomy specimens. MATERIALS AND METHODS: Retrospective, multicentric study of 443 patients who underwent SB and TB using MRI/US fusion technique (Urostation® and Trinity®) prior to radical prostatectomy between 2010 and 2017. Cochran's Q test and McNemar test were conducted as a post hoc test. Uni-multivariable analyses were performed on several clinic-pathological variables to analyze factors predicting histopathological concordance for targeted biopsies. RESULTS: Concordance in ISUP (International Society of Urological Pathology) grade between SB, TB and SB + TB with final histopathology was 49.4%, 51.2%, and 63.2% for overall prostate cancer and 41.2%, 48.3%, and 56.7% for significant prostate cancer (ISUP grade ≥ 2), respectively. Significant difference in terms of concordance, downgrading and upgrading was found between SB and TB (ISUP grade ≥ 2 only), SB and SB + TB, TB and SB + TB (overall ISUP grade and ISUP grade ≥ 2) (p < 0.001). Total number of cores and previous biopsies were significant independent predictive factors for concordance with TB technique. CONCLUSION: In this retrospective study, combination of SB and TB significantly increased concordance with final histopathology despite a limited additional number of cores needed.

[Evaluation of stone size before flexible ureteroscopy: Which measurement is best?] / Évaluation de la taille des calculs urinaires avant urétéroscopie souple : quelle mesure choisir ?

PURPOSE: To retrospectively assess the clinical utility in ureteroscopy (URS) planning of radiological parameters as predictor of stone-free status after a single flexible ureteroscopy. MATERIAL: Sixty-seven patients with renal stones treated by flexible URS were retrospectively evaluated. To assess the clinical utility of radiological parameters, relationships between stone-free (SF) status and stone burden (maximal diameter, calculated area, calculated volume, cumulative diameter, and tridimentionnal volume [V3D]) were analyzed using the area under the receiver operating characteristics curve and logistic regression. RESULTS: Maximal diameter (AUC=0.75), calculated area (AUC 0.79), calculated volume (AUC=0.79), cumulative diameter (AUC=0.80) and tridimensional volume (AUC=0.82) revealed ability to predict SF status after URS. CONCLUSION: Stone burden evaluation is critical in predicting SF status after a single URS. Planar and volumetric measurements showed equal ability to predict SF status. V3D is more accurate but diameter measurement remains easier in clinical practice. LEVEL OF EVIDENCE: 4.