Which men with non-malignant pathology at magnetic resonance imaging-targeted prostate biopsy and persistent PI-RADS 3-5 lesions should repeat biopsy?

PURPOSE: To assess predictors of clinically significant (cs) prostate cancer (PCa) in men who had a non-malignant Multiparametric magnetic resonance imaging (mpMRI)-targeted biopsy and persistent Prostate Imaging-Reporting Data System (PI-RADS) 3 to 5 lesions in subsequent mpMRI. MATERIALS AND METHODS: We retrospectively analyzed MRI-targeted biopsy database in three centers. INCLUSION CRITERIA: persistence of at least one PI-RADS ≥3 lesion found negative for cancer in a previous MRI-targeted plus systemic biopsy (baseline biopsy). EXCLUSION CRITERIA: downgrading to PI-RADS 1-2. A logistic regression analysis was performed to estimate the predictors of csPCa. RESULTS: Fifty-seven patients were included. Median interval between biopsies was 12.9(2.43) months. Median age was 68.0(12) years. Median PSA was 7.0(5.45) ng/ml. At follow-up, 24.6%, 54.4%, and 21% of patients had a PI-RADS score 3, 4, and 5 index lesion (IL), respectively. At re-biopsy, 28/57(49.1%) men were found to harbor PCa. Among these, 22(78.6%) had csPCa. csPCa was found outside the IL in only 2 patients. Eleven, 13, and 5 patients with PI-RADS 3, 4, and 5, respectively, had no cancer. Three patients with a PI-RADS 3 lesion had cancer (2 with Gleason score 3+3, 1 with Gleason score 3+4). 14/43 men with a PI-RADS 4/5 lesion harbored Gleason score ≥3+4 PCa. Logistic regression analysis found that PSA (HR 1.281, 95% CI: 1.013-1.619, P = 0.039) and IL size (HR 1.146, 95% CI: 1.018-1.268, P = 0.041) were the predictors of csPCa at re-biopsy. CONCLUSIONS: Patients with non-malignant pathology from PI-RADS ≥3 lesions targeted biopsy should be follow-up with mpMRI, and those with persistent PI-RADS 4 to 5 lesions should repeat MRI-targeted and systematic biopsy.

Combination of Multiparametric Magnetic Resonance Imaging With Elastic-fusion Biopsy Has a High Sensitivity in Detecting Clinically Significant Prostate Cancer in Daily Practice.

BACKGROUND: The index lesion (IL) is the largest cancer focus, usually harbors the highest grade, and might drive the history of prostate cancer (PCA). Multiparametric magnetic resonance imaging (mp-MRI) has a high negative predictive value in ruling out clinically significant (cs)PCA. We aimed evaluating the efficiency of mp-MRI and targeted biopsy in detecting csPCA and the concordance between the MRI index lesion (MRI-IL) and the presence of csPCA inside it. MATERIALS AND METHODS: We retrospectively evaluated 158 men who underwent prostate biopsy after a positive pre-biopsy mp-MRI scan. All mp-MRI lesions were biopsied using a transrectal ultrasound elastic-fusion approach (2-4 targeted plus 10-12 random systematic biopsies). csPCA was defined as grading group ≥ 2 or > 3 cores with cancer or ≥ 50% of core involved by tumor. RESULTS: mp-MRI detected 158 ILs and 46 non-ILs. One hundred were Prostate Imaging-Reporting and Data System version 2 (PI-RADS v2) score 3, 84 score 4, and 20 score 5. csPCA was found in 63.9% of the MRI-ILs. Eighty percent of detected cancer using mp-MRI and targeted biopsy was clinically significant. Eighty-seven percent of the transitional zone lesions were clinically non-significant or negative for cancer. The probability of detecting csPCA increases with increasing size of MRI-IL, and every extra millimeter raises the odds of detecting csPCA of 12.2%. All PI-RADS v2 score lesions showed a strong association with csPCA. The risk of matching between MRI-IL and csPCA inside it increases by 36.2% as the total percentage of cancer in all cores increases. CONCLUSIONS: mp-MRI showed high sensitivity in detecting csPCA in the peripheral zone, with concordance between MRI-IL and csPCA.

A structured framework for optimizing high-intensity focused ultrasound ablative treatment in localized prostate cancer.

High-intensity focused ultrasound (HIFU) treatment has recently been pursued to reduce radical treatment-related morbidity in low-to-intermediate-risk localized prostate cancer (PCa), especially in older men. The aim of this study was to develop a dedicated framework for HIFU therapy. All clinical data, such as risk categories, magnetic resonance with functional parametric imaging, and histopathology, are essential for driving proper HIFU treatment. All needed data can be added to the framework to localize areas that need to be treated. Once PCa areas have been featured, quantified, and located, planning can be adapted to drive accurate HIFU treatment. Our planning framework may be useful for all ablative therapies in order to standardize treatment for both clinical and scientific purposes.

Italian Prostate Biopsies Group: 2016 Updated Guidelines Insights.

AIM: To present a summary of the updated guidelines of the Italian Prostate Biopsies Group following the best recent evidence of the literature. MATERIALS AND METHODS: A systematic review of the new data emerging from 2012-2015 was performed by a panel of 14 selected Italian experts in urology, pathology and radiology. The experts collected articles published in the English-language literature by performing a search using Medline, EMBASE and the Cochrane Library database. The articles were evaluated using a systematic weighting and grading of the level of the evidence according to the Grading of Recommendations Assessment, Development and Evaluation framework system. RESULTS: An initial prostate biopsy is strongly recommended when i) prostate specific antigen (PSA) >10 ng/ml, ii) digital rectal examination is abnormal, iii) multiparametric magnetic resonance imaging (mpMRI) has a Prostate Imaging Reporting and Data System (PIRADS) ≥4, even if it is not recommended. The use of mpMRI is strongly recommended only in patients with previous negative biopsy. At least 12 cores should be taken in each patient plus targeted (fusion or cognitive) biopsies of suspicious area (at mpMRI or transrectal ultrasound). Saturation biopsies are optional in all settings. The optimal strategy for reducing infection complications is still a controversial topic and the instruments to reduce them are actually weak. The adoption of Gleason grade groups in adjunction to the Gleason score when reporting prostate biopsy results is advisable. CONCLUSION: These updated guidelines and recommendations are intended to assist physicians and patients in the decision-making regarding when and how to perform a prostatic biopsy.

[Role of 3D-ultrasonography in the assessment of transitional zone PSA]. / Il ruolo dell'ecografia 3d nella valutazione del PSA TZ.

OBJECTIVE: Valute 3 TRUS to study the transitional zone of the prostate to calculate the PSA density Tz in patient with first negative biopsy, PSA Tot > 4 ng/ml and clinical suspicion of cancer. METHODS: During a 12 months period we performed 429 biopsies. All patients had PSA = 4-10 ng/ml and/or suspected DRE. We repeated biopsy in 35 patients with PSA > 4 ng/ml, normal DRE but clinical suspicion of cancer. We used 3 TRUS to calculate the PSA density Tz and we performed standard sextant biopsies and additionally two biopsies of the transitional zone one on each side. RESULTS: Of the 429 patients, 304 (70.8%) had IPB, 100 (23.3%) had cancer in peripherical and/or apex zone, 25 (5.9%) cancer in the transitional zone only. CONCLUSIONS: The use of 3 DUS is very important to study and estimate the volume of the transitional zone to calculate the PSA density Tz. The clear visualization of the Tz permit a careful execution of the biopsy. The biopsy of the TZ is not a method for the early detection to cancer prostate but only for specifics cases: negative first biopsy, negative DRE, PSA Tot > 4 ng/ml and clinical suspicion of cancer.