Validating the screening criteria for bone metastases in treatment-naïve unfavorable intermediate and high-risk prostate cancer - the prevalence and location of bone- and lymph node metastases.

OBJECTIVE: The European Association of Urology (EAU) recommends a bone scan for newly diagnosed unfavorable intermediate- and high-risk prostate cancer. We aimed to validate the screening criteria for bone metastases in patients with treatment-naïve prostate cancer. METHODS: This single-center retrospective study included all patients with treatment-naïve unfavorable intermediate- or high-risk prostate cancer. All underwent MRI of the lumbar column (T2Dixon) and pelvis (3DT2w, DWI, and T2 Dixon). The presence and location of lymph node and bone metastases were registered according to risk groups and radiological (rad) T-stage. The risk of lymph node metastases was assessed by odds ratio (OR). RESULTS: We included 390 patients, of which 68% were high-risk and 32% were unfavorable intermediate-risk. In the high-risk group, the rate of regional- and non-regional lymph node metastases was 11% and 6%, respectively, and the rate of bone metastases was 10%. In the unfavorable intermediate-risk group, the rate of regional- and non-regional lymph node metastases was 4% and 0.8%, respectively, and the rate of bone metastases was 0.8%. Metastases occurred exclusively in the lumbar column in 0.5% of all patients, in the pelvis in 4%, and the pelvis and lumbar column in 3%. All patients with bone metastases had radT3-4, and patients with radT3-4 showed a four-fold increased risk of lymph node metastases (OR 4.48, 95% CI: 2.1-9.5). CONCLUSION: Bone metastases were found in 10% with high-risk prostate cancer and 0.8% with unfavorable intermediate-risk. Therefore, we question the recommendation to screen the unfavorable intermediate-risk group for bone metastases. KEY POINTS: • The rate of bone metastases was 10% in high-risk patients and 0.8% in the unfavorable intermediate-risk group. • The rate of lymph-node metastases was 17% in high-risk patients and 5% in the unfavorable intermediate-risk group. • No bone metastases were seen in radiologically localized disease.

Examining the upper urinary tract in patients with hematuria-time to revise the CT urography protocol?

BACKGROUND: Three-phase CT urography (CTU) is the gold standard for evaluating the upper urinary tract in patients with hematuria. We aimed to evaluate the accuracy of CTU for detecting upper urothelial cell carcinomas (UCC) in patients with hematuria and negative cystoscopy. Secondly, we aimed to determine the tumor visibility on each CTU phase. MATERIAL AND METHODS: This retrospective study included all patients with hematuria referred to CTU after a negative cystoscopy during 2016 and 2017. The original CTU reports were dichotomized as negative or positive. All patient charts were reviewed after a minimum of 18-month follow-up in order to register missed cancers. The results of biopsies and clinical follow-up were used as the reference standard. Two reviewers retrospectively evaluated the tumor visibility of each CT sequence in all true-positive CTUs. RESULTS: We included 376 patients with hematuria who underwent CTU after a negative cystoscopy. Macroscopic and microscopic hematuria occurred in 87% (327) and 13% (49), respectively. The incidence of upper urothelial cell carcinoma was 1.9% (7), and the sensitivity of CTU was 100% (95% CI, 59-100), specificity was 99% (95% CI, 98-100), positive predictive value was 88% (95% CI, 47-99), and negative predictive value was 100% (95% CI, 99-100). The accuracy was 99% (95% CI, 90-100). All UCCs were visible on the nephrographic phase for both reviewers. CONCLUSION: CTU is highly accurate for detecting upper UCCs. All cases were seen on the nephrographic phase. This suggests that the CTU protocol can be simplified. KEY POINTS: • CT urography is highly accurate for detecting upper urothelial cell carcinomas. • All cancers were seen on the nephrographic phase. • All cancers were detected in patients with macroscopic hematuria.

Computed tomography for visible haematuria - a single nephrographic phase is sufficient for detecting renal cell carcinoma.

OBJECTIVES: No previous studies have compared two computed tomography (CT) protocols in patients presenting with visible haematuria, and most patients undergo a multiphase CT in order to detect upper tract malignancies. We aimed to prospectively compare the diagnostic performance of single- and four-phase CT for detecting renal cell carcinoma (RCC) in patients with visible haematuria. MATERIALS & METHODS: 'A Prospective Trial for Examining Hematuria using Computed Tomography' (PROTEHCT) was a single-centre prospective paired diagnostic study in patients referred for CT due to painless visible haematuria between September 2019 and June 2021. All patients underwent four-phase CT (control) from which a single nephrographic phase dual energy CT (experimental) was extracted. Both were independently assessed for RCC by randomised radiologists. Histologically verified RCC defined a positive reference standard. Follow-up ascertainment of RCC diagnosis was completed in May 2022. Descriptive statistics were used to calculate the accuracies. Inter-reader agreement was assessed by kappa statistics. RESULTS: A total of 308 patients (median age, 68 years [interquartile range 53-77, range 18-96], 250 males) were included for analysis. RCC was diagnosed in seven (2.3%) patients during a median follow-up time of 19 months (interquartile range: 15-25). For the control and experimental CT, sensitivity was 100% versus 100%, specificity was 97% versus 98% and accuracy 97% versus 97%. The positive predictive value was 44% versus 50%, and the negative predictive value was 100% versus 100%. The agreement between the control and experimental CT was 98% (k = 0.79). CONCLUSION: A single nephrographic phase dual energy CT is sufficient for detecting RCC in patients with visible haematuria.

Predictive Performance of Prospectively Applied ISUP and Fuhrman Grade in Nonmetastatic Renal Cell Carcinoma.

BACKGROUND/AIM: In 2012, the International Society of Urological Pathology (ISUP) recommended replacing Fuhrman with ISUP for grading renal cell carcinoma (RCC). Our aim was to report recurrence-free survival (RFS) and assess prognostic value of ISUP and Fuhrman for predicting recurrence using original pathology assessment and routine follow-up data. PATIENTS AND METHODS: In this single-institution retrospective cohort study, 686 patients underwent a single session total or partial nephrectomy due to nonmetastatic RCC (nmRCC). Of those, 564 had tumors prospectively graded according to either ISUP or Fuhrman, which defined the cohorts. RFS was defined as the interval from surgery to local recurrence and/or metastasis. Differences in RFS were calculated with log rank test. Cox models adjusted for risk factors were used for predicting recurrence. RESULTS: During a median follow-up of 36 months in the ISUP group (n=152), 11% developed recurrent disease. RFS was significantly lower for grade 4 compared to 1-3 (p<0.001), but non-significant between 1-3. Grade was the only significant predictor in multivariate analyses. During a median follow-up time of 50 months in the Fuhrman group (n=412), 16% developed recurrent disease. There was a significant difference in RFS between grades 2 and 3 (p=0.003) and between 3 and 4 (p<0.001), but non-significant between 1 and 2 (p=0.063). Grade, positive surgical margin, tumor size ≥4 cm, and pT were significant predictors of recurrence in multivariate analyses. CONCLUSION: ISUP grading alone is an accurate tool for predicting recurrence in patients with nmRCC.

Cancer Detection Rates in Targeted Transperineal MRI-TRUS Elastic Fusion-guided Prostate Biopsies Performed Under Local Anesthesia.

BACKGROUND/AIM: The aim of this study was to evaluate the cancer detection rate (CDR) using magnetic resonance imaging-transrectal ultrasound (MRI-TRUS) fusion-guided transperineal targeted biopsy (TB). PATIENTS AND METHODS: We included 401 consecutive patients, of which 161 were biopsy-naïve. All underwent prebiopsy bi-parametric MRI; patients with positive MRI [prostate imaging reporting and data system (PI-RADS≥3)] underwent TB. Biopsy-naïve patients with positive MRI underwent TB and systematic biopsies (SBs). MRI-negative patients underwent SBs. Clinically significant prostate cancer (csPCa) was defined as ISUP ≥2. The added value of SB was defined as an upgrade from a negative biopsy or ISUP of 1 in TB to csPCa in SB. RESULTS: The median (interquartile range) age was 69 (range=63-74) years, and PSA was 6.9 (range=4.5-11) ng/ml. The overall CDR was 65%, with csPCa occurring in 48%. In cases of PI-RADS 5, CDR was 91%, and csPCa was 77%. The added value of SB was 2%. CONCLUSION: Transperineal TB biopsies using MRI-TRUS fusion yield a high CDR.

Multicenter transperineal MRI-TRUS fusion guided outpatient clinic prostate biopsies under local anesthesia.

INTRODUCTION: Transperineal Prostate biopsies (TPBx) are usually performed under general anesthesia without image fusion. This study aimed to evaluate prostate cancer (Pca) detection rates (CDR), pain, and adverse events using a novel, free-hand TPBx technique, based on elastic fusion of magnetic resonance imaging (MRI) and transrectal ultrasound (TRUS) under local anesthesia. MATERIALS AND METHODS: This multicenter retrospective study included all consecutive patients scheduled for a TPBx. All had clinical suspicion of Pca, active surveillance scheduled for a re-biopsy, or suspicion of local recurrence after previous treatment. Bi-parametric or multiparametric MRI was performed in all patients and classified as positive in the case of Prostate Imaging-Reporting and Data System (PIRADS) suspicion ≥3. At least 1 targeted TPBx was realized from each PIRADS ≥3 index lesion. Six to 12 systematic random TPBx were done in patients with negative MRI. All biopsies were performed under local anesthesia in an outpatient clinic with MRI-TRUS fusion and the 3D navigation system Trinity Perine (Koelis, France). Any- and clinically significant Pca (csPca) (ISUP gr. ≥2) was recorded. Biopsy-related pain and adverse events were reported according to a visual analogue score of 0-10. RESULTS: In total, 377 patients were included for analyses. The mean age was 67 years (95% Confidence Interval: 66-68) and the median prostate-specific antigen was 7.2 ng/ml (interquartile range [IQR] 4.8-11.0). MRI was negative in 6% and positive in 94%. The median MRI prostate volume was 43 ml (IQR 31-60) and the median MRI index tumor volume was 0.9 ml (IQR 0.5-2.1). The median number of TPBx was 4 (IQR 3-4). The overall detection of any- and csPca was 64% and 52%, respectively. The overall CDR according to PIRADS 3, 4, and 5 was 30%, 70%, and 94%, respectively. In patients with negative MRI, any- and csPca was detected in 23% and 9%, respectively. The median visual analogue score score was 2 (IQR 1-3, range 0-7). Two patients (0.5%) developed postbiopsy infection, of which one developed urosepsis. Treatment requiring haematuria or urinary retention did not occur. CONCLUSION: Free-hand MRI/TRUS fusion-guided and systematic random TPBx in LA is a feasible, safe, and well-tolerated technique for diagnosing Pca.