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MP15-17 MP-MRI UPGRADES MEN WHO HAVE HAD A BIOPSY SHOWING PRIOR CANCER
THE JOURNAL OF UROLOGYâ
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pathologic reclassification (Gleason upgrade and/or volume progression); overall pooled HR 0.19 (95% CI 0.17-0.21), or PSA progression; overall pooled HR 0.03 (95% CI 0.02-0.04). Less common triggers included MRI progression or local symptomatic progression. CONCLUSIONS: Marked heterogeneity among AS series makes firm conclusions difficult. There was remarkable increased risk of metastasis and cancer death in studies including patients with Gleason 7. Significant proportion was treated due to patient preference triggered by anxiety with no signs of disease progression. There is a strong need for a robust evidence from prospective trials with longer follow-up. Source of Funding: None
MP15-17 MP-MRI UPGRADES MEN WHO HAVE HAD A BIOPSY SHOWING PRIOR CANCER Cayce Nawaf*, James Rosoff, Jeffrey Weinreb, Peter Humphrey, Angelique Levi, Steffen Huber, Preston Sprenkle, New Haven, CT INTRODUCTION AND OBJECTIVES: Appropriate risk stratification of men on active surveillance for prostate cancer is essential to identify men in whom it is safe to take this deferred treatment approach. This study evaluates upstaging rates using MRI-US fusion targeted biopsy in men who have had a prior positive standard 12-core biopsy. METHODS: Between 12/2012 and 06/2015, 374 men with an indication for prostate biopsy presented to our institution and underwent pre-biopsy mpMRI followed by 12-core standard trans-rectal mapping biopsy (Mbx) and MRI-Ultrasound fusion targeted biopsy (Tbx) of lesions identified on mpMRI. The combination of Mbx and Tbx, when both occurred, constitutes a fusion biopsy (Fbx). Men who underwent both Mbx with or without Tbx using the Artemis/Pro-Fuseâ system with a previous non-MRI-guided biopsy and a diagnosis of prior Gleason 6 prostate cancer were included. Patients without a lesion on MRI underwent Mbx only. Maximum Gleason scores (GS) were assigned on a per patient basis with Mbx GS available for all patients in the cohort and Tbx GS available only for patients with a lesion visible on MP-MRI. Clinically significant (CS) cancer was defined as GS 3+4. GS per patient was compared by chi-square and McNemar’s test. RESULTS: Overall, 118 patients met inclusion criteria (Mean PSA¼6.9, Mean age¼62.5). 40 patients (34%) were upstaged by Fbx to Gleason 7. Of those upstaged, 17 men (14%) would have been missed by Mbx alone, in comparison to 7 (6%) that were missed by Tbx alone. Total number of prior biopsies (p¼0.28) and number of years on Active Surveillance (p¼0.22) were not related to the likelihood of upgrade on Fbx. Older men (65.3 vs. 60.9, p¼0.033) and those with higher PSA (8.7 vs 5.8, p¼0.002) were more likely to be upgraded on Fbx than those not upgraded. Tbx was more likely to identify CS cancer than standard biopsy (85% vs 56%; p < 0.012) CONCLUSIONS: MP-MRI Fusion biopsy more accurately stratifies men with a previous prostate biopsy than those receiving a template mapping 12-core biopsy alone. Tbx should be strongly considered before enrolling a patient in active surveillance since up 14% of clinically significant cancer would have been missed with a 12core biopsy alone.
Source of Funding: None
Vol. 195, No. 4S, Supplement, Friday, May 6, 2016
MP15-18 MULTIPARAMETRIC MRI OUTPERFORMS PSA VELOCITY FOR PATHOLOGIC PROGRESSION IN MEN ON ACTIVE SURVEILLANCE FOR PROSTATE CANCER Michael Kongnyuy*, Arvin George, Bethesda, MD; Minhaj Siddiqui, Baltimore, MD; Akhil Muthigi, Meet Kadakia, Thomas Frye, Abhinav Sidana, Amichai Kilchevsky, Hui Han, Francesca Mertan, Daniel Su, Maria Merino, Baris Turkbey, Peter Choyke, Bradford Wood, Peter Pinto, Bethesda, MD INTRODUCTION AND OBJECTIVES: Pathologic progression is identified in >25% of patients on active surveillance (AS) for prostate cancer (CaP). However, the ability to identify which patients are at risk for progression is limited to PSA-based triggers with variable utility. Recently, multiparametric MRI (mpMRI) and fusion-guided prostate biopsy (FBx) has demonstrated utility in risk stratification for patients considering AS. We aim to compare mpMRI characteristics with PSA kinetics for the prediction of pathologic progression in men on AS. METHODS: A review of men on AS with mpMRI and 2 or more FBx sessions was performed. FBx sessions consisted of targeted biopsies and 12-core systematic (SBx). Men who met NIH Expanded AS criteria included those with low and intermediate risk CaP, Gleason score ¼ 3+4¼7 with no restriction on percent core involvement or number of cores positive. Progression was defined by patients with initial Gleason 3+3¼6 to any Gleason 4, and Gleason 3+4¼7 disease progressing to a primary Gleason 4 or higher. MRI progression was defined as increase in lesion suspicion score, size, or new lesion on followup. PSA velocity (PSAV) and imaging characteristics were examined for association with pathologic progression at protocol surveillance biopsy. RESULTS: A total of 166 men were included for analysis. Median length of follow-up was 19.3 months (3.2-96.4). Median age, PSA, and prostate volume of our cohort were 62.7 years (6.8), 5.8ng/ml (4.0) and 52.6cc (25.6) at enrollment. MRI progression was associated with pathologic progression (OR 2.4, p¼0.04). PSAV had no association with pathologic progression (p¼0.8) and on receiver operator curve analysis demonstrated poor predictive ability for pathologic progression (AUC¼0.53). Decision curve analysis demonstrated that at essentially all clinically relevant levels of risk-tolerance, MRI was superior to PSAV for detection of pathologic progression (Figure 1). CONCLUSIONS: Progression on mpMRI outperforms PSAV for prediction of pathologic progression in men on AS for prostate cancer. The addition of mpMRI into AS monitoring may improve upon current risk stratification tools and better determine appropriate candidacy for surveillance.
Source of Funding: This research was supported by the Intramural Research Program of the National Institutes of Health (NIH), National Cancer Institute, Center for Cancer Research,
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pathologic reclassification (Gleason upgrade and/or volume progression); overall pooled HR 0.19 (95% CI 0.17-0.21), or PSA progression; overall pooled HR 0.03 (95% CI 0.02-0.04). Less common triggers included MRI progression or local symptomatic progression. CONCLUSIONS: Marked heterogeneity among AS series makes firm conclusions difficult. There was remarkable increased risk of metastasis and cancer death in studies including patients with Gleason 7. Significant proportion was treated due to patient preference triggered by anxiety with no signs of disease progression. There is a strong need for a robust evidence from prospective trials with longer follow-up. Source of Funding: None
MP15-17 MP-MRI UPGRADES MEN WHO HAVE HAD A BIOPSY SHOWING PRIOR CANCER Cayce Nawaf*, James Rosoff, Jeffrey Weinreb, Peter Humphrey, Angelique Levi, Steffen Huber, Preston Sprenkle, New Haven, CT INTRODUCTION AND OBJECTIVES: Appropriate risk stratification of men on active surveillance for prostate cancer is essential to identify men in whom it is safe to take this deferred treatment approach. This study evaluates upstaging rates using MRI-US fusion targeted biopsy in men who have had a prior positive standard 12-core biopsy. METHODS: Between 12/2012 and 06/2015, 374 men with an indication for prostate biopsy presented to our institution and underwent pre-biopsy mpMRI followed by 12-core standard trans-rectal mapping biopsy (Mbx) and MRI-Ultrasound fusion targeted biopsy (Tbx) of lesions identified on mpMRI. The combination of Mbx and Tbx, when both occurred, constitutes a fusion biopsy (Fbx). Men who underwent both Mbx with or without Tbx using the Artemis/Pro-Fuseâ system with a previous non-MRI-guided biopsy and a diagnosis of prior Gleason 6 prostate cancer were included. Patients without a lesion on MRI underwent Mbx only. Maximum Gleason scores (GS) were assigned on a per patient basis with Mbx GS available for all patients in the cohort and Tbx GS available only for patients with a lesion visible on MP-MRI. Clinically significant (CS) cancer was defined as GS 3+4. GS per patient was compared by chi-square and McNemar’s test. RESULTS: Overall, 118 patients met inclusion criteria (Mean PSA¼6.9, Mean age¼62.5). 40 patients (34%) were upstaged by Fbx to Gleason 7. Of those upstaged, 17 men (14%) would have been missed by Mbx alone, in comparison to 7 (6%) that were missed by Tbx alone. Total number of prior biopsies (p¼0.28) and number of years on Active Surveillance (p¼0.22) were not related to the likelihood of upgrade on Fbx. Older men (65.3 vs. 60.9, p¼0.033) and those with higher PSA (8.7 vs 5.8, p¼0.002) were more likely to be upgraded on Fbx than those not upgraded. Tbx was more likely to identify CS cancer than standard biopsy (85% vs 56%; p < 0.012) CONCLUSIONS: MP-MRI Fusion biopsy more accurately stratifies men with a previous prostate biopsy than those receiving a template mapping 12-core biopsy alone. Tbx should be strongly considered before enrolling a patient in active surveillance since up 14% of clinically significant cancer would have been missed with a 12core biopsy alone.
Source of Funding: None
Vol. 195, No. 4S, Supplement, Friday, May 6, 2016
MP15-18 MULTIPARAMETRIC MRI OUTPERFORMS PSA VELOCITY FOR PATHOLOGIC PROGRESSION IN MEN ON ACTIVE SURVEILLANCE FOR PROSTATE CANCER Michael Kongnyuy*, Arvin George, Bethesda, MD; Minhaj Siddiqui, Baltimore, MD; Akhil Muthigi, Meet Kadakia, Thomas Frye, Abhinav Sidana, Amichai Kilchevsky, Hui Han, Francesca Mertan, Daniel Su, Maria Merino, Baris Turkbey, Peter Choyke, Bradford Wood, Peter Pinto, Bethesda, MD INTRODUCTION AND OBJECTIVES: Pathologic progression is identified in >25% of patients on active surveillance (AS) for prostate cancer (CaP). However, the ability to identify which patients are at risk for progression is limited to PSA-based triggers with variable utility. Recently, multiparametric MRI (mpMRI) and fusion-guided prostate biopsy (FBx) has demonstrated utility in risk stratification for patients considering AS. We aim to compare mpMRI characteristics with PSA kinetics for the prediction of pathologic progression in men on AS. METHODS: A review of men on AS with mpMRI and 2 or more FBx sessions was performed. FBx sessions consisted of targeted biopsies and 12-core systematic (SBx). Men who met NIH Expanded AS criteria included those with low and intermediate risk CaP, Gleason score ¼ 3+4¼7 with no restriction on percent core involvement or number of cores positive. Progression was defined by patients with initial Gleason 3+3¼6 to any Gleason 4, and Gleason 3+4¼7 disease progressing to a primary Gleason 4 or higher. MRI progression was defined as increase in lesion suspicion score, size, or new lesion on followup. PSA velocity (PSAV) and imaging characteristics were examined for association with pathologic progression at protocol surveillance biopsy. RESULTS: A total of 166 men were included for analysis. Median length of follow-up was 19.3 months (3.2-96.4). Median age, PSA, and prostate volume of our cohort were 62.7 years (6.8), 5.8ng/ml (4.0) and 52.6cc (25.6) at enrollment. MRI progression was associated with pathologic progression (OR 2.4, p¼0.04). PSAV had no association with pathologic progression (p¼0.8) and on receiver operator curve analysis demonstrated poor predictive ability for pathologic progression (AUC¼0.53). Decision curve analysis demonstrated that at essentially all clinically relevant levels of risk-tolerance, MRI was superior to PSAV for detection of pathologic progression (Figure 1). CONCLUSIONS: Progression on mpMRI outperforms PSAV for prediction of pathologic progression in men on AS for prostate cancer. The addition of mpMRI into AS monitoring may improve upon current risk stratification tools and better determine appropriate candidacy for surveillance.
Source of Funding: This research was supported by the Intramural Research Program of the National Institutes of Health (NIH), National Cancer Institute, Center for Cancer Research,