1443 PSA STRATIFIES RISK OF PROSTATE CANCER AFTER HIGH GRADE PROSTATIC INTRAEPITHELIAL NEOPLASIA

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THE JOURNAL OF UROLOGY姞

uncommon and deaths from prostate biopsy were reported. Febrile complications after prostate biopsy seem to be increasing. There is a need to perform a well-controlled trial to determine the best prophylaxis for prostate biopsy. We believe this data will help us design one for our institution. Source of Funding: Oakland University William Beaumont Hospital Research Foundation

1443 PSA STRATIFIES RISK OF PROSTATE CANCER AFTER HIGH GRADE PROSTATIC INTRAEPITHELIAL NEOPLASIA Ravi Kacker, Sherif Elsobky*, Kevin Loughlin, Boston, MA INTRODUCTION AND OBJECTIVES: Patients with high-grade prostatic intraepithelial neoplasia (HGPIN) may have an increased risk of developing prostate cancer (CaP). We examined the risk of HGPIN based on PSA stratification. METHODS: An institutional review board approved database identified 476 men who underwent prostate needle biopsy at our institution and had PSA follow-up data available in the medical record. High grade CaP was defined as Gleason 4⫹3 or greater. The risk of CaP after HGPIN was examined based on PSA follow-up. RESULTS: HGPIN was present in 91 men (19.1%) and conferred an increased risk of CaP (OR 5.965; p⬍0.0001) and high grade CaP (OR 3.598; p⬍0.0001) over a median follow-up of 24 months. On logistic regression models, PSA is associated with an increased risk of CaP (OR 1.21; p⫽0.0113) for men with HGPIN. The increased risk of CaP did not reach significance until PSA exceeded 6 ng/ml (OR 3.917; p⫽0.0043). PSA is not significantly associated with high grade CaP after HGPIN (p⫽0.274). However, all 9 patients (9.78%) who developed high grade CaP had PSA ⬎ 4ng/ml (mean 7.15 ⫾ 4.04 ng/ml). CONCLUSIONS: There is an increased risk of CaP for patients with HGPIN and elevated PSA, particularly for those with PSA ⬎6ng/ ml. Further research is needed to determine optimal PSA screening guidelines after identification of HGPIN. Source of Funding: None

1444 WHAT BURDEN OF PROSTATE CANCER IS MISSED BY A NEGATIVE MULTI-PARAMETRIC MRI? AN ANALYSIS BASED ON TEMPLATE PROSTATE MAPPING AS THE REFERENCE STANDARD Hashim Ahmed*, Nimalan Arumainayagam, Alex Freeman, S Aslam Sohaib, Alex Kirkham, Clare Allen, Mark Emberton, London, United Kingdom INTRODUCTION AND OBJECTIVES: Much discussion has recently centred on the role of multi-parametric (mp)MRI in ruling-out clinically significant prostate cancer. Studies to date have set the target condition at various thresholds of ‘clinical significance’: from ‘all cancer’ or those lesions of volume ⬎/⫽0.2cc or ⬎/⫽0.5cc. The performance characteristics of mpMRI has a positive correlation with cancer volume, but there is uncertainty as to the disease burden that mpMRI misses when it is called ‘negative’or ‘normal2’. METHODS: From 2006 to 2008, 64 men seeking reclassification of disease status (previous positive TRUS⫽51, no previous TRUS⫽3, previous negative TRUS⫽10) underwent mpMRI (1.5T, pelvic phased array, T2W, Diffusion, Dynamic Contrast) followed by Template Prostate Mapping (TPM). 3 radiologists independently reported scans blind to pathology using an ordinal scale of 1-5 (1⫽highly likely benign, 5⫽highly likely malignant) and 4 sectors per prostate (quadrants). The target condition to indicate a positive outcome on TPM was derived by varying the Maximum Cancer Core Length (MCCL) and Total Cancer Core Length (TCCL) thresholds from 1mm to 10mm. TCCL indicated the total amount of cancer from all positive cores in a sector of analysis. Sensitivity, specificity, negative and positive predic-

Vol. 187, No. 4S, Supplement, Tuesday, May 22, 2012

tive values were calculated at each MCCL and TCCL threshold. The MCCL and TCCL values that gave rise to a negative predictive value (NPV) of ⬎/⫽95% for mpMRI were derived. RESULTS: Mean age was 62 years (range 40-76) and mean PSA 8.2ug/L (range 2.1– 43). 54 men had cancer on TPM of which 18 had Gleason ⬍/⫽3⫹3. 127/256 (50%) sectors had cancer of which 83/127 (67%) had Gleason ⬍/⫽3⫹3. The sectors with no Gleason pattern 4 were used to derive endpoints for the purpose of this study, as this excluded the strong confounding variable of Gleason grade. Using a radiological score of ⬎/⫽3, the MCCL and TCCL values that gave rise to a NPV of 95% for mpMRI were 4-6mm and 4-8mm, respectively. Using a radiological score of ⬎/⫽4, the MCCL and TCCL values that gave rise to a NPV of 95% for mpMRI were 5-7mm and 6-10mm, respectively. If the MCCL values we have derived are used as diameters for a perfect sphere, then lesion volumes would be 0.03ml to 0.18ml. The NPV cancer with Gleason ⬎/⫽3⫹4 was 90-95%, regardless of MCCL/TCCL. CONCLUSIONS: If a prostate is deemed ‘negative’ on mpMRI, the maximum amount of prostate cancer that can still be present is 0.18ml and Gleason 3⫹3. mpMRI seems to have the ideal attributes of a triage diagnostic test to identify those men that could be advised to avoid a prostate biopsy. Source of Funding: Medical Research Council (UK), Pelican Cancer Foundation, Prostate Action, St Peters Trust

1445 IMPACT OF SERIAL PROSTATE BIOPSIES ON LOWER URINARY TRACT SYMPTOMS IN MEN ON ACTIVE SURVEILLANCE FOR PROSTATE CANCER Allison S. Glass*, Joan F. Hilton, Samuel L. Washington, Jared M. Whitson, Janet E. Cowan, Katsuto Shinohara, Matthew R. Cooperberg, Maxwell V. Meng, Kirsten L. Greene, Peter R. Carroll, San Francisco, CA INTRODUCTION AND OBJECTIVES: Patients with low-risk prostate cancer are increasingly choosing active surveillance (AS) as an initial management strategy. Monitoring includes regular transrectal ultrasound (TRUS) guided biopsies. Such biopsies may induce lower urinary tract symptoms (LUTS) by a variety of mechanisms. We attempt to describe the long-term cumulative effects of serial TRUS-guided biopsies on LUTS in men with prostate cancer on AS. METHODS: The study group included men on AS who received TRUS guided biopsies at 12-18 month intervals and completed one or more quality of life questionnaires after biopsy. Urinary symptoms were assessed using the total International Prostate Symptom Score (IPSS) 7-question survey. Associations between age, partner status, biopsy number, diagnosis year, prostate volume, and total IPSS score were tested using Pearson correlation and chi-square. Relationships of demographic and clinical variables with IPSS scores across biopsies were evaluated using repeated measures mixed modeling. RESULTS: Since 2003, 421 men have undergone TRUSguided prostate biopsy and 1413 provided post-biopsy IPSS surveys. Median age was 61 years (interquartile range, IQR 57-66) and 79% of men had spouses or life partners. At diagnosis, 69% had cT1 disease and 93% had biopsy Gleason score 2-6. Median prostate volume was 36 mL (IQR 26-49 mL). Median IPSS score was 7 (IQR 4-10) at 1st biopsy and 10 (IQR 5-13) at 5th biopsy. Only patients who underwent ⱖ5 biopsies had higher IPSS scores (p ⫽ 0.04). Other variables associated with higher IPSS score included age (p ⬍0.01), relationship status (p ⫽ 0.03) and prostate volume (p⬍0.01). IPSS score was not associated with year of cancer diagnosis. CONCLUSIONS: Total IPSS score was associated with having 5 or more biopsies, age, prostate volume and partner status. Though patients may experience a small worsening in urinary symptoms after repeated biopsy, the expected clinical impact appears limited. Source of Funding: None