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860 NERVE SPARING RADICAL PROSTATECTOMY PLANNING USING T2 WEIGHTED ENDORECTAL COIL MRI IMAGING
and 30 of them (25%) had TR12-negative cancers. Sixty of the 306 patients (20%) had anterior positive MP-MRI finding; of these, 22 patients (37%) actually had TR12-negative cancers. The sensitivity, specificity, positive predictive value, and negative predictive value of anterior positive imaging by MP-MRI finding for predicting TR12-negative cancer were 73, 88, 37 and 97%, respectively. Of the 30 TR12-negative cancers, 15/12/3 cancers had biopsy Gleason score 6/7/810, respectively. Pathological examination of radical prostatectomy specimen in 11 patients with TR12-negative cancer revealed that 8 and 3 index cancers were located in the anterior portion and the apical portion of the gland, respectively. Conclusions: Our results indicate that prebiopsy MP-MRI has high diagnostic ability in detecting anterior cancers missed by TR12PBx.
858
Is it suitable to eliminate bone scan for prostate cancer patients with PSA ≤20 ng/mL in Korean population?
Yom C.D., Lee S.H., Chung M.S., Park K.K., Chung B.H., Mah S.Y. Yonsei University Health System, Dept. of Urology, Seoul, South Korea Introduction & Objectives: Detection of bone metastasis (BM) is important when deciding on the treatment strategy of prostate cancer. According to AUA and EAU guidelines, scanning may not be necessary for those with a serum PSA £ 20 ng/ mL when they have Gleason scores (GS) £ 7. However, it has not been researched that this standard is suitable in Asians whose prostate size or serum PSA are relatively small. Therefore, we evaluated the relationship between bone metastasis and clinical or pathological variables, including the serum PSA concentration. With this evaluation, we tried to determine the clinical profiles of patients for whom bone scanning could be eliminated due to a low probability of bone metastasis. Materials & Methods: This retrospective study included 579 consecutive patients with newly diagnosed adenocarcinoma of the prostate who underwent a bone scan study at our institution between 2002 and July 2010. We excluded the patients who had a past history of antiandrogen treatment for benign prostatic hyperplasia or that of other malignant diseases with possible development of BM. We used receiver operating characteristics (ROC) curves to evaluate accuracy of bone metastasis with serum PSA £ 20 ng/mL or serum PSA £ 10 ng/mL. The diagnostic performance was assessed by calculating the area under the curve (AUC). The statistically significant differences in the AUC were determined using Student’s T-test. Results: 83/579 men (14.3%) with prostate cancer had a positive bone scan. However, 27/579 men (4.6%) with a serum PSA between 10 and 20 ng/mL, 29/579 men (5.0%) with GS £ 7, 21/83 (25.3%) with a serum PSA £ 20 ng/mL and GS £ 7 had positive bone scans. In the logistic regression analyses, clinical T stage (odds ratio [OR] =3.26; 95% CI, 2.29 to 4.33; p=0.021), GS (OR=3.41; 95% CI, 2.91 to 4.93; p=0.019), and serum PSA (OR=8.37; 95% CI, 3.91 to 19.21; p<0.001) were the predictive factor of detecting the BM. When the serum PSA concentration £ 20 ng/mL and GS £ 7, the mean sensitivity, specificity, and the area under the curve (AUC) value of bone scans for the detection of BM were 74.7%, 92.9%, and 0.642, respectively (p=0.79; 95% CI, 0.430 to 0.803). When the serum PSA lowered at 10ng/ml and GS £ 7, the mean sensitivity, specificity, and the AUC values of bone scans were 100%, 83.9%, and 0.760, respectively (p=0.041; 95% CI, 0.642 to 0.897). Conclusions: Based on our findings, bone scans are necessary in men with a serum PSA between 10 and 20 ng/mL. Different guidelines for eliminating bone scans in newly diagnosed prostate cancer are needed especially in Asians.
859
Prostate cancer detection using power Doppler contrast-enhanced ultrasonography and elastography for targeted biopsies
Budau M.1, Jinga V.2, Braticevici B.2, Ambert V.2, Radavoi G.D.2, Calin C.2 1 ’TH. Burghele’ Hospital, Dept. of Radiology, Bucharest, Romania, 2’TH. Burghele’ Hospital, Dept. of Urology, Bucharest, Romania Introduction & Objectives: Transrectal ultrasound-guided needle biopsy of the prostate is the standard procedure to diagnose prostate cancer. Systematic biopsies may not reveal an important amount of clinically relevant cancers. Realtime elastography (RTE) and Power Doppler contrast-enhanced ultrasonography (PDCE) provides information about tissue elasticity and vasculature flow and therefore these techniques can be used for the detection of prostate cancer areas. The aim of this study is to compare the prostate cancer detection rate of RTE and PDCE targeted biopsies with conventional ultrasound guided systematic biopsies. Materials & Methods: A prospective study was performed on 144 men referred for prostate biopsy due to an increased PSA level or abnormal DRE. 70 patients (mean age, 64 years; range 54-75), mean PSA 7,5 ng/ml, were subjected to RTEguided targeted biopsies (up to 5 cores) prior to systematic approach (10 cores). The stiffness of the lesion was displayed and color-coded from red (soft) to blue (hard). Hard lesions were targeted by biopsy. Another group of 74 patients (mean age, 62 years; range 50-78), mean PSA 8,3 ng/ml, underwent PDCE-targeted biopsies, with 5 or less cores, in hypervascular areas of peripheral zone during administration of the ultrasound contrast agent; subsequently a 10 core systematic biopsy was taken. The cancer detection rates of these techniques were compared. Results: Sensitivity for PCa detection (26 of 70 patients; 37,1%) was 80,7% for
RTE-targeted biopsy (21/26) and 76,9% (20/26) for systematic biopsy. Cancer was detected by targeted biopsy alone in 6 patients and by systematic biopsy alone in 5 patients. RTE-targeted cores were positive in 46 of 229 cores (20%) and in 61 of 700 systematic biopsy cores (8,7%). Among the 26 subjects with prostate cancer, targeted biopsy cores were more likely to detect PCa as compared with systematic biopsy. Overall, cancer detection rate for the second group was 40,5% (30/74). PDCE-directed biopsy and systematic 10 cores biopsy could independently detect 25 (83,3%) and 21 (70%) cancer cases, respectively. Cancer was detected by targeted biopsy alone in 9 patients and by systematic biopsy alone in 5 patients. The detection rate for PDCE-targeted biopsy cores (16%, 52 of 324) was significantly better than for systematic biopsy core (7,43%, 55 of 740). Conclusions: •1. RTE and PDCE targeted biopsy are superior to systematic prostate biopsy in CaP detection. The targeted approach detects more cancers with a lower number of biopsy cores. •2. Systematic gray-scale biopsy still cannot be ignored on first biopsy setting. •3. An increase in cancer detection was achieved by combining targeted and systematic techniques
860
Nerve sparing radical prostatectomy planning using T2 weighted endorectal coil MRI imaging
Davis J.W., Achim M. MD Anderson Cancer Center, Dept. of Urology, Houston, United States of America Introduction & Objectives: Endorectal coil magnetic resonance (EC-MRI) imaging of the prostate is an option for staging prostate cancer with established sensitivity and specificity metrics. Updates to the standard T2 weighted analysis are emerging that may increase the performance. We sought to examine our contemporary results with standard T2 weighted EC-MRI in the context of planning the nerve-sparing step of the robot-assisted radical prostatectomy (RARP) and to identify the areas of need for improved imaging performance. Materials & Methods: In a series of 853 consecutive RARPs from 5/20067/2010, we identified two cohorts of men who underwent pre-treatment EC-MRI: 1) Intermediate risk patients who would be candidates for surgery or brachytherapy: cT1x-cT2b, Gleason 7, and PSA < 10 ng/mL, and 2) high risk patients: cT2c-cT3b, Gleason 8-10, or PSA > 20ng/mL. Any degree of suspicion for extraprostatic extension (ECE) was considered a positive study. Nerve preservation was planned combining the side specific biopsy risk for ECE and the EC-MRI findings, and prospectively categorized as nerve-sparing with high versus low lateral fascia release, partial nerve sparing (> 50%), non nerve-sparing (< 50%), or wide-excision (aiming for 0%). All false positive and false negative EC-MRI studies were then analyzed to determine if surgeon-estimated biopsy risk and intraoperative findings led to the avoidance of positive surgical margins resulting from nerve sparing, and avoidance of non nerve sparing in organ confined disease. Results: We identified 172 eligible intermediate risk, and 98 high risk patients. The combined EC-MRI, biopsy estimated risk for ECE, and intraoperative findings led to >50% of bilateral nerve bundle preservation in 170/172 (98.8%) of intermediate and 77/98 (78%) of high risk patients. For intermediate risk, the metrics were a sensitivity 50.9%, specificity 82.6%, positive predictive value (PPV) 59.2%, and negative predictive value (NPV) 77.2%. For high risk patients, the results were 65%, 75%, 76%, and 63%, respectively. In false negative cases, the surgeon estimate of biopsy risk and intraoperative findings was helpful in avoiding a positive margin in 82% of intermediate and 89% of high risk patients. In false positive cases, the surgeon estimates avoided unnecessary nerve excision in 80% of intermediate risk and 63% of high risk cases. Conclusions: EC-MRI metrics currently are insufficient as a stand-alone prediction of ECE and require compensation with biopsy risk tools and intraoperative judgment to achieve accurate surgical planning. Sensitivity is higher in high risk patients. Evaluation of novel techniques such as multi-parametric MRI is needed to improve our operative planning.
861
The role of preoperative MR imaging for risk stratification of patients with high risk prostate cancer
Lee C., Yoon J.H., You D., Jeong I.G., Song C., Hong J.H., Ahn H., Kim C.S. Asan Medical Center, University of Ulsan College of Medicine, Dept. of Urology, Seoul, South Korea Introduction & Objectives: The aim of this study is to investigate the additive role of magnetic resonance (MR) imaging for the pre-treatment risk stratification of patients with clinically high risk prostate cancer. Materials & Methods: A total of 587 patients with clinically high risk prostate cancer (PSA >20ng/mL or clinical T stage ≥T2c or Gleason score ≥8) underwent MR imaging before radical prostatectomy (RP) between 1991 and 2009. We assessed the predictive value of MR imaging to predict the pathologic findings (the organ confined tumor, seminal vesicle invasion, and presence of lymph node metastasis) after RP. Multivariate models using conventional parameters (PSA, clinical stage, and Gleason score) either single or combined, and conventional parameters plus MR imaging to predict the biochemical recurrence after RP were created and the Harrell’s concordance index (c-index) was calculated for each model. Results: Pathological examination revealed that 253 (43.1%) and 56 (9.5%) had
Eur Urol Suppl 2011;10(2):271
858
Is it suitable to eliminate bone scan for prostate cancer patients with PSA ≤20 ng/mL in Korean population?
Yom C.D., Lee S.H., Chung M.S., Park K.K., Chung B.H., Mah S.Y. Yonsei University Health System, Dept. of Urology, Seoul, South Korea Introduction & Objectives: Detection of bone metastasis (BM) is important when deciding on the treatment strategy of prostate cancer. According to AUA and EAU guidelines, scanning may not be necessary for those with a serum PSA £ 20 ng/ mL when they have Gleason scores (GS) £ 7. However, it has not been researched that this standard is suitable in Asians whose prostate size or serum PSA are relatively small. Therefore, we evaluated the relationship between bone metastasis and clinical or pathological variables, including the serum PSA concentration. With this evaluation, we tried to determine the clinical profiles of patients for whom bone scanning could be eliminated due to a low probability of bone metastasis. Materials & Methods: This retrospective study included 579 consecutive patients with newly diagnosed adenocarcinoma of the prostate who underwent a bone scan study at our institution between 2002 and July 2010. We excluded the patients who had a past history of antiandrogen treatment for benign prostatic hyperplasia or that of other malignant diseases with possible development of BM. We used receiver operating characteristics (ROC) curves to evaluate accuracy of bone metastasis with serum PSA £ 20 ng/mL or serum PSA £ 10 ng/mL. The diagnostic performance was assessed by calculating the area under the curve (AUC). The statistically significant differences in the AUC were determined using Student’s T-test. Results: 83/579 men (14.3%) with prostate cancer had a positive bone scan. However, 27/579 men (4.6%) with a serum PSA between 10 and 20 ng/mL, 29/579 men (5.0%) with GS £ 7, 21/83 (25.3%) with a serum PSA £ 20 ng/mL and GS £ 7 had positive bone scans. In the logistic regression analyses, clinical T stage (odds ratio [OR] =3.26; 95% CI, 2.29 to 4.33; p=0.021), GS (OR=3.41; 95% CI, 2.91 to 4.93; p=0.019), and serum PSA (OR=8.37; 95% CI, 3.91 to 19.21; p<0.001) were the predictive factor of detecting the BM. When the serum PSA concentration £ 20 ng/mL and GS £ 7, the mean sensitivity, specificity, and the area under the curve (AUC) value of bone scans for the detection of BM were 74.7%, 92.9%, and 0.642, respectively (p=0.79; 95% CI, 0.430 to 0.803). When the serum PSA lowered at 10ng/ml and GS £ 7, the mean sensitivity, specificity, and the AUC values of bone scans were 100%, 83.9%, and 0.760, respectively (p=0.041; 95% CI, 0.642 to 0.897). Conclusions: Based on our findings, bone scans are necessary in men with a serum PSA between 10 and 20 ng/mL. Different guidelines for eliminating bone scans in newly diagnosed prostate cancer are needed especially in Asians.
859
Prostate cancer detection using power Doppler contrast-enhanced ultrasonography and elastography for targeted biopsies
Budau M.1, Jinga V.2, Braticevici B.2, Ambert V.2, Radavoi G.D.2, Calin C.2 1 ’TH. Burghele’ Hospital, Dept. of Radiology, Bucharest, Romania, 2’TH. Burghele’ Hospital, Dept. of Urology, Bucharest, Romania Introduction & Objectives: Transrectal ultrasound-guided needle biopsy of the prostate is the standard procedure to diagnose prostate cancer. Systematic biopsies may not reveal an important amount of clinically relevant cancers. Realtime elastography (RTE) and Power Doppler contrast-enhanced ultrasonography (PDCE) provides information about tissue elasticity and vasculature flow and therefore these techniques can be used for the detection of prostate cancer areas. The aim of this study is to compare the prostate cancer detection rate of RTE and PDCE targeted biopsies with conventional ultrasound guided systematic biopsies. Materials & Methods: A prospective study was performed on 144 men referred for prostate biopsy due to an increased PSA level or abnormal DRE. 70 patients (mean age, 64 years; range 54-75), mean PSA 7,5 ng/ml, were subjected to RTEguided targeted biopsies (up to 5 cores) prior to systematic approach (10 cores). The stiffness of the lesion was displayed and color-coded from red (soft) to blue (hard). Hard lesions were targeted by biopsy. Another group of 74 patients (mean age, 62 years; range 50-78), mean PSA 8,3 ng/ml, underwent PDCE-targeted biopsies, with 5 or less cores, in hypervascular areas of peripheral zone during administration of the ultrasound contrast agent; subsequently a 10 core systematic biopsy was taken. The cancer detection rates of these techniques were compared. Results: Sensitivity for PCa detection (26 of 70 patients; 37,1%) was 80,7% for
RTE-targeted biopsy (21/26) and 76,9% (20/26) for systematic biopsy. Cancer was detected by targeted biopsy alone in 6 patients and by systematic biopsy alone in 5 patients. RTE-targeted cores were positive in 46 of 229 cores (20%) and in 61 of 700 systematic biopsy cores (8,7%). Among the 26 subjects with prostate cancer, targeted biopsy cores were more likely to detect PCa as compared with systematic biopsy. Overall, cancer detection rate for the second group was 40,5% (30/74). PDCE-directed biopsy and systematic 10 cores biopsy could independently detect 25 (83,3%) and 21 (70%) cancer cases, respectively. Cancer was detected by targeted biopsy alone in 9 patients and by systematic biopsy alone in 5 patients. The detection rate for PDCE-targeted biopsy cores (16%, 52 of 324) was significantly better than for systematic biopsy core (7,43%, 55 of 740). Conclusions: •1. RTE and PDCE targeted biopsy are superior to systematic prostate biopsy in CaP detection. The targeted approach detects more cancers with a lower number of biopsy cores. •2. Systematic gray-scale biopsy still cannot be ignored on first biopsy setting. •3. An increase in cancer detection was achieved by combining targeted and systematic techniques
860
Nerve sparing radical prostatectomy planning using T2 weighted endorectal coil MRI imaging
Davis J.W., Achim M. MD Anderson Cancer Center, Dept. of Urology, Houston, United States of America Introduction & Objectives: Endorectal coil magnetic resonance (EC-MRI) imaging of the prostate is an option for staging prostate cancer with established sensitivity and specificity metrics. Updates to the standard T2 weighted analysis are emerging that may increase the performance. We sought to examine our contemporary results with standard T2 weighted EC-MRI in the context of planning the nerve-sparing step of the robot-assisted radical prostatectomy (RARP) and to identify the areas of need for improved imaging performance. Materials & Methods: In a series of 853 consecutive RARPs from 5/20067/2010, we identified two cohorts of men who underwent pre-treatment EC-MRI: 1) Intermediate risk patients who would be candidates for surgery or brachytherapy: cT1x-cT2b, Gleason 7, and PSA < 10 ng/mL, and 2) high risk patients: cT2c-cT3b, Gleason 8-10, or PSA > 20ng/mL. Any degree of suspicion for extraprostatic extension (ECE) was considered a positive study. Nerve preservation was planned combining the side specific biopsy risk for ECE and the EC-MRI findings, and prospectively categorized as nerve-sparing with high versus low lateral fascia release, partial nerve sparing (> 50%), non nerve-sparing (< 50%), or wide-excision (aiming for 0%). All false positive and false negative EC-MRI studies were then analyzed to determine if surgeon-estimated biopsy risk and intraoperative findings led to the avoidance of positive surgical margins resulting from nerve sparing, and avoidance of non nerve sparing in organ confined disease. Results: We identified 172 eligible intermediate risk, and 98 high risk patients. The combined EC-MRI, biopsy estimated risk for ECE, and intraoperative findings led to >50% of bilateral nerve bundle preservation in 170/172 (98.8%) of intermediate and 77/98 (78%) of high risk patients. For intermediate risk, the metrics were a sensitivity 50.9%, specificity 82.6%, positive predictive value (PPV) 59.2%, and negative predictive value (NPV) 77.2%. For high risk patients, the results were 65%, 75%, 76%, and 63%, respectively. In false negative cases, the surgeon estimate of biopsy risk and intraoperative findings was helpful in avoiding a positive margin in 82% of intermediate and 89% of high risk patients. In false positive cases, the surgeon estimates avoided unnecessary nerve excision in 80% of intermediate risk and 63% of high risk cases. Conclusions: EC-MRI metrics currently are insufficient as a stand-alone prediction of ECE and require compensation with biopsy risk tools and intraoperative judgment to achieve accurate surgical planning. Sensitivity is higher in high risk patients. Evaluation of novel techniques such as multi-parametric MRI is needed to improve our operative planning.
861
The role of preoperative MR imaging for risk stratification of patients with high risk prostate cancer
Lee C., Yoon J.H., You D., Jeong I.G., Song C., Hong J.H., Ahn H., Kim C.S. Asan Medical Center, University of Ulsan College of Medicine, Dept. of Urology, Seoul, South Korea Introduction & Objectives: The aim of this study is to investigate the additive role of magnetic resonance (MR) imaging for the pre-treatment risk stratification of patients with clinically high risk prostate cancer. Materials & Methods: A total of 587 patients with clinically high risk prostate cancer (PSA >20ng/mL or clinical T stage ≥T2c or Gleason score ≥8) underwent MR imaging before radical prostatectomy (RP) between 1991 and 2009. We assessed the predictive value of MR imaging to predict the pathologic findings (the organ confined tumor, seminal vesicle invasion, and presence of lymph node metastasis) after RP. Multivariate models using conventional parameters (PSA, clinical stage, and Gleason score) either single or combined, and conventional parameters plus MR imaging to predict the biochemical recurrence after RP were created and the Harrell’s concordance index (c-index) was calculated for each model. Results: Pathological examination revealed that 253 (43.1%) and 56 (9.5%) had
Eur Urol Suppl 2011;10(2):271