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Thread: (C) Screening – Diagnosis – PSA – Imaging – Biopsies

  1. #91
    Fascinating, well written, and most interesting. Good find, guys!

    Am I reading this correctly:

    <<<Preoperative PSA showed a significant correlation with the presence of BCR and AP. ROC curve analysis was used to determine optimal cut-off value by the Youden Index, as shown in Fig. 2. The optimal cut-off value for PSA level that can predict BCR was determined to be 6.2 ng/ml, with an AUC of 0.799 (95% confidence interval, 0.721–0.877). This was statistically close to an excellent level.>>>
    72...LUTS for the past 7 years
    TURP 2/16,
    G3+4 discovered
    3T MRI 5/16
    MRI fusion guided biopsy 6/16
    14 cores; four G 3+3, one G3+4,
    CIPRO antibiotic = C. Diff infection 7/16
    Cured with Vanco for 14 days
    Second 3T MRI 1/17
    Worsened bulging of posterior capsule
    Oncotype DX GPS 3/17, LFP risk 63%, Likelihood of Low
    Grade Disease 81%, Likelihood of Organ Confined 80%
    RALP 7/13/17 Dr. Gonzaglo @ Univ of Miami
    G3+4 Confirmed, Organ confined
    pT2c pNO pMn/a Grade 2
    PSA 0.32 to .54 over 3 months
    DCFPyl PET & ercMRI Scans - 11/17
    A one inch tumor remains in prostate bed = failed surgery
    All met scans clear
    SRT, 2ADT, IMGT 70.2 Gys @1.8 per, completed 5/18
    PSA <.006 9/18, .054 11/18, .070 12/18
    We'll see....what is not known dwarfs what is thought to be fact

  2. #92
    I believe they are referring to diagnosis (pre-op) PSA as a predictor of post-op BCR. Mike and I exchanged very brief emails and we wondered if population (Korean men), equipment, and or MRI training might have contributed to these poor MRI detection rates. They also seem to say that some men should receive treatment without a biopsy.

  3. #93
    Thanks...they are referring to pre operative PSA.

    Good points about the efficacious results of such studies.

    In rare cases, some men SHOULD receive treatment without benefit of a biopsy.
    72...LUTS for the past 7 years
    TURP 2/16,
    G3+4 discovered
    3T MRI 5/16
    MRI fusion guided biopsy 6/16
    14 cores; four G 3+3, one G3+4,
    CIPRO antibiotic = C. Diff infection 7/16
    Cured with Vanco for 14 days
    Second 3T MRI 1/17
    Worsened bulging of posterior capsule
    Oncotype DX GPS 3/17, LFP risk 63%, Likelihood of Low
    Grade Disease 81%, Likelihood of Organ Confined 80%
    RALP 7/13/17 Dr. Gonzaglo @ Univ of Miami
    G3+4 Confirmed, Organ confined
    pT2c pNO pMn/a Grade 2
    PSA 0.32 to .54 over 3 months
    DCFPyl PET & ercMRI Scans - 11/17
    A one inch tumor remains in prostate bed = failed surgery
    All met scans clear
    SRT, 2ADT, IMGT 70.2 Gys @1.8 per, completed 5/18
    PSA <.006 9/18, .054 11/18, .070 12/18
    We'll see....what is not known dwarfs what is thought to be fact

  4. #94
    [#86]
    Prostate Cancer Screening Guidelines for African American Veterans: A New Perspective
    [2018]

    https://www.sciencedirect.com/scienc...27968418302840

    Abstract

    Background
    Prostate cancer is the most common form of cancer, other than skin cancers, in American men and the second leading cause of cancer deaths. In 2012, the US Preventative Task Force recommended against the prostate specific antigen-based screening for prostate cancer, regardless of race or age, due to overtreatment of low-risk disease and lack of impact on disease outcomes. In African-American men, however, the incidence of prostate cancer is almost 60% higher and the mortality rate is two- to three-times greater than that of Caucasian men. In the subpopulation of African-American veterans, many have been exposed to chemicals that increase incidence of high-risk prostate cancer. The yearly total number of veterans with prostate cancer based on quantification is 3471.9, and the total number of annual prostate cancer deaths is 556. Considering these facts, we examine whether or not it is appropriate to screen African-American veteran males for prostate cancer.

    Previously, we reviewed data on African-Americans in the general population. We concluded that new guidelines needed to be implemented for screening African-Americans. Here we review the pertinent issues related to African-American veterans.

    Methods
    We performed a PubMed and Google Scholar search using the keywords: African-American veteran, prostate cancer, mortality, PSA density, molecular markers, and Agent Orange. The articles that were relevant to the clinical, molecular, social, and health policy aspects of the diagnosis and treatment of prostate cancer in African-American veterans were analyzed. The data was then summarized.

    Results
    After surveying the literature, we found several areas where the African-American veteran population differed from their Caucasian counterparts. These areas were incidence, clinical course, social differences, PSA levels, mortality rate, and molecular markers. A subset of the veteran population was also exposed to Agent Orange, which has been shown to increase the incidence of aggressive forms of prostate cancer. Lastly, the current USPTF guidelines recommending against prostate cancer screening were based on patient cohorts containing disproportionately low numbers of African-Americans, limiting their extension to the African-American veteran population.

    Conclusion
    After reviewing and summarizing the literature, we contend that a need exists to develop and implement more targeted prostate cancer screening guidelines for African-American veterans.
    69 yr at Dx, BPH x 20 yr, 9 (!) negative biopsies, PCA3 -
    2013 TURP (90→30 g) then PSA 2x/yr, DRE yearly
    6-06-17 DRE nodule R, last PSA rise, on finasteride: 3.6→4.3
    6-28-17 Biopsy #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 5% RLM
    Bone scan, CTs, X-rays: negative
    8-7-17 Open RP, neg. frozen sections, Duke Regional, my Uro, 8-20 RPs/mo. x 25 yr.
    SM EPE LVI SVI LNI(16): negative, PNI +, nerves spared
    pT2c pN0, bilat. adenocarcinoma G9 (4+5) 5% of prostate (4.5 x 5 x 4 cm, 64 g)
    11-10-17 Decipher 0.37 Low Risk: 5-yr met risk 2.4%; 10-yr PCa-specific mortality 3.3%
    Dry; ED OK with sildenafil
    9-16-17 (5 weeks) PSA <0.1; Pomi-T (2 capsules/day)
    LabCorp uPSA (Roche ECLIA):
    11-28-17 (3 mo. ) 0.010
    02-26-18 (6 mo. ) 0.009
    05-30-18 (9 mo. ) 0.007
    08-27-18 (1 year) 0.018
    09-26-18 (13 mo) 0.013 (checking rise)
    11-26-18 (15 mo) 0.012

  5. #95
    [#87]
    Upgrading in familial prostate cancer
    [2018]

    https://www.eusupplements.europeanurology.com/article/S1569-9056(133752-7/pdf

    Introduction & Objectives: Postoperative upstaging and upgrading is common after radical prostatectomy (RP). Previous studies have suggested
    concordance in Gleason score among brothers with prostate cancer (Pca). The aim of this study was to assess if familial Pca is a predictor for
    postoperative upgrading or upstaging after RP.
    Materials & Methods: In a nationwide, population-based cohort in Sweden we identified, 6 854 men with low-risk prostate cancer treated with RP
    between 2003 and 2012. 1 739 (25%) had a history of prostate cancer among a first-degree relative. 289 (4%)
    had a first degree relative who died of prostate cancer before age 80 or a brother with high-risk or metastatic prostate cancer. Using logistic
    regression we calculated risk of upgrade and upstage of RP specimen in men with and without
    prostate cancer among first-degree relatives.
    Results: There was no increase in risk of upgrade for men with prostate cancer with a first-degree relative, odds ratio (OR) 1.00 (0.89-1.12).
    For men with a first-degree relative who died of prostate cancer before age 80 or had a brother with high-risk prostate cancer the risk was nonsignificantly
    increased, OR 1.17(0.91-
    1.50) and for men with a brother with distant metastasis, OR 1.31(0.94-1.87). Corresponding risks for upstage were OR 1.00(0.86-1.16) and OR
    1.06(0.76- 1.47) and 0.93(0.58-1.48 ).
    Conclusions: There was no significant increase in risk of upstaging or upgrading after RP in men with familial aggregation of prostate cancer.
    [Emphasis mine]

  6. #96
    [#88]
    Detection of Individual Prostate Cancer Foci via Multiparametric Magnetic Resonance Imaging
    [2018, Full Text]

    https://www.europeanurology.com/article/S0302-2838(130930-8/fulltext

    Abstract

    Background
    Multiparametric magnetic resonance imaging (mpMRI) undoubtedly affects the diagnosis and treatment of localized prostate cancer (CaP). However, clinicians need a better understanding of its accuracy and limitations in detecting individual CaP foci to optimize management.

    Objective
    To determine the per-lesion detection rate for CaP foci by mpMRI and identify predictors of tumor detection.

    Design, setting, and participants
    We carried out a retrospective analysis of a prospectively managed database correlating lesion-specific results from mpMRI co-registered with whole-mount pathology (WMP) prostatectomy specimens from June 2010 to February 2018. Participants include 588 consecutive patients with biopsy-proven CaP undergoing 3-T mpMRI before radical prostatectomy at a single tertiary institution.

    Outcome measurements and statistical analysis
    We measured mpMRI sensitivity in detecting individual CaP and clinically significant (any Gleason score ≥7) CaP foci and predictors of tumor detection using multivariate analysis.

    Results and limitations
    The final analysis included 1213 pathologically confirmed tumor foci in 588 patients with primarily intermediate- (75%) or high-risk (12%) CaP. mpMRI detected 45% of all lesions (95% confidence interval [CI] 42–47%), including 65% of clinically significant lesions (95% CI 61–69%) and nearly 80% of high-grade tumors. Some 74% and 31% of missed solitary and multifocal tumors, respectively, were clinically significant. The majority of missed lesions were small (61.1% ≤1 cm); 28.3% were between 1 and 2 cm, and 10.4% were >2 cm. mpMRI missed at least one clinically significant focus in 34% of patients overall, and in 45% of men with multifocal lesions. On multivariate analysis, smaller, low-grade, multifocal, nonindex tumors with lower prostate-specific antigen density were more likely to be missed. Limitations include selection bias in a prostatectomy cohort, lack of specificity data, an imperfect co-registration process, and uncertain clinical significance for undetected lesions.

    Conclusions
    mpMRI detects less than half of all and less than two-thirds of clinically significant CaP foci. The moderate per-lesion sensitivity and significant proportion of men with undetected tumor foci demonstrate the current limitations of mpMRI.

    Patient summary
    Magnetic resonance imaging of the prostate before surgical removal for prostate cancer finds less than half of all individual prostate cancer tumors. Large, solitary, aggressive tumors are more likely to be visualized on imaging.
    [Emphasis mine]

    From the Full Text:

    Our current study indicates that mpMRI may miss up to 35% of clinically significant lesions (30% when using GS ≥ 3 + 4 with cancer core length ≥6 mm as the csCaP definition) and result in at least one missed csCaP focus in 34–45% of men undergoing radical prostatectomy.

    5. Conclusions
    On a per-lesion basis, mpMRI has moderate sensitivity for detecting CaP and csCaP, and multifocality appears to increase the odds of missed tumors on mpMRI. A substantial percentage of missed lesions are clinically significant, and mpMRI misses at least one csCaP in nearly half of patients. Despite significant progress and greater experience, prostate mpMRI has room to improve. Our findings underscore the need to further refine risk stratification methods and support the continued use of systematic biopsy. Ongoing studies will help to elucidate the pathophysiologic mechanisms behind MRI-invisible lesions and their clinical significance.

  7. #97
    [#89]
    Diagnostic Imaging and Therapeutic Aspect of PSMA in Prostate Cancer
    [2018, 14-min Video]

    Flagged by Forum Brother Michael F.

    https://www.urotoday.com/video-lectu...e-cancer-daily

    Michael Hofman discusses with Alicia Morgans both the diagnostic and therapeutic aspect of prostate specific membrane antigen (PSMA) in prostate cancer. The sensitivity and specificity of the PSMA PET may offer relevant clinical advantages in the diagnosis of prostate cancer while the physical properties of Lutetium 177 may provide advantages therapeutically.

  8. #98
    [#90]
    Who Benefits from Multiparametric Magnetic Resonance Imaging After Suspicion of Prostate Cancer?
    [2018, Full Text]

    https://euoncology.europeanurology.com/article/S2588-9311(130207-4/fulltext

    Abstract

    Background
    Prostate cancer (PC) suspicion is based on prostate-specific antigen (PSA) and digital rectal examination (DRE). Multiparametric magnetic resonance imaging (mpMRI) increases prostate biopsy (PBx) specificity and sensitivity for detection of aggressive PC.

    Objective
    To identify who benefits from mpMRI according to biopsy scenario (initial biopsy [IBx] vs repeated biopsy [RBx]) and the risk of aggressive PC according to PSA-DRE groups (G1, PSA <10 ng/ml and −DRE; G2, PSA <10 ng/ml and +DRE; G3, PSA ≥10 ng/ml and −DRE; G4, PSA ≥10 ng/ml and +DRE).

    Design, setting, and participants
    We carried out a retrospective analysis for 768 consecutive men with PC suspicion and scheduled for PBx in a referral institution in 2016 and 2017.

    Intervention
    Pelvic 3-T mpMRI scanning, targeted biopsy (TBx) for suspicious lesions (Prostate Imaging-Reporting and Data System [PI-RADS] score >1), and 12-core systematic biopsy (SBx).

    Outcome measurements and statistical analysis
    We measured the rate of PBx procedures that could be avoided and the rate of high-grade PC (HGPC) that would be missed among men with negative mpMRI, and the increase in HGPC detection due to TBx. Univariate and multivariate analyses were performed.

    Results and limitations
    The rate of avoidable biopsies (PI-RADS <3) was 24.2% overall, with 25.7% for IBx and 20.5% for RBx (p = 0.057). The IBx and RBx rates were 31.2% and 19.8% in G1, 13.5% and 30.4% in G2, 23.7% and 21.9% in G3, and 2.5% and 0% in G4, respectively. The overall rate of missed HGPC was 1.0% for IBx and 6.5% for RBx (p = 0.170), while the IBx and RBx rates were 1.1% and 5.2% for G1, 2.0% and 11.1% for G2, 0% and 7.7% for G3, and 0% and 0% for G4, respectively (p < 0.001). The rate of HGPC (PI-RADS 3–5) diagnosed following TBx increased to 23.9% for IBx and to 32.6% for RBx overall (p < 0.001), while the IBx and RBx rates were 29.0% and 45.5% for G1, 20.0% and 33.3% for G2, 40.0% and 38.9% for G3, and 0% and 0% for G4, respectively (p < 0.001). Limitations are the single-institution design, the lack of randomisation, and small samples for subgroup analyses.

    Conclusions
    mpMRI was of no benefit for men with PSA ≥10 ng/ml and +DRE. Among the other men, mpMRI was of benefit in IBx and RBx as would reduce the biopsy rate by up to 25.7% and increase the net HGPC detection rate by up to 28.4%.

    Patient summary
    All men with suspected prostate cancer could benefit from multiparametric prostate cancer and targeted biopsy except for those with prostate-specific antigen ≥10 ng/ml and positive digital rectal examination. The benefits include avoiding unnecessary prostate biopsy procedures and increasing the detection of aggressive cancer.

  9. #99
    [#91]
    Intra‐ and interreader reproducibility of PI‐RADSv2: A multireader study [2018]

    https://onlinelibrary.wiley.com/doi/...002/jmri.26555

    Abstract

    Background
    The Prostate Imaging Reporting and Data System version 2 (PI‐RADSv2) has been in use since 2015; while interreader reproducibility has been studied, there has been a paucity of studies investigating the intrareader reproducibility of PI‐RADSv2.

    Purpose
    To evaluate both intra‐ and interreader reproducibility of PI‐RADSv2 in the assessment of intraprostatic lesions using multiparametric magnetic resonance imaging (mpMRI).

    Study Type
    Retrospective.

    Population/Subjects
    In all, 102 consecutive biopsy‐naοve patients who underwent prostate MRI and subsequent MR/transrectal ultrasonography (MR/TRUS)‐guided biopsy.

    Field Strength/Sequences
    Prostate mpMRI at 3T using endorectal with phased array surface coils (TW MRI, DW MRI with ADC maps and b2000 DW MRI, DCE MRI).

    Assessment
    Previously detected and biopsied lesions were scored by four readers from four different institutions using PI‐RADSv2. Readers scored lesions during two readout rounds with a 4‐week washout period.

    Statistical Tests
    Kappa (κ) statistics and specific agreement (Po) were calculated to quantify intra‐ and interreader reproducibility of PI‐RADSv2 scoring. Lesion measurement agreement was calculated using the intraclass correlation coefficient (ICC).

    Results
    Overall intrareader reproducibility was moderate to substantial (κ = 0.43–0.67, Po = 0.60–0.77), while overall interreader reproducibility was poor to moderate (κ = 0.24, Po = 46). Readers with more experience showed greater interreader reproducibility than readers with intermediate experience in the whole prostate (P = 0.026) and peripheral zone (P = 0.002). Sequence‐specific interreader agreement for all readers was similar to the overall PI‐RADSv2 score, with κ = 0.24, 0.24, and 0.23 and Po = 0.47, 0.44, and 0.54 in T2‐weighted, diffusion‐weighted imaging (DWI), and dynamic contrast‐enhanced (DCE), respectively. Overall intrareader and interreader ICC for lesion measurement was 0.82 and 0.71, respectively.

    Data Conclusion
    PI‐RADSv2 provides moderate intrareader reproducibility, poor interreader reproducibility, and moderate interreader lesion measurement reproducibility. These findings suggest a need for more standardized reader training in prostate MRI.

  10. #100
    [#92]
    A critical comparison of techniques for MRI-targeted biopsy of the prostate
    [2017, Full Text]

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5503959/

    MRI-targeted biopsy is a promising technique that offers an improved detection of clinically significant prostate cancer over standard non-targeted biopsy. It is established that prostate MRI is of use in both the primary and repeat biopsy setting for the detection of significant prostate cancer. There are three approaches to targeting biopsies to areas of interest seen on prostate MRI. They each rely on the acquisition and reporting of a diagnostic quality multi-parametric MRI scan used to identify areas of interest, and the subsequent use of those diagnostic quality images in combination with real-time images of the prostate during the biopsy procedure. The three techniques are: visual registration of the MRI images with a real-time ultrasound image; software-assisted fusion of the MRI images and the real-time ultrasound images, and in-bore biopsy, which requires registration of a diagnostic quality MRI scan with a real time interventional MRI image. In this paper we compare the three techniques and evaluate those studies where there is a direct comparison of more than one MRI-targeting technique. PubMed was searched from inception to November 2016 using the search terms (cognitive registration OR visual registration OR fusion biopsy OR in-bore biopsy OR targeted biopsy) AND (prostate cancer OR prostate adenocarcinoma OR prostate carcinoma OR prostatic carcinoma OR prostatic adenocarcinoma) AND (MRI OR NMR OR magnetic resonance imaging OR mpMRI OR multiparametric MRI). The initial search included 731 abstracts. Eleven full text papers directly compared two or more techniques of MRI-targeting, and were selected for inclusion. The detection of clinically significant prostate cancer varied from 0% to 93.3% for visual registration, 23.2% to 100% for software-assisted registration and 29% to 80% for in-bore biopsy. Detection rates for clinically significant cancer are dependent on the prevalence of cancer within the population biopsied, which in turn is determined by the selection criteria [biopsy naοve, previous negative biopsy, prostate specific antigen (PSA) selection criteria, presence of a lesion on MRI]. Cancer detection rates varied more between study populations than between biopsy approaches. Currently there is no consensus on which type of MRI-targeted biopsy performs better in a given setting. Although there have been studies supporting each of the three techniques, substantial differences in methodology and reporting the findings make it difficult to reliably compare their outcomes.[/QUOTE]


    From the Full Text:

    Conclusions

    Ideally, the optimal biopsy technique should have the highest detection rate of clinically significant prostate cancer, while simultaneously having the lowest detection rate of clinically insignificant disease. Currently there is no consensus on which type of MRI-targeted biopsy performs better in a given setting. Although there have been studies supporting each of the three techniques, substantial differences in methodology and reporting the findings make it difficult to reliably compare their outcomes. The economic implications of using software assisted registration or in-bore registration should be borne in mind when choosing an approach.
    [Emphasis mine]

 

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