Moderated Poster Session 14 Prostate Cancer: Detection MODERATED POSTER SESSIONS

Moderated Poster SessionS
Moderated Poster Session 14
Prostate Cancer: Detection
and Screening
Tuesday, October 2
15:15-16:45
MP-14.01
Trend of Prostate Biopsy for
Prostate Cancer in Chinese
Men from 2003 to 2011
Na R1, Jiang H1, Kim S2, Wu Y1, Tong S1,
Zhang L1, Xu J1,2, Ding Q1
1
Dept. of Urology, Huashan Hospital,
Fudan University, Shanghai, China;
2
Center For Cancer Genomics, Wake
Forest University Baptist Medical Center,
Winston-Salem, USA
Introduction and Objective: To understand trend of prostate biopsy for prostate cancer (PCa) in Chinese men during
the last 10 years after increasing use of
PSA tests.
Materials and Methods: All patients
who underwent prostate biopsy for PCa
at Huashan Hospital, Fudan University,
Shanghai, China during 2003-2011 were
evaluated. Prostate biopsy was performed
using six cores before October 2007 or
MP-14.01, Table 1.
2003
No. of
58
biopsies
PCa (%)
74.
GS≥8 (%)
---*
Age of
71.65
Diagnosis
(7.42
(SD)
tPSA°
52.67
(SD)
(3.44)
%fPSA
0.15
(SD)
(0.17)
Prostate
39.37
Volume°
(1.57)
(SD)
Nodule (%) 85.29
the changes of positive prostate biopsy
rate over the years. A logistic regression
was used to model the predictors of PCa.
Area under the receiver operating characteristic curve (AUC) was used to assess
predictive performance of models.
Results: The overall positive rate of
prostate biopsy for PCa was 47% and the
rate decreased significantly over the years
from 74% in 2003 to 33% in 2011 (Ptrend=0.004). Similar results were found
for high-grade PCa (Gleason Score ≥8, P
trend=2.08X10-7). Age at diagnosis was
slightly increased (P-trend=0.04) while
%fPSA was significantly decreased (Ptrend=1.11X10-5). No statistically significant trend of changes was found for tPSA
levels (P-trend=0.470), prostate volume
(P-trend=0.301), and proportion of positive nodule (P-trend=0.507). The predictive performance of positive prostate
biopsy using DRE, tPSA, %fPSA, prostate
volume, and nodule was excellent, with
AUC of 0.93.
Conclusions: Detection rates of PCa and
high-grade PCa among men underwent
prostate biopsy in China decreased significantly in the last 10 years, likely due
to increasing use of PSA tests. Predictive
performance of demographic and clinical
variables of PCa was excellent.
Introduction and Objective: The
Gleason score has been shown to offer
important information with regard to
prognosis and therapy for patients with
adenocarcinoma of the prostate gland. In
this study, Gleason scores, as determined
by 18-gauge core needle biopsies, were
compared with both Gleason scores and
the pathological staging of corresponding
radical prostatectomy specimens.
Materials and Methods: Records of 234
consecutive patients undergoing a radical
retro pubic prostatectomy between 2000
and 2010 were reviewed. In total, all our
patients were enrolled, all of whom had
been diagnosed with adenocarcinoma
by transrectal needle biopsies using an
18-gauge automated spring-loaded biopsy
gun.
Results: Grading errors were greatest
with well-differentiated tumors. The accuracy was 18 (23%) for Gleason scores
of 2-4 on needle biopsy. Of the 108 evaluable patients with Gleason scores of 5-7
on needle biopsy, 84 (78%) were graded
correctly. All of the Gleason scores of 8-10
on needle biopsy were graded correctly.
54 of 162 patients (33%), with a biopsy
Gleason score of < 7 had their cancer upgraded to above 7. Tumors in 18 patients
(60%) with both a Gleason score < 7 on
2004
2005
2006
2007
2008
2009
2010
2011
P-trend
Overall
85
268
294
180
186
196
175
208
/
1650
60
50
50
61
43
51
46
46
39
42
42
32
50
40
33
27
0.004
2.08E-07
47
44
72.49
(8.25
71.13
(7.69)
72.95
(7.84)
72.41
(9.2)
72.82
(8.86)
75.69
(7.93)
72.89
(8.64)
74.72
0.040
(8.24)
72.96
(8.30)
62.04
(3.07)
0.19
(0.21)
48.96
(2.42)
0.2
(0.16)
51.76
(2.33)
0.2
(0.16)
76.81
(5.22)
0.12
(0.08)
47.86
(3.95)
0.12
(0.08)
56.5
(4.24)
0.12 (0.07)
56.67
(4.13)
0.13
(0.07)
42.72
0.470
(4.23)
0.12
1.11E-05
(0.09)
53.55
(3.54)
0.15
(0.13)
42.75
(1.62)
43.65
(1.66)
43.35
(1.64)
46.08
(1.63)
41.91
(1.53)
41.27
(1.6)
45.54
(1.64)
41.21
0.301
(1.61)
43.0
(1.62)
76.67
80.18
81.9
86.76
81.82
84.21
80.72
75.58
81.34
0.507
* No Data about Gleason Scores in 2003
° The values are antilogarithmic
ten cores thereafter. Demographic and
clinical information was collected for
each patient, including age, digital rectal
examination (DRE), transrectal ultrasound (prostate volume and nodule),
total prostate-specific antigen (tPSA)
levels and percentage of free PSA (%fPSA)
prior to biopsy, and the pathological
results. A trend test was used to evaluate
MP-14.02
Gleason Score Discrepancies
between Needle Biopsies and
Radical Prostatectomy Specimens
in African Men Divided into
Three Prognostic Groups
Janane A, Ould Ismail T, Dakkak Y,
Ghadouane M, Ameur A, Abbar M
Dept. of Urology, Military Hospital For
Instruction MEDV, Rabat, Morroco
UROLOGY 80 (Supplement 3A), September 2012
the needle biopsy and a Gleason score of
7 for the prostatectomy specimen were
confined to the prostate.
Conclusions: The potential for grading
errors is greatest with well-differentiated
tumors and in patients with a Gleason
score of < 7 on the needle biopsy. Predictions using Gleason scores are sufficiently
accurate to warrant its use with all needle
biopsies, recognizing that the potential
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Moderated Poster SessionS
for grading errors is greatest with welldifferentiated tumors.
MP-14.03
The Evaluation of Effectiveness in the
Lesion Suspicious Biopsies Detected
by Ultrasonography and MRI
Inoue S, Honda M, Iwamoto H, Satoh M,
Morizane S, Yao A, Hinata N, Isoyama T,
Sejima T, Takenaka A
Dept. of Urology, Tottori University
School of Medicine, Yonago, Japan
Introduction and Objective: We evaluated the effectiveness of the lesion-suspicious biopsy detected by ultrasonography
and magnetic resonance imaging (MRI).
Materials and Methods: A total of 169
consecutive patients with elevated prostate specific antigen (PSA) levels of 4 to
30 ng/ml, without apparent invasion of
prostate cancer detected by digital rectal
examination (DRE). After caudal anesthesia, we underwent extended transrectal
systematic 14-core biopsy of the prostate.
Eight cores were obtained at peripheral
zone, 4 at transitional zone and 2 at apex.
In addition to the systematic biopsies,
we added targeted biopsies at cancersuspected lesions detected by ultrasonography or MRI.
Results: Cancer was histologically confirmed in 67 (39.6%) out of 169 patients
with elevated PSA. We performed lesion
suspicious biopsies in 130 (76.9%) of the
169 patients, then prostate cancer was
histologically confirmed in 54 (41.5%)
patients. Among those patients, 30 (56%)
were histologically diagnosed with prostate cancer in suspicious lesions. In the
remaining 24 (44%), prostate cancer was
only detected in systematic areas. On
the other hand, prostate cancer was not
detected in 76 (58.5%) among lesion
suspicious biopsy patients.
Conclusions: In the present study, we
diagnosed prostate cancer in only one patient with suspicious lesions. We consider
that extended 14 systematic prostate
biopsies could cover almost all prostate
areas. Therefore the effectiveness of lesion suspicious biopsy should be further
discussed with more patient numbers.
MP-14.04
Prediction of Prostate
Cancer Tumour Volume
Robinson S, Motiwala H, Karim O,
Laniado M
Wexham Park Hospital, Slough, UK
Introduction and Objective: There are
many nomograms available to predict
tumour volume. How applicable are they
to local populations.
S134
Materials and Methods: A retrospective
and prospective analysis by univariate
linear regression of up to 500 patient
characteristics generated individual correlation coefficients.
Results:
Conclusions: Predicting final pathological radical prostatectomy tumour volume
is fraught with difficulties using pre operative biopsy characteristics. We found
that the parameters were PSA, number
of cores involved, digital rectal examination and % involvement of core were
best, although each performed poorly
with correlation coefficients of around
0.3. Surprisingly bilateral disease (which
by definition is at least T2c) performed
significantly worse as did Gleason score
(there is significant upgrading on final
pathology) and age. Inner gland volume
and total gland volume were negatively
correlated. A nomogram to predict the
tumour volume is needed which will
take into account the total gland volume, inner gland volume and peripheral
gland volume. This will almost certainly
improve the predictive power of the
biopsy parameters. The clinicians’ rectal
examination experience is probably also
important but we have not been able to
prove this yet.
MP-14.05
Is There a Role for Routine
Anterior Zone Sampling During
Transrectal Ultrasound Guided
Saturation Prostate Biopsy?
Pinthus J1, Cole E1, Shayegan B1,
Daya D2, Greenspan M1, Matsumotto E1,
Patlas M3
1
Dept. of Surgery, Div. of Urology, McMaster University, Hamilton, Canada;
2
Dept. of Pathology, McMaster University,
Hamilton, Canada; 3Dept. of Radiology,
McMaster University, Hamilton, Canada
Introduction and Objective: The anterior zone (AZ) of the prostate has been
recognized as a sanctuary site for prostate
cancer (PC). We examined the diagnostic
yield of AZ biopsies as part of a saturation
template in patients with elevated PSA
levels but with previous negative extended prostate biopsies (group 1), and
in surveillance biopsies of PC patients
(group 2).
Materials and Methods: A total of 95
patients (66 group 1 and 29 group 2) underwent TRUS-guided saturation biopsy
MP-14.04, Table 1.
r
r2 proportion of variation explained by regression n
PSA 0.3454
0.119
12%
494
cores
0.3417
0.116
12%
446
DRE
0.2651
0.07
7%
424
%
0.2483
0.061
6%
398
bi
0.1902
0.036
4%
422
Gleason
0.1535
0.023
2%
482
age
0.1109
0.0122
1%
498
Inner gland volume on TRUS
-0.0727
0.00528
0.50%
141
Total gland volume on TRUS
-0.0419
0.0017
0.20%
303
approx 45% of cancer
tissue is explained
by these 9 variables
significant difference between PSA and other parameters?
psa and cores P=0.959
psa and dre P=0.184
psa and % P=0.115
psa and bi P=0.012 sig
psa and Gleason P=0.00137
psa and age P=0.000093
psa and TZ P=0.000008
psa and vol P= 0.00000005
psa test for equality of these correlation coefficients, chi = 4.04 P= 0.257, ie no difference
cores
DRE
% of core
UROLOGY 80 (Supplement 3A), September 2012
Moderated Poster SessionS
under local (n=83) or spinal (n=12)
anesthesia: 16 cores were taken from the
peripheral zone (PZ), 4-6 cores from the
transitional zone (TZ), and 4-8 cores from
the AZ. All suspicious ultrasonic areas
were targeted to a median of 26 cores.
All biopsies were completed by a single
urologist and reviewed by a specialized
uro-pathologist.
Results: Mean age of the patients was
65 and 63 and mean PSA were 11.4 (95%
CI 9.8-13.3) and 7.7(95% CI 5.9-9.9) in
groups 1 and 2 respectively. The overall
diagnostic yield was 33% (group1) and
93% (group 2). AZ cancers were detected in 18% (group 1) and 38% (group
2) (p=0.018) but were rarely the only
site involved (3%). Findings in the AZ
changed the risk stratification of the disease in only 4.5% of patients in group 1
and 10% of group 2 (P=0.36). There was
an equal incidence of ≥ Gleason 7 disease in the AZ in both groups, however,
this was often accompanied by disease of
equal grade in the PZ. Isolated TZ cancers were not detected. 28.6% and 25.9%
of patients with positive biopsies in
groups 1 and 2 met the Epstein Criteria
for insignificant PC. Overall 15/29 (52%)
of patients in the AS group showed some
progression in disease on their surveillance biopsy.
Conclusions: Saturation biopsy is almost
always positive in patients undergoing
surveillance biopsy and commonly positive in patients with clinical suspicion for
PC despite previous negative biopsies.
However, the routine addition of TZ and
AZ sampling rarely adds to the diagnostic
yield, and will seldom change a patient’s
risk stratification.
MP-14.06
Short Term Outcomes of Prostate
Biopsy in Men Tested for Cancer
by Prostate Specific Antigen:
Prospective Evaluation within
ProtecT and ProBE Studies
Lane A1, Rosario D2, Metcalfe C1,
Donovan J1, Neal D3, Hamdy F4
1
School of Social and Community
Medicine, University of Bristol, Bristol,
UK; 2Dept. of Urology, Hallamshire
Hospital, Sheffield, UK; 3Dept. of Oncolgy,
Addenbrokes’s Hospital, Cambridge, UK;
4
School of Surgical Sciences, University of
Oxford, Oxford, UK
Introduction and Objective: The
impact and acceptability of transrectal
ultrasound guided biopsy (TRUS-Bx) of
the prostate has rarely been investigated
systematically. We aimed to establish
the short term outcomes of TRUS-Bx in
asymptomatic men undergoing prostate
specific antigen testing.
Materials and Methods: Between February 2006 and May 2009, 1147 men aged
between 50-69 years with a PSA result
of 3-19.9 ng/ml ng/ml were recruited to
the ProBE study (65% of those offered)
prior to 10-core TRUS guided prostate
biopsies in the ProtecT (Prostate cancer
testing and Treatment) trial (ISRCTN
2014129769). Participant questionnaires
at 7 and 35 days post-biopsy, measured
patient symptoms and acceptability of
the procedure. Healthcare resource
utilisation was collected by nurses from
medical records. Participants were also
interviewed to assess men’s experiences
of the procedure.
Results: Pain was reported by 429/984
(43.6%), fever by 172/985 (17.5%),
haematuria by 642/976 (65.8%), haematochezia by 356/967 (36.8%), and
haemoejaculate by 605/653 (92.6%) men
during the 35 days after biopsy. Fewer
men rated these symptoms as a major/
moderate problem: 71/977 (7.3%) for
pain, 54/981 (5.5%) for fever, 59/958
(6.2%) for haematuria, 24/951 (2.5%)
for haematochezia, and 172/646 (26.6%)
for haemoejaculate. Immediately after
biopsy, 124/1142 (10.9%, 95% confidence
interval 9.2 to 12.8) men reported that a
further biopsy would be a major or moderate problem: seven days later this had
increased to 213/1085 (19.6%, 17.4% to
22.1%). 119 (10.4%, 8.7% to 12.3%) men
reported consultation with a healthcare
professional (usually their family doctor),
most commonly for infective symptoms.
Interview data revealed that most men
found biopsies unpleasant but tolerable
although for a few men they caused sig-
nificant distress.
Conclusions: Prostate biopsy is generally
well tolerated but is associated with significant symptoms in a minority of men
and influences attitudes to repeat biopsy
and primary care resource use. These
findings should inform men who seek
PSA testing and assist their physicians
during counselling about the potential
risks and effect of biopsy.
MP-14.07
Impact of Lower Urinary Tract
Symptoms on Prostate Cancer
Risk Among T1c Biopsy-Referred
Japanese Men with Prostate
Specific Antigen <10 Ng/Ml
Ito M1, Masuda H1, Kawakami S1, Fujii Y2,
Koga F1, Saito K1, Yamamoto S2, Yonese J2,
Fukui I2, Kihara K1
1
Dept. of Urology, Tokyo Medical and
Dental University, Tokyo, Japan; 2Dept.
of Urology, Cancer Institute Hospital,
Tokyo, Japan
Introduction and Objective: To investigate the association of lower urinary tract
symptoms (LUTS) evaluated by international prostate symptom score (IPSS) with prostate cancer (PCa) risk and grade at biopsy.
Materials and Methods: A retrospective
analysis was performed on 1467 Japanese
men with prostate specific antigen (PSA)
<10 ng/mL and unsuspicious digital rectal examination (DRE) undergoing initial
extended prostate biopsy. IPSS scores <8
were defined as having no LUTS. The association between LUTS and PCa risk and
grade at biopsy was examined using logistic regression. Data were also examined
stratified by age (year, < 60, 60–70, and
> 70) and prostate volume (PV) (cc, <
MP-14.07, Table 1. Associations of absence of lower urinary tract symptoms with prostate cancer
detection and grade among patients undergoing initial extended prostate biopsy
Grade
OR or RR
95% CI
P
PCa (all grades)
Crude OR
1.85
1.49–2.31
< .0001
Age-adjusted OR
2.11
1.68–2.65
< .0001
Multivariate-adjusted OR†
1.70
1.31–2.20
< .0001
Low-grade
Crude RR
1.52
1.11–2.08
0.0099
Age-adjusted RR
1.71
1.24–2.37
0.0012
Multinominal-adjusted RR†‡
1.44
1.01–2.06
0.0435
High-grade
Crude RR
2.08
1.60–2.71
< .0001
Age-adjusted RR
2.38
1.82–3.12
< .0001
Multinominal-adjusted RR†‡
1.86
1.36–2.54
0.0001
OR, odds ratio; RR, relative risk; CI, confidence interval; PCa, prostate cancer
†
Adjusted for age, BMI, PSA, free/total PSA ratio, prostate volume, and number of biopsy cores.
‡
RRs are vs no cancer.
UROLOGY 80 (Supplement 3A), September 2012
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Moderated Poster SessionS
30, 30–50, and > 50). Cancer grade was
classified into low-grade (Gleason score
[GS] ≤ 6) and high-grade (GS 7–10).
Results: Of 1467 men, 484 (33.0%) had
positive biopsy and 633 (43.1%) were
regarded as no LUTS. On multivariate
analysis, no LUTS had significant and
positive impact on the risk of PCa, both
low- and high-grade disease, at biopsy.
Despite its significant associations with
PCa risk throughout any PV category,
no LUTS exhibited higher relative risks
with larger PV category. Addition of LUTS
status significantly (P = 0.047) improved
the predictive accuracy of PCa detection
by 6.2% in men with PV > 50 cc.
Conclusions: A lack of LUTS is associated
with higher risk of PCa in T1c biopsyreferred Japanese men with PSA < 10 ng/
mL. This finding might be useful especially in patients with large prostate volumes.
the diagnostic yield of prostate base and
develop an optimal scheme for first prostate biopsy.
Materials and Methods: Prospective
study of 696 patients including 445 first
biopsies and 251 repeat biopsies. Prostate
map was obtained on pathology of the
cores obtained at each biopsy. Statistical
analysis was performed according to age,
PSA, PSA ratio F / T and PSAD.
Results: The 41% of first biopsies were
positive. Seventy four (16.6%) biopsies
had a single positive core corresponding
to 14.6% for prostate lobes. Only 3.6%
(16 patients) of prostate base biopsies
were clinically relevant, providing diagnosis, changing the side of the tumor
or raising Gleason, without influence
of PSA, age, ratio L / T and PSAD. 34%
of repeat biopsies were positive.4.8% of
the transition zone biopsies and 7% of
MP-14.09
A Systematic Review: Are MR Targeted
Biopsies as Efficient as Standard
TRUS Biopsies in the Detection of
Clinically Significant Prostate Cancer?
Moore C1,2, Robertson N1,3, Arsanious N2,
Middleton T2, Taneja S4, Villers A5, Klotz
L6, Emberton M1,2
1
Div. of Surgical & Interventional
Science, University College London,
London, UK; 2Dept. of Urology, Croydon
University Hospital, London, UK; 3Dept.
of Urology, University College London
Hospitals Trust, London, UK; 4Div. of
Urologic Oncology, New York University
Langone Medical Center, New York, USA;
5
Dept. of Urology, CHU Lille, University
Lille Nord De France, Lille, France; 6Dept.
of Urology, Sunnybrook Health Centre,
Toronto, Canada
MP-14.07, Table 2. Logistic regression analysis predicting overall prostate cancer at biopsy stratified by prostate volume
Variables
Prostate volume (cc)
< 30 (n=564)
30–50 (n=611)
> 50 (n=292)
OR (95% CI)
P
OR (95% CI)
P
Age, year
1.10 (1.08–1.13)
< .0001
1.07 (1.04–1.10)
< .0001
PSA, ng/ml
2.86 (0.78–11.04)
0.11
1.86 (0.38–9.50)
0.45
Free/total PSA ratio
0.45 (0.16–1.27)
0.13
0.13 (0.040–0.42)
0.0006
No. biopsy cores
1.03 (0.98–1.07)
0.25
1.03 (0.99–1.08)
0.18
LUTS
Yes
Reference
Reference
No
1.52 (1.04–2.23)
0.030
1.93 (1.30–2.89)
0.0012
Increment of PA
by LUTS (%)
0.9 (70.3–71.2)
Mantel-Haenszel test 0.418
1.7 (67.2–66.9)
0.318
OR (95% CI)
1.01 (0.95–1.07-
1.20 (0.068–18.62)
0.15 (0.009–2.31)
1.06 (0.98–1.15)
P
0.70
0.84
0.18
0.18
Reference
2.54 (1.21–5.25)
0.014
6.2 (56.8–63.0)
0.047
CI, confidence interval; LUTS, lower urinary tract symptom; OR, odds ratio; PA, predictive accuracy; PSA, prostate specific antigen
MP-14.08
Optimization of the UltrasoundGuided Prostate Biopsy
Perez-Carral J1, Rivas M1, González I1,
Gil Ugarteburu R2, Benito P1,
Fernandez-Pello S1, Cuervo F1
1
Hospital De Cabueñes, Gijón, Spain;
2
University Center Jove Hospital
Foundation, Gijón, Spain
Introduction and Objective: Various
schemes of prostate biopsy have been
developed looking for maximum profitability, reaching the highest diagnostic
rates with schemes of 10-12 cylinders.
One of the most commonly used schemes
is Presti’s, in which the peripheral zone
is sampled at its paramedian and lateral
part. The areas most increase the diagnostic yield in successive biopsies are the
transition zone and anterior horn. The
objective of this study is to determine
S136
the anterior horn biopsies were clinically
relevant.70% of the horn positive cores
were clinically relevant.
Conclusions: At first biopsy, sampling
of the prostate base is of little diagnostic
value, although it is important for surgical planning. Second biopsies in the transition zone do not offer a high return.
Tumors diagnosed in this area were not
very aggressive, the risk of spread is low
and no there is not added risk of positive
surgical margins, so their utility was questionable. Second biopsies in the anterior
horn provide a moderate diagnostic
yield, but high clinical significance and
considering that is a place with frequent
presence of positive surgical margins,
its utility for surgical planning is high.
Therefore be assessed for inclusion in the
scheme of first biopsy.
Introduction and Objective: There is
great interest in the use of MRI to define
biopsy targets within the prostate. We
performed a systematic review to compare the efficiency of MRI targeted biopsy
with standard transrectal biopsy, in the
detection of clinically significant prostate
cancer.
Materials and Methods: The PubMed,
EMBASE and Cochrane databases were
searched from inception until 3rd December 2011, using the search criteria: ‘prostate OR prostate cancer’ AND ‘magnetic
resonance imaging OR MRI’, AND ‘biopsy
OR target’. 4,222 records were retrieved
and the abstracts assessed independently
by 4 reviewers, with 222 records requiring full review. 50 unique records were
identified which compared an MRI-targeted with a standard transrectal approach.
Results: Where MRI was applied to all bi-
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opsy-naïve men, 62% (374/599) had MRI
abnormalities. When subjected to a targeted biopsy, 66% (248/374) had prostate
cancer detected. Both targeted and standard biopsy detected clinically significant
cancer in 43% (236 or 237/555 respectively). Missed clinically significant cancers occurred in 13 men using targeted
biopsy and 12 using a standard approach.
Targeted biopsy was more efficient. Onethird fewer men were biopsied, overall.
Those that had biopsy required a mean
of 3.8 targeted cores, compared to 12
standard cores. In addition, a targeted
approach avoided the diagnosis of clinically insignificant cancer in 53/555 (10%)
of the presenting population.
Conclusions: MRI guided biopsy detects
clinically significant prostate cancer in an
equivalent number of men to standard
biopsy, using fewer biopsies in fewer
men, and a reduction in the diagnosis of
clinically insignificant cancer. There is a
need for a robust prospective multicentre
study of targeted biopsies using contemporary MR imaging.
MP-14.10
Evaluation of Prostate Cancer
Diagnosing During Surgical Treatment
of Benign Prostatic Hyperplasia:
Single-Centre Experience
Kogan M, Iliyash A, Chibichyan M,
Shiranov K
Dept. of Urology, Rostov State Medical
University, Rostov-On-Don, Russia
Introduction and Objective: Aim of our
study was to determine clinical and morphological features of incidental PCa in
patients with negative biopsy results and
patients with no prostate biopsy prior to
surgical treatment of clinical benign prostatic hyperplasia (BPH).
Materials and Methods: A series of 359
patients undergoing surgical treatment
of BPH were included in our study. They
were divided in 2 Groups: in Group
1, patients had negative biopsy results
(n=111(31%)); in Group 2 patients with
no indication for biopsy were included
(n=248(69%)). PCa was diagnosed in 23
(5.8%) patients: 9 cases were in Group
1 (8.1%) and 14 cases were in Group 2
(5.6%). Groups were divided into subgroups, depending on detection of prostate cancer (1A, 2A) or confirming pathological diagnosis of BPH (1B and 2B).
Results: In Group 1 in prostate cancer
patients, age was significantly higher
than in patients with BPH (p1<0.05);
in Group 2 age differences wasn’t statistically significant. Total PSA level was
11.2±2; 8.4±0.5; 3.1±0.2; 2.3±0.1 in
subgroup 1A, 1B, 2A, and 2B, respectively
(p2<0.05), and total/free PSA ratio was
12.2±1.9; 19.4±1.4; 11.7±0.8; 24.4±1.4
in subgroup 1A, 1B, 2A, and 2B, respectively (p2<0.001). We found significant
difference in Group 2 between patients
with PCa and BPH; in Group 1 such difference was not statistically significant.
There were similar prostate volume and
PSA density in both groups. In Group 1
rates of palpated and hypoechogenic lesion were significantly higher in patients
with PCa (p2<0.001). In both groups
patients with BPH had less severe voiding dysfunction and better health-related
quality of life (1A-5.4±0.2; 1B-4.3±0.1;
2A-4.9±0.2; 2B-4.3±0.1). In Group 1
stage T1a was seen more frequently
(67%). In Group 2 the most common
stage was T1b (64%). In Group 1 lowand moderate-grade PCa was diagnosed
in 44.5% patients and 55.5% patients,
respectively. In 21.7 % cases high-grade
incidental PCa was determined.
Conclusions: Prevalence of incidental
PCa in patients, undergoing surgical
treatment of BPH, was 5.8%. Predictive
factors of PCa were total PSA level and
ratio free/total PSA. In most cases, PCa,
which was found after surgery of BPH,
had small size and low- or moderategrade.
MP-14.11
Correlation of Gleason Scores
with Diffusion-Weighted Imaging
Findings of Prostate Cancer
Ding X1, Wang J1, Chen L1, Jin G2
1
Dept. of Radiology, First Hospital of Jilin
University, Changchun, China; 2Dept. of
Nuclear Medicine, First Hospital of Jilin
University, Changchun, China
Introduction and Objective: The purpose of our study was to compare the
apparent diffusion coefficient (ADC)
derived from diffusion-weighted imaging
(DWI) of prostate cancer (PCa) patients
with three classes of pathological Gleason
scores (GS).
Materials and Methods: Patients whose
GS met these criteria (GS 3 + 3, GS 3 +
4, and GS 4 + 3) were included in this
study. The DWI was performed using b
values of 0, 50, and 400 s/mm(2) in 40
patients using an endorectal coil on a
1.5T MRI scanner. The apparent diffusion
coefficient (ADC) values were calculated
from the DWI data of patients with three
different Gleason scores.
Results: In patients with a high-grade
Gleason score (4 + 3), the ADC values
were lower in the peripheral gland tissue, pathologically determined as tumor
UROLOGY 80 (Supplement 3A), September 2012
compared to low grade (3 + 3 and 3 +
4). The mean and standard deviation of
the ADC values for patients with GS 3 +
3, GS 3 + 4, and GS 4 + 3 were 1.12 ±
0.12, 0.98 ± 0.11 and 0.84 ± 0.08 mm(2)/
sec. The ADC values were statistically
significant (P < 0.05) between the three
different scores with a trend of decreasing ADC values with increasing Gleason
scores by one-way ANOVA method.
Conclusions: This study shows that the
DWI-derived ADC values may help differentiate aggressive from low-grade PCa.
MP-14.12
Characteristics of Prostate Cancers
Missed by the Transrectal Biopsy
Approach: Analysis of Positive Core
Location by Transperineal Biopsy
Uno H1, Saito A1, Komeda H2, Nakano M3,
Deguchi T3
1
Chuno Kosei Hospital, Seki, Japan; 2Gifu
Municipal Hospital, Gifu, Japan; 3Gifu
University, Gifu, Japan
Introduction and Objective: Several
studies have reported that transrectal
biopsy schemes can miss one-third of
cancers. The length of the biopsy needle
notch is 17 mm; therefore, undersampling of the anterior prostate in prostates
with larger volumes is probable because
the biopsy needle cannot reach the anterior prostate. Cancers missed by the
transrectal approach were investigated by
analyzing the location of positive cores
diagnosed by transperineal biopsy.
Materials and Methods: There were
391 men <75 years old who underwent
14- to 18-core transperineal biopsies.
PSA values were <20.0 ng/mL. The parasagittal antero-posterior distance of the
prostate (a-p length) was measured by
transrectal ultrasound. Furthermore, the
prostate was divided into four regions:
front of the anterior prostate (FA), back
of the anterior prostate (BA), front of the
posterior prostate (FP), and back of the
posterior prostate (BP). If the needle did
not reach over the middle of the prostate
(a-p length >34 mm), the FA and BA regions could not be sampled. If the needle
did not reach over three quarters of the
prostate (a-p length >22.7 mm), the FA
region could not be sampled.
Results: Prostate cancer was diagnosed
in 145 of the 391 patients (37.1%). From
the analysis of a-p length and prostate
volume in 150 cases, an a-p length of 34
mm corresponded to a prostate volume
of 53.6 mL, and an a-p length of 22.7
mm corresponded to a prostate volume
of 22.9 mL. In the 130 cases with a prostate volume >53.6 mL, 31 cases were
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Moderated Poster SessionS
positive for cancer, and 7 cases of cancer
were located in the FA and BA regions.
In the 253 cases with a prostate volume
between 22.9 mL and 53.6 mL, 110 cases
were positive for cancer, and only 9 cases
were located in the FA region. Four of
these 16 cancer cases in the FA and/or BA
with a prostate volume >22.9 mL (length
>22.7 mm) had one or two positive cores
and a Gleason score ≤6.
Conclusions: The present simulation
model revealed that approximately 11%
of all cancers were missed with transrectal biopsy. Most of the missed cancers
were low-risk.
MP-14.13
Can Urologists Conduct MRIGuided TRUS Biopsy Targeting?
Simmons L1, Ramachandran N2, Kirkham
A2, Moore C1, Ahmed H1, Emberton M1
1
Div. of Surgery and Interventional
Science, University College London, UK;
2
Dept. of Radiology, University College
London Hospitals, London, UK
Introduction and Objective: Prostate
mp-MRI can be used to define a target for
biopsy. It is uncertain whether specialist
radiological skill is needed for implementing such targeting. We evaluated
whether urologists could target MRIdefined lesions at TRUS biopsy as with
comparable accuracy to radiologists.
Materials and Methods: Men undergoing a primary TRUS biopsy between
10/11/2010-05/09/2011 and who had mpMRI prior to biopsy were included. Three
operators, one urologist and two radiologists with variable prostate MRI expertise performed TRUS biopsies by ‘cognitively’ deciding where on ultrasound to
‘target’ a needle based on mp-MRI lesion.
Only patients undergoing standard biopsies with additional targeted cores to MRI
lesions scoring >/=3/5, or those having limited targeted biopsies only, were
analysed. Clinically significant disease
was defined as ≥3+4 AND/OR maximum
cancer core length ≥4mm.
Results:
Conclusions: It appears feasible for
urologists, who have been well trained
to interpret prostate mp-MRI images, to
perform accurate targeted TRUS biopsies.
By utilising high quality MRI reports and
‘cognitively’ translating MRI information
in order to target a lesion during TRUS
biopsy, comparable disease detection
rates were obtained by the urologist and
radiologists, without need for in-bore
biopsies or specialist fusion software.
MP-14.14
Validation of Prostate HistoScanningTM
in Localization of Prostate
Carcinoma: The Indian Experience
Ganpule A, Mishra S, Ganesmoni R,
Sabnis R, Desai M
Muljibhai Patel Urological Hospital,
Nadiad, India
Introduction and Objective: Prostate HistoScanningTM (PHS), a new
ultrasound-based technology which uses
computer-aided analysis to quantify tissue disorganization induced by malignant
processes, can identify and characterize
foci of prostate cancer as compared with
step-sectioned radical prostatectomy
(RP) specimens. This study was done to
determine the extent to which PHS can
identify tumor foci that correspond to a
volume of ≥ 0.50 mL.
Materials and Methods: Between October 2011 and February 2012, 16 men
underwent HistoScanningTM before
scheduled radical prostatectomy. The
three dimensional raw (grey-scaled) data
required for HistoScanningTM analysis
were acquired by transrectal ultrasonography, and analyzed using organ-specific
tissue-characterization algorithms. The
HistoScanningTM analysis results were
compared with the histology of the whole
mounted prostate, step-sectioned coro-
nally at 5-mm intervals, and each slide
analyzed by grid analysis.
Results: A total of 96 sextants were
studied in 16 patients. The prostate size
and the PHS identified lesion size were
13.49± 13.85 and 3.10± 2.06 ml. PHS
correlated well with step sectioned radical prostatectomy specimen total tumor
volume (Spearman’s coefficient of rank
correlation of 0.624,
p=0.009). Thus, using the clinically accepted volume threshold of 0.50 mL,
the sensitivity, specificity, positive and
negative predictive value of HistoScanningTM were 94.4%, 50%, 85% and 75%,
respectively.
Conclusions: PHS has the ability to accurately detect cancer foci more than 0.5
ml within the prostate. Further studies to
explore its role for the preoperative imaging in cancer prostate are required.
MP-14.15
Inter-Operator Reliability of
Prostate Histoscanning™ for the
Characterisation of Prostate Cancer
Simmons L, Robertson N, Ahmed H,
Moore C, Emberton M
Div. of Surgery and Interventional
Science, University College London,
London, UK
Introduction and Objective: For a diagnostic test to be valid, it requires not
only high performance characteristics,
but must be reliable when applied by
different operators. We carried out a pilot
study observing the change in Prostate
HistoScanning signal when the test is performed by two independent urologists.
Materials and Methods: Ten men with
low risk prostate cancer on TRUS guided
biopsies, undergoing Prostate HistoScanning had 3D TRUS acquisition performed
by two operators. The second operator
acquired images using the same equipment independently of the first operator
and without alteration of the patient posi-
MP-14.13, Table 1.
Standard Biopsy
Targeted Biopsy
Operator
PSA
Clinically All disease Positive
Average
Clinically
All disease Positive
Average
Range significant
detection
cores %
number of
significant detection cores %
number of
(Median)
disease
rate %
biopsy cores disease rate %
biopsy cores
detection
detection
rate %
rate %
1
3.1-31
48
62
22
10.7
48
65
55
2.1
Urologist
(6.91)
(n=10/21)
(n=13/21)
(54/245)
(n=11/23)
(n=15/23)
(27/59)
2
3.2-40
46
61
27
9.38
36
50
56
2.28
Radiologist (7.5)
(n=6/13)
(n=8/13)
(33/122)
(n=4/14)
(n=7/14)
(18/32)
3
1.38-200
58
83
28
10.9
69
77
79
2.2
Radiologist (7.9)
(n=7/12)
(n=10/12)
(40/142)
(n=9/13)
(n=10/13)
(23/29)
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UROLOGY 80 (Supplement 3A), September 2012
Moderated Poster SessionS
tion. The 3D TRUS data volume files were
transferred to the Prostate HistoScanning
machine at the time of acquisition for
processing. An analysis of HistoScanning
images for Prostate Volume and Prostate
HistoScanning signal was performed for
both acquisitions. HistoScanning analysis
is a semi-automated process in which the
reporter is required to define apex, base,
and left and right borders of the prostate.
Delineation of the prostate outline, division into sextants, and analysis of ultrasound signal for presence or absence of
cancer is automated. Linear regression
was used to calculate the correlation in
both gland and suspected cancer volume
generated by each acquisition. Cohen’s
kappa statistic was performed to estimate
the agreement for presence or absence
of a suspicious focus ≥0.5cc in any one
sextant. Kappa values indicate a range of
agreement (<0 indicates no agreement,
0–0.20 slight, 0.21–0.40 fair, 0.41–0.60
moderate, 0.61–0.80 substantial, and
0.81–1 almost perfect agreement).
Results: There were 60 sextants from
10 patients analysed. Operators agreed
on the presence or absence of a lesion
≥0.5cc within a sextant in 75% of sextants
(n=45). Cohen’s kappa co-efficient was
0.57 (95% CI: 0.30-0.72). Linear regression for prostate volume between the
two acquisitions exhibited strong correlation (R2= 0.98). For suspected tumour
volume, linear regression was also good
(R2= 0.76).
Conclusions: We have shown that outputs from HistoScanning spectral image analysis were stable between two
operator-acquired images. The strength
of association was greater for prostate
volume than it was for tumour volume as
reliability in the latter is very sensitive to
subtle differences in image quality.
had a short survival time thereafter. The
epidemiology data of IARC were based
on the data of inpatients cancer registration of China, not based on the screening
data. Since 2009, we launched the PSA
based cancer screening project in Beijing.
To our knowledge, this was the first community based PSA screening project in
China.
Materials and Methods: Through random sampling methods, male community
residence older than 50 was selected
to receive PSA test. The prostate biopsy
indication is repeated PSA >4ng/ml, or
DRE is abnormal. The ultra-sound guided
transrectal 12 cores prostate biopsy was
done when the participant signed the
consent form.
Results: There were 3359 male community residents older than 50 who received
PSA screening in Beijing. There were 87
cases that met the indication of prostate
biopsy. Of participants, 61/87 received
ultra-sound guided transrectal 12 cores
prostate biopsy. Finally, 19 case of prostate cancer were found; 57.9% (11/19)
were advanced prostate cancer. The standardized detection rate of prostate cancer in Beijing community residents was
estimated at 74.1/105 which was 8 times
than the data (4.34/105 person years)
from IARC.
Conclusions: The current state of prostate cancer diagnosis in China is similar
to that which existed in the United States
during the period from 1983 to 1988,
before the wide acceptance of population PSA screening. Mass PSA screening
should be advocated now because most
of the screened cases were still advanced
cases. We should rethink the PSA screening policy in China when the organ defined diseases become the majority after
decades of PSA screening.
MP-14.16
Prostate Cancer Screening
in China: Yes or No
Wang W1, Chen S1, Na Y2
1
Urology Dept., Beijing Tongren Hospital,
Capital Medical University, Beijing,
China; 2Wujieping Urology Centre,
Beijing, China
MP-14.17
How Does Circumcision Prevent
Prostate Cancer and Could
Understanding Why Reduce False
Positive PSA Screening Tests?
Oliver T
Barts & The London School of Medicine,
Queen Mary University of London,
London, UK
Introduction and Objective: Prostate
cancer screening is quite controversial
in the field of urology. In China, we are
facing different situation compared with
our colleagues in America and Europe.
According to the International Agency for
Research on Cancer (IARC) data, the incidence of prostate cancer was 4.34/105.
Most prostate cancers were in the advanced stages at the time of diagnosis and
Introduction and Objective: There is
evidence that sustained sub-clinical prostatic inflammation leads to Proliferative
Inflammatory atrophy (PIA) a known precursor of malignant change in the prostate. A circumcision trial in Africa demonstrated the dominant bacterial flora
in un-circumcised men was anaerobes.
There are reports that circumcised men
UROLOGY 80 (Supplement 3A), September 2012
have an unexplained lower incidence of
PC and conflicting reports that Vitamin D
deficiency increases death from prostate
cancer. This presentation reviews the literature as a first step in investigating the
hypothesis that lack of circumcision and
Vitamin D deficiency synergise as a cause
of PC through diminished host surveillance facilitating anaerobe colonization of
the prostate.
Materials and Methods: Four PubMed
literature searches performed using the
terms prostatic & PC and circumcision &
foreskin identified 11 studies. Globocan
2008 data has been analyzed for PC and
cervix cancer incidence and deaths on
basis of incidence of circumcision. Ten
papers in the IARC 2008 report on vitamin D and PC + 4 more published from
2008-12 and 3 papers that have examined
impact of an index of life-time sun exposure on PC risk have also been reviewed
Results: Four studies comparing people
of Jewish decent (n=2,878) vs people of
non-Jewish decent (n=40,768) demonstrated significantly reduction of PC in
people of Jewish decent (OR 0.25). Seven
reports of circumcision frequency in
PC (n=2,500) and matched controls
(n=2,463) demonstrated a reduced
frequency in patients (OR 0.86). In
Globocan 2008 data though predominantly circumcised USA, Israeli/Saudi
populations had less PC deaths than
uncircumcised Brazilians, PC deaths were
even lower in uncircumcised Japanese,
Chinese and Danes and the circumcised
Pakistani and Bangladeshi populations
had similar PC mortality as predominantly uncircumcised Indians. Only 2 of
the 13 plasma 25-OH Vit D series showed
significant reduction of PC overall though
4 did show reduced deaths. In contrast
all 3 series that have examined an index
of long-term sun exposure showed significant reduction of PC (OR 0.18, 0.32
and 0.52 n= 850)
Conclusions: The conflicting Vitamin D
data suggest that there is a need for prolonged sub-clinical immune-deficiency
to enable anaerobes to promote the
development of PC. If confirmed by
prospective studies, elimination of false
positives due to anaerobes could improve
the specificity of PSA screening. The
inconsistencies in the circumcision data
suggest that the hygiene rules associated
with religious circumcision could add
to the reduced PC in Jewish men, and
mirror the similar differences seen in the
protective value against AIDS of circumcision in Asian Muslims compared to Xhosa
African men.
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MP-14.18
PCA3 Test as an Adjunct in
Diagnosis of Prostate Cancer
Yutkin V1, Al-Zahrani A1, Williams A1,
Hidas G2, Martines C1, Izawa J1, Pode D2,
Chin J1
1
University of Western Ontario, London,
Canada; 2Hadassah and Hebrew
University Medical Center, Jerusalem,
Israel
Introduction and Objective: Early diagnosis of prostate cancer is conventionally
done with serum prostate specific antigen
(PSA) test and digital rectal examination,
but these tests lack specificity. Many men
worldwide undergo repeated, sometimes
unnecessary prostate biopsies due to
suspicious or rising PSA levels. A urine
test PCA3 is gaining popularity, predominantly in the field of managing patients
with suspicious PSA and previous benign
biopsies. In this multi-national study we
assessed the performance of the PCA3
urine test in patients who were candidates for prostate biopsies due to high or
rising PSA’s.
Materials and Methods: The PCA3
scores were determined in urine samples
in these men A PCA3 scores of 35 or
higher were considered higher probability
of cancer. Subsequent biopsy was performed as per current best practice and at
the discretion of the urologist in concert
with the patient. To retrospectively assess
the performance of PCA3, we used multiple logistic regression analysis and ROC
curves were constructed to evaluate PCA3
as a prognostic factor compared with PSA
and evaluated the influence of PCA3 testing on the decision making.
Results: There were 401 patients who
had PCA3 score available. The most common indication was rising or high PSA
after previous negative biopsies: in 256
patients (63.8%), followed by the find-
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ing of high grade prostatic intraepithelial
neoplasia (HGPIN) or atypical small
acinar proliferation (ASAP) on previous biopsy – in 101 patients (25.2%). Forty four
subjects (11%) did not undergo prostate
biopsy prior to PCA3 testing. PCA3 scores
were significantly lower in patients without malignancy using a cutoff score of 35
(OR 2.99 (95%CI) (1.42, 6.30), p=0.004).
On Receiver Operating Curve analysis
PCA3 AUC of 0.722 was significantly
greater than PSA (0.4837). Sensitivity
and specificity of PCA3 score using the 35
cutoff were 63.6% and 63.0%, respectively.
When a cutoff score of 20 was used, the
sensitivity and specificity of PCA3 score
were 86.4% and 41.3%, respectively. The
PCA3 test influenced the clinical course of
the patient in 73.5% of cases. The followup PSA values in patients who did not
perform biopsy after PCA3 testing had,
without exception, remained stable or
dropped (7.86 vs. 6.22, p=0.003) with
follow-up of at least 6 months.
Conclusions: In this multinational study
we demonstrate that urine PCA3 score test
out-performs PSA in decision making in
men facing possibility of repeat prostate biopsy. We recommend that the PCA3 results
should be integrated with other relevant
data and rather be used in continuous
fashion, and not with certain cutoff value.
MP-14.19
Evaluation of the Risk Factors
for Complications after
Prostate Needle Biopsy
Sung L, Noh C, Chung J, Yu J
Inje University Sanggye Paik Hospital,
Seoul, South Korea
Introduction and Objective: Prostate
biopsy for the diagnosis of prostate cancer
by transrectal ultrasonography (TRUS) is a
common procedure used in daily urology
practice with a low complication rate and
easy applicability. But, acute prostatitis or
sepsis could be serious complications of
the procedure. Recent studies showed that
patients with urethral catheter, diabetes
mellitus or those who planned to undergo
biopsy from more sites than the standard,
should be closely monitored after the
biopsy for more frequent complication
rate. In this study, the precipitating factors
for complications after prostate biopsy by
TRUS were evaluated in one center.
Materials and Methods: Between January 2007 and May 2011, 484 patients who
underwent prostate biopsy by TRUS were
assessed retrospectively. Standard preparations, including enema and prophylactic
oral antibiotics were given to most patients. The relationship of complications
and age, serum total PSA level, prostate
volume, number of cores, number of repeated biopsies, presence of urethral catheter and diabetes mellitus, and unprepared
prostate biopsy was assessed. Data were
analyzed using univariate and multivariate
analysis.
Results: Of the 484 patients, 24 (4.96%)
developed complications, including acute
prostatitis (18 patients, 3.72%), urinary
retention (2 patients, 0.41%), persistent
hematuria (1 patients, 0.21%), sepsis (3
patients, 0.62%) within a week after biopsy.
Seven patients were hospitalized for high
fever. On univariate analysis, unprepared
prostate biopsy was the only parameter for
complications (p=.0.037). There was no
parameter for sepsis and significant relationship between complications and other
parameters.
Conclusions: Unprepared prostate biopsy
was the only risk factor for complications.
General preparations (enema and prophylactic antibiotics) and aseptic procedure
are believed to be more important for
preventing complications, although many
studies showed various risk factors for
complications after prostate biopsy.
UROLOGY 80 (Supplement 3A), September 2012