Search

Simple Summary: Targeted biopsies of suspicious lesions detected in magnetic resonance imaging are crucial to discover clinically significant prostate cancer, especially those corresponding to index lesions. However, the optimal scheme for targeted biopsies remains unclear, despite the fact that a two- to four-core scheme is usually recommended. Saturated biopsies of the prostate gland have shown high efficiency in detecting significant PCa. In this article, we report a better efficacy for mapping using a 0.5 mm core biopsy scheme than that using the two- to four-core scheme for detecting clinically significant prostate cancer in magnetic resonance index lesions. Since the optimal scheme for targeted biopsies of magnetic resonance imaging (MRI) suspicious lesions remains unclear, we compare the efficacy of two schemes for these index lesions. A prospective trial was conducted in 1161 men with Prostate Imaging Reporting and Data System v 2.1 3–5 undergoing targeted and 12-core systematic biopsy in four centers between 2021 and 2023. Two- to four-core MRI-transrectal ultrasound fusion-targeted biopsies via the transperineal route were conducted in 900 men in three centers, while a mapping per 0.5 mm core method (saturated scheme) was employed in 261 men biopsied in another center. A propensity-matched 261 paired cases were selected for avoiding confounders other than the targeted biopsy scheme. CsPCa (grade group ≥ 2) was identified in 125 index lesions (41.1%) when the two- to four-core scheme was employed, while in 187 (71.9%) when the saturated biopsy (p < 0.001) was used. Insignificant PCa (iPCa) was detected in 18 and 11.1%, respectively (p = 0.019). Rates of csPCa and iPCa remained similar in systematic biopsies. CsPCa detected only in systematic biopsies were 5 and 1.5%, respectively (p = 0.035) in each group. The saturated scheme for targeted biopsies detected more csPCa and less iPCa than did the two- to four-core scheme in the index lesions. The rate of csPCa detected only in the systematic biopsies decreased when the saturated scheme was employed. [ABSTRACT FROM AUTHOR]

Our study explored frozen section reliability in prostate cancer (PCa) diagnoses and described surgical steps of a 3D magnetic resonance imaging (MRI)–ultrasound (US)-guided prostate biopsy (PB) and focal cryoablation of the index lesion (IL) in a single-setting procedure. Patients with a suspicious prostatic specific antigen (PSA) value, with a PIRADS 4 or 5 single lesion, were enrolled for trans perineal 3D MRI–US-guided PB and TRUS-guided focal cryoablation. Three cores were taken from the IL, three cores from the surrounding area, while systematic sampling was performed for the rest of the gland. After confirmation of PCa in frozen sections, focal cryoablation was performed. The 1st-year follow-up schedule included a PSA test at a 3-month interval, MRI 3 months and 1 year postoperatively and PB of the treated area at 1 year. Following the follow-up schedule, an involved PSA test at a 3-month interval and yearly MRI were performed. The PCa diagnosis was histologically confirmed in all three patients with frozen sections. At final histology, a single Gleason score upgrade from 6 (3 + 3) to 7 (3 + 4) was observed. All patients were discharged on postoperative day 1. At the 3-month evaluation, mean PSA values decreased from 12.54 (baseline) to 1.73 ng/mL and MRI images showed complete ablation of the IL in all patients. Urinary continence and potency were preserved in all patients. At the 1-year follow-up, one patient had suspicious ipsilateral recurrence on MRI and underwent a new analogous procedure. Post follow-up was uneventful and PSA remained stable in all patients. Three-dimensional MRI–US-guided frozen sectioning and focal cryoablation of the IL is a step forward towards a "patient-tailored" minimally invasive approach to the diagnosis and cure of PCa. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the effects of various prostate biopsy protocols with reduced cores on the detection of clinically significant prostate cancer (csPCa) in individuals with MRI-visible lesions (Prostate Imaging Reporting and Data System ≥ 3). Methods: A total of 464 patients with MRI-visible lesions were recruited. All patients underwent two or more targeted biopsies (TB) and systematic biopsies (SB). Several hypothetical biopsy schemes were set-up: TB alone, TB+ipsilateral SB, TB+contralateral SB, TB+SB of the targeted sector (TB+t-SB), and TB+SB of the non-targeted sector (TB+n-SB). A subgroup analysis of patients with multiple MRI-visible lesions was performed. The standard of reference was defined as TB+SB. McNemar test was used to compare csPCa detection rates between various sampling schemes. Results: The detection rates for prostate cancer and csPCa were 72.8% (338 of 464) and 62.1% (288 of 464), respectively. There were 8.0%, 0.3%, 6.3%, 1.0%, and 4.5% cases in which TB alone, TB+ipsilateral SB, TB+contralateral SB, TB+t-SB, and TB+n-SB would have missed csPCa, respectively. All hypothetical schemes, with the exception of TB+contralateral SB (p = 0.063), significantly outperformed TB alone in terms of csPCa detection (p < 0.05). As for the multi-focus cohort, which included 48 cases, none of the non-index lesions had a higher Gleason grade than the index lesions within the same patients. Conclusion: TB+ipsilateral SB might be the optimal biopsy scheme for detecting csPCa. As for the multi-focus cohort, the biopsy of the non-index lesions provided limited pathological information. [ABSTRACT FROM AUTHOR]

Purpose: Computer-aided diagnosis (CAD) may improve prostate cancer (PCa) detection and support multiparametric magnetic resonance imaging (mpMRI) readers for better characterization. We evaluated Watson Elementary® (WE®) CAD system results referring to definitive pathological examination in patients treated with robot-assisted radical prostatectomy (RARP) in a tertiary referral center. Methods: Patients treated with RARP between 2020 and 2021 were selected. WE® calculates the Malignancy Attention Index (MAI), starting from the information contained in the mpMRI images. Outcome measures were the capability to predict the presence of PCa, to correctly locate the dominant lesion, to delimit the largest diameter of the dominant lesion, and to predict the extraprostatic extension (EPE). Results: Overall, tumor presence was confirmed in 46 (92%) WE® highly suspicious areas, while it was confirmed in 43 (86%) mpMRI PI-RADS ≥ 4 lesions. The WE® showed a positive agreement with mpMRI of 92%. In 98% of cases, visible tumor at WE® showed that the highly suspicious areas were within the same prostate sector of the dominant tumor nodule at pathology. WE® showed a 2.5 mm median difference of diameter with pathology, compared with a 3.8 mm of mpMRI versus pathology (p = 0.019). In prediction of EPE, WE® and mpMRI showed sensitivity, specificity, positive and negative predictive value of 0.81 vs 0.71, 0.56 vs 0.60, 0.88 vs 0.85 and 0.42 vs 0.40, respectively. Conclusion: The WE® system resulted accurate in the PCa dominant lesion detection, localization and delimitation providing additional information concerning EPE prediction. [ABSTRACT FROM AUTHOR]

Simple Summary: Identifying patients with an increased risk of early recurrence of colorectal lesions is still a problem. In our study, we focused on improving this identification by determining the mutation profile of index lesions. We found a statistically significant association between the mutation in exon 7 of the TP53 gene in the index lesion and the risk of early metachronous adenoma. (1) Background: this prospective study was focused on detailed analysis of the mutation heterogeneity in colorectal lesions removed during baseline (index) colonoscopy to identify patients at high risk of early occurrence of metachronous adenomas. (2) Methods: a total of 120 patients after endoscopic therapy of advanced colorectal neoplasia size ≥10 mm (index lesion) with subsequent surveillance colonoscopy after 10–18 months were included. In total, 143 index lesions and 84 synchronous lesions in paraffin blocks were divided into up to 30 samples. In each of them, the detection of somatic mutations in 11 hot spot gene loci was performed. Statistical analysis to correlate the mutation profiles and the degree of heterogeneity of the lesions with the risk of metachronous adenoma occurrence was undertaken. (3) Results: mutation in exon 7 of the TP53 gene found in the index lesion significantly correlated with the early occurrence of metachronous adenoma (log-rank test p = 0.003, hazard ratio 2.73, 95% confidence interval 1.14–6.56). We did not find an association between the risk of metachronous adenomas and other markers monitored. (4) Conclusions: the findings of this study could lead to an adjustment of existing recommendations for surveillance colonoscopies in a specific group of patients with mutations in exon 7 of the TP53 gene in an index lesion, where a shortening of surveillance interval may be warranted. [ABSTRACT FROM AUTHOR]

Abstract Background There are often multiple lesions in breast magnetic resonance imaging (MRI) reports and radiologists usually focus on describing the index lesion that is most crucial to clinicians in determining the management and prognosis of patients. Natural language processing (NLP) has been used for information extraction from mammography reports. However, few studies have investigated NLP in breast MRI data based on free-form text. The objective of the current study was to assess the validity of our NLP program to accurately extract index lesions and their corresponding imaging features from free-form text of breast MRI reports. Methods This cross-sectional study examined 1633 free-form text reports of breast MRIs from 2014 to 2017. First, the NLP system was used to extract 9 features from all the lesions in the reports according to the Breast Imaging Reporting and Data System (BI-RADS) descriptors. Second, the index lesion was defined as the lesion with the largest number of imaging features. Third, we extracted the values of each imaging feature and the BI-RADS category from each index lesion. To evaluate the accuracy of our system, 478 reports were manually reviewed by two individuals. The time taken to extract data by NLP was compared with that by reviewers. Results The NLP system extracted 889 lesions from 478 reports. The mean number of imaging features per lesion was 6.5 ± 2.1 (range: 3–9; 95% CI: 6.362–6.638). The mean number of imaging features per index lesion was 8.0 ± 1.1 (range: 5–9; 95% CI: 7.901–8.099). The NLP system demonstrated a recall of 100.0% and a precision of 99.6% for correct identification of the index lesion. The recall and precision of NLP to correctly extract the value of imaging features from the index lesions were 91.0 and 92.6%, respectively. The recall and precision for the correct identification of the BI-RADS categories were 96.6 and 94.8%, respectively. NLP generated the total results in less than 1 s, whereas the manual reviewers averaged 4.47 min and 4.56 min per report. Conclusions Our NLP method successfully extracted the index lesion and its corresponding information from free-form text.

Objective: This study aimed to investigate the correlation between index lesion prostate imaging-reporting and data system (PI-RADS) version-2 score and histopathological outcomes of prostatectomy specimens. Materials and Methods: A total of 78 male patients with prostate cancer (PCa) treated with robot-assisted radical prostatectomy between August 2015 and June 2020 were included in this study. In this cohort, suspicious lesions on multiparametric magnetic resonance imaging (mpMRI) were scored according to PI-RADS version-2 criteria. MpMRI-targeted prostate biopsy was performed for all suspicious lesions with a PI-RADS score of =3 followed by systematic prostate biopsy. The relationship between index lesion PI-RADS score and histopathological outcomes of prostatectomy specimens were evaluated statistically. Results: The mean age of the patients was 65.0±7.0 years. The distribution of PI-RADS scores of 3, 4, and 5 of the index lesions were 6 (7.7%), 29 (37.2%), and 43 (55.1%), respectively. Lower tumor volume and tumor volume ratio were observed in patients with a PI-RADS score of 3 when they were compared with patients with PI-RADS scores of 4 and PI-RADS-5 (p<0.001, for each). No significant correlation was found between index lesion PI-RADS score in mpMRI and clinically significant PCa in prostatectomy specimens (r<0.200, p>0.05). However, a significant correlation was observed between index lesion PI-RADS score and extracapsular extension (ECE), as well as seminal vesicle invasion (SVI) and pT stage (r=0.327, p=0.004; r=0.276, p=0.014, r=0.348, p=0.002, respectively). Conclusion: Increased index lesion PI-RADS scores were associated with ECE, SVI, higher tumor volume, tumor volume ratio, and pT stages. Increased index lesion PI-RADS score in mpMRI may be helpful in prediction of locally advanced PCa in prostatectomy specimens. [ABSTRACT FROM AUTHOR]

Background: There are often multiple lesions in breast magnetic resonance imaging (MRI) reports and radiologists usually focus on describing the index lesion that is most crucial to clinicians in determining the management and prognosis of patients. Natural language processing (NLP) has been used for information extraction from mammography reports. However, few studies have investigated NLP in breast MRI data based on free-form text. The objective of the current study was to assess the validity of our NLP program to accurately extract index lesions and their corresponding imaging features from free-form text of breast MRI reports.Methods: This cross-sectional study examined 1633 free-form text reports of breast MRIs from 2014 to 2017. First, the NLP system was used to extract 9 features from all the lesions in the reports according to the Breast Imaging Reporting and Data System (BI-RADS) descriptors. Second, the index lesion was defined as the lesion with the largest number of imaging features. Third, we extracted the values of each imaging feature and the BI-RADS category from each index lesion. To evaluate the accuracy of our system, 478 reports were manually reviewed by two individuals. The time taken to extract data by NLP was compared with that by reviewers.Results: The NLP system extracted 889 lesions from 478 reports. The mean number of imaging features per lesion was 6.5 ± 2.1 (range: 3-9; 95% CI: 6.362-6.638). The mean number of imaging features per index lesion was 8.0 ± 1.1 (range: 5-9; 95% CI: 7.901-8.099). The NLP system demonstrated a recall of 100.0% and a precision of 99.6% for correct identification of the index lesion. The recall and precision of NLP to correctly extract the value of imaging features from the index lesions were 91.0 and 92.6%, respectively. The recall and precision for the correct identification of the BI-RADS categories were 96.6 and 94.8%, respectively. NLP generated the total results in less than 1 s, whereas the manual reviewers averaged 4.47 min and 4.56 min per report.Conclusions: Our NLP method successfully extracted the index lesion and its corresponding information from free-form text. [ABSTRACT FROM AUTHOR]

Highlights • Boost to DIL with permanent seed prostate implant shows a trend toward improvement of biochemical control in intermediate risk cancer patient. • Our data support previous studies which demonstrated no increased toxicity with DIL boost technique in LDR brachytherapy. • This study presents the largest population with intermediate risk prostate cancer patient treated with DIL technique and low dose brachytherapy in the literature. Abstract Background and purpose To compare bDFS and toxicity outcomes in a population of intermediate risk prostate cancer patients treated using I-125 LDR brachytherapy with or without DIL boost based on multiple core biopsy maps. Materials and methods Between January 2005 and December 2013, all our intermediate risk prostate cancer patients treated with LDR I-125 brachytherapy were reviewed. All patients were given 144 Gy to the prostate. A pathologic DIL distribution (defined by sextant biopsy) was contoured prospectively prior to planning, to be covered by the 150% isodose line. Of the 165 patients treated, 55 received a DIL boost. Patients completed prospectively the IPSS questionnaire, a sexual and bowel function questionnaire. Gastro-intestinal toxicities were graded according to CTCAE v4.03. A patient was considered to have erectile dysfunction if he was unable to achieve erection to perform intercourse. BDFS was determined according to the Phoenix consensus definitions. Results The median follow-up was 78 months. The estimated 7-year bDFS rate was 96% (95% CI, 74–99%) in the DIL group versus 89% (95% CI, 79–94%) in the control group (p = 0.188). There was no difference between groups in urinary, gastro-intestinal or sexual toxicities up to 5 years of follow-up. There was no difference in urinary obstruction with catheterization between DIL versus control groups (3,6 vs 2,8 %, p = 1.00). Only 1 patient in the DIL group had ≥grade 3 toxicity (TURP) and none in the control group. Conclusions Boost to DIL defined by sextant biopsy with permanent seed prostate implant shows a trend toward improvement of biochemical control in intermediate risk prostate cancer patient without increasing toxicity. [ABSTRACT FROM AUTHOR]

Purpose: To analyse the impact of the presence of extra-target non-clinically significant cancer (NCSC) after high-intensity focused ultrasound (HIFU) hemiablation on oncological results. To analyse radical treatment free survival (RTFS) rates at 2-3 years follow-up.Methods: Retrospective single-centre study of 55 patients treated by primary HIFU hemiablation from 2010 to 2016. Inclusion criteria were unilateral MRI detected CSC, stage ≤ T2b, Gleason score (GS) ≤ 7, at least 6 mm distant from prostate apex. MRI with systematic and targeted biopsies was performed at diagnosis. Follow-up included clinical examination, PSA every 6 month, MRI and biopsies at 1 year and in case of PSA elevation. HIFU retreatment was possible. Whole-gland treatment was indicated in case of positive biopsies with GS ≥ 7 or maximum cancer core length > 5 mm, any GS.Results: Mean follow-up was 33 months (SD: 17-49 months). Presence or not of an extra-target NCSC in the untreated part of the gland had no impact on RTFS at univariate analysis (p = 0.29). 10 (18%) patients had a salvage whole-gland treatment after a median follow-up of 26 months (IQR 17-28). RTFS at 2 and 3 years were 92% and 80%.Conclusion: Presence or not of an extra-target NCSC in the untreated part of the gland had no impact on RTFS. NCSC lesion can be left untreated and actively monitored. RTFS was 80% at 3 years which support the concept of focal/partial treatment as a treatment option of CSC prostate cancer. [ABSTRACT FROM AUTHOR]

Purpose: Primary radiation therapy is a curative treatment option for prostate cancer. The aim of this study was to evaluate the detection of the dominant intraprostatic lesion (DIL) with magnetic resonance imaging (MRI) for radiotherapy treatment planning, the comparison with transrectal ultrasound (TRUS)-guided biopsies and the examination of the dose distribution in relation to the DIL location.Materials and Methods: In all, 54 patients with treatment planning MRI for primary radiotherapy of prostate cancer from 03/2015 to 03/2017 at the Universitätsklinikum Würzburg were identified. The localization of the DIL was based on MRI with T2- and diffusion-weighted imaging. After registration of the MR image sets within Pinnacle3 (Philips Radiation Oncology Systems, Fitchburg, WI, USA), the dose distribution was analyzed. The location of the DIL was compared to the pathology reports in a side-based manner.Results: The DIL mean dose (Dmean) was 77.51 ± 0.77 Gy and in 50/51 cases within the tolerance range or exceeded the prescribed dose. There was a significant difference in Dmean between ventral (n = 21) and dorsal (n = 30) DIL (77.87 ± 0.67 vs. 77.26 ± 0.77 Gy; p = 0.005). MRI-guided localization showed an accuracy and sensitivity of up to 78.8% and 82.1% for inclusion of secondary lesions, respectively.Conclusion: Up to 82.1% of histologically verified intraprostatic lesions were identified in the context of MRI-guided radiotherapy treatment planning. As expected, dorsal DIL tend to be minimally underdosed in comparison to ventral DIL. Adequate dose coverage was achieved in over 98% of patients. [ABSTRACT FROM AUTHOR]

Radical treatment of localised prostate cancer is recognised to be an unnecessary intervention or overtreatment in many men. Consequently, there has been a rapid uptake in the use of focal ablative therapies. However, there are several biological and practical concerns about such approaches as they have yet to be proved as robust treatment options. In particular, the multifocal nature of prostate cancer argues against unifocal treatment, while limitations in imaging can preclude the accurate identification of the number, location, and extent of prostate cancer foci. To date, a number of ablative options have reported results on mainly low-risk disease. Most series are relatively immature, with a lack of consistent follow-up, and the morbidity of retreatment is often not considered. The authors consider focal therapy to be an investigational modality, and encourage prospective recording of outcomes and recruitment of suitable patients. Patient summary Focal therapy of prostate cancer is the targeted destruction of cancer within a specific part of the prostate gland, sparing the rest of the prostate and nearby tissue. This procedure could potentially reduce side effects when compared with established standard treatments, such as surgery or radiotherapy, which treat the entire prostate. Studies show that for most men with low-risk cancer, active surveillance is the preferred treatment option. However, the available data regarding all forms of focal therapy are still poor and inconclusive. Consequently, due to both the lack of clear results associated with focal therapy and the difficulties in detecting all cancerous areas of the prostate, focal therapy should be considered an investigational modality only. [ABSTRACT FROM AUTHOR]

Objectives To review the available data about focal primary partial prostate irradiation (focal radiotherapy, FRT) for early prostate cancer. Methods Inclusion criteria: Medline search for English language full paper on primary FRT for early prostate cancer including review articles, planning studies or patient series (clinical outcome available) published before May 31, 2015. Results 22 papers have been found: 11 review articles, 4 planning studies and 7 patient series. Eleven review articles were dedicated to all types of focal therapy including FRT and 2 to FRT only. All planning studies included brachytherapy and showed excellent organ-at-risk sparing. Patient series included together 715 patients (99% treated with brachytherapy) and showed promising tumour control in low-risk cancer. In intermediate-risk tumours, FRT might be suboptimal. Conclusions Primary FRT is feasible in early prostate cancer. As any other focal therapy, FRT remains investigational until numerous questions are answered. [ABSTRACT FROM AUTHOR]

Purpose: Prostate cancer (PCa) diagnosis relies on clinical suspicion leading to systematic transrectal ultrasound-guided biopsy (TRUSGB). Multiparametric magnetic resonance imaging (mpMRI) allows for targeted biopsy of suspicious areas of the prostate instead of random 12-core biopsy. This method has been shown to be more accurate in detecting significant PCa. However, the precise spatial accuracy of cognitive targeting is unknown. Methods: Consecutive patients undergoing mpMRI-targeted TRUSGB with cognitive registration (MRTB-COG) followed by robot-assisted radical prostatectomy were included in the present analysis. The regions of interest (ROIs) involved by the index lesion reported on mpMRI were subsequently targeted by two experienced urologists using the cognitive approach. The 27 ROIs were used as spatial reference. Mapping on radical prostatectomy specimen was used as reference to determine true-positive mpMRI findings. Per core correlation analysis was performed. Results: Forty patients were included. Overall, 40 index lesions involving 137 ROIs (mean ROIs per index lesion 3.43) were identified on MRI. After correlating these findings with final pathology, 117 ROIs (85 %) were considered as true-positive lesions. A total of 102 biopsy cores directed toward such true-positive ROIs were available for final analysis. Cognitive targeted biopsy hit the target in 82 % of the cases (84/102). The only identified risk factor for missing the target was an anterior situated ROI ( p = 0.01). Conclusion: In experienced hands, cognitive MRTB-COG allows for an accuracy of 82 % in hitting the correct target, given that it is a true-positive lesion. Anterior tumors are less likely to be successfully targeted. [ABSTRACT FROM AUTHOR]

Background Although localised prostate cancer is multifocal in most instances, the index lesion might be responsible for disease progression. Objective To determine the early genitourinary functional and cancer control outcomes of index lesion ablation. Design, setting, and participants This was a single-centre prospective development study in which 56 men were treated (July 2009–January 2011). The mean age was 63.9 yr (standard deviation 5.8) and median prostate-specific antigen (PSA) was 7.4 ng/ml (interquartile range [IQR] 5.6–9.5). There were seven (12.5%) low-risk, 47 (83.9%) intermediate-risk, and two (3.6%) high-risk cancers. Intervention Multiparametric magnetic resonance imaging (mpMRI) and prostate biopsies to localise disease, followed by index lesion ablation using high-intensity focused ultrasound. Outcome measurements and statistical analysis Primary outcomes were genitourinary side effects measured using validated questionnaires. Secondary outcomes included absence of clinically significant disease at 12 mo. Results and limitations The composite of leak-free, pad-free continence, and erections sufficient for penetration decreased from a baseline frequency of 40/56 (71.4%) to 33/56 (58.9%) at 12 mo. Pad-free and leak-free, pad-free continence was preserved in 48/52 (92.3%) and 46/50 (92.0%) patients, respectively. Erections sufficient for intercourse were preserved in 30/39 (76.9%) patients. The median PSA nadir decreased to 2.4 ng/ml (IQR 1.6–4.1). At 12 mo, 42/52 (80.8%) patients had histological absence of clinically significant cancer and 85.7% (48/56) had no measurable prostate cancer (biopsy and/or mpMRI). Two (3.6%) patients had clinically significant disease in untreated areas not detected at baseline. The main study limitation is the short follow-up duration. Conclusions Index lesion ablation had low rates of genitourinary side effects and acceptable short-term absence of clinically significant cancer. Comparative effectiveness trials are required to assess cancer control outcomes against radical therapy. Patient summary In this study we looked at whether it is possible to treat the largest and highest-grade tumour in men who have more than one known prostate tumour. We show that the side effects of targeted ablation were low, with acceptable rates of early cancer control. Larger studies with longer follow-up are needed. Trial registration NCT00988130 [ABSTRACT FROM AUTHOR]

Purpose There is an increasing interest for dose differentiation in prostate radiotherapy. The purpose of our study was to analyze the spatial distribution of tumor satellites inside the prostate. Methods and materials 61 prostatectomy specimens were stained with H&E. Tumor regions were delineated by the uro-pathologist. Volumes, distances and cell densities of all delineated tumor regions were measured and further analyzed. Results Multifocal disease was seen in 84% of the patients. The median number of tumor foci was 3. The median distance between the index lesion and the satellites was 1.0 cm, with a maximum of 4.4 cm. The index lesions accounted for 88% of the total tumor volume. The contribution of tumor foci < 0.1 cm 3 to the total tumor volume was 2%. The median cell density of the index lesion and all satellites, regardless of size, were significantly higher than that of the prostate. Conclusions Satellites do not appear in a limited margin around the index lesion (GTV). Consequently, a fixed CTV margin would not effectively cover all satellites. Thus if the aim is to treat all tumor foci, the entire prostate gland should be considered CTV. [ABSTRACT FROM AUTHOR]

Objective. The aim of this study was to evaluate the accuracy of multiparametric endorectal magnetic resonance imaging (mp-MRI) in detecting and characterising the largest tumour lesion, which is defined as the index tumour of prostate cancer. Material and methods. A total of 55 patients with proven histological prostate cancer underwent post-biopsy MRI at 1.5 T and subsequent radical prostatectomy. The maximum tumour diameter (MTD) of the index lesion was determined independently by MRI and histopathology in a prospective manner. The detection rate of the index lesion, the MTD and volume by pathology, and the pathological tumour (pT) stage were correlated with the MTD by MRI using Pearson's correlation. Results. Pathohistology revealed 158 cancer foci. MRI detected 55 foci. The sensitivity, specificity, accuracy, and negative and positive predictive values of mp-MRI for index lesion detection were 89%, 100%, 90%, 44% and 100%, respectively. Three positive correlations were found: one between the MTD of the index lesion by MRI and the MTD by pathology (Pearson coefficient = 0.890, p < 0.01), a second between the MTD by MRI and the index tumour volume at pathology (Pearson coefficient = 0.786, p < 0.01), and a third between the MTD and the pT stage (Pearson coefficient = 0.678, p < 0.01). Conclusion: mp-MRI can accurately detect the index lesion and estimate the TVP of localised prostate cancer. [ABSTRACT FROM AUTHOR]

Prostate cancer is a common malignancy among men, and the current screening, imaging and sampling approaches aim to detect early-stage, organ-confined disease. In such scenario, focal prostate cancer therapy currently relies on the index lesion concept as the dominant lesion that drives the disease natural history. Focal therapy demands the essential imaging and sampling techniques to strategically locate and qualify the disease, but, despite advances in technology, prostate imaging and biopsy have several limitations that need to be overcome if focal therapy is to be developed further. The I Prostate Cancer Focal Treatment International Symposium was convened to foster discussion on this topic that sits at the crossroads of multiple disciplines (Urology, Pathology, Radiology, Radiation Oncology and Medical Oncology) all of which were represented for this comprehensive multidisciplinary review of the current literature. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: To assess the ability of multiparametric (mp) MRI (mp-MRI) to identify, stratify, and localize biopsy-proven prostate cancer lesions in a risk-stratified patient population. Methods and Materials: We retrospectively analyzed 57 patients who had mp-MRI and core needle biopsy during diagnostic prostate cancer evaluation. The MRI sequences were scored for suspicion of cancer with a previously described system. Distributions of mp-MRI scores were compared across National Comprehensive Cancer Network prostate cancer risk groups. The mp-MRI–identified lesions were compared with the location of positive core needle biopsies to assess mp-MRI localization of true lesions. Results: The mp-MRI scoring system identified lesions in 84% (48/57) of the patients, including 100% (12/12) in the high-risk group. Scores assigned to lesions in patients in intermediate- and high-risk groups were statistically higher than those in the low-risk group, with a relative risk of 6.72 (95% confidence interval: 2.32–19.51, p <0.001) of having an aggressive score assigned in high-risk patients compared with the low-risk patients. In comparing the localization data from core needle biopsy, 68% of the patients had an MRI-identified lesion in or within one adjacent sextant of the same prostate hemigland, including 85% of aggressive lesions. Conclusions: Use of mp-MRI at the time of diagnosis can identify intraprostatic lesions and assign suspicion for high-risk disease. These data show that high-risk patients are more likely to have suspicious imaging-identified lesions that correlate to the location of biopsy-proven prostate cancer. At this time, the use of mp-MRI to define focal targets represents a complementary tool to patient evaluation for focal therapy strategies. [Copyright &y& Elsevier]

Objectives To assess oncological (biochemical and histological recurrence) and functional (urinary and potency) outcomes in patients with unilateral low-risk organ-confined prostate cancer ( PCa) treated with focal cryoablation ( FC)., Patients and Methods From January 2009 to March 2012, patients with localized PCa who refused active surveillance were assigned to a FC protocol., This was a prospective, single-arm cohort study. Inclusion criteria were: unilateral disease, clinical stage T1c to T2a, prostate-specific antigen ( PSA) concentration <10 ng/mL, low volume index lesion and Gleason score ≤6 (3+3). Hemi-ablation was carried out using the PreciseTM cryoablation system (Galil Medical, Inc., Arden Hills, MN, USA)., Oncological ( PSA values) and functional (International Prostate Symptom Score and International Index of Erectile Function ( IIEF)-5 score) outcomes were analysed at 3-, 6- and 12-month follow-up., The primary endpoint for oncological efficacy, no cancer in ipsilateral side, was based on the 12-month mandatory biopsy., Results A total of 48 consecutive patients with a mean age of 67 years were included. The median (interquartile range) follow-up was 13.2 (7.4-26.5) months., Follow-up prostate biopsies were negative for the treated lobe in 86% of patients., The mean PSA concentration dropped significantly at 3 months (by 55%) but did not correlate well with positive biopsy results., Urinary symptoms were unchanged. A slight decrease in the IIEF-5 score was present at 3 months, but did not differ significantly from baseline at 6-month follow-up., There were 15% grade 1 and 4% grade 2 complications ( Clavien classification)., Conclusions Focal cryoablation is a low-morbidity option in selected patients with low-risk PCa., We showed PSA concentration to be an unreliable marker for monitoring FC and recommend a protocol of mandatory biopsies for follow-up., A multicentre randomized controlled trial is necessary to confirm the low-morbidity and the biopsy-proven PCa cure rates. [ABSTRACT FROM AUTHOR]

Abstract: Introduction and Objective: Because of the improvements on detection of early stage prostate cancer over the last decade, focal therapy for localized prostate cancer (PC) has been proposed for patients with low-risk disease. Such treatment would allow the control of cancer, thereby diminishing side effects, such as urinary incontinence and sexual dysfunction, which have an enormous impact on quality of life. The critical issue is whether it is possible to preoperatively predict clinically significant unifocal or unilateral prostate cancer with sufficient accuracy. Our aim is to determine whether there is any preoperative feature that can help select the ideal patient for focal therapy. Material and methods: A total of 599 patients who underwent transrectal ultrasound (TRUS)-guided prostate biopsy followed by radical prostatectomy to treat PC were examined in our laboratory between 2001 and 2009. We established very restricted criteria to select patients with very-low-risk disease for whom focal therapy would be suitable (only 1 biopsy core positive, tumor no larger than 80% of a single core, no perineural invasion, PSA serum level < 10 ng/ml, Gleason score < 7 and clinical stage T1c, T2a–b). We defined 2 groups of patients who would be either adequately treated or not treated by focal therapy. The primary endpoint was the evaluation of preoperative features in order to identify which parameters should be considered when choosing good candidates for focal therapy. Results: Fifty-six out of 599 patients met our criteria. The mean age was 59 years, and the mean number of biopsy cores was 14.4. Forty-seven (83.9%) were staged T1c, and 9 (16.1%) were staged T2a–b. Forty-four (78.6%) patients could be considered to have been adequately treated by focal therapy, and 12 (21.4%) could not. There was no statistical difference between the 2 groups considering age, clinical stage, PSA levels, Gleason score, and tumor volume in the biopsy. All 12 patients who could be considered inadequately treated had a bilateral, significant secondary tumor, 58.3% had Gleason ≥ 7, and 25% were staged pT3. Conclusion: Although focal therapy might be a good option for patients with localized prostate cancer, we are so far unable to select which of them would benefit from it based on preoperative data, even using very restricted criteria, and a considerable proportion of men would still be left undertreated. [Copyright &y& Elsevier]

Introduction: Focal therapy of prostate cancer is gaining more and more interest. One of the drawbacks of focal therapy of prostate cancer is the problem of correct identification of prostate cancer lesions. The aim of the study was to evaluate the ability of real-time elastography to correctly identify the prostate cancer index lesion. Materials and methods: In 32 patients, real-time elastography was performed the day before prostatectomy. During the examination, the location of the main lesion suspicious for prostate cancer was prospectively recorded. Moreover, the results of the randomized multicore biopsies were also used to predict the location of the index lesion. The preoperative elastography results, the biopsy results, and a combined use of elastography and biopsy results were then compared with the pathological results to calculate the diagnostic values for correct index lesion identification. Results: When using real-time elastography alone to identify the prostate cancer index lesion, sensitivity, specificity, negative predictive value, positive predictive value, and accuracy were 58.8, 43.3, 54.1, 48.1, and 51.6%, respectively. Data from randomized biopsies alone achieved 67.8, 48.4, 56.8, 60.0, and 58.1%, respectively. The combination of elastography and biopsy data increased the values to, respectively, 84.9, 48.4, 61.9, 75.0, and 66.1%. Conclusion: In this study, real-time elastography alone did not allow to identify the prostate cancer index lesion with satisfactory reliability. The combination of real-time elastography and data from randomized 12 core biopsies allows promising ability to correctly identify the prostate cancer index lesion. [ABSTRACT FROM AUTHOR]

OBJECTIVE To determine the pathological characteristics of radical prostatectomy specimens with respect to index and secondary lesions. METHODS A total of 100 consecutive radical prostatectomy specimens examined at a single hospital were assessed. Patients undergoing salvage prostatectomy or those who had received neoadjuvant hormonal manipulation were excluded. Preoperative data and the number, volume and Gleason grade of each tumour focus were recorded. Criteria used to define a clinically significant lesion were tumour volume ≥ 0.5 mL and/or Gleason pattern 4 or 5 and/or extra-capsular disease. RESULTS Overall, 374 foci were examined. The median number of tumours per patient was 3.5 (range 1-15). The overall median tumour volume was 1.4 mL (range 0.1-18.2), the median volume of the largest (index) tumour was 0.95 mL (range 0.1-18.2) and the median volume of the largest secondary tumour was 0.2 mL (range 0.05-1.7). There were no patients in whom the index lesion was insignificant and secondary tumours were significant (by grade or extra-capsular disease). Seventy-seven fulfilled the clinical parameters of low-to-intermediate-risk disease. If focal therapy can be delivered with the aim of ablating all clinically significant disease, with untreated areas harbouring no cancer or clinically insignificant disease, between 58.5 and 67.5% might have been suitable for such a strategy. CONCLUSIONS The proportion of men with low-to-intermediate-risk prostate cancer who may potentially be suitable for a focal therapy approach is unknown. The key question is whether the volume of individual lesions points to clinically significant cancer and whether ablation of these lesions alone would lead to cancer control. This research question is currently undergoing evaluation within a prospective clinical trial. [ABSTRACT FROM AUTHOR]

Background: The place of focal therapy in prostate cancer management requires further evaluation within randomized comparative clinical trials. Methods: This review article discusses the place of focal therapy and asks whether it is an alternative to active surveillance or radical therapy. This question therefore is at the heart of whether this proposed paradigm shift should be delivered with the intent of cure or cancer control. Results: For such trials to report on outcomes that have meaningful utility in the clinic, it is necessary to discuss whether focal ablation should be delivered with intent to eradicate all cancer foci ('cure') or ablate all clinically significant lesions with surveillance of all remaining tissue (benign or harboring clinically insignificant cancer). While the former will inevitably mean that fewer men will be appropriate for focal therapy were it to become standard care, it is the safest approach. The latter strategy will open focal therapy to the majority of men with low- to intermediate-risk disease with the potential of offering a treatment strategy that treats important cancer while preserving function with a high degree of probability. Conclusion: A pragmatic randomized controlled clinical in which focal therapy is randomized against standard of care may be feasible. The pragmatic nature of such a trial would allow eligibility criteria, localization of cancer to reflect local practice (novel imaging and transrectal biopsy or template prostate mapping), and the focal intervention (ablative modality, intent to ablate all cancer foci or all clinically significant foci) to be kept broad to reflect clinical practice. Further, it would satisfy individual equipoise by allowing either active surveillance or radical therapy in the standard care arm, to be decided on by patient and physician. [ABSTRACT FROM AUTHOR]