Andreas Maxeiner

Areas suspicious for prostate cancer: MR-guided biopsy in patients with at least one transrectal US-guided biopsy with a negative finding--multiparametric MR imaging for detection and biopsy planning.

PURPOSE To prospectively investigate the incremental value of multiparametric magnetic resonance (MR) imaging compared with standard T2-weighted imaging for biopsy planning. MATERIALS AND METHODS The study was approved by the institutional review board; informed consent was obtained. Consecutive patients underwent T2-weighted imaging supplemented with multiparametric 1.5-T MR imaging, consisting of hydrogen 1 ((1)H) MR spectroscopy, diffusion-weighted (DW) imaging, and contrast material-enhanced MR imaging. Quantitative parameters were calculated: (choline plus creatine)-to-citrate ratio, apparent diffusion coefficient, and volume transfer constant and exchange rate constant. The prostate was divided into 20 standardized areas. Each area was classified as benign, inconclusive, or suspicious at T2-weighted imaging, followed by quantitative evaluation of all inconclusive and suspicious areas with multiparametric MR imaging. MR-guided biopsy was performed in lesions classified as suspicious for cancer with at least one of the techniques after transfer to three-dimensional T2-weighted images. Diagnostic parameters were calculated on a per-lesion and per-patient basis for all combinations of T2-weighted imaging with multiparametric MR imaging. RESULTS Fifty-four patients had a median of two prior transrectal ultrasonographic biopsies with negative findings. Each patient had a median of three suspicious lesions. Prostate cancer was demonstrated in 21 of 54 patients. Biopsy was performed in 178 lesions; 53 were positive for prostate cancer. Detection rates and test negative results, respectively, were as follows: T2-weighted imaging, 70% and 50%; T2-weighted imaging and (1)H MR spectroscopy, 81% and 32%; T2-weighted imaging and contrast-enhanced MR imaging, 83% and 29%; T2-weighted imaging and DW imaging, 85% and 30%; T2-weighted imaging, (1)H MR spectroscopy, and contrast-enhanced MR imaging, 91% and 13%; T2-weighted imaging, (1)H MR spectroscopy, and DW imaging, 94% and 15%; T2-weighted imaging, DW imaging, and contrast-enhanced MR imaging, 94% and 13%; T2-weighted imaging, (1)H MR spectroscopy, DW imaging, and contrast-enhanced MR imaging, 100% and 0%. CONCLUSION Only the combination of T2-weighted imaging with all three multiparametric techniques depicts all identifiable prostate cancers; a double combination with DW imaging and (1)H MR spectroscopy or contrast-enhanced MR imaging misses 6%, while reasonably reducing the number of areas needing biopsy.

Prostate cancer detection on transrectal ultrasonography-guided random biopsy despite negative real-time magnetic resonance imaging/ultrasonography fusion-guided targeted biopsy: reasons for targeted biopsy failure

To examine the value of additional transrectal ultrasonography (TRUS)‐guided random biopsy (RB) in patients with negative magnetic resonance imaging (MRI)/ultrasonography (US) fusion‐guided targeted biopsy (TB) and to identify possible reasons for TB failure.

Evaluation of the prostate imaging reporting and data system for the detection of prostate cancer by the results of targeted biopsy of the prostate.

PurposeThe purpose of this study was to evaluate the magnetic resonance prostate imaging reporting and data system (PI-RADS) for the detection of prostate cancer by the results of magnetic resonance imaging (MRI)–guided biopsy of the prostate as a reference standard. Patients and MethodsIn 55 patients who had undergone MRI-guided biopsy of the prostate, we retrospectively matched every biopsy core with the corresponding lesion in previously acquired endorectal multiparametric MRI including T2-weighted imaging (T2WI), diffusion-weighted imaging (DWI), and dynamic contrast-enhanced MRI (DCE-MRI) at 1.5 T. Two readers blinded to the results of the biopsy evaluated each biopsied lesion according to the PI-RADS scoring system. The results of the targeted biopsy were used as a reference standard. Receiver operating characteristic analysis was performed for statistical analysis. ResultsA total of 113 lesions in the 55 patients were evaluated; 30 lesions were malignant. When evaluated according to the criteria of the PI-RADS scoring system, DCE-MRI revealed a lower area under the receiver operating characteristic curve (AUC) (0.76) compared with T2WI (0.88; P = 0.06) and DWI (0.93; P = 0.004). A sum score combining T2WI, DWI, and DCE-MRI yielded an AUC of 0.93, whereas a sum score combining only T2WI and DWI yielded an AUC of 0.95. In central gland lesions, T2WI showed a numerically higher AUC compared with DWI (0.98 and 0.95), whereas, in peripheral zone lesions, DWI was superior (AUC of 0.93 and 0.73; P = 0.04). An approach assigning a PI-RADS score for T2WI to central gland lesions and for DWI to peripheral zone lesions yielded an AUC of 0.96 and was numerically superior compared with any sequence alone and sum scores combining T2WI and DWI as well as T2WI, DWI, and DCE-MRI. ConclusionsThe PI-RADS scoring system shows a good diagnostic performance for the detection of prostate cancer when using a sum score. However, DCE-MRI does not seem to add significant value when evaluated according to the recommended criteria. Assigning a score for T2WI to central gland lesions and for DWI to peripheral zone lesions might be sufficient for stratification of patients for further diagnostic workup.

Detektion des Prostatakarzinoms durch Echtzeit-MRT/US-Fusionsbiopsie: 3T MRT und moderne Ultraschalltechnik

PURPOSE Multiparametric MRI of the prostate is a noninvasive diagnostic method with high sensitivity and specificity for prostate cancer. The aim of this study is to evaluate whether prostate cancer detection rates of transrectal ultrasound (TRUS)-guided biopsy may be improved by an image fusion of state-of-the-art ultrasound (CEUS, elastography) and MR (T2w, DWI) imaging. MATERIALS AND METHODS 32 consecutive patients with a history of elevated PSA levels and at least one negative TRUS-guided biopsy with clinical indication for a systematic re-biopsy underwent multiparametric 3 T MRI without endorectal coil. MR data (T2w) were uploaded to a modern sonography system and image fusion was performed in real-time mode during biopsy. B-mode, Doppler, elastography and CEUS imaging were applied to characterize suspicious lesions detected by MRI. Targeted biopsies were performed in MR/US fusion mode followed by a systematic standard TRUS-guided biopsy. Detection rates for both methods were calculated and compared using the Chi²-test. RESULTS Patient age was not significantly different in patients with and without histologically confirmed prostate cancer (65.2 ± 8.0 and 64.1 ± 7.3 age [p = 0.93]). The PSA value was significantly higher in patients with prostate cancer (15.5 ± 9.3 ng/ml) compared to patients without cancer (PSA 10.4 ± 9.6 ng/ml; p = 0.02). The proportion of histologically confirmed cancers in the study group (n = 32) of the MR/US fusion biopsy (11/12; 34.4 %) was significantly higher (p = 0.01) in comparison to the TRUS systematic biopsy (6/12; 18.8 %). CONCLUSION Real-time MR/US image fusion may enhance cancer detection rates of TRUS-guided biopsies and should therefore be studied in further larger studies.

Added Value of Multiparametric Ultrasonography in Magnetic Resonance Imaging and Ultrasonography Fusion–guided Biopsy of the Prostate in Patients With Suspicion for Prostate Cancer

OBJECTIVE To analyze whether magnetic resonance imaging-ultrasonography (MRI-US) fusion-guided biopsy detects more and clinical significant prostate cancer (PCa) in comparison to conventional transrectal US-guided prostate biopsy (PBX) and to investigate if multiparametric (mp) US during MRI-US fusion can further characterize mpMRI-suspected lesions according to the prostate MRI reporting and data system (PI-RADS). METHODS From January 2012 to January 2014, 169 patients with a median of 2 negative conventional PBX and/or initially or consistently elevated prostate-specific antigen levels were prospectively included and underwent 3 T mpMRI. Real-time MRI-US fusion scan was used to biopsy the mpMRI-targeted lesions (n = 316). Scanning by mpUS, including B-mode, power Doppler, strain elastography, and contrast-enhanced US was performed to further characterize those lesions and to score by US modalities resulting in an mpUS score. Afterward, a conventional 10-core PBX was performed. PCa detection based on the results of targeted and conventional PBX was estimated. Performances of single US modalities were analyzed. The mpUS score was also investigated for PCa and PI-RADS score prediction. RESULTS Among 169 patients, 71 PCa (42%) were detected. From these 71 cases, clinically significant PCa (Gleason score ≥7) were detected exclusively by MRI-US fusion in 31 from 46 cases (67.4%). The highest sensitivity was observed in contrast-enhanced US (85%) and elastography (80%). The mpUS score predicts PCa and PI-RADS score with an overall accuracy of 86% and 80%, respectively. CONCLUSION MRI-US fusion-guided PBX detects more clinically significant PCa compared with conventional TRUS. The mpUS score correlates with PI-RADS in PCa prediction.

T2- and diffusion-weighted magnetic resonance imaging at 3 T for the detection of prostate cancer with and without endorectal coil: An intraindividual comparison of image quality and diagnostic performance

OBJECTIVES To intraindividually compare image quality and diagnostic performance of multiparametric MRI (mpMRI) at 3T for the detection of prostate cancer (PCa) using a pelvic phased-array coil (PAC) and a combined endorectal and pelvic phased-array coil (ERC-PAC). METHODS Forty-five patients were prospectively included and received mpMRI of the prostate using a PAC and an ERC-PAC during one imaging session. Two radiologists evaluated image quality and the most suspicious lesion according to the PI-RADS scoring system. Results of MRI-TRUS-fusion biopsy of the prostate served as reference standard. Patient comfort and acceptance were assessed using a standardized questionnaire. RESULTS Overall image quality for T2WI was rated significantly better with an ERC-PAC compared to a PAC (p=0.0038). The weighted kappa for PI-RADS scores for T2WI and DWI with a PAC and an ERC-PAC was 0.70 and 0.73, respectively. For a PI-RADS sum score including T2WI and DWI the area under the curve with a PAC and an ERC-PAC were 0.95-0.99 and 0.93-0.97, respectively (p=0.1395). CONCLUSION For T2WI and DWI performed at 3T index PCa lesion identification and evaluation did not differ significantly with both coil setups. Patients preferred MRI without an ERC. Therefore, the use of an ERC may be omitted in a prostate cancer detection setting.

MRI-guided core needle biopsy of the prostate: acceptance and side effects.

PURPOSE We aimed to study side effects, complications, and patient acceptance of magnetic resonance imaging-guided real-time biopsy (MRI-GB) of the prostate. METHODS Fifty-four men (49-78 years) with elevated prostate-specific antigen after at least one negative systematic transrectal ultrasound-guided biopsy (TRUS-GB) were included in a prospective clinical study. Suspicious areas on images were selectively sampled by obtaining a median of four specimens (range, 1-9 specimens) using MRI-GB. In TRUS-GB, a median of 10 specimens (range, 6-14 specimens) were obtained. Telephone interviews were conducted one week after outpatient MRI-GB, asking patients about pain and side effects (hematuria, hemospermia, rectal bleeding, fever, and chills) of the two biopsy procedures and which of the two procedures they preferred. Multinomial regression analysis and Fishers exact test was used to test for differences. RESULTS MRI-GB was preferred by 65% (35/54), and 82% (44/54) would undergo MRI-GB again. Pain intensity (P = 0.005) and bleeding duration (P = 0.004) were significantly lower for MRI-GB compared with TRUS-GB. Hematuria was less common after MRI-GB compared with TRUS-GB (P = 0.006). A high correlation was given between bleeding intensity and bleeding duration for TRUS-GB (r=0.77) and pain intensity and pain duration for MRI-GB (r=0.65). Although hemospermia, rectal hemorrhage, fever, and chills were less common in MRI, they showed no statistically significant difference. CONCLUSION MRI-GB of the prostate seems to have fewer side effects and less pain intensity than TRUS-GB and was preferred by the majority of patients.

The prostate health index PHI predicts oncological outcome and biochemical recurrence after radical prostatectomy - analysis in 437 patients

The purpose of this study was to investigate the Prostate-Health-Index (PHI) for pathological outcome prediction following radical prostatectomy and also for biochemical recurrence prediction in comparison to established parameters such as Gleason-score, pathological tumor stage, resection status (R0/1) and prostate-specific antigen (PSA).Out of a cohort of 460 cases with preoperative PHI-measurements (World Health Organization calibration: Beckman Coulter Access-2-Immunoassay) between 2001 and 2014, 437 patients with complete follow up data were included. From these 437 patients, 87 (19.9%) developed a biochemical recurrence. Patient characteristics were compared by using chi-square test. Predictors were analyzed by multivariate adjusted logistic and Cox regression.The median follow up for a biochemical recurrence was 65 (range 3-161) months. PHI, PSA, [-2]proPSA, PHI- and PSA-density performed as significant variables (p < 0.05) for cancer aggressiveness: Gleason-score <7 or ≥7 (ISUP grade 1 or ≥2) . Concerning pathological tumor stage discrimination and prediction, variables as PHI, PSA, %fPSA, [-2]proPSA, PHI- and PSA-density significantly discriminated between stages In conclusion, due to heterogeneity of time spans to biochemical recurrence, longer follow up periods are crucial. This study with a median follow up of more than 5 years, confirmed a clinical value for PHI as an independent biomarker essential for biochemical recurrence prediction.The purpose of this study was to investigate the Prostate-Health-Index (PHI) for pathological outcome prediction following radical prostatectomy and also for biochemical recurrence prediction in comparison to established parameters such as Gleason-score, pathological tumor stage, resection status (R0/1) and prostate-specific antigen (PSA). Out of a cohort of 460 cases with preoperative PHI-measurements (World Health Organization calibration: Beckman Coulter Access-2-Immunoassay) between 2001 and 2014, 437 patients with complete follow up data were included. From these 437 patients, 87 (19.9%) developed a biochemical recurrence. Patient characteristics were compared by using chi-square test. Predictors were analyzed by multivariate adjusted logistic and Cox regression. The median follow up for a biochemical recurrence was 65 (range 3-161) months. PHI, PSA, [-2]proPSA, PHI- and PSA-density performed as significant variables (p < 0.05) for cancer aggressiveness: Gleason-score <7 or ≥7 (ISUP grade 1 or ≥2) . Concerning pathological tumor stage discrimination and prediction, variables as PHI, PSA, %fPSA, [-2]proPSA, PHI- and PSA-density significantly discriminated between stages <pT3 and ≥pT3 with the highest AUC (0.7) for PHI. In biochemical recurrence prediction PHI, PSA, [-2]proPSA, PHI- and PSA-density were the strongest predictors. In conclusion, due to heterogeneity of time spans to biochemical recurrence, longer follow up periods are crucial. This study with a median follow up of more than 5 years, confirmed a clinical value for PHI as an independent biomarker essential for biochemical recurrence prediction.

Does the Prostate Health Index Depend on Tumor Volume?—A Study on 196 Patients after Radical Prostatectomy

The Prostate Health Index (PHI) has been used increasingly in the context of prostate cancer (PCa) diagnostics since 2010. Previous studies have shown an association between PHI and a tumor volume of >0.5 cm3. The aim of this study was to investigate the correlation between PHI and tumor volume as well as the Gleason score. A total of 196 selected patients with prostate cancer treated with radical prostatectomy at our institution were included in our study. The tumor volume was calculated and preoperative serum parameters total prostate-specific antigen (tPSA), free PSA (fPSA), [−2]proPSA, and PHI were evaluated. The association between the pathological findings such as Gleason score, pathological T-stage (pT stage), and tumor volume were evaluated. We further used logistic regression and Cox proportional hazard regression analyses for assessing the association between tumor volume and PHI and for predicting biochemical recurrence. With an area under the curve (AUC) of 0.79, PHI is the most accurate predictor of a tumor volumes >0.5 cm3. Moreover, PHI correlates significantly with the tumor volume (r = 0.588), which is significantly different (p = 0.008) from the correlation of the Gleason score with tumor volume (r = 0.385). PHI correlates more strongly with the tumor volume than does the Gleason score. Using PHI improves the prediction of larger tumor volume and subsequently clinically significant cancer.

Significant reduction in positive surgical margin rate after laparoscopic radical prostatectomy by application of the modified surgical margin recommendations of the 2009 International Society of Urological Pathology consensus

To verify retrospectively the margin status and analyse the location and characteristics of positive surgical margins (PSMs) in patients undergoing radical prostatectomy (RP), by a central pathology review, based on the consensus conference 2009 updated margin criteria from the International Society of Urological Pathology (ISUP).