Daniele Romagnoli

18F-FACBC compared with 11C-choline PET/CT in patients with biochemical relapse after radical prostatectomy: a prospective study in 28 patients.

INTRODUCTION The aim of our study was to compare the detection rate of anti-3-18F-FACBC PET/CT in comparison with 11C-choline PET/CT in the evaluation of disease recurrence of PCa after radical prostatectomy. PATIENTS AND METHODS Twenty-eight consecutive patients with biochemical relapse after radical prostatectomy were submitted to anti-3-18F-FACBC PET/CT and 11C-choline PET/CT to evaluate the site of disease recurrence. Androgen deprivation therapy was avoided in all cases. The primary end point was the overall detection rate of the 2 radiotracers. A patient-based analysis and a lesion-based analysis was performed. The target to background ratio (TBR) of each lesion was reported. RESULTS At the time of PET scan, mean age was 67 years and mean prostate specific antigen (PSA) relapse was 2.9 ng/mL (range: 0.2-14.6). In patient-based analyses, 11C-choline PET/CT was positive in 5 patients and negative in 23 (detection rate = 17.8%) and anti-3-18F-FACBC PET/CT was positive in 10 patients and negative in 18 (detection rate = 35.7%). All lesions that were positive using 11C-choline were positive using anti-3-18F-FACBC PET/CT but with the latter radiotracer, 11 (61.1%) additional tumors were identified including 5 (17.8%) additional patients. The TBR of anti-3-18F-FACBC was greater than 11C-choline in 15 of 18 lesions, confirming a better image quality and contrast. CONCLUSION This preliminary study demonstrated that the detection rate of anti-3-18F-FACBC PET/CT is greater in comparison with 11C-choline, with approximately 20% of additional patients and approximately 60% additional lesions detected. Further studies, however, are required to assess the exact added value of this new tracer.

Can Testis-Sparing Surgery for Small Testicular Masses Be Considered a Valid Alternative to Radical Orchiectomy? A Prospective Single-Center Study

BACKGROUND The aim of this study was to evaluate the incidence of malignancy in small testicular masses (STMs) treated with testis-sparing surgery (TSS) with intraoperative frozen section analysis and to assess the safety of this surgical procedure. PATIENTS AND METHODS From January 2009 to January 2013, 15 consecutive patients underwent TSS for STMs in a third-referral academic institution. Every patient was preoperatively evaluated with clinical examination and scrotal ultrasonography (US) performed by the same radiologist. Tumor markers were assessed in all cases. All the procedures were performed through inguinal access; the small mass was identified by straight palpation of the testis or with intraoperative ultrasonography (IUS). Frozen-section examination (FSE) was performed in all patients in association with multiple biopsies of the surrounding tissue. Follow-up was carried out in all patients with an ultrasonographic exploration at 6 and 12 months. RESULTS Preoperative tumor markers were normal in all patients. The mean operative time was 90 ± 31 minutes. The warm ischemia time was 18 ± 3 minutes. The mean size on US was 9.5 ± 4.4 mm. FSE results were confirmed by the final pathologic analysis in 14 patients. At final pathologic analysis, 6 patients (40%) were found not to have tumors, another 7 patients (46.7%) had benign neoplasms, and malignant tumor was found in only 2 patients (13.3%). There was no disease recurrence after a mean follow-up of 19.2 ± 11.5 months. CONCLUSION Our experience shows that TSS performed for STMs may represent a safe procedure with optimal results in terms of functional and oncologic end points.

68Ga-PSMA-PET/CT-Guided Salvage Retroperitoneal Lymph Node Dissection for Disease Relapse After Radical Prostatectomy for Prostate Cancer

Approximately 30% of patients submitted to radical therapy for prostate cancer will develop local or distant relapse within 10 years from primary treatment, thus receiving second-line treatment within 5 years. The efficacy of salvage lymph node dissection for prostate cancer relapse has been established. However, there is a lack of PET radiopharmaceuticals that might be considered a valid tool to identify nodal metastases. Ga-PSMA-PET/CT (Ga-labeled prostate-specific membrane antigen ligand HBED-CC positron emission tomography/positron emission tomography) showed higher performance compared to choline PET/CT, in particular during the early phase of biochemical relapse, with low prostate-specific antigen levels. We report a case of a patient with biochemical relapse who underwent salvage retroperitoneal lymph node dissection according to the results obtained by GaPSMA-PET/CT. The patient exhibited a complete biochemical response after surgery (prostate-specific antigen < 0.2 ng/mL) at short-term follow-up.

Survival, Continence and Potency (SCP) recovery after radical retropubic prostatectomy: a long-term combined evaluation of surgical outcomes.

OBJECTIVE To offer a comprehensive account of surgical outcomes on a defined series of patients treated with radical retropubic prostatectomy (RRP) for prostate cancer in a single European Center after 5-year minimum follow-up according to the Survival, Continence and Potency (SCP) system. MATERIAL AND METHODS We evaluated our Institutional database of patients who underwent RRP from November 1995 to September 2008. Oncological and functional outcomes were reported according to the recently proposed SCP system. RESULTS The 5- and 10-year biochemical recurrence-free survival rates were 80.1% and 55.8%, respectively. At the end of follow-up, 611 (78.5%) patients were fully continent (C0), 107 (13.8%) used 1 pad for security (C1) and 60 (7.7%) patients were incontinent (C2). Of the 112 patients who underwent nerve-sparing RRP, 22 (19.6%) were fully potent without aids (P0), 13 (11.6%) were potent with assumption of PDE-5 inhibitors (P1) and 77 (68.8%) experienced erectile dysfunction (P2). The combined SCP outcomes were reported together only in 95 (12.2%) evaluable patients. In patients preoperatively continent and potent, who received a nerve-sparing and did not require adjuvant therapy, oncological and functional success was attained by 29 (30.5%) patients. In the subgroup of 508 patients not evaluable for potency recovery, oncological and continence outcomes were obtained in 357 patients (70.3%). CONCLUSION Survival, Continence and Potency (SCP) classification offer a comprehensive report of surgical results, even in those patients who do not represent the best category, thus allowing to provide a much more accurate evaluation of outcomes after RP.

11C-choline PET/CT scan in patients with prostate cancer treated with intermittent ADT: a sequential PET/CT study.

Aim The purpose of this preliminary study was to evaluate the usefulness of 11C-choline PET/CT in patients with recurrent prostate cancer and hormone-sensitive disease treated with intermittent antiandrogen therapy scheme. Patients and Methods We retrospectively evaluated 10 patients after radical prostatectomy (n = 8) or external beam radiotherapy (n = 2) as primary therapy, studied with sequential 11C-choline PET/CT. The first PET/CT (PET1) was performed during antiandrogen therapy (ADT) and the second PET/CT (PET2) was performed after therapy interruption. Only patients with negative results at PET1 were included in the study. At the time of PET1, all patients were under ADT from at least 6 months (mean PSA 0.54 ng/mL). At the time of PET2, all patients had completed ADT for a mean period of 7 months. 11C-Choline PET/CT findings were validated by a follow-up of at least 12 months or histological confirmation in case of local relapse. Results PET2 has been able to detect the site of recurrences in all cases. At the time of PET2, mean PSA was 3.88 ng/mL; mean PSAdt was 2.46 months; and mean PSAvel was 6.94 ng/mL/year. Four out of 10 patients showed a single lesion, 5 out of 10 patients showed 2 lesions and 1 patient showed multiple lymph-node lesions. Conclusion When performed during ADT interruption, 11C-choline PET/CT has been able to detect the site of recurrence in patients with increasing PSA values. In this context, 11C-choline PET/CT may help to assess the burden of disease or to change the therapeutic approach using more aggressive and addressed therapies like guided RT or salvage lymph-node dissection.

The biopsy Gleason score 3+4 in a single core does not necessarily reflect an unfavourable pathological disease after radical prostatectomy in comparison with biopsy Gleason score 3+3: looking for larger selection criteria for active surveillance candidates

Background:To assess whether the addition of clinical Gleason score (Gs) 3+4 to the Prostate Cancer Research International: Active Surveillance (PRIAS) criteria affects pathologic results in patients who are potentially suitable for active surveillance (AS) and to identify possible clinical predictors of unfavourable outcome.Methods:Three hundred and twenty-nine men who underwent radical prostatectomy with complete clinical and follow-up data and who would have fulfilled the inclusion criteria of the PRIAS protocol at the time of biopsy except for the addition of biopsy Gs=3+4 and with at least 10 cores taken have been evaluated. One experienced genitourinary pathologist selected those with real Gs=3+3 and 3+4 in only one core according to the 2005 International Society of Urological Pathology criteria. The primary end point was the proportion of unfavourable outcome (nonorgan confined disease or Gs⩾4+3). Logistic regressions explored the association between preoperative characteristics and the primary end point.Results:Two hundred and four patients were evaluated and 46 (22.5%) patients harboured unfavourable disease at final pathology. After a median follow-up of 73.5 months, there was no cancer-specific death, and 4 (2.0%) patients had biochemical relapse. There were no significant differences in terms of high Gs, locally advanced disease, unfavourable disease and biochemical relapse-free survival among patients with clinical Gs=3+3 vs Gs=3+4. At multivariable analysis, the presence of atypical small acinar proliferation (ASAP) and lower number of core taken were independently associated with a higher risk of unfavourable disease.Conclusion:The inclusion of Gs=3+4 in patients suitable to AS does not enhance the risk of unfavourable disease after radical prostatectomy. Additional factors such as number of cores taken and the presence of ASAP should be considered in patients suitable for AS.

Nodal Occult Metastases in Intermediate- and High-Risk Prostate Cancer Patients Detected Using Serial Section, Immunohistochemistry, and Real-Time Reverse Transcriptase Polymerase Chain Reaction: Prospective Evaluation With Matched-Pair Analysis

BACKGROUND The purpose of the study was to prospectively evaluate the incidence of nodal OCM assessed using SS, IHC, and RT-PCR in prostate cancer patients compared with the standard pathological evaluation (SPE), and to evaluate short-term oncological outcomes of patients with OCM. PATIENTS AND METHODS Fifty-four consecutive patients with intermediate- or high-risk prostate cancer treated with radical prostatectomy and extended pelvic LN dissection comprised the study population (StP). The central sections with the largest diameter of each LN of the StP and a matched-pair population (MpP) with identical characteristics as the StP were used to assess the improved detection rate of OCM. Pathological characteristics and biochemical recurrence-free survival were assessed according to the presence of macroscopic or OCM. RESULTS A total of 1064 LNs were processed in the 54 patients of the StP, with 11 (20.4%) patients with evident metastases at SPE and 7 with OCM (13.0% additional patients); the percentage of positive patients improved from 16.6% (18 of 108) of the MpP to 33.3% (18 of 54) of the StP (16% additional patients). The mean diameter of the 10 additional LNs with OCM found at SS only and of the 6 additional LNs found at IHC only was significantly lower than the mean diameter of the 28 metastases found at routine pathologic examination (RPE) (P < .0001). Patients with OCM showed risk of biochemical recurrence similar to patients with no LN metastases (P = .008). CONCLUSION SS, IHC, and RT-PCR can detect a not negligible percentage of OCM missed at RPE. Patients with OCM showed short-term oncological outcomes more similar to those with macroscopic metastases. Longer follow-up studies considering cancer-specific survival are needed.

Sex-related penile fracture with complete urethral rupture: A case report and review of the literature

OBJECTIVE To present the management of a patient with partial disruption of both cavernosal bodies and complete urethral rupture and to propose a non-systematic review of literature about complete urethral rupture. MATERIAL AND METHOD - CASE REPORT: A 46 years old man presented to our emergency department after a blunt injury of the penis during sexual intercourse. On physical examination there was subcutaneous hematoma extending over the proximal penile shaft with a dorsal-left sided deviation of the penis and urethral bleeding. Ultrasound investigation showed an hematoma in the ventral shaft of the penis with a discontinuity of the tunica albuginea of the right cavernosal corporum. The patient underwent immediate emergency surgery consisted on evacuation of the hematoma, reparation the partial defect of both two cavernosal bodies and end to end suture of the urethra that resulted completely disrupted. RESULTS The urethral catheter was removed at the 12-th postoperative day without voiding symptoms after a retrograde urethrography. 6 months postoperatively the patients was evaluated with uroflowmetry demonstrating a max flow rate of 22 ml/s and optimal functional outcomes evaluated with validated questionnaires. 8 months after surgery the patients was evaluated by dynamic magnetic resonance (MRI) of the penis showing only a little curvature on the left side of the penile shaft. CONCLUSION Penile fracture is an extremely uncommon urologic injury with approximately 1331 reported cases in the literature till the years 2001. To best of our knowledge from 2001 up today, 1839 more cases have been reported, only in 159 of them anterior urethral rupture was associated and in only 22 cases a complete urethral rupture was described. In our opinion, in order to prevent long term complications, in case of clinical suspicion of penile fracture, especially if it is associated to urethral disruption, emergency surgery should be the first choice of treatment.

In-bore MRI-guided Prostate Biopsy Using an Endorectal Nonmagnetic Device: A Prospective Study of 70 Consecutive Patients

Micro‐Abstract In a cohort of 70 consecutive patients with suspected prostate cancer and ≥ 1 suspicious area at the preliminary multiparametric magnetic resonance imaging study, in‐bore endorectal magnetic resonance imaging‐guided biopsy demonstrated a high detection rate, especially for clinical significant tumors and lesions located in the central and anterior regions of the gland, with a very low number of cores needed and a negligible incidence of complications. Introduction: We investigated the diagnostic performance of in‐bore endorectal magnetic resonance imaging‐guided biopsy (MRI‐GB) with a 1.5‐T MRI scanner using a 32‐channel coil in patients with suspected prostate cancer (PCa). Patients and Methods: Seventy patients with ≥ 1 suspicious area found on the preliminary multiparametric MRI scan were enrolled. The index lesion was defined as the lesion with the greatest Prostate Imaging Reporting and Data System, version 2 (PIRADS‐v2), score. MRI‐GBs were performed with a nonmagnetic biopsy device, needle guide, and titanium double‐shoot biopsy gun with dedicated software for needle tracking. Clinically significant PCa was defined as the presence of Gleason score ≥ 7 in the biopsy specimen. Results: Seventy index lesions were scheduled for MRI‐GB. The median PIRADS‐v2 score and the median number of cores per patient was 4 of 5 (interquartile range, 3‐5) and 2 (interquartile range, 1‐3), respectively. The PCa detection rate was 45.7%. Of the 70 patients, 24 (75%) had clinically significant PCa, with a significant correlation between the PIRADS‐v2 score and the Gleason score in the MRI‐GB cores (r = 0.839; 95% confidence interval, 0.535‐0.951; P = .003). According to the PIRADs‐v2 scheme, the proportion of PCa in the central and anterior regions of the gland was greater in the entire population and in the subgroup of patients with a history of negative transrectal ultrasound‐guided biopsy findings (P ≤ .01 for all). On multivariate analysis, a PIRADS‐v2 score of 5 of 5 correlated significantly with the likelihood of PCa at biopsy (hazard ratio, 4.69; 95% confidence interval, 0.92‐23.74; P = .04). No major complications were recorded. Conclusion: MRI‐GB has a high detection rate for PCa, especially for lesions located in the central and anterior regions of the prostate.

Revised Gleason grading system is a better predictor of indolent prostate cancer at the time of diagnosis: retrospective clinical-pathological study on matched biopsy and radical prostatectomy specimens.

INTRODUCTION/BACKGROUND The increase of prostate cancer diagnosis after the introduction of prostate-specific antigen (PSA) screening resulted in overtreatment of patients with low risk tumors. The histological Gleason score (GS) revised in 2005 by the International Society of Urological Pathology (ISUP) is currently the most reliable tool to separate aggressive from indolent prostate cancer. MATERIALS AND METHODS Using the new 2005 GS criteria we retrospectively evaluated biopsy and surgical samples of 1344 patients who underwent radical prostatectomy in our institution. According to the new GS criteria we then selected 134 patients who would have been suitable for active surveillance at the time of biopsy (at least 2 positive cores, PSA < 10 ng/mL, GS ≤ 6). We finally assessed the accuracy of the revised GS in biopsy to predict indolent cancer in the prostatectomy specimens. RESULTS The mean GS increased from 6 to 7 after histological revision in biopsy and prostatectomy specimens. Histological revision determined a significant decrease of patients with GS ≤ 6 and an increase of those with GS ≥ 7 (all P < .001). The average of pathologically indolent disease (organ-confined, GS ≤ 6 at surgery, tumor of any volume) significantly decreased after histological revision (P < .001). CONCLUSION The revised ISUP 2005 criteria for Gleason grading provided better stratification of GS ≤ 6 prostate cancer and improved the accuracy for the histological diagnosis of indolent prostate cancer in biopsy and radical prostatectomy specimens.