Dordaneh Sugano

Changes in prostate cancer detection rate of MRI-TRUS fusion vs systematic biopsy over time: evidence of a learning curve

Background:To determine the effect of urologist and radiologist learning curves and changes in MRI-TRUS fusion platform during 9 years of NCI’s experience with multiparametric magnetic resonance imaging (mpMRI)/TRUS fusion biopsy.Methods:A prospectively maintained database of patients undergoing mpMRI followed by fusion biopsy (Fbx) and systematic biopsy (Sbx) from 2007 to 2016 was reviewed. The patients were stratified based on the timing of first biopsy. Cohort 1 (7/2007−12/2010) accounted for learning curve. Cohort 2 (1/2011–5/2013) and cohort 3 (5/2013–4/2016) included patients biopsied prior to and after debut of a new software platform, respectively. Clinically significant (CS) disease was defined as Gleason 7 (3+4) or higher. McNemar’s test compared cancer detection rates (CDRs) of Sbx and Fbx between time periods.Results:1528 patients were included in the study with 230, 537 and 761 patients included in three respective cohorts. Median age (interquartile range) was 61.0 (±9.0), 62.0 (±7.3), and 64.0 (±11.0) years in three cohorts, respectively (P<0.001). Fbx and Sbx had comparable CS CDR in cohort 1 (24.8 vs 22.2%, P=0.377). Fbx detected significantly more CS disease compared to Sbx in the following two periods (cohort 2: 31.5 vs 25.0%, P=0.001; cohort 3: 36.4 vs 30.3%, P<0.001) and detected significantly less low risk disease in the same period (cohort 2: 14.5 vs 19.6%, P<0.001; cohort 3: 12.6 vs 16.7%, P<0.001). Even after multivariate adjustment with age, PSA, race, clinical stage and MRI suspicion score, Fbx CS cancer detection increased in successive cohorts (cohort 2: OR 2.23, P=0.043; cohort 3: OR 2.92, P=0.007).Conclusions:In the past 9 years, there has been significant improvement in the accuracy of Fbx. Our results show that after an early learning period, Fbx detected higher rates of CS cancer and lower rates of clinically insignificant cancer than Sbx. Software advances allowed for even greater detection of CS disease.

Risk of Upgrading from Prostate Biopsy to Radical Prostatectomy Pathology—Does Saturation Biopsy of Index Lesion during Multiparametric Magnetic Resonance Imaging-Transrectal Ultrasound Fusion Biopsy Help?

Purpose: We sought to determine whether saturation of the index lesion during magnetic resonance imaging‐transrectal ultrasound fusion guided biopsy would decrease the rate of pathological upgrading from biopsy to radical prostatectomy. Materials and Methods: We analyzed a prospectively maintained, single institution database for patients who underwent fusion and systematic biopsy followed by radical prostatectomy in 2010 to 2016. Index lesion was defined as the lesion with largest diameter on T2‐weighted magnetic resonance imaging. In patients with a saturated index lesion transrectal fusion biopsy targets were obtained at 6 mm intervals along the long axis of the index lesion. In patients with a nonsaturated index lesion only 1 target was obtained from the lesion. Gleason 6, 7 and 8‐10 were defined as low, intermediate and high risk, respectively. Results: Included in the study were 208 consecutive patients, including 86 with a saturated and 122 with a nonsaturated lesion. Median patient age was 62.0 years (IQR 10.0) and median prostate specific antigen was 7.1 ng/ml (IQR 8.0). The median number of biopsy cores per index lesion was higher in the saturated lesion group (4 vs 2, p <0.001). The risk category upgrade rate from systematic only, fusion only, and combined fusion and systematic biopsy results to prostatectomy was 40.9%, 23.6% and 13.8%, respectively. The risk category upgrade from combined fusion and systematic biopsy results was lower in the saturated than in the nonsaturated lesion group (7% vs 18%, p = 0.021). There was no difference in the upgrade rate based on systematic biopsy between the 2 groups. However, fusion biopsy results were significantly less upgraded in the saturated lesion group (Gleason upgrade 20.9% vs 36.9%, p = 0.014 and risk category upgrade 14% vs 30.3%, p = 0.006). Conclusions: Our results demonstrate that saturation of the index lesion significantly decreases the risk of upgrading on radical prostatectomy by minimizing the impact of tumor heterogeneity.

Prospective comparison of PI-RADS version 2 and qualitative in-house categorization system in detection of prostate cancer: Prospective Comparison of PI-RADSv2

Prostate Imaging‐Reporting and Data System v. 2 (PI‐RADSv2) provides standardized nomenclature for interpretation of prostate multiparametric MRI (mpMRI). Inclusion of additional features for categorization may provide benefit to stratification of disease.

MP52-08 TECHNIQUE AND CASE SERIES OF MRI GUIDED IN-BORE BIOPSY FOR PATIENTS WITHOUT RECTUM

patients instead of the 5 mm instruments is common due to the shorter wrist lengths. We hypothesized that the use of 5 mm instruments for RAL pyeloplasty in infants with smaller working spaces will not affect the perioperative parameters and surgical outcomes in comparison to older children with larger working spaces. METHODS: We compared the perioperative parameters and surgical outcomes of RAL pyeloplasties performed by a single surgeon in infants and non-infant pediatric patients over a 2 year period using an 8.5 mm camera and 5 mm robotic instruments. Patient demographics, operative times, intraand postoperative complications, hospital pain medication usage, hospital length of stay, and treatment success rates were compared between the two groups. RESULTS: A total of 65 pediatric RAL pyeloplasties were included in the study (16 infants and 49 non-infant pyeloplasties). There were no significant differences in gender, laterality, proportion of re-do pyeloplasty, or preoperative hydronephrosis grade between the two groups. All procedures were performed without conversion to open surgery or significant perioperative complications. There were no differences in segmental operative times (total operative time, console time, port placement time, time for dissection to UPJO, and anastomosis time), hospital pain medication usage, and hospital length of stay between the two groups (p > 0.05 for all comparisons). The treatment success rates were 93.8% (15/16) and 100% (49/49), respectively (p 1⁄4 0.08). CONCLUSIONS: RAL pyeloplasty is a safe and effective surgical modality even in infants with comparable perioperative parameters and outcomes as those in older children. The use of 5 mm instruments in infants with smaller working spaces does not affect these parameters as well, while offering the potential for improved cosmesis.

PD61-09 INDEX TUMOR VOLUME ON MRI AS A PREDICTOR OF PATHOLOGIC OUTCOMES FOLLOWING RADICAL PROSTATECTOMY

margin. Gleason grade at the PSM was an independent predictor of BCR compared to presence of PSM alone. In patients with Gleason sum 7 disease on traditional final pathology, those with Gleason 3 at the PSM had a lower BCR rate (25.0%, 8/32) compared to those with Gleason 4+ (58.8%, 10/17, p 1⁄4 0.02). CONCLUSIONS: Our data suggests that Gleason score at the site of PSM independently predicts BCR in patients following RP with accuracy similar to traditional pathologic staging. However, in patients with a PSM and Gleason 7 on traditional pathologic staging, the presence of Gleason 4 or tertiary 5 disease at the margin can serve as an independent predictor of BCR, relative to patients with Gleason 3 at the margin. Routine reporting of the Gleason score at the site of a positive surgical margin may aid in postoperative risk stratification following RP.

MP52-13 TRANSPERINEAL MR-GUIDED PROSTATE NEEDLE INTERVENTIONS USING A PATIENT-SPECIFIC TEMPLATE

cystoscopy. Patients with UTI, chronic pelvic pain, urethral strictures were excluded. Urinalysis/culture were collected before and 14 days after cystoscopy using Visera Elite System (Olympus) or Endosheath System (Cogentix). After cystoscopy they filled a Visual Analog Scale (VAS) for pain/discomfort. Physicians filled 5-point Likert scales for the following elements: ease of insertion, manipulation, optical quality and overall use. The reprocessing time, cost analysis, which means staff-cost associated with reprocessing & retail-price per system, were compared. RESULTS: Out of 74 patients enrolled, 40 completed the 2weeks study; 20 underwent cystoscopy with Visera Elite System and 20 with Endosheath. There were 2 positive cultures at 14 days follow up in the Visera System. VAS, physicians assessment and reprocessing time data are shown in Table 1. The cost analysis are presented in Tables 2 and 3. CONCLUSIONS: There was no increase in the risk of infection using the Endosheath System. It has a lower cost and reprocessing time. Regarding patient VAS and physician subjective assessment there was no difference in a comparative analysis.

MP14-07 EFFECT OF HYPOGONADISM ON PROSTATE IMAGING AND CANCER DETECTION

METHODS: We identified 35,968 adult patients aged 18-89 years who underwent open or minimally invasive RP from 2010-2015 in the National Surgical Quality Improvement Program (NSQIP) database. Age was modeled as a categorical variable. Thirty-day complications and perioperative outcomes were assessed using a standardized protocol as part of the NSQIP. The associations of age with 30-day complications and perioperative outcomes were evaluated using logistic regression, adjusted for patient features. RESULTS: Age at surgery was distributed as follows: <60 years in 12,172 (33.8%) patients, 60-69 years in 18,076 (50.3%) patients, 70-79 years in 5,480 (15.2%) patients, and 80-89 years in 240 (0.7%) patients. Median operative time was 191 (IQR 151, 191) minutes. There were statistically significant differences in several baseline characteristics across age strata, with higher American Society of Anesthesiology (ASA) class and greater prevalence of diabetes, chronic obstructive pulmonary disease, hypertension, and renal failure among older patients. Overall, 30-day complications occurred in 1,798 (5%) patients. In multivariable analyses adjusted for patient features and surgical approach, ages 70-79 and 80-89 years were statistically significantly associated with increased risks of 30-day complications (OR 1.24, p1⁄40.01; OR 2.83, p<0.01, respectively), perioperative blood transfusion (OR 1.25, p1⁄40.01; OR 3.89, p<0.01, respectively) and 30-day mortality (OR 2.24, p1⁄40.05; OR 10.02, p<0.01, respectively). Only the 80-89 years age group was associated with an increased risk of readmissions (OR 1.75, p1⁄40.03). CONCLUSIONS: In this national, surgical cohort, older age was independently associated with increased risks of 30-day complications, perioperative blood transfusion, hospital readmissions, and 30-day mortality. However, there were no statistically significant differences among men younger than 70 years for all perioperative endpoints. These results have implications for patient counseling and decision making.

MP70-01 UTILITY OF MULTIPARAMETRIC MRI ON PATIENT SELECTION FOR FOCAL THERAPY IN INTERMEDIATE RISK PROSTATE CANCER

INTRODUCTION AND OBJECTIVES: While previous studies have evaluated the impact of malpractice caps on health care utilization and physician density, their effect on the adoption of innovative technology is unknown. We examined whether such caps impacted the national diffusion of minimally invasive radical prostatectomy (MIRP) for prostate cancer (PCa). For comparison we also examined trends in the diffusion of two technologies that antedate MIRP and are in their post-dissemination era: laparoscopic radical nephrectomy (LRN) and laparoscopic partial nephrectomy (LPN) for renal cell carcinoma (RCC). METHODS: We identified patients 66 years with non-metastatic PCa between 2003-2011 in the SEER-Medicare database. Our cohort (n1⁄4129,793) was classified based on the existence of a limit on non-economic damages in their geographical locations: states with a cap before and through our study period (cap states), states without cap before and through the study (non-cap states) and states whose cap was introduced during our study period (late-cap states). Multivariable logistic regression models were fitted to examine the influence of 0cap0 status on MIRP adoption while controlling for demographic and tumor characteristics. A similar analysis was performed for patients with non-metastatic RCC undergoing LRN and LPN. RESULTS: Median age (IQR) of our PCa cohort was 74 years (70-79 years). 84% were White; 97% had T1/ T2 disease and 52% had high-grade disease. 17% were treated with radical prostatectomy (RP): 8.1% with MIRP and 8% with open RP (0.9%-unknown). Adoption of MIRP was quicker in cap-states than in non-cap and late-cap states (p<0.0001, Figure 1). On multivariable analysis, there was a 70% higher likelihood of receipt of MIRP in patients in a cap-state compared to a non-cap state (OR: 1.7, P<0.0001). In contrast to MIRP, the diffusion of LPN and LRN were not different between cap and non-cap states on multivariable modeling (P 0.05). CONCLUSIONS: In a contemporary national cohort of PCa patients, states with malpractice caps had higher MIRP adoption rates. Diffusion rates of background technologies (LRN, LPN) in their post dissemination phase were not different in such states, highlighting the primacy of malpractice caps in explaining the differential effect on MIRP diffusion rates. Source of Funding: None

PD56-05 ELIMINATING RISK OF UPGRADE FROM MRI-TRUS FUSION BIOPSY TO RADICAL PROSTATECTOMY: COULD SATURATION BIOPSY OF THE INDEX TUMOR BE THE SOLUTION?

INTRODUCTION AND OBJECTIVES: Several studies have demonstrated the risk of upgrade from prostate biopsy (PBx) to radical prostatectomy (RP) pathology to be as high as 40%. The objective of the current study is twofold: to evaluate the prostate cancer upgrading on RP in a cohort of patients who underwent MRI-TRUS fusion biopsy (FBx) prior to RP and to determine if saturation of index tumor (IT) during PBx decreases this risk of upgrading. METHODS: Clinical and pathologic data from a prospectively maintained single institution database was analyzed for patients who underwent both FBx and standard 12-core biopsy (Sbx) followed by RP (2010-16). Index tumor was defined as the tumor with the largest diameter on T2W MRI. Patients were considered to have a saturated index tumor (SIT) if they had a fusion target (consisting of one axial and one sagittal biopsy) taken for every 6mm of IT diameter, and were considered to have a nonsaturated index tumor (NSIT) if they had only one target assigned regardless of the size of IT. Gleason 6, Gleason 7 and Gleason 8 or above were defined as low, intermediate and high risk respectively. Gleason Upgrade was defined as a higher Gleason score on RP specimen compared to PBx. Risk category upgrade was defined as higher risk category on RP specimen. Chi square and McNemar0s test were used to compare rates of upgrade. RESULTS: 206 patients (91 with SIT and 115 with NSIT) were included in the study with median age and PSA of 61.5 (IQR 9.3) yrs and 7.38 (IQR 8) ng/ml respectively. Median number of biopsy cores per index tumor was 4 in the SIT group and 2 in the NSIT group (p<0.001) . For the entire cohort, highest Gleason score from combined Fbx/Sbx was upgraded on final pathology in 36 (17.5%) patients vs 95 (46.1%) patients when compared to Sbx only (p1⁄40.001). Risk category upgrade from combined Fbx/Sbx vs Sbx only was found in 26 (12.6%) vs 83 (40.3%), p<0.0001. Patients with SIT had lower Gleason upgrade (12.1% vs 21.7% , p 1⁄40.07) and significantly lower risk category upgrade (6 (6.6%) and 20 (17.4%), p1⁄40.02) compared to patients with NSIT. CONCLUSIONS: Ensuring that high risk cancer is not missed on biopsy is crucial to treatment planning in patients with prostate cancer. Our results demonstrate that the addition of mpMRI-TRUS Fbx significantly decreases the risk of upgrade on RP pathology, proving the efficacy of Fbx in accurately characterizing PCa preoperatively. Saturation of the index tumor further decreases the risk of upgrade on final pathology by extensive sampling and minimizing the impact of tumor heterogeneity.