Marko Brock

The Impact of Real-Time Elastography Guiding a Systematic Prostate Biopsy to Improve Cancer Detection Rate: A Prospective Study of 353 Patients

PURPOSE We evaluated whether real-time elastography guided biopsy improves prostate cancer detection compared to conventional systematic gray scale ultrasound guidance. MATERIALS AND METHODS A total of 353 consecutive patients suspicious for prostate cancer were prospectively randomized for real-time elastography (178) or gray scale ultrasound (175). Each patient enrolled in the study underwent a 10-core prostate biopsy. Six lateral prostate sectors (base, mid, apex) were scanned for cancer suspicious areas, defined as stiffer blue lesions using real-time elastography and hypoechoic lesions using gray scale ultrasound. Suspicious areas were sampled by a single targeted biopsy and considered representative of a defined prostate sector. If real-time elastography or gray scale ultrasound did not visualize a suspicious area in a sector, the biopsy core was taken systematically. Imaging findings were correlated with histopathological reports. Real-time elastography and gray scale ultrasound cases were compared in terms of cancer detection rate and imaging guidance accuracy. RESULTS Characteristics of patients undergoing real-time elastography and gray scale ultrasound, including age, prostate specific antigen, prostate volume and digital rectal examination, were not significantly different (p>0.05). Prostate cancer was detected in 160 of 353 patients (45.3%). The prostate cancer detection rate was significantly higher in patients who underwent biopsy with the real-time elastography guided approach compared to the gray scale ultrasound guided biopsy at 51.1% (91 of 178) vs 39.4% (69 of 175) (p=0.027). Overall sensitivity and specificity to detect prostate cancer was 60.8% and 68.4% for real-time elastography vs 15% and 92.3% for gray scale ultrasound, respectively. CONCLUSIONS Sensitivity to visualize and detect prostate cancer improved using real-time elastography in addition to gray scale ultrasound during prostate biopsy. Overall sensitivity did not reach levels to omit a systematic biopsy approach.

Standardized assessment of complications in a contemporary series of European patients undergoing radical cystectomy.

To examine postoperative complications in a contemporary series of patients after radical cystectomy using a standardized reporting system, and to identify readily available preoperative risk factors.

Comparison of real-time elastography with grey-scale ultrasonography for detection of organ-confined prostate cancer and extra capsular extension: a prospective analysis using whole mount sections after radical prostatectomy

Study Type – Diagnostic (exploratory cohort) Level of Evidence 2b

Multiparametric ultrasound of the prostate: adding contrast enhanced ultrasound to real-time elastography to detect histopathologically confirmed cancer.

PURPOSE We prospectively assessed whether a combined approach of real-time elastography and contrast enhanced ultrasound would improve prostate cancer visualization. MATERIAL AND METHODS Between June 2011 and January 2012, 100 patients with biopsy proven prostate cancer underwent preoperative transrectal multiparametric ultrasound combining real-time elastography and contrast enhanced ultrasound. After initial elastographic screening for suspicious lesions, defined as blue areas with decreased tissue strain, each lesion was allocated to the corresponding prostate sector. The target lesion was defined as the largest cancer suspicious area. Perfusion was monitored after intravenous injection of contrast agent. Target lesions were examined for hypoperfusion, normoperfusion or hyperperfusion. Imaging results were correlated with final pathological evaluation on whole mount slides after radical prostatectomy. RESULTS Of 100 patients 86 were eligible for final analysis. Real-time elastography detected prostate cancer with 49% sensitivity and 73.6% specificity. Histopathology confirmed malignancy in 56 of the 86 target lesions (65.1%). Of these 56 lesions 52 (92.9%) showed suspicious perfusion, including hypoperfusion in 48.2% and hyperperfusion in 48.2%, while only 4 (7.1%) showed normal perfusion patterns (p = 0.001). The multiparametric approach decreased the false-positive value of real-time elastography alone from 34.9% to 10.3% and improved the positive predictive value of cancer detection from 65.1% to 89.7%. CONCLUSIONS Perfusion patterns of prostate cancer suspicious elastographic lesions are heterogeneous. However, the combined approach of real-time elastography and contrast enhanced ultrasound in this pilot study significantly decreased false-positive results and improved the positive predictive value of correctly identifying histopathological cancer.

The Impact of Prostate Biopsy and Periprostatic Nerve Block on Erectile and Voiding Function: A Prospective Study

PURPOSE We evaluated the effect of multiple core prostate biopsy and periprostatic nerve block on voiding and erectile function. MATERIALS AND METHODS A total of 198 patients in whom prostate cancer was suspected were randomly assigned to undergo 10-core prostate biopsy with (71) or without (74) periprostatic nerve block. The 53 men with a history of negative prostate biopsy underwent 20-core saturation prostate biopsy with periprostatic nerve block. The International Prostate Symptom Score and International Index of Erectile Function were completed before, and 1, 4 and 12 weeks after biopsy to measure changes in voiding and erectile function, and quality of life. Upon prostate cancer diagnosis patients were excluded from further analysis. RESULTS The International Prostate Symptom Score was significantly increased in all patients at week 1, which persisted at weeks 4 and 12 after saturation biopsy (p = 0.007 and 0.035, respectively). After 10-core prostate biopsy with periprostatic nerve block patients had a higher International Prostate Symptom Score at weeks 4 and 12 but this was not statistically significant (p >0.05). Quality of life was significantly affected at all times after saturation prostate biopsy (p = 0.001, 0.003 and 0.010, respectively). International Index of Erectile Function scores decreased significantly in all groups at week 1 (p <0.05). The decrease persisted at week 4 in each 10-core prostate biopsy group. CONCLUSIONS Prostate biopsy causes impaired voiding. Saturation prostate biopsy and periprostatic nerve block seem to have a lasting impact on voiding function. Erectile function is transiently affected by prostate biopsy regardless of periprostatic nerve block and the number of cores. Patients who undergo prostate biopsy must be informed about these side effects.

Intraoperative Frozen Section of the Prostate Decreases Positive Margin Rate While Ensuring Nerve Sparing Procedure During Radical Prostatectomy

PURPOSE We evaluated whether intraoperative frozen section analysis of the prostate surface might provide significant information to ensure nerve sparing and minimize the positive margin rate. MATERIALS AND METHODS In 236 patients treated with radical prostatectomy between June 2011 and September 2012 whole surface frozen section analysis of the removed prostate was done intraoperatively. The apex and base were circumferentially dissected as well as the whole posterolateral tissue corresponding to the neurovascular bundles. Multiple perpendicular sections were cut systematically for frozen section analysis. Pathology results were reported to navigate the procedure. RESULTS Frozen section analysis identified positive surgical margins in 22% of cases, including the neurovascular bundles in 56.9%, apex in 34.5% and base in 8.6%. Of positive frozen section cases 92.3% could be converted to negative status, while 7.7% remained positive. The final positive margin rate in the total cohort was 3%, including a false-negative frozen section rate of 1.6%. In 14.8% of cases the initial nerve sparing plan was changed intraoperatively due to the positive frozen section and the secondary resected specimen detected cancer in 25%. Final pathology results showed Gleason upgrading or up-staging in 40.7% of cases compared to preoperative variables. When comparing patients with positive vs negative frozen sections, preoperative variables did not significantly differ, while postoperatively pathological stage, tumor volume, operative time and final margin status differed significantly. Of patients with exclusively unilateral positive biopsies 13% had a positive surgical margin intraoperatively on the opposite, biopsy negative side. CONCLUSIONS The surface frozen section technique is associated with a low false-negative surgical margin rate. It might allow for safer preservation of functional anatomical structures in misclassified patients or even patients at higher preoperative risk.

Impact of Real-Time Elastography on Magnetic Resonance Imaging/Ultrasound Fusion Guided Biopsy in Patients with Prior Negative Prostate Biopsies

PURPOSE The fusion of multiparametric resonance imaging and ultrasound has been proven capable of detecting prostate cancer in different biopsy settings. The addition of real-time elastography promises to increase the precision of the outcome of targeted biopsies. We investigated whether real-time elastography improves magnetic resonance imaging/transrectal ultrasound fusion targeted biopsy in patients after previous negative biopsies. MATERIALS AND METHODS Prospectively 121 men underwent 3T magnetic resonance imaging. Using magnetic resonance imaging/real-time elastography fusion every suspicious lesion was characterized according to its tissue density and sampled by 2 fusion guided targeted biopsies. Additionally, all patients underwent 12-core systematic biopsy. The detection rate of clinically significant and insignificant cancers was compared between targeted und systematic biopsies. The accuracy to predict high grade prostate cancer was evaluated for with the PI-RADS scoring system and compared to the magnetic resonance imaging/real-time elastography fusion score. RESULTS Overall prostate cancer was detected in 52 patients (43%). Targeted fusion guided biopsy revealed prostate cancer in 32 men (26.4%) and systematic biopsy in 46 (38%). The proportion of clinically significant cancers was higher for targeted biopsy (90.6%) compared to systematic biopsy (73.9%). The detection rate per core was higher for targeted biopsies (14.7%) compared to systematic biopsies (6.5%, p <0.001). The prediction of biopsy result according to magnetic resonance imaging/real-time elastography fusion was better (AUC 0.86) than magnetic resonance imaging alone (AUC 0.79). Sensitivity and specificity for magnetic resonance imaging/real-time elastography fusion was 77.8% and 77.3% vs 74.1% and 62.9% for magnetic resonance imaging. CONCLUSIONS Magnetic resonance imaging/transrectal ultrasound fusion enhances the likelihood of detecting clinically significant cancers in a repeat biopsy setting. Adding real-time elastography to magnetic resonance imaging supports the characterization of cancer suspicious lesions.

Fusion of Magnetic Resonance Imaging and Real-Time Elastography to Visualize Prostate Cancer: A Prospective Analysis using Whole Mount Sections after Radical Prostatectomy

PURPOSE To determine whether the fusion of multiparametric magnetic resonance imaging (MRI) with transrectal real-time elastography (RTE) improves the visualization of PCa lesions compared to MRI alone. MATERIALS AND METHODS In a prospective setting, 45 patients with biopsy-proven PCa received prostate MRI prior to radical prostatectomy (RP). T2 and diffusion-weighted imaging (T2WI/DW-MRI) and, if applicable, dynamic contrast-enhanced sequences (T2WI/DW/DCE-MRI) were used to perform MRI/RTE fusion. The probability of PCa on MRI was graded according to the PI-RADS score for 12 different prostate sectors per patient. MRI images were fused with RTE to stratify suspicious from non-suspicious sectors. Imaging results were compared to whole mount sections using nonparametrical receiver operating characteristic curves and the area under these curves (AUC). RESULTS 41 of 45 patients were eligible for final analyses. Histopathology confirmed PCa in 261 (53%) of 492 prostate sectors. MRI alone provided an AUC of 0.62 (T2WI/DW-MRI) and 0.65 (T2WI/DW/DCE-MRI) to predict PCa and was meaningfully enhanced to 0.75 (T2WI/DW-MRI) and 0.74 (T2WI/DW/DCE-MRI) using MRI/RTE fusion. Sole MRI showed a sensitivity and specificity of 57.9% and 61% with the best results for ventral prostate sectors whereas RTE was superior in dorsal and apical sectors. MRI/RTE fusion improved sensitivity and specificity to 65.9% and 75.3%, respectively. Additional use of DCE sequences showed a sensitivity and specificity of 65% and 55.7% for MRI and 72.1% and 66% for MRI/RTE fusion. CONCLUSION MRI/RTE fusion provides improved PCa visualization by combining the strength of both imaging techniques in regard to prostate zonal anatomy and thereby might improve future biopsy-guided PCa detection.

Rising PSA level and negative prostate biopsy. Can prostate elastography help

ZusammenfassungBisherige Studien haben den klinischen Nutzen der Elastographie beim Staging vor radikaler Prostatektomie und als zusätzliche Bildinformation mit dem Ziel einer verbesserten Karzinomdetektion bei der Prostatabiopsie untersucht. Der rasche Fortschritt dieser Technik hat zu einer spürbaren Erleichterung der Befunderhebung und deren Reproduzierbarkeit geführt. In neueren Gerätegenerationen spiegelt sich dies bereits in ersten Studienergebnissen wieder. Um den Stellenwert dieses Verfahrens im klinischen Alltag zu bestimmen sind weitere Studien erforderlich, welche einerseits elastographiegesteuerte Biopsieschemata mit Sättigungsbiopsien und andererseits die Sensitivität und Spezifität der elastographischen Prostatakarzinomdetektion mit denen anderer bildgebender Verfahren, insbesondere der Magnetresonanztomographie und -spektroskopie, vergleichen.AbstractPrevious studies investigated the clinical impact of elastography for preoperative staging and as an additional imaging modality to improve prostate cancer detection during prostate biopsy. This rapidly improving technique has facilitated progress toward feasibility and reproducibility of transrectal elastography. Recent studies show significant improvements using the latest generation of elastographic devices. Further studies are needed to evaluate on the one hand elastography-guided prostate biopsy schemes and results of saturation biopsies and on the other hand to compare sensitivity and specificity of elastographic detection of prostate cancer with different imaging techniques, especially magnetic resonance imaging and spectroscopy.Previous studies investigated the clinical impact of elastography for preoperative staging and as an additional imaging modality to improve prostate cancer detection during prostate biopsy. This rapidly improving technique has facilitated progress toward feasibility and reproducibility of transrectal elastography. Recent studies show significant improvements using the latest generation of elastographic devices. Further studies are needed to evaluate on the one hand elastography-guided prostate biopsy schemes and results of saturation biopsies and on the other hand to compare sensitivity and specificity of elastographic detection of prostate cancer with different imaging techniques, especially magnetic resonance imaging and spectroscopy.

Steigender PSA-Wert und negative Prostatabiopsie

ZusammenfassungBisherige Studien haben den klinischen Nutzen der Elastographie beim Staging vor radikaler Prostatektomie und als zusätzliche Bildinformation mit dem Ziel einer verbesserten Karzinomdetektion bei der Prostatabiopsie untersucht. Der rasche Fortschritt dieser Technik hat zu einer spürbaren Erleichterung der Befunderhebung und deren Reproduzierbarkeit geführt. In neueren Gerätegenerationen spiegelt sich dies bereits in ersten Studienergebnissen wieder. Um den Stellenwert dieses Verfahrens im klinischen Alltag zu bestimmen sind weitere Studien erforderlich, welche einerseits elastographiegesteuerte Biopsieschemata mit Sättigungsbiopsien und andererseits die Sensitivität und Spezifität der elastographischen Prostatakarzinomdetektion mit denen anderer bildgebender Verfahren, insbesondere der Magnetresonanztomographie und -spektroskopie, vergleichen.AbstractPrevious studies investigated the clinical impact of elastography for preoperative staging and as an additional imaging modality to improve prostate cancer detection during prostate biopsy. This rapidly improving technique has facilitated progress toward feasibility and reproducibility of transrectal elastography. Recent studies show significant improvements using the latest generation of elastographic devices. Further studies are needed to evaluate on the one hand elastography-guided prostate biopsy schemes and results of saturation biopsies and on the other hand to compare sensitivity and specificity of elastographic detection of prostate cancer with different imaging techniques, especially magnetic resonance imaging and spectroscopy.Previous studies investigated the clinical impact of elastography for preoperative staging and as an additional imaging modality to improve prostate cancer detection during prostate biopsy. This rapidly improving technique has facilitated progress toward feasibility and reproducibility of transrectal elastography. Recent studies show significant improvements using the latest generation of elastographic devices. Further studies are needed to evaluate on the one hand elastography-guided prostate biopsy schemes and results of saturation biopsies and on the other hand to compare sensitivity and specificity of elastographic detection of prostate cancer with different imaging techniques, especially magnetic resonance imaging and spectroscopy.