Sasha C. Druskin

Use of the Prostate Health Index for detection of prostate cancer: results from a large academic practice

Background:The Prostate Health Index (phi) outperforms PSA and other PSA derivatives for the diagnosis of prostate cancer (PCa). The impact of phi testing in the real-world clinical setting has not been previously assessed.Methods:In a single, large, academic center, phi was tested in 345 patients presenting for diagnostic evaluation for PCa. Findings on prostate biopsy (including Grade Group (GG), defined as GG1: Gleason score (GS) 6, GG2: GS 3+4=7, GG3: GS 4+3=7, GG4: GS 8 and GG5: GS 9–10), magnetic resonance imaging (MRI) and radical prostatectomy (RP) were prospectively recorded. Biopsy rates and outcomes were compared with a contemporary cohort that did not undergo phi testing (n=1318).Results:Overall, 39% of men with phi testing underwent prostate biopsy. No men with phi<19.6 were diagnosed with PCa, and only three men with phi<27 had cancer of GG⩾2. Phi was superior to PSA for the prediction of any PCa (area under the receiver operating characteristic curve (AUC) 0.72 vs 0.47) and GG⩾2 PCa (AUC 0.77 vs 0.53) on prostate biopsy. Among men undergoing MRI and phi, no men with phi<27 and PI-RADS⩽3 had GG⩾2 cancer. For those men proceeding to RP, increasing phi was associated with higher pathologic GG (P=0.002) and stage (P=0.001). Compared with patients who did not undergo phi testing, the use of phi was associated with a 9% reduction in the rate of prostate biopsy (39% vs 48%; P<0.001). Importantly, the reduction in biopsy among the phi population was secondary to decreased incidence of negative (8%) and GG1 (1%) biopsies, whereas the proportion of biopsies detecting GG⩾2 cancers remained unchanged.Conclusions:In this large, real-time clinical experience, phi outperformed PSA alone, was associated with high-grade PCa, and provided complementary information to MRI. Incorporation of phi into clinical practice reduced the rate of unnecessary biopsies without changing the frequency of detection of higher-grade cancers.

Prostate health index density improves detection of clinically‐significant prostate cancer

To explore the utility of Prostate Health Index (PHI) density for the detection of clinically significant prostate cancer (PCa) in a contemporary cohort of men presenting for diagnostic evaluation of PCa.

Surgical histopathology for suspected oncocytoma on renal mass biopsy: a systematic review and meta-analysis

To estimate the proportion of oncocytic renal neoplasms diagnosed on renal mass biopsy (RMB) confirmed on surgical pathology, a systematic review of MEDLINE, Embase, and the Cochrane databases (1997 to 1 July 2016) was conducted quantifying all cases of reported oncocytic renal neoplasms on RMB suggestive of an oncocytoma. In addition, institutional data was assessed to identify additional cases. Concordance with surgical histopathology (positive predictive value [PPV]) was evaluated for patients undergoing surgery by performing a meta‐analysis. In all, 10 RMB series, including institutional data, were included in the meta‐analysis with 205 RMBs identifying oncocytic renal neoplasms and 46 (22.4%) proceeding to surgery. One additional study identified two neoplasms not captured by the primary RMB series for a total of 48 unique lesions included in the analysis. Surgical pathology showed oncocytoma (64.6%), chromophobe renal cell carcinoma (RCC; 12.5%), other RCC (12.5%), hybrid oncocytic/chromophobe tumour (6.3%), and other benign lesions (4.2%). PPV of oncocytoma on RMB was 67% (95% confidence interval 34–94%) with significant heterogeneity between studies (I2 = 71.8%, P < 0.01). Risk of bias was judged to be low for four of the 10 series. Confidently diagnosing a localised renal mass as a benign lesion, such as an oncocytoma, has implications for the ultimate management strategy a patient will undergo. RMB was found to be unreliable in confidently diagnosing a localised renal mass as an oncocytoma, with one in four found to be RCC on surgical pathology. Patients and physicians should be aware of the uncertainty in diagnosis when considering management strategies.

Combining Prostate Health Index density, magnetic resonance imaging and prior negative biopsy status to improve the detection of clinically significant prostate cancer

To determine the performance of Prostate Health Index (PHI) density (PHID) combined with MRI and prior negative biopsy (PNB) status for the diagnosis of clinically significant prostate cancer (PCa).

Dynamic Contrast Enhanced Magnetic Resonance Imaging Improves Classification of Prostate Lesions: A Study of Pathological Outcomes on Targeted Prostate Biopsy

Purpose: PI‐RADS™, version 2 stipulates that dynamic contrast enhanced imaging should be used to classify diffusion‐weighted imaging score 3 peripheral zone lesions as PI‐RADS score 3 (dynamic contrast enhanced imaging negative or nonenhancing) or 4 (dynamic contrast enhanced imaging positive or enhancing). However, to our knowledge it is unknown whether dynamic contrast enhanced imaging separates lesions into clinically meaningful pathological groups. We examined whether dynamic contrast enhanced imaging would improve the detection of clinically significant cancer. Materials and Methods: We identified patients without a prior diagnosis of prostate cancer who underwent multiparametric magnetic resonance imaging‐transrectal ultrasound fusion targeted biopsy of peripheral zone lesions with a diffusion‐weighted imaging score of 3 or 4. Each lesion was grouped into 1 of 3 classifications, including group 1—diffusion‐weighted imaging score 3/nonenhancing/PI‐RADS score 3, group 2—diffusion‐weighted imaging score 3/enhancing/PI‐RADS score 4 or group 3—diffusion‐weighted imaging score 4/PI‐RADS score 4. We measured the rate of grade group 2 or greater pathology detected for each lesion group with subgroup analyses in patients with vs without prior negative systematic biopsy. Results: We identified a total of 389 peripheral zone diffusion‐weighted imaging score 3 or 4 lesions in 290 patients. The rate of grade group 2 or greater cancer on biopsy for group 1, 2 and 3 lesions was 8.9%, 21% and 36.5%, respectively (p <0.03). The rate of grade group 2 or greater pathology was higher in group 2 than group 1 lesions in patients with prior negative systematic prostate biopsy (28% vs 5.0%, p <0.001) but not in those without such a biopsy (16% vs 12%, p = 0.5). Group 3 lesions had a higher rate of grade group 2 or greater cancer than group 2 lesions in the biopsy naïve subgroup (46% vs 16%, p = 0.001). However, the rates were similar in patients with prior negative systematic prostate biopsy (27% vs 28%, p = 0.9). Conclusions: Diffusion‐weighted imaging score 3 peripheral zone lesions were more likely to be clinically significant cancer (grade group 2 or greater) if they were dynamic contrast enhanced T1‐weighted imaging positive. That was most apparent in patients with a prior negative systematic prostate biopsy. In such patients including a dynamic contrast enhanced sequence in multiparametric magnetic resonance imaging allowed for optimal lesion risk stratification.

Urinary continence recovery after radical prostatectomy – anatomical/reconstructive and nerve-sparing techniques to improve outcomes

In an editorial board‐moderated debate format, two experts in prostate cancer surgery are challenged with presenting the key strategies in radical prostatectomy that improve urinary functional outcomes. Dr Bernardo Rocco was tasked with arguing the facts that support the anatomical preservation and reconstruction steps that improve urinary continence. Drs Christian Pavlovich and Sasha Druskin were tasked with arguing the facts supporting neurovascular bundle and high anterior release surgical planes that improve urinary continence. Associate Editor John Davis moderates the debate, and outlines the current status of validated patient questionnaires that can be used to evaluate urinary continence, and recent work that allows measuring what constitutes a ‘clinically significant’ difference that either or both of these surgical techniques could influence. A review of raw data from a publication from Dr Pavlovichs team demonstrates how clinically relevant differences in patient‐reported outcomes can be correlated to technique. A visual atlas is presented from both presenting teams, and Dr Davis demonstrates further reproducibility of technique. A linked video on this concept is available as a supplementary file.

Prostate MRI prior to radical prostatectomy: effects on nerve sparing and pathological margin status

Objectives The aim of this study was to assess the positive surgical margin (PSM) and nerve sparing (NS) rates in patients who underwent prostate MRI (pMRI) prior to radical prostatectomy (RP) and compare them with matched, nonimaged control RP patients. Methods We identified 204 men who underwent preoperative pelvic MRI (pelMRI), of whom 176 (86.3%) underwent pMRIs, within 60 days of RP, and compared them (1:1) with a nonim-aged control group matched by surgeon, age, race, body mass index (BMI), prostate-specific antigen (PSA), pathological Gleason score, prostate specimen weight, and RP year. Results The rates of nonfocal extracapsular extension (nfECE) on RP pathology in the MRI and control groups were similar. PSM rates were lower in the MRI group (13.7% vs 19.3%; P=0.14), but the difference did not meet statistical significance; this was also the case in patients with nfECE on RP pathology (27.7% vs 39.5%; P=0.3). NS rates were similar between groups. In the MRI group, 54 (26.5%) patients had an MRI suspicious for nfECE; their PSM rate (20.4%) was higher than that of patients with an MRI not suspicious for nfECE (11.3%; P=0.11), but the difference lacked statistical significance; the former group had significantly lower rates of NS. Limitations of the study include sample power and nonuniform heeding of MRI results by each surgeon. Conclusion MRI did not significantly decrease the rates of PSM, including in the subset of patients with nfECE on final pathology. Even wider resection may be necessary in patients with MRIs suggesting locally-advanced disease. Studies with greater power are needed.

MR Imaging for Prostate Cancer Screening and Active Surveillance

The current prostate cancer management paradigm has been criticized in recent years for contributing to the overdiagnosis and overtreatment of the disease. Active surveillance is an avenue by which to reduce overtreatment, but patient selection and monitoring remain a challenge. The use of prostate MR imaging has been growing in recent years and has been incorporated into prostate cancer screening and patient selection and monitoring for active surveillance. This review article discusses the current evidence for the use of MR imaging in each of those settings.

PD52-04 SURGICAL HISTOPATHOLOGY FOR SUSPECTED ONCOCYTOMA ON RENAL MASS BIOPSY: RETROSPECTIVE INSTITUTIONAL COHORT WITH SYSTEMATIC REVIEW AND META-ANALYSIS

disease may have worse survival than those without nodal disease, although they are currently all considered stage III. Our aim was to compare the survival of stage III RCC patients with pathologic nodal disease (pT123N1M0) to stage III patients without nodal disease (pT3N0M0), and stage IV patients. METHODS: We retrospectively studied a cohort of patients who underwent retroperitoneal lymph node dissection at the time of nephrectomy from 1993 to 2012. Stage III with (pT123N1M0) and without (pT3abcN0M0) pathologic nodal disease was noted in 115 (7.7%) and 275 (18.4%) patients. In order to compare outcomes of stage III patients to those with stage IV disease, we included 523 pT123N0M1 and 222 pTanyN1M1 patients. Cancer-specific survival (CSS) was estimated using the Kaplan-Meier Method. Univariate and multivariate Cox proportional hazards regression models were fit to identify factors significantly associated with clinical outcomes. RESULTS: Clear cell RCC was present in 86.9% and 60.0%, and high grade tumor (grade 4) was present in 26.5% and 50.4% of pT3N0 and pT123N1, respectively. Median tumor size was 9 cm and 10 cm in pT3N0 and pT123N1 patients, and median number of lymph nodes removed was 6 (range1-45) and 8 (range1-37), respectively. Cancer-specific survival was better in patients with pT3abcN0M0 than those with pT123N1M0 (5-year CSS rate: 74.8% vs 38.6%, p<0.001); however, similar 5-year CSS rates were noted in pN1M0 and pN0M1 (38.6% vs 29.8%, p1⁄40.13), while pTanyN1M1 had the worst 5-year CSS (7%). On multivariate Cox regression analysis, high-grade tumor (HR 2.96, 95% CI 2.11-4.14, p<0.0001), and pathologic lymph node involvement (HR 2.83, 95% CI 2.03-3.95, p<0.0001) were significantly associated with cancer-specific survival. CONCLUSIONS: Patients with pN1M0 disease have significantly worse survival than those with pT3N0M0 disease, although both groups are currently classified as stage III. In addition, patients with pN1M0 have survival similar to those with pN0M1 disease (stage IV), suggesting that pN1M0 patients should be reclassified as stage IV.

Dynamic Contrast Enhanced MRI Improves Classification of Prostate Lesions: A Study of Pathologic Outcomes on Targeted Prostate Biopsy

Purpose: PI‐RADS™, version 2 stipulates that dynamic contrast enhanced imaging should be used to classify diffusion‐weighted imaging score 3 peripheral zone lesions as PI‐RADS score 3 (dynamic contrast enhanced imaging negative or nonenhancing) or 4 (dynamic contrast enhanced imaging positive or enhancing). However, to our knowledge it is unknown whether dynamic contrast enhanced imaging separates lesions into clinically meaningful pathological groups. We examined whether dynamic contrast enhanced imaging would improve the detection of clinically significant cancer. Materials and Methods: We identified patients without a prior diagnosis of prostate cancer who underwent multiparametric magnetic resonance imaging‐transrectal ultrasound fusion targeted biopsy of peripheral zone lesions with a diffusion‐weighted imaging score of 3 or 4. Each lesion was grouped into 1 of 3 classifications, including group 1—diffusion‐weighted imaging score 3/nonenhancing/PI‐RADS score 3, group 2—diffusion‐weighted imaging score 3/enhancing/PI‐RADS score 4 or group 3—diffusion‐weighted imaging score 4/PI‐RADS score 4. We measured the rate of grade group 2 or greater pathology detected for each lesion group with subgroup analyses in patients with vs without prior negative systematic biopsy. Results: We identified a total of 389 peripheral zone diffusion‐weighted imaging score 3 or 4 lesions in 290 patients. The rate of grade group 2 or greater cancer on biopsy for group 1, 2 and 3 lesions was 8.9%, 21% and 36.5%, respectively (p <0.03). The rate of grade group 2 or greater pathology was higher in group 2 than group 1 lesions in patients with prior negative systematic prostate biopsy (28% vs 5.0%, p <0.001) but not in those without such a biopsy (16% vs 12%, p = 0.5). Group 3 lesions had a higher rate of grade group 2 or greater cancer than group 2 lesions in the biopsy naïve subgroup (46% vs 16%, p = 0.001). However, the rates were similar in patients with prior negative systematic prostate biopsy (27% vs 28%, p = 0.9). Conclusions: Diffusion‐weighted imaging score 3 peripheral zone lesions were more likely to be clinically significant cancer (grade group 2 or greater) if they were dynamic contrast enhanced T1‐weighted imaging positive. That was most apparent in patients with a prior negative systematic prostate biopsy. In such patients including a dynamic contrast enhanced sequence in multiparametric magnetic resonance imaging allowed for optimal lesion risk stratification.