Susanna Cattarino

Value of magnetic resonance spectroscopy imaging and dynamic contrast-enhanced imaging for detecting prostate cancer foci in men with prior negative biopsy

Purpose: This study aimed to prospectively analyze the role of magnetic resonance spectroscopy imaging (MRSI) and dynamic-contrast enhancement magnetic resonance (DCEMR) in the detection of prostate tumor foci in patients with persistently elevated prostate-specific antigen levels (in the range of ≥4 ng/mL to <10 ng/mL) and prior negative random trans-rectal ultrasound (TRUS)-guided biopsy. Experimental Design: This was a prospective randomized single-center study. One hundred and eighty eligible cases were included in the study. Patients in group A were submitted to a second random prostate biopsy, whereas patients in group B were submitted to a 1H-MRSI-DCEMR examination and samples targeted on suspicious areas were associated to the random biopsy. Results: At the second biopsy, a prostate adenocarcinoma histologic diagnosis was found in 22 of 90 cases (24.4%) in group A and in 41 of 90 cases (45.5%) in group B (P = 0.01). On a patient-by-patient basis, MRSI had 92.3% sensitivity, 88.2% specificity, 85.7% positive predictive value (PPV), 93.7% negative predictive value (NPV), and 90% accuracy; DCEMR had 84.6 % sensitivity, 82.3% specificity, 78.5% PPV, 87.5% NPV, and 83.3% accuracy; and the association MRSI plus DCEMR had 92.6% sensitivity, 88.8% specificity, 88.7% PPV, 92.7% NPV, and 90.7% accuracy, for predicting prostate cancer detection. Conclusions: The combination of MRSI and DCEMR showed the potential to guide biopsy to cancer foci in patients with previously negative TRUS biopsy. To avoid a potential bias, represented from having taken more samples in group B (mean of cores, 12.17) than in group A (10 cores), in the future a MRSI/DCEMR directed biopsy could be prospectively compared with a saturation biopsy procedure. Clin Cancer Res; 16(6); 1875–83

Multiparametric magnetic resonance imaging of the prostate can improve the predictive value of the urinary prostate cancer antigen 3 test in patients with elevated prostate-specific antigen levels and a previous negative biopsy.

Study Type – Clinical (prospective trial)

Comparative analysis of multiparametric magnetic resonance and PET-CT in the management of local recurrence after radical prostatectomy for prostate cancer

PURPOSE Our aim was to assess whether multiparametric magnetic resonance and PET-CT can have a role in detecting local recurrence in patients with biochemical recurrence after radical prostatectomy. METHODS We reviewed the recent international literature by carrying out a PUBMED search. RESULTS We critically reviewed 11 recent original studies about the use of PET-CT and 5 recent studies about the use of multiparametric magnetic resonance. PET-CT has not shown significant results in terms of detection rate for local recurrence in patients with low level of PSA. Multiparametric magnetic resonance showed encouraging results to detect local recurrence in patients with low PSA and with small diameter lesions. CONCLUSIONS Currently, most important urological societies do not consider multiparametric magnetic resonance and PET-CT in the follow-up of patients with suspected local recurrence after radical prostatectomy. We can assert that multiparametric magnetic resonance seems to have excellent results in detecting local recurrence in patients submitted to radical prostatectomy and PSA<1.5 ng/ml.

Modern role of magnetic resonance and spectroscopy in the imaging of prostate cancer

Recently, a large number of studies have shown that the addition of proton 1H-spectroscopic imaging (1H-MRSI) and dynamic contrast enhanced imaging (DCEMR) to magnetic resonance (MR) could represent a powerful tool for the management of prostate cancer (CaP) in most of its aspects. This combination of MR techniques can substantially sustain the clinical management of patients with CaP at different levels: in particular, (1) in the initial assessment, reducing the need for more extensive biopsies and directing targeted biopsies; (2) in the definition of a biochemical progression after primary therapies, distinguishing between fibrotic reaction and local recurrence from CaP.

The emerging role of targeted therapy in renal cell carcinoma (RCC): is it time for a neoadjuvant or an adjuvant approach?

PURPOSE We address whether rational and significant clinical data exist on using angiogenic targeted therapies as neoadjuvant or adjuvant options to nephrectomy in non-metastatic RCC. METHODS We reviewed the recent international literature by carrying out a PUBMED search. RESULTS Neoadjuvant: a possible indication for a neoadjuvant targeted therapy approach is to facilitate surgery, reducing risks for patients and increasing the possibility of removing the mass and improving oncological results. Adjuvant: three major phase III clinical trials are currently ongoing. The ASSURE trial (1 year on oral sunitinib, sorafenib or placebo), the SORCE trial (3 years on placebo versus 1 year on sorafenib, followed by 2 years on placebo versus 3 years on sorafenib), and the S-TRAC trial (1 year on sunitinib or placebo) analyze patients who are at high risk of relapse. CONCLUSIONS Rationale and needs for the neoadjuvant or adjuvant use of targeted therapies in RCC are relevant. Significant phase III trials on the adjuvant use of targeted therapy in RCC are ongoing.

Predictors for response to intermittent androgen deprivation (IAD) in prostate cancer cases with biochemical progression after surgery

OBJECTIVE To define characteristics of the first cycle of intermittent androgen deprivation (IAD) that would predict for outcomes in a long term follow-up. MATERIAL AND METHODS In 1996 we started a prospective study of IAD for the treatment of biochemical progression (BP) after radical prostatectomy (RP) for prostate cancer (PC). The end-points of the trial were time to clinical progression (CP) and time to castration resistance PC (CRPC). Eighty-four cases were included in the study. In all cases, after an initial induction period, an acceptable nadir to switch from on-to-off-phase of IAD was considered to be a serum PSA < 1.0 ng/ml. MEASUREMENTS As possible predictors for time to CP and CRPC, we analyzed pretreatment parameters such as age, Gleason Score, serum PSA, testosterone, chromogranina A (CgA) levels, and characteristics from the first cycle of IAD. RESULTS Mean follow-up during IAD was 88.6 ± 16.7 months; 29.7% of patients developed CRPC and 14.2% of cases showed a CP with a mean time of 88.4 ± 14.3 months and 106.5 ± 20.6 months, respectively. At univariate and multivariate analysis, the PSA nadir during the first on-phase period and the first off-phase interval resulted in significant and independent predictors (P < 0.001) of the time to CRPC and CP. In particular for cases with a PSA nadir > 0.4 ng/ml and for those with an off-phase interval ≤ 24 weeks, the risk of CRPC and CP during IAD was 2.7-2.5 and 3.0-3.1 times that for patients with a PSA nadir ≤ 0.1 ng/ml and with an off-phase interval > 48 weeks, respectively. CONCLUSIONS Cases with BP after RP selected to IAD that show at the first cycle a PSA nadir ≤ 0.1 ng/ml and a off-phase interval ≥ 48 weeks may identify candidates who will experience better response to IAD treatments and delayed CP or CRPC development.

Use of Multiparametric MR with Neurovascular Bundle Evaluation to Optimize the Oncological and Functional Management of Patients Considered for Nerve-Sparing Radical Prostatectomy

INTRODUCTION To obtain the best results with radical prostatectomy, either from an oncological or a functional point of view, a correct selection of cases and planning of surgery are crucial. Multiparametric magnetic resonance imaging (MRI) promises to make it a successful imaging tool for improving many aspects of prostate cancer management. AIM The aim of this study is to evaluate whether a modern multiparametric MRI can help either to better select prostate cancer cases for a nerve-sparing radical prostatectomy or to improve the functional evaluation related to neurovascular bundles preservation. MAIN OUTCOME MEASURES The effect of preoperative MRI on neurovascular bundle management was examined for the frequency and the appropriateness of changes of the surgical plane on the basis of MRI indications. METHODS In a prospective study, 125 consecutive patients with biopsy proven prostate cancer who were scheduled to undergo bilateral nerve-sparing surgery. All patients included into the study were submitted to a preoperative multiparametric MRI. On the basis of MRI evaluation, patients were divided into two groups. Patients in group A were then submitted to a bilateral nerve-sparing (NS) radical prostatectomy (RP), whereas patients in group B were submitted to unilateral NS or non-NS RP. RESULTS In group A, the confirmation from the MRI study to perform a bilateral NS procedure was appropriate in 70 of 73 cases (95.9%), whereas in group B, the surgical plan was appropriate in 28 of 32 cases (87.5%). On the contrary, MRI findings suggested a change in the initial surgical plan (group B) for 32 of 105 cases (30.5%). Of these 32 cases in group B, MRI suggested to perform a unilateral NS procedure in 21 of 32 cases (65.6%) and a non-NS procedure in 11 of 32 cases (34.4%). CONCLUSIONS Multiparametric MRI analysis can significantly improve the standard selection and management of prostate carcinoma cases considered for an NS RP.

Thulium Laser Supported Nephron Sparing Surgery for Renal Cell Carcinoma

PURPOSE We analyze the feasibility, advantages and results of the use of a thulium laser in nephron sparing surgery for renal cell carcinoma. MATERIALS AND METHODS In this single center prospective study 10 consecutive high risk patients underwent open or laparoscopic thulium laser assisted enucleation for small peripheral renal cell carcinoma at our department. We used a 2.0 μm continuous or pulsed thulium laser. This diode pumped solid state laser emits a wavelength of 2,013 nm in the infrared spectrum and penetrates tissue to a depth of 0.5 mm. RESULTS The entire tumor enucleation was performed using the frontal thulium laser fiber. In all cases the thulium laser produced a smooth incision of the renal parenchyma and a safe delineation of the plane between the tumor and the surrounding tissue. In addition, in the off clamp procedures bleeding was limited during the dissection and did not interfere with the definition of the surgical plane. Median surgical time from the beginning of the laser assisted tumor dissection to the end, after verification of bleeding control on the cut surface, was 15 minutes (range 12 to 20). No significant (less than 40 cc) blood loss occurred during the laser assisted tumor dissection. All cases were clear cell renal cell carcinoma and no positive surgical margins were found. In all cases postoperative management was uncomplicated without evidence of hemorrhage. CONCLUSIONS In our prospective preliminary experience, thulium laser assisted enucleation for renal cell carcinoma is a feasible, safe and effective procedure.

Role of magnetic resonance spectroscopic imaging ([1H]MRSI) and dynamic contrast-enhanced MRI (DCE-MRI) in identifying prostate cancer foci in patients with negative biopsy and high levels of prostate-specific antigen (PSA)

PurposeThe purpose of this study was to evaluate the role of magnetic resonance spectroscopic imaging (MRSI) and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) in detecting tumour foci in patients with elevated prostate-specific antigen (PSA) and negative transrectal ultrasonography (TRUS)-guided biopsy.Materials and methodsThis prospective randomised trial was conducted on 150 patients who underwent [1H]MRSI and DCE-MRI and targeted biopsies of suspicious areas on MRI associated with random biopsies.ResultsAfter the second biopsy, the diagnosis of prostate adenocarcinoma was made in 64/150 cases. On a perpatient basis, MRSI had 82.8% sensitivity, 91.8% specificity, 88.3% positive predictive value (PPV), 87.8% negative predictive value (NPV) and 85.7% diagnostic accuracy. The sensitivity, specificity, PPV, NPV and accuracy for DCE-MRI was 76.5%, 89.5%, 84.5%, 83.7% and 82%, respectively. The combination of MRSI and DCE-MRI yielded 93.7% sensitivity, 90.7% specificity, 88.2% PPV, 95.1% NPV and 90.9% accuracy in detecting prostate carcinoma.ConclusionsThe combined study with [1H]MRSI and DCE-MRI showed promising results in guiding the biopsy of cancer foci in patients with an initial negative TRUS-guided biopsy.RiassuntoObiettivoScopo del nostro lavoro è stato valutare il ruolo della risonanza magnetica (RM) con spettroscopia (MRSI) e studio dinamico (DCEMR) nell’individuazione di foci tumorali in pazienti con elevati valori di antigene prostatico specifico (PSA) e biopsia prostatica guidata tramite TRUS (trans-rectal-ultrasound)-guidata negativa.Materiali e metodiLo studio è stato di tipo prospettico randomizzato. Abbiamo esaminato 150 pazienti. Tutti sono stati sottoposti ad esame di 1H-MRSI e DCEMR ed a prelievi mirati nelle zone sospette alla RM, associate a biopsie random.RisultatiDopo la seconda biopsia, la diagnosi di adenocarcinoma prostatico è stata effettuata in 64/150 casi. Nella nostra popolazione, su una base patient by patient, l’MRSI ha mostrato i seguenti valori: sensibilità 82,8%; specificità 91,8%; valore predittivo positivo (PPV) 88,3%; valore predittivo negativo (NPV) 87,8%; accuratezza 85,7%. La DCEMR ha mostrato i seguenti valori: sensibilità 76,5%; specificità 89,5%; PPV 84,5%; NPV 83,7%; accuratezza 82%. L’associazione delle due metodiche, MRSI e DCEMR, aumenta la sensibilità (93,7%), la specificità (90,7%), il PPV (88,2%), il PNV (95,1%) e l’accuratezza (90,9%) nel predire l’individuazione del carcinoma prostatico se paragonata alla sola metodica MRSI o DCEMR.ConclusioniLo studio combinato ha mostrato risultati promettenti nella guida alla biopsia dei foci tumorali in pazienti con prima biopsia TRUS-guidata negativa.

A meta-analysis and systematic review of randomized controlled trials with degarelix versus gonadotropin-releasing hormone agonists for advanced prostate cancer.

AbstractOur aim was to systematically evaluate the benefits of degarelix as antagonist versus agonists of gonadotropin-releasing hormones (GnRH) for the treatment of advanced prostate cancer (PC). This comparison was performed either in terms of biochemical or oncological or safety profiles. To this end we, carried out a systematic review and meta-analysis of the literature.We selected only studies directly and prospectively analyzing the two treatments in the same population (randomized phase III studies). We followed the Preferred Reporting Items for Systematic Reviews and meta-analyses process for reporting studies.After we eliminated studies according to the exclusion criteria, 9 publications were considered relevant to this review. These articles described 5 clinical trials that were eligible for inclusion. The follow-up duration in all trials did not exceed 364 days. This meta-analysis and review comprised a total of 1719 men, 1061 randomized to degarelix versus 658 to GnRH agonists treatment for advanced PC. Oncological results were evaluated only in 1 trial (CS21:408 cases) and they were not the primary endpoints of the study. Treatment emerging adverse events were reported in 61.4% and 58.8% of patients in the degarelix and GnRH agonists group, respectively (odds ratio, OR = 1.17; 95% confidence interval, 95% CI: 0.78–1.77, P > 0.1). Treatment related severe cardiovascular side effects were reported (trial CS21-30-35) in 1.6% and 3.6% of patients in the degarelix and GnRH agonists group, respectively (OR = 0.55, 95% CI: 0.26–1.14, P > 0.1).Our analysis evidences relevant limitations in particular for the comparative evaluation of the efficacy and the oncological results related to degarelix.