DIGITAL RECTAL EXAMINATION FOR DETECTING PROSTATE CANCER AT PROSTATE SPECIFIC ANTIGEN LEVELS OF 4 NG./ML. OR LESS

Prostate-specific antigen screening for prostate cancer: Diagnostic performance, clinical thresholds, and strategies for refinement

Prostate specific antigen (PSA) has transformed the diagnosis and treatment of prostate cancer by enabling early detection at global scale. Due to expression in both benign and malignant cells, PSA-based prostate cancer screening using single cut-points yields imperfect diagnostic performance and has led to the detection and over-treatment of low-grade prostate cancer. Additional challenges in the interpretation of PSA include substantial inter and intrapersonal variation, differences with age and prostate volume, and selection of standardized PSA value cutoffs for clinical application. In response, refinements to PSA including risk and age-based thresholds, age and genetic adjustments, PSA density, percentage free PSA, and PSA velocity have been proposed and extensively studied. In this review, we focus on the clinical role of PSA as a screening biomarker with a particular emphasis on its test characteristics, clinically actionable thresholds, and strategies to refine its clinical interpretation.

Prostate cancer diagnostic pathway in men with lower urinary tract symptoms or performing opportunistic screening: The Italian Society of Urology (SIU) position paper

BACKGROUND

Voluntary PCa screening frequently results in excessive use of unnecessary diagnostic tests and an increasing risk of detection of indolent PCa and unaffordable costs for the various national health systems. In this scenario, the Italian Society of Urology (Società Italiana di Urologia, SIU) proposes an organized flow chart guiding physicians to improve early diagnosis of significant PCa avoiding unnecessary diagnostic tests and prostate biopsy.

METHODS

According to available evidence and international guidelines [i.e., European Association of Urology (EAU), American Association of Urology (AUA) and National Comprehensive Cancer Network (NCCN)] on PCa, a Panel of expert urologists selected by Italian Society of Urology (SIU, Società Italiana di Urologia) proposed some indications to develop a stepwise diagnostic pathway based on the diagnostic tests mainly used in the clinical practice. The final document was submitted to six expert urologists for external revision and approval. Moreover, the final document was shared with patient advocacy groups.

RESULTS

In voluntary men and symptomatic patients with elevated PSA value (>3 ng/mL), the Panel strongly discourage the use of antibiotic agents in absence of urinary tract infection confirmed by urine culture. DRE remains a key part of the urologic physical examination helping urologists to correctly interpret PSA elevation and prioritizing the execution of multiparametric Magnetic Resonance Imaging (mpMRI) in presence of suspicious PCa. Men with negative mpMRI and low clinical suspicion of PSA (PSA density < 0.20 ng/mL/cc, negative DRE findings, no family history) can be further monitored. Men with negative mpMRI and a higher risk of PCa (familial history, suspicious DRE, PSAD>0.20 ng/mL/cc or PSA>20 ng/mL) should be considered for systematic prostate biopsy. While PI-RADS 4-5 lesions represent a strong indication for prostate biopsy, PI-RADS 3 lesions should be further stratified according to PSAD values and prostate biopsy performed when PSAD is higher than 0.20. Accreditation, certification, and quality audits of radiologists and centers performing prostatic mpMRI should be strongly considered. The accessibility and/or the waiting list for MRI examinations should be also evaluated in the diagnostic pathway. The panel suggests performing transperineal or transrectal targeted plus systematic biopsies as standard of care.

CONCLUSIONS

Scientific societies must support the use of shared diagnostic pathway with the aim to increase the early detection of significant PCa reducing a delayed diagnosis of advanced PCa. Moreover, a shared diagnostic pathway can reduce the incorrect use of antibiotic, the number of unnecessary laboratory and radiologic examinations as well as of prostate biopsies.

Digital Rectal Exam in Prostate Cancer Screening and Elevated PSA Work-up-Is there a role anymore?

PURPOSE OF REVIEW

Prostate cancer (PCa) screening tools, particularly digital rectal examination (DRE), are under scrutiny. This review assesses the utility of DRE in PCa screening.

RECENT FINDINGS

Recent studies reaffirm the DRE's sensitivity and specificity, a higher PCa detection rate with PSA in conjunction with DRE, and a slightly elevated risk of clinically significant PCa (CSPC) in those with elevated PSA and suspicious DRE. Studies confirm high accuracy of MRI in identifying CSPC, with ongoing research exploring its screening potential. DRE alone lacks accuracy for PCa screening, often resulting in missed diagnoses and unnecessary biopsies. Its supplementary use with PSA marginally increases detection rates of identifying a small percentage of CSPC, but the benefit remains questionable. Emerging evidence suggests MRI has the potential as a superior screening tool compared to DRE, although direct comparative studies are lacking. Overall, the DRE has a limited role in current PCa screening.

Evaluation of miR-148a-3p and miR-106a-5p as Biomarkers for Prostate Cancer: Pilot Study

MicroRNAs (miRNAs) are a class of small non-coding RNAs that may function as tumor suppressors or oncogenes. Alteration of their expression levels has been linked to a range of human malignancies, including cancer. The objective of this investigation is to assess the relative expression levels of certain miRNAs to distinguish between prostate cancer (PCa) from benign prostatic hyperplasia (BPH). Blood plasma was collected from 66 patients diagnosed with BPH and 58 patients with PCa. Real-time PCR technology was used to evaluate the relative expression among the two groups for miR-106a-5p and miR-148a-3p. The significant downregulation of both miRNAs in plasma from PCa versus BPH patients suggests their potential utility as diagnostic biomarkers for distinguishing between these conditions. The concurrent utilization of these two miRNAs slightly enhanced the sensitivity for discrimination among the two analyzed groups, as shown in ROC curve analysis. Further validation of these miRNAs in larger patient cohorts and across different stages of PCa may strengthen their candidacy as clinically relevant biomarkers for diagnosis and prognosis.

Performance of standard systematic biopsy versus MRI/TRUS fusion biopsy using the Navigo® system in contemporary cohort

INTRODUCTION

The introduction of multi parameter magnetic resonance imaging (mpMRI) of the prostate in combination with MRI/TRUS fusion and systematic biopsy resulted in improved detection of prostate cancer. The aim of the current study was to document the performance of MRI/TRUS fusion biopsy of the prostate using the Navigo™ software in a contemporary cohort of patients from nonreferral centers.

MATERIAL AND METHODS

We performed a two centers prospective data collection (2014-2020) for men with clinically suspected Pca and patients on active surveillance for low-risk Pca that were referred for TRUS biopsy after performing mpMRI of the prostate with a visible lesion. The primary outcome was detection of clinically significant cancer (csPca) defined as ISUP grade group ≥2. Patients were stratified according to biopsy technique and PI-RADS category.

RESULTS

The study group included 236 patients of whom 129 (54.9%) were diagnosed with Pca and 82 (34.7%) with csPca (GG ≥ 2) on combined biopsy. The overall detection of csPca was 31% for targeted vs. 25.4% for systematic biopsy with an absolute difference of 5.6% in favor of the fusion technique. No significant difference between the two techniques was observed for detection of benign prostate or GG1 disease. The improved performance of the targeted approach was noted only in patients with PI-RADS 4 and 5 lesions. Of the patients with csPca 10 (12%) were diagnosed only by the systematic biopsy while 20 (24%) were detected only in the fusion biopsy. Systematic biopsy of prostate lobe without MRI lesion detected only 2 cases (∼1%) with high grade disease.

CONCLUSIONS

Detection of csPca by mpMRI/TRUS fusion biopsy using the 3D Navigo™ system is feasible. The targeted approach outperforms the systematic one, however the later technique also detects high risk disease and should be included in the biopsy procedure. The overall detection rate (34.9%) of clinically significant prostate cancer by both targeted and systematic sampling is relatively low.

Prostate Cancer Foundation Screening Guidelines for Black Men in the United States

BACKGROUND

In the United States, Black men are at highest risk for being diagnosed with and dying from prostate cancer. Given this disparity, we examined relevant data to establish clinical prostate-specific antigen (PSA) screening guidelines for Black men in the United States.

METHODS

A comprehensive literature search identified 1848 unique publications for screening. Of those screened, 287 studies were selected for full-text review, and 264 were considered relevant and form the basis for these guidelines. The numbers were reported according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

RESULTS

Three randomized controlled trials provided Level 1 evidence that regular PSA screening of men 50 to 74 years of age of average risk reduced metastasis and prostate cancer death at 16 to 22 years of follow-up. The best available evidence specifically for Black men comes from observational and modeling studies that consider age to obtain a baseline PSA, frequency of testing, and age when screening should end. Cohort studies suggest that discussions about baseline PSA testing between Black men and their clinicians should begin in the early 40s, and data from modeling studies indicate prostate cancer develops 3 to 9 years earlier in Black men compared with non-Black men. Lowering the age for baseline PSA testing to 40 to 45 years of age from 50 to 55 years of age, followed by regular screening until 70 years of age (informed by PSA values and health factors), could reduce prostate cancer mortality in Black men (approximately 30% relative risk reduction) without substantially increasing overdiagnosis.

CONCLUSIONS

These guidelines recommend that Black men should obtain information about PSA screening for prostate cancer. Among Black men who elect screening, baseline PSA testing should occur between ages 40 and 45. Depending on PSA value and health status, annual screening should be strongly considered. (Supported by the Prostate Cancer Foundation.).

Quantitative ADC: An Additional Tool in the Evaluation of Prostate Cancer?

Prostate cancer is one of the most common tumors among the male population. Magnetic resonance imaging (MRI), standardized by the PI-RADS version 2.1 scoring system, has a fundamental role in detecting prostate cancer and evaluating its aggressiveness. Diffusion-weighted imaging sequences and apparent diffusion coefficient values, in particular, are considered fundamental for the detection and characterization of lesions. In 2016 the International Society of Urological Pathology introduced a new anatomopathological 5-grade scoring system for prostate cancer. The aim of this study is to evaluate the correlation between quantitative apparent diffusion coefficient values (ADC) derived from diffusion-weighted imaging (DWI) sequences and the International Society of Urological Pathology (ISUP) and PI-RADS groups. Our retrospective study included 143 patients with 154 suspicious lesions, observed on prostate magnetic resonance imaging and compared with the histological results of the biopsy. We observed that ADC values can aid in discriminating between not clinically significant (ISUP 1) and clinically significant (ISUP 2-5) prostate cancers. In fact, ADC values were lower in ISUP 5 lesions than in negative lesions. We also found a correlation between ADC values and PI-RADS groups; we noted lower ADC values in the PI-RADS 5 and PI-RADS 4 groups than in the PI-RADS 3 group. In conclusion, quantitative apparent diffusion coefficient values can be useful to assess the aggressiveness of prostate cancer.

Could YouTubeTM encourage men on prostate checks? A contemporary analysis

Objectives: To assess YouTube™ videos’ quality on prostate checks, especially on the digital rectal exam (DRE), and to investigate if they can inform patients correctly and eradicate their beliefs and myths.Methods: A search using as keywords “digital rectal exam for prostate cancer” was performed on the YouTubeTM platform. We selected the first 100 videos. To assess video quality content, Patient Education Materials Assessment Tool for audio-visual content (PEMAT A/V) and Misinformation tool were used.Results: Seventy-three videos were suitable for the analyses. The median PEMAT A/V Understandability score and PEMAT A/V Actionability score were 46.2% (interquartile range [IQR]: 30.8-76.9) and 50.0% (IQR: 25.0-75.0), respectively. The medi-an PEMAT A/V Understandability and Actionability scores were 69.2% (IQR: 46.2-88.5) vs 46.2% (IQR: 30.8-61.5) (p = 0.01) and 100.0% (IQR: 87.5-100.0) vs 25.0% (IQR: 25.0-68.8)(p < 0.001), for healthcare workers vs patients, respectively. According to the Misinformation tool, the median misinforma-tion score of the overall videos was 2.2 (IQR:1.7-2.8). According to the target audience, the misinformation score was 2.8 (IQR: 2.4-3.5) vs 2.0 (IQR: 1.5-2.8) (p = 0.02), for healthcare workers vs patients, respectively. Conclusions: Currently, based on our analyses, YouTubeTM videos’ quality on DRE resulted unsatisfactory according to the PEMAT A/V score and the Misinformation tool. Videos targeted to healthcare workers got higher quality scores if compared to videos targeted to patients. Therefore, YouTubeTM videos’ may not be considered a reliable source of information on DRE for patients.

The additive value of mpMRI on prostate cancer detection: Comparison between patients with and without a suspicious digital rectal examination (DRE)

PURPOSE

Diagnosis of prostate cancer (CaP) is based on digital rectal examination (DRE) and/or elevated prostate specific antigen (PSA) level. This approach lacks sensitivity and specificity and is associated with many negative biopsies, high rate of diagnosing clinically insignificant disease and lacks accuracy to predict clinically significant (CS) cancer. The addition of multiparametric magnetic resonance imaging (mpMRI) before prostate biopsy reduces the detection of low-grade tumors while improving the detection of CS CaP. Most studies that evaluated mpMRI performance did not separate the DRE status of the examined patients. Therefore, the aim of our study is to investigate whether mpMRI provides similar advantages in detection of CaP according to the DRE findings.

MATERIALS AND METHODS

This prospective study included patients with clinically suspected CaP that were referred to MRI-fusion biopsy from 2014 to 2019. All patients had mpMRI of the prostate with an index lesion of PIRADS ≥3. Analysis was done comparing systemic and targeted biopsy. Patients were divided into two groups according to the DRE findings (positive or negative DRE) and the primary outcomes were compared between the 2 study groups: detection rate of CaP and the detection rate of CS disease defined as Gleason score ≥ 7.

RESULTS

The final study cohort included 86 patients: 47 with negative DRE and 39 with positive DRE. Overall cancer detection rate was higher in patients with a positive DRE (70.3% vs 48.9%, P <0.05). In the region of interest a higher overall detection rate and of CS disease was found in those with abnormal DRE (51.3% vs. 40.4% and 48.6% vs. 34.0% respectively). The systematic biopsy analysis showed an overall lower detection rate in the negative DRE group (8.5% vs. 18.9 %). The targeted biopsies detected more cancer and significant tumors per core in patients with positive DRE (29.2% vs. 18.5% and 22.1% vs. 14.5% respectively).

CONCLUSIONS

Patients submitted to fusion biopsy and have a positive DRE are diagnosed more often with CaP, have higher grade disease and larger tumors. In patients suspicious for CaP and having a significant lesion on mpMRI one should combine targeted and systematic biopsy regardless of the DRE status.

Understanding the diagnosis of prostate cancer

Prostate cancer continues to be the most commonly diagnosed cancer, and the second leading cause of cancer death among Australian men. Prostate-specific antigen testing is personalised (not dichotomous in nature) and its interpretation should take into account the patient's age, symptoms, previous results and medication (eg, 5-α reductase inhibitors such as dutasteride). Multiparametric magnetic resonance imaging of the prostate has been proven to have a 93% sensitivity for detecting clinically significant prostate cancer. It has the potential to decrease unnecessary prostate biopsies by around 27%. International Society of Urological Pathology (ISUP) grade 1 (Gleason score 6) has been shown to have very little, if any, risk of metastasis ISUP grade 1 (Gleason score 3 +3 = 6) and low percentage ISUP grade 2 (Gleason score 3 + 4 [< 10%] = 7) can be offered active surveillance. The goal of active surveillance is to defer treatment but is still curative when required. With better imaging (magnetic resonance imaging and emerging prostate-specific membrane antigen positron emission tomography-computed tomography) and transperineal prostate biopsy, more men can be offered screening after discussion of risks and benefits, knowing that overdiagnosis has been minimised and radical treatment is reserved for only the most aggressive disease.

Effectiveness of technology-enhanced simulation in teaching digital rectal examination: a systematic review narrative synthesis

Background

Digital rectal examination (DRE) is a challenging examination to learn.

Objective

To synthesise evidence regarding the effectiveness of technology-enhanced simulation (TES) for acquiring DRE skills.

Study selection

EMBASE, Medline, CINAHL, Cochrane, Web of Knowledge (Science and Social Science), Scopus and IEEE Xplore were searched; the last search was performed on 3 April 2019. Included were original research studies evaluating TES to teach DRE. Data were abstracted on methodological quality, participants, instructional design and outcomes; a descriptive synthesis was performed. Quality was assessed using a modified Medical Education Research Study Quality Instrument. The study design domain was modified by scoring the papers based on (1) evaluation of risk of bias for randomised controlled trials, (2) description of participants and (3) assessment of robustness and degree of simulation fidelity of the assessments used to evaluate learning.

Findings

863 articles were screened; 12 were eligible, enrolling 1507 prequalified medical/clinical students and 20 qualified doctors. For skill acquisition, role player was statistically significantly superior to a static manikin (2 studies). For knowledge acquisition, manikin use was significantly superior to role player (1 study); 2 studies showed no difference. For confidence, manikin use was significantly superior to no manikin (4 studies). For comfort, manikin use was significantly superior to no manikin (2 studies). For anxiety, role player was significantly superior to manikin (1 study).

Conclusions

TES training is associated with improved DRE skills and should be used more widely.

The Value of Prostate-Specific Antigen-Related Indexes and Imaging Screening in the Diagnosis of Prostate Cancer

Objective

The aim of this study was to explore the value of the prostate-specific antigen (PSA) levels, the ratio of free PSA to total PSA (fPSA/TPSA), the PSA density (PSAD), digital rectal examination (DRE), transrectal prostate ultrasound (TRUS), and multiparameter MRI (MP-MRI) in the differential diagnosis of benign prostatic hyperplasia (BPH) and prostate cancer (PCa).

Methods

From February 2016 to September 2019, data from 620 patients who underwent systematic transrectal ultrasound-guided prostate biopsy (STURS-PB) in our hospital were retrospectively collected, including the PSA levels, the fPSA/TPSA ratio, the PSAD, DRE, TRUS, MP-MRI, prostate volume, and other clinical data.

Results

Among the 620 patients, 249 patients were in the PCa group, and 371 patients in the BPH group. The positive puncture rate was 40.16%. The positive predictive values of DRE, TRUS, mpMRI, and TPSA levels for PCa were 39.91%, 39.38%, 64.14%, and 41.57%, respectively; the sensitivity of these parameters was 37.35%, 51.41%, 74.69%, and 57.43%, respectively; and the specificity of these parameters was 62.26%, 46.90%, 71.97%, and 45.82%, respectively. When the TPSA concentration was in the range of 4-20 ng/mL, the positive puncture rate of STURS-PB was 23.18%, with a high rate of misdiagnosis. When the TPSA concentration was in the range of 4-20 ng/mL, the fPSA/TPSA ratio was 0.15, the PSAD was 0.16, the comprehensive evaluation of PCa was optimal (the sensitivity of these parameters was 88.85% and 84.09%, respectively; the specificity was 80.17% and 67.29%, respectively; the positive predictive value was 57.41% and 51.39%, respectively). When the TPSA concentration >4 ng/mL, the fPSA/TPSA ratio ≤0.15 and the PSAD ≥0.16, the sensitivity, specificity, and correctness index of the PCa and BPH diagnosis were 80.54%, 82.75%, and 67.07%, respectively.

Conclusion

When using DRE, TRUS, and MP-MRI to screen for PCa, MP-MRI has a relatively high sensitivity and specificity. Using these three thresholds (TPSA >4 ng/mL combined with an fPSA/TPSA ratio ≤0.15 and a PSAD ≥0.16) is significantly better than using TPSA levels alone for the differential diagnosis of PCa and BPH.

Prostate cancer screening among elderly men in Brazil: should we diagnose or not?

PURPOSE

Prostate cancer screening in the elderly is controversial. The Brazilian government and the National Cancer Institute (INCA) do not recommend systematic screening. Our purpose was to assess prevalence and aggressiveness of prostate cancer in men aged 70 years and above, on the first Latin American database to date.

MATERIALS AND METHODS

Cross-sectional study (n=17,571) from 231 municipalities, visited by Mobile Cancer Prevention Units of a prostate-specific antigen (PSA) based opportunistic screening program, between 2004 and 2007. The criteria for biopsy were: PSA>4.0ng/ml, or PSA 2.5-4.0ng/ml with free/total PSA ratio ≤15%, or suspicious digital rectal examination findings. The screened men were stratified in two age groups (45-69 years, and ≥70 years). These groups were compared regarding prostate cancer prevalence and aggressiveness criteria (PSA, Gleason score from biopsy and TNM staging).

RESULTS

The prevalence of prostate cancer found was 3.7%. When compared to men aged 45-69 years, individuals aged 70 years and above presented cancer prevalence about three times higher (prevalence ratio 2.9, p<0.01), and greater likelihood to present PSA level above 10.0ng/ml at diagnosis (odds ratio 2.63, p<0.01). The group of elderly men also presented prevalence of histologically aggressive disease (Gleason 8-10) 3.6 times higher (p<0.01), and 5-fold greater prevalence of metastases (PR 4.95, p<0.05).

CONCLUSIONS

Prostate cancer screening in men aged over 70 may be relevant in Brazil, considering the absence of systematic screening, higher prevalence and higher probability of high-risk disease found in this age range of the population studied.

A different perspective: Can urine pH be important in the diagnosis of prostate cancer?

OBJECTIVE

The aim of our study was to investigate emphasis of urinary pH in patients with prostate cancer.

METHODS

Patients, who underwent 12-core prostate biopsy because of prostate-specific antigen elevation and suspicious digital rectal examination, were retrospectively reviewed. According to pathology, patients with prostate cancer were classified as group 1, and patients with benign prostatic hyperplasia were classified as group 2. Primary endpoint of this study was the urine pH. The age of two groups and urine pH were compared with each other. Student t test and Mann-Whitney U test were used for the intergroup analysis of continuous variables. A cut-off value for urine pH was determined with a receiver operating characteristic curve. p < 0.05 was considered as statistically significant.

RESULTS

There were 119 patients in group 1 and 99 patients in group 2. When urine pHs of both groups were compared, group 1 and group 2 were 5.1 ± 0.45 and 5.5 ± 0.79, respectively (p = 0.0001). The cut-off value determined by receiver operating characteristic curve analysis for urine pH was 5.2 (sensitivity: 42%, specificity: 79%, area under the curve: 0.61; 95% CI: [0.53, 0.68]; p = 0.003).

CONCLUSION

Acidic urine pH may be important for predicting prostate cancer according to this study.

[What primary care physicians should know about new markers in prostate cancer]

The use of prostate-specific antigen as a diagnostic tool in the screening of prostate cancer is reflected in an increase in the incidence, an increase in diagnosis at initial stages, and an increase in radical therapies, even at the expense of over-treatment in some cases. It is known from the data collected in the literature that not every patient with high prostate-specific antigen needs a biopsy, and that not every patient diagnosed with prostate cancer needs treatment. With the new emerging prostate markers, we will try to improve the specificity of prostate-specific antigen in the grey area (4-10 ng/ml) should be improved. This should avoid unnecessary biopsies. The sensitivity in the detection of significant prostate cancer with low prostate-specific antigen should also be improved in an attempt to reduce the risk of over-treatment. On the other hand, prognostic biomarkers with genomic tests will help to choose the best therapeutic option for the patient.

The application of p2PSA% and prostate health index in prostate cancer detection: A prospective cohort in a Tertiary Medical Center

BACKGROUND/PURPOSE

Prostate specific antigen (PSA) with low specificity that causes unnecessary prostate biopsies increases clinical morbidities, psychological stress, and medical expenses. We aimed to test the accuracy and cutoff value of Prostate Health Index (PHI) in men for prostate cancer detection.

METHODS

We prospectively enrolled 213 men who underwent prostate biopsy with PSA≦10 ng/ml or abnormal findings on digital rectal examination. Total PSA (tPSA), free PSA (fPSA) and p2PSA levels were measured by serum samples before prostate biopsy. PHI was calculated as (p2PSA/fPSA) × √tPSA. Multivariable logistic regression analyses were used to predict the risk of cancer and detect clinically significant prostate cancer.

RESULTS

33 (27.0%) patients were confirmed with the diagnoses of prostate cancer by prostate biopsy. The levels of p2PSA, %p2PSA, and PHI showed statistically significant differences between prostate cancer patients and non-cancer patients. %p2PSA and PHI had the highest area under the receiver operating characteristic curve (AUC) of 0.723 and 0.772 (both p < 0.001), respectively, predicting cancer detection at biopsy than other predictors (tPSA, fPSA, %fPSA, and PSA density (AUC: 0.544, 0.538, 0.593, and 0.664, respectively). In multivariable logistic regression, %p2PSA had a statistical significant odds ratio 8.51 (p = 0.003) and PHI had an odds ratio with marginal significance 4.18 (p = 0.06).

CONCLUSION

%p2PSA and PHI increased the diagnostic accuracy with significantly greater sensitivity and specificity than tPSA. We determined an optimal cut-off value of PHI among Taiwanese population. These findings support the usefulness in the decisional process of prostate biopsy.

Review of Gallium-68 PSMA PET/CT Imaging in the Management of Prostate Cancer

Over 90% of prostate cancers over-express prostate specific membrane antigen (PSMA) and these tumor cells may be accurately targeted for diagnosis by 68Ga-PSMA-positron emission tomography/computed tomography (68Ga-PSMA-PET/CT) imaging. This novel molecular imaging modality appears clinically to have superseded CT, and appears superior to MR imaging, for the detection of metastatic disease. 68Ga-PSMA PET/CT has the ability to reliably stage prostate cancer at presentation and can help inform an optimal treatment approach. Novel diagnostic applications of 68Ga-PSMA PET/CT include guiding biopsy to improve sampling accuracy, and guiding surgery and radiotherapy. In addition to facilitating the management of metastatic castrate resistant prostate cancer (mCRPC), 68Ga-PSMA can select patients who may benefit from targeted systemic radionuclide therapy. 68Ga-PSMA is the diagnostic positron-emitting theranostic pair with the beta emitter Lutetium-177 PSMA (177Lu-PSMA) and alpha-emitter Actinium-225 PSMA (225Ac-PSMA) which can both be used to treat PSMA-avid metastases of prostate cancer in the molecular tumor-targeted approach of theranostic nuclear oncology.

A 12-year follow-up of ANNA/C-TRUS image-targeted biopsies in patients suspicious for prostate cancer

PURPOSE

PSA screening has been rehabilitated. PSA is not specific and can be elevated by benign reasons. Additionally, a subgroup of patients with prostate hyperplasia may harbor prostate cancer (PCa). During monitoring, the clinician aims to detect significant tumors in time, submitting patients to minimal psychological and physical burden, especially in men with high serum PSA and repeat biopsies. We aimed to determine long-term outcomes with respect to ANNA/C-TRUS ability to detect PCa with six targeted biopsies.

METHODS

A subset of 71 patients were enrolled. During monitoring, they were subjected to primary, secondary, or even multiple prostate biopsies when needed. Protocol monitoring included PSA measurements, digital rectal examination (DRE) and imaging.

RESULTS

The median follow-up was 12 years. Forty-one patients had a history of negative systematic random biopsies (1-3 sessions). Their age ranges 62-85 years, PSA 0.5-47.3 ng/ml, and the median prostate volume 11-255 cc. During monitoring, 15 patients were diagnosed with PCa. Only two harbored aggressive tumors. The median time to diagnosis was 6 years. All PCa patients are free from biochemical relapse. From the remaining 56 patients, 11 did not have any biopsies, 12 had one, 13 had two, and 20 had three or more biopsy sessions.

CONCLUSIONS

ANNA/C-TRUS is a useful method monitoring patients with a risk of PCa. 50-75% of the usually performed biopsy cores could be spared and, after 12 years, 97% of the patients were either without evidence of a PCa or were diagnosed with a good prognosis tumor.

Prospective evaluation on the effect of interobserver variability of digital rectal examination on the performance of the Rotterdam Prostate Cancer Risk Calculator

OBJECTIVES

To assess the level of agreement between digital rectal examination findings of two urologists and its effect on risk prediction using the digital rectal examination-based Rotterdam Prostate Cancer Risk Calculator.

METHODS

The study sample consisted of a prospective cohort of asymptomatic unscreened men with prostate-specific antigen ≤50.0 ng/mL and transrectal ultrasound volume ≤110 mL who underwent transrectal ultrasound-guided prostate biopsy. Both urologists' digital rectal examination findings were graded normal or abnormal (nodularity and/or induration), and volume classified as 25, 40 or 60 mL, according to the risk calculator algorithm. Interrater agreement analysis using Cohen's kappa (κ) statistic was carried out to determine consistency of digital rectal examination outcome and volume assessment. Receiver operating characteristic curve analysis and calibration plots were constructed to determine the effect of interrater differences. Decision curve analysis was applied to evaluate the clinical usefulness of the model.

RESULTS

Of the 241 men included in the study, 41% (n = 98) had prostate cancer (81 were clinically significant, i.e. Gleason ≥3 + 4). There was substantial agreement in the digital rectal examination (abnormal/normal; κ = 0.78; P < 0.001) and volume estimation (κ = 0.79; P < 0.001). Receiver operating characteristic analyses showed good discrimination (0.75-0.78) and were comparable for both urologists. In the high-risk cohort, at a probability threshold of 25%, the risk calculator reduced the prostate biopsy rate by 9%, without missing cancers.

CONCLUSIONS

Slight differences in digital rectal examination findings seem to have very limited impact on the performance of the Rotterdam Prostate Cancer Risk Calculator. Therefore, this can be considered a useful prostate biopsy outcome prediction tool.

Prebiopsy mp-MRI Can Help to Improve the Predictive Performance in Prostate Cancer: A Prospective Study in 1,478 Consecutive Patients

Purpose: To investigate whether prebiopsy multi-parametric (mp) MRI can help to improve predictive performance in prostate cancer.Experimental Design: Based on a support vector machine (SVM) analysis, we prospectively modeled clinical data (age, PSA, digital rectal examination, transrectal ultrasound, PSA density, and prostate volume) and mp-MRI findings [Prostate Imaging and Reporting and Data System (PI-RADS) score and tumor-node-metastasis stage] in 985 men to predict the risk of prostate cancer. The new nomogram was validated in 493 patients treated at the same institution. Multivariable Cox regression analyses assessed the association between input variables and risk of prostate cancer, and area under the receiver operating characteristic curve (Az) analyzed the predictive ability.Results: At 5-year follow-up period, 34.3% of patients had systemic progression of prostate cancer. Nomogram (SVM-MRI) predicting 5-year prostate cancer rate trained with clinical and mp-MRI data was accurate and discriminating with an externally validated Az of 0.938, positive predictive value (PPV) of 77.4%, and negative predictive value of 91.5%. The improvement was significant (P < 0.001) compared with the nomogram trained with clinical data. When stratified by PSA, SVM-MRI nomogram had high PPV (93.6%) in patients with PSA > 20 ng/mL, with intermediate to low PPV in PSA 10 to 20 ng/mL (64%), PSA 4 to 10 ng/mL (55.8%), and PSA 0 to 4 ng/mL (29%). PI-RADS score (Cox HR, 2.112; P < 0.001), PSA level (HR, 1.435; P < 0.001), and age (HR, 1.012; P = 0.043) were independent predictors of prostate cancer.Conclusions: Featured with low false positive rate, mp-MRI could be the first investigation of a man with a raised PSA before prostate biopsy. Clin Cancer Res; 23(14); 3692-9. ©2017 AACR.

Plasma Levels of hsa-miR-619-5p and hsa-miR-1184 Differ in Prostatic Benign Hyperplasia and Cancer

Peripheral blood plasma profiles of circulating microRNA expression were analyzed in patients with prostatic cancer and benign hyperplasia. In prostatic cancer, significant increase in hsa-miR-619-5p and hsa-miR-1184 microRNA expression and significant decrease in hsalet-7b-5p and hsa-let-7c-5p microRNA expression were observed. The role of the relationship between the microRNA expression and the activities and functions of host genes with introns encoding these microRNA is discussed.

Contemporary outcomes in the detection of prostate cancer using transrectal ultrasound-guided 12-core biopsy in Singaporean men with elevated prostate specific antigen and/or abnormal digital rectal examination

Objective

Despite being the third commonest cancer in Singaporean men, there is a dearth of basic data on the detection rate of prostate cancer and post-procedure complication rates locally using systematic 12-core biopsy. Our objective is to evaluate prostate cancer detection rates using 12-core prostate biopsy based on serum prostate specific antigen (PSA) levels and digital rectal examination (DRE) findings in Singaporean men presenting to a single tertiary centre. The secondary objective is to evaluate the complication rates of transrectal prostate biopsies.

Methods

We retrospectively examined 804 men who underwent first transrectal-ultrasound (TRUS) guided 12-core prostate biopsies from January 2012 to April 2014. Prostate biopsies were performed on men presenting to a tertiary institution when their PSA levels were ≥4.0 ng/mL and/or when they had suspicious DRE findings.

Results

Overall prostate cancer detection rate was 35.1%. Regardless of DRE findings, patients were divided into four subgroups based on their serum PSA levels: 0–3.99 ng/mL, 4.00–9.99 ng/mL, 10.00–19.99 ng/mL and ≥20.00 ng/mL and their detection rates were 9.5%, 20.9%, 38.4% and 72.3%, respectively. The detection rate of cancer based on suspicious DRE findings alone was 59.2% compared to 36.5% based on serum PSA cut-off of 4.0 ng/mL alone. The post-biopsy admission rate for sepsis was 1.5%.

Conclusion

In conclusion, using contemporary 12-core biopsy methods, the local prostate cancer detection rate based on serum PSA and DRE findings has increased over the past decade presumably due to multiple genetic and environmental factors. Post-biopsy sepsis remains an important complication worldwide.

When to biopsy seminal vesicles

OBJECTIVES

The involvement of seminal vesicles in prostate cancer can affect the prognosis and determine the treatment. The objective of this study was to determine whether we could predict its infiltration at the time of the prostate biopsy to know when to indicate the biopsy of the seminal vesicles.

MATERIAL AND METHODS

observational retrospective study of 466 patients who underwent seminal vesicle biopsy. The indication for this biopsy was a prostate-specific antigen (PSA) level greater than 10 ng/ml or an asymmetric or obliterated prostatoseminal angle. The following variables were included in the analysis: PSA level, PSA density, prostate volume, number of cores biopsied, suspicious rectal examination, and preservation of the prostatoseminal angle, studying its relationship with the involvement of the seminal vesicles.

RESULTS

Forty-one patients (8.8%) had infiltrated seminal vesicles and 425 (91.2%) had no involvement. In the univariate analysis, the cases with infiltration had a higher mean PSA level (P < .01) and PSA density (P < .01), as well as a lower mean prostate volume (P < .01). A suspicious rectal examination (20.7% of the infiltrated vesicles) and the obliteration or asymmetry of the prostatoseminal angle (33.3% of the infiltrated vesicles) were significantly related to the involvement (P < .01). In the multivariate analysis, we concluded that the probability of having infiltrated seminal vesicles is 5.19 times higher if the prostatoseminal angle is not preserved (P < .01), 4.65 times higher for PSA levels >19.60 ng/dL (P < .01) and 2.95 times higher if there is a suspicious rectal examination (P = .014). Furthermore, this probability increases by 1.04 times for each unit of prostate volume lower (P < .01). The ROC curves showed maximum sensitivity and specificity at 19.6 ng/mL for PSA and 0.39 for PSA density.

CONCLUSIONS

In this series, greater involvement of seminal vesicles was associated with a PSA level ≥20 ng/ml, a suspicious rectal examination and a lack of prostatoseminal angle preservation.

Digital rectal examination skills: first training experiences, the motives and attitudes of standardized patients

BACKGROUND

Physical clinical examination is a core clinical competence of medical doctors. In this regard, digital rectal examination (DRE) plays a central role in the detection of abnormalities of the anus and rectum. However, studies in undergraduate medical students as well as newly graduated doctors show that they are insufficiently prepared for performing DRE. Training units with Standardized Patients (SP) represent one method to deliver DRE skills. As yet, however, it is little known about SPs' attitudes.

METHODS

This is a qualitative study using a grounded theory approach. Interviews were conducted with 4 standardized patients about their experiences before, during and after structured SP training to deliver DRE competencies to medical students. The resulting data were subjected to thematic content analysis.

RESULTS

Results show that SPs do not have any predominant motives for DRE program participation. They participate in the SP training sessions with relatively little prejudice and do not anticipate feeling highly vulnerable within teaching sessions with undergraduate medical students.

CONCLUSIONS

The current study examined SPs' motives, views, expectations and experiences regarding a DRE program during their first SP training experiences. The results enabled us to derive distinct action guidelines for the recruitment, informing and briefing of SPs who are willing to participate in a DRE program.

[Prostate biopsy. Update for indication, procedure, and future developments]

Transrectal ultrasound-guided prostate biopsy is considered the gold standard in the primary investigation of a suspicious prostate-related finding. The procedure can be carried out with ten probes or more on the lateral side of the prostate, after administering antibiotic prophylaxis and applying local anesthesia. The indication for a biopsy depends on the results of the digitorectal examination, on the serum prostate-specific antigen level, on the individual patient's wish and on his comorbidities. Whether multiparametric imaging should be used before or during the course of a primary or repeated biopsy in order to identify suspicious prostate lesions is the subject of current investigations. Extended biopsy protocols require further clinical investigations before they can become the new standard in the diagnostic work-up. This review delivers an update on the indication for, and technique of, prostate biopsies.

Multidimensional MR spectroscopic imaging of prostate cancer in vivo

Prostate cancer (PCa) is the second most common type of cancer among men in the United States. A major limitation in the management of PCa is an inability to distinguish, early on, cancers that will progress and become life threatening. One-dimensional (1D) proton ((1)H) MRS of the prostate provides metabolic information such as levels of choline (Ch), creatine (Cr), citrate (Cit), and spermine (Spm) that can be used to detect and diagnose PCa. Ex vivo high-resolution magic angle spinning (HR-MAS) of PCa specimens has revealed detection of more metabolites such as myo-inositol (mI), glutamate (Glu), and glutamine (Gln). Due to the J-modulation and signal overlap, it is difficult to quantitate Spm and other resonances in the prostate clearly by single- and multivoxel-based 1D MR spectroscopy. This limitation can be minimized by adding at least one more spectral dimension by which resonances can be spread apart, thereby increasing the spectral dispersion. However, recording of multivoxel-based two-dimensional (2D) MRS such as J-resolved spectroscopy (JPRESS) and correlated spectroscopy (L-COSY) combined with 2D or three-dimensional (3D) magnetic resonance spectroscopic imaging (MRSI) using conventional phase-encoding can be prohibitively long to be included in a clinical protocol. To reduce the long acquisition time required for spatial encoding, the echo-planar spectroscopic imaging (EPSI) technique has been combined with correlated spectroscopy to give four-dimensional (4D) echo-planar correlated spectroscopic imaging (EP-COSI) as well as J-resolved spectroscopic imaging (EP-JRESI) and the multi-echo (ME) variants. Further acceleration can be achieved using non-uniform undersampling (NUS) and reconstruction using compressed sensing (CS). Earlier versions of 2D MRS, theory of 2D MRS, spectral apodization filters, newer developments and the potential role of multidimensional MRS in PCa detection and management will be reviewed here.

EAU guidelines on prostate cancer. part 1: screening, diagnosis, and local treatment with curative intent-update 2013

CONTEXT

The most recent summary of the European Association of Urology (EAU) guidelines on prostate cancer (PCa) was published in 2011.

OBJECTIVE

To present a summary of the 2013 version of the EAU guidelines on screening, diagnosis, and local treatment with curative intent of clinically organ-confined PCa.

EVIDENCE ACQUISITION

A literature review of the new data emerging from 2011 to 2013 has been performed by the EAU PCa guideline group. The guidelines have been updated, and levels of evidence and grades of recommendation have been added to the text based on a systematic review of the literature, which included a search of online databases and bibliographic reviews.

EVIDENCE SYNTHESIS

A full version of the guidelines is available at the EAU office or online (www.uroweb.org). Current evidence is insufficient to warrant widespread population-based screening by prostate-specific antigen (PSA) for PCa. Systematic prostate biopsies under ultrasound guidance and local anesthesia are the preferred diagnostic method. Active surveillance represents a viable option in men with low-risk PCa and a long life expectancy. A biopsy progression indicates the need for active intervention, whereas the role of PSA doubling time is controversial. In men with locally advanced PCa for whom local therapy is not mandatory, watchful waiting (WW) is a treatment alternative to androgen-deprivation therapy (ADT), with equivalent oncologic efficacy. Active treatment is recommended mostly for patients with localized disease and a long life expectancy, with radical prostatectomy (RP) shown to be superior to WW in prospective randomized trials. Nerve-sparing RP is the approach of choice in organ-confined disease, while neoadjuvant ADT provides no improvement in outcome variables. Radiation therapy should be performed with ≥ 74 Gy in low-risk PCa and 78 Gy in intermediate- or high-risk PCa. For locally advanced disease, adjuvant ADT for 3 yr results in superior rates for disease-specific and overall survival and is the treatment of choice. Follow-up after local therapy is largely based on PSA and a disease-specific history, with imaging indicated only when symptoms occur.

CONCLUSIONS

Knowledge in the field of PCa is rapidly changing. These EAU guidelines on PCa summarize the most recent findings and put them into clinical practice.

PATIENT SUMMARY

A summary is presented of the 2013 EAU guidelines on screening, diagnosis, and local treatment with curative intent of clinically organ-confined prostate cancer (PCa). Screening continues to be done on an individual basis, in consultation with a physician. Diagnosis is by prostate biopsy. Active surveillance is an option in low-risk PCa and watchful waiting is an alternative to androgen-deprivation therapy in locally advanced PCa not requiring immediate local treatment. Radical prostatectomy is the only surgical option. Radiation therapy can be external or delivered by way of prostate implants. Treatment follow-up is based on the PSA level.

Spondin-2, a secreted extracellular matrix protein, is a novel diagnostic biomarker for prostate cancer

PURPOSE

SPON2 belongs to the F-spondin family of secreted extracellular matrix proteins. It is deregulated in some tumors, including prostate cancer. In this prospective study we assessed the role of serum SPON2 as a biomarker for prostate cancer diagnosis as well as any association between SPON2 levels and clinicopathological features. We also compared the diagnostic performance of this biomarker to that of serum sarcosine, and percent free-to-total and total prostate specific antigen.

MATERIALS AND METHODS

SPON2 was measured using a sandwich enzyme linked immunosorbent assay in serum samples from 286 patients with prostate cancer and 68 with no evidence of malignancy, as confirmed by 10 to 12-core ultrasound guided prostate biopsy. Nonparametric statistical tests and ROC analysis were done to assess the diagnostic performance of SPON2 vs the other biomarkers.

RESULTS

Median serum SPON2 was significantly higher in patients with prostate cancer than in those with no evidence of malignancy (77.5 vs 23.6 ng/ml, p<0.0001). ROC analysis showed a higher predictive value of SPON2 (AUC 0.952) than of serum sarcosine (AUC 0.674), percent free-to-total prostate specific antigen (AUC 0.806) and total prostate specific antigen (AUC 0.561). Moreover, patients with low grade prostate cancer had higher median SPON2 levels (p=0.001). Spearman rank correlation confirmed a negative association with Gleason score (rs=-0.29, p=0.0005).

CONCLUSIONS

We found evidence that SPON2 levels were significantly higher in patients with prostate cancer than in healthy individuals. Moreover, this biomarker had better diagnostic performance than serum sarcosine, and percent free-to-total and total prostate specific antigen. This greater accuracy was also present in a subset of patients with normal prostate specific antigen.

Association between race and follow-up diagnostic care after a positive prostate cancer screening test in the prostate, lung, colorectal, and ovarian cancer screening trial

BACKGROUND

Follow-through of a positive screening test is necessary to reap the potential benefits of cancer screening. Racial variation in follow-through diagnostic care may underlie a proportion of the known disparity in prostate cancer mortality. The authors used data from the screening arm of the Prostate, Lung, Colorectal, and Ovarian (PLCO) cancer screening trial to determine whether race is associated with the use of follow-up diagnostic testing after a positive initial screening evaluation.

METHODS

Men who had a prostate-specific antigen (PSA) level >4 ng/mL at any time during the study were included. The proportion of men who underwent follow-up evaluation with a repeat PSA, a prostate biopsy, or either test within 9 months was determined, and the authors tested for differences in follow-through according to race using mixed-effects multivariate models with a random effect for accrual site to account for clustering. Models were stratified according to age (<65 years and ≥65 years).

RESULTS

Among 6294 men who had a PSA elevation during the study period, 70% underwent a repeat PSA or prostate biopsy within 9 months. Non-Hispanic black men aged <65 years had 45% lower odds of undergoing a repeat PSA test or prostate biopsy compared with non-Hispanic white men (odds ratio, 0.55; 95% confidence interval, 0.37-0.82), whereas there was no racial difference in follow-through among older men.

CONCLUSIONS

The current results suggest that limitations in access to care among non-Hispanic black men under the age of Medicare eligibility may underlie the paradoxically low use of follow-through diagnostic care among non-Hispanic black men in the United States.

The prognostic value of transrectal ultrasound guided biopsy in patients over 70 years old with a prostate specific Antigen (PSA) level ≤ 15 ng/ml and normal digital rectal examination: a 10-year prospective follow-up study of 427 consecutive patients

INTRODUCTION

As a urologist, it is common to review a patient above the age of 70 being referred to a prostate assessments clinic with an elevated PSA. We evaluate the prognosis of these patients clinically as there is no international consensus on the exact PSA cutoff level or a single international guideline as to when these patients should be offered a prostate biopsy.

PATIENTS AND METHODS

On receiving ethic committee approval, we recruited 427 consecutive patients aged 70 years and above referred with a PSA of ≥ 4 ng/ml, from January 1996 to December 2000, into our study. All patients were assessed, examined with a digital rectal examination (DRE) of the prostate, and a subsequent prostate biopsy. We followed up on their histologic diagnosis for up to 10 years and analyzed their outcome. The main outcome measures were disease-free survival and overall survival, stratified according to the PSA level (≤ 15 vs. >15 ng/ml) and DRE findings (normal vs. sbnormal).

RESULTS

There was a statistically significant difference in the overall survival (P value < 0.011) and disease specific survival (P value < 0.0001) of cancer patients with a PSA was >15 ng/ml and an abnormal DRE. However, in patients with a PSA ≤ 15 ng/ml and normal DRE, the incidence of cancer was low and they had no disease-specific or overall survival benefit.

CONCLUSIONS

A policy of deferring prostate biopsy in patients with a PSA ≤ 15 ng/ml and normal DRE (Group A) would significantly decrease the need of unnecessary prostate biopsies. Within this group, patients did not have any survival advantage compared with those without cancer. We conclude that up to 20% of the prostate biopsies performed in this age group could have been avoided.

Optimal baseline prostate-specific antigen level to distinguish risk of prostate cancer in healthy men between 40 and 69 years of age

The present study evaluated optimal baseline prostate-specific antigen (PSA) level at different ages in order to determine the risk of developing prostate cancer (CaP). We analyzed 6,651 Korean men, aged 40-69 yr. The serum PSA levels for these men were measured at one institute from 2000 to 2004 and were determined to be between 0-4 ng/mL. Patients were divided into 4 groups of 25th-percentile intervals, based on initial PSA level. Of these, the group with an increased risk was selected, and the optimal value was determined by the maximal area under a receiver-operating characteristic curve within the selected group. The risk of CaP diagnosis was evaluated by Cox regression. The mean follow-up period was 8.3 yr. CaP was detected in 27 of the 6,651 subjects. CaP detection rate was increased according to age. The optimal PSA value to distinguish the risk of CaP was 2.0 ng/mL for 50- to 69-yr-olds. Patients with a baseline PSA level greater than the optimal value had a 27.78 fold increase in the prostate cancer risk. Baseline PSA values are useful for determining the risk of developing CaP in Korean men for 50- and 69-yr-old. We suggest that PSA testing intervals be modified based on their baseline PSA levels.

[EAU guidelines on prostate cancer. Part I: screening, diagnosis, and treatment of clinically localised disease]

OBJECTIVE

Our aim was to present a summary of the 2010 version of the European Association of Urology (EAU) guidelines on the screening, diagnosis, and treatment of clinically localised cancer of the prostate (PCa).

METHODS

The working panel performed a literature review of the new data emerging from 2007 to 2010. The guidelines were updated, and level of evidence and grade of recommendation were added to the text based on a systematic review of the literature, which included a search of online databases and bibliographic reviews.

RESULTS

A full version is available at the EAU office or Web site (www.uroweb.org). Current evidence is insufficient to warrant widespread population-based screening by prostate-specific antigen (PSA) for PCa. A systematic prostate biopsy under ultrasound guidance and local anaesthesia is the preferred diagnostic method. Active surveillance represents a viable option in men with low-risk PCa and a long life expectancy. PSA doubling time in < 3 yr or a biopsy progression indicates the need for active intervention. In men with locally advanced PCa in whom local therapy is not mandatory, watchful waiting (WW) is a treatment alternative to androgen-deprivation therapy (ADT) with equivalent oncologic efficacy. Active treatment is mostly recommended for patients with localised disease and a long life expectancy with radical prostatectomy (RP) shown to be superior to WW in a prospective randomised trial. Nerve-sparing RP represents the approach of choice in organ-confined disease; neoadjuvant androgen deprivation demonstrates no improvement of outcome variables. Radiation therapy should be performed with at least 74Gy and 78Gy in low-risk and intermediate/high-risk PCa, respectively. For locally advanced disease, adjuvant ADT for 3 yr results in superior disease-specific and overall survival rates and represents the treatment of choice. Follow-up after local therapy is largely based on PSA, and a disease-specific history with imaging is indicated only when symptoms occur.

CONCLUSIONS

The knowledge in the field of PCa is rapidly changing. These EAU guidelines on PCa summarise the most recent findings and put them into clinical practice.

Robotic palpation-based mechanical property mapping for diagnosis of prostate cancer

PURPOSE

The aim of this study was to estimate the mechanical properties (elasticity) of normal and cancer prostate tissues and to develop a tissue elasticity map for the diagnosis and localization of prostate cancer.

MATERIALS AND METHODS

A total of 735 sites from 35 radical prostatectomy specimens were used in the experiments using a robotic palpation system, and the elasticities of the specimens were estimated by a tissue characterization algorithm. The estimated elasticities from 21 regions were separated into normal and cancer tissues using the pathological information, and a tissue elasticity map was developed using numerical functions and a nonlinear surface-fitting method.

RESULTS

The mean elastic moduli of the normal and cancer tissues were 15.25 ± 5.88 and 28.80 ± 11.20 kPa, respectively. The base region had the highest elasticity, followed by the medial and apex regions. These results demonstrated the ability to separate the cancer tissue from the normal tissue based on its elastic modulus. The tissue elasticity mapping was carried out using the estimated elasticity and nonlinear surface fitting. The proposed map showed the elasticity and was used to estimate the elastic modulus of the prostate at any given region.

CONCLUSION

Tissue elasticity may be an important indicator of prostate cancer because the pathologic changes alter the tissue properties, including cell integrity and intercellular matrix. This work provides quantitative and objective information for the diagnosis of prostate cancer. In addition, these results may have implications for the localization of prostate cancers.

EAU guidelines on prostate cancer. Part 1: screening, diagnosis, and treatment of clinically localised disease

OBJECTIVE

Our aim was to present a summary of the 2010 version of the European Association of Urology (EAU) guidelines on the screening, diagnosis, and treatment of clinically localised cancer of the prostate (PCa).

METHODS

The working panel performed a literature review of the new data emerging from 2007 to 2010. The guidelines were updated, and level of evidence and grade of recommendation were added to the text based on a systematic review of the literature, which included a search of online databases and bibliographic reviews.

RESULTS

A full version is available at the EAU office or Web site (www.uroweb.org). Current evidence is insufficient to warrant widespread population-based screening by prostate-specific antigen (PSA) for PCa. A systematic prostate biopsy under ultrasound guidance and local anaesthesia is the preferred diagnostic method. Active surveillance represents a viable option in men with low-risk PCa and a long life expectancy. PSA doubling time in <3 yr or a biopsy progression indicates the need for active intervention. In men with locally advanced PCa in whom local therapy is not mandatory, watchful waiting (WW) is a treatment alternative to androgen-deprivation therapy (ADT) with equivalent oncologic efficacy. Active treatment is mostly recommended for patients with localised disease and a long life expectancy with radical prostatectomy (RP) shown to be superior to WW in a prospective randomised trial. Nerve-sparing RP represents the approach of choice in organ-confined disease; neoadjuvant androgen deprivation demonstrates no improvement of outcome variables. Radiation therapy should be performed with at least 74 Gy and 78 Gy in low-risk and intermediate/high-risk PCa, respectively. For locally advanced disease, adjuvant ADT for 3 yr results in superior disease-specific and overall survival rates and represents the treatment of choice. Follow-up after local therapy is largely based on PSA, and a disease-specific history with imaging is indicated only when symptoms occur.

CONCLUSIONS

The knowledge in the field of PCa is rapidly changing. These EAU guidelines on PCa summarise the most recent findings and put them into clinical practice.

Utility of a 3-Dimensional Transrectal Ultrasound-guided Prostate Biopsy System for Prostate Cancer Detection

The 3-D transrectal ultrasound (TRUS)-guided prostate biopsy system is a novel device that allows precise needle placement in a template fashion. We evaluate its utility for prostate cancer (PCa) detection. A retrospective analysis was performed evaluating 68 prospective patients at the Duke Prostate Center who underwent a prostate biopsy using a 3-D TRUS-guided system. After creation of a three-dimensional map of the prostate, a computer algorithm identified an ideal biopsy scheme based on the measured dimensions of the prostate. The system then used a fixed template that allowed prostate biopsy at specific locations with the ability to target the same region of the prostate in the future if needed. For all patients, a 12-core biopsy pattern was used to cover medial and lateral areas of the base, mid-gland, and apex. In total, 68 patients underwent 3-D TRUS-guided prostate biopsies between April 2006 and November 2007 for prostate cancer detection. The indication for prostate biopsy was PSA ≥ 4.0 ng/ml in 47 (69%) patients, abnormal digital rectal examination (DRE) in 17 (25%), and atypia on previous biopsy in 4 (6%) patients. Prostate cancer was detected in 18 patients (26.5%) and 7 (10.3%) had atypical small acinar proliferation (ASAP). The highest frequency (55.5%) from all cases of cancer detected was identified when 3-D TRUS biopsy was used as the initial biopsy. This study demonstrates that a 3-D TRUS-guided biopsy system translates to a more frequent detection of prostate cancer among patients undergoing an initial prostate biopsy than a subsequent one. More comprehensive studies are warranted to corroborate and extend the results of this study.

Digital rectal examination, serum prostatic specific antigen or transrectal ultrasonography: the best tool to guide the treatment of men with benign prostatic hyperplasia

PURPOSE OF REVIEW

Benign prostatic hyperplasia can be considered a progressive disease, and identifying men with progressive disease could have a significant impact on the decision to choose the different therapeutic options. Numerous pieces of evidence demonstrate the impact of the prostate volume on the disease progression. It has been accepted that digital rectal examination, serum prostatic specific antigen and transrectal prostate ultrasound are the available tools for the prostate volume estimation. This review examines the updated information on these tools for their guidance in the benign prostatic hyperplasia management.

RECENT FINDINGS

Digital rectal examination is unreliable in assessing the prostate volume; however, it is still important to use it to rule out prostate cancer or neurological problems. Prostatic specific antigens should be recommended as a part of patient evaluation because of their impact on the prediction of disease progression. Transrectal prostate ultrasound may be the best tool in the estimation of the exact prostate size.

SUMMARY

Numerous pieces of evidence have clearly demonstrated the impact of the prostate volume on the disease progression. Digital rectal examination seems to be good at identifying very large prostate. Prostatic specific antigen is the best tool for predicting disease progression and guiding the therapeutic options. For surgical guidance, transrectal prostate ultrasound is the useful tool available for the exact prostate volume estimation.

[Clinical features and histopathology of prostate cancer diagnosed from the third biopsy]

OBJECTIVE

To study of histological and clinical features of prostate cancer diagnosed after three or more prostate biopsies in order to assess its clinical relevance and to discard the overdiagnosis of prostate cancer.

MATERIAL AND METHODS

We reviewed the clinical records of 61 patients who underwent three or more prostate biopsies between January 2000 and December 2006. The analyzed variables were: age, PSA level, free/total PSA ratio, PSA density, digital rectal examination, prostate volume, sonographic findings and previous malignant lesion strongly associated to the presence of tumor on previous biopsy. We studied the pathology of the tumors diagnosed from the third biopsy, therapeutical approach and its evolution with a minimum follow-up of 3 months.

RESULTS

Fifteen out of 61 patients with more than three biopsies had prostate cancer (24,59%) in the third biopsy, 5 out of 14 patients with 4 biopsies (35,71%) and 1 of the 2 cases (50%) who underwent a fifth biopsy. According to the results of biopsy, 6 patients met the criteria of clinically insignificant cancer (28,57%). Curative treatment was performed in all patients: brachytherapy in 5, external beam radiotherapy in 6 and radical prostatectomy in 10. Clinically significant tumors were found in all cases: 2 pT2b tumors and 7 pT2c tumors with negative surgical margins and with an excellent control of the cancer after a minimum follow up of 13 months, and one pT4 tumor with bladder neck infiltration.

CONCLUSION

In our practice, overall detection rate of the third, fourth and fifth biopsy is 34,42% corresponding with tumors that could benefit from curative treatment.

Digital rectal examination and the diagnosis of prostate cancer--a study based on 8 years and three screenings within the European Randomized Study of Screening for Prostate Cancer (ERSPC), Rotterdam

BACKGROUND

Evidence indicates that an abnormal digital rectal examination (DRE) is a risk factor for high-grade prostate cancer (PC).

OBJECTIVE

To determine whether men with an initially suspicious DRE, a prostate-specific antigen (PSA) level > or = 3.0 ng/ml, and a benign prostate biopsy are at higher risk for significant PC at rescreening than men with an initially normal DRE, and whether an adaptation of the rescreening interval is warranted for this group.

DESIGN, SETTING, AND PARTICIPANTS

Within the European Randomized Study of Screening for Prostate Cancer (ERSPC), Rotterdam, 2218 men underwent biopsy of the prostate (from 1993 to 2000) with a benign result at initial screening. The serum PSA was determined every 4 yr. A PSA level of > or = 3.0 ng/ml prompted a DRE and a lateralised sextant biopsy.

MEASUREMENTS

Number and characteristics of PCs found at repeat screenings and as interval cancers (ICs) were compared between men with or without a suspicious DRE result at initial screening. Multivariate logistic regression analyses were performed to evaluate if an initially suspicious DRE was a significant predictor for detecting cancer at consecutive screenings.

RESULTS AND LIMITATIONS

After 4 yr, the total number of PCs detected in men with and without an initially suspicious DRE was, respectively, 27 (6%) versus 103 (6%) (p=0.99). After 8 yr these numbers increased, respectively, to 45 (10%) versus 167 (10%) (p=0.88). The proportion of clinically significant PCs was 2% and 3%, respectively, for the group with initially normal and abnormal DRE after 8 yr. Having a suspicious DRE result at initial screening was not a significant predictor for detecting PC after 4 yr [odds ratio (OR)=1.15, p=0.59) or 8 yr (OR=1.41, p=0.43)]. A limitation of this study is the relatively short follow-up of 8 yr.

CONCLUSIONS

During a follow-up of 8 yr after initial cancer-negative biopsy, an initially suspicious DRE did not influence the chance for detection of cancer or significant cancer at later screens. An adaptation of the rescreening interval on the basis of the initial DRE-outcome is not warranted in future population-based screening for prostate cancer.