Transperineal Versus Transrectal Magnetic Resonance Imaging-targeted Biopsies for Prostate Cancer Diagnosis: Final Results of the Randomized PERFECT trial (CCAFU-PR1)

BACKGROUND

Recent guidelines favor transperineal (TP) prostate biopsies over the transrectal (TR) approach due to a reduced sepsis risk. Yet, evidence from controlled trial comparing both approaches within the MRI-targeted pathway for significant prostate cancer (PCa) detection is lacking.

OBJECTIVE

To compare the significant PCa detection rate between magnetic resonance imaging (MRI)-targeted TR and TP approaches in biopsy-naïve patients.

DESIGN, SETTING, AND PARTICIPANTS

In this noninferiority controlled trial, we randomized (ratio 1:1) 270 MRI-positive biopsy-naïve patients.

INTERVENTION

MRI-targeted TP versus TR biopsy.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSES

The primary outcome was the detection rate of significant PCa (International Society of Urological Pathology [ISUP] ≥2) in MRI-targeted biopsies. Secondary outcomes were any-grade PCa detection, detection on concomitant systematic biopsy, complications, and functional outcomes.

RESULTS AND LIMITATIONS

Targeted biopsies identified significant PCa in 47.2% of TP and 54.2% of TR participants (-7%, p = 0.6235). On a per-lesion analysis, posterior lesions yielded higher detection rates via TR (59.0% vs 44.3%, p = 0.0443), while anterior lesions were more frequently detected via TP (40.6% vs 26.5%, p = 0.2228). The overall (any grade) cancer detection rate in targeted biopsies was comparable between groups: 71.3% (TP) versus 64.1% (TR; p = 0.2209) with significantly more ISUP 1 cases detected in the TP arm. Adverse events of grade ≥2 were not different between TP (35.7%) and TR (40.5%, p = 0.4256). One TR patient (0.8%) experienced grade 3 sepsis. Quality of life, and urinary and sexual function, as well as pain scores, were comparable between groups.

CONCLUSIONS

Despite a comparable overall detection rate for any-grade PCa, noninferiority of TP over TR for MRI-targeted biopsies for significant PCa detection was not demonstrated. However, MRI lesion location influenced biopsy route performance, suggesting that a pragmatic approach based on lesion location might enhance significant PCa assessment.

PATIENT SUMMARY

This trial compared the efficacy and safety of two biopsy approaches for prostate cancer diagnosis. Both approaches seem complementary according to the lesion location.

Reference standard for the evaluation of automatic segmentation algorithms: Quantification of inter observer variability of manual delineation of prostate contour on MRI

PURPOSE

The purpose of this study was to investigate the relationship between inter-reader variability in manual prostate contour segmentation on magnetic resonance imaging (MRI) examinations and determine the optimal number of readers required to establish a reliable reference standard.

MATERIALS AND METHODS

Seven radiologists with various experiences independently performed manual segmentation of the prostate contour (whole-gland [WG] and transition zone [TZ]) on 40 prostate MRI examinations obtained in 40 patients. Inter-reader variability in prostate contour delineations was estimated using standard metrics (Dice similarity coefficient [DSC], Hausdorff distance and volume-based metrics). The impact of the number of readers (from two to seven) on segmentation variability was assessed using pairwise metrics (consistency) and metrics with respect to a reference segmentation (conformity), obtained either with majority voting or simultaneous truth and performance level estimation (STAPLE) algorithm.

RESULTS

The average segmentation DSC for two readers in pairwise comparison was 0.919 for WG and 0.876 for TZ. Variability decreased with the number of readers: the interquartile ranges of the DSC were 0.076 (WG) / 0.021 (TZ) for configurations with two readers, 0.005 (WG) / 0.012 (TZ) for configurations with three readers, and 0.002 (WG) / 0.0037 (TZ) for configurations with six readers. The interquartile range decreased slightly faster between two and three readers than between three and six readers. When using consensus methods, variability often reached its minimum with three readers (with STAPLE, DSC = 0.96 [range: 0.945-0.971] for WG and DSC = 0.94 [range: 0.912-0.957] for TZ, and interquartile range was minimal for configurations with three readers.

CONCLUSION

The number of readers affects the inter-reader variability, in terms of inter-reader consistency and conformity to a reference. Variability is minimal for three readers, or three readers represent a tipping point in the variability evolution, with both pairwise-based metrics or metrics with respect to a reference. Accordingly, three readers may represent an optimal number to determine references for artificial intelligence applications.

[Early detection of prostate cancer: Towards a new paradigm?]

Prostate cancer (PCa) is a public health issue. The diagnostic strategy for PCa is well codified and assessed by digital rectal examination, PSA testing and multiparametric MRI, which may or may not lead to prostate biopsies. The formal benefit of organized PCa screening, studied more than 10 years ago at an international scale and for all incomers, is not demonstrated. However, diagnostic and therapeutic modalities have evolved since the pivotal studies. The contribution of MRI and targeted biopsies, the widespread use of active surveillance for unsignificant PCa, the improvement of surgical techniques and radiotherapy… have allowed a better selection of patients and strengthened the interest for an individualized approach, reducing the risk of overtreatment. Aiming to enhance coverage and access to screening for the population, the European Commission recently promoted the evaluation of an organized PCa screening strategy, including MRI. The lack of screening programs has become detrimental to the population and must shift towards an early detection policy adapted to the risk of each individual.

3.0 T prostate MRI: Visual assessment of 2D and 3D T2-weighted imaging sequences using PI-QUAL score

PURPOSE

Comparing 2D and 3D T2 weighted sequences in terms of image quality in 3.0 T MRI with readers of varied experiences, using PI-QUAL inspired criteria.

METHODS

91 male patients with suspected prostate cancer (PCa) underwent diagnostic prostate MRI on a 3.0 T MR system using a 32-channel phased-array torso coil before prostate biopsy. MRI protocol included 3D T2w images, axial 2D T2w images, axial diffusion-weighted images (DWI) with the corresponding ADC apparent diffusion coefficient maps, and axial dynamic contrast enhanced images. 3D T2w and 2D T2w imaging were compared by 4 radiologists using a Likert scale for image quality (overall anatomy, delineation of capsule, seminal vesicles, ejaculatory ducts, sphincter muscle, artifacts), tumor delimitation and conspicuity.

RESULTS

No significant differences in terms of overall quality between 3D and 2D T2w images were found. However 2D T2w demonstrated higher rating than 3D T2w images as for the image quality of the external capsule, sphincter muscle and ejaculatory ducts delineation (p < 0.05).

CONCLUSION

3D T2w sequence can't replace 2D T2w sequence, despite good quality images but it remains more prone to artifacts. Quality of 2D T2w sequences was substantially superior to 3D sequences for delineation of key structures as external capsule, sphincter muscle. The use of PI-QUAL criteria allows reproducible analysis of the quality of T2 weighted images.

What is the ideal combination therapy in de novo, oligometastatic, castration-sensitive prostate cancer?

PURPOSE

To review current evidence regarding the management of de novo, oligometastatic, castration-sensitive prostate cancer (PCa).

METHODS

A literature search was conducted on PubMed/Medline and a narrative synthesis of the evidence was performed in August 2022.

RESULTS

Oligometastatic disease is an intermediate state between localized and aggressive metastatic PCa defined by ≤ 3-5 metastatic lesions, although this definition remains controversial. Conventional imaging has limited accuracy in detecting metastatic lesions, and the implementation of molecular imaging could pave the way for a more personalized treatment strategy. However, oncological data supporting this strategy are needed. Radiotherapy to the primary tumor should be considered standard treatment for oligometastatic PCa (omPCa). However, it remains to be seen whether local therapy still has an additional survival benefit in patients with de novo omPCa when treated with the most modern systemic therapy combinations. There is insufficient evidence to recommend cytoreductive radical prostatectomy as local therapy; or stereotactic body radiotherapy as metastasis-directed therapy in patients with omPCa. Current data support the use of intensified systemic therapy with androgen deprivation therapy (ADT) and next-generation hormone therapies (NHT) for patients with de novo omPCa. Docetaxel has not demonstrated benefit in low volume disease. There are insufficient data to support the use of triple therapy (i.e., ADT + NHT + Docetaxel) in low volume disease.

CONCLUSION

The present review discusses current data in de novo, omPCa regarding its definition, the increasing role of molecular imaging, the place of local and metastasis-directed therapies, and the intensification of systemic therapies.

Micro-ultrasound-guided biopsies versus systematic biopsies in the detection of prostate cancer: a systematic review and meta-analysis

PURPOSE

The diagnosis of prostate cancer (PCa) still relies on the performance of both targeted (TB) and systematic biopsies (SB). Micro-ultrasound (mUS)-guided biopsies demonstrated a high sensitivity in detecting clinically significant prostate cancer (csPCa), which could be comparable to that of magnetic resonance imaging (MRI)-TB, but their added value has not been compared to SB yet.

METHODS

We conducted a systematic review and meta-analysis, based on Medline, EMBASE, Scopus, and Web of Science, in accordance with PRISMA guidelines, to compare mUS-guided biopsies to SB.

RESULTS

Based on the literature search of 2957 articles, 15 met the inclusion criteria (2967 patients). Most patients underwent mUS-guided biopsies, followed by MRI-TB and SB. Respectively 5 (n = 670) and 4 (n = 467) studies, providing raw data on SB, were included in a random-effect meta-analysis of the detection rate of csPCa, i.e. Gleason Grade Group (GGG) ≥ 2 or non-csPCa (GGG = 1). Overall, PCa was detected in 56-71% of men, with 31.3-49% having csPCa and 17-25.4% having non-csPCa. Regarding csPCa, mUS-guided biopsies identified 196 and SB 169 cases (Detection Ratio (DR): 1.18, 95% CI 0.83-1.68, I2 = 69%), favoring mUS-guided biopsies; regarding non-csPCa, mUS-guided biopsies identified 62 and SB 115 cases (DR: 0.55, 95% CI 0.41-0.73, I2 = 0%), also favoring mUS-guided biopsies by decreasing unnecessary diagnosis.

CONCLUSION

Micro-ultrasound-guided biopsies compared favorably with SB for the detection of csPCa and detected fewer non-csPCa than SB. Prospective trials are awaited to confirm the interest of adding mUS-guided biopsies to MRI-TB to optimize csPCa detection without increasing overdiagnosis of non-csPCa.

Automatic segmentation of prostate zonal anatomy on MRI: a systematic review of the literature

OBJECTIVES

Accurate zonal segmentation of prostate boundaries on MRI is a critical prerequisite for automated prostate cancer detection based on PI-RADS. Many articles have been published describing deep learning methods offering great promise for fast and accurate segmentation of prostate zonal anatomy. The objective of this review was to provide a detailed analysis and comparison of applicability and efficiency of the published methods for automatic segmentation of prostate zonal anatomy by systematically reviewing the current literature.

METHODS

A Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) was conducted until June 30, 2021, using PubMed, ScienceDirect, Web of Science and EMBase databases. Risk of bias and applicability based on Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) criteria adjusted with Checklist for Artificial Intelligence in Medical Imaging (CLAIM) were assessed.

RESULTS

A total of 458 articles were identified, and 33 were included and reviewed. Only 2 articles had a low risk of bias for all four QUADAS-2 domains. In the remaining, insufficient details about database constitution and segmentation protocol provided sources of bias (inclusion criteria, MRI acquisition, ground truth). Eighteen different types of terminology for prostate zone segmentation were found, while 4 anatomic zones are described on MRI. Only 2 authors used a blinded reading, and 4 assessed inter-observer variability.

CONCLUSIONS

Our review identified numerous methodological flaws and underlined biases precluding us from performing quantitative analysis for this review. This implies low robustness and low applicability in clinical practice of the evaluated methods. Actually, there is not yet consensus on quality criteria for database constitution and zonal segmentation methodology.

Clinical Trial Protocol for PERFECT: A Randomised Controlled Trial Comparing the Efficiency and Tolerance of Transperineal Fusion Versus Transrectal Imaging-targeted Prostate Biopsies (CCAFU-PR1 Study)

PERFECT is a multicentre randomised controlled clinical trial that evaluates the efficiency of fusion magnetic resonance imaging-targeted biopsies in the transperineal (TP) versus transrectal (TR) approach in terms of the detection of significant cancers. Our study builds on the hypothesis that the TP approach for prostate biopsies has at least the same diagnostic accuracy as the TR approach, with lower morbidity. Here, we describe the clinical protocol, study population, and primary and secondary outcomes.

Promoting the use of the PRECISE score for prostate MRI during active surveillance: results from the ESOR Nicholas Gourtsoyiannis teaching fellowship

Objectives

The PRECISE criteria for serial multiparametric magnetic resonance imaging (MRI) of the prostate during active surveillance recommend the use of a dedicated scoring system (PRECISE score) to assess the likelihood of clinically significant radiological change. This pilot study assesses the effect of an interactive teaching course on prostate MRI during active surveillance in assessing radiological change in serial imaging.

Methods

Eleven radiology fellows and registrars with different experience in prostate MRI reading participated in a dedicated teaching course where they initially evaluated radiological change (based on their previous training in prostate MRI reading) independently in fifteen patients on active surveillance (baseline and follow-up scan), and then attended a lecture on the PRECISE score. The initial scans were reviewed for teaching purposes and afterwards the participants re-assessed the degree of radiological change in a new set of images (from fifteen different patients) applying the PRECISE score. Receiver operating characteristic analysis was performed. Confirmatory biopsies and PRECISE scores given in consensus by two radiologists (involved in the original draft of the PRECISE score) were the reference standard.

Results

There was a significant improvement in the average area under the curve (AUC) for the assessment of radiological change from baseline (AUC: 0.60 [Confidence Intervals: 0.51–0.69] to post-teaching (AUC: 0.77 [0.70–0.84]). This was an improvement of 0.17 [0.016–0.28] (p = 0.004).

Conclusions

A dedicated teaching course on the use of the PRECISE score improves the accuracy in the assessment of radiological change in serial MRI of the prostate.

Vasectomy and Risk of Prostate Cancer: A Systematic Review and Meta-analysis

Context

Previous reports have shown an association between vasectomy and prostate cancer (PCa). However, there exist significant discrepancies between studies and systematic reviews due to a lack of strong causal association and residual confounding factors such as prostate-specific antigen (PSA) screening.

Objective

To assess the association between vasectomy and PCa, in both unadjusted and PSA screen-adjusted studies.

Evidence acquisition

We performed a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses. The PubMed, Scopus, and Web of Science databases were searched in January 2022 for studies that analyzed the association between vasectomy and PCa.

Evidence synthesis

A total of 37 studies including 16 931 805 patients met our inclusion criteria. A pooled analysis from all studies showed a significant association between vasectomy and any-grade PCa (odds ratio [OR] 1.23; 95% confidence interval [CI], 1.10–1.37; p < 0.001; I² = 96%), localized PCa (OR 1.08; 95% CI, 1.06–1.11; p < 0.00001; I² = 31%), or advanced PCa (OR 1.07; 95% CI, 1.02–1.13; p = 0.006; I² = 0%). The association with PCa remained significant when the analyses were restricted to studies with a low risk of bias (OR 1.06; 95% CI, 1.02–1.10; p = 0.02; I² = 48%) or cohort studies (OR 1.09; 95% CI, 1.04–1.13; p < 0.0001; I² = 64%). Among studies adjusted for PSA screening, the association with localized PCa (OR 1.06; 95% CI, 1.03–1.09; p < 0.001; I² = 0%) remained significant. Conversely, vasectomy was no longer associated with localized high-grade (p = 0.19), advanced (p = 0.22), and lethal (p = 0.42) PCa.

Conclusions

Our meta-analysis found an association between vasectomy and any, mainly localized, PCa. However, the effect estimates of the association were increasingly close to null when examining studies of robust design and high quality. On exploratory analyses including studies, which adjusted for PSA screening, the association for aggressive and/or advanced PCa diminished.

Patient summary

In this study, we found an association between vasectomy and the risk of developing localized prostate cancer without being able to determine whether the procedure leads to a higher prostate cancer incidence.

How PET-CT is Changing the Management of Non-metastatic Castration-resistant Prostate Cancer?: Comment la TEP-TDM Peut Modifier la Prise en Charge du Cancer de la Prostate Non Métastatique Résistant à la Castration ?

INTRODUCTION

The aim of this narrative review conducted by the Prostate Cancer Committee of the French Association of Urology (CC-AFU) was to provide an update on the current evidence for the impact of PET/CT in the management of men with non-metastatic castration-resistant prostate cancer (nmCRPC).

MATERIAL AND METHODS

This review is based on data available in the literature on PET/CT imaging for staging nmCRPC patients. A PubMed search and narrative review of the data were performed in March 2022. Only articles in French or English were considered.

RESULTS

Current guidelines recommend bone scan and CT scan as standard imaging modalities for staging and follow-up of patients with nmCRPC. Nearly one-third of asymptomatic patients with presumed nmCRPC ultimately have metastatic disease on conventional imaging. Increasing reports have shown that conventional imaging has limited accuracy in detecting metastatic disease in nmCRPC patients, leading to the development of next-generation imaging techniques. In a retrospective study, 18F-choline PET/CT detected distant metastases in 27/58 high-risk nmCRPC patients with prior negative conventional imaging. The implementation of radiolabeled ligands of the prostate-specific membrane antigen (PSMA) PET/CT in staging strategy has resulted in metastasis detection in 45% to 98% of patients with presumptive nmCRPC on conventional imaging. Such an early diagnosis of metastatic CRPC may allow patients to be referred for metastasis-directed therapies (i.e. stereotactic body radiotherapy), aimed at prolonging the efficacy of systemic therapies and improving clinical outcomes. However, current data are not strong enough to recommend this strategy, which must be properly evaluated in clinical trials. Indeed, the use of molecular imaging may lead to inappropriate undertreatment if the second-generation androgen receptor inhibitors (darolutamide, enzalutamide, apalutamide), which prolong life, are not used in the subgroup of patients with high PSA velocity (PSA doubling time <10 months).

CONCLUSION

Implementation of PSMA-PET/CT in the staging strategy would result in a migration of disease stage to extra-pelvic, M1 disease in at least half of presumed nmCRPC patients. The unprecedented accuracy of PSMA-PET/CT may pave the way for a more personalized treatment strategy. However, no data yet support this strategy for all nmCRPC patients as no oncologic benefit of early detection of M1 disease or MDT has been demonstrated. © 2022 Elsevier Masson SAS. All rights reserved.

Narrative review of PET/CT performances at biochemical recurrence in prostate cancer after radical prostatectomy and impact on patient disease management: Revue narrative à propos des performances de la TEP/TDM en cas de récidive biochimique après prostatectomie radicale dans le cancer de la prostate et impact sur la prise en charge des patients

Patients treated by radical prostatectomy (RP) for localized prostate cancer (PCa) may experience biochemical recurrence (BCR) in approximately 30% of cases. Recently, advances in imaging modalities and in particular Positron-Emission Tomography with computed tomography (PET/CT) imaging allow for better detection and characterization of lesions outside the prostatic bed at recurrence. Thus, treatment at BCR can be significantly improved by a tailored strategy based on new generation imaging. A more precise and accurate staging of the disease at recurrence paves the way to more appropriate treatment, potentially translating into better survival outcomes of these patients. This review therefore highlights the interest of PET/CT at the time of BCR, its superiority over standard imaging in terms of staging, and its impact on guiding the different therapeutic possibilities depending on the site, number, and volumes of recurrence. Indeed, we will discuss below about different strategies and their indications: salvage radiotherapy of the prostate bed, systemic therapies, stereotactic body radiotherapy and others therapeutical strategies. The various innovative approaches based on PET/CT implementation are partly underway within protocol trials to prove their benefits on clinically meaningful endpoints. © 2022 Elsevier Masson SAS. All rights reserved.

PARP Inhibitors as Monotherapy in Daily Practice for Advanced Prostate Cancers

Despite recent improvements in survival, metastatic castration-resistant prostate cancers (mCRPCs) remain lethal. Alterations in genes involved in the homologous recombination repair (HRR) pathway are associated with poor prognosis. Poly-ADP-ribose polymerase (PARP) inhibitors (PARPis) have demonstrated anti-tumoral effects by synthetic lethality in patients with mCRPCs harboring HRR gene alterations, in particular BRCA2. While both olaparib and rucaparib have obtained government approvals for use, the selection of eligible patients as well as the prescription of these treatments within the clinical urology community are challenging. This review proposes a brief review of the rationale and outcomes of PARPi treatment, then a pragmatic vision of PARPi use in terms of prescription and the selection of patients based on molecular screening, which can involve potential genetic counseling in the case of associated germinal alterations.

Targeting Local Recurrence After Surgery With MRI Imaging for Prostate Cancer in the Setting of Salvage Radiation Therapy

Magnetic resonance imaging (MRI) is being increasingly used for imaging suspected recurrence in prostate cancer therapy. Functional MRI with diffusion and perfusion imaging has the potential to demonstrate local recurrence even at low PSA value. Detection of recurrence can modify the management of postprostatectomy biochemical recurrence. MRI scan acquired before salvage radiotherapy is useful for the localization of recurrent tumors and also in the delineation of the target volume. The objective of this review is to assess the role and potential impact of MRI in targeting local recurrence after surgery for prostate cancer in the setting of salvage radiation therapy.

Automatic zonal segmentation of the prostate from 2D and 3D T2-weighted MRI and evaluation for clinical use

Purpose: An accurate zonal segmentation of the prostate is required for prostate cancer (PCa) management with MRI. Approach: The aim of this work is to present UFNet, a deep learning-based method for automatic zonal segmentation of the prostate from T2-weighted (T2w) MRI. It takes into account the image anisotropy, includes both spatial and channelwise attention mechanisms and uses loss functions to enforce prostate partition. The method was applied on a private multicentric three-dimensional T2w MRI dataset and on the public two-dimensional T2w MRI dataset ProstateX. To assess the model performance, the structures segmented by the algorithm on the private dataset were compared with those obtained by seven radiologists of various experience levels. Results: On the private dataset, we obtained a Dice score (DSC) of 93.90 ± 2.85 for the whole gland (WG), 91.00 ± 4.34 for the transition zone (TZ), and 79.08 ± 7.08 for the peripheral zone (PZ). Results were significantly better than other compared networks' ( p - value < 0.05 ). On ProstateX, we obtained a DSC of 90.90 ± 2.94 for WG, 86.84 ± 4.33 for TZ, and 78.40 ± 7.31 for PZ. These results are similar to state-of-the art results and, on the private dataset, are coherent with those obtained by radiologists. Zonal locations and sectorial positions of lesions annotated by radiologists were also preserved. Conclusions: Deep learning-based methods can provide an accurate zonal segmentation of the prostate leading to a consistent zonal location and sectorial position of lesions, and therefore can be used as a helping tool for PCa diagnosis.

Same-day-discharge Robot-assisted Radical Prostatectomy: An Annual Countrywide Analysis

There are no countrywide data regarding the utilization of same-day-discharge (SDD) surgery for robot-assisted radical prostatectomy (RARP). We aimed to evaluate the annual number of SDD RARP procedures in France and to compare postoperative outcomes in SDD versus non-SDD centers. Data for all 9651 patients undergoing RARP in France in 2020 were extracted from the central database of the national healthcare system. Endpoints were length of hospital stay, patient age, center volume, lymph node dissection, and the hospital readmission rate. Overall, 184 SDD cases (1.9%) were reported in 14.2% of RARP centers. The annual RARP and SDD RARP caseload ranged from 41 to 485, and from one to 47, respectively, in SDD centers. SDD was significantly associated with higher-volume centers (p < 0.001). No difference in readmission rate (7.9% vs 5.1%; p = 0.141) was observed for SDD versus non-SDD centers. Direct stay costs were estimated at €1457 in SDD centers compared to €2021 in non-SDD centers. The main limitation is the lack of detailed patient characteristics and readmission causes. This annual nationwide analysis suggests that SDD RARP remains infrequently used in routine practice in France despite being associated with comparable short-term outcomes after RARP and potential cost benefits.

Patient summary

We evaluated the use of robot-assisted removal of the prostate (RARP) with same-day hospital discharge in France for men with prostate cancer. In 2020, only 1.9% of the 9651 RARP procedures involved same-day discharge, even though the data show that this approach has lower costs and comparable safety.

Overview of the Development and Use of Akt Inhibitors in Prostate Cancer

Deregulation of the PI3K-Akt-mTOR pathway plays a critical role in the development and progression of many cancers. In prostate cancer, evidence suggests that it is mainly driven by PTEN loss of function. For many years, the development of selective Akt inhibitors has been challenging. In recent phase II and III clinical trials, Ipatasertib and Capivasertib associated with androgen deprivation therapies showed promising outcomes in patients with metastatic castration-resistant prostate cancer and PTEN-loss. Ongoing trials are currently assessing several Akt inhibitors in prostate cancer with different combinations, at different stages of the disease.

Oncologic Impact and Safety of Pre-Operative Radiotherapy in Localized Prostate and Bladder Cancer: A Comprehensive Review from the Cancerology Committee of the Association Française d'Urologie

Simple Summary

Radiotherapy may have an interesting role of reinforcing the loco-regional control of cancer, in addition to surgery, when used as a preoperative treatment. This sequence has demonstrated its efficacy and safety in various malignancies, but no strong data exist in the era of uro-oncology. In this review article, we aim to highlight the potential usefulness of preoperative radiotherapy in prostate and muscle-invasive bladder cancer, aiming to enhance pathological response and local control and to prevent intraoperative tumor seeding. We also emphasize the need for further clinical studies assessing the functional safety of subsequent surgical procedures in a competitive context of new systemic agents that have proven to demonstrate a survival benefit in locally advanced urologic cancers.

Abstract

Preoperative radiotherapy (RT) is commonly used for the treatment of various malignancies, including sarcomas, rectal, and gynaecological cancers, but it is preferentially used as a competitive treatment to radical surgery in uro-oncology or as a salvage procedure in cases of local recurrence. Nevertheless, preoperative RT represents an attractive strategy to prevent from intraoperative tumor seeding in the operative field, to sterilize microscopic extension outside the organ, and to enhance the pathological and/or imaging tumor response rate. Several clinical works support this research field in uro-oncology. In this review article, we summarized the oncologic impact and safety of preoperative RT in localized prostate and muscle-invasive bladder cancer. Preliminary studies suggest that both modalities can be complementary as initial primary tumor treatments and that a pre-operative radiotherapy strategy could be beneficial in a well-defined population of patients who are at a very high-risk of local relapse. Future prospective trials are warranted to evaluate the oncologic benefit of such a combination of local treatments in addition to new life-prolonging systemic therapies, such as immunotherapy, and new generation hormone therapies. Moreover, the safety and the feasibility of salvage surgical procedures due to non-response or local recurrence after pelvic RT remain poorly evaluated in that context.

Annual nationwide analysis of costs and post-operative outcomes after radical prostatectomy according to the surgical approach (open, laparoscopic, and robotic)

OBJECTIVE

Annual countrywide data are scarce when comparing surgical approaches in terms of hospital stay outcomes and costs for radical prostatectomy (RP). We aimed to assess the impact of surgical approach on post-operative outcomes and costs after RP by comparing open (ORP), laparoscopic (LRP), and robot-assisted (RARP) RP in the French healthcare system.

PATIENTS AND METHODS

Data from all patients undergoing RP in France in 2020 were extracted from the central database of the national healthcare system. Primary endpoints were length of hospital stay (LOS including intensive care unit (ICU) stay if present), complications (estimated by severity index), hospital readmission rates (at 30 and 90 days), and direct costs of initial stay.

RESULTS AND LIMITATIONS

A total of 19,018 RPs were performed consisting in ORP in 21.1%, LRP in 27.6%, and RARP in 51.3% of cases. RARP was associated with higher center volume (p < 0.001), lower complication rates (p < 0.001), shorter LOS (p < 0.001), and lower readmission rates (p = 0.004). RARP was associated with reduced direct stay costs (2286 euros) compared with ORP (4298 euros) and LRP (3101 euros). The main cost driver was length of stay. The main limitations were the lack of mid-term data, readmission details, and cost variations due to surgery system.

CONCLUSIONS

This nationwide analysis demonstrates the benefits of RARP in terms of post-operative short-term outcomes. Higher costs related to the robotic system appear to be balanced by patient care improvements and reduced direct costs due to shorter LOS.

A 5-Year Contemporary Nationwide Evolution of the Radical Prostatectomy Landscape

The evolution in the past decade of recommendations for prostate cancer (PCa) management, from screening to surgical treatment, may have affected the radical prostatectomy (RP) landscape. However, comprehensive data at a national level remain scarce. We extracted 5-yr data for RP patients in France from the central database of the national health care system. The primary endpoints were surgical approach (open [ORP], laparoscopic [LRP], and robot-assisted RP [RARP]), length of stay (LOS), and complication and readmission rates. The annual number of RPs was stable during the study period. The proportion of RARPs increased from 39.8% in 2015 to 52.6% in 2019, whereas the proportion of ORPs decreased from 34.4% to 24.5%. LOS continuously decreased over time irrespective of the surgical approach. The proportion of centres in the highest quartile of hospital volume increased from 22.0% to 28.3% (p = 0.006). LOS and complication and readmission rates were significantly lower (p < 0.001) in the LRP cohort at each time point. National trends confirmed that RARP progressively replaced ORP, with a stable number of annual RPs over time. Greater centralisation and better early postoperative outcomes were observed with laparoscopy.

Patient summary

We reviewed French data for patients undergoing removal of the prostate for prostate cancer between 2015 and 2019. We found that robot-assisted minimally invasive surgery has increased over time and the length of hospital stays has decreased. Rates of complications and readmission were lower with minimally invasive surgery.

Biomarker in Active Surveillance for Prostate Cancer: A Systematic Review

Active surveillance (AS) in prostate cancer (PCa) represents a curative alternative for men with localised low-risk PCa. Continuous improvement of AS patient's selection and surveillance modalities aims at reducing misclassification, simplifying modalities of surveillance and decreasing need for invasive procedures such repeated biopsies. Biomarkers represent interesting tools to evaluate PCa diagnosis and prognosis, of which many are readily available or under evaluation. The aim of this review is to investigate the biomarker performance for AS selection and patient outcome prediction. Blood, urinary and tissue biomarkers were studied and a brief description of use was proposed along with a summary of major findings. Biomarkers represent promising tools which could be part of a more tailored risk AS strategy aiming to offer personalized medicine and to individualize the treatment and monitoring of each patient. The usefulness of biomarkers has mainly been suggested for AS selection, whereas few studies have investigated their role during the monitoring phase. Randomized prospective studies dealing with imaging are needed as well as larger prospective studies with long-term follow-up and strong oncologic endpoints.

Challenge of prostate MRI segmentation on T2-weighted images: inter-observer variability and impact of prostate morphology

Background

Accurate prostate zonal segmentation on magnetic resonance images (MRI) is a critical prerequisite for automated prostate cancer detection. We aimed to assess the variability of manual prostate zonal segmentation by radiologists on T2-weighted (T2W) images, and to study factors that may influence it.

Methods

Seven radiologists of varying levels of experience segmented the whole prostate gland (WG) and the transition zone (TZ) on 40 axial T2W prostate MRI images (3D T2W images for all patients, and both 3D and 2D images for a subgroup of 12 patients). Segmentation variabilities were evaluated based on: anatomical and morphological variation of the prostate (volume, retro-urethral lobe, intensity contrast between zones, presence of a PI-RADS ≥ 3 lesion), variation in image acquisition (3D vs 2D T2W images), and reader’s experience. Several metrics including Dice Score (DSC) and Hausdorff Distance were used to evaluate differences, with both a pairwise and a consensus (STAPLE reference) comparison.

Results

DSC was 0.92 (± 0.02) and 0.94 (± 0.03) for WG, 0.88 (± 0.05) and 0.91 (± 0.05) for TZ respectively with pairwise comparison and consensus reference. Variability was significantly (p < 0.05) lower for the mid-gland (DSC 0.95 (± 0.02)), higher for the apex (0.90 (± 0.06)) and the base (0.87 (± 0.06)), and higher for smaller prostates (p < 0.001) and when contrast between zones was low (p < 0.05). Impact of the other studied factors was non-significant.

Conclusions

Variability is higher in the extreme parts of the gland, is influenced by changes in prostate morphology (volume, zone intensity ratio), and is relatively unaffected by the radiologist’s level of expertise.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13244-021-01010-9.

Reliability of Serial Prostate Magnetic Resonance Imaging to Detect Prostate Cancer Progression During Active Surveillance: A Systematic Review and Meta-analysis

CONTEXT

Although magnetic resonance imaging (MRI) is broadly implemented into active surveillance (AS) protocols, data on the reliability of serial MRI in order to help guide follow-up biopsy are inconclusive.

OBJECTIVE

To assess the diagnostic estimates of serial prostate MRI for prostate cancer (PCa) progression during AS.

EVIDENCE ACQUISITION

We systematically searched PubMed, Scopus, and Web of Science databases to select studies analyzing the association between changes on serial prostate MRI and PCa progression during AS. We included studies that provided data for MRI progression, which allowed us to calculate diagnostic estimates. We compared Prostate Cancer Radiological Estimation of Change in Sequential Evaluation (PRECISE) accuracy with institution-specific definitions.

EVIDENCE SYNTHESIS

We included 15 studies with 2240 patients. Six used PRECISE criteria and nine institution-specific definitions of MRI progression. The pooled PCa progression rate, which included histological progression to Gleason grade ≥2, was 27%. The pooled sensitivity and specificity were 0.59 (95% confidence interval [CI] 0.44-0.73) and 0.75 (95% CI 0.66-0.84) respectively. There was significant heterogeneity between included studies. Depending on PCa progression prevalence, the pooled negative predictive value for serial prostate MRI ranged from 0.81 (95% CI 0.73-0.88) to 0.88 (95% CI 0.83-0.93) and the pooled positive predictive value ranged from 0.37 (95% CI 0.24-0.54) to 0.50 (95% CI 0.36-0.66). There were no significant differences in the pooled sensitivity (p = 0.37) and specificity (p = 0.74) of PRECISE and institution-specific schemes.

CONCLUSIONS

Serial MRI still should not be considered a sole factor for excluding PCa progression during AS, and changes on MRI are not accurate enough to indicate PCa progression. There was a nonsignificant trend toward improved diagnostic estimates of PRECISE recommendations. These findings highlight the need to further define the optimal triggers and timing of biopsy during AS, as well as the need for optimizing the quality, interpretation, and reporting of serial prostate MRI.

PATIENT SUMMARY

Our study suggests that serial prostate magnetic resonance imaging (MRI) alone in patients on active surveillance is not accurate enough to reliably rule out or rule in prostate cancer progression. Other clinical factors and biomarkers along with serial MRI are required to safely tailor the intensity of follow-up biopsies.

Prostate cancer local staging using biparametric MRI: assessment and comparison with multiparametric MRI

PURPOSE

The value of adding dynamic contrast-enhanced (DCE) imaging to T2-weighted (T2W) magnetic resonance imaging (MRI) and diffusion-weighted imaging (DWI) to improve the detection and staging of prostate cancer (PCa) is unclear. The aim of this retrospective study was to compare the diagnostic performance of non-contrast biparametric MRI (bpMRI) with multiparametric MRI (mpMRI), for local staging of PCa.

METHODS

Ninety-two patients who underwent prostate MRI on a 3-Tesla MRI system before radical prostatectomy for PCa were included retrospectively. Four readers independently assigned a Likert score (ranging from 1 to 5) for predicting extra-prostatic extension (EPE) on T2W + DWI (bpMRI) and then on T2W + DWI + DCE imaging (mpMRI). MRI-based staging results were compared with radical prostatectomy histology. A prediction of EPE generalized linear mixed model was used to assess the added-value of DCE and discriminative power of staging accuracy by area under the receiver-operating curve (AUC ROC).

RESULTS

AUC was not significantly improved by DCE (mpMRI, AUC = 0.73 [95%CI: 0.655‒0.827] vs. bpMRI, AUC = 0.76 [95%CI: 0.681‒0.846]). After applying a selection procedure, only MRI criteria were retained in a multivariate model. The following criteria were significantly associated with local extension: localization in the peripheral zone (p < 0.001), maximal diameter of the lesion (<0.0001), curvilinear capsular contact on T2W (p < 0.0001), capsular irregularity on T2W (p < 0.0001), bulging on T2W (p < 0.001) and seminal vesicle hypo-signal (p < 0.001).

CONCLUSION

Use of bpMRI did not result in a decrease in local staging accuracy.

[French CCAFU guidelines on prostate cancer: hormone-sensitive metastatic prostate cancer-update 2020]

OBJECTIVE

The aim of the Cancerology Committee of the French Association of urology (CCAFU) is to propose an update of the guidelines in the management of hormone-sensitive metastatic prostate cancer.

METHODS

A systematic review (Medline) of the literature from 2018 to 2020 was conducted by the CCAFU Findings. Several patterns can be defined at this stage depending on prognostic, metastatic volume, and whether metastases are synchronous or metachronous. Androgenic deprivation therapy (ADT) remains the mainstay of treatment at the metastatic stage. Docetaxel in combination with ADT improves overall survival in synchronous metastatic prostate cancer. In this situation, the combination of ADT with abiraterone is also a standard of care regardless of tumor volume. Recent data have led to the recommendation that ADT should be used in conjunction with a new generation hormone therapy (Apalutamide or Enzalutamide) in metastatic synchronous or metachronous patients, regardless of tumour volume. Local treatment of prostate cancer with radiotherapy improves survival in synchronous oligometastatic patients. Metastases-directed therapy is being evaluated.

CONCLUSION

This update of the French recommendations should help improve the management of patients with prostate cancer.

Assessment of the Minimal Targeted Biopsy Core Number per MRI Lesion for Improving Prostate Cancer Grading Prediction

Background: To study the impact of MRI characteristics and of targeted biopsy (TB) core number on the final grade group (GG) prediction. Materials and Methods: The cohort was 478 consecutive patients who underwent radical prostatectomy (RP) after positive mpMRI (multiparametric magnetic resonance imaging) followed by fusion TB. Endpoints were the upgrading and concordance rates between TB and RP specimens. Results: Upgrading rate after TB was 40.6%. Patients with upgrading had lower PIRADS (Prostate Imaging-Reporting and Data System) scores (p < 0.001), smaller lesion size (p = 0.017), fewer TB cores (p < 0.001), and lower TB density (p = 0.015) compared with cases with grade concordance. There was a significant continuous improvement in upgrading rate when TB core number per lesion increased from 56.3% to 25.6% when <2 or ≥5 TB cores were taken, respectively (p = 0.002). The minimal TB number per lesion to reduce upgrading risk to approximately 30%was 4 in PIRADS 3, and 3 in PIRADS 4–5 cases. Conclusions: Grade group prediction by TB is significantly improved by higher PIRADS score, larger lesion size, and increased TB per lesion. At least four TB cores should be taken in PIRADS 3 score lesions, whereas three cores seem enough in PIRADS 4–5 cases to improve GG prediction and limit upgrading risk.

Imaging protocols for renal multiparametric MRI and MR urography: results of a consensus conference from the French Society of Genitourinary Imaging

OBJECTIVES

To develop technical guidelines for magnetic resonance imaging aimed at characterising renal masses (multiparametric magnetic resonance imaging, mpMRI) and at imaging the bladder and upper urinary tract (magnetic resonance urography, MRU).

METHODS

The French Society of Genitourinary Imaging organised a Delphi consensus conference with a two-round Delphi survey followed by a face-to-face meeting. Two separate questionnaires were issued for renal mpMRI and for MRU. Consensus was strictly defined using a priori criteria.

RESULTS

Forty-two expert uroradiologists completed both survey rounds with no attrition between the rounds. Fifty-six of 84 (67%) statements of the mpMRI questionnaire and 44/71 (62%) statements of the MRU questionnaire reached final consensus. For mpMRI, there was consensus that no injection of furosemide was needed and that the imaging protocol should include T2-weighted imaging, dual chemical shift imaging, diffusion-weighted imaging (use of multiple b-values; maximal b-value, 1000 s/mm²) and fat-saturated single-bolus multiphase (unenhanced, corticomedullary, nephrographic) contrast-enhanced imaging; late imaging (more than 10 min after injection) was judged optional. For MRU, the patients should void their bladder before the examination. The protocol must include T2-weighted imaging, anatomical fast T1/T2-weighted imaging, diffusion-weighted imaging (use of multiple b-values; maximal b-value, 1000 s/mm²) and fat-saturated single-bolus multiphase (unenhanced, corticomedullary, nephrographic, excretory) contrast-enhanced imaging. An intravenous injection of furosemide is mandatory before the injection of contrast medium. Heavily T2-weighted cholangiopancreatography-like imaging was judged optional.

CONCLUSION

This expert-based consensus conference provides recommendations to standardise magnetic resonance imaging of kidneys, ureter and bladder.

KEY POINTS

• Multiparametric magnetic resonance imaging (mpMRI) aims at characterising renal masses; magnetic resonance urography (MRU) aims at imaging the urinary bladder and the collecting systems. • For mpMRI, no injection of furosemide is needed. • For MRU, an intravenous injection of furosemide is mandatory before the injection of contrast medium; heavily T2-weighted cholangiopancreatography-like imaging is optional.

Imaging protocols for CT urography: results of a consensus conference from the French Society of Genitourinary Imaging

OBJECTIVES

To develop technical guidelines for computed tomography urography.

METHODS

The French Society of Genitourinary Imaging organised a Delphi consensus conference with a two-round Delphi survey followed by a face-to-face meeting. Consensus was strictly defined using a priori criteria.

RESULTS

Forty-two expert uro-radiologists completed both survey rounds with no attrition between the rounds. Ninety-six (70%) of the initial 138 statements of the questionnaire achieved final consensus. An intravenous injection of 20 mg of furosemide before iodinated contrast medium injection was judged mandatory. Improving the quality of excretory phase imaging through oral or intravenous hydration of the patient or through the use of an abdominal compression device was not deemed necessary. The patient should be imaged in the supine position and placed in the prone position only at the radiologist's request. The choice between single-bolus and split-bolus protocols depends on the context, but split-bolus protocols should be favoured whenever possible to decrease patient irradiation. Repeated single-slice test acquisitions should not be performed to decide of the timing of excretory phase imaging; instead, excretory phase imaging should be performed 7 min after the injection of the contrast medium. The optimal combination of unenhanced, corticomedullary phase and nephrographic phase imaging depends on the context; suggestions of protocols are provided for eight different clinical situations.

CONCLUSION

This expert-based consensus conference provides recommendations to standardise the imaging protocol for computed tomography urography.

KEY POINTS

• To improve excretory phase imaging, an intravenous injection of furosemide should be performed before the injection of iodinated contrast medium. • Systematic oral or intravenous hydration is not necessary to improve excretory phase imaging. • The choice between single-bolus and split-bolus protocols depends on the context, but split-bolus protocols should be favoured whenever possible to decrease patient irradiation.

EAU-EANM-ESTRO-ESUR-SIOG Prostate Cancer Guideline Panel Consensus Statements for Deferred Treatment with Curative Intent for Localised Prostate Cancer from an International Collaborative Study (DETECTIVE Study)

BACKGROUND

There is uncertainty in deferred active treatment (DAT) programmes, regarding patient selection, follow-up and monitoring, reclassification, and which outcome measures should be prioritised.

OBJECTIVE

To develop consensus statements for all domains of DAT.

DESIGN, SETTING, AND PARTICIPANTS

A protocol-driven, three phase study was undertaken by the European Association of Urology (EAU)-European Association of Nuclear Medicine (EANM)-European Society for Radiotherapy and Oncology (ESTRO)-European Association of Urology Section of Urological Research (ESUR)-International Society of Geriatric Oncology (SIOG) Prostate Cancer Guideline Panel in conjunction with partner organisations, including the following: (1) a systematic review to describe heterogeneity across all domains; (2) a two-round Delphi survey involving a large, international panel of stakeholders, including healthcare practitioners (HCPs) and patients; and (3) a consensus group meeting attended by stakeholder group representatives. Robust methods regarding what constituted the consensus were strictly followed.

RESULTS AND LIMITATIONS

A total of 109 HCPs and 16 patients completed both survey rounds. Of 129 statements in the survey, consensus was achieved in 66 (51%); the rest of the statements were discussed and voted on in the consensus meeting by 32 HCPs and three patients, where consensus was achieved in additional 27 statements (43%). Overall, 93 statements (72%) achieved consensus in the project. Some uncertainties remained regarding clinically important thresholds for disease extent on biopsy in low-risk disease, and the role of multiparametric magnetic resonance imaging in determining disease stage and aggressiveness as a criterion for inclusion and exclusion.

CONCLUSIONS

Consensus statements and the findings are expected to guide and inform routine clinical practice and research, until higher levels of evidence emerge through prospective comparative studies and clinical trials.

PATIENT SUMMARY

We undertook a project aimed at standardising the elements of practice in active surveillance programmes for early localised prostate cancer because currently there is great variation and uncertainty regarding how best to conduct them. The project involved large numbers of healthcare practitioners and patients using a survey and face-to-face meeting, in order to achieve agreement (ie, consensus) regarding best practice, which will provide guidance to clinicians and researchers.

The future of molecular and functional imaging in prostate cancer

The major goal of prostate cancer imaging in the next decade will be more accurate disease diagnostic, characterization and staging through the synthesisof anatomic, functional and molecular imaging.Changes are happening regarding the use of prostate MRI for evaluating primary prostate cancer and PET CT for the staging and recurrence staging of prostate cancer.This review presents a multidisciplinary perspective of the role of prostate MRI and molecular imaging in prostate cancer.

Editorial Comment: Advances in MRI and PET of the prostate: concurrence or complementarity?

This Editorial Comment refers to the articles "Diagnostic evaluation of magnetization transfer and diffusion kurtosis imaging for prostate cancer detection in a re-biopsy population" by Barrett T et al., Eur Radiol. 2017 Dec 8 and "18F-Fluciclovine PET/MRI for preoperative lymph node staging in high-risk prostate cancer patients" by Selnæs KM et al., Eur Radiol. 2018 Jan 2.

Characterization of small (<4cm) solid renal masses by computed tomography and magnetic resonance imaging: Current evidence and further development

Diagnosis of renal cell carcinomas (RCC) subtypes on computed tomography (CT) and magnetic resonance imaging (MRI) is clinically important. There is increased evidence that confident imaging diagnosis is now possible while standardization of the protocols is still required. Fat-poor angiomyolipoma show homogeneously increased unenhanced attenuation, homogeneously low signal on T2-weighted MRI and apparent diffusion coefficient (ADC) map, may contain microscopic fat and are classically avidly enhancing. Papillary RCC are also typically hyperattenuating and of low signal on T2-weighted MRI and ADC map; however, their gradual progressive enhancement after intravenous administration of contrast material is a differentiating feature. Clear cell RCC are avidly enhancing and may show intracellular lipid; however, these tumors are heterogeneous and are of characteristically increased signal on T2-weighted MRI. Oncocytomas and chromophobe tumors (collectively oncocytic neoplasms) show intermediate imaging findings on CT and MRI and are the most difficult subtype to characterize accurately; however, both show intermediately increased signal on T2-weighted with more gradual enhancement compared to clear cell RCC. Chromophobe tumors tend to be more homogeneous compared to oncocytomas, which can be heterogeneous, but other described features (e.g. scar, segmental enhancement inversion) overlap considerably between tumors. Tumor grade is another important consideration in small solid renal masses with emerging studies on both CT and MRI suggesting that high grade tumors may be separated from lower grade disease based upon imaging features.

[Evaluation and results of ablative therapies in prostate cancer]

OBJECTIVE

To perform a state of the art about methods of evaluation and present results in ablative therapies for localized prostate cancer.

METHODS

A review of the scientific literature was performed in Medline database (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) using different associations of keywords. Publications obtained were selected based on methodology, language and relevance. After selection, 102 articles were analysed.

RESULTS

Analyse the results of ablative therapies is presently difficult considering the heterogeneity of indications, techniques and follow-up. However, results from the most recent and homogeneous studies are encouraging. Oncologically, postoperative biopsies (the most important criteria) are negative (without any tumor cells in the treated area) in 75 to 95%. Functionally, urinary and sexual pre-operative status is spared (or recovered early) in more than 90% of the patients treated. More and more studies underline also the correlation between the results and the technique used considering the volume of the gland and, moreover, the "index lesion" localization.

CONCLUSION

The post-treatment pathological evaluation by biopsies (targeted with MRI or, perhaps in a near future, with innovative ultrasonography) is the corner stone of oncological evaluation of ablative therapies. Ongoing trials will allow to standardize the follow-up and determine the best indication and the best techniques in order to optimize oncological and functional results for each patient treated.

[Role of prostate MRI, TRUS fusion biopsies and new markers in the diagnostic strategy of prostate cancer]

Multiparametric MRI prostate (mp-MRI) is a powerful tool to locate lesions>0.5cm³ (below this threshold tumor volume, prostate cancers are classified as "insignificant"). The detection rate of the mp-MRI for significant cancers of small volume (0.5-1cm³) with a Gleason score≥7 is>85 %. The prostate mp-MRI optimizes the management of cancers classified as low risk of progression by providing aggressive criteria for misclassified lesions, which require an active treatment and enhance the clinicopathological criteria of indolence for subclinical lesions, which can justify of surveillance. MRI-mp coupled to the 3D ultrasound image fusion, optimizes the predictive value of biopsies and improves tumor staging, particularly when benign prostatic hyperplasia (>40cm³) is associated with clinical course. New tissue markers feasible on biopsies allow to define better the risk of progression of the small volume of cancer in order to reinforce the indications of surveillance or delayed curative treatment.

High intensity focused ultrasound with Focal-One® device: Prostate-specific antigen impact and morbidity evaluation during the initial experience

OBJECTIVE

We report our initial experience in the treatment of prostate cancer (PCa) with high-intensity focused ultrasound (HIFU) using the Focal-One^® device.

MATERIAL AND METHODS

Retrospective review of the prospectively populated database. Between June 2014 to October 2015, 85 patients underwent HIFU (focal/whole-gland) treatment for localized PCa. Preoperative cancer localization was done with multiparametric magnetic resonance imaging (mpMRI) and transperineal mapping biopsies. Treatment was carried out using the Focal-One^® device under general anesthesia. Oncological follow-up: PSA measurement and control biopsy with mpMRI according to protocol. Questionnaire-based functional outcome assessment was done. Complications were reported using Clavien classification.

RESULTS

The median PSA was 7.79ng/ml (IQR 6.32-9.16), with a median prostate volume of 38cc (IQR: 33-49.75). Focal and whole-gland therapy was performed in 64 and 21 patients respectively. Ten patients received salvage HIFU. Complications were encountered in 15% of cases, all Clavien 2 graded. Mean hospital stay was 1.8 days (0-7) and bladder catheter was removed on day 2 (1-6). Mean percentage reduction of PSA was 54%. Median follow-up was 3 months (IQR: 2-8). Functional outcomes: All patients were continents at 3 months and potency was maintained in 83% of the preoperatively potent.

CONCLUSIONS

Focal-One^® HIFU treatment appears to be a safe procedure with few complications. Functional outcomes proved no urinary incontinence and sexual function were maintained in 83%.