The Added Value of MRI-Based Targeted Biopsy in Biopsy-Naïve Patients: A Propensity-Score Matched Comparison

BACKGROUND

Multiparametric Magnetic Resonance Imaging (mpMRI)-based targeted biopsy has shown to be beneficial in detecting Clinically Significant Prostate Cancer (csPCa) and avoiding diagnosis of Non-csPCa (ncsPCa); however, its role in the treatment of biopsy-naïve patients is still under discussion.

METHODS

After identifying predictors for the diagnosis of csPCa via Multivariate Logistic Regression Analysis (MLRA), a propensity-score (1:1 nearest neighbor) matched comparison was performed between a Systematic-Only Biopsy (SOB) cohort and a mpMRI-based Combined (systematic + targeted) Biopsy (CB) cohort from two tertiary urologic centers (SOB: Department of Urology, University General Hospital of Heraklion, University of Crete, School of Medicine, Heraklion, Crete, Greece; CB: LKH Hall in Tirol, Austria). Only biopsy-naïve patients were included in the study. The study period for the included patients was from February 2018 to July 2023 for the SOB group and from July 2017 to June 2023 for the CB group. The primary outcome was the diagnosis of csPCa (≥ISUP 2); secondary outcomes were overall cancer detection, the added value of targeted biopsy in csPCa detection, and the reduction in ncsPCa diagnosis with CB compared to SOB. To estimate the Average Treatment effect of the Treated groups (ATT), cluster-robust standard errors were used to perform g-computation in the matched sample. p-values < 0.05 with a two-sided 95% confidence interval were considered statistically significant.

RESULTS

Matching achieved well-balanced groups (each n = 140 for CB and SOB). In the CB group, 65/140 (46.4%) patients were diagnosed with csPCa compared to 44/140 (31.4%) in the SOB group (RR 1.48, 95%-CI: 1.09-2.0, p = 0.01). In the CB group, 4.3% (6/140) and 1.4% (2/140) of csPCa cases were detected with targeted-only and systematic-only biopsy cores, respectively. In the CB group, 22/140 (15.7%) patients were diagnosed with ncsPCa compared to 33/140 (23.6%) in the SOB group (RR = 0.67, 95% CI: 0.41-1.08, p = 0.1). When comparing SOB to CB (ATT), the marginal OR was 0.56 (95% CI: 0.38-0.82, p = 0.003) for the diagnosis of csPCa and 0.75 (95% CI: 0.47-1.05, p = 0.085) for the diagnosis of overall cancer (≥ISUP 1).

CONCLUSION

The CB approach was superior to the SOB approach in detecting csPCa, while no additional detection of ncsPCa was seen. Our results support the application of mpMRI for biopsy-naïve patients with suspicions of prostate cancer.

Comparison of multiparametric and biparametric MRI of the prostate: are gadolinium-based contrast agents needed for routine examinations?

PURPOSE

To investigate, if and how omitting gadolinium-based contrast agents (GBCA) and dynamic contrast-enhanced imaging (DCE) influences diagnostic accuracy and tumor detection rates of prostate MRI.

METHODS

In this retrospective study, 236 patients were included. The results of biparametric (bpMRI) and multiparametric magnetic resonance imaging (mpMRI) were compared using the PI-RADS version 2 scoring system. The distribution of lesions to PIRADS score levels, tumor detection rates, diagnostic accuracy and RoC analysis were calculated and compared to the results of histopathological analysis or 5-year follow-up for benign findings.

RESULTS

Omitting DCE changed PI-RADS scores in 9.75% of patients, increasing the number of PI-RADS 3 scores by 8.89% when compared to mpMRI. No change of more than one score level was observed. BpMRI did not show significant differences in diagnostic accuracy or tumor detection rates. (AuC of 0.914 vs 0.917 in ROC analysis). Of 135 prostate carcinomas (PCa), 94.07% were scored identically, and 5.93% were downgraded only from PI-RADS 4 to PI-RADS 3 by bpMRI. All of them were low-grade PCa with Gleason Score 6 or 7a. No changes were observed for PCa ≥ 7b.

CONCLUSION

Omitting DCE did not lead to significant differences in diagnostic accuracy or tumor detection rates when using the PI-RADS 2 scoring system. According to these data, it seems reasonable to use a biparametric approach for initial routine prostate MRI. This could decrease examination time and reduce costs without significantly lowering the diagnostic accuracy.

[Molecular classification of bladder cancer. Possible similarities to breast cancer]

Therapeutic decisions for breast cancer are increasingly becoming based on subtype-specific gene expression tests. For bladder cancer very similar subtypes have been identified by genome-wide mRNA analysis, which as for breast cancer differ with respect to the prognosis and response to therapy on the basis of their hormone dependency. At the DNA level, however, the type of mutations and their frequencies within the subtypes are strikingly different between bladder and breast cancers. It will be interesting to see whether possible driver mutations can serve as therapeutic targets in both indications. In contrast, the apparent hormone dependency of a substantial number of bladder carcinomas suggests that hormonal and anti-hormonal treatment can be valid therapy options similar to breast cancer. Moreover, gender-specific differences with respect to the incidence and aggressiveness of male compared to female bladder cancers can be explained by hormonal effects. Together with forthcoming immunomodulatory therapies these multiple therapy options raise and give new hope to efficiently combat this aggressive disease.

Metabolic intervention on lipid synthesis converging pathways abrogates prostate cancer growth

One of the most conserved features of all cancers is a profound reprogramming of cellular metabolism, favoring biosynthetic processes and limiting catalytic processes. With the acquired knowledge of some of these important changes, we have designed a combination therapy in order to force cancer cells to use a particular metabolic pathway that ultimately results in the accumulation of toxic products. This innovative approach consists of blocking lipid synthesis, at the same time that we force the cell, through the inhibition of AMP-activated kinase, to accumulate toxic intermediates, such as malonyl-coenzyme A (malonyl-CoA) or nicotinamide adenine dinucleotide phosphate. This results in excess of oxidative stress and cancer cell death. Our new therapeutic strategy, based on the manipulation of metabolic pathways, will certainly set up the basis for new upcoming studies defining a new paradigm of cancer treatment.

Bone-metastatic prostate carcinoma favors mesenchymal stem cell differentiation toward osteoblasts and reduces their osteoclastogenic potential

Bone homeostasis is achieved by the balance between osteoclast-dependent bone resorption and osteoblastic events involving differentiation of adult mesenchymal stem cells (MSCs). Prostate carcinoma (PC) cells display the propensity to metastasize to bone marrow where they disrupt bone homeostasis as a result of mixed osteolytic and osteoblastic lesions. The PC-dependent activation of osteoclasts represents the initial step of tumor engraftment into bone, followed by an accelerated osteoblastic activity and exaggerated bone formation. However, the interactions between PC cells and MSCs and their participation in the disease progression remain as yet unclear. In this study, we show that bone metastatic PC-3 carcinoma cells release factors that increase the expression by human (h)MSCs of several known pro-osteoblastic commitment factors, such as α5/β1 integrins, fibronectin, and osteoprotegerin. As a consequence, as shown in an osteogenesis assay, hMSCs treated with conditioned medium (C(ed) M) derived from PC-3 cells have an enhanced potential to differentiate into osteoblasts, as compared to hMSCs treated with control medium or with C(ed) M from non-metastatic 22RV1 cells. We demonstrate that FGF-9, one of the factors produced by PC-3 cells, is involved in this process. Furthermore, we show that PC-3 C(ed) M decreases the pro-osteoclastic activity of hMSCs. Altogether, these findings allow us to propose clues to understand the mechanisms by which PC favors bone synthesis by regulating MSC outcome and properties.

Metabolism and proliferation share common regulatory pathways in cancer cells

Cancer development involves major alterations in cells' metabolism. Enhanced glycolysis and de novo fatty acids synthesis are indeed characteristic features of cancer. Cell proliferation and metabolism are tightly linked cellular processes. Others and we have previously shown a close relationship between metabolic responses and proliferative stimuli. In addition to trigger proliferative and survival signaling pathways, most oncoproteins also trigger metabolic changes to transform the cell. We present herein the view that participation of cell-cycle regulators and oncogenic proteins to cancer development extend beyond the control of cell proliferation, and discuss how these new functions may be implicated in metabolic alterations concomitant to the pathogenesis of human cancers.

The South African stroke risk in general practice study

BACKGROUND

Incidence of stroke is increasing in sub-Saharan Africa and stroke prevention is an essential component of successful stroke management. General practitioners (GPs) are well placed to manage stroke risk factors. To design appropriate strategies for risk factor reduction we need to know the risk factor prevalence in each of the population groups attending GPs. The aim of this study was to establish the prevalence of stroke risk factors in the South African general practice population.

METHOD

We conducted a multicentre, observational study of patients attending general practice in South Africa. Two hundred general practices were randomly selected from lists provided by pharmaceutical representatives. Each GP approached 50 consecutive patients aged 30 years and older. Patients completed an information sheet and the GP documented the patient's risk factors. The resulting sample is relevant if not necessarily representative in a statistical sense.

RESULTS

A total of 9 731 questionnaires were returned out of a possible 10,000. The mean age of particpants was 50.7 years. Seventy-six per cent had 1 or more risk factors and 40% had 2 or more risk factors. Hypertension was the commonest risk factor in all population groups (55%) but was highest in black patients (59%). Dyslipidaemia was commonest in whites (37%) and least common in blacks (5%). Diabetes was commonest in Asians (24%) but least common in whites (8%). Risk factors other than smoking increased with age.

CONCLUSION

This study provides unique data on the prevalence of stroke risk factors in a South African general practice population. Risk factors are common in all population groups, but differ in distribution among the groups. There is considerable opportunity to reduce the burden of stroke in South Africa through GP screening for and treatment of risk factors.

Knowledge of stroke risk factors amongst black diabetic, hypertensive and stroke patients

The objective of this study was to assess and compare theknowledge of black patients diagnosed with hypertension, diabetes and stroke about the risk factors for stroke.  Four groups made up of 33 subjects (hypertensive, diabetic, stroke and control group) were interviewed using open-ended questions and a structured questionnaire. Qualitative coding, frequencies and proportions were used to determine their knowledge.  Groups were compared with respect to percentage knowledge using the chi-square statistic at a 0.05 level of significance.  Stress was mentioned as the most important risk factor in all groups.  Although identification of stroke risk factors was  inadequate, the diabetic group was found to be significantly better in  identifying some of the risk factors (salt - p =0,05; sugar - p = 0,001; fat - p = 0,004; moderate smoking - p = 0,05; weight - p = 0,002)

Sporadic fatal insomnia: a case study

A 58-year-old man died after a 27-month illness characterized by insomnia, confirmed by polysomnography. He was homozygous for methionine at codon 129 of the prion gene but had no mutation in the prion gene. Neuropathology showed thalamic and olivary atrophy and no spongiform changes. Paraffin-embedded tissue blotting demonstrated abnormal prion protein in the brain. This is the first case of the sporadic form of fatal familial insomnia with demonstration of the disorder by polysomnography.

Multiple sclerosis in black South Africans and Zimbabweans

Multiple sclerosis is rare among the indigenous black people of Africa. The first account of a black patient with multiple sclerosis in South Africa was published as late as 1987. Since then a search to find black patients with multiple sclerosis in Southern Africa has continued. Seven black patients have now been traced in South Africa and five in Zimbabwe in whom a diagnosis of multiple sclerosis can be accepted. Six of the 12 patients became blind, or nearly so, from severe optic neuritis. Multiple sclerosis in these few black patients more often resembled the disorder as it occurs in oriental people than among white people in southern Africa or the black people of North America or the Caribbean.

Visual evoked potentials in Negro carriers of the gene for tyrosinase positive oculocutaneous albinism

Visual evoked potential testing was performed on 15 Negro carriers of the gene for tyrosinase positive oculocutaneous albinism in order to detect whether they have the same visual pathway decussation anomalies as do homozygotes. No subject showed 01-02 asymmetry on monocular testing, indicating that decussation follows the normal pattern. It is concluded that visual evoked potential testing is probably not useful in the detection of Negroes heterozygous for the gene for tyrosinase positive oculocutaneous albinism.

Fluorescence methods for localizing proteinases and proteinase inhibitors in skeletal muscle

Proteinases and proteinase inhibitors have become suspect in a wide variety of muscle wasting conditions that might be treatable if knowledge of the cellular locale and function of these molecules were known. Fluorescent probes have been useful in the localization of proteinases in muscle samples from human and animal specimens. These include the histochemical localization of proteinases based on the specific fluorescence of hydrolysis product derivatives, but this approach has been limited to the lysosomal proteinases because of the acidic requirements of the trapping reaction of the primary reaction product. Immunohistochemical techniques do not have the same restrictions and a number of lysosomal and nonlysosomal proteinases have been identified in muscle by this means. Unfortunately, they do not yield any information as to the activity of the enzymes. This is an important consideration since the extracellular environment contains a number of proteinase inhibitors, some of which may be internalized by the cell.

Life-threatening hypotension associated with azathioprine therapy. A case report

We report a case of azathioprine sensitivity manifesting with severe hypotension and diarrhoea. This sequence of events occurred on two separate occasions after administration of the drug.

Treatment of acute post-infective polyneuropathy by means of plasma exchange

15 patients with acute post-infective polyneuropathy of the Guillain-Barré type have been treated by means of plasma exchange. The clinical course and outcome of these patients is compared to that in a retrospectively matched control series who were treated with supportive therapy only. All patients had severe rapidly evolving muscle weakness and approximately half the patients in each group required ventilatory assistance. Both the duration of muscle weakness and the hospitalisation time was significantly shorter in the patients treated by means of plasma exchange. These results suggest that plasma exchange is of significant benefit in the treatment of patients with the Guillain-Barré syndrome.

Immunohistochemical localization of two proteinases in skeletal muscle

Immunohistochemical localizations of cytosolic and myofibrillar proteinases revealed a different myofiber locale for each enzyme in the rat. Although the cytosolic proteinase was most pronounced in mast cells within soleus and extensor digitorum longus (EDL) muscles, certain fibers of the EDL were also positive. The myofibrillar proteinase, on the other hand, appeared to be present in interstitial spaces between muscle fibers in the EDL but conversely present in some fibers of the soleus muscle.

Immunofluorescent localization of four serum proteinase inhibitors in normal rat liver

Four serum proteinase inhibitors, alpha 1-macroglobulin, alpha 1-proteinase inhibitor, alpha 1-inhibitor3 and alpha 2-acute phase macroglobulin, were localized in rat liver by immunofluorescent techniques. alpha 1-Macroglobulin was observed predominantly in the sinusoids and alpha 1-inhibitor3 in hepatocytes. In contrast, alpha 1-proteinase inhibitor was localized in two sites, sinusoids and parenchymal cells. The fourth inhibitor tested, alpha 2-acute phase macroglobulin, was barely detectable in normal liver. However, some appeared to be present in the extrahepatocyte space.

Experience with neuromuscular respiratory failure in an intensive care unit

Between 1976 and 1980, 32 patients with respiratory failure primarily due to neuromuscular disease were admitted on 34 occasions to the Respiratory Intensive Care Unit of the Johannesburg Hospital. Ninety-four per cent of patients admitted survived and were discharged from hospital. Ninety per cent of the survivors are fully rehabilitated and another 6.7% continue to improve. Despite a frequently prolonged illness, these patients have an excellent prognosis. Early diagnosis and management of respiratory failure in an intensive care unit are essential if their survival is to be ensured.

Treatment of familial hypercholesterolaemia by partial ileal bypass

Ten patients with heterozygous familial hypercholesterolaemia (Fredrickson type II) were treated by the operation of partial ileal bypass. Postoperatively, serum cholesterol levels fell by an average of 34% (P less than 0.005), and the decrease was satisfactorily sustained over a period of 12-30 months. Angina and xanthomas also improved in some patients. Postoperatively all patients experienced considerable diarrhoea, which lessened with time. Other complications of surgery included abdominal distension and cramps, colonic dilatation, sepsis and intestinal obstruction. It is concluded that partial ileal bypass significantly lowers serum cholesterol levels, but that in view of the complications the operation should be offered only to carefully selected patients who are intolerant of or unresponsive to conservative measures.