Direct MRI-guided In-Bore Targeted Biopsy of the Prostate: A Step-by-Step How To and Lessons Learned

Multiparametric MRI-the most accurate imaging technique for detection of prostate cancer-has transformed the landscape of prostate cancer diagnosis by enabling targeted biopsies. In a targeted biopsy, tissue samples are obtained from suspicious regions identified at prebiopsy diagnostic MRI. The authors briefly compare the different strategies available for targeting an MRI-visible suspicious lesion, followed by a step-by-step description of the direct MRI-guided in-bore approach and an illustrated review of its application in challenging clinical scenarios. In this technique, direct visualization of the needle, needle guide, and needle trajectory during the procedure provides a precise and versatile strategy to accurately sample suspicious lesions, improving detection of clinically significant cancers. Published under a CC BY 4.0 license Test Your Knowledge questions for this article are available in the supplemental material.

Gleason Grade Group Concordance between Preoperative Targeted Biopsy and Radical Prostatectomy Histopathologic Analysis: A Comparison Between In-Bore MRI-guided and MRI-Transrectal US Fusion Prostate Biopsies

Purpose

To determine and compare rates of grade group (GG) discrepancies between different targeted biopsy techniques (in-bore vs fusion) after propensity score weighting using whole-mount radical prostatectomy (RP) histopathologic analysis as the reference standard.

Materials and Methods

This retrospective study evaluated men who underwent targeted (fusion or in-bore) biopsy between April 2017 and January 2019 followed by prostatectomy. The primary endpoint of the study was a change in GG from biopsy to RP at a patient level. For downgrade and upgrade analysis, men with biopsy GG1 (downgrade not possible) and GG5 (upgrade not possible) were excluded, respectively. GG upgrade, downgrade, and concordance rates of each targeting approach were compared using propensity score weighting and logistic regression with inverse probability of treatment weighting. Significance level was set at .05. Index lesion GG on RP specimen served as the reference standard.

Results

A total of 191 men (90 in the in-bore [mean age, 63 years ± 7 (standard deviation)] and 101 in the fusion biopsy group [mean age, 65 years ± 7]) were eligible and included. Fewer GG upgrades were noted in the in-bore biopsy group (14%; 12 of 85) compared with the fusion plus systematic biopsy group (30%; 28 of 93) (P = .012). The incidence of GG downgrade in the in-bore group (25%; 21 of 84) was higher than in the fusion group (17%; 16 of 93); however, the difference was not statistically significant (P = .2). Of the 77 men misclassified by both biopsy techniques, the majority (56%, n = 43) had a change in GG of 2 to 3 or 3 to 2.

Conclusion

Superior sampling accuracy with MRI-guided in-bore biopsies offers a lower incidence of GG upgrades compared with MRI-transrectal US fusion biopsies upon RP.Keywords: Biopsy/Needle Aspiration, MR-Imaging, Oncology, Pathology, Prostate Supplemental material is available for this article.© RSNA, 2021.

Prospective evaluation of fexapotide triflutate injection treatment of Grade Group 1 prostate cancer: 4-year results

Purpose

This study was undertaken to determine the safety and efficacy of fexapotide triflutate (FT) 2.5 mg and 15 mg for the treatment of Grade Group 1 prostate cancer.

Methods

Prospective randomized transrectal intraprostatic single injection FT 2.5 mg (n = 49), FT 15 mg (n = 48) and control active surveillance (AS) (n = 49) groups were compared in 146 patients at 28 U.S. sites, with elective AS crossover (n = 18) to FT after first follow-up biopsy at 45 days. Patients were followed for 5 years including biopsies (baseline, 45 days, and 18, 36, and 54 months thereafter), and urological evaluations with PSA every 6 months. Patients with Gleason grade increase or who elected surgical or radiotherapeutic intervention exited the study and were cumulatively included in the data analysis. Percentage of normal biopsies in baseline focus quadrant, tumor grades, and volumes; and outcomes including Gleason grade in entire prostate as well as treated prostate lobe, interventions associated with Gleason grade increase and total incidence of interventions were assessed.

Results

Significantly improved long-term clinical outcomes were found after 4-year follow-up, with percentages of patients progressing to interventions with and without Gleason grade increase significantly reduced by FT single treatment. Results in the FT 15-mg group were superior to the FT 2.5-mg dose group. There were no drug-related serious adverse events (SAEs).

Conclusions

FT showed statistically significant long-term efficacy in the treatment of Grade Group 1 patients regarding clinical and pathological progression. FT 15 mg showed superior results to FT 2.5 mg. There were no drug-related SAEs; FT injection was well tolerated.

Fexapotide triflutate: results of long-term safety and efficacy trials of a novel injectable therapy for symptomatic prostate enlargement

PURPOSE

These studies were undertaken to determine if fexapotide triflutate 2.5 mg transrectal injectable (FT) has significant long-term (LT) safety and efficacy for the treatment of benign prostatic hyperplasia (BPH).

METHODS

Two placebo controlled double-blind randomized parallel group trials with 995 BPH patients at 72 sites treated 3:2 FT:placebo, with open-label FT crossover (CO) re-injection in 2 trials n = 344 and long-term follow-up (LF) 2-6.75 years (mean 3.58 years, median 3.67 years; FT re-injection CO mean 4.27 years, median 4.42 years) were evaluated. 12 months post-treatment patients elected no further treatment, approved oral medications, FT, or interventional treatment. Primary endpoint variable was change in Symptom Score (IPSS) at 12 months and at LF. CO primary co-endpoints were 3-year incidence of (1) surgery for BPH in FT treated CO patients versus patients crossed over to oral BPH medications and (2) surgery or acute urinary retention in FT-treated CO placebo patients versus placebo patients crossed over to oral BPH medications. 28 CO secondary endpoints assessed surgical and symptomatic outcomes in FT reinjected patients versus conventional BPH medication CO and control subgroups at 2 and 3 years.

RESULTS

FT injection had no significant safety differences from placebo. LF IPSS change from baseline was higher in FT treated patients compared to placebo (median FT group improvement - 5.2 versus placebo - 3.0, p < 0.0001). LF incidence of AUR (1.08% p = 0.0058) and prostate cancer (PCa) (1.1% p = 0.0116) were both reduced in FT treated patients. LF incidence of intervention for BPH was reduced in the FT group versus oral BPH medications (8.08% versus 27.85% at 3 years, p < 0.0001). LF incidence of intervention or AUR in placebo CO group with FT versus placebo CO group with oral medications was reduced (6.07% versus 33.3% at 3 years, p < 0.0001). 28/28 secondary efficacy endpoints were reached in LF CO re-injection studies.

CONCLUSIONS

FT 2.5 mg is a safe and effective transrectal injectable for LT treatment of BPH. FT treated patients also had reduced need for BPH intervention, and reduced incidence of PCa and AUR.

Preface: The 5th International Workshop on X-ray Mirror Design, Fabrication, and Metrology

Recent developments in synchrotron storage rings and free-electron laser-based x-ray sources with ever-increasing brightness and coherent flux have pushed x-ray optics requirements to new frontiers. This Special Topic gathers a set of articles derived from a subset of the key presentations of the International Workshop on X-ray Mirrors Fabrication (IWXM-2015) and Metrology held at Lawrence Berkley National Laboratory, Berkeley, California, USA, July 14-16, 2015. The workshop objective was to report on recent progress in x-ray synchrotron radiation mirrors fabrication as well as on new developments in related metrology tools and methods.

Is PSA related to serum cholesterol and does the relationship differ between black and white men?

BACKGROUND

Previously, in prostate cancer-free men, we found that statin initiation resulted in a 4.1% decline in PSA. This decline in PSA was proportional to the decline in cholesterol, suggesting a link between cholesterol and PSA levels. Whether these associations vary by race has not been explored and therefore we examined the association between pre-statin serum cholesterol and PSA in black and white prostate cancer-free men.

METHODS

We conducted a retrospective, cross-sectional analysis of 1,163 men (709 white and 454 black) without prostate cancer who initiated a statin between 1994 and 2006. Linear regression was used to test the association between pre-statin serum cholesterol and PSA levels, adjusting for potential confounders and stratifying by race.

RESULTS

Black men were younger, had higher low-density lipoprotein (LDL) and high-density lipoprotein (HDL) levels (both P < 0.05) and a trend toward higher total cholesterol (P = 0.063). There was no difference in PSA or year of statin prescription by race (P = 0.900 and P = 0.217, respectively). On multivariable analysis, we found a positive correlation between serum PSA and total cholesterol (P = 0.005) and LDL (P = 0.003) in white men, but no association among black men. HDL was not significantly related to PSA levels in black or white men (both P > 0.5).

CONCLUSIONS

Among prostate cancer-free men about to begin a statin, pre-statin total cholesterol and LDL were correlated with PSA levels in white, but not black men. If confirmed in future studies, these findings suggest that serum cholesterol may be related to prostate biology, and that this effect may vary by race.

A novel approach for the simultaneous quantification of a therapeutic monoclonal antibody in serum produced from two distinct host cell lines

Therapeutic monoclonal antibodies (mAbs) possess a high degree of heterogeneity associated with the cell expression system employed in manufacturing, most notably glycosylation. Traditional immunoassay formats used to quantify therapeutic mAbs are unable to discriminate between different glycosylation patterns that may exist on the same protein amino acid sequence. Mass spectrometry provides a technique to distinguish specific glycosylation patterns of the therapeutic antibody within the same sample, thereby allowing for simultaneous quantification of the same mAb with different glycosylation patterns. Here we demonstrate a two-step approach to successfully differentiate and quantify serum mixtures of a recombinant therapeutic mAb produced in two different host cell lines (CHO vs. Sp2/0) with distinct glycosylation profiles. Glycosylation analysis of the therapeutic mAb, CNTO 328 (siltuximab), was accomplished through sample pretreatment consisting of immunoaffinity purification (IAP) and enrichment, followed by liquid chromatography (LC) and mass spectrometry (MS). LC-MS analysis was used to determine the percentage of CNTO 328 in the sample derived from either cell line based on the N-linked G1F oligosaccharide on the mAb. The relative amount of G1F derived from each cell line was compared with ratios of CNTO 328 reference standards prepared in buffer. Glycoform ratios were converted to concentrations using an immunoassay measuring total CNTO 328 that does not distinguish between the different glycoforms. Validation of the IAP/LC-MS method included intra-run and inter-run variability, method sensitivity and freeze-thaw stability. The method was accurate (%bias range = -7.30-13.68%) and reproducible (%CV range = 1.49-10.81%) with a LOQ of 2.5 μg/mL.

Assessment of Infant Movement With a Compact Wireless Accelerometer System

There is emerging data that patterns of motor activity early in neonatal life can predict impairments in neuromotor development. However, current techniques to monitor infant movement mainly rely on observer scoring, a technique limited by skill, fatigue, and inter-rater reliability. Consequently, we tested the use of a lightweight, wireless, accelerometer system that measures movement and can be worn by premature babies without interfering with routine care. We hypothesized that this system would be useful in assessing motor activity, in identifying abnormal movement, and in reducing the amount of video that a clinician would need to review for abnormal movements. Ten preterm infants in the NICU were monitored for 1 h using both the accelerometer system and video. A physical therapist trained to recognize cramped-synchronized general movements scored all of the video data by labeling each abnormal movement observed. The parameters of three different computer models were then optimized based on correlating features computed from accelerometer data and the observer’s annotations. The annotations were compared to the model’s prediction on unseen data. The trained observer identified cramped-synchronized general movements in 6 of the 10 infants. The computer models attained between 70% and 90% accuracy when predicting the same observer label for each data point. Our study suggests that mini-accelerometers may prove useful as a clinical tool assessing patterns of movement in preterm infants.

Multicenter phase III trial studying trospium chloride in patients with overactive bladder

OBJECTIVES

To study the efficacy and safety of trospium chloride in treating overactive bladder. Trospium chloride is an anticholinergic agent with predominantly peripheral nonselective antimuscarinic activity and thus has potential therapeutic value in treating patients with overactive bladder.

METHODS

Patients with overactive bladder were randomized on a 1:1 basis to either placebo or trospium chloride 20 mg twice daily in this 12-week, multicenter, parallel, double-blind, placebo-controlled study. The primary endpoint was the change in the average number of toilet voids per 24 hours. The secondary efficacy variables were changes in the average void urgency severity, volume per toilet void, urge frequency, number of daily urge urinary incontinence episodes, and daytime sleepiness.

RESULTS

A total of 658 patients were randomized at 52 sites. Trospium chloride significantly decreased the average number of daily toilet voids, average urgency severity, urge frequency, and urge urinary incontinence episodes and increased the average volume per void at weeks 1, 4, and 12. All effects occurred by the end of week 1 and all improved and were sustained throughout the 12-week study. Adverse events included dry mouth and constipation.

CONCLUSIONS

Trospium chloride had significant and sustained effectiveness beginning at the end of week 1 and continuing through 12 weeks of treatment. Trospium chloride was also safe and generally well tolerated.

Time to onset of improvement in symptoms of overactive bladder using antimuscarinic treatment

OBJECTIVE

To evaluate the time to onset of statistically significant and clinically meaningful effects of trospium chloride in patients with an overactive bladder (OAB).

PATIENTS AND METHODS

Data from a recent Phase III clinical study of trospium chloride were obtained, in which 658 patients with OAB were randomized (1 : 1) to placebo or trospium chloride 20 mg twice daily for 12 weeks. Original study safety endpoints consisting of adverse events, vital signs, electrocardiograms, and laboratory changes were collected, while original efficacy endpoints included number of toilet voids/day, urgency severity per toilet void, urge urinary incontinence (UUI), and volume voided per toilet void at weeks 1, 4, and 12. Results were also analysed using the OAB Symptom Composite Score (OAB-SCS). The efficacy analysis focused on changes from baseline in these endpoints from 1 to 7 days of treatment to establish the earliest point at which there was statistical significance or clinical efficacy.

RESULTS

There were statistically significant improvements in efficacy over placebo in endpoints (toilet voids, urgency severity/void, UUI episodes, OAB-SCS) within a few days of treatment, with improvements in symptoms continuing to 7 days of treatment. There were clinically meaningful improvements in most endpoints by the end of the first week.

CONCLUSIONS

The time to onset of the clinical effect should be studied more extensively to identify when patients might expect a clinically meaningful improvement in their OAB-related symptoms.

Restricted Magnetic Resonance Diffusion-Weighted Imaging With Mass Lesions Presenting as Acute Lesions

Diffusion-weighted imaging is useful for diagnosis of acute ischemic stroke. However, metastatic brain lesions may also demonstrate restricted diffusion on magnetic resonance imaging. We describe 4 cases (3 with metastatic neoplasms and 1 with a meningioma) with positive findings by diffusion-weighted imaging.

Direct measurement of index of refraction in the extreme-ultraviolet wavelength region with a novel interferometer

To the best of our knowledge, the first direct measurement of the dispersive part of the refractive index is performed at extreme-ultraviolet (EUV) wavelengths, where absorption is higher as compared with hard-x-ray and visible wavelengths. A novel diffractive optical element that combines the functions of a grating and a zone plate is fabricated with Fourier optical techniques and employed here for the first time at EUV/soft-x-ray wavelengths. Both the real and the imaginary parts of the complex refractive indices are measured directly by this technique without recourse to Kramers-Kronig transformations. Data for Al and Ni in the vicinity of their L and M edges, respectively, are presented as first examples of this technique.

Delay in presentation for cardiac care by race, age, and site of care

BACKGROUND

Racial differences exist in the management of coronary artery disease. One hypothesis is that black patients delay seeking care and that this delay may influence the management of coronary artery disease.

OBJECTIVES

To assess delay in seeking care for heart disease.

RESEARCH DESIGN

Cross-sectional survey.

SUBJECTS

One thousand six hundred and fifty-two patients awaiting coronary angiography at three VA and one non-VA Medical Center.

MEASURES

Patients were asked to retrospectively report the time between symptom onset and presentation for medical care and what if any were the reasons for delay.

RESULTS

One thousand five hundred eleven patients (12% VA & 43% non-VA) answered questions regarding delay in treatment. Overall, 73% reported delaying 1 month or more and 16% reported delaying more than 6 months. Black patients and white patients were equally likely to delay as were older persons (> or = 65) compared with younger. Patients at the VA hospitals reported longer delays and patients with prior revascularization were less likely to report delays. We used ordinal logistic regression to predict delay using site type and prior revascularization as covariates. VA site of care independently predicted longer delays whereas prior revascularization predicted less delay. Among patients who reported at least a 1 month delay, patients at the non-VA hospital were more likely to cite ignoring symptoms as their reason for delay (72% vs. 61%; P = 0.03) as were those with at least a high school education 69% versus 50%; P = 0.003). Black patients reported that they ignored their symptom more often but this was marginally significant (77% vs. 63%; P = 0.053).

CONCLUSIONS

Race was not associated with delay in seeking care among patients awaiting coronary angiography. Non-VA patients, and those with past revascularization, were less likely to delay. Ignoring symptoms was the most common reason for delays greater than 1 month. Further study of the sequence of patient and provider decisions that ultimately lead to revascularization is needed.

Delayed transient neurologic toxicity due to tacrolimus: CT and MRI

We report a case of transient neurologic toxicity secondary to tacrolimus. The clinical and imaging findings are reported and their subsequent regression after interruption of therapy in the patient following a bone-marrow transplant is also described. The etiology of the neurotoxicity and its analogy with other immunosuppressant agents are discussed.

Interaction of n-3 long-chain polyunsaturated fatty acids with n-6 fatty acids in suckled rat pups

The addition of long-chain polyunsaturated fatty acids (LCP: C20, and C22) to infant formula may permit fatty acid accretion rates similar to breast-fed infants, and may have long-term outcome benefits, such as improved visual acuity and cognitive development. Although fish oil may provide a source of n-3 LCP, sources of n-6 LCP have been more difficult to identify. The present study evaluates the effects of n-3 and n-6 LCP derived from single-cell oils on liver, plasma, and brain fatty acid levels in a neonatal animal model. Newborn rat pups were suckled for 14 d by dams receiving diets containing n-3 LCP alone or combinations of n-3 LCP and increasing doses of linoleic acid (18:2n-6) or arachidonic acid (20:4n-6). Dietary groups received 2% n-3 LCP and 1, 2, or 5% of either 18:2n-6 or 20:4n-6. The 20:4n-6 source also contained modest levels of 18:2n-6. At the termination of the study, liver, plasma, and brain were obtained from the rat pups and the phospholipid fatty acid profiles determined. The results indicate complex interactions of n-3 and n-6 fatty acids. Groups receiving dietary 20:4n-6 incorporated higher levels of n-6 LCP into tissues than did the groups receiving 18:2n-6. The brain was relatively resistant to changes in fatty acid composition compared with the liver and plasma. As expected, tissue n-3 LCP levels were reciprocally related to n-6 levels. The present results document that single-cell LCP oils are bioavailable in a neonatal animal model. The use of 20:4n-6 is a more effective means of supporting n-6 status than the use of 18:2n-6. These results may have implications for the addition of LCP to infant formula.

Subjective effects of oral caffeine in formerly cocaine-dependent humans

Eleven formerly cocaine-dependent (FCD) adults (mean 4 years in recovery) and 11 with no substance dependence history (ND) drank one cup of coffee (caffeine content 0, 50, or 100 mg) per hour for 5 h (for a total of 0, 250, or 500 mg caffeine) in a double-blind, randomized crossover procedure. Participants completed self-report scales before the first cup and 50 min after each cup. Caffeine did not increase cocaine-like effect or desire-for-cocaine ratings among the FCD subjects. Ratings of 'jittery' (P < 0.05) and 'anxious/tense/nervous' (P < 0.10) increased more with caffeine in the FCD group than among ND subjects. Self-report measures of caffeine reinforcement did not differ between FCD and ND groups. These results suggest that, among FCD adults, (a) caffeine does not produce cocaine-like effects, (b) caffeine reinforcement is neither greater nor lesser than that among ND adults, and (c) chronic cocaine use may induce sensitization to some effects of stimulants.

Safety and efficacy outcome of mentor alpha-1 inflatable penile prosthesis implantation for impotence treatment

PURPOSE

We investigated safety and efficacy outcome pertaining to the Mentor Alpha-1, 3-piece inflatable penile prosthesis for impotence treatment.

MATERIALS AND METHODS

A 2-phase, multi-institutional, large scale retrospective study, with independently analyzed medical record (phase I) and questionnaire (phase II) data from consecutive eligible patients of 7 physician investigators was performed from March to October 1993.

RESULTS

In phase I there were no morbidities of any type in 394 of the 434 patients (90.8%) (mean age 61 years, range 24 to 88) who underwent Alpha-1 implantation (mean followup 22.2 months, range 0.67 to 44.5). The risk of prosthesis malfunction (fluid leak and auto-inflation) was 2.5%. No cylinder aneurysms were reported. A total of 93.1% of Alpha-1 devices was free from explantation (4.4%) or revision surgery (2.5%) for approximately 2 years from the original implant date. Kaplan-Meier actuarial analyses revealed that cumulative survival of the Alpha-1 prostheses at 12, 24 and 36 months was 98 +/- 1%, 93 +/- 2% and 85 +/- 7% until device malfunction, and 91 +/- 2% 83 +/- 4% and 75 +/- 7% until surgical intervention (revision or explantation). In phase II 89% of the men claimed fulfilled expectations with the Alpha-1 prosthesis as impotence treatment. Satisfaction responses 80% or greater were noted with regard to intercourse ability and confidence, and device rigidity and function. Implantation did not result in greater than 80% satisfaction in partner relationships or feelings (as judged by the patient), social or work confidence, or intercourse frequency. Factors adversely affecting satisfaction included partner feelings of dissatisfaction (as judged by the patient), specific physician investigators and need for explantation/revision surgery.

CONCLUSIONS

In 1 of the largest multi-institutional implant outcome studies thus far performed, safety and efficacy data concerning the Alpha-1 contemporary inflatable device were found markedly improved over earlier inflatable prostheses and now compare favorably with historical data from noninflatable rod type devices.

Ocular ischemic syndrome during carotid balloon occlusion testing

The use of a double-lumen balloon catheter for temporary occlusion testing of the internal carotid artery permits simultaneous perfusion of the distal internal carotid artery (and ophthalmic artery) with heparinized saline. If saline is infused too rapidly, the result may be total or partial replacement of oxygenated blood within the ophthalmic artery. This replacement may produce the signs and symptoms of ocular ischemic syndrome. These include ipsilateral orbital pain and progressive uniocular visual loss. Simple technical adjustments in the performance of the occlusion test can prevent the development of this syndrome. Failure to recognize the cause of the observed visual loss may produce the false impression of a positive occlusion test or may falsely suggest that a thromboembolic complication has occurred. Awareness of the occurrence of this syndrome should prevent confusion concerning the predictive result of provocative carotid occlusion testing.

Construction and characterization of adenovirus co-expressing hepatitis B virus surface antigen and interleukin-6

Coexpression of biologically active interleukin 6 (IL-6), an immunoregulator, and hepatitis B virus surface antigen (HBsAg), an immunogen, was obtained using an adenovirus type 7 (Ad7) vector. Two recombinant adenoviruses (re-Ad) containing both the HBsAg and IL6 genes were constructed: one virus was capable of expressing IL6 with its signal peptide (spIL6) (Ad7::spIL6::HBsAg), and the second virus lacked this sequence (Ad7::IL6::HBsAg). A third recombinant contained only HBsAg (Ad7::HBsAg). All three Ad constructs were plaque purified and characterized in the A549 human lung cell line. The growth kinetics of the recombinants were similar to wild-type (wt) Ad7. The production and secretion of HBsAg (p24 and gp27) from cells infected with each re-Ad were at a level greater than 9 micrograms/10(6) cells by 118 h postinfection. Two IL-6 of approx. 24 and 27 kDa were produced and secreted into the culture medium from cells infected with Ad7::spIL6::HBsAg, and maximal accumulation occurred by 92 h p.i. at a level > 260 ng/10(6) cells. One cell-associated IL-6 of approx. 23 kDa was produced from cells infected with Ad7::IL6::HBsAg at a level > 12 ng/10(6) cells. Importantly, the Ad-produced IL-6 were determined to be biologically active by enhancing immunoglobulin production in lymphoblastoid cells. The co-production of IL-6 with HBsAg did not affect growth of these recombinant Ad, immunoreactivity of HBsAg, or the biological activity of IL-6 in tissue culture cells.