[Concordance between prostate biopsy and radical prostatectomy specimen Gleason score at the Carlos Andrade Marín hospital between January 2016 and December 2018.]

INTRODUCTION

 Prostate cancer is thesecond most common neoplasm in men. The prostate biopsy is the fundamental support for the therapeutic decision, the histopathological results of the surgical piece differ from those obtained in the diagnostic prostate biopsy generating under-staging or over-staging inpatients.

MATERIALS AND METHODS

This study collects data from a total of 147 patients who under went radicalrobot-assisted prostatectomy at the Carlos Andrade Marín Hospital in the period January 2016 to December 2018, a statistical analysis is performed by the Chisquared test with a significance level of 5%.

RESULTS

The percentage agreement of prostate biopsy with the histopathological result of the surgical piece was 49%, over-staging was 14% and under-staging was 35%. The Gleason score most commonly found in this study was 6 (3 + 3) both in prostate biopsy and in the radical prostatectomy surgical piece. There were 3 patients with vanishing prostate cancer in this study group.

CONCLUSIONS

The agreement of the prostate biopsy in relation to the surgical piece of radical prostatectomy is in the context of that reported in international studies, over staging does not represent a major health problem since patients could benefit from the radical prostatectomy but under-Staging could lead to the decision not to provide the patient a curative treatment of his disease tobe referred to an active surveillance protocol. Vanishing prostate cancer in this study group is explained by the use of hormonal blockade with leuprolideacetate prior to surgical treatment in two patients and a low tumor invasion in the histopathology sample of the third patient.

Comparative analysis of the expression of metalloproteases (MMP-2, MMP-9, MMP-11 and MMP-13) and the tissue inhibitor of metalloprotease 3 (TIMP-3) between previous negative biopsies and radical prostatectomies

Metalloproteases (MMPs) and tissue inhibitor of metalloprotease-3 (TIMP-3) have been associated to the risk of having cancer and tumor aggressiveness. When facing the difficulties of prostate cancer diagnosis, the expression of MMPs and TIMP-3 in negative biopsies could be helpful to evaluate a diagnostic suspicion. Our objective is to carry out a comparative study of the expression of MMPs and TIMP-3 in previous negative biopsies and radical prostatectomies (RP).

MATERIAL AND METHODS

Retrospective analysis of a hospital-based cohort including 21 patients with suspicion of prostate carcinoma, whose expressions of MMP-2, 9, 11 and 13 and TIMP-3 were evaluated by immunohistochemistry in the tumor area from previous negative biopsies and RP.

RESULTS

Immunohistochemical staining values (Score) for MMPs (-11 and -13) and TIMP-3 showed no significant differences when comparing the areas of negative biopsies where tumors subsequently developed with those of the RP. However, we did observe a significant difference in the increased expression of MMP-2 (P=.002) and MMP-9 (P=.001) in the tumor area of the RP with respect to the corresponding area of the previous negative biopsy.

CONCLUSIONS

Our data indicate a higher overall expression of MMP-2 and MMP-9 in the tumor area of the RP compared to the corresponding areas of the negative previous biopsy, which seems to be associated to the process of malignant transformation.

In Search for risk predictors at the microscopic scenario of a negative biopsy. A systematic review

INTRODUCTION

In cases of persistent suspicion of prostate cancer (PC), repeat prostate biopsies (PB) are frequently performed in spite of their low yield. In the context of a negative PB, there is a microscopic scenario (MS), which we define as the group of recognizable non-neoplastic lesions. While some of these lesions seem to have a protective effect, the existence of others increases the risk of PC detection in posterior PB. The objective of this systematic review is to identify the lesions that may belong to the MS of a negative PB and analyse the current evidence of their association with the risk of detecting PC in subsequent PBs.

EVIDENCE ACQUISITION

Two independent reviewers conducted a literature search on Medline, Embase and Central Cochrane with the following search terms: small acinar proliferation, ASAP, prostatic intraepithelial neoplasia, HGPIN, adjacent small atypical glands, pinatyp, atrophy, proliferative inflammatory atrophy, pia, prostatic inflammation, prostatitis and prostate cancer. 1,015 references were first identified, and 57 original articles were included in the study, following the PRISMA declaration and the PICO selection principles.

EVIDENCE SYNTHESIS

Atypical small acinar proliferation is associated with PC detection in repeat PB with rates ranging between 32 and 48%. High-grade prostatic intraepithelial neoplasia (HGPIN) is related to PC in 13 to 42% of cases. Studies show that HGPIN, when multifocal, is a significant independent risk factor for PC. Prostatic atrophy, inflammatory proliferative atrophy and prostatic inflammation seem to act as protective factors on the detection of PC in repeat PB. On the other hand, the risk of PC detection reduces significantly in male patients with multifocal HGPIN and coexistent PIA.

CONCLUSIONS

The MS of a negative PB may include atypical small acinar proliferation, HGPIN, prostatic atrophy, inflammatory proliferative atrophy and prostatic inflammation lesions, since they all seem to be associated with the risk of PC detection in repeat PB. This review has led us to create the hypothesis that the MS of a negative PB might be a valuable and useful tool when considering repeat PB.

New standards in prostate biopsy

OBJECTIVES

Prostate cancer diagnosis is undergoing a significant change in recent years. The concern about prostate cancer overtreatment as well astechnological developments that allow for better visualization of prostate cancer lesions are the main drivers for this change.

METHODS

This was a narrative review of the literature on prostate cancer diagnosis.

RESULTS

The diagnostic pathway of prostate cancer based on PSA screening and systematic TRUS has remained unaltered for many years. This is not free of errorand many men with insignificant prostate cancer will be diagnosed. Secondly, men with significant prostate cancer will be missed. Moreover, TRUS approach is associated with a non-negligible rate of sepsis. With the introduction of prostate multiparametric MRI, it seems that we are moving towards a less invasive method of triaging men for prostate biopsy and adopting a biopsy technique which aims to target specific areas within the prostate rather than randomly sampling it. There are a number of other imaging modalities that have attracted attention such as Elastography, histoscanning and contrast enhanced ultrasound. A targeted-only biopsy approach is a feasible option for prostate cancer diagnosis that can improve significant cancer detection and reduce insignificant cancer detection when compared to TRUS biopsy.

CONCLUSION

The introduction of multiparametric prostate MRI has the potential to change the way that we diagnose men with prostate cancer.

[Primary circulating prostate cells, age and prostatic volumen predict the presence of prostate cancer in men with indication of a second prostate biopsy.]

INTRODUCTION

The limitations of serumPSA as a screening test to detect prostate cancer remainproblematic, especially after an initial negative prostatebiopsy. Detection of primary circulating prostate cells(CPCs) has been reported to be useful in the detectionof prostate cancer in men with a serum PSA>4.0ng/ml.We present a prospective study comparing the detectionof CPCs, total PSA, percent free PSA, digital rectal examination(DRE) and prostate volumen (PV) to establisha predictive model for the detection of prostate cancerin men with an indication for a second prostate biopsy.

OBJECTIVE

To establish a predictive model for the detectionof prostate cancer using the number of CPCs detectedper sample, DRE, age, total serum PSA, percentfree PSA and PV in men with an indication for a secondprostate biopsy.

METHODS AND PATIENTS

A prospective, observationalstudy carried out in the Hospital de Carabineros deChile, between 2006 and 2014 including 199 menundergoing a second prostate biopsy. The variables,number of CPCs detected (nCPC), DRE, age, PSA, percentfree PSA and PV were registered for each patientand based on these findings and comparing them withthe results of the prostate biopsy a multivariate logistic regressionanalysis incorporating forward predictors. Themodel was evaluated for co-lineal tendency, reliabilityand error specificity, and analyzed using non-parametricreceiver operating characteristics and area under thecurve decision for the combined model and for eachvariable separately.

RESULTS

The single variable nCPC had a superior predictivevalue with an area under the curve of 0.89 (95%CI 0.83-0.94). The final model incorporated nCPC (OR:2.03 95% CI 1.63-2.53) age (OR: 1.1 95% CI 1.04-1.17) and PV (OR: 0.96 95% CI 0.93-0.99) with anarea under the curve for the combined model of 0.92(95% CI 0.88-0.97). The combined model performedbetter than the variables used alone.

CONCLUSIONS

The model incorporating nCPC, ageand PV had a greater diagnostic yield for the predictingprostate cancer at second biopsy.

[First prostate biopsy vs rebiopsy: Analysis of our series.]

INTRODUCTION

Prostate re-biopsydoes not guarantee detection of prostate cancer(PC), sometimes leading to overdiagnosis of clinicallyinsignificant tumors. The present study shows theincidence of PC in our hospital and analyzes thedistribution of risk groups and prognosis depending inthe diagnosis obtained by first biopsy vs rebiopsy.

OBJECTIVES

1. To know the incidence of ProstateCancer (PC) in patients biopsied in our hospital duringthe years 2014, 2015 and 2016 as well as thedistribution by risk and prognosis groups.2. To know if there are significant differences in thedistribution of risk and prognostic groups among patientsdiagnosed of PC by first biopsy vs rebiopsies in ourhospital in the years 2014, 2015 and 2016.

MATERIALS AND METHODS

A longitudinal retrospectivedescriptive and analytical study was performed with496 patients undergoing prostate biopsy (PB) in ourhospital between January 1st 2014 and December31st 2016. We analyze the results of prostate biopsy,Gleason score and distribution by prognosis group toverify if there were significant differences between firstbiopsy vs prostate biopsy.

RESULTS

The rate of positive PB in first biopsy was38.3% compared to 26.8% in rebiopsy. There weresignificant differences (p=0.01). In our series wediagnosed in first biopsy 71.8% of significant PC andthe 90% of the of bad or very bad prognosis PC (groups4 and 5 according to the ISUP classification).

CONCLUSIONS

There are significant differences inthe diagnosis of prostate cancer between a first biopsyand a rebiopsy. Tumors diagnosed by rebiopsies havea better prognosis than those diagnosed by first biopsy.We must adopt mechanisms to increase the diagnosticyield of re-biopsies.

A comparison of 3 on-line nomograms with the detection of primary circulating prostate cells to predict prostate cancer at initial biopsy

INTRODUCTION

The use of nomograms which include the PSA may improve the predictive power of obtaining a prostate biopsy (PB) positive for cancer. We compare the use of three on-line nomagrams with the detection of primary malignant circulating prostate cells (CPCs) to predict the results of an initial PB in men with suspicion of prostate cancer.

METHODS AND PATIENTS

Consecutive men with suspicion of prostate cancer underwent a 12 core TRUS prostate biopsy; age, total serum PSA, percent free PSA, family history, ethnic origin and prostate ultrasound results were used for risk assessment using the online nomograms. Mononuclear cells were obtained by differential gel centrifugation from 8ml of blood and CPCs were identified using double immunomarcation with anti-PSA and anti-P504S. A CPC was defined as a cell expressing PSA and P504S and defined as negative/positive. Biopsies were classified as cancer/no-cancer. Areas under the curve (AUC) for each parameter were calculated and compared and diagnostic yields were calculated.

RESULTS

1,223 men aged>55 years participated, 467 (38.2%) had a biopsy positive for cancer of whom 114/467 (24.4%) complied with the criteria for active observation. Area under the curve analysis showed CPC detection to be superior (p<0.001), avoiding 57% of potential biopsies while missing 4% of clinically significant prostate cancers.

CONCLUSIONS

The CPC detection was superior to the nomograms in predicting the presence of prostate cancer at initial biopsy; its high negative predictive value potentially reduces the number of biopsies while missing few significant cancers, being superior to the nomograms in this aspect. Being a positive/negative test the detection of CPCs avoids defining a cutoff value which may differ between populations.

Clinical performance of transperineal template guided mapping biopsy for therapeutic decision making in low risk prostate cancer

OBJECTIVES

To evaluate the role of Transperineal Template guided Mapping Biopsy (TTMB) in determining the management strategy in patients with low risk prostate cancer (PCa).

METHODS

We retroscpectively evaluated 169 patients who underwent TTMB at our institution from February 2008 to June 2011. Ninety eight of them harbored indolent PCa defined as: Prostate Specific Antigen<10ng/ml, Gleason score 6 or less, clinical stage T2a or less, unilateral disease and a maximum of one third positive cores at first biopsy and<50% of the core involved. TTMB results were analyzed for Gleason score upgrading and upstaging as compared to initial TransRectal UltraSound (TRUS) biopsies and its influence on the change in the treatment decisions.

RESULTS

TTMB detected cancer in 64 (65%) patients. The upgrade, upstage and both were noted in 33% (n=21), 12% (n=8) and 7% (n=5) respectively of the detected cancers. The disease characteristics was similar to initial TRUS in 30 (48%) patients and TTMB was negative in 34 (35%) patients. Prostate volume was significantly smaller in patients with upgrade and/or upstage noted at TTMB (45.4 vs 37.9; P=.03). TTMB results influenced 73.5% of upgraded and/or upstaged patients to receive radical treatment while 81% of the patients with unmodified stage and/or grade continued active surveillance or focal therapy.

CONCLUSIONS

In patients with low risk PCa diagnosed by TRUS, subsequent TTMB demonstrated cancer upgrade and/or upstage in about one-third of the patients and resulted in eventual change in treatment decision.

Evolution of prostate biopsy techniques. Looking back on a meaningful journey

BACKGROUND

The technique of prostate biopsy has evolved a long way since its inception to being a safe diagnostic procedure. The principles of the biopsy technique continue to improvise with the knowledge about prostate cancer and availability of newer treatment options like active surveillance and focal therapy. Currently, we depend on accurate cancer information from the biopsy more than ever for deciding the ideal treatment option.

AIM

The aim of this review is to present the major milestones in prostate biopsy technique evolutions and its impact on the prostate cancer management.

ACQUISITION OF EVIDENCE

We performed a detailed non-systematic literature review to present the historical facts on the transformations in prostate biopsy techniques and also the direction of present research to improve accurate cancer detection.

SUMMARY OF EVIDENCE

There is a clear change in trend in biopsy technique before and after the introduction of transrectal ultrasound and prostate specific antigen. In the earlier era, the biopsies were aimed at palpable nodules and obtaining adequate prostatic tissue for diagnosis while the later era has moved towards detection of non-palpable and early prostate cancer. Recently, there is an increasing trend towards image guided targeted biopsies to extract maximum cancer information from minimum biopsy cores.

CONCLUSION

Prostate biopsy techniques have seen major changes since its inception and have a major impact on prostate cancer management. There is a great potential for research which can further support the newer treatment options like focal therapy.

Is effective a prior multiparametric magnetic resonance scan in patients candidates to prostate biopsy? CAT Study

We carried out a critically appraised topic (CAT)-type study to determine whether the relevant scientific evidence supports the recommendation of doing a multiparametric magnetic resonance imaging study of the prostate in all patients who are candidates for prostate biopsy with the aim of improving the detection of clinically significant prostate cancer and stratifying patients to receive active surveillance or treatment. After a formal literature search and an analysis of the two most relevant articles it found, we reached the conclusion that, despite promising results that point to the potential usefulness of this approach, there is still not enough clear scientific evidence to endorse it categorically. Before this approach can be endorsed, we need evidence from well-designed prospective randomized trials using widely agreed upon criteria and including large numbers of patients at multiple centers.

Optimizing prostate cancer screening; prospective randomized controlled study of the role of PSA and PCA3 testing in a sequential manner in an opportunistic screening program

OBJECTIVES

To reduce unnecessary biopsies (Bx) in an opportunistic screening programme of prostate cancer.

MATERIAL AND METHODS

We perform a prospective evaluation of PCA3 as a second line biomarker in an opportunistic screening for prostate cancer (PCa). From September-2010 until September-2012, 2,366 men, aged 40-74 years and with >10 years life expectancy, were initially screened with PSA/digital rectal examination (DRE). Men with previous Bx or with recent urine infections were excluded. Men with abnormal DRE and/or PSA >3 ng/ml were submitted for PCA3. All men with PCA3 ≥ 35 underwent an initial biopsy (IBx) -12cores-. Men with PCA3 < 35 were randomized 1:1 to either IBx or observation. Re-biopsy(16-18 cores) criteria were PSA increase >.5 ng/ml at 4-6 months or PSAv > .75 ng/ml/year.

RESULTS

With median follow-up (FU) of 10.1 months, PCA3 was performed in 321/2366 men (13.57%), 289 at first visit and 32 during FU. All 110 PCA3+ men (34.3%) were biopsied and PCa was identified in 43 men in IBx (39.1%). In the randomized arm, 110 were observed and 101 underwent biopsy, finding 12 PCa (11.9%), showing a statistically significant reduction of PCa detection rate in this cohort (P<.001). Global PCa detection rates were 40.9% and 9.5% for the PCA3+ and PCA3- branches, respectively (P<.001). Area under the curve for PSA and PCA3 were .601 and .74, respectively. This is an ongoing prospective study limited by its short follow-up period and still limited enrolment.

CONCLUSIONS

PCA3 as a second line biomarker within an opportunistic dual screening protocol, can potentially avoid 65.7% and 50.1% biopsies at first round and at median FU of 10.1 months, respectively, just missing around 3.2% of high grade PCa.