Multiparametric MRI Versus SelectMDx Accuracy in the Diagnosis of Clinically Significant PCa in Men Enrolled in Active Surveillance.

BACKGROUND/AIM: To evaluate the diagnostic accuracy of the urinary SelectMDx test in the diagnosis of clinically significant prostate cancer (csPCa) in men enrolled in an active surveillance (AS) protocol. PATIENTS AND METHODS: From July 2015 to July 2018, 125 men with very low-risk PCa were enrolled in the AS protocol; all patients underwent confirmatory transperineal saturation biopsy (SPBx). In the presence of PI-RADS score ≥3, a targeted MRI/TRUS fusion-guided biopsy was added to SPBx. Post-digital rectal examination urine was collected in 45/125 (36%) patients before SPBx; the genetic urine analysis was performed using a biomarker-based risk score model, the SelectMDx, that measured mRNA levels of distal-less homeobox 1 (DLX1) and homeobox C6 (HOXC6). RESULTS: A total of 9/45 (20%) patients were reclassified as csPCa (7 cases=Grade Group 2; 2 cases=Grade Group 3); sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of mpMRI vs. SelectMDx in the diagnosis of csPCa were equal to 66.6 vs. 55.6%, 87.7 vs. 65.8%, 54.5 vs. 27.8%, 92.3 vs. 87%, 84.9 vs. 70.3%, respectively. CONCLUSION: SPBx combined with MRI/TRUS fusion biopsy significantly outperformed the diagnostic accuracy of SelectMDx (70.3%) in the diagnosis of csPCa in men enrolled in AS.

Multiparametric pelvic MRI accuracy in diagnosing clinically significant prostate cancer in the reevaluation of biopsy microfocal tumor.

AIM: To evaluate the accuracy of multi-parametric pelvic magnetic resonance imaging (mpMRI) in diagnosing prostate cancer (PCa) in men with initial biopsy microfocal cancer. PATIENTS AND METHODS: From January 2012 to July 2014, 40 patients before undergoing repeat transperineal saturation prostate biopsy (SPBx; median, 28 cores) for the presence of a microfocal PCa were submitted to 3.0-Tesla mpMRI. RESULTS: A T1c clinical stage PCa was found in 23 (57.5%) patients submitted to SPBx; mpMRI was positive in 16/40 (40%) cases and in 11 of them a clinically significant PCa was found. On the contrary, the 12 men with negative mpMRI had a quantitative histology suitable for clinically insignificant cancer. Diagnostic accuracy of mpMRI in diagnosing significant PCa was equal to 100%. CONCLUSION: Multi-parametric pMRI should be suggested in the re-evaluation of microfocal cancer as a selection approach of patients at risk for clinically significant PCa.

Detection rate of anterior prostate cancer in 226 patients submitted to initial and repeat transperineal biopsy.

OBJECTIVE: To evaluate the detection rate of anterior zone (AZ) prostate cancer (PCa) in patients submitted to initial and repeat transperineal prostate biopsy. METHODS: From January 2013 to August 2013, 226 patients (median age 64 years) with negative digital rectal examination underwent initial (144 cases) and repeat (82 cases) transperineal prostate biopsy for PSA >10 ng/ml, PSA 4.1-10.0 or 2.6-4.0 ng/ml with free/total PSA ≤25% and ≤20%, respectively. A median of 22 versus 32 cores were performed, including 4 cores of the AZ versus 6 cores (4 anterior plus 2 cores of the transition zone, TZ) at initial versus repeat biopsy, respectively. The detection rate of PCa of the peripheral zone (PZ), AZ and TZ was prospectively evaluated. RESULTS: The median PSA was 7.6 ng/ml; overall, a stage cT1c PCa was found in 104/226 (46%) patients, in 70 (48.6%) and 34 (41.5%) of the men who underwent initial and repeat biopsy, respectively. An AZ PCa was found in 11.5 vs. 8.8% (p = 0.32) of the patients submitted to initial versus repeat biopsy, respectively. AZ cancers demonstrated a number of positive cores (p = 0.03), greatest percentage of cancer (p = 0.001) and total percentage of cancer (p = 0.001) significantly lower in comparison with PZ PCa; moreover, 56.2 vs. 36.5% of AZ versus PZ PCa were characterized by a microfocus of cancer (p = 0.001), respectively. CONCLUSIONS: AZ biopsies increase the detection rate of PCa (about 10% of cases) at initial and repeat biopsy, allowing reduction of the biopsy false-negative rate.

PSA nadir and outcome in 100 patients with pT3b prostate cancer.

AIM: The prostate-specific antigen (PSA) nadir and long-term outcome in patients with pT3b prostate cancer were evaluated. PATIENTS AND METHODS: From July 2000 to December 2012, in 100 patients (median age=62 years) with pT3b prostate cancer following radical retropubic prostatectomy (RRP) preoperative and pathological findings predictive of PSA nadir (≤0.2 vs. >0.2 ng/ml) were retrospectively evaluated; moreover, biochemical recurrence-free survival (bRFS), cancer specific survival (CSS) and overall survival (OS) in patients who underwent watchful waiting (16 cases), adjuvant (84 cases) and salvage (10 cases) therapy were recorded. RESULTS: A PSA nadir >0.2 ng/ml was correlated with node involvement, Gleason score ≥9, cT2, PSA >20 ng/ml, positive surgical margins and total cancer percentage >20%. At a median follow-up of 90 months (range=10-155 months) bRFS, OS and CSS were 92%, 96% and 80%, respectively. CONCLUSION: Radical retropubic prostatectomy combined with adjuvant and salvage treatments demonstrated a satisfactory outcome for pT3b prostate cancer.

Accuracy of 3 Tesla pelvic phased-array multiparametric MRI in diagnosing prostate cancer at repeat biopsy.

INTRODUCTION: Multiparametric pelvic magnetic resonance imaging (mpMRI) accuracy in prostate cancer (PCa) diagnosis was evaluated. MATERIALS AND METHODS: From June 2011 to December 2013, 168 patients (median 65 years) with negative digital rectal examination underwent repeat transperineal saturation biopsy (SPBx; median 28 cores) for persistently high or increasing PSA values, PSA >10 ng/ml or PSA values between 4.1-10 o r 2.6-4 ng/ml with free/total PSA < 25% and < 20%, respectively. All patients underwent mpMRI using a 3.0 Tesla scanner equipped with surface 16 channels phased-array coil and lesions suspicious for PCa were submitted to additional targeted biopsies. RESULTS: A T1c PCa was found in 66 (39%) cases; SPBx and mpMRI-suspicious targeted biopsy diagnosed 60 (91%) and 52 (78.8%) cancers missing 6 (all of the anterior zone) and 14 cancers (12 and 2 of the lateral margins and anterior zone), respectively; in detail, mpMRI missed 12 (18.1%) PCa charaterized by microfocal (1 positive core with greatest percentage of cancer and Gleason score equal to 5% and 6, respectively) disease at risk for insignificant cancer. The diameter of the suspicious mpMRI lesion was directly correlated to the diagnosis of PCa with poor Gleason score (p < 0.05); detection rate of cancer for each suspicious mpMRI core was 35.3%. Diagnostic accuracy, sensitivity, specificity, positive and negative predictive value of mpMRI in diagnosing PCa was 75.7%, 82.5%, 71.8%, 78.9%, 87.9%, respectively. CONCLUSION: Multiparametric pMRI improved SPBx accuracy in diagnosing significant anterior PCa; the diameter of mpMRI suspicious lesion resulted significantly predictive of aggressive cancers.

Erectile function after repeat saturation prostate biopsy: our experience in 100 patients.

INTRODUCTION: Erectile dysfunction (ED) incidence following repeat saturation prostate biopsy (SPBx) was evaluated. MATERIALS AND METHODS: From January 2011 to June 2012 295 patients underwent repeat transperineal SPBx (median 28 cores) under sedation. The indications for biopsy were: abnormal DRE, PSA > 10 ng/mL or included between 4.1-10 with free/total PSA < 25%. All patients were prospectively evaluated with the 5-item version of the International Index of Erectile Function (IIEF-5) at baseline and 1, 3 and 6 months from SPBx. RESULTS: 100/200 men with benign histology and normal sexual activity completed the study; median IIEF-5 score before and after SPBx was equal to 18.3 (baseline) vs 17.8 (1 month later) vs 18 (3 months later) vs 18.1 (6 months later) (p > 0.05); in detail, 1 month from biopsy 5 (5%) men referred a mild ED that disappeared at 3 and 6 months evaluation. CONCLUSIONS: Repeat transperineal SPBx under sedation did not significantly worsened erectile function; the minimal risk of temporary post-biopsy ED could be previously discussed (not emphasised) with potent patients.

Left coronary ostium isolation and aortic valve dysplasia in a young boy: a case report.

Congenital anomalies of the aortic valve represent a common malformation. Infrequently, a dysplastic aortic valve leaflet causes a severe coronary artery anomaly. Here, the case is reported of a malformed aortic valve in which the left rudimentary cusp occluded the left coronary ostium. At surgery the left coronary ostium was completely freed from the anomalous valvular tissue, a Konno operation was performed, and a 19 mm St. Jude Medical mechanical prosthesis was implanted. To date, very few reports have made of this rare malformation; moreover, to the present authors' knowledge this is the only case to have been treated.

Prostate cancer detection after one or more negative extended needle biopsy: results of a multicenter case-findings protocol.

OBJECTIVES: To evaluate PCa incidence in patients with one or more negative extended prostate biopsy who underwent repeat biopsy or TURP. MATERIAL AND METHODS: From June 2003 to February 2008, 308 patients were submitted to repeat prostate biopsy (median 20.5 cores) and 120 patients underwent TURP after one or more 12 cores prostate biopsy. Indications for biopsy were: abnormal DRE; PSA > 10 ng/mL; PSA included between 4.1-10 or 2.6-4 ng/mL with free/total PSA < or = 25% and < or = 20%, respectively 262 and 46 underwent a second and a third biopsy: 218 because for high levels of PSA, 40 and 50 patients for a previous diagnosis of HGPIN and ASAP, 28 had an abnormal DRE. PSA in patients who underwent TURP was 11.6 ng/mL (median); in all cases DRE was negative and only 76 patients referred LUTS. RESULTS: PCa incidence at repeat biopsy was 16.9%; 96.2% of cancers were diagnosed at a second biopsy and 3.8% at a third one. PCa incidence was higher in patients with previous ASAP (43.4% and 50%) vs patients with HGPIN (25% and 0%) or benign pathology (11.9% and 0%). PCa was diagnosed in 11.1% and 19% of patients who underwent TURP previously submitted to a first and a second biopsy, respectively. CONCLUSIONS: In case of persistent suspicion of PCa after a repeated negative saturation biopsy, TURP should be proposed as part of the diagnostic procedure aside from LUTS, especially in patients with a life expectancy greater than 10 years.

Prevalence and clinical significance of prostate cancer among 12,682 men with normal digital rectal examination, low PSA levels (< or =4 ng/ml) and percent free PSA cutoff values of 15 and 20%.

AIM: To report prevalence and clinical relevance of T1c prostate cancers (PCa) in a selected population of men with serum prostate-specific antigen (PSA) levels < or =4 ng/ml enrolled in a multicenter case-finding protocol. PATIENTS AND METHODS: A number of 16,298 men, aged 40-75 years, from the urology units they had been referred to, in most cases (81.6%) for lower urinary tract symptoms, were evaluated. Eighty percent of them had PSA < or =4 ng/ml and about 40% PSA < or =2.5 ng/ml. Patients with PSA < or =2.5 ng/ml and PSA between 2.6 and 4 ng/ml and with percent free PSA < or =15 and < or =20%, respectively, were eligible for biopsy; 28 patients refused it, and 11 patients were excluded from the study because of an abnormal digital rectal examination. Among 403 biopsied men, 82 had PSA < or =2.5 ng/ml (group A) and 321 PSA between 2.6 and 4 ng/ml (group B). RESULTS: A PCa was found in 109 cases (27.0%): 21 in group A and 88 in group B. 48 (44%) of the 109 patients with a PCa underwent radical prostatectomy: all cancers had a volume >0.5 cm(3), and 41% had a final Gleason sum > or =7; the PCa was organ confined in 34 patients (70.8%) and locally advanced in 14 patients (29.1%), and in 12 patients (25%) positive surgical margins were found. CONCLUSIONS: Using percent free PSA thresholds of 15 and 20%, 25.6% of the men with PSA < or =2.5 ng/ml and 27.4% of the men with PSA between 2.6 and 4 ng/ml were found to have a PCa, respectively. Most of these cancers, when submitted to radical prostatectomy, were found to be clinically significant. As these cancers are mostly organ confined, these patients are ideal candidates for curative nerve-sparing surgery.