Prostatic ductal adenocarcinoma variant predicts worse pathological and oncological outcomes: Insight from over 1000 consecutive patients from a large prospective uro-oncology registry.

OBJECTIVE: To evaluate if prostatic ductal adenocarcinoma (PDA) independently predicts poorer pathological and oncological outcomes after radical prostatectomy (RP). METHODS AND MATERIALS: Utilizing a large prospective uro-oncology registry, clinicopathological parameters of 1027 consecutive patients who underwent RP (2008-2017) were recorded. Oncological outcomes were determined by failure to achieve unrecordable PSA postoperatively and biochemical failure (BCF). RESULTS: PDA was present in 79 (7.7%) patients, whereas 948 (92.3%) patients had conventional prostatic acinar adenocarcinoma (PAA). Patients with PDA were older (mean 64.4 vs. 62.8-years old; p = .045), had higher PSA at diagnosis (mean 12.53 vs. 10.80 ng/ml; p = .034), and a higher percentage of positive biopsy cores (mean 39.34 vs. 30.53%; p = .006). Compared to PAA, PDA exhibited a more aggressive tumor biology: (1) Grade groups 4 or 5 (26.6 vs. 9.4%, p < .001), (2) tumor multifocality (89.9 vs. 83.6%; p = .049), and (3) tumor size (mean 2.97 vs. 2.00 cm; p < .001). On multivariate analysis, PDA was independently associated with locally advanced disease (p = .002, hazard ratio [HR]: 2.786, 95% confidence interval [CI]: 1.473-5.263), with a trend towards positive surgical margins (p = .055) and nodal involvement (p = .061). Translating the poorer pathological features to oncological outcomes, presence of PDA independently predicted less likelihood of achieving unrecordable PSA (p = .019, HR: 2.368, 95% CI: 1.152-4.868, and higher BCF (p = .028, HR: 1.918, 95% CI: 1.074-3.423). Subgroup analysis demonstrated that a higher ductal component greater than 15% proportionally predicted worse oncological outcomes, with a shorter time to BCF of 14.3 months compared to 19.8 months in patients with ductal component lesser than 15% (p = .040, HR: 2.660, 95% CI: 1.046-6.757). CONCLUSION: PDA is independently associated with adverse pathological and oncological outcomes after RP. A higher proportion of PDA supports a higher BCF rate with a shorter time interval. An aggressive extirpative approach with close monitoring of postoperative serum PSA levels is warranted for these patients.

Multiparametric MRI-ultrasonography software fusion prostate biopsy: initial results using a stereotactic robotic-assisted transperineal prostate biopsy platform comparing systematic vs targeted biopsy.

OBJECTIVE: To compare the detection rates of prostate cancer between systematic biopsy and targeted biopsy using a stereotactic robot-assisted transperineal prostate platform. MATERIALS AND METHODS: We identified consecutive patients with suspicious lesion(s) on multiparametric magnetic resonance imaging (mpMRI), who underwent both systematic and MRI-transrectal ultrasonography (US) fusion targeted biopsy using our proprietary transperineal robot-assisted prostate biopsy platform between January 2015 and January 2019 at our institution, for retrospective analysis. Comparative analysis was performed between systematic and targeted biopsy using McNemar's test, and the cohort was further stratified by prior biopsy status and Prostate Imaging Reporting and Data System (PI-RADS) v2.0 score. International Society of Urological Pathology (ISUP) grade group (GG) ≥2 cancers (previously known as Gleason grade ≥7) were considered to be clinically significant. RESULTS: A total of 500 patients were included in our final analysis, of whom 67 (13%) were patients with low-risk cancer on active surveillance. Of the 433 patients without prior diagnosis of cancer, 288 (67%) were biopsy-naïve. A total of 248 (57%) were diagnosed with prostate cancer, with 199 (46%) having clinically significant prostate cancer (ISUP GG ≥2). There were no statistically significant differences in the overall prostate cancer and clinically significant prostate cancer detection rate between systematic and targeted biopsy (51% vs 49% and 40% vs 38% respectively; P = 0.306 and P = 0.609). Of the 248 prostate cancers detected, 75% (187/248) were detected on both systematic and targeted biopsy, 14% (35/248) were detected on systematic biopsy alone and 11% (26/248) were detected on targeted biopsy alone. Of the 199 clinically significant cancers detected, 69% (138/199) were detected on both systematic and targeted biopsy, 17% (33/199) on systematic biopsy alone and 14% (28/199) on targeted biopsy alone. There were no statistically significant differences in the detection rate between systematic and targeted biopsy for both overall and clinically significant prostate cancer, even when the cohort was stratified by prior biopsy status and PI-RADS score. Targeted biopsy has greater sampling efficiency compared to systematic biopsy for both overall and clinically significant prostate cancer (23.2% vs 9.8%, P < 0.001 and 14.8% vs 5.6%, P < 0.001). CONCLUSIONS: Using our robot-assisted transperineal prostate platform, combined MRI-US targeted biopsy with concurrent systematic prostate systematic biopsy probably represents the optimal method for the detection of clinically significant prostate cancer.

Focal Therapy for Prostate Cancer with In-Bore MR-guided Focused Ultrasound: Two-Year Follow-up of a Phase I Trial-Complications and Functional Outcomes.

Purpose To report the safety profile and 2-year functional outcomes of in-bore magnetic resonance (MR)-guided focused ultrasound on single cancer foci in men with prostate cancer. Materials and Methods Ethics approval was obtained from the centralized institutional review board for this prospective single-arm study, and patients provided informed consent. Patients with untreated low-volume low-grade prostate cancer (clinical stage T2a or lower; Gleason score, 3+3; index tumor ≤10 mm3) underwent MR-guided focused ultrasound between July 2011 and February 2013. All patients underwent robotic transperineal mapping biopsy and multiparametric MR imaging. Only those with a maximum of two lesions smaller than 10 mm at mapping biopsy were included. Target areas were sonicated with real-time MR thermometry monitoring, excluding critical areas from the beam path. Serum prostate-specific antigen (PSA) and Expanded Prostate Index Composite (EPIC) scores were obtained at baseline and at 1, 3, 6, 12, 18, and 24 months and were plotted to observe their trend. Mean EPIC subdomain score changes at each serial time point were compared with the baseline score by using paired t tests (level of significance, P < .007). Repeat transperineal biopsy was performed at 6 and 24 months. Results Fourteen men (mean age, 62.8 years; median PSA level, 8.3 ng/mL) underwent treatment, with 12 men completing 2-year follow-up. A median reduction of PSA level by 2.9 ng/mL was observed at 6 months. Seven men had Clavien-Dindo grade 1-2 complications. There was a slight insignificant deterioration of EPIC urinary symptom score (mean increase of 7.8 points compared with baseline, P = .012) noted at 1 month, but it returned to baseline by 3 months. There was a trend to deterioration in sexual function score (mean decrease, 4.4 points; P = .04 [not significant]) that normalized at 3 months. There was no significant change in EPIC subdomain scores from baseline over the 24 months. At 6-month template biopsy, one man had cancer with a Gleason score greater than 6; at 24 months, three men had cancer with a Gleason score greater than 6. Conclusion MR-guided focused ultrasound is technically feasible for focal prostate ablation and appears to have a favorable early safety and functional profile. Further clinical trials are necessary to establish oncologic efficacy. © RSNA, 2017 Online supplemental material is available for this article.

Renal cell carcinoma in patients with end-stage renal disease is associated with more favourable histological features and prognosis.

OBJECTIVE: End-stage renal disease (ESRD) patients with acquired cystic kidney disease are at higher risk of developing renal cell carcinoma (RCC) than the general population. The aim of this study was to investigate the clinical and histopathological differences between ESRD patients and the general population with RCC. MATERIALS AND METHODS: Data were retrospectively collected from all nephrectomies performed for localized RCC from 2000 to 2010. Age at nephrectomy, gender, race, symptoms, baseline Eastern Cooperative Oncology Group (ECOG) performance status, Charlson Comorbidity Index score and histological data were extracted. Independent-samples t test and Mann-Whitney test were used for quantitative data, while chi-squared (two-sided) and Fisher's exact tests were used for qualitative data. RESULTS: This study included 627 patients: 73 with and 554 without ESRD. The majority of patients were Chinese. The male to female ratio of 2:1 was identical in both groups. Baseline ECOG performance status and Charlson Comorbidity score were higher in the ESRD group. RCC in ESRD patients was more frequently asymptomatic (56.2% vs 44.9%, p = 0.071), diagnosed earlier (53.6 ± 11.8 years vs 57.9 ± 12.2 years, p = 0.004) and of lower stage (p < 0.001). The ESRD cohort had a higher proportion of the papillary histological subtype (21.9% vs 9.7%, p < 0.001). Importantly, there was a trend towards more favourable outcomes in ESRD patients in terms of cancer-specific (p = 0.203) and relapse-free survival (p = 0.096). CONCLUSION: This study suggests that RCC in ESRD patients is associated with more favourable clinical and histological features and oncological outcome compared with that in patients with normal renal function.

Evaluation of data completeness of the prostate cancer registry after robotic radical prostatectomy.

INTRODUCTION: This study evaluated the data completeness in the registration of prostate cancer after robotic radical prostatectomy (RRP) in the Urological Cancer Registry at the Singapore General Hospital (SGH), and its compliance to the international standards of US Commission on Cancer (CoC). MATERIALS AND METHODS: A certified cancer registrar reviewed all RRP cases between June 2003 and July 2008 in the Urological Cancer Registry at SGH. RESULTS: A total of 365 cases were reviewed. The results showed that 351 (96.2%) of RRP patients' demographic data were captured and 321 (87.9%) of RRP patients were staged. According to the international standards of CoC for an academic institution, the requirement is to capture 100% of all cancer cases and stage at least 90% of them. As for data completeness, 317 (86.7%) of RRP details were captured as compared to the CoC standard requirement of 90%. CONCLUSIONS: The existing manual cancer registry does not fully meet the CoC standards. Hence, the registry increased sources of case-finding and used active case-finding. With improvements made to the data collection methodology, the number of prostate cancer cases identified has been increased by 52.1% from 215 in 2007 to 327 in 2009. The registry is expected to be fully compliant with the CoC standard with the recruitment of more full time cancer registrars when a new web-based cancer registry is in full operation.

Effect of ageing and body mass index on prostate-specific antigen levels among Chinese men in Singapore from a community-based study.

OBJECTIVE To assess the effect of ageing and body mass index (BMI) on prostate-specific antigen (PSA) among Chinese men from the results of the 2005 Prostate Awareness Week in Singapore. SUBJECTS AND METHODS In all, 2714 men participated in the programme, consisting of 2431 Chinese, 114 Malays, 117 Indians and 52 'others'. Of these, 2410 Chinese men who had a PSA level of <20 ng/mL and were aged >50 years but <80 years were included in the analysis. Height and weight were used to calculate the BMI. The relationship between age and PSA levels was analysed using linear regression and bivariate correlation, and the associations among different groups of BMI and PSA levels were analysed using analysis of variance and covariance. RESULTS PSA levels were significantly correlated with age (correlation coefficient, r = 0.27, P < 0.001). Analyses showed a significant inverse association between PSA level and BMI; mean PSA levels decreased with increasing BMI for both standards (standard classification; geometric mean, GM, PSA of 1.08, 1.06, 0.96, 0.83 ng/mL for a BMI of <18.5, 18.5-24.9, 25-29.9 and > or =30 kg/m(2), respectively, P trend <0.01; and for Asian classification, GM PSA 1.08, 1.09, 0.96, 0.91 ng/mL for a BMI of <18.5, 18.5-22.9, 23-27.5 and > or =27.5, respectively, P trend <0.001). There were significant differences (P < 0.05) in the age-adjusted GM PSA levels for the groups with BMI <25 (1.05 ng/mL) and BMI > or =25 kg/m(2) (0.97 ng/mL). Similarly, there were significant differences (P < 0.05) in the age-adjusted GM PSA levels in those with a BMI of <30 (1.03 ng/mL) and > or =30 kg/m(2) (0.85 ng/mL). CONCLUSION These data suggest that the BMI in Chinese men in Singapore is significantly associated with PSA levels, especially among the obese men aged 70-79 years.

Local experience of endorectal magnetic resonance imaging of prostate with correlation to radical prostatectomy specimens.

INTRODUCTION: We evaluated the accuracy of endorectal magnetic resonance imaging (MRI) in the staging of prostate cancer. MATERIALS AND METHODS: We retrospectively reviewed 32 patients who underwent endorectal MR prostate prior to radical prostatectomy. The tumour stage based on MR imaging was compared with the pathologic stage. The sensitivity and specificity of endorectal MR prostate in the evaluation of extracapsular extension (ECE) of the tumour were then determined. RESULTS: MR correctly diagnosed 17 cases of organ-confined prostate carcinoma and 2 cases of locally advanced disease. In the evaluation of ECE, endorectal MR achieved a high specificity of 94.4%, low sensitivity of 14.3% and moderate accuracy of 59.4%. CONCLUSION: Endorectal MR prostate has high specificity for the detection of ECE. It is useful in the local staging of prostate cancer in patients with intermediate risk as this helps to ensure that few patients will be deprived of potentially curative surgery.

Renal cell carcinoma of 4 cm or less: an appraisal of its clinical presentation and contemporary surgical management.

OBJECTIVE: Greater availability and utilization of modern radiological imaging modalities have resulted in an increase in the incidental discovery of renal cell carcinoma. Such tumours tend to be smaller than their symptomatic counterparts and may potentially be adequately treated using nephron-sparing surgery. METHODS: A retrospective review of all patients who were diagnosed with renal cell carcinoma of 4 cm or less between January 1990 and December 2001 was conducted to review clinical presentation, surgical management and survival. RESULTS: The cohort comprised 102 patients who underwent surgery, of 402 patients diagnosed with renal cell carcinoma over the study period. Sixty-eight patients (67%) had tumours detected incidentally. Thirty patients (29%) were managed with partial nephrectomy and 72 (71%) with radical nephrectomy. The median tumour size was 3.0 cm (range, 1.5-4.0 cm). Overall, median follow-up was 60 months (range, 1-148 months). Overall 5-year survival for patients who underwent partial nephrectomy and radical nephrectomy was 96.6% and 85.8%, respectively. Cancer-specific 5-year survival was 100%. CONCLUSION: A significant proportion of patients had incidental diagnosis of small renal cell carcinoma. Local control may be achieved with either radical or partial nephrectomy, with excellent survival expected.

Unresectable desmoid tumours causing obstructive uropathy in familial adenomatous polyposis.

Desmoid tumour-related ureteral obstruction in familial adenomatous polyposis presents difficult management problems. Its role in altering prognosis for the worse in young patients has been neglected. Two patients are reported and 14 cases in the literature reviewed. Both our patients developed intra-abdominal desmoid tumours following proctocolectomies with pouch reconstruction (performed 0.7 and 2.5 years earlier). Despite therapy with sulindac and tamoxifen, both suffered progressive ureteral obstruction that required initial percutaneous drainage. Ureteral stenting was effective and safe in both patients (10 and 18 months' follow-up, respectively), but the long-term outcome awaits assessment. The optimal regimen of adjuvant medical therapy is uncertain. Successful renal autotransplantation and combination chemotherapy have been tried after failure of conventional therapy.

Is photodynamic diagnosis using hypericin better than white-light cystoscopy for detecting superficial bladder carcinoma?

OBJECTIVE: To review the initial clinical results of photodynamic diagnosis (PDD) using hypericin (a new photosensitizer for PDD that helps to label flat urothelial tumours to facilitate biopsy) for the early detection of superficial bladder carcinoma, as flat noninvasive tumours of the bladder may be missed during conventional white-light cystoscopy (WLC) if there is bladder overdistension or ongoing cystitis. PATIENT AND METHODS: Between 1 January 2001 and 30 October 2004, 41 consecutive patients (mean age 66.1 years, sd 9.1, range 46-81) had transurethral resection for bladder cancer. Hypericin was introduced intravesically for 2 h before cystoscopy. Immediately after WLC, fluorescence cystoscopy (FC) was used at the same location and the same bladder site inspected using violet light. FC findings, e.g. positive or negative red fluorescence, were documented for each specific bladder site examined, and the exact location sampled for biopsy. RESULTS: The mean (sd, range) bladder capacity of the patients was 431 (86, 300-650) mL. In all, 179 biopsies were taken from the 41 patients; urothelial cancers were found in 41% (74) and 80% (33) had macroscopically visible bladder tumours; 40% (71) of the biopsies were positive under FC and 86% (61) of the 71 FC-positive biopsies showed cancer on histology. Twenty-five biopsies (14%) were positive on FC but not WLC. PDD testing with hypericin had a sensitivity of 82% (61/74) and specificity of 91% (95/105), vs WLC, at 62% (46/74) and 98% (103/105), respectively. The PDD test had a positive predictive value of 86% (61/71) and a negative predictive value of 88% (95/108), vs 96% (46/48) and 79% (103/131), respectively for WLC. There were no reports of significant complications after the procedure. CONCLUSION: PDD using hypericin shows promise, as it has a higher sensitivity but equivalent specificity than WLC. It can be used to detect flat lesions not seen on WLC. PDD testing is also well tolerated with minimal side-effects.

Early experience with robot-assisted laparoscopic radical prostatectomy.

INTRODUCTION: We assessed the feasibility of a robot-assisted laparoscopic radical prostatectomy (rLRP) programme through a review of our early experience. PATIENTS AND METHODS: Seventeen patients underwent rLRP between 1 February 2003 and 31 December 2003 at Singapore General Hospital. All patients had histologically confirmed adenocarcinoma on prostate biopsy and a negative bone scan. The Da Vinci robot was employed. The Montsouris technique was used for our first eight patients, and the Vattikuti Institute Prostatectomy technique was used for all subsequent patients. We studied perioperative parameters and early surgical outcome prospectively. RESULTS: The mean age at diagnosis was 63.9 +/- 5.6 years. The median Gleason sum was 6 (range, 5-9), and mean pretreatment prostate-specific antigen level was 10.5 +/- 5.4 ng/mL. The mean set-up time was 34 +/- 18 minutes, and mean dissection time was 247 +/- 43 minutes. Perioperative blood loss averaged 494 +/- 330 mL, and three patients required blood transfusion. Normal diet was resumed after 1.7 +/- 0.6 days. The mean duration of bladder catheterization was 9.8 +/- 6.1 days, and mean hospital stay was 2.7 +/- 1.3 days. There was no perioperative mortality or major complications, and no conversion to open radical prostatectomy. From Case 9 onwards, there was significant reduction in operating time (284 vs 215 minutes), blood loss (650 vs 400 mL) and hospital stay (3.8 vs 1.8 days). CONCLUSIONS: rLRP is feasible in a practice with a low volume of radical prostatectomies. Significant improvement in perioperative parameters occurs after the first eight cases. This technique confers the benefits of enhanced precision and dexterity for complex laparoscopic work in the pelvic cavity.