Accuracy of combined multi-parametric MRI and PSMA PET-CT in diagnosing localized prostate cancer: newer horizons for a biopsy-free pathway.

INTRODUCTION: Prostate-specific antigen (PSA) is a reliable biomarker for identification of prostate cancer, although a biopsy is still the gold standard for detecting prostate cancer. Similar to higher PIRADS lesions on MRI, the maximal standard uptake value (SUV max) on PSMA PET is linked to a higher likelihood of prostate cancer. Can an mpMRI in conjunction with PSMA PET Scan accurately predict prostate cancer and further trigger omission of biopsy similar to other solid organ urological malignancies? METHODS: Ga-68 PSMA PET and mpMRI were performed for each patient who was a part of this retrospective study. The PET-positive lesion's maximum standardized uptake value (SUVmax) was recorded. Prostate biopsies were performed on patients who had PSMA PET avid lesions and a PIRADS score of 4 or 5. Robot-assisted radical prostatectomy (RARP) was afterward performed on patients who had cancer on their prostate biopsy. The prostatectomy specimen's histopathological information was recorded. Cutoff values and correlations between the variables were determined using the ROC curves and Pearson's correlation test. RESULT: On the basis of suspicious DRE findings or elevated PSA, 70 men underwent mpMRI and PET scans. PIRADS 4 patients had a median (IQR) SUVmax of 8.75 (11.95); whereas, PIRADS 5 patients had an SUVmax of 24.5 (22). The mean SUVmax for patients whose biopsies revealed no cancer was 6.25 ± 1.41. With an AUC of 0.876 on the ROC curve, it was found that there was a significant positive correlation between the results of the mpMRI and PET scans and those of the histopathological investigation. A SUVmax ≥ 8.25 on PSMA PET for a PIRADS 4/5 lesion on mpMRI will aid in correctly predicting malignancy, with a sensitivity of 82.8% and specificity of 100%. CONCLUSION: The findings of this study were positive and indicated that patients with a high suspicion of prostate cancer on mpMRI and PSMA PET (PIRADS ≥ 4 and SUVmax ≥ 8.25). This study substantiates the fact that a combination of mpMRI and PSMA PET can accurately predict localized prostate cancer.

Surgical management of renal cell carcinoma invading the liver - a case report and systematic review.

<b>Introduction:</b> Renal cell cancer (RCC) is one of the most lethal malignancies, accounting for 2.2% of all cancer diagnoses [1] </br></br> <b> Aim:</b> This study aims to perform the first systematic review of the operative techniques of simultaneous radical nephrectomy with hepatic resection for renal cell carcinoma (RCC) with direct hepatic extension. We also report a case of collecting duct RCC invading the liver who underwent simultaneous nephrectomy with hepatic resection. </br></br> <b>Materials and methods:</b> We searched the articles between the years 1991 and 1st April 2021 in English in PubMed, EMBASE, and Scopus databases. Case reports, case series, and matched cohort studies were included. Eligible studies reported on renal mass characteristics with the nature of extension, histopathological features, operative manoeuvres, and outcomes.Data were extracted as per Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. </br></br> <b>Results:</b> The initial search strategy yielded 148 articles of which six articles were selected for review. The mean size of tumour was >10 cm, with the mean age of the patients being 51-67 years. All cases had RCC with direct extension to the liver, and all underwent simultaneous nephrectomy with liver resection. The most common histological type was clear cell carcinoma. The mean blood loss was 3.3 litres, and the mean hospital stay was 9.75 days. </br></br> <b>Conclusion:</b> This review shows that the invasion to surrounding structures, including the liver, by RCC is not so common, and it poses a treatment challenge for the clinician. Currently, en bloc surgical removal with anatomical or non-anatomical resection of the liver is the only modality that provides the best chance of control for the RCC with direct hepatic extension.

Selecting lymph node-positive patients for adjuvant therapy after radical prostatectomy and extended pelvic lymphadenectomy: An outcome analysis of 100 node-positive patients managed without adjuvant therapy.

Objective: The aim of the study is to evaluate the effect of deferred androgen deprivation therapy on biochemical recurrence (BCR) and other survival parameters in node-positive prostate cancer patients after robot-assisted radical prostatectomy with bilateral extended pelvic lymph node dissection (RARP + EPLND). Materials and methods: Of the 453 consecutive RARP procedures performed from 2011 to 2018, 100 patients with no prior use of androgen deprivation therapy were found to be lymph node (LN) positive and were observed, with initiation of salvage treatment at the time of BCR only. Patients were divided into 1 or 2 LNs (67)-and more than 2 LNs (33)-positive groups to assess survival outcomes. Results: At a median follow-up of 21 months (1-70 months), the LN group (p < 0.000), preoperative prostate-specific antigen (PSA, p = 0.013), tumor volume (TV, p = 0.031), and LND (p = 0.004) were significantly associated with BCR. In multivariate analysis, only the LN group (p = 0.035) and PSA level (p = 0.026) were statistically significant. The estimated BCR-free survival rates in the 1/2 LN group were 37.6% (27%-52.2%), 26.5% (16.8%-41.7%), and 19.9% (9.6%-41.0%) at 1, 3, and 5 years, respectively, with a hazard of developing BCR of 0.462 (0.225-0.948) compared with the more than 2 LN-positive group. Estimated 5-year overall survival, cancer-specific, metastasis-free, and local recurrence-free survival rates were 88.4% (73.1%-100%), 89.5% (74%-100%), 65.1% (46.0%-92.1%), and 94.8% (87.2%-100.0%), respectively, for which none of the factors were significant. Based on cutoff values for PSA, TV, and LND of 30 ng/mL, 30%, and 10%, respectively, the 1/2 LN group was substratified, wherein the median BCR-free survival for the low- and intermediate-risk groups was 40 and 12 months, respectively. Conclusions: Nearly one fourth and one fifth of 1/2 node-positive patients were BCR-free at 3 and 5 years after RARP + EPLND. Further substratification using PSA, TV, and LN density may help in providing individualized care regarding the initiation of adjuvant therapy.

Low-risk prostate cancer in India: Is active surveillance a valid treatment option?

INTRODUCTION AND OBJECTIVE: Carcinoma prostate is considered highly aggressive in Asian countries such as India. This raises an argument whether active surveillance (AS) gives a false sense of security as opposed to upfront radical prostatectomy (RP) in Indian males with low-risk prostate cancer (PCa). We analyzed our prospectively maintained robot-assisted RP (RARP) database to address this question. MATERIALS AND METHODS: Five hundred and sixty-seven men underwent RARP by a single surgical team from September 2013 to September 2019. Of these, 46 (8.1%) were low risk considering the National Comprehensive Cancer Network criteria. Gleason grade group and stage were compared before and after surgery to ascertain the incidence of upgrading and upstaging. Preoperative clinical and pathological characteristics were analyzed for association with the probability of upstaging and upgrading. RESULTS: The mean age was 60.8 ± 6.8 years. Average prostate-specific antigen level was 6.7 ± 2.0 ng/mL. 40 (86.9%) patients had a T1 stage disease and 6 (13%) patients were clinically in T2a stage. A total of 25 (54.3%) cases were either upstaged or upgraded, 19 (41.3%) showed no change, and the remaining 2 (4.3%) had no malignancy on the final RP specimen. Upstaging occurred in 8 (17.4%) cases: 5 (10.9%) to pT3a and 3 (6.5%) to pT3b. Upgrading occurred in 23 (50%) cases: 19 (41.3%) to Grade 2; 3 (6.5%) to Grade 3; and 1 (2.2%) to Grade 4. CONCLUSIONS: There is a 50% likelihood of upstaging or upgrading in Indian males with low-risk PCa eligible for AS. Decision to proceed with AS should be taken carefully.