Prostate-specific membrane antigen (PSMA) is a transmembrane protein expressed by normal prostatic tissue. Therefore, molecular imaging targeting PSMA (PSMA-PET) has gained particular interest and ...diffusion for PCa staging and restaging. Several factors may affect PSMA-PET results, and many tools have been proposed to improve patient selection. Furthermore, PSMA expression is not homogeneous among different tissues and within the prostate itself. The aims of this study were to evaluate immunohistochemistry (IHC) features of prostate biopsy samples and to assess their correlation with whole-mount specimens and PSMA-PET parameters.
We included consecutive high-risk PCa patients who underwent PSMA-PET for staging proposal at our institution from January 2022 to December 2022. The PET parameters selected were SUVmax, total volume (TV), and total lesion activity (TL). Each patient underwent multiparametric MRI (mpMRI) and fusion-targeted prostate biopsy prior to surgery. IHC analyses were performed on the index lesion cores. IHC visual score (VS) (1, 2, 3) and visual pattern (VP) (membranous, cytoplasmic, and combined) and the percentage of PSMA-negative tumor areas (PSMA%neg) within biopsy cores were evaluated.
Forty-three patients who underwent robotic radical prostatectomy after PSMA-PET were available for analyses. Concordance between VS and VP at biopsy and final pathology showed a Cohen's kappa coefficient of 0.39 and 0.38, respectively. Patients with PSMA%neg <20% had a higher concordance in VS and VP (Cohen's kappa 0.49 and 0.4, respectively). No difference emerged in terms of median PSMA-TV (
= 0.3) and PSMA-TL (
= 0.9) according to VS at biopsy, while median SUVmax was higher in patients with VS 3 (
= 0.04). Higher SUVmax was associated with membranous and combined VP expression (
= 0.008). No difference emerged between patients with PSMA%neg <20% or PSMA%neg >20% on biopsy cores in terms of SUVmax, PSMA-TL, and PSMA-TV (
= 0.5,
= 0.5, and
= 0.9 respectively).
We found a correlation between IHC VS and VP on targeted biopsy cores and SUVmax at PSMA-PET. However, the correlation between the IHC parameters of biopsy cores and final pathology was not as high as expected. Nevertheless, the presence of PSMA%neg <20% seems to have a better concordance in terms of visual score.
Objective
Local tumor ablation to treat small renal mass is increasing. The aim of the present study was to compare oncologic outcomes among patients with T1 renal mass treated with partial ...nephrectomy and local tumor ablation.
Methods
To reduce the inherent differences between patients undergoing laparoscopic or robot‐assisted partial nephrectomy (n = 405) and local tumor ablation (n = 137), we used a 1:1 propensity score‐matched analysis. Local tumor ablation consisted of radiofrequency ablation and cryoablation. Disease‐free survival, overall survival and other causes mortality‐free survival rates were estimated using the Kaplan–Meier method. Multivariable logistic regression and competing‐risk regression models were used to identify predictors of complications, recurrence and other causes mortality, respectively.
Results
Partial nephrectomy had higher disease‐free survival estimates, as compared with local tumor ablation (92.8% vs 80.4% at 5 years, P = 0.02), with no significant difference between radiofrequency ablation and cryoablation (P = 0.9). Ablation showed comparable overall survival estimates to partial nephrectomy (91% vs 95.8% at 5 years, P = 0.6). The 5‐year recurrence rates were 7.9% versus 23.8% for patients aged ≤70 years, and 2.5% versus 11.9% for patients aged >70 years treated with partial nephrectomy and ablation, respectively; the 5‐year other causes mortality rates were 0% and 2.2% for patients treated with partial nephrectomy and ablation aged ≤70 years, and 3% versus 10.9% for patients aged >70 years treated with partial nephrectomy and ablation, respectively. At multivariable analysis, ablation was associated with fewer complications (odds ratio 0.41; P = 0.01). At competing risks analysis, age (hazard ratio 0.96) and ablation (hazard ratio 4.56) were independent predictors of disease recurrence (all P ≤ 0.008).
Conclusions
Local tumor ablation showed a higher risk of recurrence and lower risk of complications compared with partial nephrectomy, with comparable overall survival rates.
Purpose
To perform an external validation of a recently published nomogram aimed to predict positive
68
Ga-PSMA-11 PET/CT in patients with biochemical recurrence (BCR) after radical prostatectomy ...(RP) by Rauscher et al. (Eur Urol 73(5):656–661,
2018
).
Methods
Overall, 413 PCa patients with BCR after RP (two consecutive PSA ≥ 0.2 ng/ml) and PSA value between 0.2 and 1 ng/ml were included. A multivariable logistic regression model was produced to assess the predictors of positive
68
Ga-PSMA-11 PET/CT results. The performance characteristics of the model were assessed by quantifying the predictive accuracy, according to model calibration. Yuden’s index was used to find the best nomogram’s cut-off. Finally, decision curve analysis (DCA) was implemented to quantify the nomogram’s clinical value.
Results
In the external cohort, the overall detection rate of
68
Ga-PSMA-11 PET/CT was 44% vs. 64.7% in the original population. At multivariate analysis, PSA at
68
Ga-PSMA-11 PET/CT (OR: 7.06,
p
< 0.001) and ongoing ADT at time of
68
Ga-PSMA-11 PET/CT (OR: 2.07,
p
= 0.03) were the only independent predictors of PET/CT positivity. The predictive accuracy of nomogram was suboptimal and comparable to that reported in the original model (64% vs. 67%, respectively). The calibration plot indicated suboptimal concordance. The best nomogram’s cut-off to predict positive
68
Ga-PSMA-11 PET/CT was 35% (AUC = 0.61). In DCA, the nomogram revealed clinical net benefit when the threshold probabilities of positive
68
Ga-PSMA-11 PET/CT is > 35%.
Conclusion
We assessed similar suboptimal predictive accuracies in the external cohort compared to the original one. PSA and ongoing ADT were confirmed as positive predictors, and the most informative nomogram cut-off resulted 35%.
Background: Prostate Specific Membrane Antigen-Positron Emission Tomography (PSMA-PET) is currently recommended to restage prostate cancer (PCa) and to guide the delivery of salvage treatments. We ...aim to evaluate the oncologic outcomes of patients with recurrent PCa who received PSMA-PET. Methods: 324 hormone-sensitive PCa with PSA relapse after radical prostatectomy who underwent PSMA-PET in three high-volume European Centres. Patients have been stratified as pre-salvage who never received salvage treatments (n = 134), and post-salvage, including patients who received previous salvage therapies (n = 190). Patients with oligorecurrent (≤3 lesions), PSMA-positive disease underwent PSMA-directed treatments: salvage radiotherapy (sRT) or Metastases-directed therapy (MDT). Patients with polirecurrent (>3 lesions) PSMA-positive disease were treated with systemic therapy. Patients with negative PSMA-PET were treated with sRT or systemic therapies or observation. The primary outcome of the study was Progression-free survival (PFS). Secondary outcomes were: Metastases-free survival (MFS) and Castration Resistant Pca free survival (CRPC-FS). Results: median follow up was 23 months. In the pre-salvage setting, the PFS, MFS and CRPC-FS estimates at 3 years were 66.2% vs. 38.9%, 95.2% vs. 73.7% and 94.9% vs. 93.1% in patients with negative vs. positive PSMA-PET, respectively (all p ≥ 0.2). In the post-salvage setting, the PFS, MFS and CRPC-FS estimates at 3 years were 59.5% vs. 29.1%, 92.7% vs. 65.1% and 98.8% vs. 88.8% in patients with negative vs. positive PSMA-PET, respectively (all p ≤ 0.01). At multivariable analyses, a positive PSMA-PET was an independent predictor of progression (HR = 2.15) and metastatic disease (HR 2.37; all p ≤ 0.03). Conclusion: PSMA-PET in recurrent PCa detects the site of recurrence guiding salvage treatments and has a prognostic role in patients who received previous salvage treatments.
Purpose
To assess the role of the multiparametric Magnetic Resonance Imaging (mpMRI) in predicting the cribriform pattern in both the peripheral and transition zones (PZ and TZ) clinically ...significant prostate cancers (csPCas).
Material and methods
We retrospectively evaluated 150 patients who underwent radical prostatectomy for csPCa and preoperative mpMRI. Patients with negative (
n
= 25) and positive (
n
= 125) mpMRI, stratified according to the presence of prevalent cribriform pattern (PCP, ≥ 50%) and non-PCP (< 50%) at specimen, were included. Difference between the two groups were evaluated. Multivariate logistic regression was used to identify predictors of PCP among mpMRI parameters. The receiver operating characteristic (ROC) analysis was performed to evaluate the area under the curve (AUC) of apparent diffusion coefficient (ADC) and ADC ratio in detecting lesions harboring PCP.
Results
Considering 135 positive lesions at the mpMRI, 30 (22.2%) and 105 (77.8%) harbored PCP and non-PCP PCa. The PCP lesions had more frequently nodular morphology (83.3% vs 62.9%;
p
= 0.04) and significantly lower mean ADC value (0.87 ± 0.16 vs 0.95 ± 0.18;
p
= 0.03) and ADC ratio (0.52 ± 0.09 vs 0.60 ± 0.14;
p
= 0.003) when compared with non-PCP lesions. At univariate and multivariate analyses, mean ADC and ADC ratio resulted as independent predictors of the presence of the PCP of the PZ tumors(OR: 0.025;
p
= 0.03 and OR: 0.001;
p
= 0.004, respectively). At the ROC analysis, the AUC of mean ADC and ADC ratio to predict the presence of PCP in patients with PZ suspicious lesion at the mpMRI were 0.69 (95% CI 0.56–0.81P,
p
= 0.003) and 0.72 (95% CI 0.62–0.82P,
p
= 0.001), respectively.
Conclusions
The mpMRI may correctly identify PCP tumors of the PZ and the mean ADC value and ADC ratio can predict the presence of the cribriform pattern in the PCa.
Introduction
Partial nephrectomy is the standard of care for cT1a renal masses, offering equivalent oncologic outcomes and lower renal function impairment when compared to radical nephrectomy, with ...excellent overall survival results. Robot-assisted partial nephrectomy (RAPN) allows to perform a precise tumor excision, simplifying the reconstruction steps of the procedure, especially in the treatment of complex or large renal tumors. Aim of this study was to summarize the available perioperative, functional, and oncological outcomes of RAPN performed for complex and/or large (cT1b) renal cell carcinoma (RCC).
Materials and methods
We performed a nonsystematic review of the literature using a free-text protocol in the Medline database, using the terms “robot-assisted partial nephrectomy” and “robotic partial nephrectomy.” Two Authors reviewed separately to select RAPN series reporting data about complex and cT1b RCC. Other significant studies cited in the reference lists of the selected papers were also evaluated.
Evidence synthesis
According to the currently available evidences, RAPN offers promising results in terms of perioperative, functional, and oncological outcomes for the conservative management of complex or large renal tumors, even when compared with open and laparoscopic partial nephrectomy. Robot-assisted procedure allows surgeons to treat large and challenging renal masses, even if with higher warm ischemia time, operating time, and estimated blood loss in comparison with those obtained for the treatment of smaller lesions.
Conclusions
In the hands of experienced surgeons, RAPN is a safe and reproducible approach for the treatment of cT1b and more challenging renal tumors, and could represent the way to expand the indications for minimally invasive conservative approach to RCC.
Many efforts have been carried out for the standardization of multiparametric Magnetic Resonance (mp-MR) images evaluation to detect Prostate Cancer (PCa), and specifically to differentiate levels of ...aggressiveness, a crucial aspect for clinical decision-making. Prostate Imaging—Reporting and Data System (PI-RADS) has contributed noteworthily to this aim. Nevertheless, as pointed out by the European Association of Urology (EAU 2020), the PI-RADS still has limitations mainly due to the moderate inter-reader reproducibility of mp-MRI. In recent years, many aspects in the diagnosis of cancer have taken advantage of the use of Artificial Intelligence (AI) such as detection, segmentation of organs and/or lesions, and characterization. Here a focus on AI as a potentially important tool for the aim of standardization and reproducibility in the characterization of PCa by mp-MRI is reported. AI includes methods such as Machine Learning and Deep learning techniques that have shown to be successful in classifying mp-MR images, with similar performances obtained by radiologists. Nevertheless, they perform differently depending on the acquisition system and protocol used. Besides, these methods need a large number of samples that cover most of the variability of the lesion aspect and zone to avoid overfitting. The use of publicly available datasets could improve AI performance to achieve a higher level of generalizability, exploiting large numbers of cases and a big range of variability in the images. Here we explore the promise and the advantages, as well as emphasizing the pitfall and the warnings, outlined in some recent studies that attempted to classify clinically significant PCa and indolent lesions using AI methods. Specifically, we focus on the overfitting issue due to the scarcity of data and the lack of standardization and reproducibility in every step of the mp-MR image acquisition and the classifier implementation. In the end, we point out that a solution can be found in the use of publicly available datasets, whose usage has already been promoted by some important initiatives. Our future perspective is that AI models may become reliable tools for clinicians in PCa diagnosis, reducing inter-observer variability and evaluation time.
Background: We investigated the diagnostic accuracy of the new Prostate Imaging for Recurrence Reporting (PI-RR) score and its inter-observer variability. Secondly, we compared the detection rate of ...PI-RR and PET and analyzed the correlation between Prostate Specific Antigen (PSA) levels and the PI-RR score. Methods: We included in the analysis 134 patients submitted to multiparametric magnetic resonance imaging for suspected local recurrence. The images were independently reviewed by two radiologists, assigning a value from 1 to 5 to the PI-RR score. Inter-observer agreement and diagnostic accuracy of the PI-RR score (compared to histopathological data, available for 19 patients) were calculated. The detection rate was compared to those of choline PET/CT (46 patients) and PSMA PET/CT (22 patients). The distribution of the PSA values in relation to the PI-RR scores was also analyzed. Results: The accuracy of the PI-RR score was 68.4%. The reporting agreement was excellent (K = 0.884, p < 0.001). The PI-RR showed a higher detection rate than choline PET/CT (69.6% versus 19.6%) and PSMA PET-CT (59.1% versus 22.7%). The analysis of the PSA distribution documented an increase in the PI-RR score as the PSA value increased. Conclusion: The excellent reproducibility of the PI-RR score supports its wide use in the clinical practice to standardize recurrence reporting. The detection rate of PI-RR was superior to that of PET, but was linked to the PSA level.
Prostate Specific Membrane Antigen-Positron Emission Tomography (PSMA-PET) is used to select recurrent prostate cancer (PCa) patients for metastases-directed therapy (MDT). We aimed to evaluate the ...oncologic outcomes of second-line PSMA-guided MDT in oligo-recurrent PCa patients.
we performed a retrospective analysis of 113 recurrent PCa after previous radical prostatectomy and salvage therapies with oligorecurrent disease at PSMA-PET (≤3 lesions in N1/M1a-b) in three high-volume European centres. Patients underwent second-line salvage treatments: MDT targeted to PSMA (including surgery and/or radiotherapy), and the conventional approach (observation or Androgen Deprivation Therapy ADT). Patients were stratified according to treatments (MDT vs. conventional approach). Patients who underwent MDT were stratified according to stage in PSMA-PET (N1 vs. M1a-b). The primary outcome of the study was Progression-free survival (PFS). Secondary outcomes were Metastases-free survival (MFS) and Castration Resistant PCa free survival (CRPC-FS). Kaplan-Meier analyses assessed PFS, MFS and CRPC-FS. Multivariable Cox regression models identified predictors of progression and metastatic disease.
Overall, 91 (80%) and 22 (20%) patients were treated with MDT and the conventional approach, respectively. The median follow-up after PSMA-PET was 31 months. Patients who underwent MDT had a similar PFS compared to the conventional approach (
= 0.3). Individuals referred to MDT had significantly higher MFS and CRPC-FS compared to those who were treated with the conventional approach (73.5% and 94.7% vs. 30.5% and 79.5%; all
≤ 0.001). In patients undergoing MDT, no significant differences were found for PFS and MFS according to N1 vs. M1a-b disease, while CRPC-FS estimates were significantly higher in patients with N1 vs. M1a-b (100% vs. 86.1%;
= 0.02). At multivariable analyses, age (HR = 0.96) and ADT during second line salvage treatment (HR = 0.5) were independent predictors of PFS; MDT (HR 0.27) was the only independent predictor of MFS (all
≤ 0.04) Conclusion: Patients who underwent second-line PSMA-guided MDT experienced higher MFS and CRPC-FS compared to men who received conventional management.
PDF