Prostate-specific membrane antigen positron emission tomography in addition to multiparametric magnetic resonance imaging and biopsies to select prostate cancer patients for focal therapy

OBJECTIVE

To evaluate the additional value of prostate-specific membrane antigen positron emission tomography (PSMA-PET) to conventional diagnostic tools to select patients for hemi-ablative focal therapy (FT).

PATIENTS AND METHODS

We performed a retrospective analysis on a multicentre cohort (private and institutional) of 138 patients who underwent multiparametric magnetic resonance imaging (mpMRI), PSMA-PET, and systematic biopsies prior to radical prostatectomy between January 2011 and July 2021. Patients were eligible when they met the consensus criteria for FT: PSA <15 ng/mL, clinical/radiological T stage ≤T2b, and International Society of Urological Pathology (ISUP) grade 2-3. Clinically significant prostate cancer (csPCa) was defined as ISUP grade ≥2, extracapsular extension >0.5 mm or seminal vesicle involvement at final histopathology. The diagnostic accuracy of mpMRI, systematic biopsies and PSMA-PET for csPCa (separate and combined) was calculated within a four-quadrant prostate model by receiver-operating characteristic and 2 × 2 contingency analysis. Additionally, we assessed whether the diagnostic tools correctly identified patients suitable for hemi-ablative FT.

RESULTS

In total 552 prostate quadrants were analysed and 272 (49%) contained csPCa on final histopathology. The area under the curve, sensitivity, specificity, positive predictive value and negative predictive value for csPCa were 0.79, 75%, 83%, 81% and 77%, respectively, for combined mpMRI and systematic biopsies, and improved after addition of PSMA-PET to 0.84, 87%, 80%, 81% and 86%, respectively (P < 0.001). On final histopathology 46/138 patients (33%) were not suitable for hemi-ablative FT. Addition of PSMA-PET correctly identified 26/46 (57%) non-suitable patients and resulted in 4/138 (3%) false-positive exclusions.

CONCLUSIONS

Addition of PSMA-PET to the conventional work-up by mpMRI and systematic biopsies could improve selection for hemi-ablative FT and guide exclusion of patients for whom whole-gland treatments might be a more suitable treatment option.

68Ga-PSMA-PET/CT in addition to mpMRI in men undergoing biopsy during active surveillance for low- to intermediate-risk prostate cancer: study protocol for a prospective cross-sectional study

Background

In active surveillance there is significant interest in whether imaging modalities such as multiparametric magnetic resonance imaging (mpMRI) or 68Gallium prostate-specific membrane antigen positron emission tomography/computerized tomography (68Ga-PSMA-PET/CT) can improve the detection of progression to clinically significant prostate cancer (csPCa) and thus reduce the frequency of prostate biopsies and associated morbidity. Recent studies have demonstrated the value of mpMRI in active surveillance; however, mpMRI does miss a proportion of disease progression and thus alone cannot replace biopsy. To date, prostate-specific membrane antigen positron emission tomography (PSMA-PET) has shown additive value to mpMRI in its ability to detect prostate cancer (PCa) in the primary diagnostic setting. Our objective is to evaluate the diagnostic utility of PSMA-PET to detect progression to csPCa in active surveillance patients.

Methods

We will perform a prospective, cross-sectional, partially blinded, multicentre clinical trial evaluating the additive value of PSMA-PET with mpMRI against saturation transperineal template prostate biopsy. Two hundred and twenty-five men will be recruited who have newly diagnosed PCa which is suitable for active surveillance. Following enrolment, patients will undergo a PSMA-PET and mpMRI within 3 months of a repeat 12-month confirmatory biopsy. Patients who remain on active surveillance after confirmatory biopsy will then be planned to have a further mpMRI and PSMA-PET prior to a repeat biopsy in 3-4 years. The primary outcome is to assess the ability of PSMA-PET to detect or exclude significant malignancy on repeat biopsy. Secondary outcomes include (I) assess the comparative diagnostic accuracies of mpMRI and PSMA-PET alone [sensitivity/specificity/negative predictive value (NPV)/positive predictive value (PPV)] to detect progression on biopsy based on predefined histologic criteria for progression; (II) comparison of index lesion identification by template biopsies vs. MRI targeted lesions vs. PSMA targeted lesions; (III) evaluation of concordance of lesions identified on final histopathology and each imaging modality (PSMA-PET and/or mpMRI) in the subset of patients proceeding to RP.

Discussion

The results of this trial will define the role of PSMA-PET in active surveillance and potentially reduce the number of biopsies needed to detect progression to csPCa.

Trial Registration

The current trial was registered with the ANZCTR on the 3/2/2022 with the trial ID ACTRN12622000188730, it is accessible at https://www.anzctr.org.au/.

Median 4-year outcomes of salvage irreversible electroporation for localized radio-recurrent prostate cancer

OBJECTIVES

To evaluate the safety, and short to mid-term oncological and quality-of-life (QoL) outcomes of focal irreversible electroporation (IRE) for radio-recurrent prostate cancer (PCa) at a median follow-up of 4 years.

PATIENTS AND METHODS

This was a single-centre series of men with biopsy-proven radio-recurrent PCa treated with IRE between December 2013 and February 2022, with a minimum follow-up of 6 months. Follow-up included magnetic resonance imaging at 6 months, and standard transperineal saturation template biopsies at 12 months. Further biopsies were guided by suspicion on serial imaging or prostate-specific antigen (PSA) levels. Validated questionnaires were used to measure functional outcomes. Significant local recurrence was defined as any International Society of Urological Pathology (ISUP) score ≥ 2 on biopsies. Progression-free survival was defined as no signs of local or systemic disease on either imaging or template biopsies, or according to the Phoenix criteria for biochemical recurrence.

RESULTS

Final analysis was performed on 74 men with radio-recurrent PCa (median age 69 years, median PSA level 5.4 ng/mL, 76% ISUP score 2/3). The median (range) follow-up was 48 (27-68) months. One rectal fistula occurred, and eight patients developed urethral sloughing that resolved with transurethral resection. Among patients who returned questionnaires (30/74, 41%), 93% (28/30) had preserved urinary continence and 23% (7/30) had sustained erectile function at 12-month follow-up. Local control was achieved in 57 patients (77%), who needed no further treatment. Biopsy diagnosed 41(55%) patients received follow up template biopsies, in-field recurrences occurred in 7% (3/41), and out-field recurrences occurred in 15% of patients (6/41). The metastasis-free survival rate was 91% (67/74), with a median (interquartile range) time to metastases of 8 (5-27) months. The Kaplan-Meier estimated 5-year progression-free survival rate was 60%.

CONCLUSIONS

These short- to mid-term safety, oncological and QoL outcome data endorse results from smaller series and show the ability of salvage focal IRE to safely achieve oncological control in patients with radio-recurrent PCa.

The relationship between biochemical recurrence and number of lymph nodes removed during surgery for localized prostate cancer

PURPOSE

To assess whether completeness of pelvic lymph node dissection (PLND) as measured by lymph node yield reduces biochemical recurrence (BCR) in men undergoing radical prostatectomy (RP) for prostate cancer (PCa), stratified according to Briganti nomogram-derived risk (≥5% vs. < 5%) of lymph node invasion (LNI).

METHODS

Retrospective study of 3724 men who underwent RP between January 1995 and January 2015 from our prospectively collected institutional database. All men included had minimum five years follow-up and were not given androgen deprivation therapy or radiotherapy prior to BCR. Primary endpoint was time to BCR as defined by PSA > 0.2ng/ml. Patients were analysed according to Briganti Nomogram derived risk of 'low-risk' (< 5%) vs. 'high-risk' (≥ 5%). Extent of PLND was analysed using number of nodes yielded at dissection as a continuous variable as well as a categorical variable: Group 1 (limited, 1-4 nodes), Group 2 (intermediate, 5-8 nodes) and Group 3(extensive, ≥9 nodes).

RESULTS

Median follow-up in the overall cohort was 79.7 months and 65% of the total cohort underwent PLND. There were 2402 patients with Briganti risk of LNI < 5% and 1322 with a Briganti risk of LNI ≥5%. At multivariate analysis, only PSA (HR1.01, p < 0.001), extracapsular extension at RP (HR 1.86, p < 0.001), positive surgical margin (HR 1.61, p < 0.001) and positive lymph node on pathology (HR 1.52, p = 0.02) were independently associated with BCR. In the high-risk group, increased nodal yield at PLND was associated with reduction in risk of BCR (HR 0.97, 95%CI 0.95-1.00 p = 0.05, Cochran Mantel Haenszel test, p < 0.05: respectively). In the low-risk group increased number of nodes at PLND did not reduce risk of BCR.

CONCLUSIONS

In this study of extent of PLND at RP, higher nodal yield did not reduce risk of BCR in low-risk men (Briganti risk < 5%), however there was a weak benefit in terms of reduced long-term risk of BCR in high-risk men (Briganti risk ≥5%).

Outcomes for active surveillance are similar for men with favourable risk ISUP-2 to those with ISUP-1 prostate cancer: A pair matched cohort study

Objective:

To compare medium-term outcomes of active surveillance (AS) for men with favourable risk International Society for Urologic Pathology (ISUP)-2 prostate cancer (PCa) to a pair matched group of men with ISUP-1 PCa.

Methods:

This was a retrospective analysis of prospectively collected data from a single institution clinical outcomes registry, using propensity score matching. Men enrolled on AS with favourable risk ISUP-2 PCa with minimum 5-year follow-up were 1:2 propensity score matched to men with ISUP-1 disease. We assessed rates of progression to treatment, metastatic disease, adverse surgical pathology and overall survival.

Results:

Fifty-five ISUP-2 patients were matched to 105 ISUP-1 patients by propensity score. Median follow-up was 81 months (interquartile range (IQR), 61–109 months). Fifty-seven per cent in the ISUP-1 group progressed to treatment versus 58% in the ISUP-2 group (KM log rank p = 0.24). Estimated 1-, 2- and 5-year progression free survival rates were 93%, 60% and 33% for ISUP-1 patients and 94%, 63% and 16% for ISUP-2 patients, respectively. No patient from either group died of PCa. There was no statistical difference in rates of adverse pathology or metastatic disease between ISUP-2 and ISUP-1 patients on AS.

Conclusion:

AS for carefully selected men with favourable risk ISUP-2 disease appears safe, with similar oncologic outcomes to men with ISUP-1 disease.

Level of evidence:

Level 2b.

Median 5-year outcomes of primary focal irreversible electroporation for localised prostate cancer

OBJECTIVES

To evaluate longer-term oncological and functional outcomes of focal irreversible electroporation (IRE) as primary treatment for localised clinically significant prostate cancer (csPCa) at a median follow-up of 5 years (up to 10 years).

PATIENTS AND METHODS

All patients that underwent focal IRE as primary treatment for localised PCa between February 2013 and August 2021 with a minimum 12 months of follow-up were analysed. Follow-up included 6-month magnetic resonance imaging (MRI) and standardised transperineal saturation template ± targeted biopsies at 12 months, and further biopsies in the case of clinical suspicion on serial imaging and/or prostate-specific antigen (PSA) levels. Failure-free survival (FFS) was defined as no progression to radical treatment or nodal/distant disease. Local recurrence was defined as any International Society of Urological Pathology Grade of ≥2 on biopsy.

RESULTS

A total of 229 patients were analysed with a median (interquartile range [IQR]) follow-up of 60 (40-80) months. The median (IQR) age was 68 (64-74) years, the median (IQR) PSA level was 5.9 (4.1-8.2) ng/mL, and 86% harboured intermediate-risk disease and 7% high-risk disease. In all, 38 patients progressed to radical treatment (17%), at a median (IQR) of 35 (17-53) months after IRE. Kaplan-Meier FFS rates were 91% at 3 years, 84% at 5 years and 69% at 8 years. Metastasis-free survival was 99.6% (228/229), PCa-specific and overall survival were 100% (229/229). Residual csPCa was found in 24% (45/190) during follow-up biopsy and MRI showed a complete ablation in 82% (186/226). Short-term urinary continence was preserved (98%, three of 144 at baseline, 99%, one of 131 at 12 months) and erections sufficient for intercourse decreased by 13% compared to baseline (71% to 58%).

CONCLUSION

Longer-term follow-up confirms our earlier findings that focal IRE provides acceptable local and distant oncological control in selected men with less urinary and sexual toxicity than radical treatment. Long-term follow-up and external validation of these findings, is required to establish this new treatment paradigm as a valid treatment option.

Salvage irreversible electroporation for radio-recurrent prostate cancer - the prospective FIRE trial

OBJECTIVES

To prospectively assess the safety, functional- and oncological-outcomes of irreversible electroporation (IRE) as salvage therapy for radio-recurrent focal prostate cancer in a multicenter setting.

PATIENTS AND METHODS

Men with focal recurrent PCa after external beam radiation or brachytherapy without metastatic disease on staging imaging and co-registration between mpMRI and biopsies were prospectively included in this multicenter trial. Adverse events were reported following the Clavien-Dindo classification. Validated questionnaires were used for patient-reported functional outcomes. Follow-up consisted of 3 monthly prostate specific antigen (PSA) levels, a 6-month mpMRI and standardised transperineal template mapping biopsies at 12-months. Thereafter follow-up was guided by MRI and/or PSMA-PET/CT and PSA. Local recurrence was defined as any ISUP score ≥2 on biopsies.

RESULTS

37 patients were analysed with a median (interquartile range (IQR)) follow up of 29 (22-43) months. Median age was 71 (53-83), median PSA was 3.5 ng/mL (2.7-6.1). 28 (75.5%) patients harboured intermediate risk and 9 patients (24.5%) high risk PCa. Seven patients (19%) reported self-limiting urgency, frequency, or hematuria (grade 1-2). Seven patients (19%) developed a grade 3 AE; urethral sludge requiring transurethral resection. At 12 months post treatment 93% of patients remained continent and erectile function sufficient for intercourse deteriorated from 35% to 15% (4/27). Local control was achieved in 29 patients (78%) and 27 patients (73%) were clear of local and systemic disease. Four (11%) patients had local recurrence only. Six (16%) patients developed metastatic disease with a median time to metastasis of 8 months.

CONCLUSION

The FIRE trial shows that salvage IRE after failed radiation therapy for localised PCa is safe with minimal toxicity, and promising functional and oncological outcomes. Salvage IRE can offer a possible solution for notoriously difficult to manage radio recurrent prostate tumours.

Evidence-based circumcision policy for Australia

The aim was (1) to perform an up-to-date systematic review of the male circumcision (MC) literature and (2) to determine the number of adverse medical conditions prevented by early MC in Australia. Searches of PubMed using "circumcision" with 39 keywords and bibliography searches yielded 278 publications meeting our inclusion criteria. Early MC provides immediate and lifetime benefits, including protection against: urinary tract infections, phimosis, inflammatory skin conditions, inferior penile hygiene, candidiasis, various STIs, and penile and prostate cancer. In female partners MC reduces risk of STIs and cervical cancer. A risk-benefit analysis found benefits exceeded procedural risks, which are predominantly minor, by approximately 200 to 1. It was estimated that more than 1 in 2 uncircumcised males will experience an adverse foreskin-related medical condition over their lifetime. An increase in early MC in Australia to mid-1950s prevalence of 85% from the current level of 18.75% would avoid 77,000 cases of infections and other adverse medical conditions over the lifetime for each annual birth cohort. Survey data, physiological measurements, and the anatomical location of penile sensory receptors responsible for sexual sensation indicate that MC has no detrimental effect on sexual function, sensitivity or pleasure. US studies found that early infant MC is cost saving. Evidence-based reviews by the AAP and CDC support early MC as a desirable public health measure. Although MC can be performed at any age, early MC maximizes benefits and minimises procedural risks. Parents should routinely be provided with accurate, up-to-date evidence-based information in an unbiased manner early in a pregnancy so that they have time to weigh benefits and risks of early MC and make an informed decision should they have a son. Parental choice should be respected. A well-trained competent practitioner is essential and local anaesthesia should be routinely used. Third party coverage of costs is advocated.

Microdissection oncoTESE (micro-oncoTESE) in azoospermic men with suspected testicular cancer: Analysis of outcomes from a specialist centre

Objective:

The main aim of this study was to report the outcomes of azoospermic men with suspicious testicular lesions, undergoing microsurgical sperm retrieval (micro-oncoTESE) at the time of radical/partial orchidectomy.

Patients and methods:

Testicular lesions suspicious for cancer were confirmed on ultrasound scanning. In patients undergoing radical inguinal orchidectomy, ex vivo microdissection of the unaffected testicular parenchyma was performed. Microdissection was performed in vivo for partial orchidectomy. The primary outcome measure was surgical sperm retrieval (SSR) rate.

Results:

A total of 33 patients (median age 33 years, interquartile range (IQR) 22) with suspected testicular cancer (TCa) underwent micro-oncoTESE. Histological analysis confirmed TCa in 26 patients and benign pathology in 7 patients. The overall SSR rate was 39%. Sub-analysis of patients with TCa and benign histology found that the SSR was 46% and 14%, respectively. There was no significant difference in maximum tumour length between successful and unsuccessful SSR groups 33.9 mm ± 23 (SD) versus 29.8 mm ± 17.5 (SD) ( p = 0.62).

Conclusion:

Based on our cohort, micro-oncoTESE provides an option for sperm retrieval in azoospermic men with testicular lesions.

The evolving role of multi-parametric MRI in the evaluation of bladder cancer: Revealing what lies beneath the surface

Conventional staging for bladder cancer involves CT and TURBT, and is thought to understage up to fifty-percent of T1 tumours. This report details the case of a 64-year-old male who whilst on cystoscopic surveillance for high grade bladder cancer, underwent a multi-parametric MRI Bladder due to clinical suspicion of occult muscle invasive disease. Despite minimal urothelial changes at cystoscopy, MRI demonstrated a well-defined T3 lesion. The patient proceeded to radical cystectomy and final pathology verified the MRI findings. The role of MRI in bladder cancer is yet to be defined but should be considered if clinical suspicion for understaging exists.

Brain Motor Region Diffusion Tensor Imaging in Patients with Catatonic Schizophrenia: A Case-Control Study

BACKGROUND

Only a small proportion of schizophrenia patients present with catatonic symptoms. Imaging studies suggest that brain motor circuits are involved in the underlying pathology of catatonia. However, data about diffusivity dysregulation of these circuits in catatonic schizophrenia are scarce.

OBJECTIVES

To assess the involvement of brain motor circuits in schizophrenia patients with catatonia.

METHODS

Diffusion tensor imaging (DTI) was used to measure white matter signals in selected brain regions linked to motor circuits. Relevant DTI data of seven catatonic schizophrenia patients were compared to those of seven non-catatonic schizophrenia patients, matched for sex, age, and education level.

RESULTS

Significantly elevated fractional anisotropy values were found in the splenium of the corpus callosum, the right peduncle of the cerebellum, and the right internal capsule of the schizophrenia patients with catatonia compared to those without catatonia. This finding showed altered diffusivity in selected motor-related brain areas.

CONCLUSIONS

Catatonic schizophrenia is associated with dysregulation of the connectivity in specific motoric brain regions and corresponding circuits. Future DTI studies are needed to address the neural correlates of motor abnormalities in schizophrenia-related catatonia during the acute and remitted state of the illness to identify the specific pathophysiology of this disorder.

Cytoreductive surgery for men with metastatic prostate cancer

Background

Cytoreductive surgery for metastatic prostate cancer is an emerging area of interest with a potential upside that includes local control, delayed initiation of hormone therapy, and possibly improved cancer specific survival. In order for radical prostatectomy to be an effective treatment option for men in this group, the benefits must outweigh the surgical morbidity. The aim of this study was to present a case series and assess the literature feasibility of cytoreductive surgery for men with metastatic prostate cancer.

Methods

A retrospective review of clinical notes was performed to identify men with metastatic prostate cancer who underwent cytoreductive surgery between 2012 and 2014 for a group of urologists at a single institution in Melbourne. Each patient was evaluated with regard to preoperative prostate-specific antigen, grade, stage, adjuvant therapy, and surgical outcomes.

Results

Six cases were identified. This included 1 pelvic exenteration and 5 robot-assisted radical prostatectomies. The men who underwent RARP had uncomplicated recoveries, regained continence within 3 months and remained pad-free at follow up. All patients proceeded to additional treatment of sites of metastatic disease with a variable PSA response, however, 3 of 6 men required recommencement of ADT for biochemical progression at follow up.

Conclusions

This data supports recent findings demonstrating that radical prostatectomy for metastatic prostate cancer is feasible. Further studies are needed to explore the role of cytoreductive surgery with regards to the potential oncological benefit.

Cohort study of risk of institutionalisation after hip fracture

The purpose of this study was to describe the rate of permanent placement in aged care institutions (nursing homes and hostels) after hip fracture and to assess whether or not hip fracture is an independent risk factor for institutionalisation. It was a cohort study with median follow-up time of 14 months. Subjects were 291 people living in the community in western Sydney: 13] with hip fractures and 160 controls. Permanent admission to an aged care institution and/or death during follow-up was assessed by telephone interview with study subjects of carers. Data on potential confounders were collected with an interviewer-administered questionnaire at the time of recruitment into the study. During follow-up, 27 per cent of hip fracture cases and 5 per cent of controls were admitted to an aged care institution. The age- and sex-adjusted hazard ratio for hip fracture and institutionalisation was 5.1 (95 per cent confidence interval (CI) 2.2 to 11.9). Adjusting for multiple health-related factors reduced the strength of association but the hazard ratio remained high at 4.0 (CI 1.7 to 9.5). The risk of institutionalisation after hip fracture is high; this is only partly explained by the poor pre-fracture health status of many people who fracture their hips.

Brains at necropsy: to fix or not to fix?

AIM

To investigate whether routine formalin fixation of all brains coming to necropsy increases the rate of detection of brain abnormalities relative to either selective formalin fixation of brain tissue or fresh dissection of all brain tissue at the time of post mortem examination.

METHODS

A retrospective study of 300 medicolegal necropsies was performed. One hundred cases were examined by doctors with little or no formal training in necropsy pathology. One hundred cases were examined by forensic pathologists, who used their discretion as to whether to fix the brain in formalin. A further 100 cases were examined by neuropathologists; all the brains had already been fixed at the time of necropsy.

RESULTS

When examined by doctors with little or no formal necropsy pathology training, only 15% of brains were found to be abnormal. In the case of selective fixation, 33% were found to be abnormal. When there was obligatory fixation of all brains, 51% of all brains were found to be abnormal.

CONCLUSIONS

It is concluded that formalin fixation of the whole brain at the time of necropsy, followed by detailed examination of the brain by a neuropathologist, significantly increases the detection rate of brain pathology at necropsy.

Mitotic activity in the dermis of mice during graft versus host disease: the role of fibroblast replication in dermal fibrosis

When immunocompetent cells are transferred to an allogeneic, immunologically compromised host a complex series of cellular events are initiated, referred to as graft versus host disease. This results in widespread organ damage with fibrosis being a prominent feature. The pathologic fibrosis may result from an increase in fibroblast numbers, an increase in collagen produced from individual fibroblasts, or a combination of the two processes. The relative contribution of fibroblast replication to the pathologic fibrosis seen in graft versus host disease has not been directly determined previously, and this is the main object of this paper. Graft versus host disease was induced by the transfer of lymphoid cells from B10D2 mice to irradiated Balb/c recipients. In order to study the mitotic activity of dermal cells following bone marrow transplantation, a thymidine anologue, bromo-deoxyuridine (BrDU), was administered to mice using an osmotically driven, implantable infusion device. The labeled cells were visualized immuno-histochemically and studied at weekly intervals. There is intense mitotic activity in the basal layer of the epidermis and the acrosyringal epithelium from the second week. Evidence of increased mitotic activity in the epidermis persisted until the fifth week post-transplantation. Fibroblast replication was seen from the end of the third post-transplant week. Dermal collagen deposition also occurred at this time. Peak mitotic activity was present at the end of the fourth week and was less pronounced by the fifth week. It was especially evident in the upper dermis where the developing collagen layer was being deposited. To our knowledge this is the first direct demonstration of fibroblast proliferation in an immunologically mediated fibrotic disorder. It is concluded that fibroblast replication is an important mechanism leading to the pathologic fibrosis seen in graft versus host disease and, by analogy, probably other types of immunologically mediated fibrosis.