Francis Ting

Objectives: To determine the safety, quality of life (QoL) and short‐term oncological outcomes of primary focal irreversible electroporation ( IRE ) for the treatment of localized prostate cancer ( PC a), and to identify potential risk factors for oncological failure. Patients and Methods: Patients who met the consensus guidelines on patient criteria and selection methods for primary focal therapy were eligible for analysis. Focal IRE was performed for organ‐confined clinically significant PC a, defined as high‐volume disease with Gleason sum score 6 (International Society of Urological Pathology [ ISUP ] grade 1) or any Gleason sum score of 7 ( ISUP grades 2–3). Oncological, adverse event ( AE ) and QoL outcome data, with a minimum of 6 months’ follow‐up, were analysed. Patient characteristics and peri‐operative treatment variables were compared between patients with and without oncological failure on follow‐up biopsy. Wilcoxon's signed rank test, Wilcoxon's rank sum test and the chi‐squared test were used to assess statistically significant differences in paired continuous, unpaired continuous and categorical variables respectively. Results: A total of 63 patients met all eligibility criteria and were included in the final analysis. No high‐grade AE s occurred. QoL questionnaire analysis demonstrated no significant change from baseline in physical ( P = 0.81), mental ( P = 0.48), bowel ( P = 0.25) or urinary QoL domains ( P = 0.41 and P = 0.25), but there was a mild decrease in the sexual QoL domain (median score 66 at baseline vs 54 at 6 months; P < 0.001). Compared with baseline, a decline of 70% in prostate‐specific antigen level (1.8 ng/mL, interquartile range 0.96–4.8 ng/mL) was seen at 6–12 months. A narrow safety margin ( P = 0.047) and system errors ( P = 0.010) were identified as potential early risk factors for in‐field oncological failure. In‐field and whole‐gland oncological control on follow‐up biopsies was 84% (38/45 patients) and 76% (34/45 patients); this increased to 97% (38/39 patients) and 87% (34/39 patients) when patients treated with a narrow safety margin and system errors were excluded. Conclusion: Our data support the safety and feasibility of focal IRE as a primary treatment for localized PC a with effective short‐term oncological control in carefully selected men.

Objective: To develop and externally validate a predictive model for detection of significant prostate cancer. Patients and Methods: Development of the model was based on a prospective cohort including 393 men who underwent multiparametric magnetic resonance imaging (mp MRI ) before biopsy. External validity of the model was then examined retrospectively in 198 men from a separate institution whom underwent mp MRI followed by biopsy for abnormal prostate‐specific antigen ( PSA ) level or digital rectal examination ( DRE ). A model was developed with age, PSA level, DRE , prostate volume, previous biopsy, and Prostate Imaging Reporting and Data System ( PIRADS ) score, as predictors for significant prostate cancer (Gleason 7 with >5% grade 4, ≥20% cores positive or ≥7 mm of cancer in any core). Probability was studied via logistic regression. Discriminatory performance was quantified by concordance statistics and internally validated with bootstrap resampling. Results: In all, 393 men had complete data and 149 (37.9%) had significant prostate cancer. While the variable model had good accuracy in predicting significant prostate cancer, area under the curve ( AUC ) of 0.80, the advanced model (incorporating mp MRI ) had a significantly higher AUC of 0.88 ( P < 0.001). The model was well calibrated in internal and external validation. Decision analysis showed that use of the advanced model in practice would improve biopsy outcome predictions. Clinical application of the model would reduce 28% of biopsies, whilst missing 2.6% significant prostate cancer. Conclusions: Individualised risk assessment of significant prostate cancer using a predictive model that incorporates mp MRI PIRADS score and clinical data allows a considerable reduction in unnecessary biopsies and reduction of the risk of over‐detection of insignificant prostate cancer at the cost of a very small increase in the number of significant cancers missed.

Objectives: To assess the accuracy of 68Gallium‐prostate‐specific membrane antigen (68Ga‐ PSMA ) positron emission tomography/computed tomography ( PET / CT ) for lymph node ( LN ) staging in intermediate‐ and high‐risk prostate cancer ( PC a). Materials and Methods: From April to October 2015, 30 patients with intermediate‐ ( n = 3) or high‐risk ( n = 27) PC a were prospectively enrolled. Patients underwent preoperative 68Ga‐ PSMA PET / CT . Both visual and semi‐quantitative analyses were undertaken. Subsequently, all patients underwent radical prostatectomy ( RP ) with an extended pelvic lymph node dissection. The sensitivity, specificity, and positive ( PPV ) and negative predictive value ( NPV ) for LN status of 68Ga‐ PSMA were calculated using histopathology as reference. Results: Eleven patients (37%) had lymph node metastases (LNMs); 26 LNM s were identified in the 11 patients. Patient analysis showed that 68Ga‐ PSMA PET / CT had a sensitivity of 64% for the detection of LNM s, its specificity was 95%, the PPV was 88%, and the NPV was 82%. In total, 180 LN fields were analysed. In the LN ‐region‐based analysis, the sensitivity of 68Ga‐ PSMA PET / CT for detection of LNM s was 56%, the specificity was 98%, the PPV was 90% and the NPV was 94%. The mean size of missed LNM s was 2.7 mm. Receiver‐operating characteristic curve analysis showed a high accuracy of maximum standardized uptake value ( SUV _max ) for the detection of LNM s, with an area under the curve of 0.915 (95% confidence interval 0.847–0.983); the optimum SUV _max was 2.0. Conclusions: In patients with intermediate‐ to high‐risk PC a, 68Ga‐ PSMA PET / CT had a high specificity and a moderate sensitivity for LNM detection. 68Ga‐ PSMA PET / CT had the potential to replace current imaging for LN staging of patients with PC a scheduled for RP .

Balancing overdiagnosis and overtreatment with missing clinically significant prostate cancer (PC) is an ongoing dilemma. This study aims to assess the performance of five previously described clinico-pathological definitions of low-risk PC applied to transperineal saturation biopsy in predicting insignificant disease at radical prostatectomy (RP).

Objectives: To examine the detection rates of ⁶⁸ Ga‐ PSMA ‐positron emission tomography ( PET )/computed tomography ( CT ) in patients with biochemical recurrence ( BCR ) after radical prostatectomy ( RP ), and also the impact on their management. Materials and Methods: A total of 300 consecutive patients with prostate cancer ( PC a) who underwent ⁶⁸ Ga‐ PSMA ‐ PET / CT between February and July 2015 were prospectively included in the Prostate Cancer Imaging (ProCan‐I) database. For the present analysis, we included patients with BCR (prostate‐specific antigen [ PSA ] level ≥0.05 and 68 Ga‐ PSMA ‐ PET / CT , and all positive lesions were assigned to an anatomical location. For each patient, the clinical and pathological features were recorded, their association with pathological ⁶⁸ Ga‐ PSMA uptake was investigated, and detection rates were determined according to PSA level. Results: A total of 70 patients were included, and 53 positive ⁶⁸ Ga‐ PSMA lesions were detected in 38 (54%) patients. Among patients with PSA levels 0.05–0.09 ng/mL, 8% were definitely positive; the corresponding percentages for the other PSA ranges were as follows: PSA 0.1–0.19 ng/mL, 23%; PSA 0.2–0.29 ng/ mL , 58%; PSA 0.3–0.49 ng/ mL , 36%; and PSA 0.5–0.99 ng/ mL , 57%. Eighteen of 70 patients (27%) had pathological ⁶⁸ Ga‐ PSMA uptake in the prostatic fossa, 11 (14.3%) in the pelvic nodes, and five (4.3%) in both the fossa and pelvic lymph nodes. Finally, there was uptake outside the pelvis with or without a lesion in the fossa or pelvic lymph nodes in four cases (8.6%). As a result of the ⁶⁸ Ga‐ PSMA findings there was a major management change in 20 (28.6%) patients. Conclusions: ⁶⁸ Ga‐ PSMA appears to be useful for re‐staging of PC a in patients with rising PSA levels who are being considered for salvage RT even at PSA levels 68 Ga‐ PSMA findings.