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05:03 CET
SS 1907a - Prostate biopsy and (post-)intervention
Genitourinary Oncologic Imaging
Sunday, March 4, 14:00 - 15:30
Room: N
Moderators: A. Baur (Berlin/DE), V. Panebianco (Rome/IT)

A prospective study to compare the outcomes of MRF-TB and 12-core SB in different PSA groups
J.-M. Xu, Y. Q. Chen; Shanghai/CN

Purpose: To assess and compare the rate of detection of clinically significant prostate cancer (csPCa) between magnetic resonance imaging (MRI)-ultrasound fusion-targeted prostate biopsy (MRF-TB) and 12-core systematic biopsy (SB) in the different prostate-specific antigen (PSA) groups.
Methods and Materials: This prospective study included 156 patients who underwent pre-biopsy MRI and 12-core SB between September 2014 and August 2016. In the patients with MRI-suspicious lesions (n=123), MRF-TB was performed before SB. In the clinically suspicious patients with normal MRI (n=33), SB was performed without MRF-TB. The detection rates for any cancer and csPCa were compared between MRF-TB and SB.
Results: Detection rate for any cancer was not significantly different between MRF-TB (64/123, 52.0%) and SB (66/156, 42.3%; p=0.106). For csPCa, the detection rate of MRF-TB (61/123, 49.6%) was significantly higher than that of SB (46/156, 29.5%; p=0.001). In a subset analysis of patients with PSA<10ng/ml, csPCa detection rate of MRF-TB (26/67, 38.8%) was significantly higher than that of SB (16/83, 19.3%; p=0.008). In 10≤PSA<20ng/ml group, csPCa detection rate of MRF-TB (20/38, 52.6%) was also significantly higher than that of SB (15/52, 28.8%; p=0.022). In PSA≥20ng/ml group, csPCa detection rate of MRF-TB (15/18, 83.3%) was higher than that of SB (15/21, 71.4%), but no significant difference was found (p=0.379).
Conclusion: Our prospective study revealed a similar rate of prostate cancer detection between MRF-TB and SB, and MRF-TB could improve the overall detection of csPCa compared to SB. We also found that MRF-TB was superior to SB for csPCa detection in subset patients with PSA<10ng/ml and 10≤PSA<20ng/ml, but was similar in patients with PSA≥20ng/ml.
Therefore, the traditional SB may be replaced by MRF-TB for detection of csPCa.

The accuracy of MRI/TRUS fusion biopsy in detection of high-risk prostate cancer vs random biopsies: advertisement or necessary innovation?
F. Kossov1, I. I. Abdullin1, B. Kamolov1, B. Olimov1, O. Orlov1, V. Panov1, I. Tyurin1, E. Fedorenko1, V. V. Kapustin2; 1Moscow/RU 2Moscow Oblast/RU

Purpose: Systematic biopsies (SB) are an integral part of prostate cancer (PCa) diagnostics. SB PCa detection varies from 31% to 42%; however, the number of false-negative results is high. MRI/TRUS fusion target biopsy (MRI/TRUS FTB) probably would improve the detection of high-risk cancer (HRC) both in initial biopsy and in patients with preliminary negative SB results.
Methods and Materials: 82 patients with suspected PCa were examined. The criteria of patients inclusion was the presence of: 1) PSA>4 ng/ml and positive results of the digital rectal examination; 2) mpMRI data. The examination includes: 1) prostate mpMRI; 2) MRI/TRUS FTB; 3) SB.
Results: PCa was detected in 66 cases (including 12 cases with previously negative SB). MRI/TRUS FTB PCa detection rate includes: 1) 13.3% cases with Gleason=6; 2) 33.5% with Gleason=7; 3) 53.2% with Gleason=8-10. SB evaluates PCa in: 1) 27.8% patients with Gleason=6; 2) 38.9% with Gleason=7; 3) 27.8% with Gleason=8-10. MRI/TRUS FTB data is significantly highly competitive in high malignancy potential nodes detection with SB (p<0.0001). The HRC detection accuracy using MRI/TRUS FTB appears higher in comparison with SB data (p<0.0001). MRI data (estimated by PI-RADS v.2) showed significant correlation with the MRI/TRUS FTB results (р<0.02, correlation coefficient 0.7).
Conclusion: The MRI/TRUS FTB provides an opportunity to decrease the necessary number of punctures in PCa patients for detection of the histological material with the highest malignancy rate. MRI/TRUS FTB exposes low sensibility to insignificant PCa. It increases the detection of clinically relevant forms of PCa.

Transrectal ultrasound-guided targeted biopsy of transition zone prostate cancer: usefulness of across midline sign
S. Park, S. Won; Seoul/KR

Purpose: To retrospectively evaluate diagnostic performance of transrectal ultrasound (TRUS)-guided targeted biopsy (TB) of transition zone (TZ) prostate cancer (PCa) in patients with prebiopsy magnetic resonance imaging (MRI).
Methods and Materials: Consecutive series of 38 patients who underwent TRUS-guided TB of TZ lesions were evaluated. TB (mean core number, 2.4±0.6; range, 2-4) was performed by a single experienced radiologist under cognitive registration between prebiopsy MRI and TRUS. Across midline sign was defined by a focal lesion traversing the midline of prostatic TZ on MRI and TRUS, leading to discontinuity of the midline. Prostate Imaging-Reporting and Data System version 2 (PI-RADSv2) scoring for targeted TZ lesions was also conducted with T2-weighted and diffusion-weighted MRI by the same radiologist.
Results: PI-RADSv2 categories from 2 to 5 for TZ lesions consisted of 4, 14, 7, and 13. Cancer detection rate of TRUS-guided TB for TZ lesions was 78.9% (30/38). Across midline sign was identified in 50.0% (19/38). Cancer detection rate of TRUS-guided TB for TZ lesions showing across midline sign on both MRI and TRUS was 94.7% (18/19).
Conclusion: Under cognitive registration, TRUS-guided TB for TZ lesions showing across midline sign on both MRI and TRUS may be highly predictive of TZ PCa.

In-bore biopsies of the prostate assisted by a remote-controlled manipulator at 1.5 T
N. Linder, A. Schaudinn, T.-O. Petersen, R. Stange, M. Moche, P. Stumpp, T. Kahn, H. Busse; Leipzig/DE

Purpose: To evaluate technical and clinical performance of a fully MRI-compatible, pneumatically driven remote-controlled manipulator (RCM, "robot") for 1.5-T in-bore biopsies of the prostate.
Methods and Materials: This preliminary prospective study included the first 15 patients that underwent robotic (Soteria Medical, Arnhem, Netherlands), in-bore biopsies of the prostate in a wide-bore 1.5 T MRI (Magnetom Aera, Siemens Healthcare, Erlangen, Germany). Targeting and control of the transrectal needle guide were realized by rapid MR imaging (balanced SSFP sequence with acquisition times around 10 s). Biopsies were performed by two radiologists, each with 4 years of experience with prostate interventions. Analysis involved pre-biopsy MRI reports (PIRADS version 2), procedure times (between planning and final control MRI), periprocedural complications and histopathologic results of the samples.
Results: Mean age (range) was 67 (54 - 80) years and mean PSA level was 11.1 (0.7 - 21.5) ng/dl. Twelve patients (80%) had received prior biopsies under transrectal ultrasound guidance. Prebiopsy MRI reports involved 12 cases with a single suspicious finding (2x PIRADS 3, 5x "P4" and 5x "P5") and 3 cases with two ones (2x "P3" and 1x "P5"). Histopathologic examination revealed prostate cancer in 7 of 15 cases. One patient developed urosepsis which was successfully treated with antibiotics. Procedure times ranged between 26 and 85 min.
Conclusion: In-bore, transrectal prostate biopsies could be successfully performed with a robotic manipulator at a field strength of 1.5 T. Unlike with passive interventional devices, the patient may remain inside the bore for needle-guide adjustments.

Experience with MRI guided prostate biopsies using the 3D Navigo system in an oncologic referral centre
S. Heijmink, R. van den Bergh, E. Wit, H. van der Poel; Amsterdam/NL

Purpose: Multiparametric (mp) MRI has the potential to increase biopsy yield of prostate cancer detection. This study presents experiences with the Navigo system for MRI-TRUS fusion.
Methods and Materials: Navigo MRI-TRUS fusion biopsies was performed from 2015-2017. All patients received prebiopsy 3TmpMRI. Dependent on biopsy indication, random non-guided biopsies were taken in the same session. We recorded any encountered problems, compared Navigo and NG biopsy cancer detection rates, and explored predictors for positive biopsy outcome.
Results: Navigo biopsies were planned in 228 patients for diverse indications, of whom 26 (11%) could not be performed. In 18 (9%) of the remaining patients a problem was reported during the procedure. Any of the guided biopsies was positive in 24-85%, dependent on indication. Of the 202 Navigo procedures, additional non-guided cores were taken in 99 patients. Similar results between Navigo and non-guided biopsies were found for any positive biopsy rate, %positive cores, and mean Gleason score (all p>0.05), but the absolute number of cores taken was almost half for the Navigo biopsies. Lowest lesion mean ADC was a persistent predictor in multivariable analysis for positive biopsy outcomes.
Conclusion: The benefit of 3TmpMRI targeted Navigo fusion biopsies was seen in the lower number of biopsy cores needed, but not in cancer detection rate or mean Gleason score. In patients without primary diagnosis, guided biopsies did not obviate the need for additional random biopsies. ADC was the main biopsy outcome predictor for guided and non-guided biopsies.

Typical MR imaging findings after HIFU-hemiablation of the prostate
N. Linder1, J. Michaelis1, J. Gawlitza1, H. Busse1, P. Ho-Thi1, T. Kahn1, P. Stumpp1, R. Ganzer2, A. Schaudinn1; 1Leipzig/DE 2Bad Tölz/DE

Purpose: To evaluate MR imaging features of the prostate after high-intensity focused ultrasound (HIFU) treatment of the hemigland.
Methods and Materials: Eighteen patients with a mean age of 67.1 (48.9-78.5) years, mean Prostate-specific-Antigen level of 6.35 (4.0-9.8) ng/dl and biopsy-proven unilateral Prostate Cancer (PCa) received MRI before and 12 months after HIFU (Hemiablation, Focal One). MR/ultrasound fusion-guided Biopsy was performed after 12 months to exclude recurrent/contralateral cancer. MRI (3T) followed PIRADS version 2 guidelines with T2 TSE, diffusion-weighted imaging (DWI) and dynamic-contrast enhanced-T1 imaging (DCE). MR-analysis included quantitative and qualitative imaging characteristics, such as T2-volumetry, DCE and DWI signal-intensity measurements.
Results: Treatment resulted in a mean volume reduction of the target lobe by 49.1% (27.9-69.5%) and of the whole gland by 28.1% (1.0-45.6%), respectively. The typical image patterns of the ablated lobe consisted of a centrally positioned, T2-hyperintens, well circumscribed area, defined as seroma and/or a T2-hypointens area with heterogeneous DWI signal intensity, interpreted as scar, mainly adjacent laterally to the seroma. The combination seroma/scar was observed in 16 of 18 patients, whereas only scar was observed in 2 cases. In 50% of the cases a rim-like contrast media uptake around the ablation area was observed. MRI detected one of four cases of biopsy-proven low grade contralateral PCa and none of two cases of ipsilateral recurrent PCa (Ø Gleason: 6.5).
Conclusion: MRI analysis revealed distinct image patterns at 12 months after hemiablation, such as seroma, scar and volume reduction. However detection rate of recurrent or contralateral prostate cancer was low.

Six months follow-up of periprostatic nerve plexus changes after robot-assisted radical prostatectomy using MRI tractography.
A. Cybulski, S. Brancato, V. Di Paola, R. Negrelli, E. Boninsegna, M. Catania, A. Tafuri, S. Siracusano, R. Pozzi Mucelli; Verona/IT

Purpose: To evaluate early and late modifications of periprostatic nerve plexus (PNP) after robot-assisted radical prostatectomy (RARP) with MRI tractography and their clinical correlations.
Methods and Materials: 34 patients (mean age:64,8) candidate to RARP performed 3 MRI examinations completed with 32-directions DTI sequences respectively before, 1 (mean:39,4 days) and 6 months (mean:201,7 days) after RARP. Tractography reconstructions were performed by positioning 6 ROIs of PNP, evaluating the following parameters: number of fibers(N), number of voxels(V), fractional anisotropy(FA), apparent diffusion coefficient(ADC), fiber length(L). Before each MRI, 2 questionnaires were administered to investigate urinary continence(ICIQ-SF) and erectile function(IIEF-5). Each tractography parameter of the 3 examinations was compared using Student’s T-test and was correlated with urinary incontinence and erectile dysfunction using Kendall’s-tau test.
Results: Reduction of N and V was observed 1 month after RARP, without any increment at 6 months. 1 month-MRI demonstrates reduction of FA, which returns to pre-surgery values at 6 months-control. Reduction of ADC was observed at 6 months-MRI compared with the previous examinations (p<0,001). No modification of L emerged. Positive correlation has been established between N(τ=0,297), V(τ=0,282), FA(τ=-0,249) and potency and between N(τ=-0,257), V(τ=-0,231) and urinary continence(p≤0,001).
Conclusion: MRI tractography is able to identify complex changes regarding the number of fibers(N and V reduction post-RARP) and fiber patterns of PNP(FA reduction at 1 month, growing up back to pre-surgery values at 6 months). These changes correlate both with potency and urinary continence.

Predicting and improving postprostatectomy urinary continence by pelvic floor measures on MR
S. Heijmink, N. Grivas, C. Tillier, R. van der Roest, E. van Muilekom, H. van der Poel; Amsterdam/NL

Purpose: Urinary incontinence is a frequent complication of prostatectomy. MRI imaging of pelvic floor musculature has learned that several anatomical characteristics predict postprostatectomy continence function. We used this information to attempt reconstruction of the pelvic floor after prostatectomy to improve continence outcome.
Methods and Materials: In 439 patients preprostatectomy MRI images were correlated to functional outcome continence scores (ICIQ-SF) for 10 pelvic measurements. Based on the obtained measures we changed the pelvic floor reconstruction from median fibrous raphe reconstruction only and added medialisation of the anterior muscle fibers of the levator ani muscle behind the urethra. In a prospective comparative analysis we studied the 6 months postoperative ICIQ-SF score in men with median fibrous raphe reconstruction with or without levator suspension and standard urethral-bladder anastomosis.
Results: A longer membranous urethral length (MUL), smaller interlevator distance (ILD) and more extpensive fascia preservation score were predictive of earlier continence recovery. We developed an algorithm to predict continence outcome after prostatectomy based on these predictors. Since we hypothesized that narrowing of the pelvic floor exit by medializing anterior fibers of the levator ani muscle would artificially decrease ILD and elongate MUL and therefore improve postprostatectomy continence we performed this procedure in 211 men undergoing RARP. In comparison to standard (n=1375) or median fibrous raphe reconstruction (n=271) bladder-urethral anastomosis, MALF addition improved early (3w) (p=0.01) but not late (6m) continence recovery.
Conclusion: MRI-based pelvic floor prostatometry individualizes prediction of postprostatectomy continence. Increasing pelvic floor support of the urethra improves early, but not overall continence.

Correlation of short- and long-term urinary continence after radical prostatectomy with findings of preoperative multiparametric prostate MRI
M. Sauer, R. Pompe, P. Tennstedt, L. Budaeus, G. Salomon, G. Adam, D. Beyersdorff; Hamburg/DE

Purpose: To evaluate whether preoperative multiparametric prostate MRI (mpMRI) can help to stratify the risk of urinary continence (UC) after radical prostatectomy (RP) based on specified image findings.
Methods and Materials: Our institutional review board approved this retrospective study. 233 patients (median age 66.1 years) underwent standardized mpMRI at 3T prior to prostatectomy, including high-resolution T2w-TSE-imaging in 3 planes, T1w-TSE, DWI with ADC map, PD-TSE and Gd-DCE. Membranous urethra length, urethra angle and apex shape were measured systematically in T2w sequences in the sagittal plane. Prostate volume was determined during transrectal sonography. Image findings and clinical data (age, type of surgery) were correlated to UC as evaluated by a standardized questionnaire determining the amount of necessary hygiene pads one week (response rate 100%) and one year after surgery (response rate 61.4%; n=143 patients).
Results: Of all clinical parameters, there was a small yet significant positive correlation of age with UC one week (Spearman r=0.27, p=0.0001) and one year after surgery (r=0.20, p=0.02). Urethra angle and apex shape as measured in mpMRI did not correlate significantly with UC at neither time point. Correlation of the membranous urethra length with UC was small negative after one week (r=-0.22, p=0.001) and close to medium negative after one year (r=-0.29, p=0.001). Sonographic prostate volume did not correlate with UC and will be complemented by outstanding MRI volumetries.
Conclusion: Measurements of the membranous urethra length in mpMRI correlate with short- and long-term UC after radical prostatectomy and should be acknowledged during preoperative risk stratification.

Additional value of early imaging of 68Ga-PSMA-11 PET/CT in the assessment of local recurrence in prostate cancer patients with biochemical relapse
C. Uprimny, A. Kroiss, C. Decristoforo, J. Fritz, B. Nilica, W. Horninger, I. Virgolini; Innsbruck/AT

Purpose: Evaluation of local recurrence (LR) in prostate cancer patients with biochemical recurrence is hampered by high physiologic urinary bladder activity present on 68Ga-PSMA-11 PET/CT exams, usually conducted 60 min after tracer injection (p.i.). This study aims to investigate whether additional early static PET scans could enhance diagnostic performance of 68Ga-PSMA-11 PET/CT in the evaluation of LR.
Methods and Materials: 213 prostate cancer patients with biochemical recurrence referred to 68Ga-PSMA-11 PET/CT were analysed retrospectively (median PSA: 1.47 ng/ml). In all patients an early static scan of the pelvis was performed with a median starting time of 281 sec p.i., followed by a whole-body PET/CT 60 min p.i. Image interpretation was based on visual analysis. Furthermore, calculation of maximum standardized uptake value (SUVmax) of pathologic lesions was performed.
Results: On standard PET images 60 min p.i. a LR-suggestive lesion (median SUVmax: 11.0) could be detected in 28 patients (13.1%), whereas an equivocal finding was present in 36 patients (16.9%). In contrast, on early PET scans a pathologic lesion compatible with LR was revealed in 52 patients (median SUVmax: 5.9) and an unclear finding in only nine patients (4.2%). Early PET images led to a significant rise in the detection rate (p<0.001) as well as a significant reduction of equivocal findings (p<0.001) compared to PET-imaging 60 min p.i.
Conclusion: Assessment of local recurrence in prostate cancer patients with biochemical relapse referred to 68Ga-PSMA-11 PET/CT is improved by additional early PET imaging.

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