Search

Objectives: To identify prostatic quadrants that could be preserved without intervention, using diffusion-weighted magnetic resonance imaging (DWI) and extended core biopsy, as a step toward implementation of quadrant-based focal ablation with potential preservation of erectile and ejaculatory functions, based on comparisons with unilateral hemi-gland ablation., Patients and Methods: We conducted a prebiopsy DWI study including 648 quadrants in 162 men who underwent 14-core biopsy including anterior sampling and radical prostatectomy (RP) for localised cancer. Imaging and pathology were analysed on a quadrant basis. Each quadrant was assessed through four-core sampling. Predictive performance of DWI and biopsy for quadrant status was analysed., Results: On RP specimens, 170 anterior (52.5%) and 172 posterior quadrants (53.1%) harboured significant cancer. Negative predictive values of DWI, biopsy, and their combination for significant cancer were 79.7%, 70.6%, and 91.1%, respectively, in anterior quadrants, and 78.5%, 81.3%, and 91.7%, respectively, in posterior quadrants. DWI incrementally improved the negative predictive values of biopsy in anterior (P < 0.001) and posterior quadrants (P = 0.025), without untoward impacts on positive predictive values. Negative findings on both DWI and biopsy were identified in posterior quadrants of 109 sides (33.6%), but in entire hemi-glands of 54 sides (16.7%)., Conclusions: The combination of DWI and 14-core biopsy including anterior sampling efficiently identifies quadrants without significant cancer in men with localised prostate cancer; the remaining quadrants, therefore, could be potential candidate areas for focal ablation. Focal therapy designed based on quadrant-based assessment could be superior to unilateral hemi-gland ablation for preservation of posterior quadrants and retaining of sexual function in more sides., (© 2014 The Authors BJU International © 2014 BJU International Published by John Wiley & Sons Ltd.)

Objective: To investigate the diagnostic performance and safety of a three-dimensional 14-core biopsy (3D14PBx) method, which is a combination of the transrectal six-core and transperineal eight-core biopsy methods., Patients and Methods: Between December 2005 and August 2010, 1103 men underwent 3D14PBx at our institutions and were analysed prospectively. Biopsy criteria included a PSA level of 2.5-20 ng/mL or abnormal digital rectal examination (DRE) findings, or both. The primary endpoint of the study was diagnostic performance and the secondary endpoint was safety. We applied recursive partitioning to the entire study cohort to delineate the unique contribution of each sampling site to overall and clinically significant cancer detection., Results: Prostate cancer was detected in 503 of the 1103 patients (45.6%). Age, family history of prostate cancer, DRE, PSA, percentage of free PSA and prostate volume were associated with the positive biopsy results significantly and independently. Of the 503 cancers detected, 39 (7.8%) were clinically locally advanced (≥cT3a), 348 (69%) had a biopsy Gleason score (GS) of ≥7, and 463 (92%) met the definition of biopsy-based significant cancer. Recursive partitioning analysis showed that each sampling site contributed uniquely to both the overall and the biopsy-based significant cancer detection rate of the 3D14PBx method. The overall cancer-positive rate of each sampling site ranged from 14.5% in the transrectal far lateral base to 22.8% in the transrectal far lateral apex. As of August 2010, 210 patients (42%) had undergone radical prostatectomy, of whom 55 (26%) were found to have pathologically non-organ-confined disease, 174 (83%) had prostatectomy GS ≥7 and 185 (88%) met the definition of prostatectomy-based significant cancer., Conclusions: This is the first prospective analysis of the diagnostic performance of an extended biopsy method, which is a simplified version of the somewhat redundant super-extended three-dimensional 26-core biopsy. As expected, each sampling site uniquely contributed not only to overall cancer detection, but also to significant cancer detection. 3D14PBx is a feasible systematic biopsy method in men with PSA <20 ng/mL., (© 2014 The Authors. BJU International © 2014 BJU International.)

Purpose: We evaluated the usefulness of pre-biopsy multiparametric magnetic resonance imaging and clinical variables to decrease initial prostate biopsies., Materials and Methods: We prospectively evaluated 351 consecutive men with prostate specific antigen between 2.5 and 20 ng/ml, and/or digital rectal examination suspicious for clinically localized disease. All men underwent pre-biopsy multiparametric magnetic resonance imaging and initial 14 to 29-core biopsy, including anterior sampling. Three definitions of significant cancer were defined based on Gleason score and cancer volume (percent positive core and/or maximum cancer length). The overall cohort was divided into men at low risk-prostate specific antigen less than 10 ng/ml and normal digital rectal examination, and high risk-prostate specific antigen 10 ng/ml or greater and/or abnormal digital rectal examination. We evaluated the frequency of significant cancer according to magnetic resonance imaging and risk categories. Clinical variables as significant cancer predictors were analyzed using logistic regression. The sensitivity, specificity, and positive and negative predictive values of magnetic resonance imaging were calculated with or without clinical variables for significant cancer., Results: The frequency of significant cancer in men with negative vs positive magnetic resonance imaging was 9% to 13% vs 43% to 50% in the low risk group and 47% to 51% vs 68% to 71% in the high risk group. In men at low risk with negative magnetic resonance imaging prostate volume was the only significant predictor of significant cancer. In the low risk group the negative predictive value for significant cancer of a combination of positive magnetic resonance imaging and lower prostate volume (less than 33 ml) was 93.7% to 97.5%., Conclusions: Pre-biopsy multiparametric magnetic resonance imaging along with prostate volume decreases the number of initial prostate biopsies by discriminating between significant cancer and other cancer in men with prostate specific antigen less than 10 ng/ml and normal digital rectal examination., (Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objectives: To examine whether the transrectal ultrasound-guided transperineal 14-core prostate biopsy can be carried out safely in diabetic men and to determine adequate antimicrobial prophylaxis protocol in this setting., Methods: The present study included 539 men, 135 with concurrent diabetes mellitus (DM) and 404 without DM, who underwent transperineal extended 14-core biopsy due to elevated prostate-specific antigen > or = 2.5 ng/mL and/or abnormal digital rectal examination. Any complication requiring prolonged hospitalization or rehospitalization during the 4-week post-biopsy period was considered major. All other complications were considered minor. Intensity of antimicrobial prophylaxis was prospectively reduced in a stepwise manner down to single dose of oral levofloxacin., Results: Except for DM, there was no significant difference in clinical background between the diabetic and non-diabetic men. The procedure was completed in all revealing prostate cancer in 42% of the diabetic men and 36% of the non-diabetic men (P = 0.23). Incidence of minor or major complications was not significantly different between the two groups. Minor complications were observed in 15.6% and 16.6% of each group, respectively, with voiding disturbance being the most common. No infectious major complication was observed regardless of the presence of DM. In the diabetic men, there was no statistical difference in incidence of biopsy-related complications according to modality of DM treatment, HbA1c level or antimicrobial prophylaxis protocol., Conclusions: Transperineal 14-core biopsy can be carried out without major infectious complications in diabetic men. Oral levofloxacin 300 mg once before the procedure seems to represent an effective antimicrobial prophylaxis in diabetic men without other risk of infection.

Aim: To establish whether extended transrectal (TR) and extended transperineal (TP) biopsies are equivalent in detecting prostate cancer., Methods: Due to an elevated prostate-specific antigen (PSA) greater than 2.5 ng/mL or abnormal digital rectal examination findings, 783 men underwent a transrectal ultrasound-guided three-dimensional 26-core biopsy, a combination of TR 12-core and TP 14-core biopsies. Using recursive partitioning, the best combination of sampling sites that gave the highest cancer detection rate at a given number of biopsy cores was selected either with a TR or a TP approach. The cancer detection rate and characteristics of detected cancers were compared between the TP 14-core and the TR 12-core biopsies and between selected subset biopsy schemes., Results: Prostate cancer was detected in 283 of the 783 men (36%). There was no statistical difference in cancer detection rate or in the characteristics of detected cancers between TP 14-core and TR 12-core biopsies. As far as the best combination of sampling sites was selected, there was no statistical difference in cancer detection rates or in the characteristics of detected cancers between the TP and the TR subset biopsy schemes up to 12 cores. TP and TR biopsies performed equally, regardless of a history of negative biopsy, a digital rectal examination finding, the PSA level or the prostate volume., Conclusions: We demonstrated for the first time that extended TP biopsy is as effective as its TR counterpart in detecting cancer and the characteristics of detected cancers, as far as sampling sites are selected to maximize the cancer detection rate.

Objective To investigate the association between lower urinary tract symptoms status and prostate cancer risk at initial extended biopsy. Methods Between 2005 and 2011, the International Prostate Symptom Score was completed on 1467 consecutive men with prostate-specific antigen <10 ng/mL and non-suspicious digital rectal examination. After excluding 308 men treated with alpha-blockers, the remaining 1159 men were enrolled in the present study. Lower urinary tract symptoms status was divided into absent or mild ( International Prostate Symptom Score scores of 0-7) and moderate or severe lower urinary tract symptoms ( International Prostate Symptom Score scores of 8-35). The risks of prostate cancer diagnosis and high-grade ( Gleason score ≥4 + 3) prostate cancer diagnosis in relation to lower urinary tract symptoms status was evaluated using logistic regression. A stratified analysis based on prostate volume (<30 cc, 30-50 cc and >50 cc) was also carried out. Results Of 1159 patients, 421 (36.3%) had a positive biopsy and 590 (51.0%) had moderate or severe lower urinary tract symptoms. On multivariate analysis, absent or mild lower urinary tract symptoms had a significant and positive impact on the risk of prostate cancer and high-grade disease (odds ratio 1.64 and 1.70, P = 0.0007 and 0.0121, respectively). Furthermore, the aforementioned findings for prostate cancer detection did not change throughout every prostate volume subgroup. In contrast, in men with prostate volume ≤50 cc, but not in those with prostate volume >50 cc, prostate-specific antigen or %free prostate-specific antigen remained as a significant predictor of prostate cancer. Conclusion In men with elevated prostate-specific antigen, absent or mild lower urinary tract symptoms are positively associated with prostate cancer and high-grade disease regardless of the prostate volume. This finding is especially useful in men with enlarged prostates. [ABSTRACT FROM AUTHOR]

Purpose: We clarified the diagnostic ability of multiparametric magnetic resonance imaging to reveal anterior cancer missed by transrectal 12-core prostate biopsy based on the results of 3-dimensional 26-core prostate biopsy, which is a combination of transrectal 12-core and transperineal 14-core biopsies. Materials and Methods: The study population consisted of 324 patients who prospectively underwent prebiopsy multiparametric magnetic resonance imaging and then 3-dimensional 26-core prostate biopsy at a single institution. We defined transrectal 12-core negative cancer as cancer detected by transperineal 14-core but not transrectal 12-core prostate biopsy. We focused on cancer in the anterior region. Any findings suspicious for malignancy in the region anterior to the urethra on multiparametric magnetic resonance imaging were defined as an anterior lesion on imaging. Significant cancer was defined as a biopsy Gleason score of 4 + 3 or greater, a greater than 20% positive core and/or a maximum cancer length of 5 mm or greater. Associations between an anterior lesion on imaging and transrectal 12-core negative cancer were investigated. Results: The overall cancer detection rate on 3-dimensional 26-core prostate biopsy was 39% (128 of 324 cases), of which 28% (36 of 128) were transrectal 12-core negative cancers. An anterior lesion on prebiopsy multiparametric magnetic resonance imaging was identified in 20% of men overall (65 of 324). Of men with and without an anterior lesion on imaging 40% (26 of 65) and 3.8% (10 of 259), respectively, had transrectal 12-core negative cancer. Significant transrectal 12-core negative cancer was observed in 0.4% (1 of 259 men) without an anterior lesion on imaging. Prebiopsy multiparametric magnetic resonance imaging revealed an anterior lesion in 92% of cases (11 of 12) of significant transrectal 12-core negative cancer. Conclusions: Prebiopsy multiparametric magnetic resonance imaging has the potential to efficiently select men who could advantageously undergo anterior samplings, in addition to transrectal 12-core prostate biopsy. [ABSTRACT FROM AUTHOR]

Study Type - Prognosis (inception cohort) Level of Evidence 2 What's known on the subject? and What does the study add? The criteria used for selecting patients with prostate cancer for active surveillance (AS) are still not satisfactory due to the difficulty in predicting the significance of the prostate cancer. Urologists could predict insignificant prostate cancer by incorporating cumulative cancer length and biopsy Gleason score, derived from extended biopsy. The present study has added new criteria for predicting insignificant prostate cancer, which would lead to a better selection of candidates for AS. OBJECTIVE To develop extended biopsy based criteria for predicting insignificant cancer (IC) using extended biopsy findings., PATIENTS AND METHODS From 2000 to 2009, 1575 patients with prostate cancer were primarily treated by radical prostatectomy in two referral hospitals., Of these, the study cohort comprised 499 patients with extended biopsy confirmed, clinically organ-confined (cT1-2N0M0) prostate cancer with PSA levels of <20 ng/mL., Cancer information obtained through extended biopsy included cumulative cancer length (CCL) divided by the number of biopsy cores (CCL/core)., RESULTS Pathological examination revealed 39 ICs (7.8%). All these ICs fell in a category of prostate cancer with clinical stage ≤T2a and 2005 International Society of Urological Pathology Consensus Conference (ISUP) modified biopsy Gleason score ≤7., Accordingly, we analysed predictors of IC in a subset cohort of 370 patients in this category. A multivariate logistic regression analysis revealed that 2005 ISUP modified biopsy Gleason score and CCL/core were independently significant predictors of IC., We determined a threshold value of CCL/core of 0.20 mm for predicting IC using receiver operating characteristic analysis., Based on these findings, we developed simple extended biopsy based criteria for predicting IC as follows: (i) PSA level of <20 ng/mL; (ii) Clinical stage ≤T2a; (iii) 2005 ISUP modified biopsy Gleason score ≤6; (iv) CCL/core of <0.20 mm., The specificity of the criteria was 91%, which was significantly higher than the value from a subset of criteria without item iv ( P < 0.001)., CONCLUSION We have developed extended biopsy based criteria for predicting IC incorporating the 2005 ISUP modified biopsy Gleason score and CCL/core. [ABSTRACT FROM AUTHOR]

Study Type - Diagnostic (exploratory cohort) Level of Evidence 3a What's known on the subject? and What does the study add? Initial transrectal 12-core biopsy has a small but definite risk of missing anterior significant prostate cancers irrespective of age, PSA, prostate volume and DRE findings. Our study yields valuable information for diagnosis and treatment decision of prostate cancer based on transrectal 12-core biopsy. OBJECTIVE [ABSTRACT FROM AUTHOR]

We developed a local anesthetic procedure for three-dimensional 26-core prostate biopsy (3D26PBx), a combination of transperineal 14-core biopsy (TP14PBx) and transrectal 12-core biopsy (TR12PBx). At first, a periapical triangle, confined by the levator ani, the rhabdosphincter and the external anal sphincter muscle, was made visible by transrectal ultrasound. After administration of 1 mL of 1%-lidocaine into the midline perineal skin 1.5 cm above the anus, we inserted a spinal needle toward the periapical triangle for injection of 1.5–2.0 mL of 1%-lidocaine and performed the TP14PBx. After administration of the periprostatic nerve block with 10 mL of 1%-lidocaine, we performed the TR12PBx. The efficacy of the procedure was evaluated prospectively in 45 consecutive men undergoing the 3D26PBx. The 3D26PBx was completed with just local anesthesia in all patients. The pain levels, assessed by an 11-point visual analog scale, were not different between the TP14PBx and the TR12PBx. [ABSTRACT FROM AUTHOR]

Objectives: Most of the previously reported patient selection criteria for nerve-sparing radical prostatectomy were based on conventional sextant biopsy, and those based on extended biopsy have been scarcely investigated. In the current study, we developed patient selection criteria for nerve-sparing RP based on the three-dimensional 26-core (3D26) biopsy-derived variables. Methods: We evaluated 202 non-nerve-spared sides in 109 consecutive patients in whom prostate cancer was diagnosed by the 3D26 biopsy and who underwent RP without neoadjuvant treatment. Associations of clinical and pathological variables with side-specific posterolateral extraprostatic extension (SS-PL-EPE) were analyzed. Subgroup analysis using transperineal 14-core (TP14) and transrectal 12-core (TR12) biopsies as representative subsets of the 3D26 biopsy was also performed. Results: Maximum cancer length in positive cores ≥5 mm and biopsy Gleason score ≥4 + 3 were independent and were significant risk factors of SS-PL-EPE in the 3D26 cohort at multivariate analysis. In the prostatic side with none, one, and two risk factors, the incidences of SS-PL-EPE were 0, 14 and 52% in the 3D26 cohort, 3.4,15 and 57% in the TP14 cohort and 2.6, 20 and 61% in the TR12 cohort, respectively. Conclusions: We developed simple patient selection criteria for nerve-sparing RP. According to our criteria, the nerve-sparing side can be selected in the majority of patients who undergo the 3D26, TP14 or TR12 biopsy with a less-than-4% risk of SS-PL-EPE. [ABSTRACT FROM AUTHOR]

Objectives: To examine whether history of malignancy adds any significant information to the prediction of positive prostate biopsy in referred men with moderately elevated prostate-specific antigen (PSA) and to develop a predicting nomogram that does not require extra examinations other than PSA. Methods: A total of 1767 consecutive Japanese men with PSA less than 10 ng/mL who underwent prostate biopsy were included in the study cohort. Age, digital rectal examination (DRE), PSA, body mass index, family history of prostate cancer and number of previous malignancies other than the prostate were evaluated in regard to their association with prostate cancer. A logistic regression-based nomogram for predicting prostate cancer was developed and externally validated. Results: Of the 1767 men, 269 had a history of malignancy with a total of 312 primary sites. Univariate and multivariate analyses revealed that DRE, PSA, age, family history and number of previous malignancies are independent and significant predictors of positive biopsy result. External validation revealed that the predicting accuracy of a nomogram incorporating these five variables is significantly higher than those of PSA or PSA and DRE. Using the nomogram, 8% of unnecessary biopsies would be saved at 95% sensitivity. Conclusions: We demonstrated for the first time that history of malignancy is a potent predictor of prostate cancer in men with moderately elevated PSA even if the established risk factors are adjusted. The nomogram can be a useful tool in decision-making of prostate biopsy. In daily practice, history of malignancy should be rigorously taken from these men before a decision is made regarding prostate biopsy. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: Using cohorts examined by extended biopsy, we developed and validated multivariate models predicting prostate cancer on initial biopsy and examined whether these extended biopsy-based models outperform previously established models. Methods: Initial extended biopsy (median 22 cores) was performed in 1509 Japanese men including 1083 at Tokyo Medical and Dental University Hospital (TMDU) and 426 at Cancer Institute Hospital (CIH). Logistic regression-based nomograms 1 and artificial neural network (ANN) 1 incorporating age, digital rectal examination, and prostate-specific antigen (PSA) and free PSA, and nomogram 2 and ANN2 further incorporating transrectal ultrasound (TRUS) findings and prostate volume were constructed on the TMDU data. These and previously established models were externally validated on the CIH data set and predictive accuracy was compared directly. Results: Without TRUS-derived information, nomogram 1 outperformed the ANN1. With TRUS-derived information, nomogram 2 was more accurate than ANN2. External validation revealed applicability of the Western models to Japanese population, superiority of the nomograms over ANN models, and better predictive accuracy of our extended biopsy-based nomograms than the previous 6–10-core biopsy-based models. Using nomograms 1 and 2, 16% and 19% unnecessary biopsies would be saved at 95% sensitivity. Conclusions: We developed new nomograms predicting prostate cancer on initial biopsy in men with PSA <20ng/ml. Predictive accuracy of these extended biopsy-based nomograms is better than those of previously established models based on 6–10-core biopsies. Our models might help clinicians to decide if a patient requires biopsy and to avoid unnecessary biopsies. [Copyright &y& Elsevier]

Abstract: Objectives: To evaluate whether three-dimensional 26-core (3D26) prostate biopsy improves the accuracy in predicting the presence of Gleason pattern 4/5 cancer compared with extended transrectal 12-core (TR12) or transperineal 14-core (TP14) biopsy schemes. Methods: We studied 143 consecutive men in whom prostate cancer was diagnosed by the 3D26 biopsy and who underwent radical prostatectomy (RP) without neoadjuvant treatment. All histologic grading was reevaluated by a single pathologist according to the 2005 International Society of Urological Pathology Consensus Conference on Gleason Grading. Cancer grade was categorized into high grade (Gleason pattern 4/5 cancer present) and non-high grade (absent) in both biopsy and RP specimens. Since TR12 and TP14 biopsy schemes represent subsets of the 3D26 biopsy, we could compare these schemes directly in an identical patient cohort. Results: There was a grade agreement between 3D26 biopsy and RP in 132 (92.3%) cancers. Grade concordance between biopsy and RP was significantly better in 3D26 biopsy than in TR12 (83.5%, p =0.025) biopsy. Risk of underestimation of cancer grade by 3D26 biopsy (26.5%) was significantly lower than that by TP14 (51.4%, p =0.034). Grade concordance between 3D26 biopsy and RP was not according to clinical variables including prostate volume, clinical stage, prostate-specific antigen (PSA), and PSA density. Conclusions: We demonstrated that the 3D26 biopsy can accurately predict the presence of Gleason pattern 4/5 cancer on RP specimens with a high concordance rate of 92.3%, a value significantly higher than that between extended TR12 biopsy and RP specimens. [Copyright &y& Elsevier]

Abstract: Objectives: To explore an optimal combination of sampling sites to detect prostate cancer in a repeat biopsy setting. Methods: A transrectal ultrasound-guided systematic three-dimensional 26-core biopsy (3D26PBx), a combination of transrectal 12 and transperineal 14 core biopsies, was performed in 235 Japanese men with prior negative biopsy. Using recursive partitioning, we evaluated cancer detection of all possible combinations of sampling sites and selected the combination that provides the highest cancer detection rate at a given number of biopsy cores. Results: Prostate cancer was detected in 87 of the 235 (37%) men. The 3D26PBx improved cancer detection by 89% relative to the conventional transrectal sextant biopsy. Neither Gleason score nor percentage of Gleason 4/5 cancers differed between cancers with and without positive cores within the transrectal sextant-sampling sites. A three-dimensional combination of transrectal and transperineal approaches outperformed either transrectal or transperineal approach alone. Recursive partitioning revealed that a three-dimensional 16-core (transrectal eight cores plus transperineal eight cores) biopsy could detect all the cancers with the minimum number of cores. Conclusions: We propose a three-dimensional combination of transrectal eight cores taken from the far lateral peripheral zone and the parasagittal base, and transperineal eight cores taken from the anterior and posterior apex and the transition zone as an optimal set of sampling sites for repeat biopsy. [Copyright &y& Elsevier]

The optimal biopsy strategy for prostate cancer detection, especially in men with isolated prostate-specific antigen (PSA) elevation, remains to be defined. We evaluated diagnostic yield and safety of transrectal ultrasound (TRUS)-guided transperineal systematic 14-core biopsy and compared the spatial distribution of cancer foci detected with this technique in men with and without abnormality on digital rectal examination (DRE). In a prospective study, 289 men aged between 50 and 87 years (median age, 70 years) underwent TRUS-guided transperineal systematic 14-core prostate biopsy because of elevated PSA and/or abnormal DRE findings. Using the fan technique, 12 cores from the peripheral zone and two cores from the transition zone were obtained systematically. To characterize the spatial distribution of cancer positive cores, site-specific overall and unique cancer detection rates were compared between stage T1c and T2 cancers. Prostate cancer was detected in 105 of the 289 patients (36%). Major complications requiring prolonged hospital stay or re-hospitalization during a 4-week postbiopsy period were rare (1.4%). Sixty-seven stage T1c cancers were identified. These cancers were associated with significantly lower PSA and a smaller number of cancer positive cores when compared with stage T2 cancers ( n= 38). The overall cancer detection rate was highest at the anterior peripheral zone and the posterior peripheral zone in stage T1c and stage T2 cancers, respectively. The unique cancer detection rate at the anterior peripheral zone was significantly higher in stage T1c cancers than in stage T2 cancers. Therefore, when the prostate is extensively biopsied using the transperineal approach, cancer positive cores are characteristically distributed anteriorly in stage T1c cancers and posteriorly in stage T2 cancers. TRUS-guided transperineal systematic 14-core biopsy showed an apico-anterior distribution of cancer foci in stage T1c prostate cancers. [ABSTRACT FROM AUTHOR]

The author reflects on the study about the role of prebiopsy magnetic resonance imaging (MRI) with prostate-specific antigen (PSA) density in detecting prostate cancer. He states several points that should be noted in the study including the authors recommended MRI study only to men with PSA density and protocols such as the diffusion-weighted rule. He also stresses that the findings of the research would not justify the remarkable cost of MRI study.

Objective: To investigate the association of diabetes mellitus (DM) with prostate cancer (PCa) risk and grade among Japanese patients undergoing extended biopsy and to investigate how obesity modifies these relationships. Methods: We retrospectively evaluated the data from 2038 patients with a prostate-specific antigen (PSA) level <10 ng/mL undergoing initial extended biopsy at our institutions. The DM history was determined by self-report and medication use. Multivariate analyses of DM for PCa risk and grade were done using logistic regression. Moreover, we examined whether these associations were modified by the body mass index using subgroup analyses (nonobese <25 kg/m2 or obese ≥25 kg/m2) and interaction tests. Cancer grade was classified according to the Gleason score (GS): low-grade (GS ≤6), intermediate-grade (GS 7), and high-grade (GS 8-10). Results: Of 2038 patients, obesity and DM was observed in 606 (30%) and 213 (11%), respectively. Also, 836 patients (41%) had positive biopsy findings. On multivariate analysis, we found no significant association of DM with the risk of overall PCa (P = .106) or the risk of low-grade (P = .735), intermediate-grade (P = .119), or high-grade (P = .110) disease. When stratified by obesity, the relative risk (RR) of PCa detection for diabetic men apparently increased with higher cancer grade (low grade, RR = 1.19, P = .71; intermediate grade, RR = 2.01, P = .099; high-grade, RR = 4.03, P = .025). However, in the nonobese men, no association was noted between DM and PCa risk, irrespective of grade. Obesity modified the effect of DM on high-grade disease risk with a trend (P for interaction = .087). Conclusion: DM was associated with more aggressive PCa detection among Japanese obese patients with gray-zone PSA levels undergoing extended biopsy. [ABSTRACT FROM AUTHOR]

Abstract: Background: Significant cancer in contralateral sides of the prostate that was missed on prostate biopsy (PBx) is a concern in hemiablative focal therapy (FT) of prostate cancer (PCa). However, extended PBx, a common diagnostic procedure, has a limited predictive ability for lobes without significant cancer. Objective: To identify prostate lobes without significant cancer using extended PBx combined with diffusion-weighted imaging (DWI), which has the potential to provide pathophysiologic information on pretreatment assessment. Design, setting, and participants: We conducted a prebiopsy DWI study between 2007 and 2012 that included 270 prostate lobes in 135 patients who underwent radical prostatectomy (RP) for clinically localized PCa. Intervention: Participants underwent DWI and 14-core PBx; those with PBx-proven PCa and who were treated with RP were analyzed. Outcome measurements and statistical analysis: Imaging and pathology were assessed in each side. Based on RP pathology, lobes were classified into lobes with no cancer (LNC), lobes with indolent cancer (LIC), and lobes with significant cancer (LSC). Predictive performance of DWI, PBx, and their combination in identifying lobes without significant cancer was examined. Results and limitations: LNC, LIC, and LSC were identified in 23 (8.5%), 64 (23.7%), and 183 sides (67.8%), respectively. The negative predictive values (NPV) of DWI, PBx, and their combination were 22.1%, 27.8%, and 43.5%, respectively, for lobes with any cancer (ie, either LIC or LSC), and 68.4%, 72.2%, and 95.7%, respectively, for LSC. The NPV of PBx for LSC was improved by the addition of DWI findings (p =0.001), with no adverse influence on the positive predictive value. Limitations included a possible selection bias under which the decision to perform PBx might be affected by DWI findings. Conclusions: The combination of DWI and extended PBx efficiently predicts lobes without significant cancer. This procedure is applicable to patient selection for hemiablative FT. [Copyright &y& Elsevier]