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168 Abstracts

  • Introduction & Objectives

    Prostate cancer treatment is shifting from radical to focal therapy. Instant tumor visualization on a microscopic level is crucial for clinical application of focal therapy. Optical Coherence Tomography (OCT) produces instant tissue visualization on a µm scale. OCT also provides the attenuation as a measure of tissue organization. The objective is to correlate qualitative and quantitative OCT analysis with histopathology.

    Material & Methods

    Twenty prostates were analyzed by needle based OCT after radical prostatectomy. For precise correlation, whole mount histology slides were cut through the OCT trajectory. OCT images were classified in one of eight histological categories (RvK). Two reviewers (AS & BM) independently performed assessments of the OCT images into these categories. Sensitivity and specificity for detection of malignancy on OCT were calculated. Quantitative attenuation coefficient was found to discriminate stroma and malignant tissue. Figure: Correlation of histology and OCT: The arrows in A, B & C indicate the same atrophic cyst. A: Digitized H&E stained whole mount slide with tissue annotation. Both OCT measurement trajectories are visible. B: An OCT scan at the location of the atrophic cyst. C: The longitudinal section of the OCT scan that corresponds with the upper OCT measurement trajectory shown on A.



    Results

    Visual analyses showed that OCT can reliably differentiate between fat, cystic and regular atrophy and benign glands. Differentiation of benign stroma and inflammation and also malignancy Gleason 3 and 4 is more difficult. Sensitivity and specificity for detection of malignancy on OCT were calculated at 77% and 84%. Quantitative analysis by means of the attenuation coefficient for differentiation between stroma and malignancy showed no significant difference (4.39 mm-1 vs. 5.31 mm-1).

    Conclusions

    One to one correlation of histology and OCT helps us to understand what we see and measure on OCT. Visual malignancy detection shows reasonable sensitivity and specificity. Our future studies focus on improving discrimination of malignancy with OCT for example by combining an extra imaging modality.

  • Introduction & Objectives

    Local staging of Prostate Cancer (PCa) has a crucial role in decision-making process about resection or preservation of Neurovascular Bundles (NVB) during radical prostatectomy. The clinical relevance of multiparametric Magnetic Resonance Imaging (mpMRI) in preoperative workup and its influence on planning of radical prostatectomy is still under investigation. The purpose of our study was to evaluate the diagnostic performance of 3-Tesla mpMRI in preoperative staging of PCa in men subjected to endoscopic radical prostatectomy (ERP). We investigated the influence of mpMRI on the extension of resection during ERP.

    Material & Methods

    The study was the retrospective analysis of prospectively collected data of 154 men with PCa in whom mpMRI was performed prior to ERP. Imaging results were compared with pathological reports to investigate diagnostic performance of mpMRI in detecting Extraprostatic Extension (EPE). Initial decision whether to perform NVB sparing surgery was based on EAU guidelines. mpMRI was reevaluated prior ERP to determine feasibility and extent of a NVB preservation.

    Results

    The extent of NVB sparing surgery was changed in 69 (45%) men after reevaluation of mpMRI study. NVB preservation was made in 17 (11%) men, in whom NVB would have been resected, if mpMRI had not been available. The extension of resection was broadened at the expense of narrower NVB preservation in 52 (34%) men, in whom NVB would have been spared, if the decision had been made solely based on guidelines. The change in the extension of resection either to more preserving NVB sparing or more aggressive resection was not correlated with the higher risk of positive surgical margins (PSM). mpMRI had increased diagnostic performance in men with the high-risk cancer (sensitivity 49%, specificity 89%), than in man with low-risk and intermediate-risk cancer (sensitivity 27%, specificity 93%). Despite decreased diagnostic performance of mpMRI in the low-risk and intermediate-risk group, the extension of NVB preservation was narrowed in 17 (63%) and 19 (33%) men, respectively. mpMRI failed to detect or understaged the tumor in nearly half of PSM cases.

    Conclusions

    mpMRI influences decision-making about the extension of resection during ERP irrespective of the prostate cancer risk group. The changes of the extent of resection made basing on the mpMRI result are not related to the increased risk of PSM.

  • Introduction & Objectives

    68Ga PSMA-PET/CT is a novel imaging modality introduced to improve diagnosis and staging of advanced prostate cancer. Due to its naïve nature, robust sensitivity and specificity data outlining 68Ga PSMA-PET positive scans are not available. We aimed to systematically review the current literature and perform a meta-analysis of the reported sensitivity and specificity of 68Ga PSMA-PET.

    Material & Methods

    We performed critical reviews of MEDLINE, EMBASE, ScienceDirect, Cochrane Libraries and Web of Science databases in April 2016 according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. Quality assessment was performed using Quality Assessment if Diagnostic Accuracy Studies-2 tool. Summary sensitivity and specificity values were obtained by fitting bivariate hierarchical regression models.

    Results

    Five studies reported on the predictive ability of PSMA-PET imaging with respect to histology proven disease, four on a per-patient basis and four on a per-lesion basis. On per-lesion analysis, the summary sensitivity is 80% and specificity is 97%. On per-patient analysis, the summary sensitivity and specificity is 86% though with the low numbers reported in the contributing studies, the confidence intervals are especially wide.

    Conclusions

    To date, pooled data has identified favourable sensitivity and specificity profiles compared to historical values of alternate PET imaging techniques.

  • Introduction & Objectives

    Inguinal metastases are one of the major determinants of mortality in patients with penile cancer. In high risk patients, prophylatic inguinal lymphadenectomy may offer survival advantages over watchful waiting. Radical Inguinal Lymphadenectomy (IL) is the standard of care for patients with stage T≥2, high histologic grade (2 or 3) or inguinal nodes. Some authors have described alternative procedures to reduce the morbidity of the treatment of inguinal lymph nodes. An endoscopic procedure, with small incisions away from the dissecting area, seems to be a new and attractive approach duplicating the standard open procedure with less morbidity.

    Material & Methods

    The patient is placed in supine position with thigh abduction. A 1.5 cm incision was made 2 cm distally of the lower vertex of the femoral triangle. Scissors were employed to develop a plane of dissection deep to Scarpa´s fascia. The second incision was made 2 cm proximally and 6 cm medially. Two 10 mm Hasson trocars were inserted in these incisions and the working space was insufated with CO2 at 5-15 mmHg. The last trocar was placed 2 cm proximally and 6 cm laterally from the first port. Radical endoscopic right inguinal lymphadenectomy with the same template of open surgery was performed. The main landmarks  adductor longus muscle medially, the sartorius muscle laterally and the inguinal ligament superiorly were well visualized. After the procedure, one can identify the skeletonized femoral vessels and the empty femoral channel, showing that the lymphatic tissue in this region was completely ressected. The surgical specimen was removed through the first port incision. A suction drain was placed to prevent lymphocele, and were kept until the drainage reached 50 mL or less in 24 h.

    Results

    VEIL is feasible in the clinical practice. It is possible to identify the same landmarks of the open surgery and perform a dissection following the same template of the radical IL. We can see clearly through the endoscopic view if all lymphatic tissue within the limits of dissection has been removed at the end of the procedure. VEIL can become an attractive choice for the prophylatic IL in penile cancer patients. Other possible clinical indications for this new procedure may include prophylatic dissection for urethral and vulvar cancers. The preservation of the internal saphenous vein during inguinal lymphadenectomy was first described in the treatment of neoplasms of the vulva, and it resulted in a reduction in morbidity. Since then, several papers have been published on open inguinal lymphadenectomy, with saphenous vein preservation for carcinoma of the penis, suggesting a reduction in morbidity, without oncological risks  The same as previous works, that the VEIL makes it possible to reproduce the oncological radicality . The number of nodes removed was equivalent to previous VEIL and open surgery series.

    Conclusions

    The VEIL in the complementary treatment of cancer of the penis is a safe and reproducible procedure, being an alternative to conventional lymphadenectomy. The patients with palpable adenopathies may benefit from this technique. Preserving the internal saphenous vein, seem to be viable when performing VEIL. The oncological results are suitable, although it takes longer follow-up time.

  • Introduction & Objectives

    Seminal Vesicle Invasion (SVI) by Prostate cancer (PCa), even in absence of lymph node metastasis or positive surgical margins, produces a poor prognosis when treated by Radical Prostatectomy (RP). In literature several clinical cases of RP are involved with high rates of SVI (up to 26%). In this study we attempt to define the Ultrasonographic Patterns (UPs) observed in Seminal Vesicles (SV) invaded by PCa, and propose an extended prostate biopsy protocol to provide the possibility of taking one biopsy core of each SV when SVI is suspected.

    Material & Methods

    From April 2008 to December 2015, 1.252 prostate biopsies were performed according to EAU guidelines. Transrectal Ultrasound-guided prostate Biopsy (TRUSBx) was performed with the patient in the left lateral decubitus using a General Electric Logiq 7 machine equipped with a 5-9MHz multi-frequency convex probe “end-fire”. Each TRUSBx performed included an assessment of the volume of the whole prostate, transition zone, capsule, SV characteristics, and a morphological description of potential pathological features. Sampling was carried out with a 18-Gauge Tru-Cut. A 14-core biopsy scheme was performed in each patient, as first intention, including 1 SV sample on each side when SVI is suspected: a nodule at base of prostate, determined by digital rectal examination or ultrasound; UPs that suggest SVI. UPs of SV were classified abnormal by measurement of the dimension (anterior-posterior diameter), asymmetry of the volume, measurement of parietal thickness, distance between the SV and the rectal surface, echogenicity of SV and base of the prostate. An hyperechogenicity at lobulations of SV and an hypoechogenicity at the base of the prostate have been reported to indicate SVI.

    Results

    Patients with SVI showed significantly greater PSA values (median 9.8 ng/ml) than those with SV free of tumor (median 5.9 ng/ml) (p<0.005). The difference between SVI and histological tumor differentiation grade was statistically significant (p<0.001), suggesting a higher invasion rate with de-differentiation. Of the 137 biopsies performed in SV of candidate patients, PCa was diagnosed in 91 (66.5%). The overall prevalence of SVI was 39 patients (28.5%). However, considering only PCa diagnosed, the SVI was 42.9%. Of the 215 (17.2%) patients non-T3b PCa in the initial biopsy setting, 143 patients chose RP. In the absence of candidate patients for SV biopsies, 9(6.3%) showed SVI. Of the two criteria used to achieve SV biopsies were observed in 81 (59.2%) patients (nodule at the base of the prostate) and 56 (40.8%) patients (suspicious Ups in SV). The total SVI suspicion due to only PUs was 54.8%. SV biopsies were 100% accurate in predicting the presence of SVI by PCa.

    Conclusions

    The ratio of PCa extent from the base of the prostate to SV should be taken into consideration as a predictive factor of the prognosis of PCa after RP. Therefore, the preoperative detection of SVI is an important tool for proper staging and subsequent therapeutic decisions.

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