In this 21-minute conversation, Mohammed E. Allaf, MD, Johns Hopkins University, Baltimore, Maryland, advocates for a reevaluation of current biopsy practices, suggesting that the transperitoneal approach may offer a safer option for patients, particularly in the context of rising concerns over antibiotic resistance.
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James A. Eastham, MD, FACS; Leonard S. Marks, MD; Michael A. Gorin, MD; Nelson N. Stone, MD; Arvin George, MD
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Jay D. Raman, MD addresses infections following prostate needle biopsy, presenting an evidence-based approach to managing this common problem. He notes the prevalence of infections following prostate needle biopsy in recent years, attributing this increase to antibiotic resistance and the inherent risks associated with transrectal biopsy procedures.
At the core of his presentation, Dr. Raman reviews current evidence and guidelines for preventing infections post-biopsy. He examines the role of prophylactic antibiotics and emphasizes the importance of tailoring antibiotic prophylaxis to individual patient risk profiles, including prior infection history, local resistance patterns, and patient comorbidities.
Dr. Raman also explores alternative biopsy techniques aimed at reducing infection rates. A shift towards transperineal biopsy approaches has demonstrated lower infection risks compared to traditional transrectal methods. The presentation includes an analysis of the benefits and limitations of these techniques, supported by recent clinical data.
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Peter A. Pinto, MD, explores the possibility of current imaging technology replacing the Transrectal Ultrasound (TRUS) probe in prostate cancer detection and staging. He begins with an overview of the weaknesses of the TRUS probe compared to magnetic resonance imaging (MRI) and MR/ultrasound fusion-guided biopsies in detecting and locating prostate cancer.
However, Dr. Pinto presents a comparison of the detection rates of TRUS-only biopsies with those of MR/ultrasound fusion-guided biopsies. He notes that both of these biopsy approaches can fail to detect low-risk and high-risk prostate cancers, leading to prostate cancer upgrading events.
Dr. Pinto concludes with an examination of the results from MRI-TRUS fusion biopsies. He presents the improved detection and certainty rates of the combined biopsy approach.
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Dr. Guilherme Godoy discusses research on prostate biopsy considerations, weighing both transrectal and transperineal approaches.
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Wim Van Criekinge, PhD, Professor of Computational Genomics and Bioinformatics at Ghent University in Ghent, Belgium, and Chief Scientific Officer for MDxHealth in Ghent, discusses ConfirmMDx, a test for prostate cancer from MDxHealth which uses tissue from a negative biopsy. He explains that prostate biopsies have a false negative rate of 25% since they only sample a very small percentage of the prostate and can miss the cancer entirely. ConfirmMDx, Dr. Van Criekinge notes, leverages the fact that cancer originates from changes in DNA which create a halo or field effect around the actual tumor. He details the specific ConfirmMDx genes, all of which were previously cited in a prognostic context, and explains that negative cores that are proximal to cancer will show up positive on ConfirmMDx. Dr. Van Criekinge highlights that ConfirmMDx, which has a negative predictive value of 96%, outperforms traditional methods like age, PSA, atypia, and the PCPT Risk Calculator 2.0 in identifying men harboring aggressive cancer. He also emphasizes the test’s accessibility and low cost, noting that the vast majority of patients are responsible for paying $250 or less. Dr. Van Criekinge concludes by detailing the clinical information required for the ConfirmMDx test, including PSA and DRE result, PSA and DRE date, and the pathology report, adding the caveat that tissue more than 30 months old may be rejected.
Read MoreGerald L. Andriole, Jr., MD, outgoing Robert K. Royce Distinguished Professor and Chief of Urologic Surgery at Barnes-Jewish Hospital, the Siteman Cancer Center, and Washington University School of Medicine in St. Louis, Missouri, and incoming Director of Urology in the National Capital Region at the Brady Urologic Institute at Johns Hopkins University, reviews current guidelines for prostate cancer screening and considers how screening can be improved. After an introduction from E. David Crawford, Editor-in-Chief of Grand Rounds in Urology and Professor of Urology at the University of California, San Diego, Dr. Andriole summarizes the AUA, EAU, and NCCN prostate cancer screening guidelines, highlighting the NCCN’s recommendation that men get an early-in-life PSA test to obtain a baseline, and interrogating the validity of the age cut-offs for testing in the AUA and EAU guidelines. He then proposes a series of concepts to improve screening, starting with recommendations on how to better identify which men are at above average risk. Dr. Andriole particularly emphasizes the utility of polygenomic risk scores, which have a high negative predictive value and can focus attention on which patients need to be further screened. He suggests that another key way to improve screening is to reduce confusion about the PSA test among patients and primary care providers by setting a cut-point of 1-1.5 as a threshold for referral to a urologist. Dr. Andriole then considers how to identify patients with clinically-significant prostate cancer earlier, focusing on the need for better biopsies. He also notes the importance of reducing unnecessary repeat and initial biopsies and suggests potentially using biomarkers, MRI, and PSMA-PET to decide whether a biopsy is necessary. After concluding his talk, Dr. Andriole further discusses polygenic risk score, the pros and cons of multiparametric MRI, the benefits of micro-ultrasound, transrectal versus transperineal biopsy, and the future of screening with Dr. Crawford.
Read MoreGerald L. Andriole, Jr., MD, Robert K. Royce Distinguished Professor and Chief of Urologic Surgery at Barnes-Jewish Hospital, the Siteman Cancer Center, and Washington University School of Medicine in St. Louis, Missouri, introduces the OPTIMUM trial comparing high-resolution 29 MHz micro-ultrasound to MRI in the diagnosis of prostate cancer. After an introduction by E. David Crawford, MD, Professor of Urology at the University of California, San Diego, and Editor-in-Chief of Grand Rounds in Urology, Dr. Andriole explains that micro-ultrasound is a novel ultrasound-based system operating at 29 MHz that results in a 300 percent improvement in resolution compared to conventional ultrasound. He explains that micro-ultrasound can be used for transrectal or transperineal biopsy, with or without MRI. Dr. Andriole also notes that, like MRI with PI-RADS, micro-ultrasound has its own prostate risk identification using micro-ultrasound (PRI-MUS) classification system and works with all the skills urologists already have. He observes that several small studies have found superior or comparable sensitivity and/or clinically-significant prostate cancer detection with micro-ultrasound as compared to MRI, but that level 1 evidence is lacking. Dr. Andriole explains that the OPTIMUM trial, a 3-arm randomized controlled trial, is intended to fill in that gap and provide better evidence regarding micro-ultrasound’s efficacy. He describes the design of the trial, noting that 1200 biopsy-naïve subjects will be randomized to micro-ultrasound-only biopsy, MRI/micro-ultrasound “FusionVu” biopsy, and MRI/ultrasound biopsy with conventional fusion system, and that the trial is set to begin in winter 2021 and finish by spring 2023. The discussion concludes with a question and answer session in which Drs. Crawford and Andriole discuss which fusion platforms will be used, the price of micro-ultrasound, other potential applications for micro-ultrasound, and more.
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E. David Crawford, MD, Editor-in-Chief of Grand Rounds in Urology and Professor of Urology at the University of California, San Diego, compares transperineal prostate biopsy to transrectal ultrasound (TRUS)-guided prostate biopsy, listing the pros and cons of each. He establishes that the transperineal approach is superior to the transrectal one in minimizing risk of sepsis and urinary tract infection, although transperineal biopsy is more associated with urinary retention. Dr. Crawford goes on to discuss the comparative cost and convenience of the techniques, observing that TRUS-guided biopsy is typically far less expensive and that more doctors have the requisite experience and equipment to perform such a biopsy as opposed to a transperineal one. Dr. Crawford suggests that the transrectal approach is currently easier than the transperineal one for most urologists and patients, but notes that urologists may want to consider tailoring their technique to an individual patient’s particular needs and risk factors. However, Dr. Crawford concludes by introducing a demonstration of a transperineal 3D mapping biopsy, suggesting that this may be disruptive technology capable of transforming prostate cancer care.
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