BackgroundMultiparametric magnetic resonance imaging (mpMRI) is now recommended pre-biopsy in numerous healthcare regions based on the findings of high-quality studies from expert centres. Concern remains about reproducibility of mpMRI to rule-out clinically significant prostate cancer (csPCa) in real-world settings. ObjectiveTo assess the diagnostic performance of mpMRI for csPCa in a real-world setting. Design, Setting, and ParticipantsA multicentre, retrospective cohort study including men referred with a raised PSA or abnormal digital rectal exam who had undergone mpMRI followed by transrectal or transperineal biopsy. Patients could be biopsy naïve or have had previous negative biopsies. Outcome Measurements and Statistical AnalysisThe primary definition for csPCa was defined as ISUP Grade Group 2 or higher (any Gleason >/=7); the accuracy for other definitions was also evaluated. Results and LimitationsAcross 10 sites 2642 men were included (January/2011-November/2018). Mean age and PSA were 65.3 years (SD 7.8 years) and 7.5ng/ml (SD 3.3ng/ml). 35.9% had a 'negative' MRI' (score 1-2). 51.9% underwent transrectal biopsy and 48.1% had transperineal biopsy; with 43.4% diagnosed with csPCa overall. The sensitivity and negative predictive value (NPV) for 5 ISUP GG >/=2 were 87.3% and 87.5%, respectively. The NPV was 87.4% and 88.1% for men undergoing transrectal and transperineal biopsy, respectively. Specificity and positive predictive value of MRI were 49.8% and 49.2%, respectively. The sensitivity and NPV increased to 96.6% and 90.6% when a PSA-density threshold 0.15ng/ml/ml was used in MRI scores 1-2; these metrics increased to 97.5% and 91.2%, respectively, for PSA density 0.12ng/ml/ml. ISUP GG >/=3 (Gleason >/=4+3) was found in 2.4% (15/617) of men with MRI score 1-2. They key limitation of this study is the heterogeneity and retrospective nature of the data. ConclusionsmpMRI when used in real-world settings is able to accurately rule-out csPCa suggesting that about one-third of men might avoid an immediate biopsy. Men should be counselled about the risk of missing some significant cancers.
The low incidence of partial segmental thrombosis of the corpus cavernosum (PSTCC) means its management is guided by isolated case reports. Erectile function is an important outcome that has not been described quantitatively in the literature. We present two cases of PSTCC managed conservatively. Although both patients reported resolution of local symptoms, formal analysis of sexual function at follow-up review has revealed that only one achieved complete recovery. Partial segmental thrombosis of the corpus cavernosum (PSTCC) is a rare condition with no reported UK cases and only 35 described in the world literature to date.1 The optimal management strategy of PSTCC remains elusive; both surgical and non-surgical approaches have been reported. We describe two conservatively managed cases of PSTCC and detail their formal erectile function at follow-up review, measured using the validated five-item version of the International Index of Erectile Function (IIEF-5) questionnaire. 2 Case histories Case AA 19-year-old moped user presented with a 3-day history of a painful perineal mass and no lower urinary tract symptoms, prior erectile dysfunction or priapism. He had engaged in vigorous sexual activity the night before the appearance of the mass and admitted misuse of anabolic steroids.Examination revealed a tender swelling over the proximal left corpus cavernosum with a flaccid distal penis. Admission blood tests and urinalysis were unremarkable apart from elevation of C-reactive protein at 91mg/l. Further investigation revealed hypogonadotrophic hypogonadism (low testosterone, normal luteinising hormone and follicle stimulating hormone) secondary to anabolic steroid misuse. Subsequent magnetic resonance imaging (MRI) showed thrombosis of the perineal part of the corpus cavernosum (Figure 1).The patient was managed conservatively (analgesia, 1 month of daily low molecular weight heparin [LMWH] injections and 3 months of aspirin 75mg daily). Repeat MRI at six weeks (Figure 1) showed significantly reduced thrombus volume. He subsequently reported resolution of the tender mass. However, detailed assessment using the IIEF-5 questionnaire revealed mild erectile dysfunction at 17 weeks and mild/moderate erectile dysfunction at 30 weeks (Table 1). He reported no penile curvature as the result of PSTCC. Case BA 37-year-old without any prior erectile dysfunction presented with perineal pain and dysuria. He had had vigorous sexual intercourse the preceding day, having just returned home after a two-hour flight from a long cycling holiday. Examination revealed a tender mass in the perineum arising from the left corpus cavernosum with a distal flaccid penis. Blood tests were unremarkable. Urinalysis was negative. Pelvic radiography and Doppler ultrasonography of the scrotum, inguinal and perineal region detected no abnormality. He underwent MRI, which showed low signal intensity in the base of the left corpus cavernosum, in keeping with PSTCC (Figure 2).At the six-week follow-up review, the patient reported resoluti...
Introduction: Atypical small acinar proliferation (ASAP) and high grade prostatic intraepithelial neoplasia (HGPIN) are considered precancerous. We aimed to measure the rate of repeat biopsy and adenocarcinoma in patients with ASAP and HGPIN and identify any clinico-pathologic parameters at diagnosis of ASAP/HGPIN that are predictive of adenocarcinoma. Materials and Methods: Patients with a diagnosis of ASAP/HGPIN with no previous or concomitant cancer were identified. Prostate specific antigen (PSA) and magnetic resonance imaging (MRI) changes were monitored. Re-biopsy was at clinician discretion. Results: Nineteen were diagnosed with ASAP and 17 with HGPIN. Seven with ASAP (37%) and 6 with HGPIN (35%) underwent re-biopsy. Three (16%) with ASAP and 5 with HGPIN (29%) were diagnosed with adenocarcinoma. The difference in cancer detection rates between ASAP and HGPIN was not significant (p = 0.35). Five (14%) in total required definitive therapy for adenocarcinoma. Twenty-three (64%) did not undergo repeat biopsy. Parameters at diagnosis of HGPIN and ASAP, including PSA, prostate volume and PSA density, were compared between the cancer and non-cancer cohorts with none found to be predictive of adenocarcinoma. Conclusion: By monitoring PSA and MRI changes, we managed to spare re-biopsy in two-thirds of patients. Further evaluation is necessary to characterize a surveillance protocol in these populations.
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