Laparoscopic versus open total gastrectomy for T4a gastric cancer: a propensity score-matched analysis of long-term outcomes.

Evidence of implementation of laparoscopic total gastrectomy (LTG) for surgical T4a stage (sT4a) gastric cancer (GC) remains inadequate. This study aimed to compare short- and long-term outcomes of LTG versus open total gastrectomy (OTG) for sT4a GC. This retrospective cohort study was conducted using data from patients with sT4a GC underwent total gastrectomy from 2014 to 2020. Short-term outcomes included operative characteristics and postoperative complications. Long-term oncological outcomes focused on 3-, and 5-year overall survival (OS) and disease-free survival (DFS). Propensity score matching (PSM) was applied to reduce potential biases in baseline characteristics between groups. There was a total of 161 patients, in which 96 underwent LTG and 65 underwent OTG. After PSM, both groups consisted of 51 patients each, with balanced baseline characteristics. There were no significant differences between the two groups regarding blood loss, length of proximal resected margin, postoperative hospital stays, and overall and major postoperative complications. Most of the complications were classified as minor according to the Clavien-Dindo classification. Operating time was significantly longer in the LTG group (mean: 257 min vs. 231 min, p = 0.006). LTG was superior to OTG groups in time to flatus (mean: 3.0 days vs 3.9 days, p < 0.001). Five-year OS and DFS rates were similar between the two groups (44% and 33% vs. 43% and 28% in the LTG and OTG groups, respectively). Our findings indicate that LTG is a feasible and safe technique, exhibiting comparable long-term oncological outcomes to OTG for sT4a GC. LTG may be an acceptable alternative to OTG for the treatment of sT4a GC.

Challenges in the Assessment of Medullary Bone Invasion in Oral Cavity Cancers and Its Prognostic Significance.

BACKGROUND: As per AJCC 8th edition TNM staging system, bone invasion is a poor prognostic marker that upstages oral cavity squamous carcinoma (OSCC) to pT4a. Cortical erosion alone of bone or tooth socket by a gingival primary is not sufficient to upstage a tumour. The differentiation of cortical erosion from invasion through the cortical bone into the medulla is often challenging, limiting accurate staging. This review aims to assess the difficulties in differentiating cortical erosion from medullary invasion and evaluate the prognostic significance of different patterns of bone involvement. METHODS: A retrospective review of OSCC with primary curative surgery and bone resection treated at a single-center over 10 years, was performed to assess the prognostic significance of bone invasion. Hematoxylin-eosin stained slides of a subset of cases were re-reviewed in a planned manner to assess difficulties in precise categorization (no invasion/erosion/cortical invasion and medullary invasion), evaluate interobserver agreement, and correlate with clinical outcome. RESULTS: Five hundred and ninety patients were included, with a median follow-up of 28 months. On univariate analysis, the 3-year local, nodal and distant metastasis control were not significantly different in the 3 groups of no invasion, erosion, and invasion (p = 0.43, 0.47, and 0.47, respectively). Overall survival (OS) at 3 years was 78.1% and disease-free-survival(DFS) was 63.7% in the entire cohort. On univariate analysis, there was significant difference in OS and DFS based on these groups. This did not translate into independent prognostic benefit on multivariable analysis (p = 0.75 and 0.19, respectively). The independent prognostic factors were margin positivity, tumor differentiation, perineural invasion and pathological nodal involvement. Planned re-review of a subset of 202 cases resulted in a change in bone involvement category in 26/202 cases, which was mainly due to difficulty in assessing cortico-medullary junction near the tooth socket and bone fragmentation. The assessment showed moderate to near complete agreement (kappa 0.59-0.82) between 2 observers. CONCLUSION: Our study shows that bone involvement is not an independent prognostic marker and there is no specific correlation of medullary invasion with outcome over those that showed cortical erosion. Several factors contribute to difficulties and interobserver variability in assessing bone involvement.

Converting rectangular and circular primary tanks into the AAA biologically enhanced clarification settler.

The frequent design challenge for existing water resource recovery facilities targets the accommodation of an ~50% load increase within the existing infrastructure and footprint. Off-loading this organic load at the top-end of the plant and redirection toward the digesters has proven the most efficient way of process intensification. The Triple A settler is an "activated primary treatment," stands for alternating activated adsorption, and can be retrofitted into existing rectangular or circular (mostly) primary tanks at a hydraulic retention time of 2 h and a sludge retention time of about 0.5 days. Several technology implementations demonstrate flexible designs adjusting to existing tank geometries and depths of 2.5 to 5.0 m. Different implementation scales from dry-weather flow rates ranging from 0.1 to 10 mgd show generic applicability of the functional principles at any scale: Biosorption, bioflocculation, and assimilation provide the key added value in pretreatment efficiencies of ~60/25/33 in %COD/%N/%P removal compared with application of pure physics in primary settling with typical 33%/9%/11% removal, respectively. PRACTITIONERS POINTS: Triple A is a hybrid form of A-stage and contact stabilizer for advanced primary treatment. Besides COD and TSS, also, P and N can be removed via Triple A. Triple A can be retrofitted in existing rectangular or circular tanks. This high-rate process does not worsen the conditions for enhanced biological phosphorus removal. Energy efficiency, capacity increase, and operational benefits are the main goals of Triple A.

Overcoming fear of developing country: A case report of retroperitoneal laparoscopic partial nephrectomy for T3A renal cell carcinoma.

INTRODUCTION: Renal cell carcinoma poses significant challenges in kidney diseases, particularly in the context of the T3 stage, where treatment strategies remain controversial. The utilization of laparoscopic partial nephrectomy, particularly in developing countries, has been restricted for such patients, primarily due to limited infrastructure and concerns about recurrence risk and long-term pathologic outcomes. PRESENTATION OF CASE: In this report, we present a case of a 64-year-old male diagnosed with T3aN0M0 renal cell carcinoma (RCC). Abdominal computed tomography revealed a 5.2 × 5.2 × 5.1 cm mass on the right upper part of the kidney with a possible thrombus in the superior renal polar vein. The patient underwent successful treatment with retroperitoneal laparoscopic partial nephrectomy (LPN), leading to the preservation of kidney function with <4 mL/min/1.73 m2 GFR reduced after one year postoperative (estimated GFR from 85 mL/min/1.73 m2 to 81.79 mL/min/1.73 m2). The patient was discharged after three days; no recurrence was observed during the follow-up. DISCUSSION: For stage T3a RCC, studies show that LPN induces comparable long-term outcomes to radical nephrectomy, with advantages such as preserved kidney function, reduced operative time, blood loss, and shorter hospital stays. However, due to infrastructure constraints and limited access to robotic-assisted surgery in our country, coupled with concerns about tumor recurrence, laparoscopic radical nephrectomy is predominantly employed for similar patients. Our case represents one of the very first cases in which we successfully treated a patient diagnosed with T3a RCC using retroperitoneal laparoscopic partial nephrectomy. CONCLUSION: Laparoscopic partial nephrectomy is a reliable choice for T3aN0M0 RCC with good long-term outcomes and preserved renal function, especially by the hands of an experienced laparoscopic surgeon.

Adverse pathologic features impact survival outcomes for small renal masses following nephrectomy.

PURPOSE: While most small renal masses (SRM) < 4 cm have an excellent prognosis following resection, the impact of adverse T3a pathologic features on oncologic outcomes of SRMs remains unclear. We sought to compare clinical outcomes for surgically resected pT3a versus pT1a SRMs at our institution. MATERIALS AND METHODS: We retrospectively reviewed records of patients who underwent radical or partial nephrectomy (RN, PN) for renal tumors <4 cm at our institution between 2010 and 2020. We compared features and outcomes of pT3a vs pT1a SRMs. Continuous and categorical variables were compared using Student's t and Pearson's chi-squared tests, respectively. Postoperative outcomes of interest including overall, cancer-specific, and recurrence-free survival (OS, CSS, and RFS) were analyzed using Kaplan-Meier method, Cox proportional hazard regression, and competing risk analysis. Analyses were performed using R statistical package (R Foundation, v4.0). RESULTS: We identified 1,837 patients with malignant SRMs. Predictors of postoperative pT3a upstaging included higher renal score, larger tumor size, and presence of radiologic features concerning for T3a disease (odds ratio [OR] = 5.45, 95% confidence interval [CI] 3.92-7.59, P < 0.001). On univariable modeling, pT3a SRMs had higher positive margin rates (9.6% vs 4.1%, P < 0.001), worse OS (hazard ratio [HR] = 2.9, 95% CI 1.6-5.3, P = 0.002), RFS (HR 9.32, 95% CI 2-40.1, P = 0.003), and CSS (HR = 3.6, 95% CI 1.5-8.2, P = 0.003). On multivariable modeling, pT3a status remained associated with worse RFS (HR = 2.7, 95% CI 1.04-7, P = 0.04), but not OS (HR 1.6, 95% CI = 0.83-3.1, P = 0.2); multivariable modeling was deferred for CSS due to low event rates. CONCLUSIONS: Adverse T3a pathologic features portend worse outcomes for SRMs, highlighting the crucial role of pre-operative planning and case selection. These patients have relatively poor prognosis, and should be monitored more closely and counseled for consideration of adjuvant therapy or clinical trials.

Impact of primary treatment methods on sludge characteristics and digestibility, and wastewater treatment plant-wide economics.

Biogas production from anaerobic sludge digestion plays a central role for wastewater treatment plants to become more energy-efficient or even energy-neutral. Dedicated configurations have been developed to maximize the diversion of soluble and suspended organic matter to sludge streams for energy production through anaerobic digestion, such as A-stage treatment or chemically enhanced primary treatment (CEPT) instead of primary clarifiers. Still, it remains to be investigated to what extent these different treatment steps affect the sludge characteristics and digestibility, which may also impact the economic feasibility of the integrated systems. In this study, a detailed characterization has been performed for sludge obtained from primary clarification (primary sludge), A-stage treatment (A-sludge) and CEPT. The characteristics of all sludges differed significantly from each other. The organic compounds in primary sludge consisted mainly of 40% of carbohydrates, 23% of lipids, and 21% of proteins. A-sludge was characterized by a high amount of proteins (40%) and a moderate amount of carbohydrates (23%), and lipids (16%), while in CEPT sludge, organic compounds were mainly 26% of proteins, 18% of carbohydrates, 18% of lignin, and 12% of lipids. The highest methane yield was obtained from anaerobic digestion of primary sludge (347 ± 16 mL CH4/g VS) and A-sludge (333 ± 6 mL CH4/g VS), while it was lower for CEPT sludge (245 ± 5 mL CH4/g VS). Furthermore, an economic evaluation has been carried out for the three systems, considering energy consumption and recovery, as well as effluent quality and chemical costs. Energy consumption of A-stage was the highest among the three configurations due to aeration energy demand, while CEPT had the highest operational costs due to chemical use. Energy surplus was the highest by the use of CEPT, resulting from the highest fraction of recovered organic matter. By considering the effluent quality of the three systems, CEPT had the highest benefits, followed by A-stage. Integration of CEPT or A-stage, instead of primary clarification in existing wastewater treatment plants, would potentially improve the effluent quality and energy recovery.

Exploring the stability of an A-stage-EBPR system for simultaneous biological removal of organic matter and phosphorus.

This work evaluates the performance and stability of a continuous anaerobic/aerobic A-stage system with integrated enhanced biological phosphorus removal (A-stage-EBPR) under different operational conditions. Dissolved oxygen (DO) in the aerobic reactor was tested in the 0.2-2 mgDO/L range using real wastewater amended with propionic acid, obtaining almost full simultaneous COD and P removal without nitrification in the range 0.5-1 mgDO/L, but failing at 0.2 mgDO/L. Anaerobic purge was tested to evaluate a possible mainstream P-recovery strategy, generating a P-enriched stream containing 22% of influent P. COD and N mass balances indicated that about 43% of the influent COD could be redirected to the anaerobic digestion for methane production and 66% of influent NH4+-N was discharged in the effluent for the following N-removal B-stage. Finally, when the system was switched to glutamate as sole carbon source, successful EBPR activity and COD removal were maintained for two months, but after this period settleability problems appeared with biomass loss. Microbial community analysis indicated that Propionivibrio, Thiothrix and Lewinella were the most abundant species when propionic acid was the carbon source and Propionivibrio was the most favoured with glutamate. Thiothrix, Hydrogenophaga, Dechloromonas and Desulfobacter appeared as the dominant polyphosphate-accumulating organisms (PAOs) under different operation stages.

Comparison of Long-term Outcomes for Young and Healthy Patients with cT1a and cT3a Renal Cell Carcinoma Treated with Partial Nephrectomy.

Partial nephrectomy (PN) is recommended for renal cell carcinoma (RCC) of <4 cm. We hypothesized that there is no difference in all-cause mortality (ACM) between cT1a, cT1b, and cT3a <4 cm RCC following PN. The National Cancer Database was interrogated to identify patients aged <60 yr with a Charlson comorbidity index ≤1 diagnosed between 2004 and 2017. Cox proportional-hazard models stratified for cT stage were used to predict 10-yr ACM. A total of 30 195 patients (25 121 cT1a, 4884 cT1b, and 190 cT3a <4 cm) who underwent PN with median follow-up of 64.36 mo (interquartile range 42.91-93.77) were included. Cox analysis revealed no significant difference in 10-yr ACM between cT1a and cT3a <4 cm (hazard ratio [HR] 1.05, 95% confidence interval [CI] 0.58-1.90; p = 0.88). However, the cT1b group had higher ACM (HR 1.31, 95% CI 1.15-1.48; p < 0.01). The positive surgical margin (PSM) rate was higher for cT3a <4 cm than for cT1a tumors (14.2% vs 6.3%; p < 0.01). However, there was no difference in 10-yr ACM rate between cT1a and cT3a <4 cm (10.9% vs 9.7%; p = 0.42). Our results suggest that PN is an option for cT3a RCC <4 cm, particularly in cases in which maximum nephron preservation is essential, such as patients with chronic kidney disease or a solitary kidney, although a higher PSM risk should be appreciated. PATIENT SUMMARY: We found that partial removal of the kidney for localized advanced kidney cancer is safe. The rate of surgical margins positive for the presence of tumor is higher in localized advanced kidney cancer than for less advanced cancers, but there was no difference in 10-year predicted mortality.

Enhancing bioflocculation in high-rate activated sludge improves effluent quality yet increases sensitivity to surface overflow rate.

High-rate activated sludge (HRAS) relies on good bioflocculation and subsequent solid-liquid separation to maximize the capture of organics. However, full-scale applications often suffer from poor and unpredictable effluent suspended solids (ESS). While the biological aspects of bioflocculation are thoroughly investigated, the effects of fines (settling velocity < 0.6 m3/m2/h), shear and surface overflow rate (SOR) are unclear. This work tackled the impact of fines, shear, and SOR on the ESS in absence of settleable influent solids. This was assessed on a full-scale HRAS step-feed (SF) and pilot-scale HRAS contact-stabilization (CS) configuration using batch settling tests, controlled clarifier experiments, and continuous operation of reactors. Fines contributed up to 25% of the ESS in the full-scale SF configuration. ESS decreased up to 30 mg TSS/L when bioflocculation was enhanced with the CS configuration. The feast-famine regime applied in CS promoted the production of high-quality extracellular polymeric substances (EPS). However, this resulted in a narrow and unfavorable settling velocity distribution, with 50% ± 5% of the sludge mass settling between 0.6 and 1.5 m3/m2/h, thus increasing sensitivity towards SOR changes. A low shear environment (20 s-1) before the clarifier for at least one min was enough to ensure the best possible settling velocity distribution, regardless of prior shear conditions. Overall, this paper provides a more complete view on the drivers of ESS in HRAS systems, creating the foundation for the design of effective HRAS clarifiers. Tangible recommendations are given on how to manage fines and establish the optimal settling velocity of the sludge.

The Feasibility of Maintaining Biological Phosphorus Removal in A-Stage via the Short Sludge Retention Time Approach: System Performance, Functional Genus Abundance, and Methanogenic Potential.

The increasing concerns on resource and energy recovery call for the modification of the current wastewater treatment strategy. This study synthetically evaluates the feasibility of the short sludge retention time approach to improve the energy recovery potential, but keeping steady biological phosphorus removal and system stability simultaneously. SBRS-SRT and SBRcontrol that simulated the short sludge retention time and conventional biological phosphorus removal processes, respectively, were set up to treat real domestic sewage for 120 d. SBRS-SRT achieved an efficient COD (91.5 ± 3.5%), PO43--P (95.4 ± 3.8%), and TP (93.5 ± 3.7%) removal and maintained the settling volume index around 50 mL/gSS when the sludge retention time was 3 d, indicating steady operational stability. The poor ammonia removal performance (15.7 ± 7.7%) and a few sequences detected in samples collected in SBRS-SRT indicated the washout of nitrifiers. The dominant phosphorus accumulating organisms Tetrasphaera and Hydrogenophaga, which were enriched with the shortened sludge retention time, was in line with the excellent phosphorus performance of SBRS-SRT. The calculated methanogenic efficiency of SBRS-SRT increased significantly, which was in line with the higher sludge yield. This study proved that the short sludge retention time is a promising and practical approach to integrate biological phosphorus removal in A-stage when re-engineering a biological nutrient removal process.

Primary and A-sludge treatment by anaerobic membrane bioreactors in view of energy-positive wastewater treatment plants.

Energy-rich sludge can be obtained from primary clarifiers preceding biological reactors. Alternatively, the incoming wastewater can be sent to a very-high-loaded activated sludge system, i.e., a so-called A-stage. However, the effects of applying an A-stage instead of a primary clarifier, on the subsequent sludge digestion for long-term operation is still unknown. In this study, biogas production and permeate quality, and filterability characteristics were investigated in a lab-scale anaerobic membrane bioreactor for primary sludge and A-stage sludge (A-sludge) treatment. A higher specific methane yield was obtained from digestion of A-sludge compared to primary sludge. Similarly, specific methanogenic activity was higher when the anaerobic membrane bioreactor was fed with A-sludge compared to primary sludge. Plant-wide mass balance analysis indicated that about 35% of the organic matter in wastewater was recovered as methane by including an A-stage, compared to about 20% with a primary clarifier.

Association of Extrarenal Invasion Patterns and Tumor Size with the Differences in Survival Outcomes of T3a Renal Cell Carcinoma: A Proposal Modified T3a Stage System is Needed.

OBJECTIVE: T3a renal cell carcinoma (RCC) did not consider tumor size and different extrarenal invasion patterns in the current TNM staging system. Here, we want to investigate the association of survival outcomes with different extrarenal invasion patterns and tumor size of T3a RCC. METHODS: We identified T3a RCC patients from the Surveillance, Epidemiology, and End Results database in 2004-2015. The extrarenal invasion patterns included renal vein invasion, renal sinus/peri-sinus fat invasion, or perinephric fat invasion. Cox proportional hazards models and Fine and Gray models were used to estimate overall survival (OS) and cancer-specific survival (CSS), and the hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated. C-index is used to evaluate the predictive ability of the model. Restricted cubic splines were used to estimate the HRs of tumor size on the risk of OS and CSS. RESULTS: In total, 4834 T3a RCC patients were included in the analysis. Of them, 1403 (29%) present isolated extrarenal invasion pattern, while 1403 (71%) were any combined invasion pattern, which was associated with a higher risk of lymph-node/distant metastasis and a worse OS and CSS compared with isolated extrarenal invasion pattern, but a comparable CSS and OS were observed between each isolated invasion pattern. In restricted cubic splines, a non-linear shape was observed for the association between the tumor size and OS and CSS, compared with the smallest tumor size group (≤4cm), the adjusted HR of the largest tumor size group (≥10cm) was 1.59 for all-cause mortality, and 2.27 for tumor-specific mortality, respectively. However, in a cohort of T3a RCC with a combined invasion pattern, tumor size is not an independent risk factor for prognosis. Finally, the model added two covariates of tumor size and invasion patterns that could improve the predictive ability of OS and CSS for T3a patients (c-index: +1.2%, +1.3%, respectively). CONCLUSION: Tumor size and extrarenal invasion type are valid parameters of the OS and CSS for T3a RCC patients and need to be considered for the next generation of the T-stage system.

The prognostic value of fat invasion and tumor expansion in the hilar veins in pT3a renal cell carcinoma.

PURPOSE: The 7th TNM classification summarizes renal cell carcinoma (RCC) with perirenal (PFI) and/or sinus fat invasion (SFI) as well as hilar vein involvement (RVI) as pT3a tumors. In this study, we aimed to determine the prognostic value of fat invasion (FI) in the different compartments and RVI for medium-term cancer-specific-survival (CSS) in pT3a RCC. MATERIALS AND METHODS: Patients with pT3a RCC were identified using an institutional database. All original pathological reports were reclassified according to the 7th TNM edition. The prognostic value of FI as well as divided into PFI, SFI, combined PFI + SFI, and RVI for CSS was assessed using univariate and multivariate Cox-regression analysis. Survival was estimated using the Kaplan-Meier method. RESULTS: Median follow-up in 184 pT3a tumors was 38 months. FI was detectable in 153 patients (32.7% PFI, 45.1% SFI, 22.2% PFI + SFI), 31 patients showed RVI alone. Combined PFI + SFI increased the risk of cancer-related death compared to PFI (HR 3.11, p < 0.01), SFI (HR 1.84, p = 0.023) or sole RVI (HR 2.12, p = 0.025). In multivariate analysis, a combined PFI + SFI vs. PFI or SFI as the only compartment involved was confirmed as independent prognostic factor (HR 1.83, p = 0.029). Patients with FI and simultaneous RVI had significantly shorter CSS (HR 2.63, p < 0.01). In an unweighted model, the difference between patients with combined PFI + SFI and RVI and those with PFI alone was highest (HR 4.01, p = 0.029). CONCLUSIONS: These results underline the subdivision of pT3a RCC depending on the location of FI and RVI for patient stratification.

Achieving simultaneous biological COD and phosphorus removal in a continuous anaerobic/aerobic A-stage system.

Recovering energy from wastewater in addition to its treatment is a hot trend in the new concept of water resource recovery facility (WRRF). High-rate systems operating at low solid retention time (SRT) have been proposed to meet this challenge. In this paper, the integration of Enhanced Biological Phosphorus Removal (EBPR) in an anaerobic/aerobic continuous high-rate system (A-stage EBPR) was evaluated. Successful P and COD removal were obtained operating at SRT 6, 5 and 4 days treating real wastewater, while a further decrease to 3 days led to biomass washout. The best steady state operational conditions were obtained at SRT = 4d, with high removal percentage of P (94.5%) and COD (96.3%), and without detecting nitrification. COD mineralization could be reduced to 30%, while 64 % of the entering carbon could be diverted as biomass to energy recovery. Regarding nitrogen, about 69±1% of the influent N was left as ammonium in the effluent, with 30% used for biomass growth. The aerobic reactor could be operated at low dissolved oxygen (DO) (0.5 mg/L), which is beneficial to decrease energy requirements. Biochemical methane potential (BMP) tests showed better productivity for the anaerobic sludge than the aerobic sludge, with an optimal BMP of 296±2 mL CH4/gVSS. FISH analysis at SRT = 4d revealed a high abundance of Accumulibacter (33±13%) and lower proportion of GAO: Competibacter (3.0±0.3%), Defluviicoccus I (0.6±0.1%) and Defluviicoccus II (4.3±1.1%).

Outcomes of Robot-assisted Partial Nephrectomy for Clinical T3a Renal Masses: A Multicenter Analysis.

BACKGROUND: Use of partial nephrectomy (PN) in T3 renal cell carcinoma (RCC) is controversial. OBJECTIVE: To evaluate quality outcomes of robot-assisted PN (RAPN) for clinical T3a renal masses (cT3aRM). DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective multicenter analysis of patients with cT3aN0M0 RCC who underwent RAPN. INTERVENTION: RAPN. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary endpoint was a trifecta composite outcome of negative surgical margins, warm ischemia time (WIT) ≤25 min, and no perioperative complications. The optimal outcome was defined as achieving this trifecta and ≥90% preservation of the estimated glomerular filtration rate (eGFR) and no stage upgrading of chronic kidney disease. Multivariable analysis (MVA) identified risk factors associated with lack of the optimal outcome. Kaplan-Meier analysis was conducted for survival outcomes. RESULTS AND LIMITATIONS: Analysis was conducted for 157 patients (median follow-up 26 mo). The median tumor size was 7.0 cm (interquartile range [IQR] 5.0-7.8) and the median RENAL score was 9 (IQR 8-10). Median estimated blood loss (EBL) was 242 ml (IQR 121-354) and the median WIT was 19 min (IQR 15-25). A total of 150 patients (95.5%) had negative margins. Complications were noted in 25 patients (15.9%), with 4.5% having Clavien grade 3-5 complications. The median change in eGFR was 7 ml/min/1.72 m2, with ≥90% eGFR preservation in 55.4%. The trifecta outcome was achieved for 64.3% and the optimal outcome for 37.6% of the patients. MVA revealed that greater age (odds ratio [OR] 1.06; p = 0.002), increasing RENAL score (OR 1.30; p = 0.035), and EBL >300 ml (OR 5.96, p = 0.006) were predictive of failure to achieve optimal outcome. The 5-yr recurrence-free survival, cancer-specific survival, and overall survival, were 82.1%, 93.3%, and 91.3%, respectively. Limitations include the retrospective design. CONCLUSIONS: RAPN for select cT3a renal masses is feasible and safe, with acceptable quality outcomes. Further investigation is requisite to delineate the role of RAPN in cT3a RCC. PATIENT SUMMARY: Robot-assisted partial nephrectomy in patients with stage 3a kidney cancer provided acceptable survival, functional, and morbidity outcomes in the hands of experienced surgeons, and may be considered as an option when clinically indicated.

Predictive and prognostic significance of M descriptors of the 8th TNM classification for advanced NSCLC patients treated with immune checkpoint inhibitors.

BACKGROUND: A strong association between M descriptors and prognosis of non-small cell lung cancer (NSCLC) has been demonstrated recently. However, its predictive and prognostic significance for advanced NSCLC patients treated with immune checkpoint inhibitors (ICIs) remain unclear. In this study, we aimed at investigating the impact of M descriptors on clinical outcomes in those patients. METHODS: A retrospective analysis was conducted. Patients treated with more than two cycles of ICIs were included. Detailed characteristics and clinical response after immunotherapy were recorded. M descriptors were classified into M1a, M1b, and M1c according to the 8th TNM classification. RESULTS: A total of 103 patients were enrolled, including 42 with M1a disease, 16 with M1b disease and 45 with M1c disease. Patients with M1a disease demonstrated significant longer median progress-free survival (PFS) (11.9 vs. 4.1 and 3.2 months, respectively, P=0.0002) and overall survival (OS) (35 vs. 22.1 and 12 months, P=0.02) than those with M1b and M1c disease. Patients with M1a disease showed higher objective response rate (ORR) (28.6% vs. 14.8%, P=0.08) and disease control rate (DCR) (81% vs. 59%, P=0.02) compared with those with M1b and M1c disease. Multivariate analysis identified M1a stage as being independently associated with prolonged PFS and had better OS than those with M1c disease (P=0.05) but not M1b disease (P=0.06). CONCLUSIONS: The current study demonstrated a clear association between M descriptors and the therapeutic response to ICIs and confirmed its prognostic role in advanced patients treated with ICIs monotherapy. M descriptors may need to be stratified in future study design.

Living on the edge: Prospects for enhanced biological phosphorus removal at low sludge retention time under different temperature scenarios.

The design of new wastewater treatment plants with the aim of capturing organic matter for energy recovery is a current focus of research. Operating with low sludge residence time (SRT) appears to be a key factor in maximizing organic matter recovery. In these new configurations, it is assumed that phosphorus is chemically removed in a tertiary step, but the integration of enhanced biological phosphorus removal (EBPR) into these short-SRT systems seems to be an alternative worth studying. A key point of this integration is to prevent the washout of polyphosphate accumulating organisms (PAO) despite the low SRT applied. However, the minimum SRT required to avoid PAO washout depends on temperature, due to its effects on reaction kinetics, gas transfer rates, biomass growth and decay rates. This work includes a wide range of short and long-term experiments to understand these interactions and shows which combinations of SRT and temperature are detrimental to PAO growth. For example, an EBPR system operating at 20 °C and SRT = 5 d showed good performance, but EBPR activity was lost at 10 °C. EBPR operated at SRT = 10 d had 86% P removal at 20 °C but decreased to 71% at 15 °C and progressively lost its activity at lower temperature. The temperature coefficient obtained for PAO show a low degree of temperature dependence (θ = 1.047 ± 0.014), and should be considered when designing short-SRT systems with EBPR.

Operational and structural A-stage improvements for high-rate carbon removal.

Biosorption of organics is investigated at two sites in order to optimize operation and infrastructure for carbon removal and redirection in upstream, high-rate processes. Sufficient process temperature and stable mixed liquor solids concentration were established as the key impact parameters for the process performance. Improved COD removal was achieved by either substantially enhanced aeration (elevated metabolic state) or by enhanced flocculation capability (dosed chemicals). Separation and thickening of organics are typically operated as continuous-flow processes. The optimization of performance parameters led to a new A-stage process named alternating activated adsorption. The AAA process is presented as a novel configuration linking biosorption and thickening capabilities in an alternating scheme without mechanical equipment. The performance data from its first trial indicate benefits from process dynamics including high organics capture rates and thickening capabilities reaching solid concentrations higher than 40 g(TSS)/L. COD removal could be increased further by adding biologically generated polymer, that is waste sludge from B-stage. © 2020 Water Environment Federation PRACTITIONERS POINTS: Enhanced preliminary treatment helps to increase capacity and energy efficiency. Low RAS rates, SRT control, aeration, high temperatures, and metal dosing are key performance parameters for removal rates and energy efficiency. The Triple-A process offers new possibilities for A-stage in terms of performance increase and flexibility showing similar or better results compared with conventional A-stage. Adding B-sludge improved COD and nutrient removal rates. High preliminary removal rates of COD and N foster sidestream processes.

Organics transformation and energy production potential in a high rate A-stage system: A demo-scale study.

Current high-rate activated sludge (HRAS) process is an aerobic A-stage process that would cause significant organic loss resulted from the mineralization. In this study, the feasibility of operating a high rate A-stage without aeration (HRNS) was carried out in a demo-scale plant (275 m3/h). The organics transformation and energy production potential in A-stage were explored. The developed A-stage process was demonstrated to be more effective for organics recovery compared to that operated with aeration (53.82% versus 40.94%), despite its relatively low total COD removal efficiency (54.3% versus 63.5% with aeration). Minor organics (accounted for 1.75% of incoming COD) was found to be lost in HRNS process. Moreover, sludge generated from HRNS had higher degradability and higher methane compared to that from HRAS. Overall, this study documented the feasibility of high rate A-stage without aeration, and acted as a guide in achieving energy neutrality or even energy-positive wastewater treatment.

Prognostic value of perirenal and/or sinus fat infiltration in patients with pT3a renal cell carcinoma: A multicentre cohort study. LARCG Group. / Valor pronóstico de la invasión de grasa perirrenal y/o del seno en pacientes con carcinoma de células renales pT3a: estudio de cohorte multicéntrico. Grupo LARCG.

INTRODUCTION AND OBJECTIVES: The objective of this study is to evaluate overall survival (OS), cancer-specific survival (CSS), relapse-free survival, local and distant (LRFS and DRFS, respectively) rates in patients with pT3a renal cell carcinoma (RCC) considering the perirenal and/or sinus fat infiltration (FI) as prognostic factors. MATERIALS AND METHODS: Retrospective cohort of patients with pT3a RCC who underwent radical or partial nephrectomy. The data were extracted from the LARCG (Latin American Renal Cancer Group) database. The demographic, clinical, pathological and surgical variables were evaluated. FI was divided into 4 groups (vein, perirenal, sinus and both fats infiltration). The Kaplan Meier and Cox regression curves were performed. RESULTS: 293 patients were included in the study. The mean age was 61.4 years. The median follow-up was 21 months (r: 1-194). CSS, RFS, LRFS and DRFS estimated at 3 years in the group of both fats' infiltration were 53.1, 45.1, 58.7 and 51.6 months, respectively, and always statistically lower than the rest (P˂0.005). In the multivariate analysis, the infiltration of both fats significantly increased specific mortality, overall and local relapse with respect to vein infiltration (HR: 4.5, 2.42 and 8.08, respectively). The Fuhrman grade and renal pelvis infiltration were independent predictors of CSS and RFS. CONCLUSIONS: Infiltration of both fats increases the risk of overall and local relapse in pT3a RCC. In the same way, it is associated with a lower cancer-specific survival and should be considered as a factor of poor prognosis.