[Treatment of Stage Ia Non-small Cell Lung Cancer in Patients: 
Comparison of Ablation and Sub-lobectomy].

BACKGROUND: Lung cancer has the highest mortality in China. Different treatments are of great significance to the prognosis of patients. By comparing stage Ia non-small cell lung cancer (NSCLC) patients' survival rates for ablation and for sub-lobectomy, we studied the difference in the effects of the two treatments on patient prognosis. METHODS: Using the Surveillance, Epidemiology, and End Results (SEER) database, we screened eligible patients with stage Ia NSCLC from January 2004 to December 2015. Then, 228 patients treated with ablation and 228 patients treated with sub-lobotomy were then selected based on propensity score matching. After stratification, matching, and adjustment the Kaplan-Meier analysis was performed to compare the overall survival rates of patients treated with the two procedures. RESULTS: The Kaplan-Meier survival analysis showed that there is a significant difference between the ablation group and the sub-lobectomy group (P<0.05). In the univarlable analysis, the hazard ratio (HR) of sub-lobotomy group was 0.571 (95%CI: 0.455-0.717) compared with the ablation group. Patients treated with sub-lobectomy had a 0.571 times greater risk of adverse outcomes than those treated with ablation. In the multivariable analysis, the HR for sub-lobectomy group was 0.605 (95%CI: 0.477-0.766) compared with the ablation group. Patients treated with sub-lobectomy had a 0.605 time greater risk of adverse outcomes than those treated with ablation. The results suggested that the overall survival rate of patients with stage Ia NSCLC treated with sub-lobotomy was higher than that of patients treated with ablation. CONCLUSIONS: This study suggests that there is a significant difference in overall survival of stage Ia NSCLC patients treated with ablation and with sub-lobotomy. Patients treated with sub-lobotomy for stage Ia NSCLC had higher overall survival than those treated with ablation.

A Propensity Score Matching Study Between Microwave Ablation and Radiofrequency Ablation in Terms of Safety and Efficacy for Benign Thyroid Nodules Treatment.

Background: Large benign thyroid nodules often lead to cosmetic problems and compression on trachea. Thermal ablation is an effective method for benign thyroid nodules treatment. Among all the thermal ablation techniques, microwave and radiofrequency are frequently used energy sources. However, treatment outcomes of the two ablation types have not been compared in detail. Therefore, we conducted this study aiming for comparing the safety and efficacy of the two ablation techniques in benign thyroid nodules treatment. Methods: Information was retrospectively collected from patients with benign thyroid nodules, who received radiofrequency ablation or microwave ablation between January 1, 2018, and December 31, 2019, in a main hospital in South China. Patients were divided into microwave ablation group and radiofrequency ablation group according to the techniques applied. A propensity score matching was performed to balance the baseline indexes between the two groups. We also recorded and analyzed the operative variables including operative duration, intraoperative blood loss, hospitalization time, and overall costs. Postoperative quality of life, volume reduction rates, and complication rates were routinely evaluated during the follow-up by asking patients to fulfil questionnaires at the 1st, 3rd, 6th, 12th, and 18th postoperative month. Results: A total of 943 patients receiving microwave ablation or radiofrequency ablation in the years of 2018 and 2019 met our inclusion criteria. After 1:1 propensity score matching, 289 pairs of patients were matched. There was no significant difference between the two groups in operative duration, intraoperative blood loss, hospitalization time, overall cost, quality of life scores, complication rates or volume reduction rates. Conclusion: There was no significant difference between microwave and radiofrequency ablation in terms of safety and efficacy. Both of the two techniques` are ideal therapeutic methods in benign thyroid nodules treatment. Registration number: ChiCTR2000034764.

Comparison of the ablation rates, fissures and fragments produced with 150 µm and 272 µm laser fibers with superpulsed thulium fiber laser: an in vitro study.

INTRODUCTION: Holmium:YAG(Ho:YAG) is currently the standard for lithotripsy. Superpulsed Thulium Fiber Laser(TFL) has been evaluated as an alternative for lithotripsy, using laser fibers with core-diameters(CDF) down to 50 µm and additional available settings suitable for "dusting" technique. This in-vitro study compared ablation rates, fissures and fragments' size with 150µmCDF or 272µmCDF with different laser settings using TFL and Ho:YAG. METHODS: 150CDF and 272CDF were compared using three settings for TFL "fine dusting"(FD:0.15 J/100 Hz); "dusting"(D:0.5 J/30 Hz); "fragmentation"(Fr:1 J/15 Hz) and Ho:YAG(D and Fr). An experimental setup consisting of immerged 10 mm cubes of artificial hard(H) or soft(S) stone phantoms was used with a 20 s' lasing time and a spiral trajectory, in contact mode. Fragments (acquired through sieves) and stones were observed under optical microscopy before three-dimensional scanning to measure fragments and fissures(DOF) mean diameters and ablation volumes. RESULTS: Ablation volumes in with 150CDF-TFL and 272CDF-TFL were higher than those for 272CDF-Ho:YAG in both "dusting" (twofold and threefold) and "fragmentation"(1,5-fold and twofold). "Fine dusting" ablation rates with 150CDF-TFL and 272CDF-TFL were respectively at least 1,5-fold and twofold higher than those for 272CDF-Ho:YAG in "dusting". 150CDF produced significantly smaller DOF than 272CDF in all settings against S and H except in fragmentation. 150CDF produced lower fragments' diameter than 272CDF in all settings except dusting. CONCLUSION: These preliminary studies demonstrate that at equal settings and CDF, TFL ablation rates are at least two-fold higher than those with Ho:YAG. 150CDF produces smaller fissures and fragments (that meets the definition of "dusting" lithotripsy) than 272CDF and higher ablation volumes than Ho:YAG.

Examining initial treatment and survival among men with metastatic prostate cancer: An analysis from the CaPSURE registry.

BACKGROUND: New data is emerging to guide initial treatment of patients with metastatic prostate cancer (CaP). This study utilizes the Cancer of the Prostate Strategic Urologic Research Endeavor registry to evaluate variations in survival based on initial treatment received by men with metastatic disease at diagnosis or after progression. MATERIALS AND METHODS: Cancer of the Prostate Strategic Urologic Research Endeavor is a national registry of men diagnosed with CaP and managed at 43 community, academic, and Veteran's centers. We examined socio-demographic factors, disease biology, initial and subsequent therapy received, and survival among patients who presented with de novo or recurrent metastatic disease stratified by receipt of initial local therapy vs. combined local and hormonal therapy. The outcome was prostate cancer specific mortality (PCSM). We performed Fine and Gray competing risks regression analysis to evaluate the association between timing of metastasis and PCSM, adjusted for age, initial treatment, and subsequent therapy. RESULTS: Of the 14,753 patients diagnosed with CaP from 1990 to 2016, 669 (5%) had metastatic disease. Among the examined patients, 303 (45%) had metastatic disease at diagnosis and 366 (55%) progressed to metastatic disease. Overall, 461 (69%) were ≥65 years old, 582 (87%) had Medicare, and 227 (34%) had an annual income < $30,000. Prostate-specific antigen at diagnosis was >20 ng/ml for 342 (51%) patients and biopsy Gleason grade was ≥4 + 3 for 386 (58%) patients. Among patients with metastatic disease at diagnosis, 31 (10%) received initial local therapy and 272 (90%) received initial hormonal therapy. Among patients who progressed to metastatic disease, 239 (65%) received initial local therapy and 127 (35%) received initial systemic hormonal therapy. Among patients with metastatic disease, the multivariate competing risks model, after adjusting for sociodemographics, marital status, diagnosis year, and comorbidities, revealed a significantly lower risk of PCSM among patients with de novo vs. recurrent metastatic disease (Hazard Ratio 0.66 (95% Confidence Interval 0.51, 0.85) P = 0.002). In the stratified analysis, no difference was seen for patients treated with initial hormonal vs. combined local and hormonal therapy. CONCLUSIONS: In this analysis of a nationwide cohort of men treated for CaP with all types of therapy over 25 years, we observed that among men with metastatic CaP, the risk of PCSM was lower for de novo vs. recurrent metastatic disease. Additionally, no difference was observed based on initial treatment with combined local and hormonal therapy vs. hormonal therapy alone.

Cardiac synchronization and arrhythmia during irreversible electroporation.

BACKGROUND AND OBJECTIVES: Irreversible electroporation (IRE) is a nonthermal electrical tumor ablative strategy for unresectable tumors. IRE is relatively safe around critical structures but may induce cardiac arrhythmia when its delivery is not synchronized to the cardiac cycle. We performed a systematic literature review to determine rates of arrhythmia when IRE was utilized with or without cardiac synchronization. METHODS: An online literature search was conducted with additional hand selection of articles. Data were extracted and pooled analyses were performed. RESULTS: Twelve articles were included in analysis. IRE was performed for 481 patients; 46% hepatic tumors (n = 223), 36% pancreatic lesions (n = 168), and multiple other locations including prostate. Synchronization was performed on 422 patients. Arrhythmias were noted in 3.7% of cases (n = 18/481); cardiac synchronization: 1.2% (n = 5/422) vs unsynchronized: 22.0% (n = 13/59), P < .0001. These events occurred in every organ except the prostate. CONCLUSIONS: IRE remains a potent technology for unresectable tumors, but arrhythmia is a clinical concern. This literature review confirms that cardiac gating should be used in all cases outside of prostate to prevent this potentially serious adverse event.

Liver Transplantation Outcomes in a U.S. Multicenter Cohort of 789 Patients With Hepatocellular Carcinoma Presenting Beyond Milan Criteria.

BACKGROUND AND AIMS: The Organ Procurement and Transplantation Network recently approved liver transplant (LT) prioritization for patients with hepatocellular carcinoma (HCC) beyond Milan Criteria (MC) who are down-staged (DS) with locoregional therapy (LRT). We evaluated post-LT outcomes, predictors of down-staging, and the impact of LRT in patients with beyond-MC HCC from the U.S. Multicenter HCC Transplant Consortium (20 centers, 2002-2013). APPROACH AND RESULTS: Clinicopathologic characteristics, overall survival (OS), recurrence-free survival (RFS), and HCC recurrence (HCC-R) were compared between patients within MC (n = 3,570) and beyond MC (n = 789) who were down-staged (DS, n = 465), treated with LRT and not down-staged (LRT-NoDS, n = 242), or untreated (NoLRT-NoDS, n = 82). Five-year post-LT OS and RFS was higher in MC (71.3% and 68.2%) compared with DS (64.3% and 59.5%) and was lowest in NoDS (n = 324; 60.2% and 53.8%; overall P < 0.001). DS patients had superior RFS (60% vs. 54%, P = 0.043) and lower 5-year HCC-R (18% vs. 32%, P < 0.001) compared with NoDS, with further stratification by maximum radiologic tumor diameter (5-year HCC-R of 15.5% in DS/<5 cm and 39.1% in NoDS/>5 cm, P < 0.001). Multivariate predictors of down-staging included alpha-fetoprotein response to LRT, pathologic tumor number and size, and wait time >12 months. LRT-NoDS had greater HCC-R compared with NoLRT-NoDS (34.1% vs. 26.1%, P < 0.001), even after controlling for clinicopathologic variables (hazard ratio [HR] = 2.33, P < 0.001) and inverse probability of treatment-weighted propensity matching (HR = 1.82, P < 0.001). CONCLUSIONS: In LT recipients with HCC presenting beyond MC, successful down-staging is predicted by wait time, alpha-fetoprotein response to LRT, and tumor burden and results in excellent post-LT outcomes, justifying expansion of LT criteria. In LRT-NoDS patients, higher HCC-R compared with NoLRT-NoDS cannot be explained by clinicopathologic differences, suggesting a potentially aggravating role of LRT in patients with poor tumor biology that warrants further investigation.

Direct Costs Incurred Among Women Undergoing Surgical Procedures to Treat Uterine Fibroids.

BACKGROUND: Uterine fibroids (UF) affect up to 70%-80% of women by 50 years of age and represent a substantial economic burden on patients and society. Despite the high costs associated with UF, recent studies on the costs of UF-related surgical treatments remain limited. OBJECTIVE: To describe the health care resource utilization (HCRU) and all-cause costs among women diagnosed with UF who underwent UF-related surgery. METHODS: Data from the IBM MarketScan Commercial Claims and Encounters database and Medicaid Multi-State database were independently, retrospectively analyzed from January 1, 2009, to December 31, 2015. Women aged 18-64 years with ≥ 1 UF claim from January 1, 2010, to December 31, 2014, a claim for a UF-related surgery (hysterectomy, myomectomy, uterine artery embolization [UAE], or ablation) from January 1, 2010, to November 30, 2015, and continuous enrollment for ≥ 1 year presurgery and ≥ 30 days postsurgery qualified for study inclusion. A 1-year period before the date of the first UF-related surgical claim after the first UF diagnosis was used to report baseline demographic and clinical characteristics. Surgery characteristics were reported. All-cause HCRU and costs (adjusted to 2017 U.S. dollars) were described by the 14 days pre-, peri-, and 30 days postoperative periods, and independently by the inpatient or outpatient setting. RESULTS: Overall, 113,091 patients were included in this study: commercial database, n = 103,814; Medicaid database, n = 9,277. Median time from the initial UF diagnosis to first UF-related surgical procedure was 33 days for the commercial population and 47 days for the Medicaid population. Hysterectomy was the most common UF-related surgery received after UF diagnosis (commercial, 68% [n = 70,235]; Medicaid, 75% [n = 6,928]). In both populations, 97% of patients had ≥ 1 outpatient visit from 14 days presurgery to 30 days postsurgery (commercial, n = 100,402; Medicaid, n = 9,023), and the majority of all UF-related surgeries occurred in the outpatient setting (commercial, 64% [n = 66,228]; Medicaid, 66% [n = 6,090]). Mean total all-cause costs for patients with UF who underwent any UF-related surgery were $15,813 (SD $13,804) in the commercial population (n = 95,433) and $11,493 (SD $26,724) in the Medicaid population (n = 4,785). Mean total all-cause costs for UF-related surgeries for the commercial/Medicaid populations were $17,450 (SD $13,483)/$12,273 (SD $19,637) for hysterectomy, $14,216 (SD $16,382)/$11,764 (SD $15,478) for myomectomy, $17,163 (SD $13,527)/$12,543 (SD $23,777) for UAE, $8,757 (SD $9,369)/$7,622 (SD $50,750) for ablation, and $12,281 (SD $10,080)/$5,989 (SD $5,617) for myomectomy and ablation. Mean total all-cause costs for any UF-related surgery performed in the outpatient setting in the commercial and Medicaid populations were $14,396 (SD $11,466) and $6,720 (SD $10,374), respectively, whereas costs in the inpatient setting were $18,345 (SD $16,910) and $21,805 (SD $43,244), respectively. CONCLUSIONS: This retrospective analysis indicated that surgical treatment options for UF continue to represent a substantial financial burden. This underscores the need for alternative, cost-effective treatments for the management of UF. DISCLOSURES: This study was sponsored by Allergan, Dublin, Ireland. Allergan played a role in the conduct, analysis, interpretation, writing of the report, and decision to publish this study. Harrington and Ye are employees of Allergan. Stafkey-Mailey, Fuldeore, and Yue are employees of Xcenda. Ta was a contractor at Allergan at the time the study was conducted and is currently supported by a training grant from Allergan. Bonine, Shih, and Gillard are employees of Allergan and have stock, stock options, and/or restricted stock units as employees of Allergan. Banks has no disclosures to report. This study was presented as a poster at Academy of Managed Care Pharmacy Nexus 2017; October 16-19, 2017; Dallas, TX.

Survival Benefit of Liver Transplantation for Hepatocellular Carcinoma.

BACKGROUND: In the United States, nearly 30% of liver transplants (LT) are performed for hepatocellular carcinoma (HCC). Although overall long-term survival is highest with LT, there are limited data on the incremental survival benefit of LT versus other curative options (resection or ablation) due to shunting of patients towards LT. METHODS: We performed a retrospective cohort study of patients aged 50-69 with cirrhosis and HCC in the Veterans Health Administration (population enriched with 3 curative treatments) from 2008 to 2016. The cohort was restricted to patients who received LT, resection, or ablation and a calculated model for end-stage liver disease score <15 at HCC diagnosis. RESULTS: Among 2129 veterans in the analytic cohort, 658 (26.7%) received LT, 244 (11.5%) underwent resection, and 1317 (61.59%) received ablation. In multivariable models, patients who underwent resection (hazard ratio: 5.42; 95% confidence interval: 4.15-7.08) or ablation (hazard ratio: 5.50; 95% confidence interval: 4.51-6.71) had significantly increased hazards of death. However, in absolute terms, the incremental survival benefit of LT over resection or ablation was small, between 0.02 and 0.03 years at 1 year, 0.32-0.42 years at 3 years, and 1.04-1.24 years at 5 years follow-up. These results were consistent in sensitivity analyses accounting for possible immortal time bias, as well as a cohort restricted to early/intermediate stage HCC. CONCLUSIONS: Although LT is associated with significantly increased survival compared to resection and ablation, the absolute incremental survival benefit is small over a 5-year time horizon. Optimal selection of patients for LT is critical for maximizing utilization of a scarce resource.

Differences in Pathology, Staging, and Treatment between HIV+ and Uninfected Patients with Microscopically Confirmed Hepatocellular Carcinoma.

BACKGROUND: The incidence of hepatocellular carcinoma (HCC) is substantially higher among HIV-infected (HIV+) than uninfected persons. It remains unclear if HCC in the setting of HIV infection is morphologically distinct or more aggressive. METHODS: We evaluated differences in tumor pathology in a cohort of HIV+ and uninfected patients with microscopically confirmed HCC in the Veterans Aging Cohort Study from 2000 to 2015. We reviewed pathology reports and medical records to determine Barcelona Clinic Liver Cancer stage (BCLC), HCC treatment, and survival by HIV status. Multivariable Cox regression was used to determine the hazard ratio [HR; 95% confidence interval (CI)] of death associated with HIV infection after microscopic confirmation. RESULTS: Among 873 patients with HCC (399 HIV+), 140 HIV+ and 178 uninfected persons underwent liver tissue sampling and had microscopically confirmed HCC. There were no differences in histologic features of the tumor between HIV+ and uninfected patients, including tumor differentiation (well differentiated, 19% vs. 28%, P = 0.16) and lymphovascular invasion (6% vs. 7%, P = 0.17) or presence of advanced hepatic fibrosis (40% vs. 39%, P = 0.90). There were no differences in BCLC stage (P = 0.06) or treatment (P = 0.29) by HIV status. After adjustment for risk factors, risk of death was higher among HIV-infected than uninfected patients (HR = 1.37; 95% CI, 1.02-1.85). CONCLUSIONS: We found no differences in HCC tumor characteristics or background hepatic parenchyma by HIV status, yet HIV was associated with poorer survival. Of note, pathology reports often omitted these characteristics. IMPACT: Systematic evaluation of HCC pathology by HIV status is needed to understand tumor characteristics associated with improved survival.

Evaluation of uterine patency following transcervical uterine fibroid ablation with the Sonata system (the OPEN clinical trial).

OBJECTIVE: Standard transcervical fibroid treatment via hysteroscopic myomectomy can result in a significant rate of intrauterine adhesiogenesis. The primary objective of this study was to document the incidence of de novo uterine adhesions after transcervical fibroid ablation (TFA) of symptomatic uterine fibroids with the Sonata® system. STUDY DESIGN: In this European postmarket prospective, multicenter, single-arm interventional trial, patients were eligible for inclusion if they chose TFA with the Sonata System for symptomatic fibroids and had at least 1 type 1, type 2 or type 2-5 myoma. The presence or absence of intrauterine adhesions was assessed by diagnostic hysteroscopy at baseline and at 6 weeks post-ablation. The hysteroscopy videos were scored by a committee of 3 independent readers. RESULTS: A total of 6 sites enrolled 37 patients. Fifty fibroids with a mean diameter of 3.4 ±â€¯1.8 cm (range 1-8 cm) were ablated. Of the 37 enrolled subjects, 35 completed the study follow-up and 2 electively withdrew from the study prior to the completion of study follow-up. Thirty-four out of 35 pairs of baseline and 6-week hysteroscopies were evaluated by the independent readers with none having de novo adhesions at 6 weeks after treatment with Sonata, including 6 patients with apposing myomata. One patient was excluded from the analysis due to an unevaluable hysteroscopy video. CONCLUSION: Intrauterine adhesiogenesis was not seen post-TFA with the Sonata system. These results suggest the potential for adhesiogenesis after TFA, including in women with apposing submucous and/or transmural myomata, may be minimal.

Computer-assisted needle trajectory planning and mathematical modeling for liver tumor thermal ablation: A review.

Radiofrequency ablation (RFA) and microwave ablation (MWA) have become an important means for treating liver tumors. RFA and MWA are a minimally invasive therapy which involves an ablation applicator or needle (i.e., radiofrequency electrode or microwave antenna) inserted percutaneously into a tumor under the guidance of medical imaging, so as to destroy the tumor in situ by heating-induced coagulation necrosis. Treatment planning, particularly needle trajectory planning, is crucial to RFA and MWA. In clinical procedures, however, needle trajectory planning still relies on the personal experience of clinicians. Manual needle trajectory planning is tedious and may cause inter-operator difference. Therefore, computer-assisted needle trajectory planning techniques are of clinical value and have been extensively explored. However, a literature review that focuses on computer-assisted needle trajectory planning for liver tumor RFA and MWA has not been reported. In this paper, we conducted an extensive review on computer-assisted needle trajectory planning for RFA and MWA of liver tumors. Fundamentals of needle trajectory planning are summarized. Algorithms for single-needle and multi-needle trajectory planning are analyzed. Shortcomings of current computer-assisted needle trajectory planning algorithms are discussed and future developments are suggested.

Short- and long-term outcomes of alcohol septal ablation for hypertrophic obstructive cardiomyopathy in patients with mild left ventricular hypertrophy: a propensity score matching analysis.

AIMS: Based on European guidelines, alcohol septal ablation (ASA) for hypertrophic obstructive cardiomyopathy (HOCM) is indicated only in patients with interventricular septum (IVS) thickness >16 mm. The aim of this study was to evaluate the short- and long-term outcomes in ASA patients with mild hypertrophy (IVS ≤ 16 mm). METHODS AND RESULTS: We retrospectively evaluated 1505 consecutive ASA patients and used propensity score to match 172 pairs (344 patients) in groups IVS ≤ 16 mm or IVS > 16 mm. There was no occurrence of post-ASA ventriculoseptal defect in the whole cohort (n = 1505). Matched patients had 30-day mortality rate 0% in IVS ≤ 16 mm group and 0.6% in IVS > 16 mm group (P = 1). Patients in IVS ≤ 16 mm group had more ASA-attributable early complications (16% vs. 9%; P = 0.049), which was driven by higher need for pacemaker implantation (13% vs. 8%; P = 0.22). The mean follow-up was 5.4 ± 4.3 years and the annual all-cause mortality rate was 1.8 and 3.2 deaths per 100-patient-years in IVS ≤ 16 group and IVS > 16 group, respectively (log-rank test P = 0.04). There were no differences in symptom relief and left ventricular (LV) gradient reduction. Patients with IVS ≤ 16 mm had less repeated septal reduction procedures (log-rank test P = 0.03). CONCLUSION: Selected patients with HOCM and mild hypertrophy (IVS ≤ 16 mm) had more early post-ASA complications driven by need for pacemaker implantation, but their long-term survival is better than in patients with IVS >16 mm. While relief of symptoms and LV obstruction reduction is similar in both groups, a need for repeat septal reduction is higher in patients with IVS > 16 mm.

Effectiveness of cold coagulation in treating high-grade cervical intraepithelial neoplasia: the human papillomavirus evidence of cure.

We retrospectively analysed post-treatment human papillomavirus (HPV) results in women treated for cervical intraepithelial neoplasia (CIN) to establish if 'virological cure' rates achieved by cold coagulation matched those for large-loop excision of the transformation zone (LLETZ) in the treatment of CIN. The main outcome measure was the rate of non-detection of HPV at 6- and 18-month follow-up. HPV was not detected in 82.0% and 86.0% of women at 6- and 18-month follow-up, respectively. In women with high-grade CIN (CIN 2 or worse), there was no difference in HPV non-detection rates among the two treatment methods at six-month (81.8% for cold coagulation vs. 84.0% for LLETZ, χ2=0.23, p value=.632), and 18-month follow-up (83.3% for cold coagulation vs. 89.2% for LLETZ, χ2=1.46, p value=.227). Cervical cold coagulation provides a high 'virological cure' rate for all grades of CIN, equivalent to that seen with LLETZ. Impact Statement What is already known on this subject? It is well established that CIN cure rates after treatment with cold coagulation are comparable to those of excisional methods and are over 90% on cytological follow-up post-treatment. Furthermore, there are no demonstrable adverse effects on fertility and delivery in pregnancies conceived after cold coagulation according to long-term follow-up studies. In contrast, there is a positive correlation between treatment with LLETZ and the risk of subsequent subfertility and adverse pregnancy outcomes. What the results of this study add? This study provides evidence that cold coagulation achieves similar cure rates to that of LLETZ not only in cytology but also in HPV test of cure. This finding is significant as we are moving to a primary HPV cervical screening programme. What the implications are of these findings for clinical practice and/or further research? A negative high-risk HPV test provides a greater reassurance of a low risk of CIN 3 or cancer than a negative cytology result. Therefore, given parity to LLETZ in 'virological cure' rate and having no known adverse effects on fertility and pregnancy, cold coagulation should be used to treat most cases of CIN, especially in women of reproductive age.

Analyzing the current practice patterns and views among urologists regarding focal therapy for prostate cancer.

INTRODUCTION AND OBJECTIVE: Focal therapy (FT) for localized prostate cancer (CaP) has been shown to have encouraging short-term oncological outcomes, excellent preservation of functional outcomes and is increasing in popularity in urologic community. We aim to evaluate the preferences and practice trends among urologists regarding this treatment strategy. METHODS: A 20 item online questionnaire was designed to collect information on urologists' views and use of FT. The survey was sent to the members of the Endourological Society and the American Urological Association. Multivariate logistic regression analysis was done to determine predictors for utilization of FT. RESULTS: A total of 425 responses were received [American Urological Association: 319, Endourological Society: 106]. Mean age of respondents was 53(SD: 11.3) years. Although half of the respondents (50.8%) believed FT to be moderate to extremely beneficial in the treatment of CaP, only 24.2% (103) of the respondents currently utilize FT in their practice. Respondents who were fellowship trained in urologic oncology were more likely to consider FT to be at least moderately beneficial (P < 0.001). Surgeon's experience (greater than 15 years in urology practice) (P = 0.025) and seeing more than 10 patients with new CaP diagnosis per month (P = 0.002) were independent predictors of FT utilization for localized CaP. While the most common setting for utilization of FT was in patients with unilateral intermediate-risk (72.8%) CaP, a small percentage of respondents also used FT for patients with unilateral high-risk CaP and bilateral intermediate risk (21.4% and 10.7%, respectively). Most common reasons for not using FT were the lack of belief in 'index lesion theory' (63.2%), lack of experience (41.3%), lack of belief in FT's efficacy (41.1%), lack of infrastructure (35.8%), difficult salvage treatment in cases of recurrence (22.7%) and high cost (21.8%). About 57.6% would use FT more often in an office or outpatient setting if they had access to reliable and cost-effective options. CONCLUSIONS: Only a quarter of our respondents utilize FT in their practice with surgeon's experience being the important independent predictor for using FT. Majority of respondents though consider FT to be beneficial in CaP management, would use it more often if provided more reliable and cost-effective options. Over time, experience and accessibility to reliable methods to perform FT may lead to further utilization of this novel treatment strategy.

Current status and progress of focal therapy in Asia.

PURPOSE OF REVIEW: With the increasing incidence of low-to-intermediate risk of prostate cancer (PCa) by the introduction of prostate-specific antigen (PSA) screening, focal therapy has become one of the promising treatment options in the world. In Asia, same movement are occurring using several technologies including cryoablation, high-intensity focused ultrasound, brachytherapy and irreversible electroporation. However, these are still not common strategies to treat organ-confined PCa. The purpose of this review is to summarize the most updated experience and future direction of focal therapy in Asian countries. RECENT FINDINGS: The prevalence and diagnosis of PCa are increasing in Asian countries. This increase is related to various factors including the widespread implementation of PSA testing and lifestyle changes to more Westernized diets. With the increasing detection rate of early stage PCa, overdetection and overtreatment are recognized even in Asia. In this setting, accumulating data on multiparametric MRI and MRI-targeted biopsy as well as MRI-transrectal ultrasound (TRUS) fusion biopsy suggest the potential in improving the detection of clinically significant PCa in Asia. Furthermore, targeted focal therapy has emerged as a promising treatment strategy aiming for both providing oncological outcome and maintaining functional preservation in many Asian countries. SUMMARY: At present, focal therapy is not a current standard choice for the treatment of localized PCa in Asian countries. However, with the increase of localized PCa and patient's preference for less invasive treatment with preservation of organ-function, focal therapy should become a definite treatment option for localized PCa in Asia.

Focal therapy for prostate cancer: concepts and future directions.

PURPOSE OF REVIEW: To present a perspective on the current status and future directions of focal therapy for prostate cancer (PCa). RECENT FINDINGS: Focal therapy for localized PCa is a rapidly evolving field. Various recent concepts - the index lesion driving prognosis, the enhanced detection of clinically significant PCa using multiparametric MRI and targeted biopsy, improved risk-stratification using novel blood/tissue biomarkers, the recognition that reducing radical treatment-related morbidity (along with reducing pathologic progression) is a clinically meaningful end-point - have all led to a growing interest in focal therapy. Novel focal therapy modalities are being investigated, mostly in phase 1 and 2 studies. Recently, level I prospective randomized data comparing partial gland ablation with a standard-of-care treatment became available from one study. Recent developments in imaging, including 7-T MRI, functional imaging, radiomics and contrast-enhanced ultrasound show early promise. We also discuss emerging concepts in patient selection for focal therapy. SUMMARY: PCa focal therapy has evolved considerably in the recent few years. Overall, these novel focal therapy treatments demonstrate safety and feasibility, low treatment-related toxicity and acceptable short-term and in some cases medium-term oncologic outcomes. As imaging techniques evolve, patient selection, detection of clinically significant PCa and noninvasive assessment of therapeutic efficacy will be further optimized. The aspirational goal of achieving oncologic control while reducing radical treatment-related morbidity will drive further innovation in the field.

Noninvasive follicular thyroid neoplasm with papillary-like nuclear features reclassification and its impact on thyroid malignancy rate and treatment.

BACKGROUND: The reclassification of noninvasive encapsulated follicular variant papillary thyroid carcinoma (FVPTC) to noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) may have significant implications by changing overall malignancy rates and minimizing the extent of surgical treatment. METHODS: A retrospective review of 847 patients who underwent thyroidectomy at a single institution from January 2010 to April 2016 was performed. The subgroup with FVPTC (n = 181) was re-reviewed by endocrine pathologists for reclassification to NIFTP. The overall rate of malignancy (ROM) and within each Bethesda classification was determined before and after the reclassification of NIFTP. The extent of thyroidectomy among others in patients reclassified as NIFTP was further reviewed. RESULTS: Of 847 patients who underwent thyroidectomy, there was an overall ROM of 58% (n = 495), the majority being papillary thyroid cancer (PTC) (n = 454, 92%). In 181 patients with FVPTC, 146 underwent pathology re-review. There were 32 cases (22%) reclassified as NIFTP, reducing the overall ROM to 55%. ROM decreased across Bethesda categories I to V by the following: 3% Bethesda I, 8% Bethesda II, 8% Bethesda III, 10% Bethesda IV, and 3% Bethesda V. Among NIFTP patients, 16 underwent total thyroidectomy and 16 underwent thyroid lobectomy, of which 12 had completion thyroidectomies (75%). Twenty patients (63%) underwent central neck dissection, and nine underwent postoperative radioactive iodine ablation treatment (28%). CONCLUSIONS: A significant proportion of patients with FVPTC reclassified as NIFTP may decrease the overall institutional thyroid ROM. On final pathology, NIFTP should be regarded as an indolent tumor requiring no further surgical treatment.

Validation of the current eligibility criteria for focal therapy in men with localized prostate cancer and the role of MRI.

PURPOSE: To validate current eligibility criteria for focal therapy (FT) in prostate cancer men undergoing radical prostatectomy (RP) and to assess the role of magnetic resonance imaging (MRI). METHODS: Retrospective analysis of 217 RP patients (2009-2016) with preoperative MRI (almost all in external institutions) and fulfillment of different FT eligibility criteria: unilateral tumor, clinical tumor stage ≤ cT2a, prostate volume ≤ 60 mL and either biopsy Gleason 3 + 3 or ≤ 3 + 4 and PSA ≤ 10 or ≤ 15 ng/mL. Multivariable logistic regression analyses (MVA) assessed the role of MRI to predict the presence of significant contralateral tumor or extracapsular extension (ECE), including seminal vesicle invasion. To quantify model accuracy, Receiver Operating Characteristics-derived area under the curve (AUC) was used. RESULTS: Of 217 patients fulfilling widest biopsy criteria and 113 fulfilling additional MRI criteria, 64 (29.7%) and 37 (32.7%) remained eligible for FT according to histopathological results. In MVA, fulfillment of MRI criteria reached independent predictor status for prediction of contralateral tumor but not for ECE. Addition of MRI resulted in AUC gain (57.5-64.6%). Sensitivity, specificity, PPV and NPV for MRI to predict contralateral tumor were: 41.8, 71.6, 70.9 and 42.6%, respectively. Virtually the same results were recorded for Gleason 3 + 3 and/or PSA ≤ 10 ng/mL. CONCLUSIONS: Patient eligibility criteria for FT using biopsy criteria remained insufficient with respect to contralateral tumor disease. Although, MRI improves accuracy, it cannot safely exclude or minimize chance of significant cancer on contralateral prostate side. To date, stricter eligibility criteria are needed to provide more diagnostic reliability.

Factors affecting basket catheter detection of real and phantom rotors in the atria: A computational study.

Anatomically based procedures to ablate atrial fibrillation (AF) are often successful in terminating paroxysmal AF. However, the ability to terminate persistent AF remains disappointing. New mechanistic approaches use multiple-electrode basket catheter mapping to localize and target AF drivers in the form of rotors but significant concerns remain about their accuracy. We aimed to evaluate how electrode-endocardium distance, far-field sources and inter-electrode distance affect the accuracy of localizing rotors. Sustained rotor activation of the atria was simulated numerically and mapped using a virtual basket catheter with varying electrode densities placed at different positions within the atrial cavity. Unipolar electrograms were calculated on the entire endocardial surface and at each of the electrodes. Rotors were tracked on the interpolated basket phase maps and compared with the respective atrial voltage and endocardial phase maps, which served as references. Rotor detection by the basket maps varied between 35-94% of the simulation time, depending on the basket's position and the electrode-to-endocardial wall distance. However, two different types of phantom rotors appeared also on the basket maps. The first type was due to the far-field sources and the second type was due to interpolation between the electrodes; increasing electrode density decreased the incidence of the second but not the first type of phantom rotors. In the simulations study, basket catheter-based phase mapping detected rotors even when the basket was not in full contact with the endocardial wall, but always generated a number of phantom rotors in the presence of only a single real rotor, which would be the desired ablation target. Phantom rotors may mislead and contribute to failure in AF ablation procedures.

Effect of Institutional Experience on Outcomes of Alcohol Septal Ablation for Hypertrophic Obstructive Cardiomyopathy.

BACKGROUND: The current American College of Cardiology Foundation/American Heart Association guidelines on hypertrophic cardiomyopathy state that institutional experience is a key determinant of successful outcomes and lower complication rates of alcohol septal ablation (ASA). The aim of this study was to evaluate the safety and efficacy of ASA according to institutional experience with the procedure. METHODS: We retrospectively evaluated 1310 patients with symptomatic obstructive hypertrophic cardiomyopathy who underwent ASA and were divided into 2 groups. The first-50 group consisted of the first consecutive 50 patients treated at each centre, and the over-50 group consisted of patients treated thereafter (patients 51 and above). RESULTS: In the 30-day follow-up, there was a significant difference in the occurrence of major cardiovascular adverse events (21% in the first-50 group vs 12% in the over-50 group; P < 0.01), which was driven by the occurrence of cardiovascular deaths (2.1% vs 0.4%; P = 0.01) and implanted pacemakers (15% vs 9%; P < 0.01). In the long-term follow-up (5.5 ± 4.1 years), the first-50 group was associated with a significantly higher occurrence of major adverse events (P < 0.01) and higher cardiovascular mortality (P < 0.01). Also, patients in the first-50 group were more likely to self-report dyspnea of New York Heart Association class III/IV (16% vs 10%), to have a left ventricular outflow gradient > 30 mm Hg (16% vs 10%) at the last clinical check-up (P < 0.01 for both), and a probability of repeated septal reduction therapy (P = 0.03). CONCLUSIONS: An institutional experience of > 50 ASA procedures was associated with a lower occurrence of ASA complications, better cardiovascular survival, better hemodynamic and clinical effect, and less need for repeated septal reduction therapy.