Unveiling the Genomic Landscape of Intraductal Carcinoma of the Prostate Using Spatial Gene Expression Analysis.

Intraductal carcinoma of the prostate (IDCP) has recently attracted increasing interest owing to its unfavorable prognoses. To effectively identify the IDCP-specific gene expression profile, we took a novel approach of characterizing a typical IDCP case using spatial gene expression analysis. A formalin-fixed, paraffin-embedded sample was subjected to Visium CytAssist Spatial Gene Expression analysis. IDCP within invasive prostate cancer sites was recognized as a distinct cluster separate from other invasive cancer clusters. Highly expressed genes defining the IDCP cluster, such as MUC6, MYO16, NPY, and KLK12, reflected the aggressive nature of high-grade prostate cancer. IDCP sites also showed increased hypoxia markers HIF1A, BNIP3L, PDK1, and POGLUT1; decreased fibroblast markers COL1A2, DCN, and LUM; and decreased immune cell markers CCR5 and FCGR3A. Overall, these findings indicate that the hypoxic tumor microenvironment and reduced recruitment of fibroblasts and immune cells, which reflect morphological features of IDCP, may influence the aggressiveness of high-grade prostate cancer.

Where is the gap after a 90 W/4 s very-high-power short-duration ablation of atrial fibrillation?: Association with the left atrial-pulmonary vein voltage and wall thickness.

Background: Although pulmonary vein isolation (PVI) for atrial fibrillation (AF) utilizing radiofrequency (RF) applications with a very high-power and short-duration (vHPSD) has shortened the procedure time, the determinants of pulmonary vein (PV) gaps in the first-pass PVI and acute PV reconnections are unclear. Methods: An extensive encircling PVI was performed with the QDOT MICRO catheter with a vHPSD (90 W-4 s) in 30 patients with AF (19 men, 64 ± 10 years). The association of the PV gap sites (first-pass PVI failure, acute PV reconnections [spontaneous reconnections or dormant conduction provoked by adenosine triphosphate] or both) with the left atrial (LA) wall thickness and LA bipolar voltage on the PVI line and ablation-related parameters were assessed. Results: PV gaps were observed in 29 (6%) of 480 segments (16 segments per patient) in 17 patients (56%). The PV gaps were associated with the LA wall thickness, bipolar voltage, and the number of RF points (LA wall thickness, 2.5 ± 0.5 vs. 1.9 ± 0.4 mm, p < .001; bipolar voltage, 2.59 ± 1.62 vs. 1.34 ± 1.14 mV, p < .001; RF points, 6 ± 2 vs. 4 ± 2, p = .008) but were not with the other ablation-related parameters. Receiver operating characteristic curves yielded that an LA wall thickness ≥2.3 mm and bipolar voltage ≥2.40 mV were determinants of PV gaps with an area under the curve of 0.82 and 0.73, respectively. Conclusions: The LA voltage and wall thickness on the PV-encircling ablation line were highly associated with PV gaps using the 90 W/4 s-vHPSD ablation.

Spatial Gene Expression Analysis Reveals Characteristic Gene Expression Patterns of De Novo Neuroendocrine Prostate Cancer Coexisting with Androgen Receptor Pathway Prostate Cancer.

Neuroendocrine prostate carcinoma (NEPC) accounts for less than 1% of prostate neoplasms and has extremely poorer prognosis than the typical androgen receptor pathway-positive adenocarcinoma of the prostate (ARPC). However, very few cases in which de novo NEPC and APRC are diagnosed simultaneously in the same tissue have been reported. We report herein a 78-year-old man of de novo metastatic NEPC coexisting with ARPC treated at Ehime University Hospital. Visium CytAssist Spatial Gene Expression analysis (10× genetics) was performed using formalin-fixed, paraffin-embedded (FFPE) samples. The neuroendocrine signatures were upregulated in NEPC sites, and androgen receptor signatures were upregulated in ARPC sites. TP53, RB1, or PTEN and upregulation of the homologous recombination repair genes at NEPC sites were not downregulated. Urothelial carcinoma markers were not elevated. Meanwhile, Rbfox3 and SFRTM2 levels were downregulated while the levels of the fibrosis markers HGF, HMOX1, ELN, and GREM1 were upregulated in the tumor microenvironment of NEPC. In conclusion, the findings of spatial gene expression analysis in a patient with coexisting ARPC and de novo NEPC are reported. The accumulation of cases and basic data will help with the development of novel treatments for NEPC and improve the prognosis of patients with castration-resistant prostate cancer.

Chronic Ablation Lesions after Cryoballoon and Hot Balloon Ablation of Atrial Fibrillation.

BACKGROUND: Chronological changes in ablation lesions after cryoballoon ablation (CBA) and hot balloon ablation (HBA) of atrial fibrillation (AF) remain unclear. METHODS: Of 90 patients who underwent initial balloon-based catheter ablation of AF and cardiac magnetic resonance imaging (cMRI) 3 months after ablation, data from 48 propensity score-matched patients (24 per group; 34 males; age 62±10 years) were analyzed. High-density pulmonary vein-left antrum (PV-LA) voltage mapping was performed after PV isolation, and low voltage areas around the PV ostia were defined as the total acute ablation lesion area (cm2). cMRI-derived dense fibrotic tissue localized around PVs was defined as the total chronic ablation lesion area (cm2). The percentage of total ablation lesion areas to total PV-LA surface area (%ablation lesion) was calculated during each phase, and %acute ablation lesion and %chronic ablation lesion areas were compared in patients who had undergone CBA and HBA. RESULTS: The %acute ablation lesion area was larger for the CBA group than for the HBA group (30.8±5.8% vs. 23.0±5.5%, p < 0.001). There was no difference in %chronic cMRI-derived ablation lesion area (24.8±10.8% vs. 21.1±11.6%, p = 0.26) between groups. The rates of chronic AF recurrence were 12.5% and 8.3%, respectively (p = 0.45; log-rank test). LA volume and LA surface area were strongly associated with AF recurrence, but %chronic ablation lesion area was not (27±8% vs. 23±12%, p = 0.39). CONCLUSION: Large acute ablation lesions after CBA were smaller during the chronic phase. The size of chronic ablation lesions and the rate of AF recurrence were both similar for CBA and HBA.

CD21lo B Cells Could Be a Potential Predictor of Immune-Related Adverse Events in Renal Cell Carcinoma.

Immune checkpoint inhibitor (ICI) therapy increases the risk of immune-related adverse events (irAEs). In particular, combination checkpoint blockade (CCB) targeting inhibitory CTLA-4 and PD-1 receptors could lead to irAEs at a higher rate than ICI monotherapy. Management of irAEs is important while using ICIs. However, there are no reliable biomarkers for predicting irAEs. The aim of this study was to elucidate early B cell changes after CCB therapy in patients with renal cell carcinoma (RCC) and verify whether B cells can be a predictor of irAEs. This prospective cohort study was conducted with 23 Japanese patients with metastatic RCC. An increase in the proportion of CD21lo B cells and CD21lo memory B cells was confirmed following CCB therapy. Although there were no differences in clinical outcomes between irAE and no-irAE groups, the proportion of CD21lo B cells at baseline was lower in the irAE group, with a significant increase after the first cycle of CCB therapy. Further analysis revealed a moderate correlation between irAEs and CD21lo B cell levels at baseline (area under the curve: 0.83, cut-off: 3.13%, sensitivity: 92.3, specificity: 70.0). This finding indicates that patients with low baseline CD21lo B cell levels warrant closer monitoring for irAEs. The clinical registration number by the Certified Review Board of Ehime University is No. 1902011.

Extended robot-assisted laparoscopic prostatectomy and extended pelvic lymph node dissection as a monotherapy in patients with very high-risk prostate cancer Patients.

BACKGROUND: Patients with very-high-risk prostate cancer (VHRPCa) have earlier biochemical recurrences (BCRs) and higher mortality rates. It remains unknown whether extended robot-assisted laparoscopic prostatectomy (eRALP) without neoadjuvant or adjuvant therapy can improve the outcomes of VHRPCa patients. We aimed to determine the feasibility and efficacy of eRALP as a form of monotherapy for VHRPCa. METHODS: Data from 76 men who were treated with eRALP without neoadjuvant/adjuvant therapy were analyzed. eRALP was performed using an extrafascial approach. Extended pelvic lymph node (LN) dissection (ePLND) included nodes above the external iliac axis, in the obturator fossa, and around the internal iliac artery up to the ureter. The outcome measures were BCR, treatment failure (defined as when the prostate-specific antigen level did not decrease to <0.1 ng/ml postoperatively), and urinary continence (UC). Kaplan-Meier, logistic regression, and Cox proportional-hazards model were used to analyze the data. RESULTS: The median operative time was 246 min, and median blood loss was 50 ml. Twenty-one patients experienced postoperative complications. Median follow-up was 25.2 months; 19.7% of patients had treatment failure. Three-year, BCR-free survival rate was 62.0%. Castration-resistant prostate cancer-free survival rate was 86.1%. Overall survival was 100%. In 55 patients who had complete postoperative UC data, 47 patients (85.5%) recovered from their UC within 12 months. Clinical stage cT3b was an independent preoperative treatment failure predictor (p = 0.035), and node positivity was an independent BCR predictor (p = 0.037). The small sample size and retrospective nature limited the study. CONCLUSIONS: This approach was safe and produced acceptable UC-recovery rates. Preoperative seminal vesicle invasion is associated with treatment failure, and pathological LN metastases are associated with BCR. Therefore, our results may help informed decisions about neoadjuvant or adjuvant therapies in VHRPCa cases. PRECIS: Extended robot-assisted laparoscopic prostatectomy and extended pelvic lymph node dissection without adjuvant therapy is safe and effective for some patients with very-high-risk prostate cancer. The clinical stage and node positivity status predicted monotherapy failure, which may indicate good adjuvant therapy candidate.

PSMA-positive membranes secreted from prostate cancer cells have potency to transform vascular endothelial cells into an angiogenic state.

BACKGROUND: Prostate-specific membrane antigen (PSMA) is highly expressed in poorly differentiated, metastatic, and castration-resistant prostate cancers. Recently, 68Ga-PSMA positron emission tomography/computed tomography has been successfully developed as an effective diagnostic tool for prostate cancer. However, the pathophysiological functions of PSMA in prostate tumors remain unclear. METHODS: We examined the protein expression of PSMA in tumor endothelial cells in human prostate tumors by immunohistochemistry. Prostate cancer tissues were resected by robotic surgery in 2019 at Ehime University from patients with prostate cancer. In vitro, we prepared conditioned medium (CM) derived from a PSMA-positive human prostate cancer cell line, LNCaP, cultured on collagen I gels. We then examined PSMA expression in human umbilical vascular endothelial cells (HUVECs) cultured with the CM. We assessed angiogenic activities by treatment of HUVECs with LNCaP-derived CM using a tube formation assay that mimics angiogenesis. RESULTS: Immunohistochemistry of PSMA and CD31, a marker of endothelial cells, and PSMA-expressing tumor endothelial cells were observed in 4 of 33 prostate cancer patients (12.1%). We also found that the 10,000g pellet fraction of the LNCaP-derived CM containing PSMA-positive membranes, such as microvesicles transformed HUVECs "PSMA-negative" into "PSMA-positive." Furthermore, treatment of HUVECs with the 10,000g pellet fraction of the LNCaP-derived CM significantly promoted tube formation, mimicking angiogenesis in a PSMA-dependent manner. CONCLUSIONS: Our findings revealed the existence of PSMA-positive tumor endothelial cells in human prostate tumors, which enhances tumor angiogenesis in prostate cancer tissues.

Predictors of Hypotension after Adrenalectomy for Pheochromocytoma.

The management of blood pressure is a significant concern for surgeons and anesthesiologists performing adrenalectomy for pheochromocytoma. We evaluated clinical factors in pheochromocytoma patients to identify the predictors of postoperative hypotension. The medical records of patients who underwent adrenalectomy for pheochromocytoma between 2001 and 2017 were retrospectively reviewed and clinical and biochemical data were evaluated. Of 29 patients, 13 patients needed catecholamine support in the perisurgical period while 16 patients did not. There were significant differences in median age, tumor size, and blood pressure drop (maxmin) between the 2 groups (68 vs 53 years old, p=0.045; 50 vs 32 mm diameter, p=0.022; 110 vs 71 mmHg, p=0.015 respectively). In univariate logistic analysis, age > 65.5 years, tumor size > 34.5 mm, urine metanephrine > 0.205 mg/day and urine normetanephrine > 0.665 mg/day were significant predictors of prolonged hypotension requiring postoperative catecholamine support. Tumor size and urine metanephrine and urine normetanephrine levels were correlated with postoperative hypotension. These predictors may help in the safe perioperative management of pheochromocytoma patients treated with adrenalectomy.

Hot balloon versus cryoballoon ablation for persistent atrial fibrillation: Lesion area, efficacy, and safety.

INTRODUCTION: The clinical efficacy and safety of hot balloon ablation (HBA) for the treatment of persistent AF (PerAF) remain unclear. We aimed to evaluate the clinical efficacy and safety of HBA versus cryoballoon ablation (CBA) as a treatment for PerAF. METHODS: Of 195 consecutive patients who underwent initial catheter ablation for PerAF (AF lasting for longer than 7 days but shorter than 12 months), 158 propensity score-matched (79 HBA and 79 CBA) patients were included in our retrospective study. All patients who underwent HBA received applications of energy to the upper posterior LA wall with a larger balloon in addition to single shots to each pulmonary vein (PV) ostium, whereas those who underwent CBA received simple single-shot applications. The electrically isolated surface area (ISA), including the PV antrum and part of the posterior LA wall, was assessed by high-resolution mapping. RESULTS: The success of the PV isolation with balloon shots alone did not differ between HBA and CBA (81% vs. 85%; p = .52). The ISA was generally wide in both groups and significantly larger in the HBA group than in the CBA group (61 ± 16% vs. 51 ± 12%; p < .001). The incidence of procedure-related complications did not differ significantly (HBA 4% vs. CBA 1%; p = .62) nor did the arrhythmia recurrence rate (HBA 11% vs. CBA 18% at 18 months; p = .26). CONCLUSION: Despite the difference in protocols, HBA and CBA performed for PerAF appear comparable in terms of wide antral lesion creation, clinical efficacy, and safety. Further prospective studies, based on a unified methodology, are needed.

SPOP is essential for DNA-protein cross-link repair in prostate cancer cells: SPOP-dependent removal of topoisomerase 2A from the topoisomerase 2A-DNA cleavage complex.

SPOP, speckle-type POZ protein is a substrate adaptor protein of the Cullin-3/RING ubiquitin E3 complex. The spop gene is the most commonly point mutated in human primary prostate cancers, but the pathological contribution of the SPOP mutations remains unclear. In this study, we investigated several known factors that are critical in the DNA--protein cross-link repair process. The depletion of SPOP or overexpression of a prostate cancer-associated SPOP mutant, F133V, in androgen receptor-positive prostate cancer cells increased the amount of topoisomerase 2A (TOP2A) in the nuclei together with the increased amount of γH2AX, an indication of DNA breaks. Tyrosyl-DNA phosphodiesterases (TDPs) and an endo/exonuclease MRE11 are enzymes that liberate TOP2A from the TOP2A-DNA cleavage complex, and thus is essential for the completion of the DNA repair process. We found that the amount of TDP1 and TDP2 was decreased in SPOP-depleted cells, and that of TDP2 and MRE11 was decreased in F133V-overexpressing cells. These results suggest that the F133V mutant exerts dominant-negative and gain-of-function effects in down-regulation of TDP2 and MRE11, respectively. We conclude that SPOP is involved in the DNA-protein cross-link repair process through the elimination of TOP2A from the TOP2A cleavage complex, which may contribute to the genome stability.

Optimal diameter of the pulmonary vein ostium for second-generation 28-mm cryoballoon ablation of atrial fibrillation.

BACKGROUND: Large pulmonary veins (PVs) have the risk of excessive cooling when the cryoballoon is moved into them, whereas smaller PVs may not be isolated because of insufficient balloon-tissue contact. We previously reported that the effective nadir balloon temperature (NBT) was <- 44°C for predicting early PV reconnections. However, the ideal PV and left atrial (LA) diameters for cooling temperatures during cryoballoon ablation (CBA) are unknown. METHODS: We measured the PV ostium (PVos) and LA diameters on computed tomography images in 71 atrial fibrillation patients who underwent a 28-mm CBA. We defined -60°C ≤ NBT <- 44°C as the optimal NBT. The optimal PVos diameters and elliptical area were determined using the receiver operating characteristic curve cutoff values for the optimal NBT. RESULTS: The maximum PVos diameter (PVmax), minimum PVos diameter (PVmin), and PV elliptical area correlated negatively with the NBT (PVmax: r = -.34, P < .0001; PVmin: r = -.41, P < .0001; PV elliptical area: r = -.41, P < .0001). Based on the NBT-derived definition, the optimal PVmax, PVmin, and PV elliptical area were 19 < PVmax ≤ 21 mm, 14 < PVmin ≤ 16 mm, and 186.83 < PV elliptical area ≤ 254.34 mm2 , respectively. In addition, a positive correlation between the LA longitudinal diameter and NBT was observed in the right superior PV (r = .34, P = .004), and the LA transverse diameter correlated inversely with the NBT in the left inferior PV (r = -.34, P = .004). CONCLUSIONS: We identified the optimal PV diameters and elliptical area to establish the optimal NBT during the second-generation 28-mm CBA. These data will help for the preclinical judgment for a successful CBA.

Feasibility of Laparoscopic Radical Cystectomy in Elderly Patients: A Comparative Analysis of Clinical Outcomes in a Single Institution.

Laparoscopic radical cystectomy (LRC) is a standard surgical treatment for muscle-invasive bladder cancer and high-risk non-muscle-invasive bladder cancer. LRC is a less invasive modality than conventional open surgery. Therefore, even elderly patients with invasive bladder cancer may be candidates for LRC. In this study, a comparative analysis of perioperative/oncological outcomes between elderly patients and younger patients who underwent LRC was performed to assess the feasibility of LRC in elderly patients. Sixty-eight consecutive patients who underwent LRC between October 2013 and March 2018 were enrolled and stratified into those younger than 75 years (n=37) and those ≥ 75 years old (n=31). The median follow-up period was 28.2 months. The preoperative and operative parameters and complications were similar in both groups. The 2-year overall survival (OS) was 64.4% in the younger vs. 76.4% in the elderly group (p=0.053), cancer-specific survival (CSS) was 79.3% vs. 81.7% (p=0.187), and recurrence-free survival (RFS) was 58.2% vs. 75.7% (p=0.174), respectively. No significant differences were observed in OS, CSS, or RFS between the groups. No significant differences were found between the groups with respect to peri-surgical/oncological outcomes. We conclude that LRC is feasible in elderly patients.

Electrophysiologic and anatomic factors predictive of a need for touch-up radiofrequency application for complete pulmonary vein isolation: Comparison between hot balloon- and cryoballoon-based ablation.

INTRODUCTION: Although electrophysiologic and anatomic factors associated with the need for touch-up radiofrequency (RF) applications after cryoballoon ablation (CBA) for atrial fibrillation (AF) have been well described, those associated with the need for such touch-up after hot balloon ablation (HBA) have not. We aimed to identify factors predictive of the need for touch-up applications following HBA. METHODS: Anatomic and electrophysiologic factors predictive of the need for touch-up RF ablation were compared between 46 propensity score-matched pairs of patients who underwent HBA or CBA for AF. RESULTS: Touch-up RF ablation was more frequently required after HBA than after CBA (57% vs 30%, respectively; P = .01), and mostly at the anterior aspect of the left superior pulmonary vein (LSPV) carina after HBA (35%) but at the inferior aspect of the right inferior PV (RIPV) after CBA (71%). Post HBA touch-up was associated with male gender, a CHA 2 DS 2 -VASc score ≤ 2, PV-left atrial bipolar voltage ≥ 1.35 mV, and PV trunk length ≥ 24.0 mm; post CBA touch-up associated with a history of heart failure. CONCLUSION: Following balloon ablation for AF, there may be a need for touch-up applications, especially at the LSPV ridge after HBA but at the RIPV after CBA. It may behoove operators to expect a need for touch-up following HBA when patients are male, have a CHA2 DS 2 -VASc score ≤ 2 points, when PV-LA bipolar voltage is ≥ 1.35 mV, or when the PV trunk is ≥ 24.0 mm or following CBA when there is a history of heart failure.

A Case Report of Synchronous Prostate Cancer and Rectal Gastrointestinal Stromal Tumor and its Management.

A 72-year-old Japanese man presented to the hospital with complaints of gross hematuria. Contrast enhanced com-puted tomography revealed a broad-based, approximately 3-cm bladder tumor near the right ureteral orifice and a 5-cm mass located between the prostate and rectum. The patient underwent transurethral resection of the bladder tumor and a transrectal biopsy of the lesion. Histological examination of the specimens suggested that the patient had a muscle invasive adenocarcinoma from transurethral resection and a rectal gastrointestinal stromal tumor in TRUS biopsy. Patient underwent total pelvic exenteration and ileal and colonic stomas to divert urine and faeces. Final pathology report of the resected specimen revealed a rectal gastrointestinal stromal tumor and prostatic ad-enocarcinoma, which had invaded the urinary bladder and seminal vesicles. Synchronous gastrointestinal stromal tumor in rectum and prostate cancer treated with total pelvic exenteration has not been reported before in literature.

Effect of epicardial fat and metabolic syndrome on reverse atrial remodeling after ablation for atrial fibrillation.

BACKGROUND: Metabolic syndrome/epicardial adipose tissue (EAT) plays an important role in atrial fibrillation (AF). Although reverse atrial remodeling (RAR) often occurs after AF ablation, the effects of EAT on RAR remain unknown. METHODS: Study subjects were 104 patients in whom transthoracic echocardiography (TTE) was performed before AF ablation and 3, 6, and 12 months afterward. EAT was assessed in terms of its thickness adjacent to the right ventricular anterior wall in the TTE parasternal view. RAR was defined as >10% reduction in the left atrial volume (LAV) index by the 3-month follow-up examination. RESULTS: Postablation RAR occurred in 57/104 (55%) patients. RAR absence was associated with a relatively thick EAT (4.92 ± 1.65 vs. 3.92 ± 1.17 mm, P = 0.0005), small LAV index (24.6 ± 7.5 vs. 28.8 ± 10.6 mL/m2, P = 0.0233), and metabolic syndrome (62% vs. 28%, P = 0.0006). Metabolic syndrome and EAT were shown to be independent predictors of RAR absence. Thick EAT was significantly associated with AF recurrence after ablation (5.05 ± 2.19 mm vs. 4.17 ± 1.16 mm for no AF recurrence group, P = 0.0116), but metabolic syndrome was not (48% vs. 42%, P = 0.6189). Despite no change in body weight, EAT thickness decreased significantly by 12 months in patients without AF recurrence (4.17 ± 1.16 vs. 3.65 ± 1.16 mm, P < 0.0001). CONCLUSIONS: EAT and metabolic syndrome appear to be strongly associated with RAR absence, but only the thick EAT was significantly associated with the postablation AF recurrence. Our findings, especially the thinning of EAT, suggest that thick EAT lead to AF vulnerability but that EAT reduction favorably affects ablation outcome.

No association between dormant conduction sites and pulmonary vein reconnection sites in late atrial fibrillation recurrence after catheter ablation.

OBJECTIVE: Despite use of provocation testing to unmask dormant left atrium (LA)-PV conduction after index pulmonary vein isolation (PVI) for atrial fibrillation (AF), AF recurrence still occurs, with PV reconnection as the main cause. In an effort to answer the question whether freedom from AF recurrence can be achieved by ablation that targets sites of dormant conduction, we compared sites of dormant conduction against sites of PV reconnection identified at the time of repeat ablation for AF recurrence. MATERIALS AND METHODS: The study group comprised 46 patients (30 men/16 women, aged 58.7±10.3 years) with AF (paroxysmal: n=37, persistent: n=9) who underwent repeat ablation for AF recurrence 12.3 (7.4-29.7) months after the index ablation procedure. Ipsilateral PVs were divided into 8 segments each (736 total segments), and the relation between dormant conduction sites and PV reconnection sites was determined per segment. RESULTS: Dormant LA-PV conduction was unmasked and ablated in 22 (47.8%) of the 46 patients at sites within 43 (5.8%) of the 736 PV segments. Late PV reconnection was found within 122 (17%) of the 736 PV segments at the time of re-ablation for AF recurrence. Only 22 (18%) of these 122 PV segments corresponded to dormant conduction sites identified during the index procedure. CONCLUSION: Although additional ablation to eliminate dormant PV conduction unmasked during the index ablation procedure is performed, the majority of PVs that show reconduction at the time of treatment for clinical AF recurrence are PVs that have not shown dormant conduction.

Influence of balloon temperature and time to pulmonary vein isolation on acute pulmonary vein reconnection and clinical outcomes after cryoballoon ablation of atrial fibrillation.

BACKGROUND: Limited data exist on indicators of durable pulmonary vein isolation (PVI) undergoing cryoballoon ablation (CBA) for atrial fibrillation (AF). We investigated whether balloon temperature and time to PVI can be used to predict early PV reconduction (EPVR), including residual PV conduction and adenosine triphosphate-induced dormant conduction and the relation between touch-up ablation of EPVR sites and mid-term recurrence of AF. METHODS: We obtained procedural and outcome data from the records of 130 consecutive patients who underwent CBA and followed up for 13.4 months. RESULTS: EPVR was identified in 86 (17%) PVs of 61 (47%) patients. Balloon temperatures during 30 seconds (-27 ± 5.7°C vs -31 ± 5.5°C), 60 seconds (-36 ± 5.6°C vs -41 ± 5.4°C), and at the nadir point (-41 ± 7.4°C vs -49 ± 7.0°C) were significantly higher, and the time to PVI was longer (90 ± 50 seconds vs 52 ± 29 seconds) in PVs with EPVR than in those without (P < 0.0001 for all). Among PVs without EPVR, the time to PVI was longer and balloon temperature was lower for the left superior pulmonary vein/ right inferior pulmonary vein (LSPV/RIPV) than for the right superior pulmonary vein/left inferior pulmonary vein (RSPV/LIPV) (time: 60 ± 25/73 ± 37 seconds vs 41 ± 31/45 ± 20 seconds, P < 0.0001) (temp: -39.2 ± 11.3/-39.4 ± 8.3°C vs -33.8 ± 10.6/-33.6 ± 6.8°C, P = 0.0023). AF recurrence rates were equivalent between patients with and without EPVR (13% [8/69] vs 15% [9/61], P = 0.845). CONCLUSIONS: Cryoballoon temperature and time to PVI appear to be useful in predicting durable PVI, that is, prevention of EPVR, but the balloon temperature and time required for PVI differ between PVs. Although EPVR does not predict AF recurrence, high success rates can be expected when touch-up ablation of EPVR sites is performed.

New classification of hydronephrosis on 18F-FDG-PET/CT predicts post-operative renal function and muscle-invasive disease in patients with upper urinary tract urothelial carcinoma.

OBJECTIVES: To evaluate the value of a classification of hydronephrosis on 18F-flurodeoxyglucose (FDG)-PET/CT in predicting post-operative renal function and pathological outcomes among patients with upper urinary tract urothelial carcinoma. METHODS: We retrospectively reviewed 71 patients treated with nephroureterectomy (NU) for upper urinary tract urothelial carcinoma after FDG-PET/CT between 2010 and 2016. Eight patients treated with ureteral stent or nephrostomy at the time of FDG-PET/CT were excluded. We classified hydronephrosis based on renal excretion of FDG as follows: Type 0, no hydronephrosis; Type 1, hydronephrosis with FDG excretion; and Type 2, hydronephrosis without FDG excretion. eGFR was recorded before pre-operataive FDG-PET/CT examination and after nephroureterectomy. RESULTS: Thirty-three patients (52%) had hydronephrosis, classified as Type 1 in 19 patients (30%) and Type 2 in 14 (22%). Type 2 hydronephrosis was associated with ureteral cancer and severe hydronephrosis on CT. Median changes in eGFR before and after nephroureterectomy in patients classified as Type 0, 1 and 2 were -23.9, -18.8 and 2.0 ml/min/1.73 m2, respectively. On multivariate analysis, Type 2 hydronephrosis was a significant predictor of change in eGFR (P = 0.001). Rates of muscle-invasive upper urinary tract urothelial carcinoma among Type 0, 1 and 2 patients were 37, 42 and 86%, respectively. On multivariate analysis, Type 2 hydronephrosis was a significant predictor of muscle-invasive upper urinary tract urothelial carcinoma (P = 0.032, OR 6.491). CONCLUSIONS: This classification of hydronephrosis from FDG-PET/CT is simple and useful for predicting post-operative renal function and muscle-invasive disease in patients with upper urinary tract urothelial carcinoma, especially with ureteral cancer. This classification can help in deciding eligibility for lymphadenectomy or perioperative cisplatin-based chemotherapy.

Hot Balloon Versus Cryoballoon Ablation for Atrial Fibrillation: Lesion Characteristics and Middle-Term Outcomes.

BACKGROUND: Hot balloon ablation (HBA) and cryoballoon ablation (CBA) were developed to simplify ablation for atrial fibrillation. Because the lesion characteristics and efficacy of these balloon modalities have not been clarified, we compared lesion characteristics and outcomes of HBA and CBA. METHODS: Of 165 consecutive patients who underwent initial catheter ablation for atrial fibrillation, 74 propensity scorematched (37 HBA and 37 CBA) patients were included in our study. RESULTS: Patients' clinical characteristics, including age, sex, body mass index, atrial fibrillation subtype, CHA2DS2-VASc score, and left atrial dimension, were similar between the 2 groups. Touch-up radiofrequency ablation was required for residual/dormant pulmonary vein conduction in 52% of the patients with HBA versus 24% of the patients with CBA (P=0.02) and often in the anterior aspect of the left superior pulmonary vein after HBA (41%) versus the inferior aspect of the inferior pulmonary veins after CBA (22%). HBA lesions were smaller than CBA lesions (23.8±7.9 versus 33.5±14.5 cm2; P=0.0007). Similar results were observed when lesions in each pulmonary vein were compared between groups. Twentyfour hours after the procedure, serum levels of the cardiac biomarkers, including troponin-T, creatine kinase, and creatine kinase-MB, were higher in the HBA group than in the CBA group. Atrial fibrillation recurrence did not differ between the groups within 6 (3% versus 11%; P=0.36) or 12 months (16% versus 16%; P=1.00). CONCLUSIONS: Although HBA lesions appear to be smaller than CBA lesions, middle-term outcomes are not statistically different between these balloon modalities.

A case of retroperitoneal fibrosis responding to steroid therapy

ABSTRACT A 69-year-old man presented at the hospital with complaints of prolonged stomach pain extending from the week prior. Enhanced computed tomography (CT) revealed a low density area in the retroperitoneal space. A radiologist diagnosed the patient with retroperitoneal fibrosis. One week later, an enhanced CT revealed an exponential increase of the low density area and slight right hydronephrosis. Upon admission, prednisolone administration was initiated at a dose of 40mg/day. The size of the retroperitoneal soft tissue mass decreased gradually. Although the dose of prednisolone was tapered to 5mg, the patient is doing well without any sign of recurrence.