The oncologic risk of magnetic resonance imaging-targeted and systematic cores in patients treated with radical prostatectomy.

BACKGROUND: Magnetic resonance imaging (MRI)-targeted prostate biopsy (MRI-biopsy) detects high-Grade Group (GG) prostate cancers not identified by systematic biopsy (S-biopsy). However, questions have been raised whether cancers detected by MRI-biopsy and S-biopsy, grade-for-grade, are of equivalent oncologic risk. The authors evaluated the relative oncologic risk of GG diagnosed by S-biopsy and MRI-biopsy. METHODS: This was a retrospective analysis of all patients who had both MRI-biopsy and S-biopsy and underwent with prostatectomy (2014-2022) at Memorial Sloan Kettering Cancer Center. Three logistic regression models were used with adverse pathology as the primary outcome (primary pattern 4, any pattern 5, seminal vesicle invasion, or lymph node involvement). The first model included the presurgery prostate-specific antigen level, the number of positive and negative S-biopsy cores, S-biopsy GG, and MRI-biopsy GG. The second model excluded MRI-biopsy GG to obtain the average risk based on S-biopsy GG. The third model excluded S-biopsy GG to obtain the risk based on MRI-biopsy GG. A secondary analysis using Cox regression evaluated the 12-month risk of biochemical recurrence. RESULTS: In total, 991 patients were identified, including 359 (36%) who had adverse pathology. MRI-biopsy GG influenced oncologic risk compared with S-biopsy GG alone (p < .001). However, if grade was discordant between biopsies, then the risk was intermediate between grades. For example, the average risk of advanced pathology for patients who had GG2 and GG3 on S-biopsy was 19% and 66%, respectively, but the average risk was 47% for patients who had GG2 on S-biopsy and patients who had GG3 on MRI-biopsy. The equivalent estimates for 12-month biochemical recurrence were 5.8%, 15%, and 10%, respectively. CONCLUSIONS: The current findings cast doubt on the practice of defining risk group based on the highest GG. Because treatment algorithms depend fundamentally on GG, further research is urgently required to assess the oncologic risk of prostate tumors depending on detection technique. PLAIN LANGUAGE SUMMARY: Using magnetic resonance imaging (MRI) to help diagnose prostate cancer can help identify more high-grade cancers than using a systematic template biopsy alone. However, we do not know if high-grade cancers diagnosed with the help of an MRI are as dangerous to the patient as high-grade cancers diagnosed with a systematic biopsy. We examined all of our patients who had an MRI biopsy and a systematic biopsy and then had their prostates removed to find out if these patients had risk factors and signs of aggressive cancer (cancer that spread outside the prostate or was very high grade). We found that, if there was a difference in grade between the systematic biopsy and the MRI-targeted biopsy, the risk of aggressive cancer was between the two grades.

Outcomes of Grade Group 2 and 3 Prostate Cancer on Initial Versus Confirmatory Biopsy: Implications for Active Surveillance.

BACKGROUND: Active surveillance (AS) is recommended as the preferred treatment for men with low-risk disease. In order to optimize risk stratification and exclude undiagnosed higher-grade disease, most AS protocols recommend a confirmatory biopsy. OBJECTIVE: We aimed to compare outcomes among men with grade group (GG) 2/3 prostate cancer on initial biopsy with those among men whose disease was initially GG1 but was upgraded to GG2/3 on confirmatory biopsy. DESIGN, SETTING, AND PARTICIPANTS: We reviewed patients undergoing radical prostatectomy (RP) in two cohorts: "immediate RP group," with GG2/3 cancer on diagnostic biopsy, and "AS group," with GG1 cancer on initial biopsy that was upgraded to GG2/3 on confirmatory biopsy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Probabilities of biochemical recurrence (BCR) and salvage therapy were determined using multivariable Cox regression models with risk adjustment. Risks of adverse pathology at RP were also compared using logistic regression. RESULTS AND LIMITATIONS: The immediate RP group comprised 4009 patients and the AS group comprised 321 patients. The AS group had lower adjusted rates of adverse pathology (27% vs 35%, p = 0.003). BCR rates were lower in the AS group, although this did not reach conventional significance (hazard ratio [HR] 0.73, 95% confidence interval [CI] 0.50-1.06, p = 0.10) compared with the immediate RP group. Risk-adjusted 1- and 5-yr BCR rates were 4.6% (95% CI 3.0-6.5%) and 10.4% (95% CI 6.9-14%), respectively, for the AS group compared with 6.3% (95% CI 5.6-7.0%) and 20% (95% CI 19-22%), respectively, in the immediate RP group. A nonsignificant association was observed for salvage treatment-free survival favoring the AS group (HR 0.67, 95% CI 0.42, 1.06, p = 0.087). CONCLUSIONS: We found that men with GG1 cancer who were upgraded on confirmatory biopsy tend to have less aggressive disease than men with the same grade found at initial biopsy. These results must be confirmed in larger series before recommendations can be made regarding a more conservative approach in men with upgraded pathology on surveillance biopsy. PATIENT SUMMARY: We studied men with low-risk prostate cancer who were initially eligible for active surveillance but presented with more aggressive cancer on confirmatory biopsy. We found that outcomes for these men were better than the outcomes for those diagnosed initially with more serious cancer.

Association of Family History of Cancer with Clinical and Pathological Outcomes for Prostate Cancer Patients on Active Surveillance.

PURPOSE: The impact of germline mutations associated with hereditary cancer syndromes in patients on active surveillance (AS) for prostate cancer is poorly defined. We examined the association between family history of prostate cancer (FHP) or family history of cancer (FHC) and risk of progression or adverse pathology at radical prostatectomy (RP) in patients on AS. MATERIALS AND METHODS: Patients on AS at a single tertiary-care center between 2000-2019 were categorized by family history. Disease progression was defined as an increase in Gleason grade on biopsy. Adverse pathology was defined as upgrading/upstaging at RP. Multivariable Cox and logistic regression models were used to assess association between family history and time to progression or adverse pathology, respectively. RESULTS: Among 3,211 evaluable patients, 669 (21%) had FHP, 34 (1%) had FHC and 95 (3%) had both; 753 progressed on AS and 481 underwent RP. FHP was associated with increased risk of progression (HR 1.31; 95% CI, 1.11-1.55; p=0.002) but FHC (HR 0.67; 95% CI, 0.30-1.50; p=0.3) or family history of both (HR 1.22; 95% CI, 0.81-1.85; p=0.3) were not. FHP, FHC or both were not associated with adverse pathology at RP (p >0.4). CONCLUSIONS: While FHP was associated with an increased risk of progression on AS, wide confidence intervals render this outcome of unclear clinical significance. FHC was not associated with risk of progression on AS. In the absence of known genetically defined hereditary cancer syndrome, we suggest FHP and/or FHC should not be used as a sole trigger to preclude patients from enrolling on AS.

Characterization of Symptoms after Radical Prostatectomy and Their Relation to Postoperative Complications.

PURPOSE: Many patients will experience symptoms in the initial days after radical prostatectomy (RP), but early patient-reported symptoms have not been well characterized. Our objective was to illustrate the pattern of symptoms experienced after RP and the relation of severe symptoms to postoperative complications. MATERIALS AND METHODS: In 2016, electronic patient-reported symptom monitoring began at our institution's ambulatory surgery center. We retrospectively reviewed patients treated with minimally invasive RP who were sent a daily questionnaire completed using a web interface until postoperative day 10. Severe symptoms automatically generate a "yellow alert," which messages the clinic, while very severe symptoms generate a "red alert," additionally prompting the patient to call. We summarized rates of moderate-to-very severe symptoms and fit local polynomial regressions. We compared rates of 30-day or 90-day complications (grade ≥2) based on the presence of alert symptoms. RESULTS: Of 2,266 men undergoing RP, 1,942 (86%) completed surveys. Among moderate-to-very severe symptom levels, pain (72%) and dyspnea (11%) were most common. Pain, nausea and dyspnea consistently decreased over time; fever and vomiting had a flat pattern. In patients experiencing red-alert symptoms, we observed a higher risk of 30-day complications, but rates were low and differences between groups were nonsignificant (2.9% vs 1.9%; difference 1.1%; 95% CI -1.3-3.5; p=0.3). Results were similar examining 90-day complications. CONCLUSIONS: While symptoms are common after RP, substantial improvements occur over the first 10 days. Severe or very severe symptoms conferred at most a small absolute increase in complication risk, which should be reassuring to patients and clinicians.

The Duration of Antibiotics Prophylaxis at the Time of Catheter Removal after Radical Prostatectomy: Clinically Integrated, Cluster, Randomized Trial.

PURPOSE: Prophylactic antibiotics are routinely given at the time of catheter removal post-radical prostatectomy (RP). The low rate of infectious complications entails that large sample sizes are required for randomized controlled trials, a challenge given the cost of standard randomized controlled trials. We evaluated infectious complications associated with 1 vs 3 days of prophylactic antibiotics at the time of catheter removal post-RP using a novel, clinically integrated trial with randomization at the surgeon level. MATERIALS AND METHODS: Surgeons were cluster randomized for periods of 3 months to prescribe 1-day vs 3-day regimen of prophylactic antibiotics at the time of catheter removal. The primary end point was an infectious complication as routinely captured by nursing phone call within 10 days of catheter removal and defined as positive urine cultures (≥105 CFU) and at least 1 of the following symptoms: fever (>38°C), urgency, frequency, dysuria or suprapubic tenderness. RESULTS: A total of 824 patients were consented and underwent RP with, respectively, 389 and 435 allocated to 1-day and 3-day antibiotics, predominantly ciprofloxacin. Accrual was achieved within 3 years: 95% vs 88% of patients received the allocated 3-day vs 1-day antibiotic regimen. There were 0 urinary tract infections (0%) in the 1-day regimen and 3 urinary tract infections (0.7%) in the 3-day regimen, meeting our prespecified criterion for declaring the 1-day regimen to be noninferior. CONCLUSIONS: A clinically integrated trial using cluster randomization accrued rapidly with no important logistical problems and negligible burden on surgeons. If surgeons choose to prescribe empiric prophylactic antibiotics after catheter removal following RP, then the duration should not exceed 1 day.

Photoselective Vaporization of the Prostate in the Management of Lower Urinary Tract Symptoms in Prostate Cancer Patients on Active Surveillance.

OBJECTIVE: To demonstrate the safety and efficacy of photoselective vaporization of the prostate in alleviating refractory lower urinary tract symptoms in prostate cancer patients who are managed with active surveillance and to explore the association of this procedure with prostate specific antigen (PSA) levels and cancer progression rates. METHODS: Between 2008-2018, active surveillance patients who had refractory symptoms and needed surgery were studied. Perioperative functional variables were collected and analyzed. Disease progression was defined as an upgrade or upstage on surveillance biopsies or multiparametric prostate magnetic resonance imaging. Mean postop scores were estimated using locally-weighted methods. The risk of progression was reported using Kaplan-Meier's method. RESULTS: Seventy-one patients were included in the study. The median age was 68 years and the median surveillance time before surgery was 4 years. At 12 months, there were substantial improvements in the mean International Prostate Symptom Score (18-5.9), maximum flow rate (6.8-14 mL/s), postvoid residual (240-73mL), PSA (8.1-5.2 ng/mL), and prostate volume (85-57mL). At 30-days, only 2 patients with grade-III complications. Late consequences included tissue regrowth in 4 and urethral stricture (requiring a single dilation) in 3 patients. PSA levels decreased by 36% at 12 months postoperatively. With a median follow-up of 3.7 years, 7 men progressed and received radical treatment. At 3 years, the probability of remaining on surveillance was 93% (95% CI 87%- 100%). CONCLUSION: Photoselective vaporization of the prostate offers substantial relief of symptoms in active surveillance patients with refractory symptoms, without adverse effects on disease progression rates.

Intraoperative Ureteral Stent Use at Radical Cystectomy is Associated with Higher 30-Day Complication Rates.

PURPOSE: Radical cystectomy/urinary diversion is a high risk procedure. Intraoperative stents are commonly utilized to decrease ureteroenteric anastomosis related complications. Institutionally some surgeons routinely use intraoperative stents while others do not, providing an opportunity to compare complication differences. MATERIALS AND METHODS: We queried a prospective database of 283 patients enrolled in a randomized controlled trial evaluating 30-day perioperative complications with goal directed fluid therapy following open radical cystectomy/urinary diversion between 2014 and 2018. Ureteroenteric anastomosis specific complications (ureteral obstruction, urinary leak, urinary infections/sepsis and intra-abdominal abscess) were compared between groups (intraoperative stent vs nonintraoperative stent group) using Fisher exact test and quantified using logistic regression. RESULTS: The nonintraoperative stent group (77 of 283 patients, 27%) was older (median 72 vs 69 years) and was more likely to receive neoadjuvant chemotherapy (53% vs 40%), have baseline renal insufficiency (43% vs 30%) and undergo an ileal conduit (92% vs 53%). However, despite higher comorbidity, the nonintraoperative stent group had a significantly lower rate of ureteroenteric anastomosis complications (14% vs 32%, p=0.004). Since continent diversions may be associated with higher complications, the nonintraoperative stent group with ileal conduit was also compared to intraoperative stent cohorts with ileal conduit, and ureteroenteric anastomosis complications remained lower in the nonintraoperative stent group (14% vs 28%, p=0.043). Multivariable logistic regression showed significantly increased odds of urinary complications with intraoperative stent use (OR 3.55, 95% CI 2.93-4.31; p <0.0001). Importantly there was no obstruction and only 1 leak (1.3%) in the nonintraoperative stent group. CONCLUSIONS: Contrary to conventional belief, we found intraoperative stent use in radical cystectomy/urinary diversion was associated with significantly higher infectious complications and urgent care visits, and significantly increased the odds of 30-day ureteroenteric anastomosis associated complications.

Delayed presentation of urethrocutaneous fistulae after hypospadias repair.

BACKGROUND: Delayed urethrocutaneous fistula (UCF) presentation after hypospadias repair is rarely reported. The aim of this study is to report our experience with delayed UCF presenting more than 5 years after hypospadias repair. METHODS: We conducted a retrospective review of patients who underwent UCF repair (CPT codes 54,340 and 54,344) at our institution between 1997 and 2017. Delayed UCF presentation was defined as a single normal urinary stream after initial hypospadias repair and subsequent presentation of a UCF/s urinary stream more than 5 years after initial hypospadias or UCF repair. Demographic and clinical data were reviewed after approval from our institutional review committee. RESULTS: We identified 12 patients with delayed UCF. The mean age at hypospadias repair was 12.3 months (Range 6-32). The mean time to delayed UCF presentation was 11.5 years (Range 7.1-15.8). Four patients with delayed UCF (33.3%) required additional surgery for UCF recurrence with a mean time to recurrence of 2.2 years (Range < 1-5.6). CONCLUSIONS: Delayed UCF presentation can occur more than 15 years after initial repair. Pubertal penile skin changes and increased genital awareness in older children may be contributing factors as all but one presented at age 10 years or older. LEVEL OF EVIDENCE: III.

Salvage Prostate Cryoablation for the Management of Local Recurrence After Primary Cryotherapy: A Retrospective Analysis of Functional and Intermediate-Term Oncological Outcomes Associated With a Second Therapeutic Freeze.

BACKGROUND: The purpose of the study was to examine the outcomes of salvage prostate cryoablation for managing patients with local recurrence after primary cryotherapy. PATIENTS AND METHODS: The records of 108 patients treated with salvage prostate cryoablation for biopsy-proven local recurrence after primary cryotherapy were retrospectively reviewed. Oncological outcome was defined by the rate of biochemical recurrence (BCR) after salvage ablation using Phoenix criteria. RESULTS: Whole-gland (n = 91; 84.3%) or focal (n = 17; 15.7%) salvage cryoablation after failed primary cryosurgery were used. Fifty-eight of 108 patients (53.7%) had received androgen deprivation therapy (n = 35; 32.4%)/radiotherapy (n = 23; 21.3%) before salvage ablation. Two-year and 5-year BCR rates after salvage therapy were 28.2% and 48.3%, respectively. In univariate analysis, a higher Gleason score, D'Amico risk category (P < .0001) as well as prostate-specific antigen density >0.15 ng/mL/cc (P = .02) before second cryotherapy were significantly associated with the risk of BCR. In multivariable analysis, the only significant factor associated with risk of BCR after the second ablation was a higher presalvage D'Amico risk category (P = .008). Persistent urinary incontinence (1-4 pads per day) in 8 (7.4%), temporary urinary retention in 4 (3.7%), and rectourethral fistula in 4 (3.7%) patients were reported 1 year after second cryoablation. During the same period, 13.8% of patients were able to have either spontaneous or medication-augmented erections sufficient for intercourse. CONCLUSION: This series, to our knowledge, represents the largest cohort of patients who received 2 cryoablation treatments. Local failure after primary cryoablation can be salvaged by second cryosurgery with acceptable intermediate-term disease control. Patients should be counseled regarding the side effect profile associated with second cryoablation.

Predictors of Rectourethral Fistula Formation After Primary Whole-Gland Cryoablation for Prostate Cancer: Results from the Cryo On-Line Database Registry.

PURPOSE: To define the incidence and risk factors associated with rectourethral fistula (RUF) formation following primary whole-gland cryosurgery using a multicenter centralized registry. PATIENTS AND METHODS: The Cryo On-Line Data (COLD) registry was queried for men undergoing primary whole-gland cryotherapy between 1990 and 2014 who developed a RUF. Patient factors and disease parameters were correlated with RUF using chi-square and the t-test. Variables with p < 0.25 were entered into a binary logistic regression with stepwise backward elimination to determine the factors associated with RUF formation. RESULTS: A total of 4102 men underwent primary whole-gland cryotherapy in the COLD registry at the time of analysis. Postoperative RUF was documented in 50 out of 4102 cases (1.2%). Patients with RUF had similar demographic data, prostate volume, preoperative prostate-specific antigen level, and clinical stage in comparison to those without fistula. On both univariate and multivariate analyses, postoperative urinary retention (odds ratio [OR]: 6.30; confidence interval [95% CI] 3.43-11.58, p < 0.001), preoperative Gleason score of ≥7 (OR: 1.92; 95% CI 1.08-3.43, p = 0.027), and preoperative incontinence (OR: 2.95; 95% CI 1.12-7.76, p = 0.028) were the most significant risk factors associated with RUF formation. CONCLUSION: Primary whole-gland cryotherapy for prostate cancer is associated with a historically low rate (1.2%) of postoperative RUF formation. The rate decreased further to 0.55% over the last several years, suggesting better patient selection and technical improvement. Postoperative urinary retention, Gleason score ≥7, and preoperative urinary incontinence were the key demographic, clinical, and pathologic features associated with RUF formation in this study.

Effect of blood transfusions on oncological outcomes of surgically treated localized renal cell carcinoma.

OBJECTIVE: To assess the associations between perioperative allogeneic blood transfusions (ABTs) and recurrence, overall and renal cell carcinoma (RCC)-specific survival in patients undergoing surgical treatment for clinically localized disease. MATERIALS AND METHODS: We performed a retrospective review of 1,056 consecutive patients undergoing surgical treatment (radical or partial nephrectomy) for clinically localized RCC between 2000 to 2010. Demographic (age, race, and sex) clinical (preoperative hemoglobin and hematocrit, type of surgery [partial or radical nephrectomy]), and pathological (T and N stages, RCC histotype, grade) data were compared between patients receiving perioperative (intraoperative or postoperative) blood transfusions and those who are not. Distant and local recurrence-free survival, overall survival, RCC-specific survival were recorded and Kaplan-Meier survival curves as well as multivariable proportional regression models adjusted for clinical and pathological characteristics were produced. RESULTS: On multivariable analyses adjusted for clinical and pathological characteristics, the receipt of ABTs was associated with lower recurrence-free (HR = 1.86, P = 0.002), overall (HR = 1.83, P = 0.016), and RCC-specific survival (HR = 2.12, P = 0.031). The negative effect of ABTs was apparent for distant (HR = 2.24, P<0.001) but not local recurrences (HR = 0.78, P = 0.643). Limitations include retrospective nature and lack of uniform criteria for blood transfusion during the study period. CONCLUSIONS: In this study, perioperative ABTs were independently associated with worse oncological outcomes in patients with clinically localized RCC. Receipt of ABT was associated with roughly a 2-fold increase in the hazard of metastatic progression, all-cause and RCC-specific mortality. Further research is needed on the mechanisms of transfusion-induced immunomodulation, alternative transfusion protocols and methods for autologous blood transfusion and recovery.

Liver resection for metastases not of colorectal, neuroendocrine, sarcomatous, or ovarian (NCNSO) origin: A multicentric study.

BACKGROUND: Liver resection is a well-established treatment for colorectal, neuroendocrine and sarcomatous metastases but remains ill-defined for metastases from other primary sites. This study aimed to analyze the outcomes of hepatic resection for metastases not of colorectal, neuroendocrine, sarcomatous, or ovarian (NCNSO) origin and to identify predictors of outcome. METHODS: Retrospective analysis of patients undergoing resection for NCNSO metastases in three western centers. Patients were analyzed according to the primary cancer. Outcomes were recurrence and survival. RESULTS: We analyzed 188 patients, divided in: gastrointestinal (59), breast (59) and "others" (70). Median time to recurrence was 15.3 months, while median survival was 52 months. Survival at 1, 3, and 5 years was 78%, 60.4% and 47.8%, respectively. In term of prognostic factors, metastases >35 mm from gastrointestinal tumors were associated with lower survival (p = 0.029) and age>60 years was associated with better survival in breast metastases (p = 0.018). CONCLUSIONS: Liver resection for NCNSO metastases is feasible and results in long-term survival are similar to colorectal metastases. In gastrointestinal metastases, size (<35 mm) could be used to select patients.

Subcapsular Splenic Urinoma and Splenorenal Fistula: A New Complication of Percutaneous Nephrolithotomy.

Background: Splenic urinoma has not been previously reported as a complication of percutaneous nephrolithotomy (PNL). Case Presentation: A 46-year-old Caucasian male underwent PNL for two large left renal stones. Surgery was performed in prone split-leg position, with access obtained through combined fluoroscopic guidance and direct ureteroscopic observation of the targeted calix. The tract was dilated to 30F using a pressure balloon, and complete clearance of stones was obtained through a combination of rigid and flexible nephroscopy, as well as antegrade ureteroscopy. The patient was left with a Double-J ureteral stent on a string for removal in 1 week. After overnight observation, his hemoglobin, white blood cell count, and renal function were normal and thus he was discharged home. The day after stent removal, he presented to the emergency department with abdominal pain, was found to have mild left hydronephrosis on CT, and was discharged on 1 week of antibiotics. One week later he re-presented with worsening abdominal pain and was found to have an elevated creatinine and a white blood cell count of 21 × 109/L. On contrasted CT with delayed images, an 18 cm splenic fluid collection was seen with a fistulous connection to the left kidney collecting system. He underwent emergent stent placement and improved clinically without drainage of the urinoma. A renal ultrasonography 1 month after stent placement confirmed resolution of the splenic urinoma, so the stent was removed at 1 month. Follow-up CT 1 month after stent removal was normal without any evidence of fistula or urinoma recurrence. Conclusion: This is the first report of a subcapsular splenic urinoma and splenorenal fistula post-PNL. Ureteral stent placement was sufficient for drainage and to resolve the complication.

Over half of contemporary clinical Gleason 8 on prostate biopsy are downgraded at radical prostatectomy.

INTRODUCTION: Contemporary clinical guidelines utilize the highest Gleason sum (HGS) in any one core on prostate biopsy to determine prostate cancer treatment. Here, we present a large discrepancy between prostate cancer risk stratified as high risk on biopsy and their pathology after radical prostatectomy. MATERIALS AND METHODS: We retrospectively reviewed 1424 men who underwent either open or robotic-assisted prostatectomy between 2004 and 2015. We analyzed 148 men who were diagnosed with HGS 8 on prostate biopsy. Biopsy and prostatectomy pathology were compared in aggregate and over 1 year time intervals. Chi-squared test, Fisher's exact test, Student's t-test, and Wilcoxon Rank-Sum test were used for statistical analysis. RESULTS: A total of 61.5% (91/148) of clinical HGS 8 diagnoses were downgraded on prostatectomy, with 58.8% (87/148) downgraded to Gleason 7 (Gleason 4 + 3 n = 59; Gleason 3 + 4 n = 28). Factors associated with downgrading include lower prostate-specific antigen (PSA) at biopsy (median 6.8 ng/mL versus 9.1 ng/mL, p < 0.001), number of Gleason 8 biopsy cores (median 1 versus 2, p < 0.02), presence of Gleason pattern 3 on biopsy cores (67.9% versus 44.8%, p < 0.03), pT2 staging (72.4% versus 55.1%, p < 0.04), positive margins (53.9% versus 69.1%, p < 0.04), extracapsular extension (53.4% versus 74.1%, p < 0.02), and smaller percent tumor (median 10% versus 15%, p < 0.004). CONCLUSION: The large percentage of pathology downgrading of biopsy-diagnosed HGS 8 suggests suboptimal risk-stratification that may lead to suboptimal treatment strategies and much patient distress. Our study adds great urgency to the efforts refining prostate cancer clinical assessment.

Limited Fibrosis Progression but Significant Mortality in Patients Ineligible for Interferon-Based Hepatitis C Therapy.

BACKGROUND: Individuals ineligible for interferon-based hepatitis C therapy may have a worse prognosis than patients who have failed or not received treatment. AIMS: To provide information about the limitations of medical treatment of hepatitis C in real-world patients. METHODS: We studied 969 treatment-ineligible patients and 403 treated patients enrolled between 1/1/01 and 6/30/06; data were collected until 3/31/13. Treatment barriers were grouped into five categories and classified as health-related or health-unrelated. Fibrosis stage was assessed initially and at the end of follow-up. Mortality was determined by search of the Social Security database. Death certificates of treatment-ineligible patients were reviewed. RESULTS: Initially, 288 individuals had advanced fibrosis and compensated disease; 87 untreated patients developed advanced fibrosis during follow-up. Health-related treatment barriers were more commonly associated with fibrosis progression and worse survival. During follow-up, 247 untreated patients died: 47% of liver-related and 53% of liver-unrelated causes. Patients with significant comorbid illness had the worst five- (70%) and ten-year (50.5%) survival. Despite high mortality (47%) in persons with decompensated liver disease, no treatment barrier was associated with a greater incidence of liver-related death. Only significant comorbid medical illness was an independent predictor of disease progression; however, it was not associated with a greater incidence of liver-related death. Furthermore, treated patients had better 10-year survival than untreated patients on Kaplan-Meier analysis (80.3% vs. 74.5%, P = 0.005). CONCLUSION: Many patients with hepatitis C will die of non-liver-related causes and may not be helped by anti-viral treatment.

Impact of glycemic control on colonoscopy outcomes: bowel preparation and polyp detection.

BACKGROUND: The negative effect of diabetes mellitus (DM) on the colonoscopy preparation has been previously established. Metabolic syndrome has been shown to increase risk for malignancy and possibly for premalignant lesions. This study aimed to investigate the impact of DM control on colonoscopy outcomes including bowel preparation and adenoma detection rate (ADR). METHODS: We included patients with DM who underwent colonoscopy in our hospital and had a documented glycated hemoglobin (HbA1C) within 3 months. Patients were categorized into three groups based on their HbA1C level. The clinical and endoscopic data were collected and analyzed. RESULTS: Our cohort included 352 DM patients. The mean age was 63.5 years. When patients were analyzed based on HBA1C, bowel preparation was poor in 46.7% of patients with good glycemic control, 52.1% of patients with fair control and 50% of patients with poor control. ADR was 24.3% in patients with good glycemic control, 20.2% in patients with fair glycemic control and 27.1% in patients with poor glycemic control. There was no statistically significant difference in the quality of preparation or adenoma detection amongst the groups. CONCLUSION: The degree of glycemic control did not impact the quality of bowel preparation or ADR.

The role of hepatic resection in the treatment of hepatocellular cancer.

UNLABELLED: Current guidelines recommend surgical resection as the primary treatment for a single hepatocellular cancer (HCC) with Child's A cirrhosis, normal serum bilirubin, and no clinically significant portal hypertension. We determined how frequently guidelines were followed and whether straying from them impacted survival. BRIDGE is a multiregional cohort study including HCC patients diagnosed between January 1, 2005 and June 30, 2011. A total of 8,656 patients from 20 sites were classified into four groups: (A) 718 ideal resection candidates who were resected; (B) 144 ideal resection candidates who were not resected; (C) 1,624 nonideal resection candidates who were resected; and (D) 6,170 nonideal resection candidates who were not resected. Median follow-up was 27 months. Log-rank and Cox's regression analyses were conducted to determine differences between groups and variables associated with survival. Multivariate analysis of all ideal candidates for resection (A+B) revealed a higher risk of mortality with treatments other than resection. For all resected patients (A+C), portal hypertension and bilirubin >1 mg/dL were not associated with mortality. For all patients who were not ideal candidates for resection (C+D), resection was associated with better survival, compared to embolization and "other" treatments, but was inferior to ablation and transplantation. CONCLUSIONS: The majority of patients undergoing resection would not be considered ideal candidates based on current guidelines. Not resecting ideal candidates was associated with higher mortality. The study suggests that selection criteria for resection may be modestly expanded without compromising outcomes, and that some nonideal candidates may still potentially benefit from resection over other treatment modalities.

Outcomes following resection of intrahepatic cholangiocarcinoma.

OBJECTIVES: The aim of this analysis was to examine prognostic features and outcomes in patients undergoing resection for intrahepatic cholangiocarcinoma (ICC). METHODS: A retrospective chart review was performed in all patients who underwent R0 or R1 resection for primary ICC between 1995 and 2011. Clinical data were abstracted and statistical analyses were conducted in the standard fashion. RESULTS: A total of 82 patients underwent curative hepatectomy for primary ICC; 51 patients in this cohort developed recurrence. The median follow-up of survivors was 27 months (range: 1-116 months). Recurrences were intrahepatic (65%), associated with multiple tumours (54%) and occurred during the first 2 years after hepatectomy (86%). The main factor associated with recurrence after resection was the presence of satellite lesions. Overall 5-year disease-free survival after primary resection was 16%. Factors associated with poor survival were transfusion and perineural invasion. Treatment of recurrence was undertaken in 89% of patients and repeat surgical resection was performed in 15 patients. The 3-year survival rate after recurrence was 25%. Prolonged survival after recurrence was associated with a solitary tumour recurrence. CONCLUSIONS: Despite curative resection of ICC, recurrence can be expected to occur in 79% of patients at 5 years. Predictors of survival and recurrence after resection vary in the literature. In patients with recurrence, selection of the optimal treatment remains challenging.

Recurrence of hepatocellular cancer after resection: patterns, treatments, and prognosis.

OBJECTIVE: We sought to determine the factors associated with survival after recurrence of hepatocellular cancer (HCC) after resection and the outcome of our prospectively applied treatment protocol. BACKGROUND: Very little is known about the prognosis of HCC that recurs after resection and the outcomes associated with treatments applied to recurrent tumors. METHODS: A total of 661 HCC patients undergoing resection from January 1988 to January 2011 were reviewed to identify those with recurrence. Single recurrences with preserved liver function, and no portal hypertension were treated with resection. Patients with multiple intrahepatic tumors or poor liver function and no major comorbidities were listed for transplantation. Patients with up to 3 tumors, each 4 cm or smaller, and not eligible for transplantation, received ablation. Patients not eligible for ablation received embolization. Other treatments such as systemic therapy and radiation were used in remaining patients, but not in a systematic manner. RESULTS: Recurrent HCC developed in 356 (54%) patients at a median time of 22 months from primary resection. Median survival from time of recurrence to death was 21 months. Variables independently associated with survival from recurrence included time from primary resection to recurrence, alpha-fetoprotein more than 100 ng/mL at recurrence, recurrent tumor larger than 3 cm, BCLC stage at recurrence, and type of treatment rendered for the recurrence. All variables except treatment modality were significantly correlated with characteristics of the original primary tumor. CONCLUSIONS: Most of the variables associated with outcome after recurrence are linked to the primary tumor at initial presentation. Nevertheless, meaningful survival can be achieved with appropriate treatment of recurrent tumors.

Cytoreductive surgery with or without hyperthermic intraperitoneal chemotherapy in patients with peritoneal hepatocellular carcinoma.

BACKGROUND AND OBJECTIVES: The benefit of Sorafenib is not well described in patients with peritoneal hepatocellular carcinoma (HCC). Although cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have shown favorable outcomes in certain malignancies, their role in peritoneal HCC remains unknown. We present a series of patients with peritoneal HCC treated with CRS +/- HIPEC and evaluate their clinicopathologic characteristics and outcomes. METHODS: Between 07/07-08/12, 14 patients with limited disease to the peritoneum underwent CRS. Seven of these patients received additional HIPEC treatment. Primary endpoint was overall survival. RESULTS: Operative treatment was directed for metachronous peritoneal disease in the majority (92.8%) of patients. Mean intraoperative PCI was 9.9 (± 8.3) and complete mascroscopic cytoreduction (CCR 0-1) was achieved in all but one case. Overall major morbidity rate (Clavien-Dindo III-IV) at 30 days was 7.1%. One postoperative death occurred in a patient with extensive tumor burden (PCI = 33, CCR2). Median follow-up after initial surgery was 43.8 months and the median time to metachronous peritoneal recurrence was 23 months. Three-year recurrence rate after peritoneal resection was 100%. Median survival of the cohort CCR0-1 was 35.6 months. CONCLUSION: Treatment of peritoneal HCC remains challenging and survival is poor. In well-selected candidates, however, CRS +/- HIPEC may prolong survival compared to systemic therapy alone in patients with peritoneal HCC.