Intraoperative Optical Biopsy during Robotic Assisted Radical Prostatectomy Using Confocal Endomicroscopy.

PURPOSE: Intraoperative optical biopsy technologies may aid in the identification of important anatomical landmarks and improve surgical outcomes of robotic assisted radical prostatectomy. We evaluate the feasibility of confocal laser endomicroscopy during robotic assisted radical prostatectomy. MATERIALS AND METHODS: A total of 21 patients with biopsy proven prostate cancer scheduled for robotic assisted radical prostatectomy were recruited. After intravenous administration of fluorescein 15 patients underwent in vivo intraoperative confocal laser endomicroscopy of prostatic and periprostatic structures using a 2.6 or 0.85 mm imaging probe. Standard robotic instruments were used to grasp and maneuver the confocal laser endomicroscopy probes for image acquisition. Confocal laser endomicroscopy imaging was performed ex vivo on fresh prostate specimens from 20 patients. Confocal video sequences acquired in vivo and ex vivo were reviewed and analyzed, with additional image processing using a mosaicing algorithm. Processed confocal images were compared with standard hematoxylin and eosin analysis of imaged regions. RESULTS: Confocal laser endomicroscopy was successfully integrated with robotic surgery, including co-registration of confocal video sequences with white light and probe handling with standard robotic instrumentation. Intraoperative confocal laser endomicroscopy imaging of the neurovascular bundle before and after nerve sparing dissection revealed characteristic features including dynamic vascular flow and intact axon fibers. Ex vivo confocal imaging of the prostatic parenchyma demonstrated normal prostate glands, stroma and prostatic carcinoma. CONCLUSIONS: We report the initial feasibility of optical biopsy of prostatic and periprostatic tissue during robotic assisted radical prostatectomy. Image guidance and tissue interrogation using confocal laser endomicroscopy offer a new intraoperative imaging method that has the potential to improve the functional and oncologic outcomes of prostate cancer surgery.

Trends in Adjuvant and Neoadjuvant Radiotherapy for Cancer Treatment From 1973 to 2011.

PURPOSE: Cancer care is becoming increasingly complicated, in particular with the integration of radiation and surgery. Institutions may need to increase coordination between multidisciplinary clinical teams to optimize patient care. This study examines historical trends in adjuvant and neoadjuvant radiation therapy (ANRT) before or after cancer-directed surgery to identify disease sites that may benefit from coordinated care. METHODS: The Surveillance, Epidemiology, and End Results database was queried to identify patients with bladder cancer; breast cancer; cervical cancer; colorectal cancer; kidney cancer; cancer of the lung, bronchus, and pleura; lymphoma; melanoma; cancer of the oral cavity and pharynx; ovarian cancer; pancreatic cancer; prostate cancer; thyroid cancer; and uterine cancer from 1973 to 2011. Number and percentage of patients who received ANRT were calculated from 1973 to 2011. RESULTS: Adjuvant and neoadjuvant radiation therapy usage increased from 14% in 1973 to 19% in 2011. Adjuvant and neoadjuvant radiation therapy use for breast, oral cavity/pharynx, and thyroid cancers increased from 24%, 16%, and 9% in 1973 to 53%, 32%, and 46% in 2011, respectively. Changes in ANRT were seen in gynecologic and genitourinary cancers, with increased use of ANRT in cervical cancer and declines in uterine, ovarian, bladder, prostate, and kidney cancers. There were minimal changes in ANRT usage for patients within other diagnosis groups. DISCUSSION: Overall usage of ANRT is increasing over time, with increased need for coordinated care in breast and head and neck cancers. Adjuvant and neoadjuvant radiation therapy in genitourinary and gynecologic cancers is undergoing significant change.

A Pilot Study of In Vivo Confocal Laser Endomicroscopy of Upper Tract Urothelial Carcinoma.

PURPOSE: Tissue diagnosis of upper tract urothelial carcinoma (UTUC) is limited by variance in tumor sampling by standard ureteroscopic biopsy. Optical imaging technologies can potentially improve UTUC diagnosis, surveillance, and endoscopic treatment. We previously demonstrated in vivo optical biopsy of urothelial carcinoma of the bladder using confocal laser endomicroscopy (CLE). In this study, we evaluated a new 0.85-mm imaging probe in the upper urinary tract and demonstrated feasibility and compatibility with standard ureteroscopes to achieve in vivo optical biopsy of UTUC. MATERIALS AND METHODS: Fourteen patients scheduled for ureteroscopy of suspected upper tract lesions or surveillance of UTUC were recruited. After intravenous (IV) administration of fluorescein, CLE was performed using a 0.85-mm-diameter imaging probe inserted through the working channel of standard ureteroscopes. Acquired confocal video sequences were reviewed and analyzed. A mosaicing algorithm was used to compile a series of images into a single larger composite image. Processed CLE images were compared with standard histopathologic analysis. RESULTS: Optical biopsy of the UTUC using CLE was effectively achieved during standard ureteroscopy. There were no adverse events related to IV fluorescein administration or image acquisition. Confocal imaging of UTUC showed characteristic features similar to urothelial carcinoma of the bladder, including papillary structure, fibrovascular stalks, and pleomorphism. Lamina propria in normal areas of the renal pelvis and ureter was also identified. CONCLUSIONS: We report an initial feasibility of CLE of UTUC. Pending further clinical investigation, CLE may become a useful adjunct to ureteroscopic biopsy, endoscopic ablation, and surveillance of UTUC.

Pseudo-guillain-barre syndrome due to "whippet"-induced myeloneuropathy.

Guillain-Barre syndrome (GBS) is the rubric encompassing highly variable phenotypic subgroups of acute, postinfectious, immune-mediated peripheral neuropathy. The hallmark of GBS phenomenology is a rapidly progressive ascending lower extremity weakness. GBS taxonomy includes a motor and sensory axonal neuropathy (AMSAN). Nitrous oxide (NO) abuse may create a pattern of neurological dysfunction almost identical to subacute combined degeneration. We report an adult with myeloneuropathy due to NO abuse that mimicked the presenting features of the GBS-subtype AMSAN.