[Impact of an active surveillance program and infection control measures on the incidence of carbapenem-resistant gram-negative bacilli in an intensive care unit]. / Impacto de un programa de vigilancia activa y medidas de control de infecciones sobre la incidencia de bacilos gram negativos resistentes a carbapenems en una unidad de cuidados intensivos.

Hospital-acquired infections caused by carbapenem-resistant Gram-negative bacteria (CRGNB) have been increasingly reported worldwide and are associated with high rates of mortality especially in intensive care units(ICUs). Early identification through rectal surveillance cultures and implementation of infection control measures(ICM) including contact precautions, staff education on cleaning and hand hygiene may reduce the spread of these microorganisms. The aim of this work was to assess the impact of enhanced ICM on CRGNB colonization and to describe the molecular epidemiology of these bacteria in a polyvalent ICU in a tertiary level hospital. A prospective study including audits and active surveillance culture program, with molecular characterization, was conducted before and after the implementation of prevention programs and infection control measures. Microbiological screening was performed in chromogenic media; PCR targeting ß-lactamases genes (blaKPC, blaNDM, blaVIM and blaOXA-48, blaSHV and blaCTX-M), molecular typing by PFGE; and MLST in K. pneumoniae were performed. CRGNB colonization was reduced from 16.92% to 9.67% upon implementing the infection control measures. In K. pneumoniae the most frequent carbapenemase type was KPC-2 associated with SHV-2 and CTX-M-15, and was disseminated in various STs (ST17, ST13, ST2256, ST353); there was no persistence of particular clones and virulence factors showed no association with hypervirulence. IMP-1 carbapenemase predominated in A. baumannii and the PFGE analysis individualized 3 clusters, assuming that the dissemination in the ICU was clonal. The early detection of patients colonized with CRBGN by using epidemiological surveillance cultures and the implementation of prophylactic measures are key to reducing the incidence of these microorganisms.

Clinical and histological predictive factors of reclassification of prostate cancer patients on active surveillance.

INTRODUCTION AND OBJECTIVE: Active surveillance (AS) has been established as a therapeutic strategy in patients with low-risk prostate cancer. Demographic and anatomopathological factors that increase the probability of reclassifying patients have been identified. MATERIALS AND METHODS: Laboratory and histopathological data were collected from 116 patients included on AS since 2014. Univariate analysis was performed with Chi-square, t-student and Kendall's Tau, multivariate analysis according to logistic regression and Kaplan-Meier curves were calculated. RESULTS: Of the 116 patients in AS, the median age at diagnosis was 66 years and the median follow-up was 13 months (2-72). Of these, 61 (52.6%) are still on surveillance, while 55 (47.4%) have left the program, mostly due to histological progression (52 patients (45.2%)); radical prostatectomy was performed in 27 (49.1%). Prostate volume (PV)≤60cc and the number of positive cylinders >1 in diagnostic biopsy (P=.05) were associated with higher reclassification rate in univariate analysis (P<.05). Multivariate analysis showed that these two variables significantly correlated with higher reclassification rate (PV 60 cc: OR 4.39, P=.04; >1 positive cylinder at diagnostic biopsy: OR 2.48, P=.03). CONCLUSIONS: It has been shown that initial ultrasound volume and the number of positive cylinders in the diagnostic biopsy are independent risk factors for reclassification. Initial PSA, laterality of the affected cylinders and PSA density were not predictive factors of progression in our series.

Could Prognostic Nutritional Index be a new criteria for active surveillance of prostate cancer?

OBJECTIVE: To evaluate the importance of the Prognotic Nutritional Index(PNI) value for patient selection of active surveillance(AS) in prostate cancer. METHODS: Between September 2020 and June 2022, the data of 125-patients who underwent Robot-Assisted-Laparoscopic-Prostatectomy(RALP) were retrospectively analyzed. All patients were suitable for AS preoperatively. Using the pathological results of RALP, patients have been divided two groups. Patients who met the criteria for AS were defined as the first group, others were defined second. Demographic datas, PNI values and hematological parameters of the groups were compared. RESULTS: 38% (n:48) patients were found suitable for the group1, and 62%(n:77) were found suitable for the group 2. Upgrading and upstaging were found at 76 patients (61%) and 26(21%), respectively. There is no significant difference between groups on age, BMI, PSA, PSA-density, prostate volume, and PIRADS. PNI value was found higher at first group. The value of 49.45 was calculated by ROC analysis as the ideal PNI cut-off value for predicting upgrading and upstaging of prostate cancer (P < ,001). According to the both univariate and multivariate regression analysis, PNI was found a predictor for exclusion from AS (P < ,001). CONCLUSION: Upgrading and upstaging are detected at a higher rate in patients with low PNI values. The use of PNI value in the selection of patients to AS will increase the success rate of ideal patient selection.

Optimization of PSA and its variants and other biomarkers for the follow-up of low-risk prostate cancer in active surveillance. / Optimización del PSA y sus variantes y otros biomarcadores para el seguimiento del cáncer de próstata de bajo riesgo en vigilancia activa.

INTRODUCTION AND OBJECTIVES: Active surveillance (AS) is currently a therapeuticstrategy recommended by all Clinical Guidelines forthe initial management of very low-risk, low-risk, andsome intermediate-risk prostate cancer (PCa). However,a high percentage of cases will present the need for active treatment and a quarter of them will presentunfavorable anatomopathological characteristics. METHODS: review of the biomarkers' literature oncircumscribed to the inclusion and follow-up of patientsin AS. RESULTS: PSA and its variants remain the most widelyused and most cost-effective biomarker in AS. Inparticular, the use of PSA density based on the prostatevolume detected by mpMRI has gained much weight.Different multipanel biomarkers in blood and urineare commercially available to predict progressionto PCa ≥3 + 4 (GG2), but they have not clearly beenprospectively tested in AS cohorts. Tissue biomarkersanalyze gene panels that offer predictive informationindependent of classical clinicopathological variablesand may play a role in controversial indications for AS.Lastly, risk calculators are cost-effective and validatedfor their care use in AS and are probably underused. CONCLUSIONS: Although there is no specific biomarkerfor the optimization of AS, its rational use togetherwith mpMRI may in the future optimize the inclusionof patients in AS and follow-up differentiatedby risk groups.

INTRODUCCIÓN Y OBJETIVOS: La vigilanciaactiva (VA) es actualmente una estrategia terapéuticarecomendada por todas las Guías Clínicaspara el manejo inicial del cáncer de próstata (CaP) deriesgo muy bajo, bajo riesgo y algún caso de riesgo intermedio.Sin embargo, un alto porcentaje de casospresentarán necesidad de tratamiento activo y de ellosuna cuarta parte presentarán características anatomopatológicasdesfavorables.MÉTODOS: Revisión de la literatura en biomarcadoresutilizables en práctica asistencial circunscritos a lainclusión y seguimiento de pacientes en VA.RESULTADOS: El PSA y sus variantes sigue siendo elbiomarcador más utilizado y más costo-efectivo en VA.En concreto ha ganado mucho peso el uso de la densidadde PSA basándose en el volumen prostático detectado por RMmp. Distintos biomarcadores multipanelen sangre y orina son asequibles comercialmentepara predecir la progresión a CaP ≥ 3+4 (GG2), perono han sido claramente testados prospectivamenteen cohortes de VA. Los biomarcadores tisulares analizanpaneles de genes que ofrecen una informaciónpredictiva independiente de las variables clínico-patológicasclásicas y pueden tener su papel en indicacionescontrovertidas de VA. Por último, las cálculadorasde riesgo sí que son costo-efectivas y validadaspara su uso asistencial en VA y probablemente estáninfrautilizadas.CONCLUSIONES: Si bien no existe un biomarcadorespecífico para la optimización de la VA, su uso racionaljunto a la RMmp puede optimizar en un futuro lainclusión de pacientes en VA y seguimientos diferenciadospor grupos de riesgo.

Surveillance and office management of low-grade Ta bladder tumors.

OBJECTIVE: Patients with low-grade (LG), grade 1-2, Ta bladder cancer (BC) will frequently have a "recurrence". However, they rarely progress in stage. Although current guidelines mention surveillance and office management for these new or recurrent tumors, transurethral resection (TURBT) is the most common treatment. The purpose of this study is to determine if surveillance and/or office cautery is safe. MATERIALS AND METHODS: This study was conducted as a retrospective case series analysis of 45 patients who had recurrent LG Ta appearing bladder cancer (BC) and were managed primarily with surveillance and/or office cautery. Patients with carcinoma in-situ were excluded. The primary outcome was stage progression. RESULTS: Median follow up was 62 months. 41 (91%) patients did not progress in stage. Three patients recurred with HG T1 BC; one is receiving systemic immunotherapy. One patient developed HG T2 BC and was treated with a bladder preservation protocol. 40 (89%) patients underwent office cauterization. Eleven received BCG and 26 received post-cautery intravesical chemotherapy. Five (11%) patients developed HG BC during follow up. No patients died. None of the 17 (38%) Hispanic patients had progression. CONCLUSIONS: Active surveillance and/or office cautery for patients with small recurrent LG Ta bladder tumors is safe, reduces cost and improves quality of life by avoiding TURBTs.

Active surveillance protocol in prostate cancer in Portugal.

OBJECTIVE: To examine clinical practice patterns in locally managing patients under an active surveillance protocol among Portuguese urologists. INTRODUCTION: Prostate cancer (PCa) is a heterogeneous disease with many prostate adenocarcinomas being indolent and a low probability of ever causing symptoms or death. Active surveillance (AS) is a form of conservative management aimed to reduce over-treatment for low-risk PCa patients. Over the years, experience with AS has grown considerably and is now standard in some countries, however a universal protocol still does not exist. METHODS: Nationwide anonymous e-survey concerning habits and practices on AS among Portuguese urologists, that consisted of twelve questions and was sent electronically to all 368 current members of the Portuguese Urological Association. RESULTS: 56 urologists were surveyed (15.21% answer rate), evenly distributed geographically and allocated according to years of experience as well as number of PCa patients managed monthly. The vast majority of respondents recommends AS to their patients, particularly ISUP grade 1 patients, whose PSA serum level is bellow 20 ng/mL. Observance of AS programs by patients was not in question but concerns exist over psychological morbidity while harboring disease. Majority believed that international guidelines surveillance protocols were adequate and sufficient, but there are some constraints concerning availability of periodic MRIs and re-biopsy needs. CONCLUSIONS: AS seems to be sustained in urologist clinical practice, although patients still lag to adhere and choose for active treatment. AS may not be an easy choice for patients and clinicians due to uncertainty of disease progression, risk of loss to follow-up and repeated biopsies but is also a cause for anxiety, depression, uncertainty and a perception of danger.

[Active surveillance for patients with localized prostate cáncer. Adherence and protocol drop analysis.] / La vigilancia activa en pacientes con cáncer de próstata localizado. Análisis de adherencia y salida del protocolo.

OBJECTIVE: VA is currently considered the treatment of choice for patients with low and very low risk prostate cancer. We analyzed the evolution of this treatment strategy in our series and adherence to the protocol. MATERIAL AND METHODS: Ambispective study of patients in VA in our center between 2014- 2019. 237 meet inclusion criteria, of which 142 (60%) have a minimum of 12 months of follow- up. Mean age: 68.5 (4678), median PSA 6.37 ng / ml (1-33). 229 (96.6%) are ISUP 1 and 8 (3.4%) ISUP 2. Objectives are proposed to assess our adherence to the protocol. Descriptive statistics are used to communicate the results. RESULTS: According to the classification by risk groups of the NCCN, 145 (61.2%), 49 (20.7%) and 42 (17.7%) were very low risk, low risk and favorable intermediate risk patients, respectively. The median of follow-up is 14 months (0-66). Of the patients with a minimum follow-up of 12 months, 107 (75.4%) were re-biopsied. 80 (33.8%) leave the protocol in these 5 years, 31.3% (25) by their own decision, 55% (44) due to medical criteria, and 11.3% (9) go to WW. After 5 years of follow-up, 99.2% of patients are still alive, 0.8% died of specific non-cancer causes. Of the objectives to assess adherence, 8 are achieved, 1 partially and 1 is not evaluable. CONCLUSIONS: VA in our center is already the treatment of choice for very low-risk patients, with a constant increase from year to year. Adherence to the protocol has been favorable during the period of time studied.

OBJETIVO: La VA se ha convertido en uno de los tratamientos de elección del CP localizado de bajo y muy bajo riesgo. Analizamos la evolución de esta estrategia de tratamiento en nuestra serie, así como la adherencia al protocolo.MATERIAL Y MÉTODOS: Estudio ambispectivo de los pacientes incluidos en VA en nuestro centro entre los años 2014-2019. 237 pacientes cumplen los criterios de inclusión en VA, de los cuales 142 (60%) tienen un seguimiento mínimo de 12 meses. Edad media: 68,5(46-78), mediana PSA 6,37 ng/ml (1-33). 229 pacientes (96,6%) son ISUP 1 y 8 (3,4%) ISUP 2. Se proponen unos objetivos para valorar nuestra adherencia al protocolo. Se utiliza estadística descriptiva y contraste de hipótesis para comunicar los resultados.RESULTADOS Y DISCUSIÓN: Atendiendo a la clasificación por grupos de riesgo de la NCCN, 145 (61,2%), 49 (20,7%) y 42 (17,7%) eran pacientes muy bajo riesgo, bajo riesgo y riesgo intermedio favorable respectivamente. El tiempo (mediana) de permanencia en el programa es de 14 meses (0-66). De los pacientes con un seguimiento mínimo de 12 meses, 107 (75,4%) son re ­ biopsiados. 80 pacientes (33,8%) salen del protocolo en estos 5 años, 31,3% (25) por decisión propia, 55% (44) por criterios médicos, y 11,3% (9) pasan a WW. Tras 5 años de seguimiento, el 99,2% de los pacientes continúan vivos, el 0,8% falleció por causas no cáncer específicas. De los objetivos para evaluar la adherencia, 8 de ellos se alcanzan, 1 parcialmente y 1 no es evaluable. CONCLUSIONES: La VA en nuestro centro constituye actualmente el tratamiento de elección para los pacientes con muy bajo riesgo. La adherencia al protocolo ha sido favorable durante el periodo de tiempo estudiado.

Role of PCA3 and SelectMDx in the optimization of active surveillance in prostate cancer.

INTRODUCTION & OBJECTIVES: A not negligible percentage of patients included in active surveillance (AS) for low and very low risk prostate cancer (PCa) are reclassified in the confirmatory biopsy or have disease progression during follow-up. Our aim is to evaluate the role of PCA3 and SelectMDx, in an individual and combined way, in the prediction of pathological progression (PP) in a standard AS program. MATERIALS & METHODS: Prospective and observational study comprised of 86 patients enrolled in an AS program from 2009 to 2019, with results for PCA3 and SelectMDx previous to PCa diagnosis or during their confirmatory period. Univariate and multivariate analysis were performed to correlate PCA3 and SelectMDx scores as well as clinical and pathological variables with PP-free survival (PPFS). The most reliable cut-offs for both biomarkers in the context of AS were defined. RESULTS: SelectMDx showed statistically significant differences related to PPFS (HR 1.035, 95%CI: 1.012-1.057) (p = 0.002) with a C-index of 0.670 (95%CI: 0.529-0.810) and AUC of 0.714 (95%CI: 0.603-0.825) at 5 years. In our series, the most reliable cut-off point for SelectMDx was 5, with a sensitivity and specificity for PP of 69.8% and 67.4%, respectively. Same figure for PCA3 was 65, with a sensitivity and specificity for PP of 51.16% and 74.42%, respectively. The combination of both biomarkers did not improve the prediction of PP, C-index 0.630 (95%CI: 0.455-0.805). CONCLUSIONS: In the context of low or very low risk PCa, SelectMDx > 5 predicted 5 years PP free survival with a moderate discrimination ability outperforming PCA3. The combination of both tests did not improved outcomes.

[Active surveillance for testicular tumors: adherence and safety.] / Adherencia y seguridad de la vigilancia activa en tumores de testículo.

INTRODUCTION: The active surveillance (AS) of testicular tumors (seminoma and non-seminoma) is the most frequent management option in the stage I disease. Relapses generally occurred within the first 3 years and <5% appear after this time cut-off point is fulfilled. Therefore, the adherence is one of the most important pillars in the AS protocol. The aim of this study is to evaluate the adherence to the AS protocol in a community hospital and, in turn, evaluate the safety of it emphasizing in the relapse-free rate in patients with and without risk factors. MATERIALS AND METHODS: A retrospective study of all the patients included in the AS protocol with seminoma tumors (ST) or non-seminoma tumors (NST) stage I was performed. Postoperative controls were performed according to the NCCN (National Comprehensive Cancer Network) recommendations. Different variables were taken into account, emphasizing in the risk factors: testicular tumor >4cm and the rete testis invasion in the ST, the linfovascular invasion and the percentage>40% of embrionary carcinoma in the NST. Adherence to the AS protocol was evaluated, focusing on those patients who lost it and what time it occurred. RESULTS: A total of 64 patients were included. The median follow-up was 36 months (IC 21-48 months). 12 patients lost the follow-up during the protocol with a median follow-up of 27.5 months (IC 16-30 months). A 21.8% of patients entered in the AS protocol with some associated risk factor. Adherence follow-up was successful in the first year (96.8%) and decreased over time (92.2% at 24 months and 86.3% at 36 months). CONCLUSION: We presented an important adherence to the AS protocol in patients with clinical stage I testicular cancer and in our series there no recurrences after 36 months of follow-up.

INTRODUCCIÓN: La vigilancia activa (VA) de tumores testiculares seminoma (TS) y no-seminomas (TNS) es en la actualidad, la opción de manejo más frecuente utilizada en tumores testiculares estadio clínico I. Las recaídas dentro de este seguimiento se presentan generalmente dentro de los 3 años y <5% se presentan después de este periodo. La adherencia en la VA termina siendo un pilar fundamental.OBJETIVO: El objetivo de este trabajo es evaluar la adherencia al protocolo de vigilancia activa, y a su vez evaluar la seguridad de esta opción de manejo haciendo hincapié en la tasa libre de recaída en pacientes con y sin factores de riesgo.MATERIALES Y MÉTODOS: Se realizó un estudio retrospectivo de todos los pacientes incluidos en un protocolo de VA (TS y TNS estadio I). Se tomaron en cuenta diferentes variables, realizando hincapié en la evaluación de los diferentes factores de riesgo, tomando como tal en TS al tamaño testicular > de 4 cm y a la invasión de la rete testis en el resultado anatomopatológico. En cuanto a los TNS, la ILV y un porcentaje >40% de CE fueron los factores de riesgo evaluados. Se evaluó la adherencia al seguimiento del protocolo de VA, haciendofoco en aquellos pacientes que se perdieron del mismo y en qué momento ocurrió.RESULTADOS: Un total de 64 pacientes fueron incluidos a protocolo de VA. La mediana de seguimiento fue de 36 meses (IC 21-48 meses). De todos los pacientes incluidos en este estudio, 12 de ellos perdieron el seguimiento durante el esquema propuesto, presentando una mediana de seguimiento de 27,5 meses (IC 16-30 meses). Un 21,8% de pacientes ingresó al protocolo de VA con algún factor de riesgo asociado. La adherencia al seguimiento fue exitosa en el primer año con un porcentaje de adhesión que alcanzó el 96,8% y fue descendiendo con el paso del tiempo (92,2% a los 24 meses y 86,3% a los 36 meses).CONCLUSIÓN: En nuestra serie, se evidenció una marcada adhesión al protocolo de VA en pacientes con diagnóstico de tumor testicular estadio clínico I, sin registrar recurrencias después de los 36 meses de seguimiento.

Does active surveillance avoid overtreatment in prostate cancer? Lessons learned from salvage radical prostatectomies.

OBJECTIVE: Determine whether our institution´s active surveillance (AS) protocol is a suitable strategy to minimise prostate cancer overtreatment. MATERIAL AND METHODS: Retrospective analysis of 516 patients on AS after prostate cancer diagnosis. Population divided into "per-protocol" vs "induced" AS depending on fulfilment of protocol´s inclusion criteria. Radical prostatectomies after AS were selected and stratified based on: reclassification, progression or patient anxiety. Clinicopathological features and biochemical relapse-free survival were studied. Primary endpoint was overtreatment ratio based on the presence of insignificant prostate cancer and adverse pathological features in the surgical specimen. Kaplan-Meier curves were used to estimate the biochemical relapse-free survival and compared with log-rank test. RESULTS: 304 patients fulfilled inclusion criteria; 100 proceeded to radical prostatectomy (31% "induced", 69% "per-protocol" AS). Surgery indications were reclassification, progression and anxiety in 66%, 18% and 16% of patients respectively. Rate of positive lymph nodes was higher in the progression group (11%) compared to reclassification and anxiety (5% and 0% respectively, P = .002). Positive surgical margins were more frequently reported in the progression cohort compared to reclassification (28% vs 20%). Median follow-up from diagnosis until last radical prostatectomy was 48.3 months (32.4-70). 3 year biochemical relapse-free survival in the salvage radical prostatectomy was 85.4% (95 CI 78.3-93.2). Insignificant cancer was noticed in 7% of patients (Epstein´s vs 24% Wolters´ criteria). Rate of patients with adverse pathological features was 36%. CONCLUSIONS: The majority of patients who underwent salvage surgery after AS were not overtreated. Radical prostatectomy should be considered a safe rescue treatment.

Update and optimization of active surveillance in prostate cancer in 2021. / Actualización y optimización de la vigilancia activa en cáncer de próstata en 2021.

INTRODUCTION AND OBJECTIVES: Within the paradigm shift of the last decade in the management of prostate cancer (PCa), perhaps the most relevant event has been the emergence of active surveillance (AS) as a mandatory strategy in low-risk disease. We carry out a critical review of the clinical, pathological and radiological improvements that allow optimizing AS in 2021. MATERIAL AND METHODS: Critical narrative review of the literature on improvement issues and controversial aspects of AS. RESULTS: Adequate use of traditional criteria, optimized by enhanced biopsy and calculation of the prostate volume technique thanks to multiparametric magnetic resonance imaging (mpMRI) allow a better selection of patients for AS. This management should not be limited to patients under 60years of age, and patients with intermediate-risk PCa should be carefully selected to be included. Biopsies are still required in the follow-up, which can be personalized according to risk patterns. The pathologist must identify the cribriform or intraductal histology on biopsies in order to exclude these patients from AS, in the same way as with patients with alterations in DNA repair genes. CONCLUSIONS: Controversial indications such as the inclusion of patients from intermediate-risk groups, or the transition to active treatment due to exclusive progression in tumor volume, should be further optimized. It is possible that the future competition of tissue biomarkers, the refinement of objective parameters of mpMRI and the validation of PSA kinetics calculators may sub-stratify risk groups.

The role of multiparametric magnetic resonance imaging in the selection and follow-up of patients undergoing active surveillance for prostate cancer. An European Section of Uro-Technology (ESUT) review. / Papel de la resonancia magnética multiparamétrica en la selección y el seguimiento de pacientes en vigilancia activa por cáncer de próstata. Revisión del grupo de Uro-Tecnología (ESUT) de la EAU.

INTRODUCTION: In recent years, active surveillance (AS) has gained popularity as a safe and reasonable option for patients with low-risk, clinically localized prostate cancer. OBJECTIVE: To summarize the latest information regarding the use of mpMRI in the setting of active surveillance (AS) for the management of prostate cancer (PCa). EVIDENCE ACQUISITION: A PubMed-based, English literature search was conducted through February 2020. We selected the most relevant original articles, meta-analyses and systematic reviews that could provide important information. EVIDENCE SYNTHESIS: The great importance of mpMRI of the prostate in the setting of PCa diagnosis is its ability to visualize primarily high-grade cancerous lesions potentially missed on systematic biopsies. In several studies, mpMRI has shown an improved performance over clinically based models for identifying candidates which will benefit the most from AS. Although data on prostate mpMRI during follow-up of men under AS is sparse, it holds the probability to improve significantly AS programs by a more precise selection of optimal candidates, a more accurate identification of disease progression and a reduction in number of biopsies. The goal of reassessment of patients undergoing AS is to find the most effective moment to change attitude to active treatment. CONCLUSION: The value of mpMRI has been recognized due to its high negative predictive value (NPV) for lesion upgrading in low-risk PCa patients. The improvement in imaging detection, and precise diagnosis with mpMRI could reduce misclassifications at initial diagnosis and during follow-up, reducing the number of biopsies.

Current management of small renal masses. / Manejo actual de las masas renales pequeñas.

One of the consequences of the growing use of diagnostic imaging techniques is the notable growth in the detection of small renal masses presumably corresponding to localized tumors that are potentially curable with surgical treatment. When faced with the finding of a small renal mass, radiologists must determine whether it is benign or malignant, and if it is malignant, what subtype it belong to, and whether it should be managed with surgical treatment, with ablative techniques, or with watchful waiting with active surveillance. Small renal masses are now a clinical entity that require management different from the approaches used for classical renal cell carcinomas. In this scenario, radiologists are key because they are involved in all aspects of the management of these tumors, including in their diagnosis, treatment, and follow-up.

Pathological findings in very low risk prostate cancer in surgical specimens. / Hallazgos patológicos en el cáncer de próstata de muy bajo riesgo en piezas de prostatectomía radical.

OBJECTIVE: Perform a detailed anatomopathological analysis of consecutive surgical specimens in men with clinically very low risk prostate cancer according to National Comprehensive Cancer Network (NCCN) criteria.MATERIALS AND METHODS: The study included 799 prostate cancer patients who under went radical prostatectomy between January 2005 and December 2013. We identified 81 consecutive patients with clinically very low risk prostate cancer. The slides of the patients who fulfilled the inclusion criteria were re-reviewed. The parameters studied were: pathological stage, histological grade by Gleason score (GSS), margins involvement, tumor percentage (PT), and number of apparently independent tumor foci (FT). RESULTS: The patients had organ-confined tumors in almost all of them (pT2: 97.5%). Most of the cancers studied were bilateral (pT2c: 67.9%), multifocal (FT≥2:88.8%), with a low tumor percentage (PTand with a low Gleason Score (GSS≤6: 91,3%). Non-confined disease: 2.5%, all cases extra-prostatic extension (pT3a). GSS>6: 8,6%, all cases GSS7 (3+4). CONCLUSIONS: The NCCN criteria for very low risk prostate cancer help to make a good selection of non-aggressive tumors and are a useful tool for including patients in an active surveillance program.

OBJETIVO: Realizar un análisis patológic odetallado de las piezas de prostatectomía radical en pacientes diagnosticados con cáncer de próstata de muy bajo riesgo según los criterios de la NCCN. MATERIAL Y MÉTODOS: El estudio incluye 799 pacientes con cáncer de próstata a los que se realizó una prostatectomía radical entre 2005 y 2013. 81 pacientes con cáncer de próstata clínicamente de muy bajo riesgo fueron identificados. Las laminillas de los pacientes identificados fueron revisadas. Los parámetros estudiados fueron: estadio patológico, grado de Gleason, márgenes quirúrgicos, % de tumor, y el numero de focos tumorales aparentemente independientes. RESULTADOS: La gran mayoría de pacientes presentaron tumores órgano-confinados (pT2: 97,5%). El 68% de los canceres fue bilateral (pT2c), multifocal (mas de2 focos 88%), con un porcentaje tumoral de menos del 10% en el 80% de los casos y mas del 90% con Gleason 6. La enfermedad no órgano-confinada se evidencio en 2,5% pT3a. CONCLUSIONES: Los criterios de NCCN para muy bajo riesgo nos ayudan a clasificar pacientes con tumores poco agresivos y son una buena herramienta para seleccionar pacientes para programas de vigilancia activa.

Transition from active surveillance to observation in prostate cancer patients older than 75 years. A long follow-up series. / Transición de vigilancia activa a observación en pacientes mayores de 75 años con cáncer de próstata en una serie de largo seguimiento.

INTRODUCTION: The world population is ageing, and life expectancy is increasing. This situation will have a great impact on the management of patients with prostate cancer, especially in those of low risk, susceptible to a conservative management under active surveillance (AS). Regarding these patients' profile, it is necessary to answer the following questions: ¿for how long to continue with the AS scheme?, ¿which tests will be required?, ¿is it possible to carry out a transition to observation with oncological safety? The objective of this work is to analyse those patients with prostatic cancer who have been in AS with 75 years of age or more and assess the safety of the observation in an AS series with a long follow-up. MATERIAL AND METHODS: We analysed our prospective cohort of AS patients between the years 1999 and 2018,including those who had been in follow-up with 75 years or more. They were offered treatment with curative intent when there were progression criteria and transition to observation under the urologist's decision. Some intermediate risk patients were included in the analysis. Comorbidity changes were analysed with the Charlson comorbidity index at entry and exit of AS. The progression and mortality of the patients were studied according to the management they received. RESULTS: From 347 AS patients, 90 patients fulfilled the afore mentioned criteria and 15 (16.7%) were intermediate risk. The median follow-up was 6.4 years and 73 (81.1%) had low comorbidity (Charlson<2).There were 40 (44.4%) patients who left AS, 17 (18.9%) of them went to observationand the rest, 21 (23.3%), received curative treatment. There was a significant difference in comorbidity, measured by the Charlson index, at entry and exit of AS (P<.05) among patients receiving active treatment and the ones submitted to observation.No case of cancer-specific death or progression was observed in the observation group. CONCLUSION: The transition from an active surveillance management to observation of prostate cancer elderly patients, as well as the decision to carry out a treatment with curative intent, seems controversial. In our series, this transition in patients older than 75 years does not increase the oncological risk.

Active surveillance in intermediate risk prostate cancer.

OBJECTIVES: Active Surveillance (AS) has become an established treatment option for men with low-risk prostate cancer (PCa), demonstrating superior functional outcomes and excellent oncologic outcomes.As such, it has been appealing to extend AS to patients with intermediate risk PCa. We provide a review of the current experience with AS in the intermediate-risk PCa population. METHODS: Risk stratification is the key to treatment success. Many clinical factors (age, percent Gleason 4, PSA density, race/ethnicity, and genetic predisposition) and genomic markers have proven prognostic value in the AS population. We performed a systematic review of the currently available data (randomized trials and prospective cohort studies) to establish the status of AS in the intermediate risk patient population. RESULTS: Our ability to predict the natural history of intermediate risk prostate cancer is imperfect. While the benefits of AS make it an appealing option for men with intermediate risk disease, the published experience todate demonstrates that AS for all men with intermediate risk disease leads to higher rates of metastatic disease and loss of the opportunity for cure. These same studiesalso demonstrate that a subset of patients with intermediate risk disease have indolent disease that may benefit from AS. This heterogeneity is not adequately captured with traditional histopathologic staging. Clinical, genomic, and radiologic biomarkers play a key role in appropriate risk stratification and patient selection. The optimal use of these biomarkers in the intermediate riskpatient is currently the subject of intense evaluation. CONCLUSION: Active surveillance for men at the favorable end of intermediate risk prostate cancer is an appealing alternative to radical therapy, but carries a modest but increased risk of metastatic disease compared to low risk cancer. Many biomarkers are currently being evaluated to enhance precise risk stratification of this important subgroup of patients.

OBJETIVOS: La Vigilancia Activa (VA) es un tratamiento bien establecido para pacientes con cáncer de próstata (CaP) de bajo riesgo, con mejores resultados funcionales y excelentes resultados oncológicos. Como tal, suena atractiva su aplicación en pacientes con CaP de riesgo intermedio. A seguir, presentamosuna revisión de la experiencia actual con el uso de VA en CaP de riesgo intermedio.MÉTODOS: Lo primero es una buena estratificación de riesgo. Hay múltiples factores (edad, porcentaje de Gleason 4, densidad de APE, raza/etnicidad y predisposición genética) y marcadores genéticos que han demostrado ser útiles en la población en VA. Después de hacer una revisión de estos factores en pacientes de riesgo intermedio, hicimos una revisión de la evidenciaactual (estudios aleatorizados y cohortes prospectivas) para dar una visión del uso de VA en esta población. RESULTADOS: Nuestra capacidad para predecir la evolución de pacientes de riesgo intermedio no es perfecta. Si bien los beneficios de VA son atractivos, las experiencia colectiva ha demostrado repetidamente que el uso de VA en pacientes de riesgo intermedio tiene mayor tasa de enfermedad metastásica y pérdida de la oportunidad curativa. Por el otro lado, estos mismos estudios han demostrado que existe un subgrupo de esos pacientes que cursan con enfermedad indolente y se podrían beneficiar de VA. Desafortunadamente, estaheterogeneidad no se define bien con las clasificaciones histopatológicas tradicionales. Los biomarcadores (clínicos, genómicos y radiológicos) serán la clave para una apropiada estratificación de riesgo y selección de pacientes. El uso adecuado de estos biomarcadores en pacientes de riesgo intermedio es actualmente tema de grandes estudios. CONCLUSIONES: La VA es una alternativa de tratamiento atractiva para hombres en el extremo favorable del riesgo intermedio, pero conlleva un riesgo moderadopero real de enfermedad metastásica en comparación con pacientes de riesgo bajo. Múltiples marcadores están siendo evaluados para lograr una predicciónmás precisa del subgrupo de pacientes adecuado.

Immediate versus delayed prostatectomy and the fate of patients who progress to a higher risk disease on active surveillance. / Prostatectomía inmediata versus demorada en pacientes que progresan a una enfermedad de mayor riesgo en vigilancia activa.

INTRODUCTION: Oncological outcomes of radical prostatectomy (RP) in patients progressing on active surveillance (AS) are debated. We compared outcomes of AS eligible patients undergoing RP immediately after diagnosis with those doing so after delay or disease progression on AS. METHODS: Between 2000 and 2014, 961 patients were AS eligible as per EAU criteria. RP within 6 months of diagnosis (IRP) or beyond (DRP), RP without AS (DRPa) and AS patients progressing to RP (DRPb) were compared. Baseline PSA, clinical and biopsy characteristics were noted. Oncological outcomes included adverse pathology in RP specimen and biochemical recurrence (BCR). Matched pair analysis was done between DRPb and GS7 patients undergoing immediate RP (GS7IRP). RESULTS: IRP, DRP, DRPa and DRPb had 820 (85%), 141 (15%), 118 (12.24%) and 23 (2.7%) patients respectively. IRP, DRPa and DRPb underwent RP at a median of 3, 9 and 19 months after diagnosis respectively. Baseline characteristics were comparable. DRP vs. IRP had earlier median time (31 vs. 43 months; p<.001) and higher rate of progression to BCR (7.6 vs. 3.9%;p=.045). DRPb showed higher BCR (19 vs. 5%;p=.021) with earlier median time to BCR, compared to IRP and DRPa (p=.038). There was no difference in adverse pathology and BCR rates, but time to BCR was significantly lesser in DRPb (49 vs. 6 months;p<.001), compared to GS7IRP. CONCLUSIONS: Patients progressing on AS had worst oncological outcomes. RP for GS7 progression and matched pair of GS7 patients had similar outcomes. Worse oncological outcomes in AS progressors cannot be explained by a mere delay in RP.

Vigilancia activa en cáncer de próstata en un grupo de pacientes asistidos en el Centro Docente Asociado de Oncología Médica Rivera: Cooperativa Médica de Rivera (COMERI) / Active surveillance in prostate cancer in a group of patients assisted at the Rivera Associated Teaching Center for Medical Oncology: Rivera Medical Cooperative (COMERI) / Vigilância ativa do câncer de próstata em um grupo de pacientes atendidos no Rivera Associated Teaching Center for Medical Oncology: Rivera Medical Cooperative (COMERI)

Introducción: En Uruguay el cáncer de próstata ocupa el primer lugar en incidencia y el tercer lugar en mortalidad en el hombre. La mayoría de estos cánceres se diagnostican en estadios precoces. Hoy en día, para pacientes con adenocarcinoma de muy bajo riesgo, bajo riesgo o riesgo intermedio favorable, la vigilancia activa es una opción adecuada. Objetivos: Describir una población de pacientes con cáncer de próstata de muy bajo riesgo, bajo riesgo o riesgo intermedio favorable, en vigilancia activa en COMERI. Material y métodos: Estudio descriptivo, observacional, retrospectivo. Se incluyeron pacientes con cáncer de próstata de muy bajo riesgo, bajo riesgo o riesgo intermedio favorable, tratados entre 2010 y 2018 en COMERI. Se recopilaron datos en el sistema de registro clínico electrónico. Resultados: Se incluyeron 33 pacientes, la mediana de edad al diagnóstico fue de 74 años. Todos los pacientes fueron sometidos a controles clínicos y determinación de PSA cada 3 meses. El tacto rectal se realizó en forma anual. El tiempo mediano de vigilancia activa fue de 33 meses. Durante el seguimiento, se observaron pocas variaciones en los valores de PSA. El 21% de los pacientes fue sometido a una nueva biopsia durante el seguimiento activo, y en todos los casos, el Gleason se mantuvo incambiado. Ningún paciente abandonó la modalidad de vigilancia activa. Conclusión: En nuestro entorno, la vigilancia activa se considera una opción terapéutica válida para pacientes altamente seleccionados con cáncer de próstata de muy bajo riesgo, bajo riesgo o riesgo intermedio favorable, y es bien aceptada por ellos.

Introduction: In Uruguay, prostate cancer ranks first in incidence and third in mortality among men. The majority of these cancers are diagnosed at early stages. Nowadays, active surveillance is an appropriate option for patients with adenocarcinoma of very low risk, low risk, or favorable intermediate risk. Objectives: To describe a population of patients with prostate cancer of very low risk, low risk, or favorable intermediate risk under active surveillance at COMERI. Materials and Methods: Descriptive, observational, retrospective study. Patients with prostate cancer of very low risk, low risk, or favorable intermediate risk treated between 2010 and 2018 at COMERI were included. Data were collected from the electronic clinical registry system. Results: Thirty-three patients were included, with a median age at diagnosis of 74 years. All patients underwent clinical monitoring and PSA determination every 3 months. Digital rectal examination was performed annually. The median time of active surveillance was 33 months. During follow-up, there were few variations in PSA values. 21% of patients underwent a repeat biopsy during active surveillance, and in all cases, the Gleason score remained unchanged. No patient discontinued active surveillance. Conclusion: In our setting, active surveillance is considered a valid therapeutic option for highly selected patients with prostate cancer of very low risk, low risk, or favorable intermediate risk, and it is well accepted by them.

Introdução: No Uruguai, o câncer de próstata ocupa o primeiro lugar em incidência e o terceiro lugar em mortalidade entre os homens. A maioria desses cânceres é diagnosticada em estágios precoces. Atualmente, para pacientes com adenocarcinoma de risco muito baixo, baixo risco ou risco intermediário favorável, a vigilância ativa é uma opção adequada. Objetivos: Descrever uma população de pacientes com câncer de próstata de risco muito baixo, baixo risco ou risco intermediário favorável sob vigilância ativa em COMERI. Material e métodos: Estudo descritivo, observacional, retrospectivo. Foram incluídos pacientes com câncer de próstata de risco muito baixo, baixo risco ou risco intermediário favorável, tratados entre 2010 e 2018 em COMERI. Os dados foram coletados no sistema de registro clínico eletrônico. Resultados: Foram incluídos 33 pacientes, com mediana de idade no diagnóstico de 74 anos. Todos os pacientes foram submetidos a controles clínicos e determinação de PSA a cada 3 meses. O toque retal foi realizado anualmente. O tempo médio de vigilância ativa foi de 33 meses. Durante o acompanhamento, houve poucas variações nos valores de PSA. 21% dos pacientes foram submetidos a uma nova biópsia durante a vigilância ativa, e em todos os casos, o Gleason permaneceu inalterado. Nenhum paciente abandonou a modalidade de vigilância ativa. Conclusão: Em nosso ambiente, a vigilância ativa é considerada uma opção terapêutica válida para pacientes altamente selecionados com câncer de próstata de risco muito baixo, baixo risco ou risco intermediário favorável, e é bem aceita por eles.

Recurrence factors in patients with cutaneous melanoma and positive sentinel lymph node treated in a single reference unit in Buenos Aires / Factores de recurrencia en pacientes con melanoma cu táneo y ganglio centinela positivo

Abstract Introduction : Although therapeutic advances have improved results of cutaneous melanoma (CM), senti nel node-positive patients still have substantial risk to develop recurrent disease. We aim to investigate prog nostic indicators associated with disease recurrence in positive-sentinel lymph node biopsy (SLNB) patients in a Latin-American population. Methods : Retrospective analysis of CM patients and positive-SLNB (2010-2020). Patients were divided into two groups: Group A (completion lymph node dissection, CLND), Group B (active surveillance, AS). Association of demographics, tumor data and SLN features with recurrence-free (RFS), distant metastases-free (DMFS) and melanoma specific (MSS) survival was analyzed. Results : Of 205 patients, 45 had a positive SLNB; 27(60%) belonged to Group A and 18(40%) to Group B. With a median follow-up of 36 months, 16 patients (12 in Group A and 4 in Group B) developed recurrent dis ease and estimated 5-yr RFS at any site was 60% (CI95%, 0.39 - 0.77) (44.5% in CLND group vs. 22% in AS group; P = 0.20). Estimated 5-yr DMFS and MSS: 65% (CI 95%, 0.44 - 0.81) and 73% (CI 95%, 0.59 - 0.89) with no differ ences between groups (p = 0.41 and 0.37, respectively). Independent predictors of poorer MSS were extranodal extension (ENE) and MaxSize > 2 mm of melanoma deposit in SLN. Factors independently associated with DMFS: Breslow depth > 2 mm, ENE, number (≥ 2) of posi tive SN and CLND status. Conclusion : Primary tumor and SN features in mela noma provide important prognostic information that help optimize prognosis and clinical management. AS is now the preferred approach for most positive-SLNB CM patients.

Resumen Introducción : Si bien los avances terapéuticos han permitido mejorar los resultados del melanoma cutáneo (MC), los pacientes con ganglio centinela positivo (BGCP) aún tienen riesgo elevado de desarrollar recurrencia de la enfermedad. Nuestro objetivo fue investigar in dicadores pronósticos asociados a dicho evento en una población latinoamericana. Métodos : Análisis retrospectivo de pacientes con MC y BGCP entre 2010-2020. Los pacientes se dividieron en 2 grupos: Grupo A (linfadenectomía terapéutica) y Grupo B (Vigilancia activa, VA). Se analizaron datos demográficos, tumorales y características del GC junto con sobrevida-libre de recurrencia (SLR), libre de metástasis a distancia (SLMD) y específica de melanoma (SEM). Resultados : De 205 pacientes, 45 presentaron BGCP; 27 (60%) perteneció al Grupo A y 18 (40%) al Grupo B. Con una mediana de seguimiento de 36 meses, 16 pa cientes (12 en Grupo A y 4 en Grupo B) desarrollaron enfermedad recurrente con una SLR a 5 años de 60% (IC95%: 0.39-0.77) (44.5% en Grupo B vs. 22% en Grupo A; P = 0.20). Las SLMD y SEM estimadas a 5 años fueron de 65% (CI 95%, 0.44 - 0.81) y 73% (CI 95%, 0.59 - 0.89) sin diferencias entre ambos grupos (p = 0.41 y 0.37, respec tivamente). Los predictores independientes de peor SEM fueron: extensión extranodal (ENE) y MaxSize > 2mm de depósito tumoral en GC. Los factores asociados de forma independiente con SLMD fueron Breslow >2mm, ENE, número (≥ 2) de GC positivos y el status (positividad) de la linfadenectomía. Conclusión : Características del tumor primario y del GC brindan información importante que ayuda a optimi zar el pronóstico y manejo clínico de los pacientes con MC. La VA es actualmente el abordaje de elección para la mayoría de los pacientes con BGCP.

Variability in the multicentre National Registry in Active Surveillance; a questionnaire for urologists. / Variabilidad dentro del Registro Nacional multicéntrico en Vigilancia Activa; cuestionario a urólogos.

BACKGROUND: Our main objective was to report the current use of active surveillance in Spain and to identify areas for potential improvement. METHODS: A questionnaire generated by the Platform for Multicentre Studies of the Spanish Urology Association (AEU/PIEM/2014/0001, NCT02865330) was sent to all associate researchers from January to March 2016. The questionnaire included 7 domains covering various aspects of active surveillance. RESULTS: Thirty-three of the 41 associate researchers responded to the questionnaire. Active surveillance is mainly controlled by the urology departments (87.9%). There was considerable heterogeneity in the classical clinical-pathological variables as selection criteria. Only 36.4% of the associate researchers used prostate-specific antigen density (PSAd). Multiparametric magnetic resonance imaging (mpMRI) was clearly underused as initial staging (6%). Only 27.3% of the researchers stated that their radiology colleagues had a high level of experience in mpMRI. In terms of the confirmation biopsy, most of the centres used the transrectal pathway, and only 2 out of 33 used the transperineal pathway or fusion software. Half of the researchers interviewed applied active treatment when faced with disease progression to Gleason 7 (3+4). There was no consensus on when to transition to an observation strategy. CONCLUSIONS: The study showed the underutilisation of informed consent and quality-of-life questionnaires. PSAd was not included as a decisive element in the initial strategy for most researchers. There was a lack of confidence in the urologists' mpMRI experience and an underutilisation of the transperineal pathway. There was also no consensus on the follow-up protocols and active treatment criteria, confirming the need for prospective studies to analyse the role of mpMRI and biomarkers.