Predictors and prognostic implications of clinical decisions in patients with primary high-risk non-muscle-invasive bladder cancer - results of a cross country retrospective study.

Adjuvant diagnostic and therapeutic procedures are available to reduce the risk of recurrence or progression in patients with high-risk non-muscle-invasive bladder cancer (NMIBC). However, their indications and efficacy remain a matter of debate. The aim of this study was to analyze therapeutic decisions in patients with primary high-risk NMIBC and to analyze the adherence to clinical guidelines in this field.545 consecutive patients, aged a median of 70.3 years, diagnosed with primary high-risk NMIBC in thirteen urological institutions, were enrolled into this retrospective study. Diagnostic and therapeutic decisions after transurethral resection (TUR) were recorded, and predictive factors were analyzed.Restaging TUR was offered to 260 patients (47.7%), up-front intravesical Bacillus Calmette-Guerin (BCG) therapy to 74 patients (13.6%), immediate radical cystectomy to 38 patients (7.0%), and intravesical chemotherapy with the maintenance therapy to 12 patients (2.2%). No additional procedure was performed in 161 patients (29.5%). The strongest predictive factor for restaging TUR was G3 or high-grade cancer (RR 1.68, p<0.01), for upfront BCG therapy it was carcinoma in situ (RR 3.20, p=0.01), for immediate cystectomy it was stage T1 tumor (RR 3.71, p<0.01), for no additional procedures it was G2 or low-grade cancer (RR 2.18, p<0.01).Clinical management of patients with high-risk NMIBC is suboptimal and not standardized. As this can directly influence patients' survival, urgent improvement of urological care in this field should be considered.

The role of endoscopic bladder tumour assessment in the management of patients subjected to transurethral bladder tumour resection.

Despite complete resection, non-muscle invasive bladder cancers tend to recur. Therefore, their risk stratification was implemented to select adjuvant therapy. Immediate intravesical chemotherapeutic instillations were shown to decrease the risk of recurrence in those with low-risk disease. The purpose of the study was to determine the role of endoscopic assessment in the management of patients subjected to transurethral resection of the bladder tumour (TURBT). In 262 patients submitted to TURBT due to primary bladder tumour, the size and the number of the lesion(s) were noted and the stage as well as the grade of the tumour(s) were typed. The individual features were then scored according to the European Organisation of Research and Treatment of Cancer 'Bladder Calculator' and the lesions were classified into the low, intermediate and high risk of recurrence group. Clinical evaluation was then compared with pathological report and final triage. Based on the clinical data, 95 (36.25%), 105 (40.07%) and 3 (1.14%) patients were endoscopically assigned to the groups of low, intermediate and high risk of recurrence respectively. After pathological report, correct risk stratification was confirmed in 86 (90.5%), 95 (90.5%) and 3 (100%) patients respectively. Endoscopic assessment of bladder cancers allows to accurately establish the risk of recurrence and may facilitate implementation of adjuvant therapy before histological evaluation.

Platelet aggregation and risk of stent thrombosis or bleeding in interventionally treated diabetic patients with acute coronary syndrome.

BACKGROUND: Platelet aggregation monitoring in diabetic patients treated with coronary interventions (PCI) for an acute coronary syndrome (ACS) is a promising way of optimizing treatment and outcomes in this high risk group. The aim of the study was to verify whether clopidogrel response measured by Multiplate analyzer (ADPtest) in diabetic ACS patients treated with PCI predicts the risk of stent thrombosis or cardiovascular mortality and bleeding. METHODS: Into this prospective, observational study 206 elective PCI patients were enrolled. Two cutoff points of ADPtest were used in analysis to divide patients into groups. One (345 AU x min) was calculated based on ROC curve analysis; this cutoff provided the best ROC curve fit, although it did not reach statistical significance. The other (468 AU x min) was accepted based on the consensus of the Working Group on On-Treatment Platelet Reactivity. The risk of stent thrombosis and mortality was assessed using Cox regression analysis and Kaplan-Meier curves. RESULTS: The risk of stent thrombosis was higher in the group of patients with impaired clopidogrel response for either cutoff value (for >354 AU x min - HR 12.33; 95% CI 2.49-61.1; P = 0.002). Cardiovascular mortality was also higher in the impaired clopidogrel response group (for >354 AU x min - HR 10.58; 95% CI 2.05-54.58; P = 0.005). We did not find a clear relation of increased clopidogrel response to the risk of bleeding. CONCLUSIONS: The results of this study show that in diabetic ACS patient group treated with PCI an impaired platelet response to clopidogrel measured by the Multiplate analyzer results in increased risk of stent thrombosis and cardiac death.

Stage of bladder cancer in Central Europe - Polish perspective.

Mortality rate from bladder cancer in Europe is the highest in its Central Region. This study is an attempt to find underlying factors by proper characterisation of large cohort of Polish patients with bladder cancer.This is a multicentre study enrolling 1360 consecutive patients diagnosed with primary urothelial carcinoma of the bladder in years 2012-2013 in Poland. All patients underwent transurethral resection of the bladder tumor. Data on staging and grading of all cancers were collected, as well as several demographic and clinical factors were tested for the association with muscle invasiveness of the cancer.Mean age of the cohort was 69.6 years, male to female ratio was 3:1. Bladder cancer stage Ta, T1 and muscle-invasive (MIBC) was diagnosed in 533 (39.2%), 516 (37.9%) and 296 (21.8%) patients, respectively. Patients with MIBC were older (73 vs. 68 years, p<0.05), had lower body mass index (25.4 vs. 26.5 kg/m2, p<0.05), lower haemoglobin concentration (12.2 vs. 13.4 mg/l, p<0.05), longer history of haematuria (86.2 vs. 74.4 days) and longer time interval from first symptom to diagnosis (118.0 vs. 88.2 days), compared to patients with Ta and T1 tumors.High mortality rate from bladder cancer in Central Europe can result from very high incidence of high-risk T1 tumors and high prevalence of prognostic factors of poor survival.

Total ischaemic time and 9-year outcomes in STEMI patients treated with pPCI.

BACKGROUND: Prolonged total ischaemic time (TIT) has been shown to independently predict poor myocardial perfusion in STEMI patients and affect in-hospital mortality. We aim to evaluate the influence of TIT on long-term follow-up (F/U) and identify the factors associated with TIT in patients with STEMI treated with pPCI at a high volume centre. METHODS: In a prospective "all-comer" registry, clinical, angiographic and procedural characteristics, TIT and 9-year mortality were determined in consecutive STEMI patients treated with pPCI. Patients were divided according to TIT into three groups: A) <3, B) 3-6 and C) >6h. RESULTS: Among 1064 patients, TIT was known in 1002 patients, 5 patients were lost to F/U. For censored observations F/U was 7.2-8.8 years. There were 350, 461, and 186 patients in groups A, B, and C, respectively. Patients in group A compared to B and C were younger, more often males and smokers, less frequently had history of CAD, and more frequently had occluded infarct related artery. However, final TIMI3 was obtained more frequently. Overall 30-day mortality was 4%, one-year mortality 7% and nine-year mortality 27%. Multivariable logistic regression models indicated that longer TIT was associated with a higher risk of 9-year mortality (A-21%, B-28%, C-37%, p<0.0005). TIT>6h was independently associated with advanced age, diabetes mellitus, history of CAD and higher rate of initial TIMI grade flow 3. CONCLUSIONS: TIT is strongly related with mortality in STEMI patients even after nine years of F/U. This finding reinforces the necessity of shortening the TIT in all STEMI patients.

An inherited NBN mutation is associated with poor prognosis prostate cancer.

BACKGROUND: To establish the contribution of eight founder alleles in three DNA damage repair genes (BRCA1, CHEK2 and NBS1) to prostate cancer in Poland, and to measure the impact of these variants on survival among patients. METHODS: Three thousand seven hundred fifty men with prostate cancer and 3956 cancer-free controls were genotyped for three founder alleles in BRCA1 (5382insC, 4153delA, C61G), four alleles in CHEK2 (1100delC, IVS2+1G>A, del5395, I157T), and one allele in NBS1 (657del5). RESULTS: The NBS1 mutation was detected in 53 of 3750 unselected cases compared with 23 of 3956 (0.6%) controls (odds ratio (OR)=2.5; P=0.0003). A CHEK2 mutation was seen in 383 (10.2%) unselected cases and in 228 (5.8%) controls (OR=1.9; P<0.0001). Mutation of BRCA1 (three mutations combined) was not associated with the risk of prostate cancer (OR=0.9; P=0.8). In a subgroup analysis, the 4153delA mutation was associated with early-onset (age ≤ 60 years) prostate cancer (OR=20.3, P=0.004). The mean follow-up was 54 months. Mortality was significantly worse for carriers of a NBS1 mutation than for non-carriers (HR=1.85; P=0.008). The 5-year survival for men with an NBS1 mutation was 49%, compared with 72% for mutation-negative cases. CONCLUSION: A mutation in NBS1 predisposes to aggressive prostate cancer. These data are relevant to the prospect of adapting personalised medicine to prostate cancer prevention and treatment.