Long-Term Experience of Chemoradiotherapy Combined with Deep Regional Hyperthermia for Organ Preservation in High-Risk Bladder Cancer (Ta, Tis, T1, T2).

BACKGROUND: The aim of this study was to evaluate the efficacy and safety of chemoradiotherapy (RCT) combined with regional deep hyperthermia (RHT) of high-risk bladder cancer after transurethral resection of bladder tumor (TUR-BT). MATERIALS AND METHODS: Between 1982 and 2016, 369 patients with pTa, pTis, pT1, and pT2 cN0-1 cM0 bladder cancer were treated with a multimodal treatment after TUR-BT. All patients received radiotherapy (RT) of the bladder and regional lymph nodes. RCT was administered to 215 patients, RCT + RHT was administered to 79 patients, and RT was used in 75 patients. Treatment response was evaluated 4-6 weeks after treatment with TUR-BT. RESULTS: Complete response (CR) overall was 83% (290/351), and in treatment groups was RT 68% (45/66), RCT 86% (178/208), and RCT + RHT 87% (67/77). CR was significantly improved by concurrent RCT compared with RT (odds ratio [OR], 2.32; 95% confidence interval [CI], 1.05-5.12; p = .037), less influenced by hyperthermia (OR, 2.56; 95% CI, 0.88-8.00; p = .092). Overall survival (OS) after RCT was superior to RT (hazard ratio [HR], 0.7; 95% CI, 0.50-0.99; p = .045). Five-year OS from unadjusted Kaplan-Meier estimates was RCT 64% versus RT 45%. Additional RHT increased 5-year OS to 87% (HR, 0.32; 95% CI, 0.18-0.58; p = .0001). RCT + RHT compared with RCT showed a significantly better bladder-preservation rate (HR, 0.13; 95% CI, 0.03-0.56; p = .006). Median follow-up was 71 months. The median number of RHT sessions was five. CONCLUSION: The multimodal treatment consisted of a maximal TUR-BT followed by RT; concomitant platinum-based chemotherapy combined with RHT in patients with high-grade bladder cancer improves local control, bladder-preservation rate, and OS. It offers a promising alternative to surgical therapies like radical cystectomy. IMPLICATIONS FOR PRACTICE: Radical cystectomy with appropriate lymph node dissection has long represented the standard of care for muscle-invasive bladder cancer in medically fit patients, despite many centers reporting excellent long-term results for bladder preserving strategies. This retrospective analysis compares different therapeutic modalities in bladder-preservation therapy. The results of this study show that multimodal treatment consisting of maximal transurethral resection of bladder tumor followed by radiotherapy, concomitant platinum-based chemotherapy combined with regional deep hyperthermia in patients with Ta, Tis, T1-2 bladder carcinomas improves local control, bladder-preservation rate, and survival. More importantly, these findings offer a promising alternative to surgical therapies like radical cystectomy. The authors hope that, in the future, closer collaboration between urologists and radiotherapists will further improve treatments and therapies for the benefit of patients.

Preoperative Stating of Pelvic Lymph Nodes in Prostate Cancer Patients via Endorectal Magnetic Resonance Imaging.

BACKGROUND/AIM: The aim of this study was to evaluate the diagnostic sensitivity, specificity and accuracy of endorectal magnetic resonance imaging (e-MRI), as a preoperative staging modality in the diagnosis of lymph node metastasis (LNM) in patients with prostate cancer (PCa). PATIENTS AND METHODS: Retrospectively, we analyzed data from N=168 patients who underwent radical prostatectomy (RP) between 2004 and 2013 at two tertiary medical centres. Prior to RP all patients underwent an e-MRI. Inclusion criteria were: PSA levels >20 ng/ml or Gleason score >7. Examinations were performed on a closed 1.0-T system combined with an endorectal body phased-array coil, imaging results were correlated with histopathology. RESULTS: 10.7% (N=18 patients) had histologically-proven LNM. e-MRI was true-positive in N=6 (33.3%) and false-negative N=12 patients (66.6%). N=150 (89.3%) patients without LNM e-MRI were true-negative in 96% and false-positive in 4%. Sensitivity was 96%, specificity was 33%, accuracy was 64.5%. CONCLUSION: e-MRI can be considered a useful preoperative staging modality in diagnosis of LNM.

The Value of Endorectal Magnetic Resonance Imaging of the Prostate in Improving the Detection of Anterior Prostate Cancer.

BACKGROUND/AIM: The diagnosis of anterior prostate cancer (APC) is troublesome due to its anatomical location. Patients with an APC often require multiple sets of biopsies until diagnosis is made. The objective of this study is to examine if endorectal magnetic resonance imaging (e-MRI) of the prostate could improve the detection of APC. PATIENTS AND METHODS: A retrospective review of 412 patients records with a clinical suspicion of prostate cancer (PCa) (prostate-specific antigen (PSA) levels >4 ng/ml or a suspicious finding on digital rectal examination (DRE)) who underwent conventional e-MRI (e-cMRI) and functional e-MRI (e-fMRI) of the prostate and subsequent prostate biopsy from April 2004 to July 2010 was conducted. All patients had a history of at least one prior negative set of prostate biopsy. Sixty-five percent (N=268) of patients' images were considered suspicious for PCa of which 53 (12.8%) cases were considered to be suspicious for APC (defined as the presence of PCa anterior to the urethra). All patients underwent an 18-core transrectal ultrasonography (TRUS)-guided biopsy of the peripheral zone and an additional 3-core TRUS-targeted biopsy anterior to the urethra. RESULTS: The median age and median PSA levels of the patients was 68.9 (range=56-72) years and 12.7 ng/ml (range=6.4-21.3), respectively. DRE was only positive in 6 patients (11.4%). The overall PCa detection rate was 90.5%. APC was detected through the targeted cores in 48 patients (90.5%). Seven patients (13.2%) exhibited a PCa of the peripheral zone as well. e-MRI-positive predictive value was 90.5%. CONCLUSION: e-MRI of the prostate has a high predictive value in detecting APC. Patients with a constant increase of PSA levels, negative DRE findings and prior negative sets of prostate biopsy are ideal candidates for e-MRI of the prostate and subsequent TRUS-targeted biopsies of possible suspicious anterior gland sites.

Is an Extended Prostate Biopsy Scheme Associated with an Improvement in the Accuracy Between the Biopsy Gleason Score and Radical Prostatectomy Pathology? A Multivariate Analysis.

AIM: To examine whether an extended prostate biopsy (PB) scheme is associated with an improvement in the accuracy between the PB Gleason score (GS) and radical prostatectomy (RP) pathology and to identify probable preoperative variables that stratified patients likely to harbor significant upgrading (SU). PATIENTS AND METHODS: A retrospective review of 538 patients' records diagnosed with prostate cancer (PCa) who underwent RP and exhibited a SU, at two tertiary medical centers, was conducted. The patients were divided into 3 groups: 194 who underwent a 6-core PB (36%), 156 who underwent a 12-core PB (28.9%) and 188 (34.9%) who underwent an 18-core PB. A multivariate analysis was conducted, including prostate-specific antigen (PSA) level, clinical stage, prostate size and duration from PB to RP. RESULTS: The 6-core group exhibited a 42.7% SU, the 12-core group exhibited a 38.8% SU and the 18-core group exhibited a 14.1% SU. There was a highly significant lower rate of SU in the 18-core than that in the 6-core (p<0.001) and 12-core PB group (p<0.001) but no significant difference in the rate of SU was noted between the 6- and 12-core group (p=0.913). According to the multivariate analysis, only a prostate size of >35 g significantly elevated the probability of SU in the 6-core (p<0.025) and 12-core PB groups (p<0.025), respectively. CONCLUSION: An extended PB scheme is associated with a significant improvement in the accuracy between the PB GS and RP pathology. Prostate size >35 g in patients who undergo a 6- or 12-core PB is the only preoperative variable that stratifies patients likely to harbor SU.

How good is post-biopsy multiparametric magnetic resonance imaging in detecting and characterising the index lesion of localised prostate cancer?

OBJECTIVE: The aim of this study was to evaluate the accuracy of multiparametric endorectal magnetic resonance imaging (mp-MRI) in detecting and characterising the largest tumour lesion, which is defined as the index tumour of prostate cancer. MATERIAL AND METHODS: A total of 55 patients with proven histological prostate cancer underwent post-biopsy MRI at 1.5 T and subsequent radical prostatectomy. The maximum tumour diameter (MTD) of the index lesion was determined independently by MRI and histopathology in a prospective manner. The detection rate of the index lesion, the MTD and volume by pathology, and the pathological tumour (pT) stage were correlated with the MTD by MRI using Pearson's correlation. RESULTS: Pathohistology revealed 158 cancer foci. MRI detected 55 foci. The sensitivity, specificity, accuracy, and negative and positive predictive values of mp-MRI for index lesion detection were 89%, 100%, 90%, 44% and 100%, respectively. Three positive correlations were found: one between the MTD of the index lesion by MRI and the MTD by pathology (Pearson coefficient = 0.890, p < 0.01), a second between the MTD by MRI and the index tumour volume at pathology (Pearson coefficient = 0.786, p < 0.01), and a third between the MTD and the pT stage (Pearson coefficient = 0.678, p < 0.01). CONCLUSION: mp-MRI can accurately detect the index lesion and estimate the TVP of localised prostate cancer.

Urethral diverticulum with massive lithiasis presenting as a scrotal mass.

Urethral diverticula in men are uncommon clinical entities. Their clinical manifestations include urinary tract infection, hematuria, irritative or obstructive voiding symptoms, ventral bulging and displacement of the penile shaft. Male urethral diverticulum with massive lithiasis presenting as a scrotal mass with stress urinary incontinence as the main symptom is extremely rare. Herein, we present such a case.

Inapparent tumor on endorectal multimodality magnetic resonance imaging of prostate: should we perform a biopsy?

OBJECTIVES: To examine whether one could spare patients with a clinical suspicion of prostate cancer (PCa) but inapparent tumor on multimodality endorectal magnetic resonance imaging (e-MRI) of the prostate from undergoing prostate biopsy. METHODS: A total of 109 patients with a clinical suspicion of PCa underwent conventional and functional e-MRI of the prostate and subsequently prostate biopsy. The inclusion criteria were prostate-specific antigen level>4 ng/mL or a suspicious finding on digital rectal examination. The images were interpreted by a highly experienced radiologist and were considered negative for PCa in all cases. Regardless of the negative findings, all patients underwent an 18-core prostate biopsy. Functional e-MRI included contrast-enhanced e-MRI and diffusion-weighted imaging. The examinations were performed on a closed 1.0-T system combined with an endorectal body phased-array coil. The clinicopathologic parameters of the patients included age, prostate-specific antigen level, digital rectal examination findings, PCa detection rate, clinically significant PCa detection rate, high-grade PCa detection rate, and e-MRI specificity. RESULTS: The median age of the patients was 67.4 years, and the median prostate-specific antigen level was 12.9 ng/mL. The digital rectal examination findings were positive in 42 patients (38.5%) and negative in 67 patients (61.5%). Overall, PCa was detected in 19.2% of patients, with 47.6% cases defined as clinically significant and 38.1% as high grade. Overall, the e-MRI specificity was 80.8%. CONCLUSIONS: The results of our study have shown that the absence of tumor on e-MRI scans of patients with a clinical suspicion of PCa does not rule out the probability of clinically significant and high-grade PCa, making prostate biopsy mandatory for these patients as well.

Primary leiomyosarcoma of the testis. A case report.

Primary leiomyosarcoma of the testis is an extremely rare disease entity of the genito-urinary tract. Although its clinical presentation does not seem to differ from that of other testicular malignancies, the clinical stage with which patients have been treated, as reported in contemporary literature, has always been stage 1. Diagnosis is achieved by combining histologic and immunohistochemical findings. Histologic findings refer to the presence of a spindle cell component with nuclear pleomorphism, while immunohistochemical findings refer to its reaction to specific antibodies. Although the number of reported cases is not significant and the clinical and biological behaviour of these tumors are very hard to predict, we demonstrate that radical orchidectomy followed by surveillance appears to be the treatment of choice. Retroperitoneal lymphadenectomy, radiotherapy and chemotherapy do not seem to have any place in the treatment of this type of malignancy.

Clinical and surgical experience with Wilms' tumor. Long-term results of a single institution.

BACKGROUND: Although the NWTSG and SIOP studies have included the largest number of patients, several individual institutions have made likewise important contributions to the optimization of Wilms' tumor therapy. The purpose of this study is to present our personal experience obtained in the last 42 years by treating Wilms' tumor in childhood. PATIENTS AND METHODS: Throughout the period 1965-2006, 65 children with histological confirmation of Wilms' tumour were treated in the Department of Urology, University of Erlangen Medical Centre. The records of all patients presenting to our institution with Wilms' tumour were examined. RESULTS: The results obtained by this study group indicate that prognosis according to age demonstrated no significance, but prognosis according to tumor size, lymph node involvement and distant metastasis was significant. After a 10-year follow-up, our data revealed an 89.4% survival rate. Furthermore, the statistical evaluation performed in order to evaluate the significance of surgical complications following neoadjuvant therapy in comparison to non adjuvant therapy, indicates that there is a significant increase in complications in patients who are not treated with neoadjuvant therapy. DISCUSSION: Although clinicians in the U.S.A. and Europe have different philosophies on preoperative chemotherapy, most patients with Wilms' tumor survive long term, regardless of the sequence of therapeutic interventions. In the absence of a clear choice between up-front nephrectomy and preoperative chemotherapy, it is reasonable to base the timing of resection on factors such as tumor size, the patient's clinical condition, and the experience of the surgeon.

Radical nephrectomy and nephroureterectomy in patients over 80 years old.

PURPOSE: The aim of this study was to discover if elderly patients exhibit comparable outcomes and survival benefits to those achieved in younger patients. MATERIALS AND METHODS: We assessed 35 patients over 80 years old treated by radical nephrectomy or nephroureterectomy for malignant and inflammatory conditions within the previous 4 years. A multivariate analysis regarding survival and recovery was conducted and included various preoperative parameters. The subjective opinion of patients or patient's relatives (in cases where the patient had past away) was estimated by answering the following questions: (a) are you satisfied with your decision to undergo the operation? (b) would you undergo it once more if needed? (c) would you advise it to a patient your age? RESULTS: The median age was 83.5 years. Radical nephrectomy with a flank approach was performed in 65.7% of cases and nephroureterectomy with a transabdominal approach in 34.3% of cases. The median recovery was 13 weeks. During a median follow-up of 31 months (range 12 to 53), 80% of patients were disease free. The remaining 20% passed away demonstrating a median survival of 25 months (range 13-38). Eighty-eight percent of patients were satisfied with their decision to undergo the operation, 91.4% would undergo it once more if needed and 91.4% would advise it to a patient their age. CONCLUSIONS: Radical nephrectomy and nephroureterectomy are safe and effective in well-selected patients over 80 years old. Elderly patients exhibit comparable preoperative outcomes and survival benefits to those achieved in younger patients. Various preoperative clinical variables that effect the survival of patients but not their recovery could be identified.

Guided e-MRI prostate biopsy can solve the discordance between Gleason score biopsy and radical prostatectomy pathology.

INTRODUCTION: The aim of this study is to examine if guided prostate biopsies based on abnormalities detected by conventional and functional endorectal magnetic resonance imaging (MRI) yield a more reliable representation of the radical prostatectomy pathology and to identify probable preoperative clinical variables that stratified patients likely to harbor significant upgrading. PATIENTS AND METHODS: From April 2004 to April 2009, a review of N=70 patients records diagnosed with prostate cancer by a 3-6 core guided transrectal ultrasound (TRUS) prostate biopsy based on abnormalities detected by conventional and functional endorectal MRI and who subsequently underwent radical prostatectomy and exhibited a significant upgrading was conducted. Additionally, a multivariate analysis with a significant upgrading as the outcome was performed including the following parameters: prostate specific antigen (PSA) level, clinical stage, prostate size and duration from biopsy to radical prostatectomy. RESULTS: A significant upgrading was noted in only 8.5% of patients, with 1.4% exhibiting a significant downgrading and the rest 90.1% exhibiting an exact Gleason score match. No preoperative clinical variables that stratified patients likely to harbour significant upgrading were identified. CONCLUSIONS: This type of biopsy method seems to solve the discordance between the biopsy Gleason score and radical prostatectomy pathology regardless of known preoperative clinical variables that can affect it.

Radical nephrectomy and nephroureterectomy in patients over 80 years old

PURPOSE: The aim of this study was to discover if elderly patients exhibit comparable outcomes and survival benefits to those achieved in younger patients. MATERIALS AND METHODS: We assessed 35 patients over 80 years old treated by radical nephrectomy or nephroureterectomy for malignant and inflammatory conditions within the previous 4 years. A multivariate analysis regarding survival and recovery was conducted and included various preoperative parameters. The subjective opinion of patients or patient's relatives (in cases where the patient had past away) was estimated by answering the following questions: (a) are you satisfied with your decision to undergo the operation? (b) would you undergo it once more if needed? (c) would you advise it to a patient your age? RESULTS: The median age was 83.5 years. Radical nephrectomy with a flank approach was performed in 65.7 percent of cases and nephroureterectomy with a transabdominal approach in 34.3 percent of cases. The median recovery was 13 weeks. During a median follow-up of 31 months (range 12 to 53), 80 percent of patients were disease free. The remaining 20 percent passed away demonstrating a median survival of 25 months (range 13-38). Eighty-eight percent of patients were satisfied with their decision to undergo the operation, 91.4 percent would undergo it once more if needed and 91.4 percent would advise it to a patient their age. CONCLUSIONS: Radical nephrectomy and nephroureterectomy are safe and effective in well-selected patients over 80 years old. Elderly patients exhibit comparable preoperative outcomes and survival benefits to those achieved in younger patients. Various preoperative clinical variables that effect the survival of patients but not their recovery could be identified.

Empyema of the ureteral stump. An unusual complication following nephrectomy.

A ureteral stump, which is the segment of the ureter left in place after nephrectomy, may occasionally give rise to a pathologic process called ureteral stump syndrome, which is clinically interpreted as febrile urinary tract infections, lower quadrant pain, and hematuria. Empyema of the ureteral stump, which belongs to this syndrome, is an uncommon disease entity presenting with a reported incidence of 0.8-1%. We present a case of empyema of the ureteral stump in a female patient 5 years postnephrectomy for a nonfunctioning kidney, and discuss the clinical presentation, radiologic diagnosis, and therapeutic options of this uncommon disease entity.

Quadrimodal treatment of high-risk T1 and T2 bladder cancer: transurethral tumor resection followed by concurrent radiochemotherapy and regional deep hyperthermia.

BACKGROUND AND PURPOSE: To assess the safety and effectiveness of treating high-risk T1 and T2 bladder cancer with transurethral resection (TUR-BT) followed by radiochemotherapy (RCT) combined with regional deep hyperthermia (RHT). MATERIAL AND METHODS: Between 2003 and 2007, 45 patients were enrolled. After TUR-BT patients received radiotherapy (RT) of the bladder and regional lymph nodes with 50.4 Gy, and a boost to the bladder of 5.4-9 Gy. RCT was applied to 43/45 patients. RHT was administered once weekly. Response was re-evaluated 6 weeks after RT by restaging-TUR. Toxicity was graded with the CTCAE, version 3.0. QoL was evaluated by a dedicated questionnaire. RESULTS: The median follow-up was 34 months (range 12-60). The median number of hyperthermia treatments was 5 (range 1-7). Acute toxicity grades 3 and 4 occurred in 20% (9/45) and 9% (4/45), respectively. Late toxicity grades 3/4 were seen in 24% (11/45). Complete response rate was 96% (43/45). Local recurrence-free survival was 85%, overall survival was 80%, disease-specific survival was 88%, metastasis-free survival was 89%, and the bladder-preserving rate was 96% (43/45) at 3 years. Eighty percent (24/30) were at least mostly satisfied with their bladder function. CONCLUSIONS: The quadrimodal treatment was feasible and well tolerated. Local control and bladder-preserving rates were encouraging.

Retroperitoneal ganglioneuroma in childhood--a presentation of two cases.

Ganglioneuromas are considered to be part of the neuroblastoma series of tumors, which evolve from the sympathogonia of neural crest origin. As imaging techniques have become more widely practiced, the number of ganglioneuromas detected incidentally has increased. Preoperative diagnosis of retroperitoneal ganglioneuromas is often difficult and the diagnosis is usually based on histopathological findings after surgical excision of the tumor. We present two cases of this unique disease entity and discuss its clinical presentation, therapeutic approach, and clinical outcome.

Anaplastic sarcoma of the kidney.

Wilms tumor can appear with a wide spectrum of morphologic features and can sometimes cover or delay the recognition of other clinicopathologic entities of the kidney. We present a case of a new tumor entity of the kidney, namely the anaplastic sarcoma of the kidney, a tumor of high malignancy.

The role of conventional and functional endorectal magnetic resonance imaging in the decision of whether to preserve or resect the neurovascular bundles during radical retropubic prostatectomy.

OBJECTIVE: Because the recovery of erectile function and the avoidance of positive surgical margins are important but competing outcomes, the decision whether to preserve or resect a neurovascular bundle (NVB) during radical prostatectomy (RP) is based on information concerning mostly the presence and location of extracapsular extension (ECE). Conventional endorectal magnetic resonance imaging (e-ctMRI) and functional endorectal MRI (e-ftMRI) of the prostate provide an excellent depiction of the pelvic and prostate anatomy, and are also useful in predicting the presence of prostate cancer as well as ECE, seminal vesicle invasion (SVI) and NVB involvement. Their predictive qualities, however, have shown significant interobserver variability. The aims of this study are to report on accuracy using e-ctMRI and e-ftMRI, and to assess their value in making the decision whether to preserve or resect the NVBs during RP. MATERIAL AND METHODS: From 2004 to 2007, 75 consecutive patients with a biopsy-proven prostate cancer and satisfactory erectile function, who were scheduled to undergo RP, were subjected to e-ctMRI and e-ftMRI before surgery. Interpretation was performed by a highly experienced radiologist blinded to patient clinical data. All patients underwent RP and a nerve-sparing (NS) procedure was considered appropriate if the tumour did not extend outside the capsule in the posterolateral region of the prostate as assessed by the images. RESULTS: An NSRP was performed in 78.7% of patients. Based on the e-ctMRI and e-ftMRI findings, the operative strategy was changed in 44% of patients. The findings favoured NVB preservation in 67% of patients with a high clinical probability of ECE, and opposed NVB preservation in 33% of patients with a low clinical probability of ECE. Based on the final histopathological findings, the surgical plan was successfully changed in all patients. The sensitivity, specificity and accuracy rate were 92%, 100% and 100% for ECE, SVI and NVB involvement, respectively, results which are higher than all other published international standards in this matter. CONCLUSIONS: e-ctMRI and e-ftMRI comprise a sufficient modality in detecting prostate cancer, ECE, SVI and NVB involvement. This technique seems to one of the most sensitive preoperative clinical staging methods for selective patients, and extremely useful for identifying candidates for an NSRP.