HDR brachytherapy boost using MR-only workflow for intermediate- and high-risk prostate cancer: 8-year results of a pilot study.

PURPOSE: To report 8-year clinical outcome with high-dose-rate brachytherapy (HDRBT) boost using MRI-only workflow for intermediate (IR) and high-risk (HR) prostate cancer (PC) patients. METHODS AND MATERIALS: Fifty-two patients were treated with 46-60 Gy of 3D conformal radiotherapy preceded and/or followed by a single dose of 8-10 Gy MRI-guided HDRBT. Interventions were performed in a 0.35 T MRI scanner. Trajectory planning, navigation, contouring, catheter reconstruction, and dose calculation were exclusively based on MRI images. Biochemical relapse-free- (BRFS), local relapse-free- (LRFS), distant metastasis-free- (DMFS), cancer-specific-(CCS) and overall survival (OS) were analyzed. Late morbidity was scored using the Common Terminology Criteria for Adverse Events (CTCAE 4.0) combined with RTOG (Radiation Therapy Oncology Group) scale for urinary toxicity and rectal urgency (RU) determined by Yeoh. RESULTS: Median follow-up time was 107 (range: 19-143) months. The 8-year actuarial rates of BRFS, LRFS, DMFS, CSS and OS were 85.7%, 97%, 97.6%, and 77.6%, respectively. There were no Gr.3 GI side effects. The 8-year actuarial rate of Gr.2 proctitis was 4%. The 8-year cumulative incidence of Gr.3 GU side effects was 8%, including two urinary stenoses (5%) and one cystitis (3%). EPIC urinary and bowel scores did not change significantly over time. CONCLUSIONS: MRI-only HDR-BT boost with moderate dose escalation provides excellent 8-year disease control with a favorable toxicity profile for IRPC and HRPC patients. Our results support the clinical importance of MRI across the BT workflow.

[Efficacy of the percutaneous tibial nerve stimulation in the treatment of lower urinary tract symptoms]. / A percutan nervus tibialis stimuláció szerepe egyes kismedencei kórképek kezelésében.

Percutaneous tibial nerve stimulation (PTNS) is a minimally invasive, safe and well-tolerated neuromodulation technique for the lower urinary tract dysfunctions. PTNS delivers neuromodulation to the pelvic floor through the S2-4 junction of the sacral nerve plexus via the route of the posterior tibial nerve. Using the fine needle electrode insertion above the ankle, the tibial nerve is accessed, which connected to the stimulator. To date despite of its excessive clinical use, PTNS mechanism of action still remains unclear. The technique seems to be an efficacious and safe treatment for overactive bladder syndrome (OAB). It could be recommended according to the Urinary Incontinence Guideline of the European Association of Urology in women who did not have adequate improvement or could not tolerate anti-muscarinic therapy. The success rate is comparable to sacral nerve stimulation in OAB patients. PTNS has been used for fecal incontinence since 2003, however, many of the published studies are of poor quality. PTNS has also been shown to have positive effects on chronic pelvic pain, when the usual therapeutic steps did not result in satisfactory improvement. No major complications are reported in the literature, following PTNS treatment. Orv Hetil. 2018; 159(43): 1735-1740.

Comparison of 10-year overall survival between patients with G1 and G2 grade Ta bladder tumors.

To compare long-term overall survival (OS) in patients with G1 and G2 grade Ta bladder cancer after transurethral resection of bladder tumors (TURBTs). Secondary aim was to investigate clinical and pathologic prognostic factors for OS of Ta patients, except G3/high grade (HG).A total of 243 patients, retrospectively selected, with Ta nonmuscle invasive bladder cancer (NMIBC) underwent TURBT between January 2006 and December 2008 (median follow-up 109 months). Inclusion criteria were: Ta at first manifestation, G1 or G2 grade with no associated carcinoma in situ (CIS). Seventy-nine patients were excluded due to concomitant CIS (1), G3/HG tumors (47), and lost to follow-up (31). Ethical approval was obtained from the Ethical Committee of the Mures County Hospital. Statistical analysis was performed using STATA 11.0.Following inclusion criteria, 164 patients with primary G1 or G2 Ta tumors, were enrolled. Recurrence was observed in 26 (15.8%) and progression in 5 (3%) patients. Ten-year survival in G1 patients was 67.8% (CI 54.3-78.1) and in G2 patients 59% (CI 49-67.3) (P = .31). Univariable and multivariable logistic regression analysis underlined that advanced age at diagnosis (hazard ratio [HR] 1.10) and no Bacillus Calmette-Guerin (BCG) treatment (HR 0.24 and 0.29) were independent predictors for death at 10 years after diagnosis.Long-term analysis confirms that patients with well differentiated (G1) and moderately well differentiated (G2) Ta tumors have similar OS. A longer OS was even reported in those who underwent BCG adjuvant therapy.

Fluorescence diagnosis of bladder cancer with new water soluble hypericin bound to polyvinylpyrrolidone: PVP-hypericin.

Although conventional white light endoscopy (WLE) is currently the gold standard for diagnosing bladder tumors, rates of false negative results and residual tumors after transurethral resection are relatively high. The goal of the present clinical study is to investigate whether using new water soluble hypericin (PVP-hypericin) as a fluorescent dye improves bladder cancer detection and diagnosis. Following instillation of PVP-hypericin (total amount of 0.25 mg hypericin bound to 25 mg polyvinylpoyrrolidone [PVP], reconstituted in 50 mL phys. sodium chloride solution), WLE and fluorescence cystoscopy (photodynamic diagnosis; PDD) were performed on patients with suspected primary or recurrent bladder malignancies (n = 57). Incubation time was 1-2 h and biopsies (n = 163) were taken from fluorescing regions and/or from regions which were suspicious under WLE. Histological investigations of the biopsies provided the final proof of malignancy (or the counterevidence). Results indicated that overall sensitivity with PVP-hypericin and PDD is significantly higher (95%) than with WLE (85%). The sensitivity of PDD in the diagnosis of carcinoma in situ (n = 12) was 100% compared with 33% for WLE. In the diagnosis of dysplasia, the sensitivity of PDD was 85% compared with 31% for WLE. PDD has a positive predictive value (PPV) of 0.75% and a negative predictive value (NPV) of 0.86%, in comparison to WLE PPV = 0.66% NPV = 0.58%. Biopsies were not taken from healthy tissues, thus specificity was markedly lower in our study (53%) than that reported in other studies (98-100%). As a conclusion, PDD using PVP-hypericin is superior to WLE in terms of sensitivity in the diagnosis of malignancies of the bladder. Results suggest that PVP-hypericin is a promising formulation for various diagnostic and therapeutic applications.

Evaluation of transition zone and lateral sextant biopsies for prostate cancer detection after initial sextant biopsy.

OBJECTIVES: To assess the value of transition zone and lateral sextant biopsies for the detection of prostate cancer after a previous sextant biopsy was negative. METHODS: A total of 74 prostates after radical prostatectomy were used to perform biopsies ex vivo. First, a sextant biopsy was taken, then two different rebiopsy techniques were performed. Rebiopsy technique A consisted of a laterally placed sextant biopsy and two cores per side of the transition zones only. Rebiopsy technique B included a standard sextant biopsy and two cores per side from the lateral areas of the prostate. The biopsies were taken using ultrasound guidance to sample the areas of interest precisely. RESULTS: The initial sextant biopsy found 39 prostate cancers. Rebiopsy technique A found 12 cancers (34%). In this group, a laterally placed sextant biopsy found 12 cancers; transition zone biopsies revealed cancer in 5 cases, but no additional tumor was found. Rebiopsy technique B detected 23 prostate cancers (66%). Fourteen tumors were found after a second standard sextant biopsy, and nine additional tumors were found in the lateral areas. CONCLUSIONS: Sextant biopsy has a low sensitivity of only 53%. A biopsy including the transition zones is not the ideal technique for detecting the remaining tumors. Therefore, transition zone biopsies should be reserved for patients with multiple previous negative biopsies of the peripheral zone. A subsequent sextant biopsy with additional cores from the lateral areas of the prostate is favorable if rebiopsy is necessary after a negative sextant biopsy.

New aspect of photodynamic diagnosis of bladder tumors: fluorescence cytology.

OBJECTIVES: To establish a new diagnostic method for the detection and follow-up of bladder cancer that combines the principles of photodynamic diagnosis and urinary cytology. METHODS: We investigated 46 patients scheduled for transurethral resection of a bladder tumor immediately before the resection was carried out. After intravesical instillation of either 5-aminolevulinic acid (ALA) or hypericin, urinary cytology specimens were obtained. Induced fluorescence of urothelial cells was detected by fluorescence microscopy. The results were compared with the conventional cytologic and histologic findings. RESULTS: In the 46 patients, 42 cases of urothelial carcinoma and 4 cases of nonspecific inflammation were diagnosed. Of the 42 patients with cancer, 19 had Stage Ta, 9 had T1, 3 had carcinoma in situ, and 11 had invasive bladder cancer. The grading was G1 in 17 patients, G2 in 6 patients, and G3 in 19 patients. In 38 cases we instilled ALA and in 8 hypericin. All 4 patients diagnosed with nonspecific inflammation had received ALA. We detected ALA-induced fluorescence in 34 of 38 cases. One of the four histologically negative cases had a false-positive finding and 1 case of urothelial carcinoma did not show fluorescence. After instillation of hypericin we could detect induced fluorescence in all cases. CONCLUSIONS: Our first results suggest that fluorescence cytology is more sensitive than other noninvasive tests. After additional investigation, it may become a valuable diagnostic method and may reduce the number of cystoscopies in the follow-up of bladder tumors.