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1.
Harefuah ; 160(9): 594-597, 2021 Sep.
Artigo em Hebraico | MEDLINE | ID: mdl-34482672

RESUMO

BACKGROUND: Urinary Incontinence (UI) following Robot-Assisted Laparoscopic-Radical Prostatectomy (RALP) adversely affects patients' quality of life. OBJECTIVES: To find parameters that predict full urinary continence (FUC) following RALP. METHODS: Out of an established prospective RALP database, we retrieved and analyzed parameters that potentially predict FUC: age, Body Mass Index, American Anesthesiology Association (ASA) score, previous abdominal surgeries, pre-operative IPSS (International Prostate-Symptom Score), operative time (OT), estimated blood loss (EBL), peritoneum closure and prostate weight. FUC has been defined as 0 pads/day. Univariate analysis has been executed for comparison between patient groups, whereas multivariate analysis has been implemented for the detection of predicting factors for FUC. Data are presented as median (interquartile range) or numeric value (%). RESULTS: A total of 431 RALP cases were recorded between the years 2010-2019. Final analysis included 364 patients with full medical records; 81% gained FUC within 15 weeks (8-28); 96% gained FUC or used 1 pad/day within 17.5 weeks (8-36). Among those who gained FUC, smaller prostates (p=0.028) and low EBL (p=0.025) have been observed. On multivariate analysis EBL has been associated with UI (OR=0.9). CONCLUSIONS: Most patients gained FUC following RALP. EBL was found as risk factor for UI.


Assuntos
Laparoscopia , Neoplasias da Próstata , Robótica , Humanos , Masculino , Estudos Prospectivos , Próstata/cirurgia , Prostatectomia/efeitos adversos , Neoplasias da Próstata/cirurgia , Qualidade de Vida
2.
Harefuah ; 160(9): 598-602, 2021 Sep.
Artigo em Hebraico | MEDLINE | ID: mdl-34482673

RESUMO

BACKGROUND: Partial nephrectomy is the gold standard treatment for renal tumors less than 7 cm. OBJECTIVES: To describe surgical techniques and trends of treating renal tumors less than 7 cm at our department and present the clinical outcomes of our experience with Robot-Assisted Partial Nephrectomy (RAPN). METHODS: Out of an established prospective RAPN database, we retrieved demographic, clinical, surgical and pathological parameters. Operation length was defined as the time between the first surgical incision and the last suture (skin to skin). Warm ischemia time (WIT) was defined as the time between the renal artery clamping and clamp releasing. Data is presented as mean (range, standard deviation) or numeric value (%). RESULTS: Overall, 250 RAPN cases were recorded between the years 2013-2020. Mean tumor size was 32 mm. Mean operation length was 153 minutes. Mean warm ischemia time was 17.5 minutes. Intra-operative complication rates, including converting the surgery to an open approach or to radical nephrectomy, was low. Mean estimated blood loss was 359 cc. An increase in the utilization of the robotic approach has been recorded throughout the years, with a concurrent decrease in the open and laparoscopic approaches. CONCLUSIONS: RAPN is associated with lower complication rates and superior perioperative outcomes, therefore considered a good alternative to the open and laparoscopic approaches. Thus, RAPN is the gold standard treatment for renal tumors less than 7 cm at our institute.


Assuntos
Neoplasias Renais , Laparoscopia , Procedimentos Cirúrgicos Robóticos , Robótica , Humanos , Neoplasias Renais/cirurgia , Nefrectomia/efeitos adversos , Estudos Prospectivos , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Resultado do Tratamento
3.
Harefuah ; 160(9): 608-614, 2021 Sep.
Artigo em Hebraico | MEDLINE | ID: mdl-34482675

RESUMO

INTRODUCTION: Focal treatment for prostate cancer has been proposed as an innovative strategy that aims to achieve oncological benefit while reducing treatment-related morbidity. This treatment is suitable for patients with low and intermediate risk, organ-confined disease. Focal therapy can be categorized as follows: unifocal index lesion ablation, multifocal ablation, hemi-gland ablation or subtotal gland ablation. Different types of energies are applied in focal therapy including high intensity focal ultrasound (HIFU), cryotherapy, focal laser ablation (FLA), irreversible electroporation (IRE) and Photodynamic therapy (PDT). In this review we will briefly present a summary of leading techniques and the available data regarding their oncological outcomes and adverse events. Whole-gland therapies were excluded from this review.


Assuntos
Ablação por Cateter , Fotoquimioterapia , Neoplasias da Próstata , Crioterapia , Humanos , Masculino , Neoplasias da Próstata/diagnóstico , Neoplasias da Próstata/terapia , Resultado do Tratamento
4.
J Pers Med ; 11(7)2021 Jul 15.
Artigo em Inglês | MEDLINE | ID: mdl-34357132

RESUMO

BACKGROUND: The substantial burden of kidney disease fosters interest in new ways of screening for early disease diagnosis, especially by non-invasive imaging. Increasing evidence for an association between retinal microvascular signs and kidney disease prompted us to investigate the relevant current literature on such an association systematically by performing a meta-analysis of our findings. METHODS: We scrutinized the current literature by searching PubMed and Embase databases from for clinical studies of the association between retinal microvascular signs and prevalent or incident kidney disease. After excluding cases that did not meet our criteria, we extracted relevant data from 42 published studies (9 prospective, 32 cross-sectional, and 1 retrospective). RESULTS: Our investigation yielded significant associations between retinal vascular changes (including retinopathy and retinal vascular diameter) and kidney dysfunction (including chronic kidney disease (CKD), end-stage renal disease (ESRD), albuminuria, and estimated glomerular filtration rate (eGFR) decline). According to our meta-analysis, retinopathy was associated with ESRD (hazard ratio (HR) 2.12 (95% confidence interval CI; 1.39-3.22)) and with CKD prevalence in the general population (odds ratio (OR) 1.31 (95% CI; 1.14-1.50)), and specifically in type 2 diabetic patients (OR 1.68 (95% CI; 1.68-2.16)). CRAE was associated with prevalent CKD (OR 1.41 (95% CI; 1.09-1.82)). CONCLUSIONS: Our findings suggest that the retinal microvasculature can provide essential data about concurrent kidney disease status and predict future risk for kidney disease development and progression.

5.
Cancer Med ; 10(18): 6354-6364, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34374489

RESUMO

BACKGROUND: Docetaxel (D) or secondary hormonal therapy (SHT) each combined with androgen deprivation therapy (ADT) represent possible treatment options in males with metastasized hormone-sensitive prostate cancer (mHSPC). Real-world data comparing different protocols are lacking yet. Thus, our objective was to compare the efficacy and safety of abiraterone acetate (AA)+ADT versus D+ADT in mHSPC. METHODS: In a retrospective multicenter analysis including males with mHSPC treated with either of the aforementioned protocols, overall survival (OS), progression-free survival 1 (PFS1), and progression-free survival 2 (PFS2) were assessed for both cohorts. Median time to event was tested by Kaplan-Meier method and log-rank test. The Cox-proportional hazards model was used for univariate and multivariate regression analyses. RESULTS: Overall, 196 patients were included. The AA+ADT cohort had a longer PFS1 in the log-rank testing (23 vs. 13 mos., p < 0.001), a longer PFS2 (48 vs. 33 mos., p = 0.006), and longer OS (80 vs. 61 mos., p = 0.040). In the multivariate analyses AA+ADT outperformed D+ADT in terms of PFS1 (HR = 0.34, 95% CI = 0.183-0.623; p = 0.001) and PFS2 (HR = 0.33 95% CI = 0.128-0.827; p = 0.018), respectively, while OS and toxicity rate were similar between both groups. CONCLUSIONS: AA+ADT is mainly associated with a similar efficacy and overall toxicity rate as D+ADT. Further prospective research is required for validation of the clinical value of the observed benefit of AA+ADT for progression-free end-points.

6.
Sci Rep ; 11(1): 4842, 2021 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-33649388

RESUMO

Locally advanced urothelial cancer has high recurrence and progression rates following surgical treatment. This highlights the need to develop neoadjuvant strategies that are both effective and well-tolerated. We hypothesized that neoadjuvant sub-ablative vascular-targeted photodynamic therapy (sbVTP), through its immunotherapeutic mechanism, would improve survival and reduce recurrence and progression in a murine model of urothelial cancer. After urothelial tumor implantation and 17 days before surgical resection, mice received neoadjuvant sbVTP (WST11; Tookad Soluble, Steba Biotech, France). Local and systemic response and survival served as measures of therapeutic efficacy, while immunohistochemistry and flow cytometry elucidated the immunotherapeutic mechanism. Data analysis included two-sided Kaplan-Meier, Mann-Whitney, and Fischer exact tests. Tumor volume was significantly smaller in sbVTP-treated animals than in controls (135 mm3 vs. 1222 mm3, P < 0.0001) on the day of surgery. Systemic progression was significantly lower in sbVTP-treated animals (l7% vs. 30%, P < 0.01). Both median progression-free survival and overall survival were significantly greater among animals that received sbVTP and surgery than among animals that received surgery alone (P < 0.05). Neoadjuvant-treated animals also demonstrated significantly lower local recurrence. Neoadjuvant sbVTP was associated with increased early antigen-presenting cells, and subsequent improvements in long-term memory and increases in effector and active T-cells in the spleen, lungs, and blood. In summary, neoadjuvant sbVTP delayed local and systemic progression, prolonged progression-free and overall survival, and reduced local recurrence, thereby demonstrating therapeutic efficacy through an immune-mediated response. These findings strongly support its evaluation in clinical trials.

7.
Sci Rep ; 11(1): 5912, 2021 Mar 15.
Artigo em Inglês | MEDLINE | ID: mdl-33723317

RESUMO

While penile metastases are rare, PET/CT has facilitated their detection. We aimed to describe penile secondary lesions (PSL) identified by PET/CT. We reviewed 18F-FDG and Ga68-PSMA PET/CT records performed in a single center during May 2012-March 2020, for PSL. Of 16,774 18F-FDG and 1,963 Ga68-PSMA-PET scans, PSL were found in 24(0.13%) men with a mean age of 74. PSMA detected PSL in 12 with prostate cancer; FDG identified PSL in 4 with lymphoma, 3 with colorectal cancer, 2 with lung cancer, and one each with bladder cancer, pelvic sarcoma, and leukemia. Mean SUVmax of PSL was 7.9 ± 4.2 with focal uptake in 13(54%). Mean lesion size was 16.5 ± 6.8 mm; 8 at the penile root, 4 along the shaft, and 1 at the glans. CT detected loss of the penile texture in 15(63%). PSL were observed only during relapse or follow-up of disseminated disease. Among those with prostate cancer, PSA varied widely. Fifteen (62.5%) died, at a mean 13.3 ± 15.9 months following PSL demonstration, nine had non-prostate malignancies. PET/CT identified and characterized PSL in a fraction of cancer patients, most commonly those with prostate cancer. PSL universally surfaced in advanced disease, and signaled high mortality, especially in non-prostate cancers.

8.
Isr Med Assoc J ; 23(2): 111-115, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33595217

RESUMO

BACKGROUND: Little is known about oncologic outcomes following robot-assisted-radical-prostatectomy (RALP) for clinical T3 (cT3) prostate cancer. OBJECTIVES: To investigate oncologic outcomes of patients with cT3 prostate cancer treated by RALP. METHODS: Medical records of patients who underwent RALP from 2010 to 2018 were retrieved. cT3 cases were reviewed. Demographic and pre/postoperative pathology data were analyzed. Patients were followed in 3-6 month intervals with repeat PSA analyses. Adjuvant/salvage treatments were monitored. Biochemical recurrence (BCR) meant PSA levels of ≥ 0.2 ng/ml. RESULTS: Seventy-nine patients met inclusion criteria. Median age at surgery was 64 years. Preoperative PSA level was 7.14 ng/dl, median prostate weight was 54 grams, and 23 cases (29.1%) were down-staged to pathological stage T2. Positive surgical margin rate was 42%. Five patients were lost to follow-up. Median follow-up time for the remaining 74 patients was 24 months. Postoperative relapse in PSA levels occurred in 31 patients (42%), and BCR in 28 (38%). Median time to BCR was 9 months. The overall 5-year BCR-free survival rate was 61%. Predicting factors for BCR were age (hazard-ratio [HR] 0.85, 95% confidence interval [95%CI] 0.74-0.97, P = 0.017) and prostate weight (HR 1.04, 95%CI 1.01-1.08, P = 0.021). Twenty-six patients (35%) received adjuvant/salvage treatments. Three patients died from metastatic prostate cancer 31, 52, and 78 months post-surgery. Another patient died 6 months post-surgery of unknown reasons. The 5-year cancer-specific survival rate was 92. CONCLUSIONS: RALP is an oncologic effective procedure for cT3 prostate cancer. Adjuvant/salvage treatment is needed to achieve optimal disease-control.


Assuntos
Antígeno Prostático Específico/análise , Prostatectomia/métodos , Neoplasias da Próstata/cirurgia , Procedimentos Cirúrgicos Robóticos/métodos , Idoso , Intervalo Livre de Doença , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia , Estadiamento de Neoplasias , Neoplasias da Próstata/patologia , Estudos Retrospectivos , Terapia de Salvação , Taxa de Sobrevida , Resultado do Tratamento
9.
Can Urol Assoc J ; 15(5): E244-E247, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33119495

RESUMO

INTRODUCTION: We aimed to compare systematic biopsies (SBs) of in-bore magnetic resonance-guided prostate biopsy (MRGpB) with those performed under transrectal ultrasound (TRUS) guidance in the clinical setting. METHODS: Data on all 161 consecutive patients undergoing prostate biopsy at our institution between November 2017 and July 2019 were retrospectively collected. The patients were referred to biopsy due to elevated prostate-specific antigen (PSA) and/or abnormal digital rectal examination (DRE) and/or at least one Prostate Imaging Reporting and Data System (PI-RADS) lesion score of ≥3 on multiparametric magnetic resonance imaging (mpMRI). We included patients with PSA levels ≤20 ng/ml and those with 8-12 core biopsies. Histology results of SBs performed by in-bore MRGpB were compared to TRUS SBs. Chi-squared, Fischer's exact, and multivariate Pearson regression tests were used for statistical analysis (SPSS, IBM Corporation). RESULTS: In total, 128 patients were eligible for analysis. Their median age was 68 years (interquartile range [IQR] 61.5-72), mean prostate size 55±29 cc, and mean PSA and PSA density levels 7.6±3.5 ng/ml and 0.18±0.13 ng/ml/cc, respectively. Thirty-five patients (27.3%) had suspicious DRE findings. Both biopsy groups were similar for these parameters. Thirty-eight (62.3%) MRGpB patients had a previous biopsy vs. five (7.1%) TRUS-SB patients (p<0.0001). The number of patients diagnosed with clinically significant and non-significant disease was similar for both groups. High-risk disease was more prevalent in the TRUS-SB group (22.4% vs. 4.9%, p<0.01). CONCLUSIONS: Our data suggest that in-bore MRGpB is no better than TRUS for guiding SBs for the detection of clinically significant prostate cancer.

10.
Urol Oncol ; 38(12): 929.e1-929.e10, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33036903

RESUMO

OBJECTIVE: Ad-hoc guidelines for managing the COVID-19 pandemic are published worldwide. We investigated international applications of such policies in the urologic-oncology community. METHODS: A 20-item survey was e-mailed via SurveyMonkey to 100 international senior urologic-oncology surgeons. Leaders' policies regarding clinical/surgical management and medical education were surveyed probing demographics, affiliations, urologic-oncologic areas of interest, and current transportation restrictions. Data on COVID-19 burden were retrieved from the ECDC. Statistical analyses employed non-parametric tests (SPSS v.25.0, IBM). RESULTS: Of 100 leaders from 17 countries, 63 responded to our survey, with 58 (92%) reporting university and/or cancer-center affiliations. Policies on new-patient visits remained mostly unchanged, while follow-up visits for low-risk diseases were mostly postponed, for example, 83.3% for small renal mass (SRM). Radical prostatectomy was delayed in 76.2% of cases, while maintaining scheduled timing for radical cystectomy (71.7%). Delays were longer in Europe than in the Americas for kidney cancer (SRM follow-up, P = 0.014), prostate cancer (new visits, P = 0.003), and intravesical therapy for intermediate-risk bladder cancer (P = 0.043). In Europe, COVID-19 burden correlated with policy adaptation, for example, nephrectomy delays for T2 disease (r = 0.5, P =0.005). Regarding education policies, trainees' medical education was mainly unchanged, whereas senior urologists' planned attendance at professional meetings dropped from 6 (IQR 1-11) to 2 (IQR 0-5) (P < 0.0001). CONCLUSION: Under COVID-19, senior urologic-oncology surgeons worldwide apply risk-stratified approaches to timing of clinical and surgical schedules. Policies regarding trainee education were not significantly affected. We suggest establishment of an international consortium to create a directive for coping with such future challenges to global healthcare.


Assuntos
COVID-19/epidemiologia , Oncologia/tendências , Urologistas/estatística & dados numéricos , Urologia/tendências , COVID-19/prevenção & controle , Previsões , Humanos , Oncologia/educação , Oncologia/normas , Guias de Prática Clínica como Assunto , SARS-CoV-2 , Inquéritos e Questionários , Neoplasias Urológicas/diagnóstico , Neoplasias Urológicas/terapia , Urologistas/tendências , Urologia/educação , Urologia/normas
11.
Urology ; 145: 73-78, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32781078

RESUMO

OBJECTIVE: To assess the outreach and influence of the main recommendations of surgical governing bodies on adaptation of minimally invasive laparoscopic surgery (MIS) procedures during the coronavirus disease 2019 (COVID-19) pandemic in an anonymized multi-institutional survey. MATERIALS AND METHODS: International experts performing MIS were selected on the basis of the contact database of the speakers of the Friends of Israel Urology Symposium. A 24-item questionnaire was built using main recommendations of surgical societies. Total cases/1 Mio residents as well as absolute number of total cases were utilized as surrogates for the national disease burden. Statistics and plots were performed using RStudio v0.98.953. RESULTS: Sixty-two complete questionnaires from individual centers performing MIS were received. The study demonstrated that most centers were aware of and adapted their MIS management to the COVID-19 pandemic in accordance to surgical bodies' recommendations. Hospitals from the countries with a high disease burden put these adoptions more often into practice than the others particularly regarding swabs as well as CO2 insufflation and specimen extraction procedures. Twelve respondents reported on presumed severe acute respiratory syndrome coronavirus 2 transmission during MIS generating hypothesis for further research. CONCLUSION: Guidelines of surgical governing bodies on adaptation of MIS during the COVID-19 pandemic demonstrate significant outreach and implementation, whereas centers from the countries with a high disease burden are more often poised to modify their practice. Rapid publication and distribution of such recommendation is crucial during future epidemic threats.


Assuntos
COVID-19/epidemiologia , Fidelidade a Diretrizes/estatística & dados numéricos , Laparoscopia/normas , Procedimentos Cirúrgicos Robóticos/normas , SARS-CoV-2 , Procedimentos Cirúrgicos Urológicos/normas , Pesquisas sobre Serviços de Saúde , Humanos , Internacionalidade , Laparoscopia/estatística & dados numéricos , Procedimentos Cirúrgicos Minimamente Invasivos/normas , Guias de Prática Clínica como Assunto , Padrões de Prática Médica , Procedimentos Cirúrgicos Robóticos/estatística & dados numéricos , Sociedades Médicas , Procedimentos Cirúrgicos Urológicos/métodos , Procedimentos Cirúrgicos Urológicos/estatística & dados numéricos , Urologia
12.
J Am Soc Nephrol ; 31(12): 2757-2772, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-32753400

RESUMO

BACKGROUND: Cell-based therapies aimed at replenishing renal parenchyma have been proposed as an approach for treating CKD. However, pathogenic mechanisms involved in CKD such as renal hypoxia result in loss of kidney function and limit engraftment and therapeutic effects of renal epithelial progenitors. Jointly administering vessel-forming cells (human mesenchymal stromal cells [MSCs] and endothelial colony-forming cells [ECFCs]) may potentially result in in vivo formation of vascular networks. METHODS: We administered renal tubule-forming cells derived from human adult and fetal kidneys (previously shown to exert a functional effect in CKD mice) into mice, alongside MSCs and ECFCs. We then assessed whether this would result in generation of "renovascular units" comprising both vessels and tubules with potential interaction. RESULTS: Directly injecting vessel-forming cells and renal tubule-forming cells into the subcutaneous and subrenal capsular space resulted in self-organization of donor-derived vascular networks that connected to host vasculature, alongside renal tubules comprising tubular epithelia of different nephron segments. Vessels derived from MSCs and ECFCs augmented in vivo tubulogenesis by the renal tubule-forming cells. In vitro coculture experiments showed that MSCs and ECFCs induced self-renewal and genes associated with mesenchymal-epithelial transition in renal tubule-forming cells, indicating paracrine effects. Notably, after renal injury, renal tubule-forming cells and vessel-forming cells infused into the renal artery did not penetrate the renal vascular network to generate vessels; only administering them into the kidney parenchyma resulted in similar generation of human renovascular units in vivo. CONCLUSIONS: Combined cell therapy of vessel-forming cells and renal tubule-forming cells aimed at alleviating renal hypoxia and enhancing tubulogenesis holds promise as the basis for new renal regenerative therapies.


Assuntos
Células Endoteliais/citologia , Glomérulos Renais/citologia , Túbulos Renais/citologia , Transplante de Células-Tronco Mesenquimais/métodos , Células-Tronco Mesenquimais/citologia , Animais , Técnicas de Cultura de Células , Diferenciação Celular , Proliferação de Células , Terapia Baseada em Transplante de Células e Tecidos , Técnicas de Cocultura , Humanos , Camundongos , Neovascularização Fisiológica
13.
Abdom Radiol (NY) ; 45(12): 4194-4201, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-32671440

RESUMO

OBJECTIVES: To compare the ability of 68Ga -PSMA PET/CT (PSMA PET/CT) and multiparametric MRI (mpMRI) to exclude lymph node invasion (LNI) in patients who undergo radical prostatectomy (RP). MATERIALS AND METHODS: A multicenter cohort of patients who underwent PSMA PET/CT and pelvic mpMRI prior to RP with pelvic lymph node dissection (PLND) was analyzed. Increased Ga68-PSMA uptake on PET/CT and enlarged (> 10 mm) or abnormal lymph nodes on mpMRI were considered positive findings. The final surgical pathology served as the standard of reference. The negative predictive value (NPV) was calculated for each modality separately, as well as the combined value. RESULTS: Included were 89 patients with D'Amico intermediate (45%) or high-risk (55%) prostate cancer. The median number of extracted LN was 9 (IQR 6-14). LNI was found in 12 (13.5%) patients. The NPV of mpMRI, PSMA PET/CT, and the two tests combined were 87%, 89%, and 90%, in the entire cohort, 95%, 97%, and 97% in patients with intermediate-risk disease, and 80%, 82%, and 83% in patients with high-risk disease, respectively. The median diameter of LN missed by both imaging and the median intranodal tumor diameter was 5.5 (IQR 3-10) mm and 1 (IQR 1-3) mm, respectively. CONCLUSIONS: PSMA PET/CT and mpMRI demonstrated similar performance in excluding pelvic LNI with NPV of approximately 90%. The combination of both tests does not improve NPV significantly. Therefore, even in the era of advanced imaging, PLND is still recommended for accurate staging, especially in the high-risk population.


Assuntos
Imageamento por Ressonância Magnética Multiparamétrica , Neoplasias da Próstata , Radioisótopos de Gálio , Humanos , Masculino , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada , Próstata , Prostatectomia , Neoplasias da Próstata/diagnóstico por imagem , Neoplasias da Próstata/cirurgia
14.
Urol Oncol ; 38(10): 793.e13-793.e18, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32303407

RESUMO

PURPOSE: Prostate multiparametric magnetic resonance imaging (mpMRI) improves diagnosis of clinically significant cancer and reduces over-detection of nonsignificant cancer. Disagreement in the interpretation of mpMRI readings is well-known, with a reported discrepancy rate of 10% to 42%. We report the clinical repercussions of this variability on prostate biopsy candidates. MATERIALS AND METHODS: Medical records of patients referred from 11 medical centers for MR-guided prostate biopsy (MRGpB) between October, 2017 and January, 2019 were retrospectively analyzed. Patients with at least one prostate imaging reporting and data system (PI-RADS) 3 or greater prostate lesion were selected, and the mpMRI studies (all read by others) were reviewed by our prostate mpMRI reader. Outcomes included changes in PI-RADS score and the subsequent effect on total needle samples and indication for biopsy. RESULTS: Eighty-two patients with 128 lesions were suitable for analysis (mean age 66.5 ± 7.1 years, mean PSA 6.8 ± 8.5 ng/ml). Nine (11%) patients had suspicious rectal exams (T2a). Following our prostate mpMRI reader's imaging revisions, the PI-RADS score was downgraded in 66 (52%) lesions, upgraded in 15 (12%), and unchanged in 47 (37%), leaving a total of 84 suspected lesions (kappa = 0.17). Biopsy was deferred in 22 (27%) patients, and an estimated 136.4 (34.4%) samples were avoided (P = 0.0001 for both). There was a trend toward prostate size to correlate with imaging revision and abortion of biopsy (P = 0.06) while enrollment in active surveillance correlated with proof from such outcome (P = 0.007). CONCLUSION: These data suggest that high interobserver disagreement in prostate mpMRIs from diverse institutes significantly affects prostate biopsy practice. The clinical consequences of this discord are significant.


Assuntos
Imageamento por Ressonância Magnética Multiparamétrica/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Próstata/diagnóstico por imagem , Neoplasias da Próstata/diagnóstico , Idoso , Biópsia com Agulha de Grande Calibre/estatística & dados numéricos , Tomada de Decisão Clínica , Humanos , Masculino , Pessoa de Meia-Idade , Gradação de Tumores , Variações Dependentes do Observador , Seleção de Pacientes , Próstata/patologia , Neoplasias da Próstata/patologia , Estudos Retrospectivos , Carga Tumoral , Conduta Expectante/estatística & dados numéricos
15.
Urol Oncol ; 38(5): 521-525, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32139289

RESUMO

INTRODUCTION AND OBJECTIVE: Adjuvant studies with checkpoint inhibitors have attracted new interest in accurate pathological lymph node (LN) staging in renal cell carcinoma. Sentinel lymph node (SN) studies in cN0 patients revealed the pattern of lymphatic radiotracer drainage from renal tumors. The aim of this study was to describe the location of single- or oligometastatic LN and analyze if the topography of these first landing sites matches the drainage pattern observed in SN studies of renal tumors. MATERIALS AND METHODS: We collected data from 8 referral centers from 1990 to 2018 of all patients with pT1-4 cN0 or cN1 M0 renal cell carcinoma with pathologically confirmed single- or oligometastases in locoregional LN. The location of LN metastases, number, size of metastatic LN, and survival were analyzed using descriptive statistics with SPSS version 22 (IBM, Chicago, IL). RESULTS: From 3,794 patients with histologically confirmed pN1, a total of 76 patients (2%) with single- or oligometastatic pN1 were identified, of whom 24 (31.6%) and 52 (68.4%) were cN0 and cN1, respectively. On the left side, LN metastases were predominantly located in the para-aortal (48.0%; 95% confidence interval [CI] 29.22-63.12%) and hilar (31.42%; 95% CI 17.4-49.4%) area. On the right side, metastases located in retrocaval (26.82%; 95% CI 14.7-43.2%), hilar (26.82%; 95% CI 14.7-43.2%), interaortocaval (26.82%; 95% CI 14.7-43.2%), and paracaval (17.07%; 95% CI 7.6-32.6%) LNs. These landing sites exactly matched the lymphatic drainage pattern of intratumorally injected radiotracer reported in SN studies for both sides. CONCLUSIONS: Single- or oligometastatic LNs in renal cancer are mainly located in the hilar, retro-, para, and interaortocaval region on the right side and para-aortal region on the left side. These first landing sites match the drainage pattern reported in SN trials.


Assuntos
Carcinoma de Células Renais/secundário , Neoplasias Renais/patologia , Metástase Linfática/patologia , Linfonodo Sentinela/patologia , Idoso , Humanos , Pessoa de Meia-Idade , Estudos Retrospectivos
16.
Endocr Pract ; 26(9): 974-982, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-33471702

RESUMO

OBJECTIVE: Autonomous cortisol secretion (ACS) is the most common endocrine abnormality in the evaluation of adrenal incidentalomas. The categorization of ACS is derived from a 1 mg dexamethasone suppression test (DST). Impaired DST is associated with several metabolic derangements. In this study we analyzed the association between post-DST cortisol level, analyzed as a continuous parameter, and indices of glycemic metabolism. METHODS: We prospectively collected data of 1,976 patients evaluated for adrenal incidentalomas in a large tertiary medical center between December 1, 2017, and August 31, 2019. Seventy-three patients completed the evaluation process. Post-DST cortisol levels were analyzed for correlation with various metabolic parameters, including fasting plasma glucose (FPG) and hemoglobin A1c (HbA1c) among the general cohort and for subgroups stratified by the number of metabolic syndrome (MS) criteria. RESULTS: Post-DST cortisol demonstrated a linear association with FPG and HbA1c across its entire cortisol range (R = 0.51 and 0.41, respectively; P≤.01). The association between post-DST cortisol and FPG was strengthened with an increased number of metabolic syndrome criteria. Patients with 4 MS criteria show a stronger association (R = 0.92) compared to patients with only a single criterion (R = 0.509). Furthermore, mean post-DST cortisol levels increased as the number of MS criteria accumulated. CONCLUSION: Post-DST cortisol should be viewed as a continuous parameter in risk stratification algorithms for the development of MS and particularly dysglycemia.


Assuntos
Neoplasias das Glândulas Suprarrenais , Síndrome Metabólica , Secreções Corporais , Dexametasona , Humanos , Hidrocortisona , Síndrome Metabólica/epidemiologia
17.
Int J Urol ; 26(3): 414-422, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30659668

RESUMO

OBJECTIVE: To investigate the effectiveness of combination treatment of vascular targeted photodynamic therapy and anti-cytotoxic T-lymphocyte-associated antigen 4 immunotherapy in a mouse model of urothelial carcinoma. METHODS: We used C57BL/6 mice injected with murine bladder 49 cell line. Mice were randomly allocated into four treatment groups: vascular targeted photodynamic therapy only, anti-cytotoxic T-lymphocyte-associated antigen 4 only, combination therapy and control. We carried out three separate experiments that used distinct cohorts of mice: tumor growth and development of lung metastases monitored with bioluminescent imaging (n = 91); survival evaluated with Kaplan-Meier curves (n = 111); and tumor cell population studied with flow cytometry (n = 20). In a fourth experiment, we re-challenged tumors in previously treated mice and compared tumor growth with that of naïve mice. RESULTS: Combination therapy provided significant benefits over the other three treatment groups: prolonged survival (P < 0.0001), lower tumor signal (P < 0.0001) and decreased lung signal uptake (P ≤ 0.002). We also observed that mice previously treated with vascular targeted photodynamic therapy only or combination therapy did not present tumor growth after re-challenged tumors. CONCLUSIONS: Combination of vascular targeted photodynamic therapy with anti-cytotoxic T-lymphocyte-associated antigen 4 is an effective therapy in a urothelial carcinoma syngeneic mouse model. The present results suggest this therapy as a potential treatment option for both bladder and upper tract tumors in future clinical trials.


Assuntos
Antígeno CTLA-4/antagonistas & inibidores , Carcinoma de Células de Transição/terapia , Neoplasias Pulmonares/tratamento farmacológico , Fotoquimioterapia/métodos , Neoplasias da Bexiga Urinária/terapia , Animais , Antígeno CTLA-4/imunologia , Carcinoma de Células de Transição/irrigação sanguínea , Carcinoma de Células de Transição/imunologia , Carcinoma de Células de Transição/secundário , Linhagem Celular Tumoral/transplante , Modelos Animais de Doenças , Humanos , Medições Luminescentes , Pulmão/irrigação sanguínea , Pulmão/diagnóstico por imagem , Pulmão/efeitos dos fármacos , Pulmão/efeitos da radiação , Neoplasias Pulmonares/irrigação sanguínea , Neoplasias Pulmonares/imunologia , Neoplasias Pulmonares/secundário , Masculino , Camundongos , Camundongos Endogâmicos C57BL , Bexiga Urinária/irrigação sanguínea , Bexiga Urinária/efeitos dos fármacos , Bexiga Urinária/imunologia , Bexiga Urinária/efeitos da radiação , Neoplasias da Bexiga Urinária/irrigação sanguínea , Neoplasias da Bexiga Urinária/imunologia , Neoplasias da Bexiga Urinária/patologia
18.
PLoS One ; 12(7): e0180350, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28727768

RESUMO

BACKGROUND AND OBJECTIVES: Pre-operative kidney volume is an independent predictor of glomerular filtration rate in renal cell carcinoma patients. Compensatory renal growth (CRG) can ensue prior to nephrectomy in parallel to tumor growth and benign parenchyma loss. We aimed to test whether renal metabolite abundances significantly associate with CRG, suggesting a causative relationship. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: Tissue metabolomics data from 49 patients, with a median age of 60 years, were previously collected and the pre-operative fold-change of their contra to ipsi-lateral benign kidney volume served as a surrogate for their CRG. Contra-lateral kidney volume fold-change within a 3.3 +/- 2.1 years follow-up interval was used as a surrogate for long-term CRG. Using a multivariable statistical model, we identified metabolites whose abundances significantly associate with CRG. RESULTS: Our analysis found 13 metabolites in the benign (e.g. L-urobilin, Variable Influence in Projection, VIP, score = 3.02, adjusted p = 0.017) and 163 metabolites in the malignant (e.g. 3-indoxyl-sulfate, VIP score = 1.3, adjusted p = 0.044) tissues that significantly associate with CRG. Benign/tumor fold change in metabolite abundances revealed three additional metabolites with that significantly positively associate with CRG (e.g. p-cresol sulfate, VIP score = 2.945, adjusted p = 0.033). At the pathway level, we show that fatty-acid oxidation is highly enriched with metabolites whose benign tissue abundances strongly positively associate with CRG, both pre-operatively and long term, whereas in the tumor tissue significant enrichment of dipeptides and benzoate (positive association), glycolysis/gluconeogenesis, lysolipid and nucleotide sugar pentose (negative associations) sub-pathways, were observed. CONCLUSION: These data suggest that specific biological processes in the benign as well as in the tumor parenchyma strongly influence compensatory renal growth.


Assuntos
Carcinoma de Células Renais/metabolismo , Neoplasias Renais/metabolismo , Rim/metabolismo , Tecido Parenquimatoso/metabolismo , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma de Células Renais/patologia , Carcinoma de Células Renais/cirurgia , Feminino , Humanos , Rim/patologia , Rim/cirurgia , Neoplasias Renais/patologia , Neoplasias Renais/cirurgia , Masculino , Metabolômica , Pessoa de Meia-Idade , Nefrectomia , Tecido Parenquimatoso/patologia , Carga Tumoral
19.
Urology ; 107: 166-170, 2017 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-28416299

RESUMO

OBJECTIVE: To describe clinical management and outcomes of a cohort of patients with malignant mesothelioma of the tunica vaginalis testis (MMTVT) who received treatments beyond radical orchiectomy. METHODS: Patients with confirmed MMTVT at a single tertiary care institution were identified. Treatments, pathologic outcomes, and survival were recorded. Prognostic variables associated with survival were analyzed with a Cox proportional hazards model and Kaplan-Meier curves. RESULTS: Overall, 15 patients were included. Initial presentation was a scrotal mass in 7 of 15 (47%) and hydrocele in 5 of 15 (33%) patients. Clinical staging revealed enlarged nodes in 5 of 15 (33%) patients. Radical orchiectomy was the initial treatment in 5 of 15 (33%) patients. Positive surgical margins were found in 6 of 14 (43%) radical orchiectomies and were associated with worse survival (P = .007). The most frequent histologic subtype was epithelioid, associated with better survival (P = .048). Additional surgeries were performed on 12 of 15 (80%) patients. Pathologic examination revealed MMTVT in 6 of 12 (50%) hemiscrotectomies, 7 of 8 (88%) retroperitoneal lymph node dissections, 1 of 7 (14%) pelvic lymph node dissections, and 10 of 10 (100%) groin dissections. Five patients received adjuvant chemotherapy. Two also received adjuvant radiation therapy. Three patients with lymph node involvement remain no evidence of disease over 6 years after diagnosis. After a median follow-up of 3.5 years (interquartile range: 1.2-7.2), 5 patients have died, all of MMTVT; the median overall survival has not been reached. Common sites of relapse were lungs (5 of 7) and groin (3 of 7). CONCLUSION: The pattern of metastatic spread of MMTVT is predominantly lymphatic. Nodes in the retroperitoneum and the groin are commonly involved. Prognosis is poor, but there may be a role for aggressive surgical resection including hemiscrotectomy, and inguinal and retroperitoneal lymph nodes.


Assuntos
Gerenciamento Clínico , Previsões , Neoplasias Pulmonares/cirurgia , Excisão de Linfonodo/métodos , Linfonodos/patologia , Mesotelioma/cirurgia , Orquiectomia/métodos , Neoplasias Testiculares/cirurgia , Adulto , Idoso , Seguimentos , Humanos , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/secundário , Metástase Linfática , Masculino , Mesotelioma/diagnóstico , Mesotelioma/secundário , Mesotelioma Maligno , Pessoa de Meia-Idade , Período Pós-Operatório , Espaço Retroperitoneal , Estudos Retrospectivos , Neoplasias Testiculares/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Resultado do Tratamento
20.
Cancer ; 123(10): 1741-1750, 2017 05 15.
Artigo em Inglês | MEDLINE | ID: mdl-28152158

RESUMO

BACKGROUND: Prior studies examining the value of lymph node (LN) dissection (LND) in patients with urothelial carcinoma of the upper urinary tract (UTUC) have produced conflicting results. The objective of the current study was to assess the relationship between LN yield and survival among patients undergoing radical nephroureterectomy (RNU). METHODS: The National Cancer Data Base was used to identify patients with non-metastatic UTUC who were treated with RNU between 2004 and 2012. The association between LN yield and overall survival (OS) was assessed using Cox proportional hazards regression, with adjustment for patient, tumor, and facility characteristics. RESULTS: Of the 14,472 patients, 2926 (20%) underwent LND. The median yield was 2 LNs (interquartile range 1-6 LNs). Among the entire cohort and the LN-negative (pN0) subgroup, a higher LN yield was associated with lower all-cause mortality (multivariable hazard ratio [HR] 0.94 per 5 LNs removed, 95% confidence interval [95% CI] 0.89-1.00 [P = .034] for the entire cohort and HR 0.86, 95% CI 0.79-0.94 [P = .001] for the pN0 subgroup). Among patients with positive LNs (pN+), there was no association noted between LN yield and OS; however, positive and negative LN counts were found to be independent predictors of OS (HR 1.27 per 5 positive LNs, 95% CI 1.16-1.39 [P<.001] and HR 0.90 per 5 negative LNs, 95% CI 0.82-1.00 [P = .049]). CONCLUSIONS: In this large, contemporary cohort of patients with UTUC, LND was found to be used infrequently despite evidence that a higher LN yield is associated with lower all-cause mortality. Cancer 2017;123:1741-1750. © 2017 American Cancer Society.


Assuntos
Carcinoma de Células de Transição/cirurgia , Neoplasias Renais/cirurgia , Excisão de Linfonodo , Linfonodos/patologia , Nefrectomia , Neoplasias Ureterais/cirurgia , Idoso , Carcinoma de Células de Transição/mortalidade , Carcinoma de Células de Transição/patologia , Causas de Morte , Feminino , Humanos , Neoplasias Renais/mortalidade , Neoplasias Renais/patologia , Pelve Renal , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Modelos de Riscos Proporcionais , Taxa de Sobrevida , Ureter/cirurgia , Neoplasias Ureterais/mortalidade , Neoplasias Ureterais/patologia , Procedimentos Cirúrgicos Urológicos
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