Focal laser ablation as clinical treatment of prostate cancer: report from a Delphi consensus project.

PURPOSE: To define the role of focal laser ablation (FLA) as clinical treatment of prostate cancer (PCa) using the Delphi consensus method. METHODS: A panel of international experts in the field of focal therapy (FT) in PCa conducted a collaborative consensus project using the Delphi method. Experts were invited to online questionnaires focusing on patient selection and treatment of PCa with FLA during four subsequent rounds. After each round, outcomes were displayed, and questionnaires were modified based on the comments provided by panelists. Results were finalized and discussed during face-to-face meetings. RESULTS: Thirty-seven experts agreed to participate, and consensus was achieved on 39/43 topics. Clinically significant PCa (csPCa) was defined as any volume Grade Group 2 [Gleason score (GS) 3+4]. Focal therapy was specified as treatment of all csPCa and can be considered primary treatment as an alternative to radical treatment in carefully selected patients. In patients with intermediate-risk PCa (GS 3+4) as well as patients with MRI-visible and biopsy-confirmed local recurrence, FLA is optimal for targeted ablation of a specific magnetic resonance imaging (MRI)-visible focus. However, FLA should not be applied to candidates for active surveillance and close follow-up is required. Suitability for FLA is based on tumor volume, location to vital structures, GS, MRI-visibility, and biopsy confirmation. CONCLUSION: Focal laser ablation is a promising technique for treatment of clinically localized PCa and should ideally be performed within approved clinical trials. So far, only few studies have reported on FLA and further validation with longer follow-up is mandatory before widespread clinical implementation is justified.

Incidence and microbiology of post-operative infections after radical cystectomy and ureteral stent removal; a retrospective cohort study.

BACKGROUND: Post-operative infections are frequent after radical cystectomy with urinary diversion surgery (UDS). Reduction of post-operative infections necessitates appropriate peri-operative antimicrobial prophylaxis targeting causative bacteria. We assessed the incidence and microbiology of infections in the 30-day post-operative period after UDS and investigated effectiveness of the currently used peri-operative antibacterial prophylaxis. METHODS: Retrospective cohort study of all patients undergoing UDS in a tertiary university medical center from January 2014 until September 2016. Antibiotic prophylaxis consisted of cefazolin plus metronidazol according to the Dutch national guideline. Primary outcome was the incidence of post-operative infections within 30 days. Risk factors for post-operative infections and antimicrobial susceptibility profiles of cultured bacteria were also assessed. RESULTS: 147 patients were included. 69 patients (46.9%) had 82 post-operative infections, 27 of which were patients with bacteremia (18.4%). Highest incidence of infections was on day 4-5 and on day 8-10 postoperatively. The second peak was associated with ureteral stent removal. 4.8% of 147 study patients developed bacteremia 24 h after stent removal, which counted for 25.9% of all bacteremia episodes found in this study. Enterobacteriaceae were cultured in 67.9% of blood cultures and were only highly susceptible to ciprofloxacine, piperacillin-tazobactam (90%), meropenem and gentamicin (100%). Multivariate logistic regression analysis showed orthotopic Hautmann neobladder to be associated with increased infections complications: odds ratio 4.1 (95% confidence interval 1.6-10.5), p = 0.03. CONCLUSIONS: The incidence of infections after radical cystectomy is high and particularly ureteral stent removal was associated with both bacteremia and complicated urinary tract infections. Based on the results of this study, antibiotic prophylaxis might need to be broadened for patients undergoing radical cystectomy. Further research is required to investigate whether current guidelines need to be altered concerning administration of antibiotic prophylaxis just before stent removal.

Association of visceral and subcutaneous adiposity with tumor stage and Fuhrman grade in renal cell carcinoma.

Higher BMI has been associated with lower tumor stage and grade and improved survival in renal cell cancer (RCC). BMI cannot distinguish between visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT). We examined associations of BMI, VAT, SAT, total adipose tissue (TAT) and relative VAT (rVAT) with tumor stage and grade in RCC patients. In a Dutch multicenter population-based historical cohort study 1039 RCC patients diagnosed between 2008 and 2012 were assessed for VAT and SAT using Computed Tomography images at L3. Sex-stratified multinomial logistic regression analyses were performed (linearly per 10-unit increase) between BMI, VAT, SAT, TAT and relative VAT (rVAT) with tumor stage and Fuhrman grade. Higher VAT, TAT and rVAT were associated with a lower risk of stage IV versus stage I in males (OR 0.93; 95%CI 0.91-0.96, OR 0.95; 95%CI 0.93-0.98, OR 0.97; 95%CI 0.96-0.99, respectively). Females showed similar associations, but only higher VAT was statistically significantly associated with reduced risk of stage IV (OR 0.95 95%CI 0.89-1.00). No associations with grade, SAT or BMI were found. In conclusion, higher VAT and TAT was associated with lower risk of stage IV RCC. This might be due to weight loss or cancer cachexia in stage IV patients.

Preoperative PSMA-PET/CT as a predictor of biochemical persistence and early recurrence following radical prostatectomy with lymph node dissection.

BACKGROUND: This study aims to evaluate the predictive value of lymph nodes (LN) suspicious for metastases on preoperative prostate-specific membrane antigen (PSMA) PET/CT for biochemical persistence (BCP) and early biochemical recurrence (BCR) following robotic-assisted radical prostatectomy (RARP) with extended pelvic LN dissection (ePLND). METHODS: We evaluated 213 patients with intermediate and high-risk prostate cancer (PCa) who underwent clinical staging with preoperative 68Ga- or 18F-PSMA-PET/CT scan and subsequent RARP with ePLND. Patients were grouped as PSMA- or PSMA+ depending on their LN status on PSMA-PET/CT and subdivided according to histological LN status in pN0 or pN1. Diagnostic accuracy of PSMA-PET/CT for the detection of pN1 was evaluated. BCP was defined as a first postoperative serum PSA level ≥0.1 ng/mL 6-12 weeks following RP. Early BCR was defined as detectable PSA > 0.2 ng/mL within 12 months of follow-up. Univariable logistic regression analyses were used to evaluate the effect of PSMA+ on BCP and BCR. RESULTS: Forty patients (19%) were PSMA+. The overall incidence of pN1 was 23%. Sensitivity, specificity, PPV and NPV on a per patient level for the detection of pN1 was 29%, 84%, 35%, and 80% respectively. BCP was observed in 26 of 211 patients (12%) and early BCR in 23 of 110 patients (21%). The presence of PSMA+ was a significant predictor for BCP (OR 7.1, 2.9-17.1 95% CI) and BCR (OR 8.1, 2.9-22.6 95% CI). CONCLUSION: Preoperative PSMA-PET/CT may be a valuable tool for patient counseling for RARP and ePLND as it is a significant predictor for the risk of postoperative BCP and early BCR. We conclude that an ePLND should not be avoided in men with intermediate or high-risk PCa and preoperative negative PSMA-PET/CT, as 20% have microscopic LN metastasis.

[Carcinoma of the colon with bladder invasion; what is the role of preoperative chemotherapy?] / Coloncarcinoom met doorgroei in de blaas.

Preoperative chemotherapy followed by surgery was applied in three patients, aged 68 years (male), 48 years (female), and 80 years (male) with locally advanced cancer of the colon with bladder invasion. Achieving a resection with free margins (R0) is essential in colon-cancer surgery, but the role of preoperative chemotherapy in colon cancer remains unknown. When a tumour is presumed to be unresectable, guidelines recommend discussing the case and possibly referring the patient to an oncological expertise centre, where each patient will be individually assessed for the most suitable preoperative treatment and surgery during a multidisciplinary tumour board meeting. All three patients showed that preoperative chemotherapy led to down-staging and reduction of the tumour size, although removal of the bladder was still necessary in one patient. All patients underwent a complete resection, which resulted in long-term disease-free and overall survival.

Transrectal ultrasound imaging of the prostate: review and perspectives of recent developments.

We present a critical review of the recent literature and discuss the development and prospective view of the evaluations of transrectal ultrasound with regard to prostate malignancy. We illustrate this with personal experiences. Material and Methods: Based on a critical evaluation of clinical data we address the apparent shortcoming of greyscale transrectal ultrasonography in the assessment of prostate cancer. New developments and future possibilities are also discussed. Evaluation of the value of greyscale transrectal ultrasonography in the diagnosis of prostate cancer indicates a limited role, because of the non-uniform appearance of prostate cancer on the ultrasound images. Ameliorating of transrectal ultrasound, like the use of contrast ultrasonography, could improve the detection of prostate cancer. Although the use of greyscale transrectal ultrasonography lacks sensitivity and specificity for the diagnosis of prostate cancer, its use in volume measurement of the prostate and biopsy guidance is unquestionable. The first results of the application of contrast ultrasonography are promising, both in detection of prostate cancer as in treatment follow up. Other developments like improvement of transducer and computer technology could make the use of ultrasound more versatile. However, future research will indicate whether all these improvements will lead to clinical applications.

Value of contrast ultrasonography in the detection of significant prostate cancer: correlation with radical prostatectomy specimens.

BACKGROUND: The presented study has investigated a possible improvement of imaging prostate cancer: three-dimensional contrast-enhanced power Doppler ultrasonography (3D-CE-PDU). METHODS: Seventy patients with biopsy proven prostate cancer and scheduled for radical retropubic prostatectomy received a 3D-CE-PDU investigation before surgery. Two experts analyzed the ultrasound images. The ultrasound images were correlated to the whole-mount sections of the prostate specimen. The correlation protocol consisted of three evaluation steps. RESULTS: In total, 153 prostate tumors were found in the 70 prostate specimens: 61 tumors <5 mm, 93 tumors >or=5 mm. The diagnosis of clinical significant and insignificant prostate cancer was made in 85 and 88% of the patients for expert I and II, respectively. Diagnosis by imaging improved from 61% (43 of 70 of the prostate cancers) for standard detection tools to an average 86% (60 of 70 prostate cancers) for 3D-CE-PDU. CONCLUSION: 3D-CE-PDU improves the detection of prostate cancer in this group of prostate cancer patients. The use of 3D-CE-PDU in the clinic is questionable as indications are still unclear.