Over-diagnosed prostate cancer in solid organ recipients: lessons from the last 3 decades

Introduction

Prostate cancer (PC) is the most common neoplasia in men. With aging of solid organ transplant recipients (SOTR), its incidence is likely to increase. The aim of this study was to analyze PC screening results retrospectively in renal transplant recipients (RTR), hepatic transplant recipients (HTR) and cardiac transplant recipients (CTR).

Patients and methods

A retrospective monocentric study of PC diagnosed in renal, hepatic or cardiac transplanted patients since 1989 was performed. All the patients were followed annually by digital rectal examination and prostate serum antigen (PSA) dosage.

Results

57 PC were diagnosed in 1565 SOTR male patients (3.6%): 35 RTR, 15 HTR, and 7 CTR. Standard incidence ratio (SIR) was 41.9. Mean age at the time of diagnosis was 64.5 (60.5–69.2). Mean time between transplantation and PC diagnosis was 95.7 (39.0–139.5) months. Median PSA rate was 7.0 (6.2–13) ng/mL. Clinical stages were T1, T2, and T3, respectively, for 29, 22 and 6 patients. Diagnosis was done by screening in 52 patients, after prostatitis in 1 and bone pain in another. Three PC were discovered on prostate chips after transurethral resection. Two patients were treated by active surveillance. 39 (68%) patients (25 RTR, 11 HTR and 3 CTR) were treated by radical prostatectomy. Histological results were 30 pT2 and 9 pT3 tumors, with 7 positive surgical margins. Gleason score was 5, 6, 7, 8 and 9 in, respectively, in 2, 24, 11, 1 and 1 patients. One patient with positive pelvic nodes was treated with hormonal therapy (HT). One had a biochemical relapse at 10 months and underwent salvage radiotherapy. Median follow-up was 85.2 months (46.1–115.0). 23 (40.4%) patients died. Two (3.6%) RTR and 1 (1.8%) CTR died from their PC. Standard incidence ratio were, respectively, 42.4, 48.2 and 39 in RTR, HTR and CTR.

Conclusion

Systematic screening in male SOTR after 50 years old could not be recommended. In the last 3 decades, we diagnosed too many low-risk prostate cancers strongly increasing the SIR but failing to decrease prostate cancer related mortality. SOTR should undergo individual screening with prior MRI when PSA rates are high. Management should not be different from that of the general population.

     

Effectiveness of adjuvant radiotherapy for high recurrence risk patients with upper tract urothelial carcinoma

PurposeA recent study has shown that upper tract urothelial carcinoma (UTUC) patients with high-risk factors have a high local recurrence rate. The purpose of this work was to investigate the benefit of adjuvant radiotherapy (ART) for patients with high recurrence factors.MethodsFour hundred twenty-four UTUC patients who received radical nephroureterectomy (RNU) in our hospital between 2010 and 2018 were reviewed. The significance of factors on cancer-specific survival (CSS) and recurrence-free survival (RFS) were assessed using Cox multivariate analysis. In patients with high recurrence factors, propensity score matching was used to adjust the confounding factors for ART.ResultsThe median follow-up time was 40 (range 3–77) months. Multivariate analysis showed that multifocal tumor, G3, pT3/4 stage and positive lymph node (N+) were independent predictors for worse RFS. Multifocal tumor and pT3/4 stage were independent predictors of worse CSS in UTUC after surgery. A total of 286 patients with these high recurrence factors were identified: 192 (67.1%) patients received RNU only, and 94 (32.9%) patients received ART. Overall, ART did not improve CSS (ART 86.1% vs. RNU 78.5%.; P = 0.11). After propensity score matching, ART significantly improved the CSS of patients with high recurrence factors. The 3-year CSS was 73.1% in patients treated with RNU alone vs. 86.1% in patients treated with ART (P = 0.016).ConclusionsResults of our study demonstrated benefit of adjuvant radiotherapy in cancer specific survival in UTUC patients with high recurrence factors(multifocal tumor ,pT3/4,G3 and positive lymph node).     

A single thyroid nodule revealing early metastases from clear cell renal carcinoma: case report and review of literature

IntroductionWe report the case of an incidental solitary renal cancer cell (RCC) thyroid metastatic nodule treated by thyroidectomy.Presentation of caseA 53 year male presented with a solitary, asymptomatic thyroid nodule. He was treated with left nephrectomy 1 year before for a RCC. Radiological standard follow-up was negative for secondary lesions but ultrasound (US) 12 months after surgery revealed a 1.5 cm solid nodule in the right lobe of the gland. Fine needle aspiration biopsy (FNAB) was inadequate and the patient was submitted to total thyroidectomy. Histology showed the presence of solitary metastasis from RCC. At 2 years follow-up, no evidence of recurrence has been found.DiscussionSolitary RCC metastasis to the thyroid usually occurs late from nephrectomy and have no specific US pattern. When FNAB provides an uncertain cytological results, the patient received thyroidectomy for primary thyroid tumors and diagnosis of metastases from RCC was incidentally made.ConclusionThyroid nodules in a patient with history of malignancy can pose a diagnostic challenge. The presence of a solitary thyroid nodule in a patient with history of RCC should be carefully suspected for metastasis. We suggest to extend at neck the thorax and abdomen CT scan routinely recommended during the follow-up in high-risk cases. Thyroidectomy may result in prolonged survival in selected cases of isolated thyroid metastasis from RCC.     

Impaired estimated glomerular filtration rate is a significant predictor for non–muscle-invasive bladder cancer recurrence and progression—Introducing a novel prognostic model for bladder cancer recurrence

PurposeTo evaluate the influence of preoperative patient-associated parameters and comorbidities, with special focus on preoperative renal function on non–muscle-invasive bladder carcinoma (NMIBC) recurrence and progression.Patients and methodsMedical records of 192 patients with first diagnosis of NMIBC from 1996 to 2006 treated at our department were reviewed for tumor stage and grade, comorbidities, and putative preoperative risk factors (diabetes mellitus, smoking habits, C-reactive protein levels, estimated glomerular filtration rate [eGFR] by chronic kidney disease-epidemiology collaboration formula, patient age, and sex).ResultsMedian follow-up was 80 months. Tumor recurrence was observed in 104 patients (54%); progression to higher pT category or grade was found in 43 patients (22%). Overall, 20 (10%) patients had progression to category pT2, with a median time to progression of 11 months (95% CI: 3.16–55.77). Overall, median time to recurrence was 11.91 months (8.00–14.94), while median time to progression to higher category/grade was 15 months (8.60–36.95). Cancer-specific death was recorded for 12 patients (6%). Univariate analysis revealed category, grade, and eGFR<60 ml/min as significant predictive determinants for recurrence, overall progression, and progression to pT2-category disease. Based on the results of multivariate analysis, a risk factor model was created to classify patients with high and low risk of recurrence.ConclusionseGFR is a significant predictive variable of NMIBC recurrence and progression. Integrating eGFR into NMIBC risk calculation helped to discriminate individuals with high and low risk of cancer recurrence. Confirmatory studies and external validation are needed to corroborate these findings. Furthermore, the role of tumor multifocality and size should be analyzed for the proposed prediction model.     

Preoperative characteristics of men with unfavorable high-Gleason prostate cancer at radical prostatectomy

IntroductionSome men with Gleason sum 8–10 prostate cancer (PC) at RP have favorable outcomes: Biochemical recurrence free (BFS) and prostate cancer-specific survival (CSS) are improved for such men with pT2 or pT3a disease compared with pT3b or N1 disease at radical prostatectomy (RP). We examine biopsy characteristics of men with high-grade PC at RP to better select those who may benefit from surgery.Materials and MethodsA total of 1,174 men from our Institutional Database (1982–2010) had Gleason 8–10 cancer at RP. Their demographic and prostate biopsy characteristics were compared among those with disease defined as favorable (pT2 or pT3a) vs. unfavorable (pT3b or N1). Logistic regression was used to determine predictors of unfavorable disease. Kaplan-Meier analysis was used to determine survival outcomes.ResultsBiopsy data were available for 1,157 men (median cores 12 [2–20]); 779 (66.4%) favorable, 394 (33.6%) unfavorable; 102 (8.7%), 515 (44.1%), and 552 (47.2%) were low, intermediate, and high-risk. For favorable and unfavorable cases, 10-year BFS was 40.0% and 5.7% (P < 0.001) and CSS was 84.9% and 60.3% (P < 0.001). Multivariate logistic regression revealed that PSA ≥ 20 and perineural invasion (PNI) at biopsy increased the likelihood of unfavorable, high-grade disease. Considering PSA ≥ 20 and PNI as adverse features, 23.7%, 40.1%, and 71.4% of patients with none, 1, or 2 adverse features had unfavorable, high-Gleason PC (P < 0.001).ConclusionsHigh-Gleason PC was not uniformly associated with poor outcomes after RP, though men with unfavorable (pT3b/N1) disease fared poorly. Preoperative predictors of high-Gleason, unfavorable disease in a cohort of predominantly intermediate and high-risk patients were PSA ≥ 20 and PNI.     

Validation of tertiary Gleason pattern 5 in Gleason score 7 prostate cancer as an independent predictor of biochemical recurrence and development of a prognostic model

ObjectiveTo validate the biological and prognostic value of tertiary Gleason pattern 5 (TGP5) in patients with Gleason score 7 (GS 7) prostate cancer (PCa) and to develop a prognostic model to identify the high-risk group of patients with TGP5.Material and methodsWe retrospectively reviewed the data from 4,146 patients with localized (pT2–3 N0 M0) GS 7 PCa treated by radical prostatectomy (RP) without adjuvant therapy. The primary end point was biochemical recurrence (BCR), and the secondary one was to build a bootstrap-corrected multivariable Cox model.ResultsOf the 4,146 patients, 416 (10%) had a TPG5 in the RP specimen. TGP5 was associated with BCR in both univariable and multivariable analyses that adjusted for the effects of standard pathological features (P<0.001). A prognostic model based on preoperative prostate-specific antigen levels (<10 vs.≥10 ng/ml), primary and secondary Gleason pattern (3+4 vs. 4+3), pathological tumor category (pT2/pT3a vs. pT3b), and surgical margin status (R0 vs. R+) stratified patients with a discrimination of 72.2%. Patients in the low-risk group had a 5-year BCR-free survival rate of 76.3% compared with only 18.5% for those in the high-risk group (P<0.001).ConclusionsKnowledge of TGP5 improves our prognostication of patients with GS 7 PCa treated with RP. We developed a statistical tool to help identify the patients with TGP5 who are at the highest risk of BCR after RP, thereby helping with the clinical decision making regarding adjuvant trials and follow-up scheduling.     

Oncological outcomes of pathologically organ-confined,lymph node-positive prostate cancer after radical prostatectomy

BackgroundThe aim of this study was to investigate the impact of lymph-node involvement on oncological outcomes in patients with pathologically organ-confined prostate cancer (pT2 CaP) after radical prostatectomy (RP).MethodsWe retrospectively analyzed 9,631 pT2 CaP patients who underwent RP at a single institution between 1998 and 2018. Kaplan-Meier plots and Cox regression models (CRMs) assessed biochemical recurrence (BCR)-free survival and metastasis-free survival (MFS) according to N-stage. In subgroup analyses of N1 patients, Kaplan-Meier plots and CRMs were stratified according to adjuvant treatment.ResultsOf 9,631 pT2 staged patients, 241 (2.5%) harbored lymph-node metastases after RP (pN1). The median follow-up was 60.8 months. No pT2 N1-staged patient died due to CaP. The 5-year BCR-free survival rates were 54.7 vs. 88.4% in pT2 N1 vs. pT2 N0 patients, respectively (P < 0.001). The 5-year MFS rates were 92.5 vs. 98.9% in pT2 N1 vs. pT2 N0 patients, respectively (P < 0.001). Within pT2 N1 patients, presence of ≥3 positive lymph nodes was an independent risk factor for BCR (hazard ratio [HR] 3.4, P < 0.001) and for metastatic progression (HR 1.7, P = 0.04). Finally, 3-year BCR-free survival was improved in pT2 N1 patients treated with adjuvant radiation therapy (87.1% vs. 63.7% for patients who received other treatment options [P < 0.001]).ConclusionPatients with pathologically organ-confined but lymph node-positive CaP exhibited favorable oncological outcomes after RP. Presence of ≥3 positive LNs predicted higher rates of BCR and metastatic progression. In consequence, in pT2 N1 patients treated with RP with ≥3 positive LNs, adjuvant treatment may be considered.9     

Surgical Management and Outcomes of Patients with Multifocal Hepatoblastoma

ObjectiveTo compare the outcomes of patients with multifocal hepatoblastoma (HB) treated at our institution with either orthotopic liver transplant (OLTx) or hepatic resection to determine outcomes and risk factors for recurrence.BackgroundMultifocality in HB has been shown to be a significant prognostic factor for recurrence and worse outcome. The surgical management of this type of disease is complex and primarily involves OLTx to avoid leaving behind microscopic foci of disease in the remnant liver.MethodsWe performed a retrospective chart review on all patients <18 years of age with multifocal HB treated at our institution between 2000 and 2021. Patient demographics, operative procedure, post-operative course, pathological data, laboratory values, short- and long-term outcomes were analyzed.ResultsA total of 41 patients were identified as having complete radiologic and pathologic inclusion criteria. Twenty-three (56.1%) underwent OLTx and 18 (43.9%) underwent partial hepatectomy. Median length of follow-up across all patients was 3.1 years (IQR 1.1–6.6 years). Cohorts were similar in rates of PRETEXT designation status identified on standardized imaging re-review (p = .22). Three-year overall survival (OS) estimate was 76.8% (95% CI: 60.0%–87.3%). There was no difference in rates of recurrence or overall survival in patients who underwent either resection or OLTx (p = .54 and p = .92 respectively). Older patients (>72 months), patients with a positive porta hepatis margin, and patients with associated tumor thrombus experienced worse recurrence rates and survival. Histopathology demonstrating pleomorphic features independently associated with worse rates of recurrence.ConclusionsThrough proper patient selection, multifocal HB was adequately treated with either partial hepatectomy or OLTx with comparable outcome results. HB with pleomorphic features, increased patient age at diagnosis, involved porta hepatis margin on pathology, and the presence of associated tumor thrombus may be associated with worse outcomes regardless of the local control surgery offered.Level of EvidenceIII.     

Management of High-Risk Localised Prostate Cancer

ContextHigh-risk localised prostate cancer (PCa) is defined as significant likelihood of death from PCa or development of distant metastases. It is important to identify patients at high risk of progression who may benefit from neoadjuvant or adjuvant therapies.ObjectiveTo review definitions for high-risk localised PCa and review outcomes of different treatment modalities.Evidence acquisitionRandomised and nonrandomised clinical trials addressing the characterisation of patients with high-risk PCa and treatment options for this patient population were reviewed, mainly focusing on comparison of monotherapy with multimodality approaches.Evidence synthesisRadical prostatectomy (RP) represents a treatment option for selected high-risk patients and can result in long-term progression-free survival (PFS) in a subset without hormone therapy (HT). HT prior to RP is not considered as a standard treatment in high-risk, clinically localised PC, because survival advantage has never been conclusively demonstrated. Adjuvant “early” androgen-deprivation therapy (ADT) is not recommended for patients with high-risk disease except for pathologically confirmed nodal disease. Adjuvant radiotherapy (RT) after RP in patients with adverse risk factors decreases biochemical recurrence risk with improved local control but without a clear advantage in overall survival (OS). RT with long-term adjuvant HT improves OS. However, the exact period of HT is still controversial, and one must consider the cardiovascular comorbidity status of the patients before initiating ADT. Neoadjuvant chemotherapy can be administered safely in patients with high-risk disease prior to definitive therapy. Although complete responders are very rare, prostate-specific antigen (PSA) responses were present in a substantial number of patients. Early results of adjuvant chemotherapy trials are promising, but ongoing phase 3 trials should be completed to establish any survival advantage.ConclusionsIntegrating local and systemic therapies may be beneficial in the management of high-risk localised or locally advanced PCa.     

Evaluating the effect of time from prostate cancer diagnosis to radical prostatectomy on cancer control: Can surgery be postponed safely?

Objective

To test the prognostic role of treatment delay in patients affected by prostate cancer (PCa).

Underutilization of local salvage therapy after radiation therapy for prostate cancer

ObjectiveTo evaluate the rates at which patients are offered and receive local salvage therapy (LST) after failure of primary radiotherapy for localized prostate cancer, as it is the only potentially curative treatment for localized recurrence but appears to be underutilized when compared with androgen-deprivation therapy (ADT) or observation.Materials and methodsPatients with localized prostate cancer who received primary radiotherapy with curative intent between 1999 and 2000 were identified in the British Columbia Tumour Registry. Exclusion criteria included patient age >72 years, prostate-specific antigen>40 ng/ml, and clinical stage T4 at diagnosis. Data on clinicopathologic features, primary therapy, prostate-specific antigen kinetics, and salvage therapy were collected retrospectively. Radiation failure was defined as biochemical recurrence according to the Phoenix criteria or by initiation of salvage therapy.ResultsOf 1,782 patients treated in the study period, 1,067 met inclusion criteria. Of these, 257 failed radiation therapy. Radiation therapy failure was managed with observation (>12 mo) in 126 patients and ADT in 119. Of the observed patients, 66 subsequently received ADT. Five patients (1.8%) received LST (3 radical prostatectomy and 2 brachytherapy).ConclusionsOnly 2% of patients relapsing after radiation therapy for localized prostate cancer received LST. Although the benefits of LST are unproven, these findings reveal a possible underutilization of LST and indicate a need for enhanced collaboration between specialties to optimize care of this challenging cohort.     

Safety and Early Oncologic Outcomes of Lung Resection in Patients with Isolated Pulmonary Recurrent Prostate Cancer: A Single-center Experience

The introduction of novel imaging approaches for recurrent prostate cancer (PC) has paved the way for the use of nonsystemic approaches in patients with recurrent disease. While use of surgery or radiotherapy is standard for men with nodal or bone recurrence only, there are no significant data on the possible curative role of surgery for pulmonary metastases. We aimed to assess the efficacy of lung resection in patients with isolated pulmonary recurrence after radical prostatectomy (RP) for clinically localized PC. Overall, nine patients with biochemical recurrence after RP and either single (n = 4) or multiple (n = 5) pulmonary uptake spots on fluorodeoxyglugose, choline, or prostate-specific membrane antigen positron emission tomography/computed tomography underwent a total of 20 lung resections between 2011 and 2017 at our institution. No postoperative complications occurred. After lung resection, seven of the nine patients experienced a biochemical response (defined as prostate-specific antigen <0.2 ng/ml at 40 d after surgery). All patients except for one were free of clinical recurrence (CR) at median follow-up of 23 mo. One patient experienced CR and received androgen deprivation therapy at the time of bone recurrence. Although larger prospective studies are needed, our series demonstrates that surgical resection of isolated pulmonary metastases is safe and effective in selected PC patients with recurrent disease.     

Inflammatory Myofibroblastic Tumor After Lung Transplant—A Rare and Aggressive Complication: A Case Report

IntroductionMalignant diseases are well-known complications after lung transplantation (LT). Among these, inflammatory myofibroblastic tumor (IMT) is a rare neoplasm with a not well-known and often aggressive biological behavior.Material and MethodsWe hereby describe 2 cases of cystic fibrosis patients who underwent bilateral sequential LT (BSLT) complicated by IMT.ResultsA 26-year-old man presented a right endobronchial lesion 6 months after BSLT. Two consecutive fiber bronchoscopic biopsies showed granulation tissue. For the persistent lesion growth, the patient underwent a transthoracic biopsy showing histologic diagnosis of IMT. Therefore, he underwent to right pneumonectomy that was unfortunately complicated after 6 months with a late bronchopleural fistula and empyema with exitus 6 months later. A 31-year-old woman 1 year after BSLT presented with a left voluminous pleural-parenchymal lesion; the histologic examination after biopsy revealed an IMT. She underwent a removal of the lesion with a macroscopic R0 resection. Histologic, immunophenotypic, and cytogenetic examinations showed a strong overexpression of anaplastic lymphoma kinase requiring biological adjuvant therapies; however, the patient refused it. Four years later, she presented a recurrence treated with debulking procedure and adjuvant radiotherapy. At last follow-up, the patient was alive with stable disease and optimal graft function.ConclusionsAlthough IMT is a rare complication after lung transplant, to obtain a careful diagnosis, an early and aggressive treatment is mandatory.     

A Competing Risk Analysis of Cancer-Specific Mortality of Initial Treatment with Radical Prostatectomy versus Radiation Therapy in Clinically Localized High-Risk Prostate Cancer

Background

There is no consensus on the optimal treatment for localized high-risk prostate cancer (PC), and much debate exists regarding the ideal treatment approach. For these reasons, we evaluated the competing risks of PC-specific mortality after initial therapy with radical prostatectomy (RP) versus radiotherapy (RT) in men with clinically localized high-risk PC.

Methods

We reviewed patients treated with RP and RT combined with androgen-deprivation therapy between 1990 and 2009. High-risk PC is defined as clinical stage ≥T3a, serum prostate-specific antigen (PSA) >20 ng/mL, or a biopsy Gleason sum of 8–10 according to National Comprehensive Cancer Network guidelines. Competing risk analysis was conducted to assess the association of RP (n = 251) or RT (n = 125) with cancer-specific mortality (CSM). Thereafter, secondary analysis with propensity score matching was conducted to further elucidate patient characteristics, with optimal matching of 0.25 times the standard deviation of propensity scores.

Results

With an overall median follow-up of 76 months, 35 (9.3 %) men with high-risk PC died due to PC (23 in the RT group and 12 in the RP group). The 5-year estimates of cancer-specific survival rate for men treated with RP and RT were 96.5 % (95 % confidence interval [CI] 94.2–98.9) and 88.3 % (95 % CI 82.8–94.3), respectively. Cumulative incidence estimates for CSM were statistically increased amongst men treated with RT (p = 0.002). Propensity score matching extracted 168 men with high-risk PC from the total patient cohort. Cumulative incidence estimates for CSM were statistically different amongst men treated with RT (p < 0.001).

Conclusions

Initial treatment with RP versus RT was associated with a decreased risk of CSM in men with clinically localized high-risk PC.     

A decade of declining prostatectomy margin positivity within a prostate cancer clinical quality registry

ContextPositive surgical margin (PSM) on radical prostatectomy (RP) is associated with an increased risk of biochemical recurrence and use of salvage therapies. Given these adverse consequences, exploration of time trends and predictors of PSM will improve the patient outcomes following surgery for prostate cancer.MethodsPathological data from RP patients treated from 2011 to 2020 was extracted from the Victorian Prostate Cancer Outcomes Registry. This is a clinical quality registry that regularly benchmarks and reports back to individual clinicians the PSM percentage for their patients. Trends in PSM over time were visualized with separate running mean plots for both pT2 and pT3/4 disease. Predictors of PSM were explored with multivariable regression with date of surgery, surgical method, and hospital type, public or private, entered as covariates.ResultsIn total, 12,394 patients formed the sample with PSM recorded in 25% (n = 3,141) of patients, 12% (777/6,640) in pT2 disease and 41% (2,364/5,754) in pT3/4 disease. Comparing 2011–12 to 2019–20, the pT3/4 PSM proportion declined from 50% to 38% while pT2 percentages were steady at 13%. In “high volume” institutions, pT2 PSM fell from 12% to 6.5%. Independent predictors of lower PSM were robotic vs. open method and being treated at a private vs. public institution.ConclusionA clear decline in the proportion of pT3 PSM was observed in a large prostate cancer registry. Proposed explanatory factors include improved technical proficiency with robotic surgery and participation in a registry-based quality improvement initiative.     

Can anesthetics affect bladder cancer recurrence? Total intravenous versus volatile anesthesia in patients undergoing robot-assisted radical cystectomy: A single institution retrospective analysis

BackgroundRadical cystectomy is standard of care and part of a multidisciplinary approach for long-term survival in patients with muscle-invasive bladder cancer (MIBC) or high-grade non-MIBC. Recent data have suggested that anesthetic technique can affect long-term survival and recurrence in patients undergoing cancer related surgery.MethodsThe records of all patients who underwent robot-assisted radical cystectomy for high-risk non-MIBC or MIBC at a single academic institution from 2014 to 2020 were retrospectively reviewed. Patients were grouped according to whether they received total intravenous (TIVA) or volatile inhalation anesthesia (VIA). Univariable and multivariable cox proportional hazards models were used to compare hazard ratios for distant recurrence. Kaplan-Meier recurrence-free survival curves were constructed from the date of surgery to recurrence.ResultsA total of 231 patients were included, of which 126 (55%) received TIVA and 105 (45%) received VIA. Distant recurrence occurred in 8.7% and 26.7% of patients who received TIVA and VIA, respectively (P < 0.001). Kaplan-Meier analysis demonstrated significant improvement in distant recurrence-free survival with TIVA (log-rank P < 0.001). Multivariable analysis revealed a significant increase in recurrence risk with VIA (HR: 3.4, 95%CI: 1.5–7.7, P < 0.01) and increasing tumor pathological stage (pT2, pT3, pT4, all P < 0.05).ConclusionsThe use of volatile inhalation anesthetics during robot-assisted radical cystectomy may be associated with an increased risk of distant recurrence. Further studies will be necessary to validate these findings.     

Feasibility of postmastectomy radiation therapy after TRAM flap breast reconstruction

Background: Postoperative radiotherapy (PORT) has been shown to decrease locoregional failure rates in high-risk breast cancer patients following modified radical mastectomy. However, there had not been a study evaluating the effect of PORT in patients after transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. Therefore, we evaluated flap viability, cosmetic results, and locoregional recurrence in patients who underwent TRAM flap reconstruction and PORT. Methods: The charts of patients who had undergone modified radical mastectomy with TRAM flap reconstruction and PORT at our institution were reviewed. Patients were examined in the clinic and interviewed by telephone to evaluate their perceptions of the cosmetic result. Results: PORT was delivered to 19 patients with TRAM flaps (3 pedicled and 16 free flaps) between 1988 and 1994. There were no TRAM flap losses as a result of either surgical or radiotherapy complications. Two patients developed fat necrosis, one with a pedicled and one with a free TRAM flap. Patients with pedicled TRAM flaps noted more volume loss in the breast after radiation therapy. Eighty-four percent of patients felt their overall cosmetic result was excellent or good; only one patient reported a poor cosmetic result. Local control was achieved in three of the four patients who received PORT for local recurrence. There was only one local recurrence among the 14 patients who received PORT because they were at high risk of local recurrence. Conclusions: These results suggest that PORT can be given safely to high-risk patients following TRAM flap breast reconstruction with excellent cosmetic results and good locoregional control.     

Prognosis following surgical resection versus local excision of stage pT1 colorectal cancer: A population-based cohort study

AimsTo evaluate patient management following stage pT1 colorectal cancer (CRC) diagnosis, and to determine if surgical resection improved outcome compared with local excision, within a population-based study.MethodsData were collected from the Northern Ireland Cancer Registry. Cases of stage pT1 CRC diagnosed from 2007 to 2012 were identified. Analyses were conducted using Cox proportional hazard models to calculate hazard ratios (HR) and 95% confidence intervals (CI) for cancer-specific and all-cause mortality for individuals undergoing formal surgery versus local excision.Results394 patients with pT1 CRC were included. Of these, 37.1% were treated by local resection, 36.8% had biopsy followed by surgery and 26.1% had local excision followed by surgery. There were 60 deaths over a mean 4.8 years of follow-up, including 10 CRC-specific deaths. An additional 12 patients had a CRC recurrence or metastases during follow-up. Of the CRC-specific deaths or recurrences, 27.3% had local excision only. Individuals treated by formal surgery did not have a reduced risk of CRC-specific death (adjusted HR = 1.51, 95% CI 0.29, 7.89), but did have a reduced risk of all-cause mortality (adjusted HR = 0.51 95% CI 0.30, 0.87) compared with those undergoing local excision only.ConclusionsPatients with stage pT1 CRC undergoing formal surgery had a reduced risk of all-cause mortality compared with those treated by local excision only. However, this was not explained by a reduced risk of recurrence/disease-free survival or CRC death, and suggests that the observed benefits may simply reflect selection of a healthier patient population in the formal surgery group.     

Intravesical docetaxel for high-risk non-muscle invasive bladder cancer after Bacillus Calmette-Guérin failure

Background:There are limited bladder-preserving therapeutic options for patients with high-risk non-muscle invasive bladder cancer (NMIBC) after failed Bacillus Calmette-Guérin (BCG) therapy. Salvage intravesical docetaxel therapy was described in 2006 but has not been validated outside of the original institution. In this study, we presented the first external report on the oncologic outcomes of intravesical docetaxel.Materials and methods:We identified 13 patients with high-risk NMIBC treated with ≥1 course of intravesical BCG who received salvage intravesical docetaxel. Recurrence-free survival (RFS) was estimated using the Kaplan–Meier method. Associations of clinicopathologic features with RFS were evaluated using Cox regression.Results:Median age was 75.2 years, and 46.2% of patients were male. Of the patients 92.3% had a prior diagnosis of high-grade T1 disease, 38.5% had a prior diagnosis of carcinoma in situ, and 46.2% had received ≥2 courses of BCG. Only 1 (7.7%) patient experienced docetaxel-related toxicity. Nine (69.2%) patients had a complete response at initial post-docetaxel cystoscopy. During a median follow-up of 12.0 (interquartile range 5.0–18.1) months, a total of 7 (53.8%) patients developed recurrence. Median time to recurrence was 10.1 (interquartile range 4.8–11.6) months. Estimated RFS at 6-, 12-, 18-, and 24-months was 75%, 50%, 50%, and 25%. Three (23.1%) patients ultimately underwent cystectomy. On univariable analysis, multiple courses of induction BCG were associated with decreased RFS, although this did not reach statistical significance (hazard ratio 4.69, p = 0.08).Conclusions:In this first external validation study, intravesical docetaxel was associated with excellent response rates and intermediate-term RFS among patients with high-risk NMIBC after failed BCG therapy.     

Hepatic hemangioendothelioma – A rare case report

Introduction and importanceHepatic hemangioendothelioma (HHE) is a very rare mild-moderate malignant tumor of the hepatic vascular endothelium. The etiology is yet not fully understood. Patients can be asymptomatic or may present with non-specific symptoms or hepatic insufficiency. CT and MRI scans show various radiographic features but a definitive diagnosis can be made with histological analysis and immunohistochemistry. Here we report a case of a patient who presented with a non-resectable disease for which living donor liver transplantation was done.Case presentationA 19-year-old female patient presented with intermittent moderate dull pain in the right hypochondrium for 9 months. Examination revealed mild tender hepatomegaly. On abdominal ultrasound, two hypoechoic lesions were noted in both lobes of the liver that were confirmed on CT scan. Histologic examination of the ultrasound-guided fine-needle aspiration cytology of the voluminous right lobe lesion clinched the diagnosis of HHE. The patient underwent successful living donor liver transplantation due to the multifocal bi-lobar nature of the lesions. At 8 months follow up, she is fine and doing well.ConclusionHHE is a very rare mild-moderate malignant tumor of hepatic vascular origin. Resection is the preferable treatment option in patients with resectable disease. However, liver transplantation has become the treatment of choice for patients with non-resectable multifocal and bi-lobar lesions. The long-term outcome of this malignancy is not fully known and there is a need for long-term follow-up studies to determine the actual recurrence rate of this disease.