Influence of age on false positive rates of urine-based tumor markers

Introduction

Several influencing factors on false positive rates (FPRs) of urine-based tumor markers in the detection of urothelial cancer (UC) have been identified. We evaluated age as a possible influencing factor.

Methods

Urinary cytology (Cyt), UroVysion (FISH), ImmunoCyt (uCyt+) and NMP22 were determined in 1,554 patients suspicious for UC of the bladder before cystoscopy and in case of cancer detection before TURB. Additionally, upper urinary tract imaging was performed. Maker sensitivity, specificity and FPRs were evaluated in the entire cohort and in subgroups divided by age into <50, ≥50–70 and ≥70 years. Contingency tables and the Cochrane Armitage tests were used for statistical comparisons.

Results

UC was found in 377 and no UC in 1,177 (75 %) patients. A total of 336 patients were diagnosed with UC of the bladder and 41 with UC of the upper urinary tract. Overall sensitivity and specificity for Cyt were 82 and 82 %: for FISH, 73 and 79 % and for uCyt+, 79 and 75 %, respectively. For NMP22, regardless of the exclusion criteria they were 72 and 34 % and after exclusion of urinary tract infection (UTI) or prior to manipulation 46 and 86 %, respectively. Significantly higher FPRs were found with increasing age for Cyt (p = 0.001), a trend to higher FPRs for uCyt+ (p = 0.11) and almost no difference for FISH (p = 0.63). For NMP22, differences became significant after exclusion of patients with UTI or prior manipulation (p = 0.02).

Conclusions

The results of the present study give evidence that false positive rates of Cyt and NMP22 increase with age indicating that age should be respected for their correct interpretation.     

Segmental ureterectomy does not compromise the oncologic outcome compared with nephroureterectomy for pure ureter cancer

Purpose

Pure ureter cancers are rare and account for only 1–3 % of urothelial carcinomas with limited data. Nowadays, nephron-sparing methods are reserved mainly for imperative cases. This study intends to assess the oncologic outcome between segmental ureterectomy (SU) and radical nephroureterectomy (RNU) for pure ureteral urothelial carcinoma.

Methods

From July 2004 to August 2010, 112 patients at a single tertiary referral center were included. Perioperative data were obtained from our institutional database. Postoperative CT scan, cystoscopy, and contralateral renal echo were performed regularly for survey of disease recurrence.

Results

The mean length of follow-up was 43.8 and 48.3 months for the RNU and SU group, respectively. The bladder recurrences, local recurrences, distant metastasis, and cancer-specific survival rates showed no significant differences between RNU and SU (36.4 vs. 34.2 %, p = 0.83; 23.4 vs. 14.3 %, p = 0.27; and 16.9 vs. 8.6 %, p = 0.244, and 13.0 vs. 5.7 %, p = 0.249, respectively).

Conclusion

The study suggested that SU is not inferior to RNU for ureter cancer in oncologic outcomes and is less invasive and better nephron preservation.     

Fluorescence In Situ Hybridisation in the Diagnosis of Upper Urinary Tract Tumours

Background

Upper urinary tract (UUT) tumours are often a diagnostic challenge. Because of delayed diagnosis at an advanced stage, prognosis is less qualitative when compared to bladder tumours. There is, therefore, a need for reliable markers to improve diagnosis.

Objective

Because of the difficulty in interpreting washing cytologies of the UUT, we evaluated the reliability of fluorescence in situ hybridisation (FISH) in the detection of upper tract urothelial cancer.

Design, setting, and participants

A prospective, multicentre cohort study was carried out on 55 consecutive patients with a suspected UUT tumour.

Measurements

Between May 2007 and May 2009, 55 consecutive patients (mean age 71.7 yr; range: 52–93) with a suspected urinary tract tumour were studied with intravenous pyelography, cytology, washing cytology, ureterorenoscopy, and endoscopic biopsies. The patients were followed for a mean observation time of 12.21 mo (range: 0.5–20; standard deviation: 6.12). A multicolour-FISH approach was performed on a liquid-based washing urinary cytology in all cases.

Results and limitations

Twenty-one out of 55 patients had a histologically proven urothelial carcinoma, of which 10 had stage pTa disease, 6 had pT1 disease, 2 had pT2 disease, 2 had pTis disease, and 1 had pTx disease (6 G1, 6 G2, and 9 G3). Three patients had a papilloma, 2 had renal cell carcinoma, 27 had a negative histologic report, and 2 had a nondiagnostic histology. In total, 68 analyses were performed. The cytology was negative or doubtful in 60 out of a total 68 specimens (88.2%) and was suspicious or positive for malignancy in 7 (10.3%) specimens. One specimen was not diagnostic. FISH was negative in 37 of 68 analyses (54.4%) and positive in the other 30 analyses (44.1%). One FISH analysis was not diagnostic as a result of insufficient cellular material. The overall sensitivity of the cytology was 20.8% and of FISH 100%. The specificity was 97.4% for cytology and 89.5% for FISH. Even though this is the largest UUT cohort studied with FISH, the sample size is relatively small.

Conclusions

The UroVysion FISH test is a reliable method in the diagnosis of UUT tumours in cases with clinical suspicion but negative or doubtful cytology and no diagnostic histology.     

Transperitoneal laparoscopic nephroureterectomy for native upper tract urothelial carcinoma in renal transplant recipients

Purpose

To analyze the safety and clinical outcome of laparoscopic nephroureterectomy (LNUT) for native upper tract urothelial carcinoma (UC) in renal transplant (RT) recipients.

Methods

We conducted a retrospective analysis of 956 RT recipients from January 2003 to December 2010 to evaluate the benefit of LNUT for patients who were diagnosed with de novo UC after renal transplantation.

Results

Women predominated (10/11, 91 %) in the 11 patients with upper tract UC who underwent LNUT. Five patients underwent LNUT ipsilateral to the transplanted kidney, 4 patients underwent contralateral LNUT, and 2 patients underwent bilateral LNUT. Nine were operated with LNUT combining resection of bladder cuff, 2 with right ureteral cancer underwent open ureterectomy with bladder cuff due to severe adhesions attached to the lesion. The mean surgical duration was 184.2 min (105–305), the mean blood loss was 182.3 ml (20–500), and the mean hospitalization time was 6.7 days (5–9). The mean levels of preoperative and postoperative serum creatinine were 0.99 mg/dl (0.78–1.16) and 1.01 mg/dl (0.89–1.18), respectively. No intraoperative complications occurred. One patient died of multiple metastases at 13 months after LNUT. The mean follow-up of the remaining 10 patients after diagnosis was 21.7 months (3–48). Two patients had recurrent bladder cancer and underwent transurethral resection of the tumor. Eight patients showed no evidence of disease during the follow-up.

Conclusions

LNUT is a safe and effective approach with low morbidity in transplant recipients, and this therapy provides less trauma, quicker recovery, and acceptable oncological outcomes.     

Preoperative prognostic factors after radical nephroureterectomy in patients with upper urinary tract urothelial carcinoma

Purpose

To evaluate the clinical significance of preoperative biomarkers such as laboratory data, Eastern Cooperative Oncology Group Performance Status (ECOG PS) and clinicopathological factors in patients undergoing radical nephroureterectomy for upper urinary tract urothelial carcinoma.

Methods

Between 1995 and 2011, a total of 99 patients treated at our institution for upper urinary tract urothelial carcinoma were enrolled in this study. The prognostic significance of various preoperative data and clinicopathological factors were analyzed. Univariate and multivariate analyses were performed using the Kaplan–Meier method with the log-rank test and a Cox proportional hazards regression model.

Results

Median patient age was 73 years (range 44–86 years), and the median follow-up period after radical nephroureterectomy was 37.9 months (range 6.6–171.4 months). The 5-year intravesical recurrence-free survival and cancer-specific survival estimates were 47.1 and 70.0 %, respectively. On multivariate analysis, concomitant bladder carcinoma was an independent predictor of intravesical recurrence (hazard ratio 3.689; P = 0.002), and infiltration (hazard ratio 14.842; P = 0.002), preoperative serum creatinine level (hazard ratio 9.992; P = 0.005), preoperative serum hemoglobin level (hazard ratio 6.370; P = 0.018) and ECOG PS (hazard ratio 4.326; P = 0.037) were associated with worse cancer-specific survival. This study is limited by biases associated with its retrospective design.

Conclusions

This study indicates that not only clinicopathological factors, but also preoperative biomarkers, such as serum creatinine and hemoglobin levels and ECOG PS, predict a poor survival in patients with upper urinary tract urothelial carcinoma.     

Radiologic versus endoscopic evaluation of the conduit after esophageal resection: a prospective,blinded, intraindividually controlled diagnostic study

Background

Anastomotic leakage is a major complication in esophageal surgery. Although contrast swallow is performed by many surgical centers before reintroduction of oral intake to exclude anastomotic leakage postoperatively, endoscopy is increasingly used in this situation and may be superior. This study compares radiographic contrast study and endoscopy for the identification of local complications after subtotal esophagectomy.

Methods

Between January 2006 and September 2007, a prospective, blinded, intraindividually controlled study was conducted in patients who underwent transthoracic esophagectomy due to esophageal cancer. A radiographic contrast study was performed prior to endoscopy on postoperative day 5–7. Technical feasibility, sensitivity, and specificity of the radiologic and endoscopic evaluations of the esophageal substitute were described.

Results

Radiographic contrast study was possible in only 64 % of the patients (35 of 55). The contrast study could not be performed in 20 patients due to contraindications or mechanical ventilation. Endoscopy could be performed in all patients (p < 0.001). Pathologic findings were detected in 13 patients by endoscopy but in only 1 patient by contrast swallow. Leakage of the anastomosis or the conduit was correctly detected in 7 patients by endoscopy but in only 1 patient by contrast swallow (p = 0.01). Endoscopy detected focal conduit necrosis or ischemia in six additional patients. Contrast studies showed false-positive results in two patients. Both sensitivity and specificity of endoscopy were 100 %, while sensitivity and specificity of the contrast study were only 20 and 94 %. No complications resulted from postoperative endoscopy or radiologic imaging.

Conclusions

Endoscopic evaluation of the esophageal substitute in the early postoperative course is possible in all patients without complications. Endoscopy is superior to the contrast study in detecting pathological findings after esophageal reconstruction. Radiologic contrast swallow in the early postoperative days is often not possible, has no further relevance, and should be replaced by endoscopic evaluation.     

Rolle der Immunzytologie in der Abklärung von Patienten mit schmerzloser Makrohämaturie

Objective

Gross hematuria is a highly worrisome episode in a patient’s history mainly due to the fact that the prevalence of bladder cancer is significant in this group of patients. In this prospective study the role of immunocytology in the evaluation of patients with gross hematuria was investigated.

Materials and methods

Ucyt® is an immunocytological assay based on microscopic detection of tumor-associated antigens on urothelial cells. The study included 103 consecutive patients with a first episode of painless gross hematuria without prior transitional cell carcinoma. Urine samples were obtained from all patients and examined cytologically and immunocytologically.

Results

Clinical assessment by physical examination, laboratory tests, endoscopy, and imaging modalities yielded urothelial cancer in 22 cases (21%). Further diagnoses were BPH (30%), inflammation (10%), urolithiasis (7%), and“further conditions” (16%). In 17 patients the reasons for hematuria were not determined. For cystoscopy, immunocytology, and conventional urine cytology a sensitivity of 89 (excluding UUT), 86, and 45% was observed. Specificity was 94, 82, and 89%, respectively. Two and three bladder tumors were not detected by cystoscopy and immunocytology, respectively.

Conclusions

The combination of cystoscopy and immunocytology yielded 100% sensitivity, while combining cystoscopy and cytology only marginally improved the sensitivity of cystoscopy alone. Since sensitivity appears to be of key relevance in the assessment of patients with gross hematuria, the authors suggest the addition of a sensitive noninvasive test to the diagnostic armamentarium in this situation.     

Ureteral tumours showing a worse prognosis than renal pelvis tumours may be attributed to ureteral tumours more likely to have hydronephrosis and less likely to have haematuria

Purpose

To demonstrate the relationships among tumour location, hydronephrosis, and tumour stage in patients with Upper Urinary Tract Urothelial Carcinoma (UUT-UC). Moreover, we want to determine whether primary tumour location is an independent predictor of prognosis in those patients.

Methods

Retrospective analysis of 251 UUT-UC patients from our centre treated with radical nephroureterectomy between 2000 and 2010. Patients who had previous radical cystectomy, preoperative chemotherapy, previous contralateral UUT-UC, multifocal tumours, or metastatic disease at presentation were excluded. Overall, 217 patients were then available for evaluation. The relationships among tumour location, hydronephrosis, and tumour stage were analysed. Tumour location was categorized as renal pelvis or ureter. Progression-free survival (PFS) and cancer-specific survival (CSS) probabilities were estimated using Kaplan–Meier and Cox regression analyses.

Results

Tumour location was renal pelvis in 146 cases (67 %), ureter in 71 cases (33 %). Median follow-up was 52 months. Compared with renal pelvic tumours, ureteral tumours were more likely to have hydronephrosis and to be associated with advanced stages (p < 0.001), but less likely to have haematuria. The 5-year CSS estimate was 79.3 % for renal pelvic tumours and 64.7 % for ureteral tumours (p = 0.03). The 5-year PFS probability was 68.7 % for renal pelvic tumours and 54.2 % for ureteral tumours (p = 0.02). On univariable and multivariable analysis, tumour location was an independent prognostic factor for CSS (p < 0.05).

Conclusions

Ureteral tumours were associated with a worse prognosis than renal pelvis tumours. The possible hypothesis may be due partially to that ureteral tumours are more likely to have hydronephrosis and less likely to have haematuria.     

The method of bladder cuff excision during laparoscopic radical nephroureterectomy does not affect oncologic outcomes in upper tract urothelial carcinoma

Purpose

To determine whether the method of bladder cuff excision (BCE) during laparoscopic radical nephroureterectomy for upper urinary tract urothelial carcinoma is associated with rates of disease recurrence or metastases.

Methods

We performed a retrospective review of all laparoscopic radical nephroureterectomies performed at our institution over 10 years. Three methods of BCE were used: transurethral incision (TUI) with Collins knife and a single intravesical port, open extravesical, and open intravesical via cystotomy. Logistic regression analyses were performed to determine whether BCE method was associated with recurrence or metastases.

Results

Laparoscopic radical nephroureterectomy was performed in 110 patients. BCE was performed via TUI in 61 patients, open extravesical in 29, and open intravesical in 20. After a median follow-up of 22 months, 36 patients (32.7 %) developed recurrences. Metastases were observed in 18 patients (16.4 %). Recurrence rates were 32.8, 27.6, and 40.0 % in the TUI, extravesical, and intravesical groups, respectively (p = 0.69). Positive surgical margins occurred in nine patients with no significant difference between groups. Factors associated with recurrence or metastases in a multivariate regression analysis were stage, positive surgical margins and carcinoma in situ (CIS). The method of BCE was not associated with oncologic outcomes.

Conclusions

The three methods of bladder cuff excision (TUI, extravesical, and intravesical) are oncologically valid with similar recurrence and metastases rates when performed during laparoscopic radical nephroureterectomy. Stage, positive margin status and CIS are predictive of adverse oncologic outcomes and can facilitate postoperative prognostication.     

Comparison of post-operative intravesical recurrence and oncological outcomes after open versus laparoscopic nephroureterectomy for upper urinary tract urothelial carcinoma

Object

To retrospectively evaluate intravesical recurrence and oncological outcomes after open or laparoscopic radical nephroureterectomy (RNU) for the upper urinary tract urothelial carcinoma (UUT-UC).

Patients and methods

This study comprised 122 patients diagnosed UUT-UC and subsequently nephroureterectomy was performed on. Several clinical and pathological parameters were emphasized for comparison of clinical outcomes.

Results

Among 122 patients with UUT-UC, 101 (82.8 %) and 21 (17.2 %) underwent open or laparoscopic radical nephroureterectomy (ONU or LNU), respectively. In univariable and multivariable Cox regression models, the surgical procedure exerted an impact neither on post-operative intravesical recurrence rate (p = 0.179 and 0.213, respectively) nor on cancer-specific mortality rate (p = 0.561 and 0.159, respectively). The 1-, 2- and 5-year cancer-specific survival (CSS) rates of patients undergoing ONU or LNU were 92.1 versus 95.2 %, 87.1 versus 90.5 %, 79.2 versus 85.7 %, respectively, and the Kaplan–Meier plot illustrated that patients from two groups enjoyed an equivalent survival rate (p = 0.559). Moreover, we added that previous history of bladder tumor and pre-operative hydronephrosis was associated with intravesical recurrence, whereas three prognostic factors, including pathological tumor stage, grade, and lymphovascular invasion, showed possibility to be predictors of cancer-specific mortality.

Conclusion

There existed no significant difference of intravesical recurrence and CSS between patients after ONU and LNU. Conclusively, laparoscopic radical nephroureterectomy did not present superiority to open management for patients with UUT-UC.     

The Role of Laparoscopy-assisted Renal Autotransplantation in the Treatment of Primary Ureteral Tumor

Background

To evaluate the effect and safety of laparoscopy-assisted renal autotransplantation treatment for primary ureteral cancer (PUC).

Methods

Medical records of patients undergoing hand-assisted retroperitoneoscopic nephroureterectomy–extracorporeal total ureterectomy–renal autotransplantation–pyelocystostomy (Lap AutoTx) were analyzed. Demographic, intraoperative, and postoperative data were assessed.

Results

Fifteen patients diagnosed with PUC underwent this novel approach. Three kidneys were abandoned owing to the detection of residual cancer on the renal pelvic junction, surgeon’s judgment on three severe atherosclerotic arteries, and palpable pelvic lymph nodes proven to be evidence of metastatic disease by frozen section analysis. Twelve patients (mean ± SD age 67.5 ± 7.5 years) were treated with Lap AutoTx for PUC successfully. No perioperative mortality occurred. One patient with solitary kidney experienced delayed graft function that required short-term hemodialysis. Three recurrent superficial diseases in three patients were treated with transurethral resection. The mean ± SD follow-up duration was 12.1 ± 6.7 months (range 3–24 months). The renal pelvicaliceal system was easily examined by flexible cystoscopy.

Conclusions

Lap AutoTx is less invasive compared with the traditional two-incisional manner and can be performed safely even among elderly patients. Compared with other currently used therapies, this novel treatment can be used to successfully treat PUC with the added advantages of total resection of the ureteral lesion, preservation of the renal function, and simplification of follow-up procedures.     

Comparison of oncological outcomes after segmental ureterectomy or radical nephroureterectomy in urothelial carcinomas of the upper urinary tract: results from a large French multicentre study

Study Type – Therapy (multi‐centre retrospective cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Upper urinary tract urothelial carcinomas (UUT‐UCs) are rare tumours. Because of the aggressive pattern of UC, radical nephroureterectomy (RNU) with bladder cuff removal remains the ‘gold‐standard’ treatment. However, conservative strategies, such as segmental ureterectomy (SU) or endourological management, have also been developed in patients with imperative indications. Some teams are now advocating the use of conservative management more commonly in cases of elective indications of UUT‐UCs. Due to the paucity of cases of UUT‐UC, only limited data are available on the oncological outcomes afforded by conservative management. We retrospectively investigated the oncological outcomes after SU and RNU in a large multi‐institutional database. Overall, 52 patients were treated with SU and 416 with RNU. There was no statistical difference between the RNU and SU groups for the 5‐year probability of cancer‐specific survival, recurrence‐free survival and metastasis‐free survival. The type of surgery was not a significant prognostic factor in univariate analysis. The results were the same in a subgroup analysis of only unifocal tumours of the distal ureter with a diameter of <2 cm and of low stage (≤T2). Our results suggest that oncological outcomes after conservative treatment with SU are comparable to RNU for the management of UUT‐UC in select cases.

OBJECTIVE

• ? To compare recurrence‐free survival (RFS), metastasis‐free survival (MFS) and cancer‐specific survival (CSS) after segmental ureterectomy (SU) vs radical nephroureterectomy (RNU) for urothelial carcinoma (UC) of the upper urinary tract (UUT‐UC) located in the ureter.

PATIENTS AND METHODS

• ? We performed a multi‐institutional retrospective review of patients with UUT‐UC who had undergone RNU or SU between 1995 and 2010.
• ? Type of surgery, Tumour‐Node‐Metastasis status, tumour grade, lymphovascular invasion and positive surgical margin were tested as prognostic factors for survival.

RESULTS

• ? In all, 52 patients were treated with SU and 416 with RNU. The median (range) follow‐up was 26 (10–48) months.
• ? The 5‐year probability of CSS, RFS and MFS for SU and RNU were 87.9% and 86.3%, respectively (P= 0.99); 37% and 47.9%, respectively (P= 0.48); 81.9% and 85.4%, respectively (P= 0.51).
• ? In univariable analysis, type of surgery (SU vs RNU) failed to affect CSS, RFS and MFS (P= 0.94, 0.42 and 0.53, respectively).
• ? In multivariable analyses, pT stage and pN stage achieved independent predictor status for CSS (P= 0.005 and 0.007, respectively); the positive surgical margin and pT stage were independent prognostic factors of RFS and MFS (P= 0.001, 0.04, 0.009 and 0.001, respectively).
• ? The main limitation of the study is its retrospective design, which is due to the rarity of the disease.

CONCLUSIONS

• ? Short‐term oncological outcomes after conservative treatment with SU are comparable to RNU for the management of UUT‐UC in select cases and should be considered an option.
• ? In every other case, RNU still represents the ‘gold standard’ for the treatment of UUT‐UC.

     

Upper urinary tract and urethral recurrences following radical cystectomy: review of risk factors and outcomes between centres with different follow-up protocols

Purpose

To examine which patient-related and tumour-related characteristics predict upper urinary tract recurrence (UUTR) and urethral recurrence (UR) of bladder cancer post-radical cystectomy (RC). Secondary objective is to evaluate whether or not recurrence patterns are similar between two centres with different post-RC follow-up (F/U) protocols.

Methods

A retrospective cohort study of 574 consecutive patients undergoing radical cystectomy for urothelial carcinoma of the bladder at two tertiary centres was performed. Clinicopathological factors associated with bladder cancer recurrence and patient-related outcomes, including time to recurrence and death, were collected. Risk factors for recurrences were examined using univariate and multivariable regression analyses. Likelihood of recurrence, time to recurrence, and survival were compared.

Results

There was a 3.7 % risk of UUTR (21/574) and a 3.6 % risk of UR (18/503) for the combined cohort at a median F/U of 45 months. When controlling for the effects of all variables modelled, female gender was a significant risk factor for UUT recurrence (OR 3.2, 95 % CI 1.0–9.5, p = 0.03) and prostatic urethral involvement was a significant risk factor for urethral recurrence (OR 7.8, 95 % CI 2.2–27.6, p = 0.001). UUTR were similar (p = 0.82) between Turku (8/205) and Toronto (12/369). Urethral recurrences trended (p = 0.06) towards being more common in Turku (9/151, 6.0 %) versus Toronto (9/352, 2.6 %), but no difference in overall survival was demonstrated between sites.

Conclusion

The frequency of UUT and urethral recurrences post-cystectomy is relatively low and remained stable for the past 15 years. The ideal F/U protocol to maximize patient-survival remains unknown.     

Impact of the length of time between diagnosis and surgical removal of urologic neoplasms on survival

Objective

Our aim was to assess the effect of surgical wait time on the survival of patients with urological neoplasms, including prostate, bladder, penile, and testicular cancers and upper tract tumours (UTUC).

Materials and methods

Current, relevant studies were identified from the literature. Keywords used for article retrieval were as follows: delay; surgery; prostate cancer; urothelial carcinoma; renal cell carcinoma; testicular cancer; bladder; renal pelvis; ureter; and survival.

Results

Regarding the length of surgical wait time, it does not matter in cases of incidental T1a renal cell carcinomas. In other cases of renal cell carcinomas, surgery should be considered within <1 month; it is of crucial importance in bladder cancer and should be <1 month for a TURBT in cases of non-muscle-invasive bladder cancer and <1 month for a radical cystectomy in cases of muscle-invasive bladder cancer; it is important in invasive UTUC and should be <1 month for a radical nephroureterectomy; it is not crucial in cases of low-risk prostate cancer. In any other case, radical prostatectomy should be considered within <2 months; it is important in testicular cancer and should be fewer than 10 days for an orchiectomy.

Conclusion

Prolonged surgical wait times have an impact on the overall quality of life and anxiety of the patient. Extending the wait time beyond a given threshold can also have a negative impact on the patient’s clinical outcomes, but this threshold differs between urological neoplasms.     

Endoscopic papillectomy,single-centre experience

Background

Endoscopic removal of benign tumours of papilla is increasing. Our aim was to evaluate the outcome of endoscopic resection of papillary tumours.

Methods

In the years 2000–2012, 61 papillectomies were performed in Helsinki University Central Hospital. The cases were analysed retrospectively.

Results

There were 35 patients with benign tumour of papilla without familial adenomatous polyposis (FAP), 16 patients with FAP and 10 patients with ampullary cancer. Jaundice and bile duct dilation were risk factors for malignancy (p < 0.001). In benign tumours, the recurrence rate was 25.5 %. In 5/51 benign tumour cases (9.8 %), a pancreaticoduodenectomy was performed. The remaining cases were treated endoscopically. Neither tumour size, resection in one piece or piecemeal technique, nor coagulation of resection margins had an effect on the development of residual tumour. The total complication rate was 24.6 %. Pancreatitis developed in six patients (9.8 %, 3 mild and 3 moderate). In benign tumour cases, pancreatic stent decreased pancreatitis rate (p = 0.045). In cases where only a pancreatic sphincterotomy was performed, the risk of pancreatitis was high 4/7 (57 %). Bleeding was the most common complication (18 %). Only one patient was operated due to complication, a post-papillectomy bleeding. In six out of seven non-operated cancer patients, the disease progressed.

Conclusion

Endoscopic papillectomy is an effective procedure for treating benign papillary tumours. Jaundice and bile duct dilation are more common in malignant tumours. Pancreatic stent decreases the risk of post-papillectomy pancreatitis. Pancreatic sphincterotomy without stenting carries a high risk of pancreatitis. For papillary cancer, surgery is recommended.     

Results and outcomes after endoscopic treatment of upper urinary tract carcinoma: the Austrian experience

Introduction

Through evolution in technology, endoscopic treatment has gained popularity for the treatment of upper tract urothelial carcinoma (ENDO-UTUC).

Methods

A total of 20 patients with ENDO-UTUC were compared to 178 treated by radical nephroureterectomy (RNU) for a pTa-1 UTUC, and a systematic review was performed.

Results

Mean age for ENDO-UTUC was 71.9 ± 16.0 years, and tumor features were favorable (90 % papillary, 14 low grade, 11 pTa). All ENDO-UTUC were performed ureteroscopically. Mean follow-up was 20.4 ± 30 months. The 5-year overall survival (OS) rate was 45 %. Local (LR) and bladder recurrence (BR) was 25 and 15 %. Time to definitive treatment was longer, ASA higher, LR rates higher, OS lower for ENDO-UTUC (all p < 0.001), but no difference was recorded for BR (p = 0.056) and cancer-specific survival (CSS) (p = 0.364). Postoperative kidney function (KF) was better in the ENDO-UTUC (p = 0.048), though preoperative KF showed no difference. The maximal level of evidence was 3b, patients were highly selected, numbers of patients were low, and ASA scores high. OS was rather low and CSS high. LR rate was high (61 %) and BR rate moderate (39 %) for ureteroscopic and 36 and 28 %, respectively, for percutaneous approach.

Conclusions

LR for ENDO-UTUC is high. In high-grade UTUC, oncological outcome is worse. RNU is associated with a significant loss of KF, but LR is rare. ENDO-UTUC is reserved for selected cases if elective. In imperative cases, it has to be balanced between KF, morbidity of the procedure, risk of operation and tumor control. ENDO-UTUC is not necessarily underused in Austria, because of lack in evidence, but 41 % of all RNU were performed in pTa/pTis/pT1 lesions.     

C-reactive protein, white blood cells, and neutrophils as early predictors of postoperative complications in patients undergoing laparoscopic sleeve gastrectomy

Background

Early detection and treatment of complications after laparoscopic sleeve gastrectomy (LSG) are mandatory. This study aimed to evaluate C-reactive protein (CRP), white blood cell (WBC) count, and neutrophil (NEU) count in relation to the early diagnosis of major surgical complications after LSG.

Methods

A prospective study of 177 patients who underwent LSG during 2008–2011 was performed. Measurements of WBC, NEU, and CRP performed on postoperative days 0, 1, 3, 5, 7, 9, 11, 13, and 30 were correlated with postoperative surgical complications.

Results

Both WBC and NEU were correlated with leak or abscess on postoperative days 3, 5, 7, 9, and 11, whereas on day 1, only NEU was significantly increased. Elevated CRP was correlated with leak or abscess on all the days (p < 0.001). The parameters measured were not correlated with postoperative bleeding unless leak or abscess coexisted. According to receiver operating characteristic (ROC) analysis, CRP detected leak or abscess with remarkably higher sensitivity and specificity than WBC or NEU on all the days. Moreover, the area under the curve (AUC) of CRP was higher than the AUC of WBC or NEU, suggesting important statistical significance. On day 1, WBC and NEU achieved 77.8 and 78.3 % sensitivity, respectively, and an even lower specificity (68.4 and 52.6 %), whereas a CRP cutoff at 150 mg/l achieved 83.2 % sensitivity and 100 % specificity. On day 3, the sensitivity and specificity of CRP reached 100 % (cutoff level, 200 mg/l), and on day 5, CRP achieved 83.2 % sensitivity and 100 % specificity (cutoff level, 150 mg/l), whereas for WBC and NEU, specificity was high (>92 %), but sensitivity did not exceed 78.2 %.

Conclusion

Because CRP detected leak or abscess after LSG with remarkably higher sensitivity and specificity than WBC or NEU, CRP seems to be a more accurate market for the early detection of these complications.     

Surveillance MR Imaging is Superior to Serum Tumor Markers for Detecting Early Tumor Recurrence in Patients with Appendiceal Cancer Treated with Surgical Cytoreduction and HIPEC

Background

The purpose of this study was to determine if MRI surveillance is better than serum tumor makers in detecting early recurrence in patients with mucinous appendiceal neoplasm.

Materials and Methods

A total of 50 patients with appendiceal neoplasm (DPAM 11, PMCA 39) underwent abdominal and pelvic MRI prior to surgical cytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC). Patients then entered follow-up surveillance with serial MRI every 6 months and serial laboratory studies including CA 125, CEA, and CA19-9. Written reports for surveillance MRI exams were reviewed for tumor recurrence and compared with results of serial laboratory tests. Proof of tumor recurrence was by a consensus of surgery and histopathology, as well as clinical and imaging findings on serial examinations.

Results

During surveillance tumor recurrence was documented in 30 patients (60 %) with median time to recurrence of 13 months (range 3–56 months). MRI detected recurrent tumor in 28 patients, including 11 patients with normal laboratory values (sensitivity 0.93, specificity 0.95, accuracy 0.94, PPV 0.97, and NPV 0.90). Serial laboratory values showed tumor recurrence in 14 patients (sensitivity 0.48, specificity 1.00, accuracy 0.69, PPV 1.0, and NPV 0.57). Median survival was 50 months for 11 patients with earlier MRI detection of recurrence vs 33 months for the other 19 patients with recurrence.

Conclusions

Following cytoreductive surgery and HIPEC MRI detects tumor recurrence earlier and with greater accuracy than serial tumor markers alone.     

The value of immediate postoperative MR imaging following endoscopic endonasal pituitary surgery

Background

Although the value of early MR imaging has been justified for microscopic transphenoidal surgery, there is no literature evaluating immediate postoperative MR imaging following endoscopic endonasal resection of pituitary adenomas. We hypothesized that MRI of the pituitary gland performed on the first postoperative day is just as effective at detecting residual disease and/or reconstruction materials as the MRI at 3 months following surgery.

Methods

We retrospectively evaluated 102 consecutive patients who underwent endoscopic endonasal surgery for presumed pituitary adenomas. Sixty-four patients met the inclusion criteria with immediate and 3 months MR imaging. Imaging was evaluated by two sets of observers. The following parameters were assessed: enhancement pattern of the pituitary gland, pituitary stalk, nodular enhancement (residual tumor) or linear enhancement (non-tumoral) and residual reconstruction/packing materials.

Results

Gross total resection of the tumors with no cavernous sinus involvement was achieved in 49 out of 52 (94 %) patients. Eleven out of 12 remaining patients with cavernous sinus invasion had residual cavernous sinus component visible on both immediate and 3 month MR imaging. The pituitary gland, position of stalk, and nasoseptal flap could be identified on both post-operative MRIs in all patients. The sensitivity and specificity for residual tumor detection on immediate MRI was 100 % and 97.9 %, respectively. The kappa index evaluating interobserver agreement for identification of residual tumor and packing/reconstruction material on immediate MR was 0.83 and 0.72 indicating near perfect and substantial agreement, respectively.

Conclusion

Immediate MR imaging performed following endoscopic endonasal resection of pituitary lesions provides accurate and reliable information regarding the presence of residual tumor compared to reconstruction and packing materials.