Postchemotherapy residual masses in advanced seminoma: current management and outcomes

Although pure testicular seminoma is most often confined to the testis, it can present with advanced-stage bulky retroperitoneal metastases in nearly a quarter of cases. While highly treatable with cisplatin-based chemotherapy, up to 80% of patients with advanced disease are found to have a radiographically detectable residual mass after chemotherapy. The management of these postchemotherapy residual masses remains controversial. Surgical resection is technically challenging due to a desmoplastic reaction resulting from seminoma treatment and regression. In addition, these residual masses often demonstrate a protracted period of regression that can span several months to years. Surveillance protocols, therefore, may be appropriate for most patients. Several retrospective studies have supported surgical resection only for discrete, well-delineated masses over 3 cm in size. Despite the highly radiosensitive nature of seminoma, radiation therapy in this setting has not been shown to provide significant benefit, and may limit the tolerability of subsequent salvage chemotherapy. The incorporation of noninvasive imaging modalities, such as positron emission tomography, into the management algorithm may better delineate the presence of viable residual tumor and thus allow better risk stratification.     

Platelet Functions in Cardiopulmonary Bypass Surgery

Background

Haemorrhage after Cardio Pulmonary Bypass (CPB) Surgery is a well recognised complication that leads to significant morbidity and mortality. The incidence varies between 5-25% depending upon the clinical situation. Several factors are implicated as causative but none have been precisely proved.

Methods

Our study was an attempt to evaluate the haemostatic defect with particular reference to platelet function abnormalities during cardio pulmonary bypass surgery, in order to reduce the morbidity and mortality associated with post CPB haemorrhage. Flow cytometric evaluation of different platelet glycoproteins like GPIb/IX, GPIIb/IIIa and GMP-140 was done.

Results

The marker expression showed deregulation during surgery which returned to base after bypass was terminated. In contrast, the cases with bleeding showed significant variation. P-Selectin (GMP 140) expression decreased progressively till 3^rd post-operative day showing lack of activation of platelets in cases of severe bleeding.

Conclusion

Longer duration of CPB initiates plasmin generation through heparin, which raises the PAI-1-tPA complex and thereby down regulating the functions of platelets. This suggests a link between duration of CPB, bleeding, platelet dysfunction and fibrinolysis. Hence serial estimations of the levels of GMP-140 and tPA can predict severe bleeding.Key Words: CardioPulmonary Bypass, Platelet dysfunction, flowcytometry, platelet glycoproteins, haemorrhage     

Radical cystectomy for primary neuroendocrine tumors of the bladder: the university of southern california experience

PURPOSE: Primary neuroendocrine tumors of the bladder are rare and they include small and large cell variants. We reviewed our experience with treating these tumors with radical cystectomy to evaluate their histopathological characteristics and clinical outcomes. MATERIALS AND METHODS: From August 1971 to June 2004, 2,005 patients underwent radical cystectomy for primary bladder cancer at our institution, of whom 25 (1.2%) had neuroendocrine tumors of the bladder, including small cell carcinoma in 20 and large cell carcinoma in 5. Pure neuroendocrine-type histology was identified in 16 cases, including 1 with small and large cell features, while the remaining 9 had mixed histology, that is transitional cell carcinoma in 8 and adenocarcinoma in 1. Multi-agent chemotherapy was administered to 14 patients. RESULTS: Median patient age was 68 years (range 40 to 82) and 19 patients were male (76%). A total of 19 patients (76%) had lymph node involvement, of whom 2 had small liver metastases found intraoperatively, while only 4 (16%) had organ confined tumors and 2 (8%) had extravesical, node negative disease. These tumors tended to have a flat, ulcerative gross appearance with lymphovascular invasion, carcinoma in situ and necrosis present microscopically. Median followup was 11.8 years (range 18 days to 15.1 years). Five-year overall and recurrence-free survival was 10% and 13%, respectively. There was no significant survival difference between small and large cell carcinoma. Mixed histologies tended to do better than pure neuroendocrine tumors, although this did not attain statistical significance (p = 0.064). Patients receiving multimodality therapy had significantly better overall (p = 0.051) and recurrence-free (p = 0.003) survival than those treated with cystectomy alone. CONCLUSIONS: Neuroendocrine tumors of the bladder usually present with advanced pathological stage and portend a poor prognosis. Adjuvant chemotherapy protocols may provide improved survival compared with cystectomy alone.     

Phased-array magnetic resonance imaging of the prostate with correlation to radical prostatectomy specimens: local experience

PURPOSE: To evaluate local experience of phased-array magnetic resonance imaging (MRI) in the staging of locally advanced prostate carcinoma with comparison to clinical staging. METHODS: The study population was 21 patients who underwent preoperative MRI with pelvic phased-array coils followed by radical prostatectomy. The MRI findings were correlated with completely embedded serially sliced and whole-mounted sections of the prostate gland and clinical staging. RESULTS: Overall accuracy of 57.1% was obtained, with specificity of 90.0% and sensitivity of 27.3%. All but one case of locally advanced disease missed by MRI was microscopic. Clinical staging in these cases also achieved accuracy of 57.1%, specificity of 90.0% and sensitivity of 27.3%. CONCLUSIONS: MRI with a phased-array coil has high specificity but low sensitivity for detection of extraprostatic disease. Phased-array MRI does not image microscopic tumour extension. It did not perform better than clinical staging and is not recommended for routine staging.     

TEM and STEM analysis on heat-treated and in vitro plasma-sprayed hydroxyapatite/Ti-6Al-4V composite coatings

A cogent understanding of the microstructure, and indeed nano-structure, of hydroxyapatite (HA) and the interface between Ti-6Al-4V and HA is crucial to its appropriateness as a biomaterials. This paper reports the analysis of plasma-sprayed HA/Ti-6Al-4V composites by transmission electron microscopy (TEM) and scanning transmission electron microscopy (STEM) to elucidate the intricate nature of the materials following plasma spray processing and in vitro evaluation. The novel Ti-6Al-4V/HA composite coating, with approximately 48 wt% HA, had demonstrated attractive tensile adhesion strength (approximately 28 MPa) and improved Young's modulus (approximately 55 GPa). Experimental results demonstrated that amorphous calcium phosphate and fine HA grains were formed during rapid splat solidification in the as-sprayed composite coatings. Small Ti-6Al-4V grains were observed adjacent to the amorphous calcium phosphate. The coatings were further heat treated at 600 degrees C for 6 h, and significant crystallisation of the amorphous calcium phosphate phase took place. However, complete crystallisation was not achieved at this temperature, as the coatings invariably contained a small amount of amorphous calcium phosphate phase in some local regions. After immersion in simulated body fluid for 2 weeks and 10 weeks, TEM and STEM confirmed that the interfaces inside the coating maintained good microstructural integrity.     

Microcapsules with improved mechanical stability for hepatocyte culture

Packed-bed or fluidized-bed bioreactor filled with microencapsulated hepatocytes has been proposed as one of the promising designs for bioartificial liver assist device (BLAD) because of potential advantages of high mass transport rate and optimal microenvironment for hepatocyte culture. Recently, we have developed a microcapsule system for the encapsulation of hepatocytes. The microcapsules consist of an inner core of modified collagen and an outer shell of terpolymer of methyl methacrylate, methacrylate and hydroxyethyl methacrylate. Cells encapsulated in these microcapsules exhibit enhanced cellular functions. Improving the mechanical stability of the microcapsules to withstand the shear stress induced by high perfusion rate would be crucial to the success of BLAD applications. In this study, we investigated the effects of terpolymer molecular weight (M(w)) on the mechanical property of these microcapsules and the differentiated functions of encapsulated hepatocytes. Six terpolymers with different M(w) were synthesized using radical polymerization in solution by adjusting the reaction temperature and the initiator concentration. All the terpolymers formed microcapsules with the methylated collagen. While the terpolymer M(w) had little effect on the capsule membrane thickness and permeability of serum albumin, the mechanical property of the microcapsules was significantly improved by the higher M(w) of the terpolymer. Differentiated functions of the hepatocytes cultured in the microcapsules, including urea synthesis, albumin synthesis and cytochrome P450 metabolic activity, were not significantly affected by the terpolymer M(w).     

Radiologists' detection of mammographic abnormalities with and without a computer-aided detection system

The aim of this study was to to evaluate the role of a computer-aided program (CAD) in assisting detection of mammographic lesions by radiologists not specifically trained in mammography and its potential utility in breast screening. Mammograms were evaluated by radiologists not specifically trained in mammography first without, and then with, the CAD. Finally, the mammograms were evaluated by experienced mammographers who formed the reference standard. Two hundred and ninety four breasts were studied. In 257 breasts (87.4%), the CAD system did not help with the detection of abnormalities. It assisted radiologists in detecting abnormalities in 21 breasts (7.1%) with potential for detecting abnormalities in a further 13 breasts (4.4%). Only in three cases (1%) did it cause confusion in interpretation. There is overall increased sensitivity in detecting mammographic abnormalities with the aid of the CAD system from 74.4 to 87.2%, which is statistically significant. However, it failed to detect suspicious abnormalities in 71 breasts (24.1%). The CAD system improved detection of suspicious mammographic abnormalities by radiologists who are not specifically trained in mammography. However, there is also a substantial failure to detect suspicious mammographic features that cautions against over-reliance on the system, emphasizing its role as a second reader at best.