Survival after radical cystectomy of non-bilharzial squamous cell carcinoma vs urothelial carcinoma: a competing-risks analysis

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? To date, there is controversy about the impact of histological subtype of bladder cancer (nonbilharzial squanous cell carcinoma vs. urothelial carcinoma) on cancer control outcomes. Our study shows that the histological subtype may have an impact on the stage of bladder cancer at presentation. However, after adjusting to stage, the histological subtype has no impact on cancer control outcomes.

OBJECTIVES

• ? To test the effect of histological subtype (NBSCC vs UC) on cancer‐specific mortality (CSM), after adjusting for other‐cause mortality (OCM).
• ? In Western countries, non‐bilharzial squamous cell carcinoma (NBSCC) is the second most common histological subtype in bladder cancer (BCa) after urothelial carcinoma (UC).

PATIENTS AND METHODS

• ? We identified 12 311 patients who were treated with radical cystectomy (RC) between 1988 and 2006, within 17 Surveillance, Epidemiology and End Results (SEER) registries.
• ? Univariable and multivariable competing‐risks analyses tested the relationship between histological subtype and CSM, after accounting for OCM.
• ? Covariates consisted of age, sex, year of surgery, race, pathological T and N stages, as well as tumour grade.

RESULTS

• ? Histological subtype was NBSCC in 614 (5%) patients vs UC in 11 697 (95%) patients.
• ? At RC, the rate of non‐organ confined (NOC) BCa was higher in NBSCC patients than in their UC counterparts (71.7% vs 52.2%; P < 0.001).
• ? After adjustment for OCM, The 5‐year cumulative CSM rates were 25.0% vs 19.8% (P= 0.2) for patients with NBSCC vs UC organ confined (OC) BCa, respectively. The same rates were 46.3% vs 49.3% in patients with NOC BCa (P= 0.1).
• ? In multivariable competing‐risks analyses, histological subtype (NBSCC vs UC) failed to achieve independent predictor status of CSM in patients with OC (hazard ratio, 1.2; P= 0.06) or NOC BCa (hazard ratio, 1.1; P= 0.1).

CONCLUSIONS

• ? At RC, the rate of NOC BCa is higher in NBSCC patients than in their UC counterparts.
• ? Despite a more advanced stage at surgery, NBSCC histological subtype is not associated with a less favourable CSM than UC histological subtype, after accounting for OCM and the extent of the disease (OC vs NOC).

     

Comparative effects of hydroxocobalamin and cyanocobalamin on plasma homocysteine concentrations in end-stage renal disease

End-stage renal disease (ESRD) is associated with marked hyperhomocysteinemia which is only partially corrected by folic acid and pyridoxine supplementation. We and others have reported that various forms of parenteral cobalamin reduce plasma total homocysteine (tHcy) concentrations of patients with ESRD substantially below the lowest levels attainable with folic acid. We here report a 16-week randomized controlled crossover trial which directly compared the Hcy-lowering effect of intravenous hydroxocobalamin (HC) with that of cyanocobalamin (CC). Folic acid- and vitamin B12-replete maintenance hemodialysis patients were randomly assigned to receive either 1 mg intravenous HC weekly for 8 weeks followed by CC for a further 8 weeks, or CC for 8 weeks followed by HC for 8 weeks. Hydroxocobalamin increased serum cobalamin concentrations 40-fold, whereas CC increased them only 10-fold, but both treatments reduced plasma tHcy concentrations similarly by 33% (P < .001). Crossover to the alternate form of the vitamin greatly affected the serum cobalamin concentration but was without further effect on the plasma tHcy concentration. These results confirm that weekly cobalamin injections lower plasma tHcy concentrations of hemodialysis patients well below the level attainable with folic acid. Hydroxocobalamin and CC are equipotent despite producing very different serum cobalamin concentrations.     

Synthesis and pharmacological studies of some pyrone and benzodifuran derivatives

The michael adducts2a,b were obtained from the reaction of the phenylacetyl derivative1 with benzaldehyde and p-anisaldehyde respectively.2a and2b were subjected to react with cyanoethanoic acid hydrazide, malononitrile, cyanothioacetamide, cyanoacetamide and 1,1,3-tricyano-2-amino propene to yield4a-h and5a,b respectively. Hydrogen peroxide oxidation of2a,b gave the aurone derivative6a,b. The pyrone derivatives8a,b were obtained from2a,b by addition of chloroacetyl chloride followed by dehydrochlorination.     

Synthesis and biological activities of new substituted indoles

2,3-Diphenyl-6-formyl-5-methoxyindole reacts with ethyl cyano acetate to yield the arylidene derivative which forms with urea and thiourea the corresponding pyrimidine derivatives. The arylidene derivatives react with hydrazines and with active methylenes to form the respective pyrazole derivatives and the α, β-disubstituted acrylonitriles. Seven new compounds were tested for their effects on the arterial blood pressure of rats and analgesic activity.     

Timing and surgical management of neonatal testicular torsions

Background

The timing and surgical management of neonatal testicular torsions (NTTs) remain controversial, varying from immediate orchiectomy with empirical contralateral orchiopexy to expectant management with resulting atrophy of the affected testicle. The goal of the present study is to review the management of this entity at our institution.

Materials and methods

A retrospective study of all patients with NTT from 1989 to 2007 was undertaken. The age, clinical presentation, investigation, management, and short- and long-term outcomes were noted.

Results

Forty-four patients were included. Most presented with a firm testicular mass, scrotal discoloration, and hydrocele (42), whereas a few presented with testicular atrophy (2). The median age at presentation was 1 day of age (range, 0-84 days), with NTT occurring on the right side in 22 patients and the left side in 20. Two patients (5%) had bilateral torsion at presentation. In 33 patients, the diagnosis was confirmed by Doppler ultrasonography, whereas 11 patients did not undergo any additional investigation. Surgical management included ipsilateral orchiectomy and contralateral orchiopexy (IOCO) (27), orchiopexy of the contralateral testis (CO) (7), bilateral orchiopexy (4), orchiectomy of the ipsilateral testis (1), orchiopexy of the ipsilateral testis (2), and observation (1). The 2 bilateral torsions underwent bilateral orchiectomy (2). The median age at surgery was 25 days (range, 1-912 days). Postoperative complications occurred in 8 patients (18%), mainly in those with IOCO (4) and CO (4) operated before 12 days of age, and included recurrent hydrocele (3), wound infection (2), urinary tract infection (1), and others (2). Upon follow-up, patients who underwent CO developed ipsilateral testicular atrophy (6). No patients were readmitted for recurrence of torsion or other complications.

Conclusion

At our institution, the most frequent management of unilateral neonatal testicular torsions is IOCO or CO, but this carries an 18% complication rate, particularly if surgery is performed early. There seems to be no advantage to early intervention, and the need for orchiectomy is debatable because torsion leads to ipsilateral testicular atrophy. Contralateral orchiopexy done to decrease the incidence of bilateral asynchronous torsion should, at the very least, be deferred until the risks of anesthesia and surgery are improved, given its rarity. Given the fact that most patients underwent IOCO or CO, we cannot conclude which strategy is the best for neonatal testicular torsions. A prospective study is welcomed.     

Effect of needle size on cancer detection, pain, bleeding and infection in TRUS-guided prostate biopsies: a prospective trial

Introduction:

Transrectal ultrasound (TRUS)-guided prostate biopsies using 18G calibre needles are widely used; most often 12-core tissue samples of the peripheral zone are obtained. Although the diagnostic yield of prostate biopsies is fair, there is still a potential for false negative results, which necessitates repeat biopsies. In an effort to improve the accuracy of prostate biopsies, different sampling schemes have been developed. One strategy has been to increase the number of core biopsies performed on each patient. Another strategy has been to improve the reliability of prostate biopsies using larger calibre needles, thereby increasing the amount of tissue obtained for each core biopsy.

Methods:

After approval by our institutional review board, we prospectively compared two biopsy needle sizes (18G vs. 16G) in relation to prostate cancer diagnosis, pain, bleeding and infection rates on 105 patients. Each patient underwent 6 TRUS-guided prostate biopsies with the standard 18G needle and 6 other biopsies with the experimental 16G needle. To evaluate possible complications related to the use of a larger 16G needle in the experimental group, we compared pain, bleeding and infection rates with a control group of 100 patients who underwent 12 biopsies with a single 18G needle (18G group). Pain, bleeding assessment and infection events were evaluated using patient questionnaires and telephone interviews.

Results:

TRUS-guided prostate biopsies using 16G calibre needles did not increase cancer detection or non-malignant pathology rate, including prostatic intraepithelial neoplasia (PIN) and atypical small acinar proliferatio (ASAP). Pain, bleeding and infectious complications were similar in both groups. Infection was defined as temperature above 38°C occurring within 48 hours after the procedure. We identified 4 patients with post-biopsy fever in the experimental (16/18G) group and 4 other patients in the (18G) control group. The post-biopsy infection rate is higher than reported just a few years ago and indicates that quinolone resistant Escherichia coli seems to be more prevalent in our urban setting than previously suspected. Limitations to our study include small group numbers.

Conclusion:

Larger 16G needles appear to be safe for TRUS-guided prostate biopsies. Further study in a larger, multi-institutional, prospective, randomized manner with 16G needles is warranted to assess the theoretical benefit of larger core biopsies in prostate cancer detection.