Salvage partial gland ablation for recurrent prostate cancer following primary partial gland ablation: Functional and oncological outcomes.

INTRODUCTION AND OBJECTIVE: Partial gland ablation (PGA) for localised prostate cancer (CaP) aims to eradicate clinically significant tumours while preserving healthy tissue, thereby decreasing the likelihood of side effects compared to whole-gland approaches. Although salvage radical prostatectomy (sRP) is a well-described salvage option in cases of PGA failure, the evidence supporting salvage PGA (sPGA) is limited. We hereby report the oncologic and functional outcomes of patients treated with sPGA following initial treatment with primary PGA (pPGA). METHODS: We describe the findings of a retrospective review of patients who had a CaP recurrence after pPGA and then underwent sPGA, at 3 medical centers in Ontario, Canada, between 2005 and 2017. Oncological outcomes following sPGA were assessed for biochemical recurrence (BCR) and biopsy-proven recurrence (BPR). Functional outcomes were described using the international prostate symptom score (IPSS), international index of erectile function (IIEF), and rates of urinary incontinence (use of >1 pad/day). RESULTS: We identified 25 patients who underwent sPGA following pPGA (hemiablation in 48% and zonal ablation in 52% of the patients). The median length of time was 16.8 months (interquartile range [IQR] 14.0-19.1) from pPGA to sPGA and 47.06 months (IQR 19.9-171.3) from pPGA to date of last follow up. High intensity focused ultrasound (HIFU) was the only modality used in all patients. At baseline, the median age was 65 years (IQR 52-77) and median prostate specific antigen (PSA) level was 7.46 ng/mL (IQR 1-25). The median time from pPGA to BPR was 12.7 months (IQR 5.19-36). At BPR following pPGA, 4 patients (17%) had CaP grade group (GG) 1, 10 patients (42%) had GG2, 6 patients (25%) had GG3, and 4 patients (17%) had GG4 disease, with a median PSA of 3.58 ng/mL (IQR 0.67-19). The median length of follow up after sPGA was 27.3 months (IQR 14.5-86.3). Following sPGA, 13/25 patients (52%) had BCR with median time to recurrence of 14 months (IQR 2.5-82.15), with a recurrence-free survival of 24.5 months (95% confidence interval: 15.3-not reached). Of those 13 patients, 4 were managed with sRP, 4 were managed with salvage radiotherapy, 3 were managed with androgen-deprivation therapy, 1 had a third PGA with HIFU, and 1 was managed with active surveillance. The mean change from baseline to last follow up in IPSS and IIEF scores was +1.3 (P = 0.66) and -2.3 (P = 0.32), respectively. Urinary incontinence was reported by 9% of patients at baseline, with only one additional patient developing incontinence following sPGA. CONCLUSION: Our present study demonstrates that after a median follow-up of 27 months, sPGA for recurrent CaP following pPGA provides disease control in up to 50% of patients with nonsignificant detrimental effects on functional outcomes. Appropriate patient selection and adequate staging are important to consider before offering PGA to patients.

Value of separate tumor base biopsy in transurethral resection of bladder tumors.

INTRODUCTION: The aim of our study was to evaluate whether a biopsy from the tumor base after transurethral resection of bladder tumor (TURBT) has an impact on subsequent management of patients with bladder tumors. While tumor base biopsy at the completion of TURBT is a common practice, there is no definition of its role within the major international professional guidelines. MATERIAL AND METHODS: We retrospectively reviewed the records of consecutive patients undergoing TURBT between 2015 and 2019 at our institution. We recorded demographic and tumor characteristics of initial TURBT, tumor base biopsy and restaging TURBT pathology outcomes. The pathologic outcomes were correlated to assess the additional value of a separate tumor base biopsy. RESULTS: A total of 532 patients underwent TURBT. A separate tumor base biopsy after completion of TURBT was performed in 154 patients. The mean patient's age was 72.8 ±11.7 years (range 48-94) and 119 (77.2%) were men. In 40 patients (25.9%) muscle was absent in the pathological specimen of the tumor resection. Muscle was present in all but 6 (3.9%) tumor base biopsies. Of the 33 patients who underwent repeated transurethral resection for pT1 tumors, 2 had residual low-grade pTa, 1 had residual high-grade pT1, and 3 patients were upstaged to pT2. CONCLUSIONS: Although tumor base biopsy at the completion of TURBT is a common practice, our analysis fails to demonstrate any tangible benefit in the staging of bladder tumors. In our experience tumor base biopsy did not change the management in patients with superficial or muscle invasive disease.

Oncologic and Functional Outcomes of Partial Gland Ablation with High Intensity Focused Ultrasound for Localized Prostate Cancer.

PURPOSE: We assessed the outcomes of high intensity focused ultrasound as primary treatment of localized prostate cancer in a retrospective series. This represents one of the largest published series of patients at intermediate and high risk. MATERIALS AND METHODS: We performed a retrospective multicenter analysis of patients who underwent partial gland ablation between January 2013 and September 2017. Patients with biopsy proven localized disease and limited multifocality based on magnetic resonance imaging who preferred minimally invasive outpatient therapy were treated with the Sonablate® 500 system. Oncologic and functional outcomes were analyzed as well as risk factors for recurrence. RESULTS: A total of 166 procedures were performed in 150 patients. Grade Group 2 or greater was present in 89% of cases. Mean ± SD followup was 24.3 ± 14.4 months. Mean prostate specific antigen decreased 65% from 7.9 ± 6.8 ng/ml to a nadir of 2.7 ± 3.1 ng/ml. Confirmatory biopsies were performed in 87 patients (52%) at high risk for recurrence. Clinically significant cancer (Grade Group 2 or greater) was detected in 37 cases (42%). Patients with a higher number of positive cores, a medial tumor location or higher prostate specific antigen had a higher probability of recurrence. Salvage treatment was done in 37 patients (24.6%), including 16 repeat partial gland ablation procedures. CONCLUSIONS: Partial gland ablation with high intensity focused ultrasound therapy was safe and it had a minimal impact on functional outcomes. Local recurrence and/or failure occurred in 42% of patients at high risk for recurrence. Medially located tumors were associated with a higher failure rate. Serious complications were rare. Whole gland treatment was avoided in 81% of patients.

Oncologic and Functional Outcomes of Partial Gland Ablation with High Intensity Focused Ultrasound for Localized Prostate Cancer.

PURPOSE: We assessed the outcomes of high intensity focused ultrasound as primary treatment of localized prostate cancer in a retrospective series. This represents one of the largest published series of patients at intermediate and high risk. MATERIALS AND METHODS: We performed a retrospective multicenter analysis of patients who underwent partial gland ablation between January 2013 and September 2017. Patients with biopsy proven localized disease and limited multifocality based on magnetic resonance imaging who preferred minimally invasive outpatient therapy were treated with the Sonablate® 500 system. Oncologic and functional outcomes were analyzed as well as risk factors for recurrence. RESULTS: A total of 166 procedures were performed in 150 patients. Grade Group 2 or greater was present in 89% of cases. Mean ± SD followup was 24.3 ± 14.4 months. Mean prostate specific antigen decreased 65% from 7.9 ± 6.8 ng/ml to a nadir of 2.7 ± 3.1 ng/ml. Confirmatory biopsies were performed in 87 patients (52%) at high risk for recurrence. Clinically significant cancer (Grade Group 2 or greater) was detected in 37 cases (42%). Patients with a higher number of positive cores, a medial tumor location or higher prostate specific antigen had a higher probability of recurrence. Salvage treatment was done in 37 patients (24.6%), including 16 repeat partial gland ablation procedures. CONCLUSIONS: Partial gland ablation with high intensity focused ultrasound therapy was safe and it had a minimal impact on functional outcomes. Local recurrence and/or failure occurred in 42% of patients at high risk for recurrence. Medially located tumors were associated with a higher failure rate. Serious complications were rare. Whole gland treatment was avoided in 81% of patients.

Combining Desmopressin and Docetaxel for the Treatment of Castration-Resistant Prostate Cancer in an Orthotopic Model.

BACKGROUND/AIM: Desmopressin is a synthetic analogue of the antidiuretic hormone vasopressin. It has recently been demonstrated to inhibit tumor progression and metastasis in breast cancer models. Docetaxel is a chemotherapy agent for castrate-resistant prostate cancer (CRPC). In this study, the ability of CRPC cells to grow and develop in vivo tumors in an animal model was evaluated, in order to investigate the anti-tumor effect of desmopressin in combination with docetaxel. MATERIALS AND METHODS: The CRPC cell line PC3 was used for orthotopic inoculation in male athymic nude mice. The mice were randomly assigned to one of the four treatment groups: Control, docetaxel, desmopressin or combination therapy. Following the last treatment, tumors were excised and measured. Blood samples were processed for CTC analysis. RESULTS: Docetaxel treatment resulted in a significant reduction in tumor volume compared to control. The combination therapy resulted in even more significant reduction (31.2%) in tumor volume. There was a complete absence of CTCs in the combination group. CONCLUSION: Our pilot study demonstrated an enhanced efficacy of docetaxel-based therapy in combination with desmopressin.

Laparoscopic partial nephrectomy for tumors 7cm and above. Perioperative outcomes

ABSTRACT Purpose: To assess and report the outcomes of laparoscopic partial nephrectomy) LPN) for T2 renal masses. Materials and Methods: Retrospective review of patients undergoing LPN for clinically localized renal masses ≥7cm between the years 2005-2016. Descriptive analyses were generated for demographics, lesion characteristics, perioperative variables (operative time, warm ischemia time (WIT), estimated blood loss (EBL), intra-operative and postoperative complications (IOC and POC) and pathologic variables (pathology, subtype and Fuhrman grade). Results: A total of 27 patients underwent LPN for a T2 renal mass at our institution between 2005 and early 2016 of which 19 were males. The mean age was 66 (52-72). All procedures were transperitoneal with 16 on the right and 11 on the left. Median operative time was 200 minutes (IQR 181-236) and median WIT 19 minutes (IQR 16-23). EBL was 125mL (IQR 75-175). One case was converted to laparoscopic radical nephrectomy due to suspected tumor thrombus in the renal vein. Surgical margins were positive in one renal tumor in a patient with multiple tumors. There was a total of 2 IOC (7.4%) and 3 POC (11%) classified as Clavien grade 3. Conclusions: To our knowledge, this series is the first to describe the outcomes of LPN for cT2 renal masses. In our series, LPN for larger renal masses appears feasible with favorable perioperative outcomes. Additional data are needed to further explore the benefits of minimally invasive surgical approaches to larger renal masses.

Laparoscopic partial nephrectomy for tumors 7cm and above. Perioperative outcomes.

PURPOSE: To assess and report the outcomes of laparoscopic partial nephrectomy )LPN) for T2 renal masses. MATERIALS AND METHODS: Retrospective review of patients undergoing LPN for clinically localized renal masses ≥7cm between the years 2005-2016. Descriptive analyses were generated for demographics, lesion characteristics, perioperative variables (operative time, warm ischemia time (WIT), estimated blood loss (EBL), intra-operative and post-operative complications (IOC and POC) and pathologic variables (pathology, subtype and Fuhrman grade). RESULTS: A total of 27 patients underwent LPN for a T2 renal mass at our institution between 2005 and early 2016 of which 19 were males. The mean age was 66 (52-72). All procedures were transperitoneal with 16 on the right and 11 on the left. Median operative time was 200 minutes (IQR 181-236) and median WIT 19 minutes (IQR 16-23). EBL was 125mL (IQR 75-175). One case was converted to laparoscopic radical nephrectomy due to suspected tumor thrombus in the renal vein. Surgical margins were positive in one renal tumor in a patient with multiple tumors. There was a total of 2 IOC (7.4%) and 3 POC (11%) classified as Clavien grade 3. CONCLUSIONS: To our knowledge, this series is the first to describe the outcomes of LPN for cT2 renal masses. In our series, LPN for larger renal masses appears feasible with favorable perioperative outcomes. Additional data are needed to further explore the benefits of minimally invasive surgical approaches to larger renal masses.

Gradenigo's syndrome: is fusobacterium different? Two cases and review of the literature.

Gradenigo's syndrome is a rare but life threatening complication of acute otitis media (AOM), which includes a classic triad of otitis media, deep facial pain and ipsilateral abducens nerve paralysis. The incidence of Fusobacterium necrophorum infections has increased in recent years. We describe two cases of Gradenigo's syndrome caused by F. necrophorum. Additional four cases were identified in a review of the literature. Gradenigo's syndrome as well as other neurologic complications should be considered in cases of complicated acute otitis media. F. necrophorum should be empirically treated while awaiting culture results.

Comparison of N-terminal pro-B-type natriuretic peptide levels in critically ill children with sepsis versus acute left ventricular dysfunction.

OBJECTIVE: N-terminal pro-B-type natriuretic peptide has been shown to be a marker for cardiac dysfunction. The peptide level is also elevated in patients with sepsis. The purpose of this study was to assess whether N-terminal pro-B-type natriuretic peptide levels can differentiate pediatric patients with sepsis from patients with acute left ventricular dysfunction. PATIENTS AND METHODS: Pediatric patients admitted to an ICU with sepsis or acute left ventricular dysfunction were evaluated clinically, and the grade of systemic inflammatory-response syndrome was determined. Echocardiography was performed, and their levels of N-terminal pro-B-type natriuretic peptide were measured. The N-terminal pro-B-type natriuretic peptide level was also measured in patients with simple febrile illness. RESULTS: There were 10 patients with sepsis and 10 with acute left ventricular dysfunction. The age of the patients was similar, and systemic inflammatory-response syndrome grading was not different (sepsis: 2.8 +/- 0.4; acute left ventricular dysfunction: 2.6 +/- 0.7). N-terminal pro-B-type natriuretic peptide levels were elevated in patients with sepsis (median: 6064 pg/mL; range: 495-60,417 pg/mL) but were significantly higher in patients with acute left ventricular dysfunction (median: 65,630 pg/mL; range: 15,125-288,000). The area under the receiver operating characteristics curve for the diagnosis of acute left ventricular dysfunction was 0.9. N-terminal pro-B-type natriuretic peptide levels of patients with sepsis and impaired systolic function were not different from those of patients with sepsis and normal systolic function. The N-terminal pro-B-type natriuretic peptide levels of 20 patients with simple febrile illness were significantly lower. CONCLUSIONS: N-terminal pro-B-type natriuretic peptide levels are elevated in pediatric patients with sepsis but are higher in some, but not all, patients with acute left ventricular dysfunction. The overlap between N-terminal pro-B-type natriuretic peptide levels in sepsis and acute left ventricular dysfunction precludes the use of the peptide's level as a sole means to differentiate between these conditions. Excessive elevation in N-terminal pro-B-type natriuretic peptide levels, however, suggests cardiac etiology for acute hemodynamic deterioration in infants and children.

Respiratory failure in a neonate after folk treatment with broom bush (Retama raetam) extract.

OBJECTIVES: To increase the awareness of intoxication by folk herbal remedies in the pediatric population. METHODS: Case report of a 7-day-old baby boy admitted to a pediatric intensive care unit in a university-affiliated hospital. RESULTS: The patient presented with respiratory failure and central nervous system depression. Specific questioning of the parents revealed consumption of folk herbal remedy by the neonate. Mechanical ventilation was used for 24 hours until normal activity level resumed. CONCLUSIONS: The possibility of intoxication in a neonate should not be overlooked. Folk herbal remedies, especially if taken in larger than recommended amounts, may be hazardous. Accessible herbal and folk medicine data bank will contribute to a better treatment of patients having side effects of these remedies.