Systemic therapy in metastatic renal cell carcinoma (mRCC): an evidence-based recommendation of the German interdisciplinary RCC guidelines group.

PURPOSE: The treatment landscape in metastatic renal cell carcinoma (mRCC) has evolved dramatically in recent years. Within the German guideline committee for RCC we evaluated current medical treatments and gave recommendations. METHODS: A systematic review of published evidence for medical treatment of mRCC was performed (July 2016-August 2019) to cover the duration from last guideline update in 2016. Evidence was graded according to SIGN ( http://www.sign.ac.uk/pdf/sign50.pdf ). Recommendations were made on the basis of a nominal group work with consensus approach and included patient advocates and shareholder of the German RCC treatment landscape. Each recommendation was graded according to its strength as strong recommendation (A) or recommendation (B). Expert statements were given, where appropriate. RESULTS: Strong first-line recommendations (IA) exist for axitinib + pembrolizumab (all risk categories) and ipilimumab + nivolumab (intermediate or poor risk only). Axitinib + avelumab is a recommended first-line treatment across patients with any risk category (IB). In patients who are not candidates for immune check point inhibitor (ICI) combinations, targeted agents should be offered as an alternative treatment. Subsequent treatment after ICI-based combinations remain ill-defined and no standard of care can be formulated. CONCLUSION: ICI-based combinations are the first-line standard of care and should be considered accordingly. There is an unmet medical need for pivotal studies that define novel standards in patients with failure of ICI-based combinations.

[Priapism: Current diagnostics and therapy]. / Priapismus : Aktuelle Diagnostik und Therapie.

Priapism is characterized by involuntary persistent penile erection after or independent of sexual stimulation. The diagnostic clarification, including patient history, physical findings, duplex ultrasonography and analysis of blood gases is decisive for the underlying pathophysiology and the appropriate therapeutic procedure. Non-hypoxic and non-acidotic blood gas parameters enable a conservative approach, hypoxic, hypercarbic and acidotic parameters may lead to fibrosis of the corpora cavernosa and, in turn, to a loss of penile function. Low-flow or ischemic (veno-occlusive) priapism is an emergency situation and can lead to irreversible erectile dysfunction within 4 h. Treatment consists of blood aspiration and possibly intracavernosal injection of sympathomimetic drugs. A distal shunt is necessary in the case of treatment failure (in rare cases a proximal shunt). Management of recurrent priapism (stuttering) includes self-injection of sympathomimetic drugs and preventive long-term administration of erection inhibitory and erection promoting substances. This concept still needs to be validated. High-flow or non-ischemic priapism does not necessitate immediate treatment measures and should be kept under observation. In cases of a detectable fistula selective artery embolization is often a successful option.

Fat-containing lesions of the liver: a pictorial essay.

The presence of fat within a hepatic lesion is unusual and can help to direct the radiologist's diagnosis. The aim of this iconographic review is to specify the various hepatic lesions that may contain fat and their appearance particularly on MRI. A histological correlation is also suggested for the most commonly found tumors. The identification of fat within a hepatic tumor, along with other radiological signs and reflection on the clinical and epidemiological context, can lead to a diagnosis being reached or suggested, with confirmation if necessary, by a pathological examination.

Shear wave elastography contribution in ultrasound diagnosis management of breast lesions.

PURPOSE: To determine the diagnosis performance of shear wave elastography in the differentiation of benign and malignant breast lesions and the factors influencing the elasticity values. To suggest an appropriate management of breast lesions using the ultrasound-elastography combination. PATIENTS AND METHODS: Monocentric retrospective study of 167 breast lesions classified by conventional ultrasound as BI-RADS category 3 or higher that underwent an elastography study and histological analysis. RESULTS: The analysis of qualitative parameters, according to the classification established in this study, allows us to obtain a sensitivity of 91.1% and a specificity of 92.3%. These values are very close to or better than the quantitative parameters Emax and Emean. Different Emax thresholds values were established based on the long axis of the lesion and its palpable character, which appeared to be significant factors influencing elasticity. The management of breast lesions by combining ultrasound and elastography, as proposed here, allows us to keep the sensitivity of an ultrasound (96%), while doubling its specificity (86.2% versus 43.1%). CONCLUSION: With the complementary nature of their performance, the combination of conventional ultrasound and shear wave elastography can improve the management of breast lesions. The qualitative classification proposed appears to be relevant assistance in lesion characterization.

[Use of hydrogel as spacer in Denovier's space: optimization of IMRT radiotherapy of localized prostate cancer]. / Hydrogelapplikation als Spacer in den "Denovier-Raum" : Optimierung der IMRT-Radiotherapie des lokalisierten Prostatakarzinoms.

BACKGROUND: Radiotherapy is an appropriate primary therapy for localized prostate cancer in accordance with urological guidelines. Especially in tumors of higher grade malignancy, dose escalation up to 80,0 Gy seems to be an advantage; however rectum toxicity can be a problem. By injecting a synthetic hydrogel (SpaceOAR®) as a spacer between the prostate and rectum, rectal toxicity can be reduced. We report on our experiences with 47 patients and an average follow-up of 241 days. METHODS: From February 2012 to November 2012, 47 patients were included in the study series. Before external radiotherapy the hydrogel was injected between prostate and rectum in the so-called Denovier space. This interdisciplinary procedure was carried out with the patient under general anesthesia using transrectal ultrasound guidance and video documentation. The patients were hospitalized for 1 day. The exact position of the gel was assessed by means of magnetic resonance imaging (MRI). Radiotherapy was initiated 7-14 days after gel application in a dose escalation manner by means of intensity modulated radiation therapy (IMRT) up to a dose of 80,0 Gy. Average follow-up was 241 (100-386, SD 91) days. RESULTS: No early side effects specific for the application were observed. The achieved distance between rectum and the mid-plane of the prostate gland was on average 13.8 (6-24, SD=3.8) mm. Calculated V70 (rectal volume irradiated with 70.0 Gy or more) could be reduced to an average of 1.5 (0-8, SD=1.7) %. One patient showed an asymptomatic lesion of the rectal mucosa after irradiation with 38,0 Gy. This lesion was closely controlled and gel penetration was found. As a result radiotherapy was discontinued. Without further treatment the necrosis had completely healed 3 months later. CONCLUSIONS: Hydrogel application between prostate and rectum allows dose escalation up to 80,0 Gy and seems to reduce morbidity in patients with localized prostate cancer receiving radiotherapy. However, before final judgement of the new technique further studies must follow.

Hepatic haemangioma: common and uncommon imaging features.

The haemangioma, the most common non-cystic hepatic lesion, most often discovered by chance, may in certain situations raise diagnostic problems in imaging. In this article, the authors first demonstrate that the radiological appearance of the hepatic haemangioma, in its typical form, is closely related to three known histological sub-types. They then show that certain atypical features should be known in order to establish a diagnosis. They also observe the potential interactions between the haemangioma, an active vascular lesion, and the adjacent hepatic parenchyma. Finally, they discuss the specific paediatric features of hepatic haemangiomas and illustrate the case of a hepatic angiosarcoma.

[Multiple synchronous urinary tract tumors in a hemodialysis patient]. / Multiple synchrone urologische Tumore bei einem dialysepflichtigen Patienten.

We report the case of a 67-year-old patient on hemodialysis with asymptomatic gross hematuria and increased PSA levels who was diagnosed with invasive bladder cancer. The postoperative histological studies revealed a bilateral renal cell carcinoma, right ureter and renal pelvis carcinoma in situ and prostate cancer. We believe this to be the first case of such a combination of synchronous urinary tract tumors. When treating urological cancer patients on hemodialysis, one should be aware of a possible combination of multiple synchronous urinary tract tumors.

Channelling optics for high quality imaging of sensory hair.

A long distance microscope (LDM) is extended by a lens and aperture array. This newly formed channelling LDM is superior in high quality, high-speed imaging of large field of views (FOV). It allows imaging the same FOV like a conventional LDM, but at improved magnification. The optical design is evaluated by calculations with the ray tracing code ZEMAX. High-speed imaging of a 2 × 2 mm(2) FOV is realized at 3.000 frames per second and 1 µm per pixel image resolution. In combination with flow sensitive hair the optics forms a wall shear stress sensor. The optics images the direct vicinity of twenty-one flow sensitive hair distributed in a quadratic array. The hair consists of identical micro-pillars that are 20 µm in diameter, 390 µm in length and made from polydimethylsiloxane (PDMS). Sensor validation is conducted in the transition region of a wall jet in air. The wall shear stress is calculated from optically measured micro-pillar tip deflections. 2D wall shear stress distributions are obtained with currently highest spatiotemporal resolution. The footprint of coherent vortical structures far away from the wall is recovered in the Fourier spectrum of wall shear stress fluctuations. High energetic patterns of 2D wall shear stress distributions are identified by proper orthogonal decomposition (POD).

[Carcinoma of the rete testis with lymphogenous metastasis: multimodal treatment]. / Rete-testis-Karzinom mit lymphogener Metastasierung : Multimodale Behandlung.

Cancers of the rete testis are uncommon and usually occur in the 6th or 7th decade of life. The prognosis is dreadful. Approx. 40% of the affected patients die within 1 year after diagnosis due to progression of the disease. The primary therapy is surgical. Until now there is no effective chemotherapy. In our case following primary inguinal orchiectomy and confirmation of the diagnosis, a radical retroperitoneal lymphadenectomy and wide local resection were performed. One positive lymph node was found and adjuvant radiotherapy was performed. In this case preoperative PET/CT was not helpful. For the last 3 years now the patient has been disease free. Since cancers of the rete testis are very rare and the literature is scarce, we would like to recommend the introduction of a national registry.

Her-2/neu expression in testicular cancer--a retrospective analysis in 57 cases.

OBJECTIVES: To evaluate her-2/neu expression in testicular germ cell tumors (GCT). METHODS: In patients with primary GCT her-2/neu expression was analyzed by immunohistochemistry (IHC). Furthermore, gene amplification was analyzed by chromogene in situ hybridization (CISH). For interpretation, the most recent Asco Guidelines were used. RESULTS: The expression patterns were analyzed according to the histologic subtype. Immunohistochemical analysis demonstrated a weak (score 1) to moderate expression (score 2) in 1% of GCT; none of the GCT revealed a score 3 expression profile. By CISH analysis, we did not observe any gene amplification in the 57 GCT. CONCLUSIONS: The analysis of her-2/neu expression in primary testicular cancer is of no therapeutic relevance. However, for the future we will explore the expression of her-2/neu in residual masses after chemotherapy to assess the role of targeted therapy in chemoresistant metastases.

[Social gradient of PSA screening? 8 years follow up from the cancer registry of the tumor center in Regensburg]. / Mittelstandsorientierung des PSA-Screenings? : 8-Jahres-Nachsorgedaten des Tumorregisters Regensburg.

BACKGROUND: Prostate cancer is the most frequent male cancer. In Germany most tumors are detected by PSA testing. Data on the long-term survival of patients with localized early prostate carcinoma are insufficient. We examined the relative survival of the patients with organ-defined prostate cancer (TNM T1-2N0M0, UICC I-II) compared to the standardized age-adjusted rates of the normal male population. METHODS: Epidemiological and clinical data from 4,124 patients with prostate cancer diagnosed from 1998 to 2007 were extracted from the cancer registry of the tumor center in Regensburg; 2,087 patients suffered from localized early cancer. Kaplan-Meier analysis was used to estimate the overall survival rates in the patient cohorts irrespective of primary cancer therapy. These rates were adjusted for the expected survival rates in a comparable set of individuals from the general population. RESULTS: Eight years after diagnosis, patients with stage I and II localized prostate cancer had an approximately 10% relative increase in survival compared with the normal male population. This relative increase in survival was already observed 3 years after diagnosis. CONCLUSION: Patients with stage I-II localized prostate cancer have improved survival compared with the normal male population. This finding cannot be explained solely by the administration of prostate cancer treatments, which do not affect survival until 8-10 years after treatment, suggesting that men who participate in PSA testing may have a better overall health status. Another hypothesis may be a social gradient of PSA testing in Germany.