•Report of late MRI findings after prostate HIFU hemiablation in non-recurrent patients.•Common were shrinkage, residual prostate tissue, fluid-filled cavities and fibrosis.•Considerable number of ...cases with rim-like or diffuse contrast enhancement.
Focal therapy with high-intensity focused ultrasound (HIFU) is an emerging option for the treatment of prostate cancer and often followed up by MRI. Image assessment of treatment failure, however, requires proper knowledge about typical procedure-related changes in prostate MRI, which is sparse, in particular for unilateral HIFU treatment and late follow up (beyond 6 months). The goal of this study was therefore to compile the type and frequency of such MRI findings in selected patients without recurrent cancer 12 months after prostate hemiablation.
Data from a prospective multicenter trial on HIFU hemiablation were reviewed retrospectively. Trial patients have had a late follow-up by MRI (at around 12 months) and either MRI/transrectal ultrasound (TRUS) fusion or standard TRUS-guided biopsy. This work deliberately included patients with non-recurrent cancer in the treated prostate lobe in per-protocol biopsy leaving 30 men with initial International Society of Urological Pathology (ISUP) Grade Group of 1 or 2. Six categories of potential HIFU-related MRI features were assessed by an expert committee and then evaluated by two readers in consensus: 1. shrinkage of the treated lobe, 2. residual prostate tissue, 3. fluid-filled cavity, 4. fibrosis, 5. hematoma residuals (in the prostate or seminal vesicles) and 6. contrast enhancement of the ablated area.
Shrinkage of the ablated lobe was seen in 93% of the cases with an average percent volume change of −37% (range: −70% to +108%). In the contralateral lobe, the volume remained practically the same (–2% on average, p = 0.804). In the ablated lobe, the frequency of fibrosis was 97%. Residual prostate tissue was seen in 93% of the cases. The frequency for fluid-filled cavities was 97%, with the wide majority (90%) contiguous with the urethra. Hematoma residuals in the prostate and in seminal vesicles were found in 47% and 10% of the patients, respectively. Contrast enhancement was both rim-like (50%) as well as diffuse (33%) within the ablated area.
In our case series of HIFU hemiablation in the prostate, shrinkage, residual prostate tissue, fluid-filled cavities contiguous with the urethra and fibrosis were very common late MRI findings of the ablated lobe in non-recurrent patients. Rim-like contrast enhancement or diffuse one within the ablated area were less frequent.
Purpose
To compare the oncological long-term efficacy of whole gland high-intensity focused ultrasound (HIFU) therapy and radical prostatectomy (RP) in patients with clinically localized prostate ...cancer.
Methods
418 patients after open RP (1997–2004) were compared with 469 patients after whole gland HIFU (1997–2009) without preselection. Oncological follow-up focused on biochemical relapse, salvage treatment, life status and cause-specific mortality. The univariate log rank test was used to compare both treatment options regarding overall survival (OS), cancer-specific survival (CSS), biochemical failure-free survival (BFS) and salvage treatment-free survival (STS). To adjust the treatment effect for further prognostic baseline variables, a multivariable Cox proportional hazards regression model was calculated for each end point.
Results
Median follow-up was 13.3 years in the RP group and 6.5 years in the HIFU group. OS/CSS/BFS/STS rates at 10 years were 91/98/80/80% after RP and 76/94/70/71% after HIFU. HIFU therapy (reference RP) was a significant and independent predictor for an inferior OS, CSS and STS. In subgroup analysis, HIFU provided significantly reduced CSS for intermediate- (
p
= 0.010) and high-risk patients (
p
= 0.048); whereas no difference was observed in the low-risk group, intermediate-risk HIFU patients showed a significantly inferior STS (
p
= 0.040).
Conclusions
While whole gland HIFU offers a comparable long-term efficacy for low-risk patients, sufficient cancer control for high-risk patients is more than doubtful. For the subgroup of intermediate-risk patients, CSS rates seem to be comparable up to 10 years suggesting that HIFU may be an alternative for older patients, although a higher risk of salvage treatment should be expected.
Acute focal bacterial nephritis (AFBN) is a rare disease currently described only in case reports and small case series. In this study we summarize the clinical features of AFBN as has been ...documented in the literature and draw recommendations on the proper diagnosis and therapy.
A systematic literature review was undertaken in PUBMED, Web of Science and The Cochrane Library online databases for relevant literature on AFBN in adults.
Literature review revealed a total of 38 articles according to our inclusion criteria, of which we could extract data from 138 cases of AFBN. Fever (98%) and flank pain (80%) were most commonly reported symptoms. E. coli was the most frequent pathogen. Diagnosis was set by CT and/or MRI (52%) with or without sonography or by sonography alone (20%) as well as by sonography combined with IVU. In total, sonography was applied in 83% of cases. All but one patient received antibiotic treatment. Kidney lesions were occasionally mistaken for neoplasms or renal abscesses and as a result, cases were subjected to percutaneous puncture (12.3%), surgical exploration (5.1%) and partial or radical nephrectomy (4.4%). Four cases (2.9%) developed a renal abscess.
The diagnosis of AFBN is set by characteristic clinico-radiological findings. Differential diagnoses of this interstitial bacterial infection include renal abscess and tumor. Correct diagnosis is occasionally impeded by atypical symptoms. Invasive diagnostic and therapeutic procedures should be limited as the majority of cases respond well to conservative treatment.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Previously, we described prostate cancer (PCa) detection (83% sensitivity; 67% specificity) in seminal plasma by CE-MS/MS. Moreover, advanced disease was distinguished from organ-confined tumors with ...80% sensitivity and 82% specificity. The discovered biomarkers were naturally occurring fragments of larger seminal proteins, predominantly semenogelin 1 and 2, representing endpoints of the ejaculate liquefaction. Here we identified proteases putatively involved in PCa specific protein cleavage, and examined gene expression and tissue protein levels, jointly with cell localization in normal prostate (nP), benign prostate hyperplasia (BPH), seminal vesicles and PCa using qPCR, Western blotting and confocal laser scanning microscopy. We found differential gene expression of chymase (CMA1), matrix metalloproteinases (MMP3, MMP7), and upregulation of MMP14 and tissue inhibitors (TIMP1 and TIMP2) in BPH. In contrast tissue protein levels of MMP14 were downregulated in PCa. MMP3/TIMP1 and MMP7/TIMP1 ratios were decreased in BPH. In seminal vesicles, we found low-level expression of most proteases and, interestingly, we also detected TIMP1 and low levels of TIMP2. We conclude that MMP3 and MMP7 activity is different in PCa compared to BPH due to fine regulation by their inhibitor TIMP1. Our findings support the concept of seminal plasma biomarkers as non-invasive tool for PCa detection and risk stratification.
Purpose Studies of male pelvic neuroanatomy are mandatory to improve functional outcome after radical prostatectomy. We performed a topographical investigation of nerves on the course from the ...seminal vesicles along the prostate toward the striated urethral sphincter. Materials and Methods Serial whole mount sections (1 mm intervals) of pelvic blocks of human adult male autopsy cadavers were investigated after immunohistochemical nerve staining. Computerized nerve quantification and planimetry of the total nerve surface area were performed within defined regions (ventral, ventrolateral, dorsolateral and dorsal) at the levels of the seminal vesicles and prostate, and at the striated urethral sphincter. The distance between the seminal vesicles and the nerves was measured. For improved topographical understanding 3-dimensional reconstructions were created. Differences between 3 independent variables were tested with the nonparametric Kruskal-Wallis test. Results We studied a total of 969 whole mount sections of 5 cadavers. Nerves were arranged in a vertical plate lateral to the seminal vesicles. Mean ± SD distance to the seminal vesicles was 1.68 ± 0.84, 1.50 ± 0.12 and 1.76 ± 0.37 mm at the tip, middle and base, respectively. Periprostatic nerves were mainly found dorsolaterally. At the striated urethral sphincter 38.9% of nerves had shifted to the dorsal region. The total nerve surface area decreased significantly from the seminal vesicle tip (50.2 mm2 ) to the striated urethral sphincter level (13.3 mm2 ) (p = 0.0004). Conclusions Our findings underline that during nerve sparing prostatectomy nerve damage might occur during mobilization of the entire seminal vesicles, apical dissection and posterior reconstruction of the rhabdosphincter. Nerve planimetry revealed that 75% of the nerves from the seminal vesicles do not reach the striated urethral sphincter level and seem to innervate structures other than the corpora cavernosa.
OBJECTIVES
To compare the specificity and sensitivity of different definitions of biochemical failure in patients treated with high‐intensity focused ultrasound (HIFU) for prostate cancer, to ...identify the most accurate predictor of clinical failure after HIFU.
PATIENTS AND METHODS
Consecutively treated patients who underwent HIFU between October 1997 and July 2006 at two centres (Lyon, France; and Regensburg, Germany) were prospectively maintained within a central database and retrospectively reviewed for this study. Clinical failure was defined as a positive prostate biopsy after treatment, radiographic evidence of lymphatic or bony metastatic disease, or salvage treatment for prostate cancer (surgery, radiation, hormonal therapy or second HIFU). The serum prostate‐specific antigen (PSA) values after HIFU were assessed as a biochemical surrogate of a therapeutic success or failure. PSA threshold values, ‘PSA nadir plus’, PSA velocity, PSA doubling time and the American Society or Therapeutic Radiotherapy and Oncology and Phoenix definition of biochemical failure were all considered. The sensitivity, specificity, positive predictive value and negative predictive value of each biochemical definition for predicting clinical failure were determined.
RESULTS
The data from 285 patients (stage ≤ T2, PSA <15 ng/mL, Gleason score ≤7) were analysed. The median (range) follow‐up was 4.7 (2–10.9) years. The median PSA nadir was 0.13 ng/mL, which occurred at a median of 12.9 weeks after HIFU, and the median PSA at the last follow‐up was 0.76 (1.6–2.7) ng/mL. Clinical failure occurred in 71 patients (25%); 24 due to a positive biopsy and 47 through the use of an additional therapy. Biochemical events that best predicted clinical failure were ‘PSA nadir plus’ values of 1.1–1.3 ng/mL, PSA velocities of <0.3 ng/mL/year and PSA doubling times of 1.25–1.75 years.
CONCLUSION
A new definition of biochemical failure that is specific to patients treated with HIFU therapy is established, i.e. the ‘Stuttgart definition’, the ‘PSA nadir plus 1.2 ng/mL’.
Owing to the morbidity of established radical treatment options for prostate cancer, alternative whole-gland and focal treatment strategies have emerged. High-intensity focused ultrasound (HIFU) is ...one of the most studied sources for tissue ablation and has been used since the 1990s.
To provide 21-yr oncological long-term follow-up data of an unselected series of patients who underwent whole-gland HIFU for nonmetastatic prostate cancer.
A total of 674 patients were treated between November 1997 and November 2012 in one university center.
The oncological outcome was assessed by biopsy failure–free survival (BFFS), salvage treatment–free survival (STFS), metastasis-free survival (MFS), cancer-specific survival (CSS), and overall survival (OS). Multivariable Cox proportional hazard regression analyses were performed to estimate the prognostic relevance of clinical variables.
In total, 560 patients were included into the evaluation and the median follow-up was 15.1 yr, with a range up to 21.4 yr. At 15 yr, CSS rates for low-, intermediate-, and high-risk patients were 95%, 89%, and 65%, respectively; MFS, STFS-1 (salvage treatment other than HIFU), STFS-2 (salvage treatment including repeat HIFU), and BFFS rates were 91%, 85%, and 58%; 77%, 63%, and 29%; 67%, 52%, and 28%; and 82%, 73%, and 47%, respectively. Preoperative high-risk category was an independent predictor of inferior OS, CSS, MFS, STFS, and BFFS.
Although whole-gland HIFU achieved good long-term cancer control in low- and intermediate-risk patients, high-risk patients should not be treated routinely by HIFU. Intermediate-risk patients achieve high CSS and MFS rates, but a relevant salvage treatment rate has to be reckoned with. Long-term data after whole-gland therapy might help derive implications for focal treatment sources and patient selection.
Long-term data after whole-gland high-intensity focused ultrasound (HIFU) therapy are crucial to prove its oncological efficacy, and may help derive implications for focal treatment strategies and patient selection. In this context, whole-gland HIFU achieved good long-term cancer control up to 21 yr in low- and intermediate-risk prostate cancer (PCa) patients. Owing to considerably inferior long-term cancer control, it should not routinely be used in high-risk PCa patients.
While high-intensity focused ultrasound (HIFU) achieved good long-term cancer control in low- and intermediate-risk patients, its performance in high-risk patients was considerably inferior and such patients should not be treated routinely by HIFU. In intermediate-risk patients, a relevant risk of salvage treatment has to be expected.
Multiple laser systems for the treatment of benign prostatic hyperplasia (BPH) have been introduced. Current laser systems have limitations due to their laser physics. The RevoLix laser combines the ...advantages of the Holmium:YAG laser with the comfort of a continuous wave (cw) laser beam. This study reports the preliminary results of vaporesection (simultaneous vaporization and resection) of the prostate, using the 2 microm cw laser. A total of 54 consecutive patients were treated with the 70 W RevoLix laser for BPH. The mean age was 61 years. Mean prostate volume was 30.3 cc. A 550 microm RigiFib bare-ended fiber was used in combination with a 26 French laser resectoscope. Measured outcomes were resection time, decrease in hemoglobin and transfusion rate. Furthermore, the catheter time, improvement in the urinary flow rate (Q(max)), post-voiding residual urine (PVR), International Prostate Symptom Score (IPSS) and Quality of Life Index (QoL) were recorded. Average resection time was 52 min. After crossing the learning curve, a tissue ablation of 1.5 g/min was possible. Transfusions were not necessary in any patient. Catheter time was 1.7 days. Q(max) significantly improved from 4.2 to 20.1 ml on average. PVR decreased from 86 to 12 ml. IPSS and QoL-Score improved from 19.8 to 6.9 and 4 to 1, respectively. No patient required re-hospitalization. These preliminary results indicate that RevoLix vaporesection of the prostate is safe and efficient. One-year follow-up data showed a significant improvement in voiding symptoms and patients' quality of life. A longer follow-up is needed to prove the durability of these promising results.
Objective To compare the outcome of intrafascial nerve-sparing endoscopic extraperitoneal radical prostatectomy (nsEERPE) with interfascial (standard) nsEERPE. Methods Four-hundred patients underwent ...nsEERPE; 200 patients underwent bilateral intrafascial nsEERPE (group A) and 200 bilateral standard nsEERPE (group B). Tumor stages of T1 and T2a, prostate-specific antigen level <10 ng/mL, maximal Gleason score 3+4 (not 4+3) and preoperative potency were considered as candidates for nsEERPE. Patients were randomized to the aforementioned groups. Perioperative data, and functional and oncological outcome were reviewed. Patients not requiring any pads or requiring 1 pad for safety were defined as continent. Patients responding positively to sexual encounter profile diary question numbers 2, 3, and 5 were considered as potent. Results Perioperative data were similar between groups. At 3 months, 74% of group A and and 63% of group B were continent. At 6 months, the respective figures were 87.9% and 76.2%, respectively (A, B). At 12 months, 93.2% of group A and 90.7% of group B were continent. Potency rates of group A were 93.5% (<55 years), 83.3% (55-65 years), and 60% (>65 years) at 12 months. The respective figures for Group B were 77.1%, 50%, and 40%. Positive surgical margins were detected in 9% and 9.5% of groups A and B, respectively. Conclusions Intrafascial nsEERPE provides significantly better potency in patients <55 years of age at 12 months and in patients 55-65 years of age at 6 and 12 months, with probably limited effect on the oncological outcome. Significantly improved continence was observed at 3 and 6 months in favor of intrafascial nsEEPRE.
PDF
