Background
Surgery for catecholamine‐producing tumours can be complicated by intraoperative and postoperative haemodynamic instability. Several perioperative management strategies have emerged but ...none has been evaluated in randomized trials. To assess this issue, contemporary perioperative management and outcome data from 21 centres were collected.
Methods
Twenty‐one centres contributed outcome data from patients who had surgery for phaeochromocytoma and paraganglioma between 2000 and 2017. The data included the number of patients with and without α‐receptor blockade, surgical and anaesthetic techniques, complications and perioperative mortality.
Results
Across all centres, data were reported on 1860 patients with phaeochromocytoma or paraganglioma, of whom 343 underwent surgery without α‐receptor blockade. The majority of operations (78·9 per cent) were performed using minimally invasive techniques, including 16·1 per cent adrenal cortex‐sparing procedures. The cardiovascular complication rate was 5·0 per cent overall: 5·9 per cent (90 of 1517) in patients with preoperative α‐receptor blockade and 0·9 per cent (3 of 343) among patients without α‐receptor blockade. The mortality rate was 0·5 per cent overall (9 of 1860): 0·5 per cent (8 of 517) in pretreated and 0·3 per cent (1 of 343) in non‐pretreated patients.
Conclusion
There is substantial variability in the perioperative management of catecholamine‐producing tumours, yet the overall complication rate is low. Further studies are needed to better define the optimal management approach, and reappraisal of international perioperative guidelines appears desirable.
Antecedentes
La cirugía de los tumores productores de catecolaminas puede complicarse por la inestabilidad hemodinámica intraoperatoria y postoperatoria. Se han propuesto distintas estrategias de manejo perioperatorio, pero ninguna ha sido evaluada en ensayos aleatorizados. Para evaluar este tema, se han recogido los datos de los resultados y del manejo perioperatorio contemporáneo de 21 centros.
Métodos
Veintiún centros aportaron datos de los resultados de los pacientes operados por feocromocitoma y paraganglioma entre 2000‐2017. Los datos incluyeron el número de pacientes con y sin bloqueo del receptor α, las técnicas quirúrgicas y anestésicas, las complicaciones y la mortalidad perioperatoria.
Resultados
Los centros en su conjunto aportaron datos de 1.860 pacientes con feocromocitoma y paraganglioma, de los cuales 343 pacientes fueron intervenidos sin bloqueo del receptor α. La gran mayoría (79%) de las cirugías se realizaron utilizando técnicas mínimamente invasivas, incluido un 17% de procedimientos con preservación de la corteza suprarrenal. La tasa de complicaciones cardiovasculares fue de 5,0% en total; 5,9% (90/1517) en pacientes con bloqueo preoperatorio de los receptores α y 0,9% (3/343) en pacientes no pretratados. La mortalidad global fue del 0,5% (9/1860); 0,5% (8/1517) en pacientes pretratados y 0,3% (1/343) en pacientes no tratados previamente.
Conclusión
Existe una variabilidad sustancial en el manejo perioperatorio de los tumores productores de catecolaminas, aunque la tasa global de complicaciones es baja. Este estudio brinda la oportunidad para efectuar comparaciones sistemáticas entre estrategias de prácticas terapéuticas variables. Se necesitan más estudios para definir mejor el enfoque de manejo óptimo y parece conveniente volver a evaluar las guías internacionales perioperatorias.
Morbidity and mortality rates are difficult to determine in rare diseases like phaeochromocytoma. To date there has been no randomized study of the perioperative management of these patients. Therefore, an international and interdisciplinary effort was made to provide a broad overview of the current management of phaeochromocytoma.
Adverse effects frequent with preoperative blocking
Purpose
To examine national treatment trends of muscle-invasive bladder cancer (MIBC) in Germany with a special focus on radical cystectomy (RC).
Patients and methods
Population-based data were ...derived from the nationwide hospital billing database of the German Federal Statistical Office and institution-related information from the reimbursement.INFO tool based on hospitals’ quality reports from 2006 to 2019. Additionally, we used the German National Center for Cancer Registry data to analyze all cases of bladder cancer with stage ≥ T2 who received RC, chemotherapy, radiation therapy or a combination from 2006 to 2017.
Results
The annual number of RC cases in Germany increased by 28% from 5627 cases in 2006 to 7292 cases in 2019 (
p
= 0.001). The proportion of patients undergoing RC remained constant at about 75% in all age groups between 2006 and 2017 (
p
= 0.3). Relative to all performed RC, the proportion of patients > 75 years increased from 25% in 2006 to 38% in 2019 (
p
= 0.03). The proportion of patients receiving a combination of RC and chemotherapy increased from 9% in 2006 to 13% in 2017 (
p
= 0.005). In 2006, 8 of 299 urology departments (2.7%) performed more than 50 RCs per year, which increased to 17 of 360 (4.7%) in 2019. In 2019, 107 departments (29%) performed 25–49 RCs and 236 (66%) departments performed < 25 RCs.
Conclusion
In Germany, three out of four patients with MIBC receive RC and the proportion of patients > 75 years is increasing. The combination of surgery and chemotherapy is increasingly used. With overall increasing case numbers, there is a slight tendency towards centralization.
Different patients want to take different roles in the treatment decision-making process; these roles can be classified as passive, collaborative, and active. The aim of this study was to investigate ...the correlation between decision-making preferences among patients with prostate cancer and personal, disease-related, and structural factors. In four survey studies, we asked 7169 prostate cancer patients about their decision-making preferences using the Control Preferences Scale (CPS) and collected clinical, psychological, and quality-of-life measures. Most patients (62.2%) preferred collaborative decision-making, while 2322 (32.4%) preferred an active role, and only 391 (5.5%) preferred a passive role. Age (
p
< 0.001), data collection mode (
p
< 0.001), peer-to-peer support (
p
= 0.018), treatment status (
p
< 0.001), performed or planned radical prostatectomy (
p
< 0.001), metastatic disease (
p
= 0.001), and quality of life (
p
< 0.001) showed significant associations with patients’ preferred decision-making roles. Oncologic risk group, anxiety, and depression were not significant in the model. In particular, younger prostate cancer patients with higher quality of life completing an online survey want to play a more active role in treatment decision-making. Before treatment has started, patients tend to prefer collaborative decision-making. Few prostate cancer patients in Germany prefer a passive role. These patients are mostly older patients, patients with a metastatic disease, and patients who have opted for prostatectomy. Whether this finding reflects a generational effect or a tendency by age group and disease phase should be investigated. Further research is also needed to describe the causalities of these relationships. The CPS offers valuable information for personal counselling and should be applied in clinical routine. In a large group of patients with prostate cancer, we found that there is a strong desire for joint decision-making with the physician before the actual treatment. Especially younger men, men with active online behaviour, and men with a high quality of life want to be actively involved in therapy decision-making processes.
To assess trends in the distribution of patients for radical prostatectomy in Germany from 2006 to 2013 and the impact of robotic surgery on annual caseloads. We hypothesized that the advent of ...robotics and the establishment of certified prostate cancer centers caused centralization in the German radical prostatectomy market.
Using remote data processing we analyzed the nationwide German billing data from 2006 to 2013. We supplemented this database with additional hospital characteristics like the prostate cancer center certification status. Inclusion criteria were a prostate cancer diagnosis combined with radical prostatectomy. Hospitals with certification or a surgical robot in 2009 were defined as 'early' group. Linear covariant-analytic models were applied to describe trends over time.
Annual radical prostatectomy numbers declined from 28 374 (2006) to 21 850 (2013). High-volume hospitals (⩾100 cases) decreased from 87 (22.0%) in 2006 to 43 (10.4%) in 2013. Low-volume hospitals (<50 cases) increased from 193 (48.7%) to 280 (67.4%). Mean radical prostatectomy caseloads of hospitals with early vs without certification declined from 155 to 130 vs 77 to 39 (P=0.021 for trend comparison). Early robotic hospitals maintained their volume >200 cases per year contrary to the overall trend (P<0.001 for trend comparison). A multivariate model for caseload numbers of 2013 indicated a robotic system to be the most important factor for higher caseloads (multiplication factor 7.3; 95% confidence interval: 6.6-8.0). A prostate cancer center certification (multiplication factor 1.6; 95% confidence interval: 1.50-1.59) had a much smaller impact.
We found decentralization of radical prostatectomy in Germany. The driving force for this development might consist in the overall decline of radical prostatectomy numbers. The most important factor for achieving higher caseloads was the presence of a robotic system. In order to optimize outcomes of radical prostatectomy additional health policy measures might be necessary.
Summary
The Internet is an important source of health information with relevant impact on the physician–patient relationship. The German urological associations host one of the most comprehensive ...platforms for patient information on urological diseases. The aim of the study was to characterise its users and their specific needs. We invited users of the website www.urologenportal.de via pop‐up to complete a 26‐item online survey to evaluate health‐related behaviour, distress and decision‐making preferences. We received n = 551 complete responses. The most frequently requested topics were from the field of andrology (45.4%, n = 250). Of these, the most popular topics were circumcision (28.9%, n = 159) and erectile dysfunction (18.1%; n = 100). Overall, 216 users (39.2%) searched for information prior to their first doctor's appointment, and 89.3% (n = 492) preferred autonomous or shared decision‐making. Users seeking information on circumcision were less frequently under urological treatment (p < .001), and more self‐determined regarding healthcare decisions (p = .01). Circumcision was the only information on the website, which received relevant critical comments. Andrology was the most frequently requested urological topic. The vast majority of patients wanted to take self‐determined healthcare decisions and searched for information prior to a doctor's appointment. This might have an impact on the physician–patient relationship and causes a high demand for good‐quality health information websites.
IntroductionPathophysiological conditions within the tumour microenvironment induce metabolic adaptations of cancer cells. These metabolic features correlating with aggressive tumour growth pattern ...and the relapse risk after radiotherapy. Beside glucose, fast-growing cancer cells consume glutamine for energy production. Within the presented project we investigated the potential of the glutamine metabolism as putative therapeutic target and predictive biomarker for an individualised radiotherapy of prostate cancer (PC) patients.Material and methodsGenome and metabolome analysis of radioresistant PC cells identified the glutamine metabolism as regulator for intrinsic sensitivity to irradiation. Radiosensitizing effects of glutamine deprivation, molecular targeting and genetic suppression of key enzymes were determined for clonogenic survival, DNA repair and sphere-formation ability to determine the cancer stem cell (CSC) potential in PC cell lines, primary culture models and ex vivo treated primary biopsies. Analysis of tumour growth after glutamine deprivation were performed in xenograft models. The intracellular level of the glutamine metabolism and tricarboxylic acid cycle metabolites, reactive oxygen species (ROS) and glutathione (GSH) were determined. The clinical validation of the identified metabolic biomarkers was carried out with the NanoString technology.Results and discussionsRadioresistant PC cells exhibit an accelerated glutaminolysis with enhanced α-ketoglutarate to succinate ratio. The elevated α-ketoglutarate is leading to GSH consumption, increased intracellular ROS level, modulated epigenetic regulators and induction of a CSC phenotype. Metabolic, chemical and genetic targeting of glutaminolysis results in the inhibition of mTOR signalling, enhanced endoplasmic reticulum stress and reduction of DNA repair. In combination with irradiation this targeting therapy is effectively radiosensitizing PC cells in vitro and in vivo. Moreover, the c-MYC gene expression, a key regulator of glutaminolysis, significantly correlates with the PSA-free survival after radiotherapy.ConclusionThis study shows that the enhanced glutaminolysis of PC cells is conferring resistance to radiotherapy. The therapeutic targeting of the glutamine metabolism is elevating the cytotoxic effects of irradiation. In addition, metabolic enzymes involved in the glutamine metabolism can be potentially used to predict clinical outcome of PC patients after radiotherapy.
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