We conducted a retrospective study on the long-term effect of mitotane treatment on testicular adrenal rest tumors (TARTs) in five adult patients with classic 21-hydroxylase deficiency. After 60 ...months of mitotane treatment, a decrease in adrenal steroids was observed in four patients. Testicular ultrasonography showed complete disappearance of TART in two patients, stabilization in two patients and a halving of TART volume in the remaining patient. Sperm count improved notably in two patients who had normal baseline inhibin B levels and small inclusions, thus enabling cryopreservation of the subjects' semen. Four years of follow-up of these two patients after the withdrawal of mitotane showed no recurrence of TART and persistent normal testicular function. In conclusion, mitotane could be used as a last resort in CAH patients in the cases of azoospermia associated with TARTs but normal inhibin B levels, as it can improve long-term endocrine and exocrine testicular function.
Abstract Context There is an ongoing debate about the factors that influence intravesical recurrence (IVR) after radical nephrouretectomy (RNU) to treat upper tract urothelial carcinoma (UTUC). ...Objective To assess significant predictors of IVR after RNU from a systematic review of the literature and meta-analysis. Evidence acquisition A computerized bibliographic search of the Medline, Embase, and Cochrane databases was performed for all reports that included detailed results of multivariate analyses on the predictors of IVR. According to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines, we selected 18 retrospective studies that each included more than 100 patients treated exclusively with RNU between 2007 and 2014. Cumulative analyses of available hazard ratios (HRs) and their corresponding 95% confidence intervals were conducted using R software to assess the potential predictors of IVR. Evidence synthesis Among the 8275 patients included, 2402 (29%) were diagnosed with IVR within a median time of 22.2 mo (range 6.7–56.5). Patient-specific predictors were as follows: male gender (HR 1.37; p < 0.001), previous bladder cancer (HR 1.96; p < 0.001), and preoperative chronic kidney disease (HR 1.87; p = 0.002). Tumor-specific predictors were as follows: positive preoperative urinary cytology (HR 1.56; p < 0.001), ureteral location (HR 1.27; p < 0.001), multifocality (HR 1.61; p = 0.002), invasive pT stage (HR 1.38; p < 0.001), and necrosis (HR 2.17; p = 0.02). Treatment-specific predictors were as follows: a laparoscopic approach (HR 1.62; p = 0.003), extravesical bladder cuff removal (HR 1.22; p = 0.02), and positive surgical margins (HR 1.90; p = 0.004). Conclusions A meta-analysis of available data identified significant predictors of IVR that should be systematically assessed to propose a risk-adapted approach to adjuvant intravesical instillation of chemotherapy and cystoscopic surveillance after RNU. Patient summary In this report, we looked at the factors linked to intravesical recurrence after radical nephroureterectomy to treat upper urinary tract urothelial carcinoma. We identified patient-, tumor- and treatment-specific characteristics that should be systematically assessed to guide postoperative decision-making.
Background
Accurate prostate zonal segmentation on magnetic resonance images (MRI) is a critical prerequisite for automated prostate cancer detection. We aimed to assess the variability of manual ...prostate zonal segmentation by radiologists on T2-weighted (T2W) images, and to study factors that may influence it.
Methods
Seven radiologists of varying levels of experience segmented the whole prostate gland (WG) and the transition zone (TZ) on 40 axial T2W prostate MRI images (3D T2W images for all patients, and both 3D and 2D images for a subgroup of 12 patients). Segmentation variabilities were evaluated based on: anatomical and morphological variation of the prostate (volume, retro-urethral lobe, intensity contrast between zones, presence of a PI-RADS ≥ 3 lesion), variation in image acquisition (3D vs 2D T2W images), and reader’s experience. Several metrics including Dice Score (DSC) and Hausdorff Distance were used to evaluate differences, with both a pairwise and a consensus (STAPLE reference) comparison.
Results
DSC was 0.92 (± 0.02) and 0.94 (± 0.03) for WG, 0.88 (± 0.05) and 0.91 (± 0.05) for TZ respectively with pairwise comparison and consensus reference. Variability was significantly (
p
< 0.05) lower for the mid-gland (DSC 0.95 (± 0.02)), higher for the apex (0.90 (± 0.06)) and the base (0.87 (± 0.06)), and higher for smaller prostates (
p
< 0.001) and when contrast between zones was low (
p
< 0.05). Impact of the other studied factors was non-significant.
Conclusions
Variability is higher in the extreme parts of the gland, is influenced by changes in prostate morphology (volume, zone intensity ratio), and is relatively unaffected by the radiologist’s level of expertise.
Although magnetic resonance imaging (MRI) is broadly implemented into active surveillance (AS) protocols, data on the reliability of serial MRI in order to help guide follow-up biopsy are ...inconclusive.
To assess the diagnostic estimates of serial prostate MRI for prostate cancer (PCa) progression during AS.
We systematically searched PubMed, Scopus, and Web of Science databases to select studies analyzing the association between changes on serial prostate MRI and PCa progression during AS. We included studies that provided data for MRI progression, which allowed us to calculate diagnostic estimates. We compared Prostate Cancer Radiological Estimation of Change in Sequential Evaluation (PRECISE) accuracy with institution-specific definitions.
We included 15 studies with 2240 patients. Six used PRECISE criteria and nine institution-specific definitions of MRI progression. The pooled PCa progression rate, which included histological progression to Gleason grade ≥2, was 27%. The pooled sensitivity and specificity were 0.59 (95% confidence interval CI 0.44–0.73) and 0.75 (95% CI 0.66–0.84) respectively. There was significant heterogeneity between included studies. Depending on PCa progression prevalence, the pooled negative predictive value for serial prostate MRI ranged from 0.81 (95% CI 0.73–0.88) to 0.88 (95% CI 0.83–0.93) and the pooled positive predictive value ranged from 0.37 (95% CI 0.24–0.54) to 0.50 (95% CI 0.36–0.66). There were no significant differences in the pooled sensitivity (p = 0.37) and specificity (p = 0.74) of PRECISE and institution-specific schemes.
Serial MRI still should not be considered a sole factor for excluding PCa progression during AS, and changes on MRI are not accurate enough to indicate PCa progression. There was a nonsignificant trend toward improved diagnostic estimates of PRECISE recommendations. These findings highlight the need to further define the optimal triggers and timing of biopsy during AS, as well as the need for optimizing the quality, interpretation, and reporting of serial prostate MRI.
Our study suggests that serial prostate magnetic resonance imaging (MRI) alone in patients on active surveillance is not accurate enough to reliably rule out or rule in prostate cancer progression. Other clinical factors and biomarkers along with serial MRI are required to safely tailor the intensity of follow-up biopsies.
Serial prostate magnetic resonance imaging (MRI) in patients on active surveillance is not accurate enough to reliably rule out or rule in prostate cancer progression. Prostate Cancer Radiological Estimation of Change in Sequential Evaluation (PRECISE) recommendations offer some improvements in serial MRI assessment; however, at present, other clinical factors along with serial MRI are required to safely tailor active surveillance and follow-up biopsies.
Purpose We analyzed all available studies assessing the management of node only recurrence after primary local treatment of prostate cancer. Materials and Methods We systematically reviewed the ...literature in January 2015 using the PubMed®, Web of Sciences and Embase® databases according to PRISMA guidelines. Studies exclusively reporting visceral or bone metastatic disease were excluded from analysis. Eight radiotherapy and 12 salvage lymph node dissection series were included in our qualitative study. Results All 248 radiotherapy and 480 salvage lymph node dissection studies were single arm case series including a total of 728 patients. Choline positron emission tomography/computerized tomography was the reference imaging technique for nodal recurrence detection. Globally 50% of patients remained disease-free after short-term followup. Nevertheless, approximately two-thirds of patients received adjuvant hormone therapy, leading an overestimation of prostate specific antigen-free survival rates obtained after salvage treatment. Combining radiotherapy with salvage lymph node dissection may improve oncologic control in the treated region without improving the outfield relapse risk or the prostate specific antigen response. Great heterogeneity among series in adjuvant treatments, endpoints, progression definitions and study populations made it difficult to assess the precise impact of salvage treatment on the prostate specific antigen response and compare outcomes between radiotherapy and salvage lymph node dissection series. Toxicity after radiotherapy or salvage lymph node dissection was acceptable without frequent high grade complications. The benefit of early hormone therapy as the only salvage treatment remains unknown. Conclusions Although a high level of evidence is currently missing to draw any strong conclusion, published clinical series show that in select patients salvage treatment directed to nodal recurrence could lead to good oncologic outcomes. Although the optimal timing of androgen deprivation therapy in this setting is still unknown, such an approach could delay time to systemic treatment with an acceptable safety profile. Future prospective trials are awaited to better clarify this potential impact on well-defined endpoints.
Purpose
To review the contemporary data on the role of lymph node dissection (LND) at the time of radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC).
Methods
A computerized ...bibliographic search using the following protocol (“Nephroureterectomy”) AND (“Lymphadenectomy” OR “Lymph node” OR “Lymphatic”) was performed in MEDLINE to identify all original and review articles that addressed the role of LND for UTUC.
Results
Regional lymph node (LN) boundaries of UTUC have been recently investigated in mapping studies to propose anatomic templates of LND according to the laterality and location of primary tumor. Although these anatomic templates remained poorly described, most reports supported the staging benefit of LND that allowed for risk stratification of patients with (pN+) or without (pN0) LN metastases from those who did not undergo such a procedure (pNx). In addition, the therapeutic benefit of LND at the time of RNU was supported by better oncological outcomes obtained after complete LND when compared to incomplete or no LND, especially in the group of patients with advanced disease. The number of LNs removed was also correlated with both, more accurate staging and greater cancer-specific survival after LND, whose feasibility and safety have been validated in prospective studies.
Conclusions
Despite mostly based on data with level of evidence 3, our comprehensive review of the literature supports the staging and therapeutic benefits of LND at the time of RNU for UTUC, which are particularly significant for patients with muscle-invasive or locally advanced disease.
Magnetic resonance imaging (MRI) is being increasingly used for imaging suspected recurrence in prostate cancer therapy. Functional MRI with diffusion and perfusion imaging has the potential to ...demonstrate local recurrence even at low PSA value. Detection of recurrence can modify the management of postprostatectomy biochemical recurrence. MRI scan acquired before salvage radiotherapy is useful for the localization of recurrent tumors and also in the delineation of the target volume. The objective of this review is to assess the role and potential impact of MRI in targeting local recurrence after surgery for prostate cancer in the setting of salvage radiation therapy.
Objectives
Accurate zonal segmentation of prostate boundaries on MRI is a critical prerequisite for automated prostate cancer detection based on PI-RADS. Many articles have been published describing ...deep learning methods offering great promise for fast and accurate segmentation of prostate zonal anatomy. The objective of this review was to provide a detailed analysis and comparison of applicability and efficiency of the published methods for automatic segmentation of prostate zonal anatomy by systematically reviewing the current literature.
Methods
A Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) was conducted until June 30, 2021, using PubMed, ScienceDirect, Web of Science and EMBase databases. Risk of bias and applicability based on Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) criteria adjusted with Checklist for Artificial Intelligence in Medical Imaging (CLAIM) were assessed.
Results
A total of 458 articles were identified, and 33 were included and reviewed. Only 2 articles had a low risk of bias for all four QUADAS-2 domains. In the remaining, insufficient details about database constitution and segmentation protocol provided sources of bias (inclusion criteria, MRI acquisition, ground truth). Eighteen different types of terminology for prostate zone segmentation were found, while 4 anatomic zones are described on MRI. Only 2 authors used a blinded reading, and 4 assessed inter-observer variability.
Conclusions
Our review identified numerous methodological flaws and underlined biases precluding us from performing quantitative analysis for this review. This implies low robustness and low applicability in clinical practice of the evaluated methods. Actually, there is not yet consensus on quality criteria for database constitution and zonal segmentation methodology.
Key points
Several limitations exist with current methods of automatic prostate segmentation.
There is wide variability of databases, imaging tasks and assessment criteria.
No preferred methodology for prostate zonal segmentation methodology and terminology was used.
Vast majority of papers share common methodological flaws discussed in this review.
Purpose We determined the cancer control provided by nephron sparing surgery for renal cell carcinoma greater than 4 cm. Materials and Methods We performed a retrospective review of data on patients ...treated between 1980 and 2005. The case characteristics analyzed were patient age, surgical procedure, intraoperative parameters, complications, tumor size, Fuhrman grade, TNM stage, pathological data and outcome. Kaplan-Meier survival curves were generated. Results Median age of the 61 patients was 64 years (range 40 to 83). Mean ± SD intraoperative blood loss was 622 ml ± 691 (range 50 to 4,800) and mean operative time was 155.7 ± 82 minutes (range 52 to 360). Mean creatinine preoperatively and immediately postoperatively was 1.16 and 1.25 mg/dl, respectively. Mean renal cell carcinoma size was 56.3 ± 18 mm (range 41 to 100). Margin status was positive in 11 cases (18%). Median followup was 70.7 months. The 5 and 10-year cancer specific survival rate was 81% and 78%, respectively. The tumor-free survival rate was 92% at 5 years and 88% at 10 years. On univariate analysis tumor size more than 7 cm (p = 0.002), pathological stage (p = 0.001) and Fuhrman grade (p = 0.004) were associated with survival. On multivariate analysis only pathological stage and Fuhrman grade were significant (p <0.0001 and 0.007, respectively). Conclusions Our results support the fact that nephron sparing surgery is a useful and acceptable approach to renal cell carcinoma greater than 4 cm. When technically possible, nephron sparing surgery provides acceptable long-term cancer specific survival rates. However, oncological safety is less evident in cases of renal cell carcinoma greater than 7 cm. To date in such cases nephron sparing surgery should only be considered for absolute indications.
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