Abstract Background Most early stage kidney cancers are renal cell carcinomas (RCCs), and most are diagnosed incidentally by imaging as small renal masses (SRMs). Indirect evidence suggests that most ...small RCCs grow slowly and rarely metastasize. Objective To determine the progression and growth rates for newly diagnosed SRMs stratified by needle core biopsy pathology. Design, setting, and participants A multicenter prospective phase 2 clinical trial of active surveillance of 209 SRMs in 178 elderly and/or infirm patients was conducted from 2004 until 2009 with treatment delayed until progression. Intervention Patients underwent serial imaging and needle core biopsies. Measurements We measured rates of change in tumor diameter (growth measured by imaging) and progression to ≥4 cm, doubling of tumor volume, or metastasis with histology on biopsy. Results and limitations Local progression occurred in 25 patients (12%), plus 2 progressed with metastases (1.1%). Of the 178 subjects with 209 SRMs, 127 with 151 SRMs had > 12 mo of follow-up with two or more images, with a mean follow-up of 28 mo. Their tumor diameters increased by an average of 0.13 cm/yr. Needle core biopsy in 101 SRMs demonstrated that the presence of RCC did not significantly change growth rate. Limitations included no central review of imaging and pathology and a short follow-up. Conclusions This is the first SRM active surveillance study to correlate growth with histology prospectively. In the first 2 yr, the rate of local progression to higher stage is low, and metastases are rare. SRMs appear to grow very slowly, even if biopsy proven to be RCC. Many patients with SRMs can therefore be initially managed conservatively with serial imaging, avoiding the morbidity of surgical or ablative treatment.
Purpose Recently, a new renal cell cancer syndrome has been linked to germline mutation of multiple subunits ( SDHB / C / D ) of the Krebs cycle enzyme, succinate dehydrogenase. We report our ...experience with the diagnosis, evaluation and treatment of this novel form of hereditary kidney cancer. Materials and Methods Patients with suspected hereditary kidney cancer were enrolled on a National Cancer Institute institutional review board approved protocol to study inherited forms of kidney cancer. Individuals from families with germline SDHB , SDHC and SDHD mutations, and kidney cancer underwent comprehensive clinical and genetic evaluation. Results A total of 14 patients from 12 SDHB mutation families were evaluated. Patients presented with renal cell cancer at an early age (33 years, range 15 to 62), metastatic kidney cancer developed in 4 and some families had no manifestation other than kidney tumors. An additional family with 6 individuals found to have clear cell renal cell cancer that presented at a young average age (47 years, range 40 to 53) was identified with a germline SDHC mutation (R133X) Metastatic disease developed in 2 of these family members. A patient with a history of carotid body paragangliomas and an aggressive form of kidney cancer was evaluated from a family with a germline SDHD mutation. Conclusions SDH mutation associated renal cell carcinoma can be an aggressive type of kidney cancer, especially in younger individuals. Although detection and management of early tumors is most often associated with a good outcome, based on our initial experience with these patients and our long-term experience with hereditary leiomyomatosis and renal cell carcinoma, we recommend careful surveillance of patients at risk for SDH mutation associated renal cell carcinoma and wide surgical excision of renal tumors.
Most reports of active surveillance (AS) of small renal masses (SRMs) lack biopsy confirmation, and therefore include benign tumors and different subtypes of renal cell carcinoma (RCC).
We compared ...the growth rates and progression of different histologic subtypes of RCC SRMs (SRMRCC) in the largest cohort of patients with biopsy-characterized SRMs on AS.
Data from patients in a multicenter Canadian trial and a Princess Margaret cohort were combined to include 136 biopsy-proven SRMRCC lesions managed by AS, with treatment deferred until progression or patient/surgeon decision.
Growth curves were estimated from serial tumor size measures. Tumor progression was defined by sustained size ≥4 cm or volume doubling within 1 yr.
Median follow-up for patients who remained on AS was 5.8 yr (interquartile range 3.4–7.5 yr). Clear cell RCC SRMs (SRMccRCC) grew faster than papillary type 1 SRMs (0.25 and 0.02 cm/yr on average, respectively, p = 0.0003). Overall, 60 SRMRCC lesions progressed: 49 (82%) by rapid growth (volume doubling), seven (12%) increasing to ≥4 cm, and four (6.7%) by both criteria. Six patients developed metastases, and all were of clear cell RCC histology. Limitations include the use of different imaging modalities and a lack of central imaging review.
Tumor growth varies between histologic subtypes of SRMRCC and among SRMccRCC, which likely reflects individual host and tumor biology. Without validated biomarkers that predict this variation, initial follow-up of histologically characterized SRMs can inform personalized treatment for patients on AS.
Many small kidney cancers are suitable for surveillance and can be monitored over time for change. We demonstrate that different types of kidney cancers grow at different rates and are at different risks of progression. These results may guide better personalized treatment.
Tumor growth varies within and between histological subtypes of small renal masses (renal cell carcinomas), which likely reflects individual host and tumor biology. Histology-specific growth rates and initial monitoring of small renal masses can inform personalized treatment for patients on active surveillance.
Abstract Background The optimum treatment of prostate cancer recurrence following radiation therapy (RT) remains controversial due to the lack of long-term data. Objective Our aim was to review the ...survival of patients who underwent salvage cryotherapy to the prostate gland for biopsy-proven recurrent prostate cancer and establish prognostic indicators. Design, setting, and participants A retrospective analysis was performed on all patients undergoing salvage cryotherapy at an academic urology unit for biopsy-proven locally recurrent prostate cancer after RT from 1995 to 2004. Patients’ preoperative, perioperative, and postoperative data were reviewed and recorded. Intervention Two freeze-thaw cycles of transperineal cryotherapy were performed under transrectal ultrasound guidance by a single surgeon. Measurements The primary outcome was survival. Secondary outcomes were disease-free survival (DFS), metastasis-free survival, and progression to androgen-deprivation therapy. Results and limitations Of 187 patients, 176 had records available for follow-up (follow-up rate: 94%). Mean follow-up was 7.46 yr (range: 1–14 yr). Fifty-two patients were followed for >10 yr. DFS at 10 yr was 39%. Risk factors for recurrence were presalvage prostate-specific antigen (PSA), preradiation, and presalvage Gleason score. A PSA nadir >1.0 ng/dl was highly predictive of early recurrence. Conclusions Salvage cryotherapy led to an acceptable 10-yr DFS. Presalvage PSA and Gleason score were the best predictors of disease recurrence. A PSA nadir >1 ng/dl following cryotherapy indicated a poor prognosis, and recurrence of disease was universal in these patients.
Today's surgical practice has evolved, with increasing emphasis on quality assurance. Many forms of quality-control monitoring have been suggested, but they are often impractical or difficult to ...implement. Cumulative summation (CUSUM) is a simple method to provide visual feedback before significant quality issues arise. We present our initial use and practical application of CUSUM in a surgical practice.
A retrospective analysis was applied to a prospectively collected database of 577 sequential patients who have undergone robot-assisted radical prostatectomy from a single surgeon over a 10-year period. Outcome measures were analyzed with CUSUM, which included a composite complication score, continence rates, length of hospital stay, biochemical recurrence, and need for adjuvant radiation. If any outcomes were out of control, they would cross the CUSUM failure line.
CUSUM chart-plotting for incontinence demonstrated an initial upward slope followed by trending to a new safety limit. Additionally, outcomes in complications and biochemical recurrence did not reach the established safety boundaries. Length of stay and radiation outcomes did initially cross the safety line, but were improved over time.
The use of CUSUM in clinical practice can fulfill the need for quality assurance. CUSUM plotting in our practice reflected the initial learning curve, followed by ongoing maintenance and improvement in performance. These changes were consistent with the implementation of changes in surgical techniques. Although this tool was used retrospectively, this strengthens our argument to implement the tool prospectively and assess real-time refinement of surgeon skill. We have demonstrated that CUSUM can be appropriately used to assure quality control in a surgical practice.
Vision-Based Surgical Field Defogging Xiongbiao Luo; McLeod, A. Jonathan; Pautler, Stephen E. ...
IEEE transactions on medical imaging,
10/2017, Letnik:
36, Številka:
10
Journal Article
Fogged surgical field visualization that is a common and potentially harmful problem can lead to inappropriate device use and incorrectly targeted tissue and increase surgical risks in endoscopic ...surgery. This paper aims to remove fog or smoke on endoscopic video sequences to augment and maintain a direct and clear visualization of the operating field. A new visibility-driven fusion defogging framework is proposed for surgical endoscopic video processing. This framework first recovers the visibility and enhances the contrast of hazy images. To address the color infidelity problem introduced by the visibility recovery, the luminances of the recovered and enhanced images are fused in the gradient domain, and the fused luminance is reconstructed by solving the Poisson equation in the frequency domain. The proposed method is evaluated on clinical videos that were collected from prostate cancer surgery. The experimental results demonstrate that the proposed framework defogs endoscopic images more robustly than currently available methods. Additionally, our method also provides an effective way to improve the visual quality of medical or high-dynamic range images.
Associations between procedure volumes and outcomes can inform minimum volume standards and the regionalization of health services. Robot-assisted surgery continues to expand globally; however, data ...are limited regarding which hospitals should be using the technology.BACKGROUNDAssociations between procedure volumes and outcomes can inform minimum volume standards and the regionalization of health services. Robot-assisted surgery continues to expand globally; however, data are limited regarding which hospitals should be using the technology.Using administrative health data for all residents of Ontario, Canada, this retrospective cohort study included adult patients who underwent a robot-assisted radical prostatectomy (RARP), total robotic hysterectomy (TRH), robot-assisted partial nephrectomy (RAPN), or robotic portal lobectomy using 4 arms (RPL-4) between January 2010 and September 2021. Associations between yearly hospital volumes and 90-day major complications were evaluated using multivariable logistic regression models adjusted for patient characteristics and clustering at the level of the hospital.STUDY DESIGNUsing administrative health data for all residents of Ontario, Canada, this retrospective cohort study included adult patients who underwent a robot-assisted radical prostatectomy (RARP), total robotic hysterectomy (TRH), robot-assisted partial nephrectomy (RAPN), or robotic portal lobectomy using 4 arms (RPL-4) between January 2010 and September 2021. Associations between yearly hospital volumes and 90-day major complications were evaluated using multivariable logistic regression models adjusted for patient characteristics and clustering at the level of the hospital.A total of 10,879 patients were included, with 7567, 1776, 724, and 812 undergoing a RARP, TRH, RAPN, and RPL-4, respectively. Yearly hospital volume was not associated with 90-day complications for any procedure. Doubling of yearly volume was associated with a 17-min decrease in operative time for RARP (95% confidence interval CI - 23 to - 10), 8-min decrease for RAPN (95% CI - 14 to - 2), 24-min decrease for RPL-4 (95% CI - 29 to - 19), and no significant change for TRH (- 7 min; 95% CI - 17 to 3).RESULTSA total of 10,879 patients were included, with 7567, 1776, 724, and 812 undergoing a RARP, TRH, RAPN, and RPL-4, respectively. Yearly hospital volume was not associated with 90-day complications for any procedure. Doubling of yearly volume was associated with a 17-min decrease in operative time for RARP (95% confidence interval CI - 23 to - 10), 8-min decrease for RAPN (95% CI - 14 to - 2), 24-min decrease for RPL-4 (95% CI - 29 to - 19), and no significant change for TRH (- 7 min; 95% CI - 17 to 3).The risk of 90-day major complications does not appear to be higher in low volume hospitals; however, they may not be as efficient with operating room utilization. Careful case selection may have contributed to the lack of an observed association between volumes and complications.CONCLUSIONThe risk of 90-day major complications does not appear to be higher in low volume hospitals; however, they may not be as efficient with operating room utilization. Careful case selection may have contributed to the lack of an observed association between volumes and complications.
Introduction
Robotic surgery has integrated into the healthcare system despite limited evidence demonstrating its clinical benefit. Our objectives were (i) to describe secular trends and (ii) ...patient- and system-level determinants of the receipt of robotic as compared to open or laparoscopic surgery.
Methods
This population-based retrospective cohort study included adult patients who, between 2009 and 2018 in Ontario, Canada, underwent one of four commonly performed robotic procedures: radical prostatectomy, total hysterectomy, thoracic lobectomy, partial nephrectomy. Patients were categorized based on the surgical approach as robotic, open, or laparoscopic for each procedure. Multivariable regression models were used to estimate the temporal trend in robotic surgery use and associations of patient and system characteristics with the surgical approach.
Results
The cohort included 24,741 radical prostatectomy, 75,473 total hysterectomy, 18,252 thoracic lobectomy, and 4608 partial nephrectomy patients, of which 6.21% were robotic. After adjusting for patient and system characteristics, the rate of robotic surgery increased by 24% annually (RR 1.24, 95%CI 1.13–1.35): 13% (RR 1.13, 95%CI 1.11–1.16) for robotic radical prostatectomy, 9% (RR 1.09, 95%CI 1.05–1.13) for robotic total hysterectomy, 26% (RR 1.26, 95%CI 1.06–1.50) for thoracic lobectomy and 26% (RR 1.26, 95%CI 1.13–1.40) for partial nephrectomy. Lower comorbidity burden, earlier disease stage (among cancer cases), and early career surgeons with high case volume at a teaching hospital were consistently associated with the receipt of robotic surgery.
Conclusion
The use of robotic surgery has increased. The study of the real-world clinical outcomes and associated costs is needed before further expanding use among additional providers and hospitals.
Birt-Hogg-Dubé syndrome (BHDS) is an autosomal, dominantly inherited genodermatosis that predisposes to fibrofolliculomas, kidney neoplasms, lung cysts, and spontaneous pneumothorax.
We evaluated 198 ...patients from 89 families with BHDS to characterize the risk factors for pneumothorax and genotype-pulmonary associations.
Helical computed tomography scans of the chest were used to screen for pulmonary abnormalities. BHD mutation data were used for genotype-pulmonary associations. We examined the relationship of pneumothorax with categorical parameters (sex, smoking history, and lung cysts) and continuous parameters (number of cysts, lung cyst volume, and largest cyst diameter and volume). Logistic regression analyses were used to identify the risk factors associated with pneumothorax.
Twenty-four percent (48/198) of patients with BHDS had a history of pneumothorax. The presence of lung cysts was significantly associated with pneumothorax (p = 0.006). Total lung cyst volume, largest cyst diameter and volume, and every parameter related to the number of lung cysts were significantly associated (p < 0.0001) with pneumothorax. A logistic regression analysis showed that only the total number of cysts in the right parenchymal lower lobe and the total number of cysts located on the pleural surface in the right middle lobe were needed to classify a patient as to whether or not he or she was likely to have a pneumothorax. Exon location of the BHD mutation was associated with the numbers of cysts (p = 0.0002).
This study indicates that patients with BHDS have a significant association between lung cysts and spontaneous pneumothorax.
Abstract Purpose Partial nephrectomy (PN) for early stage renal cancer preserves renal function better than radical nephrectomy (RN) and is generally considered oncologically similar. The Intergroup ...European Organisation for Research and Treatment of Cancer trial comparing outcomes after PN vs. RN, however, showed reduced overall survival in the PN group. Our aim was to evaluate recurrence, death, and renal function after PN vs. RN for T1 tumors in a Canadian population. Materials and methods From 2000 to 2015, 2,358 patients with a first occurrence of a clinical T1 renal cancer who underwent PN or RN were identified from the Canadian Kidney Cancer Information System. Clinical, surgical, and pathologic parameters were analyzed. Time to progression was compared after PN vs. RN using a Cox proportional hazards model, adjusted for pertinent variables. Results Inclusion criteria were met in 1,615 PN and 743 RN. Preoperative characteristics appeared similar in both groups. Time to progression was not different after PN vs. RN, adjusted for potential confounders (hazard ratio = 1.17 95% CI: 0.8–1.72, P = 0.42). Postoperative estimated glomerular filtration rate at 1 and 3 years was significantly greater for PN vs. RN in a linear regression model, accounting for preoperative estimated glomerular filtration rate. Conclusions These results suggest that progression-free survival after PN and RN in patients with T1 renal cancer was similar, but that there was better preservation of renal function after PN. This suggests that both PN and RN have similar oncological efficiency, and that selection of surgical approach should be based on other factors such as technical feasibility, potential complications, and preservation of renal function.
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