Currently, the role of adjuvant chemotherapy (ADJ) in muscle invasive bladder tumor (MIBC) remains controversial.
To evaluate the effect of ADJ on cancer specific survival (CSS) of MIBC after radical ...cystectomy (RC).
Retrospective analysis of 292 patients diagnosed with urothelial bladder tumor (BT) pT3-4pN0/+ cM0 stage, treated with RC between 1986-2009. Total cohort was divided in two groups: 185 (63.4%) patients treated with ADJ and 107 (36.6%) without ADJ. Median follow-up was 40.5 months (IQR 55–80.5).
Comparative analysis was performed with Chi-square test and Student’s t test/ANOVA. Survival analysis was carried out with the Kaplan–Meier method and log-rank test. Multivariate analysis (Cox regression) was made to identify independent predictors of cancer-specific mortality (CSM).
42.8% of the series presented lymph node involvement after RC. At the end of follow-up, 22.9% were BC-free and 54.8% had died due to this cause. The median CSS was 30 months. No significant differences were observed in CSS regarding the treatment with ADJ in pT3pN0 (p = .25) or pT4pN0 (p = .29) patients, but it was significant in pT3-4pN+ (p = .001).
Multivariate analysis showed pathological stage (p = .0001) and treatment with ADJ (p = .007) as independent prognostic factors for CSM. ADJ reduced the risk of CSM (HR:0.59,95%CI 0.40–0.87, p = .007).
pT and pN stages were identified as independent predictors of CSM after RC. The administration of ADJ in our series behaved as a protective factor reducing the risk of CSM, although only pN + patients were benefited in the stage analysis.
El papel de la quimioterapia adyuvante (QTAdy) en el tumor vesical músculo invasivo (TVMI) sigue siendo controvertido actualmente.
Evaluar el efecto de la QTAdy en la supervivencia cáncer específica (SCE) del TVMI tras cistectomía radical (CR).
Análisis retrospectivo de 292 pacientes diagnosticados de tumor vesical (TV) urotelial tratados con CR entre 1986-2009 con estadio pT3-4pN0/+cM0, divididas en dos cohortes:185(63.4%) pacientes tratados con QTAdy y otra con 107(36.6%) sin QTAdy. Mediana de seguimiento de 40,5 meses (IQR 55-80,5).
Análisis comparativo con test Chi Cuadrado y t Student/ANOVA. Cálculo de supervivencia con el método de Kaplan-Meier y test de long-rank. Análisis multivariante (regresión de Cox) para identificar variables predictoras independientes de mortalidad cáncer específica (MCE).
El 42.8% de la serie presentó afectación ganglionar tras CR. Al finalizar el seguimiento, 22.9% estaban libres de TV y 54.8% habían fallecido por esa causa. La mediana de SCE fue de 30 meses. No se observaron diferencias significativas en SCE en función del tratamiento con QTAdy en pacientes pT3pN0p = 0,25 ni pT4pN0p = 0,29, pero sí en pT3-4pN+p = 0,001.
En el análisis multivariante se identificaron el estadio patológicop = 0,0001 y el tratamiento con QTAdyp = 0,007 como factores pronósticos independientes de MCE. La QTAdy redujo el riesgo de MCEHR:0.59,IC95%0,40-0,87, p = 0,007.
El estadio pT y pN se identificaron como variables predictoras independientes de MCE tras CR. La administración de QTAdy en nuestra serie se comportó como factor protector reduciendo el riesgo de MCE, aunque en el análisis por estadios, únicamente los pacientes pN + se vieron beneficiados.
This article discusses the rationale for inclusion of flow cytometry (FCM) in the diagnostic investigation and evaluation of cytopenias of uncertain origin and suspected myelodysplastic syndromes ...(MDS) by the European LeukemiaNet international MDS Flow Working Group (ELN iMDS Flow WG). The WHO 2016 classification recognizes that FCM contributes to the diagnosis of MDS and may be useful for prognostication, prediction, and evaluation of response to therapy and follow‐up of MDS patients.
There is no consensus on the follow-up protocol after nephrectomy for renal cell carcinoma (RCC), and the identification of recurrence risk groups (RRG) is required.
Establish recurrence risk groups ...(RRG).
A retrospective analysis of 696 patients with renal cancer submitted to surgery between 1990 and 2010; 568 (81.6%) patients treated with radical nephrectomy and 128 (18.4%) treated with partial nephrectomy.
Pathological variables were classified as: 1st-level variables (1LPV): pTpN stage and Fuhrman grade (FG); and 2nd level pathological variables (2LPV): sarcomatoid differentiation (SD), tumor necrosis (TN), microvascular invasion (MVI) and positive surgical margins (PSM).
Univariate and multivariate analysis have been performed using Cox regression to determine 1LPV related to recurrence. Based on 1LPV, we classified patients into three RRG: Low (LRG) <25%; Intermediate (IRG) 26–50% and High (HRG) >50%.
We performed univariate and multivariate analysis with the 2LPVs for each RRG. With these data, patients were reclassified as RRG +.
ROC curves were used for comparison of RRG and RRG+.
The median follow-up was 105 months (range 63–148). There were 177 (25.4%) patients with recurrence: 111 (15.9%) distant, 34 (4.9%) local and 32 (4.6%) distant and local.
In the multivariable analysis, Fuhrman grade HR = 2,75; p = 0,0001 and pTpN stage HR = 2,19;p = 0,0001 behaved as independent predictive variables of recurrence.
Patients were grouped as RRG AUC = 0,76; p = 0,0001:
- LRG (pT1pNx-0 G1-4; pT2pNx-0 G 1-2 ): 456 (65.5%) patients.
- IRG (pT2pNx-0 G 3-4 ; pT 3-4 pNx-0 G 1-2 ): 110 (15.8%) patients.
- HRG (pT 3-4 pNx-0 G 3-4 ; pT1-4pN+): 130 (18.6%) patients.
After multivariate analysis with 2LPV, RRG were reclassified RRG+ AUC = 0,84, p = 0,0001:
-LRG+ (LRG without TN, SD and/or PSM(+))
-IRG+ (IRG; LRG with TN)
-HRG+ (HRG; LRG with SD and/or PSM(+); IRG with TN and/or SD)
The inclusion of 2LPV to the classification according to VP1N improves the discriminating capacity of RRG classification.
No existe consenso sobre el seguimiento tras nefrectomía por cáncer renal (CCR), siendo necesario establecer grupos de riesgo de recurrencia(GRR).
Análisis retrospectivo de 696 pacientes con CCR intervenidos entre 1990-2010;568(81.6%)pacientes con nefrectomía radical y 128(18.4%) con nefrectomía parcial.
Se clasificaron las variables patológicas como variables de 1ernivel(VP1N): estadio pTpN y grado de Furhman(GF); y variables patológicas de 2ºnivel(VP2N):diferenciación sarcomatoide(DS),necrosis tumoral(NT), infiltración microvascular(IMV) y márgenes de resección(MR).
Realizamos un análisis multivariante(regresión de Cox) para identificar las variables de 1ernivel relacionadas con la recurrencia. Clasificamos a los pacientes en tres GRR según las VP1N: Bajo(GRB)<25%; Intermedio(GRI) 26-50% y Alto(GRA)>50%.
Tras ello realizamos un análisis univariante y multivariante con las VP2N para cada GRR. Con estos datos se reclasificaron a los pacientes en GRR+.
Para la comparación de los GRR con los GRR + se utilizaron curvas ROC.
La mediana de seguimiento fue de 105(IQR 63-148) meses. Recurrieron 177(25.4%)pacientes: 111(62.7%) pacientes con recidiva a distancia, 34(19.2%) recidiva local y 32(18%) a distancia y local.
Se comportaron como factores predictores independientes de recurrencia el grado de FuhrmanHR = 2,75;p = 0,0001 y el estadio pTpNHR = 2,19;p = 0,0001.
Se agruparon los pacientes en GRR ABC = 0,76;p = 0,0001:
-Grupo de riesgo bajo-GRB(pT1pNx-0 G1-4; pT2pNx-0 G 1-2 ): 456(65.5%)pacientes.
-Grupo de riesgo intermedio-GRI(pT2pNx-0 G 3-4 ; pT 3-4 pNx-0 G 1-2 ): 110(15.8%)pacientes.
-Grupo de riesgo alto-GRA(pT 3-4 pNx-0 G 3-4 ; pT1-4pN+): 130(18.6%)pacientes.
Tras el análisis multivariable con las VP2N, los GRR se reclasificaron GRR+ ABC = 0,84,p = 0,0001:
-GRB+(GRB sin NT,DS y/o MR(+))
-GRI+(GRI; GRB con NT)
-GRA+(GRA; GRB con DS y/o MR(+); GRI con NT y/o DS)
La adicción de las variables patológicas de segundo nivel a la clasificación según las variables de primer nivel mejora la capacidad de discriminación de la clasificación en GRR.
The AEU Guidelines of 2017 consider laparoscopic and robot-assisted approaches as investigational procedures. The surgical learning curve is defined as the minimum number of cases that a surgeon has ...to perform in order to reproduce a technique considered as standard.
The aim of this study is to analyze, within our department, the implementation of a laparoscopic radical cystectomy (LRC) program compared with a well consolidated and standardized open radical cystectomy (ORC) program.
Retrospective cohort analysis of two cystectomy groups: LRC (n = 196) (20062016) vs ORC (n = 96) (2003–2005).
Comparison of the evolution over time of the following parameters: operative time, blood transfusion rates, resection margins, postoperative complications, hospital stay and recurrence.
Three time periods have been defined for LRC: implementation (2006–09) (LRC-I), development (2010–14) (LRC-D) and consolidation (2015–16) (LRC-C); comparing each of them with the control group (ORC).
The chi-square test was used for the comparison of the qualitative variables and the Anova test for the numerical ones.
When compared to ORC, LRC presented longer operative times in LRC-I and LRC-D periods. We observed a trend toward shorter operative time than ORC in the consolidation period (LRC-C).
LRC also presented lower intraoperative transfusion rates in all periods and lower postoperative rates in CRL-D and CRL-C. Overall complications in LRC-D and LRC-C were lower in LRC, having fewer major complications (Clavien ≥ 3) in the 3 periods. A decrease in mortality and hospital stay after the LRC-I phase was also observed. These results were consolidated during the two last periods of the study.
We have not observed significant differences between ORC and LRC when comparing surgical margins and recurrence rates, neither in the total series, nor in the comparison between the different periods. These results endorse the oncologic safety of LRC from the beginning of the implementation process.
When compared to ORC, LRC improves perioperative transfusion rates, complications and hospital stay from its implementation period, maintaining oncological safety. On the contrary, longer operative times during implementation and development were observed. However, in our series, we observed a trend toward shorter operative times than ORC approach in the consolidation period. We have validated the laparoscopic approach for radical cystectomy in our service.
Las Guidelines de la AEU de 2017, consideran el acceso laparoscópico o asistido por robot como procedimientos en investigación. La curva de aprendizaje se define por el número mínimo de casos que es necesario realizar para reproducir la técnica considerada como estándar.
El objetivo de este estudio es analizar en el mismo servicio, la implantación de un programa de cistectomía laparoscópica (CRL), comparándolo con un programa consolidado y estandarizado de cistectomía abierta (CRA).
Análisis de cohortes retrospectivo de dos grupos de cistectomías: CRL (n = 196) (2006–2016) frente a CRA (n = 96) (2003–2005).
Comparación de la evolución en el tiempo de los siguientes parámetros: tiempo quirúrgico, las necesidad de transfusión, el estado de los márgenes quirúrgicos de resección, las complicaciones postoperatorias, la duración de la estancia hospitalaria y las recidivas.
Se han definido 3 periodos de tiempo para CRL: implantación (2006–09) (CRLI), desarrollo (2010–14) (CRL-D) y consolidación (2015–16) (CRL-C); comparándose cada uno de ellos con el grupo control (CRA).
Para el contraste de variables cualitativas se ha utilizado el test de la Chi cuadrado y para las variables numéricas el test de Anova.
La CRL, en comparación con la CRA, presentó un mayor tiempo quirúrgico en las fases de CRL-I y CRL-D, observando una tendencia de menores tiempos operatorios que la CRA en el periodo de consolidación.
La CRL presenta además menor trasfusión intraoperatoria en los 3 periodos y postoperatoria en CRL-D y CRL-C, menos complicaciones totales en CRL-D y CRL-C, menos complicaciones graves(Clavien ≥ 3) en las 3 fases; así como una disminución de la mortalidad y estancia hospitalaria desde la fase de CRL-I, consolidándose esta disminución en los otros dos periodos de estudio.
No hemos observado diferencias significativas entre CRA y CRL en cuanto a márgenes quirúrgicos y recurrencias ni en el total de la serie ni en la comparación entre los distintos periodos, lo que avala la seguridad de la CRL, desde su inicio.
La CRL frente a CRA mejora desde su implantación el porcentaje de transfusiones, de complicaciones y la estancia hospitalaria, con seguridad oncológica, a expensas de un mayor tiempo quirúrgico en las fases de implantación y desarrollo. Sin embargo, en nuestra serie observamos una tendencia de menores tiempos quirúrgicos que la CRA en el periodo de consolidación. En nuestro servicio el abordaje laparoscópico se ha validado en el tratamiento de la cistectomía radical.
We have analysed the incidence and risk factors for the occurrence of invasive fungal infections (IFI) among 395 recipients of an allogeneic peripheral blood stem cell transplantation (PBSCT) from a ...human leucocyte antigen (HLA)‐identical sibling. IFI (n = 50) occurred in 46 patients, giving an overall probability of 14%. There were 12 cases of invasive candidiasis (3%), with only one death. Non‐Candida IFI occurred in 37 patients (12% probability), mostly invasive aspergillosis (n = 32). In multivariate analysis the only two significant variables associated with a higher risk of developing a non‐Candida IFI were the development of moderate‐to‐severe graft‐versus‐host disease (GvHD, P < 0·0001; OR 4·6) and having received steroid prophylaxis for GvHD (P = 0·04; OR 2·1). In multivariate analysis the variables associated with a lower overall survival after PBSCT were development of a non‐Candida IFI (P < 0·0001; OR 5·6), non‐early disease phase (P = 0·0001; OR 1·9), steroid prophylaxis (P = 0·02; OR 1·4), moderate‐to‐severe GvHD (P = 0·01; OR 1·6) and cytomegalovirus infection post transplant (P = 0·001; OR 1·8). Our results show that non‐Candida IFI (in particular aspergillosis) was an important cause of infectious morbidity and mortality after an HLA‐identical sibling PBSCT, while invasive candidiasis was rare. Use of steroid prophylaxis and, in particular, the development of moderate‐to‐severe GvHD post transplant were risk factors for non‐Candida IFI. Prophylactic strategies for these infections should thus take into account these risk factors.
INTRODUCTION AND OBJECTIVEMinimally invasive surgery represents an attractive surgical approach in radical cystectomy. However, its effect on the oncological results is still controversial due to the ...lack of definite analyses. The objective of this study is to evaluate the effect of the laparoscopic approach on cancer-specific mortality. MATERIAL AND METHODA retrospective cohort study of two groups of patients in a pT0-2pN0R0 stage, undergoing open radical cystectomy (ORC) (n=191) and laparoscopic radical cystectomy (LRC) (n=74). Using Cox regression, an analysis has been carried out to identify the predictor variables in the first place, and consequently, the independent predictor variables related to survival. RESULTS90.9% were males with a median age of 65years and a median follow-up period of 65.5 (IQR27.75-122) months. Patients with laparoscopic access presented a significantly higher ASA index (P=.0001), a longer time between TUR and cystectomy (P=.04), a lower rate of intraoperative transfusion (P=.0001), a lower pT stage (P=.002) and a lower incidence of infection associated with surgical wounds (P=.04). When analyzing the different risk factors associated with cancer-specific mortality, we only found the ORC approach (versus LRC) as an independent predictor of cancer-specific mortality (P=.007). Open approach to cystectomy multiplied the risk of mortality by 3.27. CONCLUSIONSIn our series, the laparoscopic approach does not represent a risk factor compared to the open approach in pT0-2N0R0 patients.
INTRODUCTION AND AIMThe main aim of the study was to establish the oncological safety of the laparoscopic approach to radical cystectomy for high-risk, non-organ-confined urothelial tumours. MATERIAL ...AND METHODSA retrospective cohort study of 216 stage pT3-4 cystectomies operated between 2003 and 2016; using an open approach (ORC, n=108), and using a laparoscopic approach (LRC, n=108). RESULTSBoth groups have similar pathological features except, in G3 TUR, there were more lyphadenectomies and greater pN+, and more adjuvant chemotherapies using the LRC. The median follow-up of the series was 15 (IQR: 8-10.5) months. Sixty-eight point one percent of the series relapsed, with no differences between either group (p=.11). The estimated differences for cancer-specific survival was greater in the LRC group (p=.03), as was overall survival (p=.009). There were no differences between either group in estimated recurrence-free survival (p=.26). The type of surgical approach (p=.03), pTpN stage (p=.0001), and administration of adjuvant chemotherapy (p=.003) were related to cancer-specific mortality (CSM) in the univariate analysis. Only the pTpN stage (p=.0001), and not giving adjuvant chemotherapy (p=.003) behaved as independent predictive factors of CSM. CONCLUSIONThe type of surgical approach to cystectomy (ORC vs. LRC) did not influence CSM. Lymph node involvement and not giving adjuvant chemotherapy were identified as predictive factors of CSM. Our study supports the oncological safety of the laparascopic approach for cystectomy in patients with locally advanced muscle-invasive bladder tumours.
Abstract
An international working group within the European LeukemiaNet gathered, aiming to determine the role of flow cytometry (FC) in myelodysplastic syndromes (MDS). It was agreed that FC has a ...substantial application in disease characterization, diagnosis and prognosis. FC may also be useful in predicting treatment responses and monitoring novel and standard therapeutic regimens. In this article the rationale is discussed that flow cytometry should be integrated as a part of diagnostic and prognostic scoring systems in MDS.
•Female victims of sexual assault have a high predisposition to develop acute stress disorder.•Nationality, psychiatric history, peritraumatic dissociation and type of assault are risk factors ...associated to acute stress disorder.•The risk factors can be used in the emergency department to detect vulnerable victims that require early interventions.
Sexual assault is one of the most traumatic events a person can experience. Despite this, information regarding the risk factors associated with the development of Acute Stress Disorder (ASD) in sexual assault victims is scarce. A follow-up prospective cohort study was designed to examine the prevalence and risk factors of ASD in women exposed to a recent sexual assault. A total of 156 women were treated at the Emergency Department of a university general hospital shortly after sexual assault. Sociodemographic, clinical and sexual assault-related variables were collected. The Acute Stress Disorder Interview was used to estimate the prevalence of ASD at three weeks post-SA. From the 156 victims, 66.6% (N = 104) met ASD diagnosis using DSM-5 criteria, whereas 59.6% (N = 93) met ASD diagnosis using DSM-IV criteria. The risk factors associated with the development of ASD were nationality, psychiatric history, peritraumatic dissociation and type of assault. In conclusion, the prevalence of ASD in female victims of recent sexual assault was high, affecting approximately two thirds of them. The recognition of the risk factors associated with ASD development, like peritraumatic dissociation or type of assault, may aid in the prompt detection of vulnerable women that require early and specific interventions shortly after trauma.
Minimally invasive surgery regarding cystectomy has not had the same development as other urological surgeries. This could be due to the lack of published studies defining the advantages of this ...approach versus open surgery.
The main objective of this study is to establish the role of minimally invasive surgery, laparoscopic radical cystectomy, versus open surgery by analyzing their perioperative complications.
Retrospective cohort analysis of perioperative complications of 2 homogeneous series of cystectomies: laparoscopic (n=196) versus open (n=197). Identification of independent predictors of perioperative complications by multivariate analysis.
In the comparative analysis between laparoscopic cystectomies and open cystectomies we observed a lower rate of perioperative blood transfusion (p<0.0001), a lower rate of global postoperative complications (p<0.0001) and a lower rate of serious complications (Clavien >3; p<0.001) in the LRC group. There was also a lower mortality rate in the laparoscopic series compared to open ones (p<0.0001). Surgical approach and surgical time (p<0.001) were identified as independent predictors of complications.
We have identified the laparoscopic approach as a complication shield for radical cystectomy. The open approach almost triples the risk of complications.
La cirugía mínimamente invasiva en la cistectomía no ha tenido el mismo desarrollo que en otras cirugías urológicas, entre otros motivos por la falta de estudios publicados que definan las ventajas de este abordaje frente a la cirugía abierta.
El principal objetivo de este estudio es establecer el papel de la cirugía mínimamente invasiva, laparoscopia, en la cistectomía radical frente a la cirugía abierta en un análisis de complicaciones perioperatorias.
Análisis de cohortes retrospectivo de complicaciones perioperatorias de 2series homogéneas de cistectomías: laparoscópica (n=196) frente a abierta (n=197). Identificación mediante análisis multivariante de factores independientes predictores de complicaciones perioperatorias.
En el análisis comparativo entre el abordaje laparoscópico y el abierto observamos una menor tasas de trasfusión perioperatoria (p<0,0001), una menor tasa de complicaciones postoperatorias globales (p<0,0001) así como en el subgrupo de complicaciones graves (Clavien>3; p<0,001). También una menor tasa de mortalidad en la serie de laparoscópica frente a la abierta (p<0,0001). Identificamos como factor independiente predictor de complicaciones al abordaje quirúrgico y la duración de la cirugía (p<0,001).
En nuestro estudio identificamos el abordaje laparoscópico como protector de complicaciones en la cistectomía radical. El abordaje abierto casi triplica el riesgo de tener complicaciones.
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