Initial experience of focal therapy for prostate cancer using I-125 seed implantation: Unilateral ablation for patients selected by extended biopsy and MRI findings

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Background: Focal therapy for prostate cancer could be a minimally invasive therapeutic option with the preservation of genitourinary function to reduce treatment associated complication under the appropriate selection of patients. We have reported the good predict ability to unilateral prostate cancer by extended prostate biopsy combined with transperineal and transrectal approaches (Eur Urol supple, 2009). Among the candidate ablative, brachytherapy which has been proved as a definitive therapy and applied worldwide has been thought to have potential for focal ablation due to its ability of dose and location adjustment by seed implantation under real-time monitoring. Based on the findings, focal therapy with hemiablation using I-125 seed implantation has been started in our instituion. The aim of study is to describe the initial experience of focal therapy for patients selected by extended biopsy and MRI findings.

Methods: The eligible criteria for focal therapy to prostate cancer are as follows. Clinical stage is T2a or less. The positive cores of cancer are proven within unilateral lobe by extended prostate biopsy. There was no cancerous lesion in contralateral lobe by MRI. Gleason score in positive cores was 3 + 4 or less. Maximum cancer length was less than 5 mm. PSA value is less than 10 ng/mL. On the treatment, I-125 seeds were implanted to ablate the unilateral lobe with 160 Gy of the prescription dose. The protocol has been approved by the institutional ethics commit.

Results: At present, 3 patients were enrolled in this study and underwent focal therapy with written informed consents. In all three cases, I-125 seeds implanted (number od seeds: 43, 39, and 37) to unilateral lobe without severe acute complication such as acute urinary retention. In one case that has been followed over 3months among the initial three cases, PSA values decreased to 2.07 mg/ml at 3 months after the seed implantation.

Conclusions: To our knowledge, this is the first report about focal therapy by brachytherapy with hemiablative technique. In our initail experience, severe treatment associated complication has not been observed.

No significant financial relationships to disclose.

C-reactive protein kinetics superior to radiographic response as a surrogate endpoint for survival in patients with advanced renal cell carcinoma

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Background: As cytokines and targeted agents against advanced renal cell carcinoma (aRCC) are considered to achieve high stable disease (SD) rate rather than objective response (OR) by radiographic measurement, we often face the therapeutic dilemma in deciding whether to continue the ongoing treatment and when to change it. Therefore, other valid surrogate endpoints have been desired. We have previously demonstrated C-reactive protein (CRP) kinetics could predict prognosis of pts with aRCC (Eur Urol. 2009:1145-53).

Methods: This study was performed on 56 pts with aRCC (metastatic: 54, unresectable: 2) enrolled in a phase II trial of interferon-alpha, cimetidine, COX-2 inhibitor and renin-angiotensin-system inhibitor (I-CCA; Cancer Sci. in press). CRP levels were measured at pretreatment, thereafter almost every visit. Pts were divided into 3 groups according to CRP kinetics. Pts whose pretreatment CRP levels were < 5 mg/l were assigned to nonelevated group. Pts whose pretreatment CRP levels were > 5 mg/l but normalized (< 5 mg/l) at least one time during I-CCA were assigned to normalized group. Pts whose CRP level never decreased to normal level were assigned to non-normalized group. Radiographic response was assessed by WHO criteria; survivals were estimated by Kaplan–Meier method and prognostic factors were assessed by Cox's proportional hazard model.

Results: Median follow-up was 26 mo. An OR and clinical benefit rate to I-CCA were 20 and 64%, respectively. The median progression-free and overall survival (OS) was 12 and 45 mo, respectively. The median OS was 74, 83 and 13 mo in in non-elevated (n=26), normalized (n=16) and non-normalized (n=14) group, respectively (p<0.0001). Of the 25 pts achieving SD, CRP kinetics was independent prognostic factor for OS (p<0.0001). Of the pts whose pretreatment CRP was elevated, all pts achieving OR had CRP normalization and multivariate analysis revealed CRP normalization was independent prognostic factor for OS (p=0.0008), whereas achieving OR was not (p=0.19).

Conclusions: CRP kinetics compares favorably with objective response to systemic therapy as a valid surrogate endpoint for survival.

No significant financial relationships to disclose.

Does induction chemoradiotherapy compromise subsequent radical cystectomy? A single-institutional comparative study on perioperative complications according to the Clavien-Dindo classification

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Background: Recently, bladder-sparing protocols incorporating TUR + chemoradiotherapy (CRT) have been developed. Patients who achieve CR after CRT are subjects for bladder preservation treatment and those who with non-CR undergo radical cystectomy (RC). However, early studies suggest that RC following pelvic irradiation associates with a higher mortality. To validate the impact of induction CRT on perioperative morbidity of RC, we compared complications of RC in patients treated with or without induction CRT at a single university hospital.

Methods: Records of consecutive 193 patients who underwent RC for bladder cancer between April 1989 and May 2010 were reviewed. Induction CRT consists of radiation at 40 Gy to the small pelvis and 2 cycles of concurrent cisplatin at 20 mg/d for 5 days. Any complications occurred within 30 days after RC were graded according to the Clavien-Dindo classification system. Complications of grade I or II were classified as minor and complications of grade III or greater were classified as major.

Results: Eighty-seven patients underwent induction CRT (CRT group) while 106 did not (control group). Patients of CRT group had significantly more advanced disease. No patient died within 90 days. Twenty one (11%) patients experienced at least one major complications; there was no significant difference in the incidence of major complications between CRT and control group (14% vs. 8%, p = 0.26). The details were as follows; infectious (3.5% vs. 3.8%, p = 1.0), gastrointestinal (4.6% vs. 0.9%, p = 0.18), surgical (6.9% vs. 3.8%, p = 0.35), cardiovascular (1.2% vs. 0.9%, p = 1.0). There was no significant difference between the incidence of minor complications (61% vs. 51%, p = 0.19).

Conclusions: Induction CRT at 40 Gy is unlikely to compromise subsequent RC.

No significant financial relationships to disclose.

Incidence of benign pathologic lesions at nephrectomy for renal masses presumed to be stage I renal cell carcinoma in Japanese patients: Impact of sex, age, and tumor size

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Background: The widespread use of modern imaging techniques has resulted in the increased detection of small, asymptomatic renal tumors. Some recent studies from Western countries have reported that the incidence of benign lesions is approximately 15% in patients undergoing definitive surgery for renal masses presumed to be clinical stage I renal cell carcinoma (RCC). The high level of noncancerous lesions is, to some extent, due to the fact that no imaging feature can accurately distinguish either oncocytoma or lipid-poor angiomyolipma (AML) from RCC. This study attempts to determine the incidence of benign pathologic findings for such renal masses in Asian patients.

Methods: Between 1991 and 2009, 711 consecutive patients (218 women and 493 men) underwent partial (n=206) or radical (n=505) nephrectomy for renal masses presumed to be stage T1N0M0 (T1a/T1b= 503/208) sporadic RCC on preoperative imaging in two Japanese centers. The mean size of the lesions was 3.3 cm (range 0.3-7.0). The pathologic features were reviewed by an experienced pathologist.

Results: Of the 711 masses, 53 (7.5%) revealed benign pathologic findings. Twenty-two (3.1%) were AMLs, 13 (1.8%) were oncocytomas, 8 (1.1%) were complicated cysts, and 10 were others. Twenty-eight (12.8%) of the 218 females and 25 (5.1%) of the 493 males had benign lesions (p=0.0005). Of the 357 patients aged 60 years or younger, 37 (10.4%) had benign lesions while only 16 (4.5%) of the 354 patients over 60 years did (p=0.024). Forty six (9.2%) of the 503 T1a and 7 (3.4%) of the 203 T1b masses were benign (p=0.0071). A multivariate logistic regression model showed that sex, age and tumor size were all independently predictive of benign histology, particularly of AML.

Conclusions: The present incidence (7.5%) of benign lesions in presumed clinical stage T1N0M0 RCC masses at nephrectomy was lower than the incidence of approximately 15% previously reported from Western countries, probably because of the low incidence of oncocytomas in Japanese patients. Female gender, young age and small tumor size are all independently predictive of benign lesions, particularly of AML in Japanese patients.

No significant financial relationships to disclose.

Minimum incision endoscopic surgery (MIES) in Japanese urology: results of adrenalectomy, radical nephrectomy and radical prostatectomy

AIM

The aim of this study was to evaluate the feasibility of our minimum incision endoscopic surgeries (MIES), adrenalectomy, radical nephrectomy and radical prostatectomy, which are operated via a single minimum incision which narrowly permits extraction of the specimen, using an endoscope, without gas insufflation, without any trocar ports and without injury to the peritoneum. These operations have been developed in our department in the late 1990 s and have since been performed in more than 1000 patients and certified as advanced surgery by the Japanese government in 2006.

METHODS

Adrenalectomy, radical nephrectomy and radical prostatectomy were carried out via a single minimum incision under the conditions of gasless, portless (without trocar ports), intact peritoneum and at low cost with reusable devices. The anatomic plane was separated through the incision and a wide working space was made extraperitoneally. New devices were made especially for this operation in our department, which are now commercially available. The results of the most recent consecutive cases (2005-2007) are evaluated. The results of adrenalectomy and radical nephrectomy performed by 12 operators including inexperienced doctors were compared with the initial results performed by 2 operators, mostly by one operator.

RESULTS

In the recent 60 cases of adrenalectomy, the average length of incision, operative time, estimated blood loss were 5.7 cm (5.6 cm in the initial 30 cases), 156 min (147 min) and 174 ml (139 ml), respectively. A complication was observed in one case, injury to the renal artery. Blood transfusion was not performed. Average days to oral feeding, to long walking (more than 100 m) and to possible minimal hospital stay were 1.3 days (2 days), 1.1 days (1.1 days) and 1.9 days (4.6 days), respectively. In the recent 80 cases of radical nephrectomy, the average length of incision, operative time, estimated blood loss were 6.6 cm (6.6 cm in the initial 80 cases), 192 min (186 min) and 315 ml (324 ml), respectively. Complications were not observed in any of the cases (2) and blood transfusion was performed in 1 case (3). Average days to oral feeding, to long walking (more than 100 m) and to possible minimal hospital stay were 1.1 days (1.4 days), 1.2 days (1.4 days) and 1.9 days (4.8 days), respectively. In the recent 50 cases of radical prostatectomy, the average length of incision and operative time were 5.9 cm and 261 min, respectively. Two complications (small rectal injuries) were observed and one blood transfusion was performed. Average days to oral feeding, to long walking (more than 100 m) and possible minimal hospital stay were 1.0 days, 1.0 days and 2.4 days, respectively. Wound pain was minimal and analgesics were generally not required on the second postoperative day in the above 3 operations. Although prophylactic antibiotics were not used in the recent cases of adrenalectomy and radical nephrectomy, surgical site infection was not observed.

CONCLUSION

Minimum incision endoscopic surgery (MIES) in Japanese urology is a safe, reproducible, cost-effective and minimally invasive treatment option for adrenal tumor, renal cell carcinoma and prostate carcinoma.

Mesothelial cells from tunica vaginalis, a practical source for mesothelial transplantation

Transplantation of mesothelial cells is used to repair peritoneum that is damaged by surgery, peritonitis, and peritoneal dialysis. The largest obstacle for clinical application of mesothelial cell transplantation is the lack of a reliable source of mesothelial cells. So far, they are isolated from omentum, mesentery, parietal wall and ascites. Procedures used to obtain mesothelial cells from the omentum or mesentery are invasive, however, especially in pre-operative situations. Sufficient amounts of ascites for aspiration can not be obtained under physiological conditions. We have developed a novel method of isolating mesothelial cells from the tunica vaginalis. The tunica vaginalis originates from the peritoneum and descends into the scrotum along with the testis during fetal development. This region provides a source of mesothelial cells that is convenient to approach and free from abdominal complications. Transplantation of autologous mesothelial cells that were isolated from tunica vaginalis was effective in preventing post-operative adhesions. In this review, we summarize mesothelial cell transplantation trials and describe the method of isolating mesothelial cells form the tunica vaginalis. Mesothelial cell transplantation might be widely accepted for clinical use in the near future.

[Conformation of the ribosomal protein S1 of Thermus thermophilus in solution under different ionic conditions]

The structure of protein SI of Thermus thermophilus (M = 61 kDa) in solution at low and moderate ionic strengths (0 M and 100 mM NaCl, respectively) has been studied by small-angle X-ray and neutron scattering. It was found that protein S1 has a globular conformation under both ionic conditions. The modelling of different packing of six homologous domains of S1 on the basis of the NMR-resolved structure of one domain showed that the best fit of calculated scattering patterns from such complexes to experimental ones is observed at a compact package of the domains. The calculated value of the radius of gyration of the models is 28-29 angtroms, which is characteristic for globular proteins with a molecular mass of about 60 kDa. It was found that protein S1 has a tendency to form associates, and the type of the associate depends on ionic strength. These associates have, in general, two or three monomers at a moderate ionic strength, while at a low ionic strength the number of monomers exceeds three and they are packed in a compact manner. Strongly elongated associates were observed in neutron experiments at a moderate ionic strength in heavy water. The association of protein molecules was also confirmed by the data of dynamic light scattering. From these data, the translational diffusion coefficient of protein S1 at a moderate ionic strength was calculated to be (D20,w = (2.7 +/- 0.1) x 10(-7)cm2/s). This value is essentially smaller than the expected value (D20,w = (5.8 - 6.0) x 10(-7)cm2/s) for the S1 monomer in the globular conformation, indicating the association of protein molecules under equilibrium conditions.

Malignant transformation in a mature testicular teratoma left untreated for more than 50 years since childhood

Although testicular teratoma in childhood is regarded as a benign tumor, little is known about the consequences of pediatric teratoma being left untreated. We report herein a case of malignant transformation observed in a mature testicular teratoma that was presumed to have remained benign for >50 years.

Long-term outcome of bladder papillary urothelial neoplasms of low malignant potential

OBJECTIVE

To evaluate the long-term outcome of bladder papillary urothelial neoplasms of low malignant potential (PUNLMP).

PATIENTS AND METHODS

Of 475 consecutive patients with newly diagnosed bladder tumours between 1976 and 1993, 330 (69%) had superficial (Ta and T1) tumours and 53 (11%) were diagnosed as having PUNLMP. Fifty patients (mean age at presentation 57.2 years, range 26-83; male-to-female ratio 6 : 1) who were followed for> 5 years or until they died, were included in the present study. All histological slides were reviewed, and fulfilled the diagnostic criteria of the 1998 World Health Organization/International Society of Urological Pathology classification system.

RESULTS

The mean (median, range) follow-up was 11.7 (10.8, 1.3-24.4) years. During the follow-up, 30 patients (60%) had local recurrences. The 2, 5 and 10-year recurrence-free rates were 66%, 51% and 36%, respectively. No patients developed high-grade or muscle-invasive (>/= T2) carcinomas, or upper urinary tract tumours, or died from the disease. At the last follow-up, 34 patients (68%) had been disease-free for> 5 years.

CONCLUSIONS

Despite a high recurrence rate, PUNLMP carries a very low malignant potential. We agree with the use of the term 'papillary urothelial neoplasms of low malignant potential' instead of 'superficial bladder carcinoma (cancer)' for these tumours.

Spontaneous regeneration of the seriously injured sympathetic pathway projecting to the prostate over a long period in the dog

OBJECTIVES

To explore the spontaneous regeneration, over a long period, of the seriously injured sympathetic pathway controlling the prostate.

MATERIALS AND METHODS

The hypogastric nerve (HGN), which is part of the sympathetic pathway from the spinal cord to the prostate, was partly removed over half of its length on both sides in six dogs. Four years after surgery the responses of the prostate to electrical stimulation of the lumbar splanchnic nerve (LSN) or the HGN proximal to the site removed, were assessed.

RESULTS

In six dogs, 10 of the 17 LSNs (second to fourth) and four of the 10 HGNs stimulated elicited prostatic contraction. The pathways via the ipsilateral HGN and/or the contralateral HGN from the LSNs to the prostate were identified as having regenerated in four of six dogs.

CONCLUSION

These results indicate that the sympathetic pathways via the HGN to the canine prostate can regenerate spontaneously over a long period after serious injury, and that their cross-innervation system can also be repaired.