Associations of Matrix Metalloproteinase-8 Genotypes to Renal Cell Carcinoma in Taiwan

BACKGROUND/AIM

Renal cell carcinoma (RCC) presents a formidable clinical challenge due to its aggressive behavior and limited therapeutic options. Matrix metalloproteinase-8 (MMP-8) has recently emerged as a potential biomarker and therapeutic target for various cancers. However, the genetic involvement of MMP-8 in RCC has remained largely obscure. This study aimed to elucidate the role of MMP-8 genotypes in RCC susceptibility.

MATERIALS AND METHODS

The polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) technique was employed to scrutinize the genotypes of MMP-8 C-799T (rs11225395), Val436Ala (rs34009635), and Lys460Thr (rs35866072) among 118 RCC patients and 590 controls. Furthermore, potential associations between MMP-8 genotypes and age, sex, smoking, alcohol consumption, hypertension, diabetes, and family history status in relation to RCC risk were assessed.

RESULTS

No significant disparities in the distribution of MMP-8 rs11225395, rs34009635, and rs35866072 genotypes were observed between the RCC case and control cohorts (p>0.05). Individuals with CT and TT genotypes at MMP-8 rs11225395 exhibited 0.86- and 0.80-fold RCC risks, respectively (OR=0.57-1.31 and 0.42-1.55, p=0.5585 and 0.6228, respectively). Intriguingly, hypertensive individuals carrying the MMP-8 rs11225395 CT or TT genotype demonstrated an elevated risk for RCC compared to those with wild-type CC genotype (p=0.0440). No interactions of MMP-8 genotypes with age, sex, smoking, alcohol consumption, or diabetes status were evident (all p>0.05). No significant association was discerned for MMP-8 rs34009635 or rs35866072 genotypes.

CONCLUSION

MMP-8 genotypes appear to have a modest influence on individual susceptibility to RCC. Hypertensive patients with the CT or TT MMP-8 rs11225395 genotype may have an elevated risk of RCC.

Prognostic factors of intravesical recurrence after radical nephroureterectomy for upper tract urothelial carcinoma

PURPOSE

To evaluate predictive factors of increasing intravesical recurrence (IVR) rate in patients with upper tract urothelial carcinoma (UTUC) after receiving radical nephroureterectomy (RNUx) with bladder cuff excision (BCE).

MATERIALS AND METHODS

A total of 2114 patients were included from the updated data of the Taiwan UTUC Collaboration Group. It was divided into two groups: IVR-free and IVR after RNUx, with 1527 and 587 patients, respectively. To determine the factors affecting IVR, TNM stage, the usage of pre-operative ureteroscopy, and pathological outcomes were evaluated. The Kaplan-Meier estimator was used to estimate the rates of prognostic outcomes in overall survival (OS), cancer-specific survival (CSS), disease-free survival (DFS), and bladder recurrence-free survival (BRFS), and the survival curves were compared using the stratified log-rank test.

RESULTS

Based on our research, ureter tumor, female, smoking history, age (< 70 years old), multifocal tumor, history of bladder cancer were determined to increase the risk of IVR after univariate analysis. The multivariable analysis revealed that female (BRFS for male: HR 0.566, 95% CI 0.469-0.681, p < 0.001), ureter tumor (BRFS: HR 1.359, 95% CI 1.133-1.631, p = 0.001), multifocal (BRFS: HR 1.200, 95% CI 1.001-1.439, p = 0.049), history of bladder cancer (BRFS: HR 1.480, 95% CI 1.118-1.959, p = 0.006) were the prognostic factors for IVR. Patients who ever received ureterorenoscopy (URS) did not increase the risk of IVR.

CONCLUSION

Patients with ureter tumor and previous bladder UC history are important factors to increase the risk of IVR after RNUx. Pre-operative URS manipulation is not associated with higher risk of IVR and diagnostic URS is feasible especially for insufficient information of image study. More frequent surveillance regimen may be needed for these patients.

Impact of pathological response on oncological outcomes in patients with upper tract urothelial cancer receiving neo-adjuvant chemotherapy

PURPOSE

The purpose of this study is to evaluate the rates of pathological complete response (ypT0N0/X) and pathological response (ypT1N0/X or less) in patients with upper tract urothelial cancer who were treated with neo-adjuvant chemotherapy and to examine their impact on oncological outcomes.

METHODS

This study is a multi-institutional retrospective analysis of patients with high-risk upper tract urothelial cancer who underwent neoadjuvant chemotherapy and radical nephroureterectomy between 2002 and 2021. Logistic regression analyses were used to investigate all clinical parameters for response after neoadjuvant chemotherapy. Cox proportional hazard models were performed to assess the effect of the response on the oncological outcomes.

RESULTS

A total of 84 patients with UTUC who received neo-adjuvant chemotherapy were identified. Among them, 44 (52.4%) patients received cisplatin-based chemotherapy, and 22 (26.2%) patients had a carboplatin-based regimen. The pathological complete response rate was 11.6% (n = 10), and the pathological response rate was 42.9% (n = 36). Multifocal tumors or tumors larger than 3 cm significantly reduced the odds of pathological response. In the multivariable Cox proportional hazard model, pathological response was independently associated with better overall survival (HR 0.38, p = 0.024), cancer-specific survival (HR 0.24, p = 0.033), and recurrence-free survival (HR 0.17, p = 0.001), but it was not associated with bladder recurrence-free survival (HR 0.84, p = 0.69).

CONCLUSION

Pathological response after neo-adjuvant chemotherapy and radical nephroureterectomy is strongly associated with patient survival and recurrence, and it might be a good surrogate for evaluating the efficacy of neo-adjuvant chemotherapy in the future.

LED-pumped eye-safe pulse laser with an extracavity optical parametric oscillator

An LED-side-pumped Nd:YAG/Cr⁴⁺:YAG passively Q-switched (PQS) laser containing an extracavity optical parametric oscillator (EOPO) is demonstrated. As far as we know, it is the first LED-pumped eye-safe laser. The Nd:YAG pump module is optimized to increase the PQS pulse energy to 24 mJ at 1064 nm. By using a single-pass EOPO design, the output energy of the signal pulse at 1573 nm is 7.44 mJ with a pulse width of 16 ns, the peak power is 434 kW, and the pump-to-signal conversion efficiency is 31%. For double-pass EOPO operation, the pump-to-signal conversion efficiency increases to 45.8%, the output energy of signal pulse is up to 10.98 mJ with a pulse width of 23.5 ns, and the peak power is 459 kW.

Enzalutamide Prior to Radium-223 Is Associated with Better Overall Survival in Metastatic Castration-Resistant Prostate Cancer Patients Compared to Abiraterone-A Retrospective Study

Metastatic castration-resistant prostate cancer (mCRPC) is a progressive stage of prostate cancer that often spreads to the bone. Radium-223, a bone-targeting radiopharmaceutical, has been shown to improve the overall survival in mCRPC in patients without visceral metastasis. However, the impact of prior systemic therapy on the treatment outcome of mCRPC patients receiving radium-223 remains unclear. This study aimed to investigate the optimal choice of systemic therapy before radium-223 in mCRPC patients. The study included 41 mCRPC patients who received radium-223 therapy, with 22 receiving prior enzalutamide and 19 receiving prior abiraterone. The results showed that the median overall survival was significantly longer in the enzalutamide group than in the abiraterone group (25.1 months vs. 14.8 months, p = 0.049). Moreover, the number of patients requiring blood transfusion was higher in the abiraterone group than in the enzalutamide group (9.1% vs. 26.3%, p = 0.16). The study also found that the number of doses of Radium-223 received was significantly associated with overall survival (≥5 vs. <5, HR 0.028, 95%CI 0.003-0.231, p = 0.001). Our study provides insights into the optimal treatment choice for mCRPC prior to radium-223, indicating that enzalutamide prior to radium-223 administration may have better outcomes compared to abiraterone in mCRPC patients without visceral metastasis.

Combined Immunotherapy and Tyrosine Kinase Inhibitor Treatment for Metastatic Renal Cell Carcinoma With Unknown Primary Origin: A Report of Two Cases and Literature Review

BACKGROUND/AIM

Renal cell carcinoma (RCC) of unknown primary origin is rarely identified and accounts for only 5% of cancers of unknown primary origin (CUP). The disease prognosis is typically poor because of no standard and effective therapy. Our review indicated that 23 cases have been reported and treated with conventional chemotherapy or tyrosine-kinase inhibitors alone; accordingly, most patients showed partial response or progression diseases with short survival time.

CASE REPORT

Herein, we present two cases of metastatic RCC of unknown primary origin. One case was papillary type and the other was clear cell type. According to the recent clinical trials in patients with metastatic RCC, a combination of immunotherapy and tyrosine-kinase inhibitors exhibited better response than conventional therapy or tyrosine-kinase inhibitors alone. Both present cases accepted a combination treatment with immunotherapy and tyrosine-kinase inhibitor and showed stable diseases. The radiological progression-free time for the case with metastatic papillary RCC was 5 months, and that with clear cell RCC was 6 months until now.

CONCLUSION

The combination of immunotherapy and tyrosine-kinase inhibitors is at least as effective as a tyrosine-kinase inhibitor alone, and superior to conventional chemotherapy for treating metastatic RCC of unknown primary origin.

Determination of potential sources of heavy metals in patients with urothelial carcinoma in central Taiwan: a biomonitoring case-control study

The clarification of possible exposure sources of multiple metals to identify associations between metal doses and urothelial carcinoma (UC) risk is currently limited in the literature. We sought to identify the exposure sources of 10 metals (Vanadium, chromium, manganese, cobalt, nickel, copper, zinc, arsenic, cadmium, and lead) using principal component analysis (PCA) and then linked various principal component (PC) scores with environmental characteristics, including smoking-related indices, PM2.5, and distance to the nearest bus station. In addition, urinary 8-hydroxy-2'-deoxyguanosine (8-OHdG) and DNA hypomethylation markers (5-methyl-2'-deoxycytidine levels; %5-MedC) were investigated in combination with UC risks. We conducted this hospital-based case control study in 359 UC patients with histologically confirmed disease and 718 controls. All data were collected from face-to-face interviews and medical records. Approximately 6 mL blood was collected from participants for analysis of multiple heavy metal and DNA methylation in leukocyte DNA. Further, a 20 mL urine sample was collected to measure urinary cotinine and 8-OHdG levels. In addition, average values for PM2.5 for individual resident were calculated using the hybrid kriging/land-use regression model. In UC patients, significantly higher cobalt, nickel, copper, arsenic, and cadmium (μg/L) levels were observed in blood when compared with controls. Three PCs with eigenvalues > 1 accounted for 24.3, 15.8, and 10.7% of UC patients, and 26.9, 16.7, and 11.1% of controls, respectively. Environmental metal sources in major clusters were potentially associated with industrial activities and traffic emissions (PC1), smoking (PC2), and food consumption, including vitamin supplements (PC3). Multiple metal doses were linked with incremental urinary 8-OHdG and DNA hypomethylation biomarkers. For individuals with high PC1 and PC2 scores, both displayed an approximate 1.2-fold risk for UC with DNA hypomethylation.In conclusion, we provide a foundation for health education and risk communication strategies to limit metal exposure in environment, so that UC risks can be improved potentially.

Learning Curve of Transperineal MRI/US Fusion Prostate Biopsy: 4-Year Experience

This study aimed to evaluate the learning curve of transperineal magnetic resonance imaging (MRI)/ultrasound (US) fusion biopsy in a team composed of a single surgeon, a single radiologist, and a single pathologist. We prospectively enrolled 206 patients undergoing MRI/US fusion prostate biopsy and divided them into four cohorts by the year of biopsy. We analyzed temporal changes in clinically significant prostate cancer (csPC) detection rate, percentage of positive cores on biopsy, and Gleason upgrading rate after radical prostatectomy. The csPC detection rate by MRI/US fusion targeted biopsy (TB) increased significantly (from 35.3% to 60.0%, p = 0.01). With increased experience, the csPC detection rates for small (≤1 cm) and anterior target lesions gradually increased (from 41.2% to 51.6%, p = 0.5; from 54.5% to 88.2%, p = 0.8, respectively). The percentage of positive cores on TB increased significantly (from 18.4% to 44.2%, p = 0.001). The Gleason upgrading rate gradually decreased (from 22.2% to 11.1%, p = 0.4). In conclusion, with accumulated experience and teamwork, the csPC detection rate by TB significantly increased. Multidisciplinary team meetings and a free-hand biopsy technique were the key factors for overcoming the learning curve.

Sodium-Glucose Transport Protein 2 Inhibitor Use for Type 2 Diabetes and the Incidence of Acute Kidney Injury in Taiwan

IMPORTANCE

The association between sodium-glucose transport protein 2 inhibitor (SGLT2i) use and the incidence of acute kidney injury (AKI) remains controversial. The benefits of SGLT2i use in patients to reduce AKI requiring dialysis (AKI-D) and concomitant diseases with AKI as well as improve AKI prognosis have not yet been established.

OBJECTIVE

To investigate the association between SGLT2i use and AKI incidence in patients with type 2 diabetes (T2D).

DESIGN, SETTING, AND PARTICIPANTS

This nationwide retrospective cohort study used the National Health Insurance Research Database in Taiwan. The study analyzed a propensity score-matched population of 104 462 patients with T2D treated with SGLT2is or dipeptidyl peptidase 4 inhibitors (DPP4is) between May 2016 and December 2018. All participants were followed up from the index date until the occurrence of outcomes of interest, death, or the end of the study, whichever was earliest. Analysis was conducted between October 15, 2021, and January 30, 2022.

MAIN OUTCOMES AND MEASURES

The primary outcome was the incidence of AKI and AKI-D during the study period. AKI was diagnosed using International Classification of Diseases diagnostic codes, and AKI-D was determined using the diagnostic codes and dialysis treatment during the same hospitalization. Conditional Cox proportional hazard models assessed the associations between SGLT2i use and the risks of AKI and AKI-D. The concomitant diseases with AKI and its 90-day prognosis, ie, the occurrence of advanced chronic kidney disease (CKD stage 4 and 5), end-stage kidney disease, or death, were considered when exploring the outcomes of SGLT2i use.

RESULTS

In a total of 104 462 patients, 46 065 (44.1%) were female patients, and the mean (SD) age was 58 (12) years. After a follow-up of approximately 2.50 years, 856 participants (0.8%) had AKI and 102 (<0.1%) had AKI-D. SGLT2i users had a 0.66-fold risk for AKI (95% CI, 0.57-0.75; P < .001) and 0.56-fold risk of AKI-D (95% CI, 0.37-0.84; P = .005) compared with DPP4i users. The numbers of patients with AKI with heart disease, sepsis, respiratory failure, and shock were 80 (22.73%), 83 (23.58%), 23 (6.53%), and 10 (2.84%), respectively. SGLT2i use was associated with lower risk of AKI with respiratory failure (hazard ratio [HR], 0.42; 95% CI, 0.26-0.69; P < .001) and shock (HR, 0.48; 95% CI, 0.23-0.99; P = .048) but not AKI with heart disease (HR, 0.79; 95% CI, 0.58-1.07; P = .13) and sepsis (HR, 0.77; 95% CI, 0.58-1.03; P = .08). The 90-day AKI prognosis for the risk of advanced CKD indicated a 6.53% (23 of 352 patients) lower incidence in SGLT2i users than in DPP4i users (P = .045).

CONCLUSIONS AND RELEVANCE

The study findings suggest that patients with T2D who receive SGLT2i may have lower risk of AKI and AKI-D compared with those who receive DPP4i.

Oncologic impact of delay between diagnosis and radical nephroureterectomy

Purpose

This study aimed to evaluate the oncological outcome of delayed surgical wait time from the diagnosis of upper tract urothelial carcinoma (UTUC) to radical nephroureterectomy (RNU).

Methods

In this multicenter retrospective study, medical records were collected between 1988 and 2021 from 18 participating Taiwanese hospitals under the Taiwan UTUC Collaboration Group. Patients were dichotomized into the early (≤90 days) and late (>90 days) surgical wait-time groups. Overall survival, disease-free survival, and bladder recurrence-free survival were calculated using the Kaplan-Meier method and multivariate Cox regression analysis. Multivariate analysis was performed using stepwise linear regression.

Results

Of the 1251 patients, 1181 (94.4%) were classifed into the early surgical wait-time group and 70 (5.6%) into the late surgical wait-time group. The median surgical wait time was 21 days, and the median follow-up was 59.5 months. Our study showed delay-time more than 90 days appeared to be associated with worse overall survival (hazard ratio [HR] 1.974, 95% confidence interval [CI] 1.166-3.343, p = 0.011), and disease-free survival (HR 1.997, 95% CI 1.137-3.507, p = 0.016). This remained as an independent prognostic factor after other confounding factors were adjusted. Age, ECOG performance status, Charlson Comorbidity Index (CCI), surgical margin, tumor location and adjuvant systemic therapy were independent prognostic factors for overall survival. Tumor location and adjuvant systemic therapy were also independent prognostic factors for disease-free survival.

Conclusions

For patients with UTUC undergoing RNU, the surgical wait time should be minimized to less than 90 days. Prolonged delay times may be associated with poor overall and disease-free survival.

METTL4-mediated nuclear N6-deoxyadenosine methylation promotes metastasis through activating multiple metastasis-inducing targets

BACKGROUND

DNA N6-methyldeoxyadenosine (6mA) is rarely present in mammalian cells and its nuclear role remains elusive.

RESULTS

Here we show that hypoxia induces nuclear 6mA modification through a DNA methyltransferase, METTL4, in hypoxia-induced epithelial-mesenchymal transition (EMT) and tumor metastasis. Co-expression of METTL4 and 6mA represents a prognosis marker for upper tract urothelial cancer patients. By RNA sequencing and 6mA chromatin immunoprecipitation-exonuclease digestion followed by sequencing, we identify lncRNA RP11-390F4.3 and one novel HIF-1α co-activator, ZMIZ1, that are co-regulated by hypoxia and METTL4. Other genes involved in hypoxia-mediated phenotypes are also regulated by 6mA modification. Quantitative chromatin isolation by RNA purification assay shows the occupancy of lncRNA RP11-390F4.3 on the promoters of multiple EMT regulators, indicating lncRNA-chromatin interaction. Knockdown of lncRNA RP11-390F4.3 abolishes METTL4-mediated tumor metastasis. We demonstrate that ZMIZ1 is an essential co-activator of HIF-1α.

CONCLUSIONS

We show that hypoxia results in enriched 6mA levels in mammalian tumor cells through METTL4. This METTL4-mediated nuclear 6mA deposition induces tumor metastasis through activating multiple metastasis-inducing genes. METTL4 is characterized as a potential therapeutic target in hypoxic tumors.

Pembrolizumab versus placebo as post-nephrectomy adjuvant therapy for clear cell renal cell carcinoma (KEYNOTE-564): 30-month follow-up analysis of a multicentre, randomised, double-blind, placebo-controlled, phase 3 trial

BACKGROUND

The first interim analysis of the KEYNOTE-564 study showed improved disease-free survival with adjuvant pembrolizumab compared with placebo after surgery in patients with clear cell renal cell carcinoma at an increased risk of recurrence. The analysis reported here, with an additional 6 months of follow-up, was designed to assess longer-term efficacy and safety of pembrolizumab versus placebo, as well as additional secondary and exploratory endpoints.

METHODS

In the multicentre, randomised, double-blind, placebo-controlled, phase 3 KEYNOTE-564 trial, adults aged 18 years or older with clear cell renal cell carcinoma with an increased risk of recurrence were enrolled at 213 hospitals and cancer centres in North America, South America, Europe, Asia, and Australia. Eligible participants had an Eastern Cooperative Oncology Group performance status of 0 or 1, had undergone nephrectomy 12 weeks or less before randomisation, and had not received previous systemic therapy for advanced renal cell carcinoma. Participants were randomly assigned (1:1) via central permuted block randomisation (block size of four) to receive pembrolizumab 200 mg or placebo intravenously every 3 weeks for up to 17 cycles. Randomisation was stratified by metastatic disease status (M0 vs M1), and the M0 group was further stratified by ECOG performance status and geographical region. All participants and investigators involved in study treatment administration were masked to the treatment group assignment. The primary endpoint was disease-free survival by investigator assessment in the intention-to-treat population (all participants randomly assigned to a treatment). Safety was assessed in the safety population, comprising all participants who received at least one dose of pembrolizumab or placebo. As the primary endpoint was met at the first interim analysis, updated data are reported without p values. This study is ongoing, but no longer recruiting, and is registered with ClinicalTrials.gov, NCT03142334.

FINDINGS

Between June 30, 2017, and Sept 20, 2019, 994 participants were assigned to receive pembrolizumab (n=496) or placebo (n=498). Median follow-up, defined as the time from randomisation to data cutoff (June 14, 2021), was 30·1 months (IQR 25·7-36·7). Disease-free survival was better with pembrolizumab compared with placebo (HR 0·63 [95% CI 0·50-0·80]). Median disease-free survival was not reached in either group. The most common all-cause grade 3-4 adverse events were hypertension (in 14 [3%] of 496 participants) and increased alanine aminotransferase (in 11 [2%]) in the pembrolizumab group, and hypertension (in 13 [3%] of 498 participants) in the placebo group. Serious adverse events attributed to study treatment occurred in 59 (12%) participants in the pembrolizumab group and one (<1%) participant in the placebo group. No deaths were attributed to pembrolizumab.

INTERPRETATION

Updated results from KEYNOTE-564 support the use of adjuvant pembrolizumab monotherapy as a standard of care for participants with renal cell carcinoma with an increased risk of recurrence after nephrectomy.

FUNDING

Merck Sharp & Dohme LLC, a subsidiary of Merck & Co, Inc, Rahway, NJ, USA.

Surgical outcome predictor analysis following hand-assisted or pure laparoscopic transperitoneal nephroureterectomy using the Taiwan upper urinary tract urothelial carcinoma database

Purpose

Taiwan has a high incidence of upper tract urothelial carcinoma (UTUC). This study aimed to compare the surgical outcomes following transperitoneal hand-assisted laparoscopic nephroureterectomy (TP-HALNU) and transperitoneal pure laparoscopic nephroureterectomy (TP-LNU) from the Taiwan nationwide UTUC collaboration database using different parameters, including surgical volumes.

Materials and methods

The nationwide UTUC collaboration database includes 14 hospitals in Taiwan from the Taiwan Cancer Registry. We retrospectively reviewed the records of 622 patients who underwent laparoscopic nephroureterectomy between July 1988 and September 2020. In total, 322 patients who received TP-LNU or TP-HALNU were included in the final analysis. Clinical and pathological data and oncological outcomes were compared.

Results

Of the 322 patients, 181 and 141 received TP-LNU and TP-HALNU, respectively. There were no differences in clinical and histopathological data between the two groups. No differences were observed in perioperative and postoperative complications. There were no significant differences in oncological outcomes between the two surgical approaches. In the multivariate analysis, the cohort showed that age ≥70 years, positive pathological lymph node metastasis, tumors located in the upper ureter, and male sex were predictive factors associated with an increased risk of adverse oncological outcomes. A surgical volume of ≥20 cases showed a trend toward favorable outcomes on cancer-specific survival [hazard ratio (HR) 0.154, p = 0.052] and marginal benefit for overall survival (HR 0.326, p = 0.019) in the multivariate analysis.

Conclusion

Although different approaches to transperitoneal laparoscopic nephroureterectomy showed no significant differences in surgical outcomes, age, sex, lymph node metastasis, and tumor in the upper ureter in the following period were predictive factors for oncological outcomes. Higher surgical volume did not impact disease-free survival and bladder recurrence-free survival but was associated with improved overall survival and cancer-specific survival. Exploration of unknown influencing factors is warranted.

The Resolution Rate of Pulmonary Embolism on CT Pulmonary Angiography: a Prospective Study

PURPOSE

To prospectively assess the rate of clot resolution from CT pulmonary angiography (CTPA) in patients with acute pulmonary embolism (PE).

MATERIALS AND METHODS

This prospective cohort study included 290 patients (136 men, 154 women; mean age, 51.9 years) with acute PE. All patients had a CTPA at the presentation and had at least one follow-up within 6 months (mean 72.7 days). Sixty-four percent of patients had follow-up scans for research purposes within a pre-determined period (between 28 and 184 days; mean, 78.27 days) and 36 % had (between 2 and 184 days; mean, 62.78 days) for a clinical indication. The volume of each clot was measured using a semi-automated quantification program. The resolution rate was evaluated by interval-censored analysis.

RESULTS

The overall estimated probability of complete resolution was 42 % at 7 days, 56 % at 10 days, and 71 % at 45 days. Achieving complete resolution was significantly faster in patients with peripheral clots (HR: 1.78; CI: 1.05-3.03, p = 0.032) but slower in patients with consolidation and history of venous thromboembolism (VTE), (HR: 0.37; CI: 0.18-0.79, p = 0.01 and HR: 0.57; CI: 0.35-0.91, p = 0.019, respectively). Although the patients with cancer showed a faster resolution rate (HR: 1.67; CI: 1.05-2.68, p = 0.032), the mortality rate was significantly higher than non-cancer patients.

CONCLUSION

The resolution rate of clot burden in acute PE was associated with patients' clinical presentation variables and CTPA imaging biomarkers. This information may be incorporated into designing a prediction rule and determining the appropriate duration of anticoagulation therapy in patients with acute PE.

The Value of Preoperative Local Symptoms in Prognosis of Upper Tract Urothelial Carcinoma After Radical Nephroureterectomy: A Retrospective, Multicenter Cohort Study

Purpose

We aimed to evaluate the impact of preoperative local symptoms on prognosis after radical nephroureterectomy in patients with upper tract urothelial carcinoma (UTUC).

Methods

This retrospective study consisted of 2,662 UTUC patients treated at 15 institutions in Taiwan from 1988 to 2019. Clinicopathological data were retrospectively collected for analysis by the Taiwan UTUC Collaboration Group. The Kaplan-Meier method was used to calculate overall survival (OS), cancer-specific survival (CSS), disease-free survival (DFS), and bladder recurrence-free survival (BRFS). The prognostic value of preoperative local symptoms in OS, CSS, DFS, and BRFS was investigated using Cox proportional hazards models.

Results

The median follow-up was 36.6 months. Among 2,662 patients, 2,130 (80.0%) presented with hematuria and 398 (15.0%) had symptomatic hydronephrosis at diagnosis. Hematuria was associated with less symptomatic hydronephrosis (p <0.001), more dialysis status (p = 0.027), renal pelvic tumors (p <0.001), and early pathological tumor stage (p = 0.001). Symptomatic hydronephrosis was associated with female patients (p <0.001), less dialysis status (p = 0.001), less bladder cancer history (p <0.001), ureteral tumors (p <0.001), open surgery (p = 0.006), advanced pathological tumor stage (p <0.001), and postoperative chemotherapy (p = 0.029). Kaplan-Meier analysis showed that patients with hematuria or without symptomatic hydronephrosis had significantly higher rates of OS, CSS, and DFS (all p <0.001). Multivariate analysis confirmed that presence of hematuria was independently associated with better OS (HR 0.789, 95% CI 0.661-0.942) and CSS (HR 0.772, 95% CI 0.607-0.980), while symptomatic hydronephrosis was a significant prognostic factor for poorer OS (HR 1.387, 95% CI 1.142-1.683), CSS (HR 1.587, 95% CI 1.229-2.050), and DFS (HR 1.378, 95% CI 1.122-1.693).

Conclusions

Preoperative local symptoms were significantly associated with oncological outcomes, whereas symptomatic hydronephrosis and hematuria had opposite prognostic effects. Preoperative symptoms may provide additional information on risk stratification and perioperative treatment selection for patients with UTUC.

Development and verification of the coaxial heterogeneous hyperspectral imaging system

A hyperspectral imaging system (HIS) is a helpful tool that acquires spatial and spectral information from a target. This study developed a coaxial heterogeneous HIS (CHHIS) to collect spectral images with wavelengths ranging from 400 to 1700 nm. In this system, a visible (VIS) spectrometer and a short-wave infrared (SWIR) spectrometer are combined with a coaxial optical path to share the same field of view. This structure reduces the complexity of spatial registration and maintains the scanning duration of two spectrometers as that of a single spectrometer. The spectrometers are also replaceable for extending the detecting spectral range of the system. The calibration methodologies, including spatial correction, spectral calibration, and reflectance calibration, were developed for this system. The signal-to-noise ratio of VIS and SWIR spectrometers in the CHHIS was up to 40 and 60 dB when the exposure time of the VIS and SWIR imaging sensors was 1000 and 10 ms, respectively. When the target distance was at 600 mm, the spatial error of VIS and SWIR images in the scanning direction was less than 1 pixel; these results proved that the system was stable.

A comparative study of transperineal software-assisted magnetic resonance/ultrasound fusion biopsy and transrectal cognitive fusion biopsy of the prostate

BACKGROUND

The advantages and disadvantages of transperineal and transrectal biopsies remain controversial in the era of prostate targeted biopsy. In this study, we compared the cancer detection and complication rates of transperineal magnetic resonance/ultrasound (MR/US) fusion biopsy and transrectal cognitive fusion biopsy of the prostate.

METHODS

This was a comparative study of two prospectively collected cohorts. Men with clinically suspected prostate cancer and prostate imaging reporting and data system (PI-RADS) score ≥ 3 lesions on multi-parametric magnetic resonance imaging (mpMRI) were enrolled. They underwent either transperineal software fusion biopsy or transrectal cognitive fusion biopsy and systematic biopsy. The detection rates of any prostate cancer and clinically significant prostate cancer (csPC, defined as Gleason score ≥ 3 + 4) and the complication rates between both groups were analysed.

RESULTS

Ninety-two and 85 patients underwent transperineal software fusion and transrectal cognitive fusion biopsies, respectively. The detection rate for any prostate cancer was similar between both groups (60.8% vs. 56.4%, p = 0.659). In terms of csPC detection, transperineal fusion biopsy outperformed transrectal fusion biopsy (52.2% vs. 36.5%, p = 0.036). In multivariate regression analysis, age, PI-RADS score > 3, and transperineal route were significant predictors of csPC. Meanwhile, transperineal biopsy resulted in a higher rate of urinary retention than transrectal biopsy (18.5% vs. 4.7%, p = 0.009). No serious infectious complications were noted, although a patient developed sepsis after transrectal biopsy.

CONCLUSIONS

Transperineal software fusion biopsy provided a higher csPC detection rate than transrectal cognitive fusion biopsy and carried minimal risk for infectious complications in patients with MRI-visible prostate lesions.

Is Lymph Node Dissection Necessary During Radical Nephroureterectomy for Clinically Node-Negative Upper Tract Urothelial Carcinoma? A Multi-Institutional Study

Purpose

This study aimed to compare the oncological outcomes of patients with upper tract urothelial carcinoma (UTUC) without clinical lymph node metastasis (cN0) undergoing lymph node dissection (LND) during radical nephroureterectomy (NU).

Methods

From the updated data of the Taiwan UTUC Collaboration Group, a total of 2726 UTUC patients were identified. We only include patients with ≥ pT2 stage and enrolled 658 patients. The Kaplan–Meier estimator and Cox proportional hazards model were used to analyze overall survival (OS), cancer-specific survival (CSS), disease-free survival (DFS), and bladder recurrence-free survival (BRFS) in LND (+) and LND (−) groups.

Results

A total of 658 patients were included and 463 patients without receiving LND and 195 patients receiving LND. From both univariate and multivariate survival analysis, there are no significant difference between LND (+) and LND (-) group in survival rate. In LND (+) group, 18.5% patients have pathological LN metastasis. After analyzing pN+ subgroup, it revealed worse CSS (p = 0.010) and DFS (p &lt; 0.001) compared with pN0 patients.

Conclusions

We found no significant survival benefit related to LND in cN0 stage, ≥ pT2 stage UTUC, irrespective of the number of LNs removed, although pN+ affected cancer prognosis. However, from the result of pN (+) subgroup of LND (+) cohort analysis, it may be reasonable to not perform LND in patients with cT2N0 stage due to low positive predictive value of pN (+). In addition, performing LND may be considered for ureter cancer, which tends to cause lymphatic and hematogenous tumor spreading. Further large prospective studies are needed to validate our findings.

Factors Predicting Oncological Outcomes of Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma in Taiwan

Background

Taiwan is one of the endemic regions where upper tract urothelial carcinoma (UTUC) accounts for approximately a third of all urothelial tumors. Owing to its high prevalence, extensive experience has been accumulated in minimally invasive radical nephroureterectomy (RNU). Although a variety of predictive factors have been explored in numerous studies, most of them were on a single-center or limited institutional basis and data from a domestic cohort are lacking.

Objective

This study aims to identify significant predicting factors of oncological outcomes, including overall survival (OS), cancer-specific survival (CSS), disease-free survival (DFS), and intravesical recurrence-free survival (IVRFS), following RNU for UTUC in Taiwan.

Methods

A multicenter registry database, Taiwan UTUC Collaboration Group, was utilized to analyze oncological outcomes of 3,333 patients undergoing RNU from 1988 to 2021 among various hospitals in Taiwan. Clinicopathological parameters were recorded according to the principles established by consensus meetings. The Kaplan-Meier estimator was utilized to estimate the survival rates, and the curves were compared using the stratified log-rank test. Univariate and multivariate analyses were performed with the Cox proportional hazard model to explore potential predicting factors.

Results

With a median follow-up of 41.8 months in 1,808 patients with complete information, the 5-year IVRFS, DFS, CSS, and OS probabilities were 66%, 72%, 81%, and 70%, respectively. In total, 482 patients experienced intravesical recurrence, 307 died of UTUC, and 583 died of any cause. Gender predominance was female (57%). A total of 1,531 patients (84.7%) had high-grade tumors; preoperative hydronephrosis presented in 1,094 patients (60.5%). Synchronous bladder UC was identified in 292 patients (16.2%). Minimally invasive procedures accounted for 78.8% of all surgeries, including 768 hand-assisted laparoscopic (42.5%) and 494 laparoscopic (27.3%) approaches. Synchronous bladder UC was the dominant adverse predicting factor for all survival outcomes. Other independent predicting factors for OS, CSS, and DFS included age ≧70, presence of preoperative hydronephrosis, positive surgical margin, LVI, pathological T and N staging, and laparoscopic RNU.

Conclusion

Synchronous UC of the urinary bladder is an independent adverse prognostic factor for survival in UTUC. The presence of preoperative hydronephrosis was also corroborated as a disadvantageous prognostic factor. Our multivariate analysis suggested that laparoscopic RNU might provide better oncological control.

Combining prostate health index and multiparametric magnetic resonance imaging in estimating the histological diameter of prostate cancer

Background

Although multiparametric magnetic resonance imaging (mpMRI) is widely used to assess the volume of prostate cancer, it often underestimates the histological tumor boundary. The aim of this study was to evaluate the feasibility of combining prostate health index (PHI) and mpMRI to estimate the histological tumor diameter and determine the safety margin during treatment of prostate cancer.

Methods

We retrospectively enrolled 72 prostate cancer patients who underwent radical prostatectomy and had received PHI tests and mpMRI before surgery. We compared the discrepancy between histological and radiological tumor diameter stratified by Prostate Imaging-Reporting and Data System (PI-RADS) score, and then assessed the influence of PHI on the discrepancy between low PI-RADS (2 or 3) and high PI-RADS (4 or 5) groups.

Results

The mean radiological and histological tumor diameters were 1.60 cm and 2.13 cm, respectively. The median discrepancy between radiological and histological tumor diameter of PI-RADS 4 or 5 lesions was significantly greater than that of PI-RADS 2 or 3 lesions (0.50 cm, IQR (0.00–0.90) vs. 0.00 cm, IQR (−0.10–0.20), p = 0.02). In the low PI-RADS group, the upper limit of the discrepancy was 0.2 cm; so the safety margin could be set at 0.1 cm. In the high PI-RADS group, the upper limits of the discrepancy were 1.2, 1.6, and 2.2 cm in men with PHI < 30, 30–60, and > 60; so the safety margin could be set at 0.6, 0.8, and 1.1 cm, respectively.

Conclusions

Radiological tumor diameter on mpMRI often underestimated the histological tumor diameter, especially for PI-RADS 4 or 5 lesions. Combining mpMRI and PHI may help to better estimate the histological tumor diameter.

Association of Sodium-Glucose Transport Protein 2 Inhibitor Use for Type 2 Diabetes and Incidence of Gout in Taiwan

IMPORTANCE

The use of sodium-glucose transport protein 2 (SGLT2) inhibitors is currently a standard intervention in patients with type 2 diabetes (T2DM) and exerts favorable pleiotropic effects to consistently lower blood urate levels. However, to date, no association between SGLT2 inhibitor use and the incidence of gout have been established.

OBJECTIVE

To investigate whether prescribed SGLT2 inhibitors are associated with lower gout incidence in patients with T2DM.

DESIGN, SETTING, AND PARTICIPANTS

In a cohort study, all patients with incident T2DM in Taiwan National Health Institution databases between May 1, 2016, and December 31, 2018, were retrospectively analyzed. As a comparator, patients using dipeptidyl peptidase 4 (DPP4) inhibitors were included. A total of 47 905 individuals receiving an SGLT2 inhibitor and 183 303 receiving a DPP4 inhibitor were evaluated, along with 47 405 pairs of patients using an SGLT2 inhibitor or DPP4 inhibitor in 1:1 propensity score-matched analyses. Data analysis was conducted from April 1 to June 30, 2021.

MAIN OUTCOMES AND MEASURES

A gout diagnosis was based on the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and the International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). Multiple Cox proportional hazards regression models were used to calculate hazard ratios (HRs) and 95% CIs.

RESULTS

In total, 231 208 patients with T2DM were included in the population; 113 812 individuals (49.22%) were women, and the mean (SD) age was 61.53 (12.86) years. The overall gout incidence was 20.26 per 1000 patient-years for SGLT2 inhibitor users and 24.30 per 1000 patient-years for DPP4 inhibitor users. When potential risk factors were adjusted in the propensity score-matched population, use of SGLT2 inhibitors was associated with a lower risk of gout (HR, 0.89; 95% CI, 0.82-0.96) compared with DPP4 inhibitors, particularly for patients receiving dapagliflozin (HR, 0.86; 95% CI, 0.78-0.95). A sensitivity analysis, performed when a gout diagnosis was ascertained using the ICD-9-CM or ICD-10-CM code with gout-related medication, also showed a significantly lower risk for gout incidence of 15% with SGLT2 inhibitors (HR, 0.85; 95% CI, 0.74-0.97). Subgroup analysis indicated that SGLT2 inhibitor benefits in patients with T2DM to achieve a lower gout risk were not different across subgroups.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that patients with T2DM who are receiving SGLT2 inhibitors may have a lower risk for gout compared with those receiving DPP4 inhibitors.

Comparing Oncological Outcomes and Surgical Complications of Hand-Assisted, Laparoscopic and Robotic Nephroureterectomy for Upper Tract Urothelial Carcinoma

Purpose

This study aimed to compare the oncological outcomes and surgical complications of patients with upper tract urothelial carcinoma (UTUC) treated with different minimally invasive techniques for nephroureterectomy.

Methods

From the updated data of the Taiwan UTUC Collaboration Group, a total of 3,333 UTUC patients were identified. After excluding ineligible cases, we retrospectively included 1,340 patients from 15 institutions who received hand-assisted laparoscopic nephroureterectomy (HALNU), laparoscopic nephroureterectomy (LNU) or robotic nephroureterectomy (RNU) between 2001 and 2021. Kaplan-Meier estimator and Cox proportional hazards model were used to analyze the survival outcomes, and binary logistic regression model was selected to compare the risks of postoperative complications of different surgical approaches.

Results

Among the enrolled patients, 741, 458 and 141 patients received HALNU, LNU and RNU, respectively. Compared with RNU (41.1%) and LNU (32.5%), the rate of lymph node dissection in HALNU was the lowest (17.4%). In both Kaplan-Meier and univariate analysis, the type of surgery was significantly associated with overall and cancer-specific survival. The statistical significance of surgical methods on survival outcomes remained in multivariate analysis, where patients undergoing HALNU appeared to have the worst overall (p = 0.007) and cancer-specific (p = 0.047) survival rates among the three groups. In all analyses, the surgical approach was not related to bladder recurrence. In addition, HALNU was significantly associated with longer hospital stay (p = 0.002), and had the highest risk of major Clavien-Dindo complications (p = 0.011), paralytic ileus (p = 0.012), and postoperative end-stage renal disease (p <0.001).

Conclusions

Minimally invasive surgery can be safe and feasible. We proved that compared with the HALNU group, the LNU and RNU groups have better survival rates and fewer surgical complications. It is crucial to uphold strict oncological principles with sophisticated technique to improve outcomes. Further prospective studies are needed to validate our findings.

Graft kidney hydronephrosis caused by transplant ureter inguinal hernia: A case report

RATIONALE

Ureteral obstruction of the graft kidney is a common complication of kidney transplantation. However, ureteral obstruction caused by inguinal hernia has rarely been reported. We present a rare case of ureteral obstruction with allograft dysfunction caused by an inguinal hernia.

PATIENT CONCERNS

A 76-year-old man, who was a renal transplant recipient, presented with bilateral pitting oedema, reduced urine output, and right inguinal hernia.

DIAGNOSES

Abdominal computed tomography revealed severe hydroureteronephrosis of the kidney allograft. A right inguinal hernia with ureteral incarceration was observed.

INTERVENTIONS

The patient underwent graft percutaneous nephrostomy, followed by antegrade insertion of a double-J tube (DJ). Gradual improvement was observed in his renal function. Right inguinal herniorrhaphy was performed 5 days later.

OUTCOMES

The renal function returned to normal after percutaneous nephrostomy and insertion of the DJ. A right inguinal direct-type hernia with ureter adhesion to the hernial sac was observed during the surgery. The posterior wall defect was repaired by the McVay technique. The DJ was removed after 1 month. The patient's renal function remained stable at 6-month follow-up.

LESSONS

The orientation of the graft kidney has a significant influence on the location of the ureter. Upward orientation of the hilum will result in superficial location of the ureter, rendering it close to the hernial sac and susceptible to incarceration. The transplant surgeon should be aware of such a presentation of graft dysfunction with inguinal hernia to prevent a delay in the diagnosis and graft loss.

Relationships among cigarette smoking, urinary biomarkers, and urothelial carcinoma risk: a case-control study

Cigarette smoke is a known risk factor for urothelial carcinoma (UC). However, there is limited information about the distributions and effects of volatile organic compounds (VOCs) on smoking-related UC risk. With this hospital-based case-control study, we explored the associations between urinary levels of cotinine and VOC metabolites (acrylamide, 1,3-butadiene, and benzene) and the risk of UC. Urological examinations and pathological verifications were used to confirm the diagnoses of UC. All study participants provided smoking-related information via questionnaires and face-to-face interviews; they also provided urine samples for the measurement of VOC metabolites, cotinine, and 8-hydroxydeoxyguanosine (8-OHdG), which was used as an indicator of oxidative stress. We applied multiple logistic regression analysis to estimate the risk of UC, and we found that levels of urinary cotinine and 8-OHdG were higher in the UC group than in the control group. Furthermore, urinary levels of VOC metabolites, including N-acetyl-S-(2-carbamoylethyl)-L-cysteine (AAMA), N-acetyl-S-(2-carbamoyl-2-hydroxyethyl)-L-cysteine, N-acetyl-S-(4-hydroxy-2-buten-1-yl)-L-cysteine-3, trans,trans-muconic acid (t,t-MA), and S-phenylmercapturic acid (SPMA), increased with increasing levels of urinary cotinine. After adjusting for potential risk factors, dose-response relationships were observed between UC risk and urinary levels of AAMA, t,t-MA, SPMA, and 8-OHdG. Participants with high urinary levels of cotinine, AAMA, t,t-MA, SPMA, and 8-OHdG had risks of UC that were 3.5- to 6-fold higher than those of participants with lower levels. Future, large-scale investigations of the risks of UC should be explored, and repeated measurement of VOC metabolites should be assessed.

A retroperitoneal cavernous hemangioma arising from the gonadal vein: A case report

RATIONALE

Cavernous hemangioma (CH) is not commonly found within the abdomen or the retroperitoneum. We report the first case of CH originating from the gonadal vein.

DIAGNOSIS

A retroperitoneal tumor was found incidentally in a 57-year-old female patient. The differential diagnoses from the initial imaging studies included gastrointestinal stromal tumor, carcinoid tumor, neurogenic tumor, metastasis, lymphadenopathy, or another rare tumor.

INTERVENTIONS

A surgical en-bloc excision was performed via a subcostal incision and intravenous CH arising from a gonadal vein was diagnosis by the urological pathologist.

OUTCOMES

After the surgery, no complications were noted. A computed tomography scan was performed after 3 months follow-up and no tumor recurrence was found.

LESSONS

This case reminds us that CH should be listed as one of the differential diagnoses for a retroperitoneal tumor. A definite diagnosis of CH relies on surgical resection. The prognosis is well if adequate resection is performed.

External validation of the Simplified PADUA REnal (SPARE) nephrometry system in predicting surgical outcomes after partial nephrectomy

BACKGROUND

Pentafecta is a major goal in the era of partial nephrectomy (PN). Simplified PADUA REnal (SPARE) nephrometry system was developed to evaluate the complexity of tumor. However, the predictive ability in pentafecta of SPARE system is yet to be determined. The aim of this study was to externally validate the applicability of SPARE nephrometry system in predicting pentafecta achievement after partial nephrectomy, and to examine inter-observer concordance.

METHODS

We retrospectively reviewed data of 207 consecutive patients who underwent PN between January 2012 and August 2018 at a tertiary referral center. We obtained SPARE, R.E.N.A.L., and PADUA scores and evaluated correlations among the nephrometries and surgical outcomes including pentafecta by Spearman test. Logistic regression analysis was used to identify independent predictors of pentafecta outcomes. We compared the nephrometries to determine the predictive ability of achieving pentafecta using receiver operating characteristic curve analysis. Fleiss' generalized kappa was used to assessed interobserver variation in the SPARE system.

RESULTS

Based on the SPARE system, 120, 74, and 13 patients were stratified into low-risk, intermediate-risk, and high-risk groups, respectively. Regarding the individual components of pentafecta, there were significant differences in the complication rate (p = 0.03), ischemia time (p < 0.001), and percent change of eGFR (p < 0.001) among the three risk groups. In addition, higher tumor complexity was significantly associated with a lower achievement rate of pentafecta (p = 0.01). In Spearman correlation tests, SPARE nephrometry was correlated with ischemia time (ρ:0.37, p < 0.001), operative time (ρ:0.28, p < 0.001), complication rate (ρ:0.34, p < 0.001), percent change of eGFR (ρ:0.34, p < 0.001), and progression of chronic kidney disease stage (ρ:0.17, p = 0.02). Multivariate analysis revealed that SPARE significantly affected pentafecta (OR: 0.67, p < 0.001). In ROC curve analysis, SPARE showed fair predictive ability in the achievement pentafecta (AUC: 0.71). The predictive ability of pentafecta was similar between nephrometries (SPARE vs. R.E.N.A.L., p = 0.78; SPARE vs. PADUA, p = 0.66). The interobserver concordance of SPARE was excellent (Kappa: 0.82, p = 0.03).

CONCLUSIONS

SPARE system was a predictive factor of surgical outcomes after PN. This refined nephrometry had similar predictive abilities for pentafecta achievement compared with R.E.N.A.L. and PADUA.

Is combined peritoneal dialysis and hemodialysis redundant? A nationwide study from Taiwan

Background

Combined peritoneal dialysis (PD) and hemodialysis (HD) therapy (combined therapy) has numerous clinical benefits and should be emphasized for PD patients encountering technique failure.

Methods

This 12-year nationwide retrospective study was conducted to compare long-term outcomes (including admission and mortality risks) between combined therapy patients (combined group) and patients directly transferred from PD to HD (transfer group).

Results

All 12,407 incidental PD patients from 2000 to 2010 were enrolled and followed up until the end of 2011. A total of 688 patients in the combined group and 688 patients in the transfer group were selected after 1:1 frequency matching based on age, sex, and PD duration. The overall admission and mortality risks of the two groups were comparable in a Cox proportional hazards model (adjusted hazard ratio [HR] = 1.06 [95% confidence interval (CI) = 0.95–1.19] and 1.02 [95% CI = 0.80–1.30]), respectively). Compared with the transfer group, combined group patients with recent peritonitis or frequent hemodialysis (four HD sessions per month) had significantly higher risk of admission while combined group patients without peritonitis had significantly lower risk. The number of incidents in the combined group increased over time. On average, patients stayed on combined therapy for 2 years.

Conclusions

Combined therapy (two HD sessions per month) is not redundant but a rational and cost-effective treatment, particularly for patients without recent peritonitis. Dialysis staff should be familiar with the advantages and disadvantages of combined therapy and consider it an essential part of integrated dialysis care.

De Novo Malignancy After Heart, Kidney, and Liver Transplant: A Nationwide Study in Taiwan

OBJECTIVES

In the Asian population, patterns and risk factors for de novo malignancies after solid-organ transplant are not well understood.

MATERIALS AND METHODS

Insurance claims from Taiwan's National Health Institute Research Database from 1997 to 2011 revealed 687 deceased-donor heart transplant recipients, 5038 kidney transplant recipients (50% living related-donor, 50% deceased-donor transplants), and 2127 liver transplant recipients (mainly living related-donor transplants, 30% deceased-donor transplants). During the follow-up period, rates of malignancy incidence were calculated with standardization based on national age, sex, and year-specific incidence. We used multivariate regression analyses to determine risk factors of posttransplant de novo malignancies.

RESULTS

Compared with the general population, several de novo cancers were more common posttransplant (P < .05): lung cancer (2.6-fold), non-melanoma skin cancer (5.8-fold), and non-Hodgkin lymphoma (5.4-fold) in heart recipients; transitional cell carcinoma (31.4-fold), renal cell carcinoma (37.3-fold), and non-Hodgkin lymphoma (3.6-fold) in kidney recipients; and gastric cancer (3.0-fold) and lymphatic-hematopoietic malignancy (4.5-fold) in liver recipients. Independent risk factors for posttransplant malignancy in kidney transplant recipients were increased age, female, hepatitis B virus, and mycophenolate use (adjusted hazard ratio 1.5; 95% confidence interval, 1.2-1.8; P < .001). In liver transplant recipients, old age was an independent risk factor. Kidney transplant recipients without diabetes or hypertension had higher risk of transitional cell carcinoma (adjusted hazard ratio 3.0; 95% confidence interval, 2.1-4.4; P < .001) and renal cell carcinoma (adjusted hazard ratio 1.9; 95% confidence interval, 1.1-3.3; P < .05).

CONCLUSIONS

Regional endemic epidemiologic factors play significant roles in the development of de novo cancers, particularly in kidney transplant recipients due to causes of renal failure other than diabetes and hypertension. Each regional organ transplant program should tailor and establish its surveillance protocol based on epidemiologic data. However, the type and intensity of surveillance require further and long-term investigations in this patient cohort.

Clinical burden of autosomal dominant polycystic kidney disease

There are no specific therapies for autosomal dominant polycystic kidney disease (ADPKD), and clinical data evaluating the effects of non-specific therapies on ADPKD patients are scarce. We therefore evaluated those effects using data from a longitudinal health insurance database collected from 2000-2010. We individually selected patients with and without ADPKD from inpatient data files as well as from the catastrophic illness registry in Taiwan based on 1:5 frequency matching for sex, age, and index year. The hazard ratios (HR) of all-cause mortality, ischemic stroke, hemorrhagic stroke and end-stage renal disease (ESRD) in ADPKD inpatients were elevated as compared to the controls. Similarly, ADPKD patients from the catastrophic illness registry had an increased risk of hemorrhagic stroke and ESRD. Allopurinol users also had an increased risk of all-cause mortality. The HR for developing ESRD after medication exposure was 0.47-fold for statin and 1.93-fold for pentoxifylline. These results reveal that patients with ADPKD (either inpatient or from the catastrophic illness registry) are at elevated risk for hemorrhagic stroke and ESRD, and suggest that allopurinol and pentoxifylline should not be prescribed to ADPKD patients due to possible adverse effects.

Examining the association between oral health status and dementia: A nationwide nested case-controlled study

Alzheimer’s disease as a consequence of chronic brain inflammation mediated by infectious microbes including the oral microbiome continues to attract support. Taiwan’s National Insurance database was used to evaluate associations between dental health and Alzheimer’s disease; 209,112 new cases of Alzheimer’s disease were matched 1:4 with 836,448 dementia-free controls to test the hypothesis that better dental health would be associated with less occurrence of dementia. Ten year dental records and conditional logistic regression models were used to estimate the odds ratios associated with Alzheimer’s disease. Subgroup analyses compared vascular Alzheimer’s disease and sporadic Alzheimer’s disease. As the population aged, Alzheimer’s disease diagnoses were more frequent with a 10 fold upward inflection after 60. Nearly 56% of sporadic Alzheimer’s disease patients were women but less than 50% had vascular Alzheimer’s disease. Comorbidities were 10–20% higher in the Alzheimer’s disease patients than in controls, but stroke, chronic infection, and pneumonia were 40–45% more common in the vascular Alzheimer’s disease patients. Heart disease, hypertension, diabetes, stroke, peripheral artery disease, pneumonia, and herpetic disease (HSV) were all associated with higher odds of Alzheimer’s disease. HSV was not a factor in the vascular Alzheimer’s disease. Routine dental procedures tended to lower odds ratios. Root canals and extractions that restore oral homeostasis were associated with lower odds of dementia. However, when extractions exceeded four, the odds of Alzheimer’s disease rose. The fact that Alzheimer’s disease was not associated with periodontal procedures per se but with more frequent periodontal emergencies suggested again a chronic issue. Dental health costs suggest that good dental care was associated with lower odds of Alzheimer’s disease except for radiographic costs which were consistently associated with higher odds, independent of oral health. Common comorbid conditions were associated with higher odds of Alzheimer’s disease and oral health care was associated with lower odds, providing support for the hypothesis that the oral microbiome is a factor in the development of Alzheimer’s disease.

Impact statement

This study clearly demonstrates the power and value of a nationally applied digital medical record. Longitudinal studies of gradually developing pathologies like dementia have often been limited by sample size and narrow and incomplete medical histories. The Taiwan National Insurance database provides an unparalleled opportunity for detailed analyses of associations between current medical conditions and a spectrum of prior medical and dental events. The temporal impact of the database will only become more important as the past historical record progressively expands going forward. The inclusion of dental records in assessing the relationship with subsequent dementia is very important because this information is often unavailable or dependent on subject recall. This study clearly establishes associations between a variety of suspected cardiovascular and metabolic factors and the odds of dementia. A critical outcome should include the design of targeted interventions and the subsequent assessment of their efficacy.

Subsequent risk of acute urinary retention and androgen deprivation therapy in patients with prostate cancer: A population-based retrospective cohort study

Acute urinary retention (AUR) is associated with hormone imbalance in men. However, limited studies focused on exploring the complications of AUR in patients with prostate cancer (PC) who receive androgen deprivation therapy (ADT). Therefore, we aim to evaluate the subsequent risk of AUR in ADT-treated PC patients. We collected data from 24,464 male patients who were newly diagnosed with prostate malignancy from a longitudinal health insurance database of catastrophic illness in 2000 to 2008. All PC patients were categorized into 2 cohorts, namely, ADT cohort and non-ADT cohort, based on whether or not the patient receives ADT. The patients were followed up until the occurrence of AUR. Multivariate Cox proportional hazard regression and Kaplan-Meier analysis were performed. After a 12-year follow-up, the incidence rates of AUR were 12.49 and 9.86 per 1000 person-years in ADT and non-ADT cohorts, respectively. Compared with the non-ADT cohort, the ADT cohort had a 1.21-fold increase in AUR risk based on the adjusted model (95% CI = 1.03-1.43). In addition, PC patients receiving early ADT treatment within 6 months or receiving only luteinizing hormone-releasing hormone treatment also had significantly increased risk of AUR. ADT was positively associated with AUR risk. PC patients receiving ADT should be informed about the risks of bladder outlet obstruction and AUR, and they may benefit from screening for related risk factors. New guidelines and treatments should be proposed in the future to manage ADT-related lower urinary tract symptoms and reduce the risk of AUR.

Increased risk of prostatitis in male patients with depression

Objectives: To investigate whether male patients with depression are at an increased risk of prostatitis.Methods: We used a universal insurance claims database in Taiwan from 2000 to 2010 to identify patients with newly diagnosed depression (n = 13,019) (depression cohort) and those without depression (n = 53,026) (comparison cohort). Both cohorts were matched by age and index year of depression incidence. Hazard ratios of prostatitis were calculated by multivariable Cox proportional hazard models.Results: The incidence of prostatitis demonstrated a 2-fold increase in the depression cohort in comparison with that observed in the non-depression cohort, with an adjusted hazard ratio of 1.70 after adjustment for age, occupation, urbanisation level, potential comorbidity and medication. Furthermore, patients with depression, relative to the non-depression cohort, were 1.85-fold more likely to develop acute prostatitis, 1.76-fold more likely to develop chronic prostatitis and 1.63-fold more likely to develop unspecific prostatitis. Major associations still existed; even those stratified by age, occupation, urbanisation level and comorbidity all showed greater increased risks of prostatitis in the depression cohort than in the non-depression cohort.Conclusions: Depression can be an independent factor associated with the increased risk of prostatitis for men. The incidence of chronic prostatitis is greater than that of acute prostatitis. Close surveillance for UTI and depression treatment and lifestyle intervention should be considered for men with high risk for prostatitis. The mechanism associated with the development of prostatitis in men with depression requires further study. In addition, the mechanism of prostatitis may need comprehensive investigation.

Different androgen deprivation therapies might have a differential impact on cognition - An analysis from a population-based study using time-dependent exposure model

BACKGROUND

Androgen deprivation therapy (ADT) remains the mainstay treatment for locally advanced or metastatic prostate cancer (PC). However, potential effects of ADT treatment on neurocognitive dysfunction remain unclear. The present study was conducted to assess the relation between ADT treatment and risk of cognitive decline in Asian men with PC.

METHODS

A population-based cohort of 24,464 men with PC, each newly diagnosed between 2000 and 2008, was selected from the Taiwan National Health Insurance Database. Subjects were further grouped by treatment as non-ADT (n = 4685) or ADT (n = 12,740), members of the latter subjected to bilateral orchiectomy or medical treatment (ie, luteinizing hormone-releasing hormone agonists, antiandrogens, or combination therapy). A multivariable Cox proportional hazard model with ADT as time-dependent covariate was used to generate adjusted hazard ratios (HRs) of subsequent cognitive decline, including dementia, Alzheimer's disease (AD), and Parkinson's disease (PD).

RESULTS

ADT showed a significant association with overall risk of cognitive decline (HR = 1.51, 95 % CI: 1.31-1.74), especially for PD, dementia, and non-Alzheimer dementia (non-AZD). When stratified by various ADT regimens, antiandrogen-only recipients displayed significantly heightened risks of subsequent AD, non-AZD, and PD. However, combined androgen blockade also imposed an increased risk of PD. There was no apparent correlation between duration of ADT exposure and cognitive dysfunction.

CONCLUSIONS

Various ADT therapies may have disparate impacts on cognitive function. Prospective studies exploring pertinent clinical characteristics more fully are needed to confirm these findings.

Internal hernia from the interureteric space after robot-assisted radical cystectomy and urinary diversion: Two case reports

RATIONALE

Radical cystectomy and urinary diversion remains the definite management for muscle invasive bladder urothelial cancer. Internal herniation caused by ureteral adhesion is an extremely rare complication after the procedure. To the best of our knowledge, this is the first case report of small bowel obstruction and internal herniation occurring between bilateral ureters and urinary diversion after robot-assisted radical cystectomy (RARC).

PATIENT CONCERNS

A 64-year-old woman presented with symptom of small bowel obstruction such as nausea, vomiting, and abdominal fullness after RARC and Indiana pouch. Another 61-year-old man presented with left obstructive hydronephrosis and recurrent pyelonephritis after RARC and ileal conduit.

DIAGNOSIS

Both patients received computed tomography scans and the results were suggestive of small bowel herniation between bilateral ureters and urinary diversion.

INTERVENTIONS

The 2 patients underwent open ureterolysis and internal hernia reduction. During the operation, bowel loop herniation between the interureteral spaces were found.

OUTCOMES

Both patients recovered smoothly after second operation.

LESSONS

The incidence of internal herniation may increase by the growing use of RARC. Suitable stoma position, appropriate length of ureter dissection, and retroperitonealization can help prevent this complication.

Combining prostate health index and multiparametric magnetic resonance imaging in the diagnosis of clinically significant prostate cancer in an Asian population

Objective

To evaluate the practicability of combining prostate health index (PHI) and multiparametric magnetic resonance imaging (mpMRI) for the detection of clinically significant prostate cancer (csPC) in an Asian population.

Patients and methods

We prospectively enrolled patients who underwent prostate biopsy due to elevated serum prostate-specific antigen (PSA > 4 ng/mL) and/or abnormal digital rectal examination in a tertiary referral center. Before prostate biopsy, the serum samples were tested for PSA, free PSA, and p2PSA to calculate PHI. Besides, mpMRI was performed using a 3-T scanner and reported in the Prostate Imaging Reporting and Data System version 2 (PI-RADS v2). The diagnostic performance of PHI, mpMRI, and combination of both was assessed.

Result

Among 102 subjects, 39 (38.2%) were diagnosed with PC, including 24 (23.5%) with csPC (Gleason ≥ 7). By the threshold of PI-RADS ≥ 3, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) to predict csPC were 100%, 44.9%, 35.8%, and 100%, respectively. By the threshold of PHI ≥ 30, the sensitivity, specificity, PPV, and NPV to predict csPC were 91.7%, 43.6%, 33.3%, and 94.4%, respectively. The area under the receiver operator characteristic curve of combining PHI and mpMRI was greater than that of PHI alone (0.873 vs. 0.735, p = 0.002) and mpMRI alone (0.873 vs. 0.830, p = 0.035). If biopsy was restricted to patients with PI-RADS 5 as well as PI-RADS 3 or 4 and PHI ≥ 30, 50% of biopsy could be avoided with one csPC patient being missed.

Conclusion

The combination of PHI and mpMRI had higher accuracy for detection of csPC compared with PHI or mpMRI alone in an Asian population.

The role of RENAL, PADUA, C-index, CSA nephrometry systems in predicting ipsilateral renal function after partial nephrectomy

Background

Functional outcome is an important issue in nephron-sparing surgery. Various nephrometries have been developed to predict renal function preservation. The aim of this study was to examine the applicability of R.E.N.A.L., PADUA, C-index, and mathematical tumor contact surface area (CSA) in predicting ipsilateral renal function after partial nephrectomy using radio-isotope scans.

Methods

We performed this retrospective study in patients who underwent partial nephrectomy between May 2013 and April 2017, and used abdominopelvic computerized tomography or magnetic resonance imaging to obtain R.E.N.A.L., C-index, and CSA. Renal function was measured by 99mTc mercaptoacetyltriglycine (MAG3). We evaluated correlations between nephrometries and perioperative parameters, and comparatively analyzed different nephrometries to determine the predictive ability in the percent change of effective renal plasma flow of the affected kidney.

Results

Three, two, and 35 patients received partial nephrectomy in open, laparoscopic, and robotic approaches, respectively. The median (IQR) tumor size was 3.13 (2.4) cm. The median (IQR) R.E.N.A.L., PADUA, C-index, and CSA scores were 7 (3), 8 (2), 2.01 (1.87), and 14.14 (19.25) cm², respectively. Spearman correlation analysis showed that four nephrometries were correlated with each other. The strongest correlations were between CSA and C-index (coefficient: − 0.885, p < 0.001), followed by R.E.N.A.L. and PADUA (coefficient: 0.778, p < 0.001). Ischemia time was significantly correlated with R.EN.A.L. (coefficient: 0.35, p = 0.025), PADUA (coefficient: 0.42, p = 0.007), C-index (coefficient: − 0.45, p = 0.004), and CSA (coefficient: 0.41, p = 0.009). In multivariate analysis, PADUA significantly affected ischemia time (p = 0.04). The percent change in effective renal plasma flow (PCE) of the operated kidney was correlated with PADUA (coefficient: 0.48 p = 0.002), C-index (coefficient: − 0.74, p < 0.001), and CSA (coefficient: 0.75, p < 0.001). Only CSA and C-index independently affected PCE (both p < 0.05) in multivariate analysis. In ROC curve analysis, both C-index and CSA could predict 20% change in effective renal plasma flow (AUC: 0.91 vs 0.86, p = 0.2) of the affected kidney.

Conclusions

We suggest using PADUA to evaluate surgical complexity and ischemia time. Regarding the accuracy of the prediction of post-operative ipsilateral renal function, both CSA and C-index outperformed R.E.N.A.L. and PADUA nephrometries.

Measurement of urinary arsenic profiles and DNA hypomethylation in a case-control study of urothelial carcinoma

Environmental exposure to arsenic may be involved in the disturbance of DNA hypomethylation. The aim of this study is the first to explore the effect of interactions of urinary total arsenic levels, arsenic methylation capacity, 8-hydroxy-2'-deoxyguanosine (8-OHdG), plasma folate, and global 5-methyl-2'-deoxycytidine (5-MedC) levels on the risk of urothelial carcinoma (UC). A hospital-based case-control study was constructed. The research involved the histological recruitment and pathological verification of 178 UC patients and 356 age-/sex-matched controls without prior history of cancer. Arsenic species were determined by high-performance liquid chromatography (HPLC)-hydride generation and atomic absorption. 5-MedC levels were detected by HPLC and triple-quadrupole mass spectrometry (MS). 8-OHdG was processed by an online solid-phase extraction LC-MS/MS. Plasma folate levels were measured using the chemiluminescent technology. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated by multiple logistic regression analysis. Results indicate that the high levels of total urinary arsenic, inorganic arsenic percentage, and 8-OHdG and the low levels of DMA % and plasma folate were independent factors of UC. In addition, global 5-MedC levels in the first quartile versus fifth quartile significantly increased the twofold OR of UC after potential factors were adjusted (95% CI:1.10-4.03). The interaction of 5-MedC level and high total arsenic level, insufficient arsenic capacity, high 8-OHdG, and low folate levels was insignificant. Results of stepwise logistic regression analysis indicate that high total urinary arsenic levels (Q3 versus Q1), low plasma folate level, and low global 5-MedC (Q4 versus Q5) significantly increased the ORs of UC. The above results suggest that high total arsenic, low plasma folate, and 5-MedC levels affect the ORs of UC independently.

Adjuvant axitinib dose modification in renal cell carcinoma (RCC): Analysis of the ATLAS study

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Background: The ATLAS trial compared axitinib vs placebo in patients (pts) with locoregional RCC at risk of recurrence after nephrectomy. ATLAS was stopped due to futility at a pre-planned interim analysis; results showed no difference in disease-free survival (DFS) between the treatment arms. We explored whether pts treated longer with axitinib achieved better outcomes and the impact of axitinib dose reduction or increase on DFS – the trial required dose reduction for toxicity and allowed dose escalation in the event of no or minimal toxicity. Methods: Pts in ATLAS received a maximum of 3 y of study treatment. A landmark analysis was conducted comparing pts treated with axitinib ≤1 y vs > 1 y. Pts who recurred or censored prior to 1 y were excluded. An analysis of daily dose characteristics was undertaken to compare patients whose dose was reduced and whose dose was increased to those with a stable dose of axitinib. Cox proportional hazard model was used for DFS analysis. Toxicity analysis using a 90-day landmark was also conducted. Results: Overall, 264 axitinib-treated pts were included in this analysis. Of these 42 pts were treated for ≤1 y and 222 pts for > 1 y. Pts remaining on axitinib > 1 y vs ≤1 y did not have different DFS (hazard ratio [HR] = 0.572, 95% confidence interval [CI]: 0.247–1.327, P= 0.1874). Pts with dose reduction had longer DFS than those with a stable dose (HR = 0.458, CI: 0.305–0.687, P= 0.0001). Pts with dose increase did not have DFS different to stable dose pts (HR = 1.936, CI: 0.937–3.997, P= 0.0685). No difference in DFS in pts experiencing grade ≥2 adverse events (AEs) vs grade < 2 AEs within 90 d of start of treatment was observed (HR = 0.885, CI: 0.419–1.869, P= 0.7488). Pts experiencing grade ≥3 AEs within 90 d of start of treatment had shorter DFS compared to those that did not (HR = 1.643, CI: 0.963–2.801, P= 0.0653). Conclusions: DFS did not vary based on duration of axitinib treatment, however, pts with dose reductions had longer DFS vs pts with stable dose or dose increases. This difference suggests that there is a relation between axitinib exposure and DFS as seen with sunitinib in the advanced setting and pazopanib in the PROTECT study.

Endothelial Cell-Targeted Deletion of PPARγ Blocks Rosiglitazone-Induced Plasma Volume Expansion and Vascular Remodeling in Adipose Tissue

Thiazolidinediones (TZDs) are peroxisome proliferator-activated receptor γ (PPARγ) agonists that represent an effective class of insulin-sensitizing agents; however, clinical use is associated with weight gain and peripheral edema. To elucidate the role of PPARγ expression in endothelial cells (ECs) in these side effects, EC-targeted PPARγ knockout (Pparg ΔEC) mice were placed on a high-fat diet to promote PPARγ agonist-induced plasma volume expansion, and then treated with the TZD rosiglitazone. Compared with Pparg-floxed wild-type control (Pparg f/f) mice, Pparg ΔEC treated with rosiglitazone are resistant to an increase in extracellular fluid, water content in epididymal and inguinal white adipose tissue, and plasma volume expansion. Interestingly, histologic assessment confirmed significant rosiglitazone-mediated capillary dilation within white adipose tissue of Pparg f/f mice, but not Pparg ΔEC mice. Analysis of ECs isolated from untreated mice in both strains suggested the involvement of changes in endothelial junction formation. Specifically, compared with cells from Pparg f/f mice, Pparg ΔEC cells had a 15-fold increase in focal adhesion kinase, critically important in EC focal adhesions, and >3-fold significant increase in vascular endothelial cadherin, the main component of focal adhesions. Together, these results indicate that rosiglitazone has direct effects on the endothelium via PPARγ activation and point toward a critical role for PPARγ in ECs during rosiglitazone-mediated plasma volume expansion.

Risk of subsequent health disorders among living kidney donors

Few studies have investigated the risk of physiological sequelae in living kidney donors (KDs). We conducted a population-based cohort study using the National Health Insurance Research Database of Taiwan, which covers more than 99% of citizens.We comprehensively investigated the risk of medical disorders after kidney donation in living KDs using a maximum follow-up of 13 years. From January 1997 to December 2010, 1081 living KDs and 1082 age- and sex-matched non-KDs were eligible. Primary outcomes comprised end-stage renal disease, chronic kidney disease, stroke, cancer, acute myocardial infarction, acute renal failure (ARF), and diabetes.The adjusted hazard ratios (HRs) for developing ARF, diabetes, hyperlipidemia, hypertension, cancer, end-stage renal disease, acute myocardial infarction, and stroke were similar between the KD and non-KD cohorts (P > .05). Although differences in the adjusted HRs of ARF were nonsignificant, the cumulative incidence rate of ARF 13 years after donation was 7.48 per 1000 person-years in the KD cohort compared with 3.46 in the matched non-KD cohort. The incidence rate ratio for ARF between donors and nondonors significantly increased to 2.16 (95% confidence interval, 1.61-2.71).Living KDs experienced no significant health disorders following kidney donation but should be alert to the higher incidence rate of ARF.

Outcomes of stage II-IV upper-tract urothelial carcinoma and adjuvant chemotherapy for locally advanced cancer

The present retrospective study aimed to examine the outcomes of stage II-IV upper-tract urothelial carcinoma (UTUC) and determine whether adjuvant chemotherapy is a beneficial treatment for patients with locally advanced UTUC (specifically, stage III-IV). The analysis included 126 patients with muscle-invasive UTUC who were treated between June 2003 and June 2012. All patients underwent laparoscopic or open nephroureterectomy and bladder cuff excision. Overall survival (OS), disease-free survival (DFS), distant metastasis-free survival (DMFS) and locoregional recurrence-free survival (LRFS) were assessed. Outcomes were compared between groups of patients with stage II (high-stage localized) disease, stage III-IV (high-stage locally advanced) disease treated with chemotherapy, and stage III-IV disease not treated with chemotherapy. Among patients with high-stage locally advanced UTUC (stage III-IV), those who received adjuvant chemotherapy had significantly better rates of OS (67.1 vs. 33.7%; P=0.004), DFS (70.2 vs. 46.0%; P=0.030) and DMFS (86.3 vs. 65.2%; P=0.048) at 5-years compared with those who did not undergo adjuvant chemotherapy. However, there was no significant difference between the 5-year LRFS rates in these two groups (78.2 vs. 62.5%; P=0.525). Importantly, the survival curve of patients with high-stage UTUC who received adjuvant chemotherapy was similar to that of patients with low-stage UTUC who underwent surgery only. Multivariate analysis revealed that adjuvant chemotherapy was an independent risk factor for OS [without adjuvant chemotherapy vs. with adjuvant chemotherapy: Hazard ratio (HR), 0.29; 95% confidence interval (CI), 0.129-0.654; P=0.003] and DFS (without adjuvant chemotherapy vs. with adjuvant chemotherapy: HR, 0.381; 95% CI, 0.168-0.865; P=0.021). In conclusion, adjuvant chemotherapy may improve the outcome for patients with high-stage locally advanced UTUC.

Outcome of Patients with Metastatic Castration-resistant Prostate Cancer After PSA Progression with Abiraterone Acetate

BACKGROUND/AIM

The main purpose of this study was to evaluate the outcome of patients with prostate-specific antigen (PSA) progression after abiraterone acetate (AA) treatment for metastatic castration-resistant prostate cancer (mCRPC).

PATIENTS AND METHODS

Between 2012 and 2017, 83 patients with clinically-confirmed mCRPC previously treated with docetaxel with/without cabazitaxel followed by AA were included in this retrospective study. All patients received 1,000 mg AA with 5 or 10 mg prednisolone. Among them, 59 were eligible for this study based on PSA progression during the clinical course. Patients were divided into two groups, AA responders and AA non-responders according to previous PSA response to AA treatment. Overall survival and treatment response to subsequent therapy were analyzed.

RESULTS

The median overall survival of the 59 patients after AA-treated PSA progression was 12 (95% confidence interval(CI)=7.6-16.4) months and was longer in the AA-responding group compared to the non-responding group (25 vs. 8 months, p<0.001). The survival time after PSA progression on AA was longer in the AA-responsive group despite not being statistically different (13 vs. 7 months, p=0.126). Patients with AA treatment who received subsequent therapies after PSA progression had better overall survival than those without (18 vs. 4 months, p=0.003). In addition, there was a trend for better chemotherapy response in AA non-responders than AA responders, 62.5% (5/8) vs. 12.5% (1/8) respectively.

CONCLUSION

In our small retrospective patient experience, effective sequential treatments for patients with mCRPC provided overall survival benefit. Previous treatment response can act as a clinical predictor for subsequent treatment.