Dosimetric and Clinical Results of a Volumetric-Based Skin-Sparing Planning Technique for Patients Treated to the Breast and Chest Wall with Pencil Beam Scanning Proton Therapy

PURPOSE/OBJECTIVE(S)

Given clinical concerns for more brisk acute skin toxicity with proton compared with photon RT due to differences in the energy deposition properties, our institution implemented a novel volumetric skin-sparing planning technique (SSPT) for intensity modulated proton therapy (IMPT) for patients treated to the breast or chest wall (CW). This study evaluates SSPT dosimetry and the hypothesis that a SSPT will reduce acute dermatitis during IMPT to the breast and CW.

MATERIALS/METHODS

Prior to the development of a consensus technique, skin dose evaluation in IMPT plans was limited to mitigation of skin hot spots and cropping off the skin surface by 3mm for CW and 5mm for intact breast targets (except indications for deliberate skin dosing). In January 2022 our center added volumetric-based skin sparing objectives in addition to hot-spot evaluation as a SSPT. A skin evaluation structure (skin-eval) was defined as a skin rind of 3 mm for CW and 5 mm for intact breast within 5mm of the CTV, bound by the patient's surface. The SSPT incorporated an objective to limit the volume of skin-eval receiving 95% of the prescription dose or more (V95%Rx) to ideally <50% (goal<60%) while still prioritizing CTV coverage and robustness. We compared target coverage, robustness, and skin-eval dosimetry as well as acute on-treatment skin toxicity in patients treated with and without incorporation of this SSPT. Patients with skin/dermal lymphatic invasion or inflammatory breast cancer were excluded.

RESULTS

84 patients who were planned to receive breast or CW IMPT were included (43 planned without and 41 with the SSPT). There was no difference in percentages of patients treated to the intact breast/CW/immediate CW reconstruction between the groups (37%/23%/40% without and 34%/27%/39% with SSPT, p>0.05). Mean skin-evalV95%Rx was 72% vs. 30%, p<0.0001, for those treated without vs. with a SSPT. Maximum %Rx to the skin volume of 0.03 cc, 0.3cc, and 1cc, was higher in patients treated without compared to those with a SSPT (103.1% vs. 101.5%; 101.3% vs. 100.4%; and 101.8% vs. 99.7% (all p=<0.0001)), respectively. There was a small statistical difference in the mean CTV V97.5%Rx in patients treated without vs. with the SSPT (97.8% vs. 96.5%, p=0.0003). Patients planned utilizing the SSPT demonstrated reduced rates of Grade 1 breast pain at Week 2 (12% vs. 33%, p=0.0424) and Grade 2 and 3 dermatitis at Week 5 (grade 2 38% vs. 42%; grade 3, 0% vs. 11%, p=0.0016). There were numerically more patients requiring a treatment break or not completing full intended prescription (4 vs. 1) in the pre-SSPT cohort.

CONCLUSION

A volumetric-based SSPT appears to reduce the frequency of brisk onset dermatitis and near-end of RT significant dermatitis while still maintaining acceptable target coverage and robustness in patients receiving IMPT to the breast and CW.

Characterization and functional analysis of microbiome in bladder cancer

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Background: The role of microbiome in genitourinary cancer is an emerging field, with evidence implicating the important role of microbiome as causative factors or cofactors in tumorigenesis and drug metabolism. Our study aims to characterize healthy and bladder cancer enterotypes in the gut and identify functional alterations through the use of metagenomics data. Methods: After prospective collection of 29 rectal swab samples of bladder cancer (BCa) patients undergoing cystectomy, and 32 healthy volunteers, we perform 16S rRNA amplicon sequencing on 61 samples (29 with bladder cancer, 32 without cancer). Phylogenetic Investigation of Communities by Reconstruction of Unobserved States (PICRUSt) was applied to infer functional categories associated with taxonomic composition. The p values were adjusted using the false discovery rate. The a- and b-diversity analyses were performed using QIIME. The Mann-Whitney U test was employed to evaluate the statistical significance of b-diversity distances within and between groups of interest. Results: Across all the bladder cancer stool samples, estimation of relative abundance revealed of the five most dominant bacterial populations was Bacteroidales ( 46.21%), Clostridiales ( 32.29%), Burkholderiales (9.07%), Erysipelotrichales (3.20%) and Lactobacillales ( 2.20%). In contrast, healthy controls exhibited an increased relative abundance of Enterobacteriales ( 10.75% vs 0.52%) and Pseudomonadales (8.33% vs 0.18%) as compared to tumor samples. The microbial diversity differences between Bca and normal samples showed no differences across alpha diversity metrics (Shannon diversity p>0.05) as compared to normal tissue. However, there was significant difference in clustering of organisms as determined by principal coordinate analysis ( PCoA) ordination of unweighted UniFrac Distances, (p=0.002). Furthermore, upon stratification of patients on smoking status (all healthy=nonsmokers), clustering persisted, albeit non smokers with bladder cancer displayed an intermediate across PCoA. Bca samples exhibited higher LDA score Campylobacterales (log change 8.0, p<0.001, padj <0.001) ,Fusobacteriales (log change 6.11, p<0.001/ padj<0.01), Epysipelotrichales (log 2.55, p<0.001/ padj <0.001 ), Actinomycetales (log change 1.86, p=0.001/ padj<0.001), Verrucomicrobiales (log change 1.78, p=0.017/padj=0.031) and Enterobacteriales (log change -1.54,p=0.017/ padj= 0.132). Conclusions: In conclusion, our study provides preliminary evidence that the GI microbiota is different in bladder cancer patients. Collectively, our study highlights distinct microbial overexpression of Campylobacter and Fusobacterium in Bca cohort not previously reported, both implicated in tumorigenesis, and could serve as a target that could be modulated to enhance treatment response.

Female Urgency, Trial of Urodynamics as Routine Evaluation (FUTURE study): a superiority randomised clinical trial to evaluate the effectiveness and cost-effectiveness of invasive urodynamic investigations in management of women with refractory overactive bladder symptoms

BACKGROUND

Overactive bladder (OAB) syndrome is a symptom complex affecting 12-14% of the UK adult female population. Symptoms include urinary urgency, with or without urgency incontinence, increased daytime urinary frequency and nocturia. OAB has a negative impact on women's social, physical, and psychological wellbeing. Initial treatment includes lifestyle modifications, bladder retraining, pelvic floor exercises and pharmacological therapy. However, these measures are unsuccessful in 25-40% of women (refractory OAB). Before considering invasive treatments, such as Botulinum toxin injection or sacral neuromodulation, most guidelines recommend urodynamics to confirm diagnosis of detrusor overactivity (DO). However, urodynamics may fail to show evidence of DO in up to 45% of cases, hence the need to evaluate its effectiveness and cost-effectiveness. FUTURE (Female Urgency, Trial of Urodynamics as Routine Evaluation) aims to test the hypothesis that, in women with refractory OAB, urodynamics and comprehensive clinical assessment is associated with superior patient-reported outcomes following treatment and is more cost-effective, compared to comprehensive clinical assessment only.

METHODS

FUTURE is a pragmatic, multi-centre, superiority randomised controlled trial. Women aged ≥ 18 years with refractory OAB or urgency predominant mixed urinary incontinence, and who have failed/not tolerated conservative and medical treatment, are considered for trial entry. We aim to recruit 1096 women from approximately 60 secondary/tertiary care hospitals across the UK. All consenting women will complete questionnaires at baseline, 3 months, 6 months and 15 months post-randomisation. The primary outcome is participant-reported success at 15 months post-randomisation measured using the Patient Global Impression of Improvement. The primary economic outcome is incremental cost per quality-adjusted life year gained at 15 months. The secondary outcomes include adverse events, impact on other urinary symptoms and health-related quality of life. Qualitative interviews with participants and clinicians and a health economic evaluation will also be conducted. The statistical analysis of the primary outcome will be by intention-to-treat. Results will be presented as estimates and 95% CIs.

DISCUSSION

The FUTURE study will inform patients, clinicians and policy makers whether routine urodynamics improves treatment outcomes in women with refractory OAB and whether it is cost-effective.

TRIAL REGISTRATION

ISRCTN63268739 . Registered on 14 September 2017.

Presence of Specific Periodontal Pathogens in Prostate Gland Diagnosed With Chronic Inflammation and Adenocarcinoma

Background

Intraprostatic inflammation is frequently observed in the prostate and linked to prostatic diseases, including prostatitis, benign prostatic hyperplasia (BPH), and cancer. The etiology of prostate diseases is unclear. Periodontal diseases are associated with an increased risk of prostate diseases. In men, chronic prostatitis and moderate/severe periodontitis have significantly elevated serum prostate-specific antigen (PSA) levels. Treatment of periodontal disease reduced PSA levels in men. The presence of periodontal pathogens deoxyribonucleic acid (DNA) was identified in the prostate fluid of prostatitis patients. These pathogenic bacteria might have the potential to trigger prostatitis progressing to prostatic adenocarcinoma. The mechanism(s) explaining the etiology of association between periodontal disease and prostate cancer remains unclear. However, the presence of periodontal pathogens has not been analyzed in the prostate gland.

Objective

To identify and compare the presence of specific periodontal pathogens in the areas of BPH, inflammation, and cancer of the prostate glands diagnosed with malignancy.

Materials and methods

Whole-mount radical prostatectomy sections from men (n=30) were identified for BPH, inflammation, and cancer areas and marked for tissue procurement. The tissues were subjected to DNA isolation and analysis of microbial DNA and total bacterial load for the following pathogens, including Porphyromonas gingivalis strain ATCC 33277, Prevotella intermedia strain B422, Treponema denticola strain 35405, Fusobacterium nucleatum subsp. fusiform strain, Tannerella forsythia strain ATCC 43037, and Campylobacter​​​​​​​ rectus strain ATCC 33238performed real-time PCR. The universal bacterial primer pairs were used to detect genomic DNA (gDNA) from the total bacteria present in the samples. All species-specific primers were designed to target the variable regions of the 16S ribosomal RNA (rRNA). Data were analyzed using the 2-ΔΔCT method, statistically validated using unpaired t-test and ANOVA test.

Results

A total of 90 samples of prostate tissue specimens were analyzed for periodontal pathogens; only one pathogen (F. nucleatum subsp. fusiform strain ATCC 51190) showed a significant difference compared to the expression of S. epidermidis (internal control). In particular, F. nucleatum expression was 9, 11.9, and 10.3-fold higher in BPH, inflammation, and cancer, respectively, at p-value <0.05. Moreover, the bacterial load abundance/expression was almost similar in BPH (46.8-fold), inflammation (40.9 fold), and cancer (41.5 fold) higher. There was no significant difference in bacterial load (folder change) among the three areas of BPH, inflammation, and cancer (p-valve>0.05). Similarly, there was no significant difference between F. nucleatum (folder change) among the three areas (p-valve>0.05).

Conclusion 

Fusobacterium nucleatum is identified in the prostates that harbor cancer, chronic inflammation, and BPH.

Focal Prostate Stereotactic Body Radiation Therapy With Correlative Pathological and Radiographic-Based Treatment Planning

Introduction

Advances in multiparametric MRI (mpMRI) combining anatomic and functional imaging can accurately identify foci of adenocarcinoma within the prostate, offering the possibility of partial gland therapy. We performed tandem prospective pilot trials to investigate the feasibility of focal prostate SBRT (f-SBRT) based on correlating diagnostic mpMRI and biopsies with confirmatory pathology in treatment planning.

Materials and Methods

Patients with pathologic focal Gleason 6–7 disease and a corresponding PIRADS 4–5 lesion on mpMRI underwent targeted and comprehensive biopsies using MRI/ultrasound fusion under electromagnetic sensor navigation. After rigorous analysis for imaging biopsy concordance, five of 18 patients were eligible to proceed to f-SBRT. Chi-squared test was used for differences from expected outcomes, and concordance was estimated with binomial distribution theory and Wilson’s method.

Results

Six patients had Gleason 6 and 12 had Gleason 3 + 4 disease (mean PSA: 5.8 ng/ml, range: 2.2–8.4). Absolute concordance was 43.8% (95% CI: 0.20, 0.64). Patterns of discordance included additional sites of ipsilateral disease, bilateral disease, and negative target. Five were upstaged to a new NCCN risk category necessitating treatment escalation. The five patients with concordant pathology completed three-fraction f-SBRT with sparing of the surrounding normal structures (including contralateral neurovascular bundle), with no reported grade 2+ toxicities and favorable PSA responses (mean: 41% decrease).

Conclusions

On our pilot trials of f-SBRT planning using rigorous imaging and pathology concordance, image-guided confirmatory biopsies frequently revealed additional disease, suggesting the need for caution in partial-gland therapy. For truly focal disease, f-SBRT provided excellent dosimetry, minimal toxicity, and encouraging biochemical response. Clinical Trial Registration: www.clinicaltrials.gov, NCT02681614; NCT02163317.

Gender Disparities in Bladder Cancer-Specific Survival in High Poverty Areas Utilizing Ohio Cancer Incidence Surveillance System (OCISS)

OBJECTIVE

To better understand the interplay of socioeconomic and demographic traits on bladder cancer outcomes utilizing the Ohio state cancer registry, Ohio Cancer Incidence Surveillance System (OCISS).

METHODS

We obtained demographic, clinical and outcome data on 47,182 bladder cancer cases diagnosed from 1996 to 2016 from OCISS. Multivariable Cox proportional hazards regression to calculate hazard ratios (HRs) and 95% confidence intervals (95% CIs) for the association between sex, race and poverty and survival, adjusting age, stage, and primary treatment.

RESULTS

Within the OCISS database, there were 47,182 patients with a diagnosis of bladder cancer identified, with females representing 12,056 (26%) of the population. There were a total of 9255(35.2%) deaths due to bladder cancer, with median follow-up time of 4.4 years. After adjusting for confounding variables, women were statistically significantly less likely to die from any cause (HR: 0.94, 95% CI: 0.91-0.96), compared with men, but more likely to die from bladder cancer (HR: 1.21, 95% CI: 1.15-1.27). We also found that after adjusting for confounding variables, including sex and poverty, black race was statistically significantly associated with a higher risk of overall (HR: 1.12, 95% CI: 1.06-1.18) and bladder cancer-specific mortality (HR: 1.25, 95% CI: 1.15-1.36).

CONCLUSION

Using the OCISS database, female gender, self-reported black race, and neighborhood poverty level were associated with worse bladder cancer-specific survival. By recognizing these disparities, we can prospectively address risk factors in efforts to improve survival among these patient populations.

Emerging clinical phenotype of bone metastatic urothelial cancer (mUC): Association of early osseous metastases (EOM) and outcomes

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Background: Outcomes of patients (pts) with mUC with EOM have not thoroughly been described in the age of immuno-oncology. We hypothesized that EOM is associated with worse outcomes when compared to pts with non-osseous metastases (NOM). Methods: We used a multi-institutional database of pts with mUC who received systemic treatment (trt) between March 2005 and August 2019, to assess survival and palliative outcomes of pts with EOM vs NOM at the time of metastatic diagnosis (met dx). Wilcoxon rank-sum and chi-square tests were performed. Survival was estimated by Kaplan-Meier method, Cox regression analysis was performed. Results: We identified 270 pts, 72% men, mean age 67 ± 11 years, 28% never smokers. At met dx, 27% (n = 72) had ≥ 1 EOM; these pts were more likely to have de novo metastases vs. those with recurrent metastases (42% vs 19%, p < 0.001). Pts with EOM were more likely to have a change or stop in 1st line trt due to clinical progression (30.6% vs 15.7%, p = 0.006), and received fewer total lines of systemic trt, median of 1.0 (1.0-5.0) vs. 2.0 (1.0-8.0), p = 0.05. Pts with EOM had shorter median overall survival (OS) vs. those with NOM, (6.1 vs 13.7 months, p < .0001), HR = 2.79 (95% CI:1.95-3.97, p < .0001). Median OS was shorter for pts with EOM who received 1st line immune checkpoint inhibitor (n = 14) vs platinum-based chemotherapy (n = 43), (1.6 vs 9.1 months, p = 0.003). Pts with EOM received higher opioid analgesic doses at the first and last oncology outpatient visits compared to pts with NOM with mean morphine milligram equivalent (MME) dose of 60 ± 91 vs 28 ± 65 at first visit, p = 0.004, and 171 ± 214 vs. 94 ± 229 at last visit, p < 0.001. Conclusions: The presence of EOM in mUC is associated with worse outcomes vs. pts with NOM. Pts with EOM may benefit from 1st line platinum-based chemotherapy vs. checkpoint immunotherapy. Furthermore, pts with EOM experience more pain than pts with NOM and may benefit from early engagement with palliative care. Pts with EOM represent a population with a highly unmet need for systemic, targeted and/or radiation interventions. Molecular subtypes may further define these pts and analysis is planned. We encourage ongoing clinical trials to report outcomes in pts with EOM. A consensus on reporting of non-measurable disease is also needed. [Table: see text]

Mesh inlay, mesh kit or native tissue repair for women having repeat anterior or posterior prolapse surgery: randomised controlled trial (PROSPECT)

OBJECTIVE

To compare standard (native tissue) repair with synthetic mesh inlays or mesh kits.

DESIGN

Randomised controlled trial.

SETTING

Thirty-three UK hospitals.

POPULATION

Women having surgery for recurrent prolapse.

METHODS

Women recruited using remote randomisation.

MAIN OUTCOME MEASURES

Prolapse symptoms, condition-specific quality-of-life and serious adverse effects.

RESULTS

A Mean Pelvic Organ Prolapse Symptom Score at 1 year was similar for each comparison (standard 6.6 versus mesh inlay 6.1, mean difference [MD] -0.41, 95% CI -2.92 to 2.11: standard 6.6 versus mesh kit 5.9, MD -1.21 , 95% CI -4.13 to 1.72) but the confidence intervals did not exclude a minimally important clinical difference. There was no evidence of difference in any other outcome measure at 1 or 2 years. Serious adverse events, excluding mesh exposure, were similar at 1 year (standard 7/55 [13%] versus mesh inlay 5/52 [10%], risk ratio [RR] 1.05 [0.66-1.68]: standard 3/25 [12%] versus mesh kit 3/46 [7%], RR 0.49 [0.11-2.16]). Cumulative mesh exposure rates over 2 years were 7/52 (13%) in the mesh inlay arm, of whom four women required surgical revision; and 4/46 in the mesh kit arm (9%), of whom two required surgical revision.

CONCLUSIONS

We did not find evidence of a difference in terms of prolapse symptoms from the use of mesh inlays or mesh kits in women undergoing repeat prolapse surgery. Although the sample size was too small to be conclusive, the results provide a substantive contribution to future meta-analysis.

TWEETABLE ABSTRACT

There is not enough evidence to support use of synthetic mesh inlay or mesh kits for repeat prolapse surgery.

ELECtric Tibial nerve stimulation to Reduce Incontinence in Care homes: protocol for the ELECTRIC randomised trial

BACKGROUND

Urinary incontinence (UI) is highly prevalent in nursing and residential care homes (CHs) and profoundly impacts on residents' dignity and quality of life. CHs predominantly use absorbent pads to contain UI rather than actively treat the condition. Transcutaneous posterior tibial nerve stimulation (TPTNS) is a non-invasive, safe and low-cost intervention with demonstrated effectiveness for reducing UI in adults. However, the effectiveness of TPTNS to treat UI in older adults living in CHs is not known. The ELECTRIC trial aims to establish if a programme of TPTNS is a clinically effective treatment for UI in CH residents and investigate the associated costs and consequences.

METHODS

This is a pragmatic, multicentre, placebo-controlled, randomised parallel-group trial comparing the effectiveness of TPTNS (target n = 250) with sham stimulation (target n = 250) in reducing volume of UI in CH residents. CH residents (men and women) with self- or staff-reported UI of more than once per week are eligible to take part, including those with cognitive impairment. Outcomes will be measured at 6, 12 and 18 weeks post randomisation using the following measures: 24-h Pad Weight Tests, post void residual urine (bladder scans), Patient Perception of Bladder Condition, Minnesota Toileting Skills Questionnaire and Dementia Quality of Life. Economic evaluation based on a bespoke Resource Use Questionnaire will assess the costs of providing a programme of TPTNS. A concurrent process evaluation will investigate fidelity to the intervention and influencing factors, and qualitative interviews will explore the experiences of TPTNS from the perspective of CH residents, family members, CH staff and managers.

DISCUSSION

TPTNS is a non-invasive intervention that has demonstrated effectiveness in reducing UI in adults. The ELECTRIC trial will involve CH staff delivering TPTNS to residents and establish whether TPTNS is more effective than sham stimulation for reducing the volume of UI in CH residents. Should TPTNS be shown to be an effective and acceptable treatment for UI in older adults in CHs, it will provide a safe, low-cost and dignified alternative to the current standard approach of containment and medication.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03248362. Registered on 14 August 2017. ISRCTN, ISRCTN98415244. Registered on 25 April 2018. https://www.isrctn.com/.

Photodynamic Therapy Is an Effective Adjuvant Therapy for Image-Guided Surgery in Prostate Cancer

Local and metastatic relapses of prostate cancer often occur following attempted curative resection of the primary tumor, and up to 66% of local recurrences are associated with positive margins. Therefore, technologies that can improve the visualization of tumor margins and adjuvant therapies to ablate remaining tumor tissues are needed during surgical resection of prostate adenocarcinoma. Photodynamic agents have the potential to combine both fluorescence for image-guided surgery (IGS) and photodynamic therapy (PDT) to resect and ablate cancer cells. The objective of this study was to determine the utility of a targeted PDT agent for IGS and adjuvant PDT. Using a previously developed prostate-specific membrane antigen (PSMA)-targeted PDT agent, PSMA-1-Pc413, we showed that PSMA-1-Pc413 selectively highlighted PSMA-expressing tumors, allowing IGS and more complete tumor resection compared with white light surgery. Subsequent PDT further reduced tumor recurrence and extended animal survival significantly. This approach also enabled identification of tumor cells in lymph nodes. In summary, this study presents a potential new treatment option for patients with prostate cancer undergoing surgery, which improves tumor visualization and discrimination during surgery, including identification of cancer in lymph nodes. SIGNIFICANCE: These findings present a photodynamic agent that can be used for both photodynamic therapy and image-guided surgery, allowing better visualization of tumor margins and elimination of residual tumor tissues.

Controversial issues in Gleason and International Society of Urological Pathology (ISUP) prostate cancer grading: proposed recommendations for international implementation

The Gleason Grading system has been used for over 50 years to prognosticate and guide the treatment for patients with prostate cancer. At consensus conferences in 2005 and 2014 under the guidance of the International Society of Urological Pathology (ISUP), the system has undergone major modifications to reflect modern diagnostic and therapeutic practices. The 2014 consensus conference yielded recommendations regarding cribriform, mucinous, glomeruloid and intraductal patterns, the most significant of which was the removal of any cribriform pattern from Gleason grade 3. Furthermore, a Gleason score grouping system was endorsed which consisted of five grades where Gleason score 6 (3+3) was classified as grade 1 which better reflected the mostly indolent behaviour of these tumours. Another issue discussed at the meeting and subsequently endorsed was that in Gleason score 7 cases, the percentage pattern 4 should be recorded. This is especially important in situations where modern active surveillance protocols expand to include men with low volume pattern 4. While major progress was made at the conference, several issues were either not resolved or not discussed at all. Most of these items relate to details of assignment of Gleason score and ISUP grade in specific specimen types and grading scenarios. This detailed review looks at the 2014 ISUP conference results and subsequent literature from an international perspective and proposes several recommendations. The specific issues addressed are percentage pattern 4 in Gleason score 7 tumours, percentage patterns 4 and 5 or 4/5 in Gleason score 8-10 disease, minor (≤5%) high grade patterns when either 2 or 3 patterns are present, level of reporting (core, specimen, case), dealing with grade diversity among site (highest and composite scores) and reporting scores in radical prostatectomy specimens with multifocal disease. It is recognised that for many of these issues, a strong evidence base does not exist, and further research studies are required. The proposed recommendations mostly reflect consolidated expert opinion and they are classified as established if there was prior agreement by consensus and provisional if there was no previous agreement or if the item was not discussed at prior consensus conferences. For some items there are reporting options that reflect the local requirements and diverse practice models of the international urological pathology community. The proposed recommendations provide a framework for discussion at future consensus meetings.

Association of early bone metastases and outcomes of the bone predominant metastatic urothelial carcinoma (BP mUC) phenotype

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Background: Prior analyses demonstrated worse outcomes with the BP mUC clinical phenotype. UC molecular subtypes that may correlate with the BP phenotype have been defined, however molecular subtyping is not a readily available standard practice. We hypothesized that BP mUC has worse prognosis vs. non-BP (NBP) mUC and evaluated patient (pt) characteristics associated with the mUC subtype, responses and outcomes. Methods: We searched the electronic medical record (EMR) to identify pts with mUC who received systemic therapy in the metastatic setting. Demographic, clinicopathologic, treatment (trt), response, progression-free survival (PFS), overall survival (OS ) from start of first line trt. Imaging was reviewed to identify NBP or BP disease. Logistic regression, Cox proportional-hazards and Kaplan-Meier analyses were performed. Results: 149 mUC pts were identified (64% male, 68% smokers ), median age at 1st line trt was 68 years. 70% had de-novo mets, 46% to lung and 27% to liver. 22% of pts were BP, of these, 36% were de-novo metastatic. In non- de-novo metastatic pts (70% of pts), first progression of disease to bone was associated with development of the BP phenotype (OR = 30.46, 95% CI 6.37 to 145.61; p < 0.0001). BP pts had higher rate of death (HR = 2.28, 95% CI 1.45 to 3.58, p = 0.0004), shorter PFS from 1st line trt, (11.7 vs 14.9 weeks, p = 0.032) as well as shorter OS from 1st line trt (24.6 vs 56.6 weeks, p = 0.002) compared to NBP pts. There was no difference in PFS between BP and NBP groups for pts treated with 1st line platinum-based chemotherapy (11.8 vs 18.3 weeks, p = 0.091) or for BP pts treated with 1st line immunotherapy vs platinum-based chemotherapy (11.71 vs 11.86 weeks, p = 0.135). Conclusions: Early bone metastases are associated with the development of the BP metastatic phenotype. BP pts have worse PFS and OS from 1st line trt compared to NBP pts. PFS remains poor when BP pts are treated with either platinum-based chemotherapy or immunotherapy in the first line setting. Imaging to determine the presence of bone metastases may routinely be pursued and careful attention paid on follow up imaging. Clinical trials and prospective registries focusing on efficacy endpoints for BP mUC are needed.

Is trigonitis a neglected, imprecise, misunderstood, or forgotten diagnosis?

To consolidate our understanding of "trigonitis" and its relevance in current urologic practice, we reviewed the literature on this entity. The MEDLINE, EMBASE, and Cochrane databases (1905 to present) were systematically reviewed for any English language articles addressing the following terms: trigonitis, cystitis trigoni, cystitis cystica, squamous metaplasia, pseudomembranous trigonitis, vaginal metaplasia, infection or inflammation of the trigone, and trigonitis in recurrent urinary tract infections (rUTI). Abstracts or articles not focused on trigonitis, or those only repeating findings from other original articles on trigonitis, and studies in children or men were excluded. Reported histologic findings on trigonitis, theories regarding its pathophysiology, and therapeutic strategies were reviewed. From 57 relevant articles, only 27 focused on trigonitis. Cystoscopic evaluation of the trigone described inflammatory lesions of cystitis cystica, occasionally small stones or pus-filled lesions, an appearance that should be differentiated from white patches of squamous metaplasia. Embryologic formation of the trigone, history of rUTIs, and effects of hormones on the trigone have been proposed as underlying pathophysiologic mechanisms. Numerous therapeutic strategies have been reported to treat symptomatic trigonitis, including antibiotic therapy, intravesical instillation of different agents, electrofulguration, and laser coagulation. However, no treatment indication criteria have been well established so far, and long-term data are lacking. Despite several reports describing histologic and endoscopic findings of trigonitis, its prevalence, pathophysiology, and treatment have remained poorly defined. Its relevance in the management of rUTIs should be further evaluated.

Diagnostic Accuracy of a Rapid Biparametric MRI Protocol for Detection of Histologically Proven Prostate Cancer

OBJECTIVE

To evaluate the performance of a rapid, low cost, noncontrast MRI examination as a secondary screening tool in detection of clinically significant prostate cancer.

METHODS

In this prospective single institution study, 129 patients with elevated prostate-specific antigen levels or abnormal digital rectal examination findings underwent MRI with an abbreviated biparamatric MRI protocol consisting of high-resolution axial T2- and diffusion-weighted images. Index lesions were classified according to modified Prostate Imaging - Reporting and Data System (mPI-RADS) version 2.0. All patients underwent standard transrectal ultrasound-guided biopsy after MRI with the urologist being blinded to MRI results. Subsequently, all patients with suspicious lesions (mPI-RADS 3, 4, or 5) underwent cognitively guided targeted biopsy after discussion of MRI results with the urologist. Sensitivity and negative predictive value for identification of clinically significant prostate cancer (Gleason score 3+4 and above) were determined.

RESULTS

Rapid biparametric MRI discovered 176 lesions identified in 129 patients. Rapid MRI detected clinically significant cancers with a sensitivity of 95.1% with a negative predictive value of 95.1% and positive predictive value of 53.2%, leading to a change in management in 10.8% of the patients. False negative rate of biparametric (bp) MRI was 4.7%.

CONCLUSION

We found that a bp-MRI examination can detect clinically significant lesions and changed patient management in 10.8% of the patients. A rapid MRI protocol can be used as a useful secondary screening tool in men presenting with suspicion of prostate cancer.

Outcomes in bone predominant (BP) urothelial carcinoma (UC)

441

Background: The clinical phenotype of BP UC includes those patients (pts) with at least as many or more bone lesions than non-bone lesions. UC molecular subtypes that may correlate with prognosis have been defined. Better understanding of the clinical BP phenotype, which might correspond to the p53-like molecular subtype, is needed. Methods: We searched our biorepository to identify pts with metastatic UC. Electronic records of identified pts were reviewed and those with accessible records who received treatment at our institution were selected. Demographic, pathologic, treatment, response, progression-free and overall survival (PFS, OS) data were recorded. Imaging was reviewed to identify non-bone predominant (NBP) or BP disease based on imaging criteria. Results: 23 NBP and 9 BP pts, (59% men) were identified. Of BP pts, 44% had bone metastatic disease present at diagnosis (dx) vs. none of the NBP. Only 8% of NBP pts developed bone metastases during their course. The median number of lines of therapy in the metastatic setting was 2 for each cohort. All BP pts received platinum therapy vs. 74% of NBP. 11% of BP pts were treated with checkpoint immunotherapy (CPI) vs. 34% of NBP. 70% of BP pts received palliative radiation (all to bone) vs. 4% of the NBP cohort. The median OS from date of UC dx was 27.5 months. There was a significant difference in OS between BP and NBP cohorts from UC dx date (16.9 vs. 30.6 months, p < 0.0001) as well as from muscle invasive bladder cancer (MIBC) dx date (15.2 vs. 22.8 months, p = 0.019), respectively. OS from initiation of 1st line treatment in the metastatic setting for the entire cohort was 12.5 months and was not significantly different between the cohorts (p = 0.633). PFS from dx of MIBC to date of 1st progression or death was not significant (p = 0.08) with median PFS of 8.4 vs. 13.6 months for BP vs. NBP cohorts, respectively. Conclusions: BP pts require more frequent palliative radiation and have shorter OS measured from time of dx, but not significantly different when measured from the initiation of 1st line treatment, compared to NBP pts. Further analysis with a larger cohort is ongoing for validation. Molecular analysis on pathological specimens is planned.

Reporting and dealing with missing quality of life data in RCTs: has the picture changed in the last decade?

PURPOSE

Missing data are a major problem in the analysis of data from randomised trials affecting power and potentially producing biased treatment effects. Specifically focussing on quality of life outcomes, we aimed to report the amount of missing data, whether imputation was used and what methods and was the missing mechanism discussed from four leading medical journals and compare the picture to our previous review nearly a decade ago.

METHODS

A random selection (50 %) of all RCTS published during 2013-2014 in BMJ, JAMA, Lancet and NEJM was obtained. RCTs reported in research letters, cluster RCTs, non-randomised designs, review articles and meta-analysis were excluded.

RESULTS

We included 87 RCTs in the review of which 35 % the amount of missing primary QoL data was unclear, 31 (36 %) used imputation. Only 23 % discussed the missing data mechanism. Nearly half used complete case analysis. Reporting was more unclear for secondary QoL outcomes. Compared to the previous review, multiple imputation was used more prominently but mainly in sensitivity analysis.

CONCLUSIONS

Inadequate reporting and handling of missing QoL data in RCTs are still an issue. There is a large gap between statistical methods research relating to missing data and the use of the methods in applications. A sensitivity analysis should be undertaken to explore the sensitivity of the main results to different missing data assumptions. Medical journals can help to improve the situation by requiring higher standards of reporting and analytical methods to deal with missing data, and by issuing guidance to authors on expected standard.

Behavioural recovery after treatment for varicose veins

BACKGROUND

The aim of this study was to assess behavioural recovery from the patient's perspective as a prespecified secondary outcome in a multicentre parallel-group randomized clinical trial comparing ultrasound-guided foam sclerotherapy (UGFS), endovenous laser ablation (EVLA) and surgery for the treatment of primary varicose veins.

METHODS

Participants were recruited from 11 UK sites as part of the CLASS trial, a randomized trial of UGFS, EVLA or surgery for varicose veins. Patients were followed up 6 weeks after treatment and asked to complete the Behavioural Recovery After treatment for Varicose Veins (BRAVVO) questionnaire. This is a 15-item instrument that covers eight activity behaviours (tasks or actions an individual is capable of doing in an idealized situation) and seven participation behaviours (what the individual does in an everyday, real-world situation) that were identified to be important from the patient's perspective.

RESULTS

A total of 798 participants were recruited. Both UGFS and EVLA resulted in a significantly quicker recovery compared with surgery for 13 of the 15 behaviours assessed. UGFS was superior to EVLA in terms of return to full-time work (hazard ratio 1·43, 95 per cent c.i. 1·11 to 1·85), looking after children (1·45, 1·04 to 2·02) and walks of short (1·48, 1·19 to 1·84) and longer (1·32, 1·05 to 1·66) duration.

CONCLUSION

Both UGFS and EVLA resulted in more rapid recovery than surgery, and UGFS was superior to EVLA for one-quarter of the behaviours assessed. The BRAVVO questionnaire has the potential to provide important meaningful information to patients about their early recovery and what they may expect to be able to achieve after treatment.

Miniature forward-viewing common-path OCT probe for imaging the renal pelvis

We demonstrate an ultrathin flexible cone-scanning forward-viewing OCT probe which can fit through the working channel of a flexible ureteroscope for renal pelvis imaging. The probe is fabricated by splicing a 200 µm section of core-less fiber and a 150 µm section of gradient-index (GRIN) fiber to the end of a single mode (SM) fiber. The probe is designed for common-path OCT imaging where the back-reflection of the GRIN fiber/air interface is used as the reference signal. Optimum sensitivity was achieved with a 2 degree polished probe tip. A correlation algorithm was used to correct image distortion caused by non-uniform rotation of the probe. The probe is demonstrated by imaging human skin in vivo and porcine renal pelvis ex vivo and is suitable for imaging the renal pelvis in vivo for cancer staging.

Endoscopic snare resection of bladder tumors: evaluation of an alternative technique for bladder tumor resection

Transurethral resection of bladder tumor (TURBT) is the standard of care for initial bladder tumor management. In response to its shortcomings, we propose an alternative technique for tumor resection and retrieval: The endoscopic snare resection of bladder tumor (ESRBT). Eleven tumors managed by ESRBT were reviewed retrospectively. Via cystoscopy, tumors were resected en bloc with an electrosurgical polypectomy snare and retrieved transurethrally. Safety and efficacy were assessed by clinical and pathologic outcomes. ESRBT was highly effective for appropriate tumors. Tumor size and location varied: Two small, six medium, three large; six lateral wall, two dome, two trigone, one posterior wall. Half of initial urothelial carcinoma specimens contained muscle. There were no intraoperative or postoperative complications (mean follow-up: 17 mos; range 10-25 mos). ESRBT is a feasible technique for the resection of pedunculated bladder tumors. It offers evident and theoretical advantages over TURBT and may augment bladder tumor management. Further study is needed.

The clinical effectiveness and cost-effectiveness of different surveillance mammography regimens after the treatment for primary breast cancer: systematic reviews registry database analyses and economic evaluation

BACKGROUND

Following primary breast cancer treatment, the early detection of ipsilateral breast tumour recurrence (IBTR) or ipsilateral secondary cancer in the treated breast and detection of new primary cancers in the contralateral breast is beneficial for survival. Surveillance mammography is used to detect these cancers, but the optimal frequency of surveillance and the length of follow-up are unclear.

OBJECTIVES

To identify feasible management strategies for surveillance and follow-up of women after treatment for primary breast cancer in a UK setting, and to determine the effectiveness and cost-effectiveness of differing regimens.

METHODS

A survey of UK breast surgeons and radiologists to identify current surveillance mammography regimens and inform feasible alternatives; two discrete systematic reviews of evidence published from 1990 to mid 2009 to determine (i) the clinical effectiveness and cost-effectiveness of differing surveillance mammography regimens for patient health outcomes and (ii) the test performance of surveillance mammography in the detection of IBTR and metachronous contralateral breast cancer (MCBC); statistical analysis of individual patient data (West Midlands Cancer Intelligence Unit Breast Cancer Registry and Edinburgh data sets); and economic modelling using the systematic reviews results, existing data sets, and focused searches for specific data analysis to determine the effectiveness and cost-utility of differing surveillance regimens.

RESULTS

The majority of survey respondents initiate surveillance mammography 12 months after breast-conserving surgery (BCS) (87%) or mastectomy (79%). Annual surveillance mammography was most commonly reported for women after BCS or after mastectomy (72% and 53%, respectively). Most (74%) discharge women from surveillance mammography, most frequently 10 years after surgery. The majority (82%) discharge from clinical follow-up, most frequently at 5 years. Combining initiation, frequency and duration of surveillance mammography resulted in 54 differing surveillance regimens for women after BCS and 56 for women following mastectomy. The eight studies included in the clinical effectiveness systematic review suggest surveillance mammography offers a survival benefit compared with a surveillance regimen that does not include surveillance mammography. Nine studies were included in the test performance systematic review. For routine IBTR detection, surveillance mammography sensitivity ranged from 64% to 67% and specificity ranged from 85% to 97%. For magnetic resonance imaging (MRI), sensitivity ranged from 86% to 100% and specificity was 93%. For non-routine IBTR detection, sensitivity and specificity for surveillance mammography ranged from 50% to 83% and from 57% to 75%, respectively, and for MRI from 93% to 100% and from 88% to 96%, respectively. For routine MCBC detection, one study reported sensitivity of 67% and specificity of 50% for both surveillance mammography and MRI, although this was a highly select population. Data set analysis showed that IBTR has an adverse effect on survival. Furthermore, women experiencing a second tumour measuring >20 mm in diameter were at a significantly greater risk of death than those with no recurrence or those whose tumour was <10 mm in diameter. In the base-case analysis, the strategy with the highest net benefit, and most likely to be considered cost-effective, was surveillance mammography alone, provided every 12 months at a societal willingness to pay for a quality-adjusted life-year of either £20,000 or £30,000. The incremental cost-effectiveness ratio for surveillance mammography alone every 12 months compared with no surveillance was £4727.

LIMITATIONS

Few studies met the review inclusion criteria and none of the studies was a randomised controlled trial. The limited and variable nature of the data available precluded any quantitative analysis. There was no useable evidence contained in the Breast Cancer Registry database to assess the effectiveness of surveillance mammography directly. The results of the economic model should be considered exploratory and interpreted with caution given the paucity of data available to inform the economic model.

CONCLUSIONS

Surveillance is likely to improve survival and patients should gain maximum benefit through optimal use of resources, with those women with a greater likelihood of developing IBTR or MCBC being offered more comprehensive and more frequent surveillance. Further evidence is required to make a robust and informed judgement on the effectiveness of surveillance mammography and follow-up. The utility of national data sets could be improved and there is a need for high-quality, direct head-to-head studies comparing the diagnostic accuracy of tests used in the surveillance population.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Three-dimensional imaging of ureter with endoscopic optical coherence tomography

OBJECTIVES

To verify the ability to identify the layered structures of the ureteral wall and to image a segment of the ureter in 3 dimensions with high-speed, endoscopic optical coherence tomography (EOCT).

METHODS

We imaged a porcine ureter ex vivo using a spectral-domain EOCT with a specially designed circumferential scanning fiber catheter. The images were correlated with the histologic findings to identify the corresponding structures. Three-dimensional images and en face images at different depths from the luminal surface were reconstructed from the multiple cross-sectional images to visualize the layered structure of a segment of the ureter from different perspectives.

RESULTS

The EOCT images clearly revealed all layers of the ureteral wall as shown in the histologic images. In particular, with the specially designed fiber catheter, the light beam was well centered during the rotation and pull back, allowing constant acquisition of high-fidelity images and unambiguous identification of the smooth muscle layers in all images. With high-speed EOCT, a segment of ureter (20 mm) can be imaged in <90 seconds at a high resolution.

CONCLUSIONS

With its ability to visualize all layers of the ureteral wall, EOCT offers the potential to stage urothelial cancers that have infiltrated the muscular wall (Stage T2). This information will be complimentary to the diagnostic information obtained through ureteroscopic biopsy and computed tomography urogram.

High-grade transitional cell carcinoma and melanosis of urinary bladder: case report and review of the literature

Melanosis of the urinary bladder is a rare entity. It is generally regarded as a benign condition, but it is sometimes associated with primary malignant melanoma of the urinary bladder. It has never been reported to be connected with transitional cell carcinoma. We present a case of a woman with melanosis of the bladder who a year later developed high grade transitional cell bladder carcinoma.

Renal pseudotumors

OBJECTIVE

Renal cell carcinoma is the most common malignant tumor to involve the kidneys; however, a number of other entities--called renal pseudotumors--may mimic renal neoplasms on imaging. This article presents the imaging features and pathologic correlation of some of the common and uncommon renal pseudomasses.

CONCLUSION

Many renal lesions look similar to renal cell carcinoma on radiologic imaging. The imaging features of renal pseudotumors presented in this article will help radiologists to identify them and to triage these patients for appropriate management.

Effectiveness of strategies to disseminate and implement clinical guidelines for the management of impacted and unerupted third molars in primary dental care, a cluster randomised controlled trial

OBJECTIVE

To investigate the effectiveness and cost-effectiveness of different guideline implementation strategies, using the Scottish Intercollegiate Guidelines Network (SIGN) Guideline 42 "Management of unerupted and impacted third molar teeth" (published 2000) as a model.

DESIGN

A pragmatic, cluster RCT (2x2 factorial design).

SUBJECTS

Sixty-three dental practices across Scotland. Clinical records of all 16-24-year-old patients over two, four-month periods in 1999 (pre-intervention) and 2000 (post-intervention) were searched by a clinical researcher blind to the intervention group. Data were also gathered on the costs of the interventions.

INTERVENTIONS

Group 1 received a copy of SIGN 42 Guideline and had an opportunity to attend a postgraduate education course (PGEC). In addition to this, group 2 received audit and feedback (A and F). Group 3 received a computer aided learning (CAL) package. Group 4 received A and F and CAL. PRINCIPAL OUTCOME MEASUREMENT: The proportion of patients whose treatment complied with the guideline.

RESULTS

The weighted t-test for A and F versus no A and F (P=0.62) and CAL versus no CAL (P=0.76) were not statistically significant. Given the effectiveness results (no difference) the cost effectiveness calculation became a cost-minimisation calculation. The minimum cost intervention in the trial consisted of providing general dental practitioners (GDPs) with guidelines and the option of attending PGEC courses. Routine data which subsequently became available showed a Scotland-wide fall in extractions prior to data collection.

CONCLUSION

In an environment in which pre-intervention compliance was unexpectedly high, neither CAL nor A and F increased the dentists' compliance with the SIGN guideline compared with mailing of the guideline and the opportunity to attend a postgraduate course. The cost of the CAL arm of the trial was greater than the A and F arm. Further work is required to understand dental professionals' behaviour in response to guideline implementation strategies.

A randomised controlled trial of a tailored multifaceted strategy to promote implementation of a clinical guideline on induced abortion care

OBJECTIVE

To evaluate the effectiveness and efficiency of a tailored multifaceted strategy, delivered by a national clinical effectiveness programme, to implement a guideline on induced abortion.

DESIGN

Cluster randomised controlled trial.

SETTING AND PARTICIPANTS

All 26 hospital gynaecology units in Scotland providing induced abortion care.

INTERVENTION

Following the identification of barriers to guideline implementation, intervention units received a package comprising audit and feedback, unit educational meetings, dissemination of structured case records and promotion of a patient information booklet. Control units received printed guideline summaries alone.

MAIN OUTCOME MEASURES

Compliance with five key guideline recommendations (primary outcomes) and compliance with other recommendations, patient satisfaction and costs of the implementation strategy (secondary outcomes).

RESULTS

No effect was observed for any key recommendation: appointment with a gynaecologist within five days of referral (odds ratio 0.89; 95% confidence interval 0.50 to 1.58); ascertainment of cervical cytology history (0.93; 0.36 to 2.40); antibiotic prophylaxis or screening for lower genital tract infection (1.70; 0.71 to 5.99); use of misoprostol as an alternative to gemeprost (1.00; 0.27 to 1.77); and offer of contraceptive supplies at discharge (1.11; 0.48 to 2.53). Median pre-intervention compliance was near optimal for antibiotic prophylaxis and misoprostol use. No intervention benefit was observed for any secondary outcome. The intervention costs an average of pound 2607 per gynaecology unit.

CONCLUSIONS

The tailored multifaceted strategy was ineffective. This was possibly attributable to high pre-intervention compliance and the limited impact of the strategy on factors outside the perceived control of clinical staff.

Effectiveness and efficiency of guideline dissemination and implementation strategies

OBJECTIVES

To undertake a systematic review of the effectiveness and costs of different guideline development, dissemination and implementation strategies. To estimate the resource implications of these strategies. To develop a framework for deciding when it is efficient to develop and introduce clinical guidelines.

DATA SOURCES

MEDLINE, Healthstar, Cochrane Controlled Trial Register, EMBASE, SIGLE and the specialised register of the Cochrane Effective Practice and Organisation of Care (EPOC) group.

REVIEW METHODS

Single estimates of dichotomous process variables were derived for each study comparison based upon the primary end-point or the median measure across several reported end-points. Separate analyses were undertaken for comparisons of different types of intervention. The study also explored whether the effects of multifaceted interventions increased with the number of intervention components. Studies reporting economic data were also critically appraised. A survey to estimate the feasibility and likely resource requirements of guideline dissemination and implementation strategies in UK settings was carried out with key informants from primary and secondary care.

RESULTS

In total, 235 studies reporting 309 comparisons met the inclusion criteria; of these 73% of comparisons evaluated multifaceted interventions, although the maximum number of replications of a specific multifaceted intervention was 11 comparisons. Overall, the majority of comparisons reporting dichotomous process data observed improvements in care; however, there was considerable variation in the observed effects both within and across interventions. Commonly evaluated single interventions were reminders, dissemination of educational materials, and audit and feedback. There were 23 comparisons of multifaceted interventions involving educational outreach. The majority of interventions observed modest to moderate improvements in care. No relationship was found between the number of component interventions and the effects of multifaceted interventions. Only 29.4% of comparisons reported any economic data. The majority of studies only reported costs of treatment; only 25 studies reported data on the costs of guideline development or guideline dissemination and implementation. The majority of studies used process measures for their primary end-point, despite the fact that only three guidelines were explicitly evidence based (and may not have been efficient). Respondents to the key informant survey rarely identified existing budgets to support guideline dissemination and implementation strategies. In general, the respondents thought that only dissemination of educational materials and short (lunchtime) educational meetings were generally feasible within current resources.

CONCLUSIONS

There is an imperfect evidence base to support decisions about which guideline dissemination and implementation strategies are likely to be efficient under different circumstances. Decision makers need to use considerable judgement about how best to use the limited resources they have for clinical governance and related activities to maximise population benefits. They need to consider the potential clinical areas for clinical effectiveness activities, the likely benefits and costs required to introduce guidelines and the likely benefits and costs as a result of any changes in provider behaviour. Further research is required to: develop and validate a coherent theoretical framework of health professional and organisational behaviour and behaviour change to inform better the choice of interventions in research and service settings, and to estimate the efficiency of dissemination and implementation strategies in the presence of different barriers and effect modifiers.

Women's perceptions of decision-making about hysterectomy

OBJECTIVE

To explore women's views of decision-making relating to hysterectomy.

DESIGN

Structured questionnaire and in-depth interview surveys.

SETTING

A teaching hospital and a district general hospital in northeast Scotland.

SAMPLE

Women scheduled for hysterectomy for benign menstrual problems.

METHODS

Pre-operative questionnaires were sent to a consecutive sample of women booked for hysterectomy. A purposive sample was interviewed post-operatively.

MAIN OUTCOME MEASURES

Women's experiences of, and satisfaction with, information provision, communication and decision-making processes; the relationship between views of decision-making processes and decisions made.

RESULTS

One hundred and four women (66%) returned questionnaires. Most responded positively to structured questions about the process by which the decision to have a hysterectomy was reached. Almost all (97%) reported satisfaction with the decision made. Twenty women were interviewed post-operatively. A number, including some who had responded positively on the questionnaire, described aspects of the decision-making process that were suboptimal. Women's perceptions of the decision-making process, including the way their doctors communicated with them, did impinge on their views of the course of action selected. Some women had residual doubts about the appropriateness of hysterectomy.

CONCLUSIONS

In a significant minority of women, there are important shortcomings in current patterns of information provision and communication relating to decision-making. These are unlikely to be picked up by conventional structured patient feedback surveys. Further efforts are required to ensure that women are adequately informed and involved in decisions about gynaecological treatments.

Hemoptysis as an unusual presenting symptom of invasion of a descending thoracic aortic aneurysmal dissection by lung cancer

A 70-year-old woman with a known chronic dissecting aneurysm of the descending thoracic aorta presented with new-onset back pain and hemoptysis. The hemoptysis was thought to be the result of invasion of the bronchial tree by the aneurysm. During surgical repair, a lesion that appeared to be a pulmonary abscess was discovered to be adhering to the aortic tissue, and the patient underwent a localized pulmonary resection. The pathology report of the surgical specimens revealed squamous cell carcinoma of the lung with infiltration of the aortic wall. The patient died of lung cancer 6 months later. Hemoptysis was an unusual presentation in a case of lung cancer that had invaded a stable chronic aortic aneurysm.