An exploration of testicular cancer survivors' experience of ejaculatory dysfunction following retroperitoneal lymph node dissection-a sub-study of the PREPARE clinical trial

PURPOSE

Ejaculatory dysfunction secondary to retrograde ejaculation or anejaculation is a complication of retroperitoneal lymph node dissection (RPLND) for survivors of testicular cancer. We explored survivors' experiences of ejaculatory dysfunction following RPLND.

METHODS

In a sub-study of a single-arm phase 2 clinical trial (ACTRN12622000537752/12622000542796), participants reporting ejaculatory dysfunction ≥ 6 months following RPLND were invited to complete semi-structured interviews. Purposive sampling was used. Interviews continued until thematic saturation occurred, and codebook thematic analysis of interviews was performed.

RESULTS

Of 58 individuals recruited to the trial, 33 (57%) reported ejaculatory dysfunction. Of these, 32 (97%) agreed to interview and 15 participated. Participants interviewed had median age 34 years (range 24-66), 12 (80%) in a long-term relationship with median time from surgery 36 months (range 11-112). Three overarching themes were identified. The first reflected the value of RPLND despite ejaculatory dysfunction. The second illuminated the impact(s) of ejaculatory dysfunction closely mapped to life stage, with flow-on impacts to fertility, sex, psychological wellbeing and communication. The third reflected information needs. Fertility was a substantial source of concern for some participants. Ejaculatory dysfunction had no effect on sex for some, whilst for others, sex was less pleasurable. Some reported benefits. Few reported ejaculatory dysfunction challenged masculinity, confidence, or self-esteem.

CONCLUSIONS

Future research should examine interventions to reduce distress related to fertility, challenged masculinity and body image.

IMPLICATIONS FOR CANCER SURVIVORS

Whilst most participants considered ejaculatory dysfunction to have little impact on their sexual function and relationships, some reported significant difficulties varying by life stage and relationship status.

TROG 15.03/ANZUP International Multicenter Phase II Trial of Focal Ablative STereotactic RAdiotherapy for Cancers of the Kidney (FASTRACK II)

PURPOSE/OBJECTIVE(S)

Stereotactic body radiotherapy (SBRT) is an emerging non-invasive alternative for primary renal cell cancer (RCC) in patients unsuitable for surgery. The objective of the FASTRACK II clinical trial was to investigate the efficacy of SBRT for primary RCC.

MATERIALS/METHODS

This non-randomized, intergroup multi-institutional phase II study was activated in 7 Australian centers and 1 Dutch center, through the Trans Tasman Radiation Oncology Group (TROG) and the Australian and New Zealand Urogenital and Prostate Cancer Trials Group (ANZUP). Eligible patients had biopsy confirmed diagnosis of primary RCC with a single lesion within a kidney, ECOG performance ≤2 and were medically inoperable, high risk or declined surgery. For tumors ≤4 cm a single fraction of 26 Gy was prescribed, for tumors > 4 cm, 42 Gy in three fractions was prescribed. The primary outcome of the study was to estimate the efficacy of SBRT for primary RCC, defined as local control based on RECIST criteria. The study was powered assuming that 1-year local control would be 90%, with the null hypothesis of ≤80% considered undesirable and not worthy of proceeding to a future randomized controlled trial.

RESULTS

Between July 2016 and February 2020, 70 patients were enrolled with a median follow-up of 42 months. Median age was 77 years. Forty-nine patients were male (70%), median BMI was 32 and median Charlson comorbidity score was 7. The median [IQR] RENAL complexity score was 8 [7-10]. Biopsy confirmation was 100%. Twenty-three patients (33%) had T1a disease. The median (interquartile range [IQR]) tumor size was 4.6cm [3.7-5.5]; it was 3.3cm [3.0-3.6] in those receiving single fraction (n = 23), and 5.3cm [4.6-6.0] in those receiving 3-fraction SBRT (n = 47). During real-time pre-treatment quality assurance review, 10 cases (14.3%) required resubmission for protocol deviation, 2119 variables were assessed at final review, and final protocol compliance was 99.3%. Seven (10%) patients experienced grade 3 treatment-related adverse events, with no grade 4 or 5 events observed. Eleven (16%) patients reported no adverse events. Local control was 100% throughout the lifetime of the trial (p<0.001). Cancer-specific survival was also 100% throughout the lifetime of the trial. Freedom from distant failure (95% CIs) at 1 and 3 years was 99% (90-100%). Overall survival (95% CIs) at 1 and 3 years was 99% (90-100%) and 82% (70-89%), respectively. Baseline mean eGFR (95% CI) was 61.1 mLs/min (56.6; 65.6) and reduced by -10.8 mLs/min (-13.0; -8.6) by 1-year, by -14.6 mLs/min (-17.0; -12.2) by 2-years and plateaued thereafter.

CONCLUSION

In the first multicenter prospective trial of a non-surgical primary RCC cohort, enrolling mostly T1b+ disease, SBRT was an effective treatment strategy with no observed local failures. We observed an acceptable side effect profile and renal function after SBRT. These outcomes support the design of a future randomized clinical trial of SBRT versus surgery for primary RCC. The trial was registered with ID: NCT02613819.

A systematic scoping review of multidisciplinary cancer team and decision-making in the management of men with advanced prostate cancer

PURPOSE

The early diagnosis of prostate cancer and subsequent access to the treatment options helps to achieve optimal cancer outcomes. As the treatment options for patients with advanced prostate cancer continues to evolve, patients need to access a multidisciplinary team (MDT) meeting to receive best-practice care.

METHODS

In this paper a MEDLINE review was performed to assess clinical decision making in the context of MDT discussions for patients with advanced prostate cancer.

RESULTS

From 441 returned articles and abstracts, 50 articles were assessed for eligibility and 16 articles included for analysis. Sixteen articles were identified, 9 of the 16 articles used quantitative methodology including three retrospective analysis of clinical registry data, patient medical records and/or MDT meeting notes and three cross-sectional surveys. Other study designs included one observation study and one study using a combination of qualitative and quantitative methodologies and one mini-review. There were also four editorials included in the review and two consensus statements.

CONCLUSION

This paper highlights the important role the inter-disciplinary MDT has on shared decision making for men with advanced prostate cancer. The application of MDT care is a rapidly growing trend in uro-oncology and an efficient MDT service requires further research to assess its efficiency so that it may expand through all aspect of uro-oncology.

Navigating systemic therapy for metastatic castration-naïve prostate cancer

INTRODUCTION

The last decade has seen a remarkable shift in the treatment landscape of advanced prostate cancer, none more so than in the management of metastatic castration-naïve disease.

METHODS

This narrative review will examine existing and emerging evidence supporting systemic therapy use for metastatic castration-naïve prostate cancer (mCNPC) and provide guidance on the selection of these agents with respect to optimising patient outcomes.

RESULTS

The addition of either docetaxel (chemohormonal approach) or an AR pathway inhibitor (abiraterone, enzalutamide or apalutamide) is a reasonable standard of care option for men commencing long-term ADT for mCNPC. While the issue of disease volume as a predictive biomarker for docetaxel benefit has previously been debated, recent data support consideration of upfront docetaxel in all patients, regardless of metastatic burden. Decisions regarding systemic treatment for men with mCNPC should be based on comprehensive consideration of disease, patient and logistical factors. Multiple novel therapeutics for mCNPC are currently under active investigation.

CONCLUSION

The introduction of potent systemic therapy earlier in the mCNPC disease course has resulted in dramatic improvements in clinical outcomes for patients. As the management of mCNPC continues to evolve, the future remains promising, with the expectation of ongoing improvements to patient outcomes and quality of life.

Assessment of Intrafraction Motion of the Urinary Bladder Using Magnetic Resonance Imaging (cineMRI)

AIM

To assess the intrafraction motion of the urinary bladder and delineate the appropriate margin size for radiotherapy planning, for both the full and empty bladder.

MATERIALS AND METHODS

This was a single-site, single-arm study of 20 patients planned to undergo radical cystectomy for histologically confirmed muscle-invasive bladder cancer. Patients underwent magnetic resonance imaging (cineMRI) of the entire pelvis using a 3-Tesla system, prior to cystectomy. Patients first underwent a cineMRI with a full bladder, then voided and underwent a second MRI with an empty bladder. All MRI sequences were acquired over 18 min. We assessed the differences in bladder filling and subsequent bladder wall displacement, between the empty and full bladder, during a time period consistent with radiotherapy treatment delivery.

RESULTS

Twenty patients underwent cineMRI of the entire pelvis. The maximum mean directional displacements of the bladder walls over the 18 min duration of the scan for the empty bladders were 9.8 mm superiorly, 1.1 mm inferiorly, 2.39 mm anteriorly, 3.73 mm posteriorly, 2.74 mm to the left and 2.48 mm to the right. The maximal mean displacements for the full bladders were 9.2 mm superiorly, 1.1 mm inferiorly, 2.28 mm anteriorly, 1.08 mm posteriorly, 1.85 mm to the left and 1.73 mm to the right. Statistically significant differences were seen in the posterior, left and right displacements but were quantitatively small.

CONCLUSIONS

Intrafractional motion secondary to bladder filling showed minimal variation between the full and empty bladder. Similar clinical target volume to planning target volume margins can be applied for the delivery of radiotherapy for a full and empty bladder.

PSMA PET applications in the prostate cancer journey: from diagnosis to theranostics

The heterogeneity of prostate cancer has made imaging modalities of crucial importance in this disease. Accurate diagnosis and staging of the volume and extent of disease, especially in advanced and metastatic prostate cancer, can help to tailor the timing and modalities of treatment. While MRI has been effective in the detection of significant prostate cancer, its use in the identification and quantification of extraprostatic disease is limited. This gap is now being filled by PSMA PET. PSMA PET scans have now been shown to have a role in all stages in the prostate cancer journey. Emerging evidence has shown its promise in primary staging, restaging and theranostics. In this paper, we review the evidence for the use of PSMA PET in the various stages of prostate cancer, from initial diagnosis to advanced metastatic disease where other systemic treatments have failed.

Medical therapy versus transurethral resection of the prostate (TURP) for the treatment of symptomatic benign prostatic enlargement (BPE): a cost minimisation analysis

PURPOSE

A cost minimisation analysis compares the costs of different interventions' to ascertain the least expensive over time. We compared different prostate targeted drug treatments with TURP to identify the optimal cost saving duration of a medical therapy for symptomatic benign prostatic enlargement (BPE).

METHODS

The Evolution registry is a prospective, multicentre registry, conducted by the European Association of Urology Research Foundation (EAUrf) for 24 months in 5 European countries. Evolution was designed to register the management of symptomatic BPE in clinical practice settings in 5 European countries. Direct cost evaluation associated with prostate targeted medical therapies and TURP was also recorded and analysed.

RESULTS

In total, 1838 men were enrolled with 1246 evaluable at 24 months. Medical therapies were more cost saving than TURP for treatment durations ranging from 2.9 to 70.4 years. Cost saving depended on both medication class and individual country assessed. Daily tamsulosin monotherapy was more cost saving than TURP for ≤ 13.9 years in Germany compared to ≤ 32.7 years in Italy. Daily finasteride monotherapy was more cost saving for ≤ 5.9 years in France compared to ≤ 36.9 years in Spain. Combination therapy was more cost saving for ≤ 5.9 years for Italian patients versus ≤ 13.8 years in Germany.

CONCLUSIONS

BPE medical management was more cost saving than TURP for different specific treatment durations. Information from this study will allow clinicians to convey medical and surgical costs over time, to both patients and payors alike, when considering BPE treatment.

Single-use flexible ureteropyeloscopy: a systematic review

PURPOSE

Data assessing the effectiveness of single-use flexible ureteropyeloscopy (FURS) are limited. This study evaluates and compares single-use FURS with conventional reusable FURS.

METHODS

A systematic search using electronic databases (Pubmed and Embase) was performed for studies evaluating single-use FURS in the setting of urinary tract stone disease. Outcome measures included a comparative evaluation of their mechanical, optical and clinical outcomes.

RESULTS

Eleven studies on 466 patients met inclusion criteria. In vitro comparative data were available on three single-use flexible ureteropyeloscopes (LithoVue™, Polyscope™ and SemiFlex™) and clinical data were available on two (LithoVue™ and Polyscope™). The overall stone-free rate and complication rate associated with single-use FURS was 87 ± 15% and 9.3 ± 9%, respectively. There were no significant differences in procedure duration, stone size, stone clearance and complication rates when single-use FURS and reusable FURS were compared (duration: 73 ± 27 versus 74 ± 13 min, p = 0.99; stone size: 1.36 ± 0.2 versus 1.34 ± 0.18 cm, p = 0.93; stone-free rate: 77.8 ± 18 versus 68.5 ± 33%, p = 0.76; complication rate 15.3 ± 10.6 versus 15 ± 1.6%, p = 0.3).

CONCLUSIONS

Single-use FURS demonstrates comparable efficacy with reusable FURS in treating renal calculi. Further studies on clinical efficacy and cost are needed to determine whether single-use FURS will reliably replace its reusable counterpart.

Health information quality on the internet in gynecological oncology: a multilingual evaluation

BACKGROUND

Oncological internet information quality is considered variable, but no comprehensive analysis of gynecological malig- nancies exists. The present authors' objectives were to compare the quality of common malignancy websites and to assess for language or disease differences; and secondly, to perform a quality comparison between medical and layperson terminology.

MATERIALS AND METHODS

World Health Organization (WHO) Health on the Net (HON) principles may be applied to websites using an automated toolbar function. Using a search engine (www.Google.com) 8,400 websites were assessed using keywords 'endometrial, 'uterine', 'cervical', 'ovarian', 'vaginal', 'vulvar', plus 'cancer', in English, French, German, and Spanish; repeated for alternate terms e.g. 'cervix', 'womb'.

RESULTS

Searches for "vaginal' 'uterine', 'cervical', and 'endometrial' each returned millions of websites. The total percentage of all assessed HON-accredited sites was notably low across all search terms (median 15%; range 3-19%). Significant differences by malignancy type (p < 0.0001), language (p < 0.0001), and tertiles (thirds) of the first 150 websites returned (p < 0.0001). French language had most accredited websites. Using alternate terms demonstrated significant differences (p < 0.001) in accredited websites for most gynecological cancers.

CONCLUSIONS

Internet data on gynecological malignancies is overwhelming. Further, a lack of validation of the majority of gynecological oncologic sites should be appreciated with discrepancies in quality and number of websites across diseases, languages, and also between medical and layperson terms. Physicians should encourage and more importantly their professional bodies should participate in the development of informative, ethical, and reliable health websites on the internet and direct patients to them.

Radiation delivered to patients during endourological surgery – are they overexposed?

Introduction:

Ionising radiation is commonly used in urological practice in the form of fluoroscopy. To date there is a remarkable scarcity of information concerning patient exposure to ionising radiation during urological procedures and the potential risk of developing of a lethal malignancy due to excessive radiation exposure.

Objectives:

We aimed to determine the radiation exposure for a patient during the most commonly performed urological procedures, and to assess the potential risk of developing a fatal cancer as a result of endourological fluoroscopy.

Methods:

Data was collected prospectively in two institutions on endoscopic urological operations. Procedures were classified as retrographic, semi-rigid ureteroscopic and flexible ureterorenoscopic (FURS). Data collected included procedure type and difficulty, Dose Area Product [DAP (Gy*Cm2)]. The effective dose (ED) measured in millisievert (mSv) was determined from the DAP by using the Monte Carlo calculation.

Results:

In total 395 consecutive operations from two institutions were assessed. The mean ED for all procedures in this study was 0.394 mSv, IQR (0.1184–0.7583). The maximum ED was 5.93 mSv. The radiation exposure for all procedures was relatively small; for diagnostic retrographic procedures the median ED was 0.112 mSv. For retrograde procedures that involved stent insertion, the median ED was 0.438 mSv. The median ED for all ureteroscopic surgeries was 0.295 mSv, and the median ED for all FURS procedures was 0.491.

Conclusion:

The findings of this study are reassuring. Endoscopic urological procedures appear to expose patients to relatively small radiation compared with other procedures requiring fluoroscopy, thus conferring a very low lifetime risk of malignancy.

Candida growth in urine cultures: a contemporary analysis of species and antifungal susceptibility profiles

BACKGROUND

Recent publications suggest the distribution of Candida species causing candiduria may vary geographically, which has implications for the continued efficacy of antifungal therapy and emerging resistance.

AIM

To investigate the incidence of Candiduria at a university hospital in the UK. Further, to assess the distribution of species and the accompanying antifungal susceptibility profile, in order to monitor the clinical utility of current antifungal treatment guidelines for candiduria so that patients receive the best possible outcomes from the most up to date care.

DESIGN

Retrospective audit.

METHODS

From 1st January 2005 to 31st October 2014, we retrospectively reviewed 37 538 positive urine cultures recorded in a computerized laboratory results database. Identification and susceptibility testing was performed using the VITEK® 2 fungal susceptibility card (bioMérieux, Marcy d'Etoile, France).

RESULTS

In total, 96 cultures were positive for Candida species, of which 69 (72%) were C.albicans, which translates to a prevalence of 2.6 per 1000 positive urine cultures. Candiduria was more common in younger patients, males and catheterized females. We report 94 and 73% of isolates of C.albicans and other non-C.albicans Candida species were susceptible to fluconazole. All isolates were susceptible to amphotericin B.

CONCLUSIONS

Our results add weight to the evidence supporting current European and North American guidelines recommending fluconazole or amphotericin B for treatment of candiduria, if antifungal treatment is clinically indicated.

Radical cystectomy and orthotopic bladder substitution: surgical tricks and management of complications

AIM

Bladder cancer is the second most common urological malignancy, with urothelial carcinoma (transitional cell carcinoma) comprising almost 90% of all primary bladder tumours. Over recent decades, radical cystectomy has emerged as the predominant treatment modality for patients with high-grade, invasive urothelial cancers and for those with less-invasive disease who fail treatment with bladder-preservation strategies. Bladder substitution following radical cystectomy has become increasingly common and in many centers has evolved to become the standard method of urinary diversion. The main goal of this paper is to review intraoperative considerations for patients undergoing radical cystectomy with a focus on issues specific to surgical tricks with neobladder construction and postoperative complications.

METHODS

Systematic literature review in Pubmed and Embase including bladder cancer, urinary diversion, neobladder, surgical technique and complications as key words.

RESULTS

Intraoperative techniques and modifications have made neobladder construction more amenable and the standard in suitable patients. Postoperative complications still occur in a significant number of patients but may be minimised and recognised early for better outcomes.

CONCLUSION

Orthotopic bladder substitution does not compromise oncological outcome and importantly can be performed with relatively good results regarding functional and quality of life issues. Modifications to intraoperative technique can assist with neobladder construction to aid better outcomes. Where possible orthotopic bladder substitution should be the diversion of choice. Of paramount importance is the active postoperative management and regular long-term follow-up of patients with an orthotopic bladder substitution.

Is fosfomycin a potential treatment alternative for multidrug-resistant gram-negative prostatitis?

BACKGROUND

Multidrug-resistant gram-negative bacterial (MDR-GNB) infections of the prostate are an increasing problem worldwide, particularly complicating transrectal ultrasound (TRUS)-guided prostate biopsy. Fluoroquinolone-based regimens, once the mainstay of many protocols, are increasingly ineffective. Fosfomycin has reasonable in vitro and urinary activity (minimum inhibitory concentration breakpoint ≤64 µg/mL) against MDR-GNB, but its prostatic penetration has been uncertain, so it has not been widely recommended for the prophylaxis or treatment of MDR-GNB prostatitis.

METHODS

In a prospective study of healthy men undergoing a transurethral resection of the prostate for benign prostatic hyperplasia, we assessed serum, urine, and prostatic tissue (transition zone [TZ] and peripheral zone [PZ]) fosfomycin concentrations using liquid chromatography-tandem mass spectrometry, following a single 3-g oral fosfomycin dose within 17 hours of surgery.

RESULTS

Among the 26 participants, mean plasma and urinary fosfomycin levels were 11.4 ± 7.6 µg/mL and 571 ± 418 µg/mL, 565 ± 149 minutes and 581 ± 150 minutes postdose, respectively. Mean overall prostate fosfomycin levels were 6.5 ± 4.9 µg/g (range, 0.7-22.1 µg/g), with therapeutic concentrations detectable up to 17 hours following the dose. The mean prostate to plasma ratio was 0.67 ± 0.57. Mean concentrations within the TZ vs PZ prostate regions varied significantly (TZ, 8.3 ± 6.6 vs PZ, 4.4 ± 4.1 µg/g; P = .001). Only 1 patient had a mean prostatic fosfomycin concentration of <1 µg/g, whereas the majority (70%) had concentrations ≥4 µg/g.

CONCLUSIONS

Fosfomycin appears to achieve reasonable intraprostatic concentrations in uninflamed prostate following a single 3-g oral dose, such that it may be a potential option for prophylaxis pre-TRUS prostate biopsy and possibly for the treatment of MDR-GNB prostatitis. Formal clinical studies are now required.

Should follow-up biopsies for men on active surveillance for prostate cancer be restricted to limited templates?

OBJECTIVE

To investigate if prostate biopsy templates with fewer cores can be used during active surveillance (AS) for prostate cancer.

METHODS

At present, we use an AS protocol template (ASPT) consisting of 13-17 cores. We hypothesize in the setting of known cancer, sextant (6 cores) or standard extended (10-12 cores) templates, could be used with similar effect. We identified patients in our referral institution database (1997-2009) with entry prostate-specific antigen <10 ng/mL, stage ≤cT2, Gleason sum ≤6, ≤3 cores positive for cancer, <50% of single core involved, and age ≤75 years (N = 272). Patients fulfilling standard criteria for pathologic reclassification (N = 94) at any follow-up biopsy were selected for evaluation. By mapping tumor location on the pathologic reclassification determining biopsy, hypothetical scenarios of sextant or standard extended templates (SET) were compared with our ASPT and examined for frequency of cancer detection and pathologic reclassification.

RESULTS

For the 94 patients analyzed, the median number of cores taken was 9.7 (6-22) at baseline and 15 (14-17) for the reclassification biopsy. The median time between baseline and the pathologic reclassification determining biopsy was 15.4 months. Analysis of subgroupings showed that sextant template would identify 84% of cancers and 47.9% of the reclassification events, whereas SET detected 99% of cancers and 81.9% of patients who pathologically reclassified. When only considering Gleason sum ≥7 related progression events, SET found 16.2% less (n = 57) compared with ASPT (n = 68).

CONCLUSION

When monitoring patients on AS, a 13-17 core template detects more pathologic reclassification than standard sextant (18.1%) or extended (52.1%) biopsy templates.

Prevention strategies in prostate cancer

Prostate cancer (PCa) prevention has been an exciting and controversial topic since the results of the Prostate Cancer Prevention Trial (PCPT) were published. With the recently published results of the reduce (Reduction by Dutasteride of Prostate Cancer Events) trial, interest in this topic is at a peak. Primary pca prevention will be unlikely to affect mortality significantly, but the reduction in overtreatment and the effect on quality of life from the avoidance of a cancer diagnosis are important factors to consider.This review provides a comparative update on the REDUCE and PCPT trials and some clinical recommendations. Other potential primary preventive strategies with statins, selective estrogen response modulators, and nutraceutical compounds-including current evidence for these agents and their roles in clinical practice-are discussed. Many substances that have been examined in the primary prevention of pca and for which clinical data are either negative or particularly weak are not covered.The future of PCa prevention continues to expand, with several ongoing clinical trials and much interest in tertiary prostate cancer prevention.

Role of surgery in high-risk localized prostate cancer

Men with high-risk localized prostate cancer (PCa) remain a challenge for clinicians. Until recently, surgery was not the preferred approach, in part because risk of subclinical metastatic disease, elevated rates of positive surgical margins, absence of randomized studies, and suboptimal cancer control did not justify the morbidity of surgery. No randomized data comparing surgery with radiation therapy are yet available. Data for and comparisons between treatment options should therefore be analyzed with extreme caution.When selecting the best treatment for patients with clinically localized high-risk PCa, considerations should include the life expectancy of the patient, the natural history of PCa, the curability of the disease, and the morbidity of treatment. High-grade PCa managed with noncurative intent greatly reduces life expectancy, but overall, it must also be remembered that radical prostatectomy (RP) and radiotherapy (RT) appear to have similar effects on quality of life. In this population, RP necessitates an extended pelvic lymph node dissection (PLND), but in selected cases, nerve-sparing is a therapeutic possibility and may offer a significant advantage over rt in terms of local control and-although absolutely not yet proved-maybe even in survival. One clear advantage is the ease of administering adjuvant or salvage external-beam rt (EBRT) after rp; conversely, salvage rp after failed EBRT is an exceedingly difficult surgery, with major complications. Surgery therefore has its place, but must be considered in the context of multimodality treatment and the risk of micrometastatic disease. Awaited trial results will help to further refine management in this group of patients.

18F-fluorodeoxyglucose positron emission tomography in evaluation of germ cell tumor after chemotherapy

OBJECTIVES

To evaluate the role of 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) in the assessment of germ cell tumors after chemotherapy.

METHODS

We reviewed patients' records for the histologic findings and clinical outcome. 18F-FDG PET results were correlated with tissue histologic features where available; and if not available, the correlation was with the clinical outcome.

RESULTS

A total of 45 PET studies were performed on 38 patients (age range 19 to 64 years, median 31). All patients had received chemotherapy. In the nonseminomatous germ cell tumor (NSGCT) group, of the 31 patients with one scan, 18 PET scans were reported as positive, with only 2 not having active disease. Of the 12 negative scans, 6 showed teratoma, 1 tumor, and 5 did not show active disease. The equivocal scan revealed thyroid adenoma. In the seminoma group, the PET scans correlated well with the clinical and histologic outcomes. Four patients underwent salvage chemotherapy, and in this subgroup, the PET findings also correlated with the outcome.

CONCLUSIONS

(18)F-FDG PET is a promising tool as an adjunct to current imaging techniques in detecting residual viable germ cell tumor after chemotherapy. In NSGCT, a positive PET scan was accurate in 16 of 18 patients, although negative PET studies did not exclude the presence of disease, mainly because of the presence of teratoma. In seminoma, a negative 18F-FDG PET study correlated with a favorable clinical outcome. PET was also predictive of the response to salvage chemotherapy and was highly specific for active tumor in both NSGCT and seminoma.

The use of oxidised cellulose as a topical haemostatic dressing on a bleeding stomal wound

Surgical staff were unable to obtain haemostasis using standard methods, such as suturing, in a patient undergoing stomal construction. Topical application of oxidised cellulose stopped the haemorrhaging within seconds with no ill effects.