French ccAFU guidelines – Update 2018–2020: Bladder cancer

Objective

To propose updated French guidelines for non-muscle invasive (NMIBC) and muscle-invasive (MIBC) bladder cancers.

Methods

A Medline search was achieved between 2015 and 2018, as regards diagnosis, options of treatment and follow-up of bladder cancer, to evaluate different references with levels of evidence.

Results

Diagnosis of NMIBC (Ta, T1, CIS) is based on a complete deep resection of the tumor. The use of fluorescence and a second-look indication are essential to improve initial diagnosis. Risks of both recurrence and progression can be estimated using the EORTC score. A stratification of patients into low, intermediate and high risk groups is pivotal for recommending adjuvant treatment: instillation of chemotherapy (immediate post-operative, standard schedule) or intravesical BCG (standard schedule and maintenance). Cystectomy is recommended in BCG-refractory patients. Extension evaluation of MIBC is based on contrast-enhanced pelvic-abdominal and thoracic CT-scan. Multiparametric MRI can be an alternative. Cystectomy associated with extended lymph nodes dissection is considered the gold standard for non-metastatic MIBC. It should be preceded by cisplatin-based neoadjuvant chemotherapy in eligible patients. An orthotopic bladder substitution should be proposed to both male and female patients with no contraindication and in cases of negative frozen urethral samples; otherwise transileal ureterostomy is recommended as urinary diversion. All patients should be included in an Early Recovery After Surgery (ERAS) protocol. For metastatic MIBC, first-line chemotherapy using platin is recommended (GC or MVAC), when performans status (PS < 1) and renal function (creatinine clearance > 60 mL/min) allow it (only in 50 % of cases). In second line treatment, immunotherapy with pembrolizumab demonstrated a significant improvement in overall survival.

Conclusion

These updated French guidelines will contribute to increase the level of urological care for the diagnosis and treatment for NMIBC and MIBC.

[Functional stereotactic radiosurgery: Indications and perspectives]

Stereotactic radiosurgery (SRS) is a non-invasive technique that enables to create brain focal lesions with a high precision and localization. Thus, functional brain disorders can be treated by SRS in case of pharmacoresistance or inoperability. To date, treatment of trigeminal neuralgia is the most described and known indication. Other indications will be developed in the future like movement disorders, refractory epilepsy, obsessive compulsive disorder and severe depression. We present here a review of actual and future indications of functional brain SRS with their level of evidence. All these SRS treatments have to be strictly conducted by trained teams with an excellent collaboration between radiation physicists, medical physicists, neurosurgeons, neurologists, psychiatrists and probably neuroradiologists.

Saturable elimination of piperacillin in critically ill patients: implications for continuous infusion

The study aimed to evaluate saturation of piperacillin elimination in critically ill adult patients. Seventeen critically ill adult patients received continuous and intermittent infusion of piperacillin/tazobactam. Piperacillin plasma concentrations (n = 217) were analysed using population pharmacokinetic (PopPK) modelling. Post-hoc simulations were performed to evaluate the type I error rate associated with the study. Unseen data were used to validate the final model. The mean error (ME) and root mean square error (RMSE) were calculated as a measure of bias and imprecision, respectively. A PopPK model with parallel linear and non-linear elimination best fitted the data. The median and 95% confidence interval (CI) for the model parameters drug clearance (CL), volume of central compartment (V), volume of peripheral compartment (V_p) and intercompartmental clearance (Q) were 9 (7.69-11) L/h, 6.18 (4.93-11.2) L, 11.17 (7.26-12) L and 15.61 (12.66-23.8) L/h, respectively. The Michaelis-Menten constant (K_m) and the maximum elimination rate for Michaelis-Menten elimination (V_max) were estimated without population variability in the model to avoid overfitting and inflation of the type I error rate. The population estimates for K_m and V_max were 37.09 mg/L and 353.57 mg/h, respectively. The bias (ME) was -20.8 (95% CI -26.2 to -15.4) mg/L, whilst imprecision (RMSE) was 49.2 (95% CI 41.2-56) mg/L. In conclusion, piperacillin elimination is (partially) saturable. Moreover, the population estimate for K_m lies within the therapeutic window and therefore saturation of elimination should be accounted for when defining optimum dosing regimens for piperacillin in critically ill patients.

RETRACTED: Recommandations françaises du Comité de Cancérologie de l’AFU — Actualisation 2018—2020 : tumeurs de la vessie French ccAFU guidelines — Update 2018—2020: Bladder cancer

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). Cet article est retiré de la publication à la demande des auteurs car ils ont apporté des modifications significatives sur des points scientifiques après la publication de la première version des recommandations. Le nouvel article est disponible à cette adresse: doi:10.1016/j.purol.2019.01.006. C’est cette nouvelle version qui doit être utilisée pour citer l’article. This article has been retracted at the request of the authors, as it is not based on the definitive version of the text because some scientific data has been corrected since the first issue was published. The replacement has been published at the doi:10.1016/j.purol.2019.01.006. That newer version of the text should be used when citing the article.

RETRACTED: Recommandations françaises du Comité de Cancérologie de l’AFU — Actualisation 2018—2020 : tumeurs de la voie excrétrice supérieure French ccAFU guidelines — Update 2018—2020: Upper tract urothelial carcinoma

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). Cet article est retiré de la publication à la demande des auteurs car ils ont apporté des modifications significatives sur des points scientifiques après la publication de la première version des recommandations. Le nouvel article est disponible à cette adresse: doi:10.1016/j.purol.2019.01.005. C’est cette nouvelle version qui doit être utilisée pour citer l’article. This article has been retracted at the request of the authors, as it is not based on the definitive version of the text because some scientific data has been corrected since the first issue was published. The replacement has been published at the doi:10.1016/j.purol.2019.01.005. That newer version of the text should be used when citing the article.

Pharmacokinetic-pharmacodynamic model for propofol for broad application in anaesthesia and sedation

BACKGROUND

Pharmacokinetic (PK) and pharmacodynamic (PD) models are used in target-controlled-infusion (TCI) systems to determine the optimal drug administration to achieve a desired target concentration in a central or effect-site compartment. Our aim was to develop a PK-PD model for propofol that can predict the bispectral index (BIS) for a broad population, suitable for TCI applications.

METHODS

Propofol PK data were obtained from 30 previously published studies, five of which also contained BIS observations. A PK-PD model was developed using NONMEM. Weight, age, post-menstrual age (PMA), height, sex, BMI, and presence/absence of concomitant anaesthetic drugs were explored as covariates. The predictive performance was measured across young children, children, adults, elderly, and high-BMI individuals, and in simulated TCI applications.

RESULTS

Overall, 15 433 propofol concentration and 28 639 BIS observations from 1033 individuals (672 males and 361 females) were analysed. The age range was from 27 weeks PMA to 88 yr, and the weight range was 0.68-160 kg. The final model uses age, PMA, weight, height, sex, and presence/absence of concomitant anaesthetic drugs as covariates. A 35-yr-old, 170 cm, 70 kg male (without concomitant anaesthetic drugs) has a V₁, V₂, V₃, CL, Q₂, Q₃, and k_e0 of 6.28, 25.5, 273 litres, 1.79, 1.75, 1.11 litres min^-1, and 0.146 min^-1, respectively. The propofol TCI administration using the model matches well with recommendations for all age groups considered for both anaesthesia and sedation.

CONCLUSIONS

We developed a PK-PD model to predict the propofol concentrations and BIS for broad, diverse population. This should be useful for TCI in anaesthesia and sedation.

[Medication screening by the community pharmacist in Belgium]

About 20% of the European population is older than 65 years. Because of multimorbidity (i.e. multiple chronic condition within a patient), older patients are often prescribed multiple drugs [i.e. polypharmacy). Both older age and polypharmacy significantly increase the risk for adverse drug events. International research showed that more or less 5% of all unplanned hospital admissions is related to the use of medication. About 70% of these drug related admissions happened in patients older than 65 years. Moreover, about half of the admissions could have been avoided. These preventable hospital admissions were caused by the intake of medication without an indication, problems with medication adherence, interactions and/or insufficient monitoring. We define this as (potential Drug Related Problems [DRPI. DRPs can occur on multiple occasions during the medication management process: prescribing, dispensing, intake and monitoring. When DRPs can be detected in an early stage, significant consequences can be avoided. To accomplish this, multiple strategies are possible. One of the possibilities is performing a periodic medication screening by the community pharmacist in patient groups at risk. During such a medication screening, the pharmacotherapy is critically evaluated in a systematic and structured way. The implementation of medication screening in first-line health care is currently limited. The community pharmacist is nevertheless ideally placed to perform this task. There is an important relation of trust between him and the patient and the community pharmacist has access to a full medication history. Furthermore, as an expert in drug-related issues, he possesses all necessary knowledge to perform the pharmacotherapeutic analysis.

[CCAFU french national guidelines 2016-2018 on upper tract tumors]

INTRODUCTION

The purpose was to propose an update of the french guidelines from the national committee CCAFU on upper tract urothelial carcinomas (UTUC).

METHODS

A systematic Medline search was performed between 2013 and 2016, as regards diagnosis, options of treatment and follow-up of UTUC, to evaluate different references with levels of evidence.

RESULTS

The diagnosis of this rare pathology is based on CT-scan acquisition during excretion and ureteroscopy with histological biopsies. Radical nephroureterectomy (RNU) remains the gold standard for surgical treatment, nevertheless a conservative endoscopic approach can be proposed for low risk lesion: unifocal tumour, possible complete resection and low grade and absence of invasion on CT-scan. Close monitoring with endoscopic follow-up (flexible ureteroscope) in compliant patients is therefore necessary. After RNU, bladder instillation of chemotherapy is recommended to reduced risk of baldder recurrence. The place of systemic therapy (adjuvant and neoadjuvant chemotherapy) remains to define.

CONCLUSION

These updated guidelines will contribute to increase the level of urological care for diagnosis and treatment for UTUC. © 2016 Elsevier Masson SAS. All rights reserved.

[Radiotherapy of benign intracranial tumors]

Most of the benign intracranial tumors are meningiomas, vestibular schwannomas, pituitary adenomas, craniopharyngiomas, and glomus tumors. Some of them grow very slowly, and can be observed without specific treatment, especially if they are asymptomatic. Symptomatic or growing tumors are treated by surgery, which is the reference treatment. When surgery is not possible, due to the location of the lesion, or general conditions, radiotherapy can be applied, as it is if there is a postoperative growing residual tumor, or a local relapse. Indications have to be discussed in polydisciplinary meetings, with precise evaluation of the benefit and risks of the treatments. The techniques to be used are the most modern ones, as multimodal imaging and image-guided radiation therapy. Stereotactic treatments, using fractionated or single doses depending on the size or the location of the tumors, are commonly realized, to avoid as much a possible the occurrence of late side effects.

[Observational survey of the French Urological Association Oncology Committee (CCAFU) evaluating the practice of immediate postoperative instillation (IPOP) using mitomycin C for non-muscle invasive bladder cancer (NMIBC) treatment]

OBJECTIVE

To evaluate the practice of immediate postoperative instillation (IPOP) using mitomycin C for non-muscle invasive bladder cancer (NMIBC) treatment by urologists members of the French Association of Urology (AFU).

MATERIAL AND METHOD

Internet-based observational survey evaluating indications and practical modalities of IPOP in NMIBC treatment using questionnaire sent in May 2014 to 915 urologists.

RESULTS

Two hundred ninety-eight urologists participated in the survey (response rate: 32.6%) and 57% prescribed the IPOP. The median frequency of IPOP prescription was 3.3%, and was higher in the academic public sector. The CASE recommendations were self-assessed as known or well-known in 67% of cases. The selections criteria for IPOP were adequately identified by 62% of urologists, without differences according to sectors of activity. The IPOP prescription modalities were declared as an obstacle to the completion for 41.9% of urologists, and especially in the private sector. Completion times of IPOP were declared <24h in 91% of cases. We see that 28.5% of urologists prescribed an urinary alkalization. The average frequency of complications of IPOP was 0.91 per urologist.

CONCLUSIONS

The IPOP prescription frequency was higher among urologists practicing in the academic sector. Neither the level of knowledge of the recommendations nor the frequency of complications of IPOP had explained this difference. However, the prescription modalities were more frequently reported as an obstacle to their completion in the private sector.

LEVEL OF EVIDENCE

3.

[Molecular, preclinical, and clinical comparative data regarding different strains of bacillus Calmette-Guérin (BCG): Review by the French Urological Association Oncology Committee (CCAFU)]

OBJECTIVE

To review the differences between the BCG strains used for the treatment of non-muscle invasive bladder cancer (NMIBC) at the molecular level, regarding cytotoxicity, immunogenicity, clinical efficiency, and safety.

MATERIAL AND METHOD

A systematic review of the literature search was performed from the database MedLine, focused on the following keywords: BCG; bladder; strain; genome; cytotoxicity; immune response; efficiency; safety.

RESULTS

Genetic differences between BCG strains have been identified and correlated to their time to differentiation from their initial cultures start, assuming a lower resistance to the host immune defenses of Tice and Danish strains compared to the Connaught strain. Preclinical comparative data showed superior cytotoxic effect and immunogenicity of the Connaught strain compared to Tice and Danish strains. The phase III trials have shown superior efficiency of BCG Connaught compared to BCG Tice and BCG Danish compared to BCG Tice regarding recurrence-free survival.

CONCLUSIONS

Among BCG strains used in France in NMIBC treatment, preclinical and clinical efficiency of Connaught strain was higher than that of the Tice strain. The limits of the currently available studies lie primarily in the lack of use of maintenance therapy.

A novel orally administered trimebutine compound (GIC-1001) is anti-nociceptive and features peripheral opioid agonistic activity and Hydrogen Sulphide-releasing capacity in mice

BACKGROUND

Trimebutine maleate, a noncompetitive spasmolytic agent with some affinity for peripheral μ- and κ-opioid receptors has been evaluated as a treatment in a limited number of patients undergoing sedation-free full colonoscopy. The efficiency of such treatment was comparable to sedation-based colonoscopies to relieve from pain and discomfort.

METHODS

A new and improved trimebutine salt capable of releasing in vivo hydrogen sulphide (H2S), a gaseous mediator known to reduce nociception, has been developed. This drug salt (GIC-1001) is composed of trimebutine bearing a H2S-releasing counterion (3-thiocarbamoylbenzoate, 3TCB), the latter having the ability to release H2S. GIC-1001 has been tested here in a mouse model of colorectal distension.

RESULTS

In mice, while orally given trimebutine (the maleate salt, non-H2 S-releaser) only slightly reduced the nociceptive response to increasing pressures of colorectal distension, oral administration of GIC-1001 (the H2S-releaser) was able to significantly reduce nociceptive response to all noxious stimuli, in a dose-dependent manner. This effect of GIC-1001 was significantly better than the effects of its parent compound trimebutine administered at equimolar doses.

CONCLUSIONS

Taken together, these results demonstrated increased antinociceptive properties for GIC-1001 compared to trimebutine, suggesting that this compound would be a better option to relieve from visceral pain and discomfort induced by lumenal distension.

An image guided treatment platform for prostate cancer photodynamic therapy

This study describes a multimodality images based platform to drive photodynamic therapies of prostate cancer using WST 11 TOOKAD Soluble drug. The platform integrates a pre-treatment planning tool based on magnetic resonance imaging and a per-treatment guidance tool based on transrectal ultrasound images. Evaluation of the platform on clinical data showed that prediction of the therapy outcome was possible with an accuracy of 90 %.

[Carcinogenic pathways and natural history of upper tract urothelial carcinomas: state-of-the-art review for the yearly scientific report of the French National Association of Urology]

OBJECTIVE

To describe natural history and carcinogenesis of upper tract urothelial carcinoma (UTUC).

METHODS

A systematic review of the scientific literature was performed in the Medline database (Pubmed) using different associations of the following keywords: upper tract urothelial carcinoma; clonality; carcinogenesis; mutation; chromosomal instability; Lynch syndrome; genetic polymorphism.

RESULTS

Local development of UTUC is characterized by a highly prevalent multifocality that might be explained by the overlap of "field change" and "intraluminal seeding and implantation" theories. UTUC and bladder tumors share common carcinogenesis mechanisms such as mutations of FGFR3 and TP53 defining two distinct pathways of pathogenesis. Epigenetic alterations corresponding to the hypermethylation of different promoters regulating genes expression and chromosomal instability such as chromosome 9 deletions are also involved in UTUC carcinogenesis. Furthermore, specific genetic risk factors fro UTUC including Lynch syndrome and different polymorphisms might explain an individual susceptibility for developing these tumors.

CONCLUSIONS

Significant advances have been done in the field of basic research in UTUCs in recent years and have been of particular interest to provide better descriptions of their natural history. Despite these important findings however, some carcinogenic mechanisms remains not elucidated and unknown in the field of UTUC so far.