Opportunistic screening with multiphase contrast-enhanced dual-layer spectral CT for osteoblastic lesions in prostate cancer compared with bone scintigraphy

Our study aimed to compare bone scintigraphy and dual-layer detector spectral CT (DLCT) with multiphase contrast enhancement for the diagnosis of osteoblastic bone lesions in patients with prostate cancer. The patients with prostate cancer and osteoblastic bone lesions detected on DLCT were divided into positive bone scintigraphy group (pBS) and negative bone scintigraphy group (nBS) based on bone scintigraphy. A total of 106 patients (57 nBS and 49 pBS) was included. The parameters of each lesion were measured from DLCT including Hounsfield unit (HU), 40-140 keV monochromatic HU, effective nuclear numbers (Zeff), and Iodine no water (InW) value in non-contrast phase (N), the arterial phase (A), and venous phase (V). The slope of the spectral curve at 40 and 100 keV, the different values of the parameters between A and N phase (A-N), V and N phase (V-N), and hybrid prediction model with multiparameters were used to differentiate pBS from nBS. Receiver operating characteristic analysis was performed to compare the area under the curve (AUC) for differentiating the pBS group from the nBS group. The value of conventional HU values, slope, and InW in A-N and V-N, and hybrid model were significantly higher in the pBS group than in the nBS group. The hybrid model of all significant parameters had the highest AUC of 0.988, with 95.5% sensitivity and 94.6% specificity. DLCT with arterial contrast enhancement phase has the potential to serve as an opportunistic screening tool for detecting positive osteoblastic bone lesions, corresponding to those identified in bone scintigraphy.

Feasibility of Computed Tomography-guided Percutaneous Renal Cryoablation Under Local Anesthesia: A Single Center Experience in Taiwan

BACKGROUND/AIM

To survey the safety and efficacy of percutaneous cryoablation for renal tumors under local anesthesia and pain control by using the -40°C lethal isotherm of the ice ball to cover the tumor margin as well as the coaxial cryoablation technique.

PATIENTS AND METHODS

All procedures were performed between February 2014 and November 2021 with computed tomography (CT) guidance. All tumors were ablated by following the aforementioned plan, according to which tumor margins were covered by the -40°C lethal isotherm. Hydrodissection and coaxial cryoablation were performed in some cases to avoid organ injury and massive bleeding. 2% xylocaine was used for local anesthesia and 50 mg of pethidine (meperidine) was injected intramuscularly for pain control and sedation. The complications were evaluated and the Kaplan-Meier method was used to estimate local recurrence-free survival (LRFS).

RESULTS

Sixty-five tumors [49 renal cell carcinomas (RCC) and 16 angiomyolipomas] were ablated in 55 patients (median Charlson Comorbidity Index=5.0). Local recurrence occurred in three of the 49 RCC cases. Two received a second cryoablation. LRFS at three and five years were both 91%. LRFS at three and five years reached 100% in tumors <3 cm. A large tumor (≥3 cm) was observed in the recurrence group. Hemorrhage was the most common complication (76.9%). Two patients who needed blood transfusion did not receive coaxial cryoablation. Three (4.6%) major complications (Clavien-Dindo grade ≥3) occurred.

CONCLUSION

By using -40°C as the pre-plan tumor coverage, with the aid of coaxial cryoablation and multiplanar reconstruction method, CT-guided percutaneous renal cryoablation under local anesthesia is a safe and effective procedure in patients with many comorbidities.

Assessment of Prostate Volume and Prostate-specific Antigen Density With the Segmentation Method on Magnetic Resonance Imaging

BACKGROUND/AIM

This study aimed to compare the prostate volume (PV) and prostate-specific antigen density (PSAD) obtained using the ellipsoid volume formula or segmentation methods on magnetic resonance imaging (MRI) and further predict prostate cancer (PCa).

PATIENTS AND METHODS

Retrospectively, the enrolled patients underwent prostate MRI and had PSA levels between 4 and 10 ng/ml. The PV was measured with both the ellipsoid volume formula (PVe) and the segmentation method (PVs). The transitional zone volume (TZV) was measured with the segmentation method. The PSADe, PSADs, and PSAD_TZV were calculated. Bland-Altman plots were used to compare the agreements. ROC curve analysis was used to compare the diagnostic accuracies to predict PCa. The results were also compared between the PCa and the no-PCa groups, and among tumors with different locations and different Gleason scores (GS).

RESULTS

Seventy-six of the 117 enrolled patients were classified into the PCa group. There were high agreements between PVs and PVe as well as between PSADs and PSADe, while several outliers were mainly due to post-transurethral resection of the prostate changes and irregular hyperplastic nodules. The diagnostic accuracy of PSADe (AUC: 0.732) was slightly higher than that of PSADs (AUC: 0.729) and PSAD_TZV (AUC: 0.715). The PSADe and PSADs were not different among different tumor locations but were higher in GS ≥7 lesions (both p=0.006).

CONCLUSION

The segmentation method can be an alternative method to measure PV and calculate PSAD before prostate biopsy, particularly in post-transurethral resection of the prostate patients or those with irregular hyperplastic nodules.

A para-aortic malignant melanotic nerve sheath tumor mimicking a gastrointestinal stromal tumor: a rare case report and review of literature

Background

Malignant melanotic nerve sheath tumor (MMNST), formerly called melanotic schwannoma, is a rare tumor of neural crest derivation which most frequently arises from the region of spinal or autonomic nerves near the midline. Recent studies have reported malignant behavior of MMNST, and there still has no standard management guidelines. Intra-abdominal MMNST, which has never been reviewed as an entity, is even rarer. In this study, we present a rare case of a cystic MMNST arising from the para-aortic region and mimicking an intra-abdominal gastrointestinal stromal tumor (GIST), and review the literature regarding MMNSTs located in the abdominal cavity.

Case presentation

A 59-year-old female was incidentally found a tumor located in the left para-aortic area by non-contrast computed tomography. A Magnetic Resonance Imaging showed a cystic mass originated from the inferior mesenteric artery (IMA) territory. A GIST was initially diagnosed. The tumor was resected en bloc by laparoscopic surgery and was found between mesocolon and Gerota’s fascia with blood supply of IMA. Grossly, dark brown materials were noted at the inner surface of the cystic wall. Microscopically, the tumor cells were melanin-containing, and no psammomatous bodies were present. Immunohistochemically, the tumor showed positivity for MART1, HMB45, collagen IV, and SOX10, and negativity for AE1/AE3. MMNST was favored over malignant melanoma, since the tumor was located near ganglia and had cells with less atypical cytology and a low mitotic rate, and subsequent adjuvant radiotherapy was performed. The patient was alive with no evidence of recurrent or metastatic disease 11 months after radiotherapy.

Conclusions

Our review of abdominal MMNST cases showed a female predominance, with an average age of 54.8 years, and a trend toward being a larger tumor showing cystic or necrotic changes. Local recurrence and metastasis rate were reviewed, and both showed a low rate. Diagnosis of MMNST should combine all the available findings, and complete excision of the tumor should be performed, followed by long-term patient monitoring.

Common Subtype of Small Renal Mass MR Imaging Characterisation: A Medical Center Experience in Taiwan

Purpose

Many studies have shown that multiparametric magnetic resonance imaging (MRI) may be helpful for differentiating malignant renal cell carcinomas (RCCs) from benign lesions. However, the key imaging characteristics that differ between malignant and benign tumors still require further discussion.

Methods

We analyzed 60 adult patients diagnosed with 72 small renal masses (SRMs) who received preoperative MRI from 2014 to 2019 at a hospital in Taiwan. The MRI features included conventional MRI parameters, diffusion-weighted imaging (DWI) data, and dynamic contrast-enhanced (DCE) patterns, which were documented and compared among the four common subtypes: clear cell RCC (ccRCC), papillary RCC (pRCC), angiomyolipoma (AML) and other types of RCC. The apparent diffusion coefficient (ADC) values of high- and low-grade RCCs were also analyzed.

Results

The results show that ccRCC had higher T2-weighted signal intensity than the other three subgroups, a higher arterial wash-in index (AWI) and ADC value than AML and pRCC, and manifested a plateau (n = 9, 25%) or washout (n = 27, 75%) enhancement pattern. AMLs exhibited more intravoxel fat than the other three subtype groups, and half of the AMLs (6 in 12) contained bulk fat. pRCC demonstrated a more progressive (n = 3, 60%) enhancement pattern than the other three subgroups. The ADC value of high-grade RCCs was significantly lower than that of low-grade RCCs.

Conclusion

These findings may indicate that multiparametric MRI is useful in differentiating among four common pathological types of SRMs, and the ADC value may be helpful in evaluating the histological grade of malignancy.

O-145 Green Tea catechins EGCG and pro-drug of EGCG (Pro-EGCG) inhibit endometriosis through targeting molecules regulating macrophages and B cells

Study question

What are the therapeutic targets and mechanisms of green tea EGCG and Pro-EGCG in treating endometriosis?

Summary answer

EGCG and Pro-EGCG have unique molecular targets to regulate interactions of B cells, macrophages and endometriotic cells and limit the growth and development of endometriosis.

What is known already

Current treatments of endometriosis are mainly hormonal suppression and surgical ablation or removal. Our previous studies showed EGCG significantly inhibits development of experimental endometriosis in mice. Pro-EGCG is more effective than EGCG in term of anti-endometriosis, anti-angiogenesis and anti-oxidation (Wang, et. al., 2013; Xu, et al., 2011). Dysfunctional immunological activities of macrophages and B cells were found in women with endometriosis. The molecular targets, underlying mechanism and differential therapeutic efficacy of EGCG and Pro-EGCG, as well as their anti-inflammatory activities are still not known.

Study design, size, duration

Multiplexed Proteome Integral Stability Alteration (PISA) assay (Gaetani et al.,2019), followed by MS/MS was applied to identify the molecular targets of EGCG and Pro-EGCG in endometriotic cells. Pharmacological studies of EGCG and Pro-EGCG on endometriotic cell line and endometriosis models in mice were performed to characterise their anti-endometriosis and anti-inflammatory effects. Gene silencing and over-expression experiments were conducted to confirm the immunoregulatory mechanisms.

Participants/materials, setting, methods

Endometriotic (Hs832(C)T) cell lines in culture and lysate were treated for chemical proteomics analysis. SiRNA and overexpression vectors were transfected to the cells in vitro and lesions in vivo. Hs832(C).T, monocytic cells (THP-1) and control B cell (Raji null) lines were used for co-culture assays to study the interaction between endometriotic and immune cells in vitro. Endometriosis mice model was established for immunostaining and microarray analysis of lesions to characterise the molecular pathways in vivo.

Main results and the role of chance

MTDH and PXK were the strongest and most differential targets of EGCG and Pro-EGCG in both cells lysate and cell culture of Hs832(C).T, respectively. Gene silencing and overexpression of the protein targets in vitro and in vivo significantly altered expressions of downstream proteins, including BLK and EGF after PXK, and MYC and AKT after MTDH, as well as endometriosis-related genes such as VEGFC and MMP9. Co-culture assays of Hs832(C).T with Raji null or THP-1 induced macrophages showed that expressions of PXK, MTDH, downstream targets, and immune-related genes were significantly increased after incubation of recombinant proteins, but were significantly decreased after EGCG and Pro-EGCG treatment. M1 and M2 macrophages, as well as B cells were significantly reduced after the treatments in vitro and in vivo. Double immunofluorescent staining of lesions showed that CD68, CD163 or CD20 co-expressed with MTDH, PXK and downstream targets, and numbers of the co-expressed cells were significantly reduced after treatments in vivo. Microarray experiment further identified the upstream and downstream genes of MTDH or PXK contributing to the growth and development of endometriosis.

Limitations, reasons for caution

Results of this pharmacological and mechanistic study require clinical samples to validate the anti-endometriosis effects of EGCG and Pro-EGCG. Effects of other potential pharmaceuticals targeting the macrophages and B cells on endometriosis are needed.

Wider implications of the findings

The findings provide pharmacological and mechanistic data for future development of EGCG and Pro-EGCG as new treatment for endometriosis. This study shows that macrophage and B cell could be potential therapeutic targets for treatment of endometriosis, which opens up new horizon for the novel immunotherapy for endometriosis.

Trial registration number

NA

The Role of Social Problem Solving, Criminal Attitude, and ADHD in Aggression Among Incarcerated Youth in Hong Kong

It is not atypical for young offenders to use aggression to handle problems. This exploratory study examined the contribution of social problem-solving deficit, criminal attitude, and attention-deficit/hyperactivity disorder (ADHD) symptoms to aggression among incarcerated young offenders in Hong Kong. Correlational and regression analyses were conducted to identify factors that help to predict aggression. To control for the influence of ADHD symptoms, hierarchical regression analysis was conducted to reexamine the contribution of the identified factors. The results showed that negative problem orientation (NPO) and contemptuous attitudes toward the law, court, and police (LCP) helped to predict aggression at the current moment and 3 months later. After controlling for ADHD symptoms, only LCP but not NPO remained a significant predictor of both current and near-future aggression. This finding suggests that the contribution of criminal attitude to aggression tends to be independent of the effects of ADHD and social problem-solving deficit. We conclude by discussing the theoretical and practical implications of conceptualizing aggression and improving psychological services for young offenders.

Adjuvant therapy with traditional Chinese medicine in a heart failure patient complicated by hospital-acquired pneumonia: A case report

Objective

We report a case of congestive heart failure complicated by hospital-acquired pneumonia that was successfully treated with traditional Chinese medicine (TCM) and antibiotics.

Clinical features and outcome

A 33-year-old man with a history of heart failure developed pneumonia during hospitalization. After the standard antibiotic therapy for 3 days, he continued to experience persistent fever and progressive cough with purulent sputum. Broad spectrum antibiotics did not relieve the fever or the purulent sputum; therefore, the patient requested TCM for integrated therapy, and was subsequently treated with a regiment of “clearing heat and damp excreting” decoction according to TCM theory. After three days of TCM combination therapy, the pneumonia patches significantly improved on chest X-ray. His sputum was obviously decreased in amount and the fever was complete remission in the 5^th day of TCM adjuvant therapy.

Conclusion

Integrated therapy with a “clearing heat and damp excreting” decoction may have improved hospital-acquired pneumonia in a patient comorbid with congestive heart failure. The anti-pyretic, anti-inflammatory, antitussive and diuretic effects of TCM may be responsible for the observed improvement. Further experimental studies are warranted to confirm the efficacy and mechanism of TCM action in the treatment of pneumonia.

Pathological outcomes in men with prostate cancer who are eligible for active surveillance

BACKGROUND

In order to prevent over treatment of prostate cancer and significant adverse effects after surgical intervention, active surveillance was suggested in low risk or very low risk patients. This study aimed to retrospectively analyze the adverse pathological results of candidates eligible for active surveillance.

METHODS

A total of 904 patients underwent robot-assisted laparoscopic radical prostatectomy in this single institute, from 2005 to April 2014. One hundred and thirty-two patients were eligible for active surveillance (AS). Candidates for active surveillance were defined as low risk (T1/T2a, prostate specific antigen 10 ng/ml or less, and Gleason score 6 or less) and very low risk (T1c, prostate specific antigen density 0.15 or less, Gleason score 6 or less, 2 or fewer positive biopsy cores, 50% or less cancer involvement per core) patients. Adverse pathological results were defined as Gleason sum more than 6, and non-organ-confined disease.

RESULTS

There were 132 patients eligible for active surveillance. One hundred and thirteen (85.6%, 113/132) patients had low risk disease and nineteen (14.4%, 19/132) patients had very low risk disease. The adverse pathological results of low risk disease were upgrading Gleason sum and non-organ-confined disease, 41.6% (47/113) and 28.3% (32/113), respectively. The adverse pathological results of very low risk disease were upgrading Gleason sum and non-organ-confined disease, 15.8% (3/19) and 15.8% (3/19), respectively.

CONCLUSION

We conclude that although AS may prevent over treatment and significant adverse effects after surgical intervention, stratification of patients with low risk prostate cancer is of paramount importance when choosing appropriate candidate for AS. The risk of adverse pathological results should be well informed in the pretreatment counseling.

Adult-to-adult living donor liver transplantation preoperative survey using MDCT, a single medical center experience in Taiwan

This study evaluated multi-detector computed tomography (MDCT) scans performed on potential living donors for adult-to-adult liver transplantation (LDLT), with the aim of identifying significant findings that could be used to exclude potential transplantation donors. We retrospectively reviewed the medical records of 151 consecutive potential adult donors for LDLT from May 2007 to January 2015. Liver parenchyma steatosis, focal hepatic mass or intraabdominal malignancy, vascular variations, and donor liver volume were evaluated via MDCT. Grounds for excluding potential donors were also recorded and analyzed. Of the 151 potential donors, nine (6.0%) had moderate to severe fatty liver, 37 (24.5%) had hepatic arterial variants, 22 (14.6%) had significant portal venous variants, and more than half were found to have right accessory inferior hepatic vein. No intraabdominal malignancies were found. Eighty-eight potential donors were rejected, with the most common cause being insufficient recipient volume or remnant donor volume (47.7%), moderate to severe parenchymal steatosis (10.2%), and recipient expiration prior to transplantation (8.0%). An additional 16 potential donors were excluded by the surgical team due to the complexity of their portal venous variations. The rate of exclusion by pre-transplant imaging evaluation with MDCT was 33.8%. MDCT can provide accurate quantification of donor liver volume and steatosis severity along with precise demonstration of vascular variants, which are crucial for the preoperative evaluation of LDLT. However, MDCT may be ineffective for evaluating the biliary system without hepatobiliary-excreted contrast agent and has the disadvantage of ionizing radiation.

Ectopic Thyroid Tissue in the Adrenal Gland Mimicking a Pheochromocytoma

Ectopic thyroid tissue in the adrenal gland (ETTAG) usually presents as a well-circumscribed cystic mass on a CT scan. However, the MRI features of ETTAG are incompletely understood. We report a case of ectopic thyroid tissue in the adrenal gland, which demonstrates findings similar to those of a pheochromocytoma on the MRI.

Salvage Robotic-assisted Laparoscopic Radical Prostatectomy: Experience with 14 Cases

AIM

To report the outcomes of salvage robot-assisted radical prostatectomy (S-RaRP).

PATIENTS AND METHODS

Fourteen patients underwent S-RaRP. The mean initial prostatic-specific antigen level was 14.3 ng/ml and mean Gleason score was 6.93. Initial definitive treatment was external irradiation in 11 cases, cyberknife in two, and high-intensity focused ultrasound in one. Time from definitive treatment to S-RaRP was a mean of 36.5 months.

RESULTS

The mean console time was 134.9 min and blood loss was 99.6 ml. Stage pT2N0, T3N0, and T3N1 were found in eight, four, and two cases, respectively. A positive surgical margin was found in 21.4% (3/14) of the patients. The continence rate was 71.4% (10/14). Mild stress urinary incontinence (one or two pads/day) was noted in 28.6% (4/14) of patients. Biochemical recurrence-free status was noted in 11 (78.5%) patients with a mean follow-up of 32.4 months.

CONCLUSION

S-RaRP is feasible with a low complication rate, good continence rate, and an acceptable potency rate. The short-term oncological outcomes are encouraging.

Prophylactic Robotic-assisted Laparoscopic Radical Prostatectomy for Preoperative Suspicion of Prostate Cancer: Experience with 55 Cases

BACKGROUND/AIM

Expanded indications are not yet reported for robotic-assisted laparoscopic radical prostatectomy (RARP) performed by experienced surgeons for patients with preoperative suspicion of prostate cancer. We report our experience with 55 cases of prophylactic RARP for preoperative suspicion of prostate cancer, including postoperative pathological characteristics and outcomes.

PATIENTS AND METHODS

This retrospective study reviewed data of a subset of 55 consecutive patients among 1,060 patients who underwent RARP for preoperative suspicion of prostate cancer. Pathological characteristics and outcomes of patients with suspected prostate cancer were analyzed and preoperative, intraoperative and postoperative parameters were compared between three groups. Patients were stratified by final pathology reports of RARP specimens: Group I: Prostate cancer, N=22 (40%); group II: abnormal (prostate intraepithelial neoplasia; atypical small acinar proliferation), N=18 (32.7%); and group III: benign (nodular hyperplasia or inflammation), N=15 (27.3%).

RESULTS

Mean preoperative prostate-specific antigen (PSA) was 16.04±2.21 ng/ml. Twenty-two patients with adenocarcinoma had pathology stage pT2a/T2b/ T2c/T3a/T3b (6/7/2/6/1 patients, respectively), with positive surgical margins in 18.2% (4/22). Preoperative incidence of PSA velocity >0.75 ng/ml/yr was significantly higher in group I than in groups II and III (81.8% vs. 38.9% vs. 33.3%, p=0.004). Predictive parameters of prostate cancer showed that PSA velocity (>0.75 vs. ≤0.75 ng/ml/yr) had crude odds ratio of 9.0 for group I vs. group III, p=0.005. Posteperatively, statistically significant improvements were found in uroflow rate, post-voiding residual urine and symptom scores (all p<0.0001).

CONCLUSION

Prophylactic RARP with bilateral neurovascular bundle preservation performed by experienced surgeons is a safe and viable option for preoperative suspicion of prostate cancer.

Prevention and Management of Complications During Robotic-assisted Laparoscopic Radical Prostatectomy Following Comprehensive Planning: A Large Series Involving a Single Surgeon

AIM

To report a series of 1,000 patients treated by a single surgeon using robotic-assisted laparoscopic radical prostatectomy (RALP) and to show how to prevent and manage complications of the procedure.

PATIENTS AND METHODS

Complication rates were prospectively assessed in a series of 1,000 consecutive patients who underwent RALP (group I, cases 1-200; IIa, 201-400; IIb, 401-600; IIIa, 601-800; and IIIb, 801-1000). Preoperative evaluation focused on patients' history of gout, use of drugs that can influence clotting time, and cardiopulmonary problems. Magnetic resonance imaging (MRI) was routinely performed. Operative difficulty was assessed based on the following variables: neoadjuvant hormonal therapy (NHT), obesity [body mass index (BMI) >30 kg/m(2)], prostate volume >70 g, presence of a large median lobe with intravesical protrusion >1 cm, previous transurethral resection of the prostate, previous pelvic surgery, previous extended pelvic lymph node dissection (EPLND), and salvage robotic radical prostatectomy (SRP).

RESULTS

Operative difficulty tended to increase significantly with greater age, higher American Society of Anesthesiologists' anesthetic/surgical risk class scores, increased BMI, and more advanced clinical stage. The number of cases with NHT, obesity, previous pelvic surgery, EPLND, and SRP significantly increased from early to later groups of patients. Conversely, significantly less blood loss occurred in later groups of patients (group I, 179 ml to 97 ml in group IIIb; p<0.001). The need for blood transfusions gradually reduced from 3.5% to 0.5% in groups I and IIIb, respectively (p=0.022). The total complication rate was 6.4% (64/1,000; surgical/medical=5%/1.4%). Complication rates decreased significantly: 12%, 6%, 6%, 4%, and 4% in groups I, IIa, IIb, IIIa, and IIIb, respectively (p=0.003). The most common complications were blood transfusion and bowel problems (11/1,000=1.1%).

CONCLUSION

Assessed in terms of groups of 200 cases, the surgeon's learning curve for RALP showed significantly fewer complications even as the operative difficulty of cases increased. The keys to preventing complications were meticulous preoperative evaluation of patients, MRI planning, and a dedicated robotic team for performing RALP. Early diagnosis and management of complications are paramount in patients who present any deviation from the normal postoperative course and clinical care pathway.

Pentafecta Outcomes of 230 Cases of Robotic-assisted Radical Prostatectomy with Bilateral Neurovascular Bundle Preservation

AIM

We analyzed pentafecta outcomes [complication-free, continence, potency, negative surgical margins (NSM)], biochemical recurrence (BCR)-free] of 230 patients undergoing robotic-assisted radical prostatectomy (RARP) with bilateral neurovascular (NVB) preservation.

PATIENTS AND METHODS

Patient outcomes (group I, cases 1-115; group II, cases 116-230) were assessed prospectively. Definitions were: continence, using no pads; potency, ability to achieve/maintain erections firm enough for sexual intercourse; positive surgical margin, presence of tumor tissue on inked specimen surface; and BCR, two consecutive PSA levels >0.2 ng/ml after RALP.

RESULTS

The mean patient age was 62.5 years, mean PSA=8.62 ng/ml. The complication-free rate was 93.9% (216/230), continence rate 98.3% (226/230), potency 86.1% (198/230), NSM 77.0% (177/230) and BCR-free 92.6% (213/230). The trifecta rate (continence, potency, BCR-free) was 81.7% (188/230). The pentafecta rate was 60.4% (139/230).

CONCLUSION

Pentafecta is the new standard of outcomes for RARP with bilateral NVB, with patient selection and reduced positive surgical margins attaining best outcomes.

The surgical learning curve for robotic-assisted laparoscopic radical prostatectomy: experience of a single surgeon with 500 cases in Taiwan, China

To analyze the learning curve for cancer control from an initial 250 cases (Group I) and subsequent 250 cases (Group II) of robotic-assisted laparoscopic radical prostatectomy (RALP) performed by a single surgeon. Five hundred consecutive patients with clinically localized prostate cancer received RALP and were evaluated. Surgical parameters and perioperative complications were compared between the groups. Positive surgical margin (PSM) and biochemical recurrence (BCR) were assessed as cancer control outcomes. Patients in Group II had significantly more advanced prostate cancer than those in Group I (22.2% vs 14.2%, respectively, with Gleason score 8–10, P= 0.033; 12.8% vs 5.6%, respectively, with clinical stage T3, P= 0.017). The incidence of PSM in pT3 was decreased significantly from 49% in Group I to 32.6% in Group II. A meaningful trend was noted for a decreasing PSM rate with each consecutive group of 50 cases, including pT3 and high-risk patients. Neurovascular bundle (NVB) preservation was significantly influenced by the PSM in high-risk patients (84.1% in the preservation group vs 43.9% in the nonpreservation group). The 3-year, 5-year, and 7-year BCR-free survival rates were 79.2%, 75.3%, and 70.2%, respectively. In conclusion, the incidence of PSM in pT3 was decreased significantly after 250 cases. There was a trend in the surgical learning curve for decreasing PSM with each group of 50 cases. NVB preservation during RALP for the high-risk group is not suggested due to increasing PSM.

Outcome of vesicourethral anastomosis after robot-assisted laparoscopic radical prostatectomy: A 6-year experience in Taiwan

BACKGROUND/PURPOSE

The use of a da Vinci robotic system may improve the outcome of urological surgery. This study reports 6 years of experience with vesicourethral anastomosis (VUA) following robot-assisted laparoscopic radical prostatectomy (RALP) performed in Taichung Veterans General Hospital, Taichung, Taiwan.

METHODS

A total of 350 patients who underwent RALP by a single surgeon were reviewed. We followed Dr Patel's RALP procedure with minor modifications. VUA was checked with 120 mL and 200 mL saline in sequence. The urinary bladder was then pressed with endoscopic instruments. If a VUA leak was detected, it was sutured immediately. An 18-French silicon Foley's catheter was inserted and removed 7-14 days after RALP. Preoperative characteristics and perioperative complications were assessed.

RESULTS

Overall, 332 (94.85%) patients were without any leakage in the first step of the challenge, eight of whom had leakage in the second step. After repair, all were free from leakage. The other 18 patients had leakage in the first step of the challenge (5.14%). After repair, 12 patients were without leakage in the second step. However, one patient had urine leakage postoperatively. The other six patients had leakage in the second step. After repair, two patients were free from leakage, but the remaining four suffered from persistent minor urine leakage postoperatively. The urine leakage rate after RALP was 1.43% (5/350). The potential urine leakage after bladder challenge and endoscopic instruments pressing could be minimized to 0.29% (1/346).

CONCLUSION

VUA leakage after RALP is rare. Intraoperative VUA challenge is simple and feasible compared to postoperative retrograde cystography.

Transarterial embolization of metastatic mediastinal hepatocellular carcinoma

This paper introduces an innovative treatment for extra-hepatic metastasis of hepatocellular carcinoma. A 71-year-old patient had a stable liver condition following treatment for hepatocellular carcinoma, but later developed symptomatic mediastinal metastasis. This rapidly growing mediastinal mass induced symptoms including cough and hoarseness. Serial sessions of transarterial embolization (TAE) successfully controlled this mediastinal mass with limited side effects. The patient’s survival time since the initial diagnosis of the mediastinal hepatocellular carcinoma was 32 mo, significantly longer than the 12 mo mean survival period of patients with similar diagnoses: metastatic hepatocellular carcinoma and a liver condition with a Child-Pugh class A score. Currently, oral sorafenib is the treatment of choice for metastatic hepatocellular carcinoma. Recent studies indicate that locoregional treatment of extra-hepatic metastasis of hepatocellular carcinomas might also significantly improve the prognosis in patients with their primary hepatic lesions under control. Many effective locoregional therapies for extrahepatic metastasis, including radiation and surgical resection, may provide palliative effects for hepatocellular carcinoma-associated mediastinal metastasis. This case report demonstrates that TAE of metastatic mediastinal hepatocellular carcinoma provided this patient with tumor control and increased survival time. This finding is important as it can potentially provide an alternative treatment option for patients with similar symptoms and diagnoses.

Renal tuberculosis presenting as a complicated renal cyst

A 74-year-old woman presented with a 3-day history of fever and left flank pain. The imaging study revealed a huge complicated cyst in the left kidney. The cyst had a mass effect to the abdomen. We performed laparoscopic renal cyst unroofing. The histopathologic examination disclosed renal tuberculosis of the cyst wall and cystic fluid. Renal tuberculosis is not uncommon; however, renal tuberculosis presenting as a renal cyst is very rare.

Endovascular treatment for traumatic thoracic aortic pseudoaneurysm: a case report

Cases of an endovascular treatment for traumatic aortic injury are extremely rare. A prompt diagnosis of traumatic thoracic aortic pseudoaneurysm through a 3-dimensional computed tomographic angiography of aorta and emergency repair are mandatory to rescue the life-threatening condition. An endovascular treatment is a trend for traumatic aortic injury because of lower invasivity, morbidity and mortality. We reported a rare case of traumatic aortic injury with thoracic aortic pseudoaneurysm definitively diagnosed by the reconstructional computed tomographic angiography of aorta and successfully treated with endovascular stent-graft.

The trifecta outcome in 300 consecutive cases of robotic-assisted laparoscopic radical prostatectomy according to D'Amico risk criteria

BACKGROUND

To analyze the trifecta outcome (continence, potency, and cancer control) in 300 cases of robotic-assisted laparoscopic radical prostatectomy (RARP).

METHODS

A prospective assessment of outcomes in 300 consecutive patients that underwent a RARP performed by a single surgeon. Patients were grouped according to D'Amico risk criteria: Group I consisted of 'low-risk' cases (n = 64), Group II consisted of 'intermediate-risk' cases (n = 88), and Group III consisted of 'high-risk' cases (n = 148). Patients were evaluated for perioperative complications and the trifecta outcome.

RESULTS

The operation time, blood loss, post-operative stay, duration of urethral catheterization, and perioperative complication rate were similar among all groups. The incidence of bilateral neurovascular bundle (NVB) preservation was significantly decreased with the increasing risk of cases (P < 0.001). The continence rates at the 1-week, 1-month, 3-month, 6-month, and 12-month follow-ups did not differ significantly between groups. The potency rates at the 12-month follow-up were not significantly different. The positive surgical margin and positive lymph node metastasis rate increased with the increasing risk of cases (P < 0.001). The biochemical recurrence rate (BCR, PSA >0.2 ng/mL) was 3.1, 11.36, and 19.59% in Groups I, II and III, respectively (P = 0.004). The trifecta outcome for RARP with bilateral NVB preservation showed no significant differences among groups.

CONCLUSIONS

Undergoing a RARP is safe and feasible in high-risk prostate cancer patients. Compared to low-risk and intermediate-risk groups, the high-risk group had a significant higher incidence of positive surgical margin, positive lymph node metastasis, and BCR rate.

Renal mucinous tubular and spindle cell carcinoma with an aorto-caval mass mimicking metastatic lymphadenopathy

A 54-year-old female had a 9-cm left renal mass with a 12-cm aorto-caval mass lesion mimicking an enlarged lymph node. Retroperitoneal dissection and left radical nephrectomy were performed, and pathology revealed a left renal mucinous tubular and spindle cell carcinoma combined with a retroperitoneal ganglioneuroma. The patient has had no local recurrence or distant metastasis after 3 years' follow-up. A misdiagnosis of metastatic renal cell carcinoma may be upheld by the primary imaging studies. Even in the targeted therapy era, cytoreductive nephrectomy is still an important step in the diagnosis and treatment of suspicious metastatic renal cell carcinomas.

Metallic stent in the treatment of ureteral obstruction: experience of single institute

BACKGROUND

The Resonance(®) metallic stent has been reported to be sufficient for the management of malignant extrinsic ureteral obstructions within a 12-month time period. To determine the effectiveness in each specific patient group, we report our experience using the Resonance(®) stent in the treatment of ureteral obstructions.

METHODS

We retrospectively reviewed 20 patients (23 stents) who successfully received the Resonance(®) metallic stents and divided them into a patent group (n = 19) and an obstructive group (n = 4) according to the treatment results. Twenty-one stents were inserted via cystoscopy or ureteroscopy in a retrograde fashion. The remaining two were inserted via percutaneous nephrostomy in an antegrade manner. Follow-up serum creatinine measurements and sonography were performed. The overall ureteral patency rate and the risk of stent failure were evaluated.

RESULTS

The overall ureteral patency rate was 82.6% (19/23). Patients with previous radiotherapy had a 50% (4/8) patency rate which was significantly lower than non-radiotherapy patients (100%, 15/15, p = 0.028). Malignant obstructions in those other than radiotherapy patients had a 100% patency rate (5/5). Benign obstructions in those other than radiotherapy patients had a 100% patency rate (10/10). In the radiotherapy patients, the mode of therapy did not dominate the stent outcome.

CONCLUSION

Patients with ureteral obstructions can be treated sufficiently with the Resonance(®) metallic stent. Patients who had gynecological malignancies and received radiotherapy had a higher failure rate after Resonance(®) metallic stent insertion.

Color Doppler twinkling artifact of calcified cardiac valves in vitro: a not well known phenomenon in echocardiography

The color Doppler twinkling artifact manifests as a rapidly changing mixture of red and blue colors behind strongly reflective structures. The twinkling artifact occurs behind diseased cardiac valves, although the phenomenon is not well described. This study sought to determine the presence of the color Doppler twinkling artifact in calcified cardiac valves in vitro using soft tissue radiography for reference. Seventeen specimens of diseased cardiac valves from patients undergoing valve replacement surgery were studied. The overall sensitivity and specificity for the detection of calcifications using the presence of the twinkling artifact were 66.7% and 81.8%, respectively. If valves with only microcalcifications or smooth calcifications were eliminated from the analysis, all (100%) of the three valves with irregular macrocalcifications exhibited the twinkling artifact. It is important to recognize this artifact because it may lead to misdiagnosis of vascular flow in echocardiography.

Patient perception of dyskinesia in Parkinson's disease

OBJECTIVE

To evaluate the perception of patients with Parkinson's disease (PD) regarding dyskinesia.

DESIGN

Multicentre survey.

SETTING

Tertiary referral centres.

PATIENTS

Patients with PD participated in a survey: those not on dopaminergic medications (group I), those on dopaminergic medications without dyskinesia (group II) and those on dopaminergic medications with dyskinesia (group III).

INTERVENTION

After a short standardised description and explanation of dyskinesia was provided, patients were asked about the nature and source of prior knowledge of dyskinesia. They were then asked about their perceptions of dyskinesia. Patients in group III were also asked about the duration, the severity of dyskinesia and whether their perception of this problem had changed since its appearance.

MAIN OUTCOME MEASURES

Level of concern regarding dyskinesia and whether their perception of dyskinesia would have changed their preference of treatment. Results 259 PD patients completed the survey (group I, 52; group II, 102; group III, 105). Patients with dyskinesia were significantly less concerned about dyskinesia than patients without dyskinesia and were more likely to choose dyskinesia over being parkinsonian. Patients who required fewer changes in medications because of dyskinesia were more likely to choose dyskinesia over parkinsonism.

CONCLUSION

Patients with PD experiencing dyskinesia are less likely to be concerned about dyskinesia and more likely to prefer dyskinesia over parkinsonian symptoms than patients without dyskinesia.

Invasive adenocarcinoma of the prostate with urethral tumor

Metastases of prostate cancer to the penis and urethra are rare and often represent advanced disease. We describe a case of newly diagnosed prostatic adenocarcinoma with metastases to the corpus spongiosum, cavernosum, and the anterior urethra. A male patient, 77 years of age, initially had lower urinary tract obstruction symptoms. His prostate-specific antigen level was 5.02 ng/mL. Digital rectal examination disclosed stony hard tumors at both lobes of the prostate. Transrectal ultrasound-guided biopsy of the prostate revealed adenocarcinoma over both lobes; the Gleason score was 4 + 4 = 8. Cystoscopy showed a penile urethral tumor and biopsy disclosed metastatic adenocarcinoma of the prostate; the Gleason score was 4 + 4 = 8. The patient initially received hormone therapy. Biochemical failure developed after 15 months and rapidly progressed to a hormone-refractory stage. Docetaxel was then prescribed. The patient died in the 25(th) month after the diagnosis.

Pallidal stimulation in cervical dystonia: clinical implications of acute changes in stimulation parameters

BACKGROUND AND PURPOSE

Deep brain stimulation (DBS) of the globus pallidus internus (GPi) is successful in dystonia, but the role of each electrical parameters of stimulation is unclear. We studied the clinical effects of acute changes of different parameters of GPi-DBS in cervical dystonia (CD).

METHODS

Eight CD patients with bilateral GPi-DBS at 28.6 +/- 19.2 (mean +/- SD) months after surgery were recruited. Mean improvement in the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) severity score was 54.5% compared to before surgery. Ten settings, including a combination of a wide range of pulse widths (PWs), low and high frequencies and voltage, were administered in a randomized double blinded fashion. Clinical benefit was assessed by two raters using the TWSTRS and by the patients using an analogue rating scale.

RESULTS

The TWSTRS severity scores were reduced by 56.7% with stimulation at the best settings. Improvement was significantly associated with high frequency (> or = 60 Hz) and high voltage. Stimulation at 130 Hz showed the best clinical improvement. Increasing PWs (from 60 to 450 micros) did not result in a significant improvement.

CONCLUSION

Frequency and amplitude appear to be the most important factors in the acute anti-dystonic effects in GPi-DBS patients with CD.

Physician and nurse job climates in hospital-based emergency departments in Taiwan: management and implications

This study evaluates how emergency physicians and nurses perceive their job climates in their hospital-based emergency departments (ED). In total, 208 emergency physicians and 234 emergency nurses were surveyed, applying a validated survey instrument covering the job facets of medical and nursing autonomy, professional accomplishments and outcomes, leadership, communication, management, hospital policies and regulations, and external health policy environments germane to emergency medicine. The findings reveal that the average satisfaction score for professional growth and accomplishments was ranked highest by emergency physicians, and job communication within EDs was ranked highest by emergency nurses. Several emergency medical professional characteristics, including age, education, medical authority, employment duration, full-time or part-time statuses, perceived workloads, and hospital accreditation levels, were all related to job satisfaction in this surveyed population. New insights generated from this study could provide increased guidance to hospital and ED unit managers toward enhancing wellness and limiting dissatisfaction and disharmony relative to long-term career survival and the well-being of ED specialists.

Severe emphysematous pyelonephritis in a renal allograft: successful treatment with percutaneous drainage and antibiotics

Emphysematous pyelonephritis is a rare, severe gas-forming infection of the kidney. Herein we report a case of a 51-year-old man who had received a cadaveric renal transplant 12 years ago. Post-transplant diabetes mellitus occurred 8 years later. He experienced urinary tract infection with graft pain one week before admission and presented with septic shock at the emergency room. Plain X-ray of the abdomen showed retroperitoneal air. A computed tomography scan of the abdomen showed retroperitoneal and extraperitoneal air being released from the graft kidney. These findings were compatible with extensive emphysematous pyelonephritis. The patient underwent percutaneous drainage. Blood culture and urine culture yielded Escherichia coli. After repeated percutaneous drainage and strong antibiotics for a prolonged period, the patient finally recovered.

Gastrointestinal stromal tumors: computed tomographic features and prediction of malignant risk from computed tomographic imaging

BACKGROUND

Gastrointestinal stromal tumors (GISTs) are specific, generally Kit (CD117)-positive, mesenchymal tumors of the gastrointestinal tract encompassing a majority of tumors previously considered gastrointestinal smooth muscle tumors. Our aim was to characterize the computed tomographic findings and predict malignant risk from computed tomography for the evaluation of GISTs.

METHODS

The computed tomographic images of 39 patients with pathologically and immunohistochemically proven GISTs were reviewed by 2 radiologists, and the final interpretations were reached by consensus. Images were assessed for the size, contour, growth pattern, boundary, degree of enhancement, and necrosis of the tumors. The presence of calcification within the lesions, abdominal lymphadenopathy, ascites, and bowel obstruction were also recorded. Categorical variables were compared using Fishers exact test. Univariate and multivariate logistic regression analyses were used for selection of significant predictors of high-risk malignancy. In addition, the relationships between computed tomographic features and tumor size were assessed by means of nonparametric univariate analysis with the MannWhitney U test and KruskalWallis test.

RESULTS

Both old age and larger tumor size (>or= 5 cm) were statistically significant in the univariate logistic analysis for high-risk malignant tumors (p < 0.25). However, in multivariate logistic regression, only larger tumor size (>or= 5 cm) was found to have final statistical significance for high-risk malignant GISTs (p < 0.05). In addition, more exophytic growth pattern (p < 0.01), more lobulated appearance (p < 0.01), good enhancement (p < 0.05),and more necrosis (p < 0.01) of masses were more often observed in larger GISTs than small ones on computed tomography.

CONCLUSION

Larger tumor size (>or= 5 cm) was found to have a predictive value with respect to high-risk malignant GISTs.

Long-term outcome of bilateral pallidal deep brain stimulation for primary cervical dystonia

Ten patients with severe cervical dystonia (CD) unresponsive to medical treatment underwent bilateral globus pallidus internus (GPi) deep brain stimulation (DBS) and were followed for 31.9 +/- 20.9 months. At last follow-up, the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) severity score improved by 54.8%, the TWSTRS disability score improved by 59.1%, and the TWSTRS pain score improved by 50.4%. Bilateral GPi DBS is an effective long-term therapy in patients with CD.

A rare hernia of intra-abdominal fat in the thorax under an intact diaphragm: multidetector computed tomography

Neither abdominal wall hernia nor diaphragmatic hernia is an unusual disease. But some may have difficulty diagnosing the presence of intra-abdominal fat in the thorax under an intact diaphragm. We report a case with an external compression of the right lower lung from intra-abdominal fat owing to a hernia through the right lateral abdominal wall and secondary through the ninth intercostal space of the chest wall to the right lower thorax without traumatic history. Multiple images, including multidetector row computed tomography, are reviewed.

Genetic association of blaSHV-5 with transposable elements IS26 and IS5 in Klebsiella pneumoniae from Taiwan

A cloned 5,248-bp EcoRI fragment from the Klebsiella pneumoniae transferable plasmid pKP53 (> 70 kb) containing bla(SHV-5) was sequenced. Insertion sequences IS26 and IS5 were found downstream from bla(SHV-5). The DNA sequences of the genetic environment surrounding bla(SHV-5) were homologous to plasmid p1658/97 from Escherichia coli, containing a truncated recF gene and a truncated deoR gene upstream and downstream from bla(SHV-5), respectively. RecF may be involved in bla(SHV-5) translocation to the plasmid by RecF-dependent recombination. This novel genetic environment may be associated with the successful proliferation and/or expression of SHV-5 in K. pneumoniae strains from Taiwan.

Laparoscopic excision of a ureteral diverticulum

Ureteral diverticula are a rare anomaly of the ureteral structure and were reported as case reports in the literature. We report an acquired ureteral diverticulum that was managed with laparoscopic resection. The clinical presentation is demonstrated and the follow-up image is illustrated. The laparoscopic application could be expanded to this area.

Computer-aided kidney segmentation on abdominal CT images

In this paper, an effective model-based approach for computer-aided kidney segmentation of abdominal CT images with anatomic structure consideration is presented. This automatic segmentation system is expected to assist physicians in both clinical diagnosis and educational training. The proposed method is a coarse to fine segmentation approach divided into two stages. First, the candidate kidney region is extracted according to the statistical geometric location of kidney within the abdomen. This approach is applicable to images of different sizes by using the relative distance of the kidney region to the spine. The second stage identifies the kidney by a series of image processing operations. The main elements of the proposed system are: 1) the location of the spine is used as the landmark for coordinate references; 2) elliptic candidate kidney region extraction with progressive positioning on the consecutive CT images; 3) novel directional model for a more reliable kidney region seed point identification; and 4) adaptive region growing controlled by the properties of image homogeneity. In addition, in order to provide different views for the physicians, we have implemented a visualization tool that will automatically show the renal contour through the method of second-order neighborhood edge detection. We considered segmentation of kidney regions from CT scans that contain pathologies in clinical practice. The results of a series of tests on 358 images from 30 patients indicate an average correlation coefficient of up to 88% between automatic and manual segmentation.