Oncologic outcomes of patients with incidental prostate cancer who underwent RARC: a comparison between nerve sparing and non-nerve sparing approach

BACKGROUND

Incidental Prostate cancer (iPCa) is a relatively common finding during histopathological evaluation of radical cystectomy (RC) specimens. To reduce the high impact of RC on erectile function, several sexual-preserving techniques have been proposed. The aim of this study was to evaluate and compare the oncologic outcomes of patients with iPCa who underwent nerve spring and no-nerve sparing robot-assisted radical cystectomy (RARC).

METHODS

The clinicopathologic data of male patients who underwent RARC at our institution between 2006 and 2016 were retrospectively analysed. Patients with iPCa at definitive pathological examinations were stratified in two groups, according to the preservation of the neurovascular bundles (nerve sparing vs no nerve sparing). Significant PCa was defined as any Gleason score ≥ 3 + 4. Biochemical recurrence (BR) was defined as a sustained PSA level > 0.2 ng/mL on two or more consecutive appraisals. BR rate was assessed only in patients with incidental prostate cancer and at least 2 years of follow-up. Differences in categorical and continuous variables were analysed using the chi-squared test and the Mann-Withney U test, respectively. Biochemical recurrence curves were generated using the Kaplan-Meier method and compared with the Log-rank test.

RESULTS

Overall, 343 male patients underwent RARC for bladder cancer within the study period. Nerve-sparing surgery was performed in 143 patients (41%), of these 110 had at least 2 years of follow up after surgery. Patients who underwent nerve-sparing surgery were significantly younger (p < 0.001). Clinically significant PCa was found in 24% of patients. No significant differences regarding preoperative PSA value (p = 0.3), PCa pathological stage (p = 0.5), Gleason score (p = 0.3) and positive surgical margin rates (p = 0.3) were found between the two groups. After a median follow-up of 51 months only one patient, in the no-nerve-sparing group had developed a biochemical recurrence (p = 0.4).

CONCLUSIONS

In our series most of the iPca detected in RC specimens can be considered as insignificant with a low rate of BR (0.9%). Nerve-sparing RARC is a safe procedure which did not affect oncological outcomes of patients with iPCa.

Retroperitoneal approach for robot-assisted partial nephrectomy: technique and early outcomes

OBJECTIVES

The aim of our study is to present early outcomes of our series of retroperitoneal-RAPN (Robot Assisted Partial Nephrectomy).

MATERIALS AND METHODS

From September 2010 until December 2015, we performed 81 RAPN procedures (44 at left kidney and 37 at right). Average size was 3cm (1-9). Average PADUA score 7.1 (5-10). Average surgical time (overall and only robot time), ischemia time, blood loss, pathological stage, complications and hospital stay have been recorded.

RESULTS

All of the cases were completed successfully without any operative complication or surgical conversion. Average surgical time was 177 minutes (75-340). Operative time was 145 minutes (80-300), overall blood loss was 142cc (60-310cc). In 30 cases the pedicle was late clamped with an average ischemia time of 4 minutes (2-7). None of the patient had positive surgical margins at definitive histology (49pT1a, 12pT1b, 3pT2a, 2pT3a). Hospital stay was 3 days (2-7).

CONCLUSIONS

The retroperitoneal robotic partial nephrectomy approach is safe and allows treatment of even quite complex tumors. It also combines the already well known advantages guaranteed by the da Vinci® robotic surgical system, with the advantages of the retroperitoneoscopic approach.

Scintimammography with a high resolution dedicated breast camera in comparison with SPECT/CT in primary breast cancer detection

AIM

We evaluated the usefulness of planar scintimammography (SM) with a high resolution dedicated breast camera (DBC) in comparison with single photon emission computed tomography (SPECT)/computed tomography (CT) in primary breast cancer detection.

METHODS

A consecutive series of 157 patients with breast lesions suspicious for cancer at conventional diagnostic procedures were studied with both DBC planar SM and SPECT/CT using [99mTc]tetrofosmin as radiotracer. Scintigraphic data have been related with definitive histopathological findings in all cases.

RESULTS

Breast cancer was ascertained in 127/157 patients and benign disease in the remaining 30 cases, with a total of 140 carcinomas and 33 benign lesions. DBC planar SM detected 95.7% of overall carcinomas, while SPECT/CT 90.7% (P<0.01). In =or<10 mm carcinomas, sensitivity was 89.1% for DBC planar SM and 78.3% for SPECT/CT (P<0.05); in carcinomas >10 mm the corresponding values were 98.9% and 96.8%, respectively. Specificity value was 87.9% for both procedures; accuracy value was 94.2% for DBC and 90.2% for SPECT/CT (P<0.01). Forty-six out of 127 breast cancer patients had axillary lymph node metastases; SPECT/CT was positive in 36/46 (78.3%) cases and showed a 96.4% specificity value. DBC planar SM identified metastases in only 4 cases.

CONCLUSIONS

DBC planar SM proved a useful diagnostic method in primary breast cancer detection, showing significantly higher sensitivity and accuracy values than SPECT/CT, especially in small size carcinomas. Thus, DBC planar SM should be preferred, although SPECT/CT, given its high performance, could represent a useful alternative when DBC is not available. Moreover, SPECT/CT, but not DBC, can contribute to providing information on axillary lymph node status.

Serum leptin and bone metabolism in HIV patients treated with highly active antiretroviral therapy

AIM

The role of leptin in bone metabolism has not yet been fully elucidated and results remain controversial. We investigated whether changes in serum leptin correlated to bone mineral density (BMD) occur in human immunodeficiency virus (HIV) patients on highly active antiretroviral therapy (HAART).

METHODS

The study population was 117 HIV patients (67 men, 50 women) on HAART and 50 healthy controls, all with normal body mass index (BMI). Based on whole body BMD as measured by dual energy x-ray absorptiometry (DEXA), patients were classified as having a low (< -1) T-score (L) or a normal (> -1) T-score (N); DEXA scans were also used to determine total body fat (TFM) and percent fat (F%); radioimmunologic assays were used to measure leptin, osteocalcin (OC), bone alkaline phosphatase (BAP), 1,25 (OH)2 D in serum, and pyridinium cross-links (PYD & DPD) in urine.

RESULTS

Of the 117 HIV patients, 54 (46.1%) were classified as L and 63 (53.9%) as N; BMD in both sexes was lower (P <0.01) among the L patients than among either the N patients or the controls; 25/32 L men and 19/22 women were osteopenic, the remaining were osteoporotic. The mean TFM, F%, OC, BAP and PYD & DPD values were higher and the mean 1,25 (OH)2 D values were lower in the L than in the N patients; leptin was higher among the L men (P <0.002) and the L women (P <0.03) than in the N patients. In both sexes. leptin positively correlated with TFM, F%, BAP and PYD & DPD; however, leptin, TFM and F% correlated negatively with BMD. A negative correlation was found between 1,25 (OH)2 D and PYD & DPD in women. At follow-up assessment of 56 HIV patients continuing HAART, leptin and BAP increased and 1,25 (OH)2 D decreased, but not significantly; BMD significantly decreased in women and PYD & DPD increased in men (P <0.02).

CONCLUSIONS

An inverse relationship was found between leptin and BMD in HIV patients with osteopenia/osteoporosis treated with HAART. While the role of leptin in bone metabolism in a setting of HIV is still unclear, an inhibitory effect of leptin associated with a negative action by HAART may be hypothesized.

Scintimammography with high resolution dedicated breast camera and mammography in multifocal, multicentric and bilateral breast cancer detection: a comparative study

AIM

The aim of this study was to compare preoperative planar scintimammography (SM) with high resolution dedicated breast camera (DBC) and conventional mammography in the detection of multifocal, multicentric and bilateral breast cancer and its impact on surgical planning.

METHODS

A series of 264 consecutive patients, 232 with breast cancer and 32 with benign lesions, underwent [(99m)Tc]tetrofosmin planar SM with a newly developed DBC (LumaGEM 3200S/12K, Gamma Medica-Ideas Inc.). Scintigraphic with mammography data were compared and correlated with histopathological findings.

RESULTS

At surgery, ipsilateral multifocal or multicentric breast cancer in 40 patients, invasive in 24 cases (group 1) and in situ in 16 (group 2) was ascertained, and synchronous bilateral breast cancer in 4 patients (group 3). Globally, SM was positive for cancer in 41 out of the 44 breast cancer patients (93.2%) and mammography was positive in 40 out of 44 (90.1%). SM revealed multifocal/multicentric disease in 87.5% of group 1/goup 2 patients and mammography in 47.5% (P<0.0005): SM detected a significantly higher number of additional invasive foci than mammography (89.6% vs 37.9%, P<0.0005); only SM revealed ipsilateral multifocality/multicentricity in 35% of cases. Bilaterality was detected by SM in 100% of group 3 patients and by mammography in 75%. Overall specificity was 88.2% for SM and 52.9% for mammography. SM correctly changed surgical management in 16% of cases.

CONCLUSIONS

DBC planar SM proved a more highly sensitive diagnostic method than mammography in the preoperative assessment of both ipsilateral multifocal/multicentric breast cancer and synchronous bilateral breast cancer. The procedure contributed to correctly changing patient surgical management in some cases, suggesting its wider use complementary to mammography.

Integrated approach to TYLCD management in Sardinia (Italy)

In Sardinia (Italy) Tomato yellow leaf curl disease (TYLCD) re-emerged in 2003, after a period of decline, producing severe yield losses in protected tomato crops. This epidemic outbreak highlighted the inadequacy of the approach to TYLCD management based chiefly on the chemical control of its vector, the whitefly Bemisia tabaci, and the use of 40-mesh nets for greenhouse screening. To evaluate the reliability of alternative practices for implementation within IP&DM programmes, in 2007 and 2008 we carried out two field experiments on greenhouse tomato crops planted in summer. In both trials we tested the use of UV-reflective mulches (UVRM) or floating row covers (NWRC), against an uncovered control on clear mulch. Furthermore, we assessed the effectiveness of acibenzolar-S-methyl, a SAR elicitor, as subplot factor in a split plot design. In 2007 because of the low incidence of the disease it was not possible to assess differences among the treatments. However a significant increase in plant growth, and production was observed in UVRM plots. By contrast, in 2008 the study crop was seriously affected by TYLCD. In the plots not treated with acibenzolar-S-methyl, the disease progression was initially slowed down in NWRC and, to a lesser extent, in UVRM plots compared to control plots but, during the second month of the cropping period, the differences among treatments became statistically not significant. In the plots treated with acibenzolar-S-methyl the dynamics of TYLCD infection during the first five weeks exhibited the same trend as in the untreated plots. Thereafter, the combination of UVRM and, to a lesser extent, of NWRC with the SAR elicitor resulted in a reduction of disease incidence with respect to the control. In conclusion, all the control measures tested in the present work showed the potential for TYLCD management in greenhouse tomatoes. However, the most promising results were achieved using UV-reflective mulch and non-woven row cover in combination with acibenzolar-S-methyl. In view of its positive impact on plant growth and yield in summer planted tomato crops, as well as on TYLCD infection, the use of UV-reflective mulch warrants further investigation.

Isolation, culture, and characterization of embryonic cell lines from vitrified sheep blastocysts

This study was conducted to isolate, to culture, and to characterize embryonic cell lines from in vitro produced vitrified sheep blastocysts. Embryos were produced and vitrified at the expanded blastocyst stage. Ten inner cell masses arising from day 6-7 blastocysts were isolated by immunosurgery, disaggregated, and cultured onto mitomocin-C-inactivated mouse STO fibroblasts (MIF). After 5 or 6 days of culture the primary cell colonies were disaggregated, seeded in a new MIF, and cultured for 3 or 4 days to form new colonies called Passage 1. These cells were then disaggregated and cultured for other two passages. The primary cell colonies and Passage 2 colonies expressed stage specific embryonic markers SSEA-1, SSEA-3, and SSEA-4, and were alkaline phosphatase positive. In the absence of feeder layer and human leukemia inhibitory factor (LIF), these cells differentiated into variety of cell types and formed embryoid bodies. When cultured for an extended period of time, embryoid bodies differentiated into derivatives of three embryonic germ (EG) layers. These were characterized by detection of specific markers for differentiation such early mesoderm (FE-C6), embryonic myosin (F1-652), neural precursor (FORSE-1), and endoderm (anti-cytokeratin 18). To our knowledge, this is the first time that embryonic cell lines from in vitro produced and vitrified ovine blastocysts have been isolated and examined for detection of SSEA markers, and embryoid bodies have been cultured and examined for specific cell surface markers for differentiation.

Bone mass loss and vitamin D metabolism impairment in HIV patients receiving highly active antiretroviral therapy

AIM

Given the few controversial data about the effect of highly active antiretroviral therapy (HAART) on bone mass in HIV patients, we investigated whether a relationship between osteopenia/osteoporosis risk and HAART exists.

METHODS

In 172 HIV patients, 152 on HAART, 92 including and 60 not including protease inhibitors (PI), 20 naïve and 64 controls, we measured spine/femur bone mineral density (BMD) by DEXA, and assayed serum osteocalcin (O), bone alkaline phosphatase (BAP), 1,25(OH)2 D, parathormone (PTH), calcium (Ca) and urinary pyridinium cross-links (PYD & DPD).

RESULTS

Following WHO BMD t-score criteria, osteopenia was ascertained in >35% of all HAART groups and in 30% of naive. Only HAART patients had osteoporosis, PI patients more frequently, significantly (p<0.03) in spine (21.7% vs 8.3%). Males, intravenous drug users and B-C stage patients have a higher risk for low bone mass. Mean t-score was significantly lower in both spine and femur and O and PYD & DPD higher in PI than non PI patients and controls; 1,25(OH)2 D was significantly lower in all HIV groups than controls, PI patients having the lowest values positively correlating with BMD and negatively with OC and PYD & DPD, and it decreased further in 27 non selected monitored patients continuing on HAART. PTH was higher and Ca lower in HAART patients than controls but not significantly, PTH negatively correlating with BMD.

CONCLUSION

HAART could be associated with osteopenia, even osteoporosis, and it could aggravate the loss in bone mass due to HIV infection itself. We hypothesize that HAART may directly affect bone remodelling and/or may indirectly affect vitamin D metabolism.

Sexing of in vitro produced ovine embryos by duplex PCR

The aim of this article was to develop a fast and easy duplex polymerase chain reaction (PCR) method, for sex determination of ovine in vitro produced embryos prior to implantation. We tested the approach with 107 samples of autosomal cells (oviductal sheep cells and male lamb fibroblasts), divided into three groups for each sex according to the number of cells employed (30, 5, 2, respectively). We then used the test on 21 embryos at blastocyst stage. On the same day the embryos were transferred in pairs into 11 recipient synchronized ewes. The PCR utilized two different sets of primers: the first pair recognized a bovine Y-chromosome-specific sequence (SRY), that showed 100% homology with the corresponding sequence of the ovine Y-chromosome and is amplified in males only. The second pair recognized the bovine 1.715 satellite DNA (SAT) which was amplified in all ovine samples but, when submitted to the GenBank database did not show homology with any of the reported ovine sequences. However, after sequencing, ovine amplification product showed 98% homology with the bovine specific satellite sequence. The autosomal samples were amplified with 85.0% efficiency and 91.2% accuracy, while amplification was successful with all 21 embryos (100% efficiency). Eight lambs were born and the sex as determined by PCR corresponded to the anatomical sex in seven (87.5% accuracy). These results confirm that this method can be applied in ovine breeding programs to manipulate sex ratio of offspring.

The role of (99m)Tc-tetrofosmin pinhole-SPECT in breast cancer non palpable axillary lymph node metastases detection

AIM

We evaluated the usefulness of (99m)Tc-tetrofosmin axillary pinhole (P)-SPECT in breast cancer (BC) non palpable axillary lymph node metastasis detection compared with conventional planar and SPECT scintimammography.

METHODS

We studied prospectively 188 consecutive patients with suspected primary BC, negative at axillary clinical examination. Ten minutes after 740 MBq (99m)Tc-tetrofosmin injection, planar and SPECT scintimammography were acquired, followed by axillary P-SPECT imaging.

RESULTS

At histology, 12 patients had benign mammary lesions and 176 had BC. Axillary lymph node dissection (ALND) was performed in all BC patients, bilaterally in 3 cases: 74/179 axillae had metastases. P-SPECT showed a significantly higher overall sensitivity than SPECT and planar (93.2% vs 85.1% and 36.5%, respectively; p<0.05 and p<0.0005, respectively) and was false negative in 5 patients with 1 metastatic node each, micrometastatic in 4/5 cases; SPECT and planar were also false negative in these 5 cases and in 6 and in 42 further cases, respectively. P-SPECT added important prognostic information by distinguishing single from multiple and pound 3 from >3 nodes; only P-SPECT defined the exact number of nodes in 15/25 patients with 2-4 nodes. P-SPECT showed the highest accuracy and NPV: 92.7% and 95%, respectively (SPECT 90.5% and 90%, respectively; planar 73.2% and 68.9%, respectively).

CONCLUSION

(99m)Tc-tetrofosmin axillary P-SPECT appears highly accurate in BC non palpable axillary lymph node metastasis detection and significantly more sensitive than both planar and SPECT, its few false negative results predominantly concerning micrometastases; moreover, only P-SPECT gave additional important prognostic information. Given its very high NPV, P-SPECT could also be used to better select patients who might avoid ALND.

The usefulness of 99mTc tetrofosmin scintigraphy in patients with breast cancer recurrences

To verify the usefulness of 99mTc tetrofosmin scintigraphy in the follow-up of breast cancer patients, we studied 72 surgically treated breast cancer patients with suspected local recurrences (20 cases) or distant metastases (52 cases) at clinical examination and/or at conventional imaging procedures (CIPs). In all patients, a whole-body scan followed by planar and single photon emission tomography (SPET) images of selected sites were acquired 10 min after the intravenous injection of 740 MBq of 99mTc tetrofosmin, using a rectangular dual-head gamma camera equipped with high-resolution parallel-hole collimators. Loco-regional recurrences were diagnosed in 19 patients and distant metastases in 44 cases, while benign lesions were ascertained in nine cases. 99mTc tetrofosmin SPET showed higher sensitivity, specificity and accuracy per patient than did CIP (96.8% vs 85%, 77.7% vs 55.5% and 94.4% vs 81.1%, respectively) with statistical significance for accuracy (P <0.05). The combined use of SPET and CIP achieved 100% sensitivity and 98.6% accuracy. Planar imaging did not give additional information in respect of either SPET or CIP, showing significantly lower sensitivity and accuracy values (47.6% and 52.8%, respectively). Our data seem to suggest that 99mTc tetrofosmin SPET, but not planar, may be useful in the follow-up for the detection of loco-regional and distant recurrences in patients with breast cancer. The technique can play a complementary role to conventional diagnostic imaging procedures in selected patients.

Usefulness of ^99mTc-Tetrofosmin Scintigraphy in Different Variants of Kaposi’s Sarcoma

We investigated ^99mTc-tetrofosmin scintigraphy in 27 patients with Kaposi’s sarcoma: 20 had classic (CK), 5 AIDS-associated (AK) and 2 transplantation-associated (TK) variants. Twenty-three patients had clinically evident cutaneous and/or mucosal lesions, 9 of them with associated sarcomatous lymphadenopathy; 2 TK patients had only lymph nodes or other extracutaneous Kaposi sites. Both planar and SPECT ^99mTc-tetrofosmin scintigraphies were performed in all cases and neck pinhole (P)-SPECT in selected patients. ^99mTc-tetrofosmin uptake was observed in 88% of patients with clinically evident cutaneous and/or extracutaneous Kaposi lesions. Scintigraphy gave additional information on cutaneous lesion extent, particularly SPECT regarding deep invasion and subclinical sites in some cases. However, scintigraphy was less sensitive in the detection of small, isolated and scattered lesions. SPECT/P-SPECT were positive in 8/8 patients with sarcomatous lymph nodes, planar imaging in 5/8, ultrasonography in 7/8, while all procedures were negative in 6 other patients with reactive or HIV infection lymph nodes. SPECT demonstrated lymphadenopathy remission in 1 TK patient after immunosuppressive therapy modification and, like planar imaging, ascertained an associated lymphoma with ⁶⁷Ga-citrate combined. ^99mTc-tetrofosmin scintigraphy, especially SPECT, can be useful both in the detection and staging of Kaposi sarcoma lesions as a complementary tool to clinical and other conventional diagnostic methods.

99mTc-Tetrofosmin pinhole-SPECT (P-SPECT) and radioguided sentinel node (SN) biopsy and in breast cancer axillary lymph node staging

We compared 99mTc-Tetrofosmin P-SPECT with radioguided SN biopsy in 101 T1/T2 BC pts to predict axillary lymph node status. The day before surgery all pts underwent lymphoscintigraphy (LS) to mark the SN, following subdermal injection of 99mTc-colloidal sulphur surrounding the breast lesion. LS was combined with pre and intraoperative gamma probe. Previously, all pts had also undergone P-SPECT. ALND was performed in all cases. The SN(s) was detected in 97/101 cases (96%) by LS and gamma probe; in the 4 missed cases P-SPECT predicted lymph node status. In the 97 comparable cases, radioguided SN biopsy showed a slightly higher accuracy than P-SPECT (94.8% vs 93.8%), but a higher false-negative rate (14.3% vs 8.6%); P-SPECT had a higher NPV (95.2% vs 92.5%). The two procedures when combined achieved 100% accuracy. Radioguided SN biopsy alone had 100% accuracy only in pts with BC < 15 mm. P-SPECT had 3 false negative cases, 2 of which were micrometastatic SNs, and 3 false positives. P-SPECT identified 81.2% of cases with a single node, determined the exact number of nodes in 82.6% of cases with 1 to 3 node and correctly classified 93.7% of pts as having < or = 3 or > 3 metastatic nodes. Radioguided SN biopsy seems indicated in selected, early stage, small BC pts, while P-SPECT shows a high sensitivity independent of primary tumor size, giving additional important preoperative prognostic information. The two procedures combined provided a better axillary lymph node status prediction in T1/T2 carcinomas, and could thus improve ALND pt selection.

(99)mTc-tetrofosmin SPET in the detection of both primary breast cancer and axillary lymph node metastasis

The aim of this study was to evaluate the usefulness of (99m)Tc-tetrofosmin single-photon emission tomography (SPET) in the detection of both primary breast cancer and axillary lymph node metastasis. We studied 192 consecutive patients in whom primary breast cancer was suspected on the basis of mammography and/or physical examination. After intravenous injection of 740 MBq (99m)Tc-tetrofosmin, both planar and SPET scintimammography was performed in all patients using a rectangular dual-head gamma camera equipped with low-energy, high-resolution, parallel-hole collimators. In 175 patients with breast cancer at histology, the per-lesion overall sensitivity of SPET and planar imaging for the detection of breast cancer was 95.8% and 75.9% (P<0.0005), respectively. The sensitivity of SPET and planar imaging was, respectively, 96.5% and 79.5% in palpable (P<0.0005) and 90% and 45% in non-palpable lesions (P<0.01). With regard to lesion size, the sensitivity of SPET and planar imaging was, respectively, 90.5% and 45.2% in lesions < or =10 mm ( P<0.0005), 95.3% and 81.4% in lesions of 11-20 mm (P<0.005), 100% and 84.6% in lesions of 21-30 mm (P<0.05) and 100% and 95.8% in lesions >30 mm (P>0.05). In the remaining 17 patients with benign mammary lesions at histology, per-lesion overall specificity of SPET and planar imaging was 76.2% and 85.7% (P>0.05), respectively. Neither SPET nor planar imaging showed false-positive results in non-palpable lesions or in those < or =10 mm. In 173 breast cancer patients submitted to axillary lymph node dissection (ALND), per-axilla overall sensitivity of SPET and planar imaging in the detection of axillary lymph node metastasis was 93% and 52.3% ( P<0.0005), respectively. The sensitivity of SPET and planar imaging was, respectively, 100% and 82.6% in palpable nodes (P>0.05), 90.5% and 41.3% in non-palpable nodes (P<0.0005), 92.8% and 35.7% in the presence of < or =3 nodes ( P<0.0005) and 93.2% and 68.2% in the presence of >3 nodes (P<0.005). The specificity of SPET and planar imaging was 91% and 100% (P<0.05), respectively. (99m)Tc-tetrofosmin SPET appears to be a reliable method for the detection of both primary BC and axillary lymph node metastasis, and its diagnostic accuracy exceeds that of (99m)Tc-tetrofosmin planar scintimammography. The use of SPET is particularly important in the identification of small non-palpable primary carcinomas and metastatic axillae with < or =3 non-palpable lymph nodes. More extensive use of SPET appears warranted in the management of breast cancer patients.