In2Q2: A New Entry of 16-Membered Tetraazamacrocycle Concatenating Indole and Quinoline Units

A new family of 16-membered macrocycles comprising two indole (In) and two quinoline (Q) units, coined In2Q2, was synthesized. Each unit is diagonally located and concatenated in a head-to-tail fashion, furnishing a non-flat saddle-shaped architecture with C2 symmetry. The synthetic protocol utilizing macrocyclic diamide as a pivotal precursor allowed us to access a series of In2Q2 derivatives bearing various substituents on the periphery. The In2Q2 derivatives and their Zn2+ complexes were emissive in both solution phase and solid state. While the entire architecture of In2Q2 is similar to that of quinoline tetramer TEtraQuinoline, a couple of contrasting physicochemical properties were revealed.

Measurement of Direct-Photon Cross Section and Double-Helicity Asymmetry at sqrt[s]=510 GeV in p[over →]+p[over →] Collisions

We present measurements of the cross section and double-helicity asymmetry A_{LL} of direct-photon production in p[over →]+p[over →] collisions at sqrt[s]=510  GeV. The measurements have been performed at midrapidity (|η|<0.25) with the PHENIX detector at the Relativistic Heavy Ion Collider. At relativistic energies, direct photons are dominantly produced from the initial quark-gluon hard scattering and do not interact via the strong force at leading order. Therefore, at sqrt[s]=510  GeV, where leading-order-effects dominate, these measurements provide clean and direct access to the gluon helicity in the polarized proton in the gluon-momentum-fraction range 0.02<x<0.08, with direct sensitivity to the sign of the gluon contribution.

Investigation of air bubble properties: Relevance to prevention of coronary air embolism during cardiac surgery

Although de-airing procedures are commonly performed during cardiac surgery, use of these procedures is not necessarily based on evidence. Uncertainly remains around the size of bubbles that can be detected by echocardiography, whether embolized air or carbon dioxide can be absorbed, and the reasons for embolic events occurring despite extensive de-airing. Since air bubbles are invisible in the blood, we used simple experimental models employing water and 10% dextran solution to determine the correlation between actual bubble size and the depicted size on echocardiography, bubble size, and floatation velocity and the absorption of carbon dioxide under embolization and irrigation conditions. Bubbles depicted as larger than 1 mm were overestimated by echocardiography: the actual size was larger than 0.4 mm in diameter. While bubbles of 0.5 mm had a floatation velocity of 2 to 3 cm/s, the buoyancy of bubbles smaller than 0.3 mm was negligible. Thus, bubbles that are depicted as larger than 1 mm on echocardiography or that present with apparent buoyancy should be visible and need to be meticulously removed. However, echocardiography cannot distinguish bubbles of around 0.1 mm in diameter from those of capillary size (<10 μm). Thus, we advise continuous venting of dense bubbles until they become sparse. While carbon dioxide was rapidly absorbed when circulating, the absorption of embolized carbon dioxide was negligible. These results suggest that detected intracardiac air represents residual "air," with carbon dioxide already absorbed. Therefore, the use of conventional de-airing procedures needs reconsideration: air and buoyant bubbles should be removed from the heart before they are expelled into the aorta; this requires timely and precise assessment with transesophageal echocardiography and effective collaboration between surgeons, anesthesiologists, and perfusionists.

Cell-Based Biohybrid Sensor Device for Chemical Source Direction Estimation

This paper describes a method to estimate the direction from which the signal molecule reaches the sensor by using living cells. In this context, biohybrid sensors that utilize a sophisticated sensing system of cells can potentially offer high levels of chemical-detection sensitivity and selectivity. However, biohybrid-sensor-based chemical-source-direction estimation has not received research attention because the cellular response to chemicals has not been examined in the context of directional information. In our approach, we fabricated a device that can limit the interface between the cell-laden hydrogel and the chemical solution of interest to enhance the time difference over which the chemical solution reaches the cells. Chemical detection by cells that express specific receptors is reflected as the fluorescence of the calcium indicator within the cells. Our device has eight chambers that each house 3D cell-laden collagen hydrogels facing circularly outward. The device also works as a cover to prevent chemicals from permeating the hydrogel from above. In our study, by observing the time course of the fluorescence emission of each chamber, we were able to successfully estimate the chemical-source direction within an error range of 7–13°. Our results suggest that a combination of microstructure devices embedded with living cells can be used to exploit cell functionalities to yield chemical-source directional information.

Intraoperative Transesophageal Echocardiography for Coronary Artery Assessment

Background: In surgical aortic valve replacement (SAVR), coronary arteries are routinely assessed by transesophageal echocardiography (TEE) to prevent undesirable complications. This study evaluated the capabilities and pitfalls of TEE assessment. Methods and Results: Of 147 consecutive SAVR patients undergoing aortic stenosis, the TEE records for 130 patients, in which the procedures were conducted by a single examiner, were analyzed retrospectively regarding data acquisition and the accuracy of detecting an anomalous origin, high or low takeoff, ostial diameter, and short left main truncus (LMT). The left and right coronary arteries could be visualized in every patient. A left coronary ostium >5 mm was found in 33 patients (25.4%). TEE revealed an anomalous origin in 2 patients (1.5%) that had not been diagnosed, but missed it in another patient. High takeoff was noted in 11 patients (8.3%), often associated with aortic disease necessitating aortic repair. In one such patient, occlusion of the right coronary artery was detected, necessitating coronary revascularization. Short LMT was found in 15 patients (11.8%) but misdiagnosed due to artifact in 1. During selective cardioplegia, malperfusion of the left anterior descending artery due to deep cannula placement was detected. Conclusions: TEE provides fairly accurate assessment in SAVR, including detection of undiagnosed pathologies or pitfalls related to coronary arteries, although misdiagnosis due to artifacts should be kept in mind.

Eastern observers cannot inhibit their gaze to eye and nose regions in face perception

It has been found that Western observers cannot inhibit their gaze to the eye region, even if they are told to avoid doing so when they observe face stimuli because of the importance of the eye region. However, studies indicate that the nose region is more important for face processing among Eastern observers. We used the "don't look" paradigm with Eastern observers, in which participants were told to avoid fixating on a specific region (eye, nose, and mouth). The results extend previous findings as both the eye and nose regions attracted their gaze. Interestingly, the fixation behaviors differed for the eyes and nose in terms of the time-dependent view, in which reflexive saccades to the eye with a persistent fixation to the nose were observed. The nose regions could have stronger attractiveness than previously thought.

Advantages of Transesophageal Echocardiography during Stent Grafting for Aortic Dissection: A Report of Three Cases

We report the cases of three patients who underwent thoracic endovascular aortic repair for type B aortic dissection in which transesophageal echocardiography (TEE) was used to guide the procedure in addition to fluoroscopy. TEE was found to be advantageous because it can visualize vascular structures along with the guidewire and devices. Furthermore, it provides real-time hemodynamic and hematological information without the need for contrast injection or radiation exposure. Although TEE assessment requires expertise, the efficient use of TEE appears to be helpful for further improving the outcomes of endovascular surgery for aortic dissection.

[Ascending Aortic Thrombus Recognized by Acute Brachial Arterial Occlusion]

We report a case of ascending aortic thrombus with acute arterial occlusion of the brachial artery. A 49-year-old woman had sudden pain in her right arm due to acute occlusion of the right brachial artery. Contrast-enhanced computed tomography and echocardiography revealed a large mobile thrombus in the ascending aorta, which prompted surgical intervention. The thrombi were removed via aortotomy under circulatory arrest. Trans-esophageal echocardiography was useful for watching a potential detachment of the thrombus in the aorta during surgical manipulations or systemic perfusion. Despite no evidence of either inherited or acquired thrombotic predisposition, thrombosis in the right atrium and deep veins of the lower extremities was found postoperatively. Since antiplatelet and anticoagulant therapy was started, she has suffered from no thrombotic event.

Iatrogenic subintimal aortic dissection that disappeared without a trace

A case of an unusual iatrogenic aortic dissection is reported. A 77-year-old male patient in shock status due to acute type A aortic dissection underwent emergency surgery. Systemic perfusion was started via the femoral artery, but another dissection appeared in the descending aorta detected by transoesophageal echocardiography. However, the flap was unusually thin, and there was no change in the pre-existing thrombosed false lumen. These findings suggested subintimal development of dissection. After systemic perfusion was promptly switched to antegrade perfusion, the new dissection could no longer be detected. Since there was no malperfusion or aortic rupture, the ascending aorta was repaired. His postoperative course was uneventful, and there were no significant complications. Unless the aorta is carefully observed at the right time during the operation, such vanishing aortic dissection may be missed and potentially result in 'organ damage of unknown cause'.

Intima migration from the iliac artery to a debranched graft after thoracic endovascular aortic repair

An 84-year-old woman underwent single-debranched thoracic endovascular aortic repair for aortic aneurysm. A few hours later, malperfusion of the left upper extremity occurred. Surgical exploration revealed a tubular-shaped intima packed in the debranched graft. As computed tomography showed localized dissection in the right external iliac artery probably due to access route injury, the intima roll was thought to have migrated from the iliac artery. This extremely rare case is described in detail with a discussion of the potential mechanism.

Description of the Surgical Strategy Used for the Treatment of a Complex Disease: Report of a Case

We report a rare case in which a patient required three surgeries with competing priorities. In a 68-year-old man diagnosed with an abdominal aortic aneurysm (AAA), computed tomography (CT) revealed an infrarenal AAA, unusual thickening of the sigmoid colon that suggested cancer, and a filling defect in the left atrium. We considered the disease stage, which affects prognosis, and the risk of complications that could interfere with the treatment of the other pathologies and developed a three-stage surgical strategy: (i) endovascular aortic repair, (ii) sigmoid colectomy, and (iii) resection of the left atrial mass. The patient’s postsurgical recovery was uneventful.

Avoidance of Coronary Sinus Injury During Retrograde Cardioplegia

Coronary sinus injury is a rare but critical complication of retrograde cardioplegia. Even after detection, successful repair with a pericardial patch is not always attained. Malalignment of the infusion cannula relative to the coronary sinus is likely to be partially responsible for the injury. Monitoring the location of the cannula tip can help prevent injury. Transesophageal echocardiography can indicate the vascular structure within which the cannula is located. This finding may be useful in preventing injury to the coronary sinus or middle cardiac vein.

A Case of Dissection and Rupture of the Innominate Artery in Acute Type A Aortic Dissection

We report the case of a 59-year-old male presenting with dissection and rupture of the innominate artery with acute type A aortic dissection. We performed total arch replacement via median sternotomy with extension into the right side of the neck. The innominate artery was reconstructed just proximal to the bifurcation of the right subclavian artery and common carotid artery using the 1st limb of a 4-branched graft. This case illustrates an unusual aspect of an isolated innominate artery rupture in the absence of aortic rupture in acute type A aortic dissection.

Abstract P4-11-02: Endocrine-related symptoms during neoadjuvant endocrine therapy for breast cancer: Agreement between patient and physician reporting in a prospective clinical trial

Background: There is a high risk of under-reporting subjective toxicities by physicians, even when collected prospectively in clinical trials. It has been recommended to include patient reported measures regarding symptoms in prospective clinical comparative effectiveness trials. However, there have been few reports of agreement in endocrine related symptoms between patient and physician reporting.

Patients and Method: The National Surgical Adjuvant Study of Breast Cancer 06 (N-SAS BC 06) is a multicenter, randomized clinical trial of postmenopausal, hormone receptor-positive breast cancer patients, with a two-stage (preoperative and postoperative) enrollment, and intervention. The primary aim was to evaluate the need for adjuvant chemotherapy in the treatment of postmenopausal breast cancer patients who responded to neoadjuvant treatment with Letrozole (LET) for 24-28 weeks. After surgery, responders were randomized into two arms receiving either chemotherapy plus LET, or LET alone. The primary endpoint was disease-free survival, and the secondary endpoints included adverse events, quality of life and health economic evaluation. This study enrolled 497 subjects from the N-SAS BC 06 who were evaluated by Patient Reported Outcomes (PROs). The concordance rate between Clinician Reported Outcomes (CROs) and PROs in their endocrine symptoms during neoadjuvant endocrine therapy was examined. Symptoms were collected prospectively by physicians using the Common Toxicity Criteria for Adverse Events at enrollment, i.e., baseline, and 4 and 16 weeks after starting neoadjuvant LET. Patients also completed the FACT-G (General), B (Breast), ES (Endocrine Symptoms), and HADS. The endocrine symptoms according to the PROs, included nausea, hot flushes, cold sweats, headaches, and HADS-Depression score. In FACT, "Not at all" was used to express the absence of the symptoms, and "A little bit", "Some-what", "Quite a bit", and "Very much" were used to express the presence of symptoms. The HADS-Depression score threshold was 10/11. According to the CROs, grade 0 was defined as the absence of symptoms and grade 1 or more was defined as the presence of symptoms. Cohen's kappa was used to determine the concordance between CROs and PROs. The sensitivity of CROs was also calculated.

Results: The calculated point estimates of Cohen's kappa at Weeks 4 and 16 after starting neoadjuvant LET were 0.12 and 0.01 for nausea, 0.16 and 0.18 for hot flushes, 0.12 and 0.09 for cold sweats, 0.03 and 0.02 for headaches, and 0.11 and 0.11 for dysthymia/depression, respectively; the concordance was quite low. The sensitivity of CROs at Weeks 4 and 16 after starting neoadjuvant LET was 0.07 and 0.03 for nausea, 0.16 and 0.17 for hot flushes, 0.1 and 0.08 for cold sweats, 0.03 and 0.03 for headaches, and 0.11 and 0.1 for dysthymia/depression, respectively; the sensitivity was quite low.

Conclusion: This study showed that there were big differences between CROs and PROs in endocrine symptoms associated with endocrine therapy for breast cancer and that physicians could not obtain sufficient information on the endocrine symptoms. It is recommended that PROs be used to evaluate adverse events caused by endocrine therapy.

Citation Format: Fujisawa T, Iwata H, Sakai T, Nakamura R, Hasegawa Y, Ohtani S, Kashiwaba M, Taira N, Toyama T, Masuda N, Yamamoto Y, Kihara K, Shimozuma K, Ohashi Y, Mukai H. Endocrine-related symptoms during neoadjuvant endocrine therapy for breast cancer: Agreement between patient and physician reporting in a prospective clinical trial. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-11-02.

Trapping and isolation of single prokaryotic cells in a micro-chamber array using dielectrophoresis

The vast majority of prokaryotic species are difficult or impossible to culture in laboratories, which makes it difficult to study these organisms using conventional biochemical techniques.

[Aortoesophageal Fistula Long after Single Staged Hybrid Procedure for Extended Thoracic Aortic Aneurysm]

70-year-old male who had a history of Y-shaped graft replacement of abdominal aortic aneurysm was referred to our hospital for surgical intervention of extended thoracic aortic aneurysm. Although 1 debranching thoracic endovascular aortic repair (TEVAR) was initially scheduled, deployment of the main endograft was eventually cancelled due to severely tortuous bilateral rims of Y-shaped graft, and left carotid artery-left subclavian artery bypass followed by the coil embolization to the orifice of left subclavian artery to prepare for the next operation was performed. Single hybrid operation, including total aortic arch replacement along with elephant trunk insertion and TEVAR was performed at 3 months after the initial operation. On the 191th postoperative day, he was readmitted to our hospital due to marked elevation of C-reactive protein and unknown fever, and enhanced computed tomography showed the pneumomediastinum. Also, fistula formation was identified at the middle portion of the esophagus on the esophagogastroduodenoscopy, and the contrast agent leakage to the outside of the esophagus was demonstrated on the esophagography. He was transferred to another hospital at 7th day after readmission under the definitive diagnosis of mediastinitis due to aortoesophageal fistula for surgical of esophagectomy and mediastinum drainage. Currently, he is discharged from the hospital, and returning for follow-up visit for taking a course of antibiotics.

Hybrid Three-Stage Repair for Extended Thoracoabdominal Aortic Aneurysm: Report of A Case

A 67-year-old man complicated with back pain. The computed tomography (CT) scan showed an extended thoracoabdominal aneurysm. We successfully performed a three-stage hybrid repair using the visceral-renal debranching technique. For the first stage operation we performed Y-grafting with the debranching technique to create a distal landing zone. Then, for the second stage operation, we performed the hybrid procedure including total arch replacement (TAR) and antegrade stent graft deployment to create a proximal landing zone. Finally, additional thoracic endovascular aortic repair (TEVAR) between the distal and proximal landing zones was successfully accomplished as the third stage operation.

Diffusion-weighted MRI as a potential imaging biomarker reflecting the metastatic potential of upper urinary tract cancer

OBJECTIVE

To evaluate the role of diffusion-weighted MRI (DW-MRI) as an imaging biomarker for upper urinary tract cancer (UUTC) that has already metastasized or will metastasize soon.

METHODS

61 patients clinically diagnosed with UUTC were prospectively enrolled in this study. All the patients underwent MRI, including DW-MRI, prior to any interventions. Correlations between apparent diffusion coefficient (ADC) and other clinicopathological variables, including metastasis-free survival, were analysed.

RESULTS

Median follow-up period was 938 days. Of the 61 patients, 12 had any metastases at the initial diagnosis. 11 patients developed metastases during the follow-up period. These 23 patients were categorized as "Metastatic". Of the remaining 38 patients, 35 with a follow-up period longer than 400 days were categorized as "Localized". ADC was significantly lower in the Metastatic category than in the Localized (p = 0.0002) category. Multivariate analysis of pre-operative variables identified ADC (cut-off value, 1.08 × 10(-3) mm(2) s(-1)) and clinical T stage based on T2 weighted MRI as an independent predictive factor of metastatic UUTC. 46 patients without any metastases during the initial diagnosis were stratified into a high-risk group (16 patients with low ADC and clinical T3-4) and a low-risk group (30 patients with high ADC or clinical Ta-2). The 3-year metastasis-free survivals were 45% and 93%, respectively.

CONCLUSION

In the current study, UUTC with lower ADC value is more likely to have metastatic potential. Incorporating ADC with clinical T stage helps to differentiate metastatic UUTC at the initial diagnosis.

ADVANCES IN KNOWLEDGE

DW-MRI is a potential imaging biomarker reflecting metastatic propensity of UUTC.

Intraoperative migration of open stent graft detected by transesophageal echocardiography: report of two cases

We report two cases of graft migration during open stent grafting, detected by transesophageal echocardiography (TEE). The incidence was 3.7% in our series. The length of landing zone was reduced from 45 mm to 25 mm in case 1 and from 50 mm to 22 mm in case 2 before chest closure. Aneurysmal protrusion on the greater curvature with thin mural thrombus were findings common in both cases. Although additional intervention was not done based on the TEE findings of no endoleak and thrombus formation in the aneurysm, and postoperative course was uneventful, meticulous imaging check-up was needed.

[Pacemaker infection in a child; report of a case]

In the treatment for pacemaker infection, removal of infected devices and intensive antibiotics therapy are in principle and new devices should be implanted apart from the infected site. However, there are some problems in the case of children:it is not easy to remove infected devices because epicardial leads are often used for them. If endocardial leads are chosen as a new system, extension of the lead would be concerned with their growth. We report a pediatric case of infection of pacemaker using epicardial leads. It was difficult to cure infection by repeated local treatment leaving epicardial leads and antibiotics therapy was obliged to continue for 9 years to keep infection under control. After growing up, we implanted endocardial leads for her and removed infected devices to cure infection completely.

Cardiac calcified amorphous tumor stuck in the aortic valve that mimicked a chameleon's tongue: report of a case

A calcified amorphous tumor (CAT) is a rare intracardiac mass that carries a risk of embolism. We herein present the case of a club-shaped CAT that originated from the calcified mitral annulus. Echocardiography indicated a pendular motion of the mass and repeated entrapment by a stenotic aortic valve that was sustained for several beats, mimicking a chameleon's tongue. An emergency operation was performed because of the risk of embolism, as well as potential progression of cardiac failure due to worsening aortic valve stenosis. The histological findings were consistent with the diagnosis of a CAT. This report describes a case of an intracardiac tumor that showed unique motion like a chameleon's tongue.

Development of a new selective coronary perfusion cannula

The two most common types of coronary perfusion cannulae currently being used are the "balloon type", with a balloon at the tip, and the "fenestrated type", which has holes along the side near the tip. However, on occasion an unusually high perfusion pressure or a considerable amount of leakage is encountered during infusion of the cardioplegic solution. We have examined the properties of a newly developed Kochi Medical School (KMS)-type cannula and compared these to the properties of the balloon-type and fenestrated-type cannulae in an ex vivo experimental model that contains ostia of 4, 3, or 2 mm in diameter. Ejected flow velocity, circuit pressure, and the amount of leakage were measured at an infusion rate of 100 and 200 mL/min, with the latter two parameters measured under the counterpressure of 0 and 50 cmH2O to examine the influence of coronary vascular resistance. Without counterpressure, the balloon type presented with the highest flow velocity (263 cm/s at 200 mL/min) and perfusion pressure (64 mmHg at 200 mL/min) but without leakage. The fenestrated type yielded a considerable amount of leakage (40 % at an ostium size of 2 mm). The KMS type showed a lower flow velocity and circuit pressure with less leakage. Under 50 cmH2O counterpressure, however, only the KMS-type cannula could inject the water to any ostium size at both flow rates. These results suggest that the concept of the KMS-type cannula may be advantageous to achieving a secure infusion to a diseased coronary ostium.

Intraoperative continuous hemodiafiltration with selective venous drainage of ischemic limbs

We report two cases of acute limb ischemia with threatened myonephropathic metabolic syndrome (MNMS) in which continuous hemodiafiltration (CHDF) was started before revascularization with selective drainage from the clamped femoral vein of ischemic limb and return of processed blood into the contralateral femoral vein. It was aimed to optimise the removal of metabolites which were produced by myolysis following reperfusion as well as to minimize the deviation of metabolites into the systemic circulation. Both cases had uneventful postoperative course without MNMS and the limbs were salvaged.

The SOCS and STAT from JAK/STAT signaling pathway of kuruma shrimp Marsupenaeus japonicus: molecular cloning, characterization and expression analysis

Signal transducer and activators of transcription (STAT) gene, suppressors of cytokine signaling (SOCS) has been isolated from kuruma shrimp, Marsupenaeus japonicus and characterized. The kuruma shrimp STAT (MjSTAT) cDNA was composed of 2901 bp consisting of 801 amino acid residues which includes a protein interaction domain, all alpha domain, DNA binding domain and SH2 domain. Homology analysis of MjSTAT showed 94.1% and 34.0% identities with Penaeus monodon STAT (PmSTAT) and Drosophila melanogaster STAT92E (DmSTAT), respectively. The kuruma shrimp SOCS (MjSOCS) cDNA was composed of 1675 bp consisting of 342 amino acid residues including a SH2 domain and C-terminal SOCS domain. Homology analysis of MjSOCS showed 52.6% and 21.3% identities with Chinese mitten crab (Eriocheir sinensis) SOCS2 and fruit fly (D. melanogaster) SOCS44A, respectively. The MjSTAT and MjSOCS genes are constitutively expressed in the muscle, stomach, brain and gill of kuruma shrimp. In lymphoid organ cells, an enhanced expression of both MjSTAT and MjSOCS genes are observed following stimulation with peptidoglycan and polycytidylic acid. These observations suggest that MjSTAT and MjSOCS might play a major role in the innate immune defense of kuruma shrimp. The discovery of JAK/STAT signaling pathway in shrimp will allow a complete and concrete understanding of shrimp cytokine signaling.

A surgical case report of off-pump onlay patch grafting for pseudoaneurysm with diffusely calcified coronary artery

Coronary pseudoaneurysm usually occurs after catheter-based intervention as a result of traumatic dissection or perforation of a coronary artery in 4%-5% of cases. Here, we report the successful case of pseudoaneurysm occurring after percutaneous coronary angioplasty (PTCA) against the severely calcified coronary artery treated with off-pump long onlay patch bypass technique using internal thoracic arteries. We report the case of a 59-year-old woman treated with off-pump onlay patch grafting for pseudoaneurysm after coronary angioplasty against the diffusely calcified coronary lesion. The portion of the endoarterectomized left anterior descending coronary artery proximal to the resected aneurysm extending 5cm distally was successfully reconstructed with long onlay patch using the internal thoracic arterial graft.

A novel repeat biopsy nomogram based on three-dimensional extended biopsy

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Background: There is no perfect cohort in which nomograms are developed because no biopsy method can detect all cancers. To minimize this inherent verification bias, having a cohort with fewer false negative cases is advantageous. Based on a cohort examined with three-dimensional (3D) extended biopsy protocol, we developed a novel nomogram for diagnosis of prostate cancer on repeat biopsy.

Methods: Of 4,074 consecutive male patients undergoing prostate biopsy at our institutions between 2000 and 2009, 775 men with at least one previous negative biopsy underwent repeat biopsy with 3D protocol. Men with previous atypical glands or atypical small acinar proliferation and/or without available prostate-specific antigen (PSA) kinetics information were excluded. The remaining 515 men constituted the study cohort. We developed a logistic regression-based nomogram with 70% of the cohort selected randomly; we validated it with the remaining 30%. Predictive accuracy and performance characteristics were assessed using the area under the receiver operating characteristic curve (AUC) and calibration plots, respectively. The threshold probability was evaluated with decision curve analysis.

Results: We developed a novel repeat biopsy nomogram incorporating age, free to total PSA ratio, prostate volume, history of previous extended biopsy, and PSA doubling time. Validation confirmed predictive accuracy with an AUC value of 0.791. Calibration plots showed good agreement. The decision curve of the nomogram was superior to the decision curve of biopsying all men in a range of threshold probability over 0.15. At the threshold of 0.2, the number of unnecessary biopsies could be reduced by 10 per 100, without missing PCa.

Conclusions: We developed a novel repeat biopsy nomogram based on a cohort examined with 3D extended biopsy. This repeat biopsy nomogram is clinically beneficial, saving a substantial number of unnecessary biopsies.

No significant financial relationships to disclose.

Maintenance of the suppressed level of serum testosterone by administration of three-monthly formulations of luteinizing hormone-releasing hormone agonists at six-month intervals in Japanese patients with prostate cancer: A prospective study

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Background: Treatment with an LH-RH agonist is a standard alternative to surgical castration for prostate cancer patients. The serum testosterone level is kept at castrate levels continuously during LH-RH agonist therapy in almost all patients (Fujii Y, BJU Int 2008). LH- RH agonists, however, are more expensive than surgical castration, with drugs costing between US $300 and $500 per month in Japan. Recent studies suggest that 3-monthly formulations of LH-RH agonists suppress the serum testosterone levels far longer than the 3-month dosing interval.

Methods: A total of 43 Japanese patients with prostate cancer who were treated with 3-monthly LH-RH agonists (23 with 11.25mg leuprolide, and 20 with 10.8 mg goserelin) for one year or longer and whose testosterone levels were kept at castrate level (defined as < 50 ng/dL) were entered into this prospective, longitudinal study. After entry, the 43 men received the same 3-monthly LH-RH agonists at 6-month intervals, and had serum LH and testosterone tests performed at 3-month intervals. Bicalutamide was combined with the LH-RH agonists in 12 of the patients.

Results: At entry, median patient age was 74 years (range 59 to 89), median duration of LH-RH agonists treatment was 26 months (12 to 125), and median LH and testosterone levels were <10 ng/dL (<10 to 60) and 5 ng/dL (<5 to 18), respectively. The 43 patients received a total of 162 administrations (median 5, range 1 to 6) of the LH-RH agonists at 6-month intervals, and had a total 335 hormonal tests (median 10, range 2 to12) performed during the median followup period of 30 months. Serum LH and testosterone levels were kept suppressed during the treatment. Of the 43 patients, two had serum testosterone just above the castrate level (54 and 56 ng/dL) once each among their 12 and 8 hormonal assays, respectively.

Conclusions: Administration of 3-monthly LH-RH agonists, either leuprolide or goserelin, at 6-month intervals could maintain the castrate level of serum testosterone at least in Japanese prostate cancer patients who have received LH-RH agonists treatment for one year or longer.

No significant financial relationships to disclose.

Use of C-reactive protein to predict perinephric or renal sinus fat invasion in patients with clinical T1N0M0 renal cell carcinoma

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Background: Indication of nephron sparing surgery (NSS) for renal cell carcinoma (RCC) has been extending, as NSS can be considered for not only cT1a but also cT1b tumors. However, some cT1 diseases have pathological perinephric or renal sinus fat invasion. It is useful to know the probability of the presence of fat invasion before surgery, but diagnostic ability of imaging studies such as CT for predicting pT3a disease is limited. Therefore, estimation of the risk for pT3a disease in cT1 RCC patients could be helpful. C-reactive protein (CRP) has been shown to be a strong prognostic factor in RCC patients, reflecting tumor aggressiveness. We evaluated the predictive ability of preoperative CRP for pT3a disease in cT1N0M0 RCC patients.

Methods: Of consecutive 386 patients treated with radical nephrectomy for cT1a-bN0M0 RCC, 82 were excluded due to hemodialysis, inflammatory disease, bilateral synchronous renal tumors, synchronous other malignant disease or loss of each data. The remaining 304 patients constituted the current study cohort. Cut off point of CRP was 3 mg/L. Associations were analyzed between pT3a and preoperative factors including age, sex, BMI, laterality, tumor size, CRP, hemoglobin, platelet, LDH, ALP, calcium and albumin. We developed a multivariate model for predicting pT3a disease in cT1 RCC.

Results: Of the 304 patients, 28 (9%) had pT3a disease. Of 43 patients with elevated CRP level, 10 (23%) had pT3a disease. In contrast, of the remaining 261 patients with non-elevated CRP level, 18 (7%) had (p=0.002). Univariate and then multivariate analyses identified age (p=0.021), tumor size (p=0.007), and CRP (p=0.024) as independent and significant predictors for pT3a disease. Incorporating these three factors, we developed a predictive model for pT3a disease with predictive accuracy of area under the ROC curve of 0.772.

Conclusions: Preoperative CRP is an independent predictor for pT3a disease in cT1 RCC along with age and tumor size. The model could be useful to estimate the risk of the probability of fat invasion before surgery, especially NSS.

No significant financial relationships to disclose.

Surgical outcomes of gasless single port retroperitoneal radical nephrectomy for dialysis patients: A comparative analysis with nondialysis patients

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Background: Gasless single port retroperitoneal radical nephrectomy is minimally invasive, curative and cost effective operation which we have developed since 1998 (Eur Urol Suppl 2009; 8: 392), and covered by the Japanese universal insurance system from April, 2008. Patients necessitating dialysis are considered high risk operative candidates because of their multiple comorbidities. We compared surgical outcomes of dialysis patients with non-dialysis patients to evaluate this operation as treatment for high risk group.

Methods: We reviewed 304 consecutive patients including 59 (19.4%) dialysis patients who underwent CO2 gasless single port retroperitoneal radical nephrectomy at our institute between 2000 and 2009. Complications within the first 30 days after the surgery were graded retrospectively according to the modified Clavien classification system. Patient demographics, operative outcomes, and complications were compared between dialysis and non-dialysis patients.

Results: In all patients, the median patient age and body mass index were 60 years and 23.0 kg/m2. The median length of surgical incision, operative time (OT) and estimated blood loss (EBL) were 6.5 cm, 189 minutes and 214 mL, respectively. The transfusion rate was 3.3%. The intra and postoperative complication rate were 3.9% and 10.1%. Two grade 3a (ureteral obstruction, 1; diverticulitis, 1), three grade 3b (occlusion of peripheral hemodialysis shunt, 3) and two grade 4 (pulmonary embolism, 1; acute heart failure, 1) surgical complications occurred. In dialysis patients, the mean BMI was lower (20.4 vs. 23.3, p<0.0001), the mean OT was shorter (170 vs. 201 minutes, p<0.0001) and the mean EBL was lower (216 vs. 311mL, p<0.0001) than non-dialysis patients. There was no Clavien grade 3 or 4 surgical complications except dialysis access occlusion in dialysis patients. The average time to oral feeding and walking were equivalent, but possible discharge were longer in dialysis patients (4.3 vs. 3.4 days, p<0.0037).

Conclusions: Our data supports the safety and feasibility of gasless single port retroperitoneal radical nephrectomy for dialysis patients.

No significant financial relationships to disclose.

Initial experience of focal therapy for prostate cancer using I-125 seed implantation: Unilateral ablation for patients selected by extended biopsy and MRI findings

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Background: Focal therapy for prostate cancer could be a minimally invasive therapeutic option with the preservation of genitourinary function to reduce treatment associated complication under the appropriate selection of patients. We have reported the good predict ability to unilateral prostate cancer by extended prostate biopsy combined with transperineal and transrectal approaches (Eur Urol supple, 2009). Among the candidate ablative, brachytherapy which has been proved as a definitive therapy and applied worldwide has been thought to have potential for focal ablation due to its ability of dose and location adjustment by seed implantation under real-time monitoring. Based on the findings, focal therapy with hemiablation using I-125 seed implantation has been started in our instituion. The aim of study is to describe the initial experience of focal therapy for patients selected by extended biopsy and MRI findings.

Methods: The eligible criteria for focal therapy to prostate cancer are as follows. Clinical stage is T2a or less. The positive cores of cancer are proven within unilateral lobe by extended prostate biopsy. There was no cancerous lesion in contralateral lobe by MRI. Gleason score in positive cores was 3 + 4 or less. Maximum cancer length was less than 5 mm. PSA value is less than 10 ng/mL. On the treatment, I-125 seeds were implanted to ablate the unilateral lobe with 160 Gy of the prescription dose. The protocol has been approved by the institutional ethics commit.

Results: At present, 3 patients were enrolled in this study and underwent focal therapy with written informed consents. In all three cases, I-125 seeds implanted (number od seeds: 43, 39, and 37) to unilateral lobe without severe acute complication such as acute urinary retention. In one case that has been followed over 3months among the initial three cases, PSA values decreased to 2.07 mg/ml at 3 months after the seed implantation.

Conclusions: To our knowledge, this is the first report about focal therapy by brachytherapy with hemiablative technique. In our initail experience, severe treatment associated complication has not been observed.

No significant financial relationships to disclose.

C-reactive protein kinetics superior to radiographic response as a surrogate endpoint for survival in patients with advanced renal cell carcinoma

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Background: As cytokines and targeted agents against advanced renal cell carcinoma (aRCC) are considered to achieve high stable disease (SD) rate rather than objective response (OR) by radiographic measurement, we often face the therapeutic dilemma in deciding whether to continue the ongoing treatment and when to change it. Therefore, other valid surrogate endpoints have been desired. We have previously demonstrated C-reactive protein (CRP) kinetics could predict prognosis of pts with aRCC (Eur Urol. 2009:1145-53).

Methods: This study was performed on 56 pts with aRCC (metastatic: 54, unresectable: 2) enrolled in a phase II trial of interferon-alpha, cimetidine, COX-2 inhibitor and renin-angiotensin-system inhibitor (I-CCA; Cancer Sci. in press). CRP levels were measured at pretreatment, thereafter almost every visit. Pts were divided into 3 groups according to CRP kinetics. Pts whose pretreatment CRP levels were < 5 mg/l were assigned to nonelevated group. Pts whose pretreatment CRP levels were > 5 mg/l but normalized (< 5 mg/l) at least one time during I-CCA were assigned to normalized group. Pts whose CRP level never decreased to normal level were assigned to non-normalized group. Radiographic response was assessed by WHO criteria; survivals were estimated by Kaplan–Meier method and prognostic factors were assessed by Cox's proportional hazard model.

Results: Median follow-up was 26 mo. An OR and clinical benefit rate to I-CCA were 20 and 64%, respectively. The median progression-free and overall survival (OS) was 12 and 45 mo, respectively. The median OS was 74, 83 and 13 mo in in non-elevated (n=26), normalized (n=16) and non-normalized (n=14) group, respectively (p<0.0001). Of the 25 pts achieving SD, CRP kinetics was independent prognostic factor for OS (p<0.0001). Of the pts whose pretreatment CRP was elevated, all pts achieving OR had CRP normalization and multivariate analysis revealed CRP normalization was independent prognostic factor for OS (p=0.0008), whereas achieving OR was not (p=0.19).

Conclusions: CRP kinetics compares favorably with objective response to systemic therapy as a valid surrogate endpoint for survival.

No significant financial relationships to disclose.

Does induction chemoradiotherapy compromise subsequent radical cystectomy? A single-institutional comparative study on perioperative complications according to the Clavien-Dindo classification

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Background: Recently, bladder-sparing protocols incorporating TUR + chemoradiotherapy (CRT) have been developed. Patients who achieve CR after CRT are subjects for bladder preservation treatment and those who with non-CR undergo radical cystectomy (RC). However, early studies suggest that RC following pelvic irradiation associates with a higher mortality. To validate the impact of induction CRT on perioperative morbidity of RC, we compared complications of RC in patients treated with or without induction CRT at a single university hospital.

Methods: Records of consecutive 193 patients who underwent RC for bladder cancer between April 1989 and May 2010 were reviewed. Induction CRT consists of radiation at 40 Gy to the small pelvis and 2 cycles of concurrent cisplatin at 20 mg/d for 5 days. Any complications occurred within 30 days after RC were graded according to the Clavien-Dindo classification system. Complications of grade I or II were classified as minor and complications of grade III or greater were classified as major.

Results: Eighty-seven patients underwent induction CRT (CRT group) while 106 did not (control group). Patients of CRT group had significantly more advanced disease. No patient died within 90 days. Twenty one (11%) patients experienced at least one major complications; there was no significant difference in the incidence of major complications between CRT and control group (14% vs. 8%, p = 0.26). The details were as follows; infectious (3.5% vs. 3.8%, p = 1.0), gastrointestinal (4.6% vs. 0.9%, p = 0.18), surgical (6.9% vs. 3.8%, p = 0.35), cardiovascular (1.2% vs. 0.9%, p = 1.0). There was no significant difference between the incidence of minor complications (61% vs. 51%, p = 0.19).

Conclusions: Induction CRT at 40 Gy is unlikely to compromise subsequent RC.

No significant financial relationships to disclose.

Incidence of benign pathologic lesions at nephrectomy for renal masses presumed to be stage I renal cell carcinoma in Japanese patients: Impact of sex, age, and tumor size

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Background: The widespread use of modern imaging techniques has resulted in the increased detection of small, asymptomatic renal tumors. Some recent studies from Western countries have reported that the incidence of benign lesions is approximately 15% in patients undergoing definitive surgery for renal masses presumed to be clinical stage I renal cell carcinoma (RCC). The high level of noncancerous lesions is, to some extent, due to the fact that no imaging feature can accurately distinguish either oncocytoma or lipid-poor angiomyolipma (AML) from RCC. This study attempts to determine the incidence of benign pathologic findings for such renal masses in Asian patients.

Methods: Between 1991 and 2009, 711 consecutive patients (218 women and 493 men) underwent partial (n=206) or radical (n=505) nephrectomy for renal masses presumed to be stage T1N0M0 (T1a/T1b= 503/208) sporadic RCC on preoperative imaging in two Japanese centers. The mean size of the lesions was 3.3 cm (range 0.3-7.0). The pathologic features were reviewed by an experienced pathologist.

Results: Of the 711 masses, 53 (7.5%) revealed benign pathologic findings. Twenty-two (3.1%) were AMLs, 13 (1.8%) were oncocytomas, 8 (1.1%) were complicated cysts, and 10 were others. Twenty-eight (12.8%) of the 218 females and 25 (5.1%) of the 493 males had benign lesions (p=0.0005). Of the 357 patients aged 60 years or younger, 37 (10.4%) had benign lesions while only 16 (4.5%) of the 354 patients over 60 years did (p=0.024). Forty six (9.2%) of the 503 T1a and 7 (3.4%) of the 203 T1b masses were benign (p=0.0071). A multivariate logistic regression model showed that sex, age and tumor size were all independently predictive of benign histology, particularly of AML.

Conclusions: The present incidence (7.5%) of benign lesions in presumed clinical stage T1N0M0 RCC masses at nephrectomy was lower than the incidence of approximately 15% previously reported from Western countries, probably because of the low incidence of oncocytomas in Japanese patients. Female gender, young age and small tumor size are all independently predictive of benign lesions, particularly of AML in Japanese patients.

No significant financial relationships to disclose.