[Patients with bladder cancer in clinical stage T2 : survival benefit of downstaging in comparison to patients with confirmed muscle invasion in cystectomy specimens]

BACKGROUND

Few and partially contradictory data are available regarding the prognostic signature of downstaging of muscle-invasive clinical tumour stages in patients treated with radical cystectomy.

MATERIALS AND METHODS

Clinicopathological parameters of 1,643 patients (study group, SG) treated with radical cystectomy due to muscle-invasive urothelial bladder cancer were summarized in a multi-institutional database. Patients of the SG fulfilled the following conditions: clinical tumour stage T2 N0 M0 and no administration of neoadjuvant radiation or chemotherapy. Cancer-specific survival (CSS) rates were calculated referring to pathological tumour stages in cystectomy specimens (<pT2, pT2, >pT2) (mean follow-up: 51 months). Furthermore, a multivariable model integrating clinical information was developed in order to predict the probability of downstaging.

RESULTS

A total of 173 patients (10.5%) of the SG presented with downstaging in pathological tumour stages (pT0: 4.8%, pTa: 0.4%, pTis: 1.3%, pT1: 4.1%); 12 of these patients had positive lymph nodes (7%, in comparison with 21% pN+ of pT2 tumours and 43% of >pT2 tumours). Patients with tumour stages <pT2, pT2 and >pT2 had CSS rates after 5 years of 89, 69 and 46%, respectively (p<0.001). In a multivariable Cox model the presence of pathological downstaging resulted in a significant reduction of cancer-specific mortality (HR 0.30; 95% CI 0.18-0.50). By logistic regression analysis the date of TURB (benefit for more recent operations) was identified as the only independent predictor for downstaging of muscle-invasive clinical tumour stages. Age, gender, grading and associated Tis in the TURB did not reveal any significant influence.

CONCLUSION

Patients with muscle-invasive clinical tumour stages and downstaging in cystectomy specimens represent a subgroup with significantly enhanced CSS rates. Further trials that integrate the parameters tumour size, stages cT2a vs cT2b and focality are required in order to define the independent prognostic signature of downstaging of tumour stages more precisely.

[A non-abscess-forming inflammation of the corpora cavernosa in a diabetic patient - case report]

An inflammation of the corpus cavernosum is relatively rare and must be differentiated from a tumour, abscess, thrombosis or embolism of the penile vessels. Most frequently inflammation of the corpus cavernosum is caused by iatrogenic interventions, followed by general infections and acute occlusion of penile vessels. Diabetes mellitus seems to be a predisposing factor. In the case of a 51-year-old diabetic patient with painful induration of the penis, an MR imaging study was undertaken to identify an inflammation of the corpora by exclusion of abscess formation. The inflammation responded well to a two-week oral Fluorchinolon treatment. Due to its high soft-tissue contrast, multiplanar layer images and, the MR scan was performed to identify an inflammation of the corpora cavernosa and to exclude an abscess formation. We consider a therapy with oral antibiotics to be sufficient for a non-abscess-forming cavernitis.

[Abscess-forming retroperitoneal actinomycosis after urogynaecological surgery]

Human actinomycosis is an infrequent chronic infection caused by gram-positive anaerobic bacteria with predominantly cervicofacial and intestinal manifestation. Retroperitoneal abscess formation displays a very rare localisation and is mostly incidentally diagnosed by histological examination. We report on a 44-year-old woman with left-sided flank pain and retroperitoneal abscess formation diagnosed by CT scan. Case history revealed preceding nephroureterectomy of the left kidney due to loss of kidney function and recurrent ureteral-vaginal fistulas. After CT scan-guided puncture and negative bacterial culture, actinomycosis could only be diagnosed by histopathological examination. Subsequently, besides abscess drainage calculated antibiotic therapeutic regimen was initiated. During the follow-up of 9 months there was no local or systemic recurrence. In the present case report, aetiology, clinical symptoms as well as diagnostic and therapeutic consequences are discussed.

[Retroperitoneal bronchogenic cyst treated by laparoscopic surgery]

The diagnosis of primary retroperitoneal cystic tumors is very infrequent in surgical pathology. We report the case of a 51-year-old woman presenting with an incidental left-sided retroperitoneal mass (32 x 24 mm in diameter) suspected of being an adrenal tumor. Intraoperatively the tumor was identified as a cystic lesion filled with mucous secretion and laparoscopically completely resected. The diagnosis was histopathologically confirmed as a bronchogenic cyst. In this article the laparoscopic removal of such a rare benign congenital aberration resulting from an abnormal budding of the tracheobronchial tree is presented.

[Concordance of the Gleason score in prostate multibiopsy and definitive histology]

BACKGROUND

Due to an insufficient mean agreement between the Gleason score (GS) revealed from multibiopsy and definitive histology after radical prostatectomy (RP) of merely about 45 %, a modification of the GS including an elimination of GS 2-4 was -accomplished in 2005. The aim of the present study was to evaluate the concordance of GS and WHO grading in biopsy and definitive histology and to -determine parameters influencing the diagnostic accuracy of the biopsy and the prognosis.

MATERIALS AND METHODS

Within a 10-year-period before modification of the GS, radical prostatectomy was performed in 856 patients (study group, SG; mean age 64.2 years). The grade of agreement between GS and WHO grading in biopsy and definitive histology was calculated by kappa statistics (kappa) (for the complete and single time -periods). Furthermore, we assessed the univariable and multivariable influence of different preoperatively available parameters on disease-free survival (DFS). The mean follow-up period was 39 months (range: 10-139 months).

RESULTS

Undergrading of GS and WHO grading decreased continuously within the three time -periods in favour of a higher agreement regarding the histological results revealed from biopsy and definitive histology. However, we found only a poor to moderate agreement in the complete time period (kappa values of 0.354 for GS and 0.404 for WHO grading) that - with regard to both parameters - was improved by an increased number of biopsy cores taken. PSA value, clinical -tumour stage, number of positive cores (dichotomised at 34 %), annual RP case load (dichotomised at 75), and GS revealed an independent significant influence on DFS. Patients with GS 2-4 in the biopsy exhibited an upgrade to GS > or = 7 in only 5.7 %, and -showed, -independent of the definitive histology, a significantly better prognosis in comparison with patients presenting with a higher GS.

CONCLUSIONS

The results of the present study again suggest the independent prognostic impact of the GS revealed from biopsy. However, the concordance with the GS in the definitive histology remains deficient and is improvable by taking a higher number of biopsy cores. Although the elimination of GS 2-4 might be comprehensible for the pathologist's purpose, it results in a considerable loss of pretherapeutic prognostic information.

Towards a combined prognostic index for survival in HIV infection: the role of 'non-HIV' biomarkers

BACKGROUND

As those with HIV infection live longer, 'non-AIDS' condition associated with immunodeficiency and chronic inflammation are more common. We ask whether 'non-HIV' biomarkers improve differentiation of mortality risk among individuals initiating combination antiretroviral therapy (cART).

METHODS

Using Poisson models, we analysed data from the Veterans Aging Cohort Study (VACS) on HIV-infected veterans initiating cART between 1 January 1997 and 1 August 2002. Measurements included: HIV biomarkers (CD4 cell count, HIV RNA and AIDS-defining conditions); 'non-HIV' biomarkers (haemoglobin, transaminases, platelets, creatinine, and hepatitis B and C serology); substance abuse or dependence (alcohol or drug); and age. Outcome was all cause mortality. We tested the discrimination (C statistics) of each biomarker group alone and in combination in development and validation data sets, over a range of survival intervals, and adjusting for missing data.

RESULTS

Of veterans initiating cART, 9784 (72%) had complete data. Of these, 2566 died. Subjects were middle-aged (median age 45 years), mainly male (98%) and predominantly black (51%). HIV and 'non-HIV' markers were associated with each other (P < 0.0001) and discriminated mortality (C statistics 0.68-0.73); when combined, discrimination improved (P < 0.0001). Discrimination for the VACS Index was greater for shorter survival intervals [30-day C statistic 0.86, 95% confidence interval (CI) 0.80-0.91], but good for intervals of up to 8 years (C statistic 0.73, 95% CI 0.72-0.74). Results were robust to adjustment for missing data.

CONCLUSIONS

When added to HIV biomarkers, 'non-HIV' biomarkers improve differentiation of mortality. When evaluated over similar intervals, the VACS Index discriminates as well as other established indices. After further validation, the VACS Index may provide a useful, integrated risk assessment for management and research.

[The significance of rebiopsy in the diagnosis of prostate cancer]

OBJECTIVE

The objective of this study was to evaluate whether rebiopsy of the prostate leads to a significant increase in the detection rate of prostate cancer compared with performing a single biopsy.

METHODS

Data from 406 patients were evaluated retrospectively. The patients had undergone ultrasound-guided transrectal biopsy of the prostate between January 2004 and August 2005. Besides demographic data, the patient information was reviewed with regard to the number of biopsy samples taken per patient, histological results, and the occurrence of complications during or after the examination. If prostate cancer was detected, data acquisition included the number of positive biopsy samples taken per examination as well as the subsequent therapy and the TNM classification of the tumor. After a follow-up time between 24 and 42 months, all patients with a histologically negative first biopsy were reevaluated regarding rebiopsy. We evaluated the follow-up time (in months) and the histological results. If prostate cancer was detected, we assessed the number of positive biopsy cores as well as the subsequent therapy and the TNM classification.

RESULTS

In 37.7% of all patients (n=153), prostate cancer was detected in the first biopsy. In 56.9% of these (n=87), a high-grade carcinoma with a Gleason score >or=7 was diagnosed. In 108 patients, a second biopsy was performed. The mean time between the first biopsy and rebiopsy was 21.7 months (range 1.3-41.2 months). With the second biopsy, prostate cancer was detected in 29 cases (26.9%), of which 51.7% (n=15) showed a high-grade carcinoma. There was no significant difference between the first biopsy and the second biopsy concerning either the detection rate of carcinomas related to the total number of transrectal multibiopsies or the detection of high-grade carcinomas related to the number of detected carcinomas. Provided that values beyond the second standard deviation were excluded from analysis, prostate-specific antigen (PSA) values at the time of rebiopsy were significant elevated compared with PSA values at the time of first biopsy. More than two-thirds of all patients with a histologically positive result in the second biopsy revealed a PSA velocity >or=0.6 ng/ml/year. Furthermore, there was no significance between the number of histologically positive samples per multibiopsy when prostate cancer was diagnosed in the first biopsy compared with the number of positive samples in the second biopsy. Complications after biopsy were noted in 19 patients. In three cases, hospitalization was necessary.

CONCLUSION

As a result of performing a rebiopsy, the detection rate of prostate cancer increased significantly compared with the detection rate after a single biopsy. Thus, the number of patients who could receive therapy was also increased. Due to the relatively low complication rate of prostate multibiopsy, this examination can be widely indicated. There was not a higher detection rate of high-grade prostate cancer in the second biopsy compared with performing only a single biopsy. The indication for a second biopsy as well as the determination of the time interval between the first and second biopsy should consider the current PSA value and PSA dynamics. Therapeutic consequences should also be taken into consideration. In the event of a PSA velocity >0.6 ng/ml/year, a rebiopsy should definitely be performed.

[Value of radical oncological surgery in bilateral synchronous renal cell cancer and coincidental simultaneous prostate cancer]

To date, the current literature does not report on oncological surgery in bilateral renal cell cancer and coincidental simultaneous prostate cancer. We present the case of a 66-year-old patient presenting as a challenge due to this oncological-surgical constellation. Based on the present case study and the postoperative follow-up, we discuss possible surgical strategies and demonstrate that, even in the case of multiple tumour locations, a satisfying oncological and functional long-term result is achievable.

Socio-demographic factors predict the likelihood of not returning home after hospital admission following a fall

BACKGROUND

Falls in older people result in a substantial use of resources in the NHS and care homes. One way to reduce the burden would be to identify the factors associated with the likelihood of being discharged to a care home rather than being discharged home after fall-related hospitalization. We investigate the associations between discharge destination after fall-related hospital admission with ecological factors (area deprivation, ethnicity and rurality) and individual level factors (age, gender and co-morbidities).

METHODS

We extracted data for patients aged over 50 admitted from their 'usual residence' with a fall-related diagnosis from the Hospital Episode Statistics (HES) database.

RESULTS

Increasing age, people with severe co-morbidities and people who live in less deprived, predominantly white or rural areas, were more likely to be discharged to a different residence (all P-values < 0.001). We estimated that 88.3% of people from an area classified as most deprived, urban and >5% Asian would return home, compared with 78.0% from least deprived, village/isolated and all white area.

CONCLUSION

Further research is required to examine whether these patterns reflect appropriate care or alternatively that some sub-groups of society have less access to care homes than others. These factors may have public health implications for the equitable allocation of budgets for the provision of care for elderly patients discharged from hospital after a fall.

Significance of the time period between diagnosis of muscle invasion and radical cystectomy with regard to the prognosis of transitional cell carcinoma of the urothelium in the bladder

OBJECTIVE

Standard treatment of muscle-infiltrated transitional cell carcinoma (TCC) of the urothelium consists of radical cystectomy. In some cases there is a delay between the initial diagnosis and a definitive treatment being administered. The objective of this study was to determine the effect of the time window between evidence of muscle invasion and radical cystectomy on the pathological stage and progression-free survival.

MATERIAL AND METHODS

Between February 1992 and August 2002, 239 radical cystectomies were carried out as a result of TCC of the bladder. In a total of 189 patients (79%), cystectomy was carried out due to muscle-infiltrated TCC with no evidence of distant metastases (>/=T2, M0). The time between the diagnosis of muscle invasion and cystectomy was determined for all of these patients, who were then divided into two groups on the basis of a 3-month cut-off period. Univariate and multivariate analyses were used to determine the effect of the time period on clinical factors and progression-free survival.

RESULTS

The average age of the patients was 63 (range 35-80) years. A median follow-up of 40 months showed a progression-free survival rate of 49% after 5 years. The average time between the diagnosis of muscle invasion and cystectomy was 1.8 (0.3-12.1) months. For a time window of >3 months, 30/42 patients (72%) showed signs of extravesical tumor growth and/or tumor-positive lymph nodes, compared to 89/147 patients (60%) (p = 0.198) for a time window of </=3 months. In terms of the distribution of tumor stages according to the time groups, there were significantly more pT4 stage tumors in patients with delayed cystectomy (p = 0.009). Patients with a time interval of </=3 months between diagnosis of muscle invasion and cystectomy had a significantly better progression-free survival rate (55%) than those with a longer time window (34%) (p = 0.04). In contrast to lymph node status, clinical stage, pathological tumor stage and differentiation level, the prognostic relevance of the time window fell just short of the significance level in Cox's multivariate regression analysis (p = 0.057). Lymph node status (p < 0.001) and pathological tumor stage (p = 0.05) were the only independent prognostic parameters which could be used to predict progression-free survival.

CONCLUSION

Patients with a time window of >3 months between diagnosis of muscle invasion and radical cystectomy were associated with an advanced pathological stage and a poorer progression-free survival. These results underline the need for early cystectomy within the 3-month period between diagnosis of muscle invasion and cystectomy.

[Rare tumor of the epididymis]

A 51-year-old man with known ethyl toxic chronic pancreatitis presented with a tumor of the left epididymis. Immunohistological examination disclosed it as a metastasis of a pancreatic carcinoma. Paratesticular metastases of a pancreatic carcinoma are very rare. Nevertheless a metastasis of a primary pancreatic carcinoma should be included in the differential diagnosis of a tumor of the paratesticular tissue. The epididymis should be integrated in the diagnostic procedures of pancreatic carcinoma.