Is the Post-Radical Prostatectomy Gleason Score a Valid Predictor of Mortality after Neoadjuvant Hormonal Treatment?

PURPOSE

To evaluate the validity of the Gleason score after neoadjuvant hormonal treatment as predictor of disease-specific mortality after radical prostatectomy.

PATIENTS AND METHODS

A total of 2,880 patients with a complete data set and a mean follow-up of 10.3 years were studied; 425 of them (15%) had a history of hormonal treatment prior to surgery. The cumulative incidence of deaths from prostate cancer was determined by univariate and multivariate competing risk analysis. Cox proportional hazard models for competing risks were used to study combined effects of the variables on prostate cancer-specific mortality.

RESULTS

A higher portion of specimens with a history of neoadjuvant hormonal treatment were assigned Gleason scores of 8-10 (28 vs. 17%, p < 0.0001). The mortality curves in the Gleason score strata <8 vs. 8-10 were at large congruent in patients with and without neoadjuvant hormonal treatment. In patients with neoadjuvant hormonal treatment, a Gleason score of 8-10 was an independent predictor of prostate cancer-specific mortality; the hazard ratio was, however, somewhat lower than in patients without neoadjuvant hormonal treatment.

CONCLUSION

This study suggests that the prognostic value of the post-radical prostatectomy Gleason score is not meaningfully jeopardized by heterogeneous neoadjuvant hormonal treatment in a routine clinical setting.

Decreased Overall and Bladder Cancer-Specific Mortality with Adjuvant Chemotherapy After Radical Cystectomy: Multivariable Competing Risk Analysis

Adding chemotherapy to radical cystectomy (RC) may improve outcome. Neoadjuvant treatment is advocated by guidelines based on meta-analysis data but is severely underused in clinical practice. Adjuvant treatment of patients at risk could be an alternative. We analyzed a sample of 798 patients who underwent RC between 1993 and 2011 for high-risk superficial or muscle-invasive urothelial or undifferentiated bladder cancer, of which 23% received adjuvant cisplatin-based chemotherapy and %5 received neoadjuvant chemotherapy. The use of adjuvant chemotherapy was an independent predictor of decreased overall mortality (hazard ratio [HR]: 0.50; 95% confidence interval [CI], 0.38-0.66; p<0.0001) and bladder cancer-specific mortality (HR: 0.71; 95% CI, 0.52-0.97; p=0.0321), but it was not associated with competing mortality. Similar figures were obtained when analyzing the number of cisplatin-containing cycles administered or when restricting the analysis to patients with lymph node-positive or extravesical but lymph node-negative disease, suggesting a mortality-reducing treatment effect after adjusting for several patient- and tumor-related confounders. Future trials should directly compare the concepts of neoadjuvant and adjuvant application of chemotherapy in candidates for RC.

PATIENT SUMMARY

Adjuvant chemotherapy may decrease overall and bladder cancer-specific mortality after radical cystectomy (RC). Future trials should directly compare the concepts of neoadjuvant and adjuvant application of chemotherapy in candidates for RC.

Comparison of systematic transrectal biopsy to transperineal magnetic resonance imaging/ultrasound-fusion biopsy for the diagnosis of prostate cancer

OBJECTIVES

To compare targeted, transperineal magnetic resonance imaging (MRI)/ultrasound (US)-fusion biopsy to systematic transrectal biopsy in patients with previous negative or first prostate biopsy and to evaluate the gain in diagnostic information with systematic biopsies in addition to targeted MRI/US-fusion biopsies.

PATIENTS AND METHODS

In all, 263 consecutive patients with suspicion of prostate cancer were investigated. All patients were evaluated by 3-T multiparametric MRI (mpMRI) applying the European Society of Urogenital Radiology criteria. All patients underwent MRI/US-fusion biopsy transperineally (mean nine cores) and additionally a systematic transrectal biopsy (mean 12 cores).

RESULTS

In all, 195 patients underwent repeat biopsy and 68 patients underwent first biopsy. The median age was 66 years, median PSA level was 8.3 ng/mL and median prostate volume was 50 mL. Overall, the prostate cancer detection rate was 52% (137/263). MRI/US-fusion biopsy detected significantly more cancer than systematic prostate biopsy (44% [116/263] vs 35% [91/263]; P = 0.002). In repeat biopsy, the detection rate was 44% (85/195) in targeted and 32% (62/195) in systematic biopsy (P = 0.002). In first biopsy, the detection rate was 46% (31/68) in targeted and 43% (29/68) in systematic biopsy (P = 0.527). In all, 80% (110/137) of biopsy confirmed prostate cancers were clinically significant. For the upgrading of Gleason score, 44% (32/72) more clinically significant prostate cancer was detected by using additional targeted biopsy than by systematic biopsy alone. Conversely, 12% (10/94) more clinically significant cancer was found by systematic biopsy additionally to targeted biopsy.

CONCLUSIONS

MRI/US-fusion biopsy was associated with a higher detection rate of clinically significant prostate cancer while taking fewer cores, especially in patients with prior negative biopsy. Due to a high portion of additional tumours with Gleason score ≥7 detected in addition to targeted biopsy, systematic biopsy should still be performed additionally to targeted biopsy.

Effects of physical activity training in patients with Alzheimer's dementia: results of a pilot RCT study

Background

There is evidence that physical activity (PA) is of cognitive benefit to the ageing brain, but little is known on the effect in patients with Alzheimer’s disease (AD). The present pilot study assessed the effect of a home-based PA training on clinical symptoms, functional abilities, and caregiver burden after 12 and 24 weeks.

Methods

In an RCT thirty patients (aged 72.4±4.3 years) with AD (MMSE: 20.6±6.5 points) and their family caregivers were allocated to a home-based 12-week PA intervention program or the usual care group. The program changed between passive, motor-assisted or active resistive leg training and changes in direction on a movement trainer in order to combine physical and cognitive stimuli.

Results

Analysis of activities of daily living in the patients (ADCS ADL total score) revealed a significant group × time interaction effect (95% CI of the difference between both groups at T2: 5.01–10.51). The control group experienced decreases in ADL performance at week 12 and 24 whereas patients in the intervention group remained stable. Analyses of executive function and language ability revealed considerable effects for semantic word fluency with a group × time interaction (95% CI of the difference between both groups at T2: 0.18–4.02). Patients in the intervention group improved during the intervention and returned to initial performance at week 12 whereas the controls revealed continuous worsening. Analyses of reaction time, hand-eye quickness and attention revealed improvement only in the intervention group. Caregiver burden remained stable in the intervention group but worsened in the control group.

Conclusions

This study suggests that PA in a home-based setting might be an effective and intrinsically attractive way to promote PA training in AD and modulate caregiver burden. The results demonstrate transfer benefits to ADL, cognitive and physical skill in patients with AD.

Trial Registration

ClinicalTrials.gov NCT02196545

Effect of the Precessing Vortex Core on Primary Atomization

The present work is focused on the airblast atomization in a gas turbine model combustor. Swirl flows in such combustion chambers form an inner recirculation zone that can develop a precessing vortex core. This instability affects the velocity field at the exit of the nozzle, where the fuel is atomized. The influence of the precessing vortex core on the airblast atomization is examined in this work. The flow field in the combustion chamber is examined under reacting and non-reacting conditions. The velocity amplitudes under reacting conditions are more than twice as high compared to non-reacting conditions. The influence of the precessing vortex core on the airblast atomization process is examined in detail at an atomization test rig with a perspex nozzle. High speed shadowgraphy and POD analysis have been performed of the liquid film on the prefilmer as well as on the ligaments formed at the atomizing edge. It was observed that although the PVC does affect the liquid film flow of the prefilming surface, it does not affect the breakup into ligaments, i. e. primary atomization.

Lee mortality index as comorbidity measure in patients undergoing radical cystectomy

To investigate the recently described Lee mortality index as predictor of mortality after radical cystectomy.

A total of 735 patients who underwent radical cystectomy for bladder cancer between 1993 and 2010 were studied. Median patient age was 67 years and the median follow-up was 7.8 years (censored patients). The Lee mortality index was assigned based on data derived from patient history, preoperative cardiopulmonary risk assessment and discharge records. The age-adjusted Charlson score and preoperative cardiopulmonary risk assessment classifications were used for comparison. Competing risk analysis and Cox proportional hazard models for competing risks were used for the statistical analysis.

The Lee mortality index predicted competing mortality in a dose–response relationship with somewhat lower 10-year mortality rates than predicted (p = 0.0120). Beside the age-adjusted Charlson score, the Lee mortality index was an independent predictor of overall mortality (hazard ratio per unit increase 1.06, p = 0.0415) and replaced the age-adjusted Charlson score as predictor of competing mortality (hazard ratio (HR) per unit increase 1.27, p < 0.0001). The American Society of Anesthesiologists (ASA) physical status classification was also an independent predictor of overall (HR for ASA 3–4 versus 1–2: 1.53, p = 0.0002) and competing mortality (HR for ASA 3–4 versus 1–2: 1.62, p = 0.0044).

The Lee mortality index is a promising and easily applicable tool to predict competing mortality after radical cystectomy. It is at least equal to the age-adjusted Charlson score and may be supplemented by information provided by the ASA classification.

Growth, structure and morphology of epitaxial Fe(0 0 1) films on GaAs(0 0 1)c(4 × 4)

We studied epitaxy, growth, structure and morphology of thin Fe(0 0 1) films on the As-rich GaAs(0 0 1)-c(4 × 4) surface, deposited by molecular beam epitaxy at growth temperatures between room temperature and 250° C. Electron and x-ray diffraction (XRD) techniques evidence epitaxial growth with Fe(0 0 1)[1 0 0] ∥ GaAs(0 0 1)[1 0 0]. The residual strain derived from the XRD results is consistent with recent stress measurements. Cross-sectional transmission electron microscopy reveals an abrupt interface for room-temperature films and the formation of a ∼10 nm thick crystalline Fe-Ga-As intermediate layer at 250° C. The dependence of the surface morphology on growth temperature and annealing evidences a kinetic roughening of the Fe surface at growth temperatures of 100-200° C due to the presence of step-edge barriers.

‘Green' Synthesis of 2-Substituted 6-Hydroxy-[3H]-pyrimidin-4-ones and 4,6-Dichloropyrimidines: Improved Strategies and Mechanistic Study

An improved route to 2-substituted 6-hydroxy-[3H]-pyrimidin-4-ones 4 and to 2-substituted 4,6-dichloropyrimidines 5 is reported. Without using highly toxic reactants, compounds 4 can be prepared conveniently in a one pot synthesis on a one mol scale with average yields up to 80 %. 4,6-Dichloropyrimidines 5, which are usually prepared in small quantities, are synthesized with average yields of 80 %, using up to 80 g of starting material. The mechanism of the chlorination of 4 is investigated computationally for the first time. The results suggest that the chlorination with phosphoryl chloride occurs in an alternating phosphorylation–chlorination manner (pathway 1) which is preferred over a sequence which starts with two phosphorylations. The investigated 4,6-dichloropyrimidines described herein form strong complexes with dichlorophosphoric acid but weak complexes with hydrochloric acid (generated during workup). These latter complexes explain the necessity of using aqueous sodium carbonate during the working up. In order to prevent possible formation of pyrimidinium salts between intermediates or the final dichloropyrimidines and unreacted hydroxypyrimidone, the latter could be deactivated with a strong acid such as dichlorophosphoric acid, thus allowing chlorination but prohibiting salt formation. Because of its general applicability to all nitrogen heterocycle chlorinations with phosphoryl chloride, the proposed route to dichloropyrimidines without solvent or side products, using less toxic reactants, is of general synthetic interest.

Oximes in the Isoxazolone, Pyrazolone, and 1,2,3-Triazolone Series: Experimental and Computational Investigation of Energies and Structures of E/Z Isomers of α-Oxo-Oximes in the Gas Phase and in Solution

The structures of a series of heterocyclic α-oxo-oximes, viz. 4-oximinoisoxazolone-5(4H)-ones 1 and 2,4-oximino-5(4H)-pyrazolones 3–5, and 4-oximino-1-phenyl-1,2,3-triazol-5(4H)-one 6, were investigated experimentally and computationally. Whereas the intramolecularly H-bonded ZZ isomers of these oximes are usually the most stable in the gas phase, this preference is overcome by intermolecular H-bonding to a solvent or another molecule. For 1,3-dimethyl-4-oximino-5(4H)-pyrazolone 3b a turnaround is seen when going from the solid (predominantly Z isomer) to DMSO solution (predominantly E isomer), which can be ascribed to an intermolecular H-bond between the oxime OH function and a DMSO molecule. Such isomerization is not seen in CDCl3, where intermolecular H-bonding is unimportant. The Z/E-isomerization in DMSO solution is accelerated by photolysis. Calculations of the energies of different conformers, and of 13C NMR data at the GIAO-ωb97xD/6-31G(d)//M06-2X/6-311++G(d,p) level permit a clear-cut correlation of conformer structures with observed 13C NMR spectra.