281 Impact of Using Risk Communication Tools in Counselling Patients with Newly Diagnosed Non-Metastatic Prostate Cancer

Introduction

There have been substantial advances in risk communication tools that help patients understand prognosis associated with prostate cancer and the benefit/gain from treatment. Over the last three years, two tools; Cambridge Prognostic Groups (CPG), and Predict Prostate (https://prostate.predict.nhs.uk), along with decision-making consultations with clinical nurse specialists (CNS) have been integrated into the new diagnosis pathway in our unit.

Method

Treatment decisions for patients with new non-metastatic prostate cancer were audited after (2019–2020) and before (2016–2017) new risk communication tools were implemented. Data were compared between the two time periods and also benchmarked against national level data from the National Prostate Cancer Audit (NPCA) (Parry et al 2020; PMID: 32460859). The main outcome measured was comparison of rates of over and under-treatment of disease.

Results

168 and 95 patients were included in the 2019–2020 and 2016–2017 cohorts, respectively. Following implementation there was a reduction in over-treatment (use of radical surgery/radiotherapy) in patients with low risk/CPG1 (23% to 4%). These rates were also better than the national average from NPCA data (4% vs 11%). In parallel, there was an increase in use of radical treatment (reduced under-treatment) in high risk and very high-risk/CPG4-5 disease (84% vs 73%). Again, these rates were also superior to national level data from the NPCA (84% vs 76%).

Conclusions

Incorporating personalised risk-communication tools and dedicated CNS counselling in our unit has reduced over-treatment of early disease and under-treatment of advanced disease. Wider uptake could enhance risk-appropriate treatment of patients with a new prostate cancer diagnosis.

Pathological complete response due to a prolonged time interval between preoperative chemoradiation and surgery in locally advanced rectal cancer: analysis from the German StuDoQ|Rectalcarcinoma registry

Background

Preoperative chemoradiotherapy is the recommended standard of care for patients with local advanced rectal cancer. However, it remains unclear, whether a prolonged time interval to surgery results in an increased perioperative morbidity, reduced TME quality or better pathological response. Aim of this study was to determine the time interval for best pathological response and perioperative outcome compared to current recommended interval of 6 to 8 weeks.

Methods

This is a retrospective analysis of the German StuDoQ|Rectalcarcinoma registry. Patients were grouped for the time intervals of “less than 6 weeks”, “6 to 8 weeks”, “8 to 10 weeks” and “more than 10 weeks”. Primary endpoint was pathological response, secondary endpoint TME quality and complications according to Clavien-Dindo classification.

Results

Due to our inclusion criteria (preoperative chemoradiation, surgery in curative intention, M0), 1.809 of 9.560 patients were suitable for analysis. We observed a trend for increased rates of pathological complete response (pCR: ypT0ypN0) and pathological good response (pGR: ypT0-1ypN0) for groups with a prolonged time interval which was not significant. Ultimately, it led to a steady state of pCR (16.5%) and pGR (22.6%) in “8 to 10” and “more than 10” weeks. We were not able to observe any differences between the subgroups in perioperative morbidity, proportion of rectal extirpation (for cancer of the lower third) or difference in TME quality.

Conclusion

A prolonged time interval between neoadjuvant chemoradiation can be performed, as the rate of pCR seems to be increased without influencing perioperative morbidity.

[Selection criteria for neoadjuvant chemoradiotherapy of rectal cancer : Neoadjuvant therapy even for locally advanced colon cancer?]

During the last two decades a neoadjuvant treatment concept has been established for an increasing number of malignant tumors of the gastrointestinal tract; however, these concepts are still subject to a constant change concerning the indications and type of treatment. A prime example for this is rectal cancer. The rate of local recurrence in particular was significantly reduced by neoadjuvant therapy but until now it has not been possible to validly show an improvement in overall or disease-free survival. At the beginning of the millennium it was recommended to treat every rectal carcinoma in UICC stages II and III with neoadjuvant therapy, independent of the height localization. In the meantime this has increasingly been relativized and only locally advanced tumors of the middle and lower thirds of the rectum should be pretreated, whereas tumors of the upper third of the rectum should basically be treated in the same way as colon cancer. It is to be expected that there will be further differentiation concerning the indications in this context in the future mainly based on a preoperative magnetic resonance imaging (MRI) examination. At the same time, initial studies for colon cancer show that neoadjuvant chemotherapy can be beneficial and that an optimized computed tomography (CT) scan can be a worthwhile tool with respect to pretherapeutic stratification of patients.

Nationwide in-hospital mortality rate following rectal resection for rectal cancer according to annual hospital volume in Germany

Background

The impact of hospital volume after rectal cancer surgery is seldom investigated. This study aimed to analyse the impact of annual rectal cancer surgery cases per hospital on postoperative mortality and failure to rescue.

Methods

All patients diagnosed with rectal cancer and who had a rectal resection procedure code from 2012 to 2015 were identified from nationwide administrative hospital data. Hospitals were grouped into five quintiles according to caseload. The absolute number of patients, postoperative deaths and failure to rescue (defined as in‐hospital mortality after a documented postoperative complication) for severe postoperative complications were determined.

Results

Some 64 349 patients were identified. The overall in‐house mortality rate was 3·9 per cent. The crude in‐hospital mortality rate ranged from 5·3 per cent in very low‐volume hospitals to 2·6 per cent in very high‐volume centres, with a distinct trend between volume categories (P < 0·001). In multivariable logistic regression analysis using hospital volume as random effect, very high‐volume hospitals (53 interventions/year) had a risk‐adjusted odds ratio of 0·58 (95 per cent c.i. 0·47 to 0·73), compared with the baseline in‐house mortality rate in very low‐volume hospitals (6 interventions per year) (P < 0·001). The overall postoperative complication rate was comparable between different volume quintiles, but failure to rescue decreased significantly with increasing caseload (15·6 per cent after pulmonary embolism in the highest volume quintile versus 38 per cent in the lowest quintile; P = 0·010).

Conclusion

Patients who had rectal cancer surgery in high‐volume hospitals showed better outcomes and reduced failure to rescue rates for severe complications than those treated in low‐volume hospitals.

Targeting bromodomain-containing protein 4 (BRD4) inhibits MYC expression in colorectal cancer cells

The transcriptional regulator BRD4 has been shown to be important for the expression of several oncogenes including MYC. Inhibiting of BRD4 has broad antiproliferative activity in different cancer cell types. The small molecule JQ1 blocks the interaction of BRD4 with acetylated histones leading to transcriptional modulation. Depleting BRD4 via engineered bifunctional small molecules named PROTACs (proteolysis targeting chimeras) represents the next-generation approach to JQ1-mediated BRD4 inhibition. PROTACs trigger BRD4 for proteasomale degradation by recruiting E3 ligases. The aim of this study was therefore to validate the importance of BRD4 as a relevant target in colorectal cancer (CRC) cells and to compare the efficacy of BRD4 inhibition with BRD4 degradation on downregulating MYC expression. JQ1 induced a downregulation of both MYC mRNA and MYC protein associated with an antiproliferative phenotype in CRC cells. dBET1 and MZ1 induced degradation of BRD4 followed by a reduction in MYC expression and CRC cell proliferation. In SW480 cells, where dBET1 failed, we found significantly lower levels of the E3 ligase cereblon, which is essential for dBET1-induced BRD4 degradation. To gain mechanistic insight into the unresponsiveness to dBET1, we generated dBET1-resistant LS174t cells and found a strong downregulation of cereblon protein. These findings suggest that inhibition of BRD4 by JQ1 and degradation of BRD4 by dBET1 and MZ1 are powerful tools for reducing MYC expression and CRC cell proliferation. In addition, downregulation of cereblon may be an important mechanism for developing dBET1 resistance, which can be evaded by incubating dBET1-resistant cells with JQ1 or MZ1.

[Incidental finding of mucinous neoplasia of the appendix : Treatment strategies]

Tumors of the appendix are not a uniform group but differ significantly in terms of their origin/histology and metastatic behavior. Furthermore, tumors of the appendix are often diagnosed as incidental findings after appendectomy for acute appendicitis. A subgroup of these neoplasms are low-grade appendiceal mucinous neoplasms (LAMN). These are mucus-forming tumors of the appendiceal lumen, which can lead to rupture of the appendix and seeding into the abdominal cavity. Therefore LAMN are considered precursors of pseudomyxoma peritonei (PMP). It is essential to clearly differentiate the subgroups of LAMN as well as the resection status. According to this it is determined whether (radical) appendectomy is a sufficient therapy or further treatment, such as ileocecal resection with hyperthermic intraperitoneal chemotherapy (HIPEC) or cytoreductive surgery (CRS) is necessary. There is no standardized concept regarding the follow-up after resection of LAMN. Generally, it is recommended to perform a computed tomography (CT) scan of the abdomen and determination of tumor markers 6 months postoperatively and then once a year. A recommendation regarding the duration of follow-up is difficult as there are case reports in which PMP has occurred more than 15 years after removal of LAMN.

Laparoscopic versus open right hemicolectomy in colon carcinoma: A propensity score analysis of the DGAV StuDoQ|ColonCancer registry

Objective

To assess whether laparoscopy has any advantages over open resection for right-sided colon cancer.

Summary background data

Right hemicolectomy can be performed using either a conventional open or a minimally invasive laparoscopic technique. It is not clear whether these different access routes differ with regard to short-term postoperative outcomes.

Methods

Patients documented in the German Society for General and Visceral Surgery StuDoQ|ColonCancer registry who underwent right hemicolectomy were analyzed regarding early postoperative complications according to Clavien-Dindo (primary endpoint), operation (OP) time, length of postoperative hospital stay (LOS), MTL30 and number of lymph nodes retrieved (secondary endpoints).

Results

A total of 4.997 patients were identified as undergoing oncological right hemicolectomy without additional interventions. Of these, 4.062 (81.3%) underwent open, 935 (18.7%) laparoscopic surgery. Propensity score analysis showed a significantly shorter LOS (OR: 0.55 CI 95%0.47-.64) and a significantly longer OP time (OR2.32 CI 1.98–2.71) for the laparoscopic route. Risk factors for postoperative complications, anastomotic insufficiency, ileus, reoperation and positive MTL30 were higher ASA status, higher age and increasing BMI. The surgical access route (open / lap) had no influence on these factors, but the laparoscopic group did have markedly fewer lymph nodes retrieved.

Conclusion

The present registry-based analysis could detect no relevant advantages for the minimally invasive laparoscopic access route. Further oncological analyses are needed to clarify the extent to which the smaller lymph node harvest in the laparoscopic group is accompanied by a poorer oncological outcome.

Nationwide in-hospital mortality following colonic cancer resection according to hospital volume in Germany

Background

Colonic cancer is the most common cancer of the gastrointestinal tract. The aim of this study was to determine mortality rates following colonic cancer resection and the effect of hospital caseload on in‐hospital mortality in Germany.

Methods

Patients admitted with a diagnosis of colonic cancer undergoing colonic resection from 2012 to 2015 were identified from a nationwide registry using procedure codes. The outcome measure was in‐hospital mortality. Hospitals were ranked according to their caseload for colonic cancer resection, and patients were categorized into five subgroups on the basis of hospital volume.

Results

Some 129 196 colonic cancer resections were reviewed. The overall in‐house mortality rate was 5·8 per cent, ranging from 6·9 per cent (1775 of 25 657 patients) in very low‐volume hospitals to 4·8 per cent (1239 of 25 825) in very high‐volume centres (P < 0·001). In multivariable logistic regression analysis the risk‐adjusted odds ratio for in‐house mortality was 0·75 (95 per cent c.i. 0·66 to 0·84) in very high‐volume hospitals performing a mean of 85·0 interventions per year, compared with that in very low‐volume hospitals performing a mean of only 12·7 interventions annually, after adjustment for sex, age, co‐morbidity, emergency procedures, prolonged mechanical ventilation and transfusion.

Conclusion

In Germany, patients undergoing colonic cancer resections in high‐volume hospitals had with improved outcomes compared with patients treated in low‐volume hospitals.

Comparison of conventional access routes for right hemicolectomy in colon cancer-data from the DGAV StuDoQ registry

BACKGROUND

Access for right hemicolectomy can be gained by median or transverse incision laparotomy. It is not known whether these routes differ with regard to short-term postoperative outcomes.

METHODS

Patients in the DGAV StuDoQ|ColonCancer registry who underwent open oncological right hemicolectomy by median (n = 2389) or transverse laparotomy (n = 1311) were compared regarding Clavien-Dindo classification (CDC) complications (primary endpoint) as well as specific postoperative complications, operation time, length of stay, and MTL30 status (secondary endpoints).

RESULTS

A total of 3700 StuDoQ registry patients underwent open oncological right hemicolectomy by median (n = 2389) or transverse laparotomy (n = 1311) without additional interventions. The median and transverse access routes did not differ regarding CDC complication rates (CDC &gt; =3a: 13.1% vs. 12.6%; p = 0.90). However, univariate and multivariate analyses showed that operation times (OR 0.71, 95% CI 0.62-0.81; p &lt; 0.001), length of stay (OR 0.69, 95% CI 0.6-079; p &lt; 0.001), and MTL30 (OR 0.7, 95% CI 0.61-0.81, p &lt; 0.001) were significantly reduced in the transverse laparotomy group.

CONCLUSIONS

For oncological right hemicolectomy, open transverse upper abdominal laparotomy appears to be superior to median laparotomy in short-term course.

Effects of anastomotic technique on early postoperative outcome in open right-sided hemicolectomy

Background

Despite recent improvements in colonic cancer surgery, the rate of anastomotic leakage after right hemicolectomy is still around 6–7 per cent. This study examined whether anastomotic technique (handsewn or stapled) after open right hemicolectomy for right‐sided colonic cancer influences postoperative complications.

Methods

Patient data from the German Society for General and Visceral Surgery (StuDoQ) registry from 2010 to 2017 were analysed. Univariable and multivariable analyses were performed. The primary endpoint was anastomotic leakage; secondary endpoints were postoperative ileus, complications and length of postoperative hospital stay (LOS).

Results

A total of 4062 patients who had undergone open right hemicolectomy for colonic cancer were analysed. All patients had an ileocolic anastomosis, 2742 handsewn and 1320 stapled. Baseline characteristics were similar. No significant differences were identified in anastomotic leakage, postoperative ileus, reoperation rate, surgical‐site infection, LOS or death. The stapled group had a significantly shorter duration of surgery and fewer Clavien–Dindo grade I–II complications. In multivariable logistic regression analysis, ASA grade and BMI were found to be significantly associated with postoperative complications such as anastomotic leakage, postoperative ileus and reoperation rate.

Conclusion

Handsewn and stapled ileocolic anastomoses for open right‐sided colonic cancer resections are equally safe. Stapler use was associated with reduced duration of surgery and significantly fewer minor complications.

Laparoscopic right-sided colon resection for colon cancer-has the control group so far been chosen correctly?

Background

The treatment strategies for colorectal cancer located in the right side of the colon have changed dramatically during the last decade. Due to the introduction of complete mesocolic excision (CME) with central ligation of the vessels and systematic lymph node dissection, the long-term survival of affected patients has increased significantly. It has also been proposed that right-sided colon resection can be performed laparoscopically with the same extent of resection and equal long-term results.

Methods

A retrospective evaluation of a prospectively expanded database on right-sided colorectal cancer or adenoma treated at the University Hospital of Wuerzburg between 2009 and 2016 was performed. All patients underwent CME. This data was analyzed alone and in comparison to the published data describing laparoscopic right-sided colon resection for colon cancer.

Results

The database contains 279 patients, who underwent right-sided colon resection due to colorectal cancer or colorectal adenoma (255 open; 24 laparoscopic). Operation data (time, length of stay, time on ICU) was equal or superior to laparoscopy, which is comparable to the published results. Surprisingly, the surrogate parameter for correct CME (the number of removed lymph nodes) was significantly higher in the open group. In a subgroup analysis only including patients who were feasible for laparoscopic resection and had been operated with an open procedure by an experienced surgeon, operation time was significantly shorter and the number of removed lymph nodes is significantly higher in the open group.

Conclusion

So far, several studies demonstrate that laparoscopic right-sided colon resection is comparable to open resection. Our data suggests that a consequent CME during an open operation leads to significantly more removed lymph nodes than in laparoscopically resected patients and in several so far published data of open control groups from Europe. Further prospective randomized trials comparing the long-term outcome are urgently needed before laparoscopy for right-sided colon resection can be recommended ubiquitously.

Sub-differentiating equivocal PI-RADS-3 lesions in multiparametric magnetic resonance imaging of the prostate to improve cancer detection

PURPOSE

To evaluate sub-differentiation of PI-RADS-3 prostate lesions using pre-defined T2- and diffusion-weighted (DWI) MRI criteria, to aid the biopsy decision process.

METHODS

143 patients with PIRADS-3 index lesions on MRI underwent targeted transperineal-MR/US fusion biopsy. Radiologists with 2 and 7-years experience performed blinded retrospective second-reads using set criteria and assigned biopsy recommendations. Inter-reader agreement, Gleason score (GS), positive (PPV) predictive values (±95% confidence intervals) were calculated and compared by Fisher's exact test with Bonferroni-Hom correction.

RESULTS

43% (61/143) patients had GS 6-10 and 21% (30/143) GS≥3+4 cancer. For peripheral zone lesions, significant differences in any cancer detection were found for shape (0.26±0.13 geographical vs. 0.69±0.23 rounded; p=0.0055) and ADC (mild 0.21±0.12 vs marked 0.81±0.19; p=0.0001). For transition zone, significantly increased cancer detection was shown for location (anterior 0.63±0.15 vs. mid/posterior 0.31±0.14; p=0.0048), border (pseudo-capsule 0.32±0.14 vs. ill-defined 0.61±0.15; p=0.0092), and ADC (mild 0.35±0.12 vs marked restriction 0.68±0.17; p=0.0057). Biopsy recommendations had 62% inter-reader agreement (89/143). Experienced reader PPVs were significantly higher for any cancer with "biopsy-recommended" 0.61±0.11 vs. "no biopsy" 0.21±0.10 (p=0.0001), and for GS 7-10 cancers: 0.32±0.10 vs. 0.08±0.07, respectively (p=0.0003).

CONCLUSION

Identification of certain objective imaging criteria as well as a subjective biopsy recommendation from an experienced radiologist can help to increase the predictive value of equivocal prostate lesions and inform the decision making process of whether or not to biopsy.

Impact of adjuvant chemotherapy after neoadjuvant radio- or radiochemotherapy for patients with locally advanced rectal cancer

BACKGROUND

Due to its primarily extraperitoneal location, potential affection of the anorectal continence and different metastatic behavior the rectal carcinoma (RC) is classified and treated as an independent disease. Over the past few decades various trials have led to improved multimodal therapies (including radiation, chemotherapy and surgery) for locally advanced rectal cancer and significant changes in the management of this disease whereas the benefit of adjuvant chemotherapy remains unclear.

METHODS

Based on a prospective tumor register of the University Hospital of Wuerzburg data of 263 patients having undergone neoadjuvant therapy and surgical resection for locally advanced rectal cancer were retrieved from the Wuerzburg International database (WID) between October 1992 and September 2013 analyzing the overall survival according to the application of an adjuvant therapy.

RESULTS

The cohort consisted of 263 patients with a median age of 65 years (27-89 years), mostly male gender (n = 191; 72.6%) and an ASA performance score of II or III. 143 patients (54.3%) received an adjuvant therapy. Those patients have been significant younger (median 10 years; p < 0.05) and in a better general condition (ASA-score; p < 0.05). The tumor specific overall survival of adjuvant treated patients was significant better (5-years overall-survival 87.4%; p = 0.025) than the surveillance group. In the performed subgroup analysis no significant differences in overall survival according to the kind of neoadjuvant therapy (radiation vs. radiochemotherapy) have been found whereas patients in lower UICC-stages (ypUICC 0 + I) had a significant benefit by receiving a postoperative chemotherapy (p = 0.035).

CONCLUSION

We considered patients with locally advanced rectal cancer have a significant benefit in overall survival by receiving an adjuvant chemotherapy especially in lower pathological tumor stage (ypUICC 0 + I). Especially because of the heterogeneity of our study population prospective randomized trials are necessary to determine the impact of adjuvant chemotherapy for locally advanced rectal cancer.

The Prostate Health Index adds predictive value to multi-parametric MRI in detecting significant prostate cancers in a repeat biopsy population

Both multi-parametric MRI (mpMRI) and the Prostate Health Index (PHI) have shown promise in predicting a positive biopsy in men with suspected prostate cancer. Here we investigated the value of combining both tests in men requiring a repeat biopsy. PHI scores were measured in men undergoing re-biopsy with an mpMRI image-guided transperineal approach (n = 279, 94 with negative mpMRIs). The PHI was assessed for ability to add value to mpMRI in predicting all or only significant cancers (Gleason ≥7). In this study adding PHI to mpMRI improved overall and significant cancer prediction (AUC 0.71 and 0.75) compared to mpMRI + PSA alone (AUC 0.64 and 0.69 respectively). At a threshold of ≥35, PHI + mpMRI demonstrated a NPV of 0.97 for excluding significant tumours. In mpMRI negative men, the PHI again improved prediction of significant cancers; AUC 0.76 vs 0.63 (mpMRI + PSA). Using a PHI≥35, only 1/21 significant cancers was missed and 31/73 (42%) men potentially spared a re-biopsy (NPV of 0.97, sensitivity 0.95). Decision curve analysis demonstrated clinically relevant utility of the PHI across threshold probabilities of 5-30%. In summary, the PHI adds predictive performance to image-guided detection of clinically significant cancers and has particular value in determining re-biopsy need in men with a negative mpMRI.

Utilization of multiparametric prostate magnetic resonance imaging in clinical practice and focal therapy: report from a Delphi consensus project

Purpose

To codify the use of multiparametric magnetic resonance imaging (mpMRI) for the interrogation of prostate neoplasia (PCa) in clinical practice and focal therapy (FT).

Methods

An international collaborative consensus project was undertaken using the Delphi method among experts in the field of PCa. An online questionnaire was presented in three consecutive rounds and modified each round based on the comments provided by the experts. Subsequently, a face-to-face meeting was held to discuss and finalize the consensus results.

Results

mpMRI should be performed in patients with prior negative biopsies if clinical suspicion remains, but not instead of the PSA test, nor as a stand-alone diagnostic tool or mpMRI-targeted biopsies only. It is not recommended to use a 1.5 Tesla MRI scanner without an endorectal or pelvic phased-array coil. mpMRI should be performed following standard biopsy-based PCa diagnosis in both the planning and follow-up of FT. If a lesion is seen, MRI-TRUS fusion biopsies should be performed for FT planning. Systematic biopsies are still required for FT planning in biopsy-naïve patients and for patients with residual PCa after FT. Standard repeat biopsies should be taken during the follow-up of FT. The final decision to perform FT should be based on histopathology. However, these consensus statements may differ for expert centers versus non-expert centers.

Conclusions

The mpMRI is an important tool for characterizing and targeting PCa in clinical practice and FT. Standardization of acquisition and reading should be the main priority to guarantee consistent mpMRI quality throughout the urological community.

Electronic supplementary material

The online version of this article (doi:10.1007/s00345-016-1932-1) contains supplementary material, which is available to authorized users.

Standardization of definitions in focal therapy of prostate cancer: report from a Delphi consensus project

PURPOSE

To reach standardized terminology in focal therapy (FT) for prostate cancer (PCa).

METHODS

A four-stage modified Delphi consensus project was undertaken among a panel of international experts in the field of FT for PCa. Data on terminology in FT was collected from the panel by three rounds of online questionnaires. During a face-to-face meeting on June 21, 2015, attended by 38 experts, all data from the online rounds were reviewed and recommendations for definitions were formulated.

RESULTS

Consensus was attained on 23 of 27 topics; Targeted FT was defined as a lesion-based treatment strategy, treating all identified significant cancer foci; FT was generically defined as an anatomy-based (zonal) treatment strategy. Treatment failure due to the ablative energy inadequately destroying treated tissue is defined as ablation failure. In targeting failure the energy is not adequately applied to the tumor spatially and selection failure occurs when a patient was wrongfully selected for FT. No definition of biochemical recurrence can be recommended based on the current data. Important definitions for outcome measures are potency (minimum IIEF-5 score of 21), incontinence (new need for pads or leakage) and deterioration in urinary function (increase in IPSS >5 points). No agreement on the best quality of life tool was established, but UCLA-EPIC and EORTC-QLQ-30 were most commonly supported by the experts. A complete overview of statements is presented in the text.

CONCLUSION

Focal therapy is an emerging field of PCa therapeutics. Standardization of definitions helps to create comparable research results and facilitate clear communication in clinical practice.

Hexaminolevulinate-induced fluorescence colonoscopy versus white light endoscopy for diagnosis of neoplastic lesions in the colon

BACKGROUND AND STUDY AIMS

To compare the rate of detection of colorectal neoplastic lesions using the selective photosensitizer precursor hexaminolevulinate (HAL) combined with a new fluorescence video endoscope system against that of standard white light endoscopy, and secondarily, to evaluate the safety profile of HAL-induced fluorescence colonoscopy.

PATIENTS AND METHODS

This prospective phase II clinical pilot study from two hospital study centers included 25 patients with known or highly suspected colorectal neoplasia. They underwent sensitization with locally applied 500 ml HAL enemas at a concentration of 1.6 mmol/L. At 60 minutes after enteral HAL administration, fluorescence imaging was done using a special light source capable of delivering either white light or blue excitation light. Red fluorescence induced by illumination with blue light was detected via a prototype fluorescence video colonoscope. Biopsies were taken from suspicious areas found with white or blue light.

RESULTS

Using histology as the gold standard, 55 / 93 of neoplastic lesions were detected with white light endoscopy, 53 / 93 with both white and blue light, 38 / 93 with blue light and second-pass white light, and 27/93 with blue light only. Of all neoplastic lesions, 91 / 93 revealed red fluorescence under fluorescence imaging ( P < 0.0001). Fluorescence mode showed 38.7 % (36 / 93) more neoplasms than did white light endoscopy. An isolated slight elevation of bilirubin, by a factor of 1.5, was noted after the administration of HAL.

CONCLUSIONS

Administration of HAL as enema induces selective lesion fluorescence and increases lesion detection rate in patients with colorectal neoplasia, especially of flat, nonvisible adenomas.

Early detection of premalignant conditions in the colon by fluorescence endoscopy using local sensitization with hexaminolevulinate

BACKGROUND AND STUDY AIMS

We aimed to determine the feasibility of obtaining selective fluorescence of precancerous/cancerous lesions in the colon with a new fluorescence video endoscope system in combination with the selective photosensitizer precursor hexaminolevulinate (HAL), and to carry out a dose-finding study with evaluation of the optimal dose and application time.

PATIENTS AND METHODS

12 patients with colorectal lesions underwent sensitization with locally applied HAL enemas in two concentrations (0.8 mmol and 1.6 mmol). The examination was conducted either 30 or 60 minutes after rectal administration of the sensitizer, using a special light source capable of delivering either white or blue excitation light. Red fluorescence induced by illumination with blue light was detected via a prototype fluorescence video colonoscope. Biopsies were taken from suspicious areas found with white or blue light. Corresponding endoscopic, fluorescence, and microscopic findings were compared.

RESULTS

Using histological findings as the gold standard, 52/53 of the premalignant/malignant lesions showed red fluorescence under the photodynamic diagnosis (PDD) examination; 38/53 were detected with white-light endoscopy. The PDD mode showed 28 % more polyps than did white-light endoscopic imaging. The greatest fluorescence intensity in precancerous lesions was found with retention for 60 minutes of 500 ml of 1.6 mmol HAL.

CONCLUSIONS

Administration of HAL enema induces selective lesion fluorescence and increases the lesion detection rate in patients with colorectal adenoma and early carcinoma.

The Charlson comorbidity score: a superior comorbidity assessment tool for the prostate cancer multidisciplinary meeting

INTRODUCTION

Multidisciplinary team (MDT) meetings use precise prognostic factors to select treatment options for patients with prostate cancer. Comorbidity is judged subjectively. Recent publications favour the Charlson comorbidity score (CS) for the use in the management of prostate cancer. We assess the feasibility of using the CS by our MDT in planning the treatment of patients with prostate cancer.

PATIENTS AND METHODS

Patients from the histopathology database aged less than 75 years and with a diagnosis of localized prostate cancer between 1993 and 1995 were included in a notes audit. A second group consisted of patients recommended for curative treatment for localized prostate cancer by the local MDT in 2004. Data on comorbidity, prostatic malignancy and survival up to 10 years was collected. The prognostic accuracy of the CS was assessed for those patients offered radical treatment between 1993 and 1995.

RESULTS

Of 1043 patients initially assessed, 37 patients with localized prostate cancer were identified. Using Cox regression, we found the CS to be a statistically significant predictor of survival, following radical treatment for localized prostate cancer (P=0.005). Current practice in 2004 (56 patients) shows a mean (range) Charlson probability of 10-year survival for radical prostatectomy of 0.823 (0.592-0.923) and for radical radiotherapy of 0.653 (0.07-0.936).

CONCLUSIONS

Our results support the findings of recent research. We also found the CS easy to calculate and therefore feasible to use in our MDT setting. We propose the introduction of the Charlson score by prostate cancer MDTs to assess age and comorbidity.

Measurement of immunoglobulins in seminal fluid with modified nephelometry--an alternative diagnostic tool for chronic prostatitis

The objectives of the study were to investigate the feasibility of the modified nephelometry technique to measure immunoglobulin G and A in seminal fluid and to evaluate their use in diagnosis and follow-up of chronic prostatitis.IgG and A in seminal fluid of healthy individuals (HI) and chronic prostatitis patients (CP) were measured with modified nephelometry. The literature values were confirmed. IgG reflects the long-term healing process of chronic prostatitis. IgA was significantly increased in patients with exacerbation of the disease. Nephelometry proves to be a reliable and inexpensive test to obtain IgG and IgA in seminal fluid. IgG and IgA are useful as objective parameters to confirm subjective symptom scores in a chronic prostatitis research setting.

Improving the effectiveness of the emergency management of renal colic in a district general hospital: a completed audit cycle

OBJECTIVES

To assess the current practice of emergency management of renal colic in a district hospital, review literature, implement new guidelines, and assess them.

METHODS

Data were collected about the use of analgesia, waiting time for intravenous urography (IVU), and admission status of patients presenting to the hospital with symptoms of renal colic over the period of three months. A literature search into the use of analgesia, imaging, and treatment was performed. Members of the involved departments were consulted and new guidelines developed and implemented. This was followed by further data collection over three months.

RESULTS

Seven of 14 patients were admitted. Five to wait for their IVU. Their average waiting time was 12.3 (SD 2.2) hours. Mainly intramuscular opioid analgesia was used. Literature recommended the use of diclofenac. Although computed tomography was favoured it was decided to continue to use IVU because of circumstances within the hospital. The literature recommended a cut off between conservative and surgical treatment at a calculus size of >4 mm. Existing policies of the relevant departments were obeyed and a training system for the junior doctors was introduced. Emergency department staff were encouraged to perform 3-film IVUs. After this, of 5 of 19 patients were admitted, only one of those to wait for an IVU. The average waiting time for an IVU was 4.1 (SD 0.96) hours. Rectal diclofenac was noted to be the drug of choice.

CONCLUSION

Coordination of efforts, interdepartmental communication, and a practical application of available literature has resulted in a significant improvement of effectiveness without affecting medical standards, workload, or resources. Accident and emergency senior house officers felt highly satisfied at being able to complete management from presentation to diagnosis and treatment. Interdisciplinary communication has to be continued to maintain smooth operation of the guidelines.

Familial associations of lipid profiles: a generalized estimating equations approach

Elevated plasma levels of apolipoproteins A1 (apoA1) and B (apoB) are important protective factors and risk factors, respectively, for atherosclerosis and coronary heart disease. It is well known that both apoA1 and apoB reveal strong familial aggregation. Our goal was to investigate whether exogenous variables influence these associations. We used marginal regression models for the mean and association structure (generalized estimating equations 2; GEE2) to analyse data from 1435 family members within 469 families of different sizes included in the Donolo-Tel Aviv Three-Generation Offspring Study. The usual robust variance matrix was approximated by extensions of jack-knife estimators of variance to GEE2 models. Estimation of standard errors in models with quite complex correlation structures was possible using this approach. All analyses were easily carried out using a menu-driven stand-alone software tool for marginal regression modelling. We demonstrate that a variety of hypotheses can be tested using Wald statistics by modelling regression matrices for the association structure. We show that correlation for apoB between parent-offspring pairs increased with decreasing age difference and that pairs with individuals of the same gender had more similar apoA1 levels than individuals of different gender. Associations between different relative pairs did not all agree with those expected from differences in kinship coefficients. The analysis using GEE2 models revealed structures that would not have been detected by other models and should therefore be used in addition to traditional approaches of analysing family data. GEE2 should be considered a standard method for the investigation of familial aggregation.

Fibrin specificity and procoagulant effect related to the kallikrein-contact phase system and to plasmin generation with double-bolus reteplase and front-loaded alteplase thrombolysis in acute myocardial infarction

This study was undertaken to compare the effects of reteplase and alteplase regimens on hemostasis and fibrinolysis in acute myocardial infarction (AMI). Thrombolytic treatment in patients with AMI is hampered by paradoxical procoagulant effects that favor early reocclusion. In vivo data comparing this effect and the fibrin specificity of double-bolus reteplase and front-loaded alteplase regimens are not available. In a prospective, randomized study, 50 patients with AMI were either treated with double bolus (10 + 10 U) reteplase or with front-loaded alteplase (up to 100 mg) within 6 hours of symptom onset. Thirty apparently healthy persons served as controls. Molecular markers of coagulation and fibrinolysis were serially examined for up to 5 days. Paradoxical thrombin activation at 3 hours after initiation of therapy was comparable between reteplase and alteplase. Reteplase (65 +/- 5 U/L) and alteplase (72 +/- 8 U/L) caused significantly elevated kallikrein activity at 3 hours after adminstration (p <0.01 vs controls 30 +/- 1 U/L). Fibrin specificity was less for reteplase (p <0.05) with a decrease in fibrinogen at 3 hours to 122 +/- 27 mg/dl versus 224 +/- 28 mg/dl for alteplase (p <0.01 and p <0.05 vs controls). D-Dimer levels at 3 hours were higher (p <0.05) after reteplase (5,459 +/- 611 ng/ml) versus alteplase (3,445 +/- 679 ng/ml) (both p <0.01 vs controls 243 +/- 17 ng/ml). Plasmin generation (plasmin-antiplasmin complexes) was significantly (p <0.01) increased at 3 hours with both regimens to 27,079 +/- 3,964 microg/L (reteplase) and 19,522 +/- 2,381 microg/L (alteplase). The data from 3 hours after start of thrombolytic therapy proved less marked fibrin specificity of the reteplase regimen (in vivo) compared with front-loaded alteplase. Both regimens have a moderate procoagulant effect without differences in activation of the kallikrein system.

Identifying influential families using regression diagnostics for generalized estimating equations

The Generalized Estimating Equations (GEE) is an approach to analyze correlated data. It is applied here to data from an epidemiological study of oesophageal cancer in a high incidence area in China to investigate familial aggregation. Regression diagnostics for mean structures and association structures are used to identify families that influence estimates of these structures. It is shown that most of the families influencing the mean structure have a low age of disease onset in common. Most families identified by regression diagnostics for the association structure influence the parent correlation. It is concluded that regression diagnostic techniques can be used to identify clusters influencing mean and association structures of the models.

Significant evidence for linkage of a simulated trait to D1G024--a conclusion reached using multiallelic transmission/disequilibrium tests

We applied three versions of the transmission/disequilibrium test (TDT) for detecting linkage in nuclear families using the a priori information of possibly present association. For our analyses we employed all marker data for a simulated trait. Results for replicate 11 showed significant linkage to D1G024 using the multiallelic Tmhet statistic and the extended TDT. The TDT for the most frequent parental allele which had been applied successfully in previous studies failed to detect linkage. This result may have happened because the data did not arise from a realistic simulation of the evolution of a real population, where mutations might be expected to occur against a specific haplotype. Simulation studies are required to elucidate the applicability of the TDT for the most frequent parental allele in realistic situations. Furthermore, guidelines have to be developed for how to pool categories in large, sparse contingency tables to obtain larger cell frequencies and lower degrees of freedom.

Thrombolytic therapy in acute myocardial infarction: comparison of procoagulant effects of streptokinase and alteplase regimens with focus on the kallikrein system and plasmin

BACKGROUND

Thrombolytic therapy in patients with acute myocardial infarction (AMI) is hampered by procoagulant effects. In vitro studies have indicated that plasmin stimulation activates the kallikrein-contact-phase system, resulting in thrombin activation. This prospective comparative study was designed to examine the procoagulant effects of streptokinase or alteplase in AMI.

METHODS AND RESULTS

Sixty-one patients with AMI received 1.5 million U of streptokinase or front-loaded alteplase (up to 100 mg) and systemic heparin. Twenty-four patients with AMI and no thrombolytic therapy and 30 control subjects were examined for comparison. Molecular markers of thrombin, plasmin activation, and coagulation activities were determined before therapy and serially for up to 10 days. Moderate thrombin (initial thrombin-antithrombin [TAT] complex 18+/-5 versus 4+/-0.3 microg/L, P<0.05) and kallikrein (up to 45+/-4 versus 30+/-1 U/L at 3 hours, P<0.01) activation occurs in patients with AMI. D-Dimers are increased (P<0.01), and plasmin is stimulated (P<0.01). Streptokinase and alteplase increase TAT to 50+/-17 and 51+/-18 microg/L at 3 hours and to 50+/-17 and 33+/-14 microg/L at 6 hours, respectively (P<0.01). Kallikrein activity is elevated (P<0. 01) to 76+/-5 and 71+/-7 U/L at 3 hours and 64+/-6 and 47+/-5 U/L by streptokinase and alteplase, respectively, at 6 hours. Reductions in fibrinogen and increases in D-dimers and plasmin-antiplasmin complexes are more marked (P<0.05 and 0.01) after streptokinase versus alteplase. Correlations were found among TAT, kallikrein activity, and plasmin activation (P<0.01).

CONCLUSIONS

The data indicate a more marked procoagulant action of the streptokinase regimen compared with front-loaded alteplase, thus supporting the hypothesis of a plasmin-mediated kallikrein activation with consecutive procoagulant action in vivo.

Relationship between multiple biologic effects of rapamycin and the inhibition of pp70S6 protein kinase activity. Analysis in mutant clones of a T cell lymphoma

Rapamycin (RAP) inhibits several biologic responses in the YAC-1 T cell lymphoma, including the serum-driven proliferation and cyclin A mRNA expression, the induction of Ly-6E Ag expression by IFN, and the induction of IFN-gamma production by IL-1. RAP also suppresses the enzymatic activity of the 70 kDa S6 protein kinase (pp70s6k). To define the mechanistic relationship between these multiple effects of RAP, we have generated stable somatic mutants with altered sensitivities to this drug. A first series of mutants, represented by the R19, 4R16, and 10R13 clones, showed markedly reduced sensitivity to the inhibitory effect of RAP on all biologic responses tested and on pp70s6k activity. Two other mutant types, R103 and R125, were both highly sensitive to RAP-mediated suppression of proliferation, of IL-1-induced IFN-gamma production, and of pp70s6k activity but differed in their Ly-6E response. This response was not affected by RAP in the R125 clone and was enhanced in the R103 clone. Therefore, the inhibitory effects of RAP on proliferation and IL-1-mediated IFN-gamma induction both appear associated with the inhibition of pp70s6k activity, whereas the modulation of Ly-6E induction is independent from the latter. Moreover, the cellular binding of [3H]dihydro-FK-506 was found to be blocked by RAP in all mutant types to the same extent as in wild-type YAC-1 cells, suggesting that the altered sensitivity to the effects of RAP in these mutants is not due to an inability of the drug to enter the cells or to interact with FKBP. Further biochemical characterization of the mutant cells described here is expected to help clarify the mechanisms of RAP action.

Relationship between multiple biologic effects of rapamycin and the inhibition of pp70S6 protein kinase activity. Analysis in mutant clones of a T cell lymphoma

Rapamycin (RAP) inhibits several biologic responses in the YAC-1 T cell lymphoma, including the serum-driven proliferation and cyclin A mRNA expression, the induction of Ly-6E Ag expression by IFN, and the induction of IFN-gamma production by IL-1. RAP also suppresses the enzymatic activity of the 70 kDa S6 protein kinase (pp70s6k). To define the mechanistic relationship between these multiple effects of RAP, we have generated stable somatic mutants with altered sensitivities to this drug. A first series of mutants, represented by the R19, 4R16, and 10R13 clones, showed markedly reduced sensitivity to the inhibitory effect of RAP on all biologic responses tested and on pp70s6k activity. Two other mutant types, R103 and R125, were both highly sensitive to RAP-mediated suppression of proliferation, of IL-1-induced IFN-gamma production, and of pp70s6k activity but differed in their Ly-6E response. This response was not affected by RAP in the R125 clone and was enhanced in the R103 clone. Therefore, the inhibitory effects of RAP on proliferation and IL-1-mediated IFN-gamma induction both appear associated with the inhibition of pp70s6k activity, whereas the modulation of Ly-6E induction is independent from the latter. Moreover, the cellular binding of [3H]dihydro-FK-506 was found to be blocked by RAP in all mutant types to the same extent as in wild-type YAC-1 cells, suggesting that the altered sensitivity to the effects of RAP in these mutants is not due to an inability of the drug to enter the cells or to interact with FKBP. Further biochemical characterization of the mutant cells described here is expected to help clarify the mechanisms of RAP action.

Quantitative and temporal analysis of the cellular interaction of FK-506 and rapamycin in T-lymphocytes

The structurally related immunosuppressive macrolides FK-506 and rapamycin (RAP) exert distinct biological effects: inhibition of interleukin-2 production and inhibition of interleukin-2-induced proliferation, respectively, through binding to intracellular receptors, termed FKBPs. Although the interaction of these drugs with purified FKBPs in vitro has been well characterized, little is known about their interaction with FKBPs in living cells. Here, we used [3H]-dihydro-FK-506 as a probe to examine the binding of these macrolides in both normal mouse splenic T-cells and the human Jurkat T-cell lymphoma. These cells were found to accumulate the radioligand, predominantly in the cytosol, to a saturable level corresponding to an estimated concentration of 6 to 7 microM. Half-maximal suppression of T-cell activation was shown to require radioligand occupancy of only 3 to 5% of the pool of available intracellular binding sites (FKBPs). Moreover, the binding and immunosuppressive effect of the radioligand could not be removed by extensive washing and remained stable for at least 6 hr upon incubation of the cells at 37 degrees C. However, a molar excess of either FK-506 or RAP was found to rapidly displace [3H]-dihydro-FK-506 from its cellular binding sites. Consistently, FK-506 and RAP were able to antagonize mutually their immunosuppressive activities even when added several hr after each other to T-cell cultures. We took advantage of the reciprocal antagonism of FK-506 and RAP to define their apparent affinities for the functionally relevant cellular receptors by Schild analysis. This indicated that the drugs compete for a single cellular receptor with similar KdS and, therefore, may mediate their immunosuppressive action upon interaction with similar or highly related FKBPs.