Long-Term Follow-Up in Patients Undergoing Renal Mass Biopsy: Seeding is not Anecdotal

INTRODUCTION

Renal biopsy is recommended if the outcome might alter therapeutic decisions for patients who present with renal masses of unclear etiology. However, little is known about long-term risks related to this procedure.

PATIENTS AND METHODS

We performed a retrospective analysis of an institutional database maintained by a tertiary referral center that included patients who underwent renal biopsies between 2003 and 2005 with a follow-up of at least 15 years. Renal biopsies were taken percutaneously with a coaxial technique according to guideline recommendations and included off-line ultrasound guidance.

RESULTS

We identified 106 patients who underwent biopsies for a renal mass of unclear etiology. The median age was 58.7 years (43.7-66.2). A median of 4.2 (3-6) biopsies were collected from each patient. Tumor seeding leading to local growth was identified in 6 patients (5,7%) after a median follow-up of 8.2 years. Four of these lesions that were resected exhibited the same histology as the original biopsy result; these patients experienced no further recurrence. In 45 patients (42%), the biopsy results led to a therapy other than surgery (n = 28 lymphoma, n = 6 metastasis from other malignancies, n = 11 oncocytoma). The remaining 61 patients (58%) were diagnosed with renal cell carcinoma treated either surgically or with ablation. None of the patients developed metastatic spread related to tumor seeding.

CONCLUSION

Tumor seeding after renal mass biopsy is a rare, but relevant risk associated with this procedure. As indications for renal mass biopsy increase, longer-term follow-up and improved biopsy techniques should be considered to address this complication.

[Treatment of localized renal cell carcinoma]

BACKGROUND

Both partial nephrectomy (pNx) and total nephrectomy (TNx) are the mainstay of the surgical treatment of renal cell carcinoma. In smaller masses, ablative treatment as well as surveillance are possible options.

OBJECTIVE

The aim of this article is to provide a closer look at the surgical methods, active surveillance and ablative options as well as the current evidence to support their use.

MATERIAL AND METHODS

This study is based on a selective literature review regarding pNx and TNx for renal cell carcinoma using the PubMed database and the review of current European and American guidelines on surgical treatment and conservative options for renal cell carcinoma.

RESULTS

The choice of surgical method depends on the intrarenal tumor configuration as well as patient comorbidities. While pNx is used for smaller localized masses TNx is usually performed in larger more complex tumors. Both methods can be performed using a minimally invasive (laparoscopic or robotically assisted) or an open approach. In patients with severe comorbidities or a limited life expectancy, local ablative treatment options as well as surveillance strategies are suitable strategies.

Expression of Nectin-4 in Variant Histologies of Bladder Cancer and Its Prognostic Value-Need for Biomarker Testing in High-Risk Patients?

Variant histologies of bladder cancer (BC) often present with advanced tumor stage and the status of perioperative therapy is unclear. Thereby, squamous cell carcinoma (SCC), adenocarcinoma (ADENO), and sarcomatoid urothelial carcinoma (SARCO) are the most frequent variants. Nectin-4 has emerged as a highly interesting target in BC and might guide therapeutic application of antibody−drug conjugates (ADC). We therefore aimed to investigate expression patterns and prognostic value of Nectin-4 in variant histologies of BC. A single-center retrospective analysis was conducted of patients who underwent radical cystectomy (RC) for BC and revealed variant histologies of BC in the final specimens. Immunohistochemical staining for Nectin-4 was performed on tissue microarrays with 59 SCC, 22 ADENO, and 24 SARCO, and Nectin-4 expression was scored using the histochemical scoring system (H-score). Overall survival (OS) and progression-free survival (PFS) was calculated by Kaplan−Meier method. Median expression of Nectin-4 was 150 (range 0−250) in SCC, 140.5 (range 30−275) in ADENO, and 10 (0−185) in SARCO, with significantly lower levels for SARCO compared to SCC or ADENO (p < 0.001). For SCC, ADENO or SARCO no differences regarding OS or PFS were observed based on Nectin-4 expression levels (p > 0.05). Multivariate analysis revealed nodal stage as an independent prognostic factor for OS and PFS and metastases for PFS but not Nectin-4 expression. In conclusion, Nectin-4 was not prognostic in histological subtypes of BC in our study cohort. However, the high expression of Nectin-4 in SCC and ADENO might guide future treatment with novel Nectin-4-directed ADCs and provide this high-risk patient collective with a new promising therapeutic option. Testing Nectin-4 expression as a biomarker should be considered in trials with SARCO, where low Nectin-4 expression has been observed.

[Laser Techniques in the Treatment of Benign Prostatic Syndrome]

Laser Techniques in the Treatment of Benign Prostatic Syndrome Abstract: Lasers have a wide range of applications in endourological therapy. Not only in the treatment of stones, but also in the treatment of benign prostatic syndrome (BPS), their importance continues to grow. The endourological treatment of BPH with different laser techniques will be discussed in more detail in the following. The physical differences between the individual lasers will be explained first, followed by the treatment options that can be performed with a laser. The main focus will be on the concrete comparison of the treatment methods, especially in clinical contexts. In particular, the duration of surgery, length of hospitalisation, risk of post-operative bleeding, catheterisation duration, risk of urinary retention and risk of post-operative complications such as retrograde ejaculation, bladder neck sclerosis, urethra stricture and adenoma recurrence will be listed and compared for the most important methods. Nevertheless, the distribution of TURP to laser is still 30:1 in favour for TURP [1].

Percutaneous edge-to-edge repair of severe mitral regurgitation using the MitraClip XTR versus NTR system

Background

Transcatheter mitral valve repair (TMVR) has shown to improve symptoms and functional capacity in patients with severe mitral valve regurgitation (MR). Novel device developments provide the technology to treat patients with complex anatomies and large coaptation gaps. Nevertheless, the question of superiority of one device remains unanswered. We aimed to compare the MitraClip XTR and MitraClip NTR system in a real world setting.

Hypothesis

TMVR with the MitraClip XTR system is equally effective, but associated with a higher risk of leaflet injury.

Methods

We retrospectively analyzed peri‐procedural and mid‐term clinical and echocardiographic outcomes of 113 patients treated for severe MR between March 2018 and August 2019 at the University Hospital of Munich.

Results

Postprocedural MR reduction to ≤2+ was comparable in both groups (XTR: 96.1% vs. NTR: 97.6%, p = .38). There was a significant difference in a composite safety endpoint of periprocedural Major adverse cardiac and cerebrovascular events (MACCE) including leaflet injury between groups (XTR 14.6% vs. NTR 1.7%, 95% CI [2.7, 24.6], p = .012). After a median follow‐up of 8.5 (4.4, 14.0) months, durable reduction of MR was confirmed (XTR: in 91.9% vs. NTR: 96.8%, p = .31) and clinical and symptomatic improvement was comparable in both groups accordingly.

Conclusion

While efficacy was comparable in both treatment groups, patients treated with the MitraClip XTR systems showed more events of acute leaflet tear and single leaflet device attachment (SLDA). A detailed echocardiographic assessment should be done to identify risk candidates for acute leaflet injury.

Edge-to-Edge Mitral Valve Repair With Extended Clip Arms: Early Experience From a Multicenter Observational Study

OBJECTIVES

The aim of this study was to investigate the technical success and efficacy of mitral valve edge-to-edge repair using extended clip arms.

BACKGROUND

A new iteration of the MitraClip system, the MitraClip XTR, was introduced in 2018 with the aim of addressing technical limitations observed with previous versions.

METHODS

Patients having received at least 1 new implant for the treatment of symptomatic mitral regurgitation (MR) were eligible for this study.

RESULTS

Among the 107 patients (mean age 76 ± 9 years, 69% men) included in this study, the etiology of MR was balanced, with one-half (n = 53 [50%]) classified as secondary and the remaining 54 patients having either primary (n = 40 [37%]) or mixed (n = 14 [13%]) disease. The mean number of devices implanted was 1.5 ± 0.6. Multiple device implantation was required in 46 patients (43%). Single-leaflet device attachment occurred in 4 patients and leaflet injury in 2 additional patients, requiring surgical conversion in 4 patients. Among the 102 patients discharged alive without mitral valve surgery, 95 (93%) had MR ≤2+ and 79 (77%) had MR ≤1+. The mean transmitral gradient increased from 1.9 ± 1.0 mm Hg at baseline to 3.5 ± 1.8 mm Hg at discharge (p < 0.001).

CONCLUSIONS

Technical success with the new mitral valve repair system with extended clip arm was achieved in 93% of the patients. MR ≤2+ was obtained in 95 patients (93%) and MR ≤1+ in 79 (77%). The main reasons for procedural failure were acute single-leaflet device attachment associated with leaflet damage or isolated leaflet injury and often required surgical correction.

Structural changes in amorphous Ge(x)SiO(y) on the way to nanocrystal formation

Temperature induced changes of the local chemical structure of bulk amorphous GexSiOy are studied by Ge K-edge x-ray absorption near-edge spectroscopy and Si L2/3-edge x-ray Raman scattering spectroscopy. Different processes are revealed which lead to formation of Ge regions embedded in a Si oxide matrix due to different initial structures of as-prepared samples, depending on their Ge/Si/O ratio and temperature treatment, eventually resulting in the occurrence of nanocrystals. Here, disproportionation of GeOx and SiOx regions and/or reduction of Ge oxides by pure Si or by a surrounding Si sub-oxide matrix can be employed to tune the size of Ge nanocrystals along with the chemical composition of the embedding matrix. This is important for the optimization of the electronic and luminescent properties of the material.

An attempt to clarify the influence of glycerol, propylene glycol, isopropyl myristate and a combination of propylene glycol and isopropyl myristate on human stratum corneum

The present study is a comparison of the influences of glycerol, propylene glycol (PG), isopropyl myristate (IPM) and a combination of PG and IPM (1/1; w/w) on human stratum corneum (SC) by means of differential scanning calorimetry (DSC) and wide and small angle X-ray-diffraction (WAXD and SAXD). The effects of glycerol and PG on SC structure can be attributed to their functional groups. In DSC transition temperatures of lipid fractions are decreased whereas SAXD long distances of lamellar phases reveal an additional interference due to an integration into hydrophilic regions of hexagonally packed lipids (PG) or orthorhombically packed lipids (glycerol). The increased repeat distance is attributed to the polar character of both molecules. However, with IPM the long distance remains unaffected. IPM is integrated into the lipophilic regions of SC lipid matrix as concluded from an increase of WAXD reflections of orthorhombical lipids and a decrease of WAXD reflections of hexagonal lipids. The combination of PG/IPM affects SC microstructure in a specific manner. DSC shows a decrease in transition temperatures of the lipid fractions, although not as much as expected from the single substances. Additionally, the combination of IPM/PG affects the short distances of orthorhombically and hexagonally packed lipids in WAXD measurements similar as PG alone, whereas the long distance seems to remain unaffected as in the case of IPM pretreatment. Adjuvants with penetration enhancing potential reveal different effects on SC lipid microstructure, which have to be kept in mind in terms of formulating systems for transdermal administration.

Role of Isopropyl Myristate, Isopropyl Alcohol and a Combination of Both in Hydrocortisone Permeation across the Human Stratum corneum

The influence of isopropyl myristate (IPM), isopropyl alcohol (IPA) and a combination of both was studied in view of hydrocortisone (HC) permeation across the human stratum corneum (SC). IPM, IPA and their combination were incorporated into water-containing hydrophilic ointment (WHS), and the resulting effects on HC permeation and on HC accumulation in human SC were investigated as well as the influence of these substances on the microstructure of the SC. Differential scanning calorimetry as well as wide- and small-angle X-ray diffraction show that IPM incorporation into SC results in densely packed bilayer lipids and a loss of order of the corneocyte-bonded lipids. Both effects result in a decreased diffusion coefficient of HC in SC and thus in a decreased permeation rate compared to that of HC from WHS. On the other hand, IPA fluidizes and disrupts the bilayer structure of the intercellular lipids. These effects, concomitant with an increased amount of dissolved HC within the ointment, increase the permeation rate of HC across SC. The combination of both ingredients effects a stronger fluidization and disruption of intercellular lipids than with IPA alone. Therefore, the permeation rate of HC across SC is higher than with IPA alone. Consequently, the IPM and IPA combination acts synergistically on the microstructure of SC.