Enzalutamide or Abiraterone Acetate With Prednisone in the Treatment of Metastatic Castration-resistant Prostate Cancer in Real-life Clinical Practice: A Long-term Single Institution Experience

BACKGROUND/AIM

Enzalutamide (ENZ) and abiraterone acetate with prednisone (AAP) represent novel hormonal therapies used in the treatment of metastatic castration-resistant prostate cancer (mCRPC). The aim of the study was to assess the long-term outcome of mCRPC patients treated with ENZ or AAP in real-life clinical practice.

PATIENTS AND METHODS

The outcomes of 337 mCRPC patients treated with ENZ or AAP were retrospectively analysed.

RESULTS

Median radiographic progression-free (rPFS) and overall survival (OS) of patients treated in the first line (pre-chemotherapy) was 13.89 (95% CI=12.40-16.80) and 31.02 (95% CI=24.27-37.44) months vs. 10.97 (95% CI=8.97-14.82) and 26.57 (95% CI=15.97-33.92) months for those treated in the second line (post-chemotherapy). We found inferior survival for patients with synchronous metastases, high Gleason score (GS) and visceral metastases.

CONCLUSION

The efficacy of both ENZ and AAP in mCRPC patients is herein confirmed. Synchronous metastases, high GS and visceral metastases were identified as significant adverse prognostic factors.

Expanding the morphologic spectrum of chromophobe renal cell carcinoma: A study of 8 cases with papillary architecture

Although typically arranged in solid alveolar fashion, chromophobe renal cell carcinoma (RCC) may also show several other architectural growth patterns. We include in this series 8 chromophobe RCC cases with prominent papillary growth, a pattern very rarely reported or only mentioned as a feature of chromophobe RCC, which is lacking wider recognition The differential diagnosis of such cases significantly varies from the typical chromophobe RCC with its usual morphology, particularly its distinction from papillary RCC and other relevant and clinically important entities. Of 972 chromophobe RCCs in our files, we identified 8 chromophobe RCCs with papillary growth. We performed immunohistochemistry and array Comparative Genomic Hybridisation (aCGH) to investigate for possible chromosomal aberrations. Patients were 3 males and 5 females with age ranging from 30 to 84 years (mean 57.5, median 60 years). Tumor size was variable and ranged from 2 to 14 cm (mean 7.5, median 6.6 cm). Follow-up was available for 7 of 8 patients, ranging from 1 to 61 months (mean 20.1, median 12 months). Six patients were alive with no signs of aggressive behavior, and one died of the disease. Histologically, all cases were composed of dual cell population consisting of variable proportions of leaf-like cells with pale cytoplasm and eosinophilic cells. The extent of papillary component ranged from 15 to 100% of the tumor volume (mean 51%, median 50%). Sarcomatoid differentiation was identified only in the case with fatal outcome. Immunohistochemically, all tumors were positive for CK7, CD117 and Hale's Colloidal Iron. PAX8 was positive in 5 of 8 cases, TFE3 was focally positive 3 of 8 tumors, and Cathepsin K was focally positive in 2 of 8 tumors. All cases were negative for vimentin, AMACR and HMB45. Fumarate hydratase staining was retained in all tested cases. The proliferative activity was low (up to 1% in 7, up to 5% in one case). Three cases were successfully analyzed by aCGH and all showed a variable copy number variation profile with multiple chromosomal gains and losses. CONCLUSIONS: Chromophobe RCC demonstrating papillary architecture is an exceptionally rare carcinoma. The diagnosis can be challenging, although the cytologic features are consistent with the classic chromophobe RCC. Given the prognostic and therapeutic implications of accurately diagnosis other RCCs with papillary architecture (i.e., Xp11.2 translocation RCC, FH-deficient RCC), it is crucial to differentiate these cases from chromophobe RCC with papillary architecture. Based on this limited series, the presence of papillary architecture does not appear to have negative prognostic impact. However, its wider recognition may allow in depth studies on additional examples of this rare morphologic variant.

Compressive syndrome of internal jugular veins in multiple sclerosis: does it matter?

OBJECTIVES

Condition known as chronic cerebrospinal venous insufficiency (CCSVI) is characterized by insufficient cerebral vein drainage in patients with multiple sclerosis (MS) and internal jugular vein (IJV), vertebral and/or azygos veins stenoses. However, external compression on the IJV was not clearly described as a potential cause of CCSVI. We aim to present a case of CCSVI in a patient with MS caused by bilateral IJV inverted valves combined with IJV external compression by carotid bulb.

METHODS

A 31-year-old female patient was admitted to our institute for IJV and vertebral veins morphological and haemodynamical assessment after being treated for MS for the last 14 years. Colour Doppler ultrasonography showed right IJV prestenotic dilation and inverted valves in both IJV. Computerized tomography angiography showed bilateral IJV compression by carotid bulb. Haemodynamical Doppler parameters showed that external IJV compression significantly contributed to CCSVI occurrence.

RESULTS

Bilateral IJV confluence percutaneous angioplasty (PTA) was done, and the patient was discharged for further neurological examination. Partial carbon dioxide pressure was significantly lower in the distal part of both IJV following PTA and oxygen saturation increased.

CONCLUSION

In the case presented, PTA of the IJV confluence resulted in haemodynamic improvement despite the presence of IJV external compression.

Internal jugular vein duplication: a further truncular malformation in a patient with multiple sclerosis

Different internal jugular vein (IJV) abnormalities can be found in patients with multiple sclerosis (MS): stenoses, complete occlusion, distortions and intraluminal structures, such as membranes, webs and inverted valves. IJV duplication is a very rare phenomenon. We report a case of right IJV duplication as an incidental finding during IJV morphological and haemodynamic assessment in a patient with MS. A 55-year-old female patient was admitted to our Institute for IJV and vertebral veins morphological and haemodynamic assessment. During the last seven years she had been treated for MS. Colour Doppler ultrasonography in our patient did not reveal IJV or vertebral veins stenoses or abnormal valves, but instead right IJV duplication. This finding was confirmed using multislice computed tomography angiography and by selective phlebography. In conclusion, to our knowledge, a case of IJV duplication in a patient with MS has not been described yet. This further venous malformation can be assessed by the means of Doppler ultrasounds.

Morphological and haemodynamic abnormalities in the jugular veins of patients with multiple sclerosis

Objectives

Multiple areas of stenosis and different levels of obstruction of internal jugular and azygous veins (a condition known as cronic cerebrospinal venous insufficiency) recently emerged as an additional theory to the well-known autoimmune concept, explaining etiology of multiple sclerosis (MS). The aim of our study was to evaluate internal jugular vein (IJV) morphology and haemodynamic characteristics in patients with MS and compare it with well-matched healthy individuals and to evaluate the prevalence of venous flow abnormalities in both groups.

Methods

Sixty-four patients with clinically proven MS and 37 healthy individuals were included in our study. In all patients, IJV morphology and haemodynamic characteristics were evaluated by colour Doppler sonography as well as venous flow disorder. The patients were classified into four groups according to MS clinical form presentation. The prevalence of morphological and haemodynamic abnormalities in the IJV were assessed.

Results

The presence of stenosing lesion, mostly intraluminal defects like abnormal IJV valves, were observed in 28 patients (43%) in the MS group, and in 17 patients (45.9%) in the control group ( P = NS). By adding haemodynamic Doppler information in the IJV venous outflow was significantly different in 42% of MS patients showing flow abnormalities (27/64), as compared with 8.1% of the controls (3/37), P < 0.001.

Conclusion

In our group of patients, patients suffering from MS had significantly more IJV morphological changes and haemodynamic abnormalities when compared with healthy individuals not suffering from MS. These findings can be well demonstrated by non-invasive and cost-effective Doppler ultrasound.

Variability of aortic blood flow predicts fluid responsiveness in spontaneously breathing healthy volunteers

BACKGROUND

Assessment of fluid responsiveness is an important topic in acute cardiology. Echocardiographic measurement of respiratory variations of aortic blood velocity in ventilated shock patients can accurately predict the effect of volume expansion. On the other hand, it remains unclear whether this respiratory variability is a common physiological reaction to hypovolaemia and whether its measurement is applicable also in spontaneously breathing patients.

AIM

To assess whether respiratory variability of peak aortic blood flow velocity (DVpeakao) and of aortic velocity time integral (DVTIao) reflects preload-dependent changes of cardiac index (CI) and whether it predicts fluid responsiveness in healthy spontaneously breathing volunteers.

METHODS

DVpeakao, DVTIao and CI were measured by transthoracic echocardiography in 20 volunteers at baseline and after intravenous administration of furosemide (0.5 mg/kg). Afterwards, volunteers were randomised to rapid intravenous volume expansion (group A) or no expansion (group B) and assessed finally.

RESULTS

Hypovolaemia induction was associated with a decrease of CI (from 3.25 +/- 0.50 to 2.28 +/- 0.43 l/min/m2, p < 0.001) which correlated with an increase of DVpeakao (r = -0.490, p = 0.028) and DVTIao (r = -0.554, p = 0.011) in both groups. In group A, volume expansion was followed by a drop of DVpeakao (from 16.04 +/- 1.99 to 2.97 +/- 1.65 %, p < 0.001) and DVTIao (from 20.43 +/- 5.13 to 3.43 +/- 1.68 %, p < 0.001) and CI increase (from 2.14 +/- 0.47 to 3.29 +/- 0.57 l/min/m2, p < 0.001). This increase strongly correlated with the value of DVpeakao (r = 0.782, p = 0.008) and DVTIao (r = 0.770, p = 0.009) before volume expansion. Conversely, there was no change of measured parameters in group B. Threshold values of 14% for DVaopeak and 17% for DVTIao were identified to predict fluid responsiveness (increase of CI > 15%) with a sensitivity of 89% and specificity of 100%.

CONCLUSIONS

DVpeakao and DVTIao reflect preload-dependent changes of CI in healthy spontaneously breathing volunteers and predict fluid responsiveness.

Induction of mild hypothermia in cardiac arrest survivors presenting with cardiogenic shock syndrome

BACKGROUND

Induction of mild hypothermia (MH) in patients resuscitated from cardiac arrest improves their outcome. However, benefits and risks of MH in patients who remain in cardiogenic shock after the return of spontaneous circulation (ROSC) are unclear. We analysed all cardiac arrest survivors who were treated with MH in our intensive coronary care unit (CCU) and compared the outcome of patients with cardiogenic shock syndrome (CSS) with those who were circulatory stable.

METHODS

We performed retrospective analysis of all consecutive cardiac arrest survivors treated by MH in our CCU from November 2002 to August 2006. They were classified into two groups, according to whether they met the criteria for cardiogenic shock or not before MH initiation.

RESULTS

Out of 56 consecutive patients, 28 fulfilled criteria of cardiogenic shock before MH initiation (group A) and 28 were relatively stable (group B). In-hospital mortality was 57.1% in group A and 21.4% in group B patients (P=0.013). Favourable neurological outcome anytime during hospitalization was found in 67.9% of group A patients and in 82.1% of group B subjects (P=0.355). Favourable discharge neurological outcome was reached in 39.3% in group A and in 71.4% in group B (P=0.031). The complication rate in both groups did not differ.

CONCLUSION

While in-hospital mortality in cardiac arrest survivors treated by MH was expectably higher in those with cardiogenic shock than in stable patients, the favourable neurological outcome during hospitalization was comparable in both groups. Therefore, induction of MH should be considered in cardiac arrest survivors with CSS after ROSC.

A model of animal-human brucellosis transmission in Mongolia

We developed a dynamic model of livestock-to-human brucellosis transmission in Mongolia. The compartmental model considers transmission within sheep and cattle populations and the transmission to humans as additive components. The model was fitted to demographic and seroprevalence data (Rose Bengal test) from livestock and annually reported new human brucellosis cases in Mongolia for 1991-1999 prior to the onset of a mass livestock-vaccination campaign (S19 Brucella abortus for cattle and Rev 1 Brucella melitensis for sheep and goat). The vaccination effect was fitted to livestock- and human-brucellosis data from the first 3 years of the vaccination campaign (2000-2002). Parameters were optimized on the basis of the goodness-of-fit (assessed by the deviance). The simultaneously fitted sheep-human and cattle-human contact rates show that 90% of human brucellosis was small-ruminant derived. Average effective reproductive ratios for the year 1999 were 1.2 for sheep and 1.7 for cattle.

A new method for determination of hydroperoxides in cellulose

A new chromatographic method for determination of hydroperoxides in cellulose is described, whereby the sample is dispersed in phosphate buffer solution (pH 7) of FeCl(3), EDTA and the hydroxyl radical scavenger, N,N'-(5-nitro,1,3-phenylene)bisglutaramide. The reaction time, concentration of reagents and chromatographic conditions for subsequent separation and quantification of hydroxylated products are optimised. The limit of detection is 0.14 micro mol L(-1) H(2)O(2) which corresponds to 2.1 micro mol hydroperoxides per kg of cellulose (mass of sample: 0.4 g). It was shown that in the concentration range of H(2)O(2) up to 15 micro mol L(-1) the method gives linear response and that adsorption of reaction products on fibres is negligible. For cellulose samples, this corresponds to a linear range of 2.1-225 micro mol of hydroperoxides per kg. Due to possible side reactions of hydroxyl radicals in the suspension of analyte, it is recommended that the standard addition technique is used. In purified cotton cellulose, the steady state concentration of hydroperoxides at room conditions was found to be 15.1+/-1.5 micro mol kg(-1).

The effect of a hot dry climate on the haemorrheology of healthy males and patients with acute myocardial infarction

We studied the influence of an extremely hot dry summer and temperate winter on the haemorrheology of 82 healthy males (controls) and 101 male patients with acute myocardial infarction (AMI). The haematocrit (Hct), blood viscosity (B1V) and Hct/B1V ratio were measured in these subjects working 'outdoors' and in an air-conditioned environment ('indoors'). The 'summer outdoor' controls had a higher B1V and a lower Hct/B1V when compared to the 'winter outdoor' controls (P less than 0.01), and the 'summer indoor' controls had a lower Hct and Hct/B1V when compared to the 'winter indoor' control group (P less than 0.02). The haemorrheology of 'winter indoor' AMI patients was not different from the controls, except for the Hct/B1V. The 'summer indoor' group had a higher Hct (P less than 0.05) and B1V (P less than 0.001) and a lower Hct/B1V (P less than 0.02) when compared to the controls. 'Summer outdoor' AMI patients had the most abnormal haemorrheology of all groups. AMI patients with Hct/B1V less than 7 had a significantly higher prevalence of hypotension and shock syndrome compared to those whose Hct/B1V was greater than or equal to 7 (P less than 0.05). We conclude that in healthy males, there was a seasonal difference in haemorrheology which was due to acclimatization to heat. During summer, AMI patients working outdoors had the most abnormal haemorrheology on admission and the occurrence of complications was also higher in them. We believe that these abnormalities resulted due to inadequate adjustments to heat.

Seasonal variation in the incidence of unstable angina and acute myocardial infarction: effect of dry hot climate on the occurrence of complications following acute myocardial infarction

The incidence of unstable angina (UA) and acute myocardial infarction (AMI), and the occurrence of complications following AMI were studied retrospectively by utilizing data of 7859 patients admitted during three consecutive winter and summer periods from 1979 to 1982. In all patients, UA was more frequent during summer than in winter: 58 out of 3819 (1.5%) versus 37 out of 4040 (0.9%) respectively (P less than 0.05). A similar difference was observed for the incidence of AMI: 183 out of 3819 (4.8%) in summer versus 157 out of 4040 (3.9%) in winter (P less than 0.05). This seasonal variation in the incidence of UA and AMI was significant only in male patients (P less than 0.05). Shock and mortality were higher during summer than in winter in all, and in male AMI patients with or without previous infarction. It is suggested that a hot dry summer is an important risk factor for the occurrence of UA and AMI, and the associated serious complications following the latter in males.

Experience with iopamidol in myeloradiculography

Myeloradiculography with Iopamiro 300 produced by Bracco was carried out in 110 patients. In 97.2% the diagnostic evidence produced was excellent. It was difficult to make an exact diagnosis in 2.7% of cases, in whom there was a strong dilution as the contrast material moved from the lumbar into the cervical area of the spine. The side effects were slight and occurred only in a small proportion of patients. No neurotoxic complications or psychological changes were observed.

Early two-dimensional echocardiography in acute myocardial infarction. A study of left ventricular wall motion abnormalities

Two-dimensional echocardiography (2DE) was utilized in 49 patients with a first transmural myocardial infarction, within 6 hours (+/- 3SD) after admission and again at 48 hours, in order to correlate initial left ventricular wall motion (LVWM) abnormalities with subsequent in-hospital cardiac complications. Analysis of systolic endocardial motion was made in 15 left ventricular segments in each patient and a total wall motion (WM) score was derived as a measure of the extent of myocardial involvement. LVWM abnormalities in relation to Killip class, peak total serum creatine kinase (CK) and serum glutamic oxaloacetic transaminase (SGOT) enzyme levels were also studied. Adequate echocardiograms for LVWM analysis were obtained in 43 patients. Thirteen patients had no infarct-related complications (group I) and 30 had complications (group II). The mean initial WM score in group I patients was 5.7 +/- 2.6 which was significantly lower than the 13.5 +/- 3.9 in group II (p less than 0.0001). A WM score of greater than 10 correlated with the occurrence of complications in 93% of patients. The WM score was significantly higher in admission Killip class 1 and 2 patients in group II compared with group I patients in class 1. However, no difference was noticed between the mean WM score of patients assigned to these 2 classes in group II. Peak CK and SGOT levels showed a poor correlation with the WM score in group I patients. In group II patients, only the peak SGOT levels correlated significantly with this score. We conclude that in patients with acute infarction, 2DE soon after admission can identify those likely to have in-hospital cardiac complications.