Histopathological features in fatal COVID-19 acute respiratory distress syndrome

Background

COVID-19 acute respiratory distress syndrome (ARDS) shares the common histological hallmarks with other forms of ARDS. However, the chronology of the histological lesions has not been well established.

Objective

To describe the chronological histopathological alterations in the lungs of patients with COVID-19 related ARDS.

Design

A prospective cohort study was carried out.

Setting

Intensive Care Unit of a tertiary hospital.

Patients

The first 22 consecutive COVID-19 deaths.

Measurements

Lung biopsies and histopathological analyses were performed in deceased patients with COVID-19 related ARDS. Clinical data and patient course were evaluated.

Results

The median patient age was 66 [63–74] years; 73% were males. The median duration of mechanical ventilation was 17 [8–24] days. COVID-19 induced pulmonary injury was characterized by an exudative phase in the first week of the disease, followed by a proliferative/organizing phase in the second and third weeks, and finally an end-stage fibrosis phase after the third week. Viral RNA and proteins were detected in pneumocytes and macrophages in a very early stage of the disease, and were no longer detected after the second week.

Limitation

Limited sample size.

Conclusions

The chronological evolution of COVID-19 lung histopathological lesions seems to be similar to that seen in other forms of ARDS. In particular, lung lesions consistent with potentially corticosteroid-sensitive lesions are seen.

Histopathological features in fatal COVID-19 acute respiratory distress syndrome

Background

COVID-19 acute respiratory distress syndrome (ARDS) shares the common histological hallmarks with other forms of ARDS. However, the chronology of the histological lesions has not been well established.

Objective

To describe the chronological histopathological alterations in the lungs of patients with COVID-19 related ARDS.

Design

A prospective cohort study was carried out.

Setting

Intensive Care Unit of a tertiary hospital.

Patients

The first 22 consecutive COVID-19 deaths.

Measurements

Lung biopsies and histopathological analyses were performed in deceased patients with COVID-19 related ARDS. Clinical data and patient course were evaluated.

Results

The median patient age was 66 [63–74] years; 73% were males. The median duration of mechanical ventilation was 17 [8–24] days. COVID-19 induced pulmonary injury was characterized by an exudative phase in the first week of the disease, followed by a proliferative/organizing phase in the second and third weeks, and finally an end-stage fibrosis phase after the third week. Viral RNA and proteins were detected in pneumocytes and macrophages in a very early stage of the disease, and were no longer detected after the second week.

Limitation

Limited sample size.

Conclusions

The chronological evolution of COVID-19 lung histopathological lesions seems to be similar to that seen in other forms of ARDS. In particular, lung lesions consistent with potentially corticosteroid-sensitive lesions are seen.

Delirium and encephalopathy in severe COVID-19: a cohort analysis of ICU patients

BACKGROUND

Neurotropism of SARS-CoV-2 and its neurological manifestations have now been confirmed. We aimed at describing delirium and neurological symptoms of COVID-19 in ICU patients.

METHODS

We conducted a bicentric cohort study in two French ICUs of Strasbourg University Hospital. All the 150 patients referred for acute respiratory distress syndrome due to SARS-CoV-2 between March 3 and May 5, 2020, were included at their admission. Ten patients (6.7%) were excluded because they remained under neuromuscular blockers during their entire ICU stay. Neurological examination, including CAM-ICU, and cerebrospinal fluid analysis, electroencephalography, and magnetic resonance imaging (MRI) were performed in some of the patients with delirium and/or abnormal neurological examination. The primary endpoint was to describe the incidence of delirium and/or abnormal neurological examination. The secondary endpoints were to describe the characteristics of delirium, to compare the duration of invasive mechanical ventilation and ICU length of stay in patients with and without delirium and/or abnormal neurological symptoms.

RESULTS

The 140 patients were aged in median of 62 [IQR 52; 70] years old, with a median SAPSII of 49 [IQR 37; 64] points. Neurological examination was normal in 22 patients (15.7%). One hundred eighteen patients (84.3%) developed a delirium with a combination of acute attention, awareness, and cognition disturbances. Eighty-eight patients (69.3%) presented an unexpected state of agitation despite high infusion rates of sedative treatments and neuroleptics, and 89 (63.6%) patients had corticospinal tract signs. Brain MRI performed in 28 patients demonstrated enhancement of subarachnoid spaces in 17/28 patients (60.7%), intraparenchymal, predominantly white matter abnormalities in 8 patients, and perfusion abnormalities in 17/26 patients (65.4%). The 42 electroencephalograms mostly revealed unspecific abnormalities or diffuse, especially bifrontal, slow activity. Cerebrospinal fluid examination revealed inflammatory disturbances in 18/28 patients, including oligoclonal bands with mirror pattern and elevated IL-6. The CSF RT-PCR SARS-CoV-2 was positive in one patient. The delirium/neurological symptoms in COVID-19 patients were responsible for longer mechanical ventilation compared to the patients without delirium/neurological symptoms. Delirium/neurological symptoms could be secondary to systemic inflammatory reaction to SARS-CoV-2.

CONCLUSIONS AND RELEVANCE

Delirium/neurological symptoms in COVID-19 patients are a major issue in ICUs, especially in the context of insufficient human and material resources.

TRIAL REGISTRATION

NA.

High risk of thrombosis in patients with severe SARS-CoV-2 infection: a multicenter prospective cohort study

Purpose

Little evidence of increased thrombotic risk is available in COVID-19 patients. Our purpose was to assess thrombotic risk in severe forms of SARS-CoV-2 infection.

Methods

All patients referred to 4 intensive care units (ICUs) from two centers of a French tertiary hospital for acute respiratory distress syndrome (ARDS) due to COVID-19 between March 3rd and 31st 2020 were included. Medical history, symptoms, biological data and imaging were prospectively collected. Propensity score matching was performed to analyze the occurrence of thromboembolic events between non-COVID-19 ARDS and COVID-19 ARDS patients.

Results

150 COVID-19 patients were included (122 men, median age 63 [53; 71] years, SAPSII 49 [37; 64] points). Sixty-four clinically relevant thrombotic complications were diagnosed in 150 patients, mainly pulmonary embolisms (16.7%). 28/29 patients (96.6%) receiving continuous renal replacement therapy experienced circuit clotting. Three thrombotic occlusions (in 2 patients) of centrifugal pump occurred in 12 patients (8%) supported by ECMO. Most patients (> 95%) had elevated D-dimer and fibrinogen. No patient developed disseminated intravascular coagulation. Von Willebrand (vWF) activity, vWF antigen and FVIII were considerably increased, and 50/57 tested patients (87.7%) had positive lupus anticoagulant. Comparison with non-COVID-19 ARDS patients (n = 145) confirmed that COVID-19 ARDS patients (n = 77) developed significantly more thrombotic complications, mainly pulmonary embolisms (11.7 vs. 2.1%, p < 0.008). Coagulation parameters significantly differed between the two groups.

Conclusion

Despite anticoagulation, a high number of patients with ARDS secondary to COVID-19 developed life-threatening thrombotic complications. Higher anticoagulation targets than in usual critically ill patients should therefore probably be suggested.

Electronic supplementary material

The online version of this article (10.1007/s00134-020-06062-x) contains supplementary material, which is available to authorized users.

Spontaneous ilio-psoas hematomas complicating intensive care unit hospitalizations

BACKGROUND

Ilio-psoas hematoma is a potentially lethal condition that can arise during hospital stay. However, neither the incidence nor the prognosis of patients whose stay in intensive care units (ICU) is complicated by a iatrogenic ilio-psoas hematoma is known.

METHODS

A bicentric retrospective study was conducted to compile the patients who developed an ilio-psoas hematoma while they were hospitalized in ICU between January 2009 and December 2016. Their biometric characteristics, pre-existing conditions, the circumstances in which the hematoma was diagnosed, the treatments they received and their prognosis were recorded.

RESULTS

Forty patients were diagnosed with an ilio-psoas hematoma during their ICU stay. The incidence of this complication was 3.8 cases for 1000 admissions, taking into account only patients who stayed more than three days in ICU. The median age of patients was 74 years old and the median time between admission and the diagnosis of ilio-psoas hematoma was 12.6 days. A large proportion of them was obese (42.5%) and/or under dialysis (50%) prior to developing their hematoma. Ninety-five percent of the patients had heparin at prophylactic or therapeutic doses. Only 10% of them were above the therapeutic range of anticoagulation. The ICU mortality rate was of 50% following this complication (versus a general mortality rate of 22% for the patients without IPH over the same period of time). Patients with IPH that were complicated by disseminated intravascular coagulopathy had a significantly higher mortality rate than those with IPH and no disseminated intravascular coagulopathy (OR 6.91, 95% CI [1.28; 58.8], p = 0.04).

CONCLUSION

Age, anticoagulation, a high body mass index and dialysis seem to be risk factors of developing an ilio-psoas hematoma in ICU. Iatrogenic ilio-psoas hematomas complicated by disseminated intravascular coagulopathies are more at risk of leading to death. It is noteworthy that activated partial thromboplastin time above the therapeutic range was not a good predictor of developing a hematoma for patients who received unfractioned heparin therapy.

[Narrow band imaging-assisted cystoscopy in bladder tumor follow-up: Can more tumors be identified?]

BACKGROUND

Narrow band imaging (NBI) is a new technique of urethrocystoscopy, in which only certain wavelengths [415 (blue) and 540 nm (green)] are used to detect urothelial carcinoma. The aim of the investigation was to analyze the potential benefit of NBI in the follow-up of patients with transitional cell carcinoma of the bladder.

METHODS

Between August 2013 and July 2014, patients with a history of transitional cell carcinoma of the bladder, presenting for follow-up cystoscopy, were either examined via flexible white light endoscopy (WLE) plus second look WLE (n = 251, controls) or second look NBI cystoscopy alone (n = 251) in the same session.

RESULTS

Rates of recurrences were similar in the two groups [NBI 68 (27.1 %); WLE 70 (27.9 %)]. NBI after WLE identified more tumors in 13 patients (5.69 vs. 3.92). In 8 patients NBI showed no vascularization in suspicious areas. In the control arm, in 8 cases more tumors (3.75 vs. 3.13) were identified in the second WLE.

CONCLUSIONS

The additional use of NBI in the follow-up cystoscopy of patients after transurethral resection of nonmuscle invasive bladder cancer leads to an increased number of detected tumors; however, a part of the additionally detected tumors can be explained by the double examination. NBI appears to provide information in individual cases whether transurethral resection of bladder tumor is necessary.

Endothelial Caveolin-1 regulates the radiation response of epithelial prostate tumors

The membrane protein caveolin-1 (Cav1) recently emerged as a novel oncogene involved in prostate cancer progression with opposed regulation in epithelial tumor cells and the tumor stroma. Here we examined the role of stromal Cav1 for growth and radiation response of MPR31-4 prostate cancer xenograft tumors using Cav1-deficient C57Bl/6 mice. Syngeneic MPR31-4 tumors grew faster when implanted into Cav1-deficient mice. Increased tumor growth on Cav1-deficient mice was linked to decreased integration of smooth muscle cells into the wall of newly formed blood vessels and thus with a less stabilized vessel phenotype compared with tumors from Cav1 wild-type animals. However, tumor growth delay of MPR31-4 tumors grown on Cav1 knockout mice to a single high-dose irradiation with 20 Gray was more pronounced compared with tumors grown on wild-type mice. Increased radiation-induced tumor growth delay in Cav1-deficient mice was associated with an increased endothelial cell apoptosis. In vitro studies using cultured endothelial cells (ECs) confirmed that the loss of Cav1 expression increases sensitivity of ECs to radiation-induced apoptosis and reduces their clonogenic survival after irradiation. Immunohistochemical analysis of human tissue specimen further revealed that although Cav1 expression is mostly reduced in the tumor stroma of advanced and metastatic prostate cancer, the vascular compartment still expresses high levels of Cav1. In conclusion, the radiation response of MPR31-4 prostate tumors is critically regulated by Cav1 expression in the tumor vasculature. Thus, Cav1 might be a promising therapeutic target for combinatorial therapies to counteract radiation resistance of prostate cancer at the level of the tumor vasculature.

[Superficial bladder cancer: Transurethral resection and instillation therapy]

Bladder cancer is the fifth most common tumor in men with the incidence of bladder tumors continuing to rise in industrialized and developed countries. Because 80% of all bladder tumors grow on the surface, endoscopic transurethral resection (TUR-B) can be used for complete removal. Due to continuous technical developments and improvements of endoscopic equipment, video imaging and bipolar resection (TUR-IS) offers a high level of safety. Despite optimal equipment, intra- and postoperative complications in transurethral electrosurgery of bladder tumors may occur.

[Organ and kidney function preservation in renal cell carcinoma]

BACKGROUND

The organ-preserving partial nephrectomy has increasingly established itself in small unilateral renal tumours (<4 cm) with contralateral healthy kidney and counter gained in recent years in importance. There was found a significantly increased cardiovascular mortality rate and deteriorated quality of life, the more intact kidney tissue has been removed.

OBJECTIVES

In the present study, the influence of pre- and perioperative factors on direct postoperative course was examined, including 5-year survival rate and relapse behaviour after open organ-preserving partial nephrectomy in our own collective.

MATERIALS AND METHODS

In this retrospective study of 1657 patients were collected, who underwent surgery between 2007 and 2013 in the Department of Urology at the University Hospital Essen because of a renal tumour. 38 % of these operations (n = 636) were performed organ-preserving. In this trial there are factors identified that have an impact on need of blood transfusion and length of hospitalization in organ-preserving operation method.

RESULTS

No independent parameter can be determined for the need of blood transfusion. Tumour size and thus time of resection procedure does not affect the need of erythrocytes administration. In addition, the tumour size influences neither the postoperative serum-haemoglobin nor serum-creatinine. Increased patient age and female gender are identified as non-modifiable factors, which cause a longer hospitalisation. Postoperative pain therapy can be considered as a variable size, which does not affect the length of hospital stay. Modifiable factors that increase the overall length of stay, however, are the type of direct postoperative monitoring (ICU vs. anaesthetic recovery room) and the administration of blood transfusions.

CONCLUSIONS

There are constant factors, which can be associated with a longer residence time in the framework of an organ-preserving partial nephrectomy. Further there is shown evidence of the independence of the tumour size - in addition to proven good oncological results - of an extension of indication of organ-preserving nephrectomy of tumours > 4 cm.

[Urological surgery with analogosedation and local anesthesia. What makes sense?]

OBJECTIVE

Analogosedation and local anesthesia, including regional nerve blocks are used for endoscopic diagnostic or radiological and ultrasound-guided procedures in which the patient should not move or has to be free of pain. We retrospectively analyzed patient satisfaction, complications and the risk of urological interventions with analgosedation and/or local anesthesia between 2008 and 2012.

MATERIAL AND METHODS

In total 21,690 urological patients underwent surgical treatment at the Department of Urology of the University Hospital of Essen between 2008 and 2012 and 3,327 of these cases were performed by urologists with the patient under analogosedation (n=1484) and local anesthesia (n=1843). In total 13 surgical and endoscopic procedures were separately analyzed and evaluated for safety and practicability.

RESULTS

In five cases (0.15%) the procedures with analgosedation or local anesthesia were interrupted because of agitation (n=3) and in one case the transurethal resection was stopped due to a large bladder tumor. One patient suffered anaphylactic shock after preoperative intravenous application of cefuroxim 1.5 g. After cardiopulmonary resuscitation and a short stay on the intensive care unit the patient was discharged after 2 days.Conclusions. Local anesthesia and analgosedation should be performed by urologists for minor surgery, endoscopic procedures and radiological or ultrasound-guided treatment. For safety reasons there should always be a second medical doctor present for assistance. Analgesia with deep sedation or loss of defensive reflexes should be administered by anesthesiologists.

[Failure to attend appointments: data analysis of a urological group practice over 12 months]

PURPOSE

A well-structured system of appointments is mandatory in urological practices to provide a perfect work flow. A huge problem is appointments which are not cancelled by non-attending patients and remain free during consultation hours.

METHODS

An analysis of the electronic calendar of our group practice was performed from January 2010 to December 2010.

RESULTS

In 2010, 24,764 appointments in consultation hours were scheduled and of those 1,348 (5.4%) were not cancelled but not attended by the patients. Out of 1,760 X-ray investigations 59 (3.3%) patients did not show up and of 3,828 cystoscopy appointments, 109 (2.8%) patients did not cancel although they did not attend. A total of 440 outpatient appointments for surgery were scheduled and 8 (1.8%) patients did not attend but did not cancel surgery. Out of 176 (11.4%) scheduled spermiogram appointments, 20 patients did not bring a sample for analysis.

CONCLUSIONS

Due to the experiences of the authors, combined investigations, e.g. intravenous pyelogram (IVP) and cystoscopy on one day, should therefore be avoided in order to be able to cancel the second appointment when patients do not show up for the first appointment. In cases of surgical interventions, patients should be contacted by telephone 2-3 days prior to surgery for confirmation. Currently under German law there is no way to claim compensation for missed appointments from the patients. Thus, the only way to avoid large numbers of missed appointments is to keep those as low as possible, as soon as appointments are made and scheduled (e.g. no double appointments).

Global Functional Disconnections in Post-anoxic Coma Patient

Disorders of consciousness have been related to different disconnection patterns as assessed by neuroimaging tools such as PET or fMRI. In this report, we use resting-state functional MRI acquisition and a functional connectivity analysis by graph of brain networks, to investigate the global residual connection pattern in a patient with consciousness disorders following post-anoxic injury. We then compare this pattern with those of a group of twenty controls. We observed that the patient's graph presents multiple disconnections in primary areas and in high-order associative areas. This pattern is consistent with a vegetative state, as reported by other groups. Further, the informations conveyed by this approach are consistent with those provided by PET, fMRI and EP. This new approach presents a very strong potential for diagnosis for consciousness disorder patients since it is applicable very early after the insult.

[Perioperative antibiotic prophylaxis in radical retropubic prostatectomy: a randomised pilot study of perioperative and postoperative administration]

PURPOSE

A standard protocol for perioperative antibiotic prophylaxis in radical retropubic prostatectomy has not been established until now. The present pilot study compared the perioperative single-dose of piperacillin/tazobactam to the administration of ciprofloxacin or cotrimoxazol for 5 days with regard to postoperative infections. For the first time these antibiotic regimes were described in radical retropubic prostatectomy.

MATERIAL AND METHODS

The patients were divided into three groups, each consisting of 17 patients: group 1: a single-dose of piperacillin / tazobactam 4.5 g i. v., group 2: ciprofloxacin 500 mg or cotrimoxazol 960 mg i. v. / p. o. and group 3: varying administration and duration of different kinds of antibiotics as control group. The basic characteristics of the patients such as age, body-mass-index, risk factors, diseases, former surgeries and medication were similar between all three groups. Also there were no significant differences in intraoperative parameters such as operation time, blood loss and other postoperative complications.

RESULTS

The piperacillin / tazobactam group showed a significantly lower body temperature on postoperative days (POD) 1-3. The laboratory values were not significantly different among the groups, except the piperacillin / tazobactam group showed a significantly lower CRP level on POD 1-3 than group 3. All antibiotic regimes could afford an efficient protection: None of the patients died and there were no cases of serious consequences such as pneumonia, urosepsis or bacteriuria. Although not statistically significant, the piperacillin / tazobactam group showed better clinical outcomes: here the length of hospitalisation was two days less than in the other groups, no cases of wound infection occurred, the antimicrobial resistance rates were lower and fewer patients were treated with antibiotics in the postoperative course.

CONCLUSIONS

Comparable to similar studies with a larger number of patients our pilot study demonstrated, although statistically not significant, better clinical results overall. We therefore conclude that a single-dose of piperacillin / tazobactam appears to be an efficient antibiotic prophylaxis in radical retropubic prostatectomy and even in some clinical parameters piperacillin / tazobactam seems to be equivalent or better than the usual 5-day administration of antimicrobial prophylaxis.

[Treatment of vesico-enteric fistulae in men. Pedicled bladder flap]

Genitourinary fistulae represent a rare condition for patients submitted to salvage radiotherapy due to local tumour relapse after radical prostatectomy. Nevertheless, it is associated with great morbidity and in many cases with repetitive surgeries limiting their quality of life. Many techniques have been proposed to reduce the incidence of early and late postsurgical complications, but up to now a safe and unique method to treat this disease has not been reported in the literature. Here we report on three cases of male patients who developed a vesicoenteric fistula after radiation salvage therapy following radical prostatectomy. A rotation bladder flap was used to cover the pelvic floor attempting to reduce the common complications. All of the patients underwent a urinary diversion and a protective colostomy. The 1-year follow-up showed good postsurgical outcomes with minor early complications and no signs of intestinal obstruction or recurrent fistula. Furthermore, perineal and pelvic pain improvement was also achieved.The small number of cases is a limiting factor in defining standard techniques for the treatment of actinic vesicoenteric fistulae. Nevertheless, the use of a rotational bladder flap for repair of the pelvic floor defect has shown promising results and should be indicated in special situations.

[Pudendal block or combined spinal-epidural anaesthesia in high-dose-rate brachytherapy for prostate carcinoma?]

PURPOSE

In male patients the pudendal block has been applied only in rare cases as a therapy for neuralgia of the pudendal nerve. Up to now there is no comparison of pudendal block with an anaesthesia form close to the spinal cord. In this pilot study the bilateral perineal infiltration of the pudendal nerve was compared to combined spinal-epidural anaesthesia in high-dose-rate (HDR) brachytherapy.

MATERIAL AND METHODS

In 30 patients (68.8 +/- 5.4 years) who underwent a core needle biopsy for high-risk prostate carcinoma, an HDR brachytherapy in CSE or NPB was carried out. Both anaesthesia forms were examined concerning the perioperative compatibility, the subjective feeling (German school marks principle 1-6), the pain feeling (VAS, 1-10) and the early postoperative course (mobility, complications).

RESULTS

Both anaesthesia procedures were offered to all patients. For 2 patients the NPB was favoured primarily, because they had undergone surgery of the lumbal spine, so that the CSE was not applicable. There was no change of anaesthesia form necessary. The expense of time for NPB was 10.5 +/- 2.5 min, for CSE 30.5 +/- 5.5 min (p < 0.005). The hollow needles remained in place on average for 79 +/- 11.7 min (p = 0.23). Inter- and postoperative pain feelings were in both groups between 1.3 +/- 1.1 and 1.1 +/- 1.0 (p = 0.61 and p = 0.29). The difference is not significant. The NPB group considered postoperative mobility as an advantage. All patients felt the bladder catheter as annoying, but the NPB group considered postoperative mobility as more important than complete lack of pain. The subjective feeling in the NPB group was described as 2.06 +/- 0.59 and in the CSE group 2.73 +/- 0.79. This is a significant difference (p < 0.005). No side effects or complications in both anaesthesia forms appeared.

CONCLUSIONS

The perineal pudendal block is equivalent to epidural anaesthesia in HDR brachytherapy. Concerning the objectifiable pain score measurement and the subjective feeling there are no essential significant differences.

[Informed consent for patients on early recognition of prostate carcinoma is insufficient]

Men that undergo an early detection investigation should be informed of the advantages and disadvantages as well as of the therapeutic consequences. In this study the quality of information was checked using the state of scientific knowledge of the patients.An informative consultation was carried out before the early detection investigation using a clarification brochure and an examination by a urologist. A questionnaire was also filled out after the investigation. A total of 1,536 men were questioned. Although 47% of the men had previously undertaken a PSA at least once, only 55% knew their own test result. Subjectively 82% of men felt well informed. In contrast one-third did not know the significance of an increased PSA level. In the field of patient clarification for the early detection for prostate cancer there are considerable deficits but the information received was considered adequate by the participants. However, more than one-third did not understand the significance of the PSA level.

[Molecular aspects of lymph node metastasis]

The risk of local and systemic lymphatic metastasis of a tumor increases with the size of the malignant neoplasia. Lymph vessels are generated in the tumor and seem to follow anatomically defined pathways. However, the precise molecular and biological mechanisms seem to be complex and require definition. At present, molecules belonging to the vascular endothelial growth factors family and podoplanin have been identified as key for the proliferation of the tumor's lacteals. Molecular mechanisms of the tumor origin and the hematogenic and lymphatic dissemination are increasingly better defined by the use of new diagnostic and therapeutic approaches for tumor patients. Simultaneously, we might be able to influence processes such as cell growth, apoptosis, angiogenesis, and lymphogenic dissemination by novel drugs and thereby develop novel approaches for tumor treatment. Chemokine receptors seem to control essential steps of lymphogenic dissemination such as migration, invasion, and proliferation of tumor cells.

[Proapoptotic antibodies as new therapeutic agents for tumor treatment]

To convert the concept already successful in mice into clinical practice and commercialize it, a human anti-CD95-antibody must be produced. In a second step experiments must be performed on various normal healthy cells and tissues to determine whether these human anti-CD95-antibodies administered in very low doses have any effect on human cells (particularly hepatocytes) or at least cause only minimal side effects. If these studies yield positive results, then clinical trials can be conducted in which increasing doses are given to exclude an acute hepatotoxic effect and then the effect exerted by the antibody in combination with irradiation on tumor growth can be investigated.The advantage of this concept lies in the fact that systemic stimulus (low doses of anti-CD95-antibodies) is highly intensified by local radiotherapy and only then initiates cell death. Since the anti-CD95-antibodies trigger apoptosis primarily in tumor endothelia, this approach could be employed not only for prostate cancer and melanomas, which have already been tested, but also for many other tumors.

[Dynamic transrectal ultrasound (dTRUS): a new method to diagnose anastomotic insufficiency after radical retropubic prostatectomy]

PURPOSE

To prove extravasation after radical retropubic prostatectomy (RRP) nowadays a cystoradiogram is essential. In the present study the diagnostic value of dynamic transrectal ultrasound and cystoradiogram to find an extravasation was compared.

MATERIALS AND METHODS

For detection of an extravasation Cystoradiogram and dTRUS were performed in 250 patients who had undergone RRP. TRUS was performed dynamically, that means that the urinary bladder was filled up with common salt solution backwards by using the transurethral catheter. Anastomosis was inspected by transrectal ultrasound. Detectable extravasation was measured and documented. To verify the results a cystoradiogram was carried out afterwards. In cases of detectable extravasation the results of measurement were compared to the results of dTRUS.

RESULTS

The mean age was 65 years. An extravasation could be detected in 46% within the first 7 days and in 18% after 14 days. At day 21 an extravasation could not be seen in any patient. Seven days postoperative the mean volume of extravasation was 11 ml (3-50 ml) and after 14 days 9 ml (3-25 ml) for dTRUS. For cystoradiogram 12 ml (3-45 ml) and 9 ml (4-23 ml), respectively. The average time until catheter removal was 8 days (5-35 days). 60% of the patients were continent immediately after removing the catheter, 40% were incontinent for not more than 3 months after removal of the catheter (35% ICS I and 5% ICS II). A prolonged urinary incontinence and serious postoperative complications were not observed.

CONCLUSION

Dynamic transrectal ultrasound is a reliable and reasonable method to identify extravasation after RRP. Furthermore radiation exposure (on average 60 cGy/cm(2)/cystoradiogram) can be avoided by replacing the cystoradiogram with dTRUS slips with the dTRUS.

Urogenitale Symptome und urologische Interventionsmöglichkeiten in der palliativen Situation

During the course of malignancies of nearly all tumor entities the urogenital organs are frequently influenced. The resulting disorders are subsumed under the term"urogenital symptoms". Especially with the goal of improving quality of life these symptoms have to be treated with respect. In addition further therapeutic measures, e.g. the application of a palliative chemotherapy, makes an unobstructed urinary excretion necessary. This article gives an overview of the indications for treating urogenital symptoms and contrasts different therapy concepts.

[Effect of disturbing factors on the specificity of exfoliative urinary cytology]

In the clarification of hematuria and subsequent treatment, a high specificity is expected from urinary cytology when no tumor is present, because false positive results lead to unnecessary diagnostic measures. The aim of this study was to investigate different disturbing factors to determine the specificity of urinary cytology and whether the specificity can be increased by cytometry. Out of 150 patients with no malignant disease, 125 were affected by the following disturbing factors: urinary infection, urolithiasis, transurethral electroresection, utilisation of hypo-osmolar flushing solution or administration of contrast agents. In 5 patients who were diagnosed with urinary infection or urolithiasis, the urine was falsely cytologically determined to be tumor positive, an error which was corrected by cytometric analysis. Therefore, cytometric analysis should be carried out in patients in whom a tumor has been cytologically diagnosed in order to increase the specificity of urinary cytology.

Einsatz der Siliziumchiptechnologie zur Detektion von Tumormarkern auf Proteinbasis beim Harnblasenkarzinom

The protein structure of human tumor tissue has a significant influence on the molecular attributes. It was demonstrated that the individual prognosis of tumor patients is among other things dependent on molecular tumor tissue characteristics.A promising marker is E-cadherin, an adhesion glycoprotein which plays a central role in the mediation of cell-cell contacts. Aberrant E-cadherin expressions were described in several tumors such as in bladder cancer. This was also found to be correlated with tumor invasion and survival. There are hardly any fast, quantitative and easily automated protein assays in everyday practice which can analyze several markers at the same time. With silicon chip technology we have a new detection and measurement method which makes it possible to give a quantitative analysis of numerous different proteins in tissue, urine, or serum in a few minutes.

Immuntherapie des metastasierten Nierenzellkarzinoms mit Interleukin-2, Interferon-α2a und Erythropoetin-β

BACKGROUND

The combination of interferon-alpha2a (IFN-alpha2a) and interleukin-2 (IL-2) induces objective responses in patients with metastatic renal cell carcinoma (MRCC). Anaemia is associated with poor cancer control and reduced quality of life. The aim of the study was to investigate response rate and quality of life in patients with MRCC receiving the combination of Erythropoetin, IFN-alpha2a and IL-2.

MATERIAL AND METHOD

Patients with MRCC received epoetin beta (150 IU/kg and haemoglobin <130 g/l or 75 IU/kg and haemoglobin >or=130 g/l) three times weekly, from 14 days before and continuing throughout immunotherapy. In weeks 3-6 the patients received IFN-alpha2a 6 x 10(6) IU/m2 and IL-2 4.5 x 10(6) IU/m2 three times weekly on days 1, 3 and 5. The treatment was repeated two times and in the case of success a third cycle was added. The quality of life was assessed with the FACT questionnaire for fatigue, before, during and after therapy.

RESULTS

A total of 21 patients were treated, 19 of whom could be evaluated concerning response, toxicity and quality of life. We observed 1 complete remission, 2 partial remissions, 5 cases of stable disease and 11 with progressive disease. The overall response rate was 16%. Toxicity was mild to moderate; there were no WHO grade III or IV toxicity. The quality of life increased in ten patients, nine of whom exhibited an increase in their haemoglobin during therapy. Five of the nine patients with decreased quality of life also experienced a decrease in their haemoglobin. The correlation of increased haemoglobin and quality of life was significant (p<0.05).

CONCLUSION

The combination of IFN-alpha2a, IL-2 and epoetin beta resulted in objective remissions with mild to moderate toxicity. The quality of life correlates significantly with increasing haemoglobin.

[High-dose rate brachytherapy for high-risk prostate cancer]

To estimate disease-free survival it is necessary to allocate patients into tumor risk groups: locally advanced prostate carcinoma with extracapsular spread or localized prostate carcinoma of tumor stage T2c or one of the risk factors PSA >20 or Gleason > or =8 apply for the high-risk group. Intermediate-risk carcinomas are those belonging to tumor stage T2b or with PSA >10-20 or Gleason 7. Particularly for patients with intermediate and high-risk disease early PSA relapse is of major interest. This phenomenon could be a consequence of current inadequate imaging of lymph node or bone metastasis or as a consequence subclinical metastatic spread remains undetectable during radical treatment. However, tumor biology itself could lead to the progression of the disease in the high-risk group. As a consequence, risk-adapted therapy is very important in these cases. The applied radiation dose plays an important role in radiotherapy. Several publications have shown that the biochemical relapse correlates with the generally accepted risk factors and the radiation dose. Regarding this, high-quality treatment planning and HDR brachytherapy combined with EBRT (external beam radiation therapy) leads to good treatment results in selected groups. So far in our own experience, HDR brachytherapy in combination with EBRT is a successful form of treatment with few acute and late side effects in the first 42 patients examined. First results concerning to PSA relapse-free time, quality of life, miction, and erectile function are promising.

Was muss ich praktisch bei der Umsetzung einer Chemotherapie beachten?

The patient stands at the center of a chemotherapy. The aim of the curative or palliative treatment is not only the death of the tumor cells, but also the maintenance or improvement of the patient's physical condition, especially the improvement of quality of life. Before starting the therapy, it is necessary to determine, for example, the patient's general condition and motivation, and to carry out a consultation. Examinations, for example, blood tests, audiograms, renal function and lung function should also be made. Thus, the patient's tolerance for even the most onerous chemotherapy can be investigated and patients can be individually prepared for the treatment.

Inhalative Immuntherapie beim pulmonal metastasierten Nierenzellkarzinom

Studies on immunotherapy with inhaled interleukin-2 (IL-2) for the treatment of pulmonary metastases in renal cell carcinoma patients have indicated objective response rates of 11%. The aim of the present study was to evaluate efficacy, toxicity, and quality of life during inhaled immunotherapy with IL-2. Patients with pulmonary metastases of renal cell carcinoma were treated with interferon-alpha (IFN-alpha) 3 x 10(6) IU/m(2) s.c. on days 1, 3, and 5 and inhaled twice a day 9 x 10(6) IU IL-2 on days 1-5. Treatment continued for 4 weeks and after a 2-week rest a second cycle was given. Patients who responded received two additional cycles. Quality of life was assessed according a self-administered quality of life questionnaire (QLQ-C30) before, during, and after therapy. Of 23 treated patients, 21 could be evaluated concerning response rate and toxicity [16 men, 5 women; median age: 60 years (38-72 years)]. Sixteen patients had pulmonary metastases only and five patients additionally had bone or liver metastasis or local recurrence. One patient (5%) developed a partial remission for 4 months and ten patients (47.5%) showed a stable disease for a median time of 6 months (2-24 months). The median follow-up was 9 months (3-26 months). Ten patients (47.5%) developed progressive disease. Maximal toxicity was mild and grade III-IV toxicity (WHO) was not observed. The patients' quality of life did not change significantly at any time during therapy. Inhaled immunotherapy is a treatment option with little toxicity, but achieved only a few objective responses. Whether or not it influences overall survival could not be answered in this study.

Treatment of penile curvature--how to combine the advantages of simple plication and the Nesbit-procedure by superficial excision of the tunica albuginea

Different treatment options for penile curvature exist, such as the Nesbit procedure with complete excision of the tunica albuginea or the simple plication. We prefer a modification with only superficial excision, not opening the corpora cavernosa. From January 1997 to June 2000, 68 patients were treated surgically due to penile curvature. Data was obtained from 48 patients by telephone interview. The mean penile deviation was 46 degrees. Excision of the tunica was performed only superficially and non-absorbable inverted sutures were used. The mean follow-up time in this study was 25 months. A total of 36 (75%) patients were satisfied postoperatively, 12 were unsatisfied. Eleven (23%) patients described a complete straightening, 37 (77%) a rest-curvature of 5-50 degrees (mean 14 degrees ) and 21 (44%) described a shortening of 0.5-5 cm (mean 1.2 cm). Six patients reported a recurrence. No new erectile dysfunction occurred. Superficial excision of the tunica albuginea offers the advantage of tissue-contraction due to scarring without destroying the integrity of the corpora, leading in combination with non-absorbable inverted sutures to good functional and cosmetic results.