Comparing the accuracy of prediction models to detect clinically relevant post-hepatectomy liver failure early after major hepatectomy

BACKGROUND

Arterial lactate measurements were recently suggested as an early predictor of clinically relevant post-hepatectomy liver failure (PHLF). This needed to be evaluated in the subgroup of major hepatectomies only.

METHOD

This observational cohort study included consecutive elective major hepatectomies at Karolinska University Hospital from 2010 to 2018. Clinical risk factors for PHLF, perioperative arterial lactate measurements and routine lab values were included in uni- and multivariable regression analysis. Receiver operating characteristics and risk cut-offs were calculated.

RESULTS

In total, 649 patients constituted the study cohort, of which 92 developed PHLF grade B/C according to the International Study Group of Liver Surgery (ISGLS). Lactate reached significantly higher intra- and postoperative levels in PHLF grades B and C compared to grade A or no liver failure (all P < 0.002). Lactate on postoperative day (POD) 1 was superior to earlier measurement time points in predicting PHLF B/C (AUC 0.75), but was outperformed by both clinical risk factors (AUC 0.81, P = 0.031) and bilirubin POD1 (AUC 0.83, P = 0.013). A multivariable logistic regression model including clinical risk factors and bilirubin POD1 had the highest AUC of 0.87 (P = 0.006), with 56.6% sensitivity and 94.7% specificity for PHLF grade B/C (cut-off ≥0.32). The model identified 46.7% of patients with 90-day mortality and had an equally good discriminatory potential for mortality as the established ISGLS criteria for PHLF grade B/C but could be applied already on POD1.

CONCLUSION

The potential of lactate to predict PHLF following major hepatectomy was inferior to a prediction model consisting of clinical risk factors and bilirubin on first post-operative day.

Ennoblement, corrosion, and biofouling in brackish seawater: Comparison between six stainless steel grades

In this work, six common stainless steel grades were compared with respect to ennoblement characteristics, corrosion performance and tendency to biofouling in brackish sea water in a pilot-scale cooling water circuit. Two tests were performed, each employing three test materials, until differences between the materials were detected. Open circuit potential (OCP) was measured continuously in situ. Potentiodynamic polarization and electrochemical impedance spectroscopy (EIS) measurements were conducted before and after the tests. Exposed specimens were further subjected to examinations by scanning electron microscopy (SEM) and energy-dispersive spectroscopy (EDS), and the biofouling was studied using epifluorescence microscopy, quantitative polymerase chain reaction (qPCR) and high-throughput sequencing (HTP sequencing). The results revealed dissimilarities between the stainless steel grades in corrosion behaviour and biofouling tendency. The test material that differed from the most of the other studied alloys was grade EN 1.4162. It experienced fastest and most efficient ennoblement of OCP, its passive area shrank to the greatest extent and the cathodic reaction was accelerated to a significant degree by the development of biofilm. Furthermore, microbiological analyses revealed that bacterial community on EN 1.4162 was dominated by Actinobacteria, whereas on the other five test materials Proteobacteria was the main bacterial phylum.

Leiomyoma of the urinary bladder

We report a case of rare benign bladder leiomyoma. The patient was a 42-year old man complaining impotence. Digital rectal examination revealed a palpable pelvic tumor. Transurethral ultrasonography, computed tomography (CT), and magnetic resonance image (MRI) examinations all showed a cystic tumor measuring 10 x 8 cm. On the basis of these findings leiomyoma was suspected already before operation. The tumor was removed by open resection of bladder, and the diagnosis was confirmed by histology and positive immunohistochemistry.

Leiomyoma of the urinary bladder

We report a case of rare benign bladder leiomyoma. The patient was a 42-year old man complaining impotence. Digital rectal examination revealed a palpable pelvic tumor. Transurethral ultrasonography, computed tomography (CT), and magnetic resonance image (MRI) examinations all showed a cystic tumor measuring 10 x 8 cm. On the basis of these findings leiomyoma was suspected already before operation. The tumor was removed by open resection of bladder, and the diagnosis was confirmed by histology and positive immunohistochemistry.

Management of testicular cancer--16 years' experience from southwest Finland

OBJECTIVE

This study investigated the outcome of testicular cancer treatment in Finland.

MATERIAL AND METHODS

Data on 88 testicular cancer patients treated in Turku University Central Hospital between 1976 and 1992 were studied to analyse outcome and survival.

RESULTS

The histological diagnosis was seminoma for 39 patients and non-seminoma for 49 patients. Two seminoma patients relapsed (5%) and one patient died of progressive disease (3%; initially stage II seminoma). Eleven non-seminoma patients relapsed (22%), nine of whom were cured with chemotherapy. Four non-seminoma patients died of progressive disease (8%; initially one stage I non-seminoma and three stage III non-seminomas). The median time to relapse after the completion of treatment was 9 months (range 3-50 months). Non-seminoma patients had significantly more relapses than seminoma patients (p = 0.03). Most relapses (73% of the non-seminoma relapses) were found among the stage I non-seminoma patients who had not received adjuvant chemotherapy, while none of the stage I seminoma patients relapsed (p = 0.007).

CONCLUSIONS

Close surveillance is important for all non-seminoma patients to guarantee the early detection and treatment of recurrent disease. Treatment and surveillance should be covered by national guidelines and be conducted in centres with special interest in this rare but mostly curable cancer.

Interferon-alpha inhibits cyclooxygenase-1 and stimulates cyclooxygenase-2 expression in bladder cancer cells in vitro

The enzymes cyclooxygenase-1 (Cox-1) and cyclooxygenase-2 (Cox-2) catalyze the initial step in the formation of prostaglandins (PGs). PGs are known to be involved in numerous processes, for example inflammation, immune responses, carcinogenesis, and tumor angiogenesis. The formation of PGs is stimulated in various cancers since the expression of Cox-2 is upregulated. Interferon (IFN)-alpha is used in the treatment of bladder cancer, although not all of the effects of such treatment are thoroughly known. Therefore, we investigated the expression of cyclooxygenases in two bladder cancer cell lines, 5637 and T24, under basal conditions and in the presence of human recombinant IFN-alpha (100, 1,000, and 10,000 U/ml). The mRNA of Cox-1 and Cox-2 was expressed in both cultured bladder carcinoma cell lines. The level of Cox-1 expression was low in 5637 cells and higher in T24 cells. In contrast, Cox-2 expression was prominent in 5637 cells and low in T24 cancer cells. The highest IFN-alpha concentration (10,000 U/ml) decreased the expression of Cox-1 to 47 and 28% of the control levels in 5637 and T24 cells, respectively. In contrast, Cox-2 expression increased in both cell lines. In 5,637 cells, Cox-2 expression increased 1.3-fold with 10,000 U/ml of IFN-alpha. In T24 cells, the maximum effect was achieved by 1,000 U/ml of IFN-alpha, which increased the expression of Cox-2 up to 2.4-fold. These findings may have relevance in the outcome of patients treated with IFN-alpha because upregulated Cox-2 expression may suppress the cell-mediated defense system. On the other hand, the inhibition of Cox-1 could be beneficial because Cox-1 is known to stimulate angiogenesis.

Evaluation of p21WAF1/CIP1 and cyclin D1 expression in the progression of superficial bladder cancer. Finbladder Group

Immunoreactivity of p21WAF1/CIP1 and cyclin D1 proteins was assessed in a cohort of 207 patients with superficial (pTa-pT1) bladder cancer followed up for a mean of 4.9 years. The results of the immunostainings were compared with T category, WHO grade, tumor cell proliferation rate (MIB-1 score), the expressions of p53 and bcl-2 as well as survival. Sixty-eight percent and 75% of the tumors were p21WAF1/CIP1 positive (> or = 5% of cells positive) and cyclin D1 positive (> or = 10% of cells positive), respectively. The p21WAF1/CIP1 expression was related to cyclin D1 immunolabelling (P < 0.001) but not to the other variables studied. The expression of cyclin D1 was inversely associated with T category (P = 0.001), WHO grade (P = 0.006), MIB-1 score (P = 0.014), p53 expression (P = 0.001), and bcl-2 (P = 0.011) immunoreactivity. In univariate analysis, T category (P = 0.0001), WHO grade (P < 0.0001), MIB-1 score (P < 0.0001), bcl-2 (P = 0.0092), p53 (P = 0.0016) and p21WAF1/CIP1 (P = 0.009) expressions were significant prognostic factors with regard to tumor progression, whereas cyclin D1 was without any prognostic significance (P = 0.1). Out of 123 p21 positive tumors 21 progressed, whereas only 2 out of 58 p21 negative tumors progressed. In multivariate analysis, the MIB-1 score was the only independent predictor of cancer-specific survival (P = 0.03), whereas tumor grade (P = 0.002) and cyclin D1 expression (P = 0.04) were independent predictors of tumor recurrence. Only the WHO grade (P = 0.04) retained its prognostic value indicating the risk of progression. We suggest that in superficial bladder cancer p21WAF1/CIP1 and cyclin D1 immunohistochemistry provide no additional prognostic information compared with already established prognostic factors for predicting the risk of progressive disease.

Prognostic value of MIB-1 score, p53, EGFr, mitotic index and papillary status in primary superficial (Stage pTa/T1) bladder cancer: a prospective comparative study. The Finnbladder Group

OBJECTIVE

A prospective randomized study was undertaken to determine whether cell proliferation indices (M/V index, MIB1), papillary status, the expression of p53 and epidermal growth factor receptor (EGFr) have prognostic value in superficial (pTa-pT1) bladder cancer (SBC).

METHODS

207 patients with primary SBC were followed up over a period of 4.9 (range 3.7-6.0) years. M/V index and papillary status were assessed by light microscopy, and expression of MIB1, p53 and EGFr was assessed by immunohistochemistry. The results of histopathological analyses were related to the survival data of the patients.

RESULTS

Using univariate analysis, stage (p < 0.001), grade (p < 0.001), papillary status (p < 0.001), MIB1 (p < 0.001), M/V index (p < 0.001), EGFr (p < 0.001) and p53 (p = 0.002) were significant predictors of progression. Using multivariate analysis, MIB-1 score and papillary status were independent predictors of progressive disease and cancer-specific survival. Tumor grade was the only independent predictor of recurrence.

CONCLUSION

Evaluation of tumor cell proliferation rate by M/V index or by MIB1 immunohistochemistry and assessment of papillary status by light microscopy are useful prognostic tools in tailoring treatment and follow-up schedule of patients with SBC.

Transurethral resection with perioperative instilation on interferon-alpha or epirubicin for the prophylaxis of recurrent primary superficial bladder cancer: a prospective randomized multicenter study--Finnbladder III

PURPOSE

We evaluated the efficacy of single dose of interferon or epirubicin administered immediately after transurethral resection compared with transurethral resection only on the recurrence of primary (not recurrent) superficial bladder cancer.

MATERIALS AND METHODS

A total of 283 patients with stages Ta to T1 primary superficial, grades 1 to 3 bladder cancer was randomized into study groups 1-transurethral resection only, 2-transurethral resection plus 50 million units interferon-a2b and 3-transurethral resection plus 100 mg. epirubicin. Eligible for final analysis were 200 patients, including 66 in group 1, 66 in group 2 and 68 in group 3. Patients were followed with cystoscopy every 3 months for 2 years or until the initial recurrence.

RESULTS

Group 3 had the most favorable outcome, since 45 of the 68 patients (66%) were without recurrence after 2 years compared to 24 of the 66 (37%) in group 2 and 26 of the 66 (40%) in group 1 (log rank test p <0.001). Side effects were mostly mild and transient, and no differences were found among the groups.

CONCLUSIONS

A single 100 mg. dose of epirubicin given intravesically immediately after transurethral resection is safe, and significantly decreases the recurrence of primary superficial bladder cancer. A 50 million unit dose of interferon-alpha2b is well tolerated but it has no effect on recurrence as a single dose. The long-term effect of this treatment remains to be studied.

The cytostatic effect of 9-cis-retinoic acid, tretinoin, and isotretinoin on three different human bladder cancer cell lines in vitro

Retinoids have been shown to have activity in both preclinical and clinical bladder cancer studies but their exact role in its treatment and prevention remains obscure. In this study cytostatic activity of a novel 9-cis-retinoic acid (9-cis-RA) was compared with two other retinoids: tretinoin and isotretinoin, in three different bladder cancer cell lines: RT4 (well differentiated), 5637 (moderately differentiated) and T24 (poorly differentiated). The three retinoids were incubated at concentrations of 0.3, 3 and 30 microg/ml with bladder cancer cells in microtitre plates for 3 and 6 days. The cytostatic effect was estimated by using luminometric measuring of ATP activity of viable cells in suspension. Compared with the older retinoids, tretinoin and isotretinoin, the highest concentration of 9-cis-RA had a cytostatic efficacy in all three bladder cancer cell lines tested. A clear dose response relationship was observed in isotretinoin-treated cultures after 6 days and in all 9-cis-RA-treated cultures. Tretinoin was either ineffective or had a stimulating effect on poorly differentiated tumour cells. To conclude, isotretinoin and 9-cis-RA had a cytostatic effect on human bladder cancer cells in vitro. However, the possibility of stimulating cancer growth at small doses, at least with tretinoin, and toxicity at high doses must be considered when planning clinical trials.

Expression of group II phospholipase A2 in Paneth cells of an adenoma of the rectum. A case report

A case of tubulovillous adenoma in the rectum of a 51-year-old man is presented. The tumour contained numerous Paneth cells which formed well-developed glands in the basal areas. Group II phospholipase A2 and lysozyme were found in the tumour cells by immunohistochemistry. mRNA of group II phospholipase A2 was localized in the tumour cells by in situ hybridization. It was concluded that a considerable part of this rare type of tumour consisted of Paneth cells which were capable of synthesizing group II phospholipase A2.

Transurethral prostatectomy in patients with preoperative bacteriuria: double-blind study with oral fleroxacin and cefalexin

We compared oral fleroxacin and cefalexin in the prevention of postoperative infectious complications after transurethral prostatectomy (TURP) in patients with preoperative bacteriuria. 95 patients underwent TURP due to benign prostatic hyperplasia with preoperative bacteriuria. The therapy consisted of 7 days of oral fleroxacin 400 mg once a day or cefalexin 500 mg three times daily. After 2 weeks, 62% of the urine samples were sterile in the fleroxacin groups but only 37% in the cefalexin group (p = 0.047). Patients in the cefalexin group had also statistically significantly more symptoms of urinary tract infections. After 6 weeks, the bacterial eradication rate was 53% in the fleroxacin group and 37% in the cefalexin group. There were no septicemias. TURP can be performed with reasonable safety with this oral antibiotic therapy.

Homing of mucosal leukocytes to joints. Distinct endothelial ligands in synovium mediate leukocyte-subtype specific adhesion

Inflammation and infection of the gut can be followed by reactive arthritis at a distant joint. Leukocyte recruitment into synovium is essential for this process, but nothing is known about the endothelial adhesion molecules in synovial membrane which direct the homing of activated, gut-derived leukocytes to joints. Here we analyzed the expression of the known endothelial adhesion molecules in inflamed synovium and their function in binding of mucosal leukocytes. Intercellular adhesion molecule-1 (ICAM-1/CD54) and vascular adhesion protein-1 (VAP-1) were most prominently expressed in synovial vessels. All other adhesion molecules were found at lower levels in inflamed synovia, except mucosal addressin which was absent. Binding of macrophages isolated from lamina propria of the gut to synovial endothelium was almost entirely P-selectin-dependent. In contrast, small intestinal lymphocytes and immunoblasts both relied mainly on VAP-1 in recognition of synovial vessels. Thus, endothelial P-selectin and VAP-1 mediate binding of mucosal effector cells to synovium in a leukocyte subtype-selective manner. Antiadhesive therapy against these inducible molecules should ablate the pathogenetic cascade leading to inappropriate homing of leukocytes to joints in arthritis.

Clinical experience with the detubularized ileocecal reservoir and continent appendicoumbilical stoma in urinary diversion

OBJECTIVE

To obtain clinical experience of a reservoir using a detubularized ileocecal segment (Mainz pouch) and continent appendiceal stoma connected to the umbilicus.

METHODS

The operation was performed in 23 patients. The submucosally placed in situ appendix was connected to the umbilicus acting as the continence mechanism and route for self-catheterization. The follow-up period was 8-62 months.

RESULTS

No operative mortality occurred. In 2 patients the postoperative period was complicated by catheter perforation of the appendix. In 4 patients stomal stenosis required excision of the stricture and reanastomosis. All patients are completely continent and catheterization is easy.

CONCLUSION

Both functional and cosmetic results are very satisfactory.

Expression of MIB-1, mitotic index and S-phase fraction as indicators of cell proliferation in superficial bladder cancer. Finnbladder Group

Cell proliferation of transitional cell bladder cancer (TCC) was determined by MIB-1 immunolabeling, volume-corrected mitotic index (M/V index) and S-phase fraction measurement in 207 patients with superficial (Ta-T1) bladder cancer. The results were compared to T category, WHO grade and DNA-ploidy. The MIB-1 score was related to T category (P < 0.001), WHO grade (P < 0.001), DNA ploidy (P < 0,0001), M/V index (P < 0.0001) and fraction of cells in S phase (P < 0.0001). The mean MIB-1 score was 6.37% for G1, 14.59% for G2 and 28.59% for G3 carcinomas (P < 0.001). The MIB-1 score for Ta tumors was 9.24% and for T1 tumors 25.34% (P < 0.001). The M/V index was 3.9 for G1, 11.5 for G2 and 25.9 for G3 tumors (P < 0.0001). The M/V index for Ta tumors was 6.4 and 25.3 for T1 tumors (P < 0.0001). WHO grade 1 tumors had 7.7%, grade 2 tumors 13.8% and grade 3 tumors 21.8% of cells in S phase (P < 0.001). Of grade 1 tumors, 97% were diploid and 3% aneuploid, and 78% of grade 2 tumors were diploid and 22% aneuploid. Of grade 3 tumors, 30% were diploid and 70% aneuploid (P < 0.001). Of Ta tumors, 92% were diploid and 8% aneuploid, respectively, whereas 40% of T1 tumors were diploid and 60% aneuploid (P < 0.0001). The results show that quantitative cell proliferation indices are associated with T category and WHO grade in superficial bladder cancer. The prognostic value of the S-phase fraction and mitotic index has been demonstrated in several previous analyses of prognostic factors while the value of MIB-1 score on bladder cancer prognosis remains to be established in further follow-up studies.

Serum immunoglobulin concentrations and health of dairy calves in two management systems from birth to 12 weeks of age

Fifteen dairy calves were kept with their dams for 5 d after birth and thereafter were fed milk from a nipple pail in individual pens (nursed calves). Another 15 calves were separated from their dams immediately after birth, placed in individual pens, and fed from an open pail (weaned calves). These calves received colostrum for the first three feedings. Serum Ig concentrations and the health of the calves were monitored from birth to 12 wk of age. The serum Ig concentrations developed identically for calves in both groups. A 30-min delay in intake of first colostrum decreased total Ig concentrations in serum by about 2 mg/mL. Occurrence of diarrhea was three times greater for the weaned calves than for the nursed calves. Serum Ig concentrations did not explain the differences in the diarrhea occurrence between the groups. In conclusion, the newborn calves in both management systems acquired equal passive immunity, although the time of first colostrum consumption played an important role. Open pail feeding may increase the incidence of prolonged diarrhea compared with that from nipple feeding.

Alternating mitomycin C and bacillus Calmette-Guerin instillation therapy for carcinoma in situ of the bladder. The Finnbladder Group

PURPOSE

Our aim was to prove if alternating chemotherapeutic and immunotherapeutic instillations improved efficacy and reduced toxicity in patients with carcinoma in situ of the bladder.

MATERIALS AND METHODS

Of 68 carcinoma in situ patients randomly treated with instillations 40 received mitomycin C and 28 received mitomycin C and Pasteur bacillus Calmette-Guerin (BCG) in alternating courses. Mean followup was 33 months.

RESULTS

The complete response rates with mitomycin C and mitomycin C/BCG were 45% and 71% at 3 months, 59% and 82% at 12 months, and 47% and 74% at 24 months, respectively (p = 0.041). The disease-free interval showed the superiority of alternating therapy (p = 0.043). Recurrence rates during the instillation period were 1.834 with mitomycin C and 0.922 with mitomycin C/BCG (p = 0.013). No remarkable side effects developed in the alternating group.

CONCLUSIONS

Therapy of carcinoma in situ with alternating mitomycin C and BCG is more effective than mitomycin C alone. Compared to BCG monotherapy only few side effects occur.

Cytostatic effect of different strains of Bacillus Calmette-Guérin on human bladder cancer cells in vitro alone and in combination with mitomycin C and interferon-alpha

The cytostatic activity of five Bacillus Calmette-Guérin (BCG) strains (Pasteur, Evans, Tice, RIVM and Connaught) on human transitional cell cancer T24 cells was examined. A striking effect was noted even in 2-day cultures, and the effect was more pronounced when the cells were incubated for 5 days with different BCG strains alone. The concentrations needed were about the same as those used in clinical practice (10(9) colony-forming units of Pasteur strain in 100 ml buffered saline solution). Combination with mitomycin C or interferon-alpha-2b potentiated the cytostatic effect. A slight difference in cytostatic activity between different BCG strains was found.