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178 Abstracts

  • Introduction & Objectives

    Since the introduction of tyrosine kinase inhibitors (TKI) in the treatment of metastatic renal cell carcinoma (RCC), prognostic of these patients was significantly approved and a few cases achieved a complete response (CR). However, the benefit of a maintenance treatment, taking into account the cost and tolerance, remains unclear. The purpose of this study is to evaluate and compare the outcome of six patients achieving a complete response on TKI after treatment discontinuation or maintenance.

    Material & Methods

    A retrospective analysis of patients with metastatic renal cell carcinoma who obtained complete response during treatment with TKIs (sunitinib or sorafenib). From a series of 27 patients treated in our department in first line, six patients were identified in complete response on TKI according to RECIST criteria. Median age 64,5 y (range : 49-79y). All with intermediate MSKCC prognosis and received an initial nephrectomy followed by a first line treatment by Sunitinib (n=5 ) or Sorafenib (n=1) . The median number of cycles of TKI to achieve CR was 9 (range : 4 to 17 cycles).

    Results

    Among the six patients who achieved CR with TKI, only one patient don’t interrupt TKI treatment after complete response (26 cycles of sunitinib ongoing to date with a persistent CR), whereas treatment was interrupted in 5 patients  at complete response (1pt) or after further cycles of the same TKI (11 cycles on average). Two of the 5 patients who stopped treatment still in CR (24 & 6 months of follow up). For the 3 other patients, local and or metastatic relapse occurred at 6, 13 & 18 months of treatment interruption. The treatment of relapsing disease was resumption of TKI (sunitinib : 2 pts, Sorafenib :1 pt) preceded by surgery in one case and resulting in a partial response for tow patients and a new complete response for one patient treated with sorafenib.
    Because of a significant early observed toxicity (hypertention , hypothyrreosis, fatigue , thrombopenea and hand & food syndrome ), dose of TKI was reduced after a median of 5 cycles.

    Conclusions

    Parameters associated with achievement of CR are not yet well defined, and we could not define any predictive factors to either stop or give additional cycles of TKI. As such, further research is also needed to identify factors to aid selection of patients who would be at less risk of recurrence after discontinuation of treatment.

  • Introduction & Objectives

    68Ga-DKFZ-11 (68Ga-PSMA) has been suggested as a novel tracer for detecting of PCa relapses and metastases. However there is a limited number of publications about the timing of PSMA PET/CT scan. The aim of the study is to evaluate the diagnostic value of PSMA PET/BT in the diagnosis of recurrent prostate cancer with low PSA levels.

    Material & Methods

    We performed a retrospective analysis in patients who underwent PSMA PET/CT from November 2013 to December 2014 in our department. 53 out of 178 patients who had rising PSA levels (still lower than 5ng/ml), and did not have known metastasis were included in this study.

    Results

    Patients had an average PSA of 1.41 ng/ml. A total of 31 patients (58%) showed at least one extraprostatic or prostatic lesions. Intense pathologic radiotracer uptake was observed in 15 patients (28%) at the site of primary tumor. Lymph node metastases were detected in 19 patients (36%) and bone metastases were detected in 8 patients (15%). A PET positivity rate of 31% (n=4), 54 % (n=13) and 88% (n=14) observed in patients with PSA level of <0.2, 0.2-2 and 2-5 ng/ml respectively. Those with PSA level PSA <0.2, 0.2-2and 2-5 ng/ml had 8% (n=1), 21% (n=5), 56% (n=9) local recurrence 15% (n=2), 42% (n=10), 44% (n=7) lymph node metastasis and %15 (n=2), 8% (n=2), 25% (n=4) bone metastasis. A positive correlation observed between positivity rate and gleason scores (%15 for Gleason 6, %55 for Gleason 7, 75% for Gleason 8 and 77% for Gleason 9). PSMA PET/CT positivity’s confirmed with biopsy (n=3), follow-up (n=26) and conventional imaging studies at the time of the PET/CT (n=11) or during follow up (n=13). According to patient-based analysis of 44 cases %57(n=25) of patients had true positive, %23(n=10) of patients had true negative, %2(n=1) patient had false positive, %18(n=8) of patients had false negative findings which are leading to a sensitivity of 58.1% (95%CI:42.1-72.9%) specificity of 90% (%95CI:%48.6- 98.5). Within the patients who had PSA levels from 0.2 to 5, the sensitivity was %79.3 (%95 CI: %60-91.9).

    Conclusions

    PET/CT with 68Ga PSMA is a valuable tool for assessing recurrence of PCa with a high sensitivity (%79.3) within the patients who has PSA levels between 0.2-5 ng/ml. Additionally PSMA PET/CT can be used in patients with very low (

  • Introduction & Objectives

    In patients with a prostate specific antigen (psa) failure after radical treatment for prostate cancer ,PET/CT with [11C]choline may accurately detect the presence of recurrence.
    Prostate pathology studies suggest in many cases a dominant cancer focus exists within the gland and may be a driver of the aggressiveness of the cancer and the epicenter of recurrence following radiotherapy treatment.
    We investigated the role of integrated [11C]choline PET/CT for target volume selection and delineation  in patients with recurrent prostate cancer following EBRT for a salvage focal Cyberknife Stereotactic Hypofractionated Radiotherapy (SBRT) treatment.

    Material & Methods

    From December 2012 through October 2014 a cohort of 16 patients with a median age of 76 years (range 64 -84) and an history of second locally-recurrent prostate cancer following first salvage Cyberknife SBRT in biochemical relapse after external beam radiotherapy treatment were referred to our department for a focal salvage Cyberknife SBRT.
    Primary EBRT radiotherapy doses ranged from 74 to 79.2 Gy (median 76 Gy) while Cyberknife Sbrt salvage treatment doses ranged from 30-35 Gy in 5 fractions.  The median pre- focal Ck reirradiation PSA was 4,46 ng/ml (range,1,23 -13,04 ng/ml). To reconstruct CTV and organ at risk, CT scan and MRI with T1-T2 sequences were performed and [11C]choline PET/CT images were fuse for focal prostate  target volume definition and delineation.
    In 4 patients focal Cyberknife sbrt treatment consisted of 3 fractions of 10 Gy (total Dose 30 Gy), in the other 12 patients 3 fractions of 12 Gy for a total dose of 36 Gy were delivered. The [11C]choline PET/CT median prostate node volume was of 14,3 cc (range 5,75-65,04).

    Results

    The focal salvage Cyberknife treatment was well tolerated without any rtog grade 3 acute or late toxicity. With a median follow up of 11 months (range 3-22) we observed the following results: No in field recurrence, resulting in a local control of 100%. In 3 patients, respectively at 11, 13 at 21 months after Ck focal treatment we observed a biochemical relapse, a [11C]choline PET/CT detect the presence of a new  local recurrence outside the irradiated field requiring a third Cyberknife focal salvage treatment.

    Conclusions

    In clinical practice, advances in modern imaging show promise for improved detection and characterization of prostate cancer at the different stage of its management including diagnosis, staging treatment planning and follow up. According to available literature [11C]choline PET/CT is not clinically recommendable to plan target volume, nevertheless, our promising data suggest a potential role of [11C]choline PET/CT as an image guide tool for the irradiation of focal prostate cancer relapse. Prospective trials are needed to better define the role of differential prostate treatment on imaging defined GTVs.

  • Introduction & Objectives

    In recent years, nephron-sparing surgery has replaced radical nephrectomy as the treatment of choice for patients with localized renal cell carcinoma (RCC). Oncological outcomes appear to be similar, with less reduction in renal function. Although initially reserved for T1a tumours and imperative indications, partial nephrectomy is now being performed in patients with larger renal masses, when feasible. The aim of this work is to compare laparoscopic versus open partial nephrectomy for the treatment of >4cm RCC.

    Material & Methods

    The authors retrospectively evaluated a group of 81 patients who underwent open or laparoscopic partial nephrectomy for >4cm RCC between January 2005 and June 2015 in a single department. Patient demographics, clinical symptoms, histopathologic factors, intraoperative and postoperative data were compared between the 2 groups. Statistical analysis was performed using SPSS V20.0.

    Results

    A total of 38 (46.9%) laparoscopic and 43 (53.1%) open partial nephrectomies were performed for tumours > 4cm, during the aforementioned period. 62 (76.5%) patients were males and 19 (23.5%) females, with a mean age of 61±1 years, ranging between 26 and 88 years. Most of them were asymptomatic (76.5%) and the most prevalent symptom was flank pain (8.6%). The mean tumour size was 5.48±0.19cm (4.1-16 cm). Pathological stage T1b, T2a, T3a and T3b was found in 66 (81.5%), 6 (7.4%), 8 (9.9%) and 1 (1.2%) of cases, respectively. The majority of tumours were of clear cell histology (49.4%) and Furhman grade 2 (49.4%). There were no statistically significant differences in demographics, presenting symptoms and histopathological factors between the 2 groups. Laparoscopic approach was more often performed in the five latest years (p=0.034). Tumour size was comparable in both open and laparoscopic surgeries (p=0.337), but there were significantly more endophytic tumors in the open surgery group (p=0.05). The mean operative time was 132±6.9min for open surgery and 151±7.2min for the laparoscopic group (p=0.05). Blood loss and warm ischemia time in open surgery (334±62.0mL and 16.6±1.4min) did not differ significantly from laparoscopic approach (307±44.9mL and 19.7±1.0min; p=0.727 and p=0.099, respectively). In the postoperative period, the overall complication rate was 25.9%. Urinary fistula was the most common complication (14.8%), and was not significantly different in both types of surgery (p=0.307). According to the Clavien-Dindo classification, the number of patients with grade 3, 4 and 5 was 13 (16.1%), 1 (1.2%) and 1 (1.2%), respectively. Nephrectomy due to persistent urinary fistula was performed in 1 (1.23%) following laparoscopic and in 6 (7.4%) following open surgery (p=0.761). The length of hospital stay was 7.4±1.3 days and 5.3±0.4 days following open and laparoscopic partial nephrectomy (p=0.137), respectively.

    Conclusions

    For renal tumours larger than 4cm, partial nephrectomy can be performed whenever technically possible with good results and acceptable complication rates. Our data suggest that laparoscopic technique is an effective, minimally invasive therapeutic approach, with no significant increase in warm ischemia time, intraoperative or postoperative surgical complications compared with open surgery. It also has the advantage of an earlier hospital discharge (although not statistically significant in our series).

  • Introduction & Objectives

    Inflammation plays a significant role in development and progression of various solid tumours including prostate cancer. A high neutrophil-to-lymphocyte ratio (NLR) has been reported to be a poor prognostic indicator in several malignancies. We assessed the prognostic role of pretreatment NLR Ratio in metastatic castration-resistant prostate (mCRPC) patients treated with Abiraterone.

    Material & Methods

    Patients treated with Abiraterone 1g daily with Prednisolone 10mg daily were identified from the chemotherapy prescribing system (Chemocare). 149 consecutive patients treated between Jan 2012 and May 2014 were identified. We calculated NLR using pre-treatment baseline bloods and assessed whether this affected their response to abiraterone and overall survival.

    Results

    All patients were performance status of 0 or 1. For the whole population median age was 75.1 years (Range=54.9-88.1); median PSA was 52.3 (Range=0.03-6884), and median NLR was 3.05 (Range 0.8-32.4). Median PFS was 6 months (Range 20 days-31 months) and median survival has not been reached. Based on literature review, a NLR cut off of 4 was adopted. There were 99 patients with an NLR 4. Baseline characteristics in the NLR 4 were well matched in terms of median age (75.6yrs vs 73.8yrs) and median baseline PSA (49.8 vs 56.8). More patients pre-treated with Docetaxel chemotherapy had a high NLR of >4 (48% vs 31.3% vs p=0.046).
     
    More than half (50.7%) of patients achieved ≥50% decline in prostate-specific antigen (PSA). There was no significant difference in response between groups with high and low NLR (53.5% vs 44.9% p=0.32). There was no difference in progression free survival between the groups (6 months) however there was a significant difference in overall survival (OS), with the better OS in the lower NLR group compared to the high NLR group (Not reached vs 17.1 months, p=0.05).
     
    On univariate analysis of baseline variables (age, PSA, haemoglobin and alk phos), only alkaline phosphatase level correlated significantly with PFS and OS time (weak negative correlation, r=-.25, p.002 & r=-0.331, p=0.02). Type of metastases was not predictive of survival in this cohort. When controlled for NLR, there were no differences in PFS, OS or PSA response in patients previously treated with Docetaxel pre-treated versus Docetaxel naïve patients.

    Conclusions

    NLR is an inexpensive, readily available prognostic factor and a high NLR predicts poorer overall survival. But NLR is not a predictive factor for treatment response to Abiraterone in both pre and post Docetaxel setting. Hence NLR is unlikely to aid the clinician in sequencing of hormone therapy and chemotherapy in routine clinical practice. Poor prognostic patients with high NLR do not need to be preferentially treated with Docetaxel chemotherapy.

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