Fabio Zattoni

Choline PET or PET/CT and biochemical relapse of prostate cancer: a systematic review and meta-analysis.

Aim The increase of prostate-specific antigen (PSA) after radical retropubic prostatectomy (RP) or external beam radiotherapy (EBRT) is the most sensitive tool for detecting prostate cancer (PCa) recurrence, although this measure cannot distinguish between local, regional, or distant recurrence. The aim of this meta-analysis was to evaluate the diagnostic performance of 18F-choline and 11C-choline PET or PET/CT in detection of locoregional or distant metastases in PCa. Materials and Methods Medline, Web of Knowledge, and Google Scholar search was carried out in order to select English-language articles dealing with diagnostic performance of both 18F-choline and 11C-choline PET for the detection of PCa recurrence after RP or EBRT. Articles were included only if absolute numbers of true-positive, true-negative, false-positive, and false-negative test results were available or derivable from the text and regarded local, lymph node, and distant metastases. Reviews, clinical reports, and editorial articles were excluded. All complete studies were re-analyzed thus performing a quantitative analysis. Results From the years 2000 to 2012, we found 53 complete articles that critically evaluated the role of choline PET in restaging patients with PCa recurrence. The meta-analysis was carried out and dealt with 19 selected studies (12 studies for all sites of disease, 3 for lymph node metastases, and 4 for local recurrence), with a total of 1555 patients. The meta-analysis provided a pooled sensitivity of 85.6% (95% CI: 82.9%–88.1%) and pooled specificity of 92.6% (95% CI: 90.1%–94.6%) for all sites of disease (prostatic fossa, lymph nodes, and bone), a pooled sensitivity of 75.4% (95% CI: 66.9%–82.6%) and pooled specificity of 82% (95% CI: 68.6%–91.4%) for prostatic fossa recurrence, and a pooled sensitivity of 100% (95% CI: 90.5%–100%) and pooled specificity of 81.8% (95% CI: 48.2%–97.7%) for lymph node metastases. The heterogeneity ranged between 0.00% and 88.6%. The diagnostic odds ratios were 62.123 (95% CI: 24.783–155.72), 5.869 (95% CI: 1.818–18.946), and 138.57 (95% CI: 11.27–1703.8), respectively, for all sites of disease, local recurrence, and lymph node disease. Conclusions Choline PET and PET/CT represent high sensitivity and specificity techniques for the detection of locoregional and distant metastases in PCa patients with recurrence of disease. Moreover, a high diagnostic odds ratio was found for the identification of lymph node disease in patients with biochemical recurrence of PCa.

Utility of choline positron emission tomography/computed tomography for lymph node involvement identification in intermediate- to high-risk prostate cancer: a systematic literature review and meta-analysis.

CONTEXT Determination of tumour involvement of regional lymph nodes in patients with prostate cancer (PCa) is of key importance for the proper planning of treatment. OBJECTIVES To provide a critical overview of published reports and to perform a meta-analysis about the diagnostic performance of 18F-choline and 11C-choline positron emission tomography (PET) or PET/computed tomography (CT) in the lymph node staging of PCa. EVIDENCE ACQUISITION A Medline, Web of Knowledge, and Google Scholar search was carried out to select English-language articles published before January 2012 that discussed the diagnostic performance of choline PET to individualise lymph node disease at initial staging in PCa patients. Articles were included only if absolute numbers of true-positive, true-negative, false-positive, and false-negative test results were available or derivable from the text and focused on lymph node metastases. Reviews, clinical reports, and editorial articles were excluded. All complete studies were reviewed; thus qualitative and quantitative analyses were performed. EVIDENCE SYNTHESIS From the year 2000 to January 2012, we found 18 complete articles that critically evaluated the role of choline PET and PCa at initial staging. The meta-analysis was carried out and consisted of 10 selected studies with a total of 441 patients. The meta-analysis provided the following results: pooled sensitivity 49.2% (95% confidence interval [CI], 39.9-58.4) and pooled specificity 95% (95% CI, 92-97.1). The area under the curve was 0.9446 (p<0.05). The heterogeneity ranged between 22.7% and 78.4%. The diagnostic odds ratio was 18.999 (95% CI, 7.109-50.773). CONCLUSIONS Choline PET and PET/CT provide low sensitivity in the detection of lymph node metastases prior to surgery in PCa patients. A high specificity has been reported from the overall studies. Studies carried out on a larger scale with a homogeneous patient population together with the evaluation of cost effectiveness are warranted.

Comparison between conventional imaging (abdominal–pelvic computed tomography and bone scan) and [18F]choline positron emission tomography/computed tomography imaging for the initial staging of patients with intermediate- tohigh-risk prostate cancer: A retrospective analysis

Abstract Objective. The aim of this study was to evaluate the efficiency of [18F]fluorocholine positron emission tomography/computed tomography (FCH PET/CT) in detecting lymph-node and bone involvement in comparison with conventional imaging, such as abdominal–pelvic CT and bone scan, in the initial staging of prostate cancer (PCa). Materials and methods. The study retrospectively evaluated 48 patients who had FCH PET/CT for the initial staging of PCa. At the same time, 32 of the 48 patients had a bone scan and 26 of the 48 patients had abdominal–pelvic diagnostic CT. Diagnostic performance of FCH PET/CT, i.e. sensitivity, specificity and accuracy, was evaluated on a per-patient basis for the whole population and then separately on a per-risk classification, and later in comparison with conventional imaging. Histological specimens or follow-up data were used as the standard of reference. Results. The overall accuracy of FCH PET/CT for lymph-node involvement was 83.3%. The sensitivity of FCH was higher in the high-risk subset (83.3%) than in the intermediate-risk group (33.3%), whereas FCH specificity was similar. In comparison with dedicated CT scan, FCH PET/CT showed a higher sensitivity and a similar specificity (46.2% vs 69.2% and 92.3% vs 92.3%, respectively). Moreover, the sensitivity and specificity of PET/CT were higher than those of bone scan (100% vs 90% and 86.4% vs 77.2%, respectively). In contrast with conventional imaging, PET/CT changed the staging of the PCa in 33.3% patients. Conclusions. The efficiency of FCH PET/CT in detecting both bone and lymph-node involvement of PCa at initial staging was found to be higher than that of conventional imaging. Prospective clinical trials are needed to confirm these findings.

Effect of Allogeneic Intraoperative Blood Transfusion on Survival in Patients Treated With Radical Cystectomy for Nonmetastatic Bladder Cancer: Results From a Single High-Volume Institution

BACKGROUND Previous studies have demonstrated that perioperative blood transfusion (BT) is associated with a significantly increased risk of cancer recurrence and mortality after radical cystectomy (RC). Recently, it was shown for the first time that intraoperative transfusion has a detrimental effect on cancer survival. The aim of the current study was to validate this finding in a single European institution. PATIENTS AND METHODS The study focused on 1490 consecutive nonmetastatic bladder cancer patients treated with RC at a single tertiary care referral center between January 1990 and August 2013. Kaplan-Meier analyses and Cox regression analyses were used to assess the effect of timing of BT administration (no transfusion vs. intraoperative transfusion vs. postoperative transfusion vs. intraoperative and postoperative transfusion) on cancer-specific mortality (CSM), overall mortality (OM), and disease recurrence. RESULTS Mean age at the time of RC was 67 years. Overall, 322 (21.6%) patients received intraoperative BT and 97 (6.5%) received postoperative BT. At a mean follow-up time of 125 months (median, 110 months), the 5- and 10-year CSM rate was 846 (58%) and 715 (48%), respectively. In multivariable analyses patients who received intraoperative BT had greater risk of disease recurrence (hazard ratio [HR], 1.24; P < .04), CSM (HR, 1.60; P < .02), and OM (HR, 1.45; P < .03). Conversely, this effect disappears with postoperative BT (all P > .2). CONCLUSION Our study confirms that intraoperative, but not postoperative BT, are related to a detrimental effect on survival after RC. These results should be take into account by physicians to administer BT using the correct timing.

Comparing long‐term outcomes of primary and progressive carcinoma invading bladder muscle after radical cystectomy

To assess the impact of primary or progressive status on recurrence‐free survival (RFS), cancer‐specific mortality (CSM) and overall mortality (OM) after radical cystectomy (RC) for muscle‐ invasive bladder cancer (MIBC).

18F-fluoromethylcholine or 18F-fluoroethylcholine pet for prostate cancer imaging: which is better? A literature revision

INTRODUCTION The present review was conceived for describing the differences in biodistribution and diagnostic performance of two types of (18)F-radiolabeled choline for positron emission tomography (PET) imaging in prostate cancer (PCa), such as fluoromethylcholine (FCH) and fluoroethylcholine (FEC). MATERIALS AND METHODS A collection of published data about two radiopharmaceutical agents was made by using PubMed, Web of Knowledge databases and Trip Database, and then a critical revision was discussed. RESULTS FCH was injected in 338 and 1164 patients, while FEC was injected in 20 and 139 patients, respectively for basal staging and re-staging. The diagnostic performances of FCH and FEC for the detection of lymph node metastasis before the surgical approach are typically around 50% or less and between 0% and 39%, respectively. Conversely, both the tracers appear useful for the detection of recurrent PCa in case of increase in absolute PSA value or in case of high levels of PSA velocity and PSA doubling time (sensitivity ranged between 42.9% and 96% for FCH and between 62% and 85.7% for FEC). CONCLUSIONS In according with the available information, FCH appears to be a more appropriate radiocompound as compared to FEC, although more comparative data are mandatory. A well designed and prospective trial for the evaluation of biokinetic data and diagnostic performance of both radiopharmaceutical agents seems essential. ADVANCES IN KNOWLEDGE AND IMPLICATION FOR PATIENT CARE FCH seems to be an appropriate radiopharmaceutical agent as compared to FEC. Anyway both the radiocompounds are useful in the evaluation of recurrent disease in case of a serial increase in PSA value and their performance improves when a correct preparation and acquisition protocol is employed.

Multimodal treatment for high-risk prostate cancer with high-dose intensity-modulated radiation therapy preceded or not by radical prostatectomy, concurrent intensified-dose docetaxel and long-term androgen deprivation therapy: results of a prospective phase II trial

BackgroundThe optimal management of high-risk prostate cancer remains uncertain. In this study we assessed the safety and efficacy of a novel multimodal treatment paradigm for high-risk prostate cancer.MethodsThis was a prospective phase II trial including 35 patients with newly diagnosed high-risk localized or locally advanced prostate cancer treated with high-dose intensity-modulated radiation therapy preceded or not by radical prostatectomy, concurrent intensified-dose docetaxel-based chemotherapy and long-term androgen deprivation therapy. Primary endpoint was acute and late toxicity evaluated with the Common Terminology Criteria for Adverse Events version 3.0. Secondary endpoint was biochemical and clinical recurrence-free survival explored with the Kaplan-Meier method.ResultsAcute gastro-intestinal and genito-urinary toxicity was grade 2 in 23% and 20% of patients, and grade 3 in 9% and 3% of patients, respectively. Acute blood/bone marrow toxicity was grade 2 in 20% of patients. No acute grade ≥4 toxicity was observed. Late gastro-intestinal and genito-urinary toxicity was grade 2 in 9% of patients each. No late grade ≥3 toxicity was observed. Median follow-up was 63 months (interquartile range 31–79). Actuarial 5-year biochemical and clinical recurrence-free survival rate was 55% (95% confidence interval, 35-75%) and 70% (95% confidence interval, 52-88%), respectively.ConclusionsIn our phase II trial testing a novel multimodal treatment paradigm for high-risk prostate cancer, toxicity was acceptably low and mid-term oncological outcome was good. This treatment paradigm, thus, may warrant further evaluation in phase III randomized trials.

Posterior muscolofascial reconstruction incorporated into urethrovescical anastomosis during robot-assisted radical prostatectomy.

The rationale of posterior musculofascial plate reconstruction during radical prostatectomy is to shorten the time to reach urinary continence recovery and to reduce the risk of bleeding and anastomosis leakage. We describe our original technique incorporating the posterior muscolofascial reconstruction into urethrovesical anastomosis using robot-assisted radical prostatectomy (RARP). For this reconstructive step, we use a 30-cm V-Loc 90 3-0 barbed suture (V-20 tapered needle). Specifically, the free edge of the posterior layer of the Denonvilliers fascia is approximated to the posterior part of the sphincteric apparatus in a running fashion from left to right. The musculature of the urethral wall is incorporated in this first layer of the running suture. This suture is then continued back to the left in a second layer incorporating the anterior layer of the Denonvilliers fascia (or prostatovesical muscle), the bladder neck, and again the urethra, this time also with urethral mucosa. The urethrovesical anastomosis is completed using a second running barbed suture (15-cm V-Loc 90 3-0 barbed suture, V-20 tapered needle). No intraoperative complications were observed during this step of the procedure. Anastomotic leakages were observed only in 2% of cases. Only 12.5% showed urinary incontinence after catheter removal (1-2 pads). At mean follow-up of 9 months, the urinary continence recovery was 95%, and an anastomosis stricture necessitating an endoscopic incision developed in only three (1.5%) patients. Recent systematic reviews of the literature showed only a minimal advantage in favor of posterior musculofascial reconstruction in terms of urinary continence recovery within 1 month after radical prostatectomy. We support the use of this step of RARP because it is simple, reproducible, with a very limited increase in operative time, and with only a slight risk of potential harm to the patient. Moreover, it could improve hemostasis and provide greater support for a delicate anastomosis.

Spermatic Cord Sarcoma: Our Experience and Review of the Literature

Introduction: Spermatic cord tumors represent 4% of scrotal tumors. The most common neoplasms are lipomas. Spermatic cord sarcomas (SCS) of the genitourinary tract account for 2% of all urological tumors. Herein we presented our experience in the treatment of these tumors and a review of the literature. Patients and Methods: A review of the literature was performed using the Medline database with no restriction on language and date of published papers. The literature search used the following terms: epidemiology, surgery, chemotherapy, radiotherapy and spermatic cord sarcomas. Four cases treated from December 2009 to May 2010 are described. Results: All patients were treated with radical orchiectomy. The final pathological report showed different types of sarcomas. Two of the patients were treated with adjuvant chemotherapy. 12 months after surgery, 2/4 patients were alive without signs of relapse. Conclusion: SCS are very rare tumors with a poor prognosis. SCS’s prognostic factors have been identified in grading, size, depth of invasion and surgical margin status. Age and performance status of the patient are however very important. Lymphatic and hematogenous dissemination is uncommon. Surgery is the most important treatment both in the first approach and in local relapse. The role of adjuvant chemotherapy and radiation therapy is still debated.

The Endourological Treatment of Renal Matrix Stones

Objective: To report our experience with the endourological treatment of renal matrix stones, an infrequent form of urinary calculi whose diagnosis and treatment are often difficult. Methods: From 1990 to 2010 we treated 9 female patients with matrix calculi using the endourological approach; 4 presented with renal colics, 3 with symptomatic urinary tract infection and 2 with asymptomatic bacteriuria. Six patients underwent percutaneous lithotripsy and 3 retrograde intrarenal surgery as first-line therapy. Three cases needed a multidisciplinary approach. Results: The six percutaneous procedures were successful after a single session, while the retrograde approach required multiple treatments; a single case needed a shock wave session to complete the fragmentation, in another one a percutaneous lithotripsy was necessary after the first procedure, and a third case needed multidisciplinary treatment. Conclusions: Percutaneous lithotripsy has been confirmed as the first option for matrix stones. The retrograde approach - by confirming the suspected diagnosis and being minimally invasive - may be employed to treat either lower-size stones or stones at high risk of recurrence.