L. Poissonnier

Mid-term Results Demonstrate Salvage High-Intensity Focused Ultrasound (HIFU) as an Effective and Acceptably Morbid Salvage Treatment Option for Locally Radiorecurrent Prostate Cancer

BACKGROUND Local occurrence of prostate cancer (PCa) after external beam radiation (EBRT) may benefit from definitive local therapy. OBJECTIVE To evaluate the safety and efficacy of salvage high-intensity focal ultrasound (HIFU) in local PCa recurrence after EBRT and to determine prognostic factors for optimal patient selection. DESIGN, SETTING, AND PARTICIPANTS Between 1995 and 2006, patients with a local PCa recurrence after EBRT were retrospectively included. INTERVENTION All patients received salvage HIFU with the Ablatherm device. MEASUREMENTS Prognostic factors (pre-EBRT risk group, androgen-deprivation [AD] use, pre-HIFU prostate-specific antigen [PSA], Gleason score and positive biopsy percentage) were studied in univariate and multivariate analyses. Progression was defined as positive biopsy and/or last PSA > nadir + 2 ng/ml and/or adjuvant therapy introduction. All complications were recorded. RESULTS AND LIMITATIONS Some 194 HIFU sessions for 167 patients were performed. Local cancer control was achieved with negative biopsy results in 122 (73%) patients. The median PSA nadir was 0.19 ng/ml. The mean follow-up period was 18.1 mo (range: 3-121 mo). Seventy-four patients required no hormone therapy. The actuarial 5-yr overall survival rate was 84%. The actuarial 3-yr progression-free survival rate was significantly lower in three circumstances: (1) worsening of the pre-EBRT stage with 53%, 42%, and 25% for low-, intermediate-, and high-risk patients, respectively, (2) increase in the pre-HIFU PSA, and (3) use of AD during PCa management. In multivariate analyses, the risk ratio for intermediate- and high-risk patients were 1.32 and 1.96, respectively. The risk ratio was 2.8 if patients had received AD. No rectal complications were observed. Urinary incontinence accounted for 49.5% of the urinary sphincter implantations required in 11% of patients. This is a retrospective study in which the role of the PSA doubling time and the time until recurrence was not evaluated. CONCLUSIONS Salvage HIFU is a curative treatment option for local relapse after EBRT with acceptable morbidity. Careful patient selection is imperative depending upon the aforementioned prognostic factors.

Recommandations en Onco-Urologie 2010 : Cancer du rein

Il s’agit d’une maladie a transmission autosomique dominante, a forte penetrance (95 % a 60 ans), pour laquelle un seul gene est en cause : le gene VHL situe sur le bras court du chromosome 3 (3p25-p26) (Tableau 1) [1]. La mutation causale du gene VHL est identifiable chez presque tous les patients atteints de cette affection. Il s’agit le plus souvent de mutations ponctuelles (75 % des cas) portant sur la sequence codante, mais des microdeletions, des micro-insertions, des deletions etendues ou une hypermethylation le plus souvent du promoteur ont egalement ete observees. Plus de 150 mutations differentes ont ete repertoriees sur l’ensemble des 3 exons [3-4]. Une consultation d’oncogenetique et un typage genetique du ou des sujets atteints puis des membres de la famille permet la mise en evidence de mutations du gene VHL et l’identification des sujets predisposes a cette maladie (Niveau de preuve 1). Il est recommande de depister les enfants a partir de 5 ans. Une imagerie abdominale annuelle est souhaitable car il existe un risque de 2,7 % de decouverte par an de nouvelle lesion renale (Niveau de preuve 4) [5-6].

Renal Cell Carcinoma (RCC) in Patients With End-Stage Renal Disease Exhibits Many Favourable Clinical, Pathologic, and Outcome Features Compared With RCC in the General Population

BACKGROUND Patients with end-stage renal disease (ESRD) are at risk of developing renal tumours. OBJECTIVE Compare clinical, pathologic, and outcome features of renal cell carcinomas (RCCs) in ESRD patients and in patients from the general population. DESIGN, SETTING, AND PARTICIPANTS Twenty-four French university departments of urology participated in this retrospective study. INTERVENTION All patients were treated according to current European Association of Urology guidelines. MEASUREMENTS Age, sex, symptoms, tumour staging and grading, histologic subtype, and outcome were recorded in a unique database. Categoric and continuous variables were compared by using chi-square and student statistical analyses. Cancer-specific survival (CSS) was assessed by Kaplan-Meier and Cox methods. RESULTS AND LIMITATIONS The study included 1250 RCC patients: 303 with ESRD and 947 from the general population. In the ESRD patients, age at diagnosis was younger (55 ± 12 yr vs 62 ± 12 yr); mean tumour size was smaller (3.7 ± 2.6 cm vs 7.3 ± 3.8 cm); asymptomatic (87% vs 44%), low-grade (68% vs 42%), and papillary tumours were more frequent (37% vs 7%); and poor performance status (PS; 24% vs 37%) and advanced T categories (≥ 3) were more rare (10% vs 42%). Consistently, nodal invasion (3% vs 12%) and distant metastases (2% vs 15%) occurred less frequently in ESRD patients. After a median follow-up of 33 mo (range: 1-299 mo), 13 ESRD patients (4.3%), and 261 general population patients (27.6%) had died from cancer. In univariate analysis, histologic subtype, symptoms at diagnosis, poor PS, advanced TNM stage, high Fuhrman grade, large tumour size, and non-ESRD diagnosis context were adverse predictors for survival. However, only PS, TNM stage, and Fuhrman grade remained independent CSS predictors in multivariate analysis. The limitation of this study is related to the retrospective design. CONCLUSIONS RCC arising in native kidneys of ESRD patients seems to exhibit many favourable clinical, pathologic, and outcome features compared with those diagnosed in patients from the general population.

Salvage radiotherapy after high-intensity focused ultrasound for localized prostate cancer: early clinical results.

OBJECTIVES To evaluate the first results of salvage radiotherapy after high-intensity focused ultrasound (HIFU) in terms of feasibility, tolerance, and oncologic control. METHODS From March 1995 to May 2004, 45 patients presenting with local failure after HIFU underwent salvage radiotherapy alone (n = 32) or combined with hormonal therapy (n = 13). The modalities of radiotherapy are described. Tolerance was evaluated using the Radiation Therapy Oncology Group score for urinary and digestive side effects, and incontinence was evaluated using the Ingelman Sundberg score. Patients answered a questionnaire. For the 32 patients who underwent radiotherapy alone, the oncologic early results were given by the disease-free survival rate, defined as no biochemical progression and no androgen suppression therapy. RESULTS The median and mean follow-up were 40 and 46 months, respectively, for the whole series. No additional digestive or urinary toxicity developed with salvage radiotherapy after HIFU. The data from 32 patients were evaluated, with a median follow-up of 37 months after radiotherapy. The 5-year disease-free survival rate was 64% for the 32 patients evaluated. The 5-year disease-free survival rate reached 80% for patients treated for positive biopsy findings and was 44% for those with isolated biochemical failure. CONCLUSIONS Salvage radiotherapy after HIFU for local recurrence is feasible, with no additional toxicity. The early oncologic results are encouraging when isolated local recurrence is proven but longer follow-up is needed.

Adénocarcinome prostatique en récidive locale après radiothérapie exclusive : résultats du traitement par ultrasons focalisés

OBJECTIVES To determine the efficacy and adverse effects of high intensity focused ultrasound (HIFU) for the treatment of local recurrence of prostate cancer after exclusive external beam radiotherapy. MATERIAL AND METHODS Seventy-two patients with histologically and biologically documented local recurrence after radiotherapy were treated by HIFU. The mean age was 68.27+/-5.93 years, and mean PSA was 6.64+/-7.26ng/ml. Thirty patients were treated according to standard parameters and 42 according to specific parameters. ASTRO 2005 criteria, specific for salvage therapy (Phoenix consensus), were used to define recurrence. Progression-free survival was calculated by the Kaplan-Meier method. RESULTS Mean follow-up was 39+/-28 months. The negative biopsy rate was 80% and the median nadir PSA was 0.10ng/ml. Specific survival was 94% at three years and 90% at five years, and progression-free survival was 50% at three years and 44% at five years. The urinary incontinence rate was 44% (grade 1 : 12%, grade 2/3 : 32%) and the urethral stricture or bladder neck stenosis rate was 30%. The use of specific parameters reduced the incidence of severe incontinence (19% versus 50, P=0.005) and stenosis (24% versus 40). CONCLUSIONS Treatment with HIFU achieved a five-year progression-free survival of 44%, but patients must be clearly informed about the high rate of adverse effects.

Bandelette sous-urétrale avec ancrage osseux compliquée d’une ostéomyélite pubienne : à propos de deux cas

The bulbo-urethral compression through a non-resorbable sling is a new therapeutic approach in the management of male stress urinary incontinence after prostatic surgery. Several slings are being evaluated and their way of fixing is variable according to the technique adopted. The InVancetrade mark process ensures bulbo-urethral compression by a synthetic sling anchored to the ischio-pubic rami through several titanium screws. We report the case of two patients whose operating suites of the InVancetrade mark bone-anchored male sling surgery have been marked by the appearance of a perineal suppuration associated with a pubic osteomyelitis. The healing was achieved after explantation of the material implanted (screws and sling) with bone debridement and prolonged antibiotics.

Kystes atypiques et tumeurs kystiques du rein : considérations anatomopathologiques, radiologiques et chirurgicales. Conclusions du forum AFU 2007

Malignant tumours may have a cystic appearance. They are dominated by multilocular cystic renal cell carcinoma, usually low-grade, which rarely metastasize. The Bosniak classification distinguishes non suspicious lesions (type I and II) from suspicious lesions (type III and IV) requiring resection and lesions requiring follow-up (type IIF). The main feature suggestive of malignancy is the enhancement of the septa and the walls of the cyst. Renal cysts classified as IIF require surveillance by contrast-enhanced imaging (CT, MRI or ultrasound). The treatment of cystic tumours is based on surgery. Partial nephrectomy is recommended in this type of tumour regardless of the size. Laparoscopy is a validated technique in experienced hands. Aspiration is not very effective for the treatment of benign cysts, but may be useful for diagnosis. Surgical resection of the roof of the cyst is the most effective technique.

Les traitements ablatifs modifient-ils la prise en charge des tumeurs du rein chez la personne âgée ?

The development of ablative techniques in renal oncology has profoundly changed treatment of small renal tumors. The objective of this review of the literature was to assess the arguments for treating localized kidney tumors with these techniques in the elderly patient. The two techniques retained because of their recognized use, for all approaches, are radiofrequency and cryotherapy. The data in the literature report more frequent local recurrence with these techniques than with surgical excision and an advantage to cryotherapy over radiofrequency. There seems to be no difference in terms of metastatic progression. Morbidity is not insignificant, with major complications in slightly less than 10% of cases. Given the need to consider small tumors (<4 cm), the advantage in terms of life expectancy is challenged by series studying active monitoring of the oldest patients who present co-morbidities. At present, the indications should therefore be measured and based on a general assessment of the patient, with particular consideration of the existing co-morbidities so as not to treat a patient while imposing undue complications.

[Atypical cysts and cystic tumours of the kidney: histological, radiological and surgical considerations. Conclusions of the AFU 2007 forum].

Malignant tumours may have a cystic appearance. They are dominated by multilocular cystic renal cell carcinoma, usually low-grade, which rarely metastasize. The Bosniak classification distinguishes non suspicious lesions (type I and II) from suspicious lesions (type III and IV) requiring resection and lesions requiring follow-up (type IIF). The main feature suggestive of malignancy is the enhancement of the septa and the walls of the cyst. Renal cysts classified as IIF require surveillance by contrast-enhanced imaging (CT, MRI or ultrasound). The treatment of cystic tumours is based on surgery. Partial nephrectomy is recommended in this type of tumour regardless of the size. Laparoscopy is a validated technique in experienced hands. Aspiration is not very effective for the treatment of benign cysts, but may be useful for diagnosis. Surgical resection of the roof of the cyst is the most effective technique.

Modalités de clampage au cours de la néphrectomie partielle: aspects techniques et conséquences fonctionnelles. Revue du sous-comité rein du Comité de cancérologie de l'Association française d'urologie (CCAFU)

Partial nephrectomy requires control of renal blood flow by using renal vessels clamping. Multiple clamping techniques are available. The clamping procedure can be parenchymal or vascular, involving enbloc arterial and veinous clamping or arterial onlone, being continuous or intermittent, associated or not with renal cooling. The purpose of this present review was to analyze technical aspects of clamping methods during partial nephrectomy and their functional consequences in terms of blood loss, surgical margins status and changes in renal function.