Apical Lesions Research Articles

MP70-08 FOCAL THERAPY FOR PROSTATE CANCER: DO APICAL LESIONS CORRELATE WITH WORSE OUTCOMES?

You have accessJournal of UrologyProstate Cancer: Localized: Ablative Therapy II (MP70)1 Apr 2020MP70-08 FOCAL THERAPY FOR PROSTATE CANCER: DO APICAL LESIONS CORRELATE WITH WORSE OUTCOMES? Armando Stabile*, Nicola Fossati, Giorgio Gandaglia, Marco Moschini, Petr Macek, Natalie Cathala, Xavier Cathelineau, Simone Scuderi, Daniele Robesti, Elio Mazzone, Giuseppe Rosiello, Marco Bandini, Carlo Bravi, Nazareno Suardi, Pierre I Karakiewicz, Alberto Briganti, Francesco Montorsi, and Rafael Sanchez-Salas Armando Stabile*Armando Stabile* More articles by this author , Nicola FossatiNicola Fossati More articles by this author , Giorgio GandagliaGiorgio Gandaglia More articles by this author , Marco MoschiniMarco Moschini More articles by this author , Petr MacekPetr Macek More articles by this author , Natalie CathalaNatalie Cathala More articles by this author , Xavier CathelineauXavier Cathelineau More articles by this author , Simone ScuderiSimone Scuderi More articles by this author , Daniele RobestiDaniele Robesti More articles by this author , Elio MazzoneElio Mazzone More articles by this author , Giuseppe RosielloGiuseppe Rosiello More articles by this author , Marco BandiniMarco Bandini More articles by this author , Carlo BraviCarlo Bravi More articles by this author , Nazareno SuardiNazareno Suardi More articles by this author , Pierre I KarakiewiczPierre I Karakiewicz More articles by this author , Alberto BrigantiAlberto Briganti More articles by this author , Francesco MontorsiFrancesco Montorsi More articles by this author , and Rafael Sanchez-SalasRafael Sanchez-Salas More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000950.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: In the context of focal therapy (FT) the presence of an apical lesion (AL) is typically considered a more challenging scenario characterised by a higher risk of treatment failure. METHODS: We identified 274 men receiving FT for prostate cancer (PCa) using either HIFU or cryotherapy at a high volume centre between 2009 to 2018. The primary outcome was to explore the relationship between AL and the rate of any additional treatment and radical treatment after FT. The secondary outcome was to assess whether AL was related with post-operative urinary retention (UR). Multivariable Cox regression analyses were used to address both the outcomes. Covariates for primary outcome were PSA, clinical stage (T1 vs T2), prostate volume, maximum cancer core length, percentage of positive cores and type of energy (HIFU vs Cryo), whereas for secondary outcome were type of energy and prostate volume. RESULTS: 166 and 108 men received FT with HIFU and Cryo. Overall, 39% (106) and 31% (85) received at least an additional treatment and a radical treatment after FT, respectively, with a median follow-up of 51 months (IQR: 70-29). 9% (24) men experienced post-operative UR. At Cox regression presence of an AL was not significantly associated with higher risk of both any additional treatment and radical treatment (all p>0.4), whereas PSA resulted the only independent predictor of the outcomes tested (OR: 0.12; p=0.005). AL was neither significantly associated with a higher risk of post-operative UR (p=0.66). CONCLUSIONS: The presence of an AL was associated neither with a worse oncological outcome nor with higher rate of post-operative UR. According to this single institution experience, presence of AL should not be considered an exclusion criteria for FT. Source of Funding: none © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1058-e1058 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Armando Stabile* More articles by this author Nicola Fossati More articles by this author Giorgio Gandaglia More articles by this author Marco Moschini More articles by this author Petr Macek More articles by this author Natalie Cathala More articles by this author Xavier Cathelineau More articles by this author Simone Scuderi More articles by this author Daniele Robesti More articles by this author Elio Mazzone More articles by this author Giuseppe Rosiello More articles by this author Marco Bandini More articles by this author Carlo Bravi More articles by this author Nazareno Suardi More articles by this author Pierre I Karakiewicz More articles by this author Alberto Briganti More articles by this author Francesco Montorsi More articles by this author Rafael Sanchez-Salas More articles by this author Expand All Advertisement PDF downloadLoading ...

Root-end restoration using MTA against the intractable cases of root canal treatment

Root-end restoration using Mineral Trioxide Aggregate (MTA) was performed on two patients who received root canal treatment but had poor progress. In one case, a large amount of Calcium hydroxide(Ca (OH)2), a intracanal medicament, escaped from a wide-open apex, stagnated around the tooth root, and the apical lesion did not disappear. The other case is a case where the root canal at the apical part has a complicated anatomical form, the root canal cannot be tightly packed, and the apical lesion has not disappeared. Root-end restoration using MTA was performed on these two cases, and improvement of the lesion was confirmed. From these results, it was shown that Root-end restoration using MTA is effective for patients with poor prognosis of root canal treatment for which the apical portion cannot be tightly packed for various reasons. Keywords: Mineral Trioxide Aggregate; MTA; Root-end restoration

Cell-Based Regenerative Endodontics for Treatment of Periapical Lesions: A Randomized, Controlled Phase I/II Clinical Trial

A randomized controlled phase I/II clinical trial was designed to evaluate the safety and efficacy of encapsulated human umbilical cord mesenchymal stem cells in a plasma-derived biomaterial for regenerative endodontic procedures (REPs) in mature permanent teeth with apical lesions. The trial included 36 patients with mature incisors, canines, or mandibular premolars showing pulp necrosis and apical periodontitis. Patients were randomly and equally allocated between experimental (REP) or conventional root canal treatment (ENDO) groups. On the first visit, cavity access and mechanical preparation of the root canal were performed. Calcium hydroxide medication was used, and the cavity was sealed. Three weeks later, patients were treated following their assigned protocol of ENDO or REP. Clinical follow-up examinations were performed at 6 and 12 mo. Categorical variables were evaluated by Fisher’s exact test. Quantitative variables were compared using the Mann-Whitney test. The evolution over time of the percentage of perfusion units and the dimensions of lesion and cortical compromise were explored. After the 12-mo follow-up, no adverse events were reported, and the patients showed 100% clinical efficacy in both groups. Interestingly, in the REP group, the perfusion unit percentage measured by laser Doppler flowmetry revealed an increase from 60.6% to 78.1% between baseline and 12-mo follow-up. Sensitivity tests revealed an increase of the positive pulp response in the REP group at 12-mo follow-up (from 6% to 56% on the cold test, from 0% to 28% on the hot test, and from 17% to 50% on the electrical test). We present the first clinical safety and efficacy evidence of the endodontic use of allogenic umbilical cord mesenchymal stem cells encapsulated in a plasma-derived biomaterial. The innovative approach, based on biological principles that promote dentin-pulp regeneration, presents a promising alternative for the treatment of periapical pathology (ClinicalTrials.gov NCT03102879).

Association between human cytomegalovirus and periodontitis: A systematic review and meta-analysis.

Human cytomegalovirus (HCMV) has been associated with periodontitis and apical periodontitis. The objective of this systematic review was to evaluate the association between HCMV and periodontitis, and apical periodontitis of endodontic origin. A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines and registered in the International prospective register of systematic reviews (PROSPERO). The search for potential studies was performed in MEDLINE via PubMed, Scopus, and SciELO. A quality assessment of the studies, publication bias analysis, and meta-analysis was performed. The results are presented in odds ratio with 95% confidence interval with the corresponding Forest plot. Sensitivity analysis was performed to evaluate the consistency of the results. Thirty-two studies were included in the quantitative and qualitative analyses. Of these, 26 were in periodontitis patients and 6 in apical periodontitis patients. Forest plot of combined studies revealed significant increased odds for periodontitis when subgingival HCMV was detected (OR 5.31; 95% CI 3.15-8.97). Sensitivity analysis based on quality of the included studies, showed consistent results. In contrast, the odds ratio for apical periodontitis when HCMV was detected from apical lesions was not statistically significant (OR 3.65; 95% CI 0.49-27.10). The results from the meta-analysis indicate that HCMV is significantly associated with periodontitis. In contrast, HCMV infection is not associated with apical periodontitis.

A278 TB OR NOT TB OF THE PANCREAS

Abstract Background Pancreatic TB is a rare clinical presentation which has proved difficult to diagnose. Its symptomatology and imaging characteristics mimic neoplastic findings. Aims We present the case of a previously healthy 58-year-old man, from an endemic area who presented with epigastric pain caused by pancreatic TB. Methods Case report and review of literature Results A previously well 58-year-old male presented to the emergency room with severe epigastric pain, without fevers or significant weight loss. He had immigrated to Canada from the Philippines in 2001. He denied a personal history of TB, however, he did report that his father had received treatment for active TB. An abdominal CT revealed intrahepatic and extrahepatic bile tree dilation with an abrupt transition in the pancreatic head, possible stricture, as well as mucosal thickening of the duodenum at the level of the abrupt narrowing of the dilated common bile duct, concerning for malignancy. Initial laboratory investigations revealed WBC 6.1 x10E9 cells/L, amylase 114 U/L and lipase 59 U/L. Malignancy work up revealed a normal Ca 19-9 at 29.6 kU/L. HIV testing was negative. CT chest revealed bilateral apical fibrotic lesions and smaller lesions throughout the upper and mid-zones bilaterally, suggestive of progressive massive fibrosis. This was in keeping with the patient’s former occupation as a miner. There was no evidence of granulomatous disease. EUS was undertaken and this revealed a mass in the head of the pancreas measuring 29 x 29 mm. The mass was invading into the common bile duct. The pancreatic head mass appeared to be invading into the duodenum, as a necrotic ulcerating lesion was also identified in the second part of the duodenum and this was biopsied. The surgical pathology returned as necrotizing granuloma, however, the tissue could not be tested for TB. The patient underwent a repeat endoscopy which again revealed a fungating and friable mass in the second part of the duodenum with biopsies taken. Pathology revealed mild chronic inflammation. Staining for Acid Fast Bacilli was negative, however, Mycobacterium Tuberculosis Complex was isolated on tissue culture. The patient was diagnosed with pancreatic TB and initiated on pyrazinamide, ethambutol, isoniazid and rifampin. Conclusions Pancreatic involvement by TB is very rare but it has been increasingly reported in both immunocompromised and immunocompetent populations. Symptomatically, pancreatic TB can present with a multitude of non-specific symptoms, including epigastric pain, fever, anorexia, weight loss, or jaundice. In addition, imaging findings of pancreatic TB may mimic malignancy. Our patient, from an endemic area, presented with epigastric pain consistent with the existing literature on pancreatic TB. Isolated pancreatic TB is a rare clinical entity but should be in the list of differential diagnoses in a patient with pancreatic mass especially in the setting of risk factors of TB. Funding Agencies None

Case Report: Combined nonsurgical and surgical therapy of dens invaginatus of a microdontic maxillary lateral incisor

This report describes the management of an uncommon case of dens invaginatus of a microdontic upper lateral incisor, with an extended apical lesion. Dens invaginatus is a developmental abnormality of a tooth where enamel and dentin fold into the pulpal space. This abnormal anatomy, and the separation of two distinct root canal spaces, complicates conventional treatment, making the apical portion inaccessible to instrumentation and impeding disinfection of the canal space. The coexistence of dens invaginatus affecting a microdontic tooth is a rare anomaly found in the literature. This case report describes a young female patient with dens invaginatus affecting a microdontic maxillary lateral incisor, combined with necrotic pulp and apical periodontitis. The conventional treatment was completed first to disinfect the coronal portion of the accessible pulpal space. At a subsequent appointment, it was completed by a surgical approach to cleanse and seal the apical part of the root canal space. The tooth was then restored, and the orthodontic treatment was initiated. One-year follow-up demonstrated a complete healing of the apical lesion.

Dentists\u2019 clinical decision-making about teeth with apical periodontitis using a variable-controlled survey model in South Korea

BackgroundThis study, by using a variable-controlled survey model, sought to compare clinical decisions made by dentists with different clinical backgrounds in South Korea regarding teeth with apical periodontitis and to identify factors that influenced decision-making.MethodsA questionnaire with 36 questions about identical patient information, clinical signs, and symptoms was filled out by participants. Each question referred to a radiograph that had been manipulated using computer software in order to control tooth-related factors. Participants were instructed to record their demographic information and choose the ideal treatment option related to each radiograph. Simple and multivariable logistic regression analyses (p < .05) were used to investigate factors related to the decision to extract the tooth. We divided factors into dentist-related factors (gender, years of experience, and professional registration) and tooth-related factors (tooth position, coronal status, root canal filling status, and size of the periapical radiolucency). Dentists were categorized into three groups, based on professional registration: general dental practitioners (GDPs), endodontists, and other specialists. Simple logistic regression analysis (p < .05) was used to evaluate the tooth-related factors influencing extraction, depending on the dentists’ specialty.ResultsParticipants mostly preferred saving the teeth over extraction. This preference was highest among the endodontists, followed by other specialists and GDPs. Extractions were significantly preferred for molars, teeth with previous root canal fillings, and those with apical lesions greater than 5 mm.ConclusionsThis study suggests that dentists’ decision-making regarding teeth with apical periodontitis was associated with their work experience and specialty and influenced by tooth position, root canal filling status, and size of the apical lesion.Clinical relevanceThis survey revealed that clinical decision-making related to teeth with apical periodontitis was affected by dentists’ specialty and work experience and by tooth-related factors, such as tooth position, root canal filling status, and size of the apical lesion.

Nonsurgical Retreatment Using Regenerative Endodontic Protocols: A Case Report

The aim of this case report was to describe regenerative endodontic procedures (REPs) of the previously treated mature teeth with long-term results. Regenerative endodontic procedures are aimed to treat apical periodontitis and regenerate the pulp-dentin complex in necrotic teeth. However, there is no consensus in using REPs in the previously treated mature teeth. The aim of this case report was to describe REPs of the previously treated mature teeth with long-term results. A 25-year-old woman presented pain on chewing on 15 and swelling (WHO numbering system). The tooth had been endodontically treated and restored 4 years ago. After removing the old root canal filing, the roots were irrigated with 2.5% sodium hypochlorite and 17% EDTA using sonic activation. Calcium hydroxide (CH) was used as medicament for 3 weeks. At the second visit, CH was removed, and canals were irrigated as like as the first visit. Apical bleeding was induced, and concentrated growth factors (CGFs) were placed inside the root canal. The tooth has been followed up to 3 years. The tooth was functional and asymptomatic at the recall visits. Since the first-year follow-up, the tooth responded to the electric pulp test and the thermal test. Radiological examinations revealed healing of apical lesion and hard tissue deposition. Regenerative endodontic procedures can offer an advantage over traditional endodontic procedures in terms of tertiary healing, with a predictable, user-friendly procedure also for retreatment cases.

Dental Pulpal Tissue Regeneration, Pulpal Vitality Testing, and Healing of Apical Lesions Following Stem Cell Transplant: A Systematic Review and Meta-Analysis

Objective: To analyze data obtained from animal and human studies using stem cells. Material and Methods: Medical Literature Analysis and Retrieval System Online (MEDLINE), PubMed, Cochrane Library, Embase, Information Sciences Institute (ISI), as well as Google Scholar were utilized and searched as available electronic databases to perform a systematic literature review of articles published between 2010 and 2019. The Endnote X9 for Windows was also employed to manage electronic titles and abstracts of the selected studies. Searches were conducted using keywords of “pulpal OR pulpal tissue OR pulpal vitality”, “regeneration”, “apical healing”, “stem cells OR progenitor cells”, and “mediated pulpal tissue”. Consequently, 189 titles and abstracts endowed with potential relevance were discovered based on searches into manual and electronic sources. Ultimately, a total of six articles met the inclusion criteria in the present systematic review and meta-analysis . Results: Out of the six articles identified and selected, five studies were categorized as animal experiments and one article was nominated as a human clinical trial. The greatest bias risks were accordingly observed in the majority of animal examinations, but articles related to humans revealed decreased risks of bias, while the human clinical trial showed some concerns . Conclusion: Promising parameters testing functional pulp regeneration could be represented through stem cell transplants.

Congenital left ventricular diverticulum in an asymptomatic patient: multi-modal evaluation

Congenital left ventricular diverticula are rare cardiac malformations. In our case a diverticular apical lesion of the left ventricle was accidentally found on a thoracic CT scan, acutely performed to rule out abdominal aortic rupture.

Clustering effects of oral conditions based on clinical and radiographic examinations

The intra-class correlation coefficient (ICC) is a measure of intra-subject clustering effects. A priori estimates of the ICC and the associated design effect (DE) are required for sample size estimation in clustered studies, and should be considered during their analysis, too. We aimed to determine the clustering effects of carious lesions, apical lesions, periodontal bone loss, and periodontal pocketing, assessed in clinical or radiographic examinations. A subsample of patients (n = 175) enrolled in the fifth German Oral Health Study provided data on clinically determined carious teeth (i.e., with untreated carious lesions, WHO method) as well as teeth with periodontal pocketing (i.e., with maximum probing-pocket-depths ≥ 4mm). A sample of panoramic radiographs (n = 85) from randomly chosen patients, examined from 2010 to 2017 at the Charité dental hospital, provided data on radiographically determined carious teeth (i.e., with lesions extending into dentine or enamel), teeth with apical lesions (determined by dentists via majority vote), and teeth with periodontal bone loss (≥ 20% of root-length). The ICC and its 95% confidence interval (95% CI) were determined. There were 3839 and 1961 teeth assessed in clinical and radiographic evaluations, respectively. For clinically or radiographically determined carious lesions, the ICC (95% CI) was 0.20 (0.16-0.24) or 0.19 (0.14-0.25), respectively. For clinical pocketing or radiographic bone loss, the ICC was 0.40 (0.35-0.46) or 0.30 (0.24-0.38), respectively. The lowest ICC was found for apical lesions at 0.08 (0.06-0.13). The ICC varied between assessment methods and conditions. Clustered trials should account for this during study planning and data analysis. Within the limitations of this study, and considering the risk of selection bias and the limited sample sizes of both datasets, clustering effects were substantial but varied between dental conditions. Studies not accounting for this during planning and analysis may yield misleading estimates if clustering is present.

Coccidioidomicosis. Reporte de 3 casos

La Coccidioidomicosis es una enfermedad con características endémicas desde el sur de los Estados Unidos hasta la Argentina. El agente causal es el C. immitis y C. posadasii. Los factores que favorecen su incidencia son la humedad, suelos desérticos y la inmunosupresión del hospedador. Pacientes y Métodos: Se incluyen tres pacientes diagnosticados de Coccidioidomicosis Pulmonar por estudio histopatológico obtenido a través de biopsia pulmonar abierta por mini-toracotomía basado en la sospecha clínica, epidemiológica y radiológica. Resultados: Pacientes de la séptima década de la vida con exposición al humo de leña, dos de ellos mujeres diabéticas. El síntoma predominante fue tos seca y los patrones radiológicos fueron nodular y micronodular. Un paciente presentó neumotórax espontáneo secundario a lesión cavitada apical izquierda. El tratamiento farmacológico indicado fue itraconazol, obteniendo buena repuesta clínica. Conclusiones: La Coccidioidomicosis a pesar de ser endémica en el continente americano, es una enfermedad poco frecuente en América Central. Demanda de múltiples factores que favorezcan su desarrollo y el diagnóstico requiere de una alta sospecha clínica y confirmarlo por estudio histopatológico

Success rate 1 year after apical surgery: a retrospective analysis.

The aim of the current study was the retrospective analysis of the outcomes of teeth treated with apical surgery after a 1-year follow-up period. Furthermore, potential factors associated with the success rate were investigated. All patients were treated at the Clinic of Cranio-Maxillofacial and Oral Surgery at the University of Zurich between 2010 and 2017. To be eligible for inclusion, all patients were required to have undergone apical surgery with a retrograde root-end filling, and a 1-year follow-up examination at the University of Zurich. Treatment success at the 1-year follow-up time-point was defined as an absence of clinical complaints and radiographically determined healing. Parameters that were analysed included tooth localisation, periapical index of the preoperative lesion, administration of antibiotics, smoker status, histopathology of the apical lesion, radiographically determined sufficiency of root canal treatment pain and clinical signs of inflammation at the initial examination. A total of 81 teeth fulfilled all the inclusion criteria. At the 1-year follow-up, 91.4% of the teeth exhibited successful clinical and radiographic healing. The type of tooth was significantly associated with the success of the surgery (p = 0.006), but radiological severity of periapical inflammation, lesion histopathology, administration of antibiotics, smoker status, the quality of the root canal treatment, and preoperative pain and clinical signs of inflammation were not. The results of the present study suggest that apical surgery with retrograde root-end filling is a reliable therapy for the preservation of teeth. Furthermore, there are limited factors that affect the treatment outcome.

Effectiveness of a reciprocating single file, single cone endodontic treatment approach: a randomized controlled pragmatic clinical trial.

To compare the root filling quality, the sealer extrusion, and the healing rates of apical lesions addressed via two endodontic treatment approaches. The hypothesis tested was that both techniques present similar apical periodontitis healing results. This study was a parallel-design, pragmatic, and randomized clinical trial. One hundred twenty anterior teeth with necrotic pulps and apical periodontitis were randomly allocated to be either instrumented with hand files and obturated with the lateral compaction technique or instrumented with a single file in a reciprocating movement and obturated with a single-cone technique. The root canal filling quality, the occurrence of sealer extrusion, and apical periodontitis healing were the outcomes of interest. Data were analyzed through chi-square analysis, and the odds ratio for healing was adjusted using a logistic regression model (α = 0.05). No significant differences were observed between the endodontic techniques regarding the root filling quality or sealer extrusion. Six months after treatment, both endodontic techniques presented equivalent results regarding apical periodontitis healing. The healing rate was affected only by the periapical status at baseline. The obturation of the root canal of the anterior teeth using reciprocating file-matched single cones presented a similar quality to that obtained with manual instrumentation followed by the lateral condensation technique. Similar healing rates of apical lesions were also observed. For treating anterior teeth with apical periodontitis, a reciprocating single-file, single-treatment protocol was as effective as a traditional protocol combining hand instrumentation and the lateral compaction obturation technique.

Pain and quality of life after endodontic surgery with or without advanced platelet-rich fibrin membrane application: a randomized clinical trial.

Clinical evidence of the autologous platelet concentrates effects on the patient-reported outcome measures (PROMs) after endodontic surgery is still limited. To investigate the effect of the advanced platelet-rich fibrin (A-PRF+) membrane application upon patient postoperative pain, and quality of life in endodontic surgery. A two-parallel-arm randomized clinical trial was made comparing endodontic surgery with or without A-PRF+ as adjunctive treatment. Fifty individuals comprehending 50 apical lesions (second premolar to the second premolar) of upper maxilla were included. Pain perception and quality of life (functional limitations and other symptoms) were assessed 1week after surgery using a visual analog scale and a Likert scale-based questionnaire. Descriptive analysis was done using χ2 and t test. Binary logistic regression, ANOVA-type statistic, and GEE analysis were used for inferential analysis. Pain perception was mild in both groups [A-PRF+ 12.7 ± 8.5] versus [no A-PRF+ 20.7 ± 16.3]; it proved less variable during the first 4days in test group, showing lower extreme pain values (p = 0.096). Analgesic use was similar in both groups. Controls reported significantly worse sleep and speech functions (p < 0.05). Bleeding and bad taste/breath were the most discriminative symptoms. Postoperative pain perception was mild in endodontic surgery of the upper anterior maxilla. Differences in pain perception were not statistically significant. The use of A-PRF+ afforded less variable pain perception than in the controls. Altered quality of life parameters were more prevalent in the control group and prove significant for speech and sleep functions. Patient-related outcomes are of utmost importance in clinical practice. The use of A-PRF+ provides an affordable and safe alternative to improve postoperative quality of life in endodontic surgery.

2661 A Rare Case of Poorly Differentiated Lung Carcinoma With Duodenal Metastasis

INTRODUCTION: Lung cancer metastasis to the gastrointestinal (GI) tract is uncommon, with the duodenum being particularly rare. We present a unique case of a 61-year-old male with a history of lung cancer, who was found to have a metastatic mass on esophagogastroduodenoscopy (EGD) that was histologically similar to his lung cancer, ultimately being a diagnosis of poorly differentiated carcinoma (PDC) with focal neuroendocrine differentiation (FND). CASE DESCRIPTION/METHODS: 61-year-old male presented with 1 month of worsening dizziness, fatigue, and early satiety. On physical exam, he was tachycardic with a blood pressure of 92/60. Labs were notable for a Hgb of 7.2 (baseline of 12). Of note, 6 months prior, he was having hemoptysis and was found to have a left apical lesion on computerized tomography (CT) scan of the chest. Results from a fine needle aspiration (FNA) of the mass showed PDC that was weakly positive for CK-7, and synaptophysin on immunohistochemical staining (IHCS); thus, he was started on chemoradiation therapy. His EGD showed an oozing ulcer in the third portion of the duodenum with heaped up borders. Bipolar cautery was performed, and biopsies were obtained which showed PDC, histologically and immunohistochemically similar to his previous lung biopsy. The patient’s Hgb continued to drop during the hospital course requiring multiple transfusions, and ultimately, a gastroduodenal artery embolization. He was eventually discharged after monitoring his hemodynamics, with close outpatient follow up, as he wanted to pursue continued medical management. DISCUSSION: The results of the lung FNA showed sheets of atypical cells with focal necrosis, and prominent nucleoli being dispersed without a specific pattern, consistent with a diagnosis of PDC with FND. IHCS was weakly positive (very few scattered cells) for CK-7, and synaptophysin but negative for CK-20, P63, TTF-1, chromogranin, and CDX2. The duodenal mass biopsy showed PDC with IHCS negative for CK-7, synaptophysin, CK-20, P63, P40, Napsin-A, P40, CDX-2, TTF-1, chromogranin, calretinin, CD20, and CD3; making it histologically similar to his previous lung biopsy. The IHCS of both biopsies could not identify a specific type of carcinoma and histological analysis only showed areas of FND; highlighting the unique aspect of this case. Treatment of duodenal metastasis is challenging and depends on many variables. He was deemed a poor surgical candidate due to his comorbidities/metastatic disease and eventually had a palliative embolization.

Notch – a possible mediator between Epstein-Barr virus infection and bone resorption in apical periodontitis

Objectives: This study aimed to investigate whether Epstein-Barr virus (EBV) positive periapical lesions exhibited higher mRNA levels of Notch signalling molecules (Notch2 and Jagged1), bone resorption regulators (receptor activator of nuclear factor kappa-β ligand (RANKL) and osteoprotegerin (OPG)), and proinflammatory cytokines (tumour necrosis factor-alpha (TNF-α), interleukin-1 beta (IL-1β) and IL-6) compared to EBV negative lesions. Additionally, the potential correlation between investigated molecules in periapical lesions was analyzed.Materials and methods: Sixty-four apical periodontitis lesions were obtained subsequent to standard apicoectomy procedure. The presence of EBV was determined using nested PCR. Based on the presence of EBV all periapical lesions were divided into two groups, 29 EBV positive and 35 EBV negative lesions. A reverse transcriptase real-time PCR was used to determine mRNA levels of Notch2, Jagged1, RANKL, OPG, TNF-α, IL-1β and IL-6.Results: Significantly higher mRNA levels of Notch2, Jagged1, RANKL and IL-1β were observed in EBV positive compared to EBV negative lesions. Significant positive correlation was present between Notch2 and Jagged1, Jagged1 and RANKL, and IL-β and TNF-α in EBV positive periapical lesions.Conclusions: Notch signalling pathway may be involved in alveolar bone resorption in apical periodontitis lesions infected by EBV.

Synergistic biofilm formation by Parvimonas micra and Fusobacterium nucleatum

Parvimonas micra is frequently isolated from lesions of apical periodontitis and is a major disease-related pathogen. One of the main causes of apical periodontitis is extraradicular biofilm. In this study, we investigated polymicrobial biofilm formation by P. micra and species associated with apical periodontitis. The coaggregation activity of P. micra with partner strains was investigated by visual assays. Synergistic biofilm formation was evaluated by cocultures of P. micra and partner strains. Growth of planktonic cells was measured by evaluating the absorbance at OD660, and biofilm formation was examined by staining with crystal violet. The effects of soluble components on synergistic biofilm formation and planktonic cell growth were examined after coculture of P. micra and other strains separated with a 0.4-μm pore-size porous membrane.P. micra coaggregated with Fusobacterium nucleatum, Porphyromonas gingivalis, or Capnoctyophaga ochracea. P. micra showed no coaggregation with Staphylococcus aureus, S. epidermidis, or Prevotella intermedia. In mixed cultures, biofilm formation by P. micra and F. nucleatum was greater than that by P. micra and P. gingivalis or C. ochracea. In separated cocultures, planktonic cell growth of P. micra was enhanced by each of the three species. Biofilm formation by P. micra was enhanced by F. nucleatum or C. ochracea; however, no significant enhancement was observed with P. gingivalis.These data indicated that P. micra and F. nucleatum had synergistic effects in biofilm formation and that these effects may be important for colonization by these two species in apical periodontitis lesions.

Apical periurethral transition zone lesions: MRI and histology findings.

Apical periurethral transition zone (TZ) cancers can pose unique problems for surgery and radiation therapy. Here, we describe the appearance of such cancers on multiparametric MRI (mpMRI) and correlate this with histopathology derived from MRI-targeted biopsy. Between May 2011 and January 2019, a total of 4381 consecutive patients underwent 3T mpMRI. Of these, 53 patients with 58 apical periurethral TZ lesions underwent TRUS/MRI fusion-guided biopsy and 12-core systematic TRUS-guided biopsy. Correlation was made with patient age, PSA, PSA density, whole prostate volume, and Gleason scores. A total 53 men (median age 68years, median PSA 7.94ng/ml) were identified as having at least one apical periurethral TZ lesion on mpMRI and 5 (9%) patients had more than one apical periurethral lesion. Thus, 58 lesions were identified in 53 patients. Of these 37/53 patients (69%) and 40/58 lesions were positive at biopsy for prostate cancer. Seven were diagnosed by 12-core systematic TRUS-guided biopsy and 34 were diagnosed by TRUS/MRI fusion-guided biopsy. Gleason score was ≥ 3 + 4 in 34/58 (58%) lesions. Identification of apical periurethral TZ prostate cancers is important to help guide surgical and radiation therapy as these tumors are adjacent to critical structures. Because of the tendency to undersample the periurethral zone during TRUS biopsy, MRI-guided biopsy is particularly helpful for detecting apical periurethral TZ prostate cancers many of which prove to be clinically significant.

Development of a model to predict prostate cancer at the apex (PCAP model) in patients undergoing robot-assisted radical prostatectomy.

To develop a model based on preoperative variables to predict apical prostate cancer. We performed a retrospective analysis of 459 patients who underwent a robotic assisted radical prostatectomy (RALP) between January 2016 and September 2017. All patients had a preoperative biopsy and mpMRI of the prostate. Significant apical pathology (SAP) was defined as those patients who had a dominant nodule at the apex with a Gleason score > 6 and/or ECE at the apex. Binary logistic regression analyses were adopted to predict SAP. Variables included in the model were PSA, apical lesions prostate imaging reporting and data system (PI-RADS) score and apical biopsy Gleason score. The area under the curve (AUC) of the model was computed. A total of 121 (43.2%) patients had SAP. On univariable analysis, all apex-specific variables investigated emerged as predictors of SAP (all p < 0.05). On multivariable analysis PSA and apical PI-RADS score > 3 (all p < 0.05) emerged as significant predictors of SAP. The AUC of the model was 0.722. Patients with PI-RADS 3, 4 or 5 lesions at the apex were three times as more likely to have true SAP compared to those who have PI-RADS < 3 or negative mpMRI prior to undergoing RALP.