Upgraded Patients Research Articles

Association between beta‐blocker atenolol use and prostate cancer upgrading in active surveillance1

AbstractObjectivesThe objective of this study is to investigate the association between the use of beta‐adrenergic antagonist atenolol and risk of pathologic upgrade in patients on active surveillance, considering growing literature implicating adrenergic innervation with disease progression mediated through beta‐adrenergic signalling.Patients and MethodsMen with low‐risk or favourable intermediate‐risk prostate cancer who were placed on an active surveillance protocol between 2006 and 2020 across three diverse urban hospitals were included. Exposure was duration of atenolol use, and outcome was pathologic grade group upgrading (to GG ≥ 3) on final prostate biopsy. Cox proportional hazard regression models were used to determine the associations between atenolol use and risk of upgrading with time, on a per‐examination basis.ResultsA total of 467 men with initial GG ≤ 2 were included. Postdiagnosis atenolol use was associated with a decreased risk of pathologic upgrade to GG ≥ 3 on final repeat biopsy (HR 0.81, 95% CI 0.39–0.98). Longer duration of postdiagnosis atenolol use (>2 years) and greater cumulative atenolol dose (>730 defined daily doses) were associated with a more pronounced decreased risk of upgrade to GG ≥ 3 (HR 0.41, 95% CI 0.05–0.88, and HR 0.32, 95% CI 0.15–0.99, respectively). Initiation of atenolol use prior to prostate cancer diagnosis had a slightly greater protective effect than drug initiation postdiagnosis (HR 0.79, 95% CI 0.43–0.98, and HR 0.83, 95% CI 0.30–0.99, respectively).ConclusionsBeta‐adrenergic blockade with atenolol use in men on active surveillance is associated with a reduced risk for clinically significant grade group pathologic upgrade.

MRI characteristics predict risk of pathological upgrade in patients with ISUP grade group 1 prostate cancer.

This study aims to analyse multiparametric MRI (mpMRI) characteristics of patients diagnosed with ISUP grade group (GG) 1 prostate cancer (PC) on initial target plus systematic MRI/TRUS fusion-guided biopsy and investigate histopathological progression during follow-up. A retrospective single-centre cohort analysis was conducted on consecutive patients with mpMRI visible lesions (PI-RADS ≥ 3) and detection of ISUP-1-PC at the time of initial biopsy. The study assessed clinical, mpMRI, and histopathological parameters. Subcohorts were analysed with (1) patients who had confirmed ISUP-1-PC and (2) patients who experienced histopathological upgrading to ISUP ≥ 2 PC during follow-up either at re-biopsy or radical prostatectomy (RP). A total of 156 patients (median age 65 years) between March 2014 and August 2021 were included. Histopathological upgrading to ISUP ≥ 2 was detected in 55% of patients during a median follow-up of 9.5 months (IQR 2.2-16.4). When comparing subgroups with an ISUP upgrade and sustained ISUP 1 PC, they differed significantly in contact length of the index lesion to the pseudocapsule, ADC value, PI-RADS category, and the MRI grading group (mGG) (p < 0.05). In the ISUP GG ≥ 2 subgroup, 91% of men had PI-RADS category 4 or 5 and 82% exhibited the highest mGG (mGG3). In multivariate analysis, mGG was the only independent parameter for predicting ISUP ≥ 2-PC in these patients. MRI reveals important information about PC aggressiveness and should be incorporated into clinical decision-making when ISUP-1-PC is diagnosed. In cases of specific MRI characteristics adverse to the histopathology, early re-biopsy might be considered. In cases with clear MRI characteristics for clinically significant prostate cancer (e.g., mGG 3 and/or PI-RADS 5, cT3, or clear focal PI-RADS 4 lesions on MRI) and ISUP GG 1 PC diagnosed on initial prostate biopsy, MRI findings should be incorporated into clinical decision-making and early re-biopsy (e.g., within 6 months) might be considered. MRI reveals important information about prostate cancer (PC) aggressiveness. MRI should be incorporated into clinical decision-making when ISUP GG 1 PC is diagnosed on initial prostate biopsy. In cases of specific MRI characteristics adverse to the histopathology, early re-biopsy might be considered.

Conduction system pacing upgrade versus biventricular pacing on pacemaker-induced cardiomyopathy: a retrospective observational study.

Objective: The feasibility of the conduction system pacing (CSP) upgrade as an alternative modality to the traditional biventricular pacing (BiVP) upgrade in patients with pacemaker-induced cardiomyopathy (PICM) remains uncertain. This study sought to compare two modalities of CSP (His bundle pacing (HBP) and left bundle branch pacing (LBBP)) with BiVP and no upgrades in patients with pacing-induced cardiomyopathy. Methods: This retrospective analysis comprised consecutive patients who underwent either BiVP or CSP upgrade for PICM at the cardiac department from 2017 to 2021. Patients with a follow-up period exceeding 12months were considered for the final analysis. Results: The final group of patients who underwent upgrades included 48 individuals: 11 with BiVP upgrades, 24 with HBP upgrades, and 13 with LBBP upgrades. Compared to the baseline data, there were significant improvements in cardiac performance at the last follow-up. After the upgrade, the QRS duration (127.81 ± 31.89 vs 177.08 ± 34.35ms, p < 0.001), NYHA class (2.28 ± 0.70 vs 3.04 ± 0.54, p < 0.05), left ventricular end-diastolic diameter (LVEDD) (54.08 ± 4.80 vs 57.50 ± 4.85mm, p < 0.05), and left ventricular ejection fraction (LVEF) (44.46% ± 6.39% vs 33.15% ± 5.25%, p < 0.001) were improved. There was a noticeable improvement in LVEF in the CSP group (32.15% ± 3.22% vs 44.95% ± 3.99% (p < 0.001)) and the BiVP group (33.90% ± 3.09% vs 40.83% ± 2.99% (p < 0.001)). The changes in QRS duration were more evident in CSP than in BiVP (56.65 ± 11.71 vs 34.67 ± 13.32, p < 0.001). Similarly, the changes in LVEF (12.8 ± 3.66 vs 6.93 ± 3.04, p < 0.001) and LVEDD (5.80 ± 1.71 vs 3.16 ± 1.35, p < 0.001) were greater in CSP than in BiVP. The changes in LVEDD (p = 0.549) and LVEF (p = 0.570) were similar in the LBBP and HBP groups. The threshold in LBBP was also lower than that in HBP (1.01 ± 0.43 vs 1.33 ± 0.32V, p = 0.019). Conclusion: The improvement of clinical outcomes in CSP was more significant than in BiVP. CSP may be an alternative therapy to CRT for patients with PICM. LBBP would be a better choice than HBP due to its lower thresholds.

Prostate Volume is A Predictor of Gleason Score Upgrading after Radical Prostatectomy in Low-Risk Prostate Cancer: A Systematic Review and Meta-analysis.

The prediction of Gleason score (GS) upgrading in patients diagnosed with low-risk prostate cancer is particularly important when opting for active surveillance (AS). Thus, we aimed to explore the association between prostate volume and GS upgrading after radical prostatectomy in low-risk prostate cancer through a meta-analysis. Multiple databases (Web of Science, MEDLINE, Embase, Scopus, and the Cochrane Library) were searched for eligible studies regarding this issue and reporting sufficient data up to May 2023. Specific search terms such as prostate cancer, radical prostatectomy, and prostate volume were used in our search strategy. Multivariable-adjusted odds ratios (ORs) and associated 95% confidence intervals (CIs) were calculated using random effects models according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. Twenty studies comprising 14,823 patients who underwent radical prostatectomy matched our eligibility criteria. Moreover, GS upgrading between biopsy and surgical pathological specimens occurs in 32.2% (4,771) of cases. The results showed that smaller prostate volume is significantly associated with GS upgrading in patients with low-risk prostate cancer (OR = 1.08, 95% CI = 1.05-1.11; P < 0.001; I-square [I2] = 89.8%) from biopsy to radical prostatectomy after adjusting for confounding factors. Moreover, the results of our subgroup analyses revealed that smaller prostate volume remained a substantial risk factor of GS upgrading in the studies designed as retrospective cohorts and case-control studies performed in America, Italy, Turkey, and China. The findings are robust as indicated by sensitivity and meta-regression analyses. Smaller prostate volume predicts clinically substantial GS upgrading in patients diagnosed with lowrisk prostate cancer after radical prostatectomy. The intriguing findings might be helpful when management options other than surgery are selected based on the inability to recognise the true pathological GS of patients for AS. Further studies focus on risk-stratification and treatment planning for patients with low-grade prostate cancer are still needed to verify our results.

Establishment and Evaluation of a Risk Prediction Model for Pathological Escalation of Gastric Low-Grade Intraepithelial Neoplasia.

The study aims to explore the risk factors for pathological escalation after endoscopic surgery for gastric low-grade intraepithelial neoplasia (LGIN) and to establish and evaluate a risk prediction model for LGIN. A total of 120 patients diagnosed with gastric LGIN by biopsy and endoscopic submucosal dissection (ESD) between November 2020 and June 2022 were retrospectively analyzed. Gender, age, Helicobacter pylori (HP) infection, lesion size, lesion location, morphology, gastric mucosal congestion, nodules status, surface ulceration and erosion, and ME-observation of all patients were collected and divided into upgraded and non-upgraded groups according to the biopsy and ESD postoperative pathological diagnosis results. Independent risk factors for pathological escalation after ESD surgical treatment were screened by logistic regression analysis, and a risk prediction model was established. Among the 120 patients with gastric LGIN, 49 patients developed postoperative pathological upgrading; the rate of pathological upgrading was 40.83%. Among them, 42 patients were upgraded to high-grade intraepithelial neoplasia (HGIN), 1 case was upgraded to advanced gastric cancer, and 6 cases were upgraded to early gastric carcinoma (EGC). Univariate analysis showed that age, lesion size, gastric mucosal congestion, surface ulcers, and erosion were significantly different between the groups (p < 0.05). Multivariate Logistic regression analysis revealed that age ≥60 years, focal length ≥2 cm, gastric mucosal congestion, and surface ulceration and erosion were independent risk factors for postoperative pathological escalation in patients with gastric LGIN. Final joint probability forecasting model for P = 1/[1 + e(26.515-0.161 x β1-0.357 x β2+0.039 x β3-0.269 x β4)]. Age, lesion size ≥2 cm, gastric mucosal congestion, and lesion surface ulceration and erosion are risk factors for postoperative pathological upgrading in patients with gastric LGIN. The risk prediction model established in this study based on risk factors has predictive value and can provide a scientific reference for the clinical treatment of patients with gastric LGIN.

Deep learning based on 68Ga-PSMA-11 PET/CT for predicting pathological upgrading in patients with prostate cancer.

To explore the feasibility and importance of deep learning (DL) based on 68Ga-prostate-specific membrane antigen (PSMA)-11 PET/CT in predicting pathological upgrading from biopsy to radical prostatectomy (RP) in patients with prostate cancer (PCa). In this retrospective study, all patients underwent 68Ga-PSMA-11 PET/CT, transrectal ultrasound (TRUS)-guided systematic biopsy, and RP for PCa sequentially between January 2017 and December 2022. Two DL models (three-dimensional [3D] ResNet-18 and 3D DenseNet-121) based on 68Ga-PSMA-11 PET and support vector machine (SVM) models integrating clinical data with DL signature were constructed. The model performance was evaluated using area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, and specificity. Of 109 patients, 87 (44 upgrading, 43 non-upgrading) were included in the training set and 22 (11 upgrading, 11 non-upgrading) in the test set. The combined SVM model, incorporating clinical features and signature of 3D ResNet-18 model, demonstrated satisfactory prediction in the test set with an AUC value of 0.628 (95% confidence interval [CI]: 0.365, 0.891) and accuracy of 0.727 (95% CI: 0.498, 0.893). A DL method based on 68Ga-PSMA-11 PET may have a role in predicting pathological upgrading from biopsy to RP in patients with PCa.

The Year in Hungarian Cardiology 2023: Heart failure

The year 2023 proved to be a productive period with many remarkable scientific papers published from Hungary in the field of heart failure (HF). Our aim with this brief review is to highlight the results of the most prominent landmark randomized clinical trials as well as other relevant influential publications with significant contribution from Hungarian authors. Several clinical trials were published in 2023 with the primary focus on optimizing medical management. Papers described the use of sodium-glucose cotransporter-2 inhibitors (SGLT2i) in HF in association with renal dysfunction, COVID-19 infection, and evaluating their economic impact. A comprehensive manuscript analysed the geographic differences in patient characteristics, treatments, and outcomes in the PARADISE-MI trial population. With regards to glucagon-like peptide-1 (GLP-1) receptor agonists, the STEP-HFpEF landmark clinical trial reported a favourable effect for semaglutide in patients with HFpEF and obesity. The intermittent administration of levosimendan did not improve post-hospitalization clinical stability in a population with advanced HF. In the field of cardiac resynchronization therapy (CRT), results of the BUDAPEST-CRT Upgrade trial was published in the European Heart Journal. This was the first prospective, randomized controlled trial to demonstrate that CRT upgrade in patients with intermittent or permanent RV pacing and HFrEF reduces morbidity and mortality. Several papers focused on the greater field of cardiomyopathies, including medical therapies, diuretic use, and cardiotoxicity. Finally, it is important to mention that an issue of Cardiologia Hungarica was published that was entirely dedicated to HF.

The role of PSMA PET/CT to predict upgrading in patients undergoing radical prostatectomy for ISUP grade group 1 prostate cancer.

To investigate the additive role of prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) independent from multiparametric magnetic resonance imaging (mpMRI) and clinical-pathological parameters to predict pathological upgrading in patients with ISUP grade group (GG) 1 prostate cancer (PCa) at prostate biopsy. A total of 41 patients who underwent robotic radical prostatectomy (RP) for GG1 disease at prostate biopsy with preoperative PSMA PET/CT and mpMRI images available for central review were included in the study. Univariate and multivariate logistic regression analyses were performed to determine the independent predictors of pathological upgrading (GG ≥ 2). Final RP pathology revealed upgrading in 26 patients (65.9%); to GG 2 disease in 25 cases and GG 4 disease in one case. International Society of Urological Pathology (ISUP) upgrading rates for prostate imaging-reporting and data system (PIRADS)-5, PIRADS-4, and PIRADS ≤ 3 lesions were 78%, 74%, and 38%, respectively. Fourteen out of 15 (93.3%) patients with an SUVmax ≥ 5.6 and all patients with an SUVmax ≥ 6.5 (n = 10) had pathological upgrading. The upgrading rate in patients with SUV < 5.6 was 46.2% (12/26). Intraprostatic SUVmax ≥ 5.6 was found as the only independent predictor of pathological upgrading in multivariate analysis. High prostatic PSMA uptake was found to be a very reliable predictor of pathological upgrading, but low PSMA uptake cannot exclude pathological upgrading. Intraprostatic PSMA uptake along with previously known mpMRI and biopsy-related parameters should be considered when making a treatment decision in patients with GG1 PCa at prostate biopsy.

Value of patient-reported outcome measures for evaluating the benefit of speech processor upgrading in patients with cochlear implants.

Patients with acochlear implant (CI) should be evaluated for anew speech processor every 6years. The aim of this analysis was to assess the subjective and audiological benefit of upgrades. Speech understanding and subjective benefit were analyzed in 99patients with the old and the new speech processor after 4weeks of wearing. Speech understanding was assessed using the Freiburg monosyllabic test in quiet (FBE) at 65 dB and 80 dB, and the Oldenburg Sentence Test (OLSA) at 65 dB noise with adaptive speech sound level. The Abbreviated Profile of Hearing Aid Benefit (APHAB) was used to assess subjective hearing impairment, and the Audio Processor Satisfaction Questionnaire (APSQ) was used to assess subjective satisfaction. The speech processor upgrade resulted in asignificant improvement of speech understanding in quiet at 65 dB (mean difference 8.9 ± 25.9percentage points, p < 0.001) and 80 dB (mean difference 8.1 ± 29.7percentage points, p < 0.001) and in noise (mean difference 3.2 ± 10.7 dBsignal-to-noise ratio [S/N], p = 0.006). Using the APHAB, asignificant improvement (mean difference 0.07 ± 0.16, p < 0.001) in hearing impairment was demonstrated in all listening situations. The APSQ showed significantly higher patient satisfaction with the new speech processor (mean difference 0.42 ± 1.26, p = 0.006).A comparative assessment of the benefit based on subjective and speech audiometric results identified aproportion of patients (35-42%) who subjectively benefited from the upgrade but had no measurable benefit based on speech audiometry. There was asignificant improvement in audiologically measurable and subjectively reflected speech understanding and patient satisfaction after the upgrade. In patients with only asmall improvement in audiologically measurable speech understanding, the subjective benefit should also be assessed with validated measurement instruments in order to justify an upgrade to the payers in the health sector.

Value of patient-reported outcome measures for evaluating the benefit of speech processor upgrading in patients with cochlear implants. German version

Patients with acochlear implant (CI) should be evaluated for anew speech processor every 6years. The aim of this analysis was to assess the subjective and audiological benefit of upgrades. Speech understanding and subjective benefit were analyzed in 99patients with the old and the new speech processor after 4weeks of wearing. Speech understanding was assessed using the Freiburg monosyllabic test in quiet (FBE) at 65 dB and 80 dB, and the Oldenburg Sentence Test (OLSA) at 65 dB noise with adaptive speech sound level. The Abbreviated Profile of Hearing Aid Benefit (APHAB) was used to assess subjective hearing impairment, and the Audio Processor Satisfaction Questionnaire (APSQ) was used to assess subjective satisfaction. The speech processor upgrade resulted in asignificant improvement of speech understanding in quiet at 65 dB (mean difference 8.9 ± 25.9percentage points, p < 0.001) and 80 dB (mean difference 8.1 ± 29.7percentage points, p < 0.001) and in noise (mean difference 3.2 ± 10.7 dBsignal-to-noise ratio [S/N], p = 0.006). Using the APHAB, asignificant improvement (mean difference 0.07 ± 0.16, p < 0.001) in hearing impairment was demonstrated in all listening situations. The APSQ showed significantly higher patient satisfaction with the new speech processor (mean difference 0.42 ± 1.26, p = 0.006).A comparative assessment of the benefit based on subjective and speech audiometric results identified aproportion of patients (35-42%) who subjectively benefited from the upgrade but had no measurable benefit based on speech audiometry. There was asignificant improvement in audiologically measurable and subjectively reflected speech understanding and patient satisfaction after the upgrade. In patients with only asmall improvement in audiologically measurable speech understanding, the subjective benefit should also be assessed with validated measurement instruments in order to justify an upgrade to the payers in the health sector.

MP55-07 CAN NEURONAL NETWORK-BASED MACHINE LEARNING PREDICT PATHOLOGICALLY SIGNIFICANT PROSTATE CANCER IN PATIENTS DIAGNOSED WITH GLEASON GRADE 6 ON PRE-OPERATIVE PROSTATE BIOPSY

You have accessJournal of UrologyCME1 Apr 2023MP55-07 CAN NEURONAL NETWORK-BASED MACHINE LEARNING PREDICT PATHOLOGICALLY SIGNIFICANT PROSTATE CANCER IN PATIENTS DIAGNOSED WITH GLEASON GRADE 6 ON PRE-OPERATIVE PROSTATE BIOPSY Omri Nativ, Ehud Berger, Kamil Malshy, Omer Sadeh, Alexander Kastin, Alexander Kravtzov, Edmond Sabo, Azik Hoffman, and Gilad Amiel Omri NativOmri Nativ More articles by this author , Ehud BergerEhud Berger More articles by this author , Kamil MalshyKamil Malshy More articles by this author , Omer SadehOmer Sadeh More articles by this author , Alexander KastinAlexander Kastin More articles by this author , Alexander KravtzovAlexander Kravtzov More articles by this author , Edmond SaboEdmond Sabo More articles by this author , Azik HoffmanAzik Hoffman More articles by this author , and Gilad AmielGilad Amiel More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003308.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The management of PCa is based on a risk stratification where in the case of localized disease the patients are elected for either active surveillance or an invasive treatment. This risk stratification system is based on three main parameters: PSA level, Gleason grade and the clinical stage of the disease. Despite the clinical definition of a low-risk disease, in certain cases the disease biology is actually aggressive with a potential to become a significant disease or in other cases a sampling error has undegraded the true disease pathology. The aim of our study was to determine the probability of Gleason score upgrading to a clinically significant disease using neuronal network machine learning. METHODS: Using our local radical prostatectomy registry, we have retrospectively reviewed patients' medical records for Age, BMI, PSA level at diagnosis, prostate biopsy findings, prostate volume, PSA-D, D'Amico risk classification, Gleason grade group and pathological staging following prostate biopsy and surgery. Clinically significant (CS) PCa was defined as Gleason 7(3+4) and higher (≥ GG 2). Univariant and multivariant analyses were used to predict significant PCa at radical prostatectomy specimens. Fisher exact and Mann-Whitney U tests were used for categorical and continuous variables, respectively. Next, a neural network (NN) machine learning model was trained using the above variables in order to predict the probability of pathologically upgrading to a CS disease. A back propagation algorithm was used for validation of the NN. RESULTS: 428 patients underwent robotic-assisted radical prostatectomy between 2012 and 2021 in our institution. 72 patients (17%) had a clinically insignificant disease determined by prostate biopsy. of which 34 patients (72%) were upgraded to a CS disease on the final pathology. On univariate and multivariate analysis, the only preoperative variable that predicted a CS final pathology was the PSA-density (PSAD) with a sensitivity and specificity of 36% and 74% respectively. When using the NN machine learning the probability to predict disease upgrading was more accurate with a sensitivity and specificity of 94.1% and 97.1% respectively. CONCLUSIONS: NN machine learning can be trained and used for predicting the probability of PCa upgrading in patients with a biopsy proven Gleason 6 disease. In our cohort the NN sensitivity and specificity were superior compared to the traditional descriptive statistics. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e765 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Omri Nativ More articles by this author Ehud Berger More articles by this author Kamil Malshy More articles by this author Omer Sadeh More articles by this author Alexander Kastin More articles by this author Alexander Kravtzov More articles by this author Edmond Sabo More articles by this author Azik Hoffman More articles by this author Gilad Amiel More articles by this author Expand All Advertisement PDF downloadLoading ...

Predictive Factors for Gleason Score Upgrading in Patients with Prostate Cancer after Radical Prostatectomy: A Systematic Review and Meta-Analysis

Introduction: Previous studies have revealed that Gleason score upgrading (GSU) was closely related to an increased biochemical recurrence rate and adverse oncologic outcomes in patients with prostate cancer (PC). Therefore, we performed a meta-analysis to determine the predictive factors for GSU following radical prostatectomy (RP). Methods: We performed an extensive literature search using PubMed, Embase, and Cochrane in September 2022. In order to calculate the pooled odds ratio (OR), standardized mean difference (SMD), and 95% confidence intervals, a fixed effect or a DerSimonian and Laird random effect was applied. Results: Twenty-six studies included 18,745 PC patients that were available for further analysis. Our results revealed that GSU was significantly correlated with age (summary SMD = 0.13; p = 0.004), prostate volume (PV) (summary SMD = −0.19;p < 0.001), preoperative PSA (p-PSA) (summary SMD = 0.18; p < 0.001), PSA density (PSAD) (summary SMD = 0.40; p < 0.001), number of positive cores (summary SMD = 0.28; p = 0.001), percentage of positive cores (summary SMD = 0.36; p < 0.001), Prostate Imaging Reporting and Data System (PI-RADS) scores (>3/≤3) (summary OR = 2.27; p = 0.001), clinical T stage (>T2/≤T2) (summary OR = 1.73; p < 0.001), positive surgical margins (PSM) (summary OR = 2.12; p < 0.001), extraprostatic extension (EPE) (summary OR = 2.73; p < 0.001), pathological T stage (>T2/≤T2) (summary OR = 3.45; p < 0.001), perineural invasion (PNI) (summary OR = 2.40; p = 0.008), and neutrophil to lymphocyte ratio (NLR) (summary SMD = 0.50; p < 0.001). However, we found that GSU was not significantly correlated with body mass index (BMI) (summary SMD = −0.02; p = 0.602). Moreover, our sensitivity and subgroup analyses showed that the findings were reliable. Conclusions: Age, PV, p-PSA, PSAD, number of positive cores, percentage of positive cores, PI-RADS score, clinical T stage, PSM, EPE, pathological T stage, PNI, and NLR are independent factors predicting GSU following RP. The findings may be helpful in risk stratification and personalized treatment in PC patients.

A Prediction Model Based on the Risk Factors Associated with Pathological Upgrading in Patients with Early-Stage Gastric Neoplasms Diagnosed by Endoscopic Forceps Biopsy.

The discrepancies between the diagnosis of preoperative endoscopic forceps biopsy (EFB) and endoscopic submucosal dissection (ESD) in patients with early gastric neoplasm (EGN) exist objectively. Among them, pathological upgrading directly influences the accuracy and appropriateness of clinical decisions. The aims of this study were to investigate the risk factors for the discrepancies, with a particular focus on pathological upgrading and to establish a prediction model for estimating the risk of pathological upgrading after EFB. We retrospectively collected the records of 978 patients who underwent ESD from December 1, 2017 to July 31, 2021 and who had a final histopathology determination of EGN. A nomogram to predict the risk of pathological upgrading was constructed after analyzing subgroup differences among the 901 lesions enrolled. The ratio of pathological upgrading was 510 of 953 (53.5%). Clinical, laboratorial and endoscopic characteristics were analyzed using univariable and binary multivariable logistic regression analyses. A nomogram was constructed by including age, history of chronic atrophic gastritis, symptoms of digestive system, blood high density lipoprotein concentration, macroscopic type, pathological diagnosis of EFB, uneven surface, remarkable redness, and lesion size. The C-statistics were 0.804 (95% confidence interval, 0.774 to 0.834) and 0.748 (95% confidence interval, 0.664 to 0.832) in the training and validation set, respectively. We also built an online webserver based on the proposed nomogram for convenient clinical use. The clinical value of identifying the preoperative diagnosis of EGN lesions is limited when using EFB separately. We have developed a nomogram that can predict the probability of pathological upgrading with good calibration and discrimination value.

Heart failure medication and its effect on response to cardiac resynchronisation therapy in patients with pacing-induced cardiomyopathy: an UPGRADE post hoc analysis

Abstract Funding Acknowledgements Type of funding sources: Other. Main funding source(s): Austrian National Bank Unlimited scientific grant from the Boston Scientific Investigator Sponsored Research (ISR) Committee Background/Introduction Current heart failure (HF) guidelines recommend optimal medical therapy (OMT) in patients with pacing-induced cardiomyopathy (PICM) prior upgrading to cardiac resynchronisation therapy (CRT). It is unknown, whether previous prescription of heart failure medication reduces the effect of CRT upgrading. Purpose To evaluate the effect of HF medication on CRT response in patients suffering from PICM receiving an upgrade to CRT. Methods The UPGRADE trial was a prospective investigator driven trial evaluating the effect of CRT upgrading in patients with PICM. Key inclusion criteria were symptomatic HF with left ventricular ejection fraction (LVEF) below 40% despite OMT and right ventricular pacing (RVP) above 40%. Device programming had to be adjusted to minimize RVP prior to enrolment. Echocardiographic examinations were performed prior to device implantation and 3-5 months after activation of CRT and were analyzed in blinded fashion. CRT response was defined by a reduction of &amp;gt; 15% in left ventricular end systolic volume (LVESV). Heart failure medication was assessed at implantation of the device. Results Overall, 54 patients were enrolled in the UPGRADE trial between 2014 and 2018. Beta-blockers (BB) were prescribed in 43 (79.6%), mineralcorticoid receptor antagonists (MRA) in 29 (53.7%) and either an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II receptor blockers (ARB) in 45 (83.3%) of the patients. Therapy with CRT has led to significant improvement in LVEF (mean delta: 12.8 ± 7.8%) and LVESV (delta: 30.7 ± 33.2ml), whereas CRT response was achieved in 30 (55.6%) patients. There was no statistically significant difference in patients with BB intake regarding increase of LVEF (12.4 ± 7.5% vs. 14.6 ± 9.4%, p=0.431), decrease of LVESV (42.8 ± 32.8ml vs. 27.8 ± 33.0ml, p=0.201) or CRT response (22 (53.7%) vs. 8 (80%), p=0.167). Similar results were found regarding ACE inhibitor/ARB [LVEF: 13.1 ± 6.8% vs. 11.5 ± 11.8%, p=0.705; LVESV: 32.6 ± 32.6ml vs. 21.7 ± 36.3ml, p=0.373; CRT response: 26 (61.9%) vs. 4 (44.4%), p=0.460] and MRA intake [LVEF: 13.7 ± 7.3% vs. 11.8 ± 8.4%, p=0.382; LVESV: 34.3 ± 36.8ml vs. 26.7 ± 28.8ml, p=0.423; CRT response: 15 (55.6%) vs. 15 (62.5%), p=0.777]. Conclusion Previous prescription of heart failure medication did not reduce the effect of CRT upgrading in patients suffering from PICM. It remains to be proven, whether similar results may be observed for newer HF agents like sodium-glucose co-transporter 2 inhibitors or angiotensin receptor-neprilysin inhibitors as both were not available in clinical routine at the time of study conduct.

Strength of clinical indication and therapeutic impact of the implantable cardioverter defibrillator in patients with hypertrophic cardiomyopathy

BackgroundThe implantable cardioverter defibrillator(ICD) has revolutionized the management of patients with hypertrophic cardiomyopathy (HCM) at risk of sudden cardiac death (SCD). However, the identification of ideal candidates remains challenging. We aimed to describe the long-term impact of the ICD for primary prevention in patients with HCM based on stringent (high SCD risk) vs lenient indications (need for pacing/personal choice). MethodsData from two Italian HCM Cardiomyopathy Units were retrospectively analyzed. Only patients >1 follow-up visits were divided into two groups according to ICD candidacy:stringent (high SCD risk) and lenient (need for pacing, patients' choice, physician advice despite lack of high SCD risk).Major cardiac events (composite of appropriate shock/intervention and SCD) was the primary endpoint. A safety endpoint was defined as a composite of inappropriate shocks and device-related complications. ResultsOf 2009 patients, 252(12.5%) received an ICD, including 27(1.3%) in secondary prevention and 225(11.2%) in primary prevention (age at implantation 49 ± 16 years; men 65.3%). Among those in primary prevention, 167(74.2%) had stringent, while 58(25.8%) had lenient indications.At 5 ± 4 years, only stringent ICD patients experienced major cardiac events (2.84%/year, 5-year cumulative incidence: 8.1%, 95%CI [3.5–14.1%]).ICD-related complications were similar across stringent and lenient subgroups. However, patients implanted >60 years had a significantly higher risk of adverse events. ConclusionOne third of ICD recipients with HCM in primary prevention received a lenient implantation and had no appropriate intervention. ICD implantation due to systematic upgrade in patients requiring pacing and increased risk perception may offer little advantage and increase complication rates.

Unified model involving genomics, magnetic resonance imaging and prostate-specific antigen density outperforms individual co-variables at predicting biopsy upgrading in patients on active surveillance for low risk prostate cancer.

BackgroundActive surveillance (AS) is the reference standard treatment for the management of low risk prostate cancer (PCa). Accurate assessment of tumor aggressiveness guides recruitment to AS programs to avoid conservative treatment of intermediate and higher risk patients. Nevertheless, underestimating the disease risk may occur in some patients recruited, with biopsy upgrading and the concomitant potential for delayed treatment.AimTo evaluate the accuracy of mpMRI and GPS for the prediction of biopsy upgrading during active surveillance (AS) management of prostate cancer (PCa).MethodA retrospective analysis was performed on 144 patients recruited to AS from October 2013 to December 2020. Median follow was 4.8 (IQR 3.6, 6.3) years. Upgrading was defined as upgrading to biopsy grade group ≥2 on follow up biopsies. Cox proportional hazard regression was used to investigate the effect of PSA density (PSAD), baseline Prostate Imaging‐Reporting and Data System (PI‐RADS) v2.1 score and GPS on upgrading. Time‐to‐event outcome, defined as upgrading, was estimated using the Kaplan–Meier method with log‐rank test.ResultsOverall rate of upgrading was 31.9% (n = 46). PSAD was higher in the patients who were upgraded (0.12 vs. 0.08 ng/ml2, p = .005), while no significant difference was present for median GPS in the overall cohort (overall median GPS 21; 22 upgrading vs. 20 no upgrading, p = .2044). On univariable cox proportional hazard regression analysis, the factors associated with increased risk of biopsy upgrading were PSA (HR = 1.30, CI 1.16–1.47, p = <.0001), PSAD (HR = 1.08, CI 1.05–1.12, p = <.0001) and higher PI‐RADS score (HR = 3.51, CI 1.56–7.91, p = .0024). On multivariable cox proportional hazard regression analysis, only PSAD (HR = 1.10, CI 1.06–1.14, p = <.001) and high PI‐RADS score (HR = 4.11, CI 1.79–9.44, p = .0009) were associated with upgrading. A cox regression model combining these three clinical features (PSAD ≥0.15 ng/ml2 at baseline, PI‐RADS Score and GPS) yielded a concordance index of 0.71 for the prediction of upgrading.ConclusionIn this study PSAD has higher accuracy over baseline PI‐RADS score and GPS score for the prediction of PCa upgrading during AS. However, combined use of PSAD, GPS and PI‐RADS Score yielded the highest predictive ability with a concordance index of 0.71.

Re: Development and External Validation of Multiparametric MRI-Derived Nomogram to Predict Risk of Pathologic Upgrade in Patients on Active Surveillance for Prostate Cancer.

No AccessJournal of UrologyUrological Survey1 Dec 2020Re: Development and External Validation of Multiparametric MRI-Derived Nomogram to Predict Risk of Pathologic Upgrade in Patients on Active Surveillance for Prostate Cancer Cary SiegelMD Cary SiegelCary Siegel More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001271AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Re: Development and External Validation of Multiparametric MRI-Derived Nomogram to Predict Risk of Pathologic Upgrade in Patients on Active Surveillance for Prostate Cancer." The Journal of Urology, 204(6), p. 1360 © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 204Issue 6December 2020Page: 1360-1360 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Cary Siegel More articles by this author Expand All Advertisement PDF DownloadLoading ...

The role of MRI and clinicopathologic features in predicting the invasive component of biopsy-confirmed ductal carcinoma in situ

BackgroundThe upgrade rate of biopsy-confirmed ductal carcinoma in situ (DCIS) to invasive carcinoma is up to 50% on final pathology. We investigated MRI and clinicopathologic predictors of the invasive components of DCIS diagnosed by preoperative biopsy and then compared MRI features between patients with DCIS, microinvasive ductal carcinoma (mIDC), and invasive ductal carcinoma (IDC) diagnosed on final pathology.MethodsTwo hundred and one patients with 206 biopsy-confirmed DCIS lesions were enrolled. MRI and clinicopathologic features were used to predict either mIDC or IDC via a cumulative logistic regression analysis. For the lesions detected on MRI, morphologic and kinetic analyses were performed using the Chi-square, Fisher’s exact, and Kruskal-Wallis tests.ResultsOf all the lesions, 112 (54.4%) were diagnosed as DCIS, 50 (24.3%) were upgraded to mIDC, and 44 (21.4%) to IDC. The detection on MRI as mass (Odds ratio (OR) = 8.84, 95% confidence interval (CI) = 1.05–74.04, P = 0.045) or non-mass enhancement (NME; OR = 11.17, 95% CI = 1.35–92.36, P = 0.025), negative progesterone receptor (PR; OR = 2.40, 95% CI = 1.29–4.44, P = 0.006), and high Ki-67 level (OR = 2.42, 95% CI = 1.30–4.50, P = 0.005) were significant independent predictors of histologic upgrade. On MRI, 87 (42.2%) lesions appeared as mass and 107 (51.9%) as NME. Irregularly shaped, not-circumscribed, heterogeneous, or rim-enhancing masses with intratumoral high signal intensity or peritumoral edema, clumped or clustered ring-enhancing NMEs, and high peak enhancement were significantly associated with histologic upgrade (P < 0.001).ConclusionMRI detection, negative PR, and high Ki-67 levels are associated with a histologic upgrade in patients with biopsy-confirmed DCIS. Suspicious MRI features are more frequent in such patients.

Personalised biopsy schedules based on risk of Gleason upgrading for patients with low-risk prostate cancer on active surveillance.

ObjectiveTo develop a model and methodology for predicting the risk of Gleason upgrading in patients with prostate cancer on active surveillance (AS) and using the predicted risks to create risk‐based personalised biopsy schedules as an alternative to one‐size‐fits‐all schedules (e.g. annually). Furthermore, to assist patients and doctors in making shared decisions on biopsy schedules, by providing them quantitative estimates of the burden and benefit of opting for personalised vs any other schedule in AS. Lastly, to externally validate our model and implement it along with personalised schedules in a ready to use web‐application.Patients and MethodsRepeat prostate‐specific antigen (PSA) measurements, timing and results of previous biopsies, and age at baseline from the world’s largest AS study, Prostate Cancer Research International Active Surveillance (PRIAS; 7813 patients, 1134 experienced upgrading). We fitted a Bayesian joint model for time‐to‐event and longitudinal data to this dataset. We then validated our model externally in the largest six AS cohorts of the Movember Foundation’s third Global Action Plan (GAP3) database (>20 000 patients, 27 centres worldwide). Using the model predicted upgrading risks; we scheduled biopsies whenever a patient’s upgrading risk was above a certain threshold. To assist patients/doctors in the choice of this threshold, and to compare the resulting personalised schedule with currently practiced schedules, along with the timing and the total number of biopsies (burden) planned, for each schedule we provided them with the time delay expected in detecting upgrading (shorter is better).ResultsThe cause‐specific cumulative upgrading risk at the 5‐year follow‐up was 35% in PRIAS, and at most 50% in the GAP3 cohorts. In the PRIAS‐based model, PSA velocity was a stronger predictor of upgrading (hazard ratio [HR] 2.47, 95% confidence interval [CI] 1.93–2.99) than the PSA level (HR 0.99, 95% CI 0.89–1.11). Our model had a moderate area under the receiver operating characteristic curve (0.6–0.7) in the validation cohorts. The prediction error was moderate (0.1–0.2) in theGAP3 cohorts where the impact of the PSA level and velocity on upgrading risk was similar to PRIAS, but large (0.2–0.3) otherwise. Our model required re‐calibration of baseline upgrading risk in the validation cohorts. We implemented the validated models and the methodology for personalised schedules in a web‐application (http://tiny.cc/biopsy).ConclusionsWe successfully developed and validated a model for predicting upgrading risk, and providing risk‐based personalised biopsy decisions in AS of prostate cancer. Personalised prostate biopsies are a novel alternative to fixed one‐size‐fits‐all schedules, which may help to reduce unnecessary prostate biopsies, while maintaining cancer control. The model and schedules made available via a web‐application enable shared decision‐making on biopsy schedules by comparing fixed and personalised schedules on total biopsies and expected time delay in detecting upgrading.

Factors associated with disease upgrading in patients with papillary breast lesion in core-needle biopsy.

Traditionally, surgical excision is recommended for benign papillary lesions in core-needle biopsy (CNB) because of their malignant potency. The aim of this study was to identify factors associated with disease upgrading to malignancy in patients with benign papillary lesions in CNB. A total of 179 female patients were evaluated retrospectively who were diagnosed as having a benign papillary lesion in CNB and underwent a subsequent surgical excision between January 2007 and December 2016. Ultrasonography-guided CNB was performed using a 14-gauge needle gun method. The rate of upgrade to malignancy was 10.6% (7.6% in papillary lesions without atypia vs. 33.3% in papillary lesions with atypia; P=0.001). The univariable analysis revealed that older age at diagnosis (≥50 years old), menopause, lesion size on ultrasonography, palpability, multifocality, and atypia in CNB were associated with upgrading. The multivariable analysis revealed that age ≥50 years (OR, 4.6; 95% CI, 1.5-14.1; P=0.008), lesion size of ≥2 cm (OR, 6.4; 95% CI, 1.9-21.1; P=0.002), and atypia in CNB (OR, 5.1; 95% CI, 1.5-18.2; P=0.011) were significantly associated with upgrading to malignancy. Upgrading to malignancy in patients with benign papillary lesions in CNB was associated with age ≥50 years, lesion size ≥2 cm, and atypia in CNB.