Archive | November, 2011

C-choline Offers No Advantage for Bladder Cancer Scans

Israeli researchers have recently reported that using C-choline as a tracer in positron emission tomography/computerized tomography (PET/CT) for staging urothelial carcinoma offers no advantages over fluorine-18 2-flouro-2-deoxy-D-glucose (F18-FDG).  In fact, C-choline may perform worse.

Shay Golan, MD, of Rabin Medical Center found that despite initial optimism, the use of the novel trace C-choline in PET/CT did not improve the detection of extravesical transitional cell carcinoma, compared with F-18 FDG.  FDG had a tendency toward an improved accuracy.  These results were published in the Journal of Urology.

Dr. Golan, Petah Tikva, and colleagues found that for bladder cancer staging FDG PET/CT has not shown a clear advantage over contrast CT, which may be due to urinary excretion of FDG masking the uptake.

Initial studies supported the view that because C-choline has negligible excretion into the urinary system, this would make it a potentially better metabolic marker.  To investigate this hypothesis, the research team used both methods to evaluate local and metastatic disease in 20 patients with bladder cancer.  Fifty-one lesions showed abnormal tracer activity.  C-choline had a positive predictive value of 84.7% for all detected lesions. For FDG, the proportion was 90.7%. Corresponding values for extravesical lesions were 79.4% and 88.2%.  There were discrepant findings at eleven sites and FDG found four lymph nodes metastases that were missed using C-choline.  Nevertheless, bladder tumor involvement was unrecognized by FDG in three cases in which C-choline clearly showed increased uptake.

The research team concluded that despite the limitations of their preliminary study, they found that the diagnostic performance of PET/CT in the detection of metastatic urothelial carcinoma was not improved when C-choline was used as the tracer.

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Alpha Blocker Improves Symptoms of Chronic Prostatitis

Recent findings show that treatment with a specific alpha blocker helps reduce symptoms and improve quality of life for men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).  This alpha-blocker, called silodosin, works by selectively relaxing the muscles in the neck of the urinary bladder and prostate.  It has been approved in Canada, the United States, the EU and Japan to treat symptoms of another prostate gland condition, benign prostatic hyperplasia, which is commonly referred to as an enlarged prostate.

Although CP/CPPS is the most common form of prostatitis, it is the most misunderstood and difficult to treat because the symptoms are very similar to other conditions and requires a significant amount of testing and screening to identify.

Curtis Nickel, a professor in the Department of Urology, practicing urologist at Kingston General Hospital and Canada Research Chair in Urologic Pain and Inflammation, emphasized that antibiotics are commonly used as a treatment, but they are not typically effective.  This could be because CP/CPPS does not seem to be caused by a bacterial infection.

CP/CPPS is a debilitating condition; patients with this condition suffer from discomfort in the lower pelvic area including the bladder area, testicles, and penis.  Symptoms may be severe and can include painful and frequent urination and difficult or painful ejaculation.  The cause of CP/CPPS is not known.

In Dr. Nickel’s study, about 60 percent of men reported feeling better after treatment with silodosin as opposed to 30 percent of participants who were given a placebo.  These results for patients feeling better is higher than a similar study he conducted several years ago that tested the effects of a different alpha blocker.

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Survival Chances Not Affected by Chemotherapy Before or After Bladder Cancer Surgery

According to a report in the peer-reviewed journal Cancer, in advanced bladder cancer, receiving chemotherapy before or after surgery does not affect survival, as long as it is given perioperatively.

Lead author James M. McKierman, MD, said that there is no clear cut randomized data to suggest that chemotherapy is better to give before or after surgery.  With his colleagues at Columbia University Medical Center, McKierman reviewed data on 146 patients who received multiagent platinum-based systemic chemotherapy for locally advanced bladder cancer between 1988 and 2009. Half of them received neoadjuvant chemotherapy, and the other half was treated postoperatively.

The team found no significant difference in overall or disease-specific survival between groups in the 122 patients treated with cisplatin-based protocols.  The median survival with neoadjuvant versus adjuvant therapy was 11 months versus 12.5 months, respectively.    This was also true when patients received methotrexate/vinblastine/adriamycin/cisplatin (median survival, 16 months versus 22.2 months).  Additionally, there was no significant difference between neoadjuvant and adjuvant cisplatin- or carboplatin-based chemotherapy.

There was, however, a significant difference observed in the 43 patients who received gemcitabine/cisplatin.  Postoperative treatment for this group was associated with a significantly reduced survival.  The team calls for further studies to clarify this finding, but they emphasize that these patients probably had worse pre-chemotherapy characteristics, including decreased performance status.

The study concluded there were no significant differences overall in survival between patients treated with chemotherapy before or after radical cystectomy.  Dr. McKiernan that this finding should be “considered when counseling patients regarding the sequence of perioperative chemotherapy and should be validated with a prospective randomized trial.”

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Study Finds Another Risk of Fall in Blood Pressure During Dialysis

A recent study led by researchers at the Stanford University School of Medicine found that there is an increased risk of blood clotting at the point where the patient’s blood vessels are connected to the dialysis machine known as the point of vascular access.  Researchers from the University of Utah also contributed to the study.  The study was published in the Journal of the American Society of Nephrology. This is yet another diverse consequence associated with a fall in blood pressure during dialysis for patients

Dialysis is a life-extending procedure for patients with kidney failure.  It involves sitting in a chair three or more times a week connected to an artificial kidney machine.  The patient’s blood is cleansed by exchanging fluid and electrolytes across a membrane during each three to four-hour session.

The fistula is one of the most common forms of vascular access.  It is created surgically from the patient’s own blood vessels.  The tubes used to transport blood to and from the body to the dialysis machine are connected to the body at this access point.  Clotting is one of the problems of an access point and can lead to its closure.

This study was based on results from the Hemodialysis study, known as HEMO, a National Institutes of Health-sponsored randomized clinical trial that collected data from 1,846 patients on hemodialysis from 1995 to 2000.  This study included data from 1,426 of these patients.

The team found that patients who had the most frequent episodes of low blood pressure during dialysis were two times more likely to have a clotted fistula than patients with the least episodes.

Roughly $2 billion a year is spent on vascular access in dialysis patients in the United States. Low blood pressure during dialysis occurs in about 25 percent of dialysis sessions.

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No Relationship Between Small Prostate Size and High Grade Cancer

Previously, radical prostatectomy series have shown an inverse relationship between prostate size and high grade cancer.  It was suggested that smaller sized prostates arise in a low androgen environment, which enables development of more aggressive cancer.  A recent study by a team of authors from Stanford University School of Medicine in the Journal of Urology, however, shows that small prostate size is not associated with high grade cancer.  The authors argue that previous observations are the result of ascertainment bias driven by prostate specific antigen performance.

The study’s authors analyzed 1,404 patients from the Stanford Radical Prostatectomy Database with clinical stage T1c (723) and T2 (681) disease who had surgery between 1988 and 2002 and underwent detailed morphommetric mapping by a single pathologist.  They used multivariate linear regression to analyze the effects of age, prostate weight and prostate specific antigen on total and high grade cancer volume and percentage of high grade disease.

Patients who underwent biopsy due to abnormal prostate specific antigen (stage T1c had a prostate weight that was negatively associated with total cancer volume, which is the volume of high grade disease and percentage of high grade disease.  For patients who underwent biopsy based on abnormal rectal examination (stage T2), these relationships were not present.

The authors conclude that improved prostate specific antigen performance for high grade disease results in ascertainment bias in patients with T1c disease.  For this reason, the relationship between prostate size and high grade disease may be a result of grade dependent performance of prostate specific antigen rather than true tumor biology.

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