Incidental testicular masses and the role of organ-sparing approach

Objectives: The widespread use of ultrasonography for the investigation of common urological conditions, such as infertility or pain, has resulted in an increased incidence of incidental non-palpable testicular masses. The majority of these are expected to be benign therefore a conservative approach, either active monitoring or organsparing approach, is recommended. However, there are no clinical or radiological parameters which define the exact nature of such lesions and optimal patient selection criteria are lacking. In this comprehensive review we discuss the significance of incidental, small testicular masses (STMs) and the role of organ-sparing approach in the management of these lesions. Materials and methods: A non-systematic search was performed using PubMed to identify articles that covered the following topics; clinical implications at diagnosis, role of imaging in identifying the malignant capabilities of a lesion, role of surgery and the final pathology. Results: Incidental STMs are routinely identified following ultrasound examination of infertile men. STMs usually measure a few millimeters in size and the majority of these are benign. Therefore, strict follow up or an organ-sparing approach, with utilisation of frozen section analysis (FSA), is favored for STMs. FSA has a high correlation with final pathology and prevents unnecessary orchidectomies. Advances in imaging, namely ultrasound and magnetic resonance imaging may provide enhanced assessment of STMs and guidance intraoperatively. Conclusions: The optimal approach is not well defined and there is no specific clinical parameter that can predict the nature of STMs. The increasing incidence of small, benign testicular masses has resulted in the development of organ-sparing surgery to investigate and manage these lesions. Organ-sparing surgery has been shown to be practical and carries excellent oncological outcomes.

The Role of Pelvic Lymphadenectomy in Organ-sparing Treatment of Muscule-invasive Bladder Cancer

Although radical cystectomy (RCE) with extended pelvic lymph node dissection (ePLND) is the standard of care for patients with muscule-invasive bladder cancer (MIBC), the rate of partial cystectomy (PCE) in the world remains quite high (7%). In particular, the organ-sparing approach can be chosen when it is impossible to perform RCE due to medical contraindications or at the request of the patient. Its advantages include less trauma, better functional results, no need for neocystoplasty, and a better quality of life than after RCE. Moreover, with adequate patient selection, the five-year survival after PCE corresponds to that after RCE. The high probability of metastatic/micrometastatic lesions in regional lymph nodes (LN) at the time of detection of MIBC is the basis for a combination of CE, PLND, chemotherapy, immunotherapy, radiotherapy. However, due to the lack of randomized trials on the subject, the optimal volume of PLND has not been determined to date. The objective: to evaluate the clinical efficacy and safety of standard PLND (sPLND) versus ePLND, in trimodal (combination with PCE and adjuvant chemotherapy – ACT) treatment of MIBC. Materials and methods. A retrospective analysis of the results of treatment of 48 patients with MIBC after PCE in combination with sPLND or ePLND and ACT at the Kyiv City Clinical Oncology Center and the Oncourology Clinic of the Institute of Urology of the National Academy of Medical Sciences of Ukraine from 2012 to 2019 was conducted. During sPLND groups of external/internal iliac and obturator LN were dissected, at ePLND (in addition to these groups) – general iliac and presacral. The main indicators of effectiveness: general and cancer specific survival, life expectancy, recurrence-free survival. Safety indicators: frequency and nature of postoperative complications. Inclusion criteria: diagnosis of MIBC, stage of primary tumor from T2 to T4a, use in the program of examination of computed tomography/magnetic resonance imaging with contrast, removal of primary tumor by PCE (resection of the bladder with a bipolar electric knife, retreating from the tumor 0.8– cm to healthy tissues), sPLND/ePLND, ACT. Exclusion criteria – the presence of distant metastases. Statistical analysis: the significance of intergroup differences was determined by Pearson’s test (χ2). Significance level 0.05. Results. The average age of patients (including 43 men and 5 women) in the general group was 62 years (mean age – 38-74 years). The distribution of patients by tumor location was as follows: lateral walls – 32 (66.7%), the bottom of the bladder – 16 (33.3%). According to the local spread of the tumor: T2a-T2b – 27 (56.25%), T3a-T3b – 17 (35.4%) T4a-T4b – 4 (8.3%). By histological type of tumor: transitional cell carcinoma – 39 (81.25%), adenocarcinoma – 5 (10.41%), squamous cell carcinoma – 4 (8.3%). By volume of PLND: standard – 29 (60.4%), extended – 19 (39.6%). The median follow-up was 29 months (12–42 months). By means of CT metastases in pelvic LN were detected in 8 (16.6%) patients. On average, 13 LN were removed. At sPLND the minimum volume of removal was 8 LN, at ePLND – 15 LN. In the group where PCE + sPLND + ACT was performed, metastatic LN lesions were present in 6 (20.7%) patients, in the group where PCE + ePLND + ACT – in 11 (57.9%). The number of affected LN was correspond to the depth of invasion of the primary tumor. In the group of PCE + sPLND + ACT, 80% of internal iliac LN were affected. In the group of PCE + ePLND + ACT in 63.6% of cases – general iliac LN and in 36.4% – general and obturator. ePLND on average prolonged the time of surgery by 40 minutes, but did not lead to an increase in the frequency of complications, and did not increase the duration of postoperative drainage. In the group, where ePLND was performed, the 5-year survival rate depended on the metastatic lesion of regional LN at the time of diagnosis: in the presence of metastases it was 30%, and in the absence – 62%. Patients with baseline metastatic LN lesion had a higher risk of tumor recurrence. Thus, in 7 (14.5%) of them there was a local recurrence (on average within 16 months after surgery), in 5 (10.4%) – distant metastases, in 2 (4.16%) – their combination. The most common postoperative complication in both groups was lymphorrhea, but more often after ePLND than after sPLND: 42.1% vs. 17.2%. The second most common complications were pyelonephritis (occurring in 10.5% and 6.9%, respectively) and hydronephrosis (occurring in 10.5% and 6.9%, respectively, between 30 and 90 days after ureteral reimplantation). Dynamic intestinal obstruction – 1 (5.2%) was registered least often (only in the ePLND group). Conclusion. PCE in combination with PLND and ACT is a trimodal treatment of choice in MIBC patients, which allows to achieve fairly high 5-year survival (up to 60% in the absence of metastases) with better functional results (preservation of urinary function) and less trauma than with RC. The choice of PLND volume (standard or extended) should be determined by TNM stage, and the likelihood of developing lymphorrhea/lymphostasis. In the absence of a deep invasion of the bladder wall and metastases to common iliac and presacral LN, preference should be given to sPLND, as it is associated with a lower risk of lymphorrhea (twice lower than with ePLND). Further MIBC studies are needed to most effectively stratify patients for a particular treatment regimen.

Radiation Methods in the Diagnosis and Determination of Surgical Treatment Tactics for Primary Multiple Lung Carcinoid

The early and complete diagnosis of lung carcinoid tumors is of great interest in clinical oncology, since this is the basis for the possibility of using options for organ-sparing surgical treatment. According to the 2015 WHO classification, carcinoids belong to the group of neuroendocrine tumors and are divided into two types: a typical carcinoid and an atypical one. Based on the data available in the literature, there are from 0.2 to 2 cases per 100,000 population. The paper considers the possibilities of radiation studies in the early diagnosis of this tumor, as well as those of determining the tactics, type, and scope of surgical treatment.

Quantification of fetal organ sparing in maternal low-protein dietary models

Background: Maternal malnutrition can lead to fetal growth restriction. This is often associated with organ sparing and long-lasting physiological dysfunctions during adulthood, although the underlying mechanisms are not yet well understood. Methods: Low protein (LP) dietary models in C57BL/6J mice were used to investigate the proximal effects of maternal malnutrition on fetal organ weights and organ sparing at embryonic day 18.5 (E18.5). Results: Maternal 8% LP diet induced strikingly different degrees of fetal growth restriction in different animal facilities, but adjustment of dietary protein content allowed similar fetal body masses to be obtained. A maternal LP diet that restricted fetal body mass by 40% did not decrease fetal brain mass to the same extent, reflecting positive growth sparing of this organ. Under these conditions, fetal pancreas and liver mass decreased by 60-70%, indicative of negative organ sparing. A series of dietary swaps between LP and standard diets showed that the liver is capable of efficient catch-up growth from as late as E14.5 whereas, after E10.5, the pancreas is not. Conclusions: This study highlights that the reproducibility of LP fetal growth restriction studies between laboratories can be improved by careful calibration of maternal dietary protein content. LP diets that induce 30-40% restriction of prenatal growth provide a good model for fetal organ sparing. For the liver, recovery of growth following protein restriction is efficient throughout fetal development but, for the pancreas, transient LP exposures spanning the progenitor expansion phase lead to an irreversible fetal growth deficit.