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Construction of histology images of cell density and blood vessel density.

Pimonidazole immunoscore versus time after administration, DWI parameters and histology parameters

Development of the image integration algorithm.

The established role of hypoxia-induced signaling in prostate cancer growth, metastasis, and response to treatment suggests that a method to image hypoxia in tumors could aid treatment decisions. Here, we present consumption and supply-based hypoxia (CSH) imaging, an approach that integrates images related to oxygen consumption and supply into a single image. This integration algorithm was developed in patients with prostate cancer receiving hypoxia marker pimonidazole prior to prostatectomy. We exploited the intravoxel incoherent motion (IVIM) signal in diagnostic diffusion-weighted (DW) magnetic resonance (MR) images to generate separate images of the apparent diffusion coefficient (ADC) and fractional blood volume (fBV). ADC and fBV correlated with cell density (CD) and blood vessel density (BVD) in histology and whole-mount sections from 35 patients, thus linking ADC to oxygen consumption and fBV to oxygen supply. Pixel-wise plots of ADC versus fBV were utilized to predict the hypoxia status of each pixel in a tumor and to visualize the predicted value in a single image. The hypoxic fraction (HFDWI) of CSH images correlated strongly (R2 = 0.66; n = 41) with pimonidazole immunoscore (HSPimo); this relationship was validated in a second pimonidazole cohort (R2 = 0.54; n = 54). We observed good agreement between CSH images and pimonidazole staining in whole-mount sections. HFDWI correlated with tumor stage and lymph node status, consistent with findings for HSPimo. Moreover, CSH imaging could be applied on histologic CD and BVD images, demonstrating transferability to a histopathology assay. Thus, CSH represents a robust approach for hypoxia imaging in prostate cancer that could easily be translated into clinical practice.Significance: These findings present a novel imaging strategy that indirectly measures tumor hypoxia and has potential application in a wide variety of solid tumors and other imaging modalities.Graphical Abstract: http://cancerres.aacrjournals.org/content/canres/78/16/4774/F1.large.jpg. Cancer Res; 78(16); 4774–85. ©2018 AACR.

Clinical characteristics, pimonidazole immunoscore and DWI parameters versus clinicopathological markers

Purpose The personality trait of neuroticism represents vulnerability for mental distress to somatic health problems. There are few studies of neuroticism in prostate cancer patients. This study examines the levels of self-reported adverse effects (AEs) after robot-assisted radical prostatectomy (RALP) in Norwegian men with high or low levels of neuroticism. Neuroticism is also compared to relevant factors concerning their associations with various AEs. Methods Among 982 men who had RALP at Oslo University Hospital, Radiumhospitalet between 2005 and 2010, 79% responded to a mailed questionnaire in 2011. They rated AEs by completing the EPIC-26 questionnaire, and neuroticism on the Eysenck Personality Questionnaire (EPQ). Men with Results High neuroticism was reported by 20% (95% CI 17–23%) of the patients. On the EPIC-26 dimensions men with high neuroticism had significantly lower mean scores than men with low neuroticism. Most of these between-group differences were clinically significant. In multivariate regression analyses, high neuroticism contributed significantly to all EPIC-26 domains. Conclusion Increased levels of AEs after RALP are significantly associated with high neuroticism. A short screening test should be added to the current EPIC-26 instrument to identify patients with high neuroticism. In these patients, pre-operative counseling should take into account their risk of increased AE experiences.

The combination of DNA ploidy and automatically estimated stroma fraction has been shown to correlate with recurrence and cancer death in colorectal cancer. We aimed to extend this observation and evaluate the prognostic importance of this combined marker in prostate cancer. DNA ploidy status was determined by image cytometry and the stroma fraction was estimated automatically on hematoxylin and eosin stained sections in three tumor samples from each patient to account for tumor heterogeneity. The optimal threshold for low (≤56%) and high (>56%) stroma fraction was identified in a discovery cohort (n = 253). The combined marker was validated in an independent patient cohort (n = 259) with biochemical recurrence as endpoint. The combined marker predicted biochemical recurrence independently in the validation cohort. Multivariable analysis showed that the highest risk of recurrence was observed for patients with samples that had both non-diploid ploidy status and a high stroma fraction (hazard ratio: 2.51, 95% confidence interval: 1.18-5.34). In conclusion, we suggest the combination of DNA ploidy and automatically estimated stroma fraction as a prognostic marker for the risk stratification of prostate cancer patients. It may also be a potential generic marker as concurrent results have been described in colorectal cancer.

Background Patients with high-risk prostate cancer (PC) can experience biochemical relapse (BCR), despite surgery, and develop noncurative disease. The present study aimed to reduce the risk of BCR with a personalized dendritic cell (DC) vaccine, given as adjuvant therapy, after robot-assisted laparoscopic prostatectomy (RALP). Methods Twelve weeks after RALP, 20 patients with high-risk PC and undetectable PSA received DC vaccinations for 3 years or until BCR. The primary endpoint was the time to BCR. The immune response was assessed 7 weeks after surgery (baseline) and at one-time point during the vaccination period. Results Among 20 patients, 11 were BCR-free over a median of 96 months (range: 84-99). The median time from the end of vaccinations to the last follow-up was 57 months (range: 45-60). Nine patients developed BCR, either during (n = 4) or after (n = 5) the vaccination period. Among five patients diagnosed with intraductal carcinoma, three experienced early BCR during the vaccination period. All patients that developed BCR remained in stable disease within a median of 99 months (range: 74-99). The baseline immune response was significantly associated with the immune response during the vaccination period (p = 0.015). For patients diagnosed with extraprostatic extension (EPE), time to BCR was longer in vaccine responders than in non-responders (p = 0.09). Among 12 patients with the International Society of Urological Pathology (ISUP) grade 5 PC, five achieved remission after 84 months, and all mounted immune responses. Conclusion Patients diagnosed with EPE and ISUP grade 5 PC were at particularly high risk of developing postsurgical BCR. In this subgroup, the vaccine response was related to a reduced BCR incidence. The vaccine was safe, without side effects. This adjuvant first-in-man Phase I/II DC vaccine study showed promising results. DC vaccines after curative surgery should be investigated further in a larger cohort of patients with high-risk PC.

To describe study design and procedures for a prospective randomized trial investigating whether radical prostatectomy (RP) ± radiation improves cause-specific survival in comparison with primary radiation treatment (RT) and androgen deprivation treatment (ADT) in patients with locally advanced prostate cancer (LAPC).SPCG-15 is a prospective, multi-centre, open randomized phase III trial. Patients are randomized to either standard (RT + ADT) or experimental (RP with extended pelvic lymph-node dissection and with addition of adjuvant or salvage RT and/or ADT if deemed necessary) treatment. Each centre follows guidelines regarding the timing and dosing of postoperative RT and adjuvant treatment such as ADT The primary endpoint is cause-specific survival. Secondary endpoints include metastasis-free and overall survival, quality-of-life, functional outcomes and health-services requirements. Each subject will be followed up for a minimum of 10 years.Twenty-three centres in Denmark, Finland, Norway and Sweden, well established in performing RP and RT for prostate cancer participated. Each country's sites were coordinated by national coordinating investigators and sub-investigators for urology and oncology. Almost 400 men have been randomized of the stipulated 1200, with an increasing rate of accrual.The SPCG-15 trial aims to compare the two curatively intended techniques supplying new knowledge to support future decisions in treatment strategies for patients with LAPC The Scandinavian healthcare context is well suited for performing multi-centre long-term prospective randomized clinical trials. Similar care protocols and a history of entirely tax-funded healthcare facilitate joint trials.

Objectives To assess treatment response (PSA < 0.2 ng/ml), need for additional therapy and complication rate after robot assisted salvage pelvic lymph node dissection (sPLND) Material and Methods Analysis of outcomes data from radical prostatectomy (RP) patients consecutively operated with robot assisted sPLND due to biochemical recurrence and positron-emission tomography (PET)/computed tomography (CT)-detected nodal recurrence of pelvic lymph nodes. Results Sixty-nine patients underwent robotic sPLND after a median time of 47 months post- RP. Sixty-four patients (93%) had malignant lymph nodes upon histological assessment of sPLND specimen. Twenty patients (29%) achieved PSA < 0.2 ng/ml 6 weeks postoperatively. After median (IQR) follow-up of 15 months (10–27), fourteen patients (20%) still had PSA < 0.2 ng/ml without additional therapy and forty-one patients (59%) had started additional therapy. No significant predictor for treatment response was found. Postoperative complications occurred in 14 patients (20%). Eleven of these complications were classified as Clavien-Dindo grade 1 Conclusion Oncological benefit of sPLND as the only salvage procedure seems to be limited, though almost one third of patients achieved treatment response. Clinical trials are needed to determine if sPLND as part of a multimodal treatment may improve outcome.

Background Work ability represents a person’s subjective assessment of current ability to work compared to his lifetime best. Since many men with prostate cancer are retired, work ability represents a more relevant work measure than employment status. The primary aim was to examine the prevalence of men who had high versus moderate/poor current work ability compared to their lifetime best work ability at a mean of 3.0 years after robot-assisted laparoscopic prostatectomy. The secondary aim was to study variables associated with moderate/poor work ability at survey. Methods This is a questionnaire-based study of men who had robot-assisted laparoscopic prostatectomy at Oslo University Hospital, Radiumhospitalet between January 2005 and August 2010. Among them 777 responded (79%), 730 reported on current work ability, socio-demographic data, somatic and mental health, and typical adverse effects (the EPIC-26) after prostatectomy. High versus moderate/poor work ability was the primary outcome. Descriptive statistics and logistic regression analyses were applied. Results The mean age of the sample at survey was 65.5 years (SD 5.9). At survey 42% of the sample reported moderate/poor current work ability and 58% reported high work ability. In multivariable analysis older age at survey, low basic education, comorbidity, poor self-rated health, presence of depression and low EPIC-26 hormonal domain score remained significantly associated with moderate/poor work ability. Conclusions Current work ability is a useful measure for the working capacity particularly of retired men. Socio-demographic, cancer-related, health, psychological and typical adverse effect variables were significantly associated with moderate/poor current work ability after robot-assisted laparoscopic prostatectomy, and several health and psychological variables are amenable to identification and treatment by health care providers.

Graphical abstract, Highlights • DCE MRI and dynamic FACBC PET of prostate cancer were co-registered with histology. • Dynamic FACBC and DCE MRI showed similar wash-in time curve characteristics. • At later time points, FACBC plateaued whereas MR contrast medium washed out. • Added value of the wash-in information from dynamic FACBC remains to be documented., Background and purpose Multimodal imaging is increasingly included in the assessment of prostate cancer patients, and there is a need to study whether different techniques provide similar or complementary information. In the initial perfusion phase contrast agents and radioactive labelled tracers act as blood-pool agents and may show similar characteristics. The purpose of the current work was to compare time-activity- and time-concentration-curves (TCs) of dynamic 18F-fluciclovine (18F-anti-1-amino-2-[F]-fluorocyclobutane-1-carboxylic acid, FACBC) positron emission tomography (PET) and dynamic contrast-enhanced magnetic resonance imaging (DCE MRI). Materials and methods Dynamic FACBC PET and DCE MRI were performed on 22 patients with intermediate or high-risk prostate cancer within 23 days prior to robot-assisted laparoscopic prostatectomy. Index tumour was delineated in the images using whole mount tissue sections as reference standard. Tumour TCs from PET and MRI were compared visually and quantitatively by calculating correlation coefficients between the curves at different time points after injection. Results For the first minute post injection, the mean correlation coefficient between the TCs from PET and MRI was 0.92 (range; 0.75–0.99). After the first minute, MRI showed washout while PET showed plateau kinetics. Conclusion Dynamic FACBC and DCE MRI showed similar wash-in time curve characteristics. At later time points, FACBC plateaued whereas MR contrast medium washed out. In DCE MRI, the usefulness of wash-in information is well documented. Whether wash-in information from dynamic FACBC can provide added value remains to be documented.

The established role of hypoxia-induced signaling in prostate cancer growth, metastasis, and response to treatment suggests that a method to image hypoxia in tumors could aid treatment decisions. Here, we present consumption and supply-based hypoxia (CSH) imaging, an approach that integrates images related to oxygen consumption and supply into a single image. This integration algorithm was developed in patients with prostate cancer receiving hypoxia marker pimonidazole prior to prostatectomy. We exploited the intravoxel incoherent motion (IVIM) signal in diagnostic diffusion-weighted (DW) magnetic resonance (MR) images to generate separate images of the apparent diffusion coefficient (ADC) and fractional blood volume (fBV). ADC and fBV correlated with cell density (CD) and blood vessel density (BVD) in histology and whole-mount sections from 35 patients, thus linking ADC to oxygen consumption and fBV to oxygen supply. Pixel-wise plots of ADC versus fBV were utilized to predict the hypoxia status of each pixel in a tumor and to visualize the predicted value in a single image. The hypoxic fraction (HFDWI) of CSH images correlated strongly (R2 = 0.66; n = 41) with pimonidazole immunoscore (HSPimo); this relationship was validated in a second pimonidazole cohort (R2 = 0.54; n = 54). We observed good agreement between CSH images and pimonidazole staining in whole-mount sections. HFDWI correlated with tumor stage and lymph node status, consistent with findings for HSPimo. Moreover, CSH imaging could be applied on histologic CD and BVD images, demonstrating transferability to a histopathology assay. Thus, CSH represents a robust approach for hypoxia imaging in prostate cancer that could easily be translated into clinical practice. Significance: These findings present a novel imaging strategy that indirectly measures tumor hypoxia and has potential application in a wide variety of solid tumors and other imaging modalities. Graphical Abstract: http://cancerres.aacrjournals.org/content/canres/78/16/4774/F1.large.jpg. Cancer Res; 78(16); 4774–85. ©2018 AACR.

Background In locally advanced rectal cancer (LARC), beyond total mesorectal excision (bTME) is often necessary to obtain complete resection (R0). The aim of this study was to identify prognostic determinants and compare morbidity and survival in LARC cases requiring bTME or TME surgery. Method Single centre cohort study of LARC cases where all patients received neoadjuvant radiotherapy (n = 332). Data was registered prospectively in an institutional database linked to the National Registry. Results bTME surgery was performed in 224 patients, 171 with resections of adjacent organs (bTME-o group) and 53 with pelvic side-wall resections (bTME-pw group). TME surgery was performed in 108 patients. Six deaths occurred within 100 days and severe morbidity was registered in 23.8% of the whole cohort and in 25.4% of the bTME groups. The R0 rates were 93.5%, 84.2%, and 75.5% in the TME, bTME-o, and bTME-pw groups, respectively. Five-year disease free survival (DFS) was 67.3% (TME group), 54.5% (bTME-o group) and 48.7% (bTME-pw group), and five-year overall survival (OS) 78.7%, 69.0% and 60.4% respectively. Patients with involved resection margins (R1), high pT-stage, pN-positivity or poor response to neoadjuvant therapy were associated with inferior DFS and OS. Conclusion In organ-threatening or infiltrating LARC, bTME surgery can be performed with low mortality and acceptable morbidity to obtain a good long-term outcome. Patients with pelvic side-wall infiltration were identified as a subgroup with increased risk of R1 resection and inferior long-term outcome.

We examine trends in incidence, mortality and survival of penile squamous cell carcinoma (SCC) in Norway over 60 years. Data on all cases of penile cancer diagnosed in Norway during 1956-2015 were obtained from the Cancer Registry of Norway. Trends in age-standardized rates of penile SCC incidence, mortality and 5-year relative survival were assessed by the annual percentage change statistic and joinpoint regression. A total of 1,596 penile cancer cases were diagnosed during 1956-2015, among which 1,474 (92.4%) were SCC. During 2011-2015, the age-standardized incidence and mortality of penile SCC were 0.91 (95% confidence interval (CI): 0.78; 1.05) and 0.50 (0.42; 0.60) per 100,000, respectively, and the 5-year relative survival was 61.6% (41.9; 76.4). The incidence of SCC increased during 1956-2015, with an average annual percentage change (AAPC) of 0.80% (0.46; 1.15). The increase was strongest among men diagnosed at a relatively early age (age

Simple Summary Molecular tissue-based prognostic biomarkers are anticipated to complement the current risk stratification systems in prostate cancer, but their manual assessment is subjective and time-consuming. Objective assessment of such biomarkers by machine learning-based methods could advance their adoption in a clinical workflow. PTEN and DNA ploidy status are well-studied biomarkers, which can provide clinically relevant information in prostate cancer at a low cost. Using a cohort of 253 patients who received radical prostatectomy, we developed a novel, fully-automated PTEN scoring in immunohistochemically-stained tissue slides, which could be used to assess PTEN status in a reliable and reproducible manner. In an independent validation cohort of 259 patients, automatically assessed PTEN status was significantly associated with time to biochemical recurrence after radical prostatectomy, and the combination of PTEN and DNA ploidy status further improved risk stratification. These results demonstrate the utility of machine learning in biomarker assessment. Abstract Machine learning (ML) is expected to improve biomarker assessment. Using convolution neural networks, we developed a fully-automated method for assessing PTEN protein status in immunohistochemically-stained slides using a radical prostatectomy (RP) cohort (n = 253). It was validated according to a predefined protocol in an independent RP cohort (n = 259), alone and by measuring its prognostic value in combination with DNA ploidy status determined by ML-based image cytometry. In the primary analysis, automatically assessed dichotomized PTEN status was associated with time to biochemical recurrence (TTBCR) (hazard ratio (HR) = 3.32, 95% CI 2.05 to 5.38). Patients with both non-diploid tumors and PTEN-low had an HR of 4.63 (95% CI 2.50 to 8.57), while patients with one of these characteristics had an HR of 1.94 (95% CI 1.15 to 3.30), compared to patients with diploid tumors and PTEN-high, in univariable analysis of TTBCR in the validation cohort. Automatic PTEN scoring was strongly predictive of the PTEN status assessed by human experts (area under the curve 0.987 (95% CI 0.968 to 0.994)). This suggests that PTEN status can be accurately assessed using ML, and that the combined marker of automatically assessed PTEN and DNA ploidy status may provide an objective supplement to the existing risk stratification factors in prostate cancer.

Introduction: Salvage robot-assisted radical prostatectomy (sRARP) is seen as an attractive option for salvage treatment of radiation therapy -recurrent prostate cancer (PC), thanks in part to the good visualisation that is possible using this modality. However, the results of fewer than 200 salvage sRARPs have been published in the literature. We report the outcomes in a cohort of initially high risk patients of robot-assisted radical prostatectomy as salvage local therapy for radiation-resistant PC in a Scandinavian healthcare setting. Materials and methods: A retrospective review of the charts of all patients who underwent sRARP for biochemical failure (BCF) after primary radiation treatment for localised PC at a single institution was performed. Results: Twenty-two patients, median age 67 years (range 57 to 72), had sRARP performed between June 2008 to July 2013. A median follow-up of 26 months (range 2 to 63) was observed. Perioperative complications occurred in 4 patients (18%), with one patient sustaining a rectal injury. Histo-pathological diagnosis was pT2 in three, pT3a in five, pT3b in twelve and pTx in one patient. Ten patients (45%) had a positive surgical margin (PSM). At follow-up, 54 % of patients were free of biochemical progression and 41% were continent. Conclusions: We showed that salvage RARP is technically feasible in a cohourt of patients with predominantly high risk disease. This study adds to the limited data already in the literature, demonstrating the high frequency of locally advanced (pT3b) PC, a patient group that is usually not included in salvage treatments, as e.g. high frequency ultrasound or salvage brachytherapy. Further, given that the historical barriers to salvage RP with higher rates of rectal injury and poor urinary control no longer seem to be applicable in the modern era, we think that more patients should be considered candidates for this potentially curative salvage treatment of radiation-resistant PC. However, long-term follow-up is needed to confirm if the additional burden on these patients confers to oncological control following the procedure.

324 Background: Patients with very high-risk prostate cancer (VHR-PC) features experience worse outcome after radical prostatectomy. This study was designed to assess biochemical failure and toxicity of adjuvant dendritic cells vaccine (DCV) in prostate cancer patients who are at greatest risk for cancer progression. Methods: Twenty patients with pathological stage pT2 - pT3b and Gleason score 7B-10, pN0, pN+ or pNx were enrolled into the approved study DC-005. The primary end point was clinical failure. Ten patients were tested for disseminated tumor cells (DTCs) to the bone marrow before inclusion to the study. Three patients out of 10 patients had positive DTCs detection in bone marrow. The mean age of the cohort was 63 years (SD 6.9 years), and three patients had postsurgical pN1 status. Eighteen patients had two or more high-risk factors (ISUP grade 5, T3- stage and or PSA > 20 ng/mL). Autologous dendritic cells were transfected with mRNA for hTERT, survivin and tumor mRNA. The DCV product was applied intradermally after curative intended surgery once per week the first months, then once per months the first year, thereafter every 3 months for two years or until biochemical progression (PSA relapse cut-off ≥ 0.3). Results: After 5 years follow-up (FU) 62% (12/20 patients) had not biochemically progressed and with a median FU of 69 months all patients included in the study are alive. Five patients were treated with salvage and one patient with adjuvant radiation treatment, three patients received limited ADT, and three patients are on first line ADT, none of those eight patients have experienced castration resistant prostate cancer. The toxicity was mild with no serious adverse event related to DCV. Conclusions: Adjuvant DCV mitigates the time to biochemical progression. These results appear favorably compared to historical controls in VHR-PC. The clinical outcomes of this study warrants a future enlarged clinical trial. Clinical trial information: NCT01197625.

We examine trends in incidence, mortality and survival of penile squamous cell carcinoma (SCC) in Norway over 60 years. Data on all cases of penile cancer diagnosed in Norway during 1956–2015 were obtained from the Cancer Registry of Norway. Trends in age‐standardized rates of penile SCC incidence, mortality and 5‐year relative survival were assessed by the annual percentage change statistic and joinpoint regression. A total of 1,596 penile cancer cases were diagnosed during 1956–2015, among which 1,474 (92.4%) were SCC. During 2011–2015, the age‐standardized incidence and mortality of penile SCC were 0.91 (95% confidence interval (CI): 0.78; 1.05) and 0.50 (0.42; 0.60) per 100,000, respectively, and the 5‐year relative survival was 61.6% (41.9; 76.4). The incidence of SCC increased during 1956–2015, with an average annual percentage change (AAPC) of 0.80% (0.46; 1.15). The increase was strongest among men diagnosed at a relatively early age (age, What's new? Current trends in penile cancer incidence are unclear. Some studies suggest that the disease is on the rise, while others indicate the opposite. Our study examined changes in penile squamous cell carcinoma (SCC) incidence in Norway from 1956 to 2015. The results show that penile SCC incidence climbed steadily over the 60‐year period, especially among younger men. Mortality associated with penile PCC rose somewhat, while survival did not change significantly, indicating that changes in treatment have only marginally benefited survival. The observed increase in incidence may be associated with increased human papillomavirus (HPV) transmission, which is preventable through HPV vaccination.

Background Recently, the Expanded Prostate Cancer Index Composite 26-item version (EPIC-26) was recommended for the assessment of adverse effects after the treatment of prostate cancer without clear reasons. This decision encouraged us to review the questionnaire development from the UCLA Prostate Cancer Index (UCLA-PCI) to the EPIC-16 CP with a focus on psychometric properties. We also reviewed PubMed for papers concerning such properties of the EPIC-26 since 2012 (latest review in 2011). Finally, we examined the psychometric properties of the EPIC-26 in a sample of Norwegian males treated with robot-assisted laparoscopic prostatectomy (RALP). Methods This study used three methods: (1) Comparison of the content of the UCLA-PCI, EPIC-50, EPIC-26, and EPIC-16 CP; (2) Review of EPIC-26 and EPIC-16 CP papers in PubMed from 2012 to 2016, identifying papers reporting on the psychometric properties of these questionnaires; and (3) Psychometric examination of the EPIC-26 rating in 651 Norwegian men treated with RALP at a mean of 3.2 years post-surgery. Results The questionnaire development showed a significant increase in bother versus function items, and the EPIC-26 contains eight function and 18 bother items. Twelve papers concerning the EPIC-26 available on PubMed since 2012 support the psychometric properties of the EPIC-26. The Norwegian EPIC-26 findings supported the psychometric properties of the EPIC-26, but suggested six subdomains both by exploratory and confirmatory factor analyses. Conclusions In general our examinations supported the adequate psychometric properties of the EPIC-26, although the factor structure, construct and predictive validity of the instrument should be examined further.

Laparoscopic surgery (LS) for resectable adrenocortical carcinoma (ACC) has been questioned due to uncertainty with regard to long-term oncological outcome. We analyzed the experience with LS compared to open surgery (OS) at Oslo University Hospital (OUH). Material and methods. Between 1998 and 2011 32 patients were identified with ACC stage I-III operated either by LS (17 patients) or OS (15 patients). Patients' records were reviewed retrospectively with regard to pre- and intraoperative findings, short-term surgical outcome, relapse and survival. The patients in the LS group had significantly smaller tumors and higher body mass index, otherwise the groups did not differ significantly. Thirty-one patients had been operated at surgical departments of the OUH, and all had been followed at OUH. Results. Short-term outcome favored LS by significantly shorter operation time, lower blood loss and need for transfusions, fewer postoperative complications and shorter hospitalization. The completeness of resection was similar in both groups with R0 resection accomplished in 12 patients in the LS group and 12 in the OS group. Twelve and 15 patients have relapsed in the LS and OS groups, respectively, with a similar pattern of relapse (local, peritoneal or distant). Median progression-free survival (15.2 months for LS vs. 8.1 months for OS) and median overall survival (103.6 months for LS vs. 36.5 months for OS) were not significantly different. Discussion. LS seems to offer short-term advantages and similar long-term outcome compared to OS in patients with resectable ACC stage I-III.

Summary Background & aims The effect of lycopene-containing foods in prostate cancer development remains undetermined. We tested whether a lycopene-rich tomato intervention could reduce the levels of prostate specific antigen (PSA) in prostate cancer patients. Methods Prior to their curative treatment, 79 patients with prostate cancer were randomized to a nutritional intervention with either 1) tomato products containing 30 mg lycopene per day; 2) tomato products plus selenium, omega-3 fatty acids, soy isoflavones, grape/pomegranate juice, and green/black tea (tomato-plus); or 3) control diet for 3 weeks. Results The main analysis, which included patients in all risk categories, did not reveal differences in changes of PSA-values between the intervention and control groups. Post-hoc, exploratory analyses within intermediate risk (n = 41) patients based on tumor classification and Gleason score post-surgery, revealed that median PSA decreased significantly in the tomato group as compared to controls (−2.9% and +6.5% respectively, p = 0.016). In separate post-hoc analyses, we observed that median PSA-values decreased by 1% in patients with the highest increases in plasma lycopene, selenium and C20:5 n-3 fatty acid, compared to an 8.5% increase in the patients with the lowest increase in lycopene, selenium and C20:5 n-3 fatty acid (p = 0.003). Also, PSA decreased in patients with the highest increase in lycopene alone (p = 0.009). Conclusions Three week nutritional interventions with tomato-products alone or in combination with selenium and n-3 fatty acids lower PSA in patients with non-metastatic prostate cancer. Our observation suggests that the effect may depend on both aggressiveness of the disease and the blood levels of lycopene, selenium and omega-3 fatty acids.

Background Recently two new methods for prospective studies of adverse effects after treatment have been developed: Proportions of patients regaining 90% of baseline function score (PBS-90) and Generalized Estimating Equation (GEE). We compared these methods to examine changes of sexual, urinary, and bowel functions after robot-assisted prostatectomy (RALP) and conformal external beam radiotherapy (EBRT) in patients without androgen deprivation therapy (ADT). Methods The post-treatment functional course was studied prospectively in 254 patients (N = 150 RALP and N = 104 EBRT) with PBS-90 and GEE. The time points at which functions reached stability and significant associations with function at 24 months were examined with PBS-90, and predictors were identified with GEE. The patients filled in the UCLA-PCI questionnaire at baseline and at 3, 6, 12, and 24-month post-treatment. Results The proportions reaching PBS-90 at 24 months were 69% EBRT and 34% RALP patients for urinary function, 70% of EBRT and 7% of RALP patients for sexual function, and 70% of EBRT and 86% of RALP patients for bowel function. GEE showed that the function scores at 6 months were significantly associated with the functions at 24 months. PBS-90 found that stability of function was reached at 3 months for urinary and 6 months for sexual and bowel functions. Conclusions In outcome assessment PBS-90 mainly demonstrates when post-treatment level become stabilized and GEE shows the time points at which final outcome can be predicted. The two methods therefore supplement each other. Changes of functions corresponded to those reported in samples including patients having ADT.

Prostate cancer patients diagnosed with high Gleason score (≥ 8) and large tumors (≥T2c) are considered high-risk patients and >50% will develop an early biochemical relapse following radical surgery. Presently, there is no curative therapy available for patients once when biochemical relapse occur. Based on encouraging clinical results from 6 relapsed prostate cancer patients treated under hospital exemption with dendritic cell (DC) vaccines we started an adjuvant, first in man, phase I/II study using autologous, monocyte derived DCs targeting autologous tumor antigens from primary tumor, combined with hTERT and survivin. Twenty patients were included in the study. All patients had pathological stage pT2-pT3b and Gleason score 7b-10. Following surgery prostate specific antigen (PSA) was < 0,2 µg/L in all patients. Fifteen patients have received 3-days DCs generated according to our standard protocol with a maturation cocktail composed of GM-CSF, IL-4, TNFα, IL1β and PgE2. Five patients were treated with a TLR 7/8 ligand containing maturation cocktail, resulting in DCs with a polarized release of IL-12p70 and no or low IL-10. The patients received 4 weekly vaccinations, then DTH vaccine at week 8 and thereafter-monthly vaccinations the first year, and every third month the second and third year. All patients except of two have completed vaccination. Of the 15 first patients using the standard DCs, three patients developed PSA relapse during vaccination (PSA measured twice >0,5 μg/L with minimum 4 weeks interval) and two additional patients relapsed after completed 3 years of vaccination. From the last 5 patients given the new type of DCs none have experienced PSA relapse. Seventy-five percent of the patients remain without biochemical relapse with a mean observation time of 47,5 (range 29-82) months. We confirm that the study is feasible and safe. Immune responses in the patients are under investigation. Altogether, our clinical results are promising and the use of adjuvant DC vaccines might become a new approach to prevent biochemical relapse in high-risk prostate cancer patients following radical surgery. Citation Format: Anne Merete Tryggestad, Iris Bigalke, Karol Axcrona, Bjørn Brennhovd, T Kirsti Hønnåshagen, Lisbeth Skoge, Lena Tjeldhorn, Lene Mowinckel, Stein Sæbøe-Larsen, Jens A L Jørgensen, Grete S Andreassen, Gjertrud Skorstad, Dag Josefsen, Ulrika Axcrona, Steinar Aamadal, Wolfgang Lilleby, Svein Dueland, Gunnar Kvalheim. A first in man phase I/II adjuvant dendritic cell vaccine study in high-risk prostate cancer patients following radical surgery reduce the incidence of biochemical relapse [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr CT016.

Introduction Laparoscopic adrenalectomy for metastases is considered controversial. Multicenter retrospective study was performed to gain new knowledge in this issue. Materials and Methods From January 1997 till November 2008, 41 adrenalectomies were performed during follow-up of the patients operated for malignant tumors. The median age was 64 (52–77) years. Metastases were confirmed in 31/41 cases. Metastatic lesions were further studied and to define factors influencing on survival, patients were divided to sub-groups of metachronous/synchronous, tumor origin and tumor size. Results The median operative time was 104 (50–230) min, the median blood loss was 100 (0–500) ml. One procedure (3.2%) was converted. There were 3 (10.7%) intraoperative and 2 (7.4%) postoperative complications. The median tumor size was 6 (1.5–16) cm. Pathohistological analysis revealed 12 colorectal, 9 renal cell carcinoma, 5 lung carcinoma, 4 melanoma, and 1 hepatocellular metastases. The resection margin was not free in one case (3.7%). The median hospital stay was 2 (1–21) days. The median length of survival was 29 ± 2.1 months for all patients. Conclusion Laparoscopic adrenalectomy for metastases is feasible regardless of their sizes. However these procedures should be performed by highly skilled laparoscopic surgeon in a fully equipped operating room and with a coordinated operation team. J. Surg. Oncol. 2009;100:43–47. © 2009 Wiley-Liss, Inc.

Objective. Erectile function with and without use of erectile aids was compared in high-, intermediate- and low-risk prostate cancer patients at a mean of 3 years after robot-assisted laparoscopic prostatectomy (RALP). Materials and methods. A sample of 982 men who underwent RALP at Oslo University Hospital, Radiumhospitalet, between 2005 and 2010 was invited to complete a mailed questionnaire in 2011. The response rate was 79%, but only 609 patients did not have adjuvant treatment and reported on erection. The sample consisted of 29% high-risk, 40% intermediate-risk and 25% low-risk patients according to the preoperative D'Amico classification. Based on questionnaire data, two primary outcomes were defined: ability to have intercourse (sufficient erection), and use and effect of erectile aids. Results. Sufficient erection with or without erectile aids was reported by 19% of the high-, 30% of the intermediate- and 19% of the low-risk group (not significant). Erectile aids were used by 48% of the sample, of whom 18% of the high-, 21% of the intermediate- and 14% of the low-risk group reported sufficient erection (not significant). Papaverine injections were used by 21% and phosphodiesterase-5 inhibitors by 28% of the sample. Limitations were the lack of data on erection baseline and on penile rehabilitation. Conclusions. Nearly half of the sample used erectile aids, which significantly increased the proportion with sufficient erection in all risk groups after RALP. With and without the use of erectile aids, the proportions of patients with sufficient erection were 30% or less, with non-significant differences between groups.

Objectives To study the ability to reach orgasm after robot-assisted laparoscopic prostatectomy (RALP) in relation to demographic, cancer-related, and surgical variables, and the use of erectile aids. Methods In this cross-sectional study at a mean of 3 years after RALP at Oslo University Hospital, 982 men were invited to complete a mailed questionnaire, and 777 responded. Respondents who reported postoperative radiotherapy or hormone treatment, or did not report on orgasm were omitted, leaving 609 patients for analysis. Ability to reach orgasm was rated on 1 question from The Expanded Prostate Cancer Index Composite 26-item version, and dichotomized into "good" or "poor." Results Overall, 27% of the men reported good ability to reach orgasm: 22% among those did not use erectile aids and 34% among those did (P =.001). Univariate analysis of men with good versus poor ability to reach orgasm showed many significant differences. In multivariate analysis, being older, having a reduced physical quality of life, and erectile dysfunction were significantly associated with poor ability to reach orgasm. Erectile dysfunction showed an odds ratio of 4.86 for poor orgasmic ability. The 48% of men who used erectile aids had significantly better orgasmic ability than the nonusers. Conclusion In our sample, 27% had good ability to reach orgasm at a mean of 3 years after RALP. Poor orgasmic ability was associated with being older, poor erectile function, and a reduced physical quality of life. Using erectile aids increased the rate of good ability to reach orgasm. © 2016 Elsevier Inc.

To optimize the indication for sentinel lymph node (SLN) biopsy according to tumour size in penile carcinoma.This was a retrospective analysis of 23 consecutive patients (median age 65 years; range 49-85 years) with primary penile carcinoma classified according to the TNM classification as stage T1-T3 who were identified as having SLNs in the groins. SLNs were detected by means of preoperative injection of a 99mTc nanocolloid around the tumour and peroperative use of a gamma detector probe. The average tumour size was 2.9+/-1.3 cm.In 7/25 patients with penile carcinoma examined with the SLN method, metastases to inguinal lymph nodes could be demonstrated. Two out of three patients with primary penile carcinomas classified as T1 according to the TNM classification and tumours3 cm in diameter had inguinal lymph node metastases. One of the patients had a micrometastasis, which was detected by means of immunohistochemical analysis. Seven out of eight patients with penile carcinomas3 cm in diameter had lymph node metastases. We did not observe any major surgical complications associated with the SLN procedure.These data indicate that penile carcinomas with a diameter of3 cm should be investigated with SLN biopsy regardless of stage. However, multicentre studies are needed in order to obtain the appropriate number of patients.

Robot-assisted laparoscopic prostatectomy (RALP) has increasingly become a treatment alternative for patients with high-risk prostate cancer. Few papers focus on the prevalence of operative and short-term postoperative (30 days) adverse events associated with RALP in high-risk patients. The objective of this study was to study such events in high-risk patients using intermediate- and low-risk patients as contrast groups.In total, 1076 patients who underwent RALP at Oslo University Hospital, Radiumhospitalet, between the start of 2005 and end of 2010 were studied. Based on the D'Amico classification the sample consisted of 374 (35%) high-, 475 (44%) intermediate- and 227 (21%) low-risk patients. An index of seven adverse effects was dichotomized into zero or any number of adverse effects.The high-risk group had significantly longer operation time, more positive surgical margins, larger prostate volume and less nerve-sparing than the contrast groups. No between-group differences were observed for reoperation, catheter time, bleeding volume or transfusions. Significantly more Clavien complications were observed in the high-risk than in the low-risk group. A positive adverse effect index score was associated with positive margins, no nerve-sparing surgery and no preoperative magnetic resonance imaging, and negatively associated with the second and third of three 2-year study periods.High-risk patients had a significantly higher risk of some operative and short-term postoperative adverse events than the control groups. This was not the case for the seven-items adverse event index. This study does not support any restricted attitude towards RALP in high-risk patients, except for general surgical contraindications.

Objectives To determine the accuracy and assess the clinical significance of surface-coil 1.5-T magnetic resonance imaging (MRI) for the detection of locally advanced prostate cancer (PCa). Methods Between December 2007 and January 2010, we examined 209 PCa patients (mean age = 62.5 years) who were consecutively treated with robot-assisted laparoscopic prostatectomy and prospectively staged by MRI. One hundred and thirty-five patients (64.6 %) had locally advanced disease. Conventional clinical tumour stage and MRI-assessed tumour stage were compared with histopathological tumour stage (pT). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and overall accuracy (OA) were calculated using pT as the “gold standard”. Overstaged and understaged cases at MRI were reviewed. Results Sensitivity, specificity, PPV, NPV and OA for the detection of locally advanced disease were 25.9, 95.9, 92.1, 41.2 and 50.5 % and 56.3, 82.2, 85.4, 50.4 and 65.4 % for clinical staging and MRI, respectively. Among patients understaged at MRI, the resection margins were free in 64.4 % of the cases (38/59). Conclusions Although the accuracy was limited, the detection of locally advanced disease improved substantially when MRI was added to routine clinical staging. The majority of the understaged patients nevertheless achieved free margins. When assessing the clinical significance of MRI staging the extent of extraprostatic extension has to be considered. Key Points • MRI substantially improves detection of locally advanced prostate cancer • MRI has limited overall staging accuracy • Most T3 cancers unrecognised at MRI still achieved free resection margins • Assessing the true clinical contribution of MRI remains challenging

Several authors have previously reported that transrectal prostate biopsy has a false-negative rate of 20-30%, and that a number of prostate cancers missed on transrectal biopsy can be detected by transperineal biopsy. It has also been shown that most of these tumours are located anteriorly in the prostate gland. The present study showed a high rate of prostate cancer in patients with previous negative transrectal biopsies but elevated PSA levels, and that the cancers were located anteriorly in the prostate gland. Also, most of these cancers were clinically significant in patients that underwent RP, i.e. a high proportion of cancers were high-grade/high-stage tumours. We also showed that the transperineal biopsy technique can be applied successfully to patients with a closed anal orifice after previous surgery for rectal cancer. Transperineal biopsy can be done safely without routine antibiotic prophylaxis.To investigate the outcomes of transperineal prostate biopsies in patients with elevated prostate-specific antigen (PSA) levels and negative transrectal biopsies. The aim of this retrospective study was to evaluate the diagnostic yield of the transperineal biopsy approach in these patients, and to evaluate the pathology findings in subsequent radical prostatectomy (RP) specimens in patients undergoing RP.In all, 69 consecutive patients with previous negative transrectal biopsies but elevated PSA levels investigated at urological units in Norway who had been referred to The Norwegian Radium Hospital were included. The patients had undergone a mean (median; range) of 2.42 (2; 0-7) transrectal biopsies. The mean (range) age was 63.1 (42-78) years. The median (range) PSA level was 12 (4.3-229) ng/mL. The patients were examined with transperineal biopsy of the prostate between July 2007 and February 2009. The results of the transperineal biopsies were reviewed for Gleason biopsy score, and these were compared with the histopathology results of the RP specimens, i.e. final Gleason scores. Pathological stage of the prostate specimens and tumour volume were also reviewed.Prostate cancer was found in the biopsies of 38 of 69 patients (55%). In all, 20 of 38 patients had a Gleason score estimated at ≥3 + 4 = 7. In all, 26 patients underwent RP. The surgical specimens revealed pathological stage pT2c in 65%, pT3a in 27% and pT3b in 8% of the cases. In all, 23 of the 26 RP specimens showed a final Gleason score of ≥7. The vast majority of cancers detected were situated in the anterior/ventral portion of the prostate.Transperineal biopsy of the prostate in patients with an elevated PSA level after negative transrectal prostate biopsies appears to be a feasible and important option for further investigation to detect prostate cancer. The present study shows that the transperineal biopsy allows good access of the anterior/ventral part of the prostate. Histopathology reports on the RP specimens obtained from the patients that underwent RP revealed significant cancer.

Background Most previous studies of prostate cancer (CaP) patients have focused on functional side effects. In the decision about treatment, the patients' subjective experience of function (bother) should also be considered. In this prospective study of CaP patients, we used both categorical and dimensional methods to examine changes of sexual, urinary, and bowel bother after robot-assisted prostatectomy (RALP), after high dose radiotherapy alone (RAD), or with adjuvant androgen deprivation therapy (RAD + ADT). We also studied the associations between psychosocial factors and post-treatment bother and the correlations between bother and function at the follow-up time points. Methods A total of 462 patients ( n = 150 RALP, n = 104 RAD, and n = 208 RAD + ADT) completed questionnaires at all time points (baseline, 3, 6, 12, and 24 months post-treatment). Our outcome measures were the proportion of patients who regained their baseline bother core (PBS-100) and the mean group scores on sexual, urinary, and bowel bother based on the UCLA-PCI questionnaire. Generalized estimating equation (GEE) identified the time points at which various variables were significantly associated with bother at 2 years. The time points at which the proportions of bothered patients became stable were defined. Results The different treatment modalities provided distinctive patterns over time regarding urinary, sexual, and bowel bothers. RALP gave sexual and urinary bother, RAD + ADT patients reported bowel and sexual bother, while RAD patient suffered mainly from bowel bother. According to GEE, the bother scores at 3 or 6 months were significantly associated with the bother scores at 24 months for all groups. PBS-100 and stability of the recovered bother domains was reached at 3 to 6 months. Strong correlations were observed between function and bother for the urinary and bowel domains but not for the sexual domain. The associations between psychosocial factors and bother were weak. Conclusions Two years after treatment, RALP patients mainly reported sexual and urinary bother, while irradiated patients were bothered by bowel dysfunction. Sexual, urinary, and bowel bother reached stable proportions at 3 to 6 months post-treatment. Based on GEE, bother at 6 months was in general significantly associated with bother at 24 months.

Recently two new methods for prospective studies of adverse effects after treatment have been developed: Proportions of patients regaining 90% of baseline function score (PBS-90) and Generalized Estimating Equation (GEE). We compared these methods to examine changes of sexual, urinary, and bowel functions after robot-assisted prostatectomy (RALP) and conformal external beam radiotherapy (EBRT) in patients without androgen deprivation therapy (ADT).The post-treatment functional course was studied prospectively in 254 patients (N = 150 RALP and N = 104 EBRT) with PBS-90 and GEE. The time points at which functions reached stability and significant associations with function at 24 months were examined with PBS-90, and predictors were identified with GEE. The patients filled in the UCLA-PCI questionnaire at baseline and at 3, 6, 12, and 24-month post-treatment.The proportions reaching PBS-90 at 24 months were 69% EBRT and 34% RALP patients for urinary function, 70% of EBRT and 7% of RALP patients for sexual function, and 70% of EBRT and 86% of RALP patients for bowel function. GEE showed that the function scores at 6 months were significantly associated with the functions at 24 months. PBS-90 found that stability of function was reached at 3 months for urinary and 6 months for sexual and bowel functions.In outcome assessment PBS-90 mainly demonstrates when post-treatment level become stabilized and GEE shows the time points at which final outcome can be predicted. The two methods therefore supplement each other. Changes of functions corresponded to those reported in samples including patients having ADT.

We studied compliance to guidelines of curative treatments in prostate cancer (PCa), which were of special interest due to recent introduction of new treatment technologies and the fact that there existed a real choice between surgery and radiotherapy.We did retrospective analyses of guidelines adherence for all PCa patients receiving curative treatment at the Norwegian Radium Hospital from 2004 to 2007 after the introduction of robot-assisted prostatectomy and after-loading brachytherapy. The patients were classified into three groups in relation to guidelines: the accordance, accordance after discussion, and the deviance groups. In time Period I (2004-2005) the 2003 EAU guidelines were used and in Period II (2006-2007) in-house guidelines with minor modifications of EAU were applied.During the observation period 859 patients had curative treatment for PCa, and 83% of the patients were treated according to guidelines. In the deviance group (N=146), 119 men (82%) got prostatectomy instead of radiotherapy. The reasons for deviation in the second period were age65 years (N=70) and surgery in cases with T3 tumors (N=10), Gleason score8 (N=13) and combinations (N=26). Deviances from guidelines in the radiotherapy group (N=27) mainly concerned patient selecting this treatment due to expectations of preserving sexuality and/or fertility.In spite of acceptable overall compliance to guidelines for curative PCa treatment, the proportion of non-adherence should not been overseen, in particular when new treatment technologies are introduced. Guidelines for PCa need to be monitored regularly, and the compliance to guidelines has to be assessed on a regular basis. Guidelines should avoid too strict criteria, particularly in relation to age.

Laparoscopic adrenalectomy for metastases is considered controversial. Multicenter retrospective study was performed to gain new knowledge in this issue.From January 1997 till November 2008, 41 adrenalectomies were performed during follow-up of the patients operated for malignant tumors. The median age was 64 (52-77) years. Metastases were confirmed in 31/41 cases. Metastatic lesions were further studied and to define factors influencing on survival, patients were divided to sub-groups of metachronous/synchronous, tumor origin and tumor size.The median operative time was 104 (50-230) min, the median blood loss was 100 (0-500) ml. One procedure (3.2%) was converted. There were 3 (10.7%) intraoperative and 2 (7.4%) postoperative complications. The median tumor size was 6 (1.5-16) cm. Pathohistological analysis revealed 12 colorectal, 9 renal cell carcinoma, 5 lung carcinoma, 4 melanoma, and 1 hepatocellular metastases. The resection margin was not free in one case (3.7%). The median hospital stay was 2 (1-21) days. The median length of survival was 29 +/- 2.1 months for all patients.Laparoscopic adrenalectomy for metastases is feasible regardless of their sizes. However these procedures should be performed by highly skilled laparoscopic surgeon in a fully equipped operating room and with a coordinated operation team.

Photodynamic therapy (PDT) has been investigated as an alternative treatment for cutaneous squamous cell carcinoma in situ (CIS), also known as Bowen's disease. Atypia of the squamous epithelium is graded, with the most severe atypia being equivalent to CIS. CIS on the penis is regarded as a premalignant condition and is seen either in isolation or in conjunction with carcinoma of the penis.A group of 10 patients with atypia/CIS were treated with PDT between December 2002 and April 2005. The group consisted of five patients with primary lesions and five with atypia after an organ-preserving operation for carcinoma of the penis.Eight patients were treated once, one twice and one six times. When complete remission was not achieved, a biopsy was taken for diagnosis. Three of the 10 patients had histopathological residual disease after a median follow-up period of 20 months (range 15-36 months). The first week after treatment could be painful but the cosmetic results were excellent. There was almost no loss of substance or fibrosis in the treated area, and sensitivity was restored to normal after approximately 1 month.In our experience, PDT for CIS seems to be a promising treatment modality with regard to cancer control, organ preservation, cosmetics and functional results. As with laser therapy of these lesions, careful follow-up is mandatory. Larger studies are needed and are planned.

We examined the sensitivity and specificity of Hexvix (PhotoCure ASA, Oslo, Norway) hexyl aminolevulinate (HAL) fluorescence cystoscopy in patients with superficial bladder cancer.A total of 52 patients (38 men and 14 women) with a mean age of 72 years were investigated. HAL hydrochloride (100 mg dissolved in 50 ml phosphate buffer solution) (8 mM) was instilled into the bladder 1 hour prior to the endoscopic procedure. Cystoscopy was performed with the Storz D-light (Karl Storz, Tuttlingen, Germany) system, allowing inspection of the bladder wall under white and blue light (380 to 450 nm).A total of 422 biopsies obtained in fluorescing (165) and nonfluorescing (257) areas, including 5 random biopsies per patient, were analyzed to provide the best reference for the calculation of sensitivity and specificity. There were a total of 143 histologically verified tumors in 45 patients, including carcinoma in situ (CIS), Ta or T1 lesions. A total of 43 patients were diagnosed by fluorescence cystoscopy compared with 33 diagnosed by white light for 96% and 73% per-patient sensitivity, respectively. HAL cystoscopy was found particularly useful for finding CIS tumors. Of 13 patients with CIS tumors all except 1 were diagnosed or confirmed by HAL cystoscopy. HAL cystoscopy was well tolerated with no definite drug related adverse events reported, including effects on standard blood parameters.HAL fluorescence cystoscopy is a new, sensitive, promising diagnostic procedure that showed improved detection of bladder tumors, in particular CIS. The procedure is well tolerated and can easily be implemented in current clinical practice.

We report the case of a 68-year-old man who had previously undergone heart transplantation and pelvic irradiation for Hodgkin’s lymphoma and who was under active surveillance for prostate cancer. In response to his increased prostate-specific antigen levels and elevated Gleason score, he was offered robot-assisted laparoscopic prostatectomy.