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Urolithiasis, Endourology and Laparoscopy
2742
UROLITHIASIS, ENDOUROLOGY AND LAPAROSCOPY Editorial Comment: True et al identified an 86 gene model capable of distinguishing Gleason grade 3 from 4 and 5 prostate cancers. The data presented in this article provide a good start toward developing a molecular grading system. Timothy L. Ratliff, Ph.D.
Activin A Circulating Levels in Patients With Bone Metastasis From Breast or Prostate Cancer G. Leto, L. Incorvaia, G. Badalamenti, F. M. Tumminello, N. Gebbia, C. Flandina, M. Crescimanno and G. Rini, Laboratory of Experimental Chemotherapy, Department of Surgery and Oncology, Policlinico Universitario P. Giaccone, Palermo, Italy Clin Exp Metastasis, Epub, July 14, 2006 Recent studies have highlighted that Activin A, a member of the transforming growth factor-beta (TGFbeta) superfamily, may be involved in the regulation of osteoblastic activity and in osteoclast differentiation. Therefore, we have investigated the clinical significance of its circulating levels in patients with bone metastasis. Activin A serum concentrations were determined, by a commercially available enzyme-linked immunosorbent assay kit, in 72 patients with breast cancer (BC) or prostatic cancer (PC) with (BM⫹) or without (BM⫺) bone metastases, in 15 female patients with age-related osteoporosis (OP), in 20 patients with benign prostatic hypertrophy (BPH) and in 48 registered healthy blood donors (HS) of both sex (25 female and 23 male). Activin A serum concentrations were significantly increased in BC or PC patients as compared to OP (P ⬍ 0.0001) or BPH (P ⫽ 0.045), respectively, or to sex matched HS (P ⬍ 0.0001). Additionally, these levels resulted more elevated in PC patients as compared to BC patients (P ⫽ 0.032). Interestingly, Activin A was significantly higher in BM⫹ patients than in BM⫺ patients (BC, P ⫽ 0.047; PC, P ⫽ 0.016). In BC patients, a significant correlation was observed only between Activin A and number of bone metastases (P ⫽ 0.0065) while, in PC patients, Activin A levels were strongly correlated with the Gleason score (P ⫽ 0.011) or PSA levels (P ⫽ 0.0001) and, to a lessen extent, with the number of bone metastases (P ⫽ 0.056). Receiver operating characteristic curve (ROC) analysis showed a fair diagnostic accuracy of Activin A to discriminate between BM⫹ and BM⫺ patients (BC: AUC ⫽ 0.71 ⫹/⫺ 0.09, P ⫽ 0.03; PC: AUC ⫽ 0.73 ⫹/⫺ 0.081, P ⫽ 0.005). These findings indicate that Activin A may be implicated in the pathogenesis of bone metastasis. Therefore, this cytokine may be considered a novel potential target for a more selective therapeutic approach in the treatment of skeletal metastasis and may be also useful as additional biochemical marker of metastatic bone disease. Editorial Comment: The report links activin A to bone metastases in prostate cancer, providing a novel target for therapy. Timothy L. Ratliff, Ph.D.
UROLITHIASIS, ENDOUROLOGY AND LAPAROSCOPY Differential Response of Arteries and Veins to Bipolar Vessel Sealing: Evaluation of a Novel Reusable Device S. Richter, O. Kollmar, E. Neunhoeffer, M. K. Schilling, M. D. Menger and G. Pistorius, Department of General, Visceral, Vascular and Pediatric Surgery, University of Saarland, Homburg, Germany J Laparoendosc Adv Surg Tech A, 16: 149 –155, 2006 Background: A variety of energy-based techniques for arterial and venous vessel ligation have recently been introduced. Using a porcine model we studied the efficacy of the novel reusable BiClamp versus the standard disposable LigaSure bipolar vessel sealing device. We also compared whether arteries respond differently than veins upon sealing. Materials and Methods: In five Swabian Hall pigs, splenectomy and nephrectomy were performed using two different bipolar vessel sealing devices. Measurements of the sealed arteries and veins (diameter 2–7 mm) included rate of seal failure, burst strength, and heat-associated vascular wall morphologic appearance. An additional three animals underwent splenectomy, salpingo-oophorectomy, and small bowel resection, and vessel seals were studied histologically after a seven-day survival period for vessel wall fusion, inflammation, and fibrous organization. Results: Sealing was highly successful, with only one seal failure overall and thus no difference between the two instruments analyzed. The burst pressures of BiClamp-sealed arteries (842 ⫹/⫺ 117 mm Hg) did not differ from that of arteries sealed with LigaSure (856
UROLITHIASIS, ENDOUROLOGY AND LAPAROSCOPY ⫹/⫺ 102 mm Hg), but were significantly higher than the burst pressures of veins (155 ⫹/⫺ 26 and 216 ⫹/⫺ 71 mm Hg, respectively) (P ⬍ 0.05). Independent of the sealing device used, thermal spread was found increased in veins compared to arteries. Histologic analysis after seven days revealed appropriate healing of the vessel wall, including thrombus fibrosis, fibroblast proliferation, and collagen deposition. With both devices, however, the venous but not the arterial walls still presented with massive inflammatory cell infiltrates. Conclusion: Our study indicates that the BiClamp device is as appropriate as the LigaSure instrument to successfully ligate 2–7 mm arteries and veins, demonstrating supraphysiological bursting strengths and adequate lumenal fusion healing. However, veins are more prone to collateral tissue damage and inflammatory wall infiltration. Editorial Comment: The most vexing aspect of the newer methods of achieving hemostasis (eg bipolar sealing and harmonic shears) is that the devices are disposable, and, hence, add significantly to the cost of the procedure. In this article the authors discuss a new, open surgical, reusable device, the BiClamp®, which seals vessels similarly to the LigaSure™ device. Indeed, in this porcine model the 2 devices appeared to perform identically except that the BiClamp required an extra 2 to 3 seconds to seal arteries and veins. Vessels up to 7 mm were secured with burst pressures that were supraphysiological. Interestingly, thermal spread was increased along veins compared to arteries. However, unfortunately, the precise distance of spread was not reported. While mention is made of sealing vessels 2 to 7 mm in diameter, a caveat from a realistic standpoint is that I would be hesitant to use either type of bipolar sealing device on any artery larger than 3 mm until more data are available. For veins the 7 mm size is likely accurate but, again, I usually limit the use of bipolar sealing to veins 5 mm and smaller. Hopefully, a laparoscopic model of the BiClamp is on the horizon. Ralph Clayman, M.D.
2743
UROLITHIASIS, ENDOUROLOGY AND LAPAROSCOPY Editorial Comment: True et al identified an 86 gene model capable of distinguishing Gleason grade 3 from 4 and 5 prostate cancers. The data presented in this article provide a good start toward developing a molecular grading system. Timothy L. Ratliff, Ph.D.
Activin A Circulating Levels in Patients With Bone Metastasis From Breast or Prostate Cancer G. Leto, L. Incorvaia, G. Badalamenti, F. M. Tumminello, N. Gebbia, C. Flandina, M. Crescimanno and G. Rini, Laboratory of Experimental Chemotherapy, Department of Surgery and Oncology, Policlinico Universitario P. Giaccone, Palermo, Italy Clin Exp Metastasis, Epub, July 14, 2006 Recent studies have highlighted that Activin A, a member of the transforming growth factor-beta (TGFbeta) superfamily, may be involved in the regulation of osteoblastic activity and in osteoclast differentiation. Therefore, we have investigated the clinical significance of its circulating levels in patients with bone metastasis. Activin A serum concentrations were determined, by a commercially available enzyme-linked immunosorbent assay kit, in 72 patients with breast cancer (BC) or prostatic cancer (PC) with (BM⫹) or without (BM⫺) bone metastases, in 15 female patients with age-related osteoporosis (OP), in 20 patients with benign prostatic hypertrophy (BPH) and in 48 registered healthy blood donors (HS) of both sex (25 female and 23 male). Activin A serum concentrations were significantly increased in BC or PC patients as compared to OP (P ⬍ 0.0001) or BPH (P ⫽ 0.045), respectively, or to sex matched HS (P ⬍ 0.0001). Additionally, these levels resulted more elevated in PC patients as compared to BC patients (P ⫽ 0.032). Interestingly, Activin A was significantly higher in BM⫹ patients than in BM⫺ patients (BC, P ⫽ 0.047; PC, P ⫽ 0.016). In BC patients, a significant correlation was observed only between Activin A and number of bone metastases (P ⫽ 0.0065) while, in PC patients, Activin A levels were strongly correlated with the Gleason score (P ⫽ 0.011) or PSA levels (P ⫽ 0.0001) and, to a lessen extent, with the number of bone metastases (P ⫽ 0.056). Receiver operating characteristic curve (ROC) analysis showed a fair diagnostic accuracy of Activin A to discriminate between BM⫹ and BM⫺ patients (BC: AUC ⫽ 0.71 ⫹/⫺ 0.09, P ⫽ 0.03; PC: AUC ⫽ 0.73 ⫹/⫺ 0.081, P ⫽ 0.005). These findings indicate that Activin A may be implicated in the pathogenesis of bone metastasis. Therefore, this cytokine may be considered a novel potential target for a more selective therapeutic approach in the treatment of skeletal metastasis and may be also useful as additional biochemical marker of metastatic bone disease. Editorial Comment: The report links activin A to bone metastases in prostate cancer, providing a novel target for therapy. Timothy L. Ratliff, Ph.D.
UROLITHIASIS, ENDOUROLOGY AND LAPAROSCOPY Differential Response of Arteries and Veins to Bipolar Vessel Sealing: Evaluation of a Novel Reusable Device S. Richter, O. Kollmar, E. Neunhoeffer, M. K. Schilling, M. D. Menger and G. Pistorius, Department of General, Visceral, Vascular and Pediatric Surgery, University of Saarland, Homburg, Germany J Laparoendosc Adv Surg Tech A, 16: 149 –155, 2006 Background: A variety of energy-based techniques for arterial and venous vessel ligation have recently been introduced. Using a porcine model we studied the efficacy of the novel reusable BiClamp versus the standard disposable LigaSure bipolar vessel sealing device. We also compared whether arteries respond differently than veins upon sealing. Materials and Methods: In five Swabian Hall pigs, splenectomy and nephrectomy were performed using two different bipolar vessel sealing devices. Measurements of the sealed arteries and veins (diameter 2–7 mm) included rate of seal failure, burst strength, and heat-associated vascular wall morphologic appearance. An additional three animals underwent splenectomy, salpingo-oophorectomy, and small bowel resection, and vessel seals were studied histologically after a seven-day survival period for vessel wall fusion, inflammation, and fibrous organization. Results: Sealing was highly successful, with only one seal failure overall and thus no difference between the two instruments analyzed. The burst pressures of BiClamp-sealed arteries (842 ⫹/⫺ 117 mm Hg) did not differ from that of arteries sealed with LigaSure (856
UROLITHIASIS, ENDOUROLOGY AND LAPAROSCOPY ⫹/⫺ 102 mm Hg), but were significantly higher than the burst pressures of veins (155 ⫹/⫺ 26 and 216 ⫹/⫺ 71 mm Hg, respectively) (P ⬍ 0.05). Independent of the sealing device used, thermal spread was found increased in veins compared to arteries. Histologic analysis after seven days revealed appropriate healing of the vessel wall, including thrombus fibrosis, fibroblast proliferation, and collagen deposition. With both devices, however, the venous but not the arterial walls still presented with massive inflammatory cell infiltrates. Conclusion: Our study indicates that the BiClamp device is as appropriate as the LigaSure instrument to successfully ligate 2–7 mm arteries and veins, demonstrating supraphysiological bursting strengths and adequate lumenal fusion healing. However, veins are more prone to collateral tissue damage and inflammatory wall infiltration. Editorial Comment: The most vexing aspect of the newer methods of achieving hemostasis (eg bipolar sealing and harmonic shears) is that the devices are disposable, and, hence, add significantly to the cost of the procedure. In this article the authors discuss a new, open surgical, reusable device, the BiClamp®, which seals vessels similarly to the LigaSure™ device. Indeed, in this porcine model the 2 devices appeared to perform identically except that the BiClamp required an extra 2 to 3 seconds to seal arteries and veins. Vessels up to 7 mm were secured with burst pressures that were supraphysiological. Interestingly, thermal spread was increased along veins compared to arteries. However, unfortunately, the precise distance of spread was not reported. While mention is made of sealing vessels 2 to 7 mm in diameter, a caveat from a realistic standpoint is that I would be hesitant to use either type of bipolar sealing device on any artery larger than 3 mm until more data are available. For veins the 7 mm size is likely accurate but, again, I usually limit the use of bipolar sealing to veins 5 mm and smaller. Hopefully, a laparoscopic model of the BiClamp is on the horizon. Ralph Clayman, M.D.
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