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Romanian Journal of Military Founded 1897 New Series Vol. CXIX No. 2/2016 August Medicine REVISTA DE MEDICINĂ MILITARĂ About clinical medicine: Is there still such a thing? MRI fusion biopsy vs transrectal

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Romanian Journal of Military Founded 1897 New Series Vol. CXIX No. 2/2016 August Medicine REVISTA DE MEDICINĂ MILITARĂ About clinical medicine: Is there still such a thing? MRI fusion biopsy vs transrectal ultrasound guided prostate biopsy A literature review The role of contrast-enhanced ultrasound in risk assessment of carotid atheroma The importance of life quality questionnaire in patients with prostate cancer, preand-post radical prostatectomy Tumor markers in gastroenterology: useful or useless? Air MEDEVAC in case of multiple casualties The experience of civilian-military cooperation in RoAF Finite element analysis of a modified short hip endoprosthesis Optical biopsy in laryngeal cancer detection Detection of epidermoid squamous-cell carcinoma by laser induced autofluorescence Preliminary results Mucous herpes zoster in elderly Syrian war shrapnel injury: cubital nerve defect grafting during humanitarian surgical mission. Clinical case presentation The not so good and the not so bad Journal included in Ulrich s Periodicals Directory database, Scientific World Index, Science Library Index, Directory of Open Access Journals and Open Academic Journals Index. Editorial Board of Romanian Journal of Military Medicine Under the patronage Honorary Editor Editors-in-Chief Executive Editors Associate Editor Redactors Editorial Assistants Technical Secretary Publisher Romanian Association of Military Physicians and Pharmacists Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Victor Voicu Florentina Ioniță Radu (Bucharest) Dan Mischianu (Bucharest) Daniel O. Costache (Bucharest) Victor L. Purcărea (Bucharest) Mariana Jinga (Bucharest) Doina Baltaru (Cluj Napoca) Silviu Stanciu (Bucharest) Constantin Ștefani (Bucharest) Dan Dobre Cristina Solea Oana Ciobanu International Editorial Board Natan Børnstein MD, PhD (Israel) Cris S. Constantinescu MD, PhD, FRCP (UK) Daniel Dănilă MD, PhD (USA) Mihai Moldovan MD, PhD (Denmark) Ioan Opriș BS, PhD (USA) Scientific Publishing Committee Adrian Barbilian (Bucharest) Anda Băicuş (Bucharest) Cristian Băicuş (Bucharest) Andra Bălănescu (Bucharest) Mircea Beuran (Bucharest) Daciana Brănișteanu (Iași) Dragoș Bumbăcea (Bucharest) Marian Burcea (Bucharest) Sofia Colesca (Bucharest) Gabriel Constantinescu (Bucharest) Carol Davila University of Medicine and Pharmacy Publishing House Gerard Roul MD, PhD (France) Erwin Santo MD, PhD (Israel) Adrian Săftoiu MD, PhD (Denmark) Ioanel Sinescu MD, PhD (Romania) Dan Corneci (Bucharest) Raluca S. Costache (Bucharest) Dragoș Cuzino (Bucharest) Mircea Diculescu (Bucharest) Cosmin Dobrin (Bucharest) Gabriela Droc (Bucharest) Silviu Dumitrescu (Bucharest) Carmen G. Fierbințeanu (Bucharest) Cristian Gheorghe (Bucharest) Liana S. Gheorghe (Bucharest) Mihai E. Hinescu (Bucharest) C. Ionescu Târgovişte MD, PhD (Romania) Radu Ţuţuian MD, PhD (Switzerland) Shyam Varadarajulu MD, PhD (USA) Peter Vilmann MD, PhD (Denmark) Victor Voicu MD, PhD (Romania) Viorel Jinga (Bucharest) Ruxandra Jurcuţ (Bucharest) Ovidiu Nicodin (Bucharest) Tudor Nicolaie (Bucharest) Bogdan A. Popescu (Bucharest) Emilian A. Ranetti (Bucharest) Corneliu Romanițan (Bucharest) Carmen A. Sîrbu (Bucharest) Sorin G. Țiplica (Bucharest) Dragoş Vinereanu (Bucharest) REDACTION B-dul Eroii sanitari, Nr.8, Sector 5, București, Tel/fax 021/ , tel. 021/ /Int. 199; Romanian Journal of Military Medicine (RJMM) is included in Romanian College of Physicians Medical Publications Index and credited with 5 CME credits. Romanian Journal of Military Medicine, New Series, vol. CXIX, No 2/2016, August ISSN-L ; eissn ; pissn Vol. CXIX No. 2/2016 August Romanian Journal of Military Medicine RJMM Romanian Journal of Military Medicine Founded 1897 New Series Vol. CXIX No. 2/2016 August Edited by the Romanian Association of Military Physicians and Pharmacists. Contents EDITORIAL Dan Mischianu About clinical medicine: Is there still such a thing? 3 REVIEW ARTICLE Constantin A. Rădulescu, Mihai F. Rădulescu, Agnes Ciucă, Dan Mischianu MRI fusion biopsy vs transrectal ultrasound guided prostate biopsy A literature review 5 Silviu Stanciu, Cristina Enciu, Ioana Răduţă, D. Stoicescu, Adrian Anghel, Daniela Anghel, B. Olan, L. Ciobîcă The role of contrast-enhanced ultrasound in risk assessment of carotid atheroma 9 Gina A. Ciucă, Ovidiu Bratu, Dan Spînu, Marius Dinu, Cătălin Farcaș, Andrei Rădulescu, Robert Popescu, Dragoș Marcu, Dan Mischianu, Petru Armean The importance of life quality questionnaire in patients with prostate cancer, pre- and post-radical prostatectomy 12 SYSTEMATIC REVIEWS, META-ANALYSIS Cătălina Diaconu, Daniel O. Costache, Raluca S. Costache Tumor markers in gastroenterology: useful or useless? 17 ORIGINAL ARTICLES Dragoș C. Tudose, Daniel Nică Air MEDEVAC in case of multiple casualties The experience of civilian-military cooperation in RoAF Augustin Semenescu, Florentina Ioniță Radu, Ileana M. Mateș, Petre Bădică, Nicolae D. Batalu Finite element analysis of a modified short hip endoprosthesis Romeo Costin, R. Hainarosie, V. Zainea, Corneliu Romaniţan, A. Meiuş Optical biopsy in laryngeal cancer detection Romeo Costin, Tatiana Tozar, V. Zainea, Ruxandra Pîrvulescu, I.R. Andrei, R. Hainarosie Detection of epidermoid squamous-cell carcinoma by laser induced autofluorescence Preliminary results EDUCATION AND IMAGING Daniel O. Costache, Ionel Țoropoc, Ciprian Jurcuț, Cătălina Diaconu, Laura Voicu, Raluca S. Costache Mucous herpes zoster in elderly 48 CLINICAL PRACTICE Argentina Vidrașcu, Paul Polihovici Syrian war shrapnel injury: cubital nerve defect grafting during humanitarian surgical mission. Clinical case presentation Silviu V. Dumitrescu The not so good and the not so bad ADMINISTRATIVE ISSUES Guidelines for authors Vol. CXIX No. 2/2016 August Romanian Journal of Military Medicine EDITORIAL About clinical medicine: Is there still such a thing? Dan Mischianu The other day, a distinguished and well known specialist radiologist from Bucharest shared with me two absolutely surprising things. First: not long ago, an experienced internal medicine physician addressed expressly with the request to radiologicaly examines a patient with, in his opinion acute pulmonary edema ! The radiologist told me that the acute pulmonary edema was actually a spontaneous pneumothorax probably due to rupture of emphysematous bubbles. The thoracic surgeon solved the so-called acute pulmonary edema actually spontaneous pneumothorax by specific means... The second issue told by the radiologist: I can sit at home in front of my laptop and receive scanned images of patients from different locations (clinics, private hospitals) in the country (Bacau, Constanta, Baia Mare and so on), then I say my opinion and the fee is in my account! I asked him slightly amazed: Yeah, well, but do you not feel the need to learn more about that patient? Did you forget what we learned in medical and surgical semiology that 80% of the diagnosis belongs to anamnesis? Do you not need to palpate, to auscultate or to listen to what the patient tells you...? Have you not learned anything from the mistake of the internist who din not use a stethoscope to find, in fact, that he had no vesicular murmur? My friend did not answer In fact what do I want to say in this editorial? Gral (R) Prof DAN MISCHIANU Chief of Urology Clinic, Carol Davila Central Emergency Military Hospital Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania First I want to say that our guild lives in a perfect confusion: notions or concepts of evidence-based medicine (EBM) , alternative medicine , noninvasive medicine, medicine x, y, z and many others can only leave room for speculation. Medicine, as illustrated, has always been great at removing great speculations because of phantasmagoric individuals like Paracelsus or Mesmer... Secondly, in Adevarul newspaper from 02/19/2016, Theodora Şopaltă, a journalist, was writing sententiously: There are five types of doctors. Which one do you prefer? The first type, in the opinion of the author is The clever (30% of respondents voted for him), then comes The Digital doctor (which probably specify diagnosis texting his phone! preferred by 8% of respondents), then comes The Wise man who do not talk to patients about their illness but gives them an accurate diagnosis. Go figure it! In fourth position lies The Idealist , preferred by 24% of patients, said to be a younger version of intelligence and the ending is marked by Only You , a pragmatic option of alternative medicine. Thirdly, I say that doctors may be labeled as made 3 and born to practice this noble profession, for which are made after the Hippocratic precepts and not by strange and awkward ideas, good and honest doctors with knowledge of human nature, easily grasping which in this profession gives you a disadvantage and good for nothing doctors who easily realize that there is no place for them amongst us and change their job to managers, adventurers, free thinkers and so on. To end this Editorial I conclude by saying that a good and honest clinician is the one that accepts and applies the perennial teachings of Hippocrates of Cos and takes into account the lessons of the Great surgeon and Great clinician, Professor Dr. Ion Juvara: Whatever novelty and complexity of laboratory methods of investigation, clinical retains its entire value, observation of man by man offering truths that never grow old I believe and hope that there still is the so-called Clinical medicine ! 4 Vol. CXIX No. 2/2016 August Romanian Journal of Military Medicine REVIEW ARTICLE Article received on March 2, 2016 and accepted for publishing on May 21, MRI fusion biopsy vs transrectal ultrasound guided biopsy A literature review Constantin A. Rădulescu 1, Mihai F. Rădulescu 2, Agnes Ciucă 1, Dan Mischianu 1,3 Abstract: Introduction: Current diagnosis of prostate cancer is based on transrectal ultrasound guided random biopsies. These procedures alongside with the discovery of PSA lead to a tremendous improvement of prostate cancer diagnosis rate in the last decades. Random ultrasound guided biopsy has its minuses and several attempts were made to improve the detection rate of the disease. MRI-US fusion targeted biopsies is one of them. Aim: This paper is a literature review of several important European studies and tries to draw a conclusion for the usefulness of MRI-US image fusion prostate biopsy in improving prostate cancer detection Material and methods: We have analyzed 5 papers published since 2013 which compare random ultrasound biopsies with MRI-US fusion. The analyzed parameters were clinical significant cancer detected as described by the study and any cancer detected Results: All 5 papers show superiority in cancer detection rates for both clinically significant and any cancer. Conclusions: MRI-US is a useful tool for improving detection rate of clinically significant prostate cancer. INTRODUCTION Prostate cancer is a serious public health matter, being the first cancer in men in terms of incidence and the second cause of cancer death in the U.S. Cancer, in general is taught to surpass in the following year cardiovascular diseases as the leading cause of mortality. Prostate cancer, in particular is becoming more and more important due population aging. [1] While throughout the history prostate cancer was poorly understood, with few cases recorded due to the low life expectancy, during the XXth century groundbreaking discoveries were made in understanding, diagnosing and treating the disease. Early diagnosis methods included open transperineal biopsies, blind transperineal needle biopsy and finger guided transrectal biopsy. First attempts to use transrectal ultrasound for prostate imaging were made by Takahasi and Ouchi in 1963 but they obtained poor images [2]. Watanabe in 1968 performed first clinical useful TRUS. In 1989 Hodge and al. started the modern era of standard sextant 1 Carol Davila Central University Emergency Military Hospital, Bucharest 2 Saarbrucken, Germania 3 Carol Davila University of Medicine and Pharmacy, Bucharest 5 transrectal ultrasound guided needle biopsy. Stamey developed a technique which consisted in performing a biopsy without knowing the tumor location within the prostate. Stamey s method was a major advance over older methods in which biopsy needles were guided only by the examining finger.(2) During the late 1990 s and early 2000 s standard protocol was modified introducing extended and saturation biopsies. Nowadays it is estimated that several million biopsies are performed each year around the globe. Ultrasound guided transrectal biopsies have 2 major disadvantages: detection of focal carcinomas with little or no clinical significance on one side and the important percentage of falsely negative biopsy cores. MRI was invented in 1971 by Paul C. Lauterbur for which he was granted Nobel Prize for Medicine in MRI evolved as being the most important tool for prostate cancer staging, especially if performed in a multiparametric manner. Prostate biopsies can be performed directly under IRM guidance or images may fused either in a cognitive manner, a method dependent on operator s experience, or MRI-US image fusion may be used. When using US-MRI fusion, standard transrectal ultrasound is performed and software is utilized to fuse the ultrasound images, at the time of the examination, with IRM images that were obtained before. 3D images of the prostate are obtained [3]. Fusion devices use a variety of technologies to perform image fusion. There are devices which perform robotic tracking via a mechanical arm with built-in encoders with commercial products: Artemis and BioJet. Electromagnetic tracking is used by the following UroNav and Hi-RVS. A 3D US probe is used for tracking and fusing images by Urostation. [4] MATERIALS AND METHODS We have analyzed 5 major studies which were performed since 2012 in terms of number of subjects, medium PSA level, overall cancer detection and clinically significant cancer detection rates. All 5 studies analyzed were paired cohort studies which compared transrectal standard biopsy with MRI-US fusion biopsy. The population analyzed was heterogenous. The only thing that was common to all patients was high PSA levels. One study, (Sonn GA et al, 2014)[5] had only patients with prior negative biopsy while the other 4 studies had mixed patients with or without prior negative biopsies. The percentage between patient with and without negative biopsies varied. The number of patients varied between 30 (Fiard et al, 2013) [6] and 347 (Kuru et al, 2013) [7] with a total of 677 patients. Medium PSA recorded in each study varied between 6.3 ng/ml (Fiard et al, 2013) and 9.85 ng/ml (Kuru et al, 2013). Clinically significant prostate cancer was defined by each study. Sonn et al defined clinical significance as Cancer positive cores with length 4 mm or more or Gleason 3+4. Kuru et al used the NCCN (National Comprehensive Cancer Network) criteria. Fiard et al and Rud[9] et al considered clinical significance when Gleason 7 (3+4) or higher was recorded on biopsy cores while Rastinehad et al[8] used Epstein criteria for clinical insignificant tumors: clinical stage T1c; PSA density 0.15 ng/ml; fewer than 3 positive cores and less than 50% cancer on positive cores. Clinically significant disease, defined as above, was diagnosed by means of transrectal ultrasound guided biopsy in 4.8% (Rud et al,2012) to 38% cases (Kuru et al, 2013) with a mean value of 25.26% and by means of MRI-US fusion biopsy in 21.7% (Son et al, 2014) to 50% cases (Rud et al, 2012) with a mean value of 40,76%. The difference in diagnosing clinically significant disease varied between 7% to 41.4%. MRI-US fusion biopsy was more accurate in diagnosing clinically significant prostate cancer compared to US transrectal biopsy with an overall advance of 17.36%. When analyzing all types of cancer both clinically significant and insignificant 4 out 5 studies showed superiority of MRI-US fusion biopsy ranging from 0.2% to 53.2%. Sonn GA et al reported 27.5% for 6 Vol. CXIX No. 2/2016 August Romanian Journal of Military Medicine TRUS biopsy vs 23.7 % for MRI-US fusion. This difference in favor of TRUS is probably linked to the study design as it is the only cited study that enrolled only patients that had undergone a prior negative TRUS biopsy. Paper Table1: Prostate cancer both clinically significant and any cancer Clinically Clinically significant Any cancer Any cancer significant TRUS MRI-US fusion TRUS MRI-US fusion Sonn GA et al 14,7% 21,7% 27,5% 23,7% Kuru et al 41,1% 50,4% 50,4% 50,6% Fiard et al 33,3% 50% 43% 55% Rastinehad et al 32,4% 44,8% 48,6% 50,5% Rud et al 4,8% 46,2% 14,3% 67,5% Medium values 25,26% 42,62% 36,76% 49,46% DISCUSSIONS All studies show superiority for detecting clinically significant disease with a smaller number of biopsy cores for MRI-US fusion biopsy and all but one showed overall superiority in detection of prostate cancer. The disadvantages of this review are the fact that there isn t a standardized definition of clinical significance, the lack of homogeneity of the analyzed population, the fact that some studies have enrolled both patients with prior biopsies and patients without biopsies, and the lack of standardized protocol for MRI-US fusion biopsy as there is a standard protocol for TRUS biopsy. CONCLUSIONS MRI-US fusion biopsy has proven to be more accurate in detecting clinically significant cancers but is still long way from becoming a standard procedure because of the complex technique required, the financial burden caused by the need of a prior MRI. MRI is capable of accurately diagnosing prostate cancer, in assessing its extension, its aggressiveness. MRI is also a useful tool for following patients with prior diagnosis of prostate cancer and probably, in the future it will be the major tool for focal therapy of the tumor. Transrectal ultrasonography still holds the crown for prostate cancer detection and will certainly remain the most used guidance technique for prostatic biopsies for long time with good results in the general population. Patients with negative biopsies and who experience a continuing rise in PSA levels, patients at risk when talking of hereditary antecedents of prostate cancer and some other risk categories may and will certainly benefit from the development of the MRI fusion technique. References: 1. Cancer statistics, 2015Rebecca L. Siegel, Kimberly D. Miller and Ahmedin Jemal, CA: A Cancer Journal for Clinicians Article first published online: 5 JAN 2015 DOI: /caac The Development of the Modern Prostate Biopsy Lehana Yeo, Dharmesh Patel, Christian Bach, Athanasios Papatsoris, Noor Buchholz, Islam Junaid and Junaid Masood Barts and the London NHS Trust U 3. MRI ultrasound fusion for guidance of targeted prostate biopsy Leonard Marks, Shelena Young, and Shyam Natarajan Curr Opin Urol Jan; 23(1): doi: /MOU.0b013e32835ad3ee 7 4. Geoffrey A. Sonn, M.D., Daniel J. Margolis, M.D., Leonard S. Marks, M.D.- Target detection: Magnetic resonance imaging-ultrasound fusion guided prostate biopsy J UrolOnc August 2014 Volume 32, Issue 6, Pages Sonn GA, Chang E, Natarajan S, et al. Value of targeted prostate biopsy using magnetic resonance-ultrasound fusion in men with prior negative biopsy and elevated prostate-specific antigen. Eur Urol 2014;65: Fiard G, Hohn N, Descotes JL, Rambeaud JJ, Troccaz J, Long JA. Targeted MRI-guided prostate biopsies for the detection of prostate cancer: initial clinical experience with real-time 3-dimensional transrectal ultrasound guidance and magnetic resonance/transrectal ultrasound image fusion. Urology 2013;81: Kuru TH, Roethke MC, Seidenader J, et al. Critical evaluation of magnetic resonance imaging targeted, transrectal ultrasound guided transperinea
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