Tokyo Medical and Dental University Hospital

Objective: The prognosis of patients with subarachnoid hemorrhage (SAH) who also develop cardiopulmonary arrest (CPA) is highly unfavorable, and hence they are often not aggressively treated. Presently, the therapeutic indications and factors that affect the prognosis of patients who experienced CPA remain unclear. Therefore, we analyzed SAH patients who experienced CPA, comparing the characteristics of the patients who survived with those who did not. Methods: The 36 patients were divided into the survivor group (n = 4) and the dead group (n = 32). The patient’s age, sex, location of the aneurysm, the presence of intracranial hematoma, duration of cardiopulmonary resuscitation (CPR), the presence/absence of bystanders, initial electrocardiogram waveform, recovery of brainstem reflexes with motor response, and administration of vasopressors were compared between the 2 groups. Results: There were no significant differences in age, sex, location of the aneurysm, and presence of intracranial hematoma between the 2 groups. More than 90% of patients in the dead group had a non-shockable rhythm on the initial electrocardiogram waveform. The duration of CPR in the survivor group tended to be shorter than that in the dead group. Bystander CPR was performed on 14 patients, including all 4 of the survivors. All patients in the survivor group achieved recovery of brainstem reflexes with motor response. In the survivor group, all patients either did not need or only transiently needed the administration of vasopressors after the return of spontaneous circulation (ROSC). Conclusion: Our analysis suggested the following as favorable prognostic factors in SAH patients with CPA: shockable arrhythmia on the initial electrocardiogram waveform, young age, bystander CPR, a short time from CPA to ROSC, recovery of brainstem reflexes with a motor response, and no or transient use of vasopressors. Our results indicate that aggressive treatment may be indicated in SAH patients with CPA who have stable vitals and show improvements in neurological symptoms.

Dexamethasone is an antiemetic drug widely used to prevent nausea and vomiting caused by anticancer drugs. However, dexamethasone can cause several side effects even after short-term administration. Therefore, the development of dexamethasone-free antiemetic therapies has been recognized as an important challenge. The objective of this study was to investigate the efficacy and safety of palonosetron, aprepitant, and olanzapine. Patients who were chemotherapy-naïve and scheduled to receive highly emetogenic chemotherapy for breast cancer were enrolled and assessed for nausea and vomiting occurring within 120 h after the start of chemotherapy. The primary endpoint was the total control (TC) rate of overall phases. Secondary endpoints included the complete response (CR) rate, which was evaluated during the acute, delayed, and overall phases. A total of 88 patients were enrolled from eight centers in Japan, of whom 84 were included in the analysis. The proportion of patients achieving TC throughout the overall period was 17.1%. Similarly, CR and CC rates for the overall period were 43.4% and 39.5%, respectively. Frequently reported adverse events were loss of appetite and constipation, with rates of 52.4% and 50.0%, respectively. The primary endpoint was not achieved. Therefore, antiemetic therapy without dexamethasone shows an inadequate effect on nausea, and it is generally advisable to avoid omitting dexamethasone. However, in the overall period, both CR and CC were comparable to conventional three-drug combination therapy. Thus, in patients unable to use dexamethasone, replacing it with olanzapine could be an option. Trial registration number: UMIN 000038644, November 20, 2019. The date of first trial registration: 13/03/2020.

A 38-year-old woman with a history of systemic lupus erythematosus presented at our university hospital with fever, fatigue, and oral pain and was urgently admitted based on a diagnosis of septic shock. Initially, dental infection was suspected based on the symptoms and clinical presentation of purpura accompanied by severe tenderness along the marginal gingiva in the maxilla and mandible. However, subsequent investigations, including an oral examination, radiographic studies, and blood cultures, ruled out dental infection as the cause of the septic shock. The patient received antibiotic therapy and was discharged on Day 16 after admission, with no definitive source of the infection yet being identified. The gingiva around where the purpura was observed on Day 1 gradually necrosed and detached, leading to ulcer formation by Day 8 and gingival recession by Day 15. Gingival necrosis was attributed to septic shock-induced neutropenia and circulatory disturbances, indicating the severity of the systemic conditions. Follow-up after discharge revealed no recurrence. This case underscores the importance of recognising oral symptoms as potential precursors to severe systemic conditions such as septic shock. Timely intervention and interdisciplinary collaboration are essential in effectively managing such cases. Further research is warranted to elucidate the relationship between oral health and systemic diseases to enable clinicians to provide optimal patient care.

Background: Numerous studies evaluating the effects of consumption of omega-3 fatty acids (ω3FAs) and omega-6 fatty acids (ω6FAs) on the prevention of cardiovascular disease (CVD) have yielded inconsistent results. In addition, the association between ω3FAs/ω6FAs and CVD has been suggested to vary with the daily intake levels of fatty acids among individuals. On the other hand, the longitudinal associations between plasma ω3FAs/ω6FAs and arterial stiffness, which is a predictor of CVD, have not been well elucidated. Hypothesis: We hypothesized that plasma ω3FAs are associated with the suppression of age-related increases in arterial stiffness, whereas plasma ω6FAs are associated with an increase in arterial stiffness. Aims: The objective of this study is to fill the existing research gap by investigating the longitudinal association between plasma ω3FAs/ω6FAs and arterial stiffness in a Japanese people, known for their higher intake of marine products. Methods: This prospective observational study included 2520 healthy Japanese participants (mean age:43.1±8.7y, men:83.1%) who underwent repeated annual health check-ups from 2008 to 2013. Participants with a history of CVD or treatment for CVD risk factors were excluded. Arterial stiffness was evaluated by brachial-ankle pulse wave velocity (baPWV), and plasma ω3FAs [docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA)]/ω6FAs [arachidonic acid (AA), dihomo-gamma-linolenic acid (DGLA)] were evaluated by gas chromatography. The longitudinal association between plasma ω3FAs/ω6FAs and baPWV was evaluated by a linear mixed model adjusted for conventional CVD risk factors. Results: During a median follow-up of 5 years (IQR 4-5 years), 11034 baPWV measurements were performed. The linear mix model adjusted for conventional CVD risk factors revealed that both higher plasma AA and DGLA levels were significantly associated with an increase in baPWV (1SD increase in AA; β=12±3, 1SD increase in DGLA; β=14±3, both P<0.001). However, neither plasma EPA nor DHA levels were longitudinally associated with the baPWV. Conclusion: Plasma ω3FAs were not longitudinally associated with arterial stiffness. In contrast, higher plasma ω6FAs levels were longitudinally associated with increased arterial stiffness. Our results suggest that the potential CVD-preventive effects of ω3FAs may not involve the suppression of arterial stiffness. Conversely, the increased CVD risk associated with ω6FAs may be attributed to increased arterial stiffness.

Objective To investigate the efficacy and safety of robot-assisted radical hysterectomy (RARH) as a minimally invasive procedure in patients with cervical cancer that is curable by surgery. Materials and methods This study was a multicenter, open-label, single-arm clinical trial. The short-term outcome of open radical hysterectomy was used as the historical control. The primary endpoint was successful surgery with minimal blood loss (300 mL or less) and negative surgical margins. Secondary endpoints included surgical outcomes, recurrence-free survival (RFS), and overall survival (OS) rates. Results Overall, 101 cases were enrolled in this study at 10 participating medical institutions and 100 underwent RARH. Among these cases, 89 met the primary endpoint, exceeding the threshold of 0.75 set by the lower limit. At 2 years postoperatively, 17 cases had recurrences, 4 were classified as International federation of Obstetrics and Gynecology Stage IB1 or lower, while 13 as IB2 or higher. There were three deaths, including one in Stage IB1 and two in Stage IIB in the second postoperative year, all of which had lymph node metastasis. The oncological outcomes for all cases showed RFS and OS rates of 82.7% and 96.9%, respectively, over a median observation period of 37 months. For cases with Stage IB1, RFS and OS were 94.1% and 98.5%, respectively. Conclusion RARH demonstrated a significant reduction in blood loss while ensuring radicality, indicating the safety and efficacy of this procedure compared to conventional RH. Although it is conceivable that the results of this oncological analysis could change, as the data collection has not been fully completed, we plan to further evaluate the oncologic outcomes of RARH in future studies. Trial registration UMIN-CTR: UMIN000022278, registered on 11th May 2016.

Purpose Very high‐power short‐duration (vHPSD) ablation creates shallower lesions, potentially reducing efficacy. This study aims to identify factors leading to insufficient lesions during pulmonary vein antral isolation (PVAI) with vHPSD‐ablation and to develop an optimized PVAI strategy using this technology. Methods PVAI was performed on 41 atrial fibrillation patients using vHPSD‐ablation (90 W/4 s). Lesion parameters were recorded and analyzed to identify predictors of insufficient lesions. An optimized PVAI strategy, based on these predictors, was tested in subsequent 42 patients. Results In total, 3099 RF‐applications, including 103(3.3%) insufficient lesions, were analyzed. First‐pass PVAI was achieved in 19/40(47.5%) right PVs and 24/41(58.5%) left PVs. Multivariate analysis identified significant predictors of insufficient lesions: local largest bipolar voltage (Bi‐V), average contact force, baseline impedance, impedance drop, temperature rise, inter‐lesion distance (ILD), and anatomical location (carina or not). An ILD:4‐6 mm increased the risk of insufficient lesions 2.2‐fold, and lesions at the carina increased it 3.6‐fold for both ILD < 4 mm and ILD:4‐6 mm. Local largest Bi‐V was the strongest predictor for insufficient lesions. The optimized PVAI approach, utilizing vHPSD‐ablation with an ILD < 4 mm in non‐carinal areas with Bi‐V < 4 mV, and high‐power ablation‐index guided ablation (HPAI, 50 W, ablation‐index:450–550) in remaining areas, achieved first‐pass PVAI in 92.7% of right PVs and 88.1% of left PVs, using vHPSD‐ablation in approximately 65% of total RF‐applications. The optimized PVAI achieved significantly higher first‐pass PVI rate ( p < .0001) with shorter ablation time ( p = .04). Conclusion Appropriate use of vHPSD and HPAI, based on local largest Bi‐V and anatomical information, may achieve high first‐pass PVAI rates in shorter ablation time with minimal energy delivery.

BACKGROUND Mucosa-associated lymphoid tissue (MALT) lymphoma, a type of non-Hodgkin lymphoma, originates in the mucosal lining of body organs and internal cavities, including the nose, mouth, lungs, and digestive tract. The lymphoma develops when the body produces abnormal B lymphocytes. These lymphomas develop at the edge of the lymphoid tissue, called the marginal zone, and, hence, are classified as a type of marginal zone lymphomas. They are the most common type of marginal zone lymphomas although their occurrence is rare. To date, no previous cases of MALT lymphoma in the buccal fat pad have been reported. CASE SUMMARY We report the case of a patient who presented with a mass on the frontal cheek. Magnetic resonance imaging revealed a tumor in the buccal fat pad, and histopathological and immunohistochemical findings confirmed the diagnosis of MALT lymphoma. The patient had a history of Helicobacter pylori and hepatitis C virus infection, suggesting an association between these infective agents and MALT lymphoma. CONCLUSION Consideration of MALT lymphoma is essential in the differential diagnosis of frontal cheek masses.

Objective The Drug Lymphocyte Stimulation Test (DLST), recognized for its safety as an allergy diagnostic modality, has been acknowledged for its utility in diagnosing drug-induced pathological conditions. However, reports elucidating DLST outcomes concerning local anesthetics are notably scarce. Materials and methods An exhaustive analysis was conducted on the DLST results pertaining to local anesthetics derived from 571 patients presenting with suspected allergies to these specific agents. Results Remarkably, Stimulation Index (SI) > 1.8 was discerned in 11.4% and 7.8% of patients exhibiting hives or swelling subsequent to the administration of local anesthetics, surpassing the incidence observed in those experiencing post-injection discomfort. Additionally, SI > 3.0 was observed in 3 cases with lidocaine, 3 cases with prilocaine, and 1 case with mepivacaine. The distribution of SI exhibited a non-normal pattern for all three tested local anesthetics. Noteworthy is the case of a singular patient registering an SI of 1.84, who also yielded a positive challenge test, conclusively confirming an allergy to lidocaine. Conclusions The DLST, holding promise as a potentially invaluable tool in identifying the causative factors behind adverse reactions to dental local anesthetics, lacks sufficient evidence to substantiate its efficacy definitively at present. Clinical relevance DLST, coupled with intradermal testing and challenge testing, may be elucidated in patients exhibiting indicators of suspected local anesthetic allergy.

Background Map‐like redness, pathological intestinal metaplasia, is observed in one‐fourth to one‐third of patients 1 year after Helicobacter pylori eradication therapy, mainly in the corpus, and is a newly identified endoscopic risk factor for gastric cancer development after eradication. However, it is unclear whether intestinal metaplasia is present before eradication at the site where the map‐like redness appears. We aimed to identify endoscopic findings that predict the occurrence of map‐like redness before H. pylori eradication. Materials and Methods As a prospective multicenter trial, the characteristics of patients in whom map‐like redness developed after eradication, and the association between the endoscopic severity of gastritis and the development of map‐like redness in patients who underwent endoscopy before and 1‐year after eradication were investigated. Results The rate of map‐like redness in all 93 patients 1‐year postsuccessful eradication was 30.1% (95% confidence interval [CI]: 21.0–40.5). All patients with map‐like redness were endoscopically observed to have intestinal metaplasia before eradication, in the site that subsequently developed map‐like redness. Patients who developed map‐like redness were older, had more severe intestinal metaplasia and nodularity and a higher total score on the Kyoto Classification of Gastritis both before and after eradication than patients who did not. On multivariate analysis, map‐like redness was found to be associated with posttreatment intestinal metaplasia (odds ratio: 8.144; 95% CI: 2.811–23.592). Conclusions In all patients who developed map‐like redness after eradication, endoscopic intestinal metaplasia was observed at the site developed map‐like redness before eradication therapy. Map‐like redness was especially observed in patients with more severe intestinal metaplasia at 1‐year after eradication. Such patients require increased attention at surveillance endoscopy, owing to generally having a higher risk of gastric cancer development. Trial Registration University Hospital Medical Information Network : UMIN000044707

Brachytherapy (BT), especially in high dose rate (HDR), has become increasingly complex owing to the use of image-guided techniques and the introduction of advanced applicators. Consequently, radiotherapy technologists and medical physicists (RTMPs) require substantial training to enhance their knowledge and technical skills in image-guided brachytherapy. However, the current status of the RTMP workload, individual abilities and quality control (QC) of BT units in Japan remains unclear. To address this issue, we conducted a questionnaire survey from June to August 2022 in all 837 radiation treatment facilities in Japan involving RTMPs. This survey focused on gynecological cancers treated with HDR-BT (GY-HDR) and permanent prostate implantation using low-dose-rate BT (PR-LDR). The responses revealed that the average working time in the overall process for HDR varied: 120 min for intracavitary BT and 180 min for intracavitary BT combined with interstitial BT. The QC implementation rate, in accordance with domestic guidelines, was 65% for GY-HDR and 44% for PR-LDR, which was lower than the 69% observed for external beam radiation therapy (EBRT). Additionally, the implementation rate during regular working hours was low. Even among RTMP working in facilities performing BT, the proportion of those able to perform QC for BT units was ~30% for GY-HDR and <20% for PR-LDR, significantly lower than the 80% achieved for EBRT. This study highlights the vulnerabilities of Japan’s BT unit QC implementation structure. Addressing these issues requires appropriate training of the RTMP staff to safely perform BT tasks and improvements in practical education and training systems.

Purpose: Total knee arthroplasty (TKA) is expected to improve knee pain and enable patients to regain the ability to walk, but the associations between preoperative and postoperative changes in body composition, muscle strength, and activity remain unclear. In this study, we investigated the association between changes in body composition before and after TKA surgery, the recovery process of muscle strength, and changes in activity, as well as the effects of obesity on TKA. Methods: A total of 124 patients with unilateral knee osteoarthritis (OA) who underwent TKA were retrospectively evaluated. Body weight (BW) and body composition (body fat percentage (BFP) and diseased limb muscle mass (DLMM)), measured by bioelectrical impedance analysis, quadriceps muscle strength (QMS), measured using the isometric muscle strength meter, number of steps (NOS), and Japanese Orthopaedic Association (JOA) OA knee diseases treatment outcome criteria (JOA score) before the operation, at postoperative six months (PO6M), and at postoperative one year (PO1Y) after the operation were investigated and compared between the non-obese (BMI < 25 kg/m²) group, including underweight (<18.5 kg/m²) and normal weight patients (18.5 to 24.9 kg/m²), and obese (BMI ≥ 25 kg/m²) group, including overweight (25.0 to 29.9 kg/m²) or obese patients (≥30.0 kg/m²). Results: In all patients, JOA scores significantly improved from 59.7 preoperatively to 81.2 at PO6M, and 82.7 at PO1Y (both p < 0.01). QMS significantly increased from 112.4 N preoperatively to 144.0 N at PO6M, and 151.0 N at PO1Y (both p < 0.01). On the other hand, there was no significant change in BW, BFP, NOS, and DLMM. A comparison between the obese (n = 76) and non-obese (n = 48) groups demonstrated that there was no significant difference in JOA scores preoperatively, but scores at PO1Y were significantly higher in the non-obese group (p < 0.01), and QMS increased significantly postoperatively in both groups, but the enlargement rate at PO1Y was 1.4% in the obese group versus 10.4% in the non-obese group (p = 0.04). Conclusion: In the body composition of TKA patients, BW, BFP, and DLMM/BW did not change significantly from preoperatively to PO1Y, but QMS and JOA scores showed significant improvement at PO6M and PO1Y compared to preoperatively. The obese patients showed less improvement in JOA scores than non-obese patients, and the rate of increase in QMS at PO1Y was smaller, suggesting that rehabilitation focusing on muscle-strengthening training is necessary even at PO6M, especially in obese patients.

Background Double aortic arch (DAA) is a type of vascular ring, causing stridor and dysphagia owing to compression of the trachea and esophagus. In contrast, double innominate veins, which is a relatively rare venous anomaly, usually does not cause symptoms or require intervention. Case presentation A 2 month-old boy presented with mild stridor and a hoarse voice while crying, and was diagnosed as having DAA, small atrial septal defects and double innominate vein. The double innominate veins, crossing over and underneath the ascending aorta, did not contribute to airway compression. To release the narrow vascular ring caused by the DAA, surgical resection of the atretic side of the arch was performed by lateral thoracostomy at 4 months of age, before the appearance of signs of bronchomalacia. The double innominate veins were left untouched, and open-heart surgery was avoided. Conclusions DAA should be suspected if airway symptoms are present in early infancy, particularly if a right aortic arch is noted. It is important not to hesitate to perform diagnostic imaging and release the DAA, as this might prevent or minimize airway complications. However, for double innominate veins, operative release is not necessary unless it interferes with surgical procedures or is causing symptoms.

Background. Whole-body computed tomography (WBCT) is commonly employed for primary screening in pediatric patients experiencing out-of-hospital cardiac arrest (OHCA) without prehospital return of spontaneous circulation (ROSC). This study aimed to evaluate the cause of OHCA on WBCT and compare WBCT findings between ROSC and non-ROSC groups in non-traumatic pediatric OHCA cases in an emergency department setting. Methods. A retrospective analysis was conducted on 27 pediatric patients (mean age: 32.4 months; median age: 10 months) who experienced non-traumatic OHCA without prehospital ROSC and were transported to our tertiary care hospital between January 2013 and December 2023. WBCT scans were performed to investigate the cause of OHCA, with recorded findings in the head, chest, abdomen, and subcutaneous tissues. Results. In all cases, the direct causes of OHCA were undetermined, and WBCT identified no fatal findings. Statistical comparisons of CT findings between the ROSC and non-ROSC groups revealed significant differences. The non-ROSC group had a higher incidence of brain swelling, loss of cerebral gray-white matter differentiation, symmetrical lung consolidation/ground-glass opacity, cardiomegaly, hyperdense aortic walls, narrowed aorta, gas in the mediastinum, and hepatomegaly compared to the ROSC group. Conclusions. Although WBCT did not reveal the direct cause of OHCA, several CT findings were significantly more frequent in the non-ROSC group, including brain swelling, loss of cerebral gray-white matter differentiation, symmetrical lung consolidation/ground-glass opacity, cardiomegaly, hyperdense aortic wall, narrowed aorta, gas in the mediastinum, and hepatomegaly. These findings, resembling postmortem changes, may aid in clinical decision making regarding the continuation or cessation of resuscitation efforts in pediatric OHCA cases.

Purpose Immunotherapies have led to a paradigm shift in the treatment of hepatocellular carcinoma (HCC). Studies have revealed the single-cell catalogs of tumor-infiltrating immune cells and the trajectories of their differentiation. Nevertheless, the spatial distribution of these immune cells with distinct phenotypes in the tumor microenvironment and their clinicopathologic significance in resectable and unresectable HCCs are still largely unclear. Experimental Design We analyzed the spatial dynamics of intratumoral CD4 and CD8 T cells and their association with B and plasma cells using 283 surgically resected HCC samples, 58 unresectable HCC samples before combined immunotherapy [atezolizumab plus bevacizumab (Atezo + Bev)], and autopsy specimens from 50 cases of advanced-stage HCC through multiplex IHC combined with transcriptomic and driver gene mutation analyses. Classification based on the spatial dynamics of T- and B-cell responses (refined immunosubtype) was developed, and its clinicopathologic significance was analyzed. Results We found that stem-like CD4 and CD8 T cells were mainly observed in T-cell aggregates and T-cell zone of tertiary lymphoid structure (TLS). The differentiation of T follicular helper cells was associated with the development of TLS, whereas the differentiation of CXCL13-expressing CD4 TCXCL13 cells with a phenotype resembling T peripheral helper cells was associated with the development of the lymphoplasmacytic microenvironment. The refined immunosubtype could predict clinical outcomes of resectable HCC after surgery and unresectable HCC after Atezo + Bev therapy. The immune microenvironment of metastatic lesions tended to reflect those of primary lesions. Conclusions We revealed the spatial dynamics of T- and B-cell responses in HCC, which is closely associated with the clinical outcome after surgical resection or Atezo + Bev therapy.

There is growing evidence that nocturnal hypertension is an independent risk factor for cardiovascular diseases, including heart failure. However, brachial blood pressure (BP) measurements during sleep might themselves disturb sleep quality. We initiated a nationwide, multicenter observational prospective study using a wrist-type oscillometric nighttime BP monitoring device with new algorithms to measure supine BP accurately without sleep disturbance. This study, named the Wrist ICT-based Sleep and Circadian Blood Pressure Monitoring Program-Night BP Study (WISDOM-Night Study), was designed to clarify the impact of wrist-measured daily nighttime BPs on cardiovascular prognosis (stroke, coronary artery disease, heart failure, etc.) using 7 days of BP measurements at 2:00 a.m., 3:00 a.m., 4:00 a.m., and 4 h after bedtime. A total of 2751 patients with one or more cardiovascular risk factors were recruited between March 2021 and March 2024 and are currently being followed up for 7 years. Additionally, 1416 of the WISDOM-Night Study-enrolled patients who also agreed to participate in the WISDOM-Hypertension-Mediated Organ Damage (HMOD) Study underwent echocardiography to evaluate the association between wrist-measured BP and left ventricular structure. Data from this WISDOM-Night Study should provide the prospective association between nighttime BP and cardiovascular disease and reveal the indexes of nighttime BP with clinical pathological relevance. This first report of the WISDOM-Night Study describes the study design, baseline characteristics, and BP control status.

Purpose Although arteriovenous malformations (AVMs) are typically benign lesions, massive ones can lead to severe complications, including heart failure. Notably, there is no standardized treatment for AVMs. Moreover, management of AVMs can be challenging when these lesions involve vital organ systems, such as the head and neck. In this report, we describe embolization of a massive cervical AVM in a pediatric patient with heart failure. Case report A 10-year-old boy presented with severe heart failure secondary to a massive AVM in the neck (right side). Despite 3 unsuccessful arterial embolization procedures, venous embolization of the dominant outflow vein using a coil and n-butyl-2-cyanoacrylate, lipiodol, and ethanol proved effective, and symptoms, cerebral natriuretic peptide level (568-29 pg/mL), and echocardiography were significantly improved. Although residual AVM persisted in the right upper extremity for 6 months after surgery, his cardiac function remained preserved, and his activities of daily living have improved. Conclusion Venous embolization is a valuable treatment modality for type II AVMs with a dominant outflow vein. However, considering the patient burden associated with large AVMs, multiple therapeutic interventions at appropriate intervals and long-term follow-up are important. Clinical Impact We present a pediatric patient with a type II massive arteriovenous malformation (AVM) in the neck and severe heart failure. Despite undergoing 3 arterial embolization procedures, his condition remained unchanged. However, venous embolization of the dominant outflow vein resulted in a significant improvement in symptoms. This case emphasizes the importance of considering multiple and appropriately timed therapeutic interventions, particularly for massive AVMs, to optimize patient outcomes while minimizing treatment burden.

Upfront androgen receptor signaling inhibitor (ARSI) along with androgen deprivation therapy is the current standard of care for metastatic castration-sensitive prostate cancer. However, evidence on second-line therapy after upfront ARSI is scarce. We aimed to evaluate the oncological outcome of ARSI versus docetaxel (DOC) after upfront ARSI therapy in a real-world clinical practice. Subjects were metastatic castration-resistant prostate cancer (mCRPC) patients who had progressed within 2 years of upfront ARSI therapy and received ARSI (ARSI group) or DOC (DOC group) as a second-line therapy. Second-line progression-free survival (second-line PFS), and second-line overall survival (second-line OS) were assessed. Propensity score matching (PSM) was used to adjust the clinicopathological features and treatment patterns. A total of 101 mCRPC patients, 68 in the ARSI group, and 33 in the DOC group, were included in this analysis. Median second-line PFS was 6.3 months in the ARSI group and 4.9 months in the DOC group (p = 0.21). Median second-line OS was 25.0 months in the ARSI group and 14.2 months in the DOC group (p = 0.06). Prostate-specific antigen nadir ≤ 0.2 ng/ml during upfront ARSI therapy was significantly associated with improved second-line PFS. After PSM, no significant difference in second-line PFS and second-line OS were observed between the two groups. ARSI or DOC has comparable oncologic outcomes in terms of second-line PFS and second-line OS. Further prospective research with longer follow-ups will be needed to identify the optimal treatment after upfront ARSI therapy.