Amy Tin

Impact of Ureteroscopy Before Nephroureterectomy for Upper Tract Urothelial Carcinoma on Oncologic Outcomes

OBJECTIVE To compare the oncologic outcomes of patients with upper tract urothelial carcinoma undergoing nephroureterectomy (NU) with and without prior ureteroscopy (URS). METHODS We reviewed records of all patients with no prior history of bladder cancer who underwent NU at our institution (n = 201). We compared patients who underwent URS before NU with patients who proceeded directly to NU based on imaging alone. After excluding patients undergoing URS with therapeutic intent, we used multivariable Cox proportional hazards models, adjusting for tumor characteristics with cancer-specific survival (CSS), intravesical recurrence-free survival, metastasis-free survival (MFS), and overall survival (OS) as end points. This study received institutional review board approval. RESULTS A total of 144 (72%) patients underwent URS before NU, and 57 (28%) patients proceeded directly to NU. The median follow-up time for survivors was 5.4 years from diagnosis. The performance of diagnostic URS before NU was significantly associated with IR (hazard ratio 2.58; 95% CI 1.47, 4.54; P = .001), although it was not associated with CSS, MFS, or OS. The adjusted intravesical recurrence-free survival probability 3 years after diagnosis is 71% and 42% for patients who did not and did receive URS before NU, respectively (adjusted risk difference 30%; 95% CI 13%, 47%). CONCLUSION We did not find evidence that URS adversely impacts disease progression and survival in patients with upper tract urothelial carcinoma. Although patients are at higher risk for IR after NU when they have undergone prior diagnostic URS, their CSS, MFS, and OS are not significantly affected.

Association between number of prostate biopsies and patient-reported functional outcomes after radical prostatectomy: implications for active surveillance protocols.

To evaluate whether the number of preoperative prostate biopsies affects functional outcomes after radical prostatectomy (RP).

Clinical Outcomes of Patients With T1 Nested Variant of Urothelial Carcinoma Compared to Pure Urothelial Carcinoma of the Bladder

Purpose Evaluate oncologic outcomes of patients with cT1 nested variant (NV) of urothelial carcinoma (UC) and compare with cases of pure UC of the bladder. Materials and Methods We retrospectively identified 30 patients with NV who, between 1997 and 2012, underwent transurethral resection with T1 tumor stage, followed by restaging transurethral resection within 3 months confirming non–muscle‐invasive disease. Radical cystectomy within 3 months of restaging transurethral resection was considered “early” treatment. We matched 3 patients with pure UC to each nested patient. Results Median follow‐up for survivors was 4.3 years from T1‐staged transurethral resection. Patients with NV had no statistically significant difference in metastasis‐free survival (P = .2) and cancer‐specific survival (P = .2) compared with patients with pure UC. However, it is concerning that the rate of upstaging to bladder and/or lymph nodes was 54% in patients with NV who underwent early radical cystectomy, even after rigorous restaging. Conclusions Although NV UC may be diagnosed at a higher stage, when stage matched we have not seen any statistical evidence that it is more aggressive than typical UC. Because patients with NV UC who are cT1 on restaging transurethral resection appear to have a higher propensity to develop nodal metastatic disease and a higher rate of upstaging, patients with cT1 NV UC on restaging biopsy may benefit from “early” radical cystectomy, whereas patients with <cT1 on restaging may be considered for conservative management. Micro‐Abstract It is unknown how to manage patients with cT1 nested variant (NV) urothelial carcinoma (UC). Based off of our retrospective review of 30 patients, the rate of upstaging to bladder and/or lymph nodes was 54% in patients who underwent early radical cystectomy even after rigorous restaging. Patients with cT1 NV UC on restaging biopsy may benefit from “early” radical cystectomy.

Tumor copy number alteration burden is a pan-cancer prognostic factor associated with recurrence and death

The level of copy number alteration (CNA), termed CNA burden, in the tumor genome is associated with recurrence of primary prostate cancer. Whether CNA burden is associated with prostate cancer survival or outcomes in other cancers is unknown. We analyzed the CNA landscape of conservatively treated prostate cancer in a biopsy and transurethral resection cohort, reflecting an increasingly common treatment approach. We find that CNA burden is prognostic for cancer-specific death, independent of standard clinical prognosticators. More broadly, we find CNA burden is significantly associated with disease-free and overall survival in primary breast, endometrial, renal clear cell, thyroid, and colorectal cancer in TCGA cohorts. To assess clinical applicability, we validated these findings in an independent pan-cancer cohort of patients whose tumors were sequenced using a clinically-certified next generation sequencing assay (MSK-IMPACT), where prognostic value varied based on cancer type. This prognostic association was affected by incorporating tumor purity in some cohorts. Overall, CNA burden of primary and metastatic tumors is a prognostic factor, potentially modulated by sample purity and measurable by current clinical sequencing.

Comparison of Post-Radical Cystectomy Ileus Rates Using GIA-80 versus GIA-60 Intestinal Stapler Device

OBJECTIVE To assess the impact on recovery of bowel function using an 80 mm versus 60 mm gastrointestinal anastomosis (GIA) stapler following radical cystectomy and urinary diversion (RC/UD) for bladder cancer. METHODS We identified 696 patients using a prospectively maintained RC/UD database from January 2006 to November 2010. Two nonrandomized consecutive cohorts were compared. Patients between January 2006- and December 2007 (n = 180) were treated using a 60 mm GIA stapler, and 331 patients between January 2008 and December 2010 were subject to an 80 mm GIA stapler. All patients were treated on the same standardized postoperative recovery pathway. After accounting for baseline patient and perioperative characteristics, using a multivariable logistic regression model, we directly compared rates of postoperative ileus using a standardized definition. RESULTS Of 511 evaluable patients, ileus was observed in 32% (57/180) for 60 mm GIA versus 33% (110/331) for the 80 mm GIA. Preoperative renal function, age, gender, body mass index, and type of diversion were comparable between cohorts. On multivariate analysis, stapler size was not significantly associated with the development of ileus (GIA-60 vs GIA-80: OR 1.11; 95% CI 0.75, 1.66; P = .6). Positive fluid balance was associated with an increased risk (P = .019) and female sex a decreased risk (P = .008) of developing ileus compared to patients with negative fluid balance. CONCLUSION The size of the intestinal bowel anastomosis (GIA 80 mm vs 60 mm) does not independently impact the time to bowel recovery following RC/UD.

The natural history of large renal masses followed on observation

PURPOSE The safety and feasibility of active surveillance in comorbid patients with renal masses ≥4.0cm is uncertain. The aim of this study is to describe our institutional experience with the observation of large renal masses. MATERIALS AND METHODS One hundred patients were identified with renal masses ≥ 4.0cm that were followed on observation for at least 6 months without surgical intervention between 1994 and 2016. Linear regression was conducted to determine predictors for renal mass growth and competing risk methods were used to estimate the probability of progression in the setting of death from other causes. RESULTS Median age at diagnosis was 73 years and 73% of patients had a Charlson Comorbidity index ≥ 4. At presentation, the median mass size was 4.9cm. The median growth rate was 0.4cm/y and there were no significant predictors of growth. Surveillance was discontinued in 34 patients who underwent delayed intervention. Median follow up for metastasis-free survivors was 4 years. In total, 10 patients developed metastatic disease, 3 died from kidney cancer and 30 patients died from other causes. The 5-year probability of other cause mortality was 22% (95% CI: 14%-32%) compared to 6% (95% CI: 2%-13%) for metastatic progression of kidney cancer. CONCLUSION In highly comorbid patients, the observation of large renal masses has low likelihood for metastatic progression relative to the risk of nonkidney cancer related death. This data supports the use of surveillance as an acceptable strategy for highly selected patients with competing risks from other serious illnesses.

Comparison of Physician-Documented Versus Patient-Reported Collection of Comorbidities Among Patients With Prostate Cancer Upon First Visit to the Urology Clinic

PURPOSE To determine whether patient-reported collection of comorbidities online is sufficiently accurate to warrant use as part of a physician-reviewed, baseline medical history. METHODS Comorbidities were collected for a sample of 213 new prostate cancer visits to our urology clinic through an online survey (called Baseline Medical History) before the clinical encounter. The frequency distributions of comorbidities as reported by patients before physician review were compared with those documented by physicians for a sample of 298 consecutive patients presenting to the same urology clinic before the survey went live. RESULTS The overall frequency distribution of comorbidities and life expectancy estimates were similar between the two groups. A few comorbidity categories were reported with higher frequency in the patient-reported group compared with the physician-documented group, including neurologic comorbidities (7.5% v 1.7%; difference 6%; 95% CI, 2.0% to 10%; P = .001) and back pain (24% v 13%; difference 12%; 95% CI, 4.8% to 19%; P = .001). A similar trend was seen for vascular conditions, although the difference did not meet conventional levels of statistical significance. Genitourinary comorbidities, including problems with urination and erectile dysfunction, were better captured by the physician-reported group compared with the patient-reported group (68% v 53%; difference 15%; 95% CI, 7% to 24%; P = .001), as were other musculoskeletal comorbidities (8.7% v 1.9%; difference 7%; 95% CI, 3.2% to 11%; P = .001). CONCLUSION Patients completing a medical history, at their own pace and in the comfort of their own home, provide relatively accurate and complete information, even before physician review. Patient reporting of comorbidities thus seems to be a reliable starting point for the documentation of the medical history in the clinic.

PD59-10 THE NATURAL HISTORY OF LARGE RENAL MASSES ON ACTIVE SURVEILLANCE & EXPECTANT MANAGEMENT

validate a criterion for AS eligibility based on tumour clinical size and age on a cohort of patients treated with surgery. METHODS: 1922 patients diagnosed with a cT1cN0cM0 renal mass elected for surgical treatment and collected into a prospective database were assessed. Under the assumption that older patients with smaller tumours are optimal candidates for AS relative to younger patients with larger tumours, we relied on the ratio [R] between tumour clinical size and age in order to differentiate patients suitable for AS (R<5) from patients unsuitable for AS (R 5). X2 test was used to compare the rate of malignant histology, stage pT3-pT4 and grade G3G4 at final pathology in patients suitable vs. unsuitable for AS. Smoothed Poisson’s incidence plots were used to examine the rate of cancer specific [CSM] and other cause mortality [OCM] in patients suitable vs. unsuitable for AS. RESULTS: According to the proposed definition, the rate of patients suitable for AS was 34%. Patient suitable for AS had a lower rate of malignant histology (78 vs. 87%; p<0.001), pT3-pT4 (4 vs. 10% p1⁄40.001) and grade G3-G4 (7 vs. 17% p<0.001) relative to patients unsuitable for AS. In patients suitable for AS, the 10-year rates of CSM and OCM were 1.7 and 19%, respectively (Fig. 1A). In patients unsuitable for AS, the 10-year rates of CSM and OCM were 6.7 and 11% (Fig. 1B), respectively. CONCLUSIONS: When validated in a cohort of surgically treated patients, the ratio between tumour clinical size and age is a useful parameter to differentiate patients with adverse pathologic outcomes from patients with more favourable pathologic outcomes. These differences translate into critically different relative rates of CSM and OCM. These findings suggest that the proposed strategy criterion deserve further examination as a potential criterion for AS.

PD39-06 DE NOVO URINARY STORAGE SYMPTOMS ARE COMMON AFTER RADICAL PROSTATECTOMY: INCIDENCE, NATURAL HISTORY AND PREDICTORS

demographics, bladder diaries, subjective response rates, ICIQ-OAB and PGI-I scores were recorded. Success was defined as greater than 50% symptom improvement in urgency, urge incontinence, and a greater than 50% improvement in voided volume or reduction of postvoid residual volumes. RESULTS: Twenty patients underwent stage 1 trial of SNM. Average age was 68.5 years, IQR (54.25 -76.25). 13 (65%) patients were female. 13/20 (65%) of patients had a response to the detrusor overactivity component. 10/20 (50%) of patients showed an improvement in the voiding component. 9/20 (45%) of patients showed responses to both components. 6/20 (30%) patients had no response whatsoever. Overall, 12/20 (60%) patients proceeded to insertion of an IPG. At follow up of 17 months, IQR (1.5 e 35), 11/12 (91.7%) of patients were still using the SNM device, median PGI score was 2, IQR (2 e 4). In addition, SNM resulted in statistically significant improvement in voided volume (p1⁄40.016), PVR (p1⁄40.0296), ICIQ-OAB score (p<0.0001) and ICIQ-OAB bother score (p1⁄40.016). CONCLUSIONS: SNM is a potential treatment option for DHIC with an acceptable success rate, treating both the detrusor hyperactivity, and impaired contractility components of this condition.

PD28-08 CONCORDANCE BETWEEN PHYSICIAN-DOCUMENTED VERSUS PATIENT-REPORTED COMORBIDITIES IN PROSTATE CANCER: VALIDATION OF A NOVEL INFORMATICS TOOL

INTRODUCTION AND OBJECTIVES: Gleason Score (GS) upgrading is seen during subsequent biopsy in up to one-third of men in active surveillance (A.S.) programs. Most A.S. biopsies have been performed in a blind fashion. Using MRI/US fusion biopsy, follow-up targeting of MRI lesions can now be performed. We sought to compare such MRI-targeted follow-up biopsies with biopsy of tumor spots outside of MRI-visible lesions. The latter biopsy method, called tracking biopsy, is another feature of MRI/US fusion but has been rarely reported. METHODS: Subjects were 138 consecutive men (mean age 63.4 years) enrolled in A.S. (2009-2016), who had 2 subsequent MRI/ US fusion (Artemis) biopsies: confirmatory (6-12 months after initial diagnosis) and surveillance (12 months after that). At confirmatory biopsy, MRI targets and a 12-core template were sampled. At surveillance biopsy, MRI lesions were sampled again and tumor spots detected previously by systematic biopsy were also re-sampled, using the 3D tracking function of the Artemis device (accurate within 3 mm) (Figure). At surveillance biopsy, approximately 5 cores were taken by targeting and 5 by tracking. All men had GS6 lesions at confirmatory biopsy. Upgrading to GS 3+4 at surveillance biopsy was the endpoint. RESULTS: At surveillance biopsy, mean PSA was 4.5 ng/ml (IQR 2.6-5.9) and prostate volume was 46.3 cc (IQR 34.5-59.0). Overall rate of upgrading was 19% (26/138). When MRI-visible lesions were resampled without any tracking biopsies being taken (N1⁄459), upgrading was found in 8 (13%). When prior tumor was sampled by tracking an MRI-invisible lesion (N1⁄423), upgrading was found in 6 (24%). When both targeted and tracking biopsies were performed (N1⁄456), upgrading was found in 12 (21%). Of 56 men having both biopsy methods, upgrading in 12 was detected by targeting in 8 and by tracking in 8; however, 4 of the upgrades (50%) were not detected by each method. Upgrading beyond GS7 was only seen in one patient. CONCLUSIONS: At surveillance biopsy for men on A.S., tracking biopsy detects GS upgrading as often as biopsies targeting MRI lesions. However, 50% of upgrading detected by one method were missed by the other. Combining methods increased detection of GS upgrading. Tracking of prior positive sites, even when outside of MRIvisible lesions, is a valuable addition to A.S.