Andres Correa

Large Bladder Clot—An Unusual Presentation of Neonatal Bilateral Renal Vein Thrombosis—Case Report and Review of Literature

A 1-day-old boy born at 37 weeks gestation presented with hematuria, thrombocytopenia, and palpable irregular right flank mass. Renal ultrasound demonstrated large clot within the bladder, bilateral kidney masses with loss of corticomedullary differentiation, and reversal of diastolic flow. The patient was diagnosed with bilateral renal vein thrombosis and was managed conservatively. There was complete resolution of the bladder clot with restoration of corticomedullary differentiation bilaterally. We report the first case of renal vein thrombosis associated with a large bladder clot in a neonate.

Renal Hilar Lesions: Biological Implications for Complex Partial Nephrectomy

OBJECTIVE To perform a comprehensive histopathologic review of sporadic resected solitary cT1 renal masses comparing those with and without radiographic involvement of the hilum. MATERIALS AND METHODS A prospectively maintained database was queried for all cT1 renal masses undergoing resection classified per the R.E.N.A.L. nephrometry score. Hilar masses were defined as tumors that abut the main renal artery or vein on cross-sectional imaging. Demographic, treatment, renal mass, and histopathologic characteristics were compared between hilar and nonhilar renal masses. Multivariate regression model analyses were performed to assess factors associated with renal mass upstaging and disease recurrence. RESULTS A total of 1324 stage 1 renal masses met criteria for analysis of which 226 (17.1%) were defined as hilar. Hilar masses were larger, scored with higher complexity, and more likely to undergo a radical nephrectomy. On histopathologic analysis, we found no difference between hilar and nonhilar masses regarding the incidence of malignancy, presence of high nuclear grade, or risk of upstaging. On multivariate analysis, a tumors hilar location was not associated with upstaging or disease recurrence. CONCLUSION We present a comprehensive histopathologic review of a large cohort of cT1 hilar lesions noting no difference in the risk of malignancy, high nuclear grade, upstaging, or recurrence when compared to nonhilar lesions. Together, these data suggest that there is no compelling cancer-specific rationale to perform a radical nephrectomy when managing renal hilar tumors.

Melancholia and cancer: The bladder cancer narrative: Psychiatric Illness and Bladder Cancer

Cancer and psychiatric illness have been tightly connected throughout the history of medicine. The humoral theory proposed by Hippocrates (460-320 BC) and made famous by Galen (130-201) suggested cancer as a growth arising from an excess of black bile. Melancholia, which means black bile in ancient Greek, was used to describe ailments associated with a depressed mood. The association between melancholia and cancer was reached by the observation that depression was common in patients with cancer, as recorded by Galen around 200 AD: “melancholic women are more susceptible to ‘swellings’ of the breast than were sanguine women.” The theory of cancer melancholic diathesis dominated medical science for centuries to come, with numerous medical pioneers not only supporting the theory but also providing evidence for it. In 1893, Herbert Snow (1847-1930), a British surgeon and cancer pioneer, performed the first epidemiological study linking cancer and depression. Studying 250 women with uterine and breast cancer, he noted that, “of 250 women suffering from cancer of the mammae and uterus. . . 171 had expressed history of an immediate antecedent of trouble often in very poignant form, as the loss of a near relative.” Over the 100 years that followed, advances in anatomy, physiology, and cancer biology created a significant divide between these conditions, which now belong to distinct fields of study and, in most instances, are considered completely unrelated to each other. Emerging evidence of the impact of emotional stress on cancer outcomes has shifted the philosophy of cancer treatments from a disease-focused attitude to a patient-centered one. Significant emphasis has been placed on the importance of cancer survivorship, with increasing evidence suggesting that an adequate survivorship program is as important (if not more important) than the treatment itself. Consequently, both the National Comprehensive Cancer Network and the American Society of Clinical Oncology have advocated for the screening and routine measurement of psychological stress in patients with cancer. The publication by Jazzar and colleagues in this issue of Cancer explores the impact of a posttreatment psychiatric illness on the survival of elderly patients with muscle-invasive bladder cancer. The authors used the Surveillance, Epidemiology, and End Results-Medicare–linked database, which merges demographic, clinicopathologic, and survival data with Medicare claims data, allowing extraction of psychiatric diagnoses. Following careful selection criteria, the study included 3709 patients with invasive bladder cancer (T2-T4a) who underwent some type of treatment and were free of a psychiatric diagnosis 12 months before treatment. The psychiatric illness burden in this population was surprisingly high, with more than one-half of patients having a psychiatric condition diagnosed during their first year of cancer survivorship. More distressing is the finding that Medicare claims data underreport up to 50% of psychiatric diagnoses compared with in-office screening. Factors that have been associated with underreporting are lack of recognition by the physician, patient unwillingness to report because of stigma, and the role of medical comorbidity in confounding the diagnosis. The authors focus their analysis on the 12 months after cancer treatment. Although Jazzar et al do not emphasize the importance of the timing, survivorship literature has deemed this transitional survivorship period as the most influential in determining the future psychological health of the cancer survivor. The months after cancer treatment are when the patients and their caregiver(s) are most vulnerable to emotional distress as they are faced with the reality of their diagnosis and the sequelae of their treatment. The use of this specific period in their analysis may explain the high rates of

PD62-06 NEOADJUVANT CHEMOTHERAPY FOR ELDERLY PATIENTS WITH LOCALLY ADVANCED OR EARLY NODAL DISEASE: ARE WE DOING ENOUGH?

evaluated (RECIST criteria): CR was observed in 2 pts (6%), PR in 18 (60%); PD in 1 (3%) and SD in 9 (30%) regarding primary bladder tumor. In 12 pts with enlarged lymph-nodes, the response to NGC was CR in 1, PR in 10 and SD in 1. Patients receiving neoadjuvant GC had a greater chance of achieving a pathologically lower stage compared to the untreated population: organ-confined cancer in 53,3% (16/30) vs. 33% (p < 0.001). Lymph-node metastasis resulted in 25% patients after GC (n1⁄410) vs 45.5% of untreated patients (n1⁄420; p < 0.001). Considering patients resulted CR and PR after NGC (n1⁄420), 70% had down-staging on pathologic report after RC. Complication rates were higher in NGC group (4 thromboembolisms; 2 sepsis; 12 hematologic complications); all complications were not related to surgery. Pathological TRG after NGC was not correlated to clinical regression grade. The OS (mean follow-up 30 months) of patients who received NGC resulted of 66.6% compared with 56% of patients undergoing cystectomy alone (p<0,001). Fifty percent of patients in NGC group were alive without cancer vs 40,1% in cystectomy alone group (p<0,001). CONCLUSIONS: Neoadjuvant chemotherapy for muscle-invasive bladder cancer increases the rate of down-staging and cancer specific survival. NGC is associated with an increased risk of complications that may be prevented using tailored strategies. Pathological regression grades after NGC are not correlated to RECIST criteria based on CT.

MP59-12 VALIDATION OF A MATHEMATICAL MODEL TO PREDICT RENAL FUNCTION AFTER NEPHRON SPARING SURGERY

before and after partial nephrectomy, and compare the findings with 99mTc-DMSA renal scan. METHODS: The data of 51 patients with a unilateral renal tumor managed by partial nephrectomy were retrospectively analyzed. The RCV of tumor-bearing and contralateral kidneys was measured using ImageJ software. Split estimated glomerular filtration rate (eGFR) and SRV calculated using this RCV were compared with the split renal function (SRF) measured with 99mTc-DMSA renal scan. RESULTS: A strong correlation between SRF and SRV of the tumor-bearing kidney was observed before and after surgery (r 1⁄4 0.89, p < 0.001 and r 1⁄4 0.94, p < 0.001). The preoperative and postoperative split eGRF of the operated kidney showed moderate correlation with SRF (r 1⁄4 0.39, p 1⁄4 0.004 and r 1⁄4 0.49, p < 0.001). Correlation between reductions in SRF and SRV of the operated kidney (r 1⁄4 0.87, p < 0.001) was stronger than that between SRF and percent reduction in split eGFR (r 1⁄4 0.64, p < 0.001). CONCLUSIONS: Compared with split eGFR, the SRV calculated using CT-based renal volumetry has a strong correlation with the SRF measured using 99mTc-DMSA renal scan. CT-based SRV measurement before and after partial nephrectomy can be used as a single modality for anatomical and functional assessment of the tumor-bearing kidney.

MP10-19 SYSTEMIC THERAPY AND OVERALL SURVIVAL TRENDS IN PATIENTS WITH NON-UROTHELIAL HISTOLOGIC VARIANTS OF MUSCLE INVASIVE BLADDER CANCER UNDERGOING RADICAL CYSTECTOMY

and 12 females for whom intracorporeal orthotopic neobladder (ONB) (n1⁄415) and ileal conduit (IC) (n1⁄435) were performed. ORC included 31 males and 21 females for whom ONB and IC were performed in 41 and 11 patients, respectively. There was a significant difference in global health status (QL2) for iRARC in comparison to ORC (median (range)) [75(0-100) vs 33.3(0-100), p1⁄4 0.003] and a difference across functional scales for iRARC in comparison to ORC group (p<0.05). Also, iRARC showed statistically significant lower symptom scales in comparison to ORC groups (p<0.05). (Figure 1) CONCLUSIONS: iRARC seems to provide patients with a better HRQOL compared to ORC. Large prospective studies including matched groups are still needed to assess HRQOL in these patients. However, our results suggest that HRQOL is an important outcome measure when assessing the potential benefits of iRARC and ORC.

MP52-03 CLASSIFICATION OF KIDNEY TUMORS WITH 1064 NM DISPERSIVE RAMAN SPECTROSCOPY

INTRODUCTION AND OBJECTIVES: The number of small, incidentally detected renal masses increase steadily. About 6,000 benign cases are misclassified radiographically as malignant and removed surgically yearly. Raman spectroscopy (RS) has been widely demonstrated for tissue characterization, however current implementations with either 785 or 830 nm near-infrared excitation have been ineffectual in tissues with intense auto-fluorescence such as the kidney. Recently, a RS system using 1064 nm light source was described which may have greater sensitivity for malignant and benign tissue discrimination due to decreased bulk tissue auto-fluorescence. Our aim was to evaluate the ability of 1064nm RS to distinguish normal and malignant renal tissue. METHODS: Ex vivo specimens of Renal Cell Carcinoma and healthy human kidney were obtained from the Cooperative Human Tissue Network at Vanderbilt university. Measurements were made using of a benchtop dispersive 1064 nm Raman system. Multiple spectra were acquired from at least 5 physical locations across each specimen. A total of 93 measurements were used for the final analysis. The resulting spectra were put into a machine learning algorithm, sparse multinomial logistic regression (SMLR), to predict class membership of healthy and malignant tissues, and cross-validated using a leave-one-specimen out approach. Posterior probabilities of group classifications were extracted. Spectral bands that robustly differentiated between malignant and benign tissue were identified by the SMLR algorithm. A quantitative metric based on SMLR outputs called feature importance, defined as the product of the mean weight and frequency of usage of each feature, guided the association of spectral features with biological indicators of healthy and diseased Kidney tissue. RESULTS: The SMLR algorithm identified 152 significant Raman spectral bands. most important features are depicted in figure 1. Correct classification by the SMLR algorithm was obtained in 93.33% of the trials with sensitivity, specificity, negative and positive predictive value of 93.2%, 88.6, 92.9% and 89.2% respectively. CONCLUSIONS: RS can accurately differentiate normal and malignant renal tissue. This suggests implications for utilizing RS for optical biopsy and surgical guidance in nephron sparing surgery.

PD49-09 SURVIVAL ANALYSIS OF PATIENTS WITH T2 PENILE CANCER WHO RECEIVED INGUINAL LYMPH NODE DISSECTION: RESULTS FROM THE NATIONAL CANCER DATABASE

INTRODUCTION AND OBJECTIVES: Intraoperative frozen section analysis (FSA) of biopsy or resection specimens often provides critical information for appropriate surgical management. However, to the best of our knowledge, there are no recent studies focusing on assessing the role of FSA in the status of surgical margins (SMs) relating to the outcomes of penectomy cases. Instead, a few review articles discourage its use in the intraoperative assessment of SMs during penectomy, mainly because lesions often show well differentiated squamous proliferation that can mimic nonneoplastic conditions. The current study aims to investigate the utility of routine FSA of the SMs in men undergoing penectomy for squamous cell carcinoma. METHODS: A retrospective review identified consecutive patients (n1⁄438) who underwent partial (n1⁄426) or total (n1⁄412) penectomy for squamous cell carcinoma at our institution from 2004 to 2015. FSA findings were correlated with the diagnosis of the frozen section control, the status of final SM, and patient outcomes. RESULTS: FSA of the SMs was performed in 20 (77%) partial penectomies and 9 (75%) total penectomies, while no FSA was done for SMs in other cases. FSAs were reported as positive (n1⁄43, 10%), negative (n1⁄424, 83%), and atypical (n1⁄42, 7%). All of the positive or negative FSA diagnoses, including those in 7 cases of well differentiated carcinoma, were confirmed accurate on the frozen section controls, whereas the 2 cases with atypical FSA had non-malignant and carcinoma cells, respectively, on the controls. Final SMs were positive in 5 (13%) penectomies (2 partial and 3 total), including 3 (10%) FSA cases versus 2 (22%) non-FSA cases (P1⁄40.574). Furthermore, 2 initially FSA-positive/atypical cases achieved negative conversion by excision of additional tissue sent for FSA. In contrast, 2 FSA-negative cases showed carcinoma at the final SM where FSA was not submitted. During follow-up (mean: 41.2; median: 42; range: 1-136 months), 3 patients (non-FSA/final SM-negative, non-FSA/final SM-positive, FSAnegative/final SM-negative) developed tumor recurrence, and one of them (non-FSA/SM-positive) died of cancer. Kaplan-Meier analysis revealed that the number or diagnosis of FSA was not significantly associated with disease progression. CONCLUSIONS: Overall, performing FSA during penectomy does not appear to have any significant impact on final SM status nor long-term oncologic outcomes. However, as seen in at least 2 cases, select patients may benefit from the routine FSA. Meanwhile, diagnostic accuracy of FSA of the SMs was found to be quite high.

MP80-19 TREATMENT TRENDS AND OUTCOMES FOR LYMPH NODE POSITIVE PENILE CANCER PATIENTS

INTRODUCTION AND OBJECTIVES: Embyrologically, gonads are derived from mesonephrons while kidneys are derived from metanephrons. Our previous study demonstrated a positive association between kidney injury molecule-1 (KIM-1) staining and renal cell (papillary/clear cell type), and ovarian carcinoma (clear cell). The preliminary data also revealed positive KIM-1 staining in the tubules of mesonephrons, raising the possibility of KIM-1 expression in various testicular tumors. This study was to investigate whether KIM-1 and CD133 (a progenitor cell marker known to be positive in some renal cell carcinoma) expressions can help predict or differentiate various germ cell neoplasms of testis. METHODS: A total of 29 cases of seminoma and 31 cases of mixed germ cell neoplasms were identified. Tumors were sectioned and immunohistochemically stained for KIM-1 (AKG7 monoclonal KIM-1 antibody from JV Bonventre, BWH, Boston, at dilution 1:10) and CD133 (AC133 monoclonal antibody, Miltenyi Biotec, at 1:100 dilution). The membranous staining of each marker was graded 0 to 3+ and the percent of expressive distribution was recorded. RESULTS: KIM-1 was found to stain 77.4% (24/31, intensity at 1 to 3+, and distribution ranging from 1% to 90%) of mixed germ cell neoplasms (predominantly embryonal and yolk sac components), whereas there was no KIM-1 expression in benign seminiferous tubules, mature teratoma, classic seminoma and Leydig cell tumor. Scattered and weak CD133 staining was seen in seminoma and mixed germ cell tumors (10% and 16% respectively) and absent in benign tissue, mature teratoma and Leydig cell tumor. CONCLUSIONS: Our data suggest that KIM-1 expression can be used to differentiate mixed germ cell neoplasms from pure seminomas (negative for KIM-1 staining). CD133 appears to be not as useful in differentiating various testicular tumors.

PD52-08 CAN LOOKS DECEIVE? NOT ALL CLINICALLY “CYSTIC” RENAL MASSES HARBOR INDOLENT BIOLOGY

INTRODUCTION AND OBJECTIVES: Cystic renal cell carcinomas (RCC) are suggested to be clinically indolent. As such, a distinct pathologic staging category for these lesions was recently proposed. While not without merit, these recommendations fail to account for limitations in the ability of modern imaging to differentiate cystic RCC from more biologically aggressive mimics. We evaluated the frequency of high grade kidney cancer in the highly selected cohort of surgically resected renal masses having cystic appearance on pre-operative radiographic imaging. METHODS: A prospectively maintained institutional database was queried for clinically cystic renal masses that underwent surgery from January 2000 June 2016 (n1⁄42,729 kidney surgeries). Patient and tumor characteristics including age at surgery, smoking history, Charlson comorbidity index (CCI), gender, race, BMI, surgery date, laterality, Bosniak classification, histology, grade, size, and nearness to the collecting system were tabulated. Associations between tumor grade and patient/tumor characteristics were evaluated using generalized estimating equations. RESULTS: Eighty-nine patients (n1⁄4101 cystic lesions) met strict inclusion criteria; the majority (77%) were older than 50 years of age and the mean Charlson comorbidity index was 1.15 (SD1.48) (Table 1). Of the 101 clinically cystic renal masses, 23% were confirmed pathologically as high grade RCC while 77% were low grade RCC (n1⁄456) or benign (n1⁄422). CCI was associated with high grade surgical pathology (OR 1.37, 95% CI 1.05-1.79, p 1⁄4 0.02). There was no association between tumor grade and the remainder of the patient/ tumor characteristics analyzed. CONCLUSIONS: Recently proposed changes to the kidney cancer staging system define a tumor’s cystic nature based on pathologic examination. Proceeding with surgery for a radiographically “cystic” renal mass was a rare event in our cohort; however, among those that went onto surgery, nearly a quarter harbored high grade pathology. Before making changes to the clinical RCC staging system, a better understanding of the limitations inherent to radiographic determination of low malignant potential, cystic renal masses is necessary.