Ari Adamy

Role of Prostate Specific Antigen and Immediate Confirmatory Biopsy in Predicting Progression During Active Surveillance for Low Risk Prostate Cancer

PURPOSE We evaluated predictors of progression after starting active surveillance, especially the role of prostate specific antigen and immediate confirmatory prostate biopsy. MATERIALS AND METHODS A total of 238 men with prostate cancer met active surveillance eligibility criteria and were analyzed for progression with time. Cox proportional hazards regression was used to evaluate predictors of progression. Progression was evaluated using 2 definitions, including no longer meeting 1) full and 2) modified criteria, excluding prostate specific antigen greater than 10 ng/ml as a criterion. RESULTS Using full criteria 61 patients progressed during followup. The 2 and 5-year progression-free probability was 80% and 60%, respectively. With prostate specific antigen included in progression criteria prostate specific antigen at confirmatory biopsy (HR 1.29, 95% CI 1.14-1.46, p <0.0005) and positive confirmatory biopsy (HR 1.75, 95% CI 1.01-3.04, p = 0.047) were independent predictors of progression. Of the 61 cases 34 failed due to increased prostate specific antigen, including only 5 with subsequent progression by biopsy criteria. When prostate specific antigen was excluded from progression criteria, only 32 cases progressed, and 2 and 5-year progression-free probability was 91% and 76%, respectively. Using modified criteria as an end point positive confirmatory biopsy was the only independent predictor of progression (HR 3.16, 95% CI 1.41-7.09, p = 0.005). CONCLUSIONS Active surveillance is feasible in patients with low risk prostate cancer and most patients show little evidence of progression within 5 years. There is no clear justification for treating patients in whom prostate specific antigen increases above 10 ng/ml in the absence of other indications of tumor progression. Patients considering active surveillance should undergo confirmatory biopsy to better assess the risk of progression.

The Effect of Tumor Location on Prognosis in Patients Treated with Radical Nephroureterectomy at Memorial Sloan-Kettering Cancer Center

BACKGROUND The prognostic impact of primary tumor location on outcomes for patients with upper-tract urothelial carcinoma (UTUC) is still contentious. OBJECTIVE To test the association between tumor location and disease recurrence and cancer-specific survival (CSS) in patients treated with radical nephroureterectomy (RNU) for UTUC. DESIGN, SETTING, AND PARTICIPANTS Prospectively collected data were retrospectively reviewed from 324 consecutive patients treated with RNU between 1995 and 2008 at a single tertiary referral center. Patients who had previous radical cystectomy, preoperative chemotherapy, previous contralateral UTUC, or metastatic disease at presentation were excluded. This left 253 patients for analysis. Tumor location was categorized as renal pelvis or ureter based on the location of the dominant tumor. Recurrences in the bladder only, in nonbladder sites, and in any site were analyzed. INTERVENTION All patients were treated with RNU. MEASUREMENTS Recurrence-free survival and CSS probabilities were estimated using Kaplan-Meier and Cox regression analyses. RESULTS AND LIMITATIONS Median follow-up for survivors was 48 mo. The 5-yr recurrence-free probability (including bladder recurrence) and CSS estimates were 32% and 78%, respectively. On multivariable analysis, pathologic stage was the only predictor for disease recurrence (p=0.01). Tumor location was not an independent predictor for recurrence (hazard ratio: 1.19; p=0.3), and there was no difference in the probability of disease recurrence between ureteral and renal pelvic tumors (p=0.18). On survival analysis, we also found no differences between ureteral and renal pelvic tumors on probability of CSS (p=0.2). On multivariate analysis, pathologic stage (p<0.0001) and nodal status (p=0.01) were associated with worse CSS. This study is limited by its retrospective nature. CONCLUSIONS Our study did not show any differences in recurrence and CSS rates between patients with ureteral and renal pelvic tumors treated with RNU.

Clinical Characteristics and Outcomes of Patients With Recurrence 5 Years After Nephrectomy for Localized Renal Cell Carcinoma

PURPOSE We analyzed characteristics in patients with recurrent renal cell carcinoma 5 years or later after nephrectomy and determined predictors of survival after recurrence. MATERIALS AND METHODS From July 1989 to October 2008 at total of 2,368 nephrectomies were done for clinically localized, unilateral renal cell carcinoma at our institution. Of 256 patients with disease recurrence 44 had recurrence 5 years or more after nephrectomy. We compared clinicopathological characteristics in patients with disease recurrence before vs after 5 years. Survival from time of recurrence was assessed based on Memorial Sloan-Kettering Cancer Center risk score, symptoms at recurrence, metastasectomy, tumor diameter, and recurrence stage and site. RESULTS Patients with late recurrence tended to have fewer symptoms at presentation, smaller tumors (median 8.5 vs 7 cm) and less aggressive disease (pT1 in 18% vs 39%). Median overall survival was 6.1 years from time of recurrence. Five-year actuarial survival was 85% in 28 patients at favorable risk and 14% in 10 at intermediate risk (log rank p <0.001). The 5-year estimated overall survival rate was 72% in 31 patients with incidentally detected recurrence and 39% in 11 with symptoms at recurrence (log rank p = 0.01). CONCLUSIONS Data suggest that patients with cancer recurrence 5 years after nephrectomy are at favorable risk and have long-term median survival. A favorable Memorial Sloan-Kettering Cancer Center risk score and absent symptoms related to metastasis are associated with longer survival in these patients.

Selective Arterial Embolization for Pseudoaneurysms and Arteriovenous Fistula of Renal Artery Branches Following Partial Nephrectomy

PURPOSE We describe the presentation, endovascular management and functional outcomes of 15 patients with renal arterial pseudoaneurysm following open and laparoscopic partial nephrectomy. MATERIALS AND METHODS An institutional review board approved, Health Insurance Portability and Accountability Act compliant retrospective review of a prospectively maintained database revealed that 7 of 1,160 patients who underwent open partial nephrectomy and 8 of 301 treated with laparoscopic partial nephrectomy were diagnosed with a pseudoaneurysm of a renal artery branch between 2003 and 2010. Some cases were associated with arteriovenous fistula. RESULTS Diagnosis of pseudoaneurysm was made a median of 14 days after surgery. Gross hematuria was the most frequent symptom. Median estimated glomerular filtration rate measurements at the preoperative evaluation, postoperatively, on the day the vascular lesion was diagnosed, after embolization and at the last followup were 62, 55, 55, 56 and 58 ml/minute/1.73 m(2), respectively. Median followup was 7.8 months. All patients underwent angiography and superselective coil embolization of 1 or more pseudoaneurysms with or without arteriovenous fistula. Eleven patients had immediate cessation of symptoms while 4 had persistent gross hematuria after the procedure. Of these 4 patients 2 were treated with bedside care, 1 required repeat embolization with thrombin, which was successful, and the remaining patient had coagulopathy and underwent radical nephrectomy for persistent bleeding. CONCLUSIONS Pseudoaneurysms and arteriovenous fistulas of the renal artery are rare complications of partial nephrectomy. Presentation is often delayed. Superselective coil embolization is a safe, minimally invasive treatment option that usually solves the clinical problem and preserves renal function.

Clinical Outcome of Primary Versus Secondary Bladder Carcinoma In Situ

PURPOSE Differences in clinical outcome are still unclear between primary and secondary bladder carcinoma in situ. We compared the clinical outcomes of primary and secondary carcinoma in situ, and identified predictive factors. MATERIALS AND METHODS We retrospectively analyzed the records of 476 patients with high grade cTis, including 221 with primary and 255 with secondary carcinoma in situ, from 1990 to 2008 at a high volume cancer center after transurethral resection and intravesical bacillus Calmette-Guerin therapy. End points were time to progression to invasive disease (cT1 or higher) or radical cystectomy before progression, and progression to muscle invasive disease (cT2 or higher) or radical cystectomy before progression. We used Cox proportional hazards regression models. RESULTS Patients with primary carcinoma in situ responded significantly more within 6 months of bacillus Calmette-Guerin than those with secondary carcinoma in situ (65% vs 39%, p <0.001). In the primary vs secondary groups the 5-year cumulative incidence of progression to cT1 or higher was 43% (95% CI 36-51) vs 32% (95% CI 27-39) and for progression to cT2 or higher it was 17% (95% CI 12-23) vs 8% (95% CI 5-13). On multivariate analysis primary carcinoma in situ was significantly more likely to progress to cT1 or higher (HR 1.38, 95% CI 1.05-1.81, p = 0.020) and to cT2 or higher, or radical cystectomy (HR 1.72, 95% CI 1.27-2.33, p = 0.001). We found no significance for age, gender or response to bacillus Calmette-Guerin as outcome predictors. Median followup was 5.1 years. CONCLUSIONS Patients presenting with primary carcinoma in situ have a worse outcome than those with secondary carcinoma in situ, suggesting a need to differentiate these 2 entities in the treatment decision process.

Recovery of Renal Function After Open and Laparoscopic Partial Nephrectomy

BACKGROUND Although oncologic outcomes appear to be similar after laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN), data on renal function are lacking. OBJECTIVE To evaluate the change over time in renal function after LPN and OPN. DESIGN, SETTING, AND PARTICIPANTS We identified 987 patients with a single sporadic tumor and a normal contralateral kidney who were treated by LPN (n=182) and OPN (n=805) between January 2002 and July 2009. INTERVENTION All patients underwent LPN or OPN at Memorial Sloan-Kettering Cancer Center. MEASUREMENTS Estimated glomerular filtration rate (GFR) was calculated using the abbreviated Modification of Diet in Renal Disease formula. We created a multivariable generalized estimating equations linear model that predicted GFR based on the time from surgery, preoperative GFR, tumor size, American Society of Anesthesiologists score, and ischemia time. RESULTS AND LIMITATIONS Mean patient age, tumor size, and ASA score were similar between LPN and OPN patients. The baseline preoperative GFR was lower in the laparoscopic group (67 ml/min per 1.73 m(2) vs 73 ml/min per 1.73 m(2); p<0.001). The mean ischemia time was shorter after LPN than OPN (35 min vs 40 min, respectively; p<0.001). In a multivariable model, the interaction term between time from surgery and approach was statistically significant (p=0.045), indicating that there was a differential effect on recovery of renal function over time by approach. Laparoscopically treated patients maintained a slightly higher renal function than those treated via an open approach. The 2-mo and 6-mo predicted GFR for a typical patient increased slightly from 65 ml/min per 1.73 m(2) to 67 ml/min per 1.73 m(2), respectively, for those treated laparoscopically but remained constant at 62 ml/min per 1.73 m(2) after OPN. CONCLUSIONS Our data suggest that the surgical approach has a small effect on the recovery of renal function after partial nephrectomy. Laparoscopically treated patients maintained slightly higher renal function.

Renal Oncocytosis: Management and Clinical Outcomes

PURPOSE Renal oncocytosis is a rare pathological condition in which renal parenchyma is diffusely involved by numerous oncocytic nodules in addition to showing a spectrum of other oncocytic changes. We describe our experience with renal oncocytosis, focusing on management and outcomes. MATERIALS AND METHODS A total of 20 patients with a final pathological diagnosis of renal oncocytosis from July 1995 through June 2009 were included in the analysis. Patient demographics, intraoperative variables and postoperative outcomes are reported. RESULTS Median age at nephrectomy was 71 years (IQR 59-75). Of the patients 15 (75%) had bilateral disease. There were 23 operations (9 right side, 14 left side) performed on 20 patients, and of these procedures 13 (57%) were partial nephrectomies and 10 (43%) were radical nephrectomies. Median dominant tumor mass diameter was 4.1 cm (IQR 3-6.4, range 1 to 14.6). The most common dominant tumor histology was hybrid tumor between oncocytoma and chromophobe renal cell carcinoma in 13 of 23 specimens (57%), followed by chromophobe renal cell carcinoma in 6 (26%), oncocytoma in 3 (13%) and conventional renal cell carcinoma in 1 (4%). Ten patients (50%) had preexisting chronic kidney disease before nephrectomy and chronic kidney disease developed in 5 more after surgery. After a median followup of 35 months no patients had metastatic disease. CONCLUSIONS Patients with renal oncocytosis usually present with multiple and bilateral renal nodules. Half of the patients had chronic kidney disease at diagnosis and 25% had new onset of chronic kidney disease. No patient had distant metastatic disease during followup. Our management approach is to perform partial nephrectomy when possible and then use careful surveillance of the remaining renal masses.

Routine Drain Placement After Partial Nephrectomy is Not Always Necessary

PURPOSE To our knowledge the benefit of routine drainage after partial nephrectomy has never been investigated, although a drain after partial nephrectomy can be associated with morbidity. We report our initial experience with omitting the drain in select cases of superficial renal cortical tumors. MATERIALS AND METHODS From a surgery database we identified 512 consecutive open partial nephrectomies performed by a single surgeon between January 2005 and May 2009 using standardized technique. The study group included 75 evaluable patients (14.6%) who did not have a drain placed. Clinical data, surgical information, histological type and postoperative complications within 90 days of the procedure using the modified Clavien system were included in analysis. RESULTS Median patient age was 64 years (IQR 49, 70) and 56.8% of the patients were male. Median tumor size was 2.0 cm (IQR 1.5, 3.0) and more than 70% were malignant. A total of 38 patients (50.7%) underwent renal artery clamping and cold ischemia with a median clamp time of 30 minutes. The overall complication rate was 13.3% (10 patients). In 4 patients (5.3%) complications were related to an absent drain, including grade I urinary leak, grade II perirenal collection, grade III urinoma requiring percutaneous drainage and grade III urinary leak with urosepsis, respectively. No deaths occurred in this cohort. CONCLUSIONS Omitting drainage after partial nephrectomy in a select group of patients without collecting system entry is feasible and safe. The decision to place a drain after partial nephrectomy for small renal cortical tumors must be made intraoperatively and should be tailored to each case.

Systematic classification and prediction of complications after nephrectomy in patients with metastatic renal cell carcinoma (RCC)

Study Type – Harm (case series)

Intraoperative Conversion From Partial to Radical Nephrectomy at a Single Institution From 2003 to 2008

PURPOSE Little information exists on conversion from partial to radical nephrectomy. We assessed the intraoperative reasons and predictive factors for conversion in a contemporary series of patients undergoing partial nephrectomy. MATERIALS AND METHODS We identified all patients at our institution who underwent open or laparoscopic partial nephrectomy with conversion to radical nephrectomy between 2003 and 2008. Renal function was assessed by the glomerular filtration rate using the modification of diet in renal disease equation. We used logistic regression analysis to determine whether tumor site, tumor size, body mass index, American Society of Anesthesiologists score, age or gender was associated with the conversion risk. RESULTS The rate of conversion to radical nephrectomy was 6% (61 of 1,029 patients). In the open partial nephrectomy group 59 of 865 cases (7%, 95% CI 5-9) and in the laparoscopic partial nephrectomy group 2 of 164 (1.2%, 95% CI 0.01-4) were converted. The most common reasons for conversion were invasion of hilar structures, size discrepancy and insufficient residual kidney. Patients with conversion were more likely to have larger tumors (per 1 cm increase OR 1.41, 95% CI 1.24-1.59), a central site (central vs peripheral OR 7.74, 95% CI 3.98-15) and a lower preoperative glomerular filtration rate (per 10 ml/minute/1.73 m(2) OR 0.78, 95% CI 0.67-0.91), and present with symptoms (any vs none OR 2.78, 95% CI 1.54-5.04) than those without conversion. The median postoperative glomerular filtration rate was 46 vs 61 ml/minute/1.73 m(2) in patients with vs without conversion. CONCLUSIONS Conversion to radical nephrectomy was rare in patients undergoing partial nephrectomy in this series. Increasing tumor size, central site, lower preoperative glomerular filtration rate and symptoms at presentation were associated with an increased risk of conversion, which increases the likelihood of chronic kidney disease postoperatively.