Daniel J. Canter

Nephron-sparing management vs radical nephroureterectomy for low- or moderate-grade, low-stage upper tract urothelial carcinoma

To compare overall and cancer‐specific outcomes between patients with upper tract urothelial carcinoma (UTUC) managed with either radical nephroureterectomy (RNU) or nephron‐sparing measures (NSM) using a large population‐based dataset.

Familiarity and self-reported compliance with American Urological Association best practice recommendations for use of thromboembolic prophylaxis among American Urological Association members.

PURPOSEnThromboprophylaxis with subcutaneous heparin or low molecular weight heparin is now an integral part of national surgical quality and safety assessment efforts, and has been incorporated into the current AUA Best Practice Statement. We evaluated familiarity and compliance with the AUA Best Practice Statement, assessed practice patterns in terms of perioperative thromboprophylaxis and specifically examined self-reported compliance in high risk patients undergoing radical cystectomy.nnnMATERIALS AND METHODSnAn electronic survey was sent to AUA members with valid e-mail addresses (10,966). Associations between AUA Best Practice Statement adherence and factors such as urological specialty, graduation year and guideline familiarity were assessed using chi-square analyses and generalized estimating equations.nnnRESULTSnWith 1,210 survey responses the largest group of respondents was urological oncologists and/or laparoscopic/robotic specialists (26.0%). This group was more likely to use thromboprophylaxis than nonurological oncologists and/or laparoscopic/robotic specialists in high risk patients (OR 1.3, CI 1.1-1.5). Respondents aware of the AUA Best Practice Statement guidelines (50.7%) were more likely to use thromboprophylaxis (OR 1.4, CI 1.2-1.6). Although 18.1% of urological oncologists and/or laparoscopic/robotic specialists and 34.2% of nonurological oncologists and/or laparoscopic/robotic specialists avoided routine thromboprophylaxis in patients undergoing radical cystectomy, the former were more likely to use thromboprophylaxis (p <0.0001) than other respondents. Urologists graduating after the year 2000 used thromboprophylaxis in high risk patients undergoing radical cystectomy more often than did earlier graduates (79.2% vs 63.4%, p <0.0001).nnnCONCLUSIONSnAlthough younger age and self-reported urological oncologist and/or laparoscopic/robotic specialist status correlated strongly with thromboprophylaxis use, self-reported adherence to AUA Best Practice Statement was low, even in high risk cases with clear AUA Best Practice Statement recommendations such as radical cystectomy. These data identify opportunities for quality improvement in patients undergoing major urological surgery.

Trends in regionalization of radical cystectomy in three large northeastern states from 1996 to 2009

OBJECTIVESnTo assess regionalization trends and short-term clinical outcomes in patients undergoing radical cystectomy for urothelial carcinoma.nnnMATERIALS AND METHODSnUsing 1996-2009 discharge data from New York (NY), New Jersey (NJ) and Pennsylvania (PA), all patients ≥ 18 years with urothelial carcinoma undergoing cystectomy were identified using ICD-9 coding. We assigned hospital volume status by quintiles based on relative proportions of cystectomies performed on a per hospital basis in 1996; very low volume hospitals: 0-2 (VLVH), low: 3-4 (LVH), moderate: 5-8 (MVH), high: 9-31 (HVH), and very high: ≥ 32 (VHVH). Changes in the proportion of procedures performed by volume categories were assessed over time, and patient characteristics were compared between groups.nnnRESULTSnA total of 14,404 patients met inclusion criteria. For each year increase from 1996 to 2009, the odds of having surgery performed at a VHVH increased by 22% (odds ratio [OR] 1.22, confidence interval [CI] 1.04-1.44). Patients undergoing surgery at a VHVH were less likely to be African American (OR 0.59 [CI 0.39-0.91]), or insured through Medicaid (OR 0.65 [CI 0.50-0.84]) or Medicare (OR 0.84 [CI 0.75-0.94]). Controlling for year treated, total procedures performed, and patient characteristics, median hospital length of stay (HLOS) was shorter (median difference -0.89 days [CI -1.12 to -0.66]), and patients were significantly less likely to die during their hospital stay if treated at a VHVH compared with a VLVH (OR 0.33 [CI 0.22-0.49]).nnnCONCLUSIONSnThere has been extensive regionalization of cystectomy to VHVHs in NY, NJ, and PA since 1996. Despite apparent improvements in mortality and HLOS in patients treated at higher volume centers in our sample, future investigations more rigorously adjusting for hospital structural characteristics and patient severity are necessary to confirm these findings. Disparities in access to VHVH care are still evident and must be addressed.

Multicenter evaluation of the role of UroVysion FISH assay in surveillance of patients with bladder cancer: does FISH positivity anticipate recurrence?

AbstractBackgroundThe significance of a positive UroVysion FISH assay is uncertain in patients with normal cystoscopy. This multicenter study evaluates the clinical significance of a positive FISH assay in patients with no visible tumor and excluding those with a positive cytology.MethodsA multi-institutional, retrospective study of patients with a history of urothelial carcinoma of the bladder identified 664 patients with a FISH assay after excluding those with cystoscopic evidence of a tumor and/or positive cytology. Our primary end point was cancer recurrence, defined by biopsy. Progression was defined as recurrence with a tumor stage ≥T2. Statistical analyses were performed using Fisher’s exact test as a one-tailed test and Chi-square test with significance at 0.05, using SPSS® version 19.0 (SPSS Inc., Chicago, IL, USA).ResultsOf the 664 patients in this study, tumor stage was Ta (363, 55xa0%), T1 (183, 28xa0%), and CIS (109, 16xa0%) and most were high grade (440 pts, 66xa0%). The median follow-up was 26xa0months (3–104xa0months), and 277 (41.7xa0%) patients were recurred. In patients who were FISH positive, mean time to recurrence was 12.6xa0months, compared to 17.9xa0months if FISH negative (pxa0=xa00.03). In univariate analysis, atypical cytology, positive FISH, cystoscopic findings (atypical vs. normal), and previous intravesical therapy were associated with recurrence (pxa0<xa00.05). On multivariate analysis, pathologic stage, cystoscopic findings, and cytology were independently associated with recurrence (pxa0<xa00.05). Progression to ≥T2 disease occurred in 34 (5.1xa0%) patients in this cohort. On multivariate analysis, only initial T stage and FISH result were found to be independent predictors of progression (pxa0<xa00.05).ConclusionsPatients with a positive FISH and atypical cytology are more likely to recur even in the absence of visible tumor. FISH positivity may portend a higher risk for progression. These findings require prospective validation.n

Pathological concordance and surgical outcomes of sporadic synchronous unilateral multifocal renal masses treated with partial nephrectomy.

PURPOSEnPatients with unilateral synchronous multifocal renal masses represent a unique population with renal cell carcinoma. While pathological concordance rates have been studied for bilateral cases, limited data exist on unilateral multifocal disease. We characterized pathological concordance rates in this population and evaluated the outcomes of nephron preservation.nnnMATERIALS AND METHODSnPatients who underwent surgery from 2000 to 2012 for unilateral synchronous multifocal renal masses were identified from a prospectively maintained database. Demographic, surgical and pathological outcomes of this cohort were analyzed. Malignant concordance rates were defined as agreement of all malignant tumor types in a single renal unit. Histological concordance was defined as agreement of all resected mass histologies, eg all clear cell carcinomas. Nuclear grade was considered concordant if all tumors excised were low (Fuhrman 1 or 2, type 1) or high (Fuhrman 3 or 4, type 2) grade.nnnRESULTSnUsing our institutional database of 2,569 patients with renal tumors we identified 97 with unilateral synchronous multifocal renal masses. Malignant and benign concordance rates were 77.2% and 48.6%, and histological and grade concordance rates were 58.8% and 51.5%, respectively. In this cohort we identified 76 patients (76.3% male) with a median age of 62.5 years who had a total of 241 unilateral synchronous multifocal renal masses and underwent nephron sparing surgery. Median mass size was 2.0 cm (IQR 1.1-3.1), there was a median of 3 tumors per patient and median followup was 24 months (IQR 13-40). Identified renal cell carcinoma histologies included clear cell in 49.4% of cases, papillary in 33.5%, mixed in 4.5% and chromophobe in 2.8%.nnnCONCLUSIONSnIn what is to our knowledge the largest published report of unilateral synchronous multifocal renal masses we document low pathological concordance rates. As such, percutaneous biopsy of a single renal mass in these patients may not help inform treatment decisions. Nephron sparing surgery may be performed with acceptable oncological and functional results in patients with unilateral synchronous multifocal renal masses.

External validation of the modified Glasgow prognostic score for renal cancer.

Purpose: The modified Glasgow prognostic Score (mGPS) incorporates C-reactive protein and albumin as a clinically useful marker of tumor behavior. The ability of the mGPS to predict metastasis in localized renal cell carcinoma (RCC) remains unknown in an external validation cohort. Patients and Methods: Patients with clinically localized clear cell RCC were followed for 1 year post-operatively. Metastases were identified radiologically. Patients were categorized by mGPS score as low-risk (mGPS = 0 points), intermediate-risk (mGPS = 1 point) and high-risk (mGPS = 2 points). Univariate, Kaplan-Meier and multivariate Cox regression analyses examined Recurrence -free survival (RFS) across patient and disease characteristics. Results: Of the 129 patients in this study, 23.3% developed metastases. Of low, intermediate and high risk patients, 10.1%, 38.9% and 89.9% recurred during the study. After accounting for various patient and tumor characteristics in multivariate analysis including stage and grade, only mGPS was significantly associated with RFS. Compared with low-risk patients, intermediate- and high-risk patients experienced a 4-fold (hazard ratios [HR]: 4.035, 95% confidence interval [CI]: 1.312-12.415, P = 0.015) and 7-fold (HR: 7.012, 95% CI: 2.126-23.123 P < 0.001) risk of metastasis, respectively. Conclusions: mGPS is a robust predictor of metastasis following potentially curative nephrectomy for localized RCC. Clinicians may consider mGPS as an adjunct to identify high-risk patients for possible enrollment into clinical trials or for patient counseling

Scrotal cancer survival is influenced by histology: a SEER study

IntroductionDue to the scrotum’s multiple layers of different tissues, scrotal cancer can present with several unique histologies. Historically, outcome arising from these different sources has been historically aggregated together. However, it remains unclear whether survival differs by histology of scrotal cancer.MethodsWe queried the seventeen registries of the Surveillance, Epidemiology, and End Results database for patients diagnosed with primary scrotal cancer from 1973 to 2006. Patients were initially grouped by the following histologies: basal cell carcinoma, Extramammary Paget’s Disease (EMPD), sarcoma, melanoma, squamous cell carcinoma, and adnexal skin tumors. For some analyses, the former three histologies were reclassified as Low-Risk scrotal cancer and the latter three histologies as High-Risk scrotal cancer. Kaplan–Meier survival analyses were conducted to assess the impact of histology on overall survival (OS).ResultsThe cohort consisted of 766 patients. Median (95% CI) OSs by histologies were basal cell carcinoma—143 (116–180), EMPD—165 (139–190), sarcoma—180 (141–219), melanoma—136 (70–203), squamous cell carcinoma—115 (97–133), and adnexal skin tumors—114 (55–174). Patients with Low-Risk scrotal cancer experienced a median (95% CI) OS of 166 (145–188) months, while patients with High-Risk scrotal cancer experienced a median (95% CI) OS of 118 (101–135) months.ConclusionsSurvival of scrotal cancer depends on tumor histology. Classification of histologies into Low and High Risk can be clinically useful for counseling and clinical decisions.

Nomograms incorporating serum C‐reactive protein effectively predict mortality before and after surgical treatment of renal cell carcinoma

To incorporate C‐reactive protein into nomograms estimating survival in patients with renal cell carcinoma.

Renal cell carcinoma in patients with end-stage renal disease has favorable overall prognosis

Patients with end‐stage renal disease (ESRD) demonstrate a greater risk for renal cell carcinoma (RCC) than the general population. This study compared pathological and clinical outcomes in patients with RCC with and without ESRD. Patients with ESRD who underwent nephrectomy and were found to have RCC at our institution since 1999 were identified. The control group was composed of patients from the general population with RCC. The primary outcome was risk of cancer recurrence. The study included 338 RCC patients: 84 with ESRD and 243 without ESRD. In the ESRD group, mean tumor size was smaller, there was decreased prevalence of advanced T category (>3) , and the average Karakiewicz nomogram score was lower. ESRD was associated with decreased tumor recurrence and clear cell pathology. No patients with ESRD had metastatic disease. There was no difference in overall or cancer‐specific mortality between the ESRD and control groups. Patients with ESRD who develop RCC have a better prognosis compared to RCC in patients without ESRD, which is likely secondary to favorable histopathologic phenotype as well as the likelihood of early diagnosis. Thus, the delay between nephrectomy and renal transplantation may not be necessary, especially in patients with asymptomatic, low grade tumors.

Incidence and clinical characteristics of lower urinary tract symptoms as a presenting symptom for patients with newly diagnosed bladder cancer

PURPOSEnThe incidence of lower urinary tract symptoms (LUTS) as the sole presenting symptom for bladder cancer has traditionally been reported to be low. The objective of this study was to evaluate the prevalence and clinical characteristics of newly diagnosed bladder cancer patients who presented with LUTS in the absence of gross or microscopic hematuria.nnnMATERIALS AND METHODSnWe queried our database of bladder cancer patients at the Atlanta Veterans Affairs Medical Center (AVAMC) to identify patients who presented solely with LUTS and were subsequently diagnosed with bladder cancer. Demographic, clinical, and pathologic variables were examined.nnnRESULTSn4.1% (14/340) of bladder cancer patients in our series presented solely with LUTS. Mean age and Charlson Co-morbidity Index of these patients was 66.4 years (range = 52-83) and 3 (range = 0-7), respectively. Of the 14 patients in our cohort presenting with LUTS, 9 (64.3%), 4 (28.6%), and 1 (7.1%) patients presented with clinical stage Ta, carcinoma in Situ (CIS), and T2 disease. At a median follow-up of 3.79 years, recurrence occurred in 7 (50.0%) patients with progression occurring in 1 (7.1%) patient. 11 (78.6%) patients were alive and currently disease free, and 3 (21.4%) patients had died, with only one (7.1%) death attributable to bladder cancer.nnnCONCLUSIONSnOur database shows a 4.1% incidence of LUTS as the sole presenting symptom in patients with newly diagnosed bladder cancer. This study suggests that urologists should have a low threshold for evaluating patients with unexplained LUTS for underlying bladder cancer.