Dominic H. Tang

Preoperative Nutritional Status Is an Important Predictor of Survival in Patients Undergoing Surgery for Renal Cell Carcinoma

BACKGROUND The role of malnutrition has not been well studied in patients undergoing surgery for renal cell carcinoma (RCC). OBJECTIVE Our aim was to evaluate whether nutritional deficiency (ND) is an important determinant of survival following surgery for RCC. DESIGN, SETTING, AND PARTICIPANTS A total of 369 consecutive patients underwent surgery for locoregional RCC from 2003 to 2008. ND was defined as meeting one of the following criteria: body mass index <18.5 kg/m(2), albumin <3.5 g/dl, or preoperative weight loss ≥ 5% of body weight. INTERVENTION All patients underwent radical or partial nephrectomy. MEASUREMENTS Primary outcomes were overall and disease-specific mortality. Covariates included age, Charlson comorbidity index (CCI), preoperative anemia, tumor stage, Fuhrman grade, and lymph node status. Multivariate analysis was performed using a Cox proportional hazards model. Mortality rates were estimated using the Kaplan-Meier product-limit method. RESULTS AND LIMITATIONS Eighty-five patients (23%) were categorized as ND. Three-year overall and disease-specific survival were 58.5% and 80.4% in the ND cohort compared with 85.4% and 94.7% in controls, respectively (p<0.001). ND remained a significant predictor of overall mortality (hazard ratio [HR]: 2.41, 95% confidence interval [CI], 1.40-4.18) and disease-specific mortality (HR: 2.76; 95% CI, 1.17-6.50) after correcting for age, CCI, preoperative anemia, stage, grade, and nodal status. This study is limited by its retrospective nature. CONCLUSIONS ND is associated with higher mortality in patients undergoing surgery for locoregional RCC, independent of key clinical and pathologic factors. Given this mortality risk, it may be important to address nutritional status preoperatively and counsel patients appropriately.

Salvage Robotic Assisted Laparoscopic Radical Prostatectomy: A Single Institution, 5-Year Experience

PURPOSE Salvage robotic assisted laparoscopic prostatectomy is a treatment option for certain patients with recurrent prostate cancer after primary therapy. Data regarding patient selection, complication rates and cancer outcomes are scarce. We report the largest, single institution series to date, to our knowledge, of salvage robotic assisted laparoscopic prostatectomy. MATERIALS AND METHODS We reviewed our database of 4,234 patients treated with robotic assisted laparoscopic prostatectomy at Vanderbilt University and identified 34 men who had surgery after the failure of prior definitive ablative therapy. Each patient had biopsy proven recurrent prostate cancer and no evidence of metastases. The primary outcome measure was biochemical failure. RESULTS Median time from primary therapy to salvage robotic assisted laparoscopic prostatectomy was 48.5 months with a median preoperative prostate specific antigen of 3.86 ng/ml. Most patients had Gleason scores of 7 or greater on preoperative biopsy, although 12 (35%) had Gleason 8 or greater disease. After a median followup of 16 months 18% of patients had biochemical failure. The positive margin rate was 26%, of which 33% had biochemical failure after surgery. On univariable analysis there was a significant association between prostate specific antigen doubling time and biochemical failure (HR 0.77, 95% CI 0.60-0.99, p = 0.049) as well as between Gleason score at original diagnosis and biochemical failure (HR 3.49, 95% CI 1.18-10.3, p = 0.023). There were 2 Clavien II-III complications, namely a pulmonary embolism and a rectal laceration. Postoperatively 39% of patients had excellent continence. CONCLUSIONS Salvage robotic assisted laparoscopic prostatectomy is safe, with many favorable outcomes compared to open salvage radical prostatectomy series. Advantages include superior visualization of the posterior prostatic plane, modest blood loss, low complication rates and short length of stay.

Enhancement of boron solid solubility in Si by point-defect engineering

The technique of point-defect engineering (PDE), with excess vacancies produced near the surface region by MeV Si ion implantation, has been applied to form ultrashallow junctions with sub-keV B implants. PDE can reduce boride-enhanced diffusion that dominates the enhanced diffusion of ultralow energy B implants. PDE can further sharpen the dopant profile and enhance boron activation. For 1×1015/cm2, 0.5 keV B implant, B solid solubility has been enhanced over a wide temperature range of 750–1000 °C, with an enhancement factor of 2.5 at 900 °C. These features have enabled a shallower and sharper box-like boron junction achievable by PDE in combination with ultralow energy 0.5 keV B implantation.

Lack of P16ink4a Over Expression in Penile Squamous Cell Carcinoma is Associated with Recurrence after Lymph Node Dissection

PURPOSE There have been conflicting data in studies on the prognostic role of high risk human papillomavirus in penile squamous cell carcinoma. Using P16(ink4a) over expression as a surrogate marker for high risk human papillomavirus, we evaluated high risk human papillomavirus status with respect to various clinical features, including recurrence and overall survival, among others. MATERIALS AND METHODS P16(ink4a) over expression was evaluated by immunohistochemistry for 119 consecutive patients with penile squamous cell carcinoma. Several variables were recorded including age, stage, histological grade, lymph node status, lymphovascular invasion, metastasis and recurrence. Median followup was 30 months. RESULTS P16(ink4a) over expression was detected in 49.5% (59 of 119) of samples. There was no significant difference between P16(ink4a) negative and P16(ink4a) positive tumors in terms of stage (p = 0.518), histological grade (p = 0.225), lymphovascular invasion (p = 0.388), overall survival (p = 0.156) or lymph node metastasis (p = 0.748). P16(ink4a) negative tumors were more likely to recur overall (p = 0.04), especially if patients had positive lymph nodes at diagnosis (p = 0.002). CONCLUSIONS These data suggest that P16(ink4a)/high risk human papillomavirus status is associated with recurrence, especially in patients with positive lymph nodes at diagnosis. Thus, patients with P16(ink4a) negative penile cancer, particularly those with lymph node metastases, may warrant closer observation after surgery.

Management of carcinoma in situ of the bladder: best practice and recent developments:

Management of carcinoma in situ of the bladder remains a complex and challenging endeavor due to its high rate of recurrence and progression. Although it is typically grouped with other nonmuscle invasive bladder cancers, its higher grade and aggressiveness make it a unique clinical entity. Intravesical bacillus Calmette-Guérin is the standard first-line treatment given its superiority to other agents. However, high rates of bacillus Calmette-Guérin failure highlight the need for additional therapies. Radical cystectomy has traditional been the standard second-line therapy, but additional intravesical therapies may be more appealing for non-surgical candidates and patients refusing cystectomy. The subject of this review is the treatment strategies and available therapies currently available for carcinoma in situ of the bladder. It discusses alternative intravesical treatment options for patients whose condition has failed to respond to bacillus Calmette-Guérin therapy and who are unfit or unwilling to undergo cystectomy.

Management of Renal Masses in an Octogenarian Cohort: Is There a Right Approach?

Micro‐Abstract Although several guidelines have outlined the management options for patients with renal masses, these guidelines have largely been extrapolated from studies involving younger cohorts. We compared management strategies in an exclusively octogenarian population and found no differences in survival among active surveillance, partial nephrectomy, and radical nephrectomy for small renal masses. However, larger and clinically aggressive renal masses should undergo active treatment. Background: We reviewed the outcomes for an octogenarian population to investigate whether active surveillance (AS) provides comparable survival to partial nephrectomy (PN) or radical nephrectomy (RN). Patients and Methods: Data were collected from 115 octogenarian patients referred for management of renal masses at Moffitt Cancer Center from 2000 to 2013. Patients were treated with AS, PN, or RN. Univariable and multivariable Cox regression models measured the association between management modality and survival. Kaplan‐Meier survival analysis was used to calculate survival, and log‐rank tests were used to compare survival curves. Results: The median age was 82 years (interquartile range, 81‐85 years). The median follow‐up period was 51 months (interquartile range, 23‐81 months). Of the 115 patients, 31 (27%) underwent AS, 31 (27%) underwent PN, and 53 (46%) underwent RN. The patients who underwent RN had a larger mean tumor size at 5.5 cm, with 19 patients (36%) having stage ≥ pT3 (P < .001). We found no difference in overall survival or disease‐specific survival among the 3 management strategies on univariable analysis (P = .39 and P = .1, respectively). On multivariable analysis for overall survival, only the Charlson comorbidity index was associated with worse survival (hazard ratio, 1.2; 95% confidence interval, 1.1‐1.3; P = .002). In a subgroup analysis of cT1a patients, we also found no difference in overall or disease‐specific survival among the treatment arms on univariable analysis (P = .74 and P = .9, respectively). Conclusion: Active treatment with PN and RN might not provide a survival advantage compared with AS in the octogenarian population with a small renal mass. However, larger renal masses should undergo active treatment in appropriately selected patients.

Does Implementing an Enhanced Recovery After Surgery Protocol Increase Hospital Charges? Comparisons From a Radical Cystectomy Program at a Specialty Cancer Center

OBJECTIVE To compare perioperative charges induced at the initial phase of a standardized enhanced recovery after surgery (ERAS) program from a tertiary referral center. METHODS A multidisciplinary ERAS protocol was implemented in our department on July 2015. During the subsequent year, all patients were treated according to this protocol (ERAS group). The patients were compared in terms of real in-hospital charges per surgical episode with a control group consisting of consecutive patients before the start of ERAS. Individual charges were analyzed per sample population and compared with the Wilcoxon rank-sum test or t test. Additionally, cost variances for each group were evaluated. RESULTS A total of 257 consecutive patients were evaluated of which the last 112 were ERAS patients. The median length of stay for each group was 6 days (P = .748). ERAS patients incurred higher medication charges (

Delay to Inguinal Lymph Node Dissection Greater than 3 Months Predicts Poorer Recurrence-Free Survival for Patients with Penile Cancer

1939 vs

Patterns of Regional Lymphadenectomy for Clinically Node-negative Patients With Penile Carcinoma: Analysis From the National Cancer Database From 1998 to 2012

1729, P = .036). Control patients incurred higher supplies (

Surgical management of penile carcinoma in situ: results from an international collaborative study and review of the literature

861 vs