Gina M. Badalato

Survival after partial and radical nephrectomy for the treatment of stage T1bN0M0 renal cell carcinoma (RCC) in the USA: a propensity scoring approach

Study Type – Therapy (cohort)

Relative efficacy of perioperative gemcitabine and cisplatin versus methotrexate, vinblastine, adriamycin, and cisplatin in the management of locally advanced urothelial carcinoma of the bladder.

OBJECTIVE To compare the outcomes of patients treated in the perioperative setting with methotrexate, vinblastine, adriamycin, and cisplatin (MVAC) versus gemcitabine and cisplatin (GC). Systemic cisplatin-based chemotherapy regimens are the mainstay of treatment for patients with advanced bladder cancer. GC has often been used interchangeably with MVAC in neoadjuvant or adjuvant settings for patients with locally advanced (cT2N0M0-cT4N2M0) bladder cancer without adequate evidence. METHODS A total of 114 patients treated with systemic chemotherapy for Stage T2-T4N0-N2M0 urothelial cell carcinoma of the bladder were included in the present study. The survival times were estimated and compared using the Kaplan-Meier method and log-rank test, respectively. Univariate and multivariate Cox proportional hazards models were used to determine the statistical significance. RESULTS Of the 114 patients included in the present study, 37 (32%) were treated with GC and 77 (68%) with MVAC. In the neoadjuvant group, no difference was found between the 2 chemotherapeutic regimens in terms of the pathologic complete response rate at either cystectomy or during cystoscopy (14 [31%] of 45 MVAC patients vs 4 [25%] of 16 GC patients; P=.645). On multivariate analysis, the choice of regimen was not an independent predictor of cancer-specific death (hazard ratio 1.3, 95% confidence interval 0.67-2.57; P=.421) or overall survival (hazard ratio 1.3, 95% confidence interval 0.76-2.24; P=.330). CONCLUSION Despite the lack of data on the relative efficacy of GC versus MVAC in the neoadjuvant and adjuvant settings, these regimens have been used interchangeably. The present investigation did not find the choice of cisplatin-based regimen to be an independent predictor of survival. A trend was seen toward improved survival and a greater complete response rate in the MVAC group.

Increased Risk of Overall and Cardiovascular Mortality After Radical Nephrectomy for Renal Cell Carcinoma 2 cm or Less

PURPOSE We used a large, population based registry to assess whether a difference in overall and cardiovascular survival may exist between radical nephrectomy and partial nephrectomy for renal cell carcinoma 2 cm or less. MATERIALS AND METHODS From the SEER (Surveillance, Epidemiology and End Results) registry we identified 4,216 patients with histologically confirmed renal cell carcinoma 2 cm or less who were treated with partial or radical nephrectomy. Patient and tumor characteristics were compared between the 2 patient groups. Multivariate logistic regression was done to predict the odds of undergoing radical nephrectomy. Cardiovascular survival and overall survival were compared between the 2 cohorts, adjusting for patient and tumor characteristics. RESULTS Overall 2,301 patients (55%) underwent partial nephrectomy. Partial nephrectomy use steadily increased during the study period from 27% of all cases in 1998 to 66% in 2007. Patients who underwent partial nephrectomy were an average of 2.5 years younger than those treated with radical nephrectomy (56.4 vs 58.9 years, p <0.001). They were more likely to be white and from the western or northeastern United States. Older age was the only independent predictor of radical nephrectomy (OR 1.02, 95% CI 1.01-1.03). When controlling for patient characteristics and surgery year, radical nephrectomy was associated with worse overall mortality (HR 2.24, 95% CI 1.75-2.84) and cardiovascular mortality (HR 2.53, 95% CI 1.51-4.23). CONCLUSIONS Radical nephrectomy is associated with worse overall and cardiovascular survival compared to partial nephrectomy in patients with localized renal cell carcinoma 2 cm or less. These findings justify the widespread application of nephron sparing techniques to treat localized kidney cancer.

Immediate radical cystectomy vs conservative management for high grade cT1 bladder cancer: is there a survival difference?

Study Type – Aetiology (individual cohort)

The effect of race and gender on the surgical management of the small renal mass

BACKGROUND To date, no population studies have been designed to assess the impact of race and gender on the rate of nephron-sparing surgery (NSS) across the United States. MATERIALS AND METHODS The Surveillance, Epidemiology, and End Results (SEER) registry was queried for patients with T1a renal cell carcinoma (RCC) treated over the most recent decade, 1998-2007. Baseline socio-demographic data were compared between Caucasian and African-American patients using χ(2) and t-test analysis, and rates of radical nephrectomy (RN) were compared for all permutations of race and gender. A multivariate logistic regression model was in turn created with these variables to predict the odds of undergoing a radical nephrectomy. No prior assumptions were made regarding superiority of partial nephrectomy (PN) over RN as a therapeutic intervention. RESULTS A total of 14,953 patients were eligible for inclusion in this study, and of these, 1,804 (12%) were African-American. Comparably, African-American patients were younger (<50 years; 23 vs. 28%, P < 0.001), and had an increased rate of high grade disease (13 vs. 16%, P < 0.001). Among different subsets of race and gender, African-American women received PN least often (28%) compared with all other groups, with African-American women at a 47% increased risk of undergoing RN compared with Caucasian male counterparts (95% CI: 1.24-1.73). CONCLUSIONS Significant racial and gender disparities exist with regard to utilization of nephron-sparing surgery for small renal masses, particularly in African-American women. Further efforts should be directed to elucidating and addressing the rationale behind this disparity to ensure the uniformity of care.

Serum tumor markers in the evaluation of male germ cell tumors

Serum tumor markers play a critical role in the diagnosis, staging, risk stratification, and surveillance of patients with testicular germ cell tumors (GCTs). Production of the oncofetal substances α fetoprotein and human chorionic gonadotropin can aid the diagnosis of testicular GCTs, and specific patterns of marker elevation can be used to determine the type of tumor, particularly as it pertains to nonseminoma. These markers, in addition to lactate dehydrogenase, have been incorporated in the standard TNM staging system for testicular tumors; the S stage category corresponds to serum elevation of these proteins. Furthermore, the degree of serum tumor marker elevation has been incorporated into standardized patient risk groupings, which are used to guide therapeutic management. The rate of tumor marker decay after radical orchiectomy is an important index to monitor, as a slow decline might be indicative of metastatic disease and should prompt a thorough systemic survey. The rate of tumor marker decline is already being utilized in the setting of metastatic GCTs to determine response to chemotherapy, and has been used in some scenarios to individualize the type of chemotherapy patients received. Compared to any other solid organ malignancy, the role of serum tumor markers in GCT is unprecedented; these markers are instrumental in the diagnosis and management of testicular GCT.

Prognostic indicators for upper tract urothelial carcinoma after radical nephroureterectomy: the impact of lymphovascular invasion

Study Type – Prognosis (case series)

Evaluation and Management of the Persistent/Recurrent Varicocele

OBJECTIVE To review outcomes in adolescent patients following redo varicocelectomy surgery. METHODS The composite varicocele registry of a single surgeon was queried to identify patients who had undergone redo varicocelectomy. Variables of testicular asymmetry, testicular volume, presence and degree of retrograde venous flow, and incidence of postoperative hydrocele were evaluated. RESULTS Nineteen boys were identified as having had a redo varicocelectomy (16 open, 1 laparoscopic, 2 radiographic embolization) with a minimum postoperative follow-up of 6 months (mean: 23.4; range: 6-53 months). No varicocele was palpable postoperatively among the 17 surgical redoes; one patients testicle was significantly smaller after surgery, and 3 developed a hydrocele requiring repair. One of two boys who underwent radiographic embolization had a persistent varicocele. Eight of the nine boys who had asymmetry of 10% or greater before redo demonstrated catch-up growth after repair. The consistent intraoperative finding in all redo patients was the presence of large veins within the cord, just proximal to the junction with the vas and in continuity with the dilated veins distal to the internal ring. Post-redo retrograde venous flow was not identifiable in 16 and minimal in three. CONCLUSIONS Redo varicocelectomy can be accomplished successfully and has a similar chance of achieving catch-up growth as does an initial repair. Postoperatively, there exists a small risk of testicular volume compromise and a significant risk of hydrocele development. Distal collateral veins may have a smaller role in varicocele formation and recurrence than previously thought.

Adolescent varicocele-is the 20/38 harbinger a durable predictor of testicular asymmetry?

PURPOSE Part of the management of adolescent varicocele is trying to prognosticate who with testicular asymmetry will have catch-up growth with observation and who will have persistent asymmetry. We previously reported that catch-up growth is rare when peak retrograde flow greater than 38 cm per second is associated with 20% or greater asymmetry (ie the 20/38 harbinger). We sought to determine if this 20/38 cutoff held true with a larger series, and what peak retrograde flow value should be used when 15% instead of 20% asymmetry is chosen as the cutoff. MATERIALS AND METHODS We analyzed patients from our large varicocele registry who had undergone at least 2 duplex Doppler ultrasounds and had been observed for at least 10 months in the interim. Outcomes were determined regarding those who met the 20/38 cutoff and what peak retrograde flow value could be used to recommend surgery when 15% to 19.9% asymmetry was included in the cutoff value. RESULTS Of 355 adolescent boys with left varicocele 44 (mean age 14.0 years, range 9 to 20) were followed with observation initially and met the 20/38 cutoff, while 9 additional patients met the 15/38 cutoff (initial asymmetry 15% to 19.9%). When combining both groups, only 3 boys had catch-up growth to less than 15% on followup. Thus, 50 of 53 patients did not demonstrate catch-up growth after a mean followup of 15.5 months (range 10 to 44). CONCLUSIONS Not only does a peak retrograde flow of greater than 38 cm per second hold up for predicting persistent/worsening asymmetry when combined with a 20% asymmetry cutoff, it also is an excellent predictor of persistent and/or worsening asymmetry when combined with a 15% asymmetry cutoff. Therefore, it might be unnecessary to follow an adolescent boy with observation who is at or above this 15/38 cutoff.

Persistent Overuse of Radical Nephrectomy in the Elderly

OBJECTIVE To analyze the use of radical nephrectomy (RN) and partial nephrectomy during a 10-year period in patients aged≥75 years compared with their younger counterparts. METHODS Using the Surveillance, Epidemiology, and End Results registry, we identified 18 045 cases of localized renal cell carcinoma of ≤4 cm diagnosed from 1998 to 2007. The baseline differences in demographic and tumor characteristics were compared between the 2 age cohorts (<75 vs ≥75 years), and the rates of RN were determined, stratified by tumor size. A multivariate logistic regression analysis was conducted to predict the odds of undergoing radical nephrectomy for clinical Stage T1a disease. RESULTS Overall, 2733 patients (15%) were aged≥75 years. The use of radical nephrectomy for clinical Stage T1a renal cell carcinoma decreased during the study period for all patients (79% in 1998 to 49% in 2007). Overall, 66% of patients aged≥75 years underwent RN for their disease compared with 59% of patients aged<75 years (P<.001). For patients with tumors of ≤2 cm, 51% of those aged≥75 years underwent RN compared with 41% of the younger cohort. In a multivariate logistic regression model, age≥75 years independently predicted the use of radical nephrectomy (odds ratio 1.18, 95% confidence interval 1.08-1.29). A 1-year increase in age was associated with a 1% increase in the risk of undergoing RN (odds ratio 1.01, 95% confidence interval 1.01-1.01). CONCLUSION Elderly patients with clinically localized small renal masses are treated with RN more frequently than younger patients. Additional studies should address the medical implications of the increased use of radical surgery within the geriatric population.