Guarionex Joel DeCastro

Synchronous cryoablation of multiple renal lesions: short-term follow-up of patient outcomes.

OBJECTIVES To report on various perioperative and short-term clinical outcomes of 7 patients who underwent cryoablation of multiple renal lesions during the same operative setting. Cryotherapy is the most well studied minimally invasive ablative technique for the treatment of renal tumors. METHODS A retrospective analysis of our institutional renal cryotherapy database yielded a total of 7 patients who underwent synchronous cryoablation of > 1 renal lesion between August 2005 and May 2007. RESULTS Mean patient age was 63.9 years, and median follow-up was 23.3 months (range 7-28 months). Five patients had ablation of 2 renal lesions, 1 had 3 lesions, and 1 had 4 lesions. The mean greatest diameter of any single lesion was 2.0 cm (range 0.7-7.5 cm). Mean preoperative serum creatinine was 1.5 mg/dL (range 0.7-3.6 mg/dL), which increased to a mean of 1.7 mg/dL (range 0.7-3.6) at last follow-up. Mean estimated blood loss was 138 mL (range 38-300 mL). There were 2 complications--ureteral stenting because of postoperative renal colic, and blood transfusion for decreased hematocrit. Of the 17 lesions, 7 were found to be conventional renal cell carcinoma, 4 papillary, 2 myelolipoma, and 1 oncocytoma (unavailable for 3 lesions). Mean length of hospital stay was 2.3 days (range 1-6 days). At last follow-up, computed tomography scanning demonstrated no recurrences in any patient. CONCLUSIONS Cryoablation of multiple renal lesions at one setting may be successfully performed with few complications, with minimal short-term loss of renal function as estimated by serum creatinine, and with short-term evidence of tumor destruction.

Outcomes and Prognostic Factors of Primary Urethral Cancer

OBJECTIVE To identify prognostic and treatment factors for primary urethral cancer using a nationwide database. MATERIALS AND METHODS The National Cancer Database was queried for all cases of primary urethral cancer from 2004 to 2013. Patients with other cancer diagnoses, metastasis, or diagnosis on autopsy were excluded. Proportional hazards regression was used to identify independent predictors of overall survival in patients with primary urethral cancer. Because we hypothesized that predictors may covary by sex, we also performed regression analysis stratified by sex. RESULTS We identified 1268 men and 869 women with primary urethral cancer. Women tended to have more advanced tumors and adenocarcinoma histology. Median survival for the entire cohort was 49 months (43-55), with 5- and 10-year survival rates of 46% and 31%, respectively. On multivariate analysis, age, race, stage, grade, and Charlson comorbidity index were independent predictors of overall survival. Histology was not a predictor of overall survival in the combined model; however, adenocarcinoma in women increased hazards of death, whereas it decreased hazards of death in men when compared with squamous cell carcinoma. CONCLUSION Men and women with primary urethral cancer had significant differences in histology, grade, and nodal status. In addition to several expected disease-related factors, black race was associated with increased mortality for patients with primary urethral cancer.

Collecting duct carcinoma of the kidney: Disease characteristics and treatment outcomes from the National Cancer Database

OBJECTIVE To use a large population-level database to assess survival outcomes for collecting duct renal cell carcinoma (CDRCC). MATERIALS AND METHODS The National Cancer Database was queried for all cases of CDRCC and clear cell renal cell carcinoma (CCRCC) from 2004 to 2013. After removing patients with other cancer diagnoses, the analytic cohort was composed of 201,686 CCRCC and 577 CDRCC cases. Kaplan-Meier and cox proportional hazards analysis were employed to model survival. RESULTS Compared to CCRCC, patients with CDRCC presented with higher grade and stage, node positive, and metastatic disease (70.7% vs. 30.0% with metastasis; P<0.001). Overall median survival for CDRCC was 13.2 months (95% CI: 11.0-15.5) compared to the 122.5 months (95% CI: 121.0-123.9) for CCRCC. On multivariate analysis of the CDRCC cohort, increasing T stage, high-grade disease, and metastasis were predictors of mortality. Of 184 patients with metastatic CDRCC, 113 underwent cytoreductive nephrectomy (CNx) whereas the rest were treated with chemo/radiation or observed. Survival outcomes were improved in patients who received both CNx with chemo/radiation compared to CNx alone (hazard ratio = 0.51, 95% CI: 0.32-0.79) or chemo/radiation alone (hazard ratio = 0.57, 95% CI: 0.37-0.89) on multivariate analysis. CONCLUSION CDRCC is an aggressive subtype of renal cell carcinoma. Median survival is 13 months after diagnosis, drastically lower than for CCRCC. More than 70% of patients have metastatic disease at diagnosis. Chemo/radiation in addition to CNx is associated with a survival benefit over single mode therapy.

MP15-13 A PHASE I TRIAL FOR THE USE OF INTRAVESICAL CABAZITAXEL, GEMCITABINE, AND CISPLATIN (CGC) IN THE TREATMENT OF BCG-REFRACTORY NON-MUSCLE INVASIVE UROTHELIAL CARCINOMA OF THE BLADDER

METHODS: In a prospective study, we included 105 elderly patients with NMICB, 57 patients had high grade T1 tumor, 48 patients with high grade Ta, both TA and T1 were NMICB, patients were recurrent after complete course of intavesical BCG, patients asked for bladder preservation. The multimodality treatment arm was compared with matched arm of 60 patients treatment with RC. Follow up was up to 3 4years. Overall survival (OS) and disease free survival (DFS) was calculated using Kaplan-Mayer and Cox proportional hazards model and compared to a second arm of 30 patients with similar criteria that had RC. Inclusion criteria in both arms were non-metastatic NMICB, no prior chemotherapy, glomerular filtration rate <60?mL/min. Gemcitabine (900?mg/m(2)), paclitaxel (135?mg/m(2)), and doxorubicin (40? mg/m(2)) were administered on day 1 of each 14-day cycle. Pegfilgrastim was given with every cycle on either day 1 or day. low dose radiotherapy were given following chemotherapy. RESULTS: Median age was 77 years (range 75-84). All patients had complete responses. Grade 3 and 4 nonhematologic toxicities were fatigue and mucositis (14% each). There were 12 episodes of neutropenic fever, no treatment-related deaths. Median overall survival was 28.5 months CONCLUSIONS: Results of combination of gemcitabine, paclitaxel, and doxorubicin as first-line chemotherapy combination with radiotherapy for elderly patients with recurrent high grade Ta, T1 NMICB of UC in elderly patients 1⁄475 years old. Were compatible with RC. Bladder preservation with first line chemoradiothery would be considered as an alternative to RC in elderly patients as it offers better quality of life

Conservative Management Following Complete Clinical Response to Neoadjuvant Chemotherapy of Muscle Invasive Bladder Cancer: Contemporary Outcomes of a Multi-Institutional Cohort Study

Purpose We report the outcomes in patients with muscle invasive bladder cancer from 2 institutions who experienced a clinically complete response to neoadjuvant platinum based chemotherapy and elected active surveillance. It was unknown whether conservative treatment could be safely implemented in these patients. Materials and Methods We retrospectively reviewed the records of patients with muscle invasive bladder cancer at our institutions who elected surveillance following a clinically complete response to transurethral resection of bladder tumors and neoadjuvant chemotherapy from 2001 to 2017. A clinically complete response was defined as absent tumor on post‐chemotherapy transurethral resection of bladder tumor, negative cytology and normal cross‐sectional imaging. Results In the 148 patients followed a median of 55 months (range 5 to 145) the 5‐year disease specific, overall, cystectomy‐free and recurrence‐free survival rates were 90%, 86%, 76% and 64%, respectively. Of the patients 71 (48%) experienced recurrence in the bladder, including 16 (11%) with muscle invasive disease and 55 (37%) with noninvasive disease. Salvage radical cystectomy prevented cancer specific death in 9 of 12 patients (75%) who underwent cystectomy after muscle invasive relapse and in 13 of 14 (93%) after noninvasive relapse. Conclusions We observed high rates of overall and disease specific survival with bladder preservation in patients who achieved a clinically complete response to neoadjuvant chemotherapy. These outcomes support the safety of active surveillance in carefully selected, closely monitored patients with muscle invasive bladder cancer. Future studies should aim to improve patient selection by identifying biomarkers predicting invasive relapse and developing novel imaging methods of early detection.

MP58-07 USE OF ADJUVANT CHEMOTHERAPY IN PATIENTS WITH ADVANCED BLADDER CANCER AFTER NEOADJUVANT CHEMOTHERAPY

INTRODUCTION AND OBJECTIVES: MIBC patients who respond to cisplatin based NAC, defined as stage <ypT2 at cystectomy, exhibit a high 5 year cancer specific survival (CSS) of up to 90%. In contrast, non-responders (stage 1⁄4ypT2 at cystectomy) exhibit a worse CSS (30-40%) than cystectomy alone, highlighting the need for predictors of NAC response. Recent MIBC studies have identified a gene expression based taxonomy (basal versus luminal phenotypes) similar to that of breast cancer. We evaluated the role of such a classification using immunohistochemical stains in a NAC cohort of MIBC. METHODS: Pre-treatment tissues from a cohort of 71 NAC treated MIBC patients at our institution between 2000 and 2013 were incorporated in tissue microarray and stained for CK5/6 and GATA3 (Ventana Medical Systems, AZ). Cases were assigned as luminal or basal phenotype based on the extent (70% cut off) of tumor cells with 1⁄42+ staining intensity, Figure 1A. We limited our analysis of CSS to the 40 patient who were able to tolerate 1⁄42 doses of NAC to avoid the confounding effect of patients who were not adequately dosed. RESULTS: As expected, there was an inverse association for CK5/6 and GATA3: 77% (43/56) of strong GATA3 cases exhibited weak/negative CK5/6 staining, most consistent with the luminal phenotype, and 73% (11/15) of the GATA3 weak/negative cases exhibited strong CK5/6, most consistent with the basal phenotype (Fisher’s exact p-value 0.0003). Interestingly there was a ~ 2 fold enrichment of basal the phenotype in cases with residual MIBC following NAC, Figure 1B. CONCLUSIONS: Our results suggest a differential responsiveness to NAC for MIBC based on assignment of basal and luminal phenotypes. The current findings should be further evaluated taking P53 gene expression status into account, given previous suggestion of chemotherapy resistance in P53 intact (p53-Like) MIBC. Furthermore, comparison to IHC luminal/basal MIBC phenotypes in our cohort of cystectomy only treated patients is ongoing to help discern the prognostic vs predictive role of this classification for NAC. Source of Funding: None

PD17-10 RENAL FAILURE FOLLOWING PARTIAL VS RADICAL STRATIFIED BY PREOPERATIVE CKD STAGE

METHODS: We retrospectively reviewed records of 1542 cases of RPN and 903 cases of LPN performed in 5 high volume centres across USA from 2000 to mid 2013. We limited our study renal masses ( 4 cm). Tumor complexity was assigned according to R.E.N.A.L nephrometry score (RNS). Based on RNS value, tumors were divided into simple (4-6), intermediate (7-9) and complex (10-12) group. We defined the Trifecta of negative surgical margin, zero perioperative complications and warm ischemia of less than 25 minutes, as a surrogate of ideal short-term surgical outcome. RESULTS: Total 1842 patients (1185 RPN and 657 LPN) met our inclusion criteria (tumor 4 cm). Patients in the RPN group were older (59.3 vs. 57.6 p1⁄40.003) and had higher mean Charlson Comorbidity Index (2.21 vs. 1.32 p<0.001). Higher proportions of the tumors in the RPN cohort were intermediate or complex (55.2% vs. 35.9% p<0.001). The RPN group had lower warm ischemia (19.2 vs. 26.7 minutes) time, overall complication rate (14.9 vs. 22.1%, p <0.001), and positive margin rate (3.3% vs. 9.6%, p <0.001). A significantly higher Trifecta rate was observed for RPN (70.7% vs. 32.4%, p<0.001). On multivariable analysis RPN, RNS and tumor size were predictors of achieving Trifecta. CONCLUSIONS: In this large multi-intuitional comparative series, we have demonstrated that RPN is superior to LPN in achieving the Trifecta, despite the presence of more complex tumors in the robotic cohort. Although the Trifecta does not encompass the long-term functional outcome of nephron sparing surgery, it provides us with an immediate surrogate for surgical quality control. Our results demonstrate that the robotic platform allows the surgeon to perform minimally invasive complex surgery more efficiently.