J. Rigaud

Positive Surgical Margin Appears to Have Negligible Impact on Survival of Renal Cell Carcinomas Treated by Nephron-Sparing Surgery

BACKGROUNDnThe occurrence of positive surgical margins (PSMs) after partial nephrectomy (PN) is rare, and little is known about their natural history.nnnOBJECTIVEnTo identify predictive factors of cancer recurrence and related death in patients having a PSM following PN.nnnDESIGN, SETTING, AND PARTICIPANTSnSome 111 patients with a PSM were identified from a multicentre retrospective survey and were compared with 664 negative surgical margin (NSM) patients. A second cohort of NSM patients was created by matching NSM to PSM for indication, tumour size, and tumour grade.nnnMEASUREMENTSnPSM and NSM patients were compared using student t tests and chi-square tests on independent samples. A Cox proportional hazards regression model was used to test the independent effects of clinical and pathologic variables on survival.nnnRESULTS AND LIMITATIONSnMean age at diagnosis was 61+/-12.5 yr. Mean tumour size was 3.5+/-2 cm. Imperative indications accounted for 39% (43 of 111) of the cases. Some 18 patients (16%) underwent a second surgery (partial or total nephrectomy). With a mean follow-up of 37 mo, 11 patients (10%) had recurrences and 12 patients (11%) died, including 6 patients (5.4%) who died of cancer progression. Some 91% (10 of 11) of the patients who had recurrences and 83% of the patients (10 of 12) who died belonged to the group with imperative surgical indications. Rates of recurrence-free survival, of cancer-specific survival, and of overall survival were the same among NSM patients and PSM patients. The multivariable Cox model showed that the two variables that could predict recurrence were the indication (p=0.017) and tumour location (p=0.02). No other variable, including PSM status, had any effect on recurrence. None of the studied parameters had any effect on the rate of cancer-specific survival.nnnCONCLUSIONSnPSM status occurs more frequently in cases in which surgery is imperative and is associated with an increased risk of recurrence, but PSM status does not appear to influence cancer-specific survival. Additional follow-up is needed.

Recommandations en Onco-Urologie 2010: Tumeurs germinales du testicule.

Le cancer du testicule est rare, mais avec une prise en charge adaptee, le taux de survie specifique a 5 ans de cette maladie est superieur a 90 %, tous stades confondus [1,2]. Dans ces recommandations, ne seront traitees que les tumeurs germinales testiculaires (TGT) comprenant les tumeurs germinales seminomateuses (TGS) et les tumeurs germinales non-seminomateuses (TGNS) qui restent les plus frequentes (95 % des cas).

Recommandations en onco-urologie 2013 du CCAFU : Tumeurs germinales du testicule

INTRODUCTIONnThe objective of this article is to establish guidelines proposed by the external genital organ group of the CCAFU for the diagnosis, treatment and follow-up of the germ cell tumours of the testis.nnnMATERIAL AND METHODSnThe multidisciplinary working party studied previous guidelines, exhaustively reviewed the literature, and evaluated references and their level of proof in order to attribute grades of recommendation.nnnRESULTSnThe initial work-up of testicular cancer is based on clinical, laboratory (AFP, total hCG, LDH) and imaging assessment (scrotal ultrasound and chest, abdomen and pelvis computed tomography). Inguinal orchidectomy is the first-line treatment allowing characterization of the histological type, local staging and identification of risk factors for micrometastases. The management of stage I tumours must be adapted to the risk by explaining to the patient the benefits/disadvantages of active treatment or watchful waiting as a function of the risk of relapse. Treatment options for stage 1 seminomas comprise : watchful waiting, chemotherapy (1 cycle of carboplatin) or para-aortic radiotherapy. Treatment options for stage 1 nonseminomatous germ cell tumours comprise : watchful waiting, chemotherapy (2 cycles of BEP) or staging retroperitoneal lymphadenectomy. The management of metastatic tumours essentially comprises chemotherapy with 3 or 4 cycles of BEP according to the prognostic group. Radiotherapy may be indicated in seminomas with lymph node metastasis < 3 cm. Review 3 to 4 weeks post-chemotherapy is essentially based on tumour marker assays and chest, abdomen and pelvis computed tomography. Surgical retroperitoneal lymph node dissection is indicated for all residual NSGCT masses > 1 cm and for persistent residual seminoma masses > 3 cm with (18)F-FDG PET-CT uptake.nnnCONCLUSIONSnGerm cell tumours have an excellent survival rate based on precise initial staging, adapted and strictly defined treatment and close surveillance.Resume Introduction L’objectif de cet article a ete d’etablir par le groupe organes genitaux externes du CCAFU des recommandations pour le diagnostic, le traitement et le suivi des tumeurs germinales du testicule. Materiel et methodes Le groupe de travail multidisciplinaire a etudie les recommandations precedentes, revue de maniere exhaustive la litterature, evalue les references, leur niveau de preuve afin d’attribuer des grades de recommandation. Resultats Le bilan initial d’un cancer du testicule repose sur un bilan clinique, biologique (AFP, hCG totale, LDH) et d’imagerie (echographie scrotale et tomodensitometrie thoracoabdomino-pelvienne). L’orchidectomie par voie inguinale est la premiere etape therapeutique permettant de preciser le type histologique, de definir le stade local et les facteurs de risque de micrometastases. La prise en charge des tumeurs de stade I repose sur une attitude therapeutique adaptee au risque en exposant au patient le benefice/inconvenient d’un traitement actif ou d’une surveillance en fonction du risque de rechute. Pour les TGS de stade I, le choix se fait entre une surveillance, une chimiotheraoie (1 cycle de carboplatine) ou une radiotherapie lombo-aortique. Pour les TGNS de stade I, le choix se fait entre une surveillance, une chimiotherapie (2 cycles de BEP) ou une lymphadenectomie retroperitoneale de stadification. La prise en charge des tumeurs metastatiques est dominee par une chimiotherapie par 3 ou 4 cycles de BEP en fonction du groupe pronostique. Dans les cas de TGS avec une atteinte metastatique ganglionnaire La reevaluation 3 a 4 semaines postchimiotherapie repose essentiellement sur le dosage des marqueurs tumoraux et la tomodensitometrie thoraco-abdomino-pelvienne. Un curage chirurgical retroperitonal est indique pour toutes les masses residuelles des TGNS > 1xa0cm ; et pour les masses residuelles persistantes des TGS > 3xa0cm ayant une fixation au TEP-TDM au 18FDG. Conclusions Les tumeurs germinales beneficient d’un excellent taux de survie base sur une classification initiale precise, un traitement adapte et codifie, et une surveillance stricte.

Positive surgical margins and their locations in specimens are adverse prognosis features after radical cystectomy in non-metastatic carcinoma invading bladder muscle: results from a nationwide case–control study

Positive surgical margin (PSM) frequency after radical cystectomy has been estimated to be 4–15%. Studies that have not distinguished between the different sites of PSM have failed to show that they are an independent prognostic factor for disease‐free survival. Only perivesical soft tissue PSMs have been associated with an increased risk of cancer recurrence and cancer‐specific death. This is the first comprehensive published analysis of PSMs occurring during radical cystectomy for pTx pN0 M0 bladder cancer according to their location, comparing their cancer‐specific survival (CSS) and other outcomes with those of a control group paired according to TNM status, age, sex and urinary diversion method. Local recurrence‐free survival rates were found to be lower in patients with both soft tissue and urethral PSMs. Moreover, soft‐tissue PSMs were associated with lower metastatic recurrence‐free and CSS rates.

Prospective evaluation of quality of life 54 months after high-dose intensity-modulated radiotherapy for localized prostate cancer.

ObjectiveTo determine late toxicity and quality of life (QoL) in patients with localized prostate cancer after high-dose intensity-modulated radiotherapy (IMRT).Patient and methodsThis was a prospective study in patients with localized prostate adenocarcinoma who had been treated by IMRT (76xa0Gy) between February and November 2006. Physicians scored acute and late toxicity using the Common Terminology Criteria for Adverse Events (version 3.0). Patients completed cancer and prostate-specific QoL questionnaires (EORTC QLQ-C30 and QLQ-PR25) before IMRT (baseline) and at 2, 6, 18 and 54xa0months.ResultData were available for 38 patients (median age, 73xa0years) (18% low risk; 60% intermediate risk; 32% high risk). The incidence of urinary and gastrointestinal toxicity was respectively: immediately post IMRT: 36.8% and 23.7% (grade 1), 5.3% and 5.3% (grade 2), 2.6% and 0% (grade 3); at 18xa0months: 23.7% and 10.3% (grade 1), 26.3% and 13.2% (grade 2), 0% and 2.6% (grade 3); at 54xa0months: 34.2% and 23.7% (grade 1), 5.3% and 15.8% (grade 2), 5.3% and 0% (grade 3). At 54xa0months, significant worsening was reported by patients for 11/19 QoL items but the worsening was clinically relevant (>10 points) for 7 items only: physical, role as well as social functioning, fatigue, pain, dyspnoea and constipation. There was no significant difference between 54-month and baseline QoL scores for global health, gastrointestinal symptoms, treatment-related symptoms and sexual function. However, there was significant - but clinically non-relevant (<10 points) - worsening of urinary symptom.ConclusionHigh-dose IMRT to the prostate with accurate patient positioning did not induce any clinically relevant worsening in late urinary and gastrointestinal QoL at 54xa0months. Impaired physical and role functioning may be related to age and comorbidities.

Oncologic outcomes and survival in pT0 tumors after radical cystectomy in patients without neoadjuvant chemotherapy: results from a large multicentre collaborative study.

PurposeTo assess the postsurgical survival of patients with urothelial carcinoma of the bladder with pT0 tumor at pathologic examination of cystectomy specimens.MethodsA multi-institutional, retrospective database was analyzed with data from 4758 radical cystectomy (RC) patients who underwent RC without neoadjuvant chemotherapy and who were diagnosed with pT0 on the basis of the pathologic specimen. Survival curves were estimated. A multivariate Cox model was used to evaluate the association between prognosis factors and disease recurrence or survival.ResultsOverall, 258 patients (5.4%) were included in the study. The median age was 64xa0years. At last resection, 171 tumors were invasive (at least pT2), and 87 were not. Median follow-up was 51xa0months. At multivariate analysis, initial location of the tumor and absence of lymphadenectomy were associated with tumor recurrence (Pxa0=xa00.03 and Pxa0=xa00.005, respectively) and specific mortality (Pxa0=xa00.005 and 0.001, respectively). The main limitation of the study is its retrospective design, which is due to the rarity of this situation. Cancer-specific and recurrence-free survival rates were 89 and 85%, respectively, at 5xa0years and 82 and 80%, respectively, at 10xa0years.ConclusionsDespite acceptable oncological outcomes, patients with a pT0 tumor at the time of RC are still at risk of recurrence and progression and should not be considered to be entirely cured. In this population, stringent follow-up according to current recommendations should be effective.

Predictive factors of chronic kidney disease stage V after partial nephrectomy in a solitary kidney: a multi-institutional study

OBJECTIVEnPartial Nephrectomy (PN) in a solitary kidney is at risk of chronic kidney disease (CKD) stage V and/or haemodialysis (HD). Our objective was to determine predictive factors of CKD stage V in this population.nnnMATERIAL & METHODSnData from 300 patients were retrospectively collected from 16 tertiary centres. Clinical and operative parameters, tumor characteristics and renal function before surgery were analyzed. Patients with and without CKD stage V (defined as MDRD<1 5 ml/min) were compared using χ2 and Student-t tests for qualitative and quantitative variables, respectively. Predictive factors of CKD stage V were evaluated with a multivariable analysis using a Cox regression model.nnnRESULTSnMedian age and BMI were 63 years old and 26 kg/m², respectively. Most of the patients (65%) were male with an anatomic solitary kidney (88.3%). Median tumor size was 4 cm and 98% were malignant tumors. Median operative time, blood loss and clamping time were 180 min, 350 ml and 20 min respectively. Renal cooling was used in 19.3% and clamping of the pedicle was performed in 61.6%. Twenty five patients (8.5%) presented post operative CKD stage V at last follow-up and 18 underwent HD (6%) post-operatively because of acute renal insufficiency. There was no difference between CKD stage V and non CKD stage V patients concerning Charlson index, operative time (180 min vs 179 min, p = 0.39), blood loss (475 ml vs 350 ml, p = 0.51), use of renal cooling and type of clamping. Patients with CKD stage V were older (70 vs 63 years old, p = 0.005), had a lower baseline renal function (clearance MDRD 41 vs. 62 ml/min, p<0.0001) and an increased tumor size (p = 0.02). Complications occurred in 91 patients (30%) with 16% of minor (Clavien 1-2) and 14% of major (Clavien > 2) complications, respectively. In multivariable analysis, baseline MDRD, BMI, and the occurrence of a minor complication were independent predictive factors of post operative CKD stage V.nnnCONCLUSIONnPN in a solitary kidney is at risk of post-operative CKD stage V and HD. Pre-operative altered renal function and post operative complications are the main predictive factors of permanent CKD stage V.

Intérêt de la néphrectomie partielle pour la préservation de la fonction rénale des patients ayant une tumeur rénale de plus de 4 cm

OBJECTIVEnThe objective of the present study was to analyse whether nephron-sparing surgery (NSS) was superior to radical nephrectomy (RN) in preserving renal function outcome in tumors larger than 4cm.nnnMETHODSnThe data from 888 patients who had been operated upon at eight french university hospitals were retrospectively analyzed. Glomerular filtration rate (GFR) pre- and post-surgery was calculated with the abbreviated Modification of Diet in Renal Disease (MDRD) equation. For a fair comparison between the two techniques, all imperative indications for NSS and all GFR<30 mL/min/1.73 m(2) were excluded from analysis. A shift to a less favorable DFG group following surgery was considered clinically significant.nnnRESULTSnSeven hundred and thirty patients were suitable for comparison. Median age at diagnosis was 60 years (19-88). Tumors measuring more than 4cm represented 359 (49.2%) cases. NSS and RN were performed in 384 (52.6%) and 346 (47.4%) patients, respectively. In univariate analysis, patients undergoing NSS had a smaller risk than RN of developing significant GFR change following surgery. This was true for tumors≤4cm (P=0.0001) and for tumors>4cm (P=0.018). In multivariate analysis, the following criteria were independent predictive factors for developing significant postoperative GFR loss: the use of RN (P=0.001), decreased preoperative DFG (P=0.006), increased age at diagnosis (P=0.001) and increased ASA score (P=0.004).nnnCONCLUSIONnThe renal function benefit offered by elective NSS over RN persists even when expanding NSS indications beyond the traditional 4 cm cut-off.

Valeur pronostique du curage ganglionnaire lors des cystectomies totales pour cancer de la vessie

OBJECTIVEnThe objective of this retrospective study was to analyse the impact of lymph node invasion on survival after radical cystectomy for bladder cancer.nnnMATERIAL AND METHODSnFrom 1988 to 2002, 192 patients underwent radical cystectomy for bladder cancer. Lymph node dissection was performed in 144 patients (75%) with bilateral pelvic lymph node dissection in 130 patients and extension to iliac chains in 14 patients.nnnRESULTSnLymph node dissection had no impact on medical or surgical morbidity. Lymph node invasion was demonstrated in 35.4% of cases (51/144). Tumour effraction of the lymph node capsule was reported in 70.6% (36/51) of pN+ patients. Lymph node invasion was reported in 16.7% of pT0 patients, 0% of pTa, pTis, pT1 patients and 40, 47 and 48% of pT2, pT3 and pT4 patients, respectively. The mean follow-up was 40.3+/-3.5 months (median: 26.6; range 0-207 months). Overall, specific and recurrence-free survivals were significantly influenced by lymph node invasion (p<0.0001, p<0.0001, p<0.0001, respectively) and capsular effraction (p=0.0021, p=0.0027, p=0.0113, respectively).nnnCONCLUSIONnLymph node invasion and especially capsular effraction were significant prognostic factors of overall specific and recurrence-free survival.

Particularités histologiques et principes de traitements des tumeurs du testicule du sujet âgé

After the 6th decade, primitive lymphomas are the most frequent tumors of the testis (>30%). They are usually high grade lymphomas that commonly disseminate to the central nervous system. Chemotherapy depends on histological subtype. Germ cell tumors, mainly seminomas, represent less than 20% cases. Therapy do not differ from young adults germ cell tumors. Sex cord stromal tumors, mesenchymal benign tumors, sarcomas and metastasis represent approximately 10% of cases each. The first two are usually cured after orchidectomy. Prognosis of sarcoma is bad. The one of metastasis depends on primitive tumor (prostatic or pulmonary adenocarcinoma or melanoma mainly). Spermatocytic seminoma is a rare and benign tumor, if no sarcomatous component is observed. Mesothelioma are also very rare and of bad prognosis. Other histological subtype are extraordinary rare. This particular histological profile must be in mind when considering the appropriate therapeutic approach of testis tumors in elderly. This work is based on data collected between 1990 to 2005 by the french pathologists of the GELU.Resume Au-dela de 60 ans, la pathologie testiculaire tumorale est dominee par les lymphomes (>30%). Il s’agit le plus souvent de formes de haut grade, evoluant volontiers vers des localisations cerebrales. Leur traitement repose sur une chimiotherapie adaptee. Les tumeurs germinales representent, dans cette tranche d’âge, moins de 20% des tumeurs testiculaires. Les seminomes y sont les plus frequents. Elles repondent aux memes regles de prise en charge que les formes du sujet jeune. Les tumeurs des cordons sexuels, les tumeurs conjonctives benignes, les sarcomes et les metastases se rencontrent avec une frequence proche de 10% chacune. Si les deux premieres sont le plus souvent gueries par la chirurgie, les sarcomes sont generalement de mauvais pronostic. Celui des metastases sera fonction de la tumeur primitive, habituellement prostatique pulmonaire ou melanique Le seminome spermatocytaire reste rare meme a cet âge. Il s’agit d’une tumeur benigne si elle ne contient aucun contingent heterologue. Les tumeurs mesotheliales malignes sont egalement exceptionnelles mais de pronostic sombre. Les autres types histologiques sont exceptionnels. La connaissance de ce profil histologique doit etre connue afin d’adapter la prise en charge d’une tumeur testiculaire chez un sujet âge. Le travail rapporte ici est le resultat d’une etude retrospective concernant 213 des 2 215 tumeurs testiculaires recueillies par le Groupe d’Etude des Lesions Urologiques entre 1990 et 2005.