Kamran Zargar-Shoshtari

Cryoablation for Small Renal Masses: Selection Criteria, Complications, and Functional and Oncologic Results

CONTEXT Cryoablation (CA) is a minimally invasive modality with low complication rates, but its use in urology is relatively recent. OBJECTIVE To summarize available evidence for CA for small renal masses (SRMs) and to assess the selection criteria, complications, and functional and oncologic results based on the latest CA literature. EVIDENCE ACQUISITION A systematic literature search of the Medline, Embase, and Scopus databases was performed in August 2014 using Medical Subject Headings and free-text protocol. The following search terms were included: kidney cryosurgery, renal cryosurgery, kidney cryoablation, renal cryoablation, kidney cryotherapy, and renal cryotherapy. EVIDENCE SYNTHESIS Due to the relatively recent mainstream utilization of CA and lack of long-term efficacy data from large prospective or randomized studies, most of the data available on CA are limited to treatment of SRMs in patients who are often older or are poor surgical candidates. The rates of major complications across the CA literature remain relatively low. Studies assessing renal function after CA suggest a degree of functional decline following CA because proper application includes freezing of a tumor margin; however, often this is not clinically significant. Specific oncologic outcomes should be evaluated in patients with biopsy-proven renal cell carcinoma; when SRM series include benign or unbiopsied tumors, the results of these outcomes are skewed. Although earlier series were suggestive of a higher recurrence rate after CA, some studies have challenged this view reporting recurrence rates comparable with extirpative nephron-sparing surgery. CONCLUSIONS CA represents an alternative approach to treatment for patients diagnosed with renal neoplasm. There is no consensus within the literature on the best patient selection criteria. Due to higher rates of treatment failure, it is often not offered to patients with minimal comorbidities and good life expectancy. In terms of functional outcomes, CA signifies a modality with minimum impact on renal function; however, well-designed studies precisely assessing this factor are lacking. CA is a minimally invasive modality with suitably low rates of complications, particularly if delivered via the percutaneous route. PATIENT SUMMARY Cryoablation (CA) represents an alternative approach for treating renal neoplasm. Excellent functional outcomes and low rates of complications make CA an ideal minimally invasive modality. Patient selection criteria and oncologic outcomes require further study.

A Multi-Institutional Analysis of Outcomes of Patients with Clinically Node Positive Urothelial Bladder Cancer Treated with Induction Chemotherapy and Radical Cystectomy

PURPOSE Selected patients with bladder cancer with pelvic lymphadenopathy (cN1-3) are treated with induction chemotherapy followed by radical cystectomy. However, the data on clinical outcomes in these patients are limited. In this study we assess pathological and survival outcomes in patients with cN1-3 disease treated with induction chemotherapy and radical cystectomy. MATERIALS AND METHODS Data were collected on patients from 19 North American and European centers with cT1-4aN1-N3 urothelial carcinoma who received chemotherapy followed by radical cystectomy between 2000 and 2013. The primary end points were pathological complete (pT0N0) and partial (pT1N0 or less) response rates, with overall survival as a secondary end point. Logistic regression and Cox proportional hazard ratios were used for multivariate analysis of factors predicting these outcomes. RESULTS The total of 304 patients had clinical evidence of lymph node involvement (cN1-N3). Methotrexate/vinblastine/doxorubicin/cisplatin was used in 128 (42%), gemcitabine/cisplatin in 132 (43%) and other regimens in 44 (15%) patients. The pN0 rate was 48% (cN1-56%, cN2-39%, cN3-39%, p=0.03). The complete and partial pathological response rates for the entire cohort were 14.5% and 27%, respectively. The estimated median overall survival time for the cohort was 22 months (IQR 8.0, 54). On Cox regression analysis overall survival was associated with pN0, negative surgical margins, removal of 15 or more pelvic nodes and cisplatin therapy. CONCLUSIONS Complete pathological nodal response can be achieved in a proportion of patients with cN1-3 disease receiving induction chemotherapy. The best survival outcomes are observed in male patients on cisplatin regimens with subsequent negative radical cystectomy margins and complete nodal response (pN0) with excision of 15 or more pelvic nodes.

Disparities in Penile Cancer.

BACKGROUND Although penile cancer is a rare malignancy in developed nations, racial and socioeconomic differences exist in the incidence of the disease and its associated survival-related outcomes. METHODS A search of the literature was performed for research published between the years 1990 and 2015. Case reports and non-English-language articles were excluded, instead focusing specifically on large, population-based studies. RESULTS The incidence of penile cancer is higher in Hispanic and African American men compared with whites and Asians. Men with penile cancer also appear to have a distinct epidemiological profile, including lower educational and income levels, a history of multiple sexual partners and sexually transmitted infections, and lack of circumcision with the presence of phimosis. African American men presented at a younger age with a higher stage of disease and worse survival rates when compared with white men. Rates of cancer-specific mortality increased with age, single marital status, and among those living in regions of lower socioeconomic status. CONCLUSIONS An understanding of sociodemographical differences in the incidence and survival rates of patients with penile cancer can help advance health care policy changes designed to improve access and minimize disparities in cancer care for all men alike.

Pelvic Lymph Node Dissection for Penile Cancer: Answering the Conundrum of When and How It Should Be Conducted

Extent of lymphatic metastases is an important prognostic factor in penile cancer patients, and patients with pelvic lymph node involvement have particularly bad long-term survival. Pelvic lymph node dissection (PLND) in pelvic node positive cases with micro-metastatic disease exclusively may have some curative potential with surgery alone, but for penile cancer patients with clinically enlarged or suspicious pelvic lymph nodes on cross-sectional imaging with CT, MRI, or PET-CT, neoadjuvant systemic chemotherapy is recommended followed by post-chemotherapy lymphadenectomy in responders. PLND can be done at the same time as inguinal lymph node dissection (with use of intraoperative frozen section) or in a delayed fashion through an open, midline, infraumbilical incision, or using robotic-assisted or laparoscopic technology. Since no crossover from inguinal to pelvic LNs has ever been reported, the use of unilateral versus bilateral PLND is still considered controversial in clinically indicated settings. There is increasing evidence, however, that bilateral PLND may be appropriate for certain high-risk penile cancer patients with a large volume of inguinal metastatic disease. In this chapter, we summarize the indications, technique, and controversies of pelvic lymph node dissection for advanced penile cancer, and we present novel evidence with regards to its use.

Primary Urethral Carcinomas

Primary urethral carcinomas (PUCs) account for <1 % of all genitourinary malignancies. According to the Surveillance, Epidemiology, and End Results (SEER) database, over the past three decades, the annual incidence has ranged from 1.5 per million in women and a nearly threefold larger incidence in men (4.3 per million). The prevalence of all histological subtypes increases with age, with the peak annual incidence of 32 per million in men and 9.5 per million in women, seen in the 75–84-year age group, with disease being extremely uncommon in population younger than 55 years old (0.2 per million). The incidence of the disease has been reported to be twice as high in the African-American compared to the White population. In Europe, the age standardized ratio is estimated as 1.6 per million in men and 0.6 per million in women, with a similar male-to-female ratio.