Matthew Tollefson

MP22-15 RENAL MASS SIZE AND SYNCHRONOUS METASTATIC DISEASE IN RENAL CELL CARCINOMA: AN ANALYSIS OF THE NATIONAL CANCER DATABASE

onset in adults 46 years of age. Limited data exists regarding patients with early onset RCC. Our objective was to investigate the clinical and pathologic characteristics within this unique subset of patients with RCC. METHODS: We retrospectively reviewed our surgical pathology database from 2011-2016 for patients with RCC. The clinical and pathologic characteristics of patients 46 years were compared to the overall population. RESULTS: We identified 98/604 (16%) cases of RCC in patients 46 years. The median age of patients with early onset RCC compared to our control group was 38.6 (range 19-46) vs. 64.4 (range 47-89) years, respectively. Early onset RCC patients included Caucasians (55%), African Americans (40%), Latino (4%), and Asian (1%). Histologic subtypes, included clear cell (54%), papillary (29%), unclassified (7%), chromophobe (5%), clear cell papillary (3%), multilocular cystic neoplasm (1%), and carcinoid (1%). 20/28 (71%) of early onset papillary RCCs occurred in African Americans. Risk factors for RCC included hypertension (47%), smoking (22%), obesity (12%), diabetes mellitus (9%), and chronic kidney disease (CKD) or end-stage renal disease (ESRD) (16.3%). Known genetic syndromes prior to diagnosis were identified in 7/98 (7%) patients (1 Von Hippel Lindau, 2 Familial Adenomatous Polyposis, 1 Marfan, 1 Tuberous Sclerosis, 1 Birt-Hogg-Dube). There was no significant difference between the two groups in terms of tumor size, focality, margin status, presence of necrosis, or sarcomatoid features. Non-Caucasians were more likely to develop early onset RCC (OR 1.98; p1⁄40.001). Patients with early onset RCC were more likely to receive a radical nephrectomy (OR 1.98; p1⁄40.001), have lower grade tumors (OR 0.69; p1⁄40.033) and present with organ confined disease (p1⁄40.008). CONCLUSIONS: Despite having more indolent tumor characteristics and organ confined disease, early onset RCC patients were more likely to undergo a radical nephrectomy. In addition, a high percentage of these patients had either concurrent, or risk factors for developing, CKD/ESRD. These findings suggest that this population is potentially being over treated and should undergo nephron sparing surgery if surgically feasible.

MP77-17 IMPACT OF TIME FROM BIOPSY TO SURGERY ON COMPLICATIONS, FUNCTIONAL AND ONCOLOGIC OUTCOMES FOLLOWING RADICAL PROSTATECTOMY

on AS must undergo PSA testing and repeated biopsies over time in all proposed protocols and patients are subjected to discomfort and anxiety as well as to the complications of repeated biopsies. We tried to identify the predictors of progression-free survival (PFS) at a single institution AS program in order to identify patients in whom repeated biopsies could be avoided or reduced in frequency. METHODS: Between 2009 and 2016, 235 consecutive patients affected by low-risk PCa according to PRIAS criteria (cT1/T2a; PSA<10 ng/ml; PSA density <0.2; Gleason score <7; <3 positive cores) were enrolled in our AS program. Tumor progression was defined as pathological upgrading (Gleason >6 or >2 positive cores) at repeated yearly biopsies. First, Kaplan-Meier analyses were used to quantify progression-free survival at 1, 3 and 5 years, respectively. Second, we identified patients who were progression-free at 3 years of follow-up. Finally, univariable and multivariable logistic regression analyses were used to predict 3-year PFS. Covariates consisted of age, total PSA, clinical stage (cT) and number of positive cores at the time of enrolment as well as negative (no cancer) 1-year biopsy. RESULTS: Progression-free survival rate was 85%, 55%, and 40% at 1, 3 and 5 years, respectively. Median follow-up was 19 months. Overall, 56 (23.8%) patients were progression-free at 3 years of followup. Median number of cores at enrolment in AS program was 16 (IQR: 14-20), while median number of cores at first-year biopsy was 18 (IQR: 14-20). At univariable analyses, total PSA and negative 1-year biopsy were significant predictors of 3-year PFS (all p<0.05). Patients with negative biopsy at 1 year had a 3-year PFS of 75.8 vs. 29.0% in those with positive biopsy at 1-year. These results were confirmed at multivariable analyses, where a negative 1-year biopsy represented the only independent predictor of 3-year PFS (OR: 2.47; p1⁄40.04). CONCLUSIONS: The first biopsy after enrolment in AS program is an important predictor of PCa progression in the first 3 years in men on AS. Negative findings at 1-year biopsy suggest a high chance of 3-year PFS. Patients with negative 1-year biopsy could be followedup with less stringent biopsy protocol, in order to reduce possible biopsy-related side effects and discomfort.

PD67-10 INCIDENCE AND RISK FACTORS FOR PERITONEAL CARCINOMATOSIS FOLLOWING OPEN RADICAL CYSTECTOMY

lymph node dissection, and number of lymph nodes removed. Perioperative outcomes measured included length of stay (LOS), 30-day and 90-day postoperative mortality rates, as well as 30-day readmission following surgery. To minimize selection bias, observed differences in baseline characteristics between patients who received RARC vs. ORC were controlled for using a weighted propensity score analysis. Using weighted data, all endpoints were assessed using propensity-adjusted logistic regression analyses. RESULTS: Of 9,561 patients who underwent RC, 2,048 (21.4%) and 7,513 (78.6%) underwent RARC and ORC, respectively. The use of RARC has increased over time, from 16.7% in 2010 to 25.3% in 2013. With regard to oncologic outcomes, RARC was associated with similar positive surgical margins (9.4% vs. 10.7% OR:0.86, 95%CI 0.72-1.04, p1⁄40.12), higher rates of lymphadenectomy (96.4% vs. 92.0%, OR: 2.31, 95%CI 1.68-3.19, p<0.001), higher median lymph node count (17 vs. 12, p<0.001) and higher rates of lymph node count above the median (56.8% vs. 40.4%, OR: 1.95, 95%CI 1.56-2.43, p<0.001). With regard to postoperative outcomes, receipt of RARC was associated with a shorter median LOS (7 vs. 8, p<0.001), lower rates of pLOS (45.1% vs. 54.8%, OR: 0.68, 95%CI 0.58-0.79, p<0.001), lower 30-day (1.5% vs. 2.8%, OR: 0.49, 95%CI 0.29-0.82, p1⁄40.007) and 90day postoperative mortality (5.0% vs. 6.8%, OR: 0.72, 95%CI 0.54-0.95, p1⁄40.023). CONCLUSIONS: Our large contemporary study shows the increased adoption of RARC between 2010 and 2013, with currently more than 1 out of 4 patients undergoing RARC. RARC was associated with higher LN counts, shorter LOS and lower postoperative mortality.

PD66-12 OUTCOMES ON ILEAL MUCOSAL CUFF MANAGEMENT DURING RADICAL NEPHROURETERECTOMY

characteristics associated with patients’ risk of cancer-specific mortality (CSM). Kaplan-Meier analysis was used to evaluate recurrence free survival (RFS). RESULTS: Median patient age at RNU was 73.7 years (IQR 65.4, 79.5); 67% (n1⁄4249) were male and 64% (n1⁄4238) underwent extravesical excision. Median follow-up was 47 months (IQR 16.4, 101.4), during which time 52.4% (n1⁄4195) experienced a bladder or systemic recurrence and 17.5% (n1⁄465) died due to metastatic urothelial carcinoma. There was no statistically significant difference for 5-year RFS between the two groups (p1⁄40.29). On multivariable analysis features independently associated with increased risk of CSM included smoking history (HR 2.31; p1⁄40.03), high grade (HR 4.23; p<0.001), pT2 or higher (HR 2.51; p1⁄40.01), lymph node positive disease(HR 4.29; p<0.01) and tumor size > 3 cm (HR 2.10; p1⁄40.02). Importantly, approach to the bladder cuff excision was not associated with an increased risk of disease recurrence (HR1⁄41.11; p1⁄40.60) or CSM (HR 1.26; p1⁄40.52). CONCLUSIONS: Excision of the entire ureter, including the intramural component, is an important part of RNU. However, intraor extravesical approach to the distal ureter, does not affect RFS or CSM. Therefore, our data validates the oncologic safety of both approaches to the bladder cuff for patients undergoing RNU for UTUC.

MP53-16 LONG-TERM ONCOLOGIC OUTCOMES OF ADDING RADICAL PROSTATECTOMY TO CASTRATION FOR PATHOLOGICAL NODE-POSITIVE PROSTATE CANCER

any urinary leak) after RP and post IMRT was achieved in 29 (69%) and 27 (64.3%), respectively. After a median follow up of 3.4 years, a PSA recurrence and clinical recurrence were observed in 7 (16.7%) and 4 (9.5%) patients. A 5-year biochemical and clinical recurrencefree survival rate were 70.7% and 84.0%, respectively. 5-year overall free survival was 93.6%. None of patients died for prostate cancer during follow up. CONCLUSIONS: This phase II trial test a novel multimodal treatment paradigm for high-risk prostate cancer. Toxicity was acceptably low and long term oncological outcomes were good. Further studies are needed to compare this novel treatment paradigm to the standard of care.

MP78-19 SURGICAL MANAGEMENT OF UROTHELIAL CARCINOMA IN PATIENTS WITH UPPER TRACT AND LOWER TRACT UROTHELIAL CARCINOMA: IMPACT OF SURGICAL SEQUENCE

RESULTS: The 26 (5.3%) patients who developed UUT-SPTs requiring surgical treatment after RC had predominantly invasive cancers (Ta 1⁄4 23.1%, Tis 1⁄4 11.5%, T1 1⁄4 26.9%, T2 1⁄4 19.2%, T31⁄4 15.4%, T4 1⁄4 3.9%) which were also predominantly high grade (G31⁄4 88.5%, G2 1⁄4 7.7 %, G1 1⁄4 3.8). The mean time from RC to the development of SPT was 33.8 months. In a linear regression analysis that controlled for age, bladder pathologic tumor stage was significantly associated with decreased time to SPT (p1⁄4 0.030). Neoadjuvant CBT was given to 11.5 % of bladder UC patients prior to RC and 19.2% received adjuvant CBT after RC . Mean eGFR decreased from 69.3 prior to RC to 55.7 prior to UUT-SPT surgical treatment. UUT-SPTs were managed with nephroureterectomy (92.3%) or ureterectomy (7.7%), and ipsilateral lymphadenectomy (77%). Neoadjuvant CBT prior to UUT surgery was administered to 15.4% of patients. Mean eGFR further decreased after UUT-SPT surgery to 39.5, and 23.1% of patients received adjuvant CBT following UUT surgery. Patient were followed for a mean of 76.1 months and 38.5% of patients died of disease, 29.9% died of unknown/other causes, and 34.6% are alive with no evidence of disease. CONCLUSIONS: UUT-SPTs manifest as more advanced disease after RC. Decreased renal function occurs frequently post RC and may impair the use of peri-operative CBT for patients with high grade SPTs of the UUT. This warrants further studies to develop novel nonnephrotoxic targeted therapies in the peri-operative setting of surgery for SPTs.

MP34-03 ONCOLOGIC OUTCOMES FOR PATIENTS WITH RESIDUAL CANCER AT CYSTECTOMY FOLLOWING PREOPERATIVE CHEMOTHERAPY: A PATHOLOGIC STAGE-MATCHED COMPARATIVE ANALYSIS

INTRODUCTION AND OBJECTIVES: While neoadjuvant chemotherapy prior to radical cystectomy (RC) has been demonstrated to improve survival compared to RC alone for urothelial carcinoma of the bladder (UCB), the bulk of this survival benefit has been attributed to patients who achieve ypT0 status at RC. The implications of having residual UCB (rUCB) at RC after preoperative chemotherapy (POC) are less clear. As such, we evaluated survival for patients with and without rUCB at RC after POC compared with pathologic stage-matched RC patients who did not receive POC. METHODS: Patients undergoing RC for UCB between 19802010 at Mayo Clinic were identified. All RC pathology was re-reviewed by a single genitourinary pathologist. Patients who received POC for T2-T4 and/or N1-3 M0 UCB were matched 1:2 to patients not exposed to prior chemotherapy based on pT and pN-stage, soft tissue surgical margin status, and year of RC. Kaplan Meier and Cox regression analyses were used to evaluate the associations between POC and cancer-specific (CSS) and overall survival (OS), stratified by presence or absence of rUCB at RC. RESULTS: We matched 111 patients who underwent POC + RC to 222 RC-alone patients. Median age was 68 yrs (IQR 60,74); 59 (18%) were female. Median follow-up was 7.2 yrs (IQR 6,16), during which time a total of 248 patients died, with 148 dying from UCB. In patients without rUCB at RC, there was no difference in 5-yr CSS (86% vs. 90%, p1⁄40.85) or OS (82% vs. 84%, p1⁄40.46) between patients who did versus did not receive POC. Moreover, on multivariable analysis, chemotherapy exposure was not significantly associated with CSS (HR1⁄41.0; 95%CI 0.3-3.1; p1⁄40.9) or OS (HR1⁄40.9; 95%CI 0.4-1.9; p1⁄40.8) in this subgroup. Conversely, among patients with rUCB at RC, receipt of POC was associated with significantly worse 5-yr CSS (32% vs. 56%, p<0.001) and OS (25% vs. 48%, p<0.001). Moreover, on multivariable analysis, chemotherapy exposure remained independently associated with adverse CSS (HR1⁄42.2; 95%CI 1.6-3.1; p<0.001) and OS (HR1⁄42.0; 95%CI 1.5-2.7; p<0.001) among the patients with rUCB. CONCLUSIONS: While patients who achieve a complete response to POC have excellent survival outcomes, patients with residual UCB at RC after POC have a worse prognosis compared to stage-matched RC patients not exposed to chemotherapy. Such patients should be considered for enrollment in novel adjuvant therapy trials, while continued investigation of which patients are most likely to achieve ypT0 status remains warranted.

MP93-16 IMPACT OF OBESITY ON PROSTATE CANCER RECURRENCE AFTER RADICAL PROSTATECTOMY

INTRODUCTION AND OBJECTIVES: When operating deep in the abdomen and pelvis, excess fat can interfere with accessing key anatomical structures and create difficulty in dissection and reconstruction. Since intraperitoneal fat is avoided during extraperitoneal robot assisted radical prostatectomy (eRARP), some Urologists have advocated this approach over its transperitoneal counterpart (tRARP) when operating on morbidly obese men (BMI>40). Herein, we aim to compare outcomes of eRARP vs. tRARP in the morbidly obese. METHODS: A chart review of patients who have undergone robot assisted radical prostatectomy (RARP) at a tertiary care academic center from July 1, 2003 through April 30, 2016 was undertaken. Patients with BMI >40 were identified. Those with concomitant inguinal hernia repair were excluded. The resulting eRARP and tRARP groups were compared for demographic, clinical and pathologic characteristics. Regression analysis was performed between the groups with Age, BMI, ASA score and D’Amico classification as selected covariates. RESULTS: 3168 patients underwent RARP during this time period, of which 82 patients met our inclusion and exclusion criteria; each group comprised 41 patients. No differences were noted in age, BMI, ASA score or pre-operative PSA. The tRARP group had a higher clinical stage (p1⁄40.016), biopsy Gleason score (p1⁄40.007) and D’Amico risk category (p<0.00001). The tRARP group had a higher rate of pelvic lymph node dissection (PLND, p<0.00001). No differences were noted in rate of nerve sparing. No differences were noted in OR time, estimated blood loss (EBL), length of stay (LOS) or time to catheter removal (TCR). No differences were noted in surgical margin status or overall complications (either calculated as binary or total number). On regression analysis, no differences were noted in complications, OR time, LOS, TCR or EBL. CONCLUSIONS: In this cohort, surgical approach (eRARP vs. tRARP) did not affect intraor peri-operative outcomes in morbidly obese men undergoing RARP so surgeons should tailor their approach based on comfort level.

PD66-11 ONCOLOGICAL OUTCOMES COMPARING INTRAVESICAL AND EXTRAVESICAL BLADDER CUFF EXCISION FOLLOWING RADICAL NEPHROURETERECTOMY FOR UPPER TRACT UROTHELIAL CARCINOMA

INTRODUCTION AND OBJECTIVES: Partial nephrectomy is widely utilized for surgical management of small renal masses. Robotic partial nephrectomy (RPN) has demonstrated improved postoperative morbidity and comparable oncologic outcomes compared to open partial nephrectomy (OPN). However, there is limited data regarding the utilization of RPN across different socio-economic strata and racial groups in the United States. We investigated trends and disparities in utilization of RPN for management of cT1 and cT2 renal masses. METHODS: Patients who underwent RPN and OPN for clinical stage T1 and T2, N0, M0 renal masses from 2010 to 2013 were identified in the National Cancer Data Base (NCDB). Univariate and multivariable logistic regression analyses were performed to evaluate differences in receiving RPN across various patient groups. RESULTS: A total of 23,681 patients fulfilled inclusion criteria. Utilization of RPN for management of cT1/cT2 renal masses significantly increased from 2010 to 2013 compared to OPN (Figure.1). Black (aOR1⁄40.91, 95%CI: 0.84-0.99) and Hispanic (aOR1⁄40.85, 95% CI: 0.76-0.94) patients were less likely to undergo RPN in favor of OPN. RPN was less likely to be performed in rural counties (aOR1⁄4 0.81, 95% CI: 0.66-0.98) and in patients with no insurance (aOR1⁄40.52, 95% CI: 0.45-0.61) or patients covered by Medicaid (aOR1⁄40.81, CI: 0.73-0.89). No significant difference was seen with respect to utilization of RPN between academic and non-academic facilities. Patients with higher clinical stage and co-morbidities were also less likely to undergo RPN (aOR1⁄40.23, 95% CI: 0.150.36 and 0.79, 95% CI: 0.71-0.87 respectively). CONCLUSIONS: Utilization of RPN continues to increase over time; however, there is significant disparity in utilization of RPN based on socio-economic status and race. Black or Hispanic patients and patients in rural communities and with limited insurance were more likely to be treated with OPN instead of RPN.

MP20-01 VALIDATION OF THE AMERICAN JOIN COMMITTEE ON CANCER (AJCC) 8TH EDITION PROSTATE CANCER STAGING SYSTEM

INTRODUCTION AND OBJECTIVES: In the recently published 8 edition update of the AJCC staging system for prostate cancer (PCa), pT2a/b/c sub-classifications were consolidated as pT2. Also, serum prostate-specific antigen (PSA) 20ng/ml or Grade Group (GG) 5 now classify patients as Stage III disease. We sought to validate these changes in a large institutional registry with long-term follow-up. METHODS: Men who underwent radical prostatectomy without prior therapy at Mayo Clinic between 1987-2011 were identified. The prognostic significance of a single pT2 designation was compared to previous stratification as unilateral (pT2a-b) versus bilateral (pT2c). Further, 7 edition Stage II patients were then re-categorized based on the presence or absence of PSA 20ng/ml and GG 5. Biochemical recurrence-free (BCR) survival, systemic progression-free survival (sPFS), and cancer-specific survival (CSS) were evaluated using Kaplan Meier analyses and multivariable Cox regression models, adjusting for age, Gleason score, preoperative PSA, and surgical margin status. RESULTS: The overall cohort included 17,846 men with a median follow-up of 11 years (IQR 7,16), during which time 5021 experienced BCR, 1246 progressed systemically, and 641 died from PCa. Among pT2 patients, sub-stratification was not independently associated with BCR-free survival (HR1⁄41.0; 95%CI 0.9-1.1; p1⁄40.69), sPFS (HR1⁄41.0; 95%CI 0.8-1.3; p1⁄40.68), or CSS (HR1⁄40.9; 95%CI 0.61.2; p1⁄40.41). Meanwhile, patients previously classified with Stage II disease who had a preoperative PSA 20ng/ml (now Stage III) had a 15-year CSS that was significantly worse than Stage group II patients with PSA < 20ng/ml (88% vs 94%; p<0.001), but similar to 7 edition Stage III patients (88% vs 86%; p1⁄40.12). On the other hand, Stage II patients now classified as Stage III based on GG 5 had a 15 year CSS that was significantly worse than both 7 edition Stage II patients with GG 1-4 (48% vs 68%; p<0.001) and 7 edition Stage III patients (48% vs 60%; p<0.001). Results for BCR-free survival and sPFS were similar. CONCLUSIONS: We validate the new AJCC pT2 staging classification. Moreover, our data support the designation of patients with a PSA 20ng/ml as Stage III disease. Interestingly, while upstaging GG5 patients from Stage II to III is an improvement, these patients have even worse outcomes than 7 edition Stage III patients, emphasizing the particular prognostic significance of the new GG and the importance of including GG in staging classification.