Melanie Bernstein

Contemporary Use of Partial Nephrectomy at a Tertiary Care Center in the United States

PURPOSE The use of partial nephrectomy for renal cortical tumors appears unacceptably low in the United States according to population based data. We examined the use of partial nephrectomy at our tertiary care facility in the contemporary era. MATERIALS AND METHODS Using our prospectively maintained nephrectomy database we identified 1,533 patients who were treated for a sporadic and localized renal cortical tumor between 2000 and 2007. Patients with bilateral disease or solitary kidneys were excluded from study and elective operation required an estimated glomerular filtration rate of 45 ml per minute per 1.73 m(2) or greater. Predictors of partial nephrectomy were evaluated using logistic regression models. RESULTS Overall 854 (56%) and 679 patients (44%) were treated with partial and radical nephrectomy, respectively. In the 820 patients treated electively for a tumor 4 cm or less the frequency of partial nephrectomy steadily increased from 69% in 2000 to 89% in 2007. In the 365 patients treated electively for a 4 to 7 cm tumor the frequency of partial nephrectomy also steadily increased from 20% in 2000 to 60% in 2007. On multivariate analysis male gender (p = 0.025), later surgery year (p <0.001), younger patient age (p = 0.005), smaller tumor (p <0.001) and open surgery (p <0.001) were significant predictors of partial nephrectomy. American Society of Anesthesiologists score, race and body mass index were not significantly associated with treatment type. CONCLUSIONS The use of partial nephrectomy is increasing and it is now performed in approximately 90% of patients with T1a tumors at our institution. For reasons that remain unclear certain groups of patients are less likely to be treated with partial nephrectomy.

Metastatic Renal Cell Carcinoma Risk According to Tumor Size

PURPOSE Recent evidence suggests significantly discordant findings regarding tumor size and the metastasis risk in renal cell carcinoma cases. We present our experience with renal cell carcinoma. We evaluated the association between tumor size and the metastasis risk in a large patient cohort. MATERIALS AND METHODS Using our prospectively maintained nephrectomy database we identified 2,691 patients who were treated surgically for a sporadic renal cortical tumor between 1989 and 2008. Associations between tumor size and synchronous metastasis at presentation (M1 renal cell carcinoma) were evaluated with logistic regression models. Metastasis-free survival after surgery was estimated using the Kaplan-Meier method in 2,367 patients who did not present with M1 renal cell carcinoma and were followed postoperatively. RESULTS Of the 2,691 patients 162 presented with metastatic renal cell carcinoma. Only 1 of 781 patients with a tumor less than 3 cm had M1 renal cell carcinoma at presentation and tumor size was significantly associated with metastasis at presentation (for each 1 cm increase OR 1.25, p <0.001). Of the 2,367 patients who did not present with metastasis metastatic disease developed in 171 during a median 2.8-year followup. In this group only 1 of the 720 patients with renal cell carcinoma less than 3 cm showed de novo metastasis during followup. Metastasis-free survival was significantly associated with tumor size (for each 1 cm increase HR 1.24, p <0.001). CONCLUSIONS In our experience tumor size is significantly associated with synchronous and asynchronous metastases after nephrectomy. Our results suggest that the risk of metastatic disease is negligible in patients with tumors less than 3 cm.

Chromophobe renal cell carcinoma: a clinicopathologic study of 203 tumors in 200 patients with primary resection at a single institution.

Despite multiple studies, many clinicopathologic issues about chromophobe renal cell carcinoma (RCC) remain contentious; for example, its biological behavior-whether better or similar to papillary RCC, the incidence of sarcomatoid features, and whether pathologic features such as necrosis, nuclear grade, and tumor stage predict worse outcome. We studied 203 consecutive primary chromophobe RCCs resected at our institution in an attempt to answer these and other questions. The tumors showed significant progressive decrease in size and stage (P=0.047 and 0.001) from 1980 to 2000. Five patients had metastasis at presentation, and further disease-specific events (recurrence/metastasis/death due to disease) occurred in 8 more. Only 4 of 203 tumors had sarcomatoid features. Over median follow-up of 6.1 years (range, 0.1 to 18 y), 5-year and 10-year disease-specific events occurred in 3.7% (95% CI, 1.5%, 7.4%) and 6.4% (95% CI, 2.7%, 12.2%) patients. Outcomes showed significant association with tumor size, small-vessel invasion, sarcomatoid features, and microscopic necrosis (P⩽0.05 each). pT stage or nodal metastasis tended to show some association, without reaching statistical significance (P=0.05 and 0.06, respectively). A modified tumor grading scheme, somewhat similar to that proposed recently, mitotic index, cytologic eosinophilia, and architecture, were not significantly associated with outcome. In conclusion, sarcomatoid differentiation is quite uncommon in chromophobe RCC. Tumor size, small-vessel invasion, sarcomatoid differentiation, and microscopic necrosis are the only features that are significantly associated with adverse outcome. On the basis of this long follow-up on a large number of cases, chromophobes seem to have better clinical outcomes than those reported for clear cell and papillary RCCs.

Partial nephrectomy for selected renal cortical tumours of ≥7 cm

Study Type – Therapy (case series)
Level of Evidence 4

Clinical Characteristics and Outcomes of Patients With Recurrence 5 Years After Nephrectomy for Localized Renal Cell Carcinoma

PURPOSE We analyzed characteristics in patients with recurrent renal cell carcinoma 5 years or later after nephrectomy and determined predictors of survival after recurrence. MATERIALS AND METHODS From July 1989 to October 2008 at total of 2,368 nephrectomies were done for clinically localized, unilateral renal cell carcinoma at our institution. Of 256 patients with disease recurrence 44 had recurrence 5 years or more after nephrectomy. We compared clinicopathological characteristics in patients with disease recurrence before vs after 5 years. Survival from time of recurrence was assessed based on Memorial Sloan-Kettering Cancer Center risk score, symptoms at recurrence, metastasectomy, tumor diameter, and recurrence stage and site. RESULTS Patients with late recurrence tended to have fewer symptoms at presentation, smaller tumors (median 8.5 vs 7 cm) and less aggressive disease (pT1 in 18% vs 39%). Median overall survival was 6.1 years from time of recurrence. Five-year actuarial survival was 85% in 28 patients at favorable risk and 14% in 10 at intermediate risk (log rank p <0.001). The 5-year estimated overall survival rate was 72% in 31 patients with incidentally detected recurrence and 39% in 11 with symptoms at recurrence (log rank p = 0.01). CONCLUSIONS Data suggest that patients with cancer recurrence 5 years after nephrectomy are at favorable risk and have long-term median survival. A favorable Memorial Sloan-Kettering Cancer Center risk score and absent symptoms related to metastasis are associated with longer survival in these patients.

Radical nephrectomy with vena caval thrombectomy: a contemporary experience

Study Type – Therapy (case series) 
Level of Evidence 4

The Association between Statin Medication and Progression after Surgery for Localized Renal Cell Carcinoma

PURPOSE Evidence suggests that statins may influence pathways of renal cell carcinoma proliferation, although to our knowledge no study has examined the influence of statin medications on the progression of renal cell carcinoma in humans. MATERIALS AND METHODS We identified 2,608 patients with localized renal cell carcinoma who were treated surgically between 1995 and 2010 at our tertiary referral center. Competing risks Cox proportional hazards models were used to evaluate the relationship between statin use and time to local recurrence or progression (metastases or death from renal cell carcinoma) and overall survival. Statin use was modeled as a time dependent covariate as a sensitivity analysis. Models were adjusted for clinical and demographic features. RESULTS Of 2,608 patients 699 (27%) were statin users at surgery. Statin users had similar pathological characteristics compared to nonusers. At a median followup of 36 months there were 247 progression events. Statin use was associated with a 33% reduction in the risk of progression after surgery (HR 0.67, 95% CI 0.47-0.96, p = 0.028) and an 11% reduction in overall mortality that was not significant (HR 0.89, 95% CI 0.71-1.13, p = 0.3). Modeling statin use as a time dependent covariate attenuated the risk reduction in progression to 23% (HR 0.77, p = 0.12) and augmented the risk reduction in overall survival (HR 0.71, p = 0.002). CONCLUSIONS In our cohort statin use was associated with a reduced risk of progression and overall mortality, although this effect was sensitive to the method of analysis. If validated in other cohorts, this finding warrants consideration of prospective research on statins in the adjuvant setting.

Pubovesical fistula: a rare complication after treatment of prostate cancer.

OBJECTIVE To characterize the clinicopathologic features of patients who developed pubovesical fistula (PVF) after treatment of prostate cancer and to identify some possible methods of reducing the incidence of this rare complication for which no well-established guidelines exist. METHODS We identified men at 2 centers who presented with PVF after prostate cancer treatment from January 2000 to December 2010. Prostate cancer was treated with radiotherapy (RT) or radical prostatectomy, or both. Patients with bladder neck contracture (BNC) received endoscopic treatment. The demographic and clinical data were collected. RESULTS Of the 12 patients who presented with PVF, the treatment of prostate cancer was external beam RT in 8 (5 of whom underwent subsequent salvage radical prostatectomy) and radical prostatectomy (followed by salvage RT) in 4. All patients developed BNC requiring endoscopic treatment. The median interval between primary endoscopic treatment of BNC and the development of PVF was 35.9 months (range 0.6 to 97). The most common presenting symptom was suprapubic or groin pain. Of the 12 patients, 10 ultimately required cystectomy with urinary diversion. CONCLUSION The treatment of prostate cancer with RT followed by the development of BNC requiring endoscopic intervention appears to be associated with PVF development Despite conservative measures, patients who developed PVF often required cystectomy with urinary diversion. To avoid PVF, care should be taken during endoscopic intervention for BNC in patients who have received RT for prostate cancer. PVF should be on the differential diagnosis of patients with a history of RT and BNC who develop pubic pain or recurrent urinary tract infection.

Multiparametric 3T MRI for the prediction of pathological downgrading after radical prostatectomy in patients with biopsy-proven Gleason score 3+4 prostate cancer

ObjectivesThe aim of this study was to assess the diagnostic performance of pre-treatment 3-Tesla (3T) multiparametric magnetic resonance imaging (mpMRI) for predicting Gleason score (GS) downgrading after radical prostatectomy (RP) in patients with GS 3 + 4 prostate cancer (PCa) on biopsy.MethodsWe retrospectively reviewed 304 patients with biopsy-proven GS 3 + 4 PCa who underwent mpMRI before RP. On T2-weighted imaging and three mpMRI combinations (T2-weighted imaging + diffusion-weighted imaging [DWI], T2-weighted imaging + dynamic contrast-enhanced-MRI [DCE-MRI], and T2-weighted imaging + DWI + DCE-MRI), two radiologists (R1/R2) scored the presence of a dominant tumour using a 5-point Likert scale (1 = definitely absent to 5 = definitely present). Diagnostic performance in identifying downgrading was evaluated via areas under the curves (AUCs). Predictive accuracies of multivariate models were calculated.ResultsIn predicting downgrading, T2-weighted imaging + DWI (AUC = 0.89/0.85 for R1/R2) performed significantly better than T2-weighted imaging alone (AUC = 0.72/0.73; p < 0.001/p = 0.02 for R1/R2), while T2-weighted imaging + DWI + DCE-MRI (AUC = 0.89/0.84 for R1/R2) performed no better than T2-weighted imaging + DWI (p = 0.48/p > 0.99 for R1/R2). On multivariate analysis, the clinical + mpMRI model incorporating T2-weighted imaging + DWI (AUC = 0.92/0.88 for R1/R2) predicted downgrading significantly better than the clinical model (AUC = 0.73; p < 0.001 for R1/R2).ConclusionmpMRI improves the ability to identify a subgroup of patients with Gleason 3 + 4 PCa on biopsy who are candidates for active surveillance. DCE-MRI (compared to T2 + DWI) offered no additional benefit to the prediction of downgrading.Key Points• Diagnostic performance of T2-weighted-imaging + DWI was better than T2-weighted-imaging alone.• Diagnostic performance of T2-weighted-imaging + DWI was similar to T2-weighted-imaging + DWI + DCE-MRI.• Combining clinical and T2-weighted-imaging + DWI features best predicted GS downgrading.• mpMRI might prevent overtreatment by increasing eligibility for PCa active surveillance.

Evaluating the utility of a preoperative nomogram for predicting 90‐day mortality following radical cystectomy for bladder cancer

Study Type – Prognosis (individual cohort)