Michael J. Metcalfe

Assessing Symptom Burden in Bladder Cancer: An Overview of Bladder Cancer Specific Health-Related Quality of Life Instruments

Background: A key component to monitoring and investigating patient QOL is through patient reported health related quality of life (HRQOL) outcome measures. Many instruments have been used to assess HRQOL in bladder cancer and each instrument varies in its development, validation, the context of its usage in the literature and its applicability to certain disease states. Objective: In this review, we sought to summarize how clinicians and researchers should most appropriately utilize the available HRQOL instruments for bladder cancer. Methods: We performed a comprehensive literature search of each instrument used in bladder cancer, paying particular attention to the outcomes assessed. We used these outcomes to group the available instruments into categories best reflecting their optimal usage by stage of disease. Results: We found 5 instruments specific to bladder cancer, of which 3 are validated. Only one of the instruments (the EORTC-QLQ-NMIBC24) was involved in a randomized, prospective validation study. The most heavily used instruments are the EORTC-QLQ-BLM30 for muscle-invasive disease and the FACT-Bl which is used across all disease states. Of the 5 available instruments, 4 are automatically administered with general instruments, while the BCI lacks modularity, and requires co-administration with a generalized instrument. Conclusion: There are multiple strong instruments for use in gauging HRQOL in bladder cancer patients. We have divided these instruments into three categories which optimize their usage: instruments for use following NMIBC treatments (EORTC-QLQ-NMIBC24), instruments for use following radical cystectomy (FACT-Bl-Cys and EORTC-QLQ-BLM30) and more inclusive instruments not limited by treatment modality (BCI and FACT-Bl).

Role of radical prostatectomy in metastatic prostate cancer: A review

CONTEXTnRecent demonstration of efficacy with the use of chemohormonal therapy for men with metastatic prostate cancer (mPCa) has expanded the therapeutic options for these patients. Furthermore, multimodal therapy to treat systemic disease in the context of locoregional control has gained increasing interest. Concomitantly, the role of radical prostatectomy (RP) in multimodal treatment for locally advanced prostate cancer is expanding. As a result, there is interest in investigating the potential benefit of cytoreductive RP in mPCa.nnnOBJECTIVEnTo review the literature regarding the role of cytoreductive prostatectomy in the setting of mPCa.nnnEVIDENCE ACQUISITIONnMEDLINE and PubMed electronic databases were queried for English language articles related to patients with mPCa who underwent RP from January 1990 to June 2016. Key words used in our search included cytoreductive prostatectomy, radical prostatectomy, and metastatic prostate cancer. Preclinical, retrospective, and prospective studies were included.nnnEVIDENCE SYNTHESISnThere are no published randomized control trials examining the role of cytoreduction in mPCa. Local symptoms are high in mPCa and often provide a necessity for palliative procedures with the impact on oncologic outcomes being uncertain. Recently, preclinical and retrospective population-based data suggest a benefit from treatment of the primary tumor in metastatic disease. Potential mechanisms mediating this benefit include prevention of symptomatic local progression and modulation of disease biology, resulting in an improvement in progression-free and overall survival. Current literature supports the feasibility of cytoreductive prostatectomy as it is associated with acceptable side effects that are comparable to RP for high-risk localized disease. In aggregate, these data compel prospective evaluation of the hypothesis that cytoreductive prostatectomy improves the outcome of men with mPCa.nnnCONCLUSIONSnCytoreductive prostatectomy in mPCa is a feasible procedure that may improve outcomes for men when combined with multimodal management. Preclinical, translational, and retrospective evidence supports local therapy for metastatic disease. However, currently, evidence is limited and is subject to bias. The results of ongoing prospective randomized trials are required before incorporating this therapeutic strategy into clinical practice.

Universal Point of Care Testing for Lynch Syndrome in Patients with Upper Tract Urothelial Carcinoma

Purpose Patients with Lynch syndrome are at risk for upper tract urothelial carcinoma. We sought to identify the incidence and most reliable means of point of care screening for Lynch syndrome in patients with upper tract urothelial carcinoma. Materials and Methods A total of 115 consecutive patients with upper tract urothelial carcinoma without a history of Lynch syndrome were universally screened during followup from January 2013 through July 2016. We evaluated patient and family history using AMS (Amsterdam criteria) I and II, and tumor immunohistochemistry for mismatch repair proteins and microsatellite instability. Patients who were positive for AMS I/II, microsatellite instability or immunohistochemistry were classified as potentially having Lynch syndrome and referred for clinical genetic analysis and counseling. Patients with known Lynch syndrome served as positive controls. Results Of the 115 patients 16 (13.9%) screened positive for potential Lynch syndrome. Of these patients 7.0% met AMS II criteria, 11.3% had loss of at least 1 mismatch repair protein and 6.0% had high microsatellite instability. All 16 patients were referred for germline testing, 9 completed genetic analysis and counseling, and 6 were confirmed to have Lynch syndrome. All 7 patients with upper tract urothelial carcinoma who had a known history of Lynch syndrome were positive for AMS II criteria and at least a single mismatch repair protein loss while 5 of 6 had high microsatellite instability. Conclusions We identified 13.9% of upper tract urothelial carcinoma cases as potential Lynch syndrome and 5.2% as confirmed Lynch syndrome at the point of care. These findings have important implications for universal screening of upper tract urothelial carcinoma, representing one of the highest rates of undiagnosed genetic disease in a urological cancer.

Induction and Maintenance Adjuvant Mitomycin C Topical Therapy for Upper Tract Urothelial Carcinoma: Tolerability and Intermediate Term Outcomes

PURPOSEnEndoscopic management of upper tract urothelial carcinoma (UTUC) is associated with higher recurrences, which could be reduced by application of topical therapy. Adjuvant induction Bacillus Calmette-Guerin has shown inferior outcomes for UTUC compared to bladder cancer, and maintenance regimens for UTUC are unexplored. We report on the efficacy, safety, and tolerability of Mitomycin C (MMC) induction and maintenance adjuvant topical therapy for UTUC.nnnMATERIALS AND METHODSnPatients with UTUC who received adjuvant topical therapy after complete endoscopic control of Ta/T1 tumors were retrospectively reviewed. Patients were treated using percutaneous nephrostomy tube (NT) or cystoscopically placed weekly ureteral catheters, per patient preference, and all patients were offered induction and maintenance. Standardized follow-up of every 3 months in the first year, then at a minimum every 6 months, with ureteroscopy and at least annual CT, was performed. Primary outcomes were recurrence-free, progression-free, nephroureterectomy-free rate and cancer-specific and overall survival. Secondary outcomes were safety and treatment tolerability.nnnRESULTSnTwenty-seven patients with 28 renal units received adjuvant topical therapy from January 2008 to March 2015. Median follow-up was 19 months (range 7-92). Three year recurrence-free, progression-free, and nephroureterectomy-free survival rates were 60% [confidence interval (95% CI): 42, 86%], 80% [95% CI: 64, 100%], and 76% [95% CI: 60, 97%]. Cancer-specific mortality rate was 0%, and 3-year overall survival was 92.9%. Nine patients experienced adverse outcomes, all related to interventions and none related to systemic toxicity.nnnCONCLUSIONSnInduction and maintenance adjuvant topical MMC for endoscopically resected UTUC is feasible, well tolerated and shows promising intermediate term data on recurrence, progression, and nephroureterectomy-free survival.

Malakoplakia of the prostate masquerading as locally advanced prostate cancer on mpMRI

A 66-year-old man was referred for urological evaluation for an abnormal digital rectal exam (cT2a, subtle nodule at left base, 121 cc prostate) and an elevated prostate specific antigen (PSA) of 8.0 ng/ml. Subsequent 12-core transrectal ultrasound (TRUS)-guided biopsy revealed Gleason 3+4 adenocarcinoma in seven of 12 cores, including all six cores on the right side and one core at the left apex. No extraprostatic extension was identified. Post-biopsy, the patient developed urinary retention requiring a catheter, as well as an Escherichia coli (E. coli) urinary tract infection (UTI) requiring hospitalization and intravenous antibiotics.

Oncologic outcomes of patients with positive surgical margin after partial nephrectomy: a 25-year single institution experience

PurposeTo evaluate oncologic outcomes and management of patients with microscopic positive surgical margin (PSM) after partial nephrectomy (PN) for renal cell carcinoma (RCC).MethodsWe reviewed our database to identify patients who underwent PN between 1990 and 2015 for RCC and had PSM on final pathology. A 1:3 matching was performed to a negative surgical margin (NSM) cohort. Kaplan–Meier method and log-rank test were used to estimate survival and differences in outcomes, respectively. Cox proportional hazards models were conducted to estimate the Hazards ratio.ResultsA total of 2297 patients underwent PN at our institution, of which 1863 (81%) had RCC. Microscopic PSM was found in 34 (1.8%) RCC patients who were matched to 100 patients with NSM. Of these 34 patients, local recurrence (nxa0=xa04), distant kidney recurrences (nxa0=xa04), and metastases (nxa0=xa05) developed during a median follow-up of 62xa0months. Bilateral tumors/tumors in a solitary kidney (nxa0=xa012/13, 92%), and multifocal tumors (nxa0=xa07/13, 54%) were found in patients who developed recurrence/metastasis. PSM patients were at a higher risk of shorter overall survival (pxa0=xa00.001), local recurrence-free survival (pxa0=xa00.003), distant recurrence-free survival (pxa0=xa00.032) and metastasis-free survival (pxa0=xa00.018). There was statistically significant association between PSM and bilateral tumors, prior treated RCC at presentation and higher nephrometry score in multivariable model.ConclusionsThere was a low rate of microscopic PSM in our large cohort of patients undergoing PN despite tumor complexity. Higher nephrometry score, bilateral tumors, and prior treated RCC independently predicted PSM which showed worse survival, recurrence and metastasis compared to patients with NSM.

Salvage topical therapy for upper tract urothelial carcinoma

PurposeTopical therapy (TT) for upper tract urothelial carcinoma (UTUC) has been explored as a kidney sparing approach to treat carcinoma in situ (CIS) and as adjuvant for endoscopically treated Ta/T1 tumors. In bladder cancer, data support use of salvage TT for repeat induction. We investigate the outcomes of salvage TT for UTUC in patients ineligible for or refusing nephroureterectomy.MethodsA single-center retrospective review on patients receiving salvage TT via percutaneous nephrostomy tube or cystoscopically placed ureteral catheters was performed. Primary outcome was response to therapy based on International Bladder Cancer Group criteria.Results51 patients with 58 renal units (RUs) received TT. Of these, 17 patients with 18 RUs received the second-line TT, with a median follow-up of 36.5xa0months (IQR 24.5–67xa0months). 44% (8/18) received salvage TT for refractory disease and 56% (10/18) as reinduction. 5 RUs with CIS were unresponsive to initial TT and went on to receive salvage TT, of which 20% (1/5) responded. 13 RUs recurred or relapsed following initial TT and received salvage TT for papillary tumors, with 62% (8/13) responding.ConclusionOur data provide preliminary clinical rationale for the second-line TT for refractory and recurrent, endoscopically managed papillary UTUC in patients ineligible for or refusing nephroureterectomy. However, refractory upper tract CIS appears to have poor response to salvage TT.

Intraoperative Conversion From Partial to Radical Nephrectomy: Incidence, Predictive Factors, and Outcomes

OBJECTIVEnTo evaluate preoperative and intraoperative predictors of conversion to radical nephrectomy (RN) in a cohort of patients undergoing a planned partial nephrectomy (PN) for renal cell carcinoma (RCC).nnnMETHODSnA single-center, retrospective review was conducted using our PN database that includes patients who were scheduled to undergo PN (regardless of the approach) but were converted to RN between August 1990 and December 2016. Reasons for conversion were collected from the operative report. Patient demographics and perioperative variables were compared with the successful PN group. Univariate and multivariate logistic regression analyses were conducted to assess predictors of conversion.nnnRESULTSnA total of 1857 patients were scheduled to undergo PN. Of these patients, 90 (5%) were converted to RN. The multivariate model showed that larger tumor size (odds ratio [OR]u2009=u20091.20, Pu2009=u2009.040), higher RENAL nephrometry score (ORu2009=u20091.41, Pu2009=u2009.001), hilar tumor or renal sinus invasion (ORu2009=u20092.80, Pu2009=u2009.004), laparoscopic PN (ORu2009=u20097.34, Pu2009<.001), intraoperative bleeding (ORu2009=u200919.62, Pu2009<.001), positive surgical margin (ORu2009=u200931.85, Pu2009<.001), and advanced pathologic tumor-stage (T3 or T4) (ORu2009=u20097.29, Pu2009<.001) were associated with increased odds of intraoperative conversion to RN.nnnCONCLUSIONnThe rate of conversion to RN was low in patients who were scheduled to undergo PN in this series. Larger tumor size with increasing complexity, hilar tumor location or renal sinus invasion, locally advanced tumors, laparoscopic PN but not robotic PN, bleeding complication, and positive surgical margin were associated with intraoperative conversion from scheduled PN to RN.

Cost-Effectiveness of Robot-assisted Radical Cystectomy Using a Propensity-matched Cohort

BACKGROUNDnHealth-related quality of life is important for patients undergoing radical cystectomy (RC).nnnOBJECTIVEnTo determine the cost-effectiveness of robotic-assisted RC (RARC) compared to open cystectomy (OC) for bladder cancer and factors that contribute to cost-effectiveness.nnnDESIGN, SETTING, AND PARTICIPANTSnA decision analytic model was used to compare health-related quality of life and medical costs for RARCs with intracorporeal urinary diversion and OCs performed between 2007 and 2015.nnnOUTCOME MEASUREMENTS AND STATISTICAL ANALYSISnPropensity matching was performed among 1322 cases to yield a final cohort of 100 RARC and 96 ORC cases. Probabilities were obtained from the clinical study data, while quality-adjusted life years (QALYs) and health utility values were derived from the literature. A complication, readmission, or transfusion was included in the 90-d time horizon model.nnnRESULTS AND LIMITATIONSnThere were no differences between the groups in patient demographics, pathologic staging, or length of stay. Multivariable analysis revealed that the RARC group had fewer transfusions and complications compared to the OC group. The incremental cost-effectiveness ratio was

Effects of thiazolidinedione in patients with active bladder cancer

2969. RARC cost