Narhari Timilshina

Unintended Consequences of Laparoscopic Surgery on Partial Nephrectomy for Kidney Cancer

PURPOSEnRecent evidence suggests that partial nephrectomy may be associated with improved survival compared to radical nephrectomy for renal cell carcinoma but partial nephrectomy may be underused. We examined whether the introduction of laparoscopic radical nephrectomy contributed to low partial nephrectomy use with time.nnnMATERIALS AND METHODSnWe identified all patients treated surgically for renal cell carcinoma in Ontario, Canada between 1995 and 2004 using the Ontario Cancer Registry, a population based tumor registry. A multinomial logistic regression model was used to relate the relative numbers of patients with open and laparoscopic radical nephrectomy, and partial nephrectomy to patient age, gender and surgery year. The partial nephrectomy time trend was investigated by fitting a segmented regression model.nnnRESULTSnOf 7,830 surgically treated patients 7,042 (89.9%) vs 788 (10.1%) underwent radical vs partial nephrectomy. Segmented regression showed a clear change in partial nephrectomy use with time (p = 0.001), such that the odds of partial nephrectomy increased by 18% per year before January 2003 (OR 1.18, 95% CI 1.14-1.23) and subsequently decreased by 12% per year (OR 0.88, 95% CI 0.75-1.02). In the multinomial regression model age and surgery year but not gender were independently associated with partial nephrectomy.nnnCONCLUSIONSnPartial nephrectomy use for renal cell carcinoma remains low, particularly in elderly patients. The introduction of laparoscopic radical nephrectomy coincided with decreased uptake and use of partial nephrectomy for renal cell carcinoma. Although it was hypothesized previously, to our knowledge this is the first study to suggest that the introduction of laparoscopy in renal surgery has negatively impacted partial nephrectomy use.

Troubling Outcomes From Population-level Analysis of Surgery for Upper Tract Urothelial Carcinoma

OBJECTIVESnTo review the surgical management of upper tract urothelial carcinoma (UTUC) on a population level. UTUC accounts for 5% of urothelial malignancies, making it less amenable to single-center reporting. Complete nephroureterectomy is the standard of care, and increasing evidence has shown that a suboptimal surgical technique is associated with an adverse prognosis.nnnMETHODSnWe obtained information for all patients diagnosed with UTUC (n = 830) and those treated surgically (n = 680) in the province of Ontario, Canada from the Ontario Cancer Registry from 1995 to 2004. Demographic, treatment, and vital status information was obtained for all patients, and pathology reports were available for 422 patients. The primary outcome was overall survival. The secondary outcomes included measures of surgical quality (ie, number of lymph nodes sampled, ureteral length excised, surgical margin status, and 30-day mortality) and disease-specific survival.nnnRESULTSnThe unadjusted 5-year overall survival rate was 57.2%, with a median survival of 72.5 months. For those treated surgically, the 30-day mortality rate was 1.8%, and the positive surgical margin rate was 8.5%. Lymph nodes were identified in only 27% of the specimens, with a median yield of 1 (range 1-15). An estimated 25.8% of patients might have undergone incomplete ureteral resection at the time of nephroureterectomy.nnnCONCLUSIONSnUTUC is a lethal malignancy, with nearly one half the patients dying within 5 years. Furthermore, lymphadenectomy was rarely performed and approximately one fourth of patients might have undergone incomplete ureterectomy. The published outcomes from centers of excellence do not appear to reflect the surgical quality seen on a population level for this rare, but significant, malignancy.

Prevalence and impact on survival of positive surgical margins in partial nephrectomy for renal cell carcinoma: a population‐based study

The increased detection of small renal masses (SRMs) with diagnostic imaging has highlighted the importance of preserving renal function, with many patients with SRMs being managed with nephron‐sparing procedures. The significance of positive surgical margins (PSMs) is debatable and various studies have looked at the risk factors for PSMs and recurrence. It has been suggested that tumour size may be a risk factor and the centrality of the tumour has been found to be an increased risk factor. The indication and location of the tumour has been found to be an independent predictive factor for recurrence. Various studies have assessed the outcome of patients with PSMs with short‐ to intermediate‐term follow‐up. Our study has an intermediate‐term median follow‐up of 7.9 years, and found no significant difference in 5‐year disease‐specific and overall survival rates between patients with PSMs and negative surgical margins. We also found that tumour size was not significant, but pathological stage and fat invasion were found to be significant. These risk factors have not been published in previous studies.

Do we continue to unnecessarily perform ipsilateral adrenalectomy at the time of radical nephrectomy? A population based study

PURPOSEnSince the mid 1990s evidence has supported ipsilateral adrenal gland sparing radical nephrectomy unless the gland appears involved on imaging or the primary tumor is large and located in the upper pole. However, it is unclear whether this shift in surgical practice has been adopted at the population level.nnnMATERIALS AND METHODSnUsing the Ontario Cancer Registry we identified 5,135 patients in the province of Ontario who underwent radical nephrectomy between 1995 and 2004. Ipsilateral adrenalectomy and tumor involvement of the adrenal gland were ascertained from pathology reports. Further variables analyzed included age, gender, pathology, surgeon year of graduation, academic status of hospital/surgeon, hospital and surgeon volume, and year of surgery. We used multivariable logistic regression to assess outcomes.nnnRESULTSnThe overall rate of adrenal gland involvement with cancer was 1.4%. The adrenal was involved in 3.2% of tumors larger than 7 cm vs only 0.89% of tumors 4 to 7 cm and 0.63% of tumors smaller than 4 cm. Factors predictive of adrenal involvement on multivariable analysis were tumor size greater than 7 cm and fat invasion. The overall adrenalectomy rate was 40.1%, which decreased slightly over time (40.6% in 1995 vs 34.8% in 2004). Variables predictive of adrenal removal on multivariable analysis included tumor size greater than 7 cm, presence of venous thrombus, upper pole location, higher hospital volume, and academic status of hospital or surgeon.nnnCONCLUSIONSnDespite evidence to support preservation of the ipsilateral adrenal gland during radical nephrectomy, the rate of adrenalectomy decreased only slightly in 10 years. Adrenalectomy remains overused in populations that are unlikely to benefit from the procedure.

Should Follow-up Biopsies for Men on Active Surveillance for Prostate Cancer Be Restricted to Limited Templates?

OBJECTIVEnTo investigate if prostate biopsy templates with fewer cores can be used during active surveillance (AS) for prostate cancer.nnnMETHODSnAt present, we use an AS protocol template (ASPT) consisting of 13-17 cores. We hypothesize in the setting of known cancer, sextant (6 cores) or standard extended (10-12 cores) templates, could be used with similar effect. We identified patients in our referral institution database (1997-2009) with entry prostate-specific antigen <10 ng/mL, stage ≤cT2, Gleason sum ≤6, ≤3 cores positive for cancer, <50% of single core involved, and age ≤75 years (N = 272). Patients fulfilling standard criteria for pathologic reclassification (N = 94) at any follow-up biopsy were selected for evaluation. By mapping tumor location on the pathologic reclassification determining biopsy, hypothetical scenarios of sextant or standard extended templates (SET) were compared with our ASPT and examined for frequency of cancer detection and pathologic reclassification.nnnRESULTSnFor the 94 patients analyzed, the median number of cores taken was 9.7 (6-22) at baseline and 15 (14-17) for the reclassification biopsy. The median time between baseline and the pathologic reclassification determining biopsy was 15.4 months. Analysis of subgroupings showed that sextant template would identify 84% of cancers and 47.9% of the reclassification events, whereas SET detected 99% of cancers and 81.9% of patients who pathologically reclassified. When only considering Gleason sum ≥7 related progression events, SET found 16.2% less (n = 57) compared with ASPT (n = 68).nnnCONCLUSIONnWhen monitoring patients on AS, a 13-17 core template detects more pathologic reclassification than standard sextant (18.1%) or extended (52.1%) biopsy templates.

Ipsilateral adrenalectomy at the time of radical nephrectomy impacts overall survival

Study Type – Therapy (case series)

Predictors of early mortality after radical nephrectomy with renal vein or inferior vena cava thrombectomy – a population-based study

Study Type – Prognosis (cohort)

A population based study of surgeon characteristics associated with the uptake of contemporary techniques in renal surgery

INTRODUCTIONnWe have witnessed the slow uptake of many contemporary techniques in the surgical management of renal tumours. We sought to evaluate surgeon-level characteristics associated with the uptake of laparoscopy, partial nephrectomy (PN) and adrenal-sparing approaches in surgically managing these tumours.nnnMETHODSnUsing the Ontario Cancer Registry, we identified surgeons treating renal cell carcinoma (RCC) in the province of Ontario, Canada between 2002 and 2004. We then classified individuals within this cohort as either high or low utilizers of laparoscopy, PN or adrenal-sparing approaches. Further variables analyzed included academic status, surgeon graduation year and surgical volume status. We then used univariable and multivariable logistic regression models to assess predictors of uptake.nnnRESULTSnWe evaluated a total of 108 surgeons for their uptake of both laparoscopy and adrenal-sparing approaches and 94 surgeons for their uptake of PN. We identified 32 surgeons (30%) as high users of laparoscopy. Predictors of uptake of laparoscopy included graduation year after 1990 (odds ratio [OR] 4.81, confidence interval [CI] 1.57-14.8) and high-surgeon volume (OR 4.33, CI 1.60-10.4). We identified 41 surgeons (44%) as high users of PN. The only predictor of uptake of PN was academic status (OR 5.83, CI 1.96-17.3). We identified 69 surgeons (65%) as high users of adrenal-sparing approaches, but did not identify any significant predictors for uptake in this group.nnnDISCUSSIONnWe identify unique factors contributing to the uptake of distinct surgical techniques in the management of RCC. This information sheds lights on the underlying mechanisms and helps us understand how to further encourage the dissemination of these practices.

Do quality of life, physical function, or the Wheatley index at diagnosis predict 1-year mortality with intensive chemotherapy in older acute myeloid leukemia patients?

Treatment decision-making is complicated in older adults with acute myeloid leukemia (AML) because of poor prognosis and significant treatment toxicities. Improved prognostication at the time of diagnosis, such as with the Wheatley Index, may aid clinical decision-making. Pre-treatment quality of life (QOL) or objective physical performance measures (PPMs) may also predict outcomes such as mortality in oncology. We investigated the predictive value of the Wheatley Index, QOL and PPMs at diagnosis on one-year mortality in older (60+ years) AML patients undergoing intensive chemotherapy (IC) in a large AML referral center. AML patients undergoing IC were enrolled in a single-center prospective study. The Wheatley prognostic risk category (good, standard and poor) was determined. Predictors of one-year mortality were assessed with logistic regression. Overall one-year mortality was 37.1%. QOL and PPMs at diagnosis were not good predictors of one-year mortality. Poor Wheatley risk category was the strongest predictor in both univariate and multivariable mortality models (adjusted odds ratio 7.1, 95% confidence interval 1.95-25.5, p<0.001). The Wheatley index may be useful to clinicians and patients by providing an integrated prognostic tool to guide up-front therapy in AML.

Diagnostic prostate biopsy performed in a non-academic center increases the risk of re-classification at confirmatory biopsy for men considering active surveillance for prostate cancer

Background:To examine whether diagnostic biopsy (B1), for patients on active surveillance (AS) for prostate cancer, performed at an outside referral centre (external) compared with our in-house tertiary center (internal), increased the risk of re-classification on the second (confirmatory) biopsy (B2).Methods:Patients on AS were identified from our tertiary center database (1997–2012) with PSA<10, Gleason sum (GS) ⩽6, clinical stage ⩽cT2, ⩽3 positive cores, <50% of single core involved, age ⩽75 years and having a B2. Patients who had <10 cores at B1 and delay in B2 >24u2009mo were excluded. Depending on center where B1 was performed, men were dichotomized to internal or external groups. All B2 were performed internally. Multivariate logistic regression examined if external B1 was a predictor of re-classification at B2.Results:A total of 375 patients were divided into external (n=71, 18.9%) and internal groups (n=304, 81.1%). At B2, more men in the external group re-classified (26.8%) compared with the internal group (13.8%)(P=0.008). On multivariate analysis, external B1 predicted grade-related re-classification (odds ratio (OR) 4.14, confidence interval (CI) 2.01–8.54, P<0.001) and volume-related re-classification (OR 3.43, CI 1.87–6.25, P<0.001). Other significant predictors for grade-related re-classification were age (OR 2.13 per decade, CI 1.32–3.57, P<0.001), PSA density (OR 2.56 per unit, CI 1.44–4.73, P<0.001), maximum % core involvement (OR 1.04 per percentage point, CI 1.01–1.09, P=0.02) and time between B1 and B2 (OR 1.43 per 6 months, CI 1.21–1.71, P<0.001).Conclusion:At our institution, patients on AS who had their initial B1 performed externally were more likely to have adverse pathological features and re-classify on internal B2.