Nicholas Donin

Clinicopathologic Outcomes of Cystic Renal Cell Carcinoma

BACKGROUND The purpose of this study was to describe the clinicopathologic characteristics and oncologic outcomes of patients who underwent nephrectomy for cystic renal masses. PATIENTS AND METHODS Using an institutional review board-approved database, we retrospectively reviewed the clinical, pathologic, radiologic, and oncologic outcome data of patients who received nephrectomy for a complex cystic renal mass. RESULTS Sixty-one patients were identified who received nephrectomy for a complex cystic lesion. Average age was 64 years. Thirty-nine (64%) patients were male. At the time of resection, 1 (1.6%), 3 (4.8%), 53 (86.8%), and 4 (6.5%) had a Bosniak category II, IIF, III, and IV cystic lesion, respectively. Nineteen (31.1%) patients were initially managed expectantly but underwent surgery because of progression of complexity on follow-up. Mean pathologic tumor size was 3.3 cm (range, 0.7-12 cm). Forty-eight (78.6%) of the lesions were found to be malignant. Thirty-seven (77.1%), 5 (10.4%), 4 (8.3%), and 2 (4.1%) were stage T1a, T1b, T2a, and T3a, respectively. Clear cell was the most common histologic subtype (44%), followed by papillary (21.3%), and unclassified RCC (4.9%). With a mean and median follow-up of 48.4 and 43.0 months, respectively, no patients developed a local or metastatic recurrence. All patients were alive at last follow-up. CONCLUSION In our series with moderate follow-up, cystic RCCs do not appear to recur or progress regardless of size, histologic subtype, or grade. These findings suggest the malignant potential of cRCCs is significantly less than solid RCCs. Further investigation is required to determine if cRCCs should be classified and managed independently from solid RCCs.

MRI Features of Renal Cell Carcinoma That Predict Favorable Clinicopathologic Outcomes

OBJECTIVE The purpose of this article is to determine whether MRI features of renal cell carcinoma (RCC), such as enhancing solid component and T1 signal intensity, are associated with clinicopathologic outcomes. MATERIALS AND METHODS This retrospective study included 241 RCCs in 230 patients who underwent preoperative MRI, had pathologic analysis results available, and were monitored for at least 3 months. A radiologist assessed tumor features on MRI, including unenhanced T1 signal relative to renal cortex and the percentage of solid enhancing components. The electronic medical record or follow-up images were reviewed to assess for the development of local recurrence or metastases. Statistical analysis was performed to correlate imaging features at MRI with pathologic and clinical outcome. RESULTS The following tumor features were observed: predominantly cystic morphologic features (defined as solid component≤25%, n=33), solid component greater than 25% (n=208), T1 hypointensity (n=97), and T1 intermediate intensity or hyperintensity (n=144). Local recurrence or metastases were observed in 14 patients. Compared with T1-intermediate or -hyperintense lesions, T1-hypointense RCCs were more likely to be low stage (90.7% vs 74.3%; p=0.001) and low grade (78.9% vs 41.8%; p<0.001) and had a lower rate of recurrence or metastases (3.3% vs 8%; p=0.167). Compared with lesions with greater than 25% solid enhancement, predominantly cystic RCCs were more likely to be lower stage (93.9% vs 78.8%; p=0.053) and lower grade (94.7 vs 56.5%; p<0.001) and to have no incidence of recurrence or metastasis (0% vs 6.9%; p=0.227). RCCs that were both cystic and T1 hypointense (n=14) were lower stage (100% vs 79.6%; p=0.047) and lower grade (92.9% vs 58.1%; p=0.01) and had no recurrence or metastases on follow-up. CONCLUSION Cystic and T1-hypointense RCC show less-aggressive pathologic features and favorable clinical behavior.

Partial nephrectomy is the standard of care for T1a kidney tumors

Over the past decade, elective partial nephrectomy (PN) has become the preferred treatment option for small localized renal masses. Based on equivalent oncological outcomes as well as significant renal functional benefits, PN is considered the “standard of care” at tertiary referral centers and high volume institutions. At our institution (NYU), over the past 5 years, roughly 90% of all pT1a tumors have been treated with PN, with both open and laparoscopic/robotic approaches [1]. In 2009, the American Urological Association published guidelines for the management of clinical stage Ia kidney tumors and listed PN as a treatment standard for pT1a tumors in healthy patients [2]. Unfortunately, it is well known that the utilization of PN has not been uniform across the USA. Based on analysis of the SEER Cancer Registry, up to 2007, 50% of pT1a tumors were treated with PN [3]. Explanations for the “underutilization” or slow diffusion of PN have been widely speculated. Although the reasons are likely multifactorial, the adoption of laparoscopic radical nephrectomy (RN), the technical challenges associated with PN, and the underrecognized impact of RN on kidney functional outcomes and potential non-oncological morbidity are frequently cited as deterrents to the use of PN [4–6]. Last year, the European Organization for Research and Treatment of Cancer Genito-Urinary Group (EORTC-GU) published results of the only large randomized prospective clinical trial comparing RN to PN for the treatment of a solitary renal mass 5 cm. In the intent-to-treat analysis, the investigators found that RN had a slightly higher 10year overall survival (OS) rate compared with PN [7]. Thus, given the seemingly paradoxical findings of this large randomized study, as well as the large discrepancies observed in utilization rates of PN for pT1a tumors, is it fair to say that PN should be considered the “standard of care” for localized small renal masses (SRMs)? The term standard of care, particularly in the medicolegal sense, implies that a particular treatment is appropriate based on scientific evidence and should be dutifully performed by the physician under normal circumstances. In the case of pT1a kidney tumors, we believe that the scientific evidence (listed below) strongly supports that PN is the standard of care and should therefore be dutifully performed by surgeons under normal circumstances.

Health Services ResearchEvaluation of Unplanned Hospital Readmissions After Major Urologic Inpatient Surgery in the Era of Accountable Care

OBJECTIVE To provide a multi-institutional analysis of clinical factors predicting unplanned hospital readmission after major inpatient urologic surgery. MATERIALS AND METHODS The American College of Surgeons National Surgical Quality Improvement Program is a risk-adjusted data collection mechanism for analyzing clinical outcomes data including 30-day perioperative readmissions and complications. We identified 23,108 patients who underwent major inpatient urologic surgery from 2011 to 2012. Readmission rates were determined and stratified by procedure type. Multiple logistic regression was used to determine independent risk factors for 30-day unplanned hospital readmissions. RESULTS Of a total of 23,108 patients undergoing urologic surgery, 1329 patients (5.8%) had unplanned readmissions. Upper tract reconstruction and urinary diversion without cystectomy (21/102) and with cystectomy (291/1662) had the highest rates of readmission of all procedures analyzed. Readmitted patients had a 64.2% (853/1329) and 64.4% (855/1329) rate of major and minor complications, respectively, compared with 6.7% (1459/21,779) and 15.9% (3462/21,779) for patients not readmitted (P <.02). Organ space infection (odds ratio [OR] 15.23), pulmonary embolism (OR 12.14), deep venous thrombosis (OR 10.96), and return to the operating room (OR 8.46) were the most substantial predictors of readmission. Laparoscopic-robotic procedures had significantly lower readmission rates compared with open procedures for prostatectomy, partial nephrectomy, and nephrectomy (P <.01). CONCLUSION Readmission after inpatient urologic surgery occurs at a rate of 5.8%, with cystectomy and urinary diversion demonstrating the highest rates. Major and minor postoperative complications were the most substantial predictors of readmission. These results may guide risk reduction initiatives to prevent readmissions after major urologic surgery.

Genetically adjusted prostate-specific antigen values may prevent delayed biopsies in African-American men

To evaluate whether genetic correction using the genetic variants prostate‐specific antigen (PSA)‐single nucleotide polymorphisms (SNPs) could reduce potentially unnecessary and/or delayed biopsies in African‐American men.

Genetically-Adjusted PSA Values May Prevent Delayed Biopsies in African-American Men

To evaluate whether genetic correction using the genetic variants prostate‐specific antigen (PSA)‐single nucleotide polymorphisms (SNPs) could reduce potentially unnecessary and/or delayed biopsies in African‐American men.

MP18-19 IMPACT OF MALNUTRITION ON RADICAL NEPHROURETERECTOMY MORBIDITY AND MORTALITY: OPPORTUNITY FOR PRE-OPERATIVE OPTIMIZATION

Introduction/background: Nutritional status is increasingly recognized as an important predictor of prognosis and surgical outcomes in cancer patients. We evaluated the impact of preoperative malnutrition on the development of surgical complications and mortality following radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). Materials and Methods: Using data from The American College of Surgeons National Surgical Quality Improvement Program, we evaluated the association of poor nutritional status with 30 day postoperative complications and overall mortality following RNU over years 2005-2015. Preoperative variables suggestive of poor nutritional status included hypoalbuminemia (<3.5 g/dL), weight loss 6 months before surgery (>10%), and low body mass index (BMI). Results: A total of 1,200 patients were identified who underwent RNU for UTUC. The overall complication rate was 20.5% (n=246) and mortality rate was 1.75% (n=21). On univariate analysis, patients who had a postoperative complication were more likely to have hypoalbuminemia (25.0% vs. 11.4% p<0.001) and weight loss (3.7% vs. 1.0% p=0.003). After controlling for baseline characteristics and comorbidities, hypoalbuminemia was found to be a significant independent predictor of postoperative complications (OR 2.09 95% CI 1.29-3.38 p=0.003). Hypoalbuminemia was also found to be significant independent predictor of mortality (OR 4.31 95% CI 1.45-12.79 p=0.008) on multivariable regression analysis. Conclusions: Hypoalbuminemia is a significant predictor of surgical complications and mortality following RNU for UTUC. This finding supports the importance of preoperative nutritional status in this population and suggests that effective nutritional interventions in the preoperative setting could improve patient outcomes. M AN US CR IP T AC CE PT ED ACCEPTED MANUSCRIPT 5

PD73-01 RENAL MASS BIOPSY IS ASSOCIATED WITH INCREASED INCIDENCE OF PATHOLOGICAL UPSTAGING TO PERINEPHRIC FAT INVASION IN PATIENTS WITH CLINICALLY LOCALIZED RENAL CELL CARCINOMA

Whole pelvis irradiation was a significant predictor only for early GU (OR: 1.77; p1⁄40.006) and early GI complications (OR: 3.20; p<0.001). Finally, the number of lymph nodes removed was associated with both early and late GI complications (OR: 1.12, p1⁄40.02; and OR: 1.18, p1⁄40.01). CONCLUSIONS: At long-term follow-up, the risk of complications is not negligible, despite being mostly low grade. Concomitant HT represents a significant predictor of both early and late high-grade complications. Whole pelvis irradiation is a significant risk factor for early high-grade complications, whereas number of nodes removed is significantly associated with late high-grade complications

MP22-16 CYTOREDUCTIVE PARTIAL NEPHRECTOMY FOR SMALL PRIMARY TUMORS IMPROVES OVERALL SURVIVAL IN METASTATIC KIDNEY CANCER

INTRODUCTION AND OBJECTIVES: Cytoreductive radical nephrectomy (RN) improves survival in select patients with metastatic renal cell carcinoma (mRCC). For smaller primary tumors, however, it is unknown whether cytoreductive partial nephrectomy (PN) compromises oncologic efficacy. Our objective was first to evaluate whether the size of the primary tumor is associated with overall survival (OS) in mRCC. Second, we sought to evaluate whether PN had equivalent OS compared with RN in patients with small primary tumors. METHODS: We queried the National Cancer Database from 2004-2013 and identified patients who underwent cytoreductive PN or RN for mRCC. Tumor size was categorized as T1a, T1b, and T2a. Rates of cytoreductive PN were analyzed over time. Descriptive statistics were used to compare patient demographics and tumor characteristics by surgical procedure (PN vs. RN) and tumor size. KaplanMeier survival analysis was used to compare OS. Multivariable Cox proportional hazards models were used to determine the effect of surgery type on OS. RESULTS: A total of 4,464 patients met our inclusion criteria, with 94.4% undergoing a RN and 5.6% undergoing a PN. Rates of cytoreductive PN increased over time from 3.2% in 2004 to 9.4% in 2013. One-year OS was 71.3%, 69.2%, and 61.7% in patients with T1a, T1b, and T2a primary tumors, respectively (log rank test: p<0.001). In a multivariable model controlling for age, Charlson-Deyo score, histology, receipt of systemic treatment, metastasis location, and surgical procedure, T2a was a predictor of worse OS (HR 1.2, 95% CI 1.07-1.33). OS was then evaluated in patients who received a PN vs. RN in the entire cohort, as well as within each primary tumor Tstage (Figure 1). Patients who underwent PN had significantly improved OS, which was significant for T1a and T1b tumors (p<0.01) but not for larger T2a tumors (p1⁄40.74). This was maintained in a Cox multivariable model. CONCLUSIONS: In patients with mRCC undergoing cytoreductive nephrectomy, primary tumor size affects OS. PN was associated with longer OS in select groups of patients with small primary tumors. Further studies are needed to establish patient selection criteria in order to optimize the surgical care of patients with mRCC. Source of Funding: H&H Lee Surgical Resident Research Scholarship

Genetically adjusted prostate-specific antigen values may prevent delayed biopsies in African-American men: Genetic adjustment of PSA values in African-American men

To evaluate whether genetic correction using the genetic variants prostate‐specific antigen (PSA)‐single nucleotide polymorphisms (SNPs) could reduce potentially unnecessary and/or delayed biopsies in African‐American men.