Robert Abouassaly

Active treatment of localized renal tumors may not impact overall survival in patients aged 75 years or older

Although nephrectomy cures most localized renal cancers, this oncologic benefit may be outweighed by the renal functional costs of such an approach. In this study, the authors examined overall survival in 537 patients who had localized renal tumors ≤7 cm detected at age ≥75 years to investigate whether surgical intervention improved survival compared with active surveillance.

Active Surveillance of Renal Masses in Elderly Patients

PURPOSE We identify and report on a large number of patients treated with active surveillance for incidentally diagnosed renal masses at our institution. MATERIALS AND METHODS We identified all patients 75 years or older evaluated in our department for a renal mass between January 2000 and December 2006. A total of 110 patients with enhancing renal masses were initially treated with active surveillance and this group made up the cohort for our study. Medical records were reviewed for clinical and radiological followup, and vital status was obtained from the Social Security Death Index. Clinical and radiographic followup was available for review on 104 and 89 patients, respectively. RESULTS Patients had a median age of 81 years (range 76 to 95) with a median Charlson comorbidity index of 2 (range 0 to 7) at diagnosis. Patients had as many as 9 tumors being followed (median of 1) with a median tumor size of 2.5 cm (range 0.9 to 11.2). During a median followup of 24 months (range 1 to 90) mean tumor growth rate was 0.26 cm per year. Of the 89 patients with radiological followup 38 (43%) exhibited no tumor growth on active surveillance. Comparison of the clinical and radiographic features of patients with tumor growth and those with stable disease revealed no statistical differences. Four patients (3.6%) were treated as a result of disease progression 12 to 54 months after diagnosis. At the conclusion of the study 34 patients (31%) were deceased. To our knowledge the renal mass did not contribute to the cause of death in any patient. CONCLUSIONS Active surveillance of incidental renal masses appears to be a viable option for older patients with multiple medical comorbidities and a limited life expectancy.

A Multi-Institutional Evaluation of Active Surveillance for Low Risk Prostate Cancer

PURPOSE For select men with low risk prostate cancer active surveillance is more often being considered a management strategy. In a multicenter retrospective study we evaluated the actuarial rates and predictors of remaining on active surveillance, the incidence of cancer progression and the pathological findings of delayed radical prostatectomy. MATERIALS AND METHODS A cohort of 262 men from 4 institutions met the inclusion criteria of age 75 years or younger, prostate specific antigen 10 ng/ml or less, clinical stage T1-T2a, biopsy Gleason sum 6 or less, 3 or less positive cores at diagnostic biopsy, repeat biopsy before active surveillance and no treatment for 6 months following the repeat biopsy. Active surveillance started on the date of the second biopsy. Actuarial rates of remaining on active surveillance were calculated and univariate Cox regression was used to assess predictors of discontinuing active surveillance. RESULTS With a median followup of 29 months 43 patients ultimately received active treatment. The 2 and 5-year probabilities of remaining on active surveillance were 91% and 75%, respectively. Patients with cancer on the second biopsy (HR 2.23, 95% CI 1.23-4.06, p = 0.007) and a higher number of cancerous cores from the 2 biopsies combined (p = 0.002) were more likely to undergo treatment. Age, prostate specific antigen, clinical stage, prostate volume and number of total biopsy cores sampled were not predictive of outcome. Skeletal metastases developed in 1 patient 38 months after starting active surveillance. Of the 43 patients undergoing delayed treatment 41 (95%) are without disease progression at a median of 23 months following treatment. CONCLUSIONS With a median followup of 29 months active surveillance for select patients appears to be safe and associated with a low risk of systemic progression. Cancer at restaging biopsy and a higher total number of cancerous cores are associated with a lower likelihood of remaining on active surveillance. A restaging biopsy should be strongly considered to finalize eligibility for active surveillance.

Unintended Consequences of Laparoscopic Surgery on Partial Nephrectomy for Kidney Cancer

PURPOSE Recent 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. MATERIALS AND METHODS We 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. RESULTS Of 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. CONCLUSIONS Partial 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.

Saturation Technique Does Not Decrease Cancer Detection During Followup After Initial Prostate Biopsy

PURPOSE It has been reported that the prostate cancer detection rate in men with prostate specific antigen 2.5 ng/ml or greater undergoing saturation (20 cores or greater) prostate biopsy as an initial strategy is not higher than that in men who undergo 10 to 12 core prostate biopsy. At a median followup of 3.2 years we report the cancer detection rate on subsequent prostate biopsy in men who underwent initial saturation prostate biopsy. MATERIALS AND METHODS Saturation prostate biopsy was used as an initial biopsy strategy in 257 men between January 2002 and April 2006. Cancer was initially detected in 43% of the patients who underwent saturation prostate biopsy. In the 147 men with negative initial saturation prostate biopsy followup including digital rectal examination and repeat prostate specific antigen measurement was recommended at least annually. Persistently increased prostate specific antigen or an increase in prostate specific antigen was seen as an indication for repeat saturation prostate biopsy. RESULTS During the median followup of 3.2 years after negative initial saturation prostate biopsy 121 men (82%) underwent subsequent evaluation with prostate specific antigen and digital rectal examination. Median prostate specific antigen remained 4.0 ng/ml or greater in 57% of the men and it increased by 1 ng/ml or greater in 23%. Cancer was detected in 14 of 59 men (24%) undergoing repeat prostate biopsy for persistent clinical suspicion of prostate cancer. No significant association was demonstrated between cancer detection and initial or followup prostate specific antigen, or findings of atypia and high grade prostatic intraepithelial neoplasia on initial saturation prostate biopsy. Cancers detected on repeat prostate biopsy were more likely to be Gleason 6 and organ confined at prostatectomy than were those diagnosed on initial saturation prostate biopsy. CONCLUSIONS Previous experience suggests that, while office based saturation prostate biopsy improves cancer detection in men who have previously undergone a negative prostate biopsy, it does not improve cancer detection as an initial biopsy technique. We now report that the false-negative rate on subsequent prostate biopsy after initial saturation prostate biopsy is equivalent to that following traditional prostate biopsy. These data provide further evidence against saturation prostate biopsy as an initial strategy.

Staging saturation biopsy in patients with prostate cancer on active surveillance protocol.

OBJECTIVES One option for the management of low-grade, low-stage prostate cancer is to delay or forego treatment unless evidence of an increased risk of disease progression exists. Accurate assessment of the disease extent and aggressiveness is necessary to determine the candidates for active surveillance (AS). Office-based saturation prostate biopsy (SB) provides more accurate staging than traditional biopsy; therefore, we studied its role in patients on an AS protocol. METHODS Our database identified 52 men with prostate cancer treated with AS from July 2000 to May 2007. The records were reviewed to determine the role of SB in determining the need for definitive therapy. RESULTS The patients had a median age of 69 years (range 51 to 83) and median prostate-specific antigen (PSA) level of 5.1 ng/mL (range 0.5 to 47). Patients underwent subsequent staging 20-core SB a median of 9 months (range 1 to 20 months) after diagnosis. The disease of 20 patients (38%) was upstaged as defined by an increase in Gleason score or increased disease volume, leading to a recommendation for active treatment. Patients with disease upstaging had had significantly fewer cores taken at the initial diagnostic biopsy (11% with 20 cores or more compared with 55% with fewer than 20 cores, P = 0.002). CONCLUSIONS SB might lead to a more accurate assessment of the extent and grade of disease in men with prostate cancer on an AS protocol than traditional biopsy. In our series, more than one half of patients who pursue an AS protocol delayed or avoided local therapy. No patient developed clinical metastasis, but long-term surveillance is required.

Sequelae of Treatment in Long-term Survivors of Testis Cancer

CONTEXT Testicular cancer patients are often diagnosed at a young age, and because of the advances in the treatment of this disease, the vast majority have a normal life expectancy after therapy. Thus, recognition of the long-term sequelae of treatment (ie, surgery, radiation therapy, and chemotherapy) is particularly important in these patients. OBJECTIVE To review the adverse effects and the risk of secondary malignancy in long-term survivors of testicular cancer. EVIDENCE ACQUISITION We conducted a Medline search to identify original articles and reviews on the long-term effects of testicular cancer treatment. Although the search included articles from January 1948 to February 2011, the majority of the included articles were published in the last two decades. EVIDENCE SYNTHESIS All studies examining the long-term sequelae of treatment in testicular cancer are retrospective in nature, with most classified as cohort, case-control, and/or epidemiologic studies. Given that no standardized method of reporting long-term complications exists, evidence synthesis is limited. CONCLUSIONS Recent evidence suggests an increased risk of cardiovascular disease, neurotoxicity, and mild reductions in renal function in survivors of testicular cancer. Treatment of testicular malignancy can also negatively affect gonadal function and fertility and has been shown to result in an increased risk of solid malignancy and leukemia.

Health information quality on the internet in urological oncology: a multilingual longitudinal evaluation.

OBJECTIVES To compare the quality of uro-oncological Web sites, to assess for language or disease differences across Western languages, and to perform a longitudinal comparison between 2004 and 2009. Uro-oncological Internet information quality is considered variable but no comprehensive analysis exists. METHODS Health on the Net (HON) principles may be applied to Web sites using an automated toolbar function. Using the Google search engine (http://www.Google.com), in 2004 and 2009, 2400 Web sites were assessed using the keywords prostate, bladder, kidney, and testicular cancer in English, French, German, and Spanish. The first 150 Web sites in each language had HON principles measured-a comparison between 2004 and 2009 was done. A further analysis of site sponsorship was undertaken. RESULTS Regardless of language or cancer type, most sites are not HON accredited. English has consistently more than English, French, Spanish, or German. For the respective languages in 2009, prostate has the most (29, 14%, 16%, 12%), followed by bladder (29%, 22%, 14%, 13%), kidney (25%, 15%, 10%, 13%), and testis (26%, 19%, 7.11%). Significant differences were found comparing language and organ groups. The quality improved from 2004 to 2009. Nonprofit organizations (51%), government and/or educational (39%), commercial (20%), with urologists last (14%) were accredited. CONCLUSIONS A lack of validation of most uro-oncological sites should be appreciated by urologists. Additionally, there is a discrepancy in quality and number of Web sites across uro-oncological diseases and major Western European languages, but with some improvement seen recently. We need to encourage informative, ethical, and reliable complimentary health Web sites on the Internet and direct patients to them.

Risk of Prostate Cancer After Diagnosis of Atypical Glands Suspicious for Carcinoma on Saturation and Traditional Biopsies

PURPOSE Prostatic glandular atypia is present in approximately 5% of traditional template biopsy specimens. Prior reports suggest this finding carries a 40% risk of prostate cancer on subsequent biopsy. We determined the risk of malignancy in patients with atypia diagnosed on saturation biopsy. MATERIALS AND METHODS We identified 57 patients with a diagnosis of atypia who underwent repeat biopsy between January 2001 and August 2007. Charts were reviewed for clinical and pathological information. RESULTS Median patient age was 62 years (range 46 to 79). Of the 57 patients 19 (33%) had atypia diagnosed on saturation biopsy (20 cores or greater) (group 1), whereas 38 (67%) had atypia diagnosed with a more traditional biopsy technique (12 cores or fewer) (group 2). All patients subsequently underwent saturation repeat biopsy a median of 5 months after the original biopsy. Eight group 1 patients (42%) were found to have cancer on rebiopsy compared to 15 (39.5%) in group 2 (p = 1.00). Whereas only 1 of the 8 patients (12.5%) with cancer in group 1 had a Gleason score of 7 or greater, this was found in 5 of the 15 (33%) in group 2 (p = 0.37). Interestingly patients with cancer were less likely to have inflammation on initial biopsy (p = 0.05). CONCLUSIONS The finding of atypia on prostate biopsy is associated with a high likelihood of underlying malignancy regardless of the number of cores taken on initial biopsy. Inflammation in the initial biopsy may create a false-positive finding of atypia.

Phase I dose-escalation study of stereotactic body radiotherapy (SBRT) for poor surgical candidates with localized renal cell carcinoma.

PURPOSE To evaluate the tolerability of escalating doses of stereotactic body radiotherapy (SBRT) for primary treatment of localized renal cell carcinoma (RCC) in poor surgical candidates. PATIENTS AND METHODS Eligible patients included those with clinically staged radiographic and or pathologically confirmed RCC who had not undergone previous abdominal or pelvic radiotherapy. All patients had comorbid medical conditions which precluded surgery. Median (range) patient age was 77.6years (range 59-89) years and all patients had Karnofsky Performance Status of ⩾60. Median tumor volume was 57.9cm(3) (range 13.8-174.7cm(3)). Dose-limiting toxicity (DLT) was defined as grade 3 or worse gastrointestinal/genitourinary toxicity by Common Terminology Criteria of Adverse Events (version 4). Tumor response was assessed by imaging results using Response Evaluation Criteria In Solid Tumors (RECIST) measurement and percutaneous biopsy. RESULTS A total of 19 patients (13 men and 6 women) were treated on protocol from June 2006 through August 2011. Groups of 3-6 patients received 24, 32, 40, and 48Gy in 4 fractions. Median (range) follow-up was 13. 7months (5.9-34.7months). For possibly treatment-related acute toxicities, one patient developed grade 2 fatigue and one developed grade 4 duodenal ulcer. For possibly treatment-related late toxicities, 2 patients experienced grade 3 renal toxicity (worsening chronic kidney disease), one reported grade 2 urinary incontinence and one developed grade 4 duodenal ulcer. Among the 15 patients with evaluable response, 3 and 12 had partial response and stable disease, respectively, utilizing RECIST criteria. Among the 11 patients who had post-SBRT biopsy, only one (9%) was negative on first biopsy and an additional one (9%) turned negative without further therapy on second biopsy. CONCLUSIONS Dose escalation to 48Gy in 4 fractions has been achieved successfully without dose-limiting toxicities. A planned extension of this phase I trial is currently underway treating patients to 60Gy in 3 fractions to further evaluate this experimental therapy.