Sarah P. Psutka

Comparison of partial nephrectomy and percutaneous ablation for cT1 renal masses.

BACKGROUNDnPartial nephrectomy (PN) is a preferred treatment for cT1 renal masses, whereas thermal ablation represents an alternative nephron-sparing option, albeit with higher reported rates of recurrence.nnnOBJECTIVEnTo review our experience with PN, percutaneous radiofrequency ablation (RFA), and percutaneous cryoablation for cT1 renal masses.nnnDESIGN, SETTING, AND PARTICIPANTSnA total of 1803 patients with primary cT1N0M0 renal masses treated between 2000 and 2011 were identified from the prospectively maintained Mayo Clinic Renal Tumor Registry.nnnINTERVENTIONnPN compared with percutaneous ablation.nnnOUTCOME MEASUREMENTS AND STATISTICAL ANALYSISnLocal recurrence-free, metastases-free, and overall survival rates were estimated using the Kaplan-Meier method and compared with log-rank tests.nnnRESULTS AND LIMITATIONSnOf the 1424 cT1a patients, 1057 underwent PN, 180 underwent RFA, and 187 underwent cryoablation. In this cohort, local recurrence-free survival was similar among the three treatments (p=0.49), whereas metastases-free survival was significantly better after PN (p=0.005) and cryoablation (p=0.021) when compared with RFA. Of the 379 cT1b patients, 326 patients underwent PN, and 53 patients were managed with cryoablation (8 RFA patients were excluded). In this cohort, local recurrence-free survival (p=0.81) and metastases-free survival (p=0.45) were similar between PN and cryoablation. In both the cT1a and cT1b groups, PN patients were significantly younger, with lower Charlson scores and had superior overall survival (p<0.001 for all). Limitations include retrospective review and selection bias.nnnCONCLUSIONSnIn a large cohort of sporadic cT1 renal masses, we observed that recurrence-free survival was similar for PN and percutaneous ablation patients. Metastases-free survival was superior for PN and cryoablation patients when compared with RFA for cT1a patients. Overall survival was superior after PN, likely because of selection bias. If these results were validated, an update to clinical guidelines would be warranted.nnnPATIENT SUMMARYnPartial nephrectomy and percutaneous ablation for small (<7-cm) and localized renal masses are associated with similar rates of local recurrence.

Sarcopenia in patients with bladder cancer undergoing radical cystectomy: Impact on cancer‐specific and all‐cause mortality

The authors evaluated sarcopenia as a predictor of cancer‐specific survival (CSS) and overall survival (OS) among patients with urothelial cancer of the bladder undergoing radical cystectomy (RC).

Evaluation of the National Comprehensive Cancer Network and American Urological Association Renal Cell Carcinoma Surveillance Guidelines

PURPOSEnThe National Comprehensive Cancer Network (NCCN) and American Urological Association (AUA) provide guidelines for surveillance after surgery for renal cell carcinoma (RCC). Herein, we assess the ability of the guidelines to capture RCC recurrences and determine the duration of surveillance required to capture 90%, 95%, and 100% of recurrences.nnnPATIENTS AND METHODSnWe evaluated 3,651 patients who underwent surgery for M0 RCC between 1970 and 2008. Patients were stratified as AUA low risk (pT1Nx-0) after partial (LR-partial) or radical nephrectomy (LR-radical) or as moderate/high risk (M/HR; pT2-4Nx-0/pTanyN1). Guidelines were assessed by calculating the percentage of recurrences detected when following the 2013 and 2014 NCCN and AUA recommendations, and associated Medicare costs were compared.nnnRESULTSnAt a median follow-up of 9.0 years (interquartile range, 5.7 to 14.4 years), a total of 1,088 patients (29.8%) experienced a recurrence. Of these, 390 recurrences (35.9%) were detected using 2013 NCCN recommendations, 742 recurrences (68.2%) were detected using 2014 NCCN recommendations, and 728 recurrences (66.9%) were detected using AUA recommendations. All protocols missed the greatest amount of recurrences in the abdomen and among pT1Nx-0 patients. To capture 95% of recurrences, surveillance was required for 15 years for LR-partial, 21 years for LR-radical, and 14 years for M/HR patients. Medicare surveillance costs for one LR-partial patient were

Decreased Skeletal Muscle Mass is Associated with an Increased Risk of Mortality after Radical Nephrectomy for Localized Renal Cell Cancer

1,228.79 using 2013 NCCN,

Oncologic Surveillance After Surgical Resection for Renal Cell Carcinoma: A Novel Risk-Based Approach

2,131.52 using 2014 NCCN, and

Management of inferior vena cava tumor thrombus in locally advanced renal cell carcinoma

1,738.31 using AUA guidelines. However, if 95% of LR-partial recurrences were captured, costs would total

The Impact of Targeted Therapy on Management of Metastatic Renal Cell Carcinoma: Trends in Systemic Therapy and Cytoreductive Nephrectomy Utilization

9,856.82.nnnCONCLUSIONnIf strictly followed, the 2014 NCCN and AUA guidelines will miss approximately one third of RCC recurrences. Improved surveillance algorithms, which balance patient benefits and health care costs, are needed.

Mortality after Radical Cystectomy: Impact of Obesity Versus Adiposity after Adjusting for Skeletal Muscle Wasting

PURPOSEnWe evaluate the association between severe skeletal muscle deficiency or sarcopenia, and disease progression, cancer specific mortality and all cause mortality inxa0patients with localized renal cell carcinoma treated with radical nephrectomy.nnnMATERIALS AND METHODSnThe baseline lumbar skeletal muscle index of 387 patients treated with radical nephrectomy for nonmetastatic renal cell carcinoma between 2000 and 2010 was measured on preoperative computerized tomography. Sarcopenia was classified according to gender specific consensus definitions as male-skeletal muscle index less than 55 cm(2)/m(2) and female-skeletal muscle index less than 39 cm(2)/m(2). Progression-free, cancer specific and overall survival was estimated with the Kaplan-Meier method. Associations with progression, cancer specific mortality and all cause mortality were summarized with hazard ratios.nnnRESULTSnOf 387 patients 180 (47%) had sarcopenia. Patients with sarcopenia were older, more likely to be male (77% vs 56%, p <0.001), to have a smoking history (67% vs 55%, p=0.02), and to have nuclear grade 3 or greater disease (67% vs 60%, p=0.05), but were otherwise similar to patients without sarcopenia. Median postoperative followup was 7.2 years. Patients with sarcopenia had inferior 5-year cancer specific survival (79% vs 85%, p=0.05) compared to those without sarcopenia, as well as significantly worse 5-year overall survival (65% vs 74%, p= 0.005). As a continuous variable, increasing skeletal muscle index was linearly associated with a decreased risk of cancer specific mortality and all cause mortality. Moreover, on multivariable analysis sarcopenia was associated with increased cancer specific mortality (HR 1.70, p=0.047) and all cause mortality (HR 1.48, p=0.039).nnnCONCLUSIONSnSarcopenia is independently associated with cancer specific mortality and all cause mortality after radical nephrectomy for renal cell carcinoma. These findings underscore the importance of assessing skeletal muscle index for risk stratification, patient counseling and treatment planning.

Diabetes mellitus is independently associated with an increased risk of mortality in patients with clear cell renal cell carcinoma.

PURPOSEnThe appropriate duration of surveillance for renal cell carcinoma (RCC) after radical or partial nephrectomy remains unknown, and evidence to support current guidelines are lacking. Herein, we provide an approach to surveillance that balances the risk of recurrence versus the risk of non-RCC death.nnnPATIENTS AND METHODSnWe identified 2,511 patients who underwent surgery for M0 RCC between 1990 and 2008. Patients were stratified for analysis by pathologic stage (pT1Nx-0, pT2Nx-0, pT3/4Nx-0, and pTanyN1), relapse location (abdomen, chest, bone, and other), age (< 50, 50 to 59, 60 to 69, 70-79 and ≥ 80 years), and Charlson comorbidity index (CCI; ≤ 1 and ≥ 2). Risks of disease recurrence and non-RCC death were estimated by using parametric models for time-to-failure with Weibull distributions. Surveillance duration was estimated at the point when the risk of non-RCC death exceeded the risk of recurrence.nnnRESULTSnAt a median follow-up of 9.0 years (interquartile range, 6.4 to 12.7 years), a total of 676 patients developed recurrence. By using a competing-risk model, vastly different surveillance durations were appreciated. Specifically, among patients with pT1Nx-0 disease and a CCI ≤ 1, risk of non-RCC death exceeded that of abdominal recurrence risk at 6 months in patients age 80 years and older but failed to do so for greater than 20 years in patients younger than age 50 years. For patients with pT1Nx-0 disease but a CCI ≥ 2, the risk of non-RCC death exceeded that of abdominal recurrence risk already at 30 days after surgery, regardless of patient age.nnnCONCLUSIONnWe present an individualized approach to RCC surveillance that bases the duration of follow-up on the interplay between competing risk factors of recurrence and non-RCC death. This strategy may improve the balance between the derived benefit from surveillance and medical resource allocation.

Standardizing the Definition of Biochemical Recurrence after Radical Prostatectomy—What Prostate Specific Antigen Cut Point Best Predicts a Durable Increase and Subsequent Systemic Progression?

The diagnosis of renal cell carcinoma is accompanied by intravascular tumor thrombus in up to 10% of cases, of which nearly one-third of patients also have concurrent metastatic disease. Surgical resection in the form of radical nephrectomy and caval thrombectomy represents the only option to obtain local control of the disease and is associated with durable oncologic control in approximately half of these patients. The objective of this clinical review is to outline the preoperative evaluation for, and operative management of patients with locally advanced renal cell carcinoma with venous tumor thrombi involving the inferior vena cava. Cornerstones of the management of these complex patients include obtaining high-quality imaging to characterize the renal mass and tumor thrombus preoperatively, with further intraoperative real-time evaluation using transesophageal echocardiography, careful surgical planning, and a multidisciplinary approach. Operative management of patients with high-level caval thrombi should be undertaken in high-volume centers by surgical teams with capacity for bypass and invasive intraoperative monitoring. In patients with metastatic disease at presentation, cytoreductive nephrectomy and tumor thrombectomy may be safely performed with simultaneous metastasectomy if possible. In the absence of level one evidence, neoadjuvant targeted therapy should continue to be viewed as experimental and should be employed under the auspices of a clinical trial. However, in patients with significant risk factors for postoperative complications and mortality, and especially in those with metastatic disease, consultation with medical oncology and frontline targeted therapy may be considered.