Sungwoo Hong

Obesity and prognosis in muscle-invasive bladder cancer: The continuing controversy

To investigate the association between body mass index and clinicopathological features of bladder cancer, and to assess the prognostic value of body mass index in patients undergoing radical cystectomy for bladder cancer.

Preoperative Factors Predictive of Posterolateral Extracapsular Extension After Radical Prostatectomy

Purpose In radical prostatectomy (RP) procedures, sparing the neurovascular bundles adjacent to the posterolateral aspect of the prostatic fascia has often been suggested as a possible risk factor for positive surgical margins. Here we aimed to quantify the probability of extracapsular extension (ECE) at the posterolateral side of the prostate to aid in nerve-sparing decision making. Materials and Methods We evaluated 472 patients who underwent RP between July 2007 and January 2012. All patients underwent preoperative magnetic resonance imaging (MRI) with diffusion-weighted imaging and apparent diffusion coefficient mapping. We analyzed 944 side-specific prostate lobes with preoperative variables. To quantify the risk of side-specific posterolateral ECE after RP, we developed a risk-stratification scoring system through logistic regression analysis. Results Overall, 20.6% of 944 prostate lobes had ECE. In the multivariate analysis, prostate-specific antigen (PSA), biopsy Gleason score ≥7, percentage of side-specific cores with tumor, and posterolateral ECE on MRI were independent predictive factors of posterolateral ECE. On internal and external validation to calculate the predicted risk, the Hosmer-Lemeshow goodness-of-fit test showed good calibration (p=0.396). Conclusions PSA, biopsy Gleason score, percentage of side-specific cores with tumor, and posterolateral ECE on MRI are independent predictors of posterolateral ECE. The scoring system derived from this study will provide objective parameters for use when deciding if the neurovascular bundle can be safely spared.

Retropubic Versus Robot-Assisted Laparoscopic Prostatectomy for Prostate Cancer: A Comparative Study of Postoperative Complications

PURPOSE To compare the complications of radical retropubic prostatectomy (RRP) with those of robot-assisted laparoscopic prostatectomy (RALP) performed by a single surgeon for the treatment of prostate cancer. MATERIALS AND METHODS The postoperative complications of 341 patients who underwent RRP and 524 patients who underwent RALP for prostate cancer at the Asan Medical Center between July 2007 and August 2012 were retrospectively reviewed and compared. Complications were classified according to the modified Clavien classification system. RESULTS RALP was associated with a shorter length of hospital stay (mean, 7.9 days vs. 10.1 days, p<0.001) and duration of urethral catheterization (6.2 days vs. 7.5 days, p<0.001) than RRP. Major complications (Clavien grade III-IV) were less common in the RALP group than in the RRP group (3.4% vs. 7.6%, p=0.006). There were no significant differences in medical complications between procedures. Considering surgical complications, urinary retention (7.0% vs. 2.7%, p=0.002) and wound repair (4.1% vs. 0.2%, p<0.001) were more common after RRP than after RALP. Extravasation of contrast medium during cystography was more common in the RRP group than in the RALP group (10.0% vs. 2.1%, p<0.001). CONCLUSIONS RALP is associated with a lower complication rate than RRP.

Incidence of benign results after laparoscopic radical nephroureterectomy.

Background and Objectives: Studies of patients with benign pathologic lesions who underwent laparoscopic radical nephroureterectomy (RNU) with preoperative suspicion of upper urinary tract urothelial carcinoma are lacking. The aim of this retrospective cross-sectional study was to evaluate the incidence of benign pathologic lesions on laparoscopic RNU for upper urinary tract tumors that are presumed to be urothelial carcinoma. The clinicopathologic characteristics of these lesions were also determined. Methods: Between January 2004 and December 2010, 244 patients underwent laparoscopic RNU for possible upper urinary tract urothelial carcinoma at our institute. Seven (2.9%) had benign lesions at the final pathologic examination. The preoperative features of these patients were investigated, including imaging findings, urine cytologic results, and ureteroscopic findings. Results: The 7 patients comprised 5 men and 2 women. The lesions were located in the ureter in 5 patients and in the renal pelvis in 2. All patients underwent preoperative voided urine cytology and cystoscopy. Two patients underwent preoperative ureteroscopy. In 1 patient, definite pathologic lesions were not identified in the surgical specimen. Urinary tract tuberculosis was diagnosed in 1 patient, inflammatory pseudotumor in 2, and fibroepithelial polyps in 1. In 2 patients, stones were detected (stone with atypical papillary urothelial hyperplasia and polypoid ureteritis with ureter stone, respectively) after laparoscopic RNU. Conclusion: Benign pathologic lesions were detected in 7 patients (2.9%) who had undergone laparoscopic RNU for upper urinary tract tumors that were presumed to be urothelial carcinoma. The description of these false-positive cases will help improve the preoperative counseling of these patients.

Feasibility and Safety of Laparoscopic Ablative Renal Surgery in Infants: Comparative Study with Children

PURPOSE We evaluated the feasibility and safety of laparoscopic ablative renal surgery in infants and small children 10 kg or less compared to children weighing more than 10 kg. MATERIALS AND METHODS A total of 86 cases were performed by a single surgeon who had mastered the learning curve. Subjects consisted of 25 patients 12 months or younger or weighing 10 kg or less at surgery (group A) and 61 patients older than 12 months and weighing more than 10 kg at surgery (group B). Operative and convalescence parameters, and intraoperative and postoperative complications were compared between the groups. Binary logistic regression analysis was used to estimate the association of baseline characteristics with complications. RESULTS All procedures were completed laparoscopically. There was no significant difference in operative and convalescence parameters, or overall intraoperative and postoperative complications between the 2 groups. Most intraoperative complications (10 of 13) were peritoneal tear during the retroperitoneal approach. Atelectasis was the most common postoperative complication (14 of 23 cases). Operative approach (retroperitoneal vs transperitoneal) was a significant determinant of intraoperative complications (OR 7.6, p = 0.005). Type of surgery (heminephrectomy or isthmectomy vs nephrectomy) was a significant determinant of postoperative complications (OR 5.2, p = 0.014). CONCLUSIONS Laparoscopic ablative renal surgery is safe and feasible even in infants and small children. Intraoperative and postoperative complications are associated with approach and type of surgery, respectively.

Clinicopathological features of Xp11.2 translocation renal cell carcinoma

Purpose Xp11.2 translocation renal cell carcinoma (RCC) is characterized by various translocations of the TFE3 transcription factor gene. These rare cancers occur predominantly in children and young adults. Here, we review the clinicopathological features of Xp11.2 translocation RCC. Materials and Methods We identified 21 patients with Xp11.2 translocation RCC. We retrospectively analyzed patient characteristics, clinical manifestations, and specific pathological features to assess definitive diagnosis, surgical and systemic treatments, and clinical outcomes. Results The mean age at diagnosis was 43.4±20.0 years (range, 8-80 years; 8 males and 13 females). Eleven patients were incidentally diagnosed, nine patients presented with local symptoms, and one patient presented with systemic symptoms. The mean tumor size was 6.2±3.8 cm (range, 1.9-14 cm). At the time of diagnosis, 11, 1, and 5 patients showed stage I, II, and III, respectively. Four patients showed distant metastasis. At analysis, 15 patients were disease-free after a median follow-up period of 30.0 months. Four patients received target therapy but not effectively. Conclusions Xp11 translocation RCC tends to develop in young patients with lymph node metastasis. Targeted therapy did not effectively treat our patients. Surgery is the only effective therapy for Xp11 translocation RCC, and further studies are needed to assess systemic therapy and long-term prognosis.

Histologic Variability and Diverse Oncologic Outcomes of Prostate Sarcomas

Purpose Primary prostate sarcomas are a rare type of prostate cancer that account for less than 0.1% of primary prostate malignancies. We analyzed the experience of a single institution with prostate sarcoma over 20 years. Materials and Methods In this case series, the medical records of 20 patients with prostate sarcoma were reviewed from June 1990 to December 2013 to identify symptoms at presentation, diagnostic procedures, metastasis presence and development, histologic subtype, French Fédération Nationale des Centres de Lutte Contre le Cancer grade, primary tumor grade and size, and treatment sequence, including surgery and preoperative and postoperative therapies. The average follow-up period was 23.6 months (range, 1.4-83.3 months). Results The average patient age was 46.3±16.7 years. Most patients presented with lower urinary tract symptoms (55%). The histologic subtype was spindle cell sarcoma in five patients (25%), rhabdomyosarcoma in three patients (15%), synovial sarcoma in three patients (15%), liposarcoma in three patients (15%), stromal sarcoma in three patients (15%), and Ewing sarcoma, nerve sheath tumor, and adenocarcinoma with sarcomatoid component (5% each). For liposarcoma, two patients were alive after complete surgical resection and had a good prognosis. At last follow-up, 15 patients had died of sarcoma. The 2- and 5-year actuarial survival rates for all 20 patients were 53% and 12%, respectively (medial survival, 20 months). Conclusions The disease-specific survival rate of prostate sarcoma is poor. However, sarcoma that is detected early shows a better result with proper management including surgical intervention with radio-chemotherapy than with no treatment. Early diagnosis and complete surgical resection offer patients the best curative chance.

Is Bladder Tumor Location Associated with Prostate Cancer Detection after Intravesical Bacillus Calmette-Guérin Instillation?

Objectives The aim of this study was to evaluate the effect of bladder tumor (BT) location on prostate cancer (PCa) detection in patients with elevated PSA levels after intravesical BCG instillation. Methods Between February 2004 and January 2013 prostate biopsies were performed in 59 non-muscle invasive bladder cancer (NMIBC) patients whose PSA level were elevated (≥3 ng/ml) after a 6 week course of intravesical BCG (Oncotice, 12.5 mg in 50 ml normal saline). Differences in PCa detection according to the BT location [bladder neck and/or trigone (Group 1, n = 22) vs. other locations (Group 2, n = 37)] were evaluated. The Fishers exact test and the Mann-Whitney U test were used to evaluate the association between categorical and continuous variables, respectively. Results A total of 14 patients (23.7%) were diagnosed with PCa. The mean ± standard deviation (SD) PSA before intravesical BCG instillation and prostate biopsy were 1.36±1.04 ng/ml in Group 1 and 1.09±1.12 ng/ml in Group 2 (P = 0.633), and 6.05±3.57 ng/ml in Group 1 and 5.13±3.88 ng/ml in Group 2 (P = 0.378), respectively. Interestingly, whereas PCa was detected upon biopsy in only one patient in Group 1 (4.5%), 13 cases were detected in Group 2 (35.1%) (P = 0.009). Conclusions PCa detection after intravesical BCG was highly associated with BT location. Prostate biopsy should therefore be considered when PSA level is elevated after BCG instillation and his BT is located far from the bladder neck.

MP55-18 ADJUVANT CHEMOTHERAPY AFTER RADICAL CYSTECTOMY FOR MUSCLE-INVASIVE BLADDER CANCER: A COMPARATIVE STUDY USING INVERSE-PROBABILITY-OF-TREATMENT WEIGHTING (IPTW)

INTRODUCTION AND OBJECTIVES: Inflammation plays an important role in the biology of many malignancies and is considered a hallmark of cancer. An elevated ratio of peripheral neutrophils to lymphocytes (NLR), a marker of host inflammation, has been associated with poor outcome in various solid tumors. We aimed to assess the association between pre-treatment NLR and survival in a large series of patients undergoing radical cystectomy (RC) for urothelial carcinoma of the bladder (UCB). METHODS: Patients undergoing RC for UCB between 19882012 were identified using our institutional RC database. NLR was computed using complete blood counts with differentials performed preRC, or prior to neo-adjuvant chemotherapy where applicable. Given the heterogeneity of cutpoints used in the literature, time dependent receiver operator characteristics (ROC) curves were used to determine the optimal cutpoint for predicting recurrence-free (RFS), cancer-specific (CSS) and overall survival (OS) among the range of values used in the existing literature. The predictive ability of NLR was then assessed using Kaplan-Meier analyses and multivariable Cox-proportional hazards models adjusting for age, gender, co-morbidity score, hemogloblin, platelet count, stage, surgical margin status, and receipt of neo-adjuvant or adjuvant chemotherapy. Lastly, the likelihood ratio test was used to determine if multivariable models were improved by the inclusion of NLR. RESULTS: Of the final cohort of 416 patients, median follow up was 58.4 months. There were 178 (42%) deaths overall, 110 (26%) UCB-related deaths, and 138 recurrences (33%). An NLR of 3 was determined as the optimal cut-off value for predicting survival outcomes based on the inflection point of the ROC curves. Patients with NLR 3 had significantly worse survival outcomes (5y-RFS: 53% vs. 64%, logrank p1⁄40.013; 5y-CSS: 57% vs. 75%, log-rank p<0.001; 5y-OS: 43% vs. 64%, log-rank p<0.001). Upon adjusting for patient and diseasespecific predictors, NLR 3 was significantly associated with worse RFS (HR1⁄41.79; 95%CI1⁄41.22-2.63, p1⁄40.003), CSS (HR1⁄41.94; 95% CI1⁄41.44-2.60, p<0.001) and OS (HR1⁄41.66; 95%CI1⁄41.23-2.25, p1⁄40.001). The likelyhood ratio test confirmed that prognostic models were improved by including NLR. CONCLUSIONS: NLR is an inexpensive prognostic biomarker for patients undergoing radical cystectomy for UCB. It offers pre-treatment prognostic value in addition to established patient and disease-related prognostic indicators, and may be helpful in guiding treatment decisions.

MP57-16 THE IMPACT OF SURGERY ON THE PROGNOSIS OF METASTATIC RENAL CELL CARCINOMA WITH IVC THROMBUS

INTRODUCTION AND OBJECTIVES: Biomarkers may be useful as prognostic indicators prior to and during systemic therapy. We evaluated change in platelet count (DPlt) as a biomarker for response to neoadjuvant tyrosine kinase inhibitor (TKI) therapy for metastatic renal cell carcinoma (mRCC). METHODS: Multi-center retrospective study of mRCC patients undergoing neoadjvant TKI therapy from 5/2005-8/2013. DPlt was defined as post-treatment Plt after first cycle minus pre-treatment Plt. Primary outcome was response of disease to TKI defined by RECIST criteria for partial response (PR), stable disease (SD), and progressive disease (PD). Demographic and clinical characteristics were analyzed between subgroups with stable/increased (+DPlt) and decreased (-DPlt) counts. Cox proportional hazards model evaluated factors associated with changes in tumor response. Kaplan-Meier analysis estimated overall survival (OS) and compared Plt groups with log-rank test. Sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) were calculated for DPlt and disease response PR/SD. RESULTS: A total of 69 patients treated with neoadjuvant TKI therapy were analyzed for DPlt. Overall, 15 patients (22%) were noted to have +DPlt and 54 (78%) had eDPlt after neoadjuvant TKI therapy. There were no other differences in clinical or demographic variables between these two groups (comorbidities, ECOG, tumor size, number of metastases, stage, grade and number of TKI cycles). Patients with +DPlt count had a lower post TKI treatment creatinine (1.0 vs. 1.3, p1⁄40.041). PD was more common among +DPlt 86.7% vs. eDPlt 33.3%, (p1⁄40.001), and SD/PR was more common in eDPlt 66.7% vs. +DPlt 13.3%, (p1⁄40.001). On MVA, -DPlt below baseline was a significant predictor of SD/PR (OR 6.96, p1⁄40.028). A Kaplan Meier analysis (Figure) demonstrated a higher overall survival in -DPlt versus +DPlt (p1⁄40.009), with median survival 13.8 of and 5.7 months respectively. -DPlt had sensitivity of 94.7%, specificity of 41.9%, PPV of 66.7% and NPV of 86.7% for PR/SD after neoadjuvant TKI therapy. CONCLUSIONS: Patients with -DPlt were more likely to respond to TKI therapy and had longer median overall survival. Further investigation is requisite to determine the utility of DPlt as a biomarker for RCC response to TKI.