Single-Hit and Multi-hit PIK3CA Short Variant Genomic Alterations in Clinically Advanced Prostate Cancer: A Genomic Landscape Study

BACKGROUND

Tumors harboring two or more PIK3CA short variant (SV) ("multi-hit") mutations have been linked to improved outcomes with anti-PIK3CA-targeted therapies in breast cancer. The landscape and clinical implications of multi-hit PIK3CA alterations in clinically advanced prostate cancer (CAPC) remains elusive.

OBJECTIVE

To evaluate the genomic landscape of single-hit and multi-hit PIK3CA genomic alterations in CAPC.

PATIENTS AND METHODS

The Foundation Medicine FoundationCore database was used to identify 19,978 CAPC tumors that underwent hybrid capture-based comprehensive genomic profiling to evaluate all classes of genomic alterations (GA) and determine tumor mutational burden (TMB), microsatellite instability (MSI), genomic ancestry, single-base substitution mutational signatures, and homologous recombination deficiency signature (HRDsig). Tumor cell PD-L1 expression was determined by IHC (Dako 22C3).

RESULTS

18,741 (93.8%) tumors were PIK3CA wild type (WT), 1155 (5.8%) featured single PIK3CA SV, and 82 (0.4%) featured multi-hit PIK3CA SVs. Single-hit (6.6 versus 3.8; p < 0.0001) and multi-hit (12.8 versus 3.8; p < 0.0001) featured more driver GA per tumor than PIK3CA WT CAPC, as well as higher prevalence of MMR mutational signature, MSI high status, and TMB levels versus PIK3CA WT (p < 0.0001). Other differences in GA included higher frequencies of GA in BRCA2 in multi-hit versus WT (18.3% versus 8.5%; p = 0.0191), ATM in multi-hit versus WT (13.4% versus 5.6%; p = 0.02) and PTEN in single-hit versus WT (40.2% versus 30.1%; p < 0.0001). Homologous recombination deficiency signatures were higher in PIK3CA WT versus single-hit (11.2% versus 7.6%; p = 0.0002). There were no significant differences in PD-L1 expression among the three groups.

CONCLUSIONS

Identification of multi-hit PIK3CA GA in CAPC highlights a potentially unique phenotype that may be associated with response to anti-PIK3CA targeted therapy and checkpoint inhibition, supporting relevant clinical trial designs.

The Role of Maximal TURBT in Muscle-Invasive Bladder Cancer: Balancing Benefits in Bladder Preservation and Beyond

Radical cystectomy with lymph node dissection and urinary diversion is the gold-standard treatment for non-metastatic muscle-invasive bladder cancer (MIBC). However, in patients who refuse cystectomy, or in whom cystectomy carries a high risk, bladder-preserving therapies remain potential options. Bladder preservation therapies can include maximal debulking transurethral resection of bladder tumor (TURBT), concurrent chemoradiation therapy, followed by cystoscopy to assess response. At this time, maximal TURBT is recommended for patients prior to the initiation of chemoradiation therapy or in patients with residual bladder tumors after the completion of chemoradiation therapy. That being said, TURBT carries significant risks such as bladder perforation, bleeding, and infection, ultimately risking delayed systemic treatment. Hence, understanding its role within trimodal therapy is crucial to avoid undue suffering in patients. Herein, we review the current literature on the impact of debulking TURBT in non-metastatic MIBC.

Role of Cytoreductive Nephrectomy in Metastatic Clear Cell Renal cell Carcinoma in the Era of immunotherapy: An Analysis of the National Cancer Database

BACKGROUND

The effectiveness of the clinical outcome of CN (Cytoreductive Nephrectomy) in cases of mccRCC (Metastatic Clear Cell Renal cell Carcinoma) is still uncertain despite two trials, SURTIME and CARMENA. These trials, conducted with Sunitinib as the standard treatment, did not provide evidence supporting the use of CN.

METHODS

We queried the NCDB for stage IV mccRCC patients between the years of 2004 to 2020, who received (immunotherapy) IO with or without nephrectomy. Overall survival (OS) was calculated among three groups of IO alone, IO followed by CN (IOCN), CN followed by IO (CNIO). Cox models compared OS by treatment group after adjusting for sociodemographic, health, and facility variables.

RESULTS

From 1,549,101 renal cancer cases, 7983 clear and nonclear cell renal cell carcinoma cases were identified. After adjusting for sociodemographic and health covariates, patients who received IO followed by CN or CN followed by IO had a respective 64% (adjusted Hazard Ratio [aHR] = 0.36, 95% CI = 0.30-0.43, P = .006] and 47% (aHR = 0.53, 95% CI = 0.49-0.56, P = .001) mortality risk reduction respectively compared to patients who received IO alone. Compared to White adults, individuals who identified as Black exhibited 17% higher risk mortality (aHR = 1.17, 95% CI = 1.06-1.30, P = .002). Patients who received CN prior to IO had a 59% associated mortality risk compared to patients who received IO followed by CN who had a lower risk, 35.7% (P < .001).

CONCLUSIONS

Patients receiving CN regardless of sequence with IO did better than IO alone in this national registry-based adjusted analysis for mccRCC. Presently available data indicates that the combination of CN and IO holds promise for enhancing clinical results in patients with mRCC.

Efficacy and safety of PARP inhibitors in the treatment of prostatic cancer: a systematic review and network meta-analysis

BACKGROUND

Prostate cancer (PCa) is the most common cancer and the second leading cause of cancer-related death in men. Previous studies have shown that the poly (adenosine diphosphate-ribose) polymerase (PARP) inhibitors (PARPis) improve the treatment response of patients with metastatic castration-resistant PCa (mCRPC). However, the efficacy and safety of various PARPis in mCRPC patients remain unclear, presenting a significant challenge for clinicians when making treatment decisions. To address this, this study conducted two indirect comparisons to evaluate the efficacy and safety of four PARPis (olaparib, niraparib, rucaparib, and talazoparib) in patients with mCRPC.

METHODS

A systematic review and network meta-analysis (NMA) using Bayesian statistics was conducted. A comprehensive literature search was performed of the PubMed, Web of Science, Cochrane Library, Embase, and China National Knowledge Infrastructure (CNKI) databases to identify relevant studies from the inception to November 8, 2023, using search terms such as "PARP inhibitor", "olaparib", "rucaparib", "niraparib", "talazoparib", and "mCRPC". Phase 2/3 randomized controlled trials (RCTs) related to PARPi therapy and novel hormonal therapy in patients with mCRPC were included in the analysis. The targeted outcomes included radiographic progression-free survival (rPFS), overall survival (OS), adverse events (AEs), and grade ≥3 AEs. Four reviewers screened the titles and abstracts independently to assess the eligibility of each article. Two researchers independently extracted data from the included studies. The risk of bias and quality of the studies were assessed using the Risk-of-Bias 2 tool.

RESULTS

Six high-quality phase 2/3 clinical trials, comprising 3,205 individuals, were selected for the systematic review and NMAs. Two NMAs were conducted due to the different designs of the six clinical trials. The indirect comparison with a random-effects model of olaparib, niraparib, and talazoparib showed that olaparib significantly improved rPFS with a hazard ratio (HR) of 0.67 [95% confidence interval (CI): 0.46-0.96]; however, no such significant difference was observed in relation to olaparib and rucaparib. In terms of OS, no significant difference was observed among olaparib, niraparib, and talazoparib. In relation to the AEs, the PARPi interventions using olaparib, niraparib, and talazoparib increased the rates of grade ≥3 AEs with odds ratios (ORs) of 2.0 (95% CI: 0.89-5.3), 3.0 (95% CI: 1.3-7.4), and 3.7 (95% CI: 1.1-12.0), respectively. In the rank probability analysis, according to the surface under the cumulative ranking (SUCRA), olaparib ranked first, followed by niraparib, and talazoparib. Most of the included studies were assessed to be at low risk of bias.

CONCLUSIONS

Olaparib significantly improved rPFS among olaparib, niraparib, and talazoparib. Talazoparib exhibited the highest SUCRA value. Regarding safety, olaparib and rucaparib did not significantly increase the incidence of grade ≥3 AEs. When making personalized treatment decisions, clinicians should consider individual patient characteristics, treatment efficacy, and potential AEs.

Effect of climate on emergency department admissions for renal colic: a comparative analysis of sedentary and non-sedentary lifestyles

OBJECTIVE

To investigate the impact of climate and seasonal variations on emergency department (ED) admissions for renal colic, while specifically comparing the differences between individuals with sedentary and non-sedentary lifestyles.

PATIENTS AND METHODS

A retrospective, single center study was conducted. Between the years 2017- 2020, medical records of patients admitted to the ED with renal colic, found to harbor ureteric stones on CT scans, were examined. Data on patients' occupational activities was collected through telephone questionnaires. Patients were categorized into two groups: sedentary and active. Precise weather data was obtained from the Israeli Meteorological Service website. The monthly average daily maximum temperatures were calculated.

RESULTS

In the final sample of 560 participants, 285 were in the sedentary group, and 275 were in the active group. The study population consisted of 78.1% males and 21.9% females, with consistent gender ratios in both occupational groups. Prevalence of uric acid stones was higher in the sedentary group (p < 0.05). While there was a slight increase in admissions during the summer, seasonal distribution did not significantly differ among occupational groups. The study found no significant differences in admissions across different temperature ranges. Both groups exhibited a pattern of increased referrals during the summer and reduced referrals in the colder winter months. The baseline data revealed notable differences between the sedentary and active groups, particularly in the prevalence of uric acid stones.

CONCLUSIONS

Climate factors, including temperature and seasonal variations, had limited impact on ED admissions for renal colic in patients with kidney stones, irrespective of their sedentary or active lifestyles. Both groups exhibited similar admission patterns, with a higher rate of admissions during the summer and a lower rate of admissions during the winter.

Exploring the economic landscape of ureteric stones: impact of age and gender on direct healthcare costs

OBJECTIVES

To assess whether age or gender affects ureteric stone management costs, in patients presenting to the Emergency Department (ED) with CT proven ureteric stones.

PATIENTS AND METHODS

A retrospective examination was conducted on patients admitted to the ED who were diagnosed with a ureteric stone through CT scans. Data encompassing clinical, laboratory, and imaging parameters were gathered, alongside information on admissions, ED readmissions, surgical procedures, and the overall treatment cost. Comparative analyses were performed on various cost rates in relation to different stone parameters, patient clinical presentations, laboratory results, and personal histories of urolithiasis.

RESULTS

From January 2018 to January 2020, 805 patients underwent abdominal CT scans at a single institution's ED and were diagnosed with ureteric stones. Among them, 773 patients met the inclusion criteria, with 78% (609) being males and 22% (169) females. The mean ages for males and females were 49.4 (SD 14.4) and 51.6 (SD 15.7), respectively (p = 0.08). Treatment costs exhibited a direct relationship with age, amounting to 4,025, 5,116, 6,058, and 9,225 US dollars (USD) in the 18-30, 31-50, 51-70, and over 70 age groups, respectively. Female gender was associated with higher treatment costs, averaging 6,831 USD, compared to 5,450 USD in males (p = 0.03). However, there were no significant differences between genders in terms of the type of surgical procedure (p = 0.4) or hospital stay duration (p = 0.1).

CONCLUSIONS

Age and gender exerted a significant impact on treatment costs, revealing that advanced age and female gender were both correlated with higher direct treatment costs in the care of ureteric stones.

Risk of Secondary Malignancies After Pelvic Radiation: A Population-based Analysis

Background and objective

Radiation therapy has increasingly been used in the management of pelvic malignancies. However, the use of radiation continues to pose a risk of a secondary malignancy to its recipients. This study investigates the risk of secondary malignancy development following radiation for primary pelvic malignancies.

Methods

A retrospective cohort review of the Surveillance, Epidemiology, and End Results database from 1975 to 2016 was performed. Primary pelvic malignancies were subdivided based on the receipt of radiation, and secondary malignancies were stratified as pelvic or nonpelvic to investigate the local effect of radiation.

Key findings and limitations

A total of 2 102 192 patients were analyzed (1 189 108 with prostate, 315 026 with bladder, 88 809 with cervical, 249 535 with uterine, and 259 714 with rectal/anal cancer). The incidence rate (defined as cases per 1000 person years) of any secondary malignancies (including but not limited to secondary pelvic malignancies) was higher in radiation patients than in nonradiation patients (incidence rate ratio [IRR] 1.04, confidence interval [CI] 1.03-1.05), with significantly greater rates noted in radiation patients with prostate (IRR 1.22, CI 1.21-1.24), uterine (IRR 1.34), and cervical (IRR 1.80, CI 1.72-1.88) cancer. While the overall incidence rate of any secondary pelvic malignancy was lower in radiation patients (IRR 0.79, CI 0.78-0.81), a greater incidence was still noted in the same cohorts including radiation patients with prostate (IRR 1.42, CI 1.39-1.45), uterine (IRR 1.15, CI 1.08-1.21), and cervical (IRR 1.72, CI 1.59-1.86) cancer.

Conclusions and clinical implications

Except for localized cervical cancer, when put in the context of median overall survival, the impact of radiation likely does not carry enough weight to change practice patterns. Radiation for pelvic malignancies increases the risk for several secondary malignancies, and more specifically, secondary pelvic malignancies, but with a relatively low absolute risk of secondary malignancies, the benefits of radiation warrant continued use for most pelvic malignancies. Practice changes should be considered for radiation utilization in malignancies with excellent cancer-specific survival such as cervical cancer.

Patient summary

The use of radiation for the management of pelvic malignancies induces a risk of secondary malignancies to its recipients. However, the absolute risk being low, the benefits of radiation warrant its continued use, and a change in practice patterns is unlikely.

Trends in Emergency Department Admissions Due to Renal Colic in the Pediatric Population: A Multicenter Study

BACKGROUND

Pediatric urolithiasis is relatively uncommon and is generally associated with predisposing anatomic or metabolic abnormalities. In the adult population, emergency department (ED) admissions have been associated with an increase in ambient temperature. The same association has not been evaluated in the pediatric population.

OBJECTIVES

To analyze trends in ED admissions due to renal colic in a pediatric population (≤ 18 years old) and to assess the possible effect of climate on ED admissions.

METHODS

We conducted a retrospective, multicenter cohort study, based on a computerized database of all ED visits due to renal colic in pediatric patients. The study cohort presented with urolithiasis on imaging during their ED admission. Exact climate data was acquired through the Israeli Meteorological Service (IMS).

RESULTS

Between January 2010 and December 2020, 609 patients, ≤ 18 years, were admitted to EDs in five medical centers with renal colic: 318 males (52%), 291 females (48%). The median age was 17 years (IQR 9-16). ED visits oscillated through the years, peaking in 2012 and 2018. A 6% downward trend in ED admissions was noted between 2010 and 2020. The number of ED admissions in the different seasons was 179 in autumn (30%), 134 in winter (22%), 152 in spring (25%), and 144 in summer (23%) (P = 0.8). Logistic regression multivariable analysis associated with ED visits did not find any correlation between climate parameters and ED admissions due to renal colic in the pediatric population.

CONCLUSIONS

ED admissions oscillated during the period investigated and had a downward trend. Unlike in the adult population, rates of renal colic ED admissions in the pediatric population were not affected by seasonal changes or rise in maximum ambient temperature.

Disparities Associated with Shared Decision-making in Prostate Cancer Screening

BACKGROUND

Prostate cancer screening guidelines recommend shared decision-making (SDM) regarding prostate-specific antigen (PSA) testing. However, it is unclear who undergoes SDM and whether any disparities exist.

OBJECTIVE

To examine sociodemographic differences in participation of SDM and its association with PSA testing in prostate cancer screening.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cross-sectional study was conducted among men aged 45-75 yr undergoing PSA screening, using the 2018 National Health Interview Survey database. The evaluated sociodemographic features included age, race, marital status, sexual orientation, smoking status, working status, financial difficulty, US geographic regions, and cancer history. Questions regarding self-reported PSA testing and whether respondents discussed its advantages and disadvantages with their healthcare provider were analyzed.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Our primary outcome was to evaluate the possible associations between various sociodemographic factors and undergoing PSA screening and SDM. We used multivariable logistic regression analyses to detect potential associations.

RESULTS AND LIMITATIONS

A total of 59596 men were identified, of whom 5605 answered the question regarding PSA testing, with 2288 (40.6%) undergoing PSA testing. Of these men, 39.5% (n = 2226) discussed the advantages and 25.6% (n = 1434) discussed the disadvantages of PSA testing. On a multivariable analysis, older (odds ratio [OR] 1.092; 95% confidence interval [CI] 1.081-1.103, p < 0.001) and married (OR 1.488; 95% CI 1.287-1.720, p < 0.001) men were more likely to undergo PSA testing. Although Black men were more likely to discuss PSA advantages (OR 1.421; 95% CI 1.150-1.756, p = 0.001) and disadvantages (OR 1.554; 95% CI 1.240-1.947, p < 0.001) than White men, this did not correlate with higher rates of PSA screening (OR 1.086; 95% CI 0.865-1.364, p = 0.477). The lack of important clinical data remains a limitation.

CONCLUSIONS

Overall, SDM rates were low. Older and married men had an increased likelihood of SDM and PSA testing. Despite higher rates of SDM, Black men had similar rates of PSA testing to White men.

PATIENT SUMMARY

We evaluated sociodemographic differences in shared decision-making (SDM) in prostate cancer screening using a large national database. We found that SDM had varying results in different sociodemographic groups.

Effect of gender on presentation and outcome of renal colic

OBJECTIVES

To examine gender-related differences in the presentation, management, and outcomes of patients admitted to the emergency department ED with ureteral stones.

METHODS

Retrospective analysis of all patients admitted to the ED at our institution, found to have a ureteral stone on CT. Clinical, laboratory, imaging parameters, and outcomes were collected.

RESULTS

778 patients were admitted with ureteral stones between January 2018 and December 2020. 78% (n = 609) were males and 22% (n = 169) were females. The mean ages were 49.4 (SD 14.4) and 51.6 (SD 15.7) in males and females, respectively (p = 0.08). Female patients presented with a higher body temperature (p = 0.01), pulse rate (p < 0.0001), nausea and vomiting (p < 0.0001), elevated serum C-reactive protein (CRP) (p = 0.002) compared to males. The prevalence of elevated serum creatinine was higher in males (p < 0.0001). Alpha-blockers were recommended on discharge in 54.8% (334) of males, compared to only 29.6% (50) of females (p < 0.0001). Spontaneous stone expulsion was significantly higher in males compared to females (p = 0.01).

CONCLUSIONS

Our results demonstrate that gender does effect presentation and outcome of patients presenting with renal colic. Females were found to have elevated infectious parameters, more nausea and vomiting and a higher incidence of positive urine cultures. Males admitted to the ED were found to have significantly higher serum creatinine levels. Medical expulsive therapy (MET) with alpha-blockers was prescribed significantly less in female patients, which may have resulted in a lower spontaneous stone expulsion rate.

Metastatic Testicular Cancer Patterns and Predictors: A Contemporary Population-based SEER Analysis

OBJECTIVE

To elucidate clinical and demographic predictors of metastatic testicular cancer (TC) at presentation and study the impact of these factors on prognosis. Patients with metastatic TC experience poorer outcomes than those with localized or locoregional disease. Social determinants of health may compound this trend.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was queried to identify 16,528 patients aged ≥18 with TC diagnosed from 2010 to 2016. Descriptive statistics were analyzed using Fisher exact test and Pearson chi-square test for continuous and categorical variables. Predictors of specific metastases and factors impacting cancer-specific mortality (CSM) were evaluated using multivariate logistic regression analysis and competing risks regression, respectively.

RESULTS

Of 16,474 patients with complete data, 1877 (11.39%) had distant metastases at diagnosis. These patients more commonly featured disease-specific and demographic variables associated with worse health outcomes (all P < .001). Lung metastases were the predominant site of synchronous and solitary metastases. Disease-specific predictors of metastasis included T stage, histology, tumor size, lymphovascular invasion, and cryptorchidism. Patient-specific predictors included age, geography, ethnicity, race, marital status, and socioeconomic status. Nearly one-fourth of patients with metastases died. Poor CSM was predicted by histology, age, insurance status, and socioeconomic status. All metastatic sites except bone were associated with worse CSM, with lung metastases conferring the greatest risk.

CONCLUSION

This cross-sectional study identifies variables associated with TC metastasis and survival, particularly highlighting the importance of social determinants of health in TC mortality. These findings can facilitate a risk-stratified approach to staging and management while supporting new approaches to target disparities.

Post-operative pain following percutaneous nephrolithotripsy- clinical correlates

OBJECTIVES

Management of postoperative pain following percutaneous nephrolithotripsy (PCNL) is a significant goal. We sought to identify risk factors and clinical correlates of postoperative pain in order to improve perioperative management and patient satisfaction.

MATERIALS AND METHODS

A single-center, retrospective analysis, from a prospectively maintained database, of all consecutive patients who underwent PCNL for renal calculi between January 2011 and August 2018. Postoperative pain was assessed using the visual analog scale (VAS) and analgesic use. We considered VAS score above 4 as meaningful. Pain management was standardized according to patirnt reported VAS scores. Multivariable logistic regression was performed to identify risk factors and clinical correlates.

RESULTS

A total of 496 patients were analyzed. Younger age was associated with VAS above 4 on the operative day and the first postoperative following PCNL (p = 0.003 and p < 0.001, respectively). Female gender was associated with VAS above 4 in the first 2 days following the operation (p < 0.001).

CONCLUSIONS

Younger age and female gender would most likely benefit from pre-emptive improved pain management protocols following PCNL.

Does a prior cancer diagnosis impact PSA testing? Results from the National Health Interview Survey

INTRODUCTION

Prostate-specific antigen (PSA) testing remains a controversial issue. However, most urological guidelines recommend PSA testing in men aged 55-69 through a shared decision-making process with the patient. The impact of prior cancer diagnosis on PSA testing is not well-known. To compare PSA testing in men aged 55-69 years with and without a history of cancer (excluding prostate cancer patients).

MATERIALS AND METHODS

Utilizing the National Health Interview Survey (NHIS), a retrospective cross-sectional study during the year 2018 was carried out. Multivariable logistic regression analysis was implemented to demonstrate potential associations with PSA testing and assess the association of cancer history.

RESULTS

A total of 2,892 men aged 55-69 years from the NHIS survey who met the inclusion criteria were analyzed. A total of 308 (10.7%) men had a history of cancer (non-prostate). Men with a cancer history had a higher number of PSA tests and more recent testing than men with no previous cancer history. On multivariable analysis, men who were previously diagnosed with cancer had a higher likelihood of undergoing PSA testing compared to men with no history of cancer (OR: 1.87, 95% CI 1.39-2.52, p < 0.0001).

CONCLUSIONS

Our data suggest that men aged 55-69 with a history of cancer are more likely to undergo PSA testing than men with no cancer history.

The Current Role of Lymph Node Dissection in Nonmetastatic Localized Renal Cell Carcinoma

PURPOSE

To explore the current role of lymph node dissection (LND) in the management of nonmetastatic localized renal cell carcinoma (RCC).

BACKGROUND

There is currently no proven benefit of LND in the setting of RCC, and its role remains controversial because of conflicting evidence. Patients who may benefit from LND are those at greatest risk of nodal disease, but the tools used to predict nodal involvement are limited due to unpredictable retroperitoneal lymphatics. The indications, templates, and extent of LND are also not standardized, adding to the ambiguity of current guidelines surrounding its use.

EVIDENCE ACQUISITION

A PubMed search of the literature from January 2017 to December 2022 was conducted using the search terms "renal cell carcinoma" or "renal cancer" in combination with "lymph node dissection" or "lymphadenectomy". Case studies and editorials were excluded, whereas studies investigating the therapeutic effect of LND were classified as either demonstrating a benefit or no benefit. References of the studies and review articles were also searched for notable studies and findings that were outside the five-year literature search. The studies in this review were restricted to the English language.

RESULTS

Only a number of studies in recent years have found an association between the extent of LND and increased survival. Most studies do not indicate an associated benefit, and some even suggest a negative effect on survival. Most of these studies are retrospective.

CONCLUSION

The therapeutic value of LND in RCC is still unclear, and although prospective data are needed, its declining rates and emerging new therapies make this unlikely. A better understanding of renal lymphatics and improved detection of nodal disease may help determine the role of LND in nonmetastatic localized RCC.

Age related differences in primary testicular lymphoma: A population based cohort study

INTRODUCTION

Primary testicular non-Hodgkin's lymphoma (PTL) is a very rare disease, comprising 1% of all non-Hodgkin's lymphoma and <5% of all cases of testicular tumors. With a median age at diagnosis of 67 years, PTL is the most common testicular malignancy in men aged >60 years. There is limited published data on PTL incidence and outcomes in younger patients. The aim of this study is to compare the clinical parameters and survival outcomes between the patients older and younger than 50.

METHODS

The SEER database was queried for all patients diagnosed with PTL between 1983 and 2017. Data collected consisted of demographic, and clinical parameters, including staging, pathological assessments, and survival data. Patients were stratified according to their age and compared.

RESULTS

There was a total of 1,581 patients diagnosed with PTL between the year 2000 and 2017, of whom 215 (13.6%) were younger than 50 years old. The median age at diagnosis was 41 (interquartile range [IQR] 1-50), and 72 (IQR 51-95) years old for patients ≤50 and patients > 50 years of age, respectively. Comparison of younger and older patients detected similarities in disease laterality (92% vs. 94%, P = 0.38) and Ann Arbor stage I to II at diagnosis (76% vs. 75%, P = 0.59). The most common diffuse large B-cell lymphoma (DLBCL) subtype was more common in older patients (61% vs. 87%, P < 0.001). Radical orchiectomy (71% vs. 79%, P = 0.004) and radiation treatment (40% vs. 37%, P = 0.49) rates were comparable between both groups. However, a higher proportion of younger patients underwent chemotherapy (83% vs. 72%, P < 0.001). Patients ≤50 and >50 years old had a hazard ratio (HR) of 0.63 (95% CI: 0.57-0.71) and 0.34 (95% CI: 0.31-0.37), respectively, for 10-year OS with a median survival time for patients >50 of 5.75 years (95% CI: 5.25-6.33), P < 0.001. Patients ≤50 years old had a HR of 0.33 (95% CI: 0.26-0.40) compared to HR of 0.40 (95% CI: 0.37-0.43) in patients >50 years old for cumulative disease-specific mortality (DSM, P = 0.0204). Age >50 years was associated with worse DSM with a HR of 1.39 (95% CI: 1.05- 1.86, P = 0.024). Ann Arbor stage II and higher was also associated with worse DSM, while undergoing surgery, radiotherapy, and chemotherapy were associated with improved DSM.

CONCLUSIONS

PTL is the most common testicular malignancy in men older than 60 years of age, but more than a quarter of the patients are younger than 60 and more than 13% are ≤50 years. Younger patients are more likely to receive chemotherapy and radiation, and overall do better in terms of DSM. Being younger, having a lower Ann Arbor stage and being treated with chemotherapy and radiotherapy increase the chances of survival.

Predicting perioperative complications for partial versus radical nephrectomy in T1b-T2 renal cell carcinoma

737

Background: The standard of care for larger localized RCC lesions is radical (RN) or partial (PN) nephrectomy. RN is increasingly utilized to maximize oncologic benefit in complex tumors. Although PN is a more technically complex procedure, its nephron-sparing nature confers lasting renal and cardiovascular benefits. We utilized the National Surgical Quality Improvement Program (NSQIP) database to elucidate predictors of perioperative morbidity in T1b-T2 RCC patients. Methods: Using the NSQIP Nephrectomy-Targeted PUF, 2,094 patients undergoing nephrectomy between 2019-2020 for localized T1b-T2 RCC were identified. Variables of interest included surgical procedure and approach, tumor stage, demographics, pre-operative laboratory values, comorbidities, infection and venothromboembolism (VTE) prophylaxis techniques, peri-operative complications, operative time, length of hospital stay, 30-day reoperations, and 30-day readmissions. Chi square test was used to analyze univariate associations between certain comorbidities and complications. Multivariate regression analysis was utilized to compare complication rates between PN and RN after adjusting for baseline characteristics and surgical approach. p<0.05 was considered statistically significant. Results: 816 patients received PN while 1,278 received RN. PN patients had an increase in the following events: 30-day readmissions (7.0% vs. 4.7%, p=0.026), major bleeds (9.19% vs. 5.56%, p=0.001), renal failure requiring dialysis (1.23% vs. 0.31%, p=0.013), and urine leak or ureteric fistulae (1.10% vs. 0.31%, p=0.025). Open surgery was associated with increased VTE, renal failure, bleeds, urine leaks or ureteric fistulae, readmissions, and reoperations. Multivariate analysis revealed that PN remained predictive of all four aforementioned events, although further adjustment for robotic approach led to a loss of significance for renal failure and ureteric fistulae. Additional patient-specific predictors of relevant complications across procedure type included bleeding disorder and dialysis for bleeds, and renal failure, steroid use, and COPD for readmissions. Conclusions: This is the first study to evaluate the new NSQIP Nephrectomy-Targeted PUF. This population-based cohort provides unique insights into nephrectomy for pT1b-T2 localized RCC. We demonstrate significant associations between PN and specific complications, modulated by particular comorbidities, although both PN and RN were exceedingly safe. This analysis supports the development of novel risk stratification tools which account for specific patient comorbidities in predicting near term risk. Improved understanding of case-specific determinants of morbidity following PN or RN may facilitate shared decision making in localized RCC management.

Novel synthetic lethality drug target in urothelial bladder cancer based on MTAP genomic loss

BACKGROUND

When urothelial carcinoma of the bladder (UCB) presents or progresses to chemo-refractory metastatic disease, the search for new therapeutic targets is paramount. Targeting protein arginine methyltransferase 5 accumulation in tumors with methylthioadenosine phosphorylase (MTAP) genomic loss has been proposed as a new anti-tumor strategy. We evaluated the incidence of patients with MTAP loss and correlate to treatment-guiding targets and biomarkers.

METHODS

Two thousand six hundred eighty-three cases of advanced UCB underwent hybrid-capture based comprehensive genomic profiling using the FDA-approved F1CDx assay to evaluate all classes of genomic alterations (GA) among 324 genes. Tumor mutational burden was determined on at least 0.8 Mbp of sequenced DNA and microsatellite instability was determined on at least 95 loci.

RESULTS

650 (24%) of UCB featured MTAP loss mutations (MTAP-). The gene and age distributions were similar in MTAP intact (MTAP+) and MTAP- UCB. MTAP- UCB contained higher GA/tumor frequency than MTAP+ UCB likely reflecting the frequent co-deletions of cyclin-dependent kinase inhibitor 2A/B. Of potential therapeutic targets, fibroblast growth factor receptor 3, and phosphatase and tensin homolog GA were more frequent in MTAP- UCB. In contrast, biomarkers of immunotherapy response, including higher frequencies of high tumor mutational burden and high programmed death-ligand 1 IHC staining, were observed in the MTAP+ UCB.

CONCLUSIONS

When compared with MTAP+ UCB, MTAP- UCB differs in genomic signatures including an increase in potentially targetable alterations but a lower frequency of immunotherapy drug biomarkers. Thus, the genomic landscape in MTAP- UCB may play a role in the design of clinical trials incorporating combination treatment strategies when targeting protein arginine methyltransferase 5 in MTAP- tumors.

Retrograde intrarenal surgery for lower pole stones utilizing stone displacement technique yields excellent results

Objective

To evaluate the long-term stone-free rate (SFR) of retrograde intra-renal surgery (RIRS) in the treatment of lower pole renal calculi using only basket relocation and identify independent predictors of stone-free status.

Methods

All consecutive patients undergoing RIRS lower pole renal calculi at a single high-volume tertiary center were analyzed retrospectively. Lower pole stones were relocated to the upper pole, where laser lithotripsy was performed. All patients were followed up in the clinic following the surgery and yearly thereafter. The stone-free status was assessed with a combination of an abdominal ultrasound and abdominal X-ray, or an abdominal non-contrast computed tomography if the stones were known to be radiolucent.

Results

A total of 480 consecutive patients who underwent RIRS for treatment of lower pole renal calculi, between January 2012 and December 2018, were analyzed from a prospectively maintained database of 3000 ureteroscopies. With a median follow-up time of 18.6 months, the mean SFR was 94.8%. The procedures were unsuccessful in 26 (5.4%) patients due to unreachable stones. The median stone size of the unreachable stones was 12 mm (range 10-30 mm). Multivariable logistic regression analysis revealed two predictors of SFR for lower pole stones: a small cumulative stone burden (odds ratio [OR]: 0.903, 95% confidence interval [CI]: 0.867-0.941, p<0.0001) and preoperative ureteral stent insertion (OR: 0.515, 95% CI: 0.318-0.835, p=0.007).

Conclusion

The long-term SFR of RIRS for the treatment of lower pole stones with basket displacement with appropriate patient selection is high.

Does antithrombotic use enable earlier diagnosis of bladder cancer? A brief institutional assessment

INTRODUCTION

Wallis et al (JAMA 2017) demonstrated use of antithrombotic medications (ATMs) is associated with increased prevalence of hematuria-related complications and subsequent bladder cancer diagnosis within 6 months. Stage of diagnosis was lacking in this highly publicized study. This study examined the association of ATM use on bladder cancer stage at the time of diagnosis.

MATERIALS AND METHODS

We completed a retrospective chart review of patients with a bladder cancer diagnosis at our institution. Patient demographics and bladder cancer work up information were assessed. Patients were stratified based on use of ATMs at time diagnosis. Descriptive statistics were completed to identify association between ATM use and stage of bladder cancer diagnosis, as stratified by non-muscle invasive bladder cancer (NMIBC) versus muscle invasive bladder cancer (MIBC).

RESULTS

A total of 1052 patient charts were reviewed. Eight hundred and forty-four were included and 208 excluded due to unavailability of diagnosis history. At diagnosis, 357 (42.3%) patients were taking ATMs. Patients on ATMs presented with NMIBC at similar rates as patients not taking ATMs (81.2% vs. 77.8%, p = 0.23). Subgroup analysis by ATM class similarly demonstrated no statistically significant differences in staging.

CONCLUSION

While Wallis et al established that patients on blood thinners who present with hematuria are more likely to be diagnosed with genitourinary pathology, this factor does not appear to enable an earlier diagnosis of bladder cancer. Future study may assess hematuria at presentation (gross, microscopic), type of blood thinners, and low versus high risk NMIBC presentation.

Role of Rucaparib in the Treatment of Prostate Cancer: Clinical Perspectives and Considerations

Prostate cancer is one of the most common types of cancer worldwide and has strong genetic associations. This is important for the development of therapeutics for the condition, as metastatic castrate-resistant prostate cancer (mCRPC) is resistant to standard androgen deprivation therapy (ADT) and has a relatively poor prognosis. We conducted a literature review on rucaparib, a poly(adenosine diphosphate-ribose) polymerase (PARP) inhibitor that is currently indicated for the treatment of patients with mCRPC who harbor mutations in BRCA1/2 (homologous recombination repair [HRR] genes) and who have already tried androgen receptor-axis-targeted therapies (ARAT) and a taxane chemotherapy. We describe rucaparib's FDA approval, which was based on the results of the single-arm, open-label, Phase II TRITON2 clinical trial, which found an objective response rate (ORR) of 43.5%, a duration of response (DOR) of over six months in length and an acceptable safety profile. Rucaparib's dosage and clinical considerations for use were also discussed. We also compared rucaparib's use and safety profile with Olaparib, niraparib and talazoparib, three other PARP inhibitors tested for the treatment of mCRPC. Overall, initial results show that the safety profile of all four drugs in mCRPC was relatively similar, and further testing is currently indicated for all four. Differences in their metabolism, however, also warrant further research. The clinical validity of rucaparib will be tested by the follow-up TRITON3 clinical trial, which is comparing the effect of rucaparib compared to standard therapies for mCRPC harboring BRCA1/2 or ATM mutations. Other than TRITON3, other clinical trials are testing rucaparib's ability against other cancers (prostate or otherwise) with HRR mutations, and also the efficacy of combination therapies involving rucaparib. Finally, more research is needed to elucidate rucaparib's effect on HRR mutations other than BRCA1/2. Advancements in understanding the genetic landscape of mCRPC will also assist in understanding rucaparib's full therapeutic potential.

Spontaneous stone expulsion in patients with history of urolithiasis

Objectives:

To examine differences in the presentation, management, and outcomes of patients admitted to the emergency department (ED) with ureteral stones, with prior history of urolithiasis compared to patients with a first stone event.

Patients and Methods:

Retrospective analysis of patients who visited the ED that were found to have a ureteral stone on CT. Patients were stratified into two groups: without history of urolithiasis (Group 1) and with history of urolithiasis (Group 2).

Results:

Between 2018 and 2020, 778 patients were admitted with ureteral stones. Patients in group 1 presented with a higher mean serum creatinine ( p = 0.02), larger mean stone size ( p < 0.0001), and a higher proportion of proximal ureteral stones ( p < 0.0001) than patients in group 2. The 30 day readmission rate was significantly higher in group 1 ( p = 0.02). Spontaneous stone expulsion was higher in group 2 ( p < 0.0001), whereas the need for endourological procedures was higher in group 1 ( p < 0.0001). On multivariable analysis serum creatinine (OR 0.264, 95% CI 0.091–0.769, p = 0.01) and stone size (OR 0.623, 95% CI 0.503–0.771, p < 0.0001) were associated with a lower spontaneous stone expulsion rate. History of prior endourological procedures (OR 0.225, OR 0.066–0.765, p = 0.01) was associated with a higher spontaneous stone expulsion rate.

Conclusions:

Our data suggests that patients who are first time stone formers present with larger and more proximal ureteral stones, with a lower likelihood of spontaneous stone expulsion and a subsequent need for surgical intervention. Previous stone surgery and not previous stone expulsion was found to be a predictor for spontaneous stone passage.