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Nam C, Alemozaffar M, Said M, Patil D, Master V. MP49-15 AVOIDING THE NEED FOR BOWEL ANASTOMOSIS DURING PELVIC EXENTERATION - URINARY SIGMOID CONDUIT - SHORT AND LONG TERM COMPLICATIONS. J Urol 2018. [DOI: 10.1016/j.juro.2018.02.1606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Alemozaffar M. V05-05 ROBOTIC ANTERIOR EXENTERATION IN FEMALES– TIPS AND TRICKS. J Urol 2018. [DOI: 10.1016/j.juro.2018.02.1392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Patil DH, Anastasiades EN, Torlak M, Lay A, Alemozaffar M, Pattaras J, Kucuk O, Carthon BC, Bilen MA, Ogan K, Master VA. Evaluation of serial measurements of C-reactive protein: Albumin ratio in patients with clear cell renal cell carcinoma. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.6_suppl.695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
695 Background: Sequential measurements of prognostic markers is an important protocol for accurate prediction of clinical outcomes in clear cell RCC. We propose that change in value of C-Reactive Protein to albumin ratio before and after surgery would be a good prognostic indicator for assessment of overall survival and risk stratification in clear cell RCC. Methods: Patients that underwent nephrectomy for clear cell RCC between 2007 and 2016 were followed up with CRP-Albumin measurements for 3 post-op visits (1, 3, 6 months). All measurements between post-op day 1 to 21 were excluded from analysis owing to possible confounding effect due to surgical stress. We assessed if change in CRP-Albumin ratio from pre-operative level is associated with any patient and tumor characteristics by fitting linear regression generalized estimating equations models to account for correlation in repeated measures. Average change in level for each post-op visit was used to stratify for an eventual end of follow-up outcome. Results: 302 clear cell RCC patients were treated with nephrectomy with mean age at surgery was 59.9±11 years, and mean BMI of 30.1± 6.6. 103 patients had at least 2 time-points available after surgery. Table 1 depicts mean CRP-Albumin ratio with 95% CI for each visit stratified with vital status. A linear GEE model fitted for baseline factors affecting change in ratio , identified t-stage, Fuhrman nuclear grade, gender, and BMI as significantly associated (p < 0.05). Conclusions: Serial measurement of CRP/Albumin ratio is useful factor for personalized risk-stratification for prognosticating overall survival as well as recurrence in patients with clear cell RCC. Significant effect of T-stage, tumor grade, and BMI depicts close relationship of CA-ratio and established risk predictors. [Table: see text]
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Patil DH, Williams S, Torlak M, Alemozaffar M, Lay A, Pattaras J, Kucuk O, Carthon BC, Bilen MA, Ogan K, Master VA. Evaluation of preoperative C-reactive protein: Albumin ratio in patients with clear cell renal cell carcinoma. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.6_suppl.690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
690 Background: Multiple inflammatory markers have been evaluated in predicting preoperative risk in patient’s undergoing curative nephrectomy for Clear cell renal cell carcinoma. We propose that ratio of C-Reactive Protein to albumin (CA-ratio) would prove to be a good prognostic indicator for assessment of overall survival and comparable to established nomograms in clear call RCC. Methods: Patients that underwent nephrectomy for localized clear cell RCC between 2007 and 2016 were retrospectively identified. The optimal threshold for individual biomarkers among the panel was determined using grid search methodology, receiver operating characteristic (ROC) analysis, and sensitivity-specificity trade-off analysis. Prognostic value of CA-ratio was analyzed using the Kaplan-Meier method and Cox proportional regression models. ROC and chi-square analyses were performed to compare the predictive ability of CA-ratio to SSIGN, and UISS. Results: Among the 433 clear cell RCC patients treated with nephrectomy, mean age at surgery was 58.4±12, and mean BMI was 30.6±6.8. 158 (36.5%) had CA-ratio < 0.1, while 164 (37.9%) were between 0.1-0.2, and 111 (25.6%) were 0.2+. Pathological T-stage was distributed as follows: T1: 294 (67.9%), T2: 29 (6.7%), T3: 106 (24.5%), and T4: 4 (0.9%). Overall, 60 (13.9%) patients died before end of the follow-up. Area under the curve (AUC) for CA-ratio was 0.72, comparable to SSIGN (AUC 0.73, p = 0.12). On multivariate COX proportional hazards analysis, patients with ratio 0.2 or more were more likely to die compared to patients with ratio < 0.1 [HR:3.45 95%CI:1.68-7.10, p = < 0.001], while adjusting for T-stage, grade, necrosis, and age. Conclusions: CA-ratio is an cost-effective , independent and significant predictor of overall survival in clear cell RCC with accuracy at least as good as other established prognostic tools including SSIGN and UISS. [Table: see text]
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Chopra S, Liu J, Alemozaffar M, Nichols PW, Aron M, Weisenberger DJ, Collings CK, Syan S, Hu B, Desai M, Aron M, Duddalwar V, Gill I, Liang G, Siegmund KD. Improving needle biopsy accuracy in small renal mass using tumor-specific DNA methylation markers. Oncotarget 2018; 8:5439-5448. [PMID: 27690297 PMCID: PMC5354921 DOI: 10.18632/oncotarget.12276] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 09/20/2016] [Indexed: 01/17/2023] Open
Abstract
Purpose The clinical management of small renal masses (SRMs) is challenging since the current methods for distinguishing between benign masses and malignant renal cell carcinomas (RCCs) are frequently inaccurate or inconclusive. In addition, renal cancer subtypes also have different treatments and outcomes. High false negative rates increase the risk of cancer progression and indeterminate diagnoses result in unnecessary and potentially morbid surgical procedures. Experimental Design We built a predictive classification model for kidney tumors using 697 DNA methylation profiles from six different subgroups: clear cell, papillary and chromophobe RCC, benign angiomylolipomas, oncocytomas, and normal kidney tissues. Furthermore, the DNA methylation-dependent classifier has been validated in 272 ex vivo needle biopsy samples from 100 renal masses (71% SRMs). Results In general, the results were highly reproducible (89%, n=70) in predicting identical malignant subtypes from biopsies. Overall, 98% of adjacent-normals (n=102) were correctly classified as normal, while 92% of tumors (n=71) were correctly classified malignant and 86% of benign (n=29) were correctly classified benign by this classification model. Conclusions Overall, this study provides molecular-based support for using routine needle biopsies to determine tumor classification of SRMs and support the clinical decision-making.
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Patel AP, Melnick K, Sekar R, Patil D, Pattaras JG, Alemozaffar M, Filson CP, Nieh PT, Ogan K, Master VA. Relationship Between Preoperative C-Reactive Protein and Fuhrman Nuclear Grade in Stage T1 Renal Cell Carcinoma: A Short-Term Update. J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Sekar RR, Patil D, Baum Y, Pearl J, Bausum A, Bilen MA, Kucuk O, Harris WB, Carthon BC, Alemozaffar M, Filson CP, Pattaras JG, Nieh PT, Ogan K, Master VA. A novel preoperative inflammatory marker prognostic score in patients with localized and metastatic renal cell carcinoma. Asian J Urol 2017; 4:230-238. [PMID: 29387555 PMCID: PMC5773049 DOI: 10.1016/j.ajur.2017.04.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 10/10/2016] [Accepted: 02/06/2017] [Indexed: 12/26/2022] Open
Abstract
Objective Several inflammatory markers have been studied as potential biomarkers in renal cell carcinoma (RCC), however few reports have analyzed their prognostic value in aggregate and in non-clear cell histologies. We hypothesize that a combination of specific inflammatory markers into an RCC Inflammatory Score (RISK) could serve as a rigorous prognostic indicator of overall survival (OS) in patients with clear cell and non-clear cell RCC. Methods Combination of preoperative C-reactive protein (CRP), albumin, erythrocyte sedimentation rate (ESR), corrected calcium, and aspartate transaminase to alanine transaminase (AST/ALT) ratio was used to develop RISK. RISK was developed using grid-search methodology, receiver-operating-characteristic (ROC) analysis, and sensitivity-specificity trade-off analysis. Prognostic value of RISK was analyzed using the Kaplan–Meier method and Cox proportional regression models. Predictive accuracy was compared with RISK to Size, Size, Grade, and Necrosis (SSIGN) score, University of California-LOS Angeles (UCLA) Integrated Staging System (UISS), and Leibovich Prognosis Score (LPS). Results Among 391 RCC patients treated with nephrectomy, area under the curve (AUC) for RISK was 0.783, which was comparable to SSIGN (AUC 0.776, p = 0.82) and UISS (AUC 0.809, p = 0.317). Among patients with localized disease, AUC for RISK and LPS was 0.742 and 0.706, respectively (p = 0.456). On multivariate analysis, we observed a step-wise statistically significant inverse relationship between increasing RISK group and OS (all p < 0.001). Conclusion RISK is an independent and significant predictor of OS for patients treated with nephrectomy for clear cell and non-clear cell RCC, with accuracy comparable to other histopathological prognostic tools.
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Hou R, Alemozaffar M, Yang B, Sands JM, Kong X, Chen G. Identification of a Novel UT-B Urea Transporter in Human Urothelial Cancer. Front Physiol 2017; 8:245. [PMID: 28503151 PMCID: PMC5409228 DOI: 10.3389/fphys.2017.00245] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 04/07/2017] [Indexed: 02/01/2023] Open
Abstract
The urea transporter UT-B is widely expressed and has been studied in erythrocyte, kidney, brain and intestines. Interestingly, UT-B gene has been found more abundant in bladder than any other tissue. Recently, gene analyses demonstrate that SLC14A1 (UT-B) gene mutations are associated with bladder cancer, suggesting that urea transporter UT-B may play an important role in bladder carcinogenesis. In this study, we examined UT-B expression in bladder cancer with human primary bladder cancer tissues and cancer derived cell lines. Human UT-B has two isoforms. We found that normal bladder expresses long form of UT-B2 but was lost in 8 of 24 (33%) or significantly downregulated in 16 of 24 (67%) of primary bladder cancer patients. In contrast, the short form of UT-B1 lacking exon 3 was detected in 20 bladder cancer samples. Surprisingly, a 24-nt in-frame deletion in exon 4 in UT-B1 (UT-B1Δ24) was identified in 11 of 20 (55%) bladder tumors. This deletion caused a functional defect of UT-B1. Immunohistochemistry revealed that UT-B protein levels were significantly decreased in bladder cancers. Western blot analysis showed a weak UT-B band of 40 kDa in some tumors, consistent with UT-B1 gene expression detected by RT-PCR. Interestingly, bladder cancer associate UT-B1Δ24 was barely sialylated, reflecting impaired glycosylation of UT-B1 in bladder tumors. In conclusion, SLC14A1 gene and UT-B protein expression are significantly changed in bladder cancers. The aberrant UT-B expression may promote bladder cancer development or facilitate carcinogenesis induced by other carcinogens.
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Gilbert K, Lorentz A, Patil D, Alemozaffar M, Filson C. MP21-09 PROLONGED LENGTH OF STAY NOT ASSOCIATED WITH DECREASED HOSPITAL READMISSIONS FOLLOWING UNCOMPLICATED HOSPITALIZATION AFTER RADICAL CYSTECTOMY. J Urol 2017. [DOI: 10.1016/j.juro.2017.02.3271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Alemozaffar M. V10-07 ROBOTIC REPAIR OF RIGHT URETERO-ILEAL ANASTOMOTIC STRICTURE FOLLOWING PRIOR ROBOTIC RADICAL CYSTECTOMY AND INTRACORPOREAL CONDUIT DIVERSION. J Urol 2017. [DOI: 10.1016/j.juro.2017.02.2792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Gerhard RS, Patil D, Liu Y, Ogan K, Alemozaffar M, Jani AB, Kucuk ON, Master VA, Gillespie TW, Filson CP. Treatment of men with high-risk prostate cancer based on race, insurance coverage, and access to advanced technology. Urol Oncol 2017; 35:250-256. [PMID: 28089387 DOI: 10.1016/j.urolonc.2016.12.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 11/29/2016] [Accepted: 12/06/2016] [Indexed: 11/28/2022]
Abstract
PURPOSE We characterized factors related to nondefinitive management (NDM) of patients with high-risk prostate cancer and assessed impact from race, insurance status, and facility-level volume of technologically advanced prostate cancer treatments (i.e., intensity-modulated radiation therapy, robotic-assisted laparoscopic radical prostatectomy) on this outcome. METHODS We identified men with high-risk localized prostate cancer (based on D׳Amico criteria) in the National Cancer Database (2010-2012). Primary outcome was NDM (i.e., delayed/no treatment with prostatectomy/radiation therapy or androgen-deprivation monotherapy). Treating facilities were classified by quartiles of proportions of patients treated with advanced technology. Multivariable regression estimated odds of primary outcome based on race, insurance status, and facility-level technology use, and evaluated for interactions between these covariates. RESULTS Among 60,300 patients, 9,265 (15.4%) received NDM. This was more common among non-White men (P<0.001), Medicaid/uninsured patients (P<0.001), and those managed at facilities in the lowest quartile of technology use (25.1% vs. 11.0% highest, P<0.001). Though NDM was common among non-White men with Medicaid/no insurance treated at low-technology centers (43% vs. 10% White, private/Medicare, high-tech facility; adjusted odds ratios = 7.18, P<0.001), this was less likely if this group was managed at a high-tech hospital (22% vs. 43% low-tech, P<0.001). CONCLUSIONS Technology use at a facility correlates with high-quality prostate cancer care and is associated with diminished disparities based on insurance status and patient race. More research is required to characterize other facility-level factors explaining these findings.
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Mundbjerg K, Chopra S, Alemozaffar M, Duymich C, Lakshminarasimhan R, Nichols PW, Aron M, Siegmund KD, Ukimura O, Aron M, Stern M, Gill P, Carpten JD, Ørntoft TF, Sørensen KD, Weisenberger DJ, Jones PA, Duddalwar V, Gill I, Liang G. Identifying aggressive prostate cancer foci using a DNA methylation classifier. Genome Biol 2017; 18:3. [PMID: 28081708 PMCID: PMC5234101 DOI: 10.1186/s13059-016-1129-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 12/08/2016] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Slow-growing prostate cancer (PC) can be aggressive in a subset of cases. Therefore, prognostic tools to guide clinical decision-making and avoid overtreatment of indolent PC and undertreatment of aggressive disease are urgently needed. PC has a propensity to be multifocal with several different cancerous foci per gland. RESULTS Here, we have taken advantage of the multifocal propensity of PC and categorized aggressiveness of individual PC foci based on DNA methylation patterns in primary PC foci and matched lymph node metastases. In a set of 14 patients, we demonstrate that over half of the cases have multiple epigenetically distinct subclones and determine the primary subclone from which the metastatic lesion(s) originated. Furthermore, we develop an aggressiveness classifier consisting of 25 DNA methylation probes to determine aggressive and non-aggressive subclones. Upon validation of the classifier in an independent cohort, the predicted aggressive tumors are significantly associated with the presence of lymph node metastases and invasive tumor stages. CONCLUSIONS Overall, this study provides molecular-based support for determining PC aggressiveness with the potential to impact clinical decision-making, such as targeted biopsy approaches for early diagnosis and active surveillance, in addition to focal therapy.
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Pearl JA, Patil D, Filson CP, Arya S, Alemozaffar M, Master VA, Ogan K. Patient Frailty and Discharge Disposition Following Radical Cystectomy. Clin Genitourin Cancer 2017; 15:e615-e621. [PMID: 28139446 DOI: 10.1016/j.clgc.2016.12.013] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 12/03/2016] [Accepted: 12/10/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Patients with bladder cancer who are treated with cystectomy are at high risk for complications and prolonged length of stay. This population tends to be of advanced age with underlying comorbidities, and thus more likely to have decreased physiologic reserve (ie, frailty). Our objective was to evaluate the relationship between frailty and discharge disposition for patients with bladder cancer treated with cystectomy. MATERIALS AND METHODS Using data from the National Surgical Quality Improvement Program, we identified patients with bladder cancer undergoing cystectomy (2011-2014). Our exposure of interest was frailty, based on the 11-point modified Frailty Index (mFI). Patients were deemed robust (mFI = 0), pre-frail (mFI = 0.09-0.18), or frail (mFI ≥ 0.27). Our outcome of interest was discharge disposition defined as home, skilled nursing facility, and rehabilitation dichotomized as home versus non-home for multivariable logistic regression analysis. We then generated predicted probabilities of non-home discharge based on frailty and in-hospital complications. RESULTS Among 4330 patients treated with radical cystectomy, 32.8% were robust, 65.1% were pre-frail, and 2.2% were frail. Overall, 86.2% were discharged home, 4.4% to a rehabilitation facility, and 9.4% to a skilled nursing facility. Frail patients were more likely to be discharged to non-home care (vs. robust, odds ratio, 2.33; 95% confidence interval, 1.34-4.03), which was independent of whether they experienced a major complication prior to discharge. CONCLUSION Frailty is a significant predictor of non-home discharge following radical cystectomy. This finding was independent of inpatient complications. These data will assist providers in setting patient expectations and have important implications for allocating postoperative resources.
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Jegadeesh N, Liu Y, Zhang C, Zhong J, Cassidy RJ, Gillespie T, Kucuk O, Rossi P, Master VA, Alemozaffar M, Jani AB. The role of adjuvant radiotherapy in pathologically lymph node-positive prostate cancer. Cancer 2016; 123:512-520. [DOI: 10.1002/cncr.30373] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 07/20/2016] [Accepted: 07/25/2016] [Indexed: 11/08/2022]
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Pearl J, Patil D, Arya S, Alemozaffar M, Master VA, Ogan K. Patient Frailty and Discharge Disposition after Radical Cystectomy. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.06.352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Broggi MS, Patil D, Baum Y, Nieh PT, Alemozaffar M, Pattaras JG, Ogan K, Master VA. Author Reply. Urology 2016; 96:105. [DOI: 10.1016/j.urology.2016.05.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Broggi MS, Patil D, Baum Y, Nieh PT, Alemozaffar M, Pattaras JG, Ogan K, Master VA. Onodera's Prognostic Nutritional Index as an Independent Prognostic Factor in Clear Cell Renal Cell Carcinoma. Urology 2016; 96:99-105. [PMID: 27431662 DOI: 10.1016/j.urology.2016.05.064] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 03/27/2016] [Accepted: 05/03/2016] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate the relationship between the Onodera Prognostic Nutritional Index (OPNI) and overall survival, as well as recurrence-free survival, in clear cell renal cell carcinoma (ccRCC) patients following nephrectomy. MATERIALS AND METHODS Three hundred forty-one patients who underwent nephrectomy for ccRCC were analyzed. The optimum OPNI cutoff score of 44.7 was determined by receiver operating characteristic analysis and patients were placed in either the low or high OPNI group, with OPNI values of ≤44.7 and ≥44.8, respectively. Kaplan-Meier analysis was performed to evaluate the univariate impact of the OPNI groups on overall survival and recurrence-free survival. OPNI's association with overall survival and recurrence-free survival, with adjustments for other patient and tumor qualities, was assessed with univariate and multivariate Cox regression analysis. RESULTS Median (95% CI) overall survival times for the low and high OPNI groups were 21.1 months and 37.9 months, respectively. OPNI was determined to be an independent prognostic factor in multivariate analysis, and after controlling for patient and tumor characteristics, the low OPNI group experienced a 1.67-fold (hazard ratio: 1.67, 95% confidence interval: 1.05-2.68) increased risk of overall mortality. CONCLUSION Preoperative OPNI is a valuable independent prognostic indicator of overall survival and recurrence-free survival in patients with ccRCC following nephrectomy.
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Chopra S, Alemozaffar M, Gill I, Aron M. Extended lymph node dissection in robotic radical prostatectomy: Current status. Indian J Urol 2016; 32:109-14. [PMID: 27127352 PMCID: PMC4831498 DOI: 10.4103/0970-1591.163303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Introduction: The role and extent of extended pelvic lymph node dissection (ePLND) during radical prostatectomy (RP) for prostate cancer patients remains unclear. Materials and Methods: A PubMed literature search was performed for studies reporting on treatment regimens and outcomes in patients with prostate cancer treated by RP and extended lymph node dissection between 1999 and 2013. Results: Studies have shown that RP can improve progression-free and overall survival in patients with lymph node-positive prostate cancer. While this finding requires further validation, it does allow urologists to question the former treatment paradigm of aborting surgery when lymph node invasion from prostate cancer occurred, especially in patients with limited lymph node tumor infiltration. Studies show that intermediate- and high-risk patients should undergo ePLND up to the common iliac arteries in order to improve nodal staging. Conclusions: Evidence from the literature suggests that RP with ePLND improves survival in lymph node-positive prostate cancer. While studies have shown promising results, further improvements and understanding of the surgical technique and post-operative treatment are required to improve treatment for prostate cancer patients with lymph node involvement.
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Gakis G, Schubert T, Alemozaffar M, Bellmunt J, Bochner BH, Boorjian SA, Daneshmand S, Huang WC, Kondo T, Konety BR, Laguna MP, Matin SF, Siefker-Radtke AO, Shariat SF, Stenzl A. Update of the ICUD-SIU consultation on upper tract urothelial carcinoma 2016: treatment of localized high-risk disease. World J Urol 2016; 35:327-335. [DOI: 10.1007/s00345-016-1819-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 03/23/2016] [Indexed: 12/11/2022] Open
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Pearl J, Patil D, Arya S, Alemozaffar M, Master V, Ogan K. MP06-12 FRAIL PATIENTS ARE LESS LIKELY TO BE DISCHARGED TO HOME AFTER CYSTECTOMY. J Urol 2016. [DOI: 10.1016/j.juro.2016.02.2173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Alemozaffar M, Filson CP, Master VA. The importance of surgical margins in renal cell and urothelial carcinomas. J Surg Oncol 2016; 113:316-22. [DOI: 10.1002/jso.24121] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 11/20/2015] [Indexed: 11/11/2022]
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Jegadeesh N, Liu Y, Zhang C, Zhong J, Gillespie TW, Kucuk O, Rossi PJ, Master VA, Alemozaffar M, Jani AB. The role of adjuvant radiotherapy in pathologically node positive prostate cancer. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.2_suppl.28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
28 Background: The postoperative management of prostate cancer with regional lymph nodal involvement (LNI) is controversial. Prospective evidence to guide the role of radiotherapy (RT) in this setting does not exist. Randomized studies demonstrate an improvement in disease-related outcomes with adjuvant RT in high-risk patients without LNI following prostatectomy (RP). Retrospective evidence supports the selective use of RT with LNI following extended pelvic lymph node dissection. It is unclear if this experience is generalizable to practice in the United States where extended dissection is uncommon. We sought to identify patients with LNI who may derive a survival benefit following adjuvant RT. Methods: The National Cancer Data Base was queried for M0 patients with prostate adenocarcinoma who underwent RP with pathologic LNI. Adjvuant RT was defined as delivered within 6 months following RP. Kaplan-Meier, log-rank test, and multivariable Cox proportional hazards regression were performed with overall survival (OS) as the primary outcome. Propensity score matching (PSM) was employed to further reduce treatment selection bias. Results: 7,902 patients diagnosed between 2003-2011 were eligible for analysis; 1,439 (18.2%) received RT. RT was more frequently employed in patients with lower Charlson-Deyo Comorbidity Score, higher T stage, <5 nodes examined, ≥50% nodal positivity ratio, Gleason 8-10, ≥20 PSA, positive surgical margin, and <65 years of age (all p < 0.05). Five year OS was 87.6% vs. 85% in those receiving RT vs. not (p = 0.075). With androgen deprivation (ADT) (n = 3,265), 5-year OS was 87.2% vs. 82.7% in those receiving RT vs. not (p = 0.004). In multivariable analysis, the use of RT was independently associated with improved OS (HR 0.73, 95% CI 0.59-0.89, p = 0.002). 894 remained in each cohort following PSM. In this analysis, RT remained associated with OS (HR 0.66, 95% CI 0.51-0.85, p = 0.002). Conclusions: Adjuvant RT was associated with improved OS following RP in patients with LNI in this large generalizable retrospective analysis. This effect appears stronger in those receiving ADT. This series is the largest describing adjuvant RT in this population. In the absence of prospective evidence, these results may help guide therapy in this setting.
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Sekar RR, Patil D, Pearl J, Baum Y, Alemozaffar M, Filson CP, Ogan K, Master VA. The relationship between preoperative c-reactive protein and Fuhrman nuclear grade in stage T1 renal cell carcinoma. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.2_suppl.593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
593 Background: In an era of active surveillance for small renal masses (SRMs), non-invasive predictors of tumor aggressiveness may be helpful in identifying high-risk patients for surgical intervention. In this study, we evaluate the predictive value of preoperative C-reactive protein (CRP) on Furhman Nuclear Grade (FNG) in patients with stage T1 renal cell carcinoma (RCC). Methods: Patients who underwent nephrectomy for stage T1 RCC with documented preoperative CRP within 15 days of surgery were included in the study. Surgical pathology reports were used to determine TNM stage and FNG. Receiver operating characteristic (ROC) analysis, sensitivity-specificity analysis, and Youden index were used to determine the optimal threshold of preoperative CRP in predicting FNG 4 disease versus FNG 1-3 disease. Logistic regression analysis was then performed to assess the significance and independence of preoperative CRP in predicting FNG 4 disease. Results: 351 patients were included in the study. On ROC analysis, area under the curve (AUC) was 0.7576. The optimal threshold of preoperative CRP was determined to be 4.8 mg/dL. On univariate and multivariate analysis, CRP ≥ 4.8 mg/dL was found to be a significant and independent predictor of FNG 4 disease (log-rank, p=0.014, p=0.006, respectively). Conclusions: Our data show that preoperative CRP ≥ 4.8 mg/dL is a significant and independent predictor of FNG 4 disease in patients with stage T1 RCC. These findings suggest that a standardized and cost-effective preoperative laboratory value can provide crucial prognostic information in patients undergoing active surveillance for SRMs, allowing for improved patient selection for definitive surgical therapy. [Table: see text]
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Sekar RR, Patil D, Pearl J, Baum Y, Kucuk O, Harris WB, Carthon BC, Alemozaffar M, Filson CP, Ogan K, Master VA. A novel preoperative inflammatory marker prognostic score in patients with clear cell renal cell carcinoma. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.2_suppl.566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
566 Background: Several inflammatory markers have been singularly studied as potential biomarkers in clear cell renal cell carcinoma (RCC), however few reports have analyzed their prognostic value in aggregate. We hypothesize that a combination of preoperative C-Reactive Protein (CRP), albumin, Erythrocyte Sedimentation Rate (ESR), corrected calcium, and AST/ALT ratio into a RCC Inflammatory Score (RISC) could serve as a rigorous prognostic indicator in patients with clear cell RCC. Methods: Patients that underwent nephrectomy for localized clear cell RCC were queried from our nephrectomy database. The optimal threshold for individual biomarkers was determined using grid search methodology, receiver operating characteristic (ROC) analysis, and sensitivity-specificity trade-off analysis. The final score, RISC, was the sum of all points accrued from each biomarker (Table). ROC and chi-square analysis was performed to compare the prognostic ability of RISC to SSIGN and UISS. Impact on overall survival was analyzed with multivariate logistic regression analysis. Results: 280 patients were included in the study. Area under the curve (AUC) for RISC, SSIGN and UISS was 0.77, 0.78, and 0.81, respectively. Chi-square analysis of AUCs revealed no statistically significant difference between RISC, SSIGN, and UISS (p= 0.975 and p =0.299, respectively). On multivariate analysis, after adjusting for confounding variables, each unit increase in RISC was associated with a 31% increase in mortality (HR=1.31, 95%CI 1.13-1.50, p<0.001). Conclusions: RISC is an independent and significant predictor of overall survival in clear cell RCC with accuracy at least as good as other established prognostic tools. Notably, RISC is composed of standardized laboratory markers easily and cost-effectively obtained preoperatively, allowing crucial prognostic information to be integrated into medical decision making prior to surgery. [Table: see text]
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Sekar RR, Patil D, Pearl J, Baum Y, Kucuk O, Harris WB, Carthon B, Alemozaffar M, Filson CP, Ogan K, Master VA. A novel preoperative inflammatory marker prognostic score in patients with clear cell and non-clear cell renal cell carcinoma. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.2_suppl.530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
530 Background: Several inflammatory markers have been studied as potential biomarkers in clear cell renal cell carcinoma (RCC), however few reports have analyzed their prognostic value in aggregate and in non-clear cell histologies. We hypothesize that a combination of preoperative C-Reactive Protein (CRP), albumin, Erythrocyte Sedimentation Rate (ESR), corrected calcium, and AST/ALT ratio into a RCC Inflammatory Score (RISC) could serve as a rigorous prognostic indicator in patients with clear cell and non-clear cell RCC. Methods: Patients that underwent nephrectomy for localized RCC were queried from our nephrectomy database. The optimal threshold for individual biomarkers was determined using grid search methodology, receiver operating characteristic (ROC) analysis, and sensitivity-specificity trade-off analysis. The final score, RISC, was the sum of points accrued from each biomarker (Table). ROC and chi-square analysis was performed to compare the prognostic ability of RISC to SSIGN and UISS. Impact on overall survival was analyzed with multivariate logistic regression analysis. Results: 391 patients were included in the study. Area under the curve (AUC) for RISC, SSIGN, and UISS was 0.78, 0.78, and 0.81, respectively. Chi-square analysis of AUCs revealed no statistically significant difference between RISC, SSIGN, and UISS (p= 0.820, and p =0.317, respectively). On multivariate analysis, after adjusting for confounding variables, each unit increase in RISC was associated with a 32% increase in mortality (HR=1.32, 95%CI 1.17-1.49, p<0.001). Conclusions: RISC is an independent and significant predictor of overall survival in clear cell and non-clear cell RCC with accuracy at least as good as other established prognostic tools. Notably, RISC is composed of standardized preoperative laboratory markers, allowing crucial prognostic information to be integrated into medical decision making prior to surgery. [Table: see text]
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