Comparative effectiveness of bladder-preserving tri-modality therapy versus radical cystectomy for muscle-invasive bladder cancer

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Background: Radical cystectomy (RC) has historically been considered the standard of care for muscle invasive bladder cancer (MIBC). An alternative is tri-modality therapy (TMT), a bladder-sparing approach that often achieves preservation of the native bladder. There are limited randomized data comparing these guideline-recommended approaches but, in appropriately selected patients, both are thought to have similar survival outcomes with different morbidity profiles. Therefore this study compared the effectiveness of TMT and RC using decision-analytic modeling with the primary endpoint of quality-adjusted life years (QALYs). Methods: We developed a Markov model simulating the lifetime outcomes for 67-year-old patients after definitive treatment for American Joint Committee on Cancer clinical Stage T2-T4aN0M0 MIBC using two strategies: TMT or RC +/- neoadjuvant chemotherapy (NAC). Probabilities and utilities were extracted from the literature to determine the incremental effectiveness in QALYs. Sensitivity analyses were performed. Results: TMT was the most effective strategy with an incremental gain of 1.13 QALYs over RC (8.37 versus 7.24 QALYs, respectively; Table). One-way sensitivity analyses demonstrated the model was most sensitive to the quality of life (QoL) parameters (i.e. the utilities) for RC and TMT; TMT was more effective than RC irrespective of the RC utility (the 95% confidence interval of the RC parameter demonstrated an incremental gain with TMT of 0.01 to 4.77 QALYs). The model was relatively less sensitive to the probability of death for either strategy. Probabilistic sensitivity analysis demonstrated that TMT was more effective than RC for 75% of model iterations. Conclusions: Treatment of MIBC with organ-sparing TMT in appropriately-selected patients may result in a gain of over 1 QALY relative to RC. Further prospective investigation into the QoL implications of these treatment modalities is warranted. [Table: see text]

Characterization of the effects of defined, multidimensional culture conditions on conditionally reprogrammed primary human prostate cells

The inability to propagate human prostate epithelial cells indefinitely has historically presented a serious impediment to prostate cancer research. The conditionally reprogrammed cell (CRC) approach uses the combination of irradiated J2 mouse fibroblasts and a Rho kinase inhibitor such as Y27632 to support the continuous culture of cells derived from most epithelial tissues, including the prostate. Due to their rapid establishment and overall ease of use, CRCs are now widely used in a variety of basic and preclinical settings. In addition, CRCs were successfully used to clinically treat respiratory papillomatosis. Although both normal and tumor-derived prostate CRCs have been used to study the basic biology of prostate cancer and to test new therapies, certain limitations exist. We have previously reported that prostate CRCs form functional prostate glands when implanted under the mouse renal capsule. However in conventional culture, the prostate CRCs exist in an adult stem-like, transient amplifying state and consequently do not adequately recapitulate several important features of a differentiated prostate epithelium. To address these limitations, we previously described a transwell dish-based model that supported the culturing of prostate CRCs and the collection of cells and cell extracts for molecular and genetic analyses. Using normal and tumor-derived prostate CRCs, we describe the combined effects of the multi-dimensional transwell platform and defined culture media on prostate cellular proliferation, differentiation and signaling.

Risk Factors for Disease Progression After Postprostatectomy Salvage Radiation: Long-term Results of a Single-institution Experience

BACKGROUND

Salvage radiotherapy (SRT) has been successfully used for recurrent prostate cancer after radical prostatectomy; however, the optimal timing of SRT remains controversial. Our objective was to identify the risk factors for disease progression after SRT, with a focus on the pre-SRT prostate-specific antigen (PSA) levels in the modern era of PSA testing.

PATIENTS AND METHODS

We performed a retrospective review of 551 consecutive patients who had undergone postradical prostatectomy SRT for recurrent prostate cancer from 2000 to 2013. The exclusion criteria were hormonal therapy before or concurrent with SRT, adjuvant RT, distant metastases, and missing data. Disease progression was defined as a repeat PSA level of ≥ 0.2 ng/mL greater than the post-SRT nadir, a continued increase in the PSA level despite SRT, initiation of systemic therapy, local recurrence, nodal failure, and/or distant metastases. Univariate and multivariable Cox regression analysis were performed to identify the predictors of disease progression. Secondarily, PSA kinetics were evaluated in the model and compared using the Akaike information criterion.

RESULTS

Of the 551 patients, 307 underwent SRT, of whom 134 experienced subsequent disease progression. The median interval to recurrence was 6.03 years (95% confidence interval, 3.74-8.36 years). On multivariable analysis, Gleason score, T stage, positive surgical margins, and pre-SRT PSA level were associated with progression; PSA kinetics did not independently predict for progression. When the pre-SRT PSA level was stratified (≤ 0.30, 0.31-0.50, 0.51-1.00, and > 1 ng/mL), incremental elevations were associated with an increased risk of disease progression.

CONCLUSION

Multiple factors predict for progression after SRT. These risk factors could help identify those who would derive the greatest benefit from additional systemic treatment. The findings of the present study also support initiation of early SRT, irrespective of the PSA kinetics.

Abstract 711: Mechanistic implications of COL1A1 as a prostate cancer biomarker

Prostate cancer (PCa) is the second most frequently diagnosed form of male cancer and shares similar symptoms with BPH (Benign Prostate Hyperplasia), a disease characterized by prostate enlargement. Elevated levels of prostate-specific antigen (PSA) can be observed with either benign or malignant growth of the prostate and therefore cannot effectively discriminate between these two prostate diseases. Currently, a test that sensitively and accurately distinguishes between BPH and localized prostate cancer does not exist creating an urgent need for novel biomarkers that can successfully distinguish between these two prostate diseases. The goal of this study was to identify and validate non-invasive urinary biomarkers that distinguish between BPH and PCa. Our previous proteomic study identified elevated levels of several proteins, including EGF (epidermal growth factor), HE-4 (human epididymis protein 4), COL1A1 (collagen, type I, alpha 1) and other proteins in the urine of PCa patients compared to urine samples from patients with BPH. In this current study we have analyzed and validated the presence of EGF, HE-4 and COL1A1 by enzyme-linked immunosorbent assay (ELISA). Our ELISA experiments revealed that COL1A1 was significantly (P < 0.002) elevated in the urine of patients diagnosed with early or localized PCa vs. BPH. In vitro experiments performed on seven different prostate cell lines identified cells from the tumor microenvironment that secrete the highest levels of COL1A1. Expression of COL1A1 by these cells was confirmed by immunohistochemistry (IHC) using prostate tissue microarrays (TMA). In addition, protein array experiments identified elevated levels of several proteases in the urine of PCa patients, including MMP-9, uPA, ADAM-TS1 and several cathepsins. Substrate gel electrophoresis (zymography) revealed elevated activity of both MMP-9 and MMP-2 in urine from PCa patients. These data suggest that MMP-9 and MMP-2 may participate in the cleavage of collagen type 1, resulting in elevated levels of COL1A1 in urine of PCa patients. We are currently testing this hypothesis. In summary, COL1A1 may represent a novel non-invasive urinary biomarker that can effectively discriminate between BPH vs. localized PCa. (Supported by The Ellison Foundation)

Citation Format: Andrej Jedinak, Camille Vuichoud, Andrew El-Hayek, Katherine Kaplan, Jason Savage, Sarah Prophet, Adam S. Feldman, Kevin A. Camphausen, Kevin R. Loughlin, Marsha A. Moses. Mechanistic implications of COL1A1 as a prostate cancer biomarker [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 711. doi:10.1158/1538-7445.AM2017-711

Smears are important for adequate cytologic diagnosis of kidney lesions

INTRODUCTION

Traditionally at our institution, smears with or without liquid-based cytology (LBC) and core biopsies (CBs) have been obtained by radiologists performing image-guided fine-needle aspiration biopsies (FNABs) of deep organs. Since 2015, however, there has been a shift to providing cytology with samples for LBC only when obtaining CBs. The impression among our institution's cytologists is that LBC alone is less often adequate for diagnosis compared with smears and LBC together. We examined a series of kidney FNABs pre- and post-"LBC only" to evaluate this impression.

MATERIALS AND METHODS

With institutional review board approval, we compared all kidney FNABs from 2012 to those from 2015. We recorded the type(s) of cytology preparation(s), the number of cytology slides, the cytology diagnosis, the concurrent CB diagnosis, and whether there was a subsequent excision and the excision diagnosis. We examined cytology and CB slides as needed.

RESULTS

In 2012, 105 patients underwent 111 kidney biopsies, 109 with smears made. In 2015, 58 patients underwent 62 kidney biopsies, 7 with smears made. In 2012, there were 13 (12%) nondiagnostic (ND) cytology cases and 19 (17%) cases where the cytology and CB diagnoses were discrepant. By comparison, in 2015, there were 20 (32%) ND cytology cases and 21 (33%) discrepant cases.

CONCLUSIONS

There were more cytology slides per case and fewer ND diagnoses in 2012 compared with 2015 (12% versus 32%, respectively, P = 0.001). Concordance was also better in 2012 (83% versus 67%, P = 0.015). We believe that our metrics would improve if we returned to the procedures followed in 2012.

Long-term Outcomes After Bladder-preserving Tri-modality Therapy for Patients with Muscle-invasive Bladder Cancer: An Updated Analysis of the Massachusetts General Hospital Experience

BACKGROUND

Tri-modality therapy (TMT) is a recognized treatment strategy for selected patients with muscle-invasive bladder cancer (MIBC).

OBJECTIVE

Report long-term outcomes of patients with MIBC treated by TMT.

DESIGN, SETTING, AND PARTICIPANTS

Four hundred and seventy-five patients with cT2-T4a MIBC were enrolled on protocols or treated as per protocol at the Massachusetts General Hospital between 1986 and 2013.

INTERVENTION

Patients underwent transurethral resection of bladder tumor followed by concurrent radiation and chemotherapy. Patients with less than a complete response (CR) to chemoradiation or with an invasive recurrence were recommended to undergo salvage radical cystectomy.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Disease-specific survival (DSS) and overall survival (OS) were calculated using the Kaplan-Meier method.

RESULTS AND LIMITATIONS

Median follow-up for surviving patients was 7.21 yr. Five- and 10-yr DSS rates were 66% and 59%, respectively. Five- and 10-yr OS rates were 57% and 39%, respectively. The risk of salvage cystectomy at 5 yr was 29%. In multivariate analyses, T2 disease (OS hazard ratio [HR]: 0.57, 95% confidence interval [CI]: 0.44-0.75, DSS HR: 0.51, 95% CI: 0.36-0.73), CR to chemoradiation (OS HR: 0.61, 95% CI: 0.46-0.81, DSS HR: 0.49, 95% CI: 0.34-0.71), and presence of tumor-associated carcinoma in situ (OS HR: 1.56, 95% CI: 1.17-2.08, DSS HR: 1.50, 95% CI: 1.03-2.17) were significant predictors for OS and DSS. When evaluating our cohort over treatment eras, rates of CR improved from 66% to 88% and 5-yr DSS improved from 60% to 84% during the eras of 1986-1995 to 2005-2013, while the 5-yr risk of salvage radical cystectomy rate decreased from 42% to 16%.

CONCLUSIONS

These data demonstrate high rates of CR and bladder preservation in patients receiving TMT, and confirm DSS rates similar to modern cystectomy series. Contemporary results are particularly encouraging, and therefore TMT should be discussed and offered as a treatment option for selected patients.

PATIENT SUMMARY

Tri-modality therapy is an alternative to radical cystectomy for patients with muscle-invasive bladder cancer, and is associated with comparable long-term survival and high rates of bladder preservation.

Long-term results of adjuvant versus early salvage postprostatectomy radiation: A large single-institutional experience

PURPOSE

The purpose of this study was to evaluate freedom from biochemical failure (FFBF), freedom from androgen deprivation therapy (FFADT), freedom from distant metastases (FFDM), and overall survival (OS) after adjuvant radiation therapy (ART) versus early salvage radiation therapy (ESRT) in men with prostate cancer and adverse pathologic features (pT3 and/or positive surgical margins).

METHODS AND MATERIALS

Of 718 patients consecutively treated with postoperative radiation therapy (RT) for prostate cancer between 1992 and 2013, we retrospectively identified 171 men receiving ART and 230 receiving ESRT (RT delivered at a prostate-specific antigen level ≤0.5 ng/mL) who had adverse pathologic features. Postirradiation FFBF (BF was defined as prostate-specific antigen level rise to ≥0.2 ng/mL), FFADT, FFDM, and OS were compared using Kaplan-Meier and Cox regression methods. Propensity score (PS)-matching was performed to estimate treatment effects while accounting for covariates predicting treatment allocation.

RESULTS

Median follow-up was 7.4 and 8.0 years for patients treated with ART and ESRT, respectively. Ten-year FFBF (69% vs 56%, P = .003) and 10-year FFADT (88% vs 81%, P = .046) rates were higher after ART; however, FFDM and OS did not significantly differ. After PS-matching, ART was associated with improved FFBF (P < .0001), FFADT (P = .0001), and FFDM (P = .02). Findings were confirmed in multivariable analyses in unmatched and PS-matched cohorts. Sensitivity analyses showed that FFBF benefit associated with ART lost statistical significance only after 38% of ART patients were assumed to have been cured by surgery and excluded from the model. This corresponds to the upper bound of patients with adverse pathologic features who did not recur after observation in prior randomized trials.

CONCLUSIONS

Postoperative RT confers excellent long-term cancer control. These results suggest ART may be associated with improved FFBF, FFADT, and FFDM, but comparable OS. Given the retrospective study design, these findings should be interpreted with caution. Optimal timing of postoperative RT further awaits results of ongoing trials.

Baseline Prostate-Specific Antigen Levels in Midlife Predict Lethal Prostate Cancer

PURPOSE

Prostate-specific antigen (PSA) level in midlife predicted future prostate cancer (PCa) mortality in an unscreened Swedish population. Our purpose was to determine if a baseline PSA level during midlife predicts lethal PCa in a US population with opportunistic screening.

MATERIALS AND METHODS

We conducted a nested case-control study among men age 40 to 59 years who gave blood before random assignment in the Physicians' Health Study, a randomized, placebo-controlled trial of aspirin and β-carotene among 22,071 US male physicians initiated in 1982 and then transitioned into a prospective cohort with 30 years of follow-up. Baseline PSA levels were available for 234 patients with PCa and 711 age-matched controls. Seventy-one participants who developed lethal PCa were rematched to 213 controls. Conditional logistic regression was used to estimate odds ratios and the area under the receiver operating characteristic curve, with 95% CIs, of the association between baseline PSA and risk of lethal PCa.

RESULTS

Median PSA among controls was 0.68, 0.88, and 0.96 ng/mL for men age 40 to 49, 50 to 54, and 55 to 59 years, respectively. Risk of lethal PCa was strongly associated with baseline PSA in midlife: odds ratios (95% CIs) comparing PSA in the > 90th percentile versus less than or equal to median were 8.7 (1.0 to 78.2) at 40 to 49 years, 12.6 (1.4 to 110.4) at 50 to 54 years, and 6.9 (2.5 to 19.1) at 55 to 59 years. A total of 82%, 71%, and 86% of lethal cases occurred in men with PSA above the median at ages 40 to 49, 50 to 54, and 55 to 59 years, respectively.

CONCLUSION

PSA levels in midlife strongly predict future lethal PCa in a US cohort subject to opportunistic screening. Risk-stratified screening on the basis of midlife PSA should be considered in men age 45 to 59 years.

Angiographic and volumetric effects of mammalian target of rapamycin inhibitors on angiomyolipomas in tuberous sclerosis

AIM: To investigate the angiographic and volumetric effects of mammalian target of rapamycin (mTOR) inhibitors on angiomyolipomas (AMLs) in a case series of patients with tuberous sclerosis complex.

METHODS: All patients who underwent catheter angiography prior to and following mTOR inhibitor therapy (n = 3) were evaluated. All cross-sectional imaging studies were analyzed with three-dimensional volumetrics, and tumor volume curves for all three tissue compartments (soft tissue, vascular, and fat) were generated. Segmentation analysis tools were used to automatically create a region of interest (ROI) circumscribing the AML. On magnetic resonance images, the “fat only” map calculated from the in- and opposed-phase gradient recalled echo sequences was used to quantify fat volume within tumors. Tumor vascularity was measured by applying a thresholding tool within the ROI on post-contrast subtraction images. On computed tomography images, volume histogram analysis of Hounsfield unit was performed to quantify tumor tissue composition. The angiography procedures were also reviewed, and tumor vascularity based on pre-embolization angiography was characterized in a semi-quantitative manner.

RESULTS: Patient 1 presented at the age of 15 with a 6.8 cm right lower pole AML and a 4.0 cm right upper pole AML. Embolization was performed of both tumors, and after a few years of size control, the tumors began to grow, and the patient was initiated on mTOR inhibitor therapy. There was an immediate reduction in the size of both lesions. The patient then underwent repeat embolization and discontinuation of mTOR inhibition, after which point there was a substantial regrowth in both tumors across all tissue compartments. Patient 2 presented at the age of 18 with a right renal AML. Following a brief period of tumor reduction after embolization, she was initiated on mTOR inhibitor therapy, with successful reduction in tumor size across all tissue compartments. As with patient 1, however, there was immediate rebound growth following discontinuation of inhibitor therapy, without sustained control despite repeat embolization. patient 3 presented at the age of 5 with a left renal AML and underwent two embolization procedures without lasting effect prior to starting mTOR inhibition. As with patients 1 and 2, following discontinuation of therapy, there was immediate rebound growth of the tumor. Repeat embolization, however, was notable for a substantial reduction in intratumoral aneurysms and vascularity.

CONCLUSION: AML volume reduction as well as post-treatment rebound growth due to mTOR inhibitors involves all three tissue components of the tumor.

Risk factors for disease progression after post-prostatectomy salvage radiation: Long-term results of a large institutional experience

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Background: Salvage radiotherapy (SRT) has been successfully used to treat recurrent prostate cancer following radical prostatectomy (RP). The objective of this study was to identify risk factors for disease progression post-SRT. Methods: Retrospective review of 719 consecutive patients who had RP and received post-operative radiation (adjuvant/SRT) for recurrent prostate cancer from 1992-2013. Disease progression was defined by a prostate specific antigen (PSA) ≥0.2 ng/ml, local recurrence, nodal failure, or distant metastases. Analysis was restricted to patients treated after 2000, when the PSA detectability threshold decreased to 0.2. Univariable and multivariable Cox regression analysis with backwards selection was performed with the following variables: demographics (age, race), pathological features (Gleason score, positive margins, pT-stage), surgery type, radiation details, hormone therapy, and pre-SRT PSA. Secondarily, we included PSA velocity and doubling-time as continuous variables in the model. Results: 384 patients received SRT after 2000, of which 152 had disease progression, with a median time to recurrence of 6.2 years (95% CI 4.1-7.6 years). Multivariable analysis results are reported in the Table. Gleason score, T-stage, seminal vesicle invasion, and pre-SRT PSA were associated with progression. Pre-SRT PSA ≤ 0.3 conferred the lowest rate of disease progression. In a secondary model, PSA kinetics was evaluated in which doubling-time was associated with progression (HR 0.98 per month increase, 95% CI 0.96-1.00; p=0.03). Conclusions: The lowest rate of disease progression was found amongst patients treated with a PSA ≤ 0.3. A shorter DT may also be a useful predictor of disease progression after SRT. [Table: see text]

Development and validation of contouring guidelines for post-cystectomy adjuvant radiation of bladder cancer

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Background: Several organizations are developing clinical trials to evaluate adjuvant radiotherapy (RT) for bladder cancer patients at elevated risk of locoregional failure (LF). However, the clinical target volumes (CTVs) & organs at risk (OARs) for this treatment have not been defined in detail. Our purpose was to define multi-institutional consensus CTVs & OARs for male & female bladder cancer patients undergoing adjuvant RT in clinical trials. Methods: We convened a multi-disciplinary group of bladder cancer specialists from 9 centers in 3 countries. 5 radiation oncologists (ROs) & 7 urologists participated in the development of the proposed contours. The group proposed initial language for the CTVs & OARs and contoured them on CT scans of a male & female cystectomy patient with input from ≥ 1 urologist at each center. Using the binomial maximum-likelihood estimates method, we generated 95% level initial contours. We evaluated the contours for level of agreement using the Landis & Koch interpretation of the K statistic. Based on the initial contouring, the group updated its descriptions of the CTVs & OARs. To determine if the revised language produced consistent contours, the cystectomy bed (CB) contour was redrawn on the CT sets by an additional 5 ROs. Results: The group proposed that patients at elevated risk for LF with R0 resections should be treated to the pelvic nodes alone (internal/external iliac, distal common iliac & presacral) whereas patients with ≥ R1 resections should be treated to the pelvic nodes & CB. The group proposed the rectum, bowel space, bone marrow & urinary diversion as OARs. The level of agreement for the initial CTVs & OARs from the group varied substantially (Table). Consensus language to describe CTV & OAR structures where the initial contours varied was successfully developed. Contours & feedback from the validation group are being analyzed. Conclusions: Initial descriptions of CTVs & OARs have been successfully developed. External validation & feedback are pending. The results will be applicable to clinical trials of adjuvant RT in bladder cancer. [Table: see text]

Renal function in bladder cancer patients after trimodality therapy: Long-term results of a large institutional experience

453

Background: Maintenance of renal function following treatment of bladder cancer presents an ongoing challenge. The decline following radical cystectomy is well documented. However, in patients undergoing trimodality bladder-sparing therapy consisting of transurethral resection (TURBT) and concurrent chemoradiation followed by adjuvant chemotherapy, renal function is poorly understood. Methods: We performed a retrospective review of 178 patients with muscle-invasive bladder cancer who underwent bladder-sparing therapy between 2001 and 2013 and collected nadir creatinine values in the month preceding TURBT and at 1, 3, 5, 7, and 9 years post treatment initiation. Wilcoxon signed-rank test and mixed effects analysis were performed to compare the pre-treatment and post-treatment levels of creatinine and EGFR and to analyze their temporal change. Results: Median follow-up was 48 months (range: 1 to 162 months). The mean pre-treatment creatinine and EGFR were 1.12 mg/dl and 71 mg/dl, respectively. Cr increased to 1.21 mg/dl and EGFR decreased to 65 mg/dl at 1 year following treatment initiation (p = 0.001, p = 0.002). All post-treatment values were also significantly different from pre-treatment values (all p values < 0.002), but there was no significant difference between the post-treatment values over time. Conclusions: Following bladder-sparing therapy for muscle invasive bladder cancer, renal function was generally well preserved in the long term. Although there was a modest yet statistically significant decrease in renal function that occurred during the first year, there was no further decline up to 9 years. While this initial decrease in function is of unknown clinical significance, the lack of further decline after 1 year is different from similar studies following cystectomy.

Prognostic utility of a multi-gene signature (the cell cycle proliferation score) in patients with renal cell carcinoma (RCC) after radical nephrectomy

555

Background: There are currently no RCC biomarkers being routinely used in the clinic, and prognostic nomograms rely almost entirely on tumor size, stage and age. There is a critical need for improved prognostic discrimination given the increasing awareness that some patients may be managed with active surveillance, while others with higher risk disease might benefit from adjuvant therapy following surgery. We hypothesized that a previously developed multi-gene proliferation signature would predict long-term oncologic outcomes in surgically resected RCC. Methods: The cell cycle proliferation (CCP) score was derived after radical nephrectomy in 305 patients who were treated at a single center from 2000 to 2007 for clear cell, papillary or chromophobe RCC with localized disease (N0M0). Sixty-four percent of the cohort had stage I disease. Outcomes were either disease recurrence (local or metastatic), or disease specific mortality (DSM). Association with outcomes was evaluated by CoxPH survival analysis and likelihood ratio tests. Hazard ratios (HR) are given for one-unit increase in CCP score (equivalent to a doubling of gene expression). Results: Patient data were censored at 5-years of follow-up, by which time 32 patients (10%) recurred and 16 (5%) died of disease. The median CCP score was 0.095 (IQR -0.50 to 0.60). In univariable analysis, CCP score was a significant prognostic variable for both recurrence (p < 10-4) and DSM (p < 10-5). After adjusting for clinical variables including tumor size, stage, and grade, the CCP score HR for recurrence was 1.74 (95% CI (1.14, 2.65)), and for DSM was 2.59 (95% CI (1.43, 4.67)). There was no interaction between CCP and any clinical variable. A prognostic model combining clinical and molecular information will be presented along with external validation in a second cohort (N~400). Conclusions: The CCP score appears to be a significant and independent predictor of key long-term oncologic outcomes in patients who have undergone nephrectomy for RCC, providing prognostic information beyond what is available from clinical parameters. Once validated, the CCP score may have utility in the clinical management of patients with RCC.

Early salvage versus adjuvant post-prostatectomy radiation therapy: Long-term results of a large institutional experience

99

Background: Randomized trials and consensus statements support consideration of adjuvant radiation therapy (ART) after radical prostatectomy (RP) for adverse pathologic features (pT3, positive margins), although its use remains low. Whether early salvage radiation therapy (ESRT) is as effective as ART remains unknown. The objective of this study was to compare outcomes after ART and ESRT. Methods: We performed a retrospective institutional analysis of 719 consecutive patients receiving post-RP RT from 1992 to 2013. ESRT was defined as RT for biochemical failure (BF) with post-RP PSA ≤ 0.5 ng/ml. All included ART and ESRT patients had adverse surgical pathologic features. Outcomes examined were freedom from BF (FFBF; rising PSA ≥ 0.2 ng/ml with subsequent confirmation), freedom from subsequent androgen deprivation therapy (FFADT), freedom from distant metastases (FFDM), and overall survival (OS). ART and ESRT were compared using multivariable analyses (MVA) with propensity score (PS) matching for pre-RP PSA, age at RT, Gleason score, pT-stage, and margin status. Results: 537 patients received salvage RT, of whom 195 received ESRT; 181 patients received ART. Median follow-up from RP was 7.0 and 8.1 years in the ART and ESRT cohorts, respectively. Median time to BF after RT was 4.4 and 4.7 years in the ART and ESRT cohorts, respectively. On MVA, ART was associated with improved 10-year FFBF (74 vs 60%, HR 0.36 [95% CI: 0.23-0.58], P < 0.0001) and 10-yr FFADT (91 vs 83%, HR 0.37 [95% CI: 0.18-0.76], P = 0.007). There were no significant differences in FFDM (96 vs 92%, HR 0.58 [95% CI: 0.19-1.7], P = 0.3), and OS (98 vs 95%, HR 1.24 [95% CI: 0.4-3.89], P = 0.7). After PS matching, ART (n = 169) remained significantly associated with improved FFBF (p < 0.0001) and FFADT (p = 0.01), compared to ESRT (n = 176). Conclusions: Post-prostatectomy RT confers excellent long-term prostate cancer control, a finding supported by the long follow-up in this series. ART is associated with improved FFBF and FFADT compared to ESRT, although there were no statistically significant differences in FFDM and OS. Optimal timing of postoperative RT further awaits the results of ongoing randomized trials.

Primary genitourinary melanoma: Epidemiology and disease-specific survival in a large population-based cohort

BACKGROUND

Primary genitourinary (GU) melanoma is a rare disease, which is poorly characterized.

OBJECTIVE

To examine clinical characteristics and survival outcomes of primary GU melanoma among men and women.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective study using the Surveillance, Epidemiology, and End Results database (1973-2010) was used to identify primary GU melanoma cases by tumor site and histology codes. We examined associations of GU melanoma with demographic, clinical, and pathologic characteristics, as well as disease-specific survival (DSS).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

DSS was calculated using the Kaplan-Meier method. Cox-proportional hazard models were used to calculate hazard ratios and 95% CI for factors associated with worse DSS.

RESULTS AND LIMITATIONS

A total of 1,586 histologically confirmed cases of primary GU melanoma were identified with a median age of 66.1 years (IQR: 55-80). Incidence of primary GU melanoma was 0.2cases/million among men and 1.80cases/million among women. Overall, 60.1% of patients had localized disease at presentation and 90.5% of patients had cancer-directed surgery. Patients with urothelial melanoma had the worst 5- and 10-year DSS (39% and 29%, respectively). Women with vulvar/vaginal melanoma had worse 5- and 10-year DSS compared to men with penile/scrotal melanoma. In multivariate analysis, decreased survival was associated with increasing age, distant stage, and lymph node involvement. Results are limited by the lack of standardized staging for primary GU melanoma and the retrospective design of our study.

CONCLUSIONS

Patients with primary GU melanoma present with advanced stage and have a poor prognosis. Women have worse DSS compared to men. DSS is negatively associated with advanced age at diagnosis, higher stage, and lymph node involvement.

PATIENT SUMMARY

Clinicians and patients must be aware of the poor disease-specific outcomes associated with primary GU melanoma. Most importantly, women fare worse than men and mucosal melanomas have worse outcomes compared to cutaneous melanomas.

Abstract A45: The association between type 2 diabetes mellitus and incidence of renal cell carcinoma (RCC) and fatal RCC in two prospective cohorts

Introduction: Current epidemiologic evidence suggests that type 2 diabetes (T2D) is associated with an increased risk of renal cell carcinoma (RCC), but no prospective studies have explored the association in both men and women. Postulated mechanisms include hyperinsulinemia, increases in circulating growth factors, increased endogenous estrogens, and changes in glucose availability. Given the increasing incidence of T2D it is imperative to further evaluate its role in RCC incidence.

Methods: We investigated the association between T2D and RCC using prospective cohorts of 117,616 women from the Nurses' Health Study (NHS) and 48,818 men from the Health Professionals Follow-up Study. Self-reports of physician-diagnosed diabetes were collected at baseline, updated biennially, and confirmed via supplemental questionnaires. We used multivariable Cox proportional hazards models to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for the incidence of both total and fatal pathology-confirmed RCC. Models were adjusted for BMI, hypertension, smoking, alcohol intake, NSAID use, and physical activity. Additional adjustment for race, fruit, and vegetable intake did not affect results.

Results: During 34 years of follow-up in the NHS we confirmed 309 cases of RCC, including 60 fatal cases. During 24 years of follow-up in the HPFS we confirmed 214 total cases, including 34 fatal cases. In women, T2D was associated with a significantly increased risk of incident RCC (multivariable HR 1.55; 95%CI 1.08 – 2.19), but not fatal RCC (multivariable HR 0.74; 95%CI 0.22 – 2.48). In men, T2D was not associated with an increased risk of incident RCC (multivariable HR 1.10; 95%CI 0.65 – 1.86), but men with T2D were at a non-significantly higher risk of fatal RCC (multivariable HR 2.89; 95%CI 0.93 – 9.02). Compared to non-diabetic women, the association between T2D and RCC was non-significantly stronger in women with a shorter duration of T2D (multivariable HR for ≤ 5 years: HR 2.11; 95%CI 1.31 – 3.38; for &gt; 5 years: HR 1.23; 95%CI 0.77 – 1.95; pdiff: 0.58). In men, duration of T2D was not associated with an increased risk of incident RCC.

Conclusions: Our results support previous findings of an association between T2D and incidence of RCC in women; however, we found no significant association in men. T2D may be associated with an increased risk of fatal RCC in men, though power for this analysis in men and women was low.

Citation Format: Rebecca E. Graff, Alejandro Sanchez, Jed-Sian Cheng, Dayron Rodriguez, Adam S. Feldman, Glen Barrisford, Seth Bechis, Michael L. Blute, Meir Stampfer, Mark A. Preston, Kathryn M. Wilson, Eunyoung Cho. The association between type 2 diabetes mellitus and incidence of renal cell carcinoma (RCC) and fatal RCC in two prospective cohorts. [abstract]. In: Proceedings of the Thirteenth Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2014 Sep 27-Oct 1; New Orleans, LA. Philadelphia (PA): AACR; Can Prev Res 2015;8(10 Suppl): Abstract nr A45.

Role of imaging in testicular cancer: current and future practice

The article provides a summary of the epidemiologic and clinical aspects of testicular malignancy. Current standard imaging and novel techniques are reviewed. Present data and clinical treatment trends have favored surveillance protocols over adjuvant radiation or chemotherapy for low-stage testicular malignancy. This has resulted in increasing numbers of imaging studies and the potential for increased long-term exposure risks. Understanding imaging associated risks as well as strategies to minimize these risks is of increasing importance. The development, validation and incorporation of alternative lower risk highly efficacious and cost-effective imaging techniques is essential.

Myopericytoma tumor of the glans penis

Myopericytoma is a low grade spindle cell neoplasm largely occurring in skin. We describe the first reported case of a penile myopericytoma. Histologically, the penile tumor was composed of a perivascular proliferation of tumor cells with ovoid shaped nuclei and abundant eosinophilic cytoplasm. Immunohistochemically, the tumor was reactive for markers of smooth muscle differentiation and vascular differentiation. The tumor was noted to be negative for BRAF by immunohistochemistry and wild-type upon gene sequencing using SnaPshot. Our finding serves to expand the anatomical distribution of myopericytoma and broadens the spectrum of primary mesenchymal neoplasms that may be encountered in the penis.

Preoperative Anemia as an Independent Prognostic Indicator of Papillary Renal Cell Carcinoma

OBJECTIVES

Preoperative anemia has been proposed as a prognostic factor for clear cell renal cell carcinoma. We evaluate its role in papillary renal cell carcinoma (pRCC).

METHODS

At 2 institutions, patients who underwent complete resection of localized (T1-3 N0/+ M0) pRCC by radical or partial nephrectomy were retrospectively reviewed in this study. Anemia was defined as hemoglobin < 13.5 g/dL in men and < 12 g/dL in women. The associations of preoperative anemia with clinical and pathologic variables were assessed using the Student t, Wilcoxon rank-sum, and chi-square tests. Univariable and multivariable analyses using the Kaplan-Meier method and the Cox regression model were performed to determine factors that were associated with recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS).

RESULTS

Our final cohort included 352 patients. Compared with patients without anemia, patients with anemia were older and more likely to have larger tumor size and higher Fuhrman grade. Kaplan-Meier curves showed that patients with preoperative anemia had significantly worse RFS, CSS, and OS than patients without anemia (log-rank test, all P < .001). Multivariable analyses revealed that anemia was an independent prognostic factor in terms of RFS, CSS, and OS (all P < .001).

CONCLUSIONS

Preoperative anemia is an important independent prognostic factor associated with an increased risk of recurrence and mortality in patients after surgery with a curative intent for localized pRCC. Consideration of preoperative anemia could provide urologists additional prognostic information in patients with pRCC.

The association between obesity and incidence of total and fatal renal cell carcinoma in two prospective cohorts

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Background: Recent studies suggest an “obesity paradox” in renal cell carcinoma (RCC), in which obese people are more likely to be diagnosed with RCC, but are less likely to die of the disease. We studied the association of body mass index (BMI) with risk of both total and fatal RCC in two large prospective cohorts. Methods: The Nurses’ Health Study (NHS) consists of 117,097 women followed since 1976, and the Health Professionals Follow-up Study (HPFS) consists of 48,268 men followed since 1986. Height and weight were reported at baseline and updated biennially through 2008, with disease follow-up through 2010. We used multivariable Cox proportional hazards models to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for the incidence of both total and fatal pathology-confirmed RCC by BMI immediately prior to diagnosis. Models were adjusted for diabetes, hypertension, smoking, alcohol intake, NSAID use, physical activity, and parity in women. Results: We confirmed 349 cases of RCC, including 103 fatal cases, in NHS, and 226 cases in HPFS, with 46 fatal cases. Compared to women with normal BMI (18.5-24.9 kg/m2) immediately prior to diagnosis, obese women (BMI≥30) had an increased risk of RCC (HR 1.38, 95% CI: 1.03-1.84, p-trend=0.004), adjusting for possible confounders. The HR for fatal RCC was similar but not statistically significant (HR 1.35, 95% CI: 0.79-2.29, p-trend=0.22). Obese men had a non-significantly increased risk of RCC (HR 1.45, 95% CI: 0.96-2.21, p-trend=0.05), with a significantly increased risk of fatal RCC (HR 2.56, 95% CI: 1.11-5.90, p-trend=0.13). Among women, the associations with baseline BMI (1976) were somewhat stronger (HR 1.88, 95% CI: 1.36-2.61, p-trend<0.0001 for total; HR 1.98, 95% CI: 1.07-3.66, p-trend=0.002 for fatal). For men the association with baseline BMI (1986) was weaker for fatal RCC (HR 1.34, 95% CI: 0.50-3.58, p-trend=0.27). Conclusions: Our results support that obesity is a risk factor for RCC incidence and also suggest that it is adversely associated with fatal RCC. These results are stronger for women than for men, though this may be due to the lower number of cases among men.

Quality of life in long-term survivors of muscle-invasive bladder cancer

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Background: Health-related quality of life (QOL) is not well-studied in survivors of muscle-invasive bladder cancer (MIBC). This cross-sectional multi-institutional study compared long-term QOL in MIBC patients treated with bladder-sparing trimodality therapy (TMT) vs. radical cystectomy (RC). Methods: Patients with non-metastatic cT2-T4 MIBC, diagnosed in 1990-2011 and disease-free for ≥2 years were identified. A questionnaire using validated general and disease-specific QOL instruments was administered (score ranges: 0-100). Results: Of 226 eligible patients, 173 returned the questionnaire for a response rate of 77%. Sixty-four received TMT and 109 RC (89 with ileal conduit and 18 with neobladder diversions). The median time from diagnosis to questionnaire was 9 vs. 6 years, respectively (p=0.009). Comparing TMT to RC, there was no significant difference in age at diagnosis or questionnaire, gender, smoking, clinical stage or comorbidities. On univariable analysis (UVA), patients who received TMT had significantly better general QOL than patients who received RC by 4.8 points on the EQ-5D 3L and 7.4 points on the EORTC QLQ-C30 (Table). On multivariable analysis (MVA), adjusting for age, time from diagnosis, year of treatment, gender and comorbidities, patients who received TMT had significantly better general QOL by an average 6-7 points. On MVA, TMT was associated with significantly better bowel function by an average 4.5 points on the EPIC bowel function subscale, but with no difference in bowel bother. Urinary QOL was equivalent between groups, as measured by the EORTC QLQ-BLM30. Conclusions: While both TMT and RC provide good long-term outcomes, TMT appears to be associated with higher general QOL and bowel function compared to RC. [Table: see text]