Robotic surgery does not affect upstaging of T1 renal masses

Partial nephrectomy is the mainstay of treatment for localized kidney cancer. A proportion of patients are upstaged post-operatively to locally advanced disease (pT3a). We aimed to identify the incidence of upstaging to pT3a during partial nephrectomy and its relationship to a robotic approach. The National Cancer Database was queried for patients diagnosed with cT1M0 disease between 2010 and 2015 who underwent an open or robotic partial nephrectomy with final stage pT1-3a. Our primary outcome was rate of upstaging to pT3a in patients undergoing partial nephrectomy and secondary outcomes were stage migration, rate of positive margins, and overall survival (OS). The relationship between open and robotic surgery was examined. Logistical regression and Kaplan-Meier analyses were performed. Of 68,976 patients identified, 5.9% of patients were upstaged from cT1 to pT3a post-operatively. The incidence of upstaging to pT3a disease has increased from 5.7% in 2010 to 6.9% in 2015. Similarly, the proportion of patients undergoing a robotic approach is also increasing (31.6-64.4%); however, a robotic approach is not associated with pT3a upstaging on multivariable analysis. The probability of being upstaged was significantly proportional to increasing tumor size (OR 2.634-11.641, p < 0.05). pT3a disease was associated with a significant increase in positive margins (10.7% vs 5.0%, p < 0.001). Interestingly, pT3a patients with positive margin had worsened survival (5-year OS 75.5% vs 65.9%, p < 0.001). A robotic surgical approach to partial nephrectomy does not increase risk of upstaging to pT3a disease. Those who are upstaged have increased risk of positive margins and associated risk of decreased survival.

Charlson comorbidity score is associated with readmission to the index operative hospital after radical cystectomy and correlates with 90-day mortality risk

PURPOSE

Our objective was to determine perioperative variables associated with 30-day readmission to the index operative hospital after radical cystectomy for bladder cancer and subsequent survival outcomes.

METHODS

Retrospective cohort study utilizing the United States National Cancer Database from 2004-2015. All clinical stages undergoing radical cystectomy were analyzed. Exclusion criteria included clinical suspicion of nodal disease, metastasis, or preoperative radiation therapy. Multivariable logistic regression was used for 30-day readmission risk to the index hospital. Kaplan-Meier analysis and multivariable Cox regressions were used for survival outcomes.

RESULTS

31,147 patients were identified and stratified by 30-day readmission (n = 2628) or no readmission (n = 28,519). Thirty-day readmission to the index surgery hospital was 8.4%. Groups were comparable in terms of age, gender, race, income, facility type, insurance, length of hospital stay, and pathologic stage. There were significantly more patients with higher Charlson comorbidity score in the readmission cohort. On logistic regression analysis, increasing Charlson score was the only predictor of 30-day readmission (OR 1.39-1.73, p < 0.001). The 90-day mortality rate was 7.2% overall (7.0% no readmission vs 9.9% 30-day readmission, p < 0.001). Cox regression analysis for mortality revealed increasing age (HR 1.04), higher Charlson score (HR 1.42-1.85), readmission within 30 days (HR 1.38) and pathologic stage pT ≥ 2 (HR 1.88-7.09, all p < 0.001) as independent predictors of 90-day mortality.

CONCLUSIONS

Increasing comorbidity is a strong predictor of readmission to the index surgery hospital after radical cystectomy. Readmission is associated with worsened mortality at 90 days.

Carpal tunnel decompression in primary care: what is the infection risk and is it safe and effective?

INTRODUCTION

The demand for elective hand surgery in England is predicted to double by 2030 compared with 2011. With such increase in demand, the UK must seek strategies to reduce costs of treatment while still maintaining standards of care. Carpal tunnel decompression performed in a treatment room rather than in theatre may provide a safe alternative setting. As yet, there are no UK-based studies that identify the risk of infection following surgery performed in a treatment room and there are no studies whatsoever assessing the qualitative outcomes of patients undergoing hand surgery outside a theatre environment. Our aim was to assess whether carpal tunnel decompression performed in the community is safe, in terms of infection risk, and effective.

MATERIALS AND METHODS

Patient outcome measures were prospectively recorded following carpal tunnel decompression in one single primary care centre performed by one surgeon from 2012 to 2017. Infection following surgery was evaluated for retrospectively.

RESULTS

A total of 460 patients underwent carpal tunnel decompression within the study time period. There were three superficial infections identified, giving an infection rate of 0.65%. There were no deep infections identified. There was a statistically significant improvement in both symptom and functional outcomes following surgery, with results comparable to other studies where surgery was performed in theatre.

DISCUSSION

We believe that carpal tunnel decompressions performed in a treatment room is both safe, in terms of infection risk, and effective. Surgeons should consider this location as an alternative setting to the main operating theatre.

Squamous cell carcinoma of the bladder: poor response to neoadjuvant chemotherapy

BACKGROUND

Squamous cell carcinoma (SCC) of the bladder is a rare, aggressive malignancy. Unlike urothelial cell carcinoma, SCC is resistant to chemotherapy and guidelines recommend radical cystectomy (RC) without neoadjuvant chemotherapy (NAC). We aimed to evaluate the current management and survival of patients with invasive SCC treated with or without NAC.

METHODS

671 patients with invasive SCC bladder cancer from 2004 to 2015 in the National Cancer Data Base were identified. Patients were stratified by treatment with RC alone or NAC prior to RC (NAC + RC). Survival analysis was performed with Kaplan-Meier and Cox regression. Secondary outcomes included length of stay and readmission.

RESULTS

Of 671 patients, 92.8% were treated with RC alone and 7.2% with NAC + RC. Cox regression for mortality was performed including age, Charlson score, clinical stage, and NAC. Increased risk of mortality was noted with increasing age (OR 1.01, p = 0.023) and Charlson score of 1-3 (HR 1.58-1.68, p < 0.05). NAC did not confer survival advantage (HR 1.17, p = 0.46). On Kaplan-Meier analysis, the overall survival was equivalent (log-rank p = 0.804). Hospital stay and readmission were similar between RC and NAC + RC groups.

CONCLUSIONS

Analysis of a national tumor registry suggests a lack of overall survival benefit for NAC with localized, muscle invasive SCC of the bladder. Further research directed at chemotherapy regimens for SCC is needed to optimize treatment and improve survival outcomes.

The current treatment patterns of metastatic renal cell carcinoma: A national cancer database review, 2004–2015

Objective:

Our objective was to analyze patterns of treatment for metastatic renal cell carcinoma (mRCC) (no treatment (NT), cytoreductive nephrectomy only (CN), systemic therapy only (ST), and both systemic and cytoreductive (ST+CN)), and correlate them with racial or socioeconomic factors.

Materials and Methods:

Cases of mRCC from 2004–2015 were selected from the National Cancer Database. Our primary outcome was the temporal trend of treatment types. Secondary outcomes included the association of treatment with racial and socioeconomic factors. Logistical regression was performed.

Results:

In total, 40,372 patients with mRCC were identified. Treatment modalities included 37.0% NT, 13.9% CN only, 31.6% ST only and 17.5% ST+CN. From 2004–2015, NT decreased (53.4 vs. 32.1%, p < 0.001), CN alone decreased (18.1 vs. 12.1%, p < 0.001), ST alone increased (18.1 vs. 36.7%, p < 0.001) and ST+CN increased (10.3 vs. 19.1%, p < 0.001). On logistical regression, we found non-white races (odds ratio 1.29–1.73, p < 0.001), low-volume centers (hazard ratio (HR) 1.18, p < 0.001), no insurance (HR 2.29, p < 0.001) and low income (HR 1.24, p < 0.001) increased the likelihood of receiving NT.

Conclusion:

More patients are receiving ST and ST+CN; however, racial and socioeconomic factors may affect the treatment patterns for mRCC, and the underlying cause of these health disparities is unknown.

Level of Evidence:

2c6

Trends in the treatment of clinical T1 renal cell carcinoma for octogenarians: Analysis of the National Cancer Database

OBJECTIVE

Treatment of renal cell carcinoma has evolved with emphasis on nephron preservation for small renal masses. Our objective was to evaluate the proportions of treatment types for octogenarians with clinical stage 1 renal cell carcinoma.

MATERIALS AND METHODS

The National Cancer Database was analyzed from 2004 to 2015. Patients with clinical stage 1, tumor size ≤ 7 cm, and age 80-89 years old were compared to a younger control arm of patients ≤ 70 years old. Treatment modality was categorized as radical nephrectomy (RN), partial nephrectomy (PN), percutaneous ablative therapy (PAT), and no treatment (NT). Primary outcome was treatment utilization over time using estimated annual percentage change (EAPC). Secondary outcomes included logistic regression for 30 day readmission after treatment and any definitive tumor treatment choice.

RESULTS

18,903 octogenarians were identified and compared to a control of 142,179 patients ≤ 70 years old. Overall, NT (36%) was the most common modality for octogenarians while PN (44.8%) was most common for the control arm. Using EAPC for octogenarians, we found increases for PAT (7.1%), PN (2.8%), and NT (1.6%) but a decrease for RN (-4.6%). EAPC for the younger cohort noted increases for PAT (6.8%), PN (5.4%), and NT (4.4%) but a decrease for RN (-5.5%).

CONCLUSION

For octogenarians with stage 1 renal cell carcinoma, minimally invasive treatments are increasingly utilized, while RN is decreasing. Compared to a younger cohort, a greater proportion of octogenarians are receiving NT. These findings remain encouraging for appropriate treatment of localized disease in patients with advanced age.

Invasive non-urachal adenocarcinoma of the bladder: analysis of the National Cancer Database

PURPOSE

To review the United States National Cancer Database (NCDB) from 2004 to 2015 and analyze survival outcomes of invasive non-urachal adenocarcinoma based on treatment modality.

METHODS

The NCDB 2004-2015 bladder dataset was queried for adenocarcinoma histology, excluding urachal variant, and limited to patients with clinical stage T2-T4 disease. Treatment modality was categorized as no treatment, cystectomy (partial or radical), external beam radiation therapy (EBRT), or EBRT plus cystectomy. Our primary outcome was overall survival. Cox regression (CR) and Kaplan-Meier (KM) analysis were performed.

RESULTS

851 patients were identified with invasive (cT2-T4) adenocarcinoma of the bladder. Treatment modalities included 398 (47.8%) no treatment, 298 (35.8%) cystectomy, 124 (14.9%) EBRT, and 31 (3.7%) EBRT plus cystectomy. On KM analysis excluding those with metastatic disease, the 5-year survival was significantly better (p < 0.001) for patients who underwent cystectomy (39.6%), versus no treatment (21.0%), EBRT (18.6%), or EBRT plus cystectomy (26.9%) (log rank, p < 0.001). On CR for mortality, age (HR 1.030, p < 0.001), Charlson score 1 (HR 1.287, p = 0.034), cT4 (HR 1.768, p < 0.001), and receiving treatment at a low-volume center (HR 1.289, p = 0.026) were associated with worsened survival; however, cystectomy (HR 0.593, p < 0.001) was the only factor associated with improved survival. For those undergoing cystectomy, the mean length of stay was 8.5 days and the 30-day readmission rate was 7.0%.

CONCLUSIONS

Invasive non-urachal adenocarcinoma of the bladder is a rare diagnosis. Survival benefits in patients without metastatic disease are seen only in those patients undergoing definitive surgery.

Perceptions of Urologists About the Conversational Elements Leading to Treatment Decision-Making Among Newly Diagnosed Prostate Cancer Patients

Widespread adoption and use of the practice of shared decision-making among health-care providers, especially urologists, has been limited. This study explores urologists' perceptions about their conversational practices leading to decision-making by newly diagnosed prostate cancer patients facing treatment. Semi-structured, in-depth interviews were conducted with 12 community and academic urologists practicing in the St. Louis, MO, region. Data were analyzed using a consensus coding approach. Urologists reported spending 30-60 min with newly diagnosed prostate cancer patients when discussing treatment options. They frequently encouraged family members' involvement in discussions about treatment, especially patients' spouses and children. Participants perceived these conversations to be difficult given the emotional burden associated with a cancer diagnosis, and encouraged patients to postpone their decisions or to get a second opinion before finalizing their treatment of choice. Initial discussions included a presentation of treatment options relevant to the patient's condition, side effects, outcome probabilities, and next steps. Urologists seldom used statistics while talking about treatment outcome probabilities and preferred to explain outcomes in terms of the patient's practical, emotional, and social experiences. Their styles to elicit the patient's preferences ranged from explicitly asking questions to making assumptions based on clinical experience and subtle patient cues. In conclusion, urologists' routine conversations included most elements of shared decision-making. However, shared decision-making required urologists to have nuanced discussions and be skilled in elicitation methods and risk discussions which requires further training. Further research is required to explore roles of family and clinical staff as participants in this process.

The androgen receptor is a negative regulator of eIF4E phosphorylation at S209: implications for the use of mTOR inhibitors in advanced prostate cancer

The anti-androgen bicalutamide is widely used in the treatment of advanced prostate cancer (PCa) in many countries, but its effect on castration resistant PCa (CRPC) is limited. We previously showed that resistance to bicalutamide results from activation of mechanistic target of rapamycin (mTOR). Interestingly, clinical trials testing combinations of the mTOR inhibitor RAD001 with bicalutamide were effective in bicalutamide-naïve CRPC patients, but not in bicalutamide-pre-treated ones. Here we investigate causes for their difference in response. Evaluation of CRPC cell lines identified resistant vs sensitive in-vitro models, and revealed that increased eIF4E(S209) phosphorylation is associated with resistance to the combination. We confirmed using a human-derived tumor-xenograft mouse model that bicalutamide pre-treatment is associated with an increase in eIF4E(S209) phosphorylation. Thus, AR suppressed eIF4E phosphorylation, while the use of anti-androgens relieved this suppression, thereby triggering its increase. Additional investigation in human prostatectomy samples showed that increased eIF4E phosphorylation strongly correlated with the cell proliferation marker Ki67. SiRNA-mediated knock-down of eIF4E sensitized CRPC cells to RAD001+bicalutamide, while eIF4E overexpression induced resistance. Inhibition of eIF4E phosphorylation by treatment with CGP57380 (an inhibitor of MAPK interacting serine-threonine kinases Mnk1/2, the eIF4E upstream kinase) or inhibitors of ERK1/2, the upstream kinase regulating Mnk1/2, also sensitized CRPC cells to RAD001+bicalutamide. Examination of downstream targets of eIF4E-mediated translation, including survivin, demonstrated that eIF4E(S209) phosphorylation increased cap-independent translation whereas its inhibition restored cap-dependent translation which could be inhibited by mTOR inhibitors. Thus, our results demonstrate that while combinations of AR and mTOR inhibitors were effective in suppressing tumor growth by inhibiting both AR-induced transcription and mTOR-induced cap-dependent translation, pre-treatment with AR antagonists including bicalutamide increased eIF4E phosphorylation that induced resistance to combinations of AR and mTOR inhibitors by inducing cap-independent translation. We conclude that this resistance can be overcome by inhibiting eIF4E phosphorylation with Mnk1/2 or ERK1/2 inhibitors.

The role of oral methotrexate as a steroid sparing agent in refractory eosinophilic asthma

The use of oral methotrexate for refractory eosinophilic asthma in a tertiary asthma referral centre, Glenfield Hospital, Leicester, was evaluated between January 2006 and December 2014. The patients (n = 61) were carefully phenotyped at baseline with markers of airway inflammation. In addition, a structured oral methotrexate proforma was utilized to evaluate response to therapy and adverse events. Oral steroid withdrawal was attempted 3 months after commencing treatment. Several outcomes were evaluated at 12 months, including both efficacy and adverse effects; 15% (n = 9/61) responded by achieving a decrease in daily oral corticosteroid dose (mean 8.43 (±8.76) mg), although we were unable to identify factors that predicted a treatment response. There were no other significant changes in any other clinical outcome measures. There was a high rate of adverse events (19/61 (31%)), primarily gastrointestinal/hepatitis. Our findings support the use of biological agents in preference to using oral methotrexate as a steroid sparing agent at the first instance. In the event of failure of these agents, oral methotrexate remains a therapeutic option, which can be considered in highly specialist severe asthma centres.

Do Prior Driveline Infections Increase the Risk of Infection in Heart Transplant Patients Treated With Rabbit Antithymocyte Globulin Induction Therapy?

BACKGROUND

The use of mechanical circulatory support devices (MCSDs) has been increasing over the past several years. Driveline infections (DLIs) are one of the most common complications seen in these patients; reportedly, up to 50% of patients with MCSDs can develop this complication. It is believed that the removal of the driveline results in treatment of the localized infection area. MCSD patients are also known to develop circulating antibodies. These circulating antibodies have been associated with poor outcomes after heart transplantation. The use of rabbit antithymocyte globulin (ATG) as induction therapy reportedly decreases the development of circulating antibodies; it is now commonly used in sensitized patients undergoing heart transplantation. It is unknown whether ATG induction therapy immediate posttransplant will increase the risk of infection of those MCSD patients with DLIs.

METHODS

Between 2003 and 2013, we evaluated 57 MCSD patients who subsequently underwent heart transplantation and received ATG induction therapy. Patients were divided into those with previous MCSD DLI and those without, and they were assessed for 1-year freedom from infection (specifically, sternal wound infections). One-year survival and freedom from treated rejection, both cellular and antibody mediated, were also assessed.

RESULTS

MCSD patients with DLIs who received ATG induction did not have a lower freedom from any treated infection and from sternal wound infection posttransplant compared with those MCSD patients without DLIs and not treated with ATG induction. There were also no significant differences between the 2 groups in terms of 1-year posttransplant survival and freedom from treated rejection.

CONCLUSIONS

The use of ATG induction in patients with prior DLIs did not seem to increase the risk for posttransplant infection (eg, sternal wound infection). ATG induction can therefore be safely used in this population.