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Matsubara K, Hayakawa N, Aida K, Koike J, Kikuchi E. Renal pelvic plasmacytoid subtype urothelial carcinoma accompanied with solitary mammary metastasis. Int Cancer Conf J 2024; 13:296-300. [PMID: 38962031 PMCID: PMC11217202 DOI: 10.1007/s13691-024-00681-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 04/04/2024] [Indexed: 07/05/2024] Open
Abstract
A 72-year-old female was referred to our institution for further evaluation of right renal tumor detected during work-up for macroscopic hematuria in other hospital. CT urography performed at our institution suggested renal pelvic tumor. Voiding cytology was atypical. CT also revealed a small mass in the right mammary gland. Percutaneous needle biopsies were performed on the right mammary gland and renal mass, leading to a pathological diagnosis of UC with plasmacytoid subtype, suggesting metastasis from the renal pelvic UC to the mammary gland. She had a favorable response to four cycles of dose-dense MVAC therapy; therefore, we performed nephroureterectomy. One month after nephroureterectomy, new intraperitoneal metastatic lesions were observed and pembrolizumab therapy was started. After seven doses of pembrolizumab, CT revealed a marked size reduction of intraperitoneal metastases and the mammary metastasis remained small.
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Affiliation(s)
- Keisuke Matsubara
- Department of Urology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki-shi, Kanagawa 216-8511 Japan
| | - Nozomi Hayakawa
- Department of Urology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki-shi, Kanagawa 216-8511 Japan
| | - Koichiro Aida
- Department of Urology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki-shi, Kanagawa 216-8511 Japan
| | - Junki Koike
- Department of Diagnostic Pathology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-Ku, Kawasaki-Shi, Kanagawa 216-8511 Japan
| | - Eiji Kikuchi
- Department of Urology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki-shi, Kanagawa 216-8511 Japan
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2
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Guo CC, Lee S, Lee JG, Chen H, Zaleski M, Choi W, McConkey DJ, Wei P, Czerniak B. Molecular profile of bladder cancer progression to clinically aggressive subtypes. Nat Rev Urol 2024; 21:391-405. [PMID: 38321289 DOI: 10.1038/s41585-023-00847-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2023] [Indexed: 02/08/2024]
Abstract
Bladder cancer is a histologically and clinically heterogenous disease. Most bladder cancers are urothelial carcinomas, which frequently develop distinct histological subtypes. Several urothelial carcinoma histological subtypes, such as micropapillary, plasmacytoid, small-cell carcinoma and sarcomatoid, show highly aggressive behaviour and pose unique challenges in diagnosis and treatment. Comprehensive genomic characterizations of the urothelial carcinoma subtypes have revealed that they probably arise from a precursor subset of conventional urothelial carcinomas that belong to different molecular subtypes - micropapillary and plasmacytoid subtypes develop along the luminal pathway, whereas small-cell and sarcomatoid subtypes evolve along the basal pathway. The subtypes exhibit distinct genomic alterations, but in most cases their biological properties seem to be primarily determined by specific gene expression profiles, including epithelial-mesenchymal transition, urothelial-to-neural lineage plasticity, and immune infiltration with distinct upregulation of immune regulatory genes. These breakthrough studies have transformed our view of bladder cancer histological subtype biology, generated new hypotheses for therapy and chemoresistance, and facilitated the discovery of new therapeutic targets.
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Affiliation(s)
- Charles C Guo
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sangkyou Lee
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - June G Lee
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Huiqin Chen
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael Zaleski
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Woonyoung Choi
- Johns Hopkins Greenberg Bladder Cancer Institute, Johns Hopkins University, Baltimore, MD, USA
| | - David J McConkey
- Johns Hopkins Greenberg Bladder Cancer Institute, Johns Hopkins University, Baltimore, MD, USA
| | - Peng Wei
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bogdan Czerniak
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Guzman RA, Gonzalez M, Bakroun S, Bakroun Z, Othman F, Simon JA, Dash A. Small Bowel Obstruction Secondary to Metastatic Urothelial Cell Carcinoma With Plasmacytoid Features: A Case Report. Cureus 2024; 16:e63207. [PMID: 39070369 PMCID: PMC11277245 DOI: 10.7759/cureus.63207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2024] [Indexed: 07/30/2024] Open
Abstract
Urothelial cell carcinoma (UCC) is a type of malignant cancer that affects thousands of people worldwide, especially those who smoke and have certain occupational exposures. Plasmacytoid urothelial carcinoma (PUC) is a rare histological variant of UCC that can present aggressively and insidiously. Small bowel obstruction secondary to malignancy is a rare presentation of UCC because the small bowel is a rare site of metastasis. We showcase a patient who presented with small bowel obstruction secondary to high-grade metastatic UCC with plasmacytoid features, exhibiting minimal urologic symptoms and no apparent risk factors. This case highlights the importance of high clinical suspicion for patients with possible malignancies that present with limited or unusual symptomatology and no risk factors. Further research into PUC to understand its symptoms and metastatic pattern is warranted to advance current early diagnostic criteria and further improve patient outcomes.
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Affiliation(s)
- Rafael A Guzman
- Medicine, St. George's University School of Medicine, True Blue, GRD
- General Surgery, Delray Medical Center, Delray Beach, USA
| | - Maikol Gonzalez
- Medicine, St. George's University School of Medicine, True Blue, GRD
- General Surgery, Delray Medical Center, Delray Beach, USA
| | - Sara Bakroun
- Medicine, St. George's University School of Medicine, True Blue, GRD
- General Surgery, Delray Medical Center, Delray Beach, USA
| | - Zinab Bakroun
- Medicine, St. George's University School of Medicine, True Blue, GRD
- General Surgery, Delray Medical Center, Delray Beach, USA
| | - Feras Othman
- General Surgery, University of Miami, Miami, USA
| | - Joshua A Simon
- General Surgery, Delray Medical Center, Delray Beach, USA
| | - Aruna Dash
- Pathology, Delray Medical Center, Delray Beach, USA
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Koehne EL, Bakaloudi DR, Ghali F, Nyame Y, Schade GR, Grivas P, Yezefski TA, Hawley JE, Yu EY, Hsieh AC, Montgomery RB, Psutka SP, Gore JL, Wright JL. Adjuvant Chemotherapy and Survival After Radical Cystectomy in Histologic Subtype Bladder Cancer. Clin Genitourin Cancer 2024:102100. [PMID: 38763862 DOI: 10.1016/j.clgc.2024.102100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 04/08/2024] [Accepted: 04/22/2024] [Indexed: 05/21/2024]
Abstract
OBJECTIVES Patients with histologic subtype bladder cancer (HSBC) suffer worse outcomes than those with conventional urothelial carcinoma (UC). We sought to characterize the use of adjuvant chemotherapy (AC) in HSBC after radical cystectomy (RC) using the National Cancer Database (NCDB). MATERIALS AND METHODS We retrospectively queried the NCDB (2006-2019) for patients with non-metastatic bladder cancer (BC) who underwent RC (N = 45,797). Patients were stratified by histologic subtype and receipt of AC. Multivariable logistic regression determined associations of demographic and clinicopathologic features with receipt of AC. Multivariable Cox regression evaluated associations between receipt of any AC and overall survival (OS). RESULTS We identified 4,469 patients with HSBC classified as squamous, adenocarcinoma, small cell, sarcomatoid, micropapillary, or plasmacytoid. Squamous comprised 31% of the HSBC cohort, followed by small cells and micropapillary. Black patients were presented with a higher prevalence of adenocarcinoma (119/322, 37.0%). Use of AC was highest in plasmacytoid and small cell (30% each) and lowest in squamous (11%). Neuroendocrine histology was independently associated with greater odds of receiving AC (HR 1.6, 95% CI 1.37-1.87), while squamous cell histology was associated with lower odds (HR 0.61, 95% CI 0.53-0.71). On multivariable Cox regression analysis, treatment with AC was associated with significantly longer OS (HR 0.69, 95% CI 0.59-0.81) and for squamous, sarcomatoid, and micropapillary cohorts after stratified by subtype. CONCLUSIONS AC was variably used among patients with HSBC and was associated with OS benefit in such patients.
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Affiliation(s)
- Elizabeth L Koehne
- Department of Urology, University of Washington School of Medicine, Seattle, WA.
| | - Dimitra R Bakaloudi
- Division of Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Fady Ghali
- Department of Urology, Yale University, New Haven, CT
| | - Yaw Nyame
- Department of Urology, University of Washington School of Medicine, Seattle, WA
| | - George R Schade
- Department of Urology, University of Washington School of Medicine, Seattle, WA
| | - Petros Grivas
- Division of Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA; Fred Hutchinson Cancer Center, Seattle, WA
| | - Todd A Yezefski
- Division of Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA; Fred Hutchinson Cancer Center, Seattle, WA
| | - Jessica E Hawley
- Division of Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA; Fred Hutchinson Cancer Center, Seattle, WA
| | - Evan Y Yu
- Division of Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA; Fred Hutchinson Cancer Center, Seattle, WA
| | - Andrew C Hsieh
- Division of Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA; Fred Hutchinson Cancer Center, Seattle, WA
| | - R Bruce Montgomery
- Division of Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA; Fred Hutchinson Cancer Center, Seattle, WA
| | - Sarah P Psutka
- Department of Urology, University of Washington School of Medicine, Seattle, WA.
| | - John L Gore
- Department of Urology, University of Washington School of Medicine, Seattle, WA
| | - Jonathan L Wright
- Department of Urology, University of Washington School of Medicine, Seattle, WA
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Kim JM, Choi E, Sung SH, Jo J, Lee DH, Park S. Does Bladder Cancer Subtype Influence Pathologic Complete Response (pCR) and Pelvic Diffusion-Weighted Magnetic Resonance Imaging (DW-MRI) Response Evaluation After Neoadjuvant Chemotherapy? Pathological Perspective. Clin Genitourin Cancer 2024; 22:224-236. [PMID: 38042728 DOI: 10.1016/j.clgc.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 11/04/2023] [Accepted: 11/04/2023] [Indexed: 12/04/2023]
Abstract
INTRODUCTION We aimed to provide a pathological perspective on the management of muscle-invasive bladder cancer (MIBC) by correlating the prechemotherapy transurethral resection of bladder tumor findings and postchemotherapy radiologic evaluation with final radical cystectomy (RC) findings. MATERIALS AND METHODS This retrospective study included 79 MIBC patients treated with neoadjuvant chemotherapy (NAC) and RC. Pelvic diffusion-weighted magnetic resonance imaging (DW-MRI) and pathologic reports were retrieved from our institutional database. All pathology slides were reviewed based on diagnostic criteria with high interobserver reproducibility. RESULTS Pathologic complete response (pCR) was confirmed in 32 patients (40.5%). The concordance and discordance between MRI and RC findings occurred in 68.3% and 31.7% of cases, respectively. The 21.5% of cases that were clinical CR (cCR) on MRI actually achieved pCR on RC specimens and 46.8% of cases that were non-cCR on MRI were actually non-pCR on RC specimens. In 19.0% of cases, RC findings were pCR, but MRI demonstrated residual tumor and the opposite was 12.7%. The greatest discrepancy between the 2 methods (75%, 3/4) was for the plasmacytoid subtype. Plasmacytoid histology was the most common histological subtype identified in RC specimens after NAC, followed by micropapillary and squamous histologies. CONCLUSIONS We found that all cases with plasmacytoid and micropapillary subtypes, and squamous differentiation did not show pCR. In particular, the largest discrepancy between MRI findings and RC pathology after NAC was seen in the plasmacytoid subtype. An accurate pathologic diagnosis based on strict criteria to identify histological subtypes of MIBC is necessary for proper treatment.
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Affiliation(s)
- Ji Min Kim
- Department of Pathology, Ewha Womans University Mokdong Hospital, Ewha Womans University College of Medicine, Yangcheon-Gu, Seoul, Republic of Korea
| | - Euno Choi
- Department of Pathology, Ewha Womans University Mokdong Hospital, Ewha Womans University College of Medicine, Yangcheon-Gu, Seoul, Republic of Korea
| | - Sun Hee Sung
- Department of Pathology, Ewha Womans University Mokdong Hospital, Ewha Womans University College of Medicine, Yangcheon-Gu, Seoul, Republic of Korea
| | - Jungmin Jo
- Division of Hematology-Oncology, Department of Internal Medicine, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea
| | - Dong-Hyeon Lee
- Department of Urology, Ewha Womans University Medical Center, Ewha Womans University School of Medicine, Seoul, Republic of Korea
| | - Sanghui Park
- Department of Pathology, Ewha Womans University Mokdong Hospital, Ewha Womans University College of Medicine, Yangcheon-Gu, Seoul, Republic of Korea.
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Weiss K, Gessner KH, Demzik A, Moreton E, Kim WY, Wobker SE, Rose TL, Milowsky MI, Bjurlin MA. Molecular characterization of plasmacytoid urothelial carcinoma and the impact on treatment implications. Cancer Treat Res Commun 2023; 37:100779. [PMID: 37988935 PMCID: PMC11315140 DOI: 10.1016/j.ctarc.2023.100779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 11/10/2023] [Accepted: 11/11/2023] [Indexed: 11/23/2023]
Abstract
Bladder cancer researchers and clinicians have increasingly viewed tumor biology through the lens of genomic and molecular alterations, drastically improving our knowledge of the underlying disease biology. This understanding has led to significant advances in treatment options that allow implementation of a personalized approach to cancer treatment. Large-scale genomic studies initially focused on the most common forms of bladder cancer. However, as genomic and molecular technologies become more widespread and are applied to less common variant histologies, we are gaining additional insight into the unique molecular and genomic characteristics driving the biology of variant histologies of bladder cancer. In this review, we summarize the current state of knowledge of molecular alterations underlying the distinct tumor biology of plasmacytoid urothelial carcinoma and how these alterations may impact treatment options.
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Affiliation(s)
- Kristin Weiss
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Kathryn H Gessner
- University of North Carolina Department of Urology, Chapel Hill, NC, USA
| | - Alysen Demzik
- University of North Carolina Department of Urology, Chapel Hill, NC, USA
| | | | - William Y Kim
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, NC, USA; Department of Pharmacology, University of North Carolina at Chapel Hill, NC, USA; Division of Hematology/Oncology, Department of Medicine, University of North Carolina at Chapel Hill, NC, USA; Department of Genetics, University of North Carolina at Chapel Hill, NC, USA
| | - Sara E Wobker
- University of North Carolina Department of Urology, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, NC, USA; Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, NC, USA
| | - Tracy L Rose
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, NC, USA; Division of Hematology/Oncology, Department of Medicine, University of North Carolina at Chapel Hill, NC, USA
| | - Matthew I Milowsky
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, NC, USA; Division of Hematology/Oncology, Department of Medicine, University of North Carolina at Chapel Hill, NC, USA
| | - Marc A Bjurlin
- University of North Carolina Department of Urology, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, NC, USA.
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7
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Enneli D, Baglan T. The Many Faces of Urothelial Carcinomas: An Update From Pathology to Clinical Approach and Challenges in Practice. UROLOGY RESEARCH & PRACTICE 2023; 49:147-161. [PMID: 37877864 PMCID: PMC10346099 DOI: 10.5152/tud.2023.23023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 03/25/2023] [Indexed: 10/26/2023]
Abstract
Urothelial carcinoma is a heterogeneous disease with histomorphological and genomic variations throughout the same tumor or between tumors from different patients. It has been shown that most of these histologic and genetic differences have prognostic significance and may have a guiding role in determining the appropriate treatment choice for the patient. Therefore, it is crucial for both the pathologist and the clinician to be conscious of these variations and to consider them in patient management. Recently, a consensus molecular classification has been developed and categorized urothelial carcinomas into 6 subclasses. These molecular subclasses seem to be associated with prognosis and/or response to certain therapeutic approaches like chemotherapy or immune checkpoint inhibitory therapy; however, it has not yet been sufficiently validated and has some limitations for routine application. As is well known, there are therapeutic limitations in locally advanced or metastatic urothelial carcinomas, especially those inappropriate for standard therapy with platinum-based chemotherapy regimens. Emerging new therapeutic approaches and testing for appropriate patient selection for those are discussed in this article.
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Affiliation(s)
- Duygu Enneli
- Department of Pathology, Ankara University School of Medicine, Ankara, Turkey
| | - Tolga Baglan
- Department of Pathology, Ankara University School of Medicine, Ankara, Turkey
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Aron M, Zhou M. Urothelial Carcinoma: Update on Staging and Reporting, and Pathologic Changes Following Neoadjuvant Chemotherapies. Surg Pathol Clin 2022; 15:661-679. [PMID: 36344182 DOI: 10.1016/j.path.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Staging and reporting of cancers of the urinary tract have undergone major changes in the past decade to meet the needs for improved patient management. Substantial progress has been made. There, however, remain issues that require further clarity, including the substaging of pT1 tumors, grading and reporting of tumors with grade heterogeneity, and following NAC. Multi-institutional collaborative studies with prospective data will further inform the accurate diagnosis, staging, and reporting of these tumors, and in conjunction with genomic data will ultimately contribute to precision and personalized patient management.
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Affiliation(s)
- Manju Aron
- Department of Pathology, Keck School of Medicine, University of Southern California; Department of Urology, Keck School of Medicine, University of Southern California.
| | - Ming Zhou
- Department of Anatomic and Clinical Pathology, Tufts University School of Medicine and Tufts Medical Center, 800 Washington St., Box 802, Boston, MA 02111
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9
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Zhu Z, Xiao Y, Hu S, Wang Z, Zhu Z. Neoadjuvant and Adjuvant Chemotherapy for Variant Histology Bladder Cancers: A Systematic Review and Meta-Analysis. Front Oncol 2022; 12:907454. [PMID: 35912201 PMCID: PMC9333064 DOI: 10.3389/fonc.2022.907454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 06/10/2022] [Indexed: 11/13/2022] Open
Abstract
ContextTo improve the prognosis of variant histology (VH) bladder cancers, clinicians have used neoadjuvant chemotherapy (NAC) or adjuvant chemotherapy (AC) on the basis of radical cystectomy (RC). Despite some new data, the evidence remains mixed on their efficacy.ObjectiveTo update the current evidence on the role of NAC and AC for VH bladder cancers.Evidence AcquisitionWe searched for all studies investigating NAC or AC for bladder cancer patients with variant histology in PubMed, Embase, and the Cochrane Central Register of Controlled Trials up to December 2021. The primary end points were recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS).Evidence SynthesisWe identified 18 reports comprising a total of 10,192 patients in the NAC studies. In patients with VH, the use of NAC did improve CSS (hazard ratio [HR] 0.74, 95% confidence interval [CI] 0.55–0.99, p = 0.044), and OS (HR 0.74, 95% CI 0.66–0.84, p = 0.000), but not RFS (HR 1.15, 95% CI 0.56–2.33, p = 0.706). Subgroup analyses demonstrated that receiving NAC was associated with better OS in sarcomatoid VH (HR 0.67, 95% CI 0.54–0.83, p = 0.000) and neuroendocrine VH (HR 0.54, 95% CI 0.43–0.68, p = 0.000). For AC, we identified eight reports comprising a total of 3254 patients. There was a benefit in CSS (HR 0.61, 95% CI 0.43–0.87, p = 0.006) and OS (HR 0.76, 95% CI 0.60–0.98, p = 0.032). Subgroup analyses demonstrated that only neuroendocrine VH had better CSS (HR 0.29, 95% CI 0.13–0.67, p = 0.174) when receiving AC.ConclusionsNAC or AC for VH bladder cancers confers an OS and CSS benefit compared with RC alone. For NAC, the benefit was independently observed in the sarcomatoid and neuroendocrine subgroups. As for AC, only neuroendocrine subgroups improved CSS.Systematic Review Registrationhttps://www.crd.york.ac.uk/prospero/, identifier CRD42021289487.
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Affiliation(s)
- Ziwei Zhu
- Department of Urology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, JinHua, China
| | - Yunyuan Xiao
- Department of Urology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, JinHua, China
| | - Shengye Hu
- Department of Urology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, JinHua, China
| | - Ziyuan Wang
- Key Laboratory of Laparoscopic Technique Research of Zhejiang Province, Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zaisheng Zhu
- Department of Urology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, JinHua, China
- *Correspondence: Zaisheng Zhu,
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10
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Woo S, Ghafoor S, Das JP, Gangai N, Goh AC, Vargas HA. Plasmacytoid urothelial carcinoma of the bladder: MRI features and their association with survival. Urol Oncol 2022; 40:108.e1-108.e10. [PMID: 34750054 PMCID: PMC8885786 DOI: 10.1016/j.urolonc.2021.09.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 08/20/2021] [Accepted: 09/26/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Plasmacytoid urothelial carcinomas (PUC) of the bladder are rare variants known for diffuse and infiltrative spread, however their magnetic resonance imaging (MRI) features are not well established. We aimed to evaluate MRI features of PUC of the bladder and their association with survival. METHODS AND MATERIALS This retrospective single-center study included 41 patients with pathologically-proven bladder PUC of the bladder that underwent pre-treatment MRI between January 2000 and March 2020. Two radiologists reviewed MRIs independently followed by consensus with a third radiologist. On MRI, tumor extent, size, Vesical Imaging-Reporting and Data System (VI-RADS) scores (≥4, muscle-invasive; 5, extravesical extension [EVE]), pelvic peritoneal spread (PPS), hydronephrosis, pelvic adenopathy and clinicopathological factors of age, gender, pathological stage, and treatment type were extracted. Kaplan-Meier curves and Cox proportional-hazards models were used to evaluate association with survival. RESULTS Thirty-two men and 9 women (median age 70 years, IQR 64-76) were included. Most were muscle-invasive (n = 30 [73.2%]). On MRI, most tumors were diffuse (n = 28 [68.3%]), >5 cm (n = 30 [73.2%]), VI-RADS 4 to 5 (n = 36 [87.8%]) with features of EVE and (n = 31 [75.6%]) and PPS (n = 25 [61.0%]). Variables associated with survival were: Larger tumors (>5 cm; hazard ratio [HR] = 5.0; 95% confidence interval [CI] 1.6-15.5; P < 0.01), diffuse extent (HR = 4.0; 95% CI 1.4-11.2; P = 0.01), EVE (HR = 4.5; 95% CI 1.5-13.6; P < 0.01), PPS (HR = 3.0; 95% CI 1.2-7.4; P = 0.01), hydronephrosis (HR = 13.7; 95% CI 3.1-60.9; P < 0.01), pathologic stage (≥pT3 vs. pT1; HR = 5.6; 95% CI 1.3-22.0; P = 0.02), and margin positivity (HR = 4.4 [95% CI 1.2-16.4], P = 0.03). CONCLUSION PUCs of the bladder are commonly large, diffuse VI-RADS score 4 to 5 tumors with MRI features of EVE and PPS. These features and pathological stage were associated with survival.
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Affiliation(s)
- Sungmin Woo
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY.
| | - Soleen Ghafoor
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Rämistrasse 100, CH-8091 Zürich, Switzerland
| | - Jeeban P. Das
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, USA
| | - Natalie Gangai
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, USA
| | - Alvin C. Goh
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY
| | - H. Alberto Vargas
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, USA
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11
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Sorce G, Flammia RS, Hoeh B, Chierigo F, Horlemann B, Würnschimmel C, Tian Z, Graefen M, Terrone C, Gallucci M, Chun FKH, Saad F, Shariat SF, Montorsi F, Briganti A, Karakiewicz PI. Plasmacytoid variant urothelial carcinoma of the bladder: effect of radical cystectomy and chemotherapy in non-metastatic and metastatic patients. World J Urol 2022; 40:1481-1488. [PMID: 35084543 DOI: 10.1007/s00345-022-03940-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 01/09/2022] [Indexed: 12/20/2022] Open
Abstract
PURPOSE Data about optimal management of plasmacytoid (PCV) bladder cancer patients are extremely scarce and limited by sample size. We focused on PCV bladder cancer patients to explore the effect of radical cystectomy (RC) and chemotherapy in non-metastatic (T 2-4N0-3M0), as well as in metastatic (TanyNanyM1) subgroups. METHODS Using the Surveillance, Epidemiology and End Results database (2000-2016), we identified 332 PCV patients with muscle-invasive disease or higher (≥ T2N0M0). Kaplan-Meier plots and Cox regression models addressed cancer-specific mortality (CSM). RESULTS In 332 PCV patients, median age was 68 years (Interquartile range [IQR]:58-76). Of those, 252 were non-metastatic patients (76%) vs 80 were metastatic patients (24%), at presentation. Of non-metastatic patients, 142 (56%) underwent RC and 131 (52%) underwent chemotherapy. Chemotherapy did not improve CSM in non-metastatic PCV. Conversely, RC was associated with lower CSM (hazard ratio [HR]: 0.51, p = 0.002). Median CSM-free survival was 48 vs 38 months for RC treated vs RC not treated. Of metastatic patients, 22 (28%) underwent RC and 42 (52%) underwent chemotherapy. Both chemotherapy and RC improved CSM in metastatic PCV. Median CSM-free survival was 12 vs 7 months for RC treated vs RC not treated (HR: 0.27, p < 0.001). Median CSM-free survival was 11 vs 4 months for chemotherapy exposed vs chemotherapy naïve (HR: 0.32, p = 0.002). CONCLUSIONS Although RC resulted in lower CSM, chemotherapy failed to show that effect in non-metastatic PCV patients. Conversely, both chemotherapy and RC resulted in statistically significantly lower CSM in metastatic PCV patients.
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Affiliation(s)
- Gabriele Sorce
- Department of Urology and Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy. .,Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada.
| | - Rocco Simone Flammia
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada.,Department of Maternal-Child and Urological Sciences, Sapienza University Rome, Policlinico Umberto I Hospital, Rome, Italy
| | - Benedikt Hoeh
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada.,Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Francesco Chierigo
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada.,Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy
| | - Benedikt Horlemann
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
| | - Christoph Würnschimmel
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada.,Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Zhe Tian
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
| | - Markus Graefen
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Carlo Terrone
- Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy
| | - Michele Gallucci
- Department of Maternal-Child and Urological Sciences, Sapienza University Rome, Policlinico Umberto I Hospital, Rome, Italy
| | - Felix K H Chun
- Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Fred Saad
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
| | - Shahrokh F Shariat
- Departments of Urology, Weill Cornell Medical College, New York, NY, USA.,Department of Urology, University of Texas Southwestern, Dallas, TX, USA.,Department of Urology, Second Faculty of Medicine, Charles University, Prag, Czech Republic.,Institute for Urology and Reproductive Health, I.M. Sechenov First Moscow State Medical University, Moscow, Russia.,Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan.,Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Francesco Montorsi
- Department of Urology and Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Alberto Briganti
- Department of Urology and Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Pierre I Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
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12
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Sun M, Schaap A, Robinson BD, Nanus DM, Tagawa ST. A case report of a patient with plasmacytoid urothelial cancer with significant response to HER2-targeting therapy and enfortumab vedotin. AMERICAN JOURNAL OF CLINICAL AND EXPERIMENTAL UROLOGY 2021; 9:390-396. [PMID: 34796255 PMCID: PMC8595081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 06/29/2021] [Indexed: 06/13/2023]
Abstract
In this case report, we present a patient with the rare plasmacytoid variant of urothelial cancer. Notable elements of his course include: complete response to neoadjuvant paclitaxel, gemcitabine, cisplatin, development of metastatic disease to the rectum, sustained disease control with dual HER2 targeting therapy, and subsequent complete response to enfortumab vedotin. Plasmacytoid urothelial cancer accounts for just 1-3% of all urothelial cancer cases and is associated with more aggressive disease, with a propensity for intra-abdominal spread and poor response to neoadjuvant therapy. Preliminary data indicate that the variant may generally have high levels of HER2 expression. We review the history of HER2 targeting in metastatic urothelial cancer, which has included single-agent as well as combination with chemotherapy; there are ongoing biomarker-based clinical trials. Furthermore, we highlight the complete response to enfortumab vedotin. To date, this is the first report of efficacy for enfortumab vedotin in the plasmacytoid variant.
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Affiliation(s)
- Michael Sun
- Department of Medicine, Weill Cornell MedicineNew York, United States
| | - Ariel Schaap
- Department of Medicine, Weill Cornell MedicineNew York, United States
| | - Brian D Robinson
- Department of Pathology, Weill Cornell MedicineNew York, United States
| | - David M Nanus
- Department of Medicine, Weill Cornell MedicineNew York, United States
- Department of Division of Hematology and Medical Oncology, Weill Cornell MedicineNew York, United States
| | - Scott T Tagawa
- Department of Medicine, Weill Cornell MedicineNew York, United States
- Department of Division of Hematology and Medical Oncology, Weill Cornell MedicineNew York, United States
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13
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Lockhart K, King S, Grant A, McLeod N, Tiu A. Outcomes of poorly differentiated and plasmacytoid variant bladder urothelial carcinoma. BJUI COMPASS 2021; 3:62-67. [PMID: 35475149 PMCID: PMC8988797 DOI: 10.1002/bco2.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 07/21/2021] [Accepted: 08/09/2021] [Indexed: 12/24/2022] Open
Abstract
Objectives The aim of this study is to assess the course and management of poorly differentiated bladder urothelial carcinoma (UC), including plasmacytoid UC (PUC), in our local area. Although bladder cancer is relatively common, PUC is a rare and aggressive subtype with a poor prognosis that is still poorly understood. Materials and Methods A retrospective assessment of all poorly differentiated high‐grade UC over the last 15 years (2005–2020) in the Hunter New England area was completed. In total, 37 patients were included, and PUC variant was compared with the remaining poorly differentiated UC. Results Of the included cases, eight were PUC, nine squamous variant, two neuroendocrine, and one sarcomatoid. Overall, 23 cases proceeded to cystectomy, 15 had chemotherapy (six neoadjuvant), and 11 had radiation therapy. In the PUC subgroup, three had metastatic disease at diagnosis (37.5%). Of the three PUC patients who underwent cystectomy, all were upstaged. Two PUC cases had adjuvant chemotherapy, and one case had radiation. Within the follow‐up period, the PUC group had a cause‐specific mortality of 50% with a mean survival in these patients of 202 days, compared with 37.9% cause‐specific mortality with survival of 671.55 days (p = 0.23) in all other undifferentiated UC cases; 5‐year cause‐specific mortality with Kaplan–Meier analysis was estimated at 26% compared with 59%, respectively (p = 0.058). Conclusion Poorly differentiated UC is demonstrated to have a poor prognosis with a high mortality rate, particularly when PUC is present. Given the rarity of these variants, further studies are necessary to explore the impact of current treatment options.
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Affiliation(s)
- Kathleen Lockhart
- Department of Urology John Hunter Hospital New Lambton New South Wales Australia
| | - Simon King
- Department of Pathology John Hunter Hospital New Lambton New South Wales Australia
| | - Alexander Grant
- Department of Urology John Hunter Hospital New Lambton New South Wales Australia
| | - Nicholas McLeod
- Department of Urology John Hunter Hospital New Lambton New South Wales Australia
| | - Albert Tiu
- Department of Urology John Hunter Hospital New Lambton New South Wales Australia
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14
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Sanguedolce F, Calò B, Mancini V, Zanelli M, Palicelli A, Zizzo M, Ascani S, Carrieri G, Cormio L. Non-Muscle Invasive Bladder Cancer with Variant Histology: Biological Features and Clinical Implications. Oncology 2021; 99:345-358. [PMID: 33735905 DOI: 10.1159/000514759] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 12/30/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND The most common bladder cancer (BC) histotype is pure urothelial carcinoma (UC), which may undergo divergent differentiation in some cases. Variant histology (VH) presents along variable morphologies, either single or combined between them or with pure UC. From a clinical standpoint, the vast majority of BC is diagnosed at non-invasive or minimally invasive stages, namely as non-muscle invasive BC (NMIBC). There is a wide range of therapeutic options for patients with NMIBC, according to their clinical and pathological features. However, current risk stratification models do not show optimal effectiveness. Evidence from the literature suggests that VH has peculiar biological features, and may be associated with poorer survival outcomes compared to pure UC. SUMMARY In order to describe the biological features and prognostic/predictive role of VH in NMIBC, and to discuss current treatment options, we performed a systematic literature search through multiple databases (PubMed/Medline, Google Scholar) for relevant articles according to the following terms, single and/or in combination: "non-muscle invasive bladder cancer," "variant histology," "micropapillary variant," "glandular differentiation," "squamous differentiation," "nested variant," "plasmacytoid variant," and "sarcomatoid variant." We extracted 99 studies including original articles, reviews, and systematic reviews, and subsequently analyzed data from 16 studies reporting on the outcome of NMIBC with VH. We found that the relative rarity of these forms as well as the heterogeneity in study populations and therapeutic protocols results in conflicting findings overall. Key Messages: The presence of VH should be taken into account when counseling a patient with NMIBC, since it may upgrade the disease to high-risk tumor and thus warrant a more aggressive treatment.
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Affiliation(s)
| | - Beppe Calò
- Urology Unit, University of Foggia, Bonomo Teaching Hospital, Foggia, Italy
| | - Vito Mancini
- Urology and Renal Transplantation Unit, University of Foggia, Foggia, Italy
| | - Magda Zanelli
- Pathology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Andrea Palicelli
- Pathology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Maurizio Zizzo
- Surgical Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy.,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Stefano Ascani
- Pathology Unit, Azienda Ospedaliera S. Maria di Terni, University of Perugia, Terni, Italy
| | - Giuseppe Carrieri
- Urology and Renal Transplantation Unit, University of Foggia, Foggia, Italy
| | - Luigi Cormio
- Urology Unit, University of Foggia, Bonomo Teaching Hospital, Foggia, Italy
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15
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Natural history, response to systemic therapy, and genomic landscape of plasmacytoid urothelial carcinoma. Br J Cancer 2021; 124:1214-1221. [PMID: 33473164 PMCID: PMC8007750 DOI: 10.1038/s41416-020-01244-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 12/15/2020] [Accepted: 12/17/2020] [Indexed: 12/13/2022] Open
Abstract
Background Plasmacytoid urothelial carcinoma (PUC) is a rare, aggressive histologic variant of urothelial cancer characterised by a diffuse growth pattern and CDH1 mutation. We studied the efficacy of preoperative platinum-based chemotherapy in nonmetastatic PUC and immune checkpoint inhibitors (ICIs) in advanced PUC. Methods Cases of nonmetastatic PUC and advanced PUC treated with ICIs at our institution were identified. Outcomes were compared to those of a published cohort of patients with urothelial carcinoma not otherwise specified. Results We identified 81 patients with nonmetastatic PUC. Of the patients with localised disease who underwent neoadjuvant chemotherapy, pathologic complete response and downstaging rates were 12 and 21%, respectively. Pathologic downstaging was not associated with significant improvement in clinical outcomes. Up to 18% of localised disease and 28% of locally advanced cases had unresectable disease at the time of surgery. ICI-treated advanced PUC (N = 21) had progression-free and overall survival of 4.5 and 10.5 months, respectively, and a 38% response rate. FGFR3 and DNA damage response gene alterations were observed in 3 and 15% of cases, respectively. Conclusions PUC is associated with high disease burden and poor chemosensitivity. Increased awareness and recognition of this disease variant will allow for new treatment strategies.
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16
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Jiang DM, North SA, Canil C, Kolinsky M, Wood LA, Gray S, Eigl BJ, Basappa NS, Blais N, Winquist E, Mukherjee SD, Booth CM, Alimohamed NS, Czaykowski P, Kulkarni GS, Black PC, Chung PW, Kassouf W, van der Kwast T, Sridhar SS. Current Management of Localized Muscle-Invasive Bladder Cancer: A Consensus Guideline from the Genitourinary Medical Oncologists of Canada. Bladder Cancer 2020. [DOI: 10.3233/blc-200291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND: Despite recent advances in the management of muscle-invasive bladder cancer (MIBC), treatment outcomes remain suboptimal, and variability exists across current practice patterns. OBJECTIVE: To promote standardization of care for MIBC in Canada by developing a consensus guidelines using a multidisciplinary, evidence-based, patient-centered approach who specialize in bladder cancer. METHODS: A comprehensive literature search of PubMed, Medline, and Embase was performed; and most recent guidelines from national and international organizations were reviewed. Recommendations were made based on best available evidence, and strength of recommendations were graded based on quality of the evidence. RESULTS: Overall, 17 recommendations were made covering a broad range of topics including pathology review, staging investigations, systemic therapy, local definitive therapy and surveillance. Of these, 10 (59% ) were level 1 or 2, 7 (41% ) were level 3 or 4 recommendations. There were 2 recommendations which did not reach full consensus, and were based on majority opinion. This guideline also provides guidance for the management of cisplatin-ineligible patients, variant histologies, and bladder-sparing trimodality therapy. Potential biomarkers, ongoing clinical trials, and future directions are highlighted. CONCLUSIONS: This guideline embodies the collaborative expertise from all disciplines involved, and provides guidance to further optimize and standardize the management of MIBC.
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Affiliation(s)
- Di Maria Jiang
- Department of Medicine, Division of Medical Oncology and Hematology, University Health Network, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Scott A. North
- Department of Oncology, Division of Medical Oncology, Cross Cancer Institute, University of Alberta, Edmonton, AB, Canada
| | - Christina Canil
- Department of Internal Medicine, Division of Medical Oncology, The Ottawa Hospital Cancer Centre, University of Ottawa, Ottawa, ON, Canada
| | - Michael Kolinsky
- Department of Oncology, Division of Medical Oncology, Cross Cancer Institute, University of Alberta, Edmonton, AB, Canada
| | - Lori A. Wood
- Department of Medicine, Division of Medical Oncology, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, NS, Canada
| | - Samantha Gray
- Department of Oncology, Saint John Regional Hospital, Department of Medicine, Dalhousie University, Saint John, NB, Canada
| | - Bernhard J. Eigl
- Department of Medicine, Division of Medical Oncology, BC Cancer - Vancouver, University of British Columbia, Vancouver, BC, Canada
| | - Naveen S. Basappa
- Department of Oncology, Division of Medical Oncology, Cross Cancer Institute, University of Alberta, Edmonton, AB, Canada
| | - Normand Blais
- Department of Medicine, Division of Medical Oncology and Hematology, Centre Hospitalier de l’Université de Montréal; Université de Montréal, Montreal, QC, Canada
| | - Eric Winquist
- Department of Oncology, London Health Sciences Centre, University of Western Ontario, London, ON, Canada
| | - Som D. Mukherjee
- Department of Oncology, Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
| | | | - Nimira S. Alimohamed
- Department of Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada
| | - Piotr Czaykowski
- Department of Medical Oncology and Hematology, Cancer Care Manitoba, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Girish S. Kulkarni
- Departments of Surgery and Surgical Oncology, Division of Urology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Peter C. Black
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Peter W. Chung
- Department of Radiation Oncology, Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Wassim Kassouf
- Department of Urology, McGill University Health Centre, Montreal, QC, Canada
| | | | - Srikala S. Sridhar
- Department of Medicine, Division of Medical Oncology and Hematology, University Health Network, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
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