Downstaging and Pathological Complete Response of Locally Recurrent Sarcomatoid Renal Cell Carcinoma under Pembrolizumab and Lenvatinib: A Case Report and Review of Literature

The advent of immune checkpoint inhibition opened new perspectives for patients with recurrent or metastasized renal cell carcinoma. In case of recurrent disease, surgical resection remains the most promising therapeutic option. Surgical resection is associated with improved overall survival and demonstrated curative potential given complete resection of metastases can be performed. This report presents the case of a patient with local recurrence of dedifferentiated sarcomatoid renal cell carcinoma approximately 1 year after initial open lumbar nephrectomy. After initial evaluation, surgical removal was deemed infeasible and an induction therapy with pembrolizumab and lenvatinib was initiated. After 3 months, corresponding to 5 cycles of pembrolizumab, the tumor showed a partial response on imaging control and was successfully resected en bloc. Histopathological examination of the specimen revealed no evidence of viable neoplastic cells. This is the first report describing a complete pathological response of a locally recurrent dedifferentiated sarcomatoid renal cell carcinoma after treatment with pembrolizumab and lenvatinib. Overall, the combination therapy was well tolerated with a maximum Common Terminology Criteria for Adverse Events Level of Two. These findings underline the potential of multimodal therapeutic strategies for recurrent renal cell carcinoma, such as induction therapies to downstage initially nonresectable masses, and highlight the need for prospective studies to allow for evidence-based treatment plans.

A Phase 1/2 Single-arm Clinical Trial of Recombinant Bacillus Calmette-Guérin (BCG) VPM1002BC Immunotherapy in Non-muscle-invasive Bladder Cancer Recurrence After Conventional BCG Therapy: SAKK 06/14

BACKGROUND

VPM1002BC is a genetically modified Mycobacterium bovis bacillus Calmette-Guérin (BCG) strain with potentially improved immunogenicity and attenuation.

OBJECTIVE

To report on the efficacy, safety, tolerability and quality of life of intravesical VPM1002BC for the treatment of non-muscle-invasive bladder cancer (NMIBC) recurrence after conventional BCG therapy.

DESIGN, SETTING, AND PARTICIPANTS

We designed a phase 1/2 single-arm trial (NCT02371447). Patients with recurrent NMIBC after BCG induction ± BCG maintenance therapy and intermediate to high risk for cancer progression were eligible.

INTERVENTION

Patients were scheduled for standard treatment of six weekly instillations with VPM1002BC followed by maintenance for 1 yr. Treatment was stopped in cases of recurrence.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary endpoint was defined as the recurrence-free rate (RFR) in the bladder 60 wk after trial registration. The sample size was calculated based on the assumption that ≥30% of the patients would be without recurrence at 60 wk after registration.

RESULTS AND LIMITATIONS

After exclusion of two ineligible patients, 40 patients remained in the full analysis set. All treated tumours were of high grade and 27 patients (67.5%) presented with carcinoma in situ. The recurrence-free rate in the bladder at 60 wk after trial registration was 49.3% (95% confidence interval [CI] 32.1-64.4%) and remained at 47.4% (95% CI 30.4-62.6%] at 2 yr and 43.7% (95% CI 26.9-59.4%) at 3 yr after trial registration. At the same time, progression to muscle-invasive disease had occurred in three patients and metastatic disease in four patients. Treatment-related grade 1, 2, and 3 adverse events (AEs) were observed in 14.3%, 54.8%, and 4.8% of the patients, respectively. No grade ≥4 AEs occurred. Two of the 42 patients did not tolerate five or more instillations during induction. Limitations include the single-arm trial design and the low number of patients for subgroup analysis.

CONCLUSIONS

At 1 yr after treatment start, almost half of the patients remained recurrence-free after therapy with VPM100BC. The primary endpoint of the study was met and the therapy is safe and well tolerated.

PATIENT SUMMARY

We conducted a trial of VPM100BC, a genetically modified bacillus Calmette-Guérin (BCG) strain for treatment of bladder cancer not invading the bladder muscle. At 1 year after the start of treatment, almost half of the patients with a recurrence after previous conventional BCG were free from non-muscle-invasive bladder cancer (NMIBC). The results are encouraging and VPM1002BC merits further evaluation in randomised studies for patients with NMIBC.

[Conservative management of grade IV kidney lacerations due to stab wounds]

We report on two patients who were in initially circulatory stable condition with grade IV kidney trauma after knife stab accident. Patient 1 underwent reconstructive surgery to retrieve a broken knife blade, while patient 2 was treated conservatively for bleeding that did not require intervention. Both patients could ultimately be discharged in stable condition. These case studies show that even in the case of high-grade kidney trauma with the appropriate constellation of findings, conservative management and, if exploration is necessary, a reconstructive approach is possible.

Combination of Robotic Pyeloplasty and Percutaneous Renal Surgery for Simultaneous Treatment of Ureteropelvic Junction Obstruction and Calyx Stones

INTRODUCTION

Ureteropelvic junction obstruction (UPJO) and the simultaneous presence of kidney calyx stones represent a challenge for renal surgery. We present a novel technique for the simultaneous treatment of UPJO by robotic pyeloplasty in combination with the percutaneous endoscopic treatment of kidney calyx stones by flexible nephroscopy.

PATIENTS AND METHODS

Between January 2018 and February 2020, 4 patients were diagnosed with UPJO and simultaneous pelvic or calyceal stones. UPJO was treated by conventional robotic pyeloplasty. After opening the renal pelvis, a flexible 16-French cystoscope was introduced via the 12-mm assistant trocar into the renal pelvis. The kidney calyx stones (n = 1-15) were removed endoscopically through a flexible nephroscope using a Dormia helical basket. Before suturing the anastomosis of the renal pelvis, a ureter stent was inserted.

RESULTS

After the procedure, all patients were stone free. Using the Clavien-Dindo classification, no complications were noted. The mean size of the calculi was 6.69 mm (range: 1-25). Up to 15 calyx stones (mean 3.46) were removed per patient. A complete stone clearance confirmed by postoperative X-ray imaging was achieved in all patients. The mean operative time was 149 min (range: 130-178). Mean hospital stay was 7 days (7-8). The urethral stent was removed after 4-6 weeks.

CONCLUSIONS

Robotic management of UPJO and simultaneous flexible nephroscopy for removal of calyceal stones is an effective treatment in 1 session. Combining robotic surgery with flexible percutaneous renal surgery is a feasible, safe, and effective method of the treatment of UPJO and concomitant calyceal stones.

Incidental appendectomy during robotic laparoscopic prostatectomy-safe and worth to perform?

PURPOSE

The purpose of this study is to investigate the safety and patients' benefit of incidental appendectomy during robot-assisted laparoscopic radical prostatectomy (RALRP).

METHODS

Fifty-three patients, who had incidental appendectomy during RALRP between January 2012 and March 2014, were enrolled to this study. To evaluate the safety of the procedure, following parameters were evaluated: patient age, duration of surgery, perioperative complications (classified by Clavien-Dindo), time to bowel movement, and length of hospital stay. Furthermore, intraoperative visual appearance, location, and histopathological evaluation of the appendix were evaluated. Data was analyzed by descriptive statistics.

RESULTS

Mean age of patients was 61 years, the average hospital stay 5 days. No perioperative complications occurred. The appendix was unsuspicious in 39 patients (73.6%); 14 patients (26.4%) had macroscopically signs of inflammation. Of the 53 resected appendixes, the histopathological evaluation showed 33 (62.2%) inconspicuous appendices, 11 (20.8%) post-inflammatory changes, 4 (7.5%) with chronical signs of inflammation and 3 (5.7%) with signs of acute inflammation. In 2 patients (3.8%), low-grade mucinous neoplasms were found in the specimens.

CONCLUSIONS

Incidental appendectomy during RALRP is a feasible procedure. With regard to inflammation and neoplastic changes, incidental appendectomy can be considered for patients scheduled for robot-assisted prostate surgery.

[Multiparametric MRI and MRI-TRUS fusion biopsy in patients with prior negative prostate biopsy]

BACKGROUND

Multiparametric MRI (mpMRI) plays an increasingly important role in prostate cancer (PCa) diagnostics and is recommended in men with previously negative TRUS biopsy. The optimal biopsy method after mpMRI is under discussion.

OBJECTIVE

Prospective, PIRADS- and START-conform analysis of the relevance of mpMRI and MRI-TRUS fusion biopsy in patients with prior negative TRUS biopsy and comparison of the detection rates of fusion-targeted biopsies (tB) and systematic transperineal saturation biopsies (sB).

MATERIALS AND METHODS

Between 10/2012 and 09/2015, 287 patients with prior negative TRUS biopsy underwent mpMRI and software-assisted, rigid MRI-TRUS fusion biopsy. In addition to and strictly separated from sB (median cores n = 24), tB (median cores per patient n = 4, per lesion n = 3) were performed in case of suspicious MRI lesions (PIRADS ≥ 2). Both biopsy methods were compared by using McNemar's test.

RESULTS

Of the 287 patients, 148 (52 %) had positive biopsies. Of these, 108/287 (38 %) had significant PCa (Gleason Score [GS] = 3 + 3 and PSA ≥ 10 ng/ml or GS ≥ 3 + 4) and again 43/287 (15 %) had a GS ≥ 4 + 3 PCa. sB failed to diagnose 8/148 PCa (5.4 %) and 6/108 significant PCa (5.5 %), whereas tB failed to diagnose 48 (32.4 %) PCa (p < 0.0001) and 22 (20.4 %) significant PCa (p = 0.0046). Of the PCa missed by tB, 11  had a GS ≥ 3 + 4 and 5 of these a GS = 4 + 3. On a per patient basis, MRI failed to detect 5 significant PCa, whereby 17 of the significant PCa were missed by fusion-targeted cores alone.

CONCLUSIONS

In men with unsuspicious MRI (PIRADS < 3), there is a 11 % risk of significant PCa. In case of suspicious MRI lesions, the combination of both biopsy approaches offers maximum tumor detection.