Muscle-invasive angiosarcoma of the urinary bladder: Case report

A 71-year-old male with benign prostatic hyperplasia managed by self-catheterization presented with gross hematuria. A CT scan of abdomen and pelvis demonstrated abnormal bladder appearance with right sided mass and a diverticulum. Patient underwent transurethral resection of bladder tumor. Pathology was significant for high-grade muscle-invasive angiosarcoma. The malignant cells showed positive staining for vimentin and CD31. Given patient's underlying comorbidities and following multidisciplinary discussion, hospice care was pursued. The aim of this case report is to provide an overview on clinical presentation, diagnosis, and current management of this rare entity of genitourinary sarcoma.

Aldosterone- and Cortisol Co-secreting Adrenal Cortical Neoplasm With Lipomatous and Myelolipomatous Metaplasia

We report a case of a 58-year-old woman with a history of hypertension diagnosed at aged 35 years, on 5 antihypertensive agents and a history of intermittent spontaneous hypokalemia, was found to have a 6-cm left adrenal mass on computed tomography scan of the abdomen. The unenhanced computed tomography attenuation of the adrenal mass was -16 Hounsfield units (HU). The biochemical evaluation showed potassium of 2.8 mEq/L (SI unit, mmol/L) (reference range, 3.5-5.0), plasma aldosterone concentration of 61.3 ng/dL (SI unit, 1701 pmol/L) with plasma renin activity of 0.4 ng/mL/h (SI unit, μg/L/h). An overnight 1-mg dexamethasone suppression test showed nonsuppressible serum cortisol of 10.8 μg/dL (SI unit, 298 nmol/L). Dehydroepiandrosterone sulfate and ACTH were measured at 24.5 μg/dL (age-adjusted, 26-200) (SI unit, 0.66 μmol/L; 0.70-5.43) and <5 pg/mL (SI unit, < 1.1 pmol/L), respectively. Left adrenalectomy was performed and hydrocortisone therapy was initiated. Postoperatively and thereafter, her blood pressure was controlled with no antihypertensive agent. Seven months later, hydrocortisone therapy was stopped once her cortisol level had normalized. Pathology showed adrenal cortical neoplasm of uncertain malignant potential with associated lipomatous and myelolipomatous metaplasia. This is a rare case of aldosterone and cortisol co-secreting adrenal cortical neoplasm of uncertain malignant potential with lipomatous and myelolipomatous metaplasia. Although the majority of cases of myelolipoma are benign and nonfunctioning, this case emphasizes the importance of thorough hormonal and morphologic evaluation of the tumor.

National trends in incidence of prostate cancer by age, ethnicity, region, and rurality from 2000-2018: An analysis of US NPCR Database

e17054

Background: Prostate cancer (PC) is the most common cancer and second leading cause of cancer-related death among males in the United States. Screening recommendations and treatments for PC have changed considerably over the past two decades, with differential effects across sociodemographic groups. This study aims to characterize trends in incidence of PC from 2000 to 2018 by age, race, region, and rurality to better understand these effects on incidence. Methods: Data were obtained from the National Program of Cancer Registries (NPCR), which represents patients for all 50 states. Incidence rates and average annual percent change (AAPC) were calculated using SEER*Stat software. Incident rates were calculated as the number of new cancers arising in the prostate (ICD-O-3 Site Code: C619) per 100,000 males. Trends across sociodemographic groups were analyzed and visualized in R. Results: PC incidence decreased significantly for all ages 40 and above from 2000 to 2018. Ages 85+ experienced the sharpest decline with an AAPC of -5.5% (95% CI: -6.0% to -5.1%). However, for all 5-year age brackets between 60 and 85, incidence reaches a minimum in 2014 before rising again as shown by segmented regression analysis. All race/ethnicity groups experienced a significant decline in incidence from 2000 to 2018 with sharpest decline in Hispanics -3.9% (95% CI: -4.5% to -3.3%). All regions also experienced a significant decline, with the greatest decline in the West at -4.0 (95% CI: -4.7 to -3.3). Metropolitan counties experienced a greater decline than nonmetropolitan. Patients ages 65 to 79, of Black race/ethnicity, and metropolitan groups had the highest overall incidence over the study period in their respective categories with 2018 incidences of 663, 181, and 115 per 100,000 males respectively. Conclusions: Nearly all sociodemographic groups have experienced a decline in the incidence of PC from 2000 to 2018. However, PC incidence increased from 2014 to 2018 for several sociodemographic groups. Importantly, 65 to 79 year olds, Black Americans, and metropolitan groups had the highest incidence over the study period. This study demonstrates a sustained rise in incidence of PC for several sociodemographic groups, as well as identifies groups at higher risk of PC. These trends may be due to evolving PC screening guidelines and merit further investigation.

PARP inhibitors chemopotentiate and synergize with cisplatin to inhibit bladder cancer cell survival and tumor growth

Background

Management of bladder cancer (BLCA) has not changed significantly in the past few decades, with platinum agent chemotherapy being used in most cases. Chemotherapy reduces tumor recurrence after resection, but debilitating toxicities render a large percentage of patients ineligible. Recently approved immunotherapy can improve outcomes in only a third of metastatic BLCA patients. Therefore, more options for therapy are needed. In this study, we explored the efficacy of PARP inhibitors (PARPi) as single agents or as combinations with platinum therapy.

Methods

We treated BLCA cells with PARPi (olaparib, niraparib, rucaparib, veliparib, or talazoparib) alone or as the combination of cisplatin with PARPi. We then measured their survival, proliferation, apoptosis, as well as their ability to form colonies. BLCA xenografts in male SCID mice were treated similarly, followed by the assessment of their growth, proliferation, and apoptosis.

Results

PARPi niraparib and talazoparib were effective in reducing BLCA cell survival as single agents. Combinations of Cisplatin with talazoparib and niraparib effectively reduced the survival of BLCA cells, while veliparib was not effective even at high concentrations. In vivo, the combinations of cisplatin with niraparib, rucaparib, or talazoparib reduced BLCA xenograft growth significantly.

Conclusions

We provide evidence that PARPi can be effective against BLCA as single agents or as combinatorial therapy with cisplatin.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09376-9.

Predictive model for systemic recurrence following cisplatin-based neoadjuvant chemotherapy and radical nephroureterectomy for high risk upper tract urothelial carcinoma

INTRODUCTION

Neoadjuvant chemotherapy (NAC) is increasingly used prior to radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). Systemic recurrence (SR) carries a dismal prognosis. We sought to determine risk factors associated with SR in this setting.

METHODS

We evaluated a multi-center database of patients with UTUC who received cisplatin-based NAC before RNU. Final pathology at RNU was dichotomized into ypT<2 vs ypT≥2. Univariable and multivariable analyses were performed to identify risk factors associated with SR. Three groups were defined based on the number of significant risk factors (groups 1, 2, 3 for 0-1, 2, 3 risk factors, respectively) and evaluated for recurrence-free survival (RFS) using the Kaplan-Meier method.

RESULTS

106 patients were identified between 2004 and 2018. Median age was 67.0 years [IQR = 61-73.3]; 57 (54%) and 49 (46 %) patients received MVAC and GC, respectively. Final pathological stage was ypT<2 in 57 (54%); 23% (24/106) had SR. On univariable analysis, pathological variables on final specimen including ypT≥2, lymphovascular invasion (ypLVI), and nodal involvement were associated with SR. On multivariable analysis, ypLVI OR = 4.1 (95% CI 1.2-13.6; P = 0.024) and pathological nodal involvement OR = 4.5 (95% CI 1.3-15.7; P = 0.017) were predictive of recurrence. Stratifying by the number of risk factors, the 2-year RFS was 95%, 55%, and 18% for groups 1, 2, and 3 respectively (log-rank <0.001).

CONCLUSION

This model evaluates the risk of SR following NAC and RNU to guide counseling and decision-making after surgery. Adverse pathological variable including ypLVI and nodal involvement, in combination with ypT-stage, are strongly associated with SR.

The Emerging Role of Poly (ADP-Ribose) Polymerase Inhibitors as Effective Therapeutic Agents in Renal Cell Carcinoma

Renal cell carcinoma (RCC) is the sixth most common cancer in the US. However, no significant changes in management have occurred since the tyrosine kinase era until the recent breakthrough with checkpoint inhibitors. Therefore, the need for more therapeutic options is paramount. Our objective was to determine whether PARP inhibition represents a novel therapeutic option for RCC. We used publicly available COSMIC, GDC Data Portal, and cBioPortal databases to explore mutations in DNA repair genes in RCC tissues from the TCGA cohort. We treated a human normal renal epithelial cell line RPTEC/TERT1 and two human renal cancer cell lines ACHN and CAKI-2 with PARPi niraparib, olaparib, rucaparib, veliparib, and talazoparib. Cell survival, cell proliferation, clonogenic ability, and apoptosis were assessed. RCC xenografts in SCID mice were treated with PARPi to evaluate their efficacy in vivo. Data mining revealed that ~27-32% of RCC tissues contain mutations in homologous recombination genes. Niraparib and talazoparib were the most effective at reducing cell survival, proliferation, and clonogenic ability in vitro. Niraparib, talazoparib, and rucaparib were the most effective in reducing RCC xenograft growth in vivo. Agents such as PARPi that exploit mutations in DNA damage repair genes may be effective therapeutic options for RCC.

Pretreatment Risk Stratification for Endoscopic Kidney-sparing Surgery in Upper Tract Urothelial Carcinoma: An International Collaborative Study

BACKGROUND

Several groups have proposed features to identify low-risk patients who may benefit from endoscopic kidney-sparing surgery in upper tract urothelial carcinoma (UTUC).

OBJECTIVE

To evaluate standard risk stratification features, develop an optimal model to identify ≥pT2/N+ stage at radical nephroureterectomy (RNU), and compare it with the existing unvalidated models.

DESIGN, SETTING, AND PARTICIPANTS

This was a collaborative retrospective study that included 1214 patients who underwent ureterorenoscopy with biopsy followed by RNU for nonmetastatic UTUC between 2000 and 2017.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We performed multiple imputation of chained equations for missing data and multivariable logistic regression analysis with a stepwise selection algorithm to create the optimal predictive model. The area under the curve and a decision curve analysis were used to compare the models.

RESULTS AND LIMITATIONS

Overall, 659 (54.3%) and 555 (45.7%) patients had ≤pT1N0/Nx and ≥pT2/N+ disease, respectively. In the multivariable logistic regression analysis of our model, age (odds ratio [OR] 1.02, 95% confidence interval [CI] 1.0-1.03, p = 0.013), high-grade biopsy (OR 1.81, 95% CI 1.37-2.40, p < 0.001), biopsy cT1+ staging (OR 3.23, 95% CI 1.93-5.41, p < 0.001), preoperative hydronephrosis (OR 1.37 95% CI 1.04-1.80, p = 0.024), tumor size (OR 1.09, 95% CI 1.01-1.17, p = 0.029), invasion on imaging (OR 5.10, 95% CI 3.32-7.81, p < 0.001), and sessile architecture (OR 2.31, 95% CI 1.58-3.36, p < 0.001) were significantly associated with ≥pT2/pN+ disease. Compared with the existing models, our model had the highest performance accuracy (75% vs 66-71%) and an additional clinical net reduction (four per 100 patients).

CONCLUSIONS

Our proposed risk-stratification model predicts the risk of harboring ≥pT2/N+ UTUC with reliable accuracy and a clinical net benefit outperforming the current risk-stratification models.

PATIENT SUMMARY

We developed a risk stratification model to better identify patients for endoscopic kidney-sparing surgery in upper tract urothelial carcinoma.

Novel Classification for Upper Tract Urothelial Carcinoma to Better Risk-stratify Patients Eligible for Kidney-sparing Strategies: An International Collaborative Study

BACKGROUND

The European Association of Urology risk stratification dichotomizes patients with upper tract urothelial carcinoma (UTUC) into two risk categories.

OBJECTIVE

To evaluate the predictive value of a new classification to better risk stratify patients eligible for kidney-sparing surgery (KSS).

DESIGN, SETTING, AND PARTICIPANTS

This was a retrospective study including 1214 patients from 21 centers who underwent ureterorenoscopy (URS) with biopsy followed by radical nephroureterectomy (RNU) for nonmetastatic UTUC between 2000 and 2017.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

A multivariate logistic regression analysis identified predictors of muscle invasion (≥pT2) at RNU. The Youden index was used to identify cutoff points.

RESULTS AND LIMITATIONS

A total of 811 patients (67%) were male and the median age was 71 yr (interquartile range 63-77). The presence of non-organ-confined disease on preoperative imaging (p < 0.0001), sessile tumor (p < 0.0001), hydronephrosis (p = 0.0003), high-grade cytology (p = 0.0043), or biopsy (p = 0.0174) and higher age at diagnosis (p = 0.029) were independently associated with ≥pT2 at RNU. Tumor size was significantly associated with ≥pT2 disease only in univariate analysis with a cutoff of 2 cm. Tumor size and all significant categorical variables defined the high-risk category. Tumor multifocality and a history of radical cystectomy help to dichotomize between low-risk and intermediate-risk categories. The odds ratio for muscle invasion were 5.5 (95% confidence interval [CI] 1.3-24.0; p = 0.023) for intermediate risk versus low risk, and 12.7 (95% CI 3.0-54.5; p = 0.0006) for high risk versus low risk. Limitations include the retrospective design and selection bias (all patients underwent RNU).

CONCLUSIONS

Patients with low-risk UTUC represent ideal candidates for KSS, while some patients with intermediate-risk UTUC may also be considered. This classification needs further prospective validation and may help stratification in clinical trial design.

PATIENT SUMMARY

We investigated factors predicting stage 2 or greater cancer of the upper urinary tract at the time of surgery for ureter and kidney removal and designed a new risk stratification. Patients with low or intermediate risk may be eligible for kidney-sparing surgery with close follow-up. Our classification scheme needs further validation based on cancer outcomes.

Pathologic stage as a surrogate for oncologic outcomes after receipt of neoadjuvant chemotherapy for high-grade upper tract urothelial carcinoma

OBJECTIVE

Whether pathologic stage at radical nephroureterectomy (RNU) can serve as an appropriate surrogate for oncologic outcomes in patients with high-grade (HG) upper tract urothelial carcinoma (UTUC) treated with neoadjuvant chemotherapy (NAC) is not defined. We sought to determine whether patients who achieve pathologically non-muscle-invasive (ypT0, ypTa, ypT1, ypTis) HG UTUC after receipt of NAC exhibit oncologic outcomes comparable to those who are inherently low stage without chemotherapy.

METHODS

We identified 647 UTUC patients who underwent RNU among 3 institutions from 1993to2016. Patients with low or unknown grade, pathologic muscle invasion, or receipt of adjuvant chemotherapy were excluded. We compared clinicopathologic data and oncologic outcomes between pT0-1 and ypT0-1 patients. Kaplan-Meier analysis was used to assess overall (OS), cancer-specific (CSS), and systemic recurrence-free (RFS) survival. Predictors of these endpoints were identified using Cox regression.

RESULTS

234 (43 ypT0-1, 191 pT0-1) patients with HG UTUC were included. Two patients exhibited pathologic complete response after NAC. OS (P = 0.055), CSS (P = 0.152), and RFS (P = 0.098) were similar between ypT0-1 and pT0-1 patients. Predictors of worse outcomes included African-American race (RFS, CSS, and OS), Charlson score (OS), and systemic recurrence (OS and CSS).

CONCLUSIONS

Patients with HG UTUC who achieve ypT0-1 stage after NAC exhibit favorable oncologic outcomes comparable to those inherently non-muscle-invasive who do not receive chemotherapy. Improvements in clinical staging will play an important role in better defining candidacy for NAC in treating HG UTUC while minimizing overtreatment. Furthermore, pathologic stage may serve as an appropriate early surrogate for oncologic endpoints in designing clinical trials.

Plasmacytoid variant of urothelial carcinoma of the bladder manifesting as bilateral ureteral and small bowel obstruction

Plasmacytoid urothelial carcinoma (PUC) is a rare variant of bladder cancer characterized by distinct histopathology and advanced stage at diagnosis. Multimodal treatment is usually indicated. We present a case of PUC causing bilateral ureteral obstruction with subsequent renal failure followed shortly by malignant small bowel obstruction, demonstrating the need for a high degree of clinical suspicion in diagnosis of this aggressive subtype. Moreover, the local invasiveness of the disease cannot be understated, given that it can rapidly spread with little radiologic evidence of progression until it is at an advanced stage.

Comparative effectiveness of neoadjuvant chemotherapy in bladder and upper urinary tract urothelial carcinoma

Objective

To assess the differential response to neoadjuvant chemotherapy (NAC) in patients with urothelial carcinoma of the bladder (UCB) compared to upper tract urothelial carcioma (UTUC) treated with radical surgery.

Patients and Methods

Data from 1299 patients with UCB and 276 with UTUC were obtained from multicentric collaborations. The association of disease location (UCB vs UTUC) with pathological complete response (pCR, defined as a post‐treatment pathological stage ypT0N0) and pathological objective response (pOR, defined as ypT0‐Ta‐Tis‐T1N0) after NAC was evaluated using logistic regression analyses. The association with overall (OS) and cancer‐specific survival (CSS) was evaluated using Cox regression analyses.

Results

A pCR was found in 250 (19.2%) patients with UCB and in 23 (8.3%) with UTUC (P < 0.01). A pOR was found in 523 (40.3%) patients with UCB and in 133 (48.2%) with UTUC (P = 0.02). On multivariable logistic regression analysis, patients with UTUC were less likely to have a pCR (odds ratio [OR] 0.45, 95% confidence interval [CI] 0.27–0.70; P < 0.01) and more likely to have a pOR (OR 1.57, 95% CI 1.89–2.08; P < 0.01). On univariable Cox regression analyses, UTUC was associated with better OS (hazard ratio [HR] 0.80, 95% CI 0.64–0.99, P = 0.04) and CSS (HR 0.63, 95% CI 0.49–0.83; P < 0.01). On multivariable Cox regression analyses, UTUC remained associated with CSS (HR 0.61, 95% CI 0.45–0.82; P < 0.01), but not with OS.

Conclusions

Our present findings suggest that the benefit of NAC in UTUC is similar to that found in UCB. These data can be used as a benchmark to contextualise survival outcomes and plan future trial design with NAC in urothelial cancer.

Epidemiology, clinical presentation, and evaluation of upper-tract urothelial carcinoma

An overview of epidemiological pattern of upper tract urothelial carcinoma (UTUC), including outcome of UTUC over past decades as well as factors responsible for observed epidemiological changes was performed. Gender and racial disparities influencing incidence of UTUC were reviewed. The incidence of multifocal urothelial carcinoma and relation of UTUC to urothelial carcinoma of bladder were examined.

Intraoperative prophylactic intravesical chemotherapy to reduce bladder recurrence following radical nephroureterectomy

PURPOSE

Single, postoperative instillation of prophylactic intravesical chemotherapy (pIVC) is effective in reducing bladder cancer recurrences following radical nephroureterectomy (RNU). Despite high level evidence, pIVC is underutilized. Intraoperative pIVC (I-pIVC) may be easier and safer to implement than postoperative pIVC (P-pIVC). We aimed to evaluate the efficacy of I-pIVC during RNU.

MATERIALS AND METHODS

Retrospective analysis of patients undergoing RNU and I-pIVC or postoperative pIVC (P-pVC) with 20 to 40 mg mitomycin-C or 1 to 2 g gemcitabine. Recurrence rates were evaluated using the Kaplan-Meier curves and log rank test. Cox regression was used for univariable and multivariable analysis.

RESULTS

One hundred and thirty-seven patients were included in the final analysis. 81% (111/137) had I-pIVC and 19% (26/137) had P-pIVC. In the I-pIVC group higher rates of HG, muscle invasive disease and gemcitabine use were observed. Overall, 74% (101/137) and 26% (36/137) had mitomycin-C and gemcitabine instillations, respectively. Within 12 months 14% (19/137) of the patients experienced bladder recurrence. Median time to bladder recurrence was 7 months (range 3-27). Twelve months bladder recurrence-free survival rates were 82% for the I-pIVC group, and 72% for the P-pIVC group ((log rank P = 0.365).

CONCLUSIONS

I-pIVC during RNU may reduce bladder recurrence rates. Bladder recurrence rates are comparable to those reported using postoperative instillations. Intraoperative instillations may be easier to implement and may increase usage rates.

Robotic Postchemotherapy Retroperitoneal Lymph Node Dissection for Testicular Cancer

BACKGROUND

Postchemotherapy retroperitoneal lymph node dissection (pcRPLND) is mandated in patients with nonseminomatous germ cell tumor found to have residual masses after chemotherapy. Performed via the open approach, pcRPLND can incur significant perioperative morbidity.

OBJECTIVE

To demonstrate the feasibility of robotic pcRPLND (r-pcRPLND) and provide evidence for its selection criteria.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective search identified 93 patients undergoing pcRPLND between April 2007 and March 2018, comprising 30 r-pcRPLND and 63 open pcRPLND (o-pcRPLND) procedures performed by a single surgeon.

INTERVENTION

r-pcRPLND and o-pcRPLND.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Baseline clinicopathologic characteristics and intraoperative variables including operating room (OR) time, estimated blood loss (EBL), resection of adjacent organs, and intraoperative consultation with other surgical services were recorded. Hospital length of stay (LOS) and perioperative complications were assessed as per the Clavien-Dindo classification, and oncologic outcomes such as nodal yield, histologic distribution, pathologic staging, time to recurrence, and cancer-specific survival were compared.

RESULTS AND LIMITATIONS

r-pcRPLND was performed in a well-selected cohort with lower clinical stage (p=0.006), favorable International Germ Cell Cancer Collaborative Group classification (p=0.01), and smaller retroperitoneal mass (p=0.001). o-pcRPLND required more frequent bilateral template dissection (88.9% vs 43.3%; p<0.001), resection of adjacent organs (36.5% vs 10%; p=0.007), consultation with other surgical services (46% vs 2%; p<0.001), and auxiliary procedures (54.0% vs 20%; p=0.003) to achieve complete oncologic control. OR time was similar between the two groups (o-pcRPLND 375min vs r-pcRPLND 388min; p=0.16) and EBL was significantly lower in r-pcRPLND (234 vs 825ml; p<0.001). Median LOS was significantly shorter after r-pcRPLND (2 vs 7d; p<0.001). A total of 31 patients (33%) suffered postoperative complications, of whom 18 (19.4%) had major complications. Nodal yield was similar (o-pcRPLND 23 vs r-pcRPLND 24; p=0.8). The distribution of lesion histology (necrosis/teratoma/GCT) was also similar pcRPLND (o-pcRPLND 25.4%/57.1%/17.4% vs r-pcPLND 33.3%/50%/16.7%; p=0.51). Overall, tumor recurred in 15 patients (16.1%), including three following r-pcRPLND (10%), all outside the operative field. On univariate analysis, surgical approach was not a significant predictor of time to recurrence (p=0.34). One limitation was that antegrade ejaculation was not assessed.

CONCLUSIONS

With rigorous patient selection, r-pcRPLND can be safely performed and may reduce perioperative morbidity while maintaining oncologic proficiency.

PATIENT SUMMARY

Resection of residual retroperitoneal mass after chemotherapy in patients with metastatic testicular cancer can be performed safely via a robotic approach. Robotic surgery can reduce the morbidity of the procedure.

Outcomes of nonmetastatic micropapillary variant upper tract urothelial carcinoma

PURPOSE

Micropapillary variant upper tract urothelial cancer (MP-UTUC) is a rare malignancy with little known regarding its clinical course and/or optimal treatment. In this case series, we describe patient characteristics, surgical treatment, oncologic outcomes, and response to perioperative chemotherapy.

MATERIALS AND METHODS

We conducted a review to identify patients with MP-UTUC treated at our center between January 1994 and October 2017. Clinicopathologic data was obtained. Descriptive statistics, Kaplan-Meier analysis, Cox proportional hazards, and nearest neighbor matching were used to examine the cohort.

RESULTS

Eighteen, (4.3%) of 416 patients were found to have MP-UTUC at our institution over a 23-year period. The majority of patients had ≥pT3 disease at the time of extirpative surgery (13/18, 72%) and one was identified as MP-UTUC prior to surgery. Seven patients received neoadjuvant chemotherapy and six patients received adjuvant chemotherapy. Median overall, cancer specific, and recurrence free survival were 3.29, 3.29, and 1.69 years, respectively for MP-UTUC. There was no survival difference between conventional UTUC and MP-UTUC when matched for age, stage, grade, lymphovascular invasion, and margins (HR 1.18, P = 0.567). No MP-UTUC patients receiving neoadjuvant and adjuvant chemotherapy had apparent pathologic down staging, and of those receiving adjuvant chemotherapy two-thirds died of disease within 2 years.

CONCLUSIONS

MP-UTUC is a rare, and in most cases aggressive malignancy that commonly presents as locally advanced disease. In this case series, MP-UTUC does not appear to respond to perioperative chemotherapy as neoadjuvant and adjuvant chemotherapy did not result in apparent pathologic down staging and the majority of those receiving adjuvant chemotherapy died from MP-UTUC.

Preoperative multiplex nomogram for prediction of high-risk nonorgan-confined upper-tract urothelial carcinoma

BACKGROUND

Accurate risk stratification prior to radical nephroureterectomy remains a challenge with upper-tract urothelial carcinoma (UTUC). Herein, we generated an optimized preoperative tool predicting high-risk nonorgan-confined (NOC)-UTUC.

MATERIALS AND METHODS

Retrospective evaluation of 699 patients undergoing radical nephroureterectomy at 3 academic centers. Multiplex preoperative patient, imaging, endoscopic, and laboratory values were evaluated. Model derivation and validation were based on a split-sample method. Patients were divided randomly into a development (training) cohort (70% of patients) and validation (test) cohort (30% of patients). Univariate and multivariate logistic regression addressed the prediction of NOC disease (pT3/pT4 and/or pN+) based on training cohort. A backward stepdown selection process achieved the most informative nomogram. The ROC analysis identified a cut-off point predicting high-risk disease. The test cohort served as "external" validation to verify the findings based on the training cohort. Bootstrap resampling was conducted for both internal and "external" validation to evaluate the model fitting.

RESULTS

Total of 566 patients included for analysis, mean age 69.7 years, 85% Caucasian, 64% male, 62% high grade. NOC-UTUC was found in 184 (32.5%) patients on final pathology. Of 184 patients with NOC-UTUC, an equal number of renal pelvis and ureter only tumors (n = 74; 40.2% for each location) were noted; 36 (19.6%) had tumors in both locations. Multivariate model based on development cohort (n = 396) demonstrated clinical stage (odds ratio [OR] 14.0, P < 0.01), biopsy tumor grade (OR 3.3, P = 0.01), tumor architecture (OR 2.65, P = 0.09), and Hgb (OR 0.8, P = 0.02) level were independently associated with NOC disease. A preoperative nomogram incorporating these 4 variables achieved 82% accuracy, 48% sensitivity, and 95% specificity in predicting NOC-UTUC. The cut-off point for predicting high-risk disease was ≥0.49.

CONCLUSIONS

We established and validated an accurate tool for the prediction of locally advanced NOC-UTUC. This preoperative nomogram can be used to more optimally select patients for preoperative systemic chemotherapy, and facilitate clinical trial enrollment.

Renal cell carcinoma and pathologic nodal disease: Implications for American Joint Committee on Cancer staging

BACKGROUND

Lymph node (LN) metastases are associated with poor outcomes for patients with renal cell carcinoma (RCC). This study compared the survival outcomes of patients with stage III, node-positive disease (pT₁₂₃ N₁ M₀ ) and patients with stage III, node-negative disease (pT₃ N₀ M₀ ).

METHODS

A database of 4652 patients with RCC of any histological subtype treated with surgery at The University of Texas MD Anderson Cancer Center from 1993 to 2012 was retrospectively assessed. A total of 115 patients with pT₁₂₃ N₁ M₀ disease, 274 patients with pT₃ N₀ M₀ disease, and 523 patients with pT₁₂₃ N_0/x M₁ disease were included. Overall survival (OS) and cancer-specific survival (CSS) were estimated and compared between each cohort.

RESULTS

Median OS and CSS times were significantly better for pT₃ N₀ M₀ patients than pT₁₂₃ N₁ M₀ patients (OS, 10.2 vs 2.4 years, P < .0001; CSS, not reached vs 2.8 years, P < .0001). Similar median OS and CSS times were noted for pT₁₂₃ N₁ M₀ and pT₁₂₃ N_0/x M₁ patients (OS, 2.4 vs 2.4 years; P = .62; CSS, 2.8 vs 2.4 years; P = .10). In a multivariate analysis, tumor grade (hazard ratio [HR] for OS, 2.47; P < .0001; HR for CSS, 2.99; P < .0001) and pathologic LN involvement (HR for OS, 2.44; P < .0001; HR for CSS, 2.85; P < .0001) were associated with worse OS and CSS.

CONCLUSIONS

Among RCC patients classified with stage III disease, those with pT₁₂₃ N₁ M₀ disease had significantly worse survival than those with pT₃ N₀ M₀ disease. OS and CSS were similar for patients with pT₁₂₃ N₁ M₀ disease and patients with pT₁₂₃ N_0/x M₁ disease (stage IV). If validated, these findings suggest that RCC patients with nodal disease should be reclassified as having stage IV disease.

Conditional survival of patients with small renal masses undergoing active surveillance

OBJECTIVES

To determine conditional survival for patients with small renal masses (SRMs) undergoing active surveillance (AS).

MATERIALS AND METHODS

Patients were enrolled in a prospective AS protocol at our institution between May 2005 and January 2016. Patients with SRMs ≤4 cm with serial cross-sectional imaging available in-house for review were included. Overall survival (OS) was estimated using the Kaplan-Meier method and modelled via Cox proportional hazards models. The primary endpoints analysed were the conditional probability of survival and tumour growth over time. Landmark analysis was used to evaluate survival outcomes beyond the 2-year mark after the initial scan. The relative conditional survival of patients on AS was compared to those undergoing partial nephrectomy (PN) using inverse probability of treatment weighting.

RESULTS

A total of 272 patients were included in this analysis. The mean initial SRM size was 1.74 ± 0.77 cm, and the mean mass size closest to the 2-year mark was 1.97 ± 0.83 cm. The likelihood of continued survival to 5 years improved after the 2-year landmark. Patients with masses <3 cm who survived the first 2 years on AS had a 0.84-0.85 chance of surviving to 5 years, and if they survived 3 years, the probability of surviving to 5 years improved to 0.91. A slow tumour growth (β: 0.12; P < 0.001) with parallel growth rates was found for tumours <3 cm. Patients on AS and those who underwent PN had similar OS for ~7 years, beyond which PN demonstrated a trend of lower risk of death compared with AS (hazard ratio 0.57; P = 0.07).

CONCLUSIONS

The conditional survival probability of patients with SRMs <3 cm on AS increased after 2 years. This information may prove useful to urologists and patients who are considering continuing AS vs intervention after the first 2 years on AS.

Extended Pelvic Lymph Node Dissection in Bladder Cancer

INTRODUCTION

Radical cystectomy and extended pelvic lymph node dissection (ePLND) are the gold standard treatment for muscle-invasive bladder cancer and BCG unresponsive nonmuscle-invasive bladder cancer. In this article, we review the rationale for ePLND in the treatment of bladder cancer and the evidence supporting the equipoise between robot-assisted (RA) and open ePLND. A step-by-step guide of robot-assisted ePLND (RA ePLND) is provided to illustrate the techniques currently employed at our institution.

MATERIALS AND METHODS

Medline and PubMed electronic databases were queried for English language articles on bladder cancer, ePLND, and RA ePLND. In addition, a step-by-step video of RA ePLND was assembled with narration and accompanying explanations of each step to illustrate our current techniques. Key images from the video were selected for illustration of the relevant anatomical landmarks.

RESULTS

ePLND with a minimum nodal yield of 10 to 14 is tantamount in the treatment of bladder cancer. The number of lymph nodes resected influenced survival in both pathologically node positive and negative patients. In addition, RA ePLND was found to have equipoise as open ePLND by several groups. In our surgical atlas video, we illustrate key surgical steps, including port placement and exposure. Also, anatomic landmarks of dissection for the internal iliac, external iliac/obturator, and higher nodal packets are described in detail.

CONCLUSIONS

We illustrate the techniques for a thorough RA ePLND, with the intention to help the robotic surgeon to meet the 10 to 14 nodal yield mandated by the Bladder Cancer Collaborative Group.

Endoscopic Approaches to Upper Tract Urothelial Carcinoma

A select group of patients with upper tract urothelial carcinoma (UTUC) may meet indications for endoscopic management. Strategies for disease management are provided, based on a comprehensive review of the data using PubMed and Medline databases and marrying this with our experience with endoscopic management of UTUC. Endoscopic management of UTUC via retrograde or antegrade approaches is a viable treatment option for appropriately selected patients with low-risk UTUC, including those with low-grade, low-volume, and solitary tumors. However, recurrence risk limits these procedures to compliant patients under a vigilant surveillance program. Efficacious adjuvant therapies are needed to reduce local recurrences.

The role of metastatic burden in cytoreductive/consolidative radical cystectomy

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Background: The strategy of surgical extirpation of the primary tumor in the setting of metastatic disease has gained acceptance for a variety of solid tumors. The role of cytoreductive/consolidative radical cystectomy (CCRC) for metastatic urothelial cancer (UC) is unknown. We aimed to describe our institutional experience with CCRC for metastatic UC and to investigate clinicopathologic features predicting prolonged cancer specific survival (CSS) following CCRC. Methods: We performed IRB approved review of our bladder cancer database, and identified 32 patients with metastatic cancer originating from the lower urinary tract who underwent CCRC. Of these, two patients had non−UC histology. Baseline demographics, regimen of chemotherapy, clinicopathologic features, and perioperative complications were collected. Progression free survival (PFS) and cancer specific survival (CSS) were estimated from the time of CCRC. Univariate and multivariate Cox regression models were used to identify predictors of improved CSS after CCRC. Results: Of the 32 patients, 19 (59%) had clinical evidence of distant metastases, while 13 were found to harbor occult metastases on the surgical specimen. The most common site of metastasis was the retroperitoneal lymph nodes, found in 17 patients. Solitary metastases were found in 19 patients (59%). Twenty−eight (88%) patients received chemotherapy prior to CCRC. Disease progression was detected in 29 patients after CCRC (median PFS 4.5 mo), while 28 died of metastatic cancer (median CSS 11.7 mo). On multivariate analysis, patients with solitary metastases were found to have improved CSS compared to those with multiple metastases (HR 2.51, 95% CI 1.06−5.92, p = 0.04), with median CSS of 16.9 mo vs. 5.6 mo (p = 0.003). Median postoperative LOS was 10 days. Overall, 59% suffered postoperative complications, including one perioperative mortality. Conclusions: CCRC is feasible in the setting of metastatic UC, with comparable perioperative morbidity and mortality to RC with curative intent. Patients with solitary metastasis demonstrated longer CSS than those with multiple metastases, and should be considered candidates for future trials evaluating the role of CCRC for metastatic UC.

Conditional survival and landmark analysis for patients with small renal masses undergoing active surveillance at a tertiary care center

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Background: Conditional survival can provide guidance for patients once they have survived a period of time after diagnosis of their disease. We determine conditional survival for patients with small renal masses (SRM) undergoing active surveillance (AS). Methods: Patients were enrolled in a prospective AS registry at our institution between May 2005 and January 2016. Patients with localized SRM ≤4cm were included, with serial radiologic imaging available in-house for re-review. Overall survival (OS) was estimated using the Kaplan-Meier method and modeled via Cox proportional hazards models. The primary end points analyzed were the conditional probability of survival and tumor growth over time. Landmark analysis was used to evaluate survival outcomes. Results: A total of 272 patients were included in this analysis. Mean initial tumor size was 1.74 ± 0.77 cm and mean tumor size closest to the 2-year mark was 1.97 ± 0.83 cm. The likelihood of continued survival to 5 years improved after the 2-year landmark was reached. Patients with tumors < 3cm who survived the first 2-years on AS had a 0.84-0.85 chance of surviving to 5 years, and if they survived 3 years, the probability of surviving to 5 years improved to 0.91. Multivariable Cox proportional hazards analysis of survival revealed eGFR, Charlson comorbidity index (CCI), and tumor size of 3-4cm were significantly predictive of OS both at baseline and at 2-year mark (all p < 0.05). Patients with a tumor size 3-4 cm were at a greater risk of non-RCC death (HR > 3.5; p ≤ 0.001). A linear mixed effects model revealed slow tumor growth (beta: 0.12; p < 0.001) for tumors < 3cm. Adjusted tumor size predictions disclosed parallel growth rates for SRM of < 2cm and 2-2.99cm with insignificant difference (p = 0.969). Conclusions: Our study provides insight into the survival of patients with SRM on AS who have already survived a certain period of time. The conditional survival probability of patients with SRM < 3cm on AS improved after the initial 2 years, suggesting a role for re-counseling for those who survive to the 2-year landmark. Patient factors (renal function and CCI) were significantly associated with survival at baseline and at the 2-year landmark.

Genomic analysis of same-patient metachronous upper-tract and bladder urothelial carcinoma

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Background: Despite similarities between upper-tract (UTUC) and bladder urothelial carcinoma (BUC), distinctive clinicopathologic and genomic differences are being described. We further investigate the genomic landscape of these two interrelated malignancies in same-patient metachronous (m) UTUC and BUC using next generation sequencing (NGS). Methods: Following institutional board approval, UTUC and BUC samples were obtained from patients via surgical resection or endoscopic biopsy. Tumors were macrodissected from unstained formalin-fixed, paraffin-embedded slides. Study inclusion was untreated patient samples of UTUC and/or BUC divided into 4 groups: 1) UTUC with mBUC, 2) BUC with mUTUC, 3) Synchronous BUC and UTUC, 4) UTUC with no bladder history. Exclusions were for inadequate clinical data or histological tumor purity < 30%. Whole transcriptome RNA sequencing was performed and analyzed using BASE47 panel (includes basal, luminal, p53-like and cell cycle genes). Results: A total of 95 (UTUC = 61, BUC = 34) samples from 40 patients were analyzed. UTUC samples were 33 primary ureter and 28 renal pelvis cancer. Median age was 72 years, 68% male, 76% Caucasian, 60% former smokers. Groups samples were: 1) UTUC (n = 19), mBUC (n = 12); 2) BUC (n = 12), mUTUC (n = 9); 3) Synchronous UTUC/BUC (n = 10); and 4) UTUC (n = 23). Unsupervised hierarchical clustering segregated tumors into basal-like and luminal subtypes, with 87.5% of metachronous tumors displaying conserved subtype membership. For the groups with UTUC and BUC, only 3/24 (12.5%) clusters (2 patients in Group 2, and 1 patient in Group 3) had unmatched basal/luminal subtypes. Conclusions: NGS analysis of same-patient metachronous UTUC and BUC shows that the majority stay within the same molecular subtype regardless of chronologic development or anatomic origin. Additional studies are necessary to explore differences that may occur within the subtypes, the role of methylation, and clinical correlates.

Universal Point of Care Testing for Lynch Syndrome in Patients with Upper Tract Urothelial Carcinoma

PURPOSE

Patients with Lynch syndrome are at risk for upper tract urothelial carcinoma. We sought to identify the incidence and most reliable means of point of care screening for Lynch syndrome in patients with upper tract urothelial carcinoma.

MATERIALS AND METHODS

A total of 115 consecutive patients with upper tract urothelial carcinoma without a history of Lynch syndrome were universally screened during followup from January 2013 through July 2016. We evaluated patient and family history using AMS (Amsterdam criteria) I and II, and tumor immunohistochemistry for mismatch repair proteins and microsatellite instability. Patients who were positive for AMS I/II, microsatellite instability or immunohistochemistry were classified as potentially having Lynch syndrome and referred for clinical genetic analysis and counseling. Patients with known Lynch syndrome served as positive controls.

RESULTS

Of the 115 patients 16 (13.9%) screened positive for potential Lynch syndrome. Of these patients 7.0% met AMS II criteria, 11.3% had loss of at least 1 mismatch repair protein and 6.0% had high microsatellite instability. All 16 patients were referred for germline testing, 9 completed genetic analysis and counseling, and 6 were confirmed to have Lynch syndrome. All 7 patients with upper tract urothelial carcinoma who had a known history of Lynch syndrome were positive for AMS II criteria and at least a single mismatch repair protein loss while 5 of 6 had high microsatellite instability.

CONCLUSIONS

We identified 13.9% of upper tract urothelial carcinoma cases as potential Lynch syndrome and 5.2% as confirmed Lynch syndrome at the point of care. These findings have important implications for universal screening of upper tract urothelial carcinoma, representing one of the highest rates of undiagnosed genetic disease in a urological cancer.

Intraoperative conversion from partial to radical nephrectomy: Predictive factors and outcomes

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Background: Predictive risk factors for intraoperative conversion from partial to radical nephrectomy (RN) are poorly quantified. We evaluated preoperative predictors of conversion in a cohort of patients undergoing planned partial nephrectomy (PN). Methods: A prospectively maintained database was reviewed to identify patients who were scheduled to undergo (open, laparoscopic, or robot-assisted) PN that were converted to RN between 1990 and 2015. Reasons for conversion were collected from the operative report. Patient demographics and perioperative variables were evaluated including body mass index (BMI), tumor size, nephrometry score, hilar tumors, procedure type, intraoperative complications, and oncologic outcome. Results: A total of 2298 patients underwent successful PN. The rate of conversion to RN was 4% (n=99) patients. The median patient age was 60 years and median BMI was 30 kg/m2. The median American Society of Anesthesiologists (ASA) score was 3 and median Charlson Comorbidity Index (CCI) was 2. The median tumor size for the converted cases was 4.5 cm (1.0-10.1) and median nephrometry score was 9. Histology was clear cell-RCC in 79% of the tumors. A total of 30 patients had completely endophytic tumors. The most common reasons for conversion were hilar/renal sinus extension of the renal mass in 38 (38%) patients, positive surgical margin on frozen section or gross assessment in 27 (27%) patients, insufficient renal remnant in 27 (27%) patients, and excessive intraoperative bleeding in 7 (7%) patients. RN was performed open in 79, laparoscopically in 9, and robot-assisted in 11 cases. Intraoperative complications occurred in 1 (1%) patient underwent an attempted robot-assisted PN resulted in an injury to a major renal artery branch requiring conversion to RN. Patients were followed up for a median of 33 months. In the converted cohort, evidence of disease at last follow-up was found in 13 (13%) patients. Conclusions: The rate of conversion to RN was low in patients undergoing PN in this series. The most common reason for conversion was hilar/renal sinus extension of these complex renal masses while positive surgical margin and insufficient renal remnant were contributing equally at lower rates.

Lynch syndrome-associated upper tract urothelial cancer: Assessment of clinical screening criteria and tissue-based point of care testing

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Background: Lynch syndrome (LS) is an inherited syndrome that places patients at risk for upper tract urothelial carcinoma (UTUC). Our goal was to identify the most reliable means of screening for LS in patients with UTUC at the point of care (POC). Methods: Patient information was retrospectively collected in an IRB-approved protocol on UTUC patients. LS screening was universally performed on all patients presenting from 1/2013-7/2016. We evaluated patient and family history (Amsterdam I and II criteria; AMS1 and AMS2, respectively), tumor immunohistochemistry (IHC) for 4 mismatch repair proteins (MMRP), tumor and normal tissue polymerase-chain reaction for microsatellite instability (MSI), and clinical genetic analysis and counseling (GAC), in those with undiagnosed LS. Patients who were AMS 2 positive, MSI positive, or IHC positive were considered as presumed Lynch syndrome (PLS) and were referred for GAC. Results: 101 UTUC patients without a history of LS were universally screened during clinical follow-up. A total of 15/101 (15%) patients were PLS. 7/101 (7%) patients met AMS2 criteria. 4 patients meeting AMS2 criteria had intact expression of MMRP and no MSI instability. 11 (11%) patients had either loss of one or more MMRP. There were two cases of MSI high instability, both in patients with MMRP loss. There were no cases of MSI-high instability and negative IHC. Insufficient tissue was found in 1/101 (1%) of IHC and 8/88 (9%) of MSI tests (p=0.0164). All patients with any positive screen were referred for GAC, 5 followed-up and all 5 patients had a confirmed germline mutation. The remaining did not follow through with GAC because of financial/insurance barriers. Conclusions: We identified 15% of universally screened UTUC as PLS at the POC using IHC and AMS2 criteria. IHC and AMS2 criteria appear to provide the most reliable screening. MSI is limited by requirement for normal tissue, a greater amount of tumor tissue, and can miss cases of MMRP loss. There are significant barriers to GAC. Our findings of a 15% rate of LS-related UTUC is consistent with prior laboratory tissue studies and has significant implications for universal POC testing of UTUC patients.

Current technique and results for extended pelvic lymph node dissection during robot-assisted radical prostatectomy

The practice of extended pelvic lymph node dissection (ePLND) remains one of the most controversial topics in the management of clinically localized prostate cancer. Although most urologists agree on its benefit for staging and prognostication, the role of the ePLND in cancer control continues to be debated. The increased perioperative morbidity makes it unpalatable, especially in patients with low likelihood of lymph node disease. With the advent of robotic assisted laparoscopic prostatectomy, many surgeons were slow to adopt ePLND in the robotic setting. In this study, we summarize the evidence for the prognostic and therapeutic roles of ePLND, review the clinical tools used for lymph node metastasis prediction and survey the numerous experiences of ePLND compiled by robotic urologic surgeons over the years.

Perinephric Hematoma and Hemorrhagic Shock as a Rare Presentation for an Acutely Obstructive Ureteral Stone with Forniceal Rupture: A Case Report

Background: Spontaneous perinephric hematoma (SPH) secondary to a forniceal rupture as the first presenting sign for an obstructive ureteral stone in a patient without history of urolithiasis has not been described previously.

Case presentation: We report a 70-year-old Caucasian male patient who presented to our emergency room with fever, altered mental status, and left flank pain. He had a temperature of 103.3°F, tachycardia, but stable blood pressure. He had left flank tenderness. A computed tomography scan of the abdomen/pelvis with intravenous contrast revealed an intracapsular hematoma (13.3 × 10.0 × 6.4 cm) with an active bleeding and a 1.1 cm left proximal ureteral stone. The patient became quickly hemodynamically unstable and was taken for emergent exploratory laparotomy and left nephrectomy. An active bleeding was encountered secondary to a (2.4 × 2.0 cm) lateral capsular defect in the kidney.

Conclusion: Hemorrhagic/septic shock as a presenting sign for an obstructive ureteral stone may require an emergent nephrectomy in a hemodynamically unstable patient.

Computer-assisted robotic renal surgery

Computer-assisted robotic renal surgery (CARRS) is a minimally invasive surgical treatment option for renal tumors. We review the literature regarding techniques and outcomes and the potential advantages of CARRS. We retrospectively reviewed the literature regarding techniques and outcomes of CARRS, with specific analysis on robotic radical nephrectomy (RRN) and robotic partial nephrectomy (RPN). Multiple papers on RRN and RPN were found where the techniques were performed with either a transperitoneal or a retroperitoneal approach. Preliminary outcomes with RRN and RPN were at least comparable to those of a laparoscopic approach, with some parameters of RPN improved over the laparoscopic approach (warm ischemia time, length of hospital stay and estimated blood loss). CARRS is an emerging field with preliminary outcomes at least comparable to the laparoscopic approach. Large prospective, randomized trials are needed to assess the benefit of CARRS compared with current methods.