Does the Timing of Cytoreductive Nephrectomy Impact Outcomes? Analysis of REMARCC Registry Data for Patients Receiving Tyrosine Kinase Inhibitor Versus Immune Checkpoint Inhibitor Therapy

Background and objective

The role of cytoreductive nephrectomy (CN) in the treatment of metastatic renal cell carcinoma (mRCC) has been called into question on the basis of clinical trial data from the tyrosine kinase inhibitor (TKI) era. Comparative analyses of CN for patients treated with immuno-oncology (IO) versus TKI agents are sparse. Our objective was to compare CN timing and outcomes among patients who received TKI versus IO therapy.

Methods

This was a multicenter retrospective analysis of patients who underwent CN using data from the REMARCC (Registry of Metastatic RCC) database. The cohort was divided into TKI versus IO first-line therapy groups. The primary outcome was all-cause mortality (ACM). Secondary outcomes included cancer-specific mortality (CSM). Multivariable analysis was used to identify factors predictive for ACM and CSM. The Kaplan-Meier method was used to analyze 5-yr overall survival (OS) and cancer-specific survival (CSS) with stratification by primary systemic therapy and timing in relation to CN.

Key findings and limitations

We analyzed data for 189 patients (148 TKI + CN, 41 IO +CN; median follow-up 23.2 mo). Multivariable analysis revealed that a greater number of metastases (hazard ratio [HR] 1.06; p = 0.015), greater primary tumor size (HR 1.10; p = 0.043), TKI receipt (HR 2.36; p = 0.015), and initiation of systemic therapy after CN (HR 1.49; p = 0.039) were associated with worse ACM. A greater number of metastases at diagnosis (HR 1.07; p = 0.011), greater primary tumor size (HR 1.12; p = 0.018), TKI receipt (HR 5.43; p = 0.004), and initiation of systemic therapy after CN (HR 2.04; p < 0.001) were associated with worse CSM. Kaplan-Meier analyses revealed greater 5-yr rates for OS (51% vs 27%; p < 0.001) and CSS (83% vs 30%; p < 0.001) for IO +CN versus TKI + CN. This difference persisted in a subgroup analysis for patients with intermediate or poor risk, with 5-yr OS rates of 50% for IO + CN versus 30% for TKI + CN (p < 0.001). A subanalysis stratified by CN timing revealed better 5-yr rates for OS (50% vs 30%; p = 0.042) and CSS (90% vs 30%, p = 0.019) for delayed CN after IO therapy, but not after TKI therapy.

Conclusions and clinical implications

For patients who underwent CN, systemic therapy before CN was associated with better outcomes. In addition, IO therapy was associated with better survival outcomes in comparison to TKI therapy. Our findings question the applicability of clinical trial data from the TKI era to CN in the IO era for mRCC.

Patient summary

For patients with metastatic kidney cancer treated with surgery, better survival outcomes were observed for those who also received immunotherapy in comparison to therapy targeting specific proteins in the body (tyrosine kinase inhibitors, TKIs). Immunotherapy or TKI treatment resulted in better outcomes if it was received before rather than after surgery.

Bilateral transversus abdominis plane and rectus sheath blocks with liposomal bupivacaine for patients undergoing robotic prostatectomy

As robotic prostatectomy surgery becomes more prevalent, it is important to identify any regional techniques to optimize patient's recovery. We evaluated the effectiveness of bilateral transversus abdominis plane (TAP) and rectus sheath (RS) blocks with liposomal bupivacaine. We hypothesized that these blocks would reduce perioperative opioid use and pain scores. A retrospective cohort of patients from May 2018 and May 2021 at a single large VA hospital were studied. We compared those not receiving a nerve block against those receiving the TAP and RS as part of an Enhanced Recovery After Surgery (ERAS) pathway starting in May 2019. The primary outcome was post-operative opioid use. Secondary outcomes were post-operative pain scores and hospital length of stay. One hundred and thirty-four patients were included in the final analysis. Eighty-one patients did not receive a block and fifty-three patients did receive a block. No difference existed between the groups in regard to median oral morphine equivalents (mg) used in PACU or any post-operative day. No difference existed in median opioid usage (mg) or pain scores between the two groups on any post-operative day. There was no difference in temporal association of median pain scores or narcotic usage between the two groups. Bilateral TAP and RS with liposomal bupivacaine did not significantly decrease post-operative opioid use, improve pain scores, or decrease hospital length of stay for patients undergoing robotic prostatectomy. Further studies need to be done to evaluate the effect of these blocks with liposomal bupivacaine.

Myoepithelial carcinoma of the bladder: Case report and review of the literature

Myoepithelial carcinoma is a neoplasm that classically arises in the parotid glands, nasopharynx, paranasal sinus, and nasal cavity of the head and neck. It rarely arises in other organs or soft tissues and involvement of genitourinary organs is distinctly rare. We describe a case of a 21-year-old male, presenting with nausea, weight loss, and worsening suprapubic pain over 3 months, found to have a large mass at the dome of the bladder. Partial cystectomy was ultimately performed revealing myoepithelial carcinoma of the bladder. The patient is free of disease at four years without the need for systemic therapy.

Simplified PADUA Renal (SPARE) Nephrometry Scoring System: External Validation, Interobserver Variability, and Comparison with RENAL and PADUA in a Single-center Robotic Partial Nephrectomy Series

BACKGROUND

The RENAL (radius [R], exophytic/endophytic [E], nearness to collecting system/sinus [N], anterior/posterior [A], and location relative to polar lines [L]) and the PADUA (preoperative aspects and dimensions used for an anatomical classification) scores help in quantifying tumor complexity. However, nephrometry scoring systems have low interobserver variability. To simplify and improve score reproducibility, a new Simplified PADUA Renal (SPARE) scoring system was introduced.

OBJECTIVE

To externally validate the SPARE nephrometry scoring system and to determine its interobserver variability.

DESIGN, SETTING, AND PARTICIPANTS

A total of 202 patients were included in the analysis. We performed a retrospective analysis of robot-assisted partial nephrectomy (RAPN) cases for a single renal mass performed at a single academic institution during the period 2008-2018. For each renal mass, PADUA, RENAL, and SPARE nephrometry scores were calculated.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Three urology residents (URs), two urology attendings (UAs), two radiology residents (RRs), and one radiology attending (RA) retrospectively reviewed computed tomography scans blinded to clinical outcomes. The accuracy of the SPARE nephrometry score in the prediction of any complication (Clavien grade ≥1) was compared with other scoring systems in a univariable and a multivariate fashion. The area under the curve (AUC) and kappa statistics were used to assess interobserver variability of the SPARE score.

RESULTS AND LIMITATIONS

The SPARE score was not inferior to the PADUA and RENAL scores (AUC 0.61, 0.59, and 0.57, respectively, p = 0.43). Patients with intermediate to high SPARE scores had longer operative time (158 vs 135 min, p = 0.10) and a higher rate of complications (28% vs 14%, p = 0.012). Univariable analysis predicting overall complications showed that RRs performed slightly better than URs and UAs using the SPARE score. Interobserver agreement was 84% between an RA and an RR (kappa 0.42), 85% between an RA and a UA (kappa 0.39), and 85% between an RA and a UR (kappa 0.45).

CONCLUSIONS

These findings confirm that the SPARE nephrometry scoring system is a reproducible and easy tool offering overall fair interobserver agreement regardless of years of training or type of practice, while maintaining the predictive capabilities of more established nephrometry scores.

PATIENT SUMMARY

In this study, a novel and simple classification system was assessed using a sample of cases from our institution to define surgical complexity renal masses detected on radiological imaging. Our findings suggest that this tool can be useful in clinical practice to facilitate the characterization of renal masses and predict the complications of surgical treatment.

Neoadjuvant radiotherapy followed by surgery compared with surgery alone in the treatment of retroperitoneal sarcoma: a population-based comparison

Introduction

Retroperitoneal sarcoma (rps) encompasses a heterogeneous group of malignancies with a high recurrence rate after resection. Neoadjuvant radiotherapy (nrt) is often used in the hope of sterilizing margins and decreasing local recurrence after excision. We set out to compare local recurrence-free survival (lrfs) and overall survival (os) in patients treated with or without nrt before resection.

Methods

Patients diagnosed with rps from February 1990 to October 2014 were identified in the Alberta Cancer Registry. Patients with complete gross resection of rps and no distant disease were included. Patient, tumour, treatment, and outcomes data were abstracted in a primary chart review. Baseline characteristics were compared using the Wilcoxon nonparametric test for continuous data and the Fisher exact test for dichotomous and categorical data. Survival was analyzed using Kaplan-Meier curves with log-rank test. Cox regression was performed to control for age, sex, tumour size, tumour grade, date of diagnosis, multivisceral resection, and intraoperative rupture.

Results

Resection alone was performed in 62 patients, and resection after nrt, in 40. Use of nrt was associated with multivisceral resection and negative microscopic margins. On univariate analysis, nrt was associated with superior median lrfs (89.3 months vs. 28.4 months, p = 0.04) and os (119.4 months vs. 75.9 months, p = 0.04). On multivariate analysis, nrt, younger age, and lower tumour grade predicted improved lrfs and os; sex, tumour size, date of diagnosis, multivisceral resection, and tumour rupture did not.

Conclusions

In this population-based study, nrt was associated with superior lrfs and os on both univariate and multivariate analysis. When feasible, nrt should be considered until a randomized controlled trial is completed.

A school and community outbreak of tuberculosis in Auckland

AIM

To describe a school and community outbreak of tuberculosis in South Auckland in 1997/8.

METHODS

Cases were diagnosed according to national guidelines at Middlemore, Green Lane and Starship Hospitals. Public health follow-up was conducted by Auckland Healthcare.

RESULTS

Twelve cases were diagnosed during the outbreak. Nine cases were from the same South Auckland secondary school; six reported no association outside school. Three cases were in younger children who had close household contact with two of the school cases. Nine cases (including eight from the school) had identical Mycobacterium tuberculosis isolates on restriction fragment length polymorphism testing. No microbiological culture was obtained from the three remaining cases. Contact investigation detected five of the cases. Chemoprophylaxis was prescribed for twenty-six school students, two adult staff, and nine household contacts.

CONCLUSION

This is the first published account of a tuberculosis outbreak in a New Zealand school setting for decades. Recognition of the outbreak was delayed. DNA fingerprinting played a valuable role in the investigation. The source case may have been a school student. The social impact of the outbreak and preventability with routine adolescent BCG vaccination are discussed.

Biochemical markers of bone resorption compared with estimates of bone resorption from radiotracer kinetic studies in osteoporosis

The pyridinium cross-links of collagen pyridinoline (Pyd) and deoxypyridinoline (Dpd) are released during bone resorption and are neither metabolized nor absorbed from the diet. The aim of this study was to validate their use in osteoporosis. We studied 19 women with osteoporosis and estimated the bone resorption rate from a combined calcium balance/kinetics technique without (R) and with partial (R(H)) and "complete" (Res) correction for long-term exchange. The strongest correlation was observed between the bone-specific marker (Dpd) and with complete correction for long-term exchange (Res) (r = 0.71, p < 0.001). The intercept was not different from zero, suggesting that bone was the major source for Dpd. The crude ratio of Dpd to Res in the 19 women was 54.5; but the regression coefficient relating Dpd as the dependent variable to Res was 31.8 (95% CI 15.6-48.0), which was higher, but not significantly, than the ratio between Dpd and calcium (16.4) in 10 bone samples (cortical and trabecular bone). The weakest correlations between a biochemical marker and a kinetic index were those between hydroxyproline (a nonspecific marker of bone resorption) and R or R(H). Treatment with hormone replacement therapy (HRT) or HRT and parathyroid hormone peptide 1-38 in seven women over 1 year resulted in similar percent changes in the biochemical markers and estimates of bone resorption. We conclude that the measurement of Dpd provides a reasonably accurate assessment of bone resorption in osteoporosis, and in the context of several repeat 24-h collections of urine offers measurement precision that is similar to that obtainable with methods depending on the use of radioisotopic tracers and the assessment of metabolic calcium balance.

Bone remodelling does not decline after menopause in vertebral fracture osteoporosis

There is considerable current interest in whether activators of bone remodelling, such as IL-1 and other cytokines, are involved in the pathogenesis of osteoporosis. We have therefore studied indices relating to remodelling activation in 50 patients with postmenopausal vertebral osteoporosis and 12 with hip fracture osteoporosis in comparison with 25 age- and sex-matched controls. Because of uncertainty regarding the accuracy of current biochemical markers of bone formation with respect to the estimation of whole body rates of bone formation, a 85Sr-based radioisotopic method was used. This method was previously validated by comparison with data obtained after double in vivo labelling of transiliac biopsies taken nearly simultaneously. Bone resorption was estimated from urinary hydroxyproline data. Controls selected for their continued good health showed a progressive and statistically highly significant decline in indices of bone formation with time after menopause. No such decline was seen in the vertebral fracture patients (P less than 0.005). There were no hip fracture patients within 10 years of menopause so this statistical test could not be applied appropriately to them. The hydroxyproline data were consistent with the suggestion arising from the bone formation data that remodelling declines progressively after menopause in the controls but not in the vertebral fracture patients. The data also suggested that these two fracture groups were in more negative calcium balance than the controls, this being particularly marked in the hip fracture cases. Plasma osteocalcin data correlated moderately well with the kinetic measurements of bone formation. It is concluded that vertebral fracture osteoporosis is associated with prolongation of menopausal levels of bone remodelling which is inappropriate by comparison with healthy controls.

hPTH 1-34 treatment of osteoporosis with added hormone replacement therapy: biochemical, kinetic and histological responses

Twelve patients with vertebral fracture osteoporosis were recruited into a trial of treatment with hPTH 1-34 by daily injection for 1 year combined (from the 5th month) with an anti-resorptive agent (oestrogen, n = 9; nandrolone, n = 3). Treatment outcomes were monitored by biochemical and radiotracer measurements together with histomorphometry of transiliac biopsies before and at the end of treatment following double in vivo pre-labelling with demethylchlortetracycline. Indices of whole body bone formation, obtained from the analysis of 85Sr data, showed substantial increases (P less than 0.005) for all three indices measured) while biochemical (hydroxyproline) and kinetic measurements of bone resorption showed modest and equivocal changes only. As a result calcium balance improved. Gastrointestinal calcium absorption showed a tendency to improve, while urine calcium decreased; but these changes were statistically not significant except for radiocalcium absorption in the oestrogen treated subgroup. Histomorphometry revealed substantial increases in cancellous bone volume as reported previously with hPTH 1-34 given alone. However, iliac (as distinct from whole body) indices related to bone formation and resorption appeared to have returned towards pre-treatment values by the time of the second biopsy under the influence of the anti-resorptive agent given with the hPTH 1-34. It is confirmed that hPTH 1-34 therapy can increase iliac cancellous bone mass (as well as spinal cancellous bone mass as reported earlier) without a long-term increment in whole body bone resorption, providing the hPTH is combined with an anti-resorptive agent.

Selenium induces changes in the selenocysteine tRNA[Ser]Sec population in mammalian cells

Two isoacceptors of selenocysteine tRNA[Ser]Sec are present in higher vertebrates which are responsible for donating selenocysteine to protein. One such selenocysteine containing protein, glutathione peroxidase, requires selenium for its translation and transcription. Since tRNA[Ser]Sec is a critical component of the glutathione peroxidase translational machinery, the levels and distributions of its isoacceptors were examined from both human and rat cells grown in chemically defined media with and without selenium. Not only did the level of the selenocysteine tRNA[Ser]Sec population increase approximately 20% in cells grown in the presence of selenium, but the distributions of the two isoacceptors also changed relative to each other.

Secreted and cellular polypeptide patterns of MCF-7 human breast cancer cells following either estrogen stimulation or v-H-ras transfection

The polypeptide patterns of MCF-7 human breast cancer cells (MCF-7gpt) and a stably v-H-ras-transfected subclone (MCF-7ras) have been analyzed following estradiol treatment. Since both estradiol and v-H-ras transfection increase tumorigenicity of MCF-7 cells, this study was designed to ascertain if specific changes in polypeptides were common in both treatments. Separation of cellular and secreted polypeptides was accomplished by 2-dimensional polyacrylamide gel electrophoresis, and the consequent patterns were analyzed with computer assistance. Estradiol treatment of the MCF-7gpt cells reduced the number of differences found in the polypeptide patterns between MCF-7gpt and MCF-7ras. Twelve cellular polypeptides were consistently modulated by either estradiol or v-H-ras, with four polypeptides clearly affected in the same way by both treatments. Polypeptides Gchc-0845 (Mr 54,000, pI 6.9) and Gchc-0902 (Mr 52,000, pI 6.3) were suppressed by estradiol and v-H-ras, while Gchc-1240 (Mr 34,000, pI 4.4) and Gchc-1396 (Mr 23,000, pI 5.3) were induced by estradiol and v-H-ras. Sixteen secreted polypeptides were altered by at least 2-fold subsequent to estradiol treatment or v-H-ras transfection. Transfection with v-H-ras had a greater effect than estradiol, stimulating the secretion of eight polypeptides and suppressing the secretion of seven polypeptides compared to estradiol which increased secretion of five polypeptides and decreased secretion of an additional three polypeptides, respectively. Synergistic effects by estradiol and v-H-ras were noted for three polypeptides. The secretion of Gcls-175 (Mr 50,000, pI 5.7) and Gcls-320 (Mr less than 14,000, pI 3.6, p-S2) was increased, while the secretion of Gcls-112 (Mr 76,000, pI 6.9) was decreased. Opposing effects of estradiol and v-H-ras were seen for seven polypeptides including the Mr 48,000 derivative of the Mr 52,000 protein (cathepsin D). These studies support the possibility that an extremely few, but specific polypeptides are regulated in association with quite diverse tumorigenic stimuli in MCF-7 human breast cancer cells.

A further study of air pollution in diesel bus garages

The concentrations of smoke, polycyclic aromatic hydrocarbons (PAHs), and some gaseous air pollutants have been measured in two London Transport diesel bus garages and compared with observations made in the same garages over 20 years earlier. The main feature of the results was a large reduction in the background concentrations of smoke and polycyclic aromatic hydrocarbons from sources such as coal fires, attributable to the implementation of the Clean Air Act. Contributions from the buses to the benzo(a) pyrene content of the air inside the garages were of the same magnitude as before, being small in relation to former coal smoke contributions.