Evaluation of QSAR models for predicting mutagenicity: outcome of the Second Ames/QSAR international challenge project

Quantitative structure-activity relationship (QSAR) models are powerful in silico tools for predicting the mutagenicity of unstable compounds, impurities and metabolites that are difficult to examine using the Ames test. Ideally, Ames/QSAR models for regulatory use should demonstrate high sensitivity, low false-negative rate and wide coverage of chemical space. To promote superior model development, the Division of Genetics and Mutagenesis, National Institute of Health Sciences, Japan (DGM/NIHS), conducted the Second Ames/QSAR International Challenge Project (2020-2022) as a successor to the First Project (2014-2017), with 21 teams from 11 countries participating. The DGM/NIHS provided a curated training dataset of approximately 12,000 chemicals and a trial dataset of approximately 1,600 chemicals, and each participating team predicted the Ames mutagenicity of each trial chemical using various Ames/QSAR models. The DGM/NIHS then provided the Ames test results for trial chemicals to assist in model improvement. Although overall model performance on the Second Project was not superior to that on the First, models from the eight teams participating in both projects achieved higher sensitivity than models from teams participating in only the Second Project. Thus, these evaluations have facilitated the development of QSAR models.

Postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) for seminoma: Limitations of surgical intervention after first-line chemotherapy

PURPOSE

Patients with relapsed seminoma after first-line chemotherapy can be treated with salvage chemotherapy or postchemotherapy retroperitoneal lymph node dissection (PC-RPLND). Based on prior experience, surgical management can have worse efficacy and increased morbidity compared to nonseminomatous germ cell tumor. Our aim was to characterize the surgical efficacy and difficulty in highly selected patients with residual disease after first-line chemotherapy.

MATERIALS AND METHODS

The Indiana University testis cancer database was queried to identify men who underwent PC-RPLND for seminoma between January 2011 and December 2021. Included patients underwent first-line chemotherapy and had evidence of retroperitoneal disease progression.

RESULTS

We identified 889 patients that underwent PC-RPLND, of which only 14 patients were operated on for seminoma. One patient was excluded for lack of follow-up. Out of 13 patients, only 3 patients were disease free with surgery only. Median follow up time was 29.9 months (interquartile ranges : 22.6-53.7). Two patients died of disease. The remaining 8 patients were treated successfully with salvage chemotherapy. During PC-RPLND, 4 patients required nephrectomy, 1 patient required an aortic graft, 2 patients required a partial ureterectomy, and 3 patients required partial or complete caval resection.

CONCLUSION

The decision between salvage chemotherapy and PC-RPLND as second-line therapy can be challenging. Salvage chemotherapy is effective but is associated with short and long-term morbidity. Surgical efficacy in this setting seems to be limited, but careful selection of patients may lead to surgical success without affecting the ability to receive any systemic salvage therapies if necessary or causing life-threating morbidity.

Primary Retroperitoneal Lymph Node Dissection for Stage II Seminoma: Is Surgery the New Path Forward?

PURPOSE

On the basis of National Comprehensive Cancer Network guidelines, clinical stage (CS) II seminoma is treated with radiotherapy or chemotherapy. Primary retroperitoneal lymph node dissection (RPLND) demonstrated recent success as first-line therapy for RP-only disease. Our aim was to confirm surgical efficacy and evaluate recurrences after primary RPLND for CS IIA/IIB seminoma to determine if various clinical factors could predict recurrences.

PATIENTS AND METHODS

Patients who underwent primary RPLND for seminoma from 2014 to 2021 were identified. All patients had at least 6 months of follow-up. Nineteen patients were part of a clinical trial. Patients receiving adjuvant chemotherapy were excluded from Kaplan-Meier recurrence-free survival (RFS) analysis.

RESULTS

We identified 67 patients who underwent RPLND for RP-only seminoma. One patient had pN0 disease. Median follow-up time after RPLND was 22.4 months (interquartile range, 12.3-36.1 months) and 11 patients were found to have a recurrence. The 2-year RFS for RPLND-only patients without adjuvant chemotherapy was 80.2%. Patients who developed RP disease for a period > 12 months had the lowest chance of recurrence, with a 2-year RFS of 92.2%. Seven initial CS II patients were on surveillance for 3-12 months before surgery and no patients experienced recurrence. Pathologic nodal stage and high-risk factors such as tumor size > 4 cm or rete testis invasion of the orchiectomy specimen did not affect recurrence.

CONCLUSION

CS II seminoma can be treated with surgery to avoid rigors of chemotherapy or radiotherapy. Patients with delayed development of CS II disease (> 12 months) had the best surgical results. Patients may present with borderline CS II disease, and careful surveillance may avoid overtreatment. Further study on patient selection and extent of dissection remains uncertain and warrants further investigation.

Late Relapse of Germ Cell Tumors After Prior Chemotherapy or Surgery-only

BACKGROUND

Late relapse (LR) of germ cell tumor (GCT) is defined as relapsed disease >2 years from initial treatment. LR remains a challenge both for optimal screening methods and management. We report the method of detection, treatments received, and outcomes in patients with chemotherapy-exposed vs chemotherapy-naïve LR GCT.

PATIENTS AND METHODS

The Indiana University testicular cancer database was queried identifying 131 patients with LR GCT evaluated at Indiana University from January 2000 to January 2019. Method of detection of LR was recorded along with site, treatment received, and survival outcomes. The cohort was divided into 4 groups according to seminoma versus non-seminoma GCT (NSGCT) and chemotherapy-exposed vs chemotherapy-naïve LR. Progression-free survival (PFS) and overall survival (OS) were analyzed using the Kaplan-Meier method and compared using the log-rank test. Medians with 95% confidence intervals were also calculated along with the 2-year probabilities.

RESULTS

Median age at LR was 38.3 (range, 19.3-56.8). Chemotherapy-exposed accounted for 75 (57%) and chemotherapy-naïve for 56 (43%) of cases. The 2-year OS comparing chemotherapy-exposed versus chemotherapy-naïve was 78.2% versus 100% (P = .0003). For the 72 chemo-exposed NSGCT LR pts, 2-year PFS based on treatment: surgery vs chemotherapy versus surgery + chemotherapy was 67.1% versus 0% versus 47.1% (P < 0.0001). Fifty-nine percent of chemotherapy-exposed LR had elevation of alpha fetoprotein (AFP) at LR diagnosis.

CONCLUSION

GCT pts require lifetime follow-up with annual physical exam and tumor markers. Surgical resection, when feasible, remains the preferred treatment for chemotherapy-exposed LR. Chemotherapy-exposed LR has worse outcomes compared to chemotherapy-naïve LR patients.

Primary Retroperitoneal Lymph Node Dissection for Patients With Pathologic Stage II Nonseminomatous Germ Cell Tumor-N1, N2, and N3 Disease: Is Adjuvant Chemotherapy Necessary?

PURPOSE

According to National Comprehensive Cancer Network guidelines, adjuvant chemotherapy (AC) has been advocated after primary retroperitoneal lymph node dissection (RPLND) to reduce the risk of relapse in pathologic nodal (pN) stage pN2 or pN3, whereas surveillance is preferred for pN1. We sought to explore the oncologic efficacy of primary RPLND alone for pathologic stage II in nonseminomatous germ cell tumors (NSGCTs) to reduce overtreatment with chemotherapy.

METHODS

Patients with pathologic stage II NSGCT after primary RPLND between 2007 and 2017 were identified. Patients were excluded for elevated preoperative serum tumor markers, receipt of AC, or if pure teratoma or primitive neuroectodermal tumor elements were found in the retroperitoneal pathology.

RESULTS

We identified 117 patients with active NSGCT in the retroperitoneum after primary RPLND. We excluded seven patients who lacked meaningful follow-up and 13 patients who received AC. There were 97 patients treated with RPLND alone: 41 pN1, 46 pN2, and 10 pN3. In total, 77 of 97 patients had not recurred after a median follow-up time of 52 months. The 2-year recurrence-free survival (RFS) was 80.3%, and the 5-year RFS was 79%. No differences in RFS were noted among nodal stage-pN1, pN2, and pN3-on Kaplan-Meier analysis. Lymphovascular invasion in the orchiectomy specimen, a high-risk pathologic feature, was also predictive of recurrence after primary RPLND. All 20 patients who recurred were treated with first-line chemotherapy and remained continuously disease free.

CONCLUSION

Most men with pathologic stage II disease treated with surgery alone in our series never experienced a recurrence. We did not observe a difference in recurrences between patients with pN1 and pN2. The recommendation for AC for pN2 disease may be overtreatment in most patients.

Percentage of Teratoma in Orchiectomy and Risk of Retroperitoneal Teratoma at the Time of Postchemotherapy Retroperitoneal Lymph Node Dissection in Germ Cell Tumors

PURPOSE

Presence of teratoma in the orchiectomy and residual retroperitoneal mass size are known predictors of finding teratoma during postchemotherapy retroperitoneal lymph node dissection (PC-RPLND). We sought to determine if the percentage of teratoma in the orchiectomy specimen could better stratify the risk of teratoma in the retroperitoneum.

MATERIALS AND METHODS

The Indiana University Testis Cancer Database was reviewed to identify patients who underwent PC-RPLND for nonseminomatous germ cell tumors from 2010 to 2018. A logistic regression model was fit to predict the presence of retroperitoneal teratoma using teratoma and yolk sac tumor in the orchiectomy, residual mass size and log transformed values of prechemotherapy alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin. The study cohort was split into 60% training and 40% validation sets using 200 bootstraps. A predictive nomogram was developed for predicting teratoma in the retroperitoneum.

RESULTS

A total of 422 men were included. Presence of teratoma in the orchiectomy (OR 1.02, p <0.001), residual mass size (OR 1.16, p <0.001) and log transformed prechemotherapy AFP (OR 1.12, p=0.002) were predictive factors for having teratoma in the retroperitoneum. The C-statistic using this model demonstrated a predictive ability of 0.77. Training set C-statistic was 0.78 compared to 0.75 for the validation set. A nomogram was developed to aid in clinical utility.

CONCLUSIONS

The model better predicts patients at higher risk for teratoma in the retroperitoneum following chemotherapy, which can aid in a more informed referral for surgical resection.

Robotic and open partial nephrectomy for intermediate and high complexity tumors: a matched-pairs comparison of surgical outcomes at a single institution

Objective: To compare peri-operative factors and renal function following open partial nephrectomy (OPN) and robotic partial nephrectomy (RPN) for intermediate and high complexity tumors when controlling for tumor and patient complexity.Methods: A retrospective review of 222 patients undergoing partial nephrectomy was performed. Patients with intermediate (nephrometry score NS 7-9) or high (NS 10-12) complexity tumors were matched 2:1 for RPN:OPN using NS, Charlson Comorbidity Index (CCI), and BMI. Patient demographics, peri-operative values, renal function, and complication rates were analyzed and compared.Results: Seventy-four OPN patients were matched to 148 RPN patients with no difference in patient demographics. Estimated blood loss in OPN patients was significantly higher (368.5 vs 210.5 mL, p < 0.001) as was transfusion rate (17% vs 1.6%, p < 0.001). Warm ischemia time was longer in OPN (25.5 vs 19.7 min, p = 0.001) while operative time was reduced (200.5 vs 226.5 min, p = 0.010). RPN patients had significantly shorter hospitalizations (5.3 vs 3.0 days, p < 0.001). GFR decrease after one month was not statistically significant (12.9 vs 6.6 ml/min, p = 0.130). Clavien III-V complications incidence was higher for OPN compared to RPN although not significantly (20.3% vs 10.8%, p = 0.055).Conclusion: When matching for tumor and patient complexity, RPN patients had fewer high grade post-operative complications, decreased blood loss, and shorter hospitalizations. RPN is a safe option for patients with intermediate and high complexity tumors.

Prognostic Value of Teratoma in Primary Tumor and Postchemotherapy Retroperitoneal Lymph Node Dissection Specimens in Patients With Metastatic Germ Cell Tumor

PURPOSE

Presence of teratoma in patients with metastatic testicular germ cell tumor (GCT) is of unknown prognostic significance. We report survival outcomes of patients with or without teratoma in primary tumor and postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) specimen and assess impact on prognosis.

PATIENTS AND METHODS

Patients with metastatic nonseminomatous GCT (NSGCT) who were evaluated at Indiana University between 1990 and 2016 and had primary testicular tumor specimen from orchiectomy (ORCH) were included. All patients were treated with cisplatin-based combination chemotherapy. The cohort was divided into 2 groups according to presence or absence of teratoma in ORCH specimen. Survival data were correlated with histopathologic findings. Differences in progression-free (PFS) and overall survival (OS) were evaluated using log-rank tests and Cox proportional hazards models to adjust for known adverse prognostic factors.

RESULTS

We identified 1,224 consecutive patients evaluated at Indiana University between 1990 and 2016 who met inclusion criteria. Median age was 27 years (range, 13-71 years); 689 patients had teratoma in ORCH specimen, and 535 did not. With median follow-up of 2.3 years, 5-year PFS was 61.9% (95% CI, 57.1% to 66.2%) for those with teratoma versus 63.1% (95% CI, 58.0% to 67.8%) for those without (P = .66); 5-year OS was 82.2% (95% CI, 77.9% to 85.8%) versus 81.4% (95% CI, 76.5% to 85.3%; P = .91), respectively. A total of 473 patients underwent PC-RPLND; 5-year PFS for patients with pure teratoma in PC-RPLND specimen versus necrosis only was 65.9% versus 79.1% (P = .06), and 5-year OS was 90.3% versus 93.4% (P = .21), respectively.

CONCLUSION

Presence of teratoma in ORCH and PC-RPLND specimens was not a prognostic factor in this large retrospective study of patients with NSGCT.

Improving postoperative quality of care in germ cell tumor patients: Does scheduled alvimopan, acetaminophen, and gabapentin improve short-term clinical outcomes after retroperitoneal lymph node dissection?

INTRODUCTION

To determine the benefits of alvimopan and multimodal pain management strategies in men undergoing retroperitoneal lymph node dissection for testicular cancer.

METHODS

A retrospective cohort study was completed in men undergoing retroperitoneal lymph node dissection from January 2017 to May 2018. Patients were placed into the 3-drug, 2-drug, and control cohorts as a result of a prospectively determined protocol during the study period. Men in the 3-drug group were managed using alvimopan 12 mg PO the morning of surgery then BID until bowel movement, gabapentin 300 mg daily, and acetaminophen 1,000 mg q6H. The 2-drug group was managed with the above regimen excluding alvimopan. Controls were treated per our standard perioperative pathway. Primary outcomes were length of stay, IV narcotic consumption, bowel movement during hospitalization, and time to bowel movement and assessed in multivariate models controlling for operative time, concomitant surgery, chemotherapy receipt, and residual mass size.

RESULTS

One-hundred and fifty-two consecutive patients underwent RPLND (42 3-drug, 38 2-drug, and 72 controls). Multivariable models indicated that the 3-drug (IRR 0.89, P < 0.0001) and 2-drug group (IRR 0.87, P = 0.0209) had shorter hospital stays than controls. Men in the 3-drug group required less narcotic pain medication than the 2-drug (β -8.16, P = 0.0405) and the control (β -8.16, P = 0.0302) group. Men receiving alvimopan (3-drug) were almost 6 times more likely than the 2-drug group (odds ratio 5.94, P < 0.0001) and 4 times more likely than the control group (odds ratio 3.86, P = 0.0017) to have a bowel movement during hospitalization. Men in the 3-drug group had the quickest return of bowel movements.

CONCLUSIONS

Multimodal pain management improves length of stay in men undergoing retroperitoneal lymph node dissection for testis cancer. The addition of alvimopan allows for quicker return of bowel movements and reduces overall narcotic requirements.

Adverse Surgical Outcomes Associated with Robotic Retroperitoneal Lymph Node Dissection Among Patients with Testicular Cancer

Surgery for metastatic testicular disease has been an essential factor in the long-term cure rates for men with testicular germ cell tumors. Robotic approaches to retroperitoneal lymph node dissection (R-RPLND) have been proposed as an alternative to open surgery with few if any adverse events reported. We report the clinical course for five recent patients referred to our center for recurrences after R-RPLND, focusing on recurrence patterns, treatment burden, and treatment-related morbidity and mortality. The median time to recurrence after R-RPLND was 259d. The recurrence patterns after R-RPLND were aberrant from our past experience in managing recurrences after open RPLND. One man experienced an in-field recurrence located in close proximitry to an undivided lumbar vessel. Four patients had out-of-field recurrence in abnormal locations: pericolic space invading the sigmoid colon, peritoneal carcinomatosis with a perinephric mass, large-volume liver lesions with suprahilar disease extending into the retrocrural space, and lymph nodes in the celiac axis. The treatment burden was high: the five men were subjected to 12 different chemotherapy regimens and three underwent additional surgeries. Three patients developed significant cisplatin-induced toxicity. One patient died due to progression of testicular cancer after failing all chemotherapy and surgical options. PATIENT SUMMARY: We report our initial experience in managing patients with testicular cancer referred to our institution after robotic retroperitoneal lymph node dissection (RPLND). We found that the recurrences were highly variable and in unusual locations and were associated with a high treatment burden. We conclude that further investigation into the safety and long-term oncologic efficacy of robotic RPLND is necessary before widespread implementation.

Multidisciplinary clinic approach improves overall survival outcomes of patients with metastatic germ-cell tumors

Background

To report our experience utilizing a multidisciplinary clinic (MDC) at Indiana University (IU) since the publication of the International Germ Cell Cancer Collaborative Group (IGCCCG), and to compare our overall survival (OS) to that of the National Cancer Institute (NCI) Surveillance, Epidemiology, and End Results (SEER) Program.

Patients and methods

We conducted a retrospective analysis of all patients with metastatic germ-cell tumor (GCT) seen at IU from 1998 to 2014. A total of 1611 consecutive patients were identified, of whom 704 patients received an initial evaluation by our MDC (including medical oncology, pathology, urology and thoracic surgery) and started first-line chemotherapy at IU. These 704 patients were eligible for analysis. All patients in this cohort were treated with cisplatin-etoposide-based combination chemotherapy. We compared the progression-free survival (PFS) and OS of patients treated at IU with that of the published IGCCCG cohort. OS of the IU testis cancer primary cohort (n = 622) was further compared with the SEER data of 1283 patients labeled with 'distant' disease. The Kaplan-Meier method was used to estimate PFS and OS.

Results

With a median follow-up of 4.4 years, patients with good, intermediate, and poor risk disease by IGCCCG criteria treated at IU had 5-year PFS of 90%, 84%, and 54% and 5-year OS of 97%, 92%, and 73%, respectively. The 5-year PFS for all patients in the IU cohort was 79% [95% confidence interval (CI) 76% to 82%]. The 5-year OS for the IU cohort was 90% (95% CI 87% to 92%). IU testis cohort had 5-year OS 94% (95% CI 91% to 96%) versus 75% (95% CI 73% to 78%) for the SEER 'distant' cohort between 2000 and 2014, P-value <0.0001.

Conclusion

The MDC approach to GCT at high-volume cancer center associated with improved OS outcomes in this contemporary dataset. OS is significantly higher in the IU cohort compared with the IGCCCG and SEER 'distant' cohort.

Oncologic Outcomes Following Surgical Management of Clinical Stage II Sex Cord Stromal Tumors

OBJECTIVE

To investigate the clinical history of patients with clinical stage II sex cord stromal tumors who underwent retroperitoneal lymph node dissection (RPLND) at our institution.

METHODS

Our prospectively maintained testicular cancer database was queried to identify patients who presented with or developed clinical stage II sex cord stromal tumors and underwent RPLND at our institution between 1980 and 2018. Demographic, clinical, and pathologic characteristics were reviewed. Kaplan-Meier curves were graphed to assess recurrence-free and overall survival.

RESULTS

Fourteen patients were included in the study with a median age of 44.2years. Four patients presented with clinical stage II disease and 10 patients developed metastatic disease during follow-up of initial clinical stage I disease with a median time to metastasis of 2.7years (range: 0.4-19.5 years). Of the 10 patients with orchiectomy pathology data available, all patients had at least 1 risk factor on testis pathology (mean: 2.9 risk factors). Nine patients received treatment prior to referral to our institution. All patients recurred post-RPLND at Indiana University. Median recurrence-free survival was 9.8 months. Twelve patients died of disease with a median overall survival of 14.4 months.

CONCLUSION

Metastatic sex cord stromal tumors are rare and are more resistant to standard treatment modalities than metastatic germ cell tumors. Patients presenting with sex cord stromal tumors should consider prophylactic primary RPLND in the setting of 1 or more pathologic predictor of malignancy.

Risk of Bleomycin-Related Pulmonary Toxicities and Operative Morbidity After Postchemotherapy Retroperitoneal Lymph Node Dissection in Patients With Good-Risk Germ Cell Tumors

Purpose

Three cycles of bleomycin, etoposide, and cisplatin (BEP × 3) or four cycles of etoposide and cisplatin (EP × 4) are first-line chemotherapy regimens for men with International Germ Cell Cancer Collaborative Group (IGCCCG) good-risk germ cell tumors (GCTs). We determined whether inclusion of bleomycin affected pulmonary and operative morbidity after postchemotherapy retroperitoneal lymph node dissection (PC-RPLND).

Patients and Methods

We queried our database to identify IGCCCG good-risk patients who received BEP × 3 or EP × 4 induction chemotherapy before PC-RPLND from 2006 to 2016. Patients who received combination regimens were excluded. The primary outcomes of interest were pulmonary morbidity (prolonged intubation, reintubation, supplemental oxygen use, intensive care unit stay) and operative morbidity (operative time, length of stay, concomitant procedures, estimated blood loss).

Results

We analyzed 234 patients (191 BEP × 3 v 43 EP × 4). All patients were extubated immediately after the operation. None were reintubated or discharged on oxygen. Two patients in each cohort required an intensive care unit stay for nonpulmonary reasons. Patients treated with BEP required shorter use of supplemental oxygen (0.99 v 1.63 days; P = .005). No significant differences were found in preoperative mass size ( P = .42) or concomitant surgeries ( P = .58). Operative time was significantly shorter (131 v 170 minutes; P < .01), and estimated blood loss was considerably less (194 v 226 mL; P < .01) in patients treated with BEP. Length of stay was shorter in patients treated with BEP (3.3 v 3.9 days; P < .01).

Conclusion

In a modern surgical cohort, the inclusion of bleomycin does not seem to influence pulmonary morbidity, operative difficulty, or nonpulmonary postoperative complications after PC-RPLND in men with IGCCCG good-risk GST.

Commentary on "Prognostic effect of carcinoma in situ in muscle-invasive urothelial carcinoma patients receiving neoadjuvant chemotherapy."

BACKGROUND

Carcinoma in situ (CIS) is a poor prognostic finding in urothelial carcinoma. However, its significance in muscle-invasive urothelial carcinoma (MIUC) treated with neoadjuvant chemotherapy (NAC) is uncertain. We assessed the effect of CIS found in pretreatment transurethral resection of bladder tumor (TURBT) biopsies on the pathologic and clinical outcomes.

MATERIALS AND METHODS

Subjects with MIUC treated with NAC before cystectomy were identified. The pathologic complete response (pCR) rates stratified by TURBT CIS status were compared. The secondary analyses included tumor response, progression-free survival (PFS), overall survival (OS), and an exploratory post hoc analysis of patients with pathologic CIS only (pTisN0) at cystectomy.

RESULTS

A total of 137 patients with MIUC were identified. TURBT CIS was noted in 30.7% of the patients. The absence of TURBT CIS was associated with a significantly increased pCR rate (23.2% vs. 9.5%; odds ratio = 4.08; 95% CI: 1.19-13.98; P = 0.025). Stage pTisN0 disease was observed in 19.0% of the TURBT CIS patients. TURBT CIS status did not significantly affect the PFS or OS outcomes. Post hoc analysis of the pTisN0 patients revealed prolonged median PFS (104.5 vs. 139.9 months; P = 0.055) and OS (104.5 vs. 152.3 months; P = 0.091) outcomes similar to those for the pCR patients.

CONCLUSION

The absence of CIS on pretreatment TURBT in patients with MIUC undergoing NAC was associated with increased pCR rates, with no observed differences in PFS or OS. Isolated CIS at cystectomy was frequently observed, with lengthy PFS and OS durations similar to those for pCR patients. Further studies aimed at understanding the biology and clinical effect of CIS in MIUC are warranted.

Preoperative Nomograms for Predicting Renal Function at 1 Year After Partial Nephrectomy

INTRODUCTION

Partial nephrectomy (PN) reduces the risk of postoperative chronic renal insufficiency (CRI). However, some patients still develop CRI after PN, and may eventually require dialysis. Being able to predict renal function before PN helps in counseling patients and managing expectations. We aimed to construct nomograms that predict estimated glomerular filtration rates (eGFRs), defined by the modification of diet in renal disease (MDRD) and the chronic kidney disease epidemiology collaboration (CKD-EPI) formulae, at 1 year after PN, using only preoperative covariates as predictors.

PATIENTS AND METHODS

We identified patients who underwent PN in our institution between 2004 and 2016, with known postoperative serum creatinine levels at 1 year. The preoperative covariates included patients' demographics, chronic comorbid conditions, tumor characteristics, and preoperative renal status. The endpoints were eGFRs at 1 year after PN, calculated using the MDRD and the CKD-EPI formulae. We first identified preoperative covariates with significant associations with the endpoints by Pearson correlation and independent samples t-test. Suitable covariates were then included in two multivariate linear regression models, for constructing and internally validating two nomograms.

RESULTS

461 patients were eligible for analysis. The percentage of patients with eGFR below 60 mL/min/1.73 m² increased from 25% before PN to 35% at 1 year after PN. We included age, gender, African American race, body mass index, preoperative creatinine level, ipsilateral renal volume, solitary kidney status, tumor diameter, hypertension, diabetes, ischemic heart disease, and previous stroke in the multivariate linear regression models for nomogram construction. Internal validation showed bootstrap-corrected coefficients of determination of 0.61 and 0.70, for predicting eGFRs defined by the MDRD and CKD-EPI formulae, respectively.

CONCLUSIONS

We constructed and internally validated two nomograms to predict eGFRs at 1 year after PN, using only preoperative covariates as predictors.

Long-Term Survival of Good-Risk Germ Cell Tumor Patients After Postchemotherapy Retroperitoneal Lymph Node Dissection: A Comparison of BEP × 3 vs. EP × 4 and Treating Institution

BACKGROUND

Patients with International Germ Cell Cancer Collaborative Group (IGCCCG) good-risk testicular cancer might receive either 4 cycles of etoposide and cisplatin (EP × 4) or 3 cycles of bleomycin, etoposide, and cisplatin (BEP × 3). We sought to examine differences in survival after retroperitoneal lymph node dissection (PC-RPLND) between patients who received EP × 4 compared with BEP × 3.

PATIENTS AND METHODS

The Indiana University Testis Cancer database was queried to identify IGCCCG good-risk PC-RPLND patients who received either EP × 4 or BEP × 3 induction chemotherapy. The primary outcome was overall survival (OS). Kaplan-Meier plots were generated for the EP × 4 and BEP × 3 groups and compared using the log rank test. Cox regression analysis was used to determine risk of mortality.

RESULTS

A total of 223 patients met inclusion criteria between 1985 and 2011. Induction chemotherapy consisted of EP × 4 in 45 (20%) patients and BEP × 3 in 178 (80%). Most patients (78%) received their chemotherapy at outside institutions and were subsequently referred for PC-RPLND. The location of treating institution did not influence outcomes significantly when similar chemotherapy regimens were compared in this good-risk cohort. The 10-year OS for the EP × 4 and BEP × 3 groups were 91% and 98%, respectively (log rank P < .01). The adjusted risk of death in the EP × 4 group showed a nonsignificant trend of 3 times greater compared with the BEP × 3 group (hazard ratio, 3.1; 95% confidence interval, 0.8-12.0; P = .10).

CONCLUSION

The regimen of BEP × 3 resulted in a trend toward improved survival, however, this did not reach statistical significance. The location of treating institution seems less important in this risk group of patients.

Testicular cancer: The usage of central review for pathology diagnosis of orchiectomy specimens

BACKGROUND

Radical orchiectomy specimens present a unique set of challenges for pathology assessment owing to their rarity and complexity. This study compares second opinion pathology reports generated at a single, large academic institution to primary reports from outside hospitals.

METHODS

A database search was conducted for orchiectomy cases that were sent to our institution for management of testicular cancer from 2014 to 2015. Cases sent for consultation without a finalized diagnosis from the outside hospitals were excluded. A total of 221 consecutive cases were evaluated for comparison of final diagnoses between the outside institution and central pathology review.

RESULTS

This study revealed significant discrepancy involving multiple parameters between original and second opinion pathology reports. Of 221 cases of germ cell tumors assessed, 31% showed some discrepancy of histologic subtype. Overall, reporting of lymphovascular invasion changed in 22% of cases; of those, initially called positive 23% were changed to negative and of those initially called negative 12% were changed to positive. Although the overall discrepancy for spermatic cord invasion was 9%, an initial positive diagnosis was negated 35% of the time. The pathologic stage was altered in 23% of cases, mostly secondary to differences interpreting lymphovascular and spermatic cord invasion.

CONCLUSION

Pathologists evaluating orchiectomy specimens should be aware of the major pitfalls in classification and staging, many of which may affect patient management.

A Phase II Trial of Dovitinib in BCG-Unresponsive Urothelial Carcinoma with FGFR3 Mutations or Overexpression: Hoosier Cancer Research Network Trial HCRN 12-157

Purpose: To assess the clinical and pharmacodynamic activity of dovitinib in a treatment-resistant, molecularly enriched non-muscle-invasive urothelial carcinoma of the bladder (NMIUC) population.Experimental Design: A multi-site pilot phase II trial was conducted. Key eligibility criteria included the following: Bacillus Calmette-Guerin (BCG)-unresponsive NMIUC (>2 prior intravesical regimens) with increased phosphorylated FGFR3 (pFGFR3) expression by centrally analyzed immunohistochemistry (IHC+) or FGFR3 mutations (Mut+) assessed in a CLIA-licensed laboratory. Patients received oral dovitinib 500 mg daily (5 days on/2 days off). The primary endpoint was 6-month TURBT-confirmed complete response (CR) rate.Results: Between 11/2013 and 10/2014, 13 patients enrolled (10 IHC+ Mut-, 3 IHC+ Mut+). Accrual ended prematurely due to cessation of dovitinib clinical development. Demographics included the following: median age 70 years; 85% male; carcinoma in situ (CIS; 3 patients), Ta/T1 (8 patients), and Ta/T1 + CIS (2 patients); median prior regimens 3. Toxicity was frequent with all patients experiencing at least one grade 3-4 event. Six-month CR rate was 8% (0% in IHC+ Mut-; 33% in IHC+ Mut+). The primary endpoint was not met. Pharmacodynamically active (94-5,812 nmol/L) dovitinib concentrations in urothelial tissue were observed in all evaluable patients. Reductions in pFGFR3 IHC staining were observed post-dovitinib treatment.Conclusions: Dovitinib consistently achieved biologically active concentrations within the urothelium and demonstrated pharmacodynamic pFGFR3 inhibition. These results support systemic administration as a viable approach to clinical trials in patients with NMIUC. Long-term dovitinib administration was not feasible due to frequent toxicity. Absent clinical activity suggests that patient selection by pFGFR3 IHC alone does not enrich for response to FGFR3 kinase inhibitors in urothelial carcinoma. Clin Cancer Res; 23(12); 3003-11. ©2016 AACR.

Prognostic Effect of Carcinoma In Situ in Muscle-invasive Urothelial Carcinoma Patients Receiving Neoadjuvant Chemotherapy

BACKGROUND

Carcinoma in situ (CIS) is a poor prognostic finding in urothelial carcinoma. However, its significance in muscle-invasive urothelial carcinoma (MIUC) treated with neoadjuvant chemotherapy (NAC) is uncertain. We assessed the effect of CIS found in pretreatment transurethral resection of bladder tumor (TURBT) biopsies on the pathologic and clinical outcomes.

MATERIALS AND METHODS

Subjects with MIUC treated with NAC before cystectomy were identified. The pathologic complete response (pCR) rates stratified by TURBT CIS status were compared. The secondary analyses included tumor response, progression-free survival (PFS), overall survival (OS), and an exploratory post hoc analysis of patients with pathologic CIS only (pTisN0) at cystectomy.

RESULTS

A total of 137 patients with MIUC were identified. TURBT CIS was noted in 30.7% of the patients. The absence of TURBT CIS was associated with a significantly increased pCR rate (23.2% vs. 9.5%; odds ratio, 4.08; 95% confidence interval, 1.19-13.98; P = .025). Stage pTisN0 disease was observed in 19.0% of the TURBT CIS patients. TURBT CIS status did not significantly affect the PFS or OS outcomes. Post hoc analysis of the pTisN0 patients revealed prolonged median PFS (104.5 vs. 139.9 months; P = .055) and OS (104.5 vs. 152.3 months; P = .091) outcomes similar to those for the pCR patients.

CONCLUSION

The absence of CIS on pretreatment TURBT in patients with MIUC undergoing NAC was associated with increased pCR rates, with no observed differences in PFS or OS. Isolated CIS at cystectomy was frequently observed, with lengthy PFS and OS durations similar to those for pCR patients. Further studies aimed at understanding the biology and clinical effect of CIS in MIUC are warranted.

Management of Duodenal Involvement During Retroperitoneal Lymph Node Dissection for Germ Cell Tumors

OBJECTIVE

To describe patient characteristics and outcomes after duodenal repair during postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) and to identify treatment and management patterns.

METHODS

The Indiana University Testis Cancer database was used to identify all patients who underwent simultaneous partial duodenectomy and PC-RPLND from 1983 to 2013. Patient records were reviewed to describe patient and tumor characteristics, type of duodenal restoration, postoperative management, and complications.

RESULTS

Of the 2223 PC-RPLND performed during the study period, we identified 39 patients who underwent simultaneous duodenectomy, with 1 patient requiring 2 duodenal procedures for a total of 40 duodenal procedures. The postchemotherapy median tumor mass size was 8.95 (2.5-17) cm. Fifty percent of cases were standard PC-RPLND; the remainders were redo, desperation, or late relapse cases. Preoperative gastrointestinal symptoms were present in 21% of patients and included bowel obstruction (8%) or gastrointestinal bleeding (13%). Retroperitoneal pathology consisted of teratoma (48%), cancer (33%), and necrosis (20%). Duodenal involvement was managed with primary duodenorrhaphy (68%), duodenojejunostomy (18%), duodenoduodenostomy (13%), or pancreaticoduodenectomy (3%). Starting in the year 2000, duodenostomy and gastrostomy tubes were no longer used. The most common postoperative complication was ileus (45%) with a 3% duodenal fistula rate.

CONCLUSION

Duodenal tumor involvement during PC-RPLND is most commonly managed with primary duodenorrhaphy after partial duodenectomy with an acceptable duodenal fistula rate. The routine use of duodenostomy or gastrostomy tubes is not recommended.

Neoadjuvant chemotherapy in urothelial bladder cancer: impact of regimen and variant histology

Aim: We compared the efficacy of methotrexate/vinblastine/doxorubicin/cisplatin (MVAC) versus gemcitabine/cisplatin in urothelial cancer and neoadjuvant chemotherapy (NACT) efficacy in variant histology (VH). Materials & methods: Radical cystectomy patients were retrospectively compared with those who received NACT. Factors associated with survival, pathologic complete response (pCR) and downstaging (pDS) were evaluated in multivariable models. Results: 9% of radical cystectomy patients (84/919) received NACT, with improved survival, pCR and pDS on both regimens. MVAC lead to higher pDS without an increase in pCR. On multivariable analysis, there was a nonsignificant increase in pDS with MVAC. NACT conferred similar responses in squamous and glandular differentiation VH. Conclusion: NACT was associated with improved survival, pCR and pDS. Furthermore, responses to NACT were not dependent on presence of VH.

Outcomes of postchemotherapy retroperitoneal lymph node dissection following high-dose chemotherapy with stem cell transplantation

BACKGROUND

Characterizing the role of postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) after high-dose chemotherapy (HDCT) has been limited by small sample sizes. This study reports on survival after HDCT with stem cell support and PC-RPLND as well as histologic findings in the retroperitoneum.

METHODS

The prospectively maintained testicular cancer database of Indiana University was queried for patients receiving HDCT with stem cell transplantation before PC-RPLND. The cause and date of death were obtained through patient chart review and contact with referring physicians. The Kaplan-Meier method was used to evaluate overall survival (OS). The log-rank test was used for tests of significance. A multivariate, backward, stepwise Cox regression model was built to evaluate predictors of overall mortality.

RESULTS

A total of 92 patients were included in the study. In the entire cohort, the retroperitoneal (RP) histology findings at the time of PC-RPLND were necrosis (26%), teratoma (34%), and cancer (38%). Sixty-six patients (72%) harbored either a teratoma or active cancer in the RP specimen at PC-RPLND. The median follow-up for the entire cohort was 80.6 months. A total of 28 patients (30%) died during follow-up. The 5-year OS rate of the entire cohort was 70%. The most significant predictor of death was PC-RPLND performed in the desperation setting with elevated markers.

CONCLUSIONS

Despite these patients being heavily pretreated with multiple cycles of chemotherapy, including HDCT, approximately three-fourths were found to have a teratoma and/or active cancer in the retroperitoneum. This underscores the importance of PC-RPLND for rendering patients free of disease and providing a potential for cure.

Risk for Clostridium difficile infection after radical cystectomy for bladder cancer: Analysis of a contemporary series

INTRODUCTION

This study seeks to evaluate the incidence and associated risk factors of Clostridium difficile infection (CDI) in patients undergoing radical cystectomy (RC) for bladder cancer.

METHODS

We retrospectively reviewed a single institution׳s bladder cancer database including all patients who underwent RC between 2010 and 2013. CDI was diagnosed by detection of Clostridium difficile toxin B gene using polymerase chain reaction-based stool assay in patients with clinically significant diarrhea within 90 days of the index operation. A multivariable logistic regression model was used to identify demographics and perioperative factors associated with developing CDI.

RESULTS

Of the 552 patients who underwent RC, postoperative CDI occurred in 49 patients (8.8%) with a median time to diagnosis after RC of 7 days (interquartile range: 5-19). Of the 122 readmissions for postoperative complications, 10% (n = 12) were related to CDI; 2 patients died of sepsis directly related to severe CDI. On multivariate logistic regression, the use of chronic antacid therapy (odds ratio = 1.9, 95% CI: 1.02-3.68, P = 0.04) and antibiotic exposure greater than 7 days (odds ratio = 2.2, 95% CI: 1.11-4.44, P = 0.02) were independently associated with developing CDI. The use of preoperative antibiotics for positive findings on urine culture within 30 days before surgery was not statistically significantly associated with development of CDI (P = 0.06).

CONCLUSIONS

The development of CDI occurs in 8.8% of patients undergoing RC. Our study demonstrates that use of chronic antacid therapy and long duration of antimicrobial exposure are associated with development of CDI. Efforts focusing on minimizing antibiotic exposure in patients undergoing RC are needed, and perioperative antimicrobial prophylaxis guidelines should be followed.

Risk of Recurrence for Clinical Stage I and II Patients With Teratoma Only at Primary Retroperitoneal Lymph Node Dissection

OBJECTIVE

To evaluate the oncologic outcomes of patients with retroperitoneal teratoma only at primary retroperitoneal lymph node dissection (RPLND) who did not receive adjuvant chemotherapy.

MATERIALS AND METHODS

Between 1979 and 2010, 23 patients with clinical stage (CS) I and II disease underwent primary RPLND at our institution with teratoma only in the retroperitoneum. No patient received adjuvant chemotherapy and the minimum follow-up was 2 years.

RESULTS

At the initial diagnosis, 13 patients (56.5%) had CS I disease and 10 patients (43.5%) had CS II disease. Pathologic staging demonstrated IIA in 13 patients (56.5%), IIB in 8 patients (34.8%), and IIC in 2 patients (8.7%). The 5-year disease-free survival (DFS) was 100% with a median follow-up of 5.8 years (range, 2.1-25.4). DFS was not significantly different comparing pathologic stage IIA vs IIB/IIC disease (P = .73). Two patients (14%) developed late relapses. One patient had a pelvic recurrence 11 years after primary RPLND. Final pathology from the pelvic resection demonstrated embryonal carcinoma. He remains disease free after his second surgery. The second patient had a contralateral retroperitoneal recurrence with yolk-sac tumor and teratoma 11 years after primary RPLND. He was treated with chemotherapy followed by postchemotherapy RPLND.

CONCLUSION

The relapse rate for patients with teratoma only at primary RPLND is low irrespective of PS. Adjuvant chemotherapy is therefore not recommended in the management of these patients.

The Evolution and Technique of Nerve-Sparing Retroperitoneal Lymphadenectomy

The evolution of retroperitoneal lymph node dissection technique and associated template modifications for nonseminomatous germ cell tumors have resulted in significant improvement in the long-term morbidity. Through the preservation of sympathetic nerves via exclusion from or prospective identification within the boundaries of resection, maintenance and recovery of antegrade ejaculation are achieved. Nerve-sparing strategies in early-stage disease are feasible in most patients. Postchemotherapy, select patients can be considered for nerve preservation. This article describes the anatomic and physiologic basis for, indications and technical aspects of, and functional and oncologic outcomes reported after nerve-sparing retroperitoneal lymphadenectomy in testicular cancer.

Differentiating reconstructive techniques in partial nephrectomy: a propensity score analysis

INTRODUCTION

To assess whether volumetric measurements can differentiate functional changes between reconstructive techniques after partial nephrectomy.

MATERIALS AND METHODS

One hundred and fifty-six patients undergoing partial nephrectomy for a single renal mass were retrospectively studied between 2008 and 2012. Computed tomography scans were available for volume calculations on 56 (18 non-renorrhaphy and 38 renorrhaphy). Institutional review board approval was obtained. The primary outcome was %volume loss in the operated kidney, which was calculated from three-dimensional reconstructions using a semiautomatic segmentation algorithm. Multivariable regression and propensity score analysis was performed.

RESULTS

Volumetric analysis detected a difference in mean %volume loss between two-layer reconstruction (cortical renorrhaphy and base-layer) and base-layer only (15.6% versus 3.8%, p < 0.001). The mean %glomerular filtration rate (GFR) loss was also greater in the two-layer group (8.9% versus 2.4%, p = 0.03). Demographics were similar between groups except the two-layer group was older, had more males, and increased ischemia time. On multivariable regression the presence of two-layer closure (β = -15.2%, p < 0.001) and tumor diameter (β = -7.4, p = 0.004) were significant predictors of %volume loss while ischemia time (p = 0.88) was not. Two-layer closure remained a predictor on propensity-adjusted analysis (β = -14.3, p = 0.004). The base-layer only group had two (5.3%) urine leaks and two (5.3%) bleeding complications. The two-layer group had two (1.7%) urine leaks and three (2.5%) bleeding complications (p = 0.23, 0.41).

CONCLUSIONS

Volume loss calculated from CT scans can be used to monitor postoperative renal function. Techniques for renal reconstruction and tumor diameter are associated with volume and functional loss after partial nephrectomy and should be controlled for in future studies.

Feasibility of omitting cortical renorrhaphy during robot-assisted partial nephrectomy: a matched analysis

BACKGROUND AND PURPOSE

To assess the safety of omitting cortical renorrhaphy during robot-assisted partial nephrectomy and measure preliminary functional outcomes.

PATIENTS AND METHODS

Fifteen robot-assisted partial nephrectomies were performed with a running, base-layer suture for the collecting system and vessel hemostasis but without cortical renorrhaphy. The nonrenorrhaphy group was matched 1:2 by R.E.N.A.L. nephrometry score to a running, sliding-clip cortical renorrhaphy group retrospectively. Intraoperative blood loss, urine leaks, postoperative bleeds, and functional outcomes were evaluated. Predictors of %volume loss were evaluated using multivariable regression.

RESULTS

No differences were seen between renorrhaphy and nonrenorrhaphy in sex (P=0.53), age (P=0.14), body mass index (P=0.08), Charlson score (P=0.44), tumor diameter (P=0.55), nephrometry score (P=0.77), preoperative glomerular filtration rate (GFR, P=0.63), or the amount of resected healthy kidney margin (P=0.21). Warm ischemia time was less for the nonrenorrhaphy group (P<0.002). One pseudoaneurysm necessitating embolization (1/30=3%) was seen in the renorrhaphy group compared with none in the nonrenorrhaphy group. No urine leaks occurred in either group. The median %GFR loss was 8.8% for renorrhaphy and 4.4% for nonrenorrhaphy (P=0.14) at a median follow-up of 4.1 months. The median %volume loss was 17 cm(3) for renorrhaphy and 9 cm(3) for nonrenorrhaphy (P=0.003). In a multivariable model, both cortical renorrhaphy (P=0.004) and tumor diameter (P=0.004) were predictors of %volume loss.

CONCLUSION

Omission of cortical renorrhaphy appears feasible with no urine leaks or bleeding complications observed. The percent renal volume loss was improved by omission of cortical renorrhaphy. Reconstruction technique is important to control for when studying renal function after partial nephrectomy.

Surgical management of late relapse on surveillance in patients presenting with clinical stage I testicular cancer

OBJECTIVE

To determine survival outcomes in clinical stage I germ cell tumor (GCT) patients requiring retroperitoneal lymph node dissection (RPLND) for late relapse (LR) occurring while on surveillance.

METHODS

The Indiana University Testis Cancer Database was queried from 1985 to 2013 to identify all patients who presented with clinical stage I GCT, elected surveillance, relapsed ≥ 2 years after initial diagnosis, and underwent RPLND in treatment of their LR. Clinical, pathologic, and treatment characteristics were reviewed.

RESULTS

Twenty-eight patients met inclusion criteria. The mean age at diagnosis was 29.3 years. Testicular primary was pure seminoma in 2, intratubular germ cell neoplasia with scar in 1, nonseminomatous GCT in 24, and unknown in 1 patient. The median time from diagnosis to relapse was 48.5 months (range, 28-321 months). At relapse, serum tumor markers were elevated in 13 patients (46.4%). Nineteen patients were given cisplatin-based chemotherapy at LR. RPLND was initial management of LR in 9. At RPLND, 10, 5, and 13 patients demonstrated fibrosis, teratoma, and viable malignancy, respectively. On the last follow-up, 24 patients (85.7%) were free of disease and 4 patients (14.3%) had died of their disease.

CONCLUSION

When examining outcomes among patients undergoing RPLND at LR of GCT, it appears that patients experiencing LR on surveillance have more favorable histology and survival outcomes than previously reported for unselected patients experiencing LR.

Three-tiered nodal classification system for bladder cancer: a new proposal

ABSTRACT 

Aim: To evaluate a three-tiered prognostic stratification using one, two to five and >five positive lymph nodes (LNs) and this nodal staging system performs across different pelvic LN dissection (PLND) templates and adjuvant chemotherapy status. Methods: We evaluated 244 patients with positive LN urothelial cancer who underwent radical cystectomy and PLND between 2000 and 2011. Survival analyses utilizing the Kaplan-Meier method and log rank test were performed. Median follow-up was 55.3 months (range: 0.4–141). Multivariable Cox proportional hazards models were built to evaluate the prognostic stratification. Results: Extended PLND template was performed on 152 (62.3%) patients and standard on 92 (37.7%). The median number of LNs resected was 14 in the standard group vs 22 in the extended group (p < 0.01) and positive LNs was 2 vs 3 (p = 0.09), respectively. Stratification in patients with: one positive LN, two to five positive LNs or >five positive LNs lead to 5-year recurrence-free survival of: 48.6, 34.5 and 15.9% for each group, while the 5-year overall survival was: 43.0, 22.1 and 11.3%, respectively. Stratification in the three groups was also verified irrespective of PLND template and adjuvant chemotherapy. Two multivariable models confirmed the findings when controlling for demographic features and known pathologic risk factors. Conclusion: Three-tiered nodal classification system using the number of metastatic LNs (one, two to five and >five) stratifies patients with lymphatic disease into distinct prognostic groups.

Plasmacytoid variant urothelial bladder cancer: is it time to update the treatment paradigm?

OBJECTIVES

Plasmacytoid variant (PCV) urothelial cancer (UC) of the bladder is rare, with poor clinical outcomes. We sought to identify factors that may better inform expectations of tumor behavior and improve management options in patients with PCV UC.

MATERIALS AND METHODS

A retrospective analysis of the Indiana University Bladder Cancer Database between January 2008 and June 2013 was performed comparing 30 patients with PCV UC at cystectomy to 278 patients with nonvariant (NV) UC at cystectomy who underwent surgery for muscle-invasive disease. Multivariable logistic regression was used to assess precystectomy variables associated with non-organ-confined disease at cystectomy and Cox regression analysis to assess variables associated with mortality.

RESULTS

Patients with PCV UC who were diagnosed with a higher stage at cystectomy (73% pT3-4 vs. 40%, P = 0.001) were more likely to have lymph node involvement (70% vs. 25%, P<0.001), and positive surgical margins were found in 40% of patients with PCV UC vs. 10% of patients with NV UC (P<0.001). Median overall survival and disease-specific survival were 19 and 22 months for PCV, respectively. Median overall survival and disease-specific survival had not been reached for NV at 68 months (P<0.001). Presence of PCV UC on transurethral resection of bladder tumor was associated with non-organ-confined disease (odds ratio = 4.02; 95% CI: 1.06-15.22; P = 0.040), and PCV at cystectomy was associated with increased adjusted risk of mortality (hazard ratio = 2.1; 95% CI: 1.2-3.8; P = 0.016).

CONCLUSIONS

PCV is an aggressive UC variant, predicting non-organ-confined disease and poor survival. Differentiating between non-muscle- and muscle-invasive disease in patients with PCV UC seems less important than the aggressive nature of this disease. Instead, any evidence of PCV on transurethral resection of bladder tumor may warrant aggressive therapy.

Reoperative retroperitoneal lymph node dissection for metastatic germ cell tumors: analysis of local recurrence and predictors of survival

PURPOSE

While reoperative retroperitoneal lymph node dissection results in durable long-term survival, outcomes are comparatively worse than in patients who undergo initial adequate resection. We identified predictors of cancer specific survival and correlated technical aspects of initial resection to local recurrence in patients treated with repeat retroperitoneal lymph node dissection.

MATERIALS AND METHODS

We reviewed subsequent data on 203 patients treated with reoperation for recurrent retroperitoneal germ cell tumor after initial retroperitoneal lymph node dissection with local relapse. We used multivariate Cox proportion hazard models for cancer specific survival and multivariate logistic regression for local recurrence.

RESULTS

The only 2 factors associated with local recurrence at lymph node dissection were incomplete lumbar vessel division at initial resection (p<0.01) and teratoma histology in the reoperative pathology specimen (p=0.01). Median followup was 73 months. Initial survival analysis including preoperative variables indicated that active cancer at initial operation (p=0.04), increased serum tumor markers (p=0.02), M1b stage (p<0.01) and salvage chemotherapy (p=0.01) were independent predictors of worse cancer specific survival. After introducing the final pathological data from reoperation into the final multivariate model only active cancer at reoperation (p<0.01), M1b stage (p=0.01) and salvage chemotherapy before reoperation (p=0.02) retained the association with worse oncologic outcomes.

CONCLUSIONS

Tumor biology and inadequate surgical technique (incomplete lumbar ligation) are associated with local recurrence after initial retroperitoneal lymph node dissection. Decreased cancer specific survival is expected in this population, mostly driven by active cancer in the final pathology specimen.