Efficacy of High-Intensity Local Treatment for Metastatic Urothelial Carcinoma of the Bladder: A Propensity Score–Weighted Analysis From the National Cancer Data Base

Purpose

Evidence from studies of other malignancies has indicated that aggressive local treatment (LT), even in the presence of metastatic disease, is beneficial. Against a backdrop of stagnant mortality rates for metastatic urothelial carcinoma of the bladder (mUCB) at presentation, we hypothesized that high-intensity LT of primary tumor burden, defined as the receipt of radical cystectomy or ≥ 50 Gy of radiation therapy delivered to the bladder, affects overall survival (OS).

Patients and Methods

We identified 3,753 patients within the National Cancer Data Base who received multiagent systemic chemotherapy combined with high-intensity versus conservative LT for primary mUCB. Patients who received no LT, transurethral resection of the bladder tumor alone, or < 50 Gy of radiation therapy delivered to the bladder were included in the conservative LT group. Inverse probability of treatment weighting (IPTW) –adjusted Kaplan-Meier curves and Cox regression analyses were used to compare OS of patients who received high-intensity versus conservative LT.

Results

Overall, 297 (7.91%) and 3,456 (92.09%) patients with mUCB received high-intensity and conservative LT, respectively. IPTW-adjusted Kaplan-Meier curves showed that median OS was significantly longer in the high-intensity LT group than in the conservative LT group (14.92 [interquartile range, 9.82 to 30.72] v 9.95 [interquartile range, 5.29 to 17.08] months, respectively; P < .001). Furthermore, in IPTW-adjusted Cox regression analysis, high-intensity LT was associated with a significant OS benefit (hazard ratio, 0.56; 95% CI, 0.48 to 0.65; P < .001).

Conclusion

We report an OS benefit for individuals with mUCB treated with high-intensity versus conservative LT. Although the findings are subject to the usual biases related to the observational study design, these preliminary data warrant further consideration in randomized controlled trials, particularly given the poor prognosis associated with mUCB.

The impact of histological variants on bladder cancer survival: A population-based analysis

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Background: We evaluated the clinical and prognostic impact of bladder cancer histologic variants (BCHV) using a large population-based cancer database. Methods: Using the Surveillance, Epidemiology, and End Results database (SEER), we identified bladder cancer patients from 2001-2012, and categorized them according to histological differentiation. 5 year disease-specific survival (DSS) was calculated using the Kaplan-Meier method. Cox proportional hazards regression model was used to predict association with disease-specific mortality (DSM). In addition, we fitted multivariate logistic regression models to predict the impact of histological variants on muscle-invasive status (MI), nodal involvement (NI), and metastatic disease (MD). Results: The cohort included 175,544 urothelial (96.3%) and 6,714 non-urothelial (3.7%) cancers. The latter were divided into: 2,382 squamous cell carcinoma, 1,648 adenocarcinoma, 888 small cell, 912 sarcomatoid, 292 signet-ring cell, 314 neuroendocrine and 278 micropapillary bladder tumors. Urothelial cancers overall had the best 5-year DSS. Of the non-urothelial variants, micropapillary and squamous had the best and worst DSS respectively (p < 0.001). On multivariable analysis predicting DSM, micropapillary and squamous variants had the best and worst prognosis respectively (HR 0.79, p = 0.102 and HR 2.63, p < 0.001), compared to urothelial tumors. On multivariable analysis predicting MI, NI, and MD: squamous (OR 22.76, p < 0.001), micropapillary (OR 3.17, p < 0.001) and adenocarcinoma (OR 4.14, p < 0.001), had higher likelihood respectively, compared to urothelial tumors. Conclusions: Despite accounting for a minority of bladder cancers, BCHV are associated with worst outcomes. It is essential to recognize the potential implications of these variants when deciding treatment. Additional studies are warranted to better characterize the clinical impact of these variants.

The Effect of Resident Involvement on Perioperative Outcomes in Transurethral Urologic Surgeries

OBJECTIVE

To conduct the first study of intra- and postoperative outcomes related to intraoperative resident involvement in transurethral resection procedures for benign prostatic hyperplasia and bladder cancer in a large, multi-institutional database.

DESIGN

Relying on the American College of Surgeons National Surgical Quality Improvement Program Participant User Files (2005-2012), we abstracted all cases of endoscopic prostate surgery (EPS) for benign prostatic hyperplasia and transurethral resection of bladder tumors (TURBTs). Multivariable logistic regression models were constructed to assess the effect of trainee involvement (postgraduate year [PGY] 1-2: junior, PGY 3-4: senior, PGY ≥ 5: chief or fellow) vs attending only on operative time and length of hospital stay, as well as 30-day complication, reoperation, and readmission rates.

RESULTS

In all, 5093 EPS and 3059 TURBTs for a total of 8152 transurethral resection procedures were performed during the study period for which data on resident involvement were available. In multivariable analyses, resident involvement in EPS or TURBT was associated with increased odds of prolonged operative times and hospital readmissions in 30 days independent of resident level of training. Resident involvement was not associated with overall complications or reoperation rates.

CONCLUSIONS

Resident involvement in lower urinary tract surgeries is associated with increased readmissions. Strategies to optimize resident teaching of these common urologic procedures in order to minimize possible risks to patients should be explored.

Contemporary trends in high-dose interleukin-2 use for metastatic renal cell carcinoma in the United States

BACKGROUND

Targeted therapies (TTs) have revolutionized metastatic renal cell carcinoma (mRCC) treatment in the past decade, largely replacing immunotherapy including high-dose interleukin-2 (HD IL-2) therapy. We evaluated trends in HD IL-2 use for mRCC in the TT era.

METHODS

Our cohort comprised a weighted estimate of all patients undergoing HD IL-2 treatment for mRCC from 2004 to 2012 using the Premier Hospital Database. We assessed temporal trends in HD IL-2 use including patient, disease, and hospital characteristics stratified by era (pre-TT uptake: 2004-2006, uptake: 2007-2009, and post-TT uptake: 2010-2012) and fitted multivariable regression models to identify predictors of treatment toxicity and tolerability.

RESULTS

An estimated 2,351 patients received HD IL-2 therapy for mRCC in the United States from 2004 to 2012. The use decreased from 2004 to 2008. HD IL-2 therapy became increasingly centralized in teaching hospitals (24% of treatments in 2004 and 89.5% in 2012). Most patients who received HD IL-2 therapy were men, white, younger than 60 years, had lung metastases, and were otherwise healthy. Vasopressors, intensive care unit admission, and hemodialysis were necessary in 53.4%, 33.0%, and 7.1%, respectively. Factors associated with toxicities in multivariable analyses included being unmarried, male sex, and multiple metastatic sites. African Americans and patients with single-site metastases were less likely to receive multiple treatment cycles.

CONCLUSIONS

HD IL-2 therapy is used infrequently for mRCC in the United States, and its application has diminished with the uptake of TT. Patients are being increasingly treated in teaching hospitals, suggesting a centralization of care and possible barriers to access. A recent slight increase in HD IL-2 therapy use likely reflects recognition of the inability of TT to effect a complete response.

High-dose interleukin-2 (HD IL-2) for metastatic renal Cell carcinoma (mRCC): Contemporary utilization trends in the United States

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Background: Targeted therapies (TT) have revolutionized treatment of mRCC with broad based efficacy and tolerability but ultimately all patients progress. While HD IL-2, the prior standard of care treatment, is associated with significant toxicities, it remains the only agent proven to elicit durable complete responses albeit rarely. This study evaluated trends in HD IL-2 use for patients with mRCC during the TT era. Methods: Our study cohort was comprised of a weighted sample of 2,351 patients with mRCC undergoing HDIL-2 treatment from 2004-2012, from the Premier Hospital Database (Premier Inc., Charlotte, NC), a nationally representative hospital discharge database. We employed descriptive statistics and fitted multivariable regression models, accounting for clustering and weighting, to identify predictors of treatment toxicity and tolerability. Results: We found a progressive decrease in the use of HD IL-2 from 2004 to 2008 with a general upward trend thereafter. HD IL-2 was increasingly concentrated at academic centers representing the site of treatment for 24% of patients in 2004 versus 90% of patients in 2012. Most patients were men (75.3%), Caucasian (70.7%) and aged <60 (59.6%) with lung metastases (60.9%) and otherwise healthy (64.72%, Charlson comorbidity index=0). Our adjusted analysis showed that severe hypotension was associated with patients <50 years (odds ratio [OR]: 1.35, p=0.045), while the likelihood of receiving ≥2 cycles of HDIL-2 was associated with good health (CCI=0, OR: 1.72, p=0.004) and having >1 metastatic site (OR: 4.32, p<0.001). Conclusions: Over the past decade, the use of HD IL-2 initially diminished coinciding with the widespread availability of TT but has remerged potentially due to renewed enthusiasm for immunotherapies showing promising efficacy with novel immune checkpoint inhibitors in mRCC. HD IL-2 has increasingly been limited to academic centers and our analysis suggests a strong selection bias for younger, healthier patients who can better tolerate the toxicities and those with a greater burden of metastatic disease. Future studies are warranted to determine the optimal role of HDIL-2 in the contemporary treatment of mRCC.

Predictors of positive surgical margins after radical prostatectomy at a single institution: preoperative and pathologic factors, and the impact of surgeon variability and technique on incidence and location

INTRODUCTION

To identify and assess predictive factors for positive surgical margins (PSM) in patients undergoing radical prostatectomy (RP).

MATERIALS AND METHODS

An Institution Review Board (IRB) approved retrospective review of 1751 patients that underwent RP from March 2000 to June 2013 was performed. Identified were 1740 patients whom had not received neoadjuvant therapy; these were used for the purpose of this analysis. Univariate and multivariate analysis were performed to determine factors associated with and predictive of PSMs, divided into preoperative and pathological. Variables analyzed include age, body mass index (BMI), race, surgeon, surgical modality, pathologic T-stage and Gleason sum, extracapsular extension (ECE), seminal vesicle involvement (SVI), perineural invasion (PNI) and prostate weight. Finally, each surgical technique was analyzed to determine the most common site of PSM.

RESULTS

Rate of PSM was 23.6%. Our analysis showed that preoperative prostate-specific antigen (PSA) level ≥ 10ng/mL, and pathologic T3/T4-stage and PNI significantly predicted PSM. Age > 60 years and prostate weight > 60 g were predictive against PSM. Gleason score ≥ 7 and PSM were significant risk factors for biochemical recurrence (BCR). Surgical approach did not affect the rate of PSM. Open RP was associated with a higher apical PSM rate (38.5%) and robotic RP with a higher posterolateral PSM rate (52.3%).

CONCLUSIONS

High preoperative PSA levels, and advanced TNM-staging predicted positive surgical margins in our cohort. Patients with PSM were subsequently found to have higher risk of BCR.

Practical guide to immunotherapy in castration resistant prostate cancer: the use of sipuleucel-T immunotherapy

INTRODUCTION

New treatment options for metastatic castration resistant prostate cancer (mCRPC) have become available over the last few years should primary treatments and androgen deprivation therapies fail. While historically not considered to be amenable to immunotherapy, the treatment of advanced prostate cancer using this approach is an area of intense interest and now clinical application.

MATERIALS AND METHODS

Recent literature on castration resistant prostate cancer management with a focus on immunotherapeutic strategies was reviewed. Mechanisms of action involving the immunologic treatment of cancer were identified. Agents in clinical trials with near term application in prostate cancer were also identified.

RESULTS

Numerous immunotherapeutic agents for mCRPC are in current clinical trials. The autologous, active cellular immunotherapy, sipuleucel-T, which utilizes a patient's own antigen-presenting cells, is the only Food and Drug Administration (FDA) approved agent. It provides a 4.1 month survival advantage. Other investigational agents in this area include GVAX, a whole cell irradiated vaccine, and a vaccinia-PSA-TRICOM pox virus based approach, all in phase III trials. Immune-checkpoint inhibitors that enhance T-cell activity and potentiate antitumor effects are also promising.

CONCLUSIONS

A first in class novel treatment modality, sipuleucel-T, is available in the United States for mCRPC. Other immunotherapies are in development and may be available in the near future. Understanding the detailed patient evaluation, initiation and administration of sipuleucel-T as described in this paper, will allow this novel cancer immunotherapy to be better understood and potentially benefit a larger group of appropriately selected patients.

Blue light cystoscopy for detection and treatment of non-muscle invasive bladder cancer

In patients with non-muscle invasive bladder cancer, fluorescence cystoscopy can improve the detection and ablation of bladder tumors. In this paper we describe the technique and practical aspects of hexaminolevulinate (HAL) fluorescence cystoscopy, also known as "blue light cystoscopy".