Increased expression of the collagen internalization receptor uPARAP/Endo180 in the stroma of head and neck cancer

Local growth, invasion, and metastasis of malignancies of the head and neck involve extensive degradation and remodeling of the underlying, collagen-rich connective tissue. Urokinase plasminogen activator receptor-associated protein (uPARAP)/Endo180 is an endocytic receptor recently shown to play a critical role in the uptake and intracellular degradation of collagen by mesenchymal cells. As a step toward determining the putative function of uPARAP/Endo180 in head and neck cancer progression, we used immunohistochemistry to determine the expression of this collagen internalization receptor in 112 human squamous cell carcinomas and 19 normal or tumor-adjacent head and neck tissue samples from the tongue, gingiva, cheek, tonsils, palate, floor of mouth, larynx, maxillary sinus, upper jaw, nasopharynx/nasal cavity, and lymph nodes. Specificity of detection was verified by staining of serial sections with two different monoclonal antibodies against two non-overlapping epitopes on uPARAP/Endo180 and by the use of isotype-matched non-immune antibodies. uPARAP/Endo180 expression was observed in stromal fibroblast-like, vimentin-positive cells. Furthermore, expression of the collagen internalization receptor was increased in tumor stroma compared with tumor-adjacent connective tissue or normal submucosal connective tissue and was most prominent in poorly differentiated tumors. These data suggest that uPARAP/Endo180 participates in the connective tissue destruction during head and neck squamous cell carcinoma progression by mediating cellular uptake and lysosomal degradation of collagen.

Outcomes of robot-assisted partial nephrectomy for completely endophytic renal tumors: A multicenter analysis

INTRODUCTION

Multicenter retrospective analysis of robotic partial nephrectomy for completely endophytic renal tumors (i.e. 3 points for the 'E' domain of the R.E.N.A.L. nephrometry score) was performed.

MATERIALS AND METHODS

Patients' demographics, tumor characteristics, perioperative, functional, pathological and oncological data were analyzed and compared with those of patients with exophytic and mesophytic masses (i.e. 1 and 2 points for the 'E' domain, respectively). Multivariable logistic regression analysis was used to assess variables for trifecta achievement (negative margin, no postoperative complications, and 90% estimated glomerular filtration rate [eGFR] recovery).

RESULTS

Overall, 147 patients were included in the study group. Patients with a completely endophytic mass had bigger tumors (mean 4.2 vs. 4.1 vs. 3.2 cm; p < 0.001) on preoperative imaging and higher overall R.E.N.A.L. score. There was no difference in mean operative time. Estimated blood loss was higher in the endophytic group (mean 177.75 vs. 185.5 vs. 130 ml; p = 0.001). Warm ischemia time was shorter for the exophytic group (median 16 vs. 21 vs. 22 min; p < 0.001). Postoperative complications were more frequent in patients with endophytic tumor (24.8% vs. 19.5% vs. 14.8%; p < 0.001). Six (4.5%) patients had positive surgical margins, there was no difference between groups. Trifecta was achieved in 44 patients in endophytic group (45.4 vs. 68.8 and 50.9%, p < 0.001). Multivariable analysis for trifecta revealed that clinical tumor size (odds ratio: 0.667, 95% confidence interval: 0.56-0.79, p < 0.001) was only significant predictor for trifecta achievement.

CONCLUSIONS

Our findings confirm that RAPN in case of completely endophytic renal masses can be performed with acceptable outcomes in centers with significant robotic expertise.

Eye-Tracking Metrics Predict Perceived Workload in Robotic Surgical Skills Training

OBJECTIVE

The aim of this study is to assess the relationship between eye-tracking measures and perceived workload in robotic surgical tasks.

BACKGROUND

Robotic techniques provide improved dexterity, stereoscopic vision, and ergonomic control system over laparoscopic surgery, but the complexity of the interfaces and operations may pose new challenges to surgeons and compromise patient safety. Limited studies have objectively quantified workload and its impact on performance in robotic surgery. Although not yet implemented in robotic surgery, minimally intrusive and continuous eye-tracking metrics have been shown to be sensitive to changes in workload in other domains.

METHODS

Eight surgical trainees participated in 15 robotic skills simulation sessions. In each session, participants performed up to 12 simulated exercises. Correlation and mixed-effects analyses were conducted to explore the relationships between eye-tracking metrics and perceived workload. Machine learning classifiers were used to determine the sensitivity of differentiating between low and high workload with eye-tracking features.

RESULTS

Gaze entropy increased as perceived workload increased, with a correlation of .51. Pupil diameter and gaze entropy distinguished differences in workload between task difficulty levels, and both metrics increased as task level difficulty increased. The classification model using eye-tracking features achieved an accuracy of 84.7% in predicting workload levels.

CONCLUSION

Eye-tracking measures can detect perceived workload during robotic tasks. They can potentially be used to identify task contributors to high workload and provide measures for robotic surgery training.

APPLICATION

Workload assessment can be used for real-time monitoring of workload in robotic surgical training and provide assessments for performance and learning.

Sensor-based indicators of performance changes between sessions during robotic surgery training

Training of surgeons is essential for safe and effective use of robotic surgery, yet current assessment tools for learning progression are limited. The objective of this study was to measure changes in trainees' cognitive and behavioral states as they progressed in a robotic surgeon training curriculum at a medical institution. Seven surgical trainees in urology who had no formal robotic training experience participated in the simulation curriculum. They performed 12 robotic skills exercises with varying levels of difficulty repetitively in separate sessions. EEG (electroencephalogram) activity and eye movements were measured throughout to calculate three metrics: engagement index (indicator of task engagement), pupil diameter (indicator of mental workload) and gaze entropy (indicator of randomness in gaze pattern). Performance scores (completion of task goals) and mental workload ratings (NASA-Task Load Index) were collected after each exercise. Changes in performance scores between training sessions were calculated. Analysis of variance, repeated measures correlation, and machine learning classification were used to diagnose how cognitive and behavioral states associate with performance increases or decreases between sessions. The changes in performance were correlated with changes in engagement index (rrm=-.25,p<.001) and gaze entropy (rrm=-.37,p<.001). Changes in cognitive and behavioral states were able to predict training outcomes with 72.5% accuracy. Findings suggest that cognitive and behavioral metrics correlate with changes in performance between sessions. These measures can complement current feedback tools used by medical educators and learners for skills assessment in robotic surgery training.

Outcomes of Robot-assisted Partial Nephrectomy for Clinical T3a Renal Masses: A Multicenter Analysis

BACKGROUND

Use of partial nephrectomy (PN) in T3 renal cell carcinoma (RCC) is controversial.

OBJECTIVE

To evaluate quality outcomes of robot-assisted PN (RAPN) for clinical T3a renal masses (cT3aRM).

DESIGN, SETTING, AND PARTICIPANTS

This was a retrospective multicenter analysis of patients with cT3aN0M0 RCC who underwent RAPN.

INTERVENTION

RAPN.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary endpoint was a trifecta composite outcome of negative surgical margins, warm ischemia time (WIT) ≤25 min, and no perioperative complications. The optimal outcome was defined as achieving this trifecta and ≥90% preservation of the estimated glomerular filtration rate (eGFR) and no stage upgrading of chronic kidney disease. Multivariable analysis (MVA) identified risk factors associated with lack of the optimal outcome. Kaplan-Meier analysis was conducted for survival outcomes.

RESULTS AND LIMITATIONS

Analysis was conducted for 157 patients (median follow-up 26 mo). The median tumor size was 7.0 cm (interquartile range [IQR] 5.0-7.8) and the median RENAL score was 9 (IQR 8-10). Median estimated blood loss (EBL) was 242 ml (IQR 121-354) and the median WIT was 19 min (IQR 15-25). A total of 150 patients (95.5%) had negative margins. Complications were noted in 25 patients (15.9%), with 4.5% having Clavien grade 3-5 complications. The median change in eGFR was 7 ml/min/1.72 m², with ≥90% eGFR preservation in 55.4%. The trifecta outcome was achieved for 64.3% and the optimal outcome for 37.6% of the patients. MVA revealed that greater age (odds ratio [OR] 1.06; p = 0.002), increasing RENAL score (OR 1.30; p = 0.035), and EBL >300 ml (OR 5.96, p = 0.006) were predictive of failure to achieve optimal outcome. The 5-yr recurrence-free survival, cancer-specific survival, and overall survival, were 82.1%, 93.3%, and 91.3%, respectively. Limitations include the retrospective design.

CONCLUSIONS

RAPN for select cT3a renal masses is feasible and safe, with acceptable quality outcomes. Further investigation is requisite to delineate the role of RAPN in cT3a RCC.

PATIENT SUMMARY

Robot-assisted partial nephrectomy in patients with stage 3a kidney cancer provided acceptable survival, functional, and morbidity outcomes in the hands of experienced surgeons, and may be considered as an option when clinically indicated.

Folate-targeted intraoperative fluorescence, OTL38, in robotic-assisted laparoscopic partial nephrectomy

OBJECTIVE

To investigate the safety and efficacy of OTL38, a folate-targeted, intraoperative fluorescence agent, in patients undergoing robotic-assisted laparoscopic partial nephrectomy.

METHODS

Patients with proven or suspected localized renal cell carcinoma at a single academic institution were selected from 2016 to 2018. Patients received one dose of OTL38 at 0.025 mg/kg prior to robotic-assisted laparoscopic partial nephrectomy. The da Vinci Fluorescence Imaging Vision System was used to identify the tumor and inspect for residual disease after resection. Immunohistochemistry was performed to quantify folate receptor alpha in both the tumor and surrounding normal parenchyma. Patient follow-up was 1 month. Outcome data included descriptive statistics of the patient cohort and surgeon and pathologist surveys.

RESULTS

Ten cases were performed. Mean patient age was 62.9 years (range = 50-70). Mean tumor size was 2.45 cm. Pathologic tumor stages ranged from T1a-T3a. Histologic tumor types included clear cell, chromophobe, type 1 papillary renal cell carcinoma and oncocytoma. The tumors did not fluoresce, while the surrounding normal parenchyma did show fluorescence. No adverse reactions were seen. Staining for folate receptor alpha was localized to the proximal renal tubules. Average staining in normal surrounding renal parenchyma was significantly greater than staining observed in tumor tissue (0.2086 vs 0.0467; p = 0.002). The mean difference in staining between tumor tissue and surrounding normal renal parenchyma was 0.1619 (95% CI = 0.0796-0.2442).

CONCLUSIONS

Based on our initial experience, OTL38 shows potential as a safe, effective and easy to use tool to improve visualization and resection of renal tumors.

Role of Epigenetic Modification and Immunomodulation in a Murine Prostate Cancer Model

INTRODUCTION

Decreased expression of highly immunogenic cancer-testis antigens (CTA) might help tumor to achieve low immunogenicity, escape immune surveillance and grow unimpeded. Our aim was to evaluate CTA expression in tumor and normal tissues and to investigate possible means of improving the immune response in a murine prostate cancer (CaP) model by using the combination of epigenetic modifier 5-azacitidine (5-AzaC) and immunomodulator lenalidomide. No study to date has examined the effect of this combination on the prostate cancer or its impact on antigen-presenting cells (APC).

MATERIALS AND METHODS

Gene microarrays were performed to compare expression of several CTA in murine prostate cancer (RM-1 cells) and normal prostate. RM-1 cells were treated with 5-AzaC and real-time PCR was performed to investigate the expression of several CTA. Western blotting was used to determine whether expression of CTA-specific mRNA induced by 5-AzaC resulted in increase in the corresponding protein. Effect of the epigenetic agents and immunomodulators was assessed on dendritic cells (DC) using flow cytometry, ELISA and T-cell proliferation assay.

RESULTS

Gene arrays demonstrated decreased expression of 35 CTA in CaP tissue compared to normal prostate. 5-AzaC treatment of RM-1 prostate cancer cells upregulated the expression of all 13 CTA tested in a dose-dependent fashion. DC were treated with 5-AzaC and lenalidomide and the expression of surface markers MHC Class I, MHC Class II, CD80, CD86, CD 205, and CD40 was increased. Combination of 5-AzaC and lenalidomide enhances the ability of DC to stimulate T-cell proliferation in mixed leukocyte reaction. Secretion of IL-12 and IL-15 by DC increased significantly with addition of 5-AzaC or 5-AzaC and lenalidomide.

CONCLUSIONS

Decreased expression of CTA by prostate cancer may be a means of escaping immune monitoring. Combination of epigenetic modifications and immunomodulation by 5-AzaC and lenalidomide increased tumor immunogenicity and enhanced DC function and may be used in the treatment of advanced prostate cancer. Prostate 77: 361-373, 2017. © 2016 Wiley Periodicals, Inc.

Treatment Trends and Long-Term Survival Associated with Cryotherapy and Partial Nephrectomy for Small Renal Masses in the National Cancer Database Using Propensity Score Matching

Objective: Trends in the utilization of ablative therapy are unknown for the treatment of small renal masses. Our goal is to utilize the National Cancer Database (NCDB) to both assess the utilization of ablative therapies and long-term survival. Materials and Methods: The NCDB captures 70% of all cancer cases in the United States and was queried between 1998 and 2012 for renal cell carcinomas that were treated with ablative therapy, partial nephrectomy (PN), or radical nephrectomy. The analysis was limited to clinical stage T_1a. Propensity score matching was used in 1:1 fashion. Kaplan-Meier survival analysis and a Cox proportional hazards model were used to compare overall survival (OS) for cryotherapy and PN. Results: A total of 119,240 cases of clinical stage T_1a renal masses were treated between 1998 and 2012. Cryotherapy peaked at 927 (9.1%) cases in 2010 and had 913 (8.4%) in 2012. PN accounted for 18% of the cases in 1998, but surpassed the utilization of nephrectomy in 2008. By 2012, PN accounted for 6766 (62%) of renal mass cases. After matching, Kaplan-Meier OS was lower for cryotherapy compared with PN at 24 (94.5% vs 96.5%), 48 (86.8% vs 90.9%), and 96 months (66.0% vs 74.9%). Cryotherapy also had a lower OS (hazard ratio 1.46; p < 0.001) on adjusted analysis. Conclusion: Cryotherapy for small renal masses plateaued at 9% utilization in 2009. Cryotherapy had a lower OS than PN for tumors >2 cm on adjusted analysis, but this result should be used with caution until confirmed in randomized studies.

Intrarenal Adrenocortical Adenoma Treated by Robotic Partial Nephrectomy with Adrenalectomy

Background: We present an intrarenal adrenocortical adenoma discovered incidentally after robot-assisted partial nephrectomy and total adrenalectomy for a suspicious renal mass. Current literature describes the rare occurrence of an adrenocortical adenoma arising from a renal–adrenal fusion. This case represents an uncommon, benign pathology that should be considered in the differential diagnosis of an enhancing renal mass.

Case Presentation: The patient is a 62-year-old female found to have an enhancing mass at the anterolateral aspect of the upper pole of the right kidney concerning for renal-cell carcinoma. CT imaging was performed to work up a cause for hyperparathyroidism. During robot-assisted partial nephrectomy, the lesion was found to be partially adherent to the lateral limb of the right adrenal gland. Microscopic evaluation with Melan-A staining showed the mass to be of adrenal origin with benign features and lack of capsulation, indicating an adrenal adenoma arising from intrarenal ectopic adrenal rests.

Conclusion: An intrarenal adrenal adenoma arising from ectopic adrenal tissue is a unique pathology that represents a benign differential diagnosis in the evaluation of an enhancing renal mass. However, it cannot be differentiated from renal-cell carcinoma based on cross-sectional imaging alone and requires postoperative pathologic assessment to confirm the diagnosis.

Robotic and open partial nephrectomy for tumors in a solitary kidney

Introduction and objective:

Traditionally, patients with renal masses in solitary kidneys were managed with an open partial nephrectomy. With improving techniques, robotic-assisted partial nephrectomy in the setting of a solitary kidney is increasingly utilized. The objective of this study was to compare open partial nephrectomy and robotic-assisted partial nephrectomy outcomes in solitary kidney patients.

Methods:

A retrospective study of 536 total patients who underwent partial nephrectomy between 2004–2016 was performed. Of these patients, 23 had a renal mass in a solitary kidney. Patient demographics, perioperative values, and surgical outcomes were analyzed using descriptive statistics to compare open partial nephrectomy to robotic-assisted partial nephrectomy.

Results:

Of the 23 patients in the cohort, 52% ( n=12) underwent open partial nephrectomy and 48% ( n=11) underwent robotic-assisted partial nephrectomy. Patient characteristics were not significantly different. The mean (standard deviation) nephrometry score was 6.9 (1.8) for open partial nephrectomy and 6.1 (1.9) for robotic-assisted partial nephrectomy ( p=0.290). The mean (standard deviation) pre-operative creatinine was 1.2 (0.3) in open partial nephrectomy and 1.5 (0.4) in robotic-assisted partial nephrectomy, which did not reach statistical significance ( p=0.110). No difference in postoperative kidney function, Clavien grade 3 or higher complication rate, blood loss, or hospitalization length was noted.

Conclusion:

Although traditionally patients with a tumor in a solitary kidney are counseled to undergo open partial nephrectomy, robotic-assisted partial nephrectomy is a safe alternative with no decrease in postoperative renal function when compared with a similar cohort of patients undergoing open partial nephrectomy in a solitary kidney.

Level of evidence:

Level II

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.