Clear cell papillary renal cell carcinoma: Characteristics and survival outcomes from a large single institutional series

OBJECTIVES

To investigate the clinical characteristics and survival outcomes of a large clear cell papillary renal cell carcinoma cohort.

METHODS AND MATERIALS

A retrospective review of patients with clear cell papillary renal cell carcinoma at a single academic center was performed after Institutional Review Board approval. Patients underwent either partial or radical nephrectomy from September 2009 to July 2019. Demographic and clinical characteristics, recurrence, and cancer specific and overall survival were reported.

RESULTS

A total of 90 patients were included in the study. Median follow up was 26.5 months. Median age was 61 (range 27 to 87). 47.8% of patients were African American. 26.7% of patients had end stage renal disease. 37.8% had multifocal renal tumors. 48.9% underwent partial nephrectomy, while the remainder underwent radical nephrectomy. 43.3% underwent an open surgical approach, 40.0% a robotic approach, and 16.7% a laparoscopic approach. Pathologic stage included T1a (90.0%), T1b (1.1%), and T2b (8.9%). Fuhrman grades 1-3 were present in 18.9%, 77.8%, and 3.3% of patients, respectively. There were no cancer specific deaths. There was one local recurrence and no metastases. The overall survival at a median follow up of 26.5 months was 92.1% (95% confidence interval 83.1%-96.4%).

CONCLUSIONS

Clear cell papillary renal cell carcinoma typically presents at a low stage and grade and has favorable survival outcomes. A nephron-sparing approach to treatment should be considered when feasible due to the tumor's indolent nature and propensity towards multifocality.

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.

Does Squamous Differentiation Portend Worse Outcomes in Urothelial Bladder Cancer?

INTRODUCTION

Interest on the impact of variant histology in bladder cancer prognosis is increasing. Although squamous differentiation is the most well characterized, only recently have less common variants gained increased recognition. We assessed whether squamous differentiation conferred a worse prognosis than nonvariant urothelial bladder cancer in a contemporary cohort of patients treated with radical cystectomy given the increased awareness of other less common variants.

METHODS

We identified patients with squamous differentiation or nonvariant histology on transurethral resection of bladder tumor and/or cystectomy pathology during a 10-year period. Disease specific and overall survival were evaluated using Kaplan-Meier methodology. Cox regression was used to assess variables associated with mortality.

RESULTS

Between 2003 and 2013, 934 patients underwent cystectomy for urothelial bladder cancer. Overall 617 nonvariant and 118 squamous differentiation cases were identified, and the remainder was nonsquamous differentiation variant histology. Overall 75% of patients with squamous differentiation had muscle invasive disease at diagnosis compared with 59% of those with nonvariant histology (p=0.002). Nonorgan confined disease at cystectomy was more common in patients with squamous differentiation (57% vs 44%, p=0.009). Among cases on neoadjuvant chemotherapy 20% (9 of 45) of nonvariant and 13% (1 of 8) of squamous differentiation were pT0N0 (p=0.527). Median followup was 52 months. Adjusted for demographics, pathological stage and chemotherapy, squamous differentiation was not associated with an increased risk of disease specific (HR 1.35, 95% CI 0.90-2.04, p=0.150) or all cause mortality (HR 0.90, 95% CI 0.60-1.25, p=0.515).

CONCLUSIONS

In a contemporary cohort of urothelial bladder cancer with recognition and characterization of less commonly described variants, squamous differentiation is not associated with a worse disease specific and all cause mortality when compared to a pure nonvariant cohort.

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.

Nationally representative trends and geographic variation in treatment of localized prostate cancer: the Urologic Diseases in America project

BACKGROUND

Several treatment options for clinically localized prostate cancer currently exist under the established guidelines. We aim to assess nationally representative trends in treatment over time and determine potential geographic variation using two large national claims registries.

METHODS

Men with prostate cancer insured by Medicare (1998-2006) or a private insurer (Ingenix database, 2002-2006) were identified using International Classification of Diseases-9 and Current Procedural Terminology-4 codes. Geographic variation and trends in the type of treatment utilized over time were assessed. Geographic data were mapped using the GeoCommons online mapping platform. Predictors of any treatment were determined using a hierarchical generalized linear mixed model using the logit link function.

RESULTS

The use of radical prostatectomy increased, 33-48%, in the privately insured i3 database while remaining stable at 12% in the Medicare population. There was a rapid uptake in the use of newer technologies over time in both the Medicare and i3 cohorts. The use of laparoscopic-assisted prostatectomy increased from 1% in 2002 to 41% in 2006 in i3 patients, whereas the incidence increased from 3% in 2002 to 35% in 2006 for Medicare patients. The use of neoadjuvant/adjuvant androgen deprivation therapy was lower in the i3 cohort and has decreased over time in both i3 and Medicare. Physician density had an impact on the type of primary treatment received in the New England region; however, this trend was not seen in the western or southern regions of the United States.

CONCLUSIONS

Using two large national claims registries, we have demonstrated trends over time and substantial geographic variation in the type of primary treatment used for localized prostate cancer. Specifically, there has been a large increase in the use of newer technologies (that is, laparoscopic-assisted prostatectomy and intensity-modulated radiation therapy). These results elucidate the need for improved data collection on prostate cancer treatment outcomes to reduce unwarranted variation in care.

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.

Autologous retro-pubic urethral sling: a novel, quick, intra-operative technique to improve continence after robotic-assisted radical prostatectomy

After radical prostatectomy, many men may suffer from urinary incontinence, which can have detrimental effects on quality of life. We describe a novel technique using an autologous retro-pubic urethral sling placed at the time of robotic-assisted laparoscopic prostatectomy (RALP) and evaluate its impact on post-operative urinary continence. During 2011, 153 men who underwent sling placement at the time of RALP at a high-volume academic institution were compared to 78 men who did not undergo sling placement. The primary outcomes were time to one and no pads per day. The association between these outcomes and placement of a sling was assessed using Cox proportional hazards regression. Median follow-up was 26 weeks in those who had slings and 32.5 weeks in those who did not. Clinical and pathological characteristics were similar between the groups, with the exception that sling patients were older (p < 0.01) and underwent less nerve sparing (p < 0.01). Multivariate analysis showed that sling placement did not appear to have an effect on time to one (p = 0.24) or no pads per day (p = 0.20). Although the association between sling placement and early return of urinary continence did not reach statistical significance, there was a selection bias against the sling, since it was placed in men who were expected to have more difficulty regaining their continence. A randomized trial is needed to assess the true benefit of sling placement on urinary continence.

National trends in the utilization of robotic-assisted radical cystectomy: an analysis using the Nationwide Inpatient Sample

OBJECTIVES

To determine temporal and regional trends in utilization of robotic-assisted radical cystectomy (RARC) in the United States and to explore factors associated with utilization of robotic assistance.

MATERIALS AND METHODS

Using 2009 to 2011 data from the Nationwide Inpatient Sample, we identified radical cystectomy cases that were performed using either open or robotic assistance and applied Nationwide Inpatient Sample discharge weights to determine national incidence. Univariable and multivariable logistic regressions were performed to assess regional trends and characteristics associated with having RARC. Descriptive analysis was performed using the chi-square test, the Student t test, and the Mann-Whitney U test.

RESULTS

Of the 29,719 radical cystectomy patients, 3,733 were RARC (12.6%). Although there was no change in the proportion of RARC performed annually (P = 0.702). Length of stay was 1 day longer for open cystectomy than RARC (P<0.001). On multivariate regression, patients whose primary payer was Medicaid were less likely than private insurance patients to undergo RARC (odds ratio = 0.60, P = 0.074). Additionally, patients in the south were at 50% reduced odds of undergoing RARC (odds ratio = 0.49, P = 0.044). Median hospital costs were $5,000 greater for RARC (P<0.001).

CONCLUSIONS

Regional variation in utilization should be monitored to ensure equal access to new technology and to assess potential overuse of new technology. Although RARC is associated with higher median hospital costs, further studies to assess its benefits are warranted.

Short-term morbidity and mortality of Indiana pouch, ileal conduit, and neobladder urinary diversion following radical cystectomy

PURPOSE

Literature surrounding Indiana pouch (IP) urinary diversion suggests a higher incidence of complications and longer operative time compared with ileal conduit (IC) and neobladder (NB). We sought to assess short-term complications of IP diversions compared with other diversions at our institution.

MATERIALS AND METHODS

Using institutional National Surgical Quality Improvement Program data, we identified radical cystectomy cases performed for bladder cancer at Indiana University from January 2011 until June 2013. During this time period, the National Surgical Quality Improvement Program randomly evaluated approximately 70% of radical cystectomies performed for urothelial carcinoma at our institution. Multivariable logistic regression was performed to identify factors associated with Clavien grade III-V complications.

RESULTS

A total of 233 cases were identified, 139 IC, 39 IP, and 55 NB. Mean (standard deviation) operative times for IC, IP, and NB were 257 (84), 383 (78), and 327 (88) minutes, respectively (P<0.001). Half of the patients required blood transfusion during the hospitalization. The overall rate of complications was significantly lower among NB (P = 0.009). Overall, 12% of patients developed a Clavien grade III-V complication, with no difference observed between groups (P = 0.884). After controlling for preoperative confounders, IP patients were not at increased odds of developing a Clavien III-V complication compared with IC (odds ratio = 1.38, P = 0.599).

CONCLUSIONS

At a high-volume center, the incidence of serious complications was similar between diversion types. IP patients were more likely to experience minor complications. Patients should be counseled regarding rates of short-term complications and blood transfusion.

Limited ability of existing nomograms to predict outcomes in men undergoing active surveillance for prostate cancer

OBJECTIVE

To assess the ability of current nomograms to predict disease progression at repeat biopsy or at delayed radical prostatectomy (RP) in a prospectively accrued cohort of patients managed by active surveillance (AS).

MATERIALS AND METHODS

A total of 273 patients meeting low-risk criteria who were managed by AS and who underwent multiple biopsies and/or delayed RP were included in the study. The Kattan (base, medium and full), Steyerberg, Nakanishi and Chun nomograms were used to calculate the likelihood of indolent disease ('nomogram probability') as well as to predict 'biopsy progression' by grade or volume, 'surgical progression' by grade or stage, or 'any progression' on repeat biopsy or surgery. We evaluated the associations between each nomogram probability and each progression outcome using logistic regression with (area under the receiver-operating characteristic curve (AUC) values and decision curve analysis.

RESULTS

The nomogram probabilities of indolent disease were lower in patients with biopsy progression (P < 0.01) and any progression on repeat biopsy or surgical pathology (P < 0.05). In regression analyses, nomograms showed a modest ability to predict biopsy progression, adjusted for total number of biopsies (AUC range 0.52-0.67) and any progression (AUC range 0.52-0.70). Decision curve analyses showed that all the nomograms, except for the Kattan base model, have similar value in predicting biopsy progression and any progression. Nomogram probabilities were not associated with surgical progression in a subgroup of 58 men who underwent delayed RP.

CONCLUSIONS

Existing nomograms have only modest accuracy in predicting the outcomes of patients undergoing AS. Improvements to existing nomograms should be made before they are implemented in clinical practice and used to select patients for AS.

Biomarkers in prostate cancer surveillance and screening: past, present, and future

The use of biomarkers for prostate cancer (PCa) screening, detection, and prognostication have revolutionized the diagnosis and management of the disease. Current clinical practice has been driven largely by the utilization of prostate-specific antigen (PSA). The lack of specificity of PSA for PCa has led to both unnecessary biopsies and overdiagnosis of indolent cancers. The recent controversial recommendation by the United States Preventive Services Task Force against PCa screening has highlighted the need for novel clinically useful biomarkers. We review the literature on PCa biomarkers in serum, urine, and tissue. While these markers show promise, none seems poised to replace PSA, but rather may augment it. Further validation and consideration of how these novel markers improve clinical outcome is necessary. The discovery of new genetic markers shows promise in stratifying men with aggressive PCa.

Temporal trends and predictors of salvage cancer treatment after failure following radical prostatectomy or radiation therapy: an analysis from the CaPSURE registry

BACKGROUND

Prostate cancer treatment after failure of primary therapy by either radical prostatectomy or radiation therapy can vary greatly. This study sought to determine trends and predictors of salvage treatment after failure of primary treatment in a community cohort over the past 10 years.

METHODS

From the community-based Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) database, 6275 patients were identified who initiated a form of primary treatment for prostate cancer; 839 of these were identified as failing treatment by biochemical recurrence or initiation of secondary treatment between 2000 and 2010. Salvage therapy was categorized as either systemic, local, or none. Patient characteristics were tested for association with salvage therapy using analysis of variance, Pearson chi-square tests, and multinomial logistic regression analysis.

RESULTS

Of the 839 patients identified as failing therapy, 390 (47%), 146 (17%), and 303 (36%) received systemic, local, or no salvage therapy, respectively. Type of primary treatment received was associated with type of salvage therapy (P < .01). There has been an increasing trend in the use of local salvage therapy over the past 10 years (P = .04). Primary treatment type and biopsy Gleason score were significantly associated with type of salvage therapy.

CONCLUSIONS

The use of local salvage therapy has increased over the past decade, whereas the use of systemic salvage therapy has declined. Primary treatment is an important factor in determining which type of salvage therapy a patient will receive.

Watchful waiting in the treatment of the small renal mass

Objectives:

To evaluate the role and feasibility of observation with regard to the small renal mass.

Methods:

We performed a literature search of MEDLINE, reviewing the world literature relevant to the natural history, role of percutaneous biopsy and surveillance of the small renal mass.

Results:

The average yearly growth rate of most small renal masses ranges from 0.1 to 0.70 cm/yr with obvious exceptions. Clinical predictors of growth such as radiographic size at presentation, age, gender and tumor characteristics are not reliable. Approximately 1% develops metastatic disease while under surveillance. Contemporary series of percutaneous biopsy of small renal masses report sensitivity for malignancy to be 90%-98%. However, false-negative results can occur. For the majority of patients, the gold standard remains surgical extirpation.

Conclusions:

Watchful waiting is an acceptable option for management of small renal masses in the surgically unfit and elderly population. More information regarding the natural history and metastatic potential of small renal masses is needed. Percutaneous needle biopsy can be successful in detecting malignancy in selected patients with small renal masses. The role of needle biopsy for the small renal mass continues to evolve

Primitive neuroectodermal tumor of the kidney with level II inferior vena cava involvement

Primitive neuroectodermal tumor of renal origin, PNET, is extraordinarily rare and often lethal. Here we present a case of renal PNET managed successfully by radical nephrectomy, caval thrombectomy and retroperitoneal node dissection.