Impact of variant histology on upstaging and survival in patients with nonmuscle invasive bladder cancer undergoing radical cystectomy

INTRODUCTION

Variant histology (VH) of urothelial carcinoma is uncommon and frequently presents at the muscle-invasive stage. VH is considering a significant risk factor for progression among patients with nonmuscle invasive bladder cancer (NMIBC). While there is some debate, expert opinion is generally that upfront radical cystectomy (RC) should be consider for these patients. Limited data exists to support this position. In this study, we sought to examine the rate of upstaging and overall survival for patients with VH NMIBC against patients with pure urothelial NMIBC who underwent RC, to help clarify the optimal treatment strategy for these patients.

METHODS

The institutional REDCap database was utilized to identify all patients with T1 and Ta bladder cancer that underwent RC over the study period (2004-2022). Matched-pair analysis was performed between patients with VH and pure urothelial NMIBC; 42 pairs were matched on prior intravesical therapy, presence of muscularis propria on transurethral resection of bladder tumor (TURBT), any carcinoma in situ presence on prior TURBTs, and final tumor staging on TURBT. The primary outcomes of interest were pathologic tumor upstaging rate at RC and overall survival. Secondary outcomes of interest included association of demographic or pretreatment variables with upstaging, and upstaging rates for specific variant histologies.

RESULTS

Patients with VH NMIBC undergoing RC were upstaged at a significantly higher rate than a matched cohort of patients with pure urothelial NMIBC (73.8% vs. 52.4%, P = 0.0244) and among those upstaged, had significantly higher rates of pT3 to pT4 (54.7% vs. 23.8%, P = 0.0088). Rate of node positivity at RC for VH NMIBC was also higher compared to pure urothelial NMIBC (40.5% vs. 21.4%, P = 0.0389). Among histologic variants, patients with plasmacytoid and sarcomatoid subtypes demonstrated the highest rates of upstaging; differences were not statistically significant. The overall median survival was 28.4 months for patients with VH after RC compared to 155.1 months for patients with pure urothelial NMIBC (P = 0.009).

CONCLUSION

Patients with VH NMIBC undergoing RC are at significantly higher risk of upstaging at RC when compared to patients with pure urothelial NMIBC and have worse overall survival. While this study supports the concept of an aggressive treatment approach for patients with VH NMIBC, improvements in understanding of the disease are necessary to improve outcomes.

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.

Long-term health-related quality-of-life outcomes in a racially diverse cohort of prostate cancer patients receiving retropubic versus robotic prostatectomy

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Background: This study compared 5-year health-related quality of life (HRQoL) outcomes among prostate cancer (PCa) patients who underwent a robotic-assisted radical prostatectomy (RARP) versus a radical retropubic prostatectomy (RRP), with a focus on race-specific outcomes for Caucasian American (CA) compared to African American (AA) men. RARPs have almost replaced RRPs in recent years, with few long-term studies focused on HRQoL and race. Methods: A prospective cohort study of HRQoL was conducted on patients diagnosed with PCa from 2007 to 2017 and enrolled in the Center for Prostate Disease Research (CPDR) Multicenter National Database. HRQoL was assessed with the EPIC instrument. Temporal changes in urinary and sexual-related quality of life domain scores were compared across surgery type (RARP versus RRP) at pre-treatment (“baseline”), 1-, 2-, 3-, 4-, and 5 years post-baseline. Longitudinal HRQoL patterns were modeled using generalized estimating equations (GEE), adjusting for baseline HRQoL and key clinical characteristics. Results: Of 497 PCa patients who met study inclusion criteria, 68% had RARP and 32% had RRP, with 22% AA men and 88% CA men. Baseline HRQoL domains were comparable across race and surgery type. In adjusted GEE analysis, no differences were noted between AA and CA patients. However, treatment-related differences were observed over time in urinary function (UF) and incontinence (UI) (p=0.02 and p=0.03, respectively), with lower HRQoL scores in RARP vs. RRP patients. Upon dual stratification by surgery type and race, the differences for UF and UI persisted (p=0.01 and p=0.03, respectively) with poorest outcomes observed, and similar trajectories of decline, for AA patients who received RARP. Conclusions: In this 10+ year prospective cohort study, AA patients receiving RARP had the poorest UF and UI outcomes which continued to decline for 5 years post treatment. In light of these findings, AA men considering RARP might benefit from discussions with their providers to set expectations regarding long-term urinary outcomes; though these decrements in HRQoL may be overshadowed by the minimally invasive nature of RARP.

Race, tumor location, and disease progression among low-risk prostate cancer patients

Background

The relationship between race, prostate tumor location, and BCR‐free survival is inconclusive. This study examined the independent and joint roles of patient race and tumor location on biochemical recurrence‐free (BCR) survival.

Methods

A retrospective cohort study was conducted among men with newly diagnosed, biopsy‐confirmed, NCCN‐defined low risk CaP who underwent radical prostatectomy (RP) at the Walter Reed National Military Medical Center from 1996 to 2008. BCR‐free survival was modeled using Kaplan‐Meier estimation curves and multivariable Cox proportional hazards (PH) analyses.

Results

There were 539 eligible patients with low‐risk CaP (25% African American, AA; 75% Caucasian American, CA). Median age at CaP diagnosis and post‐RP follow‐up time was 59.2 and 8.1 years, respectively. Kaplan‐Meier analyses showed no significant association between race (P = .52) or predominant tumor location (P = .98) on BCR‐free survival. In Cox PH multivariable analysis, neither race (HR = 1.18; 95% CI = 0.68‐2.02; P = .56) nor predominant tumor location (HR = 1.13; 95% CI = 0.59‐2.15; P = .71) was an independent predictor of BCR‐free survival.

Conclusions

Neither race nor predominant tumor location was associated with adverse oncologic outcome.

Longitudinal prostate cancer outcomes in a racially diverse cohort of military heath care beneficiaries: 1990-2017

e16581

Background: Prostate cancer (PCa) incidence and mortality disproportionately burden African American (AA) men compared to Caucasian American (CA) men. An interplay of biological, social, and health care factors is blamed for this disparity. However, a recent multi-center study of the Veterans Affairs population found no differences in cancer progression, disease specific survival, or overall survival for AA versus CA men. This study examines a large, racially diverse military health care beneficiary cohort, enrolled over 25+ years, to examine the roles of race and comorbidity on metastasis-free and overall survival. Methods: The Center for Prostate Disease Research (CPDR) multi-center national database was the source of study subjects. Eligible patients included all men who underwent radical prostatectomy (RP) as primary treatment for PCa between January 1, 1990 to December 31, 2017. Comprehensive demographic, clinical, treatment, and outcomes data were collected on all enrollees. Unadjusted Kaplan-Meier estimation curves and multivariable Cox proportional hazards analysis with adjustment for key clinical and pathologic factors were used to examine BCR-free, metastasis-free, and overall survival as a function of patient self-reported race (AA vs. CA). Results: There were 7,135 eligible men, among whom 22% self-reported as AA. Median age at RP and follow-up were 62 and 6.9 years, respectively. A total of 1521 BCR events, 210 metastasis events, and 879 deaths occurred. Compared to CA men, AA men were younger at diagnosis (59.4 vs. 62.7 years, p < 0.05) with higher median PSA (5.8 vs. 5.5 ng/mL, p < 0.05); however, NCCN risk strata, as well as clinical and pathologic stage and grade were distributed comparably across race. Despite slightly poorer BCR-free survival for AA men in both unadjusted and adjusted analysis, there were no statistically significant differences in 5-, 10-, and 15-year probabilities for metastasis-free or overall survival. Conclusions: In this racially diverse equal-access health care setting, this longitudinal cohort study revealed no differences in distant metastasis or overall survival between AA and CA men. Future work will examine molecular signatures of metastatic cancer.

Modeling time from bone metastasis to death in a racially diverse cohort of military health care beneficiaries

246

Background: Development of prostate cancer (PCa) metastasis, while uncommonly observed in US men, typically occurs to bone and ultimately leads to disease-specific death. The goal of this study was to estimate OS in a racially diverse cohort of military health care beneficiaries diagnosed with metastatic PCa to bone, to enhance understanding of factors such as patient race and receipt of palliative treatment, that potentially affect OS in advanced PCa patients. Methods: A retrospective cohort study was conducted, examining men consented to participate in the CPDR multi-center national database who underwent biopsy for suspicion of prostate cancer between 1989-2017 and subsequently diagnosed with bone metastasis, confirmed by bone scan, bone biopsy and/or MRI. Multivariable Cox proportional hazards (PH) analysis was used to model OS as a function of race and palliative treatment, controlling for clinical covariates. Hazard ratios (HR) and 95% Confidence intervals (CI) are reported. Results: Among 17,356 patients diagnosed with prostate cancer (PCa) between 1989 and 2017, 869 (5.0%) developed bone metastasis. Median patient age was 67 years; median follow-up time following diagnosis with bone metastasis was 2.4 years. Over one-fifth of patients (22.5%) self-reported as African American. Only 11.5% of all patients with metastasis received palliative treatment (radiation (RT) only, RT+ hormone therapy (HT), RT+HT, or RT+HT+chemotherapy). While race did not predict OS, receipt of palliative treatment was strongly predictive of better OS (p<0.0005). Conclusions: Patient race did not predict OS among those with distant metastatic PCa but receipt of palliative care and slower PSADT were critical factors in lengthening OS. This work is being extended to examine the combinations and sequencing of palliative care on OS, to provide improved patient-tailored prediction tools for men with advanced prostate cancer. [Table: see text]

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.

Longitudinal regret after treatment for low- and intermediate-risk prostate cancer

BACKGROUND

Prostate cancer patients diagnosed with low- and intermediate-risk disease have several treatment options. Decisional regret after treatment is a concern, especially when poor oncologic outcomes or declines in health-related quality of life (HRQoL) occur. This study assessed determinants of longitudinal decisional regret in prostate cancer patients attending a multidisciplinary clinic and treated with radical prostatectomy (RP), external beam radiation therapy (EBRT), brachytherapy (BT), or active surveillance (AS).

METHODS

Patients newly diagnosed with prostate cancer at the Walter Reed National Military Medical Center who attended a multidisciplinary clinic were enrolled into a prospective study from 2006 to 2014. The Decision Regret Scale was administered at 6, 12, 24, and 36 months posttreatment. HRQoL was also assessed at regular intervals using the Expanded Prostate Cancer Index Composite and 36-item RAND Medical Outcomes Study Short Form questionnaires. Adjusted probabilities of reporting regret were estimated via multivariable logistic regression fitted with generalized estimating equations.

RESULTS

A total of 652 patients met the inclusion criteria (395 RP, 141 EBRT, 41 BT, 75 AS). Decisional regret was consistently low after all of these treatments. In multivariable models, only African American race (odds ratio, 1.67; 95% confidence interval, 1.12-2.47) was associated with greater regret across time. Age and control preference were marginally associated with regret. Regret scores were similar between RP patients who did and did not experience biochemical recurrence. Declines in HRQoL were weakly correlated with greater decisional regret.

CONCLUSION

In the context of a multidisciplinary clinic, decisional regret did not differ significantly between treatment groups but was greater in African Americans and those reporting poorer HRQoL. Cancer 2017;123:4252-4258. © 2017 American Cancer Society.

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.

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.

Oncologic outcomes and prognostic impact of urothelial recurrences in patients undergoing segmental and total ureterectomy for upper tract urothelial carcinoma

INTRODUCTION

We evaluated the impact of urothelial recurrences in a cohort of patients undergoing segmental (SU) and total ureterectomy (TU) as an alternative to nephroureterectomy (NU) for upper tract urothelial carcinoma.

METHODS

Between 1999 and 2012, patients who underwent SU, TU and NU for treatment of upper tract urothelial carcinoma were evaluated. Demographic, surgical, pathologic and oncologic data were collected. Recurrence-free (RFS) and disease-specific survival (DSS) were analyzed using Kaplan-Meier and multivariable Cox methods.

RESULTS

A total 141 patients were evaluated, 35 underwent SU, 10 TU and 96 NU. Patients who underwent TU were more likely to have bilateral disease (p < 0.01), solitary kidney (p < 0.01), and multifocal disease (p = 0.01). Organ-confined (p < 0.01) and low-grade disease (p < 0.01) were more common in the TU and SU groups compared with NU. At a median follow-up of 56.9 months (range: 0.2-181.1) disease relapse occurred in 88 (55.3%) patients. Localized recurrence occurred in 31.1% of SU/TU group compared to 27.1% (p = 0.62) of the NU group. Neither total nor segmental ureterectomy demonstrated significantly worse RFS (p = 0.26 and p = 0.81), CSS (p = 0.96 and p = 0.52) or overall survival (p = 0.59 and p = 0.55) compared with complete NU. Localized urothelial recurrence did not confer increased risk of cancer-specific (p = 0.73) or overall mortality (p = 0.39). The paper's most important limitations include its retrospective nature and its relatively small number of patients.

CONCLUSION

No significant survival differences were demonstrated between surgical approaches for upper tract urothelial cancer. Localized urothelial recurrence after surgical treatment for upper tract urothelial cancer does not affect mortality in this population. TU with ileal-substitution may provide an alternative option for patients with extensive ureteral disease and poor renal function.

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.

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.

Metabolic syndrome in the development and progression of prostate cancer

Prostate cancer (PCa) is the most common noncutaneous malignancy and second leading cause of cancer-specific mortality for men in the United States. There is a wide spectrum of aggressiveness ranging from biologically significant to indolent disease, which has led to an interest in the identification of risk factors for its development and progression. Emerging evidence has suggested an association between metabolic syndrome (MetS) and PCa. MetS represents a cluster of metabolic derangements that confer an increased risk of cardiovascular disease and type 2 diabetes mellitus. Its individual components include obesity, dyslipidemias, high blood pressure, and high fasting glucose levels. MetS has become pervasive and is currently associated with a high socioeconomic cost in both industrialized and developing countries throughout the world. The relationship between MetS and PCa is complex and yet to be fully defined. A better understanding of this relationship will facilitate the development of novel therapeutic targets for the prevention of PCa and improvement of outcomes among diagnosed men in the future. In this review, we evaluate the current evidence on the role of MetS in the development and progression of PCa. We also discuss the clinical implications on the management of PCa and consider the future direction of this subject.

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.

Current and future biologic markers for disease progression and relapse in testicular germ cell tumors: a review

Testicular germ cell tumors represent a biologically unique disease process. These tumors are exquisitely sensitive to platinum-based chemotherapy, can be cured with surgical metastasectomy, and are known for the integration of biologic markers to stage and assign risk. Exploring further biologic markers that offer insight into the molecular mechanisms that contribute to disease biology is important. In this review, we attempt to summarize the utility of the current and some future biologic markers for disease monitoring and relapse.

Aggressive surgical management of germ cell tumors with somatic-type malignancy: Pathologic features, prognostic factors, and survival outcomes

4554

Background: Germ cell tumors (GCT) with somatic-type malignancy (SM) are rare occurring in approximately 3-8% of GCT cases. Prognostic factors and optimal management remain poorly-defined. Methods: The Indiana University (IU) testis cancer database was queried from 1979 to 2011 for patients demonstrating atypical histology at orchiectomy or subsequent resection of metastatic disease. Patients with transformation to PNET only were excluded due to distinct management. Chart review, pathologic review, and survival analysis were performed. Results: 122 patients met study inclusion criteria. Primary tumor site was testis in 112, retroperitoneum in 8, groin in 1, and pineal gland in 1. The most common SM histologies were sarcoma (71) and carcinoma (32). At GCT diagnosis, 24, 44, 45 patients had stage I, II, and III disease, respectively. Stage was unknown in 9. Median time from GCT diagnosis to SM was 13 months (Range, 0-397). This interval was longest for carcinomas (94.5 months) and sarcomatoid yolk sac tumors (113 months). Only 11 of 83 patients (13.3%) receiving cisplatin-based chemotherapy for measurable disease demonstrated an initial complete response. First resection at IU was reoperative in 45 patients (36.9%). 69 patients (56.6%) required extirpation of abdominal viscera/vascular structures or distant metastases. At a median follow-up of 71 months, the 5-year cancer specific survival (CSS) was 63%. Predictors of poorer CSS included SM diagnosed at late relapse (p = 0.014), referral to IU for reoperative RPLND (p = 0.022), and tumor grade (p = 0.043). SM histology subtype, stage, risk category, and number of resections for SM were not predictive of CSS. Conclusions: GCT with SM is associated with poorer CSS than traditional GCT. Established prognostic factors for GCT lose their predictive value in the setting of SM. SM can occur at any point in the course of GCT, but has a propensity for delayed presentation with later onset being associated with poorer CSS. Aggressive and serial surgical resections are often necessary to optimize CSS. Tumor grade is an important prognostic factor, particularly in sarcoma cases.

Dyslipidemia, statins and prostate cancer

Dyslipidemia and prostate cancer are two of the most common medical conditions affecting adult males in the USA. In recent years, a large volume of research has focused on investigating the relationship between these two disease processes as well as the effect of the cholesterol-lowering medications, such as 3-hydroxyl-3-methylglutaryl-coenzyme A reductase inhibitors (better known as 'statins'), on the development and progression of prostate cancer. While there is a paucity of prospective research, encouraging results have been reported in several retrospective clinical studies. Additionally, basic science research has identified interactions between lipids and prostate cancer cells in several key areas. This article will discuss recent clinical and basic science research examining the relationship between dyslipidemia, statins and prostate cancer.

Prostate cancer in men less than the age of 50: a comparison of race and outcomes

OBJECTIVE

To compare clinicopathologic features and survival outcomes for men 50 years of age in relation to other age groups stratified by race to further define prostate cancer (CaP) in young men. Controversy exists regarding the appropriate age to undergo CaP screening, outcomes for early intervention, and whether there is unique age-associated tumor biology. We compared clinicopathologic features and survival outcomes for men <50 years of age in relation to other age groups stratified by race to further define CaP in young men.

METHODS

A multi-institutional review of 12,081 records of patients diagnosed with CaP from 1989-2009 was conducted. Patients were stratified by age group, race, and decade of treatment. Demographic and clinicopathologic characteristics were compared across age groups using chi-square tests and analysis of variance. The primary study endpoints, time to biochemical recurrence and all-cause mortality, were compared across age groups using Kaplan-Meier estimation and univariable and multivariable Cox proportional hazards analysis.

RESULTS

Only 4.5% of the study sample was <50 years of age. A higher percentage of African Americans diagnosed were <50 compared with Caucasians (8.3% vs 3.3%, P<.0001). Positive family history was more prevalent in the <50 cohort (36.1% vs 22.0%, P<.0001). Despite these findings, both racial subgroups for men<50 years of age demonstrated improved clinicopathologic features than other age quartiles. Furthermore, both Kaplan-Meier and Cox proportional hazard analysis demonstrated that the <50 cohort had a lower incidence of biochemical recurrence and greater overall survival.

CONCLUSIONS

Race and family history appear to play a significant role in the incidence of CaP in younger men. Younger age at diagnosis is associated with more favorable outcomes and indicates that population-based screening at younger ages could potentially lead to improved survival for high-risk groups.

Fusion imaging: a novel staging modality in testis cancer

Objective: Computed tomography and chest radiographs provide the standard imaging for staging, treatment, and surveillance of testicular germ cell neoplasms. Positron emission tomography has recently been utilized for staging, but is somewhat limited in its ability to provide anatomic localization. Fusion imaging combines the metabolic information provided by positron emission tomography with the anatomic precision of computed tomography. To the best of our knowledge, this represents the first study of the effectiveness using fusion imaging in evaluation of patients with testis cancer.

Methods: A prospective study of 49 patients presenting to Walter Reed Army Medical Center with testicular cancer from 2003 to 2009 was performed. Fusion imaging was compared with conventional imaging, tumor markers, pathologic results, and clinical follow-up.

Results: There were 14 true positives, 33 true negatives, 1 false positive, and 1 false negative. Sensitivity, specificity, positive predictive value, and negative predictive value were 93.3, 97.0, 93.3, and 97.0% respectively. In 11 patient scenarios, fusion imaging differed from conventional imaging. Utility was found in superior lesion detection compared to helical computed tomography due to anatomical/functional image co-registration, detection of micrometastasis in lymph nodes (pathologic nodes < 1cm), surveillance for recurrence post-chemotherapy, differentiating fibrosis from active disease in nodes < 2.5cm, and acting as a quality assurance measure to computed tomography alone.

Conclusions: In addition to demonstrating a sensitivity and specificity comparable or superior to conventional imaging, fusion imaging shows promise in providing additive data that may assist in clinical decision-making.

Evaluation of the ETS-related gene mRNA in urine for the detection of prostate cancer

PURPOSE

Prevalent gene fusions in prostate cancer involve androgen-regulated promoters (primarily TMPRSS2) and ETS transcription factors (predominantly ETS-regulated gene (ERG)], which result in tumor selective overexpression of ERG in two thirds of patients. Because diverse genomic fusion events lead to ERG overexpression in prostate cancer, we reasoned that it may be more practical to capture such alterations using an assay targeting ERG sequences retained in such gene fusions. This study evaluates the potential of an assay quantitating ERG mRNA in post-digital rectal exam (DRE) urine for improving prostate cancer detection.

EXPERIMENTAL DESIGN

Patients scheduled to undergo transrectal ultrasound-guided needle biopsy of the prostate were prospectively enrolled. On the day of biopsy, patients provided a urine sample immediately following a DRE. Urine ERG mRNA was measured and normalized to urine prostate-specific antigen (PSA) mRNA using the DTS 400 system. Demographic traits, clinical characteristics and biopsy results were analyzed for association with urine ERG score.

RESULTS

The study was conducted on 237 patients. Prostate cancer was shown on biopsy in 40.9% of study subjects. A higher urine ERG score associated significantly with malignancy on biopsy (P = 0.0145), but not with clinical stage or Gleason score. Urine ERG score performed best in Caucasians and in men with a PSA of <or=4 ng/mL (area under the curve = 0.8).

CONCLUSIONS

A higher urine ERG score in post-DRE urine is associated with the diagnosis of prostate cancer on biopsy. Urine ERG score performed particularly well in men with a PSA of <or=4.0 ng/mL, a segment of the screening population in which further diagnostic markers are needed to determine in whom biopsy should be done.

Venous thromboembolism in urologic surgery: prophylaxis, diagnosis, and treatment

Venous thromboembolism (VTE) represents one of the most common and potentially devastating complications of urologic surgery. With VTE's rapid onset of symptoms, association with a precipitous clinical course, and high mortality rate, all urologists should be well versed in appropriate prophylaxis, prompt diagnosis, and expeditious treatment. A MEDLINE(R) search was performed for articles that examined the incidence, diagnosis, and treatment of VTE in urologic surgery. Additional articles were reviewed based on cited references. There is a paucity of prospective studies on VTE in the urologic literature with most recommendations for urologic surgery patients being extrapolated from other surgical disciplines. Retrospective studies place VTE incidence rates in major urologic surgeries among the highest reported-highlighting the importance of thromboprophylaxis. Conversely, VTE was rarely reported in association with endoscopic and laparoscopic procedures making mechanical thromboprophylaxis sufficient. Recent literature reveals delayed VTE occurring after hospital discharge to be a persistent threat despite inpatient preoperative prophylaxis. Computed tomographic angiography has emerged as the test of choice for diagnosing pulmonary embolism, whereas lower extremity duplex sonography is recommended for diagnosing deep venous thrombosis. Traditional angiography is rarely used. Treatment of VTE involves therapeutic anticoagulation for various lengths of time based on presence and reversibility of patient risk factors as well as number of events. Perioperative thromboprophylaxis should be considered in all major urologic surgeries. Urologists should be familiar with incidence rates, recommended prophylaxis, appropriate diagnosis, and treatment recommendations for VTE to minimize morbidity and mortality. The limited number of prospective, randomized, controlled trials evaluating the use of thromboprophylaxis in urologic surgery demonstrates the need for further research.

Synchronous urethral stricture reconstruction via 1-stage ascending approach: rationale and results

PURPOSE

We present our experience with the reconstruction of synchronous urethral strictures.

MATERIALS AND METHODS

Of 482 anterior urethroplasties performed by a single surgeon between 1997 and 2008 we identified and reviewed 30 patients who underwent reconstruction for multiple separate strictures. An ascending approach from distal to proximal was used and all repairs were completed at 1 stage. A total of 13 combinations of techniques were used to complete the repairs. A 2-phase technique was used in which the patient remained supine during buccal mucosa harvest and repair of strictures distal to the penoscrotal junction, and was then repositioned into the high lithotomy position as needed for stricture repair in the bulbar urethra. In each case normal intervening urethra was preserved intact. The number, length and location of strictures, operative time and patient outcomes were evaluated.

RESULTS

No position related complications occurred during or after surgery despite a mean operative time of 4.5 hours (range 2.5 to 6.4). No infectious wound complications were reported despite repositioning the legs to the high lithotomy position. Three patients (10%) were known to have required treatment for recurrent stricture after surgery.

CONCLUSIONS

One-stage reconstruction for synchronous urethral strictures may be safely and effectively performed using a systematic, ascending reconstructive approach with creative application of tissue transfer techniques. Decreasing patient time in the high lithotomy position appears to prevent related lower extremity complications.

Prediction of shockwave failure in patients with urinary tract stones

PURPOSE OF REVIEW

To evaluate recent developments in predicting the failure of shockwave lithotripsy when treating patients with urinary tract stones.

RECENT FINDINGS

Although the features of patients with stones, as well as of the stones themselves, associated with refractoriness to shockwave lithotripsy are fairly well defined, refining the preoperative detection of these traits and optimizing the efficacy of shockwave lithotripsy are still under investigation. Several studies have recently focused on improving the radiological appraisal of stone size and composition through the use of axial computed tomography and reconstruction software. Other investigators have researched techniques to increase the efficacy of the technology underlying shockwave lithotripsy, such as varying the shockwave delivery rate and method.

SUMMARY

Investigators have demonstrated different factors and predictors that affect shockwave lithotripsy for stone disease. Continued research will better define patient selection and the role of shockwave lithotripsy in the treatment of urolithiasis.

Effects of nifedipine on myocardial perfusion during exercise in chronic stable angina pectoris

Nifedipine may be effective in the treatment of stable angina by both decreasing myocardial oxygen demand and increasing myocardial oxygen supply. To determine the mechanism of action of nifedipine and its dose-response relation, 14 patients with stable angina were treated with nifedipine 10, 20 and 30 mg 4 times daily as single-agent therapy in a double-blind, randomized, placebo-controlled crossover trial. Treatment was continued for 1 week on each dose regimen and efficacy was determined using an exercise test at the end of each phase. Compared to placebo, a significant decrease of systolic blood pressure at peak exercise occurred with the nifedipine 20- and 30-mg regimens (p less than 0.05), accompanied by an increase in heart rate on the 10- and 20-mg regimens (p less than 0.005). There was no significant effect on the rate-pressure product compared to placebo at any exercise time on any of the nifedipine regimens. The times to onset of ST-segment depression and to angina were delayed significantly by all 3 dose regimens compared to placebo (p less than 0.02). There was a significant decrease in the magnitude of ST-segment depression at all exercise times by all dosage schedules of nifedipine compared with placebo (p less than 0.05), although there were no significant differences among the 3 dosage schedules. Data indicate that since nifedipine was effective in improving manifestations of myocardial ischemia during exercise without altering the double product at submaximal or maximal exercise, its beneficial mechanism of action may have been due to enhancing blood flow to ischemic zones or to favorably altering determinants of myocardial oxygen demand, which were not measured.