Adherence Patterns and Acceptability of a Perioperative, App-Based Mindfulness Meditation Among Surgical Patients With Chronic Pain

Identifying barriers to compliance with mindfulness-based interventions (MBIs) during the perioperative period is paramount to the design and implementation of non-pharmacologic, opiate-sparing pain regimens. We prospectively investigated the acceptability and adherence patterns of an app-based MBI amongst surgical patients with chronic pain. Patients were provided a subscription code to a meditation app and encouraged to use the app an average of 10 minutes/day over a 6-week study period. Patients reported a high level of interest in using the app prior to enrollment. 71% used the app at least once, 30% for half the recommended time, and 8% for the recommended amount of time. 88% of respondents enjoyed using the app and agreed it improved mental health and stress levels. Surgical patients with pre-existing pain report a high level of interest in utilizing MBIs perioperatively. Identifying barriers to compliance represents an important area of future investigation.

Association of Elevated C-Reactive Protein with Worsened Outcomes in Different Histologies of Renal Cortical Tumors: Analysis of the INMARC Registry

BACKGROUND

To evaluate relationship between histological subtypes of renal cell carcinoma (RCC) and preoperative c-reactive protein (CRP).

PATIENTS AND METHODS

We queried the International Marker Consortium for Renal Cancer database for patients affected by RCC. Patients were classified according to their histology: benign tumors, clear cell (cc) RCC, chromophobe (ch) RCC, papillary (p) RCC, and variant histology (vh) RCC; and according to CRP (mg/L): low CRP ≤5 and high CRP >5. Primary outcome was all-cause mortality (ACM). Secondary outcomes were cancer-specific mortality (CSM), recurrence and association between CRP and histology. Multivariable analysis (MVA) via Cox regression and multivariable logistic regression were fitted to elucidate predictors of outcomes.

RESULTS

Total 3902 patients (high CRP n = 1266) were analyzed; median follow up 51 (IQR 20-91) months. On MVA elevated CRP was an independent risk factor associated with increased risk of ACM in benign tumors (HR 5.98, P < .001), ccRCC (HR 2.69, P < .001), chRCC (HR 3.99, P < .001), pRCC (HR 1.76, P = .009) and vhRCC (HR 2.97, P =.007). MVA for CSM showed CRP as risk factor in ccRCC (HR 2.77, P < .001), chRCC (HR 6.16, P = .003) and pRCC (HR 2.29, P = .011), while in vhRCC was not (P = .27). MVA for recurrence reported CRP as risk factor for ccRCC (HR 1.30, P = .013), while in chRCC (P = .33), pRCC (P = .34) and vhRCC (P = .52) was not. On multivariable logistic regression CRP was a predictor of pRCC (OR 1.003, P = .002), while decreasing CRP was associated with benign tumors (OR 0.994, P = .048).

CONCLUSION

Elevated CRP was a robust predictor of worsened ACM in all renal cortical neoplasms. While most frequently observed in pRCC patients, elevated CRP was independently associated with worsened CSM in non-vhRCC. Conversely, elevated CRP was least likely to be noted in benign tumors, and elevation in this subgroup of patients should prompt further consideration for surveillance given increased risk of ACM. Further investigation is requisite.

Unraveling the BMI paradox in different renal cortical tumors: insights from the INMARC registry

OBJECTIVE

To investigate impact of body mass index (BMI) on survival across different histologies and stages of renal cell carcinoma (RCC).

METHODS

We conducted a retrospective multicenter analysis of clear cell (ccRCC) and non-ccRCC. Obesity was defined according to the WHO criteria (non-Asian BMI >30 Kg/m2, Asian BMI >27.5 Kg/m2). Multivariable analysis (MVA) via Cox regression model was conducted for all-cause (ACM), cancer-specific mortality (CSM) and recurrence.

RESULTS

A total of 3,880 patients with a median follow-up of 31 (IQR 9-64) months were analyzed. Overall, 1,373 (35.3%) were obese; 2,895 (74.6%) were ccRCC and 985 (25.3%) were non-ccRCC (chRCC 246 [24.9%], pRCC 469 [47.6%] and vhRCC 270 [27.4%]). MVA in ccRCC revealed obesity associated with decreased risk of ACM, CSM and recurrence (hazard ratio [HR] 0.80, P = 0.044; HR 0.71, P = 0.039; HR 0.73, P = 0.012, respectively), while in non-ccRCC was not associated with decreased risk of ACM, CSM, and recurrence (P = 0.84, P = 0.53, P = 0.84, respectively). Subset analysis in stage IV ccRCC demonstrated obesity as associated with a decreased risk of ACM, CSM, and recurrence (HR 0.68, P = 0.04; HR 0.59, P = 0.01; HR 0.59, P = 0.01, respectively), while in stage I-III ccRCC was not (P = 0.21; P = 0.30; P = 0.19, respectively).

CONCLUSION

Our findings refute a broad "obesity paradox" for RCC. Obesity was not associated with improved survival in non-ccRCC and in nonmetastatic ccRCC, while metastatic ccRCC patients with obesity had improved survival outcomes.

Adrenocortical Carcinomas: Molecular Pathogenesis, Treatment Options, and Emerging Immunotherapy and Targeted Therapy Approaches

Adrenocortical carcinoma (ACC) is a rare and aggressive malignancy in the advanced setting with poor prognosis. This narrative review provides an overview of the epidemiology of ACC and its molecular pathogenesis with a summary of the main involved signaling pathways. We then provide an update on the clinical presentation, diagnosis, and current management strategies of both localized and metastatic disease from a multidisciplinary perspective. We highlight the debate around the use of mitotane in the adjuvant setting and review the use of combination chemotherapy with etoposide, doxorubicin, and cisplatin. The review also focuses on emerging data providing hope for the use of immune checkpoint inhibitors and targeted therapies in ACC with a summary of ongoing trials.

Safety and efficacy of immune checkpoint inhibitors in advanced penile cancer: report from the Global Society of Rare Genitourinary Tumors

BACKGROUND

Treatment options for penile squamous cell carcinoma are limited. We sought to investigate clinical outcomes and safety profiles of patients with penile squamous cell carcinoma receiving immune checkpoint inhibitors.

METHODS

This retrospective study included patients with locally advanced or metastatic penile squamous cell carcinoma receiving immune checkpoint inhibitors between 2015 and 2022 across 24 centers in the United States, Europe, and Asia. Overall survival and progression-free survival were estimated using the Kaplan-Meier method. Objective response rates were determined per Response Evaluation Criteria in Solid Tumours 1.1 criteria. Treatment-related adverse events were graded per the Common Terminology Criteria for Adverse Events, version 5.0. Two-sided statistical tests were used for comparisons.

RESULTS

Among 92 patients, 8 (8.7%) were Asian, 6 (6.5%) were Black, and 24 (29%) were Hispanic and/or Latinx. Median (interquartile range) age was 62 (53-70) years. In all, 83 (90%) had metastatic penile squamous cell carcinoma, and 74 (80%) had received at least second-line treatment. Most patients received pembrolizumab monotherapy (n = 26 [28%]), combination nivolumab-ipilimumab with or without multitargeted tyrosine kinase inhibitors (n = 23 [25%]), or nivolumab (n = 16 [17%]) or cemiplimab (n = 15 [16%]) monotherapies. Median overall and progression-free survival were 9.8 months (95% confidence interval = 7.7 to 12.8 months) and 3.2 months (95% confidence interval = 2.5 to 4.2 months), respectively. The objective response rate was 13% (n = 11/85) in the overall cohort and 35% (n = 7/20) in patients with lymph node-only metastases. Visceral metastases, Eastern Cooperative Oncology Group (ECOG) performance status of 1 or higher, and a higher neutrophil/lymphocyte ratio were associated with worse overall survival. Treatment-related adverse events occurred in 27 (29%) patients, and 9.8% (n = 9) of the events were grade 3 or higher.

CONCLUSIONS

Immune checkpoint inhibitors are active in a subset of patients with penile squamous cell carcinoma. Future translational studies are warranted to identify patients more likely to derive clinical benefit from immune checkpoint inhibitors.

A randomized-controlled trial assessing the effect of intraoperative acupuncture on anesthesia-related parameters during gynecological oncology surgery

CONTEXT AND OBJECTIVES

The present study examined the impact of intraoperative acupuncture on anesthesia-related parameters in patients undergoing gynecological oncology surgery.

METHODS

Participants underwent preoperative integrative oncology (IO) touch/relaxation treatments, followed by intraoperative acupuncture (Group A); preoperative IO treatments without acupuncture (Group B); or standard care only (Group C). Mean arterial pressure (MAP), heart rate (HR), MAP variability (mean of MAP standard deviation), bispectral index (BIS), and calculated blood pressure Average Real Variability (ARV) were measured intraoperatively.

RESULTS

A total of 91 patients participated: Group A, 41; Group B, 24; Group C, 26. Among patients undergoing open laparotomy, Group A showed lower and more stable MAP and HR compared to Group B, (MAP, p = 0.026; HR, p = 0.029) and Group C (MAP, p = 0.025). Mean BIS, from incision to suture closing, was lower in Group A (vs. controls, p = 0.024). In patients undergoing laparoscopic surgery, MAP was elevated within Group A (p = 0.026) throughout surgery, with MAP variability significantly higher in Group A (P = 0.023) and Group B (P = 0.013) 10 min post-incision (vs. pre-incision). All groups showed similar intraoperative and post-anesthesia use of analgesic medication.

CONCLUSION

Intraoperative acupuncture was shown to reduce and stabilize MAP and HR, and reduce BIS in gynecology oncology patients undergoing laparotomy, with no impact on perioperative analgesic medication use. In the laparoscopic setting, intraoperative acupuncture was associated with elevated MAP. Further research is needed to explore the hemodynamic and BIS-associated benefits and risks of intraoperative acupuncture, and the impact on the use of analgesic drugs in response to these changes.

Prolonged Opioid Use Following Bladder Tumor Resection for Opioid-Naïve Patients

PURPOSE

Bladder cancer patients represent a high-risk group for opioid dependence due to the frequency of surgical procedures. Using MarketScan insurance commercial claims (CC) and Medicare-eligible (ME) databases, we sought to identify whether filling an opioid prescription following initial TURBT resulted in increased odds of prolonged opioid use.

MATERIALS AND METHODS

We analyzed 43,741 CC and 45,828 ME opioid-naïve patients with a new diagnosis of bladder cancer from 2009 to 2019. Multivariable analyses were completed to assess the odds of prolonged opioid use at 3-6 months based on initial exposure to opioids and initial opioid dose quartile. We performed subgroup analyses by sex and eventual treatment modality.

RESULTS

Those who filled an opioid prescription following initial TURBT had greater odds of persistent opioid use (CC: 27% vs 12%, OR 2.14, 95% CI (1.84-2.45), ME: 24% vs 12%, OR 1.95, 95% CI (1.70-2.22). Increasing dosage quartile of opioids was associated with increased odds of prolonged opioid use. Those going on to radical therapy had the highest rates of an initial opioid prescription (31% (CC) and 23% (ME)). Men and women had similar rates of initial prescriptions, but female sex was associated with higher odds of persistent opioid use at 3-6 months in the ME group: OR 1.08, 95% CI (1.01-1.16).

CONCLUSIONS

Opioids following initial TURBT increase the odds of continued use at 3-6 months, with the greatest odds in those prescribed the highest initial doses. These data suggest that short-term prescriptions have long-term effects, and additional research on opioid use and bladder cancer outcomes is merited.

Variations in Penile Cancer Management: Results From the Global Society of Rare Genitourinary Tumors Survey

INTRODUCTION

There is paucity of evidence and consensus on various aspects of management of penile cancer (PeCa), which is intuitive considering the rarity of this disease. We present here the details of an online survey conducted by the Global Society of Rare Genito-urinary Tumors (GSRGT) with the aim of capturing the variations in PeCa care across different regions of the world.

MATERIALS AND METHODS

An online questionnaire was developed by experts within the GSRGT and then circulated via email in English and Spanish versions to clinicians dealing with PeCa. Respondents were allowed 8 weeks to reply.

RESULTS

We received 102 responses; the majority of them were from South America (37.2%) followed by North America and Asia (17.6% each). Only 11.7% of the respondents treated more than 25 patients with PeCa annually. Total penectomy is performed by 21.5% of the respondents in >50% of their patients. Less than a fifth of the experts (19.6%) responded that >50% of their patients are clinically node-negative (cN0) at presentation. For intermediate-risk cN0 patients (T1 G2 cancer), about a third of the experts chose surveillance. For invasive inguinal staging, the options of Dynamic Sentinel Lymph Node Biopsy (DSNB), Modified Inguinal Lymph Node Dissection (MILD), Superficial Inguinal Lymph Node Dissection (SILD), and Video-Endoscopic Inguinal Lymphadenectomy (VEIL) were chosen by 28.4%, 26.4%, 31.3%, and 13.7% of the respondents respectively. Considerable variation was seen in the worldwide use of these techniques. For clinically node-positive patients, respondents were in favor of giving adjuvant chemotherapy instead of neoadjuvant chemotherapy, except for cN3 patients.

CONCLUSION

The results of this questionnaire objectified the variations in global practices in the management of PeCa. This serves as the baseline information which can help prioritize research areas for multinational collaborative efforts, a key mission of the GSRGT.

Patients' Perceptions Regarding the Relevance of Items Contained in the Functional Assessment of Cancer Therapy Kidney Symptom Index-19

BACKGROUND

There is a lack of consensus regarding the optimal method of assessing health-related quality of life (HR-QOL) among patients with metastatic renal cell carcinoma (mRCC). This study explored the perceived relevance of items that make up the Functional Assessment of Cancer Therapy Kidney Symptom Index-19 (FKSI-19), as judged by patients with mRCC.

METHODS

This was a multinational cross-sectional survey. Eligible patients responded to a questionnaire composed of 18 items that assessed the perceived relevance of each item in the FKSI-19 questionnaire. Open-ended questions assessed additional issues deemed relevant by patients. Responses were grouped as relevant (scores 2-5) or nonrelevant (score 1). Descriptive statistics were collated, and open-ended questions were analyzed and categorized into descriptive categories. Spearman correlation statistics were used to test the association between relevance and clinical characteristics.

RESULTS

A total of 151 patients were included (gender: 78.1 M, 21.9F; median age: 64; treatment: 38.4 immunotherapy, 29.8 targeted therapy, 13.9 immuno-TKI combination therapy) in the study. The most relevant questions evaluated fatigue (77.5), lack of energy (72.2), and worry that their condition will get worse (71.5). Most patients rated blood in urine (15.2), fevers (16.6), and lack of appetite (23.2) as least relevant. Qualitative analysis of open-ended questions revealed several themes, including emotional and physical symptoms, ability to live independently, effectiveness of treatment, family, spirituality, and financial toxicity.

CONCLUSION

There is a need to refine widely used HR-QOL measures that are employed among patients diagnosed with mRCC treated with contemporary therapies. Guidance was provided for the inclusion of more relevant items to patients' cancer journey.

Impact of worsening surgically induced chronic kidney disease (CKD-S) in preoperative CKD-naïve patients on survival in renal cell carcinoma

OBJECTIVES

To evaluate effects of worsening surgically induced chronic kidney disease (CKD-S) on oncological and non-oncological survival outcomes in renal cell carcinoma (RCC).

PATIENTS AND METHODS

We performed a retrospective analysis of patients who underwent partial (PN) or radical nephrectomy (RN) and were free of preoperative CKD (estimated glomerular filtration rate [eGFR] ≥60 mL/min/1.73 m² ). Patients were stratified by CKD stage at last follow-up: no CKD-S (eGFR ≥60 mL/min/1.73 m² ), de novo CKD-S 3a (eGFR 45-59 mL/min/1.73 m² ), CKD-S 3b (eGFR <45 and ≥30 mL/min/1.73 m² ) and CKD-S 4 (eGFR <30 and ≥15 mL/min/1.73 m² ). The primary outcome was all-cause mortality (ACM). Secondary outcomes included non-cancer mortality (NCM), cancer-specific mortality (CSM) and de novo CKD-S Stage 3/4. Multivariable analysis (MVA) was utilised to identify risk factors for outcomes. Kaplan-Meier analysis (KMA) was utilised to evaluate overall (OS), non-cancer (NCS), and cancer-specific survival with respect to CKD-S categories.

RESULTS

We analysed 3239 patients. The mean preoperative and last-follow-up eGFRs were 87.4 and 69.5 mL/min/1.73 m² , respectively. On last follow-up, 57.9% (n = 1876) had no CKD-S, 18.7% (n = 606) had CKD-S 3a, 15.1% (n = 489) had CKD-S 3b and 8.3% (n = 268) had CKD-S 4. On MVA, de novo CKD-S 3b and 4 were independently associated with ACM (hazard ratios [HRs] 1.3-2.1, P = 0.003-0.001) and NCM (HRs 1.5-2.8, P = 0.021-0.001), but not CSM (P = 0.219-0.909); de novo CKD-S 3a was not predictive for any mortality outcomes (P = 0.102-0.81). RN was independently associated with CKD-S 3-4 (HRs 1.78-1.99, P < 0.001-0.035). Comparing no CKD-S, CKD-S 3a, CKD-S 3b and CKD-S 4, KMA demonstrated worsening outcomes with progressive CKD-S stage: 5-year OS 84% vs 78% vs 71% vs 60% (P < 0.001) and 5-year NCS 93% vs 87% vs 83% vs 72% (P < 0.001).

CONCLUSION

Development of CKD-S Stage 3b and 4, but not 3a, was associated with worsened ACM and NCM. The decision to proceed with nephron preservation via PN should be individualised based on oncological risk and risk of functional decline to CKD-S 3b or 4, and not CKD-S 3a.

Integrative Surgery: Embedding Complementary and Nonpharmacologic Therapies into Surgical Pain Management Strategies

There has been a growing interest in the use of complementary and alternative medicine in modern pain management strategies on behalf of both patients and clinicians. Nonpharmacologic modalities such as cryotherapy, acupuncture, music, and mind-body therapies have been shown to aid in symptom control and improve quality of life in patients suffering from acute and chronic pain, and there is a growing body of literature demonstrating their feasibility, acceptability, and efficacy in the perioperative period. Here, we provide a brief review of the current evidence supporting the use of complementary therapies within existing perioperative pain management strategies and highlight evidence-based protocols to facilitate implementation into modern surgical practice.

CD8+ T cell activation in cancer comprises an initial activation phase in lymph nodes followed by effector differentiation within the tumor

Improvements in tumor immunotherapies depend on better understanding of the anti-tumor T cell response. By studying human tumor-draining lymph nodes (TDLNs), we found that activated CD8⁺ T cells in TDLNs shared functional, transcriptional, and epigenetic traits with TCF1⁺ stem-like cells in the tumor. The phenotype and TCR overlap suggested that these TDLN cells were precursors to tumor-resident stem-like CD8⁺ T cells. Murine tumor models revealed that tumor-specific CD8⁺ T cells were activated in TDLNs but lacked an effector phenotype. These stem-like cells migrated into the tumor, where additional co-stimulation from antigen-presenting cells drove effector differentiation. This model of CD8⁺ T cell activation in response to cancer is different from that of canonical CD8⁺ T cell activation to acute viruses, and it proposes two stages of tumor-specific CD8⁺ T cell activation: initial activation in TDLNs and subsequent effector program acquisition within the tumor after additional co-stimulation.

Inguinal lymph node dissection in the era of minimally invasive surgical technology

BACKGROUND

Inguinal lymph node dissection (ILND) is an essential step in both treatment and staging of several malignancies including penile and vulvar cancers. Various open, video endoscopic, and robotic-assisted techniques have been utilized so far. In this review, we aim to describe available minimally invasive surgical approaches for ILND, and review their outcomes and complications.

METHODS

The PubMed, Wiley Online Library, and Science Direct databases were reviewed in February 2020 to find relevant studies published in English within 2000-2020.

FINDINGS

There are different minimally invasive platforms available to accomplish dissection of inguinal nodes without jeopardizing oncological results while minimizing postoperative complications. Video Endoscopic Inguinal Lymphadenectomy and Robotic Video Endoscopic Inguinal Lymphadenectomy are safe and achieve the same nodal yield, a surrogate metric for oncological adequacy. When compared to open technique, Video Endoscopic Inguinal Lymphadenectomy and Robotic Video Endoscopic Inguinal Lymphadenectomy may offer faster postoperative recovery and fewer postoperative complications including wound dehiscence, necrosis, and infection. The relatively high rate and severity of postoperative complications hinders utilization of recommended ILND for oncologic indications. Minimally invasive approaches, using laparoscopic or robotic-assisted platforms, show some promise in reducing the morbidity of this procedure while achieving adequate short and intermediate term oncological outcomes.

Age-Related Differences in Oncological Outcomes in Renal Cell Carcinoma: Impact of Functional Conservation as Measured by Postoperative eGFR

INTRODUCTION

We sought to determine whether loss of renal function increases risk of recurrence and metastases in renal cell carcinoma (RCC), and whether this impact was age-related.

MATERIALS AND METHODS

We performed a retrospective analysis of the International Marker Consortium for Renal Cancer (INMARC) registry. Patients were separated into younger (<65 years old) and elder (≥65 years old) age groups, and rates of de novo estimated glomerular filtration rate (eGFR<45 mL/min/1.73m2 [eGFR<45]) were calculated. Multivariable analysis (MVA) was conducted for predictors of progression-free survival (PFS) and all-cause mortality (ACM). Kaplan-Meier Analysis (KMA) was conducted for PFS and overall survival (OS) in younger and elder age groups stratified by functional status.

RESULTS

We analyzed 1805 patients (1113 age<65, 692 age≥65). On MVA in patients <65, de novo eGFR<45 was independently associated with greater risk for worsened progression (HR=1.61, P=.038) and ACM (HR=1.82, P=.018). For patients ≥65, de novo eGFR<45 was not independently associated with progression (P=.736), or ACM (P=.286). Comparing patients with de novo eGFR<45 vs. eGFR ≥45, KMA demonstrated worsened 5-year PFS and OS in patients <65 (PFS: 68% vs. 86%, P<.001; OS: 73% vs. 90%, P<.001), while in patients ≥65, only 5-year OS was worsened (77% vs. 81%, P<.021).

CONCLUSION

Development of de novo eGFR<45 was associated with more profound impact on patients <65 compared to patients ≥65, being an independent risk factor for PFS and ACM. The mechanisms of this phenomenon are unclear but underscore desirability for nephron preservation when safe and feasible in younger patients.

Association of neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, and De Ritis ratio with mortality in renal cell carcinoma: A multicenter analysis

Background

Several markers of inflammation have been associated with oncologic outcomes. Prognostic markers are not well-defined for renal cell carcinoma (RCC). We sought to investigate the association of preoperative neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and De Ritis ratio with mortality in RCC.

Methods

Multi-center retrospective analysis of patients undergoing surgery for RCC. Primary outcome of interest was all-cause mortality (ACM). Secondary outcomes were non-cancer mortality (NCM) and cancer-specific mortality (CSM). Elevated NLR was defined as ≥2.27, elevated PLR as ≥165, and elevated De Ritis ratio as ≥ 2.72. Multivariable cox regression analysis (MVA) was conducted to elucidate risk factors for primary and secondary outcomes, and Kaplan-Meier analysis (KMA) was used to evaluate survival outcomes comparing elevated and non-elevated NLR, PLR, and De Ritis ratio.

Results

2656 patients were analyzed (874 patients had elevated NLR; 480 patients had elevated PLR and 932 patients had elevated De Ritis). Elevated NLR was a significant predictor of ACM (HR 1.32, 95% CI: 1.07-1.64, p=0.003) and NCM (HR 1.79, 95% CI: 1.30-2.46, p<0.001) in MVA. Elevated De Ritis was a significant predictor of ACM (HR 2.04, 95% CI: 1.65-2.52), NCM (HR 1.84, 95% CI: 1.33-2.55, p<0.001), and CSM (HR 1.97, 95% CI:1.48-2.63, p<0.001). KMA revealed significant difference in 5-year overall survival (OS) (48% vs. 68%, p<0.001), non-cancer survival (NCS) (69% vs. 87%, p<0.001), and cancer-specific survival (CSS) (60% vs. 73%, p<0.001) for elevated versus non-elevated NLR. For PLR, there was a difference in 5-year OS (51% vs. 61%, p<0.001) and CSS (60% vs. 73%, p<0.001) with KMA.

Conclusions

Elevated NLR was independently associated with worse ACM and NCM, while elevated De Ritis was predictive for CSM in addition to ACM and NCM. These differences may be useful in refining risk stratification with respect to cancer-related and non-cancer mortality in RCC patients and deserve further investigation.

Cancer-Related Fatigue Outcome Measures in Integrative Oncology: Evidence for Practice and Research Recommendations

Cancer-related fatigue (CRF) is one of the most common symptoms across the cancer continuum and is often underreported and undertreated. Defined as a distressing, persistent, subjective sense of tiredness or exhaustion related to cancer or its treatment, CRF includes physical, emotional, cognitive, and spiritual dimensions. Patient-reported outcome (PRO) measures are the most widely used tool to screen for and assess fatigue and the associated negative impacts on quality of life. However, selecting subjective CRF measures can be complex. This has resulted in the availability of and inconsistent use of numerous PROs, limiting the ability to cross-compare outcomes clinically and within research. To address this, the PROs that are most widely reported in the literature are recommended to support the standardization of a core set of validated measures. The National Comprehensive Cancer Network single-item tool for clinical significance is recommended for quick use in clinical environments; the Brief Fatigue Inventory allows for fast, easy, helpful cutoffs on severity threshold for triage, and measures both severity and interference with daily functioning; while the MD Anderson Symptom Inventory allows for multisymptomatic assessment. In addition, a fundamental consideration for any PRO use is the administrative burden on the patient and clinician. In this review, we aim to summarize current, validated PROs specific to CRF to aid clinicians and researchers in patient care and in study design and implementation. We conclude with suggestions for future directions in CRF research that can increase the possibility for long-term impact on future guidelines of fatigue management.

Disparities in Cancer Specific and Overall Survival Outcomes in African Americans With Renal Cell Carcinoma: Analysis From the International Marker Consortium for Renal Cancer (INMARC)

OBJECTIVE

To investigate association of African-American race and survival in Renal Cell Carcinoma (RCC).

PATIENTS AND METHODS

We queried the International Marker Consortium for Renal Cancer database for patients who underwent partial or radical (RN) nephrectomy. The cohort was divided into African American (AA) and non-African American (NAA) patients. Primary outcome was all-cause mortality. Secondary outcome was cancer-specific mortality. Multivariable Analysis and Kaplan-Meier Analysis were used to elucidate predictive factors and survival outcomes.

RESULTS

Three thousand eight hundred and ninety-three patients were analyzed (AA, n = 564/NAA, n = 3329). AA had greater Stage I (73.8% vs 63.9%, P <.001) and papillary RCC (29.8% vs 8.5%, P <.001). Multivariable Analysis revealed increasing age (HR = 1.03, P <.001), AA (HR = 1.24, P = .027), higher stage (HR = 1.30-3.19, P <.001), RN (HR = 2.45, P <.001), clear cell (HR = 1.23, P <.001), positive margin (HR = 1.34, P .004), and high-grade (HR = 1.58, P <.001) to be associated with worsened all-cause mortality. Increasing age (HR = 1.02, P <.001), AA (HR = 1.48, P = .025), RN (HR = 2.98, P <.001), high-grade (HR = 3.11, P <.001), and higher stage (HR = 3.03-13.2, P <.001) were predictive for cancer-specific mortality. Kaplan-Meier Analysis revealed worsened 5-year overall survival for AA in stage I (80% vs 88%, P = .001), stage III (26% vs 70%, P = .001), and stage IV (23% vs 44%, P = .009). Five-year cancer-specific survival was worse for AA in stage III (36% vs 81%, P <.001) and stage IV (30% vs 49%, P = .007).

CONCLUSION

Despite presenting with more indolent histology and lower stage, African-Americans were at greater risk for diminished survival, faring worse in overall survival for all stages and cancer-specific survival in for stage III/IV RCC. Further investigation into factors associated with these disparities is warranted.

CD8 T cell activation in cancer is comprised of two distinct phases

The CD8 T cell response to tumors is extremely variable with heterogenous T cell subsets, a stem-like CD8 T cell (PD1+TCF1+) that sustains the CD8 response and gives rise to a terminally differentiated (TD) cytotoxic cell (TCF1-Tim3+). Although these subsets have been described, how tumor-specific CD8 T cells are activated and differentiate in tumors are not well defined. Using a prostate cancer model that expresses the LCMV-GP (TRAMPC1-GP), we studied tumor-specific CD8 T cell activation by transferring LCMV-GP specific P14 CD8 T cells into tumor-bearing mice. We found that P14s are activated in the tumor-draining LNs (TDLNs) and acquire a stem-like phenotype. These cells migrate into the tumor as stem-like CD8 T cells and only differentiate into a TD CD8 T cell in the tumor. We found that stem-like CD8 T cells need additional co-stimulation from antigen presenting cells within the tumor to fully differentiate, even though they have been previously activated in TLDNs. Similarly, stem-like CD8s from human kidney cancer require both TCR and co-stimulatory signals to divide and differentiation ex-vivo and can differentiate when co-cultured with autologous dendritic cells. The addition of IL12 with TCR alone was not sufficient to induce differentiation, but improved differentiation when co-stimulation was present. This demonstrates the necessity of additional TCR and co-stimulation once activated stem-like CD8 T cells migrate into the tumor. Overall, these data suggest two distinct phases of CD8 T cell differentiation, the first occurs in the TDLN where they are initially activated. The second occurs in the tumor, where they require additional co-stimulation to differentiate and acquire an effector phenotype.

Dissemination of validated health literacy videos: A tailored approach

BACKGROUND

Previously, we showed that chemotherapy terminology is difficult for patients to understand. Therefore, we developed short videos explaining key terminology and though proven effective, they will only be helpful if appropriately disseminated. Therefore, we aimed to determine the best dissemination method at three different healthcare settings.

METHODS

With consent, we interviewed healthcare workers from (1) an academic cancer center, Winship Cancer Institute (Winship) serving higher SES patients, (2) an inner-city, safety-net hospital Grady Memorial (GMH), (3) clinics serving rural Georgia, from the Winship Community Network (Network). All interviews were transcribed and analyzed using a semantic content analysis method. Suggested dissemination plans were then implemented.

RESULTS

Twenty-two Winship, 11 GMH, and 4 Network healthcare workers were interviewed. Seventy-two percent (n = 8) of the GMH and 100% (n = 4) of Network healthcare workers felt that the best place for patients to view the videos was in the clinic, compared to 27% (n = 6) of the Winship clinicians. 68% (n = 15) of the Winship clinicians stated an app would be the most useful format, compared to 27% (n = 3) at GMH, and 0% at Network sites. Video viewing increased after dissemination plans were implemented.

CONCLUSION

Educational materials explaining oncology treatment terminology enhance patient understanding, yet without proper dissemination, these tools may never reach the intended patient population. Our study shows that dissemination plans need to be tailored to each individual patient population, with rural and lower SES patients needing to view the videos during clinic visits, and patients of more means viewing them using technology at home.

Examination of Provider and Patient Knowledge, Beliefs, and Preferences in Integrative Oncology at a National Cancer Institute-Designated Comprehensive Cancer Center

Purpose

The use of integrative approaches for symptom management is highly prevalent among patients undergoing cancer treatment and among cancer survivors and is increasingly endorsed by clinical practice guidelines. However, access to and implementation of integrative oncology (IO) approaches are hindered by barriers at multiple levels, including logistic, geographic, financial, organizational, and cultural barriers. The goal of this mixed-method study was to examine oncology provider and patient knowledge, beliefs, and preferences in IO to identify facilitators, barriers, and recommendations for implementation of IO modalities.

Materials and Methods

Data sources included patient surveys and provider semistructured interviews. Patients were in active treatment (n = 100) and survivors (n = 100) of heterogeneous cancer types. Patient and survivor surveys interrogated: (1) interest in types of IO approaches; and (2) preferences for delivery modality, frequency, and location. Providers (n = 18) were oncologists and nurse navigators working with diverse cancer types. Interviews queried their knowledge of and attitudes about IO, about their patients' needs for symptom management, and for recommendations for implementation of IO approaches in their clinic. We used the Consolidated Framework for Implementation Research framework to systematically analyze provider interviews.

Results

The primary interests reported among actively treated patients and survivors were massage therapy, acupuncture, and wellness/exercise. Most patients expressed interest in both group and individual sessions and in telehealth or virtual reality options. Emergent themes from provider interviews identified barriers and facilitators to implementing IO approaches in both the internal and external settings, as well as for the implementation process.

Conclusion

The emphasis on mind-body interventions as integrative rather than alternative highlights the importance of interventions as evidence-based, comprehensive, and integrated into health care. Gaining simultaneous perspectives from both patients and physicians generated insights for the implementation of IO care into complex clinical systems within a comprehensive cancer center.

A global approach to improving penile cancer care

Rare tumours such as penile carcinoma have been largely neglected by the urology scientific community in favour of more common - and, therefore, more easily fundable - diseases. Nevertheless, penile cancer represents a rising burden for health-care systems around the world, because a lack of widespread expertise, ineffective centralization of care and absence of research funds have hampered our ability to improve the global care of these patients. Moreover, a dichotomy has arisen in the field of penile cancer, further impeding care: the countries that are mainly supporting research on this topic through the development of epidemiological studies and design of clinical trials are not the countries that have the highest prevalence of the disease. This situation means that randomized controlled trials in developed countries often do not meet the minimum accrual and are intended to close before reaching their end points, whereas trials are almost completely absent in those areas with the highest disease prevalence and probability of successful recruitment, such as Africa, South America and South Asia. The scientific and organizational inaction that arises owing to this mismatch translates into a burdensome cost for our patients. A global effort to gather experts and pull together scientific data from around the world may be the best way to boost clinical research, to change clinical practice and, ultimately, to improve care for patients and their families.

Longitudinal impact of bladder cancer diagnosis on common psychiatric disorders

Background

The presence of psychiatric disorders in patients with cancer is associated with increased morbidity and poorer outcomes. We sought to determine the impact of a new bladder cancer diagnosis on the incidence of depression and anxiety.

Methods

We used a database of billing claims (MarketScan®) to identify patients newly diagnosed with bladder cancer between 2009 and 2018. Patients with preexisting psychiatric disorders or use of anxiolytics/antidepressants were excluded. We matched cases to patients without a bladder cancer or psychiatric diagnosis. Our primary outcome was a new diagnosis of depression, anxiety, or use of anxiolytics/antidepressants. Other exposures of interest included gender and treatment received. We used multivariable regression to estimate odds ratios for these exposures.

Results

We identified 65,846 cases with a new diagnosis of bladder cancer (31,367 privately insured; 34,479 Medicare‐eligible). Compared to controls, bladder cancer patients were more likely to develop new‐onset depression/anxiety at 6 months (privately insured: 6.9% vs. 3.4%, p < 0.001; Medicare‐eligible: 5.7% vs. 3.4%, p < 0.001) and 36 months (privately insured: 19.2% vs. 13.5%, p < 0.001; Medicare‐eligible: 19.3% vs. 16.0%, p < 0.001). Women (vs. men, privately insured: OR 1.65, 95%CI 1.53–1.78; Medicare‐eligible: OR 1.63, 95%CI 1.50–1.76) and those receiving cystectomy and chemotherapy (vs. no treatment, privately insured: OR 4.94, 95%CI 4.13–5.90; Medicare‐eligible: OR 2.35, 95%CI 1.88–2.94) were more likely to develop significant depression/anxiety.

Conclusion

A new diagnosis of bladder cancer was associated with increased burden of significant depression/anxiety compared with matched controls. Women and patients receiving more radical treatments had higher rates of depression and anxiety.

640 Stem-like CD4 T cells in cancer

Background

CD4 T cells can differentiate into multiple effector subsets that can mediate variable functions. In this work we aim to understand how CD4 T cells differentiate in response to tumor antigens and their respective function in the anti-tumor response.

Methods

Tumor tissue was collected from patients undergoing surgery at Emory University Hospital. Activated PD1+ CD45RA- tumor infiltrating CD4 T cells were sent for 10X single cell RNA-seq. Tumor samples were also processed for flow cytometry and ex vivo functional analyses. For in vivo studies, prostate cancer mouse model expressing the LCMV glycoprotein (TRAMPC1-GP) was used, as well as LCMV Armstrong infection.

Results

To characterize the heterogeneity of CD4 T cells infiltrating kidney tumors, we performed single cell RNAseq. We found three distinct activated (PD1+ CD45RA-) CD4 T cell populations. Two effector clusters consisting of Th1-like (EOMES+) and Treg (FOXP3+) cells, and a third cluster expressing TCF1, and genes associated with stemness and survival that did not fit defined CD4 effector lineages. We further confirmed these data by flow cytometry and found the same tumor infiltrating CD4 subsets in 100 kidney cancer patients. When placed in culture under different polarization conditions, tumor TCF1+ CD4 T cells proliferated and differentiated into the Th1-like and Treg effector populations found in the tumor, in addition to other effector lineages (Th1, Tfh) given the appropriate conditions, while the Th1-like and Treg cells underwent no proliferation or phenotype changes. These data suggests that the TCF1+ CD4s act as activated unpolarized precursors to the effector subsets in the tumor. To further test this hypothesis in vivo, we adoptively transferred tumor specific (SMARTA) CD4 T cells into mice followed by TRAMPC1-GP tumor inoculation. Transferred SMARTAs activated and first acquired a TCF1+ phenotype in the TDLN prior to predominantly differentiating into Tregs in the tumor. Given their plasticity in vitro, we asked whether TCF1+ SMARTAs primed in tumors were destined to differentiate into Tregs. To test this, we transferred 4-week activated TCF1+ SMARTAs from TDLNs of TRAMPC1-GP mice into naïve mice that were immediately infected with LCMV Armstrong. We found that the transferred SMARTAs differentiated into Th1 and Tfh cells in response to the virus, similar to the endogenous virus specific CD4 T cells.

Conclusions

Overall, this work shows that CD4 T cells remain in an activated phenotype in the tumor with the capacity to differentiate into non-suppressive effector lineages given the appropriate conditions that may benefit the anti-tumor response.

929 Dissecting intratumoral immune organization: defining the comparative cellular composition of tertiary lymphoid structures T-cell supportive antigen presenting niches in renal tumors

Background

Tumor infiltrating T-cells have a prognostic benefit in many tumor types,1–8 and we recently sought to determine whether the level of T-cell infiltration into renal tumors predicts clinical outcomes. In our recent publication,9 we showed that patients with high of CD8 T-cell infiltration have improved progression free survival (PFS). Further, we found that this T-cell response is supported by TCF1+ stem-like CD8 T-cells, which reside within dense regions of closely clustered antigen presenting cells within the tumor. Interestingly, aggregations of immune cells have also been described in other tumor types and termed ‘tertiary lymphoid structures’ (TLS), which are typically defined as B-cell-dominant aggregates, containing high endothelial venules and reactive germinal centers.10–12 Together, these findings raise several important questions, which we explore here—(1) what additional cell types comprise these niches?9 and (2) how are these niches similar to or different from TLS?

Methods

Tumor tissue was collected from patients with renal tumors undergoing surgery at Emory University Hospital. Intraoperative tumor samples were analyzed by flow cytometry, RNA sequencing, immunofluorescence, and immunohistochemistry. Immunofluorescence data was analyzed using our custom quantitative analysis pipelines, which allows for delineation of cell type and location, cell-cell distance, and density of cellular aggregation.

Results

The proportion of CD8 T-cells infiltration human renal tumors varied widely, consistent with our previous reports.9 TCF1+ stem-like CD8 T-cells were identifiable by both flow cytometry and immunofluorescence and resided in dense antigen presenting niches. Quantitative immunofluorescence revealed the location of aSMA+ fibroblasts within tumor tissue, in relation to antigen presenting niches, and in tumors with many infiltrating T-cells. Pathologist scored hematoxylin and eosin-stained slides were delineated TLS+ or TLS-. Quantitative immunofluorescence imaging analysis revealed the detailed composition of tumor infiltrating immune cell populations and the contrasting cellular organization in TLS as compared to in antigen presenting niches.

Conclusions

As we have shown CD8 T-cell infiltration to predict PFS in renal tumors and that antigen presenting niches containing stem-like cells maintain the anti-tumor T-cell response,9 it is critical to understand the additional cell types present in these niches and to understand how these niches relate to previously described phenomena of immune organization, such as TLS.10–12 This mechanistic understanding of the anti-tumor immune response represents an opportunity to inform development of enhanced prognostic tools and innovative therapeutic possibilities.

References

Azimi F, et al. Tumor-infiltrating lymphocyte grade is an independent predictor of sentinel lymph node status and survival in patients with cutaneous melanoma. J Clin Oncol 2012;30(21):2678–83. Epub 2012/06/20. doi: 10.1200/jco.2011.37.8539. PubMed PMID: 22711850.

Galon J, et al. Type, density, and location of immune cells within human colorectal tumors predict clinical outcome. Science 2006;313(5795):1960–4. Epub 2006/09/30. doi: 10.1126/science.1129139. PubMed PMID: 17008531.

Mlecnik B, et al. Integrative analyses of colorectal cancer show immunoscore is a stronger predictor of patient survival than microsatellite instability. Immunity 2016;44(3):698–711. Epub 2016/03/18. doi: 10.1016/j.immuni.2016.02.025. PubMed PMID: 26982367.

Mlecnik B, et al. Histopathologic-based prognostic factors of colorectal cancers are associated with the state of the local immune reaction. J Clin Oncol 2011;29(6):610–8. Epub 2011/01/20. doi: 10.1200/JCO.2010.30.5425. PubMed PMID: 21245428.

Pagès F, et al. Immune infiltration in human tumors: a prognostic factor that should not be ignored. Oncogene 2009;29:1093. doi: 10.1038/onc.2009.416.

Peranzoni E, et al. Macrophages impede CD8 T cells from reaching tumor cells and limit the efficacy of anti-PD-1 treatment. Proceedings of the National Academy of Sciences of the United States of America 2018;115(17):E4041–E50. Epub 2018/04/11. doi: 10.1073/pnas.1720948115. PubMed PMID: 29632196.

Savas P, et al. Single-cell profiling of breast cancer T cells reveals a tissue-resident memory subset associated with improved prognosis. Nat Med 2018;24(7):986–93. Epub 2018/06/27. doi: 10.1038/s41591-018-0078-7. PubMed PMID: 29942092.

Tosolini M, et al. Clinical impact of different classes of infiltrating T cytotoxic and helper cells (Th1, th2, treg, th17) in patients with colorectal cancer. Cancer Res 2011;71(4):1263–71. Epub 2011/02/10. doi: 10.1158/0008-5472.Can-10-2907. PubMed PMID: 21303976.

Jansen CS, et al. An intra-tumoral niche maintains and differentiates stem-like CD8 T cells. Nature 2019;576(7787):465–70. doi: 10.1038/s41586-019-1836-5.

Dieu-Nosjean MC, et al. Tertiary lymphoid structures in cancer and beyond. Trends Immunol 2014;35(11):571–80. Epub 2014/12/03. doi: 10.1016/j.it.2014.09.006. PubMed PMID: 25443495.

Goc J, et al. Characteristics of tertiary lymphoid structures in primary cancers. Oncoimmunology 2013;2(12):e26836. Epub 2014/02/06. doi: 10.4161/onci.26836. PubMed PMID: 24498556; PMCID: PMC3912008.

Sautes-Fridman C, et al. Tertiary lymphoid structures in the era of cancer immunotherapy. Nature reviews Cancer 2019;19(6):307–25. Epub 2019/05/17. doi: 10.1038/s41568-019-0144-6. PubMed PMID: 31092904.

Ethics Approval

Samples are collected under an approved IRB protocol (The Urological Satellite Specimen Bank at Emory University, IRB00055316). All patients provided informed consent.

Consent

Samples are collected under an approved IRB protocol (The Urological Satellite Specimen Bank at Emory University, IRB00055316). All patients provided informed consent.

658 CD8 T cell activation in cancer is comprised of two distinct phases

Background

CD8 T cell are a crucial part of the immune response to tumors, with CD8 infiltration predicting disease progression in numerous cancer types. Recently two subsets of CD8 T cells that respond to tumors have been described, a stem-like (TCF1+) CD8 T cell that can give rise to a more cytotoxic terminally differentiated (TD) (TCF1-Tim3+) CD8 T cell. In this study we aimed to understand the origin of stem-like TCF1+ CD8 T cells within tumors.

Methods

Human patient TDLN and tumor samples from kidney and prostate cancer were processed after resection and used for flow cytometry, RNA-seq, TCR-seq and whole genome DNA methylation analysis. We also used a prostate cancer mouse model that expresses the LCMV GP protein (TRAMPC1-LCMV-GP) to track tumor-specific CD8 T cells in both TDLNs and tumors.

Results

We studied human prostate and kidney cancer tumor-draining lymph nodes (TDLN) and found that CD8 T cells are activated but fail to acquire an effector phenotype within the TDLN. Instead, they share functional, transcriptional, and epigenetic traits with stem-like cells in the tumor. We also found that activated CD8 T cells from TDLNs shared TCR overlap with both CD8 subsets within tumors. This suggests that these activated cells are a precursor to the stem-like CD8 T cells in tumors. To further test this hypothesis, we used our TRAMPC1-LCMV-GP tumor model to study tumor-specific CD8 T cell activation. We found that CD8 T cells are activated in TDLNs but fail to acquire an effector program. These cells then establish the stem-like CD8s within tumor where they require additional co-stimulation from antigen presenting cells to differentiate into TCF1- TD CD8 T cells. This is strikingly different from canonical CD8 T cell activation to acute viruses, where the effector program is acquired immediately. We also showed that human stem-like CD8 T cells require co-stimulation and TCR stimulation to divide and differentiate into terminally differentiated CD8s in-vitro, and DCs from autologous tumors can also induce this differentiation.

Conclusions

Overall this work shows a model of CD8 T cell activation in response to tumors that has two distinct phases. The first occurs in the TDLN where CD8 T cells are initially activated, the second occurs in the tumor where CD8 T cells acquire an effector function after additional co-stimulation. This model of T cell differentiation adds to our understanding of basic CD8 T cell biology and has important implications to improve our current immunotherapies.

Clinical laboratory tests associated with survival in patients with metastatic renal cell carcinoma: A Laboratory Wide Association Study (LWAS)

BACKGROUND

Prognostic models for patients with metastatic renal cell carcinoma (mRCC) include select laboratory values. These models have important limitations, including reliance on a limited array of laboratory tests, and use of dichotomous ("high-low") cutoffs. We applied a Laboratory-Wide Association Study (LWAS) framework to systematically evaluate common clinical laboratory results associated with survival for patients diagnosed with mRCC.

METHODS

We used laboratory data for 3,385 patients diagnosed with mRCC from 2002 to 2017. We developed a LWAS framework, to examine the association with 53 common clinical laboratory tests results (641,712 measurements) and overall survival. We employed false-discovery rate to test the association of multiple laboratory tests with survival, and validated these results using 3 separate cohorts to generate a standardized hazard ratio (sHR), reported for a 1 standard deviation unit change in each laboratory test.

RESULTS

The LWAS approach confirmed the association of laboratory values currently used in prognostic models with survival, including calcium (HR 1.35, 95%CI 1.24-1.48), leukocyte count (HR 1.40, 95%CI 1.30-1.51), platelet count (HR 1.36, 95%CI 1.27-1.51), and hemoglobin (HR 0.79, 95%CI 0.72-0.86). Use of these tests as continuous variables improved model performance. LWAS also identified acute phase reactants associated with survival not typically included in prognostic models, including serum albumin (HR 0.66, 95%CI 0.61-0.72), ferritin (HR 1.25, 95%CI 1.08-1.45), alkaline phosphatase (HR 1.31, 95%CI 1.23-1.40), and C-reactive protein (HR 1.70, 95%CI 1.14-2.53).

CONCLUSIONS

Routinely measured laboratory tests can refine current prognostic models, facilitate comparisons across clinical trial cohorts, and match patients with specific systemic therapies.

Impact of radiation therapy on perineal urethrostomy for penile cancer

OBJECTIVE

A lack of demonstrated clinical benefit precludes radiotherapy (RT) from being recommended for pN1/pN2 penile cancer (PeCa) lesions; but it may be recommended in case of extranodal (pN3) disease or for positive resection margins. Perineal urethrostomy (PU) is a technique of urinary diversion in patients with PeCa requiring total or subtotal penectomy as primary therapy. Prior studies suggest PU failure rates of up to 30%, without specific mention of the potential role of RT. When RT is delivered for PeCa it is usually to the pre-pubic fat, groin and lateral pelvis, and not to the region of the PU. Here we describe the role of perioperative RT in a large, multi-institutional registry of PU for PeCa.

METHODS

In our cohort, 299 patients from seven international, high-volume centers in Belgium, Brazil, China, Netherlands, United Kingdom and the United States underwent PU as urinary diversion for PeCa between 2000 and 2020. Demographic and clinicopathologic characteristics were reviewed.

RESULTS

Median patient age was 67 years and median follow-up was 19 months. Seven patients (2.3%) received pre-operative RT; six of them with chemotherapy. 37 received RT post-operatively, 21 (57%) with chemotherapy. Stenosis of the PU occurred in 35 (12%) of the total population. The majority of these patients (74%) required surgical revision at a median of 6.1 months post-operatively. RT delivery was neither significantly related to PU stenosis (p = 0.16) or to subsequent revision (p = 0.75).

CONCLUSION

Receipt of RT was not significantly associated with increased stenosis risk in PeCa patients who underwent PU.

CD8 T cell differentiation in cancer is comprised of two distinct phases

A crucial part of the immune response to tumors are CD8 T cells, with CD8 infiltration predicting disease progression in many cancers. Recent work has shown two subsets of CD8 T cells that respond to tumors, one a stem-like CD8 T cell (TCF1+) that can give rise to a more cytotoxic terminally differentiated cell (TCF1−). To understand the CD8 T cell response to tumors it is important to study how tumor-specific CD8 T cells activate and differentiate. To study this we have made a prostate cancer model which expresses the LCMV glycoprotein (GP) and acts as a tumor-specific antigen. This model allows us to transfer LCMV GP specific P14 CD8 T cells into TRAMPC1-GP bearing mice to study how tumor-specific CD8 T cells activate. These studies have shown that tumor-specific CD8 T cells are activated in tumor draining lymph nodes (TDLN), where they retain an activated undifferentiated phenotype, upregulating CD44, PD1, while maintaining TCF1. These tumor-specific CD8 T cells only differentiate (TCF1−) once they have migrated into the tumor. This model can also be seen in human prostate cancer, with CD8 T cells in TDLNs retaining an activated undifferentiated phenotype (PD1+CD45RA-TCF1+). To determine if these cells are related to the CD8s within the tumor we have shown TCR overlap between the activated CD8s T cells in human prostate TDLNs and the CD8 T cell subsets within the tumor. These data suggest a two-step differentiation process for tumor-specific CD8 T cells where they are activated in TDLNs and differentiate further only in the tumor. This model of two distinct phases of CD8 T cell differentiation adds to the basic understanding of the immune response to cancer.

Patient-Reported Outcomes of Pain and Related Symptoms in Integrative Oncology Practice and Clinical Research: Evidence and Recommendations

Pain is a primary concern among patients with cancer and cancer survivors. Integrative interventions such as acupuncture, massage, and music therapy are effective nonpharmacologic approaches for cancer pain with low cost and minimal adverse events. Patient-reported outcomes (PROs) that have been validated in many clinical and research settings can be used to evaluate pain intensity, associated symptom burden, and quality of life. Clearly defined, reliable PROs can improve patient satisfaction and symptom control. As integrative oncology continues to evolve and expand, cancer-related pain PROs must be standardized to accurately guide clinicians and researchers. Well-validated pain PROs, such as the Brief Pain Inventory, are among the most commonly used for pain intensity assessment. Multiple symptom assessment tools such as the MD Anderson Symptom Inventory, the Memorial Symptom Assessment Scale, the Edmonton Symptom Assessment System, and the Patient-Reported Outcomes-Common Terminology Criteria for Adverse Events measurement system can also capture pain-associated symptom burden. Electronic PROs provide flexibility in collecting and analyzing PRO data. Clinical trials using carefully selected PROs and rigorous statistical analysis plans are fundamental to conducting high-quality integrative oncology research and promoting utilization of effective integrative interventions to improve patient outcomes. In this review, we aim to summarize current, validated PROs specific to cancer-related pain to aid integrative oncology clinicians and researchers in patient care and in study design and implementation.

Elevated preoperative C-reactive protein is associated with renal functional decline and non-cancer mortality in surgically treated renal cell carcinoma: analysis from the INternational Marker Consortium for Renal Cancer (INMARC)

OBJECTIVE

To investigate association of preoperative C-reactive protein (CRP) and non-cancer mortality (NCM) in a cohort of patients undergoing surgery for localised renal cell carcinoma (RCC).

PATIENTS AND METHODS

Retrospective multicentre analysis of patients surgically treated for clinical Stage 1-2 RCC from 2006 to 2017, excluding all cases of cancer-specific mortality. Descriptive analyses were obtained between the pre-treatment normal-CRP (≤5 mg/L) and elevated-CRP (>5 mg/L) groups. The primary outcome was NCM. The secondary outcomes included progression to de novo chronic kidney disease Stages 3-4 (estimated glomerular filtration rate [eGFR] of <60, <45, and <30 mL/min/1.73 m² ). Multivariable analyses (MVA) were performed to assess for risk factors associated with functional decline and NCM, and Kaplan-Meier analysis was used to obtain survival estimates for outcomes.

RESULTS

A total of 1987 patients who underwent radical or partial nephrectomy were analysed (normal-CRP group, n = 963; elevated-CRP group, n = 1024). Groups were similar in age (59 vs 60 years, P = 0.079). An elevated CRP was more frequent in males (36.8% vs 27.8%, P < 0.001), African-Americans (22.6% vs 2.9%, P < 0.001), and in those with a higher median body mass index (30 vs 25 kg/m² , P < 0.001) and larger median tumour size (4.5 vs 3.3 cm, P < 0.001). On MVA, an elevated CRP was independently associated with development of de novo eGFR of <60 mL/min/1.73 m² (hazard ratio [HR] 1.32, P = 0.015), <45 mL/min/1.73 m² (HR 1.41, P = 0.023) and <30 mL/min/1.73 m² (odds ratio 2.23, P < 0.001). The MVA for factors associated with NCM demonstrated increasing age (HR 1.06, P < 0.001), preoperative elevated CRP (HR 2.18, P < 0.001) and an eGFR of <45 mL/min/1.73 m² (HR 1.16; P = 0.021) as independent risk factors. Kaplan-Meier analysis revealed significantly higher 5-year NCM in the elevated-CRP group vs the normal-CRP group (98% vs 80%, P < 0.001).

CONCLUSIONS

Pre-treatment elevated CRP was independently associated with both progressive renal functional decline and NCM in patients undergoing surgery for Stage 1-2 RCC. Patients with elevated CRP and Stage 1 and 2 RCC may be considered as having indication for nephron-sparing strategies, which may be prioritised if oncologically appropriate.

Utility of Minimally Invasive Technology for Inguinal Lymph Node Dissection in Penile Cancer

Our aim is to review the benefits as well as techniques, surgical outcomes, and complications of minimally invasive inguinal lymph node dissection (ILND) for penile cancer. The PubMed, Wiley Online Library, and Science Direct databases were reviewed in March 2020 for relevant studies limited to those published in English and within 2000–2020. Thirty-one articles describing minimally invasive ILND were identified for review. ILND has an important role in both staging and treatment of penile cancer. Minimally invasive technologies have been utilized to perform ILND in penile cancer patients with non-palpable inguinal lymph nodes and intermediate to high-risk primary tumors or patients with unilateral palpable non-fixed inguinal lymph nodes measuring less than 4 cm, including videoscopic endoscopic inguinal lymphadenectomy (VEIL) and robotic videoscopic endoscopic inguinal lymphadenectomy (RVEIL). Current data suggest that VEIL and RVEIL are feasible and safe with minimal intra-operative complications. Perhaps the strongest appeal for the use of minimally-invasive approaches is their faster post-operative recovery and less post-operative complications. As a result, patients can tolerate this procedure better and surgeons can offer surgery to patients who otherwise would not be a candidate or personally willing to undergo surgery. When compared to open technique, VEIL and RVEIL have similar dissected nodal count, a surrogate metric for oncological adequacy, and a none-inferior inguinal recurrence rate. Larger randomized studies are encouraged to investigate long-term outcome and survival rates using these minimally-invasive techniques for ILND.

AB1126 THE RELIABILITY AND DIAGNOSTIC ACCURACY OF DIGITAL TOMOSYNTHESIS COMPARED WITH CONVENTIONAL RADIOGRAPHY FOR THE INVESTIGATION OF SACROILIITIS

Background:

Conventional radiography remains part of the diagnosis of axial spondyloarthritis and determines qualification for biologic disease modifying anti-rheumatic drugs in many countries. The standard anteroposterior radiograph (XR) incompletely images the complex sacroiliac joint with recognised unacceptably low levels of agreement between readers. Digital tomosynthesis (DTS) uses conventional radiographic projections to create a three-dimensional image and is a potential alternative for the initial radiographic detection and grading of sacroiliitis.

Objectives:

To compare the level of agreement between two radiologists when reporting sacroiliac joint imaging with digital tomosynthesis versus conventional radiography, as well as to compare the diagnostic accuracy of each imaging modality.

Methods:

229 consecutive patients that had radiography and digital tomosynthesis performed at Footscray Hospital, Melbourne, Australia were included. Two blinded radiologists independently re-reported all images according to the modified New York criteria, or listed an alternative diagnosis. An overall assessment of each image as inflammatory sacroiliitis, normal or non-inflammatory disease was also recorded. Demographic and clinical data were extracted from medical records. Agreement between and within readers was evaluated using kappa (κ) statistic. Diagnostic accuracy was calculated by comparing each reader’s overall assessment against 2 reference standard comparators: most recent rheumatologist diagnosis and fulfillment of ASAS criteria at any time point.

Results:

The intra-reader agreement of reader 1 was almost perfect for the left, right and overall sacroiliac joint assessments (κ 0.77 - 0.94), with DTS outperforming XR. Reader 2 agreement was mostly moderate (κ 0.39 - 0.69), with DTS and XR better on the left and right sacroiliac joint respectively, but XR having better overall assessment. The inter-reader agreement of DTS for all patients was moderate and better than XR as shown in the Table. When excluding non-spondyloarthritis patients, inter-reader agreement improved (κ 0.50 to 0.58) but there was no significant difference between DTS and XR. Using reader 1, the sensitivity of DTS (64.8 - 66.7%) was better than XR (54.9 - 60.7%) but low, in keeping with what is known about radiographic sacroiliitis and axial spondyloarthritis. The specificity of XR (78.5 – 80.3%) was better than DTS (72.3 – 73.1%). There were no significant differences when fulfillment of modified New York Criteria was used as a reader’s positive test.

Table.

Inter-rater reliability between the readers

All patients(N=229)*Inflammatory sacroiliitis & normal patients (N=164)**Inflammatory sacroiliitis patients (N=92)**XR Right0.360.520.56DTS Right0.390.500.51XR Left0.340.550.56DTS Left0.420.550.58XR Overall0.40DTS Overall0.45

*Non-weighted kappa statistic

**Weighted kappa statistic

Conclusion:

DTS demonstrated moderate reliability for assessment of sacroiliitis, marginally better than conventional radiography. Overall levels of agreement for both imaging modalities were however lower than radiography in previous studies, with several possible contributing factors. A prospective study in a selected spondyloarthritis cohort may better determine any benefit of DTS.

References:

[1]Christiansen AA, Hendricks O, Kuettel D, Horslev-Petersen K, Jurik AG, Nielsen S, et al. Limited Reliability of Radiographic Assessment of Sacroiliac Joints in Patients with Suspected Early Spondyloarthritis. The Journal of rheumatology. 2017;44(1):70-7.

[2]van Tubergen A, Heuft-Dorenbosch L, Schulpen G, Landewe R, Wijers R, van der Heijde D, et al. Radiographic assessment of sacroiliitis by radiologists and rheumatologists: does training improve quality? Annals of the rheumatic diseases. 2003;62(6):519-25.

Disclosure of Interests:

None declared

Tumor-specific CD8 T cell activation in draining lymph nodes supports the anti-tumor CD8 T cell response

CD8 T cells are a critical part of the immune response to tumors, with CD8 T cell infiltration predicting disease progression in many types of cancer. Recent work in CD8 T cell immunology described how CD8 T cells respond to chronic diseases, finding two subsets of CD8 T cells within tumors. One is a stem-like CD8 T cell and the other is a terminally differentiated CD8 T cell with cytotoxic capabilities. Determining how tumor-specific CD8 T cells activate and differentiate is critical to understanding why some tumors are highly infiltrated. To study how tumor-specific CD8 T cells are activated, I have made a prostate cancer model that expresses the viral LCMV glycoprotein (GP) which acts as a tumor-specific antigen. We have used this model to study tumor-specific CD8 T cell activation by adoptively transferring LCMV GP specific TCR transgenic P14 CD8 T cells into TRAMPC1-LCMV-GP bearing mice. We have found when tumor-specific CD8 T cells are activated in the tumor-draining lymph node they acquire an undifferentiated but activated program, upregulating CD44, PD1 but retaining high TCF1 and CD62L expression. These undifferentiated activated CD8 T cells do not acquire a typical effector program that is seen in an acute viral infection such as LCMV Armstrong, yet they are able to migrate to the tumor to establish the anti-tumor response. In conclusion, tumor-specific CD8 T cells do not acquire an effector program after activation and instead gain an undifferentiated activated phenotype. These data suggest that tumor-specific CD8 T cells are activated in the TDLN and differentiate to become the stem-like CD8 T cells within the tumor, establishing the anti-tumor CD8 response.