Urologic Oncology-seminars and Original Investigations最新文献

Introduction and objective: It remains unknown whether the use of nephron sparing intervention (NSI) is impacted with delayed intervention after a period of active surveillance (AS) compared with immediate intervention for patients with clinically localized renal masses ≤7cm (cT1RMs). We hypothesized that the proportion of patients undergoing NSI is similar among patients undergoing immediate and delayed intervention for cT1RMs.

Methods: We retrospective reviewed the prospectively maintained Michigan Urological Surgery Improvement Collaborative (MUSIC) registry for patients undergoing intervention for cT1RMs from 05/2017 to 09/2023. The primary outcome was type of treatment received: radical nephrectomy (RN) or NSI (partial nephrectomy, ablation, or stereotactic body radiation therapy). The main independent variable was timing of treatment: immediate (treatment within 90 days) vs. delayed intervention (>90 days). We fit a mixed-effects multivariable logistic regression model to assess for the adjusted association of immediate vs delayed intervention with the receipt of NSI and estimate an adjusted probability of NSI.

Results: We identified 2,156 patients, of whom 93% underwent immediate intervention and 7% underwent a period of AS prior to delayed intervention. Median time from initial visit to intervention was 1.4 (IQR 0.9-2.0) and 13 (IQR 7.7-21) months in the immediate vs delayed intervention groups, respectively. In the multivariable model, we did not appreciate a significant association between delayed intervention with receipt of NSI (OR 0.99, 95% CI 0.57-1.70, P >0.9). The adjusted proportion of NSI was 75% and 78% for patients in the immediate and delayed intervention cohorts, respectively.

Conclusion: Patients undergoing delayed intervention after AS had similar use of NSI compared with those undergoing immediate intervention. Active surveillance for patients with cT1RMs does not appear to compromise the ability to perform nephron sparing interventions.

Background: For patients with metastatic bladder cancer (mBC) palliative chemotherapy is one of the main treatment options. Real-world insights into outcomes are available, but a comprehensive overview of specific treatment details like number of chemotherapy cycles received and (reasons for) adjustments is lacking.

Methods: A population-based study was conducted, including all patients diagnosed with mBC in the Netherlands between 2016 and 2021 who started chemotherapy as initial treatment. Data on patient, tumor, and treatment characteristics, including number of cycles, adjustments and reasons for adjustments, and survival were collected from the Netherlands Cancer Registry. Treatment patterns and outcomes were analyzed descriptively. Logistic regression analysis was used to identify factors associated with receiving the full guideline-recommended treatment (4-6 cycles).

Results: A total of 684 patients started first-line chemotherapy, mostly carboplatin-based (54%). Of these patients, 35% did not receive the full course of treatment. Among these patients who received <4 cycles, 24% died within one month of stopping treatment. Male sex and good performance status were independently associated with receiving the full course of treatment. Among patients who did receive a full course of treatment, half still had adjustments to their treatment schedule, which mainly included dose reductions due to side effects.

Conclusions: Among patients with mBC starting first-line chemotherapy, only a small majority received the recommended number of cycles, and treatment adjustments were common. This suggests that adhering to recommended treatment is challenging, emphasizing the importance of integrating insights on treatment discontinuation and modifications into the shared decision-making process and guideline development.

Treatment monitoring in metastatic castrate-resistant prostate cancer has become a hot topic in the androgen receptor pathway inhibitors (ARPIs) era. Patients without increase in their PSA level at the time of imaging progression are not a rare phenomenon. What is the best monitoring strategy in asymptomatic cases represents a salient question. Here we presented 2 case reports involving men with metastatic castration-resistant prostate cancer who experienced disease progression without the anticipated increase in PSA levels. Our 2 cases show that imaging beyond standard PSA determination should be incorporate to monitor disease progression in patients with metastatic castrate-resistant prostate cancer even in the context of an undetectable PSA.

Objective: The Contact Surface Area (CSA) is a predictor for peri-operative parameters and represents the contact area between the tumor and the organ. A precise method for calculating CSA is yet to be found. We tested a new CSA calculation method as a predictor of intra-operative parameters in robot assisted partial nephrectomy (RAPN).

Materials & methods: The study population consisted of all consecutive patients treated with RAPN at a single high-volume European institution (between 2020 to 2023; 82 patients). We proposed a new method to measure the real value of CSA using an algorithm that leverages the geometry of kidneys and tumors obtained from 3D reconstruction. These reconstructions were obtained using the certified software Materialized Mimics InPrint. The peri-operative parameters of patients were recorded in an anonymous database. We explored the correlation between real CSA (RCSA), CSA of Hsieh (HCSA), PADUA and R.E.N.A.L. scores with peri-operative parameters using Spearman's correlation. Furthermore, we examined which of RCSA, PADUA and R.E.N.A.L. score better describes the intra-operative parameters, Warm Ischemia Time (WIT), Operating Time (OT), and Estimated Blood Loss (EBL) using Receiver Operating Characteristic (ROC) curve analysis. Multivariable linear regression analyses were performed.

Results: Seventy-eight patients were prospectively enrolled. We observed a significant correlation between RCSA and WIT (P < 0.001), OT (P < 0.001) and EBL (P < 0.001). Moreover, RCSA outperformed both the PADUA and R.E.N.A.L. score as demonstrated in the ROC curve analysis. In ROC analysis was chosen a threshold for each of the parameters: for WIT 20 minutes, for OT 180 minutes and for EBL 200 mL. At multivariable regression analysis, RCSA emerged as the only independent predictor for WIT (P = 0.002), OT (P = 0.01) and EBL (P < 0.001).

Conclusions: Our original 3D RCSA calculation method was associated to intra-operative surgical outcomes. As compared to PADUA and RENAL score, our calculated RCSA represented a more reliable predictor of intra-operative parameters.

Introduction: Studies have shown that cystectomy has a large psychological burden on patients with bladder cancer. However, there has been little work characterizing areas of improvement. This project aimed to understand cystectomy patients' experiences and to identify patient-centered methods to improve perioperative support.

Methods: Five focus groups, divided by diversion type and gender, (4 virtual, 1 in person) of patients with bladder cancer (n = 17) who underwent cystectomy were conducted. Conversations were transcribed and qualitatively analyzed using the Sort and Sift, Think and Shift© method. Transcripts were coded in NVivo and themes were summarized in higher-level analysis.

Results: Patients described feelings of depression, anger, and anxiety in response to their cancer diagnosis, need for cystectomy, and living with urinary diversion. Patients experienced daily mental hardship while adapting. They experienced distress from diversion visibility in public and private encounters. Many expressed a dichotomy of feeling grateful for the treatment while also feeling bitter about the impact on their daily life. Patients reported that while their care team provided support for tangible needs, they did not provide information for nor discuss mental and sexual health needs during this time. Patients reported that if their provider had initiated discussions and offered referrals, they would have accepted support. Patients also emphasized the benefit of social and peer support networks for emotional support.

Conclusions: Groups identified the psychological difficulties of bladder cancer diagnosis and cystectomy. Potential avenues for improvement included incorporating support resources into the care plan and perioperative discussion regarding the emotional impact of surgery.

Background: The role of primary tumor ablation (pTA) in metastatic renal cell carcinoma (mRCC) is unknown. We compared pTA-treated mRCC patients to patients who underwent no local treatment (NLT), as well as patients who underwent cytoreductive nephrectomy (CN).

Methods: Within the Surveillance, Epidemiology, and End Results database (SEER, 2004-2020), we identified mRCC patients who underwent either pTA, NLT or CN. Endpoints consisted of overall survival (OM) and other-cause mortality (OCM). Propensity score 1:1 matching (PSM), multivariable cox regression models (OM), as well as, multivariable competing risk regressions (CRR) models (OCM) were used.

Results: We identified 27,087 mRCC patients, of whom 82 (0.3%) underwent pTA, 17,266 (64%) NLT and 9,739 (36%) CN. In comparisons of pTA vs. NLT mRCC patients addressing OM, after 1:1 PSM, median survival was 19 months for pTA vs. 4 months for NLT patients (multivariable HR 0.3, 95% CI 0.22-0.47, P < 0.001). No statistically significant OCM differences were recorded in multivariable CRR (HR 1.13 95%, CI 0.52-2.44, P = 0.8). In comparisons of pTA vs. CN, after 1:1 PSM, no statistically significant differences in OM (HR 1.22, 95% CI 0.81-1.83, P = 0.32), as well as OCM (HR 1.4, 95% CI 0.56-3.48, P = 0.5) were recorded.

Conclusion: In mRCC patients, pTA is associated with significantly lower mortality compared to NLT. Interestingly, OM rates between pTA and CN mRCC patients do not exhibit statistically significant differences. This preliminary report may suggest that pTA may provide a comparable survival benefit to CN in highly selected mRCC patients.

Purpose: Combination systemic therapies (CSTs) of immuno-oncologic (IO) and VEGF-inhibiting agents (VEGFi) have become the standard of care for management of metastatic clear cell renal cell carcinoma (m-ccRCC). However, treatment outcomes vary between patients, with no established biomarkers to determine optimal CST regimens (IO/IO or IO/VEGFi). Prostate Specific Membrane Antigen (PSMA), encoded by the FOLH1 gene, is a marker of tumor neovasculature in ccRCC, the downstream target of VEGFi. We evaluated the relation between FOLH1 expression and angiogenesis, as well as clinical outcomes, in 5 m-ccRCC ST trials.

Materials and methods: using Spearman's rank correlation (SPRC) test, we assessed the correlation between FOLH1 expression and gene expression signature (GES) scores corresponding to angiogenic and immunologic features of the tumor microenvironment (TME) of m-ccRCC in our trial cohorts. Using Cox proportional hazard regression (Cox-PHR), we assessed the association between FOLH1 expression level, summarized by within-study quantiles (qFOLH1), and progression-free and overall survival (PFS, OS).

Results: Increased FOLH1 expression was significantly associated with higher TME angiogenesis GES scores (SPRC +0.5, P < 0.001), but did not consistently correlate with immune feature GES scores. Meta-analysis of PFS in the sunitinib TKI arm of trial cohorts showed an overall positive association with qFOLH1 (HR = 0.89; 95% CI = 0.85-0.94, P < 0.0001). qFOLH1 was not significantly associated with OS in the sunitinib arms of the two trials with OS data (COMPARZ, HR 0.87, 95% CI 0.71-1.07, P = 0.17; and Checkmate-214, HR 0.89, 95% CI 0.67-1.17, P = 0.70).

Conclusions: PSMA-encoding FOLH1 gene expression correlates with neoangiogenesis and predicts PFS in m-ccRCC patients treated with sunitinib TKI, suggesting that PSMA PET could be explored as a noninvasive biomarker for guiding CST choice (IO/IO or IO/VEGFi) as well as prediction of treatment response to VEGFi in m-ccRCC patients.