Urologic Oncology-seminars and Original Investigations最新文献

Robotic assisted partial nephrectomy is an effective and minimally invasive approach that has gained significant popularity in the past 20 years. Guidelines support prioritizing partial nephrectomy in small renal masses when technically feasible, given improvement in long term renal function and cardiovascular risk. Increasing surgeon comfort with the robotic platform has allowed for the removal of larger and more complex tumors. There are a vast number of surgical techniques described in the literature for dissection, hilum clamping, tumor resection and renorrhaphy. We aim to describe and summarize different considerations and techniques to utilize when performing robotic assisted partial nephrectomy in complex renal masses. In this review, we specifically focus on masses with higher tumor complexity (RENAL score ≥10, those that involve or about the hilum or are invasive into the renal sinus).

Introduction and objective: Subcentimeter pulmonary nodules (SPN) found in clinical stage I (CS I) seminoma may be early pulmonary metastases or incidental, benign entities that may lead to patient anxiety and overtreatment. This study aims to demonstrate the incidence and natural history of SPN in CS I seminoma patients.

Methods: A retrospective study reviewing the medical records of CS I seminoma patients treated at UC San Diego Health between 2003 and 2023. Data collection included demographics, serum tumor markers (STM), imaging reports, pathologic findings, treatment records, and records of disease relapse. We described SPN as a finding either from a chest X-ray (CXR) or a computed tomography (CT) scan of the chest at the time of seminoma diagnosis, with a size <1cm. The incidence of SPN and relationship with disease relapse was explored.

Results: 79 patients with CS I seminoma were included in the study, and mean follow-up time was 40 months. Our general practice is to observe all patients with stage I seminoma except under extenuating circumstances. Among them, 21 patients were found to have SPN, all which were diagnosed on CT scan of chest, resulting in an incidence rate of 26.6%. Notably, there was no statistically significant difference in the occurrence of SPN between patients with CS IA and CS IB (27.9% and 22.2%, respectively, P = 0.227). Four patients (5%) experienced disease relapse. None of the patients that had a relapse had an incidental subcentimeter nodules. Six patients received adjuvant chemotherapy (CMT); 1 patient had a pulmonary nodule and did not relapse; 1 patient experienced disease relapse without nodule. 10 patients underwent adjuvant radiation (RT), with no recurrence observed despite 4 of them having nodules. Additionally, 5 patients with nodules received adjuvant CMT or RT; none recurred. 16 patients with nodules were under surveillance, none recurred.

Conclusions: The incidence of SPN in CS I seminoma patient is high. Subcentimeter nodules do not appear to be related to risk of disease relapse. Our findings suggest that patients with CS I seminoma and incidental SPN can be counseled that this is a common, clinically insignificant finding. Further validation in a larger population is necessary.

Introduction: It is unknown whether sex-related differences in response to neoadjuvant (NAC) or adjuvant chemotherapy (ADJ) exist in urothelial carcinoma patients treated with radical cystectomy (RC). We addressed these knowledge gaps.

Material and methods: Within the Surveillance, Epidemiology, and End Results database (2007-2020), we identified NAC candidates (T2-T4N0M0) and ADJ candidates (T3-T4 and/or N1-3). We divided patients according to sex (male versus female). Subsequently, within NAC-candidate patients, survival analyses consisted of Kaplan-Meier plots and multivariable Cox regression models (MCR) addressing cancer-specific mortality (CSM) according to NAC-exposed versus RC alone. We repeated the same methodology in ADJ-candidate patients.

Results: We identified 5,745 NAC candidates, of whom 1,278 were female (22%) and 4,467 were male (78%). Among these, NAC was administered in 247 (19%) females and 986 (22%) males. In females, NAC exposure independently predicted lower CSM rates relative to RC alone (HR: HR:0.73, P = 0.03). In males, NAC exposure also independently predicted lower CSM rates, but to greater extent (HR:0.65, P < 0.001). Similarly, we identified 7,283 ADJ candidates, of whom 1,659 (23%) were females versus 5,624 (77%) males. Among these, ADJ was administered in 365 females (22%) and 1,326 (24%) males. In females, ADJ exposure independently predicted lower CSM rates relative to RC alone (HR:0.81, P = 0.02). In males, ADJ exposure also independently predicted lower CSM rates, but to greater extent (HR:0.68, P < 0.001).

Conclusion: Although both male and female patients benefit of improved survival with either NAC or ADJ, the magnitude of this benefit is significantly lower in female patients to that recorded in male counterparts.

Background: Radical cystectomy (RC) is the guideline-recommended gold standard of curative treatment for muscle-invasive bladder cancer (MIBC). Trimodality therapy (TMT) has recently emerged as a viable alternative treatment, aiming to improve long term survival and bladder preservation rates.

Methods: A systematic literature search was conducted on PubMed, Embase, Scopus and CENTRAL for randomized trials or covariate-matched studies comparing RC versus TMT for MIBC. A graphical reconstructive algorithm was used to obtain overall survival (OS) and cancer-specific survival (CSS) of individual patients, which was then pooled under random-effects individual patient data (IPD) meta-analysis using Cox-models to determine hazard ratios (HRs) and 95% CI.

Results: Altogether, 11 studies, comprising mostly cT2-T4, node-negative, nonmetastatic MIBC, were analyzed. Across 9 studies (6780 patients), TMT was associated with lower OS versus RC (shared-frailty HR = 1.14, 95% CI, 1.08-1.21, P < 0.001). Estimated OS at 1, 5 and 10 years was 86%, 47% and 18% respectively for TMT, and 86%, 57% and 22% for RC. Across 8 studies (4,776 patients), TMT was associated with lower CSS versus RC (shared-frailty HR = 1.09, 95% CI, 1.01-1.18, P = 0.024). Estimated CSS at 1, 5 and 10 years was 92%, 62% and 29% respectively for TMT, and 94%, 72% and 29% respectively for RC.

Conclusions: In the absence of large trials, our meta-analysis of studies of the next-highest quality of evidence suggests that RC may still confer OS and CSS benefit over TMT in MIBC. RC should remain the standard of care for nonmetastatic MIBC while TMT remains a valid alternative for carefully selected and informed patients.

Introduction: Bacillus Calmette-Guerin (BCG) is an immunologic treatment for patients with intermediate and high-risk Nonmuscle Invasive Bladder Cancer (NMIBC). It has been hypothesized that age related immune impairment might lead to decreased efficacy of BCG in older patients. One recent single-institution study found no association between age > 70 and worse oncologic outcomes in a cohort of 632 patients. We sought to validate these findings using a single institution database of NMIBC patients treated with BCG.

Methods: We performed a retrospective analysis of patients diagnosed with NMIBC and treated with adequate BCG between 2000 and 2023 at our institution. Patients were divided into two cohorts based on age at NMIBC diagnosis: age ≤ 70 years and age > 70 years. Fine-Gray competing risk survival analysis was performed to assess for differences in the cumulative incidence of high-grade recurrence (HGR), progression (progression to muscle invasive bladder cancer or distant metastasis) and bladder cancer specific mortality (CSM) according to patient age.

Results: We identified 473 patients treated with adequate BCG. 232 patients (49%) were aged ≤ 70 and 241 (51%) were aged > 70. Neither cohort differed significantly in terms of race, sex, or tumor characteristics. On competing risk analysis age > 70 was not significantly associated with increased HGR (HR 0.77; 95% CI 0.59-1.02, P = 0.06), progression (HR 1.17; 95% CI 0.62-2.18, P = 0.63), or CSM (HR 1.12; 95% CI 0.42-2.95, P = 0.82).

Conclusion: We did not observe an association between age > 70 and increased HG recurrence, bladder cancer progression, or CSM. Our results are consistent with other recent series and suggest that BCG efficacy in NMIBC is not negatively affected by increased patient age.

Testicular cancer represents 1% of adult neoplasms and is the most common solid malignancy in young men. Of men presenting with seminoma, approximately 20% will have clinical stage (CS) II disease, characterized by enlarged retroperitoneal lymph nodes without further metastasis. A further group of men will present with CS I disease but later experience relapse in the retroperitoneal lymph nodes. The standard treatment for many decades in these patients is either radiotherapy (30-36Gy) or chemotherapy (BEPx3, EPx4). Despite high cure rates with these modalities, concerns persist regarding short and long-term treatment-related toxicities. Survivors of testicular cancer treated with chemotherapy or radiotherapy face increased risks of cardiovascular disease (1.5-6-fold) and secondary malignancies (twice as likely for solid cancers and 5 times for leukemia). An alternative approach explored is primary Retroperitoneal Lymph Node Dissection (RPLND). Several institutional series along with 4 single-arm phase II trials have investigated primary RPLND in men with low-volume retroperitoneal metastases. Herein, we review the evidence, strengths and limitations of the current studies and future for primary RPLND for seminoma.

Background: Immune-related adverse events (irAEs) are reportedly associated with favorable outcomes in patients with metastatic urothelial carcinoma (mUC) receiving pembrolizumab. Previous studies on this topic focused on the severity of irAEs. The type and number of organs affected by irAEs may also be associated with the therapeutic outcomes.

Methods: The present, retrospective study included 146 patients with mUC receiving pembrolizumab between January 2018 and March 2022. The primary endpoints were the overall response rate (ORR), progression-free survival (PFS), and overall survival (OS) associated with the type and number of organs affected by irAEs and the severity of the symptoms. IrAEs were graded using the Common Terminology Criteria for Adverse Events version 5.0. The treatment response was assessed using the Response Evaluation Criteria in Solid Tumors version 1.1. Cox proportional hazards was used to assess for any association between the variables and survival. Time-dependent analysis was used to assess the status of irAEs as a prognostic factor.

Results: IrAEs ≥ grade (G) 2 were observed in 48 (33%) patients, of whom 9 (6%) had multiple irAEs. IrAEs ≥G2 were significantly associated with a higher ORR (57% vs. 22% for

Conclusions: The severity and number of irAEs and the organs affected by them appeared to be relevant to the therapeutic efficacy of pembrolizumab in patients with mUC.

Background: There is increasing interest in ablative focal therapy (AFT) for treating clinically localized prostate cancer. The objective of the present study is to report treatment related complications and regret, functional and oncological outcomes of primary partial gland cryo-ablation (PPGCA) for men with low-risk prostate cancer associated with a multiparametric Magnetic Resonance Imaging (mpMRI) target.

Methods: The present analysis includes 54 subjects enrolled in an Institutional Review Board (IRB) approved outcomes registry with low-risk prostate cancer undergoing PPGCA whose disease was associated with an MRI target. The surveillance protocol included mpMRI at 6 months, 2, 3.5, and 5 years, and surveillance prostate biopsies. Clinically significant prostate cancer (csPCa) recurrence was defined as any biopsy core with Gleason pattern (GP4). Freedom-from-failure (FFF) included men who: did not experience prostate cancer mortality, develop metastasis or undergo whole gland salvage treatment (WGST). All men underwent at least 1 post-treatment biopsy. The International Prostate Symptom Score (IPSS), Sexual Health Inventory for Men (SHIM) and Treatment Related Regret (TRR) surveys were self-administered at 1 year.

Results: There were no day-of-surgery or 30-day postoperative hospital admissions. There were no rectal injuries or other technical complications. The 5-year freedom from csPCa recurrence and FFF was 84% and 96%, respectively. At 1 year, only 1 man used a protective pad and no men expressed significant TRR. Overall, the mean decreases in IPSS and SHIM scores between baseline and 1-year was 3.4 (34.7%) and 3.7 (20.4%), respectively. Erectile function was preserved in 72% of men by 1 year.

Conclusion: The favorable oncological outcomes, absence of treatment related complications, Treatment Related Regret (TRR), urinary incontinence, rectal injury, improvement in lower urinary tract symptoms (LUTS), and modest changes in sexual function suggests PPGCA should be considered an option for managing selected cases of low-risk prostate cancer associated with an MRI target.

Background: The impact of cumulative smoking exposure (CSE) on oncologic outcomes for upper tract urothelial carcinoma (UTUC) remains understudied. We examined the effect of this factor on oncologic outcomes in UTUC patients undergoing radical nephroureterectomy utilizing a large contemporary multicenter, multinational cohort.

Methods: Multicenter review of 1,730 patients across 17 institutions. A total of 1,041 patients met selection criteria: nephroureterectomy for urothelial carcinoma without variant histology and complete pathologic and smoking data. Smoking exposure was stratified as light, moderate, or heavy by cigarettes per day and years smoking based on prior studies. Cancer-specific (CSS) and overall survival (OS) were assessed using Kaplan-Meier and multivariable hazards models. A sub-analysis examined the effect of smoking cessation on survival stratified by CSE.

Results: Median follow-up (IQR) was 24 (10-48) months. Light CSE was equal to a median of 2.0 pack years smoked, moderate CSE was equivalent to 13.0 pack years, and heavy CSE was equivalent to 40 pack-years. Five-year CSS and OS were 97% and 91% in nonsmokers, 96% and 89% with light exposure, 85% and 66% with moderate exposure, and 75% and 60% with heavy exposure. On multivariable hazards models, both moderate and heavy smoking exposure were associated with worse CSS and OS compared to nonsmokers. Smoking cessation was not associated with improved survival outcomes among patients with moderate or heavy CSE.

Conclusions: Increasing CSE was associated with worse general health and oncologic outcomes in this UTUC cohort. Smoking cessation can modulate cancer outcomes up to certain thresholds of smoking exposure, emphasizing the need for both early smoking cessation and continued aggressive cancer treatment in patients with UTUC.

Purpose: Patients treated with bladder-preserving therapy for muscle-invasive bladder cancer are at risk of developing recurrent nonmuscle-invasive bladder cancer. This study aims to describe the efficacy and adverse events of postoperative Bacillus Calmette-Guerin (BCG) instillation in patients with superficial recurrence following bladder-preserving therapy for muscle-invasive bladder cancer.

Methods: We retrospectively analyzed 120 patients diagnosed with nonmuscle-invasive bladder cancer who underwent transurethral resection followed by BCG instillation. The 19 patients with prior muscle-invasive bladder cancer were categorized as the NMIBC-M group, while the remaining 101 patients formed the NMIBC group. All patients completed a 6-cycle BCG course.

Results: Both groups showed no significant differences in baseline characteristics, except for the number of BCG instillations (15.5 vs. 9, P = 0.010). Between NMIBC and NMIBC-M group, 5-year overall survival were 87.4% and 75.8%, respectively. And the 5-year recurrence-free survival were 57.0% and 66.7%, respectively. The Kaplan-Meier curve of overall survival and recurrence-free survival showed on statistical significance in both groups. Adverse effects were also comparable between groups. However, patients in the group with prior muscle-invasive bladder cancer reported lower rates of urinary retention (28.7% vs. 0.0%, P = 0.017) and fever (30.7% vs. 5.3%, P = 0.044).

Conclusions: No significant differences of efficacy and side effects were observed for postoperative BCG instillation between the patients with superficial recurrence following bladder-preserving therapy for muscle-invasive bladder cancer and those without muscle-invasive bladder cancer history. Prospective study in the future should be carried out for further confirmation.