Urologic Oncology-seminars and Original Investigations最新文献

Background: Guidelines for prostate cancer treatment in men with limited life expectancy are based on expert opinion. Patient preferences for when to defer treatment based on longevity are unknown. We sought to define life expectancy thresholds at which men are more likely to choose conservative management in the context of varying risks of cancer death and treatment-related side effects.

Materials and methods: We crowdsourced a conjoint analysis exercise to 2,046 men sociodemographically matched to a US prostate cancer population. Subjects were given a longevity estimate based on their age and comorbidity. They then chose between treatment and conservative management across scenarios with varying risks of cancer death at 5, 10, and 15 years, erectile dysfunction, urinary incontinence, and irritative urinary symptoms. Multivariable multinomial logistic regression identified the life expectancy threshold when men were more likely to choose conservative management over treatment.

Results: Across all men, there was a significant interaction between longevity and treatment choice (P < 0.001), with probability of treatment decreasing 15% for every 5-year decrease in life expectancy (OR0.85, 95% CI0.82-0.89). Across all tumor risk subtypes, men were significantly more likely to choose conservative management at life expectancy<10 years(OR<1, P < 0.05). For low-, favorable-intermediate-, unfavorable-intermediate-, and high-risk cancers, men were more likely to choose conservative management at life expectancy thresholds of ≤15, ≤10, ≤9, and ≤7 years, respectively (P < 0.05).

Conclusions: Preferences for when to consider conservative management of prostate cancer based on longevity align with current guidelines recommendations, except for low-risk disease, for which men are likely to consider conservative management at even higher life expectancy thresholds.

Objective: To prospectively validate the diagnostic performance of Clino-radio-pathological Risk Scoring System (CRiSS) for prediction of inguinal lymph-node metastasis (ILNM) in squamous cell carcinoma of penis.

Materials and methods: A prospective observational study of all patients with SCC penis was conducted between January 1, 2021, and December 31, 2023, at our institute. Data regarding all CRiSS parameters and MRI features of >8mm size and presence of necrosis or irregular outline were recorded, and patients were assigned CRiSS scores and groups. All included patients were subjected to primary surgery (partial/total penectomy) along with bilateral radical inguinal lymph-node dissection. Multivariate logistic regression analysis was performed with both USG and MRI. Sensitivity and specificity were calculated for CRiSS scores and groups.

Results: A total of 86 patients were enrolled during the study period. Size of lymph-node greater than 8mm (HR: 4.502) and irregular outline or presence of necrosis (HR: 4.002) in MRI were significantly associated with ILNM along with all other CRiSS variables in multivariate analysis. CRiSS groups had a sensitivity of 100% and a specificity of 85.71%. CRiSS could diagnose ILNM with a sensitivity of 100% in both palpable and non-palpable groins.

Conclusions: CRiSS can identify patients in whom ILND can be avoided with a zero false negative rate, irrespective of clinical lymph-node status. CRiSS can identify the patients who are candidates for ILND even after a negative FNAC and biopsy of palpable lymph-nodes. It can identify patients for concomitant penectomy and ILND. MRI is a suitable replacement for ultrasonography if not standard of care (CRiSS-M).

Introduction: The nonmuscle invasive bladder cancer treated with BCG instillations in patients who smoke could potentially lead to poorer oncological results in the light of the new EAU risk groups classification for NMIBC that did not include BCG treated patients or smoking status.

Patient and methods: Outcomes from 1313 patients with nonmuscle invasive bladder cancer treated with TURBT, re-TURBT and BCG instillations at 13 academic hospital centers, since 2002, has been included in this retrospective study. The study variables, including cumulative smoking exposure have been analyzed. A multivariable Cox proportional hazard model was used to assess associations between smoking variables and disease progression and repeated in the EAU high risk and very high-risk group. The statistical significance threshold was set at 0.05, and the statistical analysis was performed using Stata/SE version 17 (StataCorp, College Station, TX, USA).

Results: Cox regression analysis revealed in 1313 patients diagnosed with T1G3 NMIBC that patients with a history of heavy and long-term smoking faced a more than twofold increased risk of disease progression compared to nonsmoker patients (HR 2.35; 95% CI: 1.7-3.2; P < 0.01) and a significantly poorer PFS for patients with a history of heavy long-term smoke exposure (P < 0.01). Patients with heavy long-term smoking exposure according to the EAU21 high-risk group had a PFS comparable to very high-risk patients and high-risk patients with heavy long-term smoking exposure showed a higher risk of progression when compared to the high-risk group (HR 1.4; 95% CI: 1.3-1.6; P < 0.01).

Conclusions: This study adds valuable information on the relationship between smoking and the progression of NMIBC and BCG therapy. The findings emphasize the need for healthcare providers to consider a patient's smoking history when managing NMIBC and express the need for individualized smoking cessation counseling and individualized treatment approach.

Objective: Bladder carcinoma (BC) is a common type of cancer. Approximately 20% of BC patients have non-muscle invasive bladder cancer (NMIBC). Despite adequate BCG treatment, recurrence occurs in approximately 40% of the patients. There is no adequate prognostic marker for recurrence in a group of patients. Forkhead box P3 (FOXP3) is a regulatory T cell marker that sometimes exhibits anti-tumoral effects and can be used as a tumor marker. T-cell immunoglobulin and mucin domain 3 (TIM-3) is an immune checkpoint inhibitor of T cells. Tertiary lymphoid structures (TLS) increase malignancy and inflammation in non-lymphoid organs. Therefore, we aimed to evaluate the prognostic value of FOXP3, TIM-3, and TLS in patients with NMIBC.

Methods: Patients with pathologically confirmed NMIBC were included in this study. Stromal and intraepithelial cells were evaluated separately using immunohistochemistry, and FOXP3, TIM-3, TLS, FOXP3/TLS, and TIM-3/TLS were calculated and noted. The cutoff value was determined using ROC analysis. Recurrence-free survival (RFS) and overall survival (OS) were evaluated using univariate and multivariate Cox proportional hazard analyses.

Results: The study included ninety-six patients. FOXP3/TLS high group had a better RFS than FOXP3/TLS low group (P = 0.001; HR, 0.079; 95% CI, 0.019-0.337). This was also significant in the multivariate analysis (P = 0.018; HR, 0.125; 95% CI, 0.022-0.705). In the group receiving BCG, FOXP3/TLS, FOXP3-TLS, TIM-3-TLS and TIM-3/TLS elevation were lower in patients with relapse than in patients without relapse and were statistically significant. Combined TIM-3 and FOXP3 elevation was found to be good prognostic regardless of whether it was found in intraepithelial, stromal or TLS.

Conclusion: FOXP3/TLS elevation is a good prognostic and predictive marker in all non-muscle invasive bladder cancer cases and in the subgroup receiving BCG. Elevation of FOXP3-TLS, TIM-3-TLS, and TIM-3/TLS is associated with longer RFS in patients receiving BCG. Combined TIM-3 and FOXP3 elevation is indicative of a low recurrence rate in NMIBC.

Introduction: Cancer patients often have complex medical needs from diagnosis to survivorship/end-of-life care. Integrated care, including care coordination, multidisciplinary rounds, and supportive care services, is crucial for high-quality cancer care. Yet, factors influencing integrated care receipt are not well understood. This study describes patterns of integrated care among individuals diagnosed with kidney or urinary bladder cancer and examines patient- and hospital-level factors associated with these services.

Methods: Analyzing 2019 National Cancer Institute Patterns-of-Care data, we assessed integrated care service receipt among stage I to IV kidney and stage 0a to IVb urinary bladder cancer patients aged ≥ 20 years using a stratified Surveillance, Epidemiology, and End Results registry sample. Integrated care services within 12 months postdiagnosis were identified by medical record abstraction. Multivariable logistic regression analyses identified patient, clinical, and hospital-level factors significantly associated with receipt of integrated care.

Results: Significant variations in receiving integrated care were observed based on insurance status; uninsured patients less likely to receive these services. Racial/ethnic differences were also noted, as non-Hispanic white patients had higher likelihoods of receiving integrated care. Stage IV kidney cancer patients were 2.63 times [1.44-4.79] more likely to receive integrated care than stage I patients. Treatment characteristics and hospital-level factors appeared to have minimal impact on receiving these services.

Conclusion: The lower likelihood of receiving integrated care among patients with no insurance and among certain racial/ethnic groups underscores gaps in equitable access to patient-centered cancer care. Future research should include patient perspectives to enhance understanding of unmet needs and influencing factors related to integrated care services.

Purpose: To determine the diagnostic value of a comprehensive model based on unenhanced computed tomography (CT) images for distinguishing fat-poor angiomyolipoma (fp-AML) from homogeneous clear cell renal cell carcinoma (hm-ccRCC).

Methods: We retrospectively reviewed 27 patients with fp-AML and 63 with hm-ccRCC. Demographic data and conventional CT features of the lesions were recorded (including sex, age, symptoms, lesion location, shape, boundary, unenhanced CT attenuation and so on). Whole tumor regions of interest were drawn on all slices to obtain histogram parameters (including minimum, maximum, mean, percentile, standard deviation, variance, coefficient of variation, skewness, kurtosis, and entropy) by two radiologists. Chi-square test, Mann-Whitney U test, or independent samples t-test were used to compare demographic data, CT features, and histogram parameters. Multivariate logistic regression analyses were used to screen for independent predictors distinguishing fp-AML from hm-ccRCC. Receiver operating characteristic curves were constructed to evaluate the diagnostic performances of the models.

Results: Age, sex, tumor boundary, unenhanced CT attenuation, maximum tumor diameter, and tumor volume significantly differed between patients with fp-AML and those with hm-ccRCC (P < 0.05). The minimum, mean, first percentile (Perc.01), Perc.05, Perc.10, Perc.25, Perc.50, Perc.75, Perc.90, Perc.95, and Perc.99 of the Fp-AML group were higher than those of the hm-ccRCC group (P < 0.05). Coefficient of variance, skewness, and kurtosis were lower than those in the hm-ccRCC group (all P < 0.05). Age, maximum tumor diameter, unenhanced CT attenuation, and Perc.25 were independent predictors for distinguishing fp-AML from hm-ccRCC (all P < 0.05). The comprehensive model, incorporating age, maximum tumor diameter, unenhanced CT attenuation, and Perc.25, showed the best diagnostic performance (AUC = 0.979).

Conclusion: The comprehensive model based on unenhanced CT imaging can accurately distinguish fp-AML from hm-ccRCC and may assist clinicians in tailoring precise therapy, while also helping to improve the diagnosis and management of renal tumors, leading to the selection of effective treatment options.

Purpose: To examine prostate cancer (PCa) screening disparities among ethnic groups in the U.S. using the All of Us database.

Material and methods: White, Black, Hispanic, and Asian males ≥ 40 years old were included, excluding diagnosis's that conflict with PCa screening. We analyzed prostate-specific antigen (PSA) screening rates by age based on American Urological Association guidelines, using multivariable logistic regression (MLR) and a Cox time-to-event models that considered race, age, income, education, insurance, and home ownership as independent variables. Initial screening ages and biopsy rates were also compared.

Results: Of 56,473 individuals, 18,088 had PSA measurements: 74% White, 15% Black, 9% Hispanic, and 2% Asian. Hispanic (20%) and Black (21%) minorities were less likely to undergo PSA screening compared to White men (39%, P < 0.001). However, minorities had their initial PSA earlier with their first test from 53-54 years old compared to White men at 58 years (P < 0.001). MLR revealed race, age, income, education, insurance type, and home ownership as screening predictors (P < 0.001). Screened Black men had higher odds of an elevated PSA (P < 0.001), but the likelihood of receiving a biopsy postelevated PSA did not significantly differ from White men (P = 0.821). Additionally, those screened at age ≥ 70 were more likely to be White, have at least a college education, and be homeowners (P < 0.001).

Conclusions: White men, despite starting at a later age, are screened with PSAs more frequently than minorities, and often undergo screening at older ages outside the recommended guidelines. Black men did not have a higher rate of biopsy after having an elevated PSA compared to White men.

Background: The impact of warm ischemia time (WIT) on renal function after partial nephrectomy (PN) remains debated. This study investigates the effect of WIT on the relationship between preoperative comorbidities and postoperative renal function impairment in renal cell carcinoma (RCC) patients.

Methods: Patients undergoing PN for T1 RCC at a European high-volume center (2000-2023) were analyzed. Logistic regressions assessed the association between patient comorbidities and acute kidney injury (AKI). Patients were stratified into low (LR), intermediate (IR), and high-risk (HR) groups based on a weighted comorbidity score derived from odds-ratio obtained from the logistic regression analysis. Interaction terms and a weighted local polynomial smoother function assessed the impact of WIT on AKI. Cox regressions and cumulative incidence were used to assess the chronic kidney disease (CKD) upstage ≥IIIB risk according to AKI and risk groups.

Results: Of 1,048 patients, 802 underwent PN with warm ischemia. Among these, 339(42%), 208(26%), 255(32%) were classified as LR, IR and HR. IR (OR:1.82, P = 0.018) and HR (OR:3.01, P < 0.001) patients had a higher AKI risk compared to LR. The increase in WIT had little impact on the LR AKI probability compared to IR (OR:1.06, P = 0.001) and HR (OR:1.08, P < 0.001). The 10-year risk of CKD-upstage ≥IIIB was higher (36% vs. 12%, HR:2.40, P = 0.004) after AKI, and in the HR group (HR:2.42, P = 0.008) CONCLUSIONS: WIT predominantly affected the risk of AKI in HR patients for renal function impairment after surgery. Preoperative counseling is essential for comorbid patients, especially when planning complex surgeries with prolonged ischemia, to mitigate AKI and long-term renal impairment.