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1280 PREOPERATIVE ACCURACY OF DIAGNOSTIC EVALUATION OF THE URACHAL MASS
Vol. 187, No. 4S, Supplement, Monday, May 21, 2012
THE JOURNAL OF UROLOGY姞
Cytology findings in Haematuria Patients No Bladder UT Cytology Path Ca TCC RCC Benign Malignant Cells 4 93 3 2 22
1281 All(%) 124 (4.46)
Atypical/suspicious
125
60
1
6
68
260 (9.63)
No Malignancy
1362
185
4
33
539
2123 (76.42)
Unsatisfactory
57
6
0
1
0
64 (2.30)
Not Recorded
153
32
0
1
21
207 (7.45)
Source of Funding: None
1280 PREOPERATIVE ACCURACY OF DIAGNOSTIC EVALUATION OF THE URACHAL MASS Joshua Meeks*, Melanie Bernstein, Harry Herr, Hikmat Al-Ahmadie, Guido Dalbagni, New York, NY INTRODUCTION AND OBJECTIVES: The urachus is a fibrous remnant of the embryologic allantois. If the urachus is clinically detectable in the adult, surgical resection is usually recommended due to risk of urachal carcinoma. Yet, some of these are benign and preoperative evaluation including imaging, endoscopy and biopsy may prevent overtreatment. The goal of our study was to determine the accuracy of preoperative evaluation of the urachal mass to predict malignant or benign urachal pathology and potentially prevent resection of the nonmalignant urachal mass. METHODS: From 1979 to 2011, 69 patients with a urachal mass presented to Memorial Sloan-Kettering Cancer Center. All patients were evaluated for clinical staging including transurethral biopsy of the urachal mass(TURBT) and 34% underwent restaging TURBT. All patients except for two with advanced disease underwent surgical resection. RESULTS: The mean age of patients was 51 years, 81% were Caucasian and 60% were male. Hematuria was the presenting symptom in 51 patients (72%) and 30 (42%) had a history of smoking. Metastases were present in 21 (31%) at first evaluation. Most patients (93%) underwent partial cystectomy with total urachectomy (including removal of umbilical skin) in 50%. A lymph node dissection was performed in 81%, with a median lymph node count of nine nodes. The urachal mass was benign in 9 (13%) patients, while most cancers were adenocarcinoma (95%). Margins were positive in 14% while lymph nodes were positive in 32% with only 53% of patients alive and 22% dying of progression of disease. Preoperative investigation of the urachal mass was evaluated for accuracy to predict carcinoma or benign pathology (summarized in the table). Despite a high specificity and positive predictive value (100%), biopsy of the urachal mass has a lower sensitivity (93%) and negative predictive value (50%). CONCLUSIONS: No preoperative test is accurate enough to exclude the diagnose urachal carcinoma and therefore prevent surgical removal of a urachal mass. With surgery as the primary modality of treatment and no effective adjuvant chemotherapy, the risk of delaying treatment of a urachal carcinoma remains too high with ineffective diagnostic modalities. Test Cytology
Accuracy of Preoperative Evaluation Sensitivity Specificity 0.17 0.80
e519
PPV 0.83
NPV 0.14
Cystoscopy
0.92
0.40
0.80
0.67
CT
0.91
0.43
0.71
0.75
EUA
0.50
1
1
0.17
TURBT (all)
0.93
1
1
0.50
First TURBT
0.91
1
1
0.44
Second TURBT
0.67
0.00
1
0.00
Source of Funding: This study was supported by the Sidney Kimmel Center for Prostate and Urologic Cancers.
INCIDENCE OF BLADDER CANCER AS A SECONDARY MALIGNANCY IN PATIENTS TREATED WITH RADIATION FOR CERVICAL CANCER Janet Baack Kukreja*, Emelian Scosyrev, Edward Messing, Guan Wu, Rochester, NY INTRODUCTION AND OBJECTIVES: The risk of bladder cancer attributable to radiation exposure in women treated with external beam radiation therapy (EBRT) with or without brachytherapy (BT) for cervical cancer has not been evaluated. The main objectives of this study were to examine the incidence of bladder cancer following radiotherapy for cervical cancer. METHODS: Data for this study was obtained from the Surveillance, Epidemiology and End-Results (SEER) Program. Women diagnosed with cervical cancer as their first malignant primary during years 1980-2005 who had follow-up data and were managed either without radiotherapy or with EBRT ⫹/⫺ BT were included in the analyses (n⫽26,528). Occurrence of bladder cancer over time was summarized with counts and person-time incidence rates (counts divided by personyears of observation). Rate contrasts were expressed as differences and ratios. Age-adjustment was performed by direct standardization to the age-specific person-time distribution of all patients included in the analyses. RESULTS: A total of 12,876 women in the study cohort received EBRT ⫹/⫺ BT as treatment for cervical cancer. The mean age at cervical cancer diagnosis was 55.1 years. After 90,403 person-years of follow-up. The crude incidence rate was 9.6 per 10,000 person-years (95%CI: 7.6-11.6) and the age-standardized incidence rate was 7.3 per 10,000 person-years (95%CI: 5.6-9.0). The control group included 13,652 women whose cervical cancer was managed without radiotherapy. The mean age at cervical cancer diagnosis was 45.3 years. The crude incidence rate was 2.3 per 10,000 person-years (95% CI: 1.63.0) and the age standardized incidence rate was 3.0 per 10,000 person-years (95%CI: 2.0-4.1). After age-adjustment, the rate of incident bladder cancer in women treated with EBRT ⫹/⫺ BT was 2.4 times greater than the rate in women managed without radiation (95%CI: 1.6-3.6). Assuming that the current estimates represent causal effects of radiation exposure, on average 4.3 incident bladder cancer cases per 10,000 person-years of follow-up could be attributed to radiation in this study cohort (95%CI: 2.4-6.2). CONCLUSIONS: EBRT ⫹/⫺ BT administered for cervical cancer may increase the subsequent risk of bladder cancer by more than two-fold. In this cohort of women, 4.3 incident bladder cancer cases per 10,000 person-years of follow-up could be attributed to radiation. Source of Funding: None
1282 GENDER DISPARITIES IN HEMATURIA EVALUATION AND BLADDER CANCER DIAGNOSIS: A POPULATION-BASED ANALYSIS Tullika Garg*, Laura Pinheiro, Coral Swartz, S. Machele Donat, Harry Herr, Elena Elkin, New York, NY INTRODUCTION AND OBJECTIVES: Men are diagnosed with bladder cancer at nearly three times the rate of women. However, women have inferior survival outcomes. Women also present with more advanced disease, suggesting possible delays in bladder cancer diagnosis. Hematuria is the initial presenting symptom in a majority of cases. In women, hematuria has multiple possible causes, which may lead to a delay in diagnostic work-up. Our objective was to assess gender-based differences in hematuria evaluation and identify predictors of inadequate and delayed evaluation. METHODS: Using Surveillance, Epidemiology and End Results cancer registry data linked with Medicare claims, we identified subjects 66 years and older who were diagnosed with bladder cancer between 2000 and 2007. Adequate hematuria evaluation was defined as the presence of claims for cystoscopy, cytology, and upper tract imaging
THE JOURNAL OF UROLOGY姞
Cytology findings in Haematuria Patients No Bladder UT Cytology Path Ca TCC RCC Benign Malignant Cells 4 93 3 2 22
1281 All(%) 124 (4.46)
Atypical/suspicious
125
60
1
6
68
260 (9.63)
No Malignancy
1362
185
4
33
539
2123 (76.42)
Unsatisfactory
57
6
0
1
0
64 (2.30)
Not Recorded
153
32
0
1
21
207 (7.45)
Source of Funding: None
1280 PREOPERATIVE ACCURACY OF DIAGNOSTIC EVALUATION OF THE URACHAL MASS Joshua Meeks*, Melanie Bernstein, Harry Herr, Hikmat Al-Ahmadie, Guido Dalbagni, New York, NY INTRODUCTION AND OBJECTIVES: The urachus is a fibrous remnant of the embryologic allantois. If the urachus is clinically detectable in the adult, surgical resection is usually recommended due to risk of urachal carcinoma. Yet, some of these are benign and preoperative evaluation including imaging, endoscopy and biopsy may prevent overtreatment. The goal of our study was to determine the accuracy of preoperative evaluation of the urachal mass to predict malignant or benign urachal pathology and potentially prevent resection of the nonmalignant urachal mass. METHODS: From 1979 to 2011, 69 patients with a urachal mass presented to Memorial Sloan-Kettering Cancer Center. All patients were evaluated for clinical staging including transurethral biopsy of the urachal mass(TURBT) and 34% underwent restaging TURBT. All patients except for two with advanced disease underwent surgical resection. RESULTS: The mean age of patients was 51 years, 81% were Caucasian and 60% were male. Hematuria was the presenting symptom in 51 patients (72%) and 30 (42%) had a history of smoking. Metastases were present in 21 (31%) at first evaluation. Most patients (93%) underwent partial cystectomy with total urachectomy (including removal of umbilical skin) in 50%. A lymph node dissection was performed in 81%, with a median lymph node count of nine nodes. The urachal mass was benign in 9 (13%) patients, while most cancers were adenocarcinoma (95%). Margins were positive in 14% while lymph nodes were positive in 32% with only 53% of patients alive and 22% dying of progression of disease. Preoperative investigation of the urachal mass was evaluated for accuracy to predict carcinoma or benign pathology (summarized in the table). Despite a high specificity and positive predictive value (100%), biopsy of the urachal mass has a lower sensitivity (93%) and negative predictive value (50%). CONCLUSIONS: No preoperative test is accurate enough to exclude the diagnose urachal carcinoma and therefore prevent surgical removal of a urachal mass. With surgery as the primary modality of treatment and no effective adjuvant chemotherapy, the risk of delaying treatment of a urachal carcinoma remains too high with ineffective diagnostic modalities. Test Cytology
Accuracy of Preoperative Evaluation Sensitivity Specificity 0.17 0.80
e519
PPV 0.83
NPV 0.14
Cystoscopy
0.92
0.40
0.80
0.67
CT
0.91
0.43
0.71
0.75
EUA
0.50
1
1
0.17
TURBT (all)
0.93
1
1
0.50
First TURBT
0.91
1
1
0.44
Second TURBT
0.67
0.00
1
0.00
Source of Funding: This study was supported by the Sidney Kimmel Center for Prostate and Urologic Cancers.
INCIDENCE OF BLADDER CANCER AS A SECONDARY MALIGNANCY IN PATIENTS TREATED WITH RADIATION FOR CERVICAL CANCER Janet Baack Kukreja*, Emelian Scosyrev, Edward Messing, Guan Wu, Rochester, NY INTRODUCTION AND OBJECTIVES: The risk of bladder cancer attributable to radiation exposure in women treated with external beam radiation therapy (EBRT) with or without brachytherapy (BT) for cervical cancer has not been evaluated. The main objectives of this study were to examine the incidence of bladder cancer following radiotherapy for cervical cancer. METHODS: Data for this study was obtained from the Surveillance, Epidemiology and End-Results (SEER) Program. Women diagnosed with cervical cancer as their first malignant primary during years 1980-2005 who had follow-up data and were managed either without radiotherapy or with EBRT ⫹/⫺ BT were included in the analyses (n⫽26,528). Occurrence of bladder cancer over time was summarized with counts and person-time incidence rates (counts divided by personyears of observation). Rate contrasts were expressed as differences and ratios. Age-adjustment was performed by direct standardization to the age-specific person-time distribution of all patients included in the analyses. RESULTS: A total of 12,876 women in the study cohort received EBRT ⫹/⫺ BT as treatment for cervical cancer. The mean age at cervical cancer diagnosis was 55.1 years. After 90,403 person-years of follow-up. The crude incidence rate was 9.6 per 10,000 person-years (95%CI: 7.6-11.6) and the age-standardized incidence rate was 7.3 per 10,000 person-years (95%CI: 5.6-9.0). The control group included 13,652 women whose cervical cancer was managed without radiotherapy. The mean age at cervical cancer diagnosis was 45.3 years. The crude incidence rate was 2.3 per 10,000 person-years (95% CI: 1.63.0) and the age standardized incidence rate was 3.0 per 10,000 person-years (95%CI: 2.0-4.1). After age-adjustment, the rate of incident bladder cancer in women treated with EBRT ⫹/⫺ BT was 2.4 times greater than the rate in women managed without radiation (95%CI: 1.6-3.6). Assuming that the current estimates represent causal effects of radiation exposure, on average 4.3 incident bladder cancer cases per 10,000 person-years of follow-up could be attributed to radiation in this study cohort (95%CI: 2.4-6.2). CONCLUSIONS: EBRT ⫹/⫺ BT administered for cervical cancer may increase the subsequent risk of bladder cancer by more than two-fold. In this cohort of women, 4.3 incident bladder cancer cases per 10,000 person-years of follow-up could be attributed to radiation. Source of Funding: None
1282 GENDER DISPARITIES IN HEMATURIA EVALUATION AND BLADDER CANCER DIAGNOSIS: A POPULATION-BASED ANALYSIS Tullika Garg*, Laura Pinheiro, Coral Swartz, S. Machele Donat, Harry Herr, Elena Elkin, New York, NY INTRODUCTION AND OBJECTIVES: Men are diagnosed with bladder cancer at nearly three times the rate of women. However, women have inferior survival outcomes. Women also present with more advanced disease, suggesting possible delays in bladder cancer diagnosis. Hematuria is the initial presenting symptom in a majority of cases. In women, hematuria has multiple possible causes, which may lead to a delay in diagnostic work-up. Our objective was to assess gender-based differences in hematuria evaluation and identify predictors of inadequate and delayed evaluation. METHODS: Using Surveillance, Epidemiology and End Results cancer registry data linked with Medicare claims, we identified subjects 66 years and older who were diagnosed with bladder cancer between 2000 and 2007. Adequate hematuria evaluation was defined as the presence of claims for cystoscopy, cytology, and upper tract imaging