- Email: [email protected]
Fluorescent (Blue Light) Cystoscopy Improved 3-Year Recurrence-Free Survival Rates of Recurrent Bladder Tumor Patients
UROLOGICAL SURGERY
that met inclusion criteria. Insulin use, HbA1c scores, and mACR data were collected. Cox proportional hazards models were used to evaluate associations with recurrence-free survival (RFS).
Computed Tomography Texture Analysis Is Associated with Histopathologic Features and Protein Expression in Small Renal Cell Carcinomas Edwin J Abel, MD, FACS, Perry Pickhardt, MD, Jered Nystrom, Meghan Lubner University of Wisconsin, Madison, WI
RESULTS: Median time to recurrence after TUR was 11.6 months. On univariate analysis, RFS was associated with: t2DM status (p¼0.009, HR 1.3), insulin use at TUR (p¼0.0028, HR 1.2), HbA1c (p¼0.013, HR 1.4), age, multifocality, perioperative Mitomycin-C, bacillus Calmette-Guerin therapy, and intravesical chemotherapy. Additionally, we found HbA1c 7 to be associated with reduced RFS (p¼0.0034, HR 1.7). The 5 year RFS was 28% for t2DM patients and 35% for non-t2DM (log rank p¼0.02). Multivariate analysis demonstrated that patients treated with insulin were more likely to experience tumor recurrence (p¼0.03, HR 1.3). Finally, in a subgroup analysis of t2DM patients who had received BCG, MVA demonstrated that mACR was a significant predictor of bCG responsiveness (p¼0.02, HR 1.02).
INTRODUCTION: The use of texture analysis may provide additional information from CT scans that are not visibly apparent. The purpose of this study was to assess CT texture features of small renal cell carcinomas for predicting key pathological features. METHODS: Quantitative CT texture analysis of small renal cancers (4cm) was performed on noncontrast and portal venous phase abdominal CT scans. Texture parameters were analyzed for associations with pathological data from surgical resection, including histology and nuclear grade, as well as microarray analysis in a subset (n¼40) including Ki67 index, CRP, and microvessel density (CD135/CD31).
CONCLUSIONS: Patients with t2DM have reduced RFS compared to matched nondiabetic controls. Among only t2DM patients, insulin use and increasing HbA1C scores are associated with reduced RFS on univariate, but not MVA. In patients who have received bCG, elevated mACR is a significant predictor of decreased RFS.
RESULTS: Portal venous phase images were available in 249 patients (105 women, 144 men, mean age, 56.6 years). CT texture features of standard deviation (SD), mean of the positive pixels, and entropy of the pixel histogram were significantly associated with histologic cell type (clear vs non clear, p<0.001). In the microarray analysis subset, kurtosis of the pixel histogram was associated with CD105/CD31 (p¼0.002). Noncontrast CT images were available in 174 patients (72 women, 102 men, mean age, 57.5 years). Although the association with histology was not as strong as on the portal venous phase, in the subset of patients with microarray data, SD was found to correlate with CRP (p¼0.08), kurtosis with CRP (p¼0.004), CD135/CD31 (p¼0.002), and with Ki 67 index (p<0.001).
Fluorescent (Blue Light) Cystoscopy Improved 3-Year Recurrence-Free Survival Rates of Recurrent Bladder Tumor Patients Tracy M Downs, MD, FACS, Timothy J Rushmer, E Jason Abel, MD, FACS, Shiva Damodaran, MD, Kyle A Richards, MD, David F Jarrard, MD University of Wisconsin School of Medicine and Public Health, Madison, WI
CONCLUSIONS: CT texture features were associated with important histopathologic features of small renal cancers. This noninvasive technology may provide useful information for risk stratification of small renal masses prior to treatment.
INTRODUCTION: Blue light cystoscopy (BLC) using Hexa aminolevulinate (HAL) has been shown to reduce recurrence-free survival (RFS) compared to white light cystoscopy (WLC) for the index transurethral resection (TUR). BLC is only FDA approved for initial TUR. Little has been reported about the use of BLC in recurrent tumors. Thus, we evaluated the association of BLC with HAL among common prognostic factors for bladder cancer recurrence in a multivariate model and evaluated the effect on recurrence-free survival (RFS).
Diabetic Metrics That Lead to Increased Recurrence Rates in Non-Muscle Invasive Bladder Cancer Tracy M Downs, MD, FACS, Timothy J Rushmer, E Jason Abel, MD, FACS, Shivashankar Damodaran, Kyle A Richards, MD, David F Jarrard, MD University of Wisconsin School of Medicine and Public Health, Madison, WI
METHODS: An institutional bladder cancer database identified 159 cases of recurrent Non-muscle invasive bladder cancer (NMIBC) treated by a single surgeon with TUR. Forty-four cases of NMIBC had BLC with HAL and the remaining 115 cases had WLC. Cox proportional hazards models were used to evaluate associations with RFS.
INTRODUCTION: Evidence for type 2 diabetes mellitus (t2DM) as an independent risk factor for non-muscle invasive bladder cancer (NMIBC) has been mixed. We sought to validate if t2DM status, insulin use, HbA1c scores, or microalbumin to creatinine ratio (mACR) affected recurrence of NMIBC.
RESULTS: Median time to next recurrence was 10.6 months (interquartile range 4.53-22.7). Median patient age was 74 years. On univariate analysis, factors associated with improved RFS included: cysview (hazard ratio 0.41, 95% CI 0.46-0.89, p¼0.0002), age, multifocality, bacillus Calmette-Guerin (bCG)
METHODS: We identified 304 cases of NMIBC in 120 unique t2DM patients treated with (TUR). There were 117 t2DM patients
e50
http://dx.doi.org/10.1016/j.jamcollsurg.2017.07.652 ISSN 1072-7515/17
Vol. 225, No. 4S2, October 2017
therapy, stage, and grade. Multivariate analysis demonstrated that patients who received BLC with HAL (HR 0.42, 95% CI 0.250.70, p¼0.001) were less likely to experience tumor recurrence. The 3-year RFS rate was 53.7% for the BLC patients and 27.4% for WLC patients (p¼0.004). CONCLUSIONS: BLC with HAL is associated with improved 3year RFS in a multivariate model of only recurrent cases of NMIBC treated with TUR. This evidence points to the need for expanded use of BLC in patients with reccurent tumors. Pelvic Lymphadenectomy in Intermediate to High-Risk Prostate Cancer (CaP) Patients: A Comparison of Robotic and Open Approaches John G Pattaras, MD, FACS, Dean Laganosky, MD, Datta Patil, Kenneth Ogan, MD, Andrew Michigan, MD Emory University School of Medicine, Atlanta, GA INTRODUCTION: Pelvic lymphadenectomy (PLND) is recommended in high-risk and certain intermediate risk CaP patients. Studies have shown improved disease-specific survival and increase in lymph node (LN) yield; however, more extensive PLND has been associated with increased complications: lymphoceles, deep venous thrombosis, and pulmonary emboli. We compared LN yield and complication rates in these patients undergoing robotic or open prostatectomy with PLND. METHODS: A retrospective analysis of patients with D’Amico risk classification intermediate to high-risk CaP who underwent robotic or open radical prostatectomy with PLND at Emory Hospitals from 2007 to 2013. RESULTS: A total of 530 patients (199 robotic, 331 open) compared had significantly higher preoperative PSA and risk in robotic vs open patients (PSA 11.7 vs 8.2ng/mL, p¼0.002) and high-risk disease (30.15% vs 16.06% p<0.001). No other significant demographic differences. Mean LN yield was higher in robotics (14.8 vs 10.5, p<0.001) as well as significant increase in LN involvement (14.07% vs 8.16%, p¼0.031) was demonstrated. Rates of complications were similar: symptomatic lymphocele (4.52% vs 3.93%, p¼0.793), deep venous thrombosis (4.5% vs 2.42%, p¼0.183), and pulmonary embolus (1.0% vs 1.51%, p¼0.622). Multivariate analysis demonstrated that robotic surgery was a significant predictor of higher LN yield (odds ratio 1.08, 95% CI, 1.05-1.10, p < 0.001), adjusting for preoperative confounders as age, preoperative PSA, and risk level.
Scientific Forum: 2017 Clinical Congress
e51
CONCLUSIONS: For intermediate and high-risk patients undergoing radical prostatectomy, robotic PLND demonstrates a significantly higher LN yield and involvement. In addition, robotic PLND is a safe and suitable alternative to open surgery with very similar complication rates. Should Active Surveillance Be the Treatment of Choice for Renal Oncocytic Neoplasms? Edwin J Abel, MD, FACS, Brady Miller, MD, Lori Mankowski Gettle, MD, MBA, Jason R Van Roo, Timothy J Ziemlewicz, Sara L Best, MD, Shane Wells, Meghan Lubner, Tracy M Downs, MD, FACS, Stephen Y Nakada, MD, FACS University of Wisconsin, Madison, WI INTRODUCTION: The increasing use of renal mass biopsy may allow diagnosis of renal oncocytic neoplasms prior to treatment. However, since it is difficult to distinguish oncocytoma pathologically from chromophobe renal cell carcinoma (chRCC), the best treatment approach is frequently unclear. The purpose of this study was to compare outcomes for patients with renal oncocytic neoplasms treated with surgery, thermal ablation or observation. METHODS: Clinical and pathologic data were analyzed for consecutive patients with a histological diagnosis of oncocytoma, oncocytic neoplasm or chRCC from 2003 to 2016 treated with surgery, thermal ablation, or active surveillance. RESULTS: A total of 171 patients were included in analysis, 125 oncocytoma, 46 chRCC, 2 oncocytic neoplasm not specified. Initial management was active surveillance, surgery or ablation in 90, 67, and 14 patients. Mean follow-up interval was 48 and 53 months for oncocytoma and chRCC. Biopsy was unable to identify chRCC in 5/19 (26%) of patients. A total of 3/46 (6.5%) patients developed metastatic RCC and 2/26 (4.3%) died of disease. All patients with metastatic chRCC had symptomatic large (5-13cm) tumors. In 117 patients with tumor 4 cm, no patients developed metastatic disease. No patients who were treated with active surveillance developed metastatic disease. CONCLUSIONS: Biopsy may not identify chRCC in 25% of patients with oncocytic neoplasms; however, small renal oncocytic neplasms are rarely aggressive and can safely be treated with active surveillance.
that met inclusion criteria. Insulin use, HbA1c scores, and mACR data were collected. Cox proportional hazards models were used to evaluate associations with recurrence-free survival (RFS).
Computed Tomography Texture Analysis Is Associated with Histopathologic Features and Protein Expression in Small Renal Cell Carcinomas Edwin J Abel, MD, FACS, Perry Pickhardt, MD, Jered Nystrom, Meghan Lubner University of Wisconsin, Madison, WI
RESULTS: Median time to recurrence after TUR was 11.6 months. On univariate analysis, RFS was associated with: t2DM status (p¼0.009, HR 1.3), insulin use at TUR (p¼0.0028, HR 1.2), HbA1c (p¼0.013, HR 1.4), age, multifocality, perioperative Mitomycin-C, bacillus Calmette-Guerin therapy, and intravesical chemotherapy. Additionally, we found HbA1c 7 to be associated with reduced RFS (p¼0.0034, HR 1.7). The 5 year RFS was 28% for t2DM patients and 35% for non-t2DM (log rank p¼0.02). Multivariate analysis demonstrated that patients treated with insulin were more likely to experience tumor recurrence (p¼0.03, HR 1.3). Finally, in a subgroup analysis of t2DM patients who had received BCG, MVA demonstrated that mACR was a significant predictor of bCG responsiveness (p¼0.02, HR 1.02).
INTRODUCTION: The use of texture analysis may provide additional information from CT scans that are not visibly apparent. The purpose of this study was to assess CT texture features of small renal cell carcinomas for predicting key pathological features. METHODS: Quantitative CT texture analysis of small renal cancers (4cm) was performed on noncontrast and portal venous phase abdominal CT scans. Texture parameters were analyzed for associations with pathological data from surgical resection, including histology and nuclear grade, as well as microarray analysis in a subset (n¼40) including Ki67 index, CRP, and microvessel density (CD135/CD31).
CONCLUSIONS: Patients with t2DM have reduced RFS compared to matched nondiabetic controls. Among only t2DM patients, insulin use and increasing HbA1C scores are associated with reduced RFS on univariate, but not MVA. In patients who have received bCG, elevated mACR is a significant predictor of decreased RFS.
RESULTS: Portal venous phase images were available in 249 patients (105 women, 144 men, mean age, 56.6 years). CT texture features of standard deviation (SD), mean of the positive pixels, and entropy of the pixel histogram were significantly associated with histologic cell type (clear vs non clear, p<0.001). In the microarray analysis subset, kurtosis of the pixel histogram was associated with CD105/CD31 (p¼0.002). Noncontrast CT images were available in 174 patients (72 women, 102 men, mean age, 57.5 years). Although the association with histology was not as strong as on the portal venous phase, in the subset of patients with microarray data, SD was found to correlate with CRP (p¼0.08), kurtosis with CRP (p¼0.004), CD135/CD31 (p¼0.002), and with Ki 67 index (p<0.001).
Fluorescent (Blue Light) Cystoscopy Improved 3-Year Recurrence-Free Survival Rates of Recurrent Bladder Tumor Patients Tracy M Downs, MD, FACS, Timothy J Rushmer, E Jason Abel, MD, FACS, Shiva Damodaran, MD, Kyle A Richards, MD, David F Jarrard, MD University of Wisconsin School of Medicine and Public Health, Madison, WI
CONCLUSIONS: CT texture features were associated with important histopathologic features of small renal cancers. This noninvasive technology may provide useful information for risk stratification of small renal masses prior to treatment.
INTRODUCTION: Blue light cystoscopy (BLC) using Hexa aminolevulinate (HAL) has been shown to reduce recurrence-free survival (RFS) compared to white light cystoscopy (WLC) for the index transurethral resection (TUR). BLC is only FDA approved for initial TUR. Little has been reported about the use of BLC in recurrent tumors. Thus, we evaluated the association of BLC with HAL among common prognostic factors for bladder cancer recurrence in a multivariate model and evaluated the effect on recurrence-free survival (RFS).
Diabetic Metrics That Lead to Increased Recurrence Rates in Non-Muscle Invasive Bladder Cancer Tracy M Downs, MD, FACS, Timothy J Rushmer, E Jason Abel, MD, FACS, Shivashankar Damodaran, Kyle A Richards, MD, David F Jarrard, MD University of Wisconsin School of Medicine and Public Health, Madison, WI
METHODS: An institutional bladder cancer database identified 159 cases of recurrent Non-muscle invasive bladder cancer (NMIBC) treated by a single surgeon with TUR. Forty-four cases of NMIBC had BLC with HAL and the remaining 115 cases had WLC. Cox proportional hazards models were used to evaluate associations with RFS.
INTRODUCTION: Evidence for type 2 diabetes mellitus (t2DM) as an independent risk factor for non-muscle invasive bladder cancer (NMIBC) has been mixed. We sought to validate if t2DM status, insulin use, HbA1c scores, or microalbumin to creatinine ratio (mACR) affected recurrence of NMIBC.
RESULTS: Median time to next recurrence was 10.6 months (interquartile range 4.53-22.7). Median patient age was 74 years. On univariate analysis, factors associated with improved RFS included: cysview (hazard ratio 0.41, 95% CI 0.46-0.89, p¼0.0002), age, multifocality, bacillus Calmette-Guerin (bCG)
METHODS: We identified 304 cases of NMIBC in 120 unique t2DM patients treated with (TUR). There were 117 t2DM patients
e50
http://dx.doi.org/10.1016/j.jamcollsurg.2017.07.652 ISSN 1072-7515/17
Vol. 225, No. 4S2, October 2017
therapy, stage, and grade. Multivariate analysis demonstrated that patients who received BLC with HAL (HR 0.42, 95% CI 0.250.70, p¼0.001) were less likely to experience tumor recurrence. The 3-year RFS rate was 53.7% for the BLC patients and 27.4% for WLC patients (p¼0.004). CONCLUSIONS: BLC with HAL is associated with improved 3year RFS in a multivariate model of only recurrent cases of NMIBC treated with TUR. This evidence points to the need for expanded use of BLC in patients with reccurent tumors. Pelvic Lymphadenectomy in Intermediate to High-Risk Prostate Cancer (CaP) Patients: A Comparison of Robotic and Open Approaches John G Pattaras, MD, FACS, Dean Laganosky, MD, Datta Patil, Kenneth Ogan, MD, Andrew Michigan, MD Emory University School of Medicine, Atlanta, GA INTRODUCTION: Pelvic lymphadenectomy (PLND) is recommended in high-risk and certain intermediate risk CaP patients. Studies have shown improved disease-specific survival and increase in lymph node (LN) yield; however, more extensive PLND has been associated with increased complications: lymphoceles, deep venous thrombosis, and pulmonary emboli. We compared LN yield and complication rates in these patients undergoing robotic or open prostatectomy with PLND. METHODS: A retrospective analysis of patients with D’Amico risk classification intermediate to high-risk CaP who underwent robotic or open radical prostatectomy with PLND at Emory Hospitals from 2007 to 2013. RESULTS: A total of 530 patients (199 robotic, 331 open) compared had significantly higher preoperative PSA and risk in robotic vs open patients (PSA 11.7 vs 8.2ng/mL, p¼0.002) and high-risk disease (30.15% vs 16.06% p<0.001). No other significant demographic differences. Mean LN yield was higher in robotics (14.8 vs 10.5, p<0.001) as well as significant increase in LN involvement (14.07% vs 8.16%, p¼0.031) was demonstrated. Rates of complications were similar: symptomatic lymphocele (4.52% vs 3.93%, p¼0.793), deep venous thrombosis (4.5% vs 2.42%, p¼0.183), and pulmonary embolus (1.0% vs 1.51%, p¼0.622). Multivariate analysis demonstrated that robotic surgery was a significant predictor of higher LN yield (odds ratio 1.08, 95% CI, 1.05-1.10, p < 0.001), adjusting for preoperative confounders as age, preoperative PSA, and risk level.
Scientific Forum: 2017 Clinical Congress
e51
CONCLUSIONS: For intermediate and high-risk patients undergoing radical prostatectomy, robotic PLND demonstrates a significantly higher LN yield and involvement. In addition, robotic PLND is a safe and suitable alternative to open surgery with very similar complication rates. Should Active Surveillance Be the Treatment of Choice for Renal Oncocytic Neoplasms? Edwin J Abel, MD, FACS, Brady Miller, MD, Lori Mankowski Gettle, MD, MBA, Jason R Van Roo, Timothy J Ziemlewicz, Sara L Best, MD, Shane Wells, Meghan Lubner, Tracy M Downs, MD, FACS, Stephen Y Nakada, MD, FACS University of Wisconsin, Madison, WI INTRODUCTION: The increasing use of renal mass biopsy may allow diagnosis of renal oncocytic neoplasms prior to treatment. However, since it is difficult to distinguish oncocytoma pathologically from chromophobe renal cell carcinoma (chRCC), the best treatment approach is frequently unclear. The purpose of this study was to compare outcomes for patients with renal oncocytic neoplasms treated with surgery, thermal ablation or observation. METHODS: Clinical and pathologic data were analyzed for consecutive patients with a histological diagnosis of oncocytoma, oncocytic neoplasm or chRCC from 2003 to 2016 treated with surgery, thermal ablation, or active surveillance. RESULTS: A total of 171 patients were included in analysis, 125 oncocytoma, 46 chRCC, 2 oncocytic neoplasm not specified. Initial management was active surveillance, surgery or ablation in 90, 67, and 14 patients. Mean follow-up interval was 48 and 53 months for oncocytoma and chRCC. Biopsy was unable to identify chRCC in 5/19 (26%) of patients. A total of 3/46 (6.5%) patients developed metastatic RCC and 2/26 (4.3%) died of disease. All patients with metastatic chRCC had symptomatic large (5-13cm) tumors. In 117 patients with tumor 4 cm, no patients developed metastatic disease. No patients who were treated with active surveillance developed metastatic disease. CONCLUSIONS: Biopsy may not identify chRCC in 25% of patients with oncocytic neoplasms; however, small renal oncocytic neplasms are rarely aggressive and can safely be treated with active surveillance.