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MP36-15 ACTIVE SURVEILLANCE, SURGICAL MANAGEMENT, AND CLINCIAL OUTCOMES OF SPORADIC BILATERAL MULTIFOCAL ONCOCYTOMA
THE JOURNAL OF UROLOGYâ
e384
a teaching institution (OR 1.6, p<0.0001) were associated with receiving NSM compared to RN. CONCLUSIONS: Over time, we noted an increase in surgical management of benign renal masses until 2008, with a subsequent decline and stabilization. Over the last 3 years of analysis, PN has become the dominant management modality for benign masses over RN, while rates of ablative therapy have remained constant. Further investigation is necessary to elucidate the driving forces behind these trends, as well as the impact of other modalities such as surveillance and angioinfarction, which are not tracked with an inpatient sample.
Vol. 191, No. 4S, Supplement, Sunday, May 18, 2014
stratification of small renal mass patients being considered for active surveillance in the absence of histologic diagnosis.
Source of Funding: Stephen Weissman Kidney Cancer Research Fund Source of Funding: None
MP36-14 CAN HEMATURIA BE USED TO PREDICT RCC VS. ONCOCYTOMA HISTOLOGY? Michael Hanzly*, Terry Creighton, Christine Murekeyisoni, Elizabeth Devine, Shervin Badkhshan, Michael Mungillo, Thomas Schwaab, Eric Kauffman, Buffalo, NY INTRODUCTION AND OBJECTIVES: Hematuria is a classic presenting sign of renal cell carcinoma (RCC), however its incidence in individual RCC histologic subtypes and the benign renal cell tumor, oncocytoma, has not been characterized. We investigated whether hematuria at presentation can be used to help predict benign versus malignant histology of renal cell tumors. METHODS: We identified all renal cell tumor patients undergoing partial or radical nephrectomy at a single National Comprehensive Cancer Network (NCCN)-designated cancer center since 2004 with preoperative urine testing, including urine dipstick and/or microscopic uranalysis. Patients with unclassified RCC or mixed histologies were excluded. Incidence of preoperative microscopic or gross hematuria was determined and statistically compared among different renal tumor histologic subtypes, including after stratification by tumor size. RESULTS: A total of 292 patients met criteria, including 211 clear cell (72%), 42 papillary (14%), 25 oncocytoma (9%) and 14 chromophobe (5%). Overall incidence of hematuria was 40%, including 12% gross and 28% microscopic only. Hematuria did not correlate with tumor size, but was significantly associated with benign versus malignant tumor histology. Specifically, oncocytoma patients had only a 16% incidence of hematuria compared to >40% incidence for each of the common RCC histologic subtypes (all RCC¼ 43%, p<0.01). (Table) Cases of isolated hematuria without pyuria were similarly less common in oncocytoma patients (4%) compared to RCC subtypes (25-36% each; all RCC¼ 25%, p<0.01). When analyzing pT1a tumors alone, oncocytoma patients again had just a 5% incidence of hematuria compared to 25-36% for individual RCC subtypes (all RCC¼ 35%, p<0.01), and a similar significant distinction between oncocytoma (5%) and RCC (25%, p<0.05) was again observed when only hematuria cases without pyuria were analyzed. CONCLUSIONS: This is the first study to our knowledge characterizing hematuria in renal oncocytoma and different RCC histologic subtypes. Our findings support hematuria as a clinical marker for renal tumor malignant potential, occurring frequently in RCC but uncommonly in oncocytoma. Urine testing for blood may aid in risk
MP36-15 ACTIVE SURVEILLANCE, SURGICAL MANAGEMENT, AND CLINCIAL OUTCOMES OF SPORADIC BILATERAL MULTIFOCAL ONCOCYTOMA Daniel Su*, Adam R. Metwalli, Lindsay Middleton, Maria Merino, Peter Pinto, W. Marston Linehan, Bethesda, MD INTRODUCTION AND OBJECTIVES: Oncocytoma is characterized by somatic mitochondrial complex I mutations in the electronic transport chain which lead to dysfunction of the oxidative phosphorylation mechanism. Bilateral mutifocal oncocytoma (BMO) is a distinct entity that is easily confused with Birt-Hogg-Dube (BHD) due to similar radiographic appearance of the kidney lesions. We describe the clinical characteristics, diagnosis, management and outcome of BMO patients at the National Cancer Institute. METHODS: From 1999 to 2013, 29 patients with 58 renal units were retrospectively identified at the National Cancer Institute. These patients possessed bilateral multifocal kidney lesions, they have a pathologic diagnosis of oncocytoma, their genetic testing is negative for mutation in the FLCN gene, and these patients do not exhibit any BHD phenotype. Patients were followed with serial body imaging and primarily managed with renal biopsy and active surveillance. RESULTS: 29 patients with an average age of 63 years, 24 (82%) male, and 23 (79%) Caucasian were identified. On presentation the average tumor diameter was 4.4 cm (range, 1.8 e 10 cm), serum creatinine was 1.29 mg/dl and eGFR was 46 ml/min. After a median of 52 months (range, 9.8 e 123 months) of follow up, the median creatinine was 1.52 mg/dl and eGFR was 42.06 ml/min. In 19 renal units with complete data, the average growth rate was 0.20 cm/year (range, 0.2 e 0.56 cm/year) over an average of 27 months of follow up. The average size at intervention (biopsy or partial nephrectomy) was 3.2 cm. No patients developed metastatic disease or renal failure requiring renal replacement therapy in this cohort. A majority of patients 13 (45%) were diagnosed via kidney biopsy, a majority of patients 20 (77%) underwent partial nephrectomy at the time of intervention. 6 patients presented to our institution after undergoing unilateral radical nephrectomy. CONCLUSIONS: BMO represent a distinct entity characterized by oncocytoma, mutation in complex I of the mitochondrial electronic transport chain, chronic kidney disease, and slow tumor growth. BMO kidney tumor is phenotypically, pathologically, and clinically separate from BHD kidney cancer. This entity may present a clinical challenge in differentiation with chromophobe carcinoma and hybrid tumor from
THE JOURNAL OF UROLOGYâ
Vol. 191, No. 4S, Supplement, Sunday, May 18, 2014
BHD. BMO is readily diagnosed with kidney biopsy and can be safely managed by active surveillance. Source of Funding:: This research was supported by the Intramural Research Program of the National Institutes of Health (NIH), National Cancer Institute, Center for Cancer Research
MP36-16 EFFECTS OF DIABETES ON RENAL CANCER PROGNOSIS Alper Otunctemur, Murat Dursun, Suleyman Sahin, Huseyin Besiroglu, Ismail Koklu, Mustafa Erkoc, Eyyup Danis, Muammer Bozkurt, Emin Ozbek*, Istanbul, Turkey INTRODUCTION AND OBJECTIVES: Diabetes is a chronic disease characterized by impaired fasting blood glucose that leads to disturbances in various organs. In this study, we evaluate the relationship between tumor size and grade with diabetes in patients with renal cell carcinoma. METHODS: Between 2007-2013, 310 patients underwent radical nephrectomy for renal tumors and pathology reported renal cell carcinoma enrolled in the study. Fasting glucose levels and HbA1c levels compared with tumor size and Fuhrman grade in patients with and without a history of diabetes. The results were statistically analyzed. RESULTS: Diabetes was found in 98 patients. The mean age of the patients with and without diabetes mellitus, respectively 64.3 (4079) and 58.4 (31-87) years. In diabetes group we determined over 7 cm tumor size in 51% of patients and over fuhrman grade 3 tumor grade in 53% of patients. In non-diabetes group we determined over 7 cm tumor size in 38% of patients and over fuhrman grade 3 tumor grade in 28% of patients. The patients with diabetes compared to the patients without diabetes, tumor size and grade were detected significantly higher (p<0,05) in diabetes goup. CONCLUSIONS: Renal cancer remains more aggressive in patients with diabetes. In this study lifestyle and risk factors with diabetes regulation observed important for renal cancer patients. Multicenter studies are needed in larger series for more accurate results. Source of Funding: none
MP36-17 STATIN USE FOR DYSLIPIDEMIA IS ASSOCIATED WITH IMPROVED ONCOLOGIC OUTCOMES OF SURGICALLY TREATED RENAL CELL CARCINOMA Hak Lee*, La Jolla, CA; Aditya Bargrodia, Memphis, TN; Song Wang, Nishant Patel, Michael Liss, La Jolla, CA; Reza Mehrazin, Anthony Patterson, Jim Wan, Memphis, TN; Ithaar Derweesh, La Jolla, CA INTRODUCTION AND OBJECTIVES: Use of statins has recently been suggested to be associated with improved cancer specific survival in RCC. We evaluated the role of statins in post-surgical RCC patients. METHODS: Multi-center retrospective study of RCC patients underwent surgery (either Radical or Partial Nephrectomy) from 7/198711/2007. Within this cohort, we selected patients who either pre-operatively had dyslipidemia or post-operatively developed dyslipidemia. Our primary outcome was progression free survival (PFS) and our secondary outcomes were cancer specific survival (CSS) and overall survival (OS). Patient demographic and clinical characteristics were analyzed between patients who received statin therapy versus those that did not. Kaplan-Meier analysis estimated the PFS, OS and CSS by comparing statin or no statin groups with log-rank test. Multivariable analysis (MVA) was performed to identify risk factors associated with primary and secondary outcomes. RESULTS: A total of 155 patients who had dyslipidemia were analyzed for PFS and 44 (28.3%) patients progressed in their disease.
e385
Of the patients that progressed, 22 (14.1%) had died of their cancer. A total 92 (59.3%) patients were on statins. Median follow-up time was 68 (IQR: 50-90) months. Univariable analysis comparing patients who were on statins vs. no statins, demonstrated that there were no differences in clinical or demographic variables (age, gender, ethnicity, smoking, ASA, diabetes, hypertension, pre and post-operative dyslipidemia, pre and post-operative eGFR, tumor stage and size). KaplanMeier analysis (Figure) demonstrated a higher PFS in patients on statins vs. no statins with 5-yr survival of 91% and 70%, respectively (p¼<0.001). In MVA, controlling for other variables, statin use was independently associated with improved PFS (OR 5.89; 95% CI 2.7312.68; p¼<0.0001) and improved CSS (OR 3.15; 95% CI 1.40-7.07; p¼0.006), but not for OS (p¼0.22). CONCLUSIONS: In a cohort of RCC patients with hyperlipidemia, statin use was associated with improved PFS and CSS. Further investigations are required to determine the mechanism and utility of statins, and its potential benefits in a broader cohort of patients with RCC.
Source of Funding: none
MP36-18 INCIDENCE OF HYBRID TUMORS FOUND IN EXCISED RENAL MASSES: A MULTI-INSTITUTIONAL ANALYSIS David Fumo*, Samay Jain, Toledo, OH; Ravi Munver, Hackensack, NJ INTRODUCTION AND OBJECTIVES: The use of renal biopsy has gained popularity as an adjunct in the work up of renal masses, particularly masses <4cm suspicious for renal cell carcinoma (RCC). Our present study attempts to quantify the prevalence of tumors that contain more than one histology as a means of determining the potential accuracy of renal biopsy. METHODS: In this IRB approved, multi-institutional study, a retrospective review of renal masses removed for RCC between the years of 1998-2012 was performed. Patients and masses were included in the study if information pertaining to demographics and pathologic stage, mass size, and histology were present. Tumors were considered to be hybrid if more than one distinct histology was reported in the final pathology. Granular cell RCC was considered a variant of clear cell RCC and, therefore, these masses were considered non-hybrid tumors. Statistical analyses were completed with paired T-tests and Chi Squared analysis, where appropriate. All analyses were completed using Microsoft Excel. RESULTS: A total of 427 tumors were included in the analysis, summarized in Table1. Of the entire cohort, 48 tumors (11%) displayed more than one distinct histology. The differences in mass size, T stage and age of patients between the two sub-groupswere not statistically significant. A majority of the hybrid tumors were pT1a and were a combination of clear cell and papillary cell RCC. Twenty three of the hybrid tumors were smaller than 4cm in size. Of all of the hybrid tumors, seven showed a combination of a malignant and benign histology, 4 of which were less than 4cm in size.
e384
a teaching institution (OR 1.6, p<0.0001) were associated with receiving NSM compared to RN. CONCLUSIONS: Over time, we noted an increase in surgical management of benign renal masses until 2008, with a subsequent decline and stabilization. Over the last 3 years of analysis, PN has become the dominant management modality for benign masses over RN, while rates of ablative therapy have remained constant. Further investigation is necessary to elucidate the driving forces behind these trends, as well as the impact of other modalities such as surveillance and angioinfarction, which are not tracked with an inpatient sample.
Vol. 191, No. 4S, Supplement, Sunday, May 18, 2014
stratification of small renal mass patients being considered for active surveillance in the absence of histologic diagnosis.
Source of Funding: Stephen Weissman Kidney Cancer Research Fund Source of Funding: None
MP36-14 CAN HEMATURIA BE USED TO PREDICT RCC VS. ONCOCYTOMA HISTOLOGY? Michael Hanzly*, Terry Creighton, Christine Murekeyisoni, Elizabeth Devine, Shervin Badkhshan, Michael Mungillo, Thomas Schwaab, Eric Kauffman, Buffalo, NY INTRODUCTION AND OBJECTIVES: Hematuria is a classic presenting sign of renal cell carcinoma (RCC), however its incidence in individual RCC histologic subtypes and the benign renal cell tumor, oncocytoma, has not been characterized. We investigated whether hematuria at presentation can be used to help predict benign versus malignant histology of renal cell tumors. METHODS: We identified all renal cell tumor patients undergoing partial or radical nephrectomy at a single National Comprehensive Cancer Network (NCCN)-designated cancer center since 2004 with preoperative urine testing, including urine dipstick and/or microscopic uranalysis. Patients with unclassified RCC or mixed histologies were excluded. Incidence of preoperative microscopic or gross hematuria was determined and statistically compared among different renal tumor histologic subtypes, including after stratification by tumor size. RESULTS: A total of 292 patients met criteria, including 211 clear cell (72%), 42 papillary (14%), 25 oncocytoma (9%) and 14 chromophobe (5%). Overall incidence of hematuria was 40%, including 12% gross and 28% microscopic only. Hematuria did not correlate with tumor size, but was significantly associated with benign versus malignant tumor histology. Specifically, oncocytoma patients had only a 16% incidence of hematuria compared to >40% incidence for each of the common RCC histologic subtypes (all RCC¼ 43%, p<0.01). (Table) Cases of isolated hematuria without pyuria were similarly less common in oncocytoma patients (4%) compared to RCC subtypes (25-36% each; all RCC¼ 25%, p<0.01). When analyzing pT1a tumors alone, oncocytoma patients again had just a 5% incidence of hematuria compared to 25-36% for individual RCC subtypes (all RCC¼ 35%, p<0.01), and a similar significant distinction between oncocytoma (5%) and RCC (25%, p<0.05) was again observed when only hematuria cases without pyuria were analyzed. CONCLUSIONS: This is the first study to our knowledge characterizing hematuria in renal oncocytoma and different RCC histologic subtypes. Our findings support hematuria as a clinical marker for renal tumor malignant potential, occurring frequently in RCC but uncommonly in oncocytoma. Urine testing for blood may aid in risk
MP36-15 ACTIVE SURVEILLANCE, SURGICAL MANAGEMENT, AND CLINCIAL OUTCOMES OF SPORADIC BILATERAL MULTIFOCAL ONCOCYTOMA Daniel Su*, Adam R. Metwalli, Lindsay Middleton, Maria Merino, Peter Pinto, W. Marston Linehan, Bethesda, MD INTRODUCTION AND OBJECTIVES: Oncocytoma is characterized by somatic mitochondrial complex I mutations in the electronic transport chain which lead to dysfunction of the oxidative phosphorylation mechanism. Bilateral mutifocal oncocytoma (BMO) is a distinct entity that is easily confused with Birt-Hogg-Dube (BHD) due to similar radiographic appearance of the kidney lesions. We describe the clinical characteristics, diagnosis, management and outcome of BMO patients at the National Cancer Institute. METHODS: From 1999 to 2013, 29 patients with 58 renal units were retrospectively identified at the National Cancer Institute. These patients possessed bilateral multifocal kidney lesions, they have a pathologic diagnosis of oncocytoma, their genetic testing is negative for mutation in the FLCN gene, and these patients do not exhibit any BHD phenotype. Patients were followed with serial body imaging and primarily managed with renal biopsy and active surveillance. RESULTS: 29 patients with an average age of 63 years, 24 (82%) male, and 23 (79%) Caucasian were identified. On presentation the average tumor diameter was 4.4 cm (range, 1.8 e 10 cm), serum creatinine was 1.29 mg/dl and eGFR was 46 ml/min. After a median of 52 months (range, 9.8 e 123 months) of follow up, the median creatinine was 1.52 mg/dl and eGFR was 42.06 ml/min. In 19 renal units with complete data, the average growth rate was 0.20 cm/year (range, 0.2 e 0.56 cm/year) over an average of 27 months of follow up. The average size at intervention (biopsy or partial nephrectomy) was 3.2 cm. No patients developed metastatic disease or renal failure requiring renal replacement therapy in this cohort. A majority of patients 13 (45%) were diagnosed via kidney biopsy, a majority of patients 20 (77%) underwent partial nephrectomy at the time of intervention. 6 patients presented to our institution after undergoing unilateral radical nephrectomy. CONCLUSIONS: BMO represent a distinct entity characterized by oncocytoma, mutation in complex I of the mitochondrial electronic transport chain, chronic kidney disease, and slow tumor growth. BMO kidney tumor is phenotypically, pathologically, and clinically separate from BHD kidney cancer. This entity may present a clinical challenge in differentiation with chromophobe carcinoma and hybrid tumor from
THE JOURNAL OF UROLOGYâ
Vol. 191, No. 4S, Supplement, Sunday, May 18, 2014
BHD. BMO is readily diagnosed with kidney biopsy and can be safely managed by active surveillance. Source of Funding:: This research was supported by the Intramural Research Program of the National Institutes of Health (NIH), National Cancer Institute, Center for Cancer Research
MP36-16 EFFECTS OF DIABETES ON RENAL CANCER PROGNOSIS Alper Otunctemur, Murat Dursun, Suleyman Sahin, Huseyin Besiroglu, Ismail Koklu, Mustafa Erkoc, Eyyup Danis, Muammer Bozkurt, Emin Ozbek*, Istanbul, Turkey INTRODUCTION AND OBJECTIVES: Diabetes is a chronic disease characterized by impaired fasting blood glucose that leads to disturbances in various organs. In this study, we evaluate the relationship between tumor size and grade with diabetes in patients with renal cell carcinoma. METHODS: Between 2007-2013, 310 patients underwent radical nephrectomy for renal tumors and pathology reported renal cell carcinoma enrolled in the study. Fasting glucose levels and HbA1c levels compared with tumor size and Fuhrman grade in patients with and without a history of diabetes. The results were statistically analyzed. RESULTS: Diabetes was found in 98 patients. The mean age of the patients with and without diabetes mellitus, respectively 64.3 (4079) and 58.4 (31-87) years. In diabetes group we determined over 7 cm tumor size in 51% of patients and over fuhrman grade 3 tumor grade in 53% of patients. In non-diabetes group we determined over 7 cm tumor size in 38% of patients and over fuhrman grade 3 tumor grade in 28% of patients. The patients with diabetes compared to the patients without diabetes, tumor size and grade were detected significantly higher (p<0,05) in diabetes goup. CONCLUSIONS: Renal cancer remains more aggressive in patients with diabetes. In this study lifestyle and risk factors with diabetes regulation observed important for renal cancer patients. Multicenter studies are needed in larger series for more accurate results. Source of Funding: none
MP36-17 STATIN USE FOR DYSLIPIDEMIA IS ASSOCIATED WITH IMPROVED ONCOLOGIC OUTCOMES OF SURGICALLY TREATED RENAL CELL CARCINOMA Hak Lee*, La Jolla, CA; Aditya Bargrodia, Memphis, TN; Song Wang, Nishant Patel, Michael Liss, La Jolla, CA; Reza Mehrazin, Anthony Patterson, Jim Wan, Memphis, TN; Ithaar Derweesh, La Jolla, CA INTRODUCTION AND OBJECTIVES: Use of statins has recently been suggested to be associated with improved cancer specific survival in RCC. We evaluated the role of statins in post-surgical RCC patients. METHODS: Multi-center retrospective study of RCC patients underwent surgery (either Radical or Partial Nephrectomy) from 7/198711/2007. Within this cohort, we selected patients who either pre-operatively had dyslipidemia or post-operatively developed dyslipidemia. Our primary outcome was progression free survival (PFS) and our secondary outcomes were cancer specific survival (CSS) and overall survival (OS). Patient demographic and clinical characteristics were analyzed between patients who received statin therapy versus those that did not. Kaplan-Meier analysis estimated the PFS, OS and CSS by comparing statin or no statin groups with log-rank test. Multivariable analysis (MVA) was performed to identify risk factors associated with primary and secondary outcomes. RESULTS: A total of 155 patients who had dyslipidemia were analyzed for PFS and 44 (28.3%) patients progressed in their disease.
e385
Of the patients that progressed, 22 (14.1%) had died of their cancer. A total 92 (59.3%) patients were on statins. Median follow-up time was 68 (IQR: 50-90) months. Univariable analysis comparing patients who were on statins vs. no statins, demonstrated that there were no differences in clinical or demographic variables (age, gender, ethnicity, smoking, ASA, diabetes, hypertension, pre and post-operative dyslipidemia, pre and post-operative eGFR, tumor stage and size). KaplanMeier analysis (Figure) demonstrated a higher PFS in patients on statins vs. no statins with 5-yr survival of 91% and 70%, respectively (p¼<0.001). In MVA, controlling for other variables, statin use was independently associated with improved PFS (OR 5.89; 95% CI 2.7312.68; p¼<0.0001) and improved CSS (OR 3.15; 95% CI 1.40-7.07; p¼0.006), but not for OS (p¼0.22). CONCLUSIONS: In a cohort of RCC patients with hyperlipidemia, statin use was associated with improved PFS and CSS. Further investigations are required to determine the mechanism and utility of statins, and its potential benefits in a broader cohort of patients with RCC.
Source of Funding: none
MP36-18 INCIDENCE OF HYBRID TUMORS FOUND IN EXCISED RENAL MASSES: A MULTI-INSTITUTIONAL ANALYSIS David Fumo*, Samay Jain, Toledo, OH; Ravi Munver, Hackensack, NJ INTRODUCTION AND OBJECTIVES: The use of renal biopsy has gained popularity as an adjunct in the work up of renal masses, particularly masses <4cm suspicious for renal cell carcinoma (RCC). Our present study attempts to quantify the prevalence of tumors that contain more than one histology as a means of determining the potential accuracy of renal biopsy. METHODS: In this IRB approved, multi-institutional study, a retrospective review of renal masses removed for RCC between the years of 1998-2012 was performed. Patients and masses were included in the study if information pertaining to demographics and pathologic stage, mass size, and histology were present. Tumors were considered to be hybrid if more than one distinct histology was reported in the final pathology. Granular cell RCC was considered a variant of clear cell RCC and, therefore, these masses were considered non-hybrid tumors. Statistical analyses were completed with paired T-tests and Chi Squared analysis, where appropriate. All analyses were completed using Microsoft Excel. RESULTS: A total of 427 tumors were included in the analysis, summarized in Table1. Of the entire cohort, 48 tumors (11%) displayed more than one distinct histology. The differences in mass size, T stage and age of patients between the two sub-groupswere not statistically significant. A majority of the hybrid tumors were pT1a and were a combination of clear cell and papillary cell RCC. Twenty three of the hybrid tumors were smaller than 4cm in size. Of all of the hybrid tumors, seven showed a combination of a malignant and benign histology, 4 of which were less than 4cm in size.