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MP84-18 SURGICAL MANAGEMENT FOR LOCAL RETROPERITONEAL RECURRENCE FOR RENAL CELL CARCINOMA AFTER RADICAL NEPHRECTOMY
THE JOURNAL OF UROLOGYâ
Vol. 193, No. 4S, Supplement, Tuesday, May 19, 2015
with the introduction of targeted therapies, with current best practice guidelines recommending a combination of surgery (cytoreductive nephrectomy [CN]) in conjunction with systemic therapy in select patients. Our objective was to evaluate contemporary trends in the management of mRCC using a large national cancer registry. METHODS: We reviewed the National Cancer Database (NCDB) to identify all patients with stage IV RCC between 2006-2010. Systemic therapy was defined as treatment with immunotherapy and/or chemotherapy (including targeted agents). We evaluated associations between clinicopathologic features and receipt of CN plus systemic therapy using multivariable logistic regression with generalized estimating equations. RESULTS: Of 20,868 patients with mRCC, 21% were treated with surgery plus systemic therapy (2.1% neoadjuvant, 18.9% adjuvant), compared to systemic therapy only (25.1%), surgery only (22.9%), or no treatment (31%). While the proportion of patients receiving systemic therapy alone significantly increased (21.2 vs. 26.9%, p<0.001) over the study period, a small but significant decrease in CN alone was noted (24.9 vs. 22.4%, p¼0.004), and no change was observed in patients treated with CN plus systemic therapy (20.5 vs. 20.9%, p¼0.98). The number of patients receiving no treatment significantly decreased (33.3 vs. 29.8%, p¼0.005). Following adjustment, patients with increasing age (51-60 years: OR 0.86 [CI 0.77-0.97]; 61-70 years: OR 0.67 [CI 0.59-0.75]; >70 years [OR 0.35 [CI 0.3-0.4]), and Medicaid (OR 0.69 [CI 0.6-0.8]), Medicare (OR 0.77 [CI 0.69-0.86]), or no insurance (OR 0.55 [CI 0.45-0.68]) were less likely to receive surgery plus systemic therapy, while patients with variant (OR 1.62 [1.36-1.94]) or sarcomatoid (OR 1.22 [CI 1.06-1.39]) histologies were more likely to receive combination therapy. CONCLUSIONS: In the targeted therapy era, utilization of systemic therapy alone has increased while the proportion of patients in the NCDB that undergo CN plus systemic therapy or CN alone have minimally changed or decreased. Maturation of existing prospective trials investigating the respective roles and timing of targeted therapy and surgical cytoreduction will help clarify the role of multimodal therapy in mRCC. Source of Funding: None
MP84-18 SURGICAL MANAGEMENT FOR LOCAL RETROPERITONEAL RECURRENCE FOR RENAL CELL CARCINOMA AFTER RADICAL NEPHRECTOMY Arun Thomas*, Mehrad Adibi, Borregales Leonardo, Ly Hoang, Pheroze Tamboli, Surena Matin, Wood Christopher, Jose Karam, Houston, TX INTRODUCTION AND OBJECTIVES: Isolated local retroperitoneal recurrence (RPR) after radical nephrectomy (RN) for renal cell carcinoma (RCC) poses a therapeutic challenge. We examined the role of aggressive surgical resection of localized RPR. METHODS: We retrospectively reviewed clinico-pathological data of patients from our institution from 1990-2014. We identified 102 patients with localized RPR after radical nephrectomy (RN) who underwent surgical resection with intent to cure. We assessed patient demographics, clinical and pathological features, location of RPR, perioperative complications, recurrence free survival (RFS) and cancerspecific survival (CSS). RESULTS: Median age at RPR diagnosis was 55 years (range 25-82). Tumor stage at nephrectomy was pT1-2 in 40 (39.2%) patients and pT3-4 in 62 (60.8%) patients. Eighty-two (80.4%) patients were nodal stage pNx/N0 at nephrectomy and 20 (19.6%) patients were pN1. Median time from nephrectomy to RPR diagnosis was 19 months (1-164). No patients had distant metatstatic disease at time of RPR resection. The median size of RPR resected was 4.5cm (range 1-29). Median follow up after RPR resection was 32 months (range 3-131). Fourteen patients (13.7%)
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had Clavien grade 3 or higher complications. Median RFS and CSS cancer after RPR resection was 23 months (range 1-124) and 66 months (range 3-102) respectively. One, 3 and 5-year CSS was 92%, 71% and 52%, respectively. After RPR resection, 40 (38.8%) patients remained NED to the time of last follow up. Overall metastatic progression was observed in 60 (58.8%) patients after RPR surgery. Neoadjuvant and salvage systemic therapy were administered in 46 (45.1%) and 48 (47.1%) patients, respectively. Univariate analysis identified pathological nodal stage at nephrectomy, time to recurrence < 1year, maximum diameter of RPR, positive margin at RPR resection and decreased hemoglobin as negative prognostic factors for CSS. On multivariate analysis, pathological nodal stage at original nephrectomy and maximum diameter of RPR were identified as independent risk factors for cancer specific death. CONCLUSIONS: This study is the largest series to date of patients undergoing surgical resection of RPR for recurrent RCC. We found that clinico-pathological factors at the time of nephrectomy as well as RPR resection are important prognosticators. Aggressive surgical resection offers potential cure in a substantial number of patients with RPR and still plays a dominant role in the management of locally recurrent RCC. Source of Funding: none
MP84-19 EXTENT OF LYMPH NODE DISSECTION IN PATIENTS WITH UPPER TRACT UROTHELIAL CARCINOMA IS ASSOCIATED WITH BETTER SURVIVAL Dominic Tang*, Nashville, TN; Sanjay Patel, Chicago, IL; Daniel Barocas, Matthew Resnick, Sam Chang, Nashville, TN INTRODUCTION AND OBJECTIVES: Several studies suggest that lymph node (LN) status may have prognostic value after radical nephroureterectomy (RNU) and lymph node dissection (LND) for upper tract urothelial carcinoma (UTUC). Given the rarity of disease, there have not been many large studies reporting impact of LND on clinical outcomes. Using a large, population-based database, we sought to determine the relationship between extent of LND and survival. METHODS: Data were collected on 8,284 patients treated for UTUC in the United States between 1998 and 2006 from the National Cancer Data Base. 1,479 of these patients underwent concomitant LND. All patients were treated with RNU þ/- bladder cuff excision. At treatment, patients were cN0/cNx, cM0, had no prior malignancies, and had at least 1 LN removed. 8 LNs removed was used as a cutoff based on prior UTUC studies. Patients were divided into 2 cohorts based on presence or absence of LN metastasis. Univariable and multivariable Cox regression models measured the association of node count and survival. Covariates include age, Charlson comorbidity index, stage, grade, positive LN number, and tumor site. RESULTS: Median age was 70 years (range 38-90). Of 1,479 patients undergoing RNU with LND, 540 patients (36%) had LN metastases. Median number of LNs removed was 2 (mean 4, range 1-27). Multivariate analysis showed removing 8 LNs to be associated with improved survival after controlling for age, stage, grade, comorbidities, and LN status (HR 0.79; p¼0.037). Stratifying by LN status (positive vs. negative), removing 8 LN was associated with improved survival on univariate (5-year survival 60.5% [95% CI 0.506-0.690], p¼0.025) and multivariable analysis (HR 0.72 [95% CI 0.52-1.0]; p¼0.05) among pN0 patients. However, pNþ patients had no difference in survival based on node count in univariate (p¼0.165) and multivariable analysis (p¼0.957). CONCLUSIONS: The extent of LND in UTUC patients is independently associated with improved overall survival after controlling for other factors. Removing 8 LNs is independently associated with better overall survival in patients without nodal metastasis. However,
Vol. 193, No. 4S, Supplement, Tuesday, May 19, 2015
with the introduction of targeted therapies, with current best practice guidelines recommending a combination of surgery (cytoreductive nephrectomy [CN]) in conjunction with systemic therapy in select patients. Our objective was to evaluate contemporary trends in the management of mRCC using a large national cancer registry. METHODS: We reviewed the National Cancer Database (NCDB) to identify all patients with stage IV RCC between 2006-2010. Systemic therapy was defined as treatment with immunotherapy and/or chemotherapy (including targeted agents). We evaluated associations between clinicopathologic features and receipt of CN plus systemic therapy using multivariable logistic regression with generalized estimating equations. RESULTS: Of 20,868 patients with mRCC, 21% were treated with surgery plus systemic therapy (2.1% neoadjuvant, 18.9% adjuvant), compared to systemic therapy only (25.1%), surgery only (22.9%), or no treatment (31%). While the proportion of patients receiving systemic therapy alone significantly increased (21.2 vs. 26.9%, p<0.001) over the study period, a small but significant decrease in CN alone was noted (24.9 vs. 22.4%, p¼0.004), and no change was observed in patients treated with CN plus systemic therapy (20.5 vs. 20.9%, p¼0.98). The number of patients receiving no treatment significantly decreased (33.3 vs. 29.8%, p¼0.005). Following adjustment, patients with increasing age (51-60 years: OR 0.86 [CI 0.77-0.97]; 61-70 years: OR 0.67 [CI 0.59-0.75]; >70 years [OR 0.35 [CI 0.3-0.4]), and Medicaid (OR 0.69 [CI 0.6-0.8]), Medicare (OR 0.77 [CI 0.69-0.86]), or no insurance (OR 0.55 [CI 0.45-0.68]) were less likely to receive surgery plus systemic therapy, while patients with variant (OR 1.62 [1.36-1.94]) or sarcomatoid (OR 1.22 [CI 1.06-1.39]) histologies were more likely to receive combination therapy. CONCLUSIONS: In the targeted therapy era, utilization of systemic therapy alone has increased while the proportion of patients in the NCDB that undergo CN plus systemic therapy or CN alone have minimally changed or decreased. Maturation of existing prospective trials investigating the respective roles and timing of targeted therapy and surgical cytoreduction will help clarify the role of multimodal therapy in mRCC. Source of Funding: None
MP84-18 SURGICAL MANAGEMENT FOR LOCAL RETROPERITONEAL RECURRENCE FOR RENAL CELL CARCINOMA AFTER RADICAL NEPHRECTOMY Arun Thomas*, Mehrad Adibi, Borregales Leonardo, Ly Hoang, Pheroze Tamboli, Surena Matin, Wood Christopher, Jose Karam, Houston, TX INTRODUCTION AND OBJECTIVES: Isolated local retroperitoneal recurrence (RPR) after radical nephrectomy (RN) for renal cell carcinoma (RCC) poses a therapeutic challenge. We examined the role of aggressive surgical resection of localized RPR. METHODS: We retrospectively reviewed clinico-pathological data of patients from our institution from 1990-2014. We identified 102 patients with localized RPR after radical nephrectomy (RN) who underwent surgical resection with intent to cure. We assessed patient demographics, clinical and pathological features, location of RPR, perioperative complications, recurrence free survival (RFS) and cancerspecific survival (CSS). RESULTS: Median age at RPR diagnosis was 55 years (range 25-82). Tumor stage at nephrectomy was pT1-2 in 40 (39.2%) patients and pT3-4 in 62 (60.8%) patients. Eighty-two (80.4%) patients were nodal stage pNx/N0 at nephrectomy and 20 (19.6%) patients were pN1. Median time from nephrectomy to RPR diagnosis was 19 months (1-164). No patients had distant metatstatic disease at time of RPR resection. The median size of RPR resected was 4.5cm (range 1-29). Median follow up after RPR resection was 32 months (range 3-131). Fourteen patients (13.7%)
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had Clavien grade 3 or higher complications. Median RFS and CSS cancer after RPR resection was 23 months (range 1-124) and 66 months (range 3-102) respectively. One, 3 and 5-year CSS was 92%, 71% and 52%, respectively. After RPR resection, 40 (38.8%) patients remained NED to the time of last follow up. Overall metastatic progression was observed in 60 (58.8%) patients after RPR surgery. Neoadjuvant and salvage systemic therapy were administered in 46 (45.1%) and 48 (47.1%) patients, respectively. Univariate analysis identified pathological nodal stage at nephrectomy, time to recurrence < 1year, maximum diameter of RPR, positive margin at RPR resection and decreased hemoglobin as negative prognostic factors for CSS. On multivariate analysis, pathological nodal stage at original nephrectomy and maximum diameter of RPR were identified as independent risk factors for cancer specific death. CONCLUSIONS: This study is the largest series to date of patients undergoing surgical resection of RPR for recurrent RCC. We found that clinico-pathological factors at the time of nephrectomy as well as RPR resection are important prognosticators. Aggressive surgical resection offers potential cure in a substantial number of patients with RPR and still plays a dominant role in the management of locally recurrent RCC. Source of Funding: none
MP84-19 EXTENT OF LYMPH NODE DISSECTION IN PATIENTS WITH UPPER TRACT UROTHELIAL CARCINOMA IS ASSOCIATED WITH BETTER SURVIVAL Dominic Tang*, Nashville, TN; Sanjay Patel, Chicago, IL; Daniel Barocas, Matthew Resnick, Sam Chang, Nashville, TN INTRODUCTION AND OBJECTIVES: Several studies suggest that lymph node (LN) status may have prognostic value after radical nephroureterectomy (RNU) and lymph node dissection (LND) for upper tract urothelial carcinoma (UTUC). Given the rarity of disease, there have not been many large studies reporting impact of LND on clinical outcomes. Using a large, population-based database, we sought to determine the relationship between extent of LND and survival. METHODS: Data were collected on 8,284 patients treated for UTUC in the United States between 1998 and 2006 from the National Cancer Data Base. 1,479 of these patients underwent concomitant LND. All patients were treated with RNU þ/- bladder cuff excision. At treatment, patients were cN0/cNx, cM0, had no prior malignancies, and had at least 1 LN removed. 8 LNs removed was used as a cutoff based on prior UTUC studies. Patients were divided into 2 cohorts based on presence or absence of LN metastasis. Univariable and multivariable Cox regression models measured the association of node count and survival. Covariates include age, Charlson comorbidity index, stage, grade, positive LN number, and tumor site. RESULTS: Median age was 70 years (range 38-90). Of 1,479 patients undergoing RNU with LND, 540 patients (36%) had LN metastases. Median number of LNs removed was 2 (mean 4, range 1-27). Multivariate analysis showed removing 8 LNs to be associated with improved survival after controlling for age, stage, grade, comorbidities, and LN status (HR 0.79; p¼0.037). Stratifying by LN status (positive vs. negative), removing 8 LN was associated with improved survival on univariate (5-year survival 60.5% [95% CI 0.506-0.690], p¼0.025) and multivariable analysis (HR 0.72 [95% CI 0.52-1.0]; p¼0.05) among pN0 patients. However, pNþ patients had no difference in survival based on node count in univariate (p¼0.165) and multivariable analysis (p¼0.957). CONCLUSIONS: The extent of LND in UTUC patients is independently associated with improved overall survival after controlling for other factors. Removing 8 LNs is independently associated with better overall survival in patients without nodal metastasis. However,