- Email: [email protected]
Re: Oncologic Outcomes following Robot-Assisted Radical Cystectomy with Minimum 5-Year Follow-up: The Roswell Park Cancer Institute Experience
BLADDER, PENIS AND URETHRAL CANCER, AND BASIC PRINCIPLES OF ONCOLOGY
Editorial Comment: This article reviews small renal masses (less than 4 cm) to differentiate angiomyolipoma (AML) without visible fat from renal cell carcinoma using unenhanced and contrast enhanced computerized tomography. Prior studies have demonstrated that certain features may indicate an angiomyolipoma without fat, including high attenuation on pre-contrast imaging and homogeneous and brisk enhancement after administration of contrast medium. These authors report a series of 23 patients with 24 proved AMLs without visible fat, and compared them to 130 patients with 148 renal cell carcinomas. They observed that a combination of CT and demographic features allowed accurate differentiation of AML and renal cell carcinoma. These data include small lesion size and female gender, both of which are good predictors of angiomyolipoma. Modest or poor enhancement (less than 75 HU) was a strong negative predictor of angiomyolipoma. The authors calculate an entropy score that is more reproducible than a visual assessment of tumor heterogeneity. This entropy score cannot be calculated on a regular workstation, and efforts must be made to decrease image noise. The entropy score, used with attenuation, enhancement, size and gender, seems promising in differentiating these 2 entities. Cary Siegel, MD
Urological Oncology: Bladder, Penis and Urethral Cancer, and Basic Principles of Oncology Re: Oncologic Outcomes following Robot-Assisted Radical Cystectomy with Minimum 5-Year Follow-up: The Roswell Park Cancer Institute Experience S. J. Raza, A. Al-Daghmin, S. Zhuo, Z. Mehboob, K. Wang, G. Wilding, E. Kauffman and K. A. Guru Departments of Urology, Biostatistics and Cancer Genetics, Roswell Park Cancer Institute, Buffalo, New York Eur Urol 2014; 66: 920e928. doi: 10.1016/j.eururo.2014.03.015
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24768522 Editorial Comment: This single institution review of robot-assisted laparoscopic radical cystectomy with open urinary diversion focuses on patients with at least 5 years of followup. All patients underwent diversion in an extracorporeal fashion and were examined from 2005 to 2013. During this period of more than 8 years 345 robotic cystectomies were performed. The authors state that no open cystectomies were performed, and as a result there is no inter-institution comparison arm. The 5-year recurrence-free, cancer specific and overall survival rates were 52.5%, 67.8% and 42.4%, respectively. These data confirm that at this institution robotic cystectomy can be performed with what appear to be comparable success rates to open series.1 Concerning to me is the higher recurrence rate than in published series, and I would want to know the type and location of recurrences as well as the time frame. It is the randomized trials such as those performed by Parekh et al2 and ongoing prospective trials that may help further clarify if any true concerning differences exist. Undoubtedly there is no margin for error in these patients, and I believe that the disease process and surgeon ultimately dictate success more than surgical technique. Sam S. Chang, MD
1. Shariat SF, Karakiewicz PI, Palapattu GS et al: Outcomes of radical cystectomy for transitional cell carcinoma of the bladder: a contemporary series from the Bladder Cancer Research Consortium. J Urol 2006; 176: 2414. 2. Parekh DJ, Messer J, Fitzgerald J et al: Perioperative outcomes and oncologic efficacy from a pilot prospective randomized clinical trial of open versus robotic assisted radical cystectomy. J Urol 2013; 189: 474.
1381
1382
BLADDER, PENIS AND URETHRAL CANCER, AND BASIC PRINCIPLES OF ONCOLOGY
Re: Prognostic Factors and Risk Groups in T1G3 Non-Muscle-Invasive Bladder rin: Results of a Cancer Patients Initially Treated with bacillus Calmette-Gue Retrospective Multicenter Study of 2451 Patients , P. Gontero, R. Sylvester, F. Pisano, S. Joniau, K. Vander Eeckt, V. Serretta, S. Larre S. Di Stasi, B. Van Rhijn, A. J. Witjes, A. J. Grotenhuis, L. A. Kiemeney, R. Colombo, € m, M. Oderda, J. Irani, N. Malats, J. Baniel, R. Mano, A. Briganti, M. Babjuk, P. U. Malmstro T. Cai, E. K. Cha, P. Ardelt, J. Varkarakis, R. Bartoletti, M. Spahn, R. Johansson, B. Frea, V. Soukup, E. Xylinas, G. Dalbagni, R. J. Karnes, S. F. Shariat and J. Palou Department of Surgical Sciences, Molinette Hospital, University of Studies of Turin, Turin, Department of Urology, Paolo Giaccone General Hospital, Palermo, Policlinico Tor Vergata-University of Rome, Rome, Dipartimento di Urologia, Universita Vita-Salute, Ospedale S. Raffaele, Milan, Department of Urology, Santa Chiara Hospital, Trento and Urology Unit, S. Maria Annunziata Hospital, University of Florence, Florence, Italy, EORTC Headquarters, Brussels, and Oncologic and Reconstructive Urology, Department of Urology, University Hospitals Leuven, Leuven, Belgium, Department of Surgical Science, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom, Department of Urology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, and Department of Urology and Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands, Departments of Urology, Motol Hospital, Second Faculty of Medicine, Charles University in Prague, Prague, and General Teaching Hospital and First Faculty of Medicine, Charles University in Praha, Praha, Czech Republic, Department of Surgical Sciences, Uppsala University, Uppsala and Department of Radiation Sciences, Division of Oncology, Umea˚ University, Umea˚, Sweden, Department of Urology, Centre Hospitalier Universitaire La Mile´trie, University of Poitiers, Poitiers and Cochin Hospital, Paris Descartes University, Paris, France, Department of Urology, University Hospital of Wuerzburg, Wuertzburg and Facharzt fur Urologie, Abteilung fur Urologie, Chirurgische Universitatsklinik, Freiburg, Germany, Departments of Urology, Spanish National Cancer Research Centre-Madrid, Madrid and Fundacio Puigvert, University of Barcelona, Barcelona, Spain, Institute of Urology, Rabin Medical Center, Petach Tikva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, Department of Urology, Sismanoglio Hospital, University of Athens, Athens, Greece, Department of Urology, Comprehensive Cancer Center, Medical University Vienna, Vienna, Austria, Department of Urology, Weill Medical College of Cornell University and Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, and Department of Urology, Mayo Clinic, Rochester, Minnesota Eur Urol 2015; 67: 74e82. doi: 10.1016/j.eururo.2014.06.040
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25043942 Editorial Comment: In this retrospective multi-institutional trial from 23 centers prognostic factors were assessed in patients with T1G3 tumors who received bacillus Calmette-Guerin (BCG) therapy. Using Cox multivariable regression, several clinical variables were assessed regarding time to recurrence, progression, cancer specific survival and overall survival. With a median followup of slightly more than 5 years 465 of 2,451 patients (19%) had progression, 509 (21%) underwent cystectomy and 221 (9%) died of bladder cancer. On multivariable analyses the most important prognostic factors for progression were age, tumor size and presence of carcinoma in situ. Cancer specific and overall survival was predicted significantly by age and tumor size. The authors categorized high risk patients (in this cohort with T1G3 disease) and recommended more aggressive treatment for those who were older than 70 years, had tumors larger than 3 cm and had carcinoma in situ. There are several interesting points worth mentioning. First, despite the fact that only 38% of these patients underwent repeat transurethral resection (TUR), perhaps a lower rate than one would expect, BCG plus maintenance was effective for the majority of patients, as has been reported in multiple other series.1 However, this finding should not lull one into believing that aggressive BCG use obviates the need for repeat TUR, and it would be interesting to know how those patients fared who underwent repeat TUR, specifically whether those findings at repeat TUR of bladder tumor made a difference in patient outcomes. In addition, the chance of progression at 10 years in patients with T1G3 disease increased to 25%, 32% and 52%, respectively, if they had 1, 2 or all 3 of the adverse prognostic factors that were identified by the authors. Furthermore, this group of patients remains at high risk. Of this cohort followed at academic centers of excellence 14% had lymph node positive disease at cystectomy. Despite different predicting algorithms that physicians may use,2 it is important that patients are counseled regarding this risk of metastatic disease as well as upper tract disease.3 The determination of when to proceed with “timely cystectomy” continues to be a difficult therapeutic balancing act. Sam S. Chang, MD 1. Sylvester RJ, van der Meijden AP and Lamm DL: Intravesical bacillus Calmette-Guerin reduces the risk of progression in patients with superficial bladder cancer: a meta-analysis of the published results of randomized clinical trials. J Urol 2002; 168: 1964. 2. Fernandez-Gomez J, Madero R, Solsona E et al: Predicting nonmuscle invasive bladder cancer recurrence and progression in patients treated with bacillus Calmette-Guerin: the CUETO scoring model. J Urol 2009; 182: 2195. 3. Cookson MS, Herr HW, Zhang ZF et al: The treated natural history of high risk superficial bladder cancer: 15-year outcome. J Urol 1997; 158: 62.
Editorial Comment: This article reviews small renal masses (less than 4 cm) to differentiate angiomyolipoma (AML) without visible fat from renal cell carcinoma using unenhanced and contrast enhanced computerized tomography. Prior studies have demonstrated that certain features may indicate an angiomyolipoma without fat, including high attenuation on pre-contrast imaging and homogeneous and brisk enhancement after administration of contrast medium. These authors report a series of 23 patients with 24 proved AMLs without visible fat, and compared them to 130 patients with 148 renal cell carcinomas. They observed that a combination of CT and demographic features allowed accurate differentiation of AML and renal cell carcinoma. These data include small lesion size and female gender, both of which are good predictors of angiomyolipoma. Modest or poor enhancement (less than 75 HU) was a strong negative predictor of angiomyolipoma. The authors calculate an entropy score that is more reproducible than a visual assessment of tumor heterogeneity. This entropy score cannot be calculated on a regular workstation, and efforts must be made to decrease image noise. The entropy score, used with attenuation, enhancement, size and gender, seems promising in differentiating these 2 entities. Cary Siegel, MD
Urological Oncology: Bladder, Penis and Urethral Cancer, and Basic Principles of Oncology Re: Oncologic Outcomes following Robot-Assisted Radical Cystectomy with Minimum 5-Year Follow-up: The Roswell Park Cancer Institute Experience S. J. Raza, A. Al-Daghmin, S. Zhuo, Z. Mehboob, K. Wang, G. Wilding, E. Kauffman and K. A. Guru Departments of Urology, Biostatistics and Cancer Genetics, Roswell Park Cancer Institute, Buffalo, New York Eur Urol 2014; 66: 920e928. doi: 10.1016/j.eururo.2014.03.015
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24768522 Editorial Comment: This single institution review of robot-assisted laparoscopic radical cystectomy with open urinary diversion focuses on patients with at least 5 years of followup. All patients underwent diversion in an extracorporeal fashion and were examined from 2005 to 2013. During this period of more than 8 years 345 robotic cystectomies were performed. The authors state that no open cystectomies were performed, and as a result there is no inter-institution comparison arm. The 5-year recurrence-free, cancer specific and overall survival rates were 52.5%, 67.8% and 42.4%, respectively. These data confirm that at this institution robotic cystectomy can be performed with what appear to be comparable success rates to open series.1 Concerning to me is the higher recurrence rate than in published series, and I would want to know the type and location of recurrences as well as the time frame. It is the randomized trials such as those performed by Parekh et al2 and ongoing prospective trials that may help further clarify if any true concerning differences exist. Undoubtedly there is no margin for error in these patients, and I believe that the disease process and surgeon ultimately dictate success more than surgical technique. Sam S. Chang, MD
1. Shariat SF, Karakiewicz PI, Palapattu GS et al: Outcomes of radical cystectomy for transitional cell carcinoma of the bladder: a contemporary series from the Bladder Cancer Research Consortium. J Urol 2006; 176: 2414. 2. Parekh DJ, Messer J, Fitzgerald J et al: Perioperative outcomes and oncologic efficacy from a pilot prospective randomized clinical trial of open versus robotic assisted radical cystectomy. J Urol 2013; 189: 474.
1381
1382
BLADDER, PENIS AND URETHRAL CANCER, AND BASIC PRINCIPLES OF ONCOLOGY
Re: Prognostic Factors and Risk Groups in T1G3 Non-Muscle-Invasive Bladder rin: Results of a Cancer Patients Initially Treated with bacillus Calmette-Gue Retrospective Multicenter Study of 2451 Patients , P. Gontero, R. Sylvester, F. Pisano, S. Joniau, K. Vander Eeckt, V. Serretta, S. Larre S. Di Stasi, B. Van Rhijn, A. J. Witjes, A. J. Grotenhuis, L. A. Kiemeney, R. Colombo, € m, M. Oderda, J. Irani, N. Malats, J. Baniel, R. Mano, A. Briganti, M. Babjuk, P. U. Malmstro T. Cai, E. K. Cha, P. Ardelt, J. Varkarakis, R. Bartoletti, M. Spahn, R. Johansson, B. Frea, V. Soukup, E. Xylinas, G. Dalbagni, R. J. Karnes, S. F. Shariat and J. Palou Department of Surgical Sciences, Molinette Hospital, University of Studies of Turin, Turin, Department of Urology, Paolo Giaccone General Hospital, Palermo, Policlinico Tor Vergata-University of Rome, Rome, Dipartimento di Urologia, Universita Vita-Salute, Ospedale S. Raffaele, Milan, Department of Urology, Santa Chiara Hospital, Trento and Urology Unit, S. Maria Annunziata Hospital, University of Florence, Florence, Italy, EORTC Headquarters, Brussels, and Oncologic and Reconstructive Urology, Department of Urology, University Hospitals Leuven, Leuven, Belgium, Department of Surgical Science, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom, Department of Urology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, and Department of Urology and Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands, Departments of Urology, Motol Hospital, Second Faculty of Medicine, Charles University in Prague, Prague, and General Teaching Hospital and First Faculty of Medicine, Charles University in Praha, Praha, Czech Republic, Department of Surgical Sciences, Uppsala University, Uppsala and Department of Radiation Sciences, Division of Oncology, Umea˚ University, Umea˚, Sweden, Department of Urology, Centre Hospitalier Universitaire La Mile´trie, University of Poitiers, Poitiers and Cochin Hospital, Paris Descartes University, Paris, France, Department of Urology, University Hospital of Wuerzburg, Wuertzburg and Facharzt fur Urologie, Abteilung fur Urologie, Chirurgische Universitatsklinik, Freiburg, Germany, Departments of Urology, Spanish National Cancer Research Centre-Madrid, Madrid and Fundacio Puigvert, University of Barcelona, Barcelona, Spain, Institute of Urology, Rabin Medical Center, Petach Tikva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, Department of Urology, Sismanoglio Hospital, University of Athens, Athens, Greece, Department of Urology, Comprehensive Cancer Center, Medical University Vienna, Vienna, Austria, Department of Urology, Weill Medical College of Cornell University and Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, and Department of Urology, Mayo Clinic, Rochester, Minnesota Eur Urol 2015; 67: 74e82. doi: 10.1016/j.eururo.2014.06.040
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25043942 Editorial Comment: In this retrospective multi-institutional trial from 23 centers prognostic factors were assessed in patients with T1G3 tumors who received bacillus Calmette-Guerin (BCG) therapy. Using Cox multivariable regression, several clinical variables were assessed regarding time to recurrence, progression, cancer specific survival and overall survival. With a median followup of slightly more than 5 years 465 of 2,451 patients (19%) had progression, 509 (21%) underwent cystectomy and 221 (9%) died of bladder cancer. On multivariable analyses the most important prognostic factors for progression were age, tumor size and presence of carcinoma in situ. Cancer specific and overall survival was predicted significantly by age and tumor size. The authors categorized high risk patients (in this cohort with T1G3 disease) and recommended more aggressive treatment for those who were older than 70 years, had tumors larger than 3 cm and had carcinoma in situ. There are several interesting points worth mentioning. First, despite the fact that only 38% of these patients underwent repeat transurethral resection (TUR), perhaps a lower rate than one would expect, BCG plus maintenance was effective for the majority of patients, as has been reported in multiple other series.1 However, this finding should not lull one into believing that aggressive BCG use obviates the need for repeat TUR, and it would be interesting to know how those patients fared who underwent repeat TUR, specifically whether those findings at repeat TUR of bladder tumor made a difference in patient outcomes. In addition, the chance of progression at 10 years in patients with T1G3 disease increased to 25%, 32% and 52%, respectively, if they had 1, 2 or all 3 of the adverse prognostic factors that were identified by the authors. Furthermore, this group of patients remains at high risk. Of this cohort followed at academic centers of excellence 14% had lymph node positive disease at cystectomy. Despite different predicting algorithms that physicians may use,2 it is important that patients are counseled regarding this risk of metastatic disease as well as upper tract disease.3 The determination of when to proceed with “timely cystectomy” continues to be a difficult therapeutic balancing act. Sam S. Chang, MD 1. Sylvester RJ, van der Meijden AP and Lamm DL: Intravesical bacillus Calmette-Guerin reduces the risk of progression in patients with superficial bladder cancer: a meta-analysis of the published results of randomized clinical trials. J Urol 2002; 168: 1964. 2. Fernandez-Gomez J, Madero R, Solsona E et al: Predicting nonmuscle invasive bladder cancer recurrence and progression in patients treated with bacillus Calmette-Guerin: the CUETO scoring model. J Urol 2009; 182: 2195. 3. Cookson MS, Herr HW, Zhang ZF et al: The treated natural history of high risk superficial bladder cancer: 15-year outcome. J Urol 1997; 158: 62.