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Chromophobe renal cell carcinoma (chRCC) is one of the less common types of kidney cancer and generally portends a more favorable prognosis. RCC with sarcomatoid differentiation has a more aggressive clinical course with poor outcomes. Four cases of chRCC with varying degrees of sarcomatoid differentiation were retrospectively reviewed at our institution, and clinicopathologic data as well as clinical courses were reported. Patients with higher degrees of sarcomatoid differentiation and larger tumors at presentation generally had and worse overall survival. chRCC with sarcomatoid differentiation portends a poor prognosis with limited data on systemic treatment options for metastatic disease.
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OBJECTIVE: Recruitment of a diverse and representative study population is critical to the external validity of oncology clinical trials. The primary objective of this study was to characterize the factors associated with clinical trial participation for patients with renal cell carcinoma and the secondary objective was to examine differences in survival outcomes. MATERIALS AND METHODS: We used a matched case-control design by querying the National Cancer Database for patients with renal cell carcinoma who were coded as having enrolled in a clinical trial. Trial patients were matched in a 1:5 ratio to the control cohort based on clinical stage and then sociodemographic variables were compared between the 2 groups. Multivariable conditional logistic regression models evaluated factors associated with clinical trial participation. The trial patient cohort was then matched again in a 1:10 ratio based on age, clinical stage, and comorbidities. Log-rank test was used to compare overall survival (OS) between these groups. RESULTS: From 2004 to 2014, 681 patients enrolled in clinical trials were identified. Clinical trial patients were significantly younger and had a lower Charlson-Deyo comorbidity score. On multivariate analysis, male patients and white patients were more likely to participate compared to their Black counterparts. Having Medicaid or Medicare negatively associated with trial participation. Median OS was greater among clinical trial participants. CONCLUSION: Patient sociodemographic factors remain significantly associated with clinical trial participation and trial participants experienced superior OS to their matched counterparts.
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Carcinoma de Células Renales , Neoplasias Renales , Anciano , Humanos , Masculino , Modelos Logísticos , Medicaid , Medicare , Estudios Retrospectivos , Estados Unidos , Estudios de Casos y ControlesRESUMEN
Renal cell carcinoma (RCC) metastases to the testicle are an extremely rare clinical entity. Here, we describe the case of a man with metastatic RCC who developed a new testicular mass. Pathologic analysis after surgical removal of this testicle confirmed the diagnosis of metastatic RCC. This report highlights the unique diagnostic and therapeutic challenges associated with such a disease process.
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Cardiac metastases from renal cell carcinoma (RCC) are very rare. We describe the case of a woman with RCC with cardiac metastases involving the entire right atrium, penetrating through the myocardium, with extension into the tricuspid valve and right ventricle. This report highlights the unique challenge of the diagnosis and treatment of cardiac metastases in RCC.
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INTRODUCTION: Several guidelines have adopted early integration of palliative intervention (PI) into oncologic care to improve quality of life among patients with advanced malignancies. However, PI utilization patterns and factors associated with its use in metastatic renal cell carcinoma are poorly understood. PATIENTS AND METHODS: Using the National Cancer Database (NCDB), we abstracted patients diagnosed with Stage IV RCC from 2004 to 2014 and evaluated the utilization of PI within this cohort. Socioeconomic and clinical factors were compared for patients receiving and not receiving PI for metastatic RCC. Multivariable logistic regression (MLR) models identified factors that were associated with receipt of PI within overall cohort and treatment-based cohorts. RESULTS: We identified 42,014 patients with Stage IV RCC, of which 7,912 patients received PI. From 2004 to 2014, the use of PI minimally increased from 17% to 20% for Stage IV RCC. MLR analysis demonstrated that increased comorbidities, insurance status, higher education status, facility location, care at a comprehensive cancer program or integrated network, sarcomatoid histology, and treatment type significantly increased the likelihood of PI use. Various socioeconomic, clinical, and geographical factors that are associated with use of PI-based on the treatment received for Stage IV RCC. CONCLUSIONS: While PI utilization has minimally increased for Stage IV RCC, there are several geographic, socioeconomic, and clinical factors that predict its use among patients with Stage IV RCC in a treatment-specific manner. Taken together, this suggests the need for earlier initiation of PI in a more equitable and systematic fashion among patients with metastatic RCC.
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Carcinoma de Células Renales , Neoplasias Renales , Carcinoma de Células Renales/patología , Carcinoma de Células Renales/terapia , Estudios de Cohortes , Humanos , Neoplasias Renales/patología , Neoplasias Renales/terapia , Estadificación de Neoplasias , Calidad de VidaRESUMEN
PURPOSE: During COVID-19, many operating rooms were reserved exclusively for emergent cases. As a result, many elective surgeries for renal cell carcinoma (RCC) were deferred, with an unknown impact on outcomes. Since surveillance is commonplace for small renal masses, we focused on larger, organ-confined RCCs. Our primary endpoint was pT3a upstaging and our secondary endpoint was overall survival. MATERIALS AND METHODS: We retrospectively abstracted cT1b-T2bN0M0 RCC patients from the National Cancer Database, stratifying them by clinical stage and time from diagnosis to surgery. We selected only those patients who underwent surgery. Patients were grouped by having surgery within 1 month, 1-3 months, or >3 months after diagnosis. Logistic regression models measured pT3a upstaging risk. Kaplan Meier curves and Cox proportional hazards models assessed overall survival. RESULTS: A total of 29,746 patients underwent partial or radical nephrectomy. Delaying surgery >3 months after diagnosis did not confer pT3a upstaging risk among cT1b (ORâ¯=â¯0.90; 95% CI: 0.77-1.05, Pâ¯=â¯0.170), cT2a (ORâ¯=â¯0.90; 95% CI: 0.69-1.19, Pâ¯=â¯0.454), or cT2b (ORâ¯=â¯0.96; 95% CI: 0.62-1.51, Pâ¯=â¯0.873). In all clinical stage strata, nonclear cell RCCs were significantly less likely to be upstaged (P <0.001). A sensitivity analysis, performed for delays of <1, 1-3, 3-6, and >6 months, also showed no increase in upstaging risk. CONCLUSION: Delaying surgery up to, and even beyond, 3 months does not significantly increase risk of tumor progression in clinically localized RCC. However, if deciding to delay surgery due to COVID-19, tumor histology, growth kinetics, patient comorbidities, and hospital capacity/resources, should be considered.
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COVID-19/prevención & control , Carcinoma de Células Renales/cirugía , Neoplasias Renales/cirugía , Oncología Médica/métodos , Nefrectomía/métodos , SARS-CoV-2/aislamiento & purificación , Anciano , COVID-19/epidemiología , COVID-19/virología , Carcinoma de Células Renales/patología , Epidemias , Femenino , Humanos , Estimación de Kaplan-Meier , Neoplasias Renales/patología , Masculino , Oncología Médica/estadística & datos numéricos , Persona de Mediana Edad , Análisis Multivariante , Estadificación de Neoplasias , Estudios Retrospectivos , SARS-CoV-2/fisiología , Tiempo de TratamientoRESUMEN
The human microbiome contains a vast network of understudied organisms that have an intimate role in our health and wellness. These microbiomes differ greatly between individuals, creating what may be thought of as a unique and dynamic microbial signature. Microbes have been shown to have various roles in metabolism, local and systemic inflammation, as well as immunity. Recent findings have confirmed the importance of both the gut and urinary microbiomes in genitourinary malignancies. Numerous studies have identified differences in microbial signatures between healthy patients and those with urologic malignancies. The microbiomes have been shown to contain microbes that may contribute to the etiology of disease state as well as yield information in regard to a person's health and their responsiveness to certain drugs such as immune checkpoint inhibitors (ICIs) and tyrosine kinase inhibitors (TKIs). Less well understood are the effects of antibiotics on oncologic outcomes in such treatment courses. This review will explore our current understanding and advancements in the field of microbiome research and discuss its intimate association with genitourinary diseases including bladder cancer, prostate cancer, and kidney cancer. With a better understanding of the association between the microbiome and genitourinary malignancy, further investigation may produce reliable predictors of disease, prognostic indicators as well as therapeutic targets.
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The Coronavirus Disease 2019 pandemic placed urologic surgeons, and especially urologic oncologists, in an unprecedented situation. Providers and healthcare systems were forced to rapidly create triage schemas in order to preserve resources and reduce potential viral transmission while continuing to provide care for patients. We reviewed United States and international triage proposals from professional societies, peer-reviewed publications, and publicly available institutional guidelines to identify common themes and critical differences. To date, there are varying levels of agreement on the optimal triaging of urologic oncology cases. As the need to preserve resources and prevent viral transmission grows, prioritizing only high priority surgical cases is paramount. A similar approach to prioritization will also be needed as nonemergent cases are allowed to proceed in the coming weeks. While these decisions will often be made on a case-by-case basis, more nuanced surgeon-driven consensus guidelines are needed for the near future.
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Betacoronavirus/patogenicidad , Infecciones por Coronavirus/prevención & control , Pandemias/prevención & control , Neumonía Viral/prevención & control , Triaje/normas , Enfermedades Urológicas/diagnóstico , Procedimientos Quirúrgicos Urológicos/normas , COVID-19 , Toma de Decisiones Clínicas , Consenso , Infecciones por Coronavirus/epidemiología , Infecciones por Coronavirus/transmisión , Infecciones por Coronavirus/virología , Humanos , Oncología Médica/normas , Selección de Paciente , Neumonía Viral/epidemiología , Neumonía Viral/transmisión , Neumonía Viral/virología , Guías de Práctica Clínica como Asunto , SARS-CoV-2 , Sociedades Médicas/normas , Enfermedades Urológicas/cirugía , Urología/normasRESUMEN
PURPOSE OF REVIEW: As the biology of metastatic renal cell carcinoma (mRCC) continues to be elucidated, novel treatments focused around immunotherapies and targeted therapies will continue to emerge. In this review, we will highlight recent treatment advances and their implications for surgical and systemic therapy. RECENT FINDINGS: Several new treatments, including the tyrosine kinase inhibitor cabozantinib, the combination of a programmed cell death protein 1 antibody (nivolumab) with a cytotoxic T-lymphocyte-associated antigen 4 antibody (ipilimumab), and the combination of axitinib with pembrolizumab or avelumab have been approved by the US Food and Drug Administration as first-line therapy for the treatment of mRCC. Although promising survival benefits have been seen with these new therapies, careful patient selection is still critical. SUMMARY: The introduction of novel therapies and the investigation of combinatorial therapies have shifted the treatment paradigm for advanced RCC. Present trials have provided promising data that could lead to further therapeutic advances.
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Carcinoma de Células Renales/tratamiento farmacológico , Carcinoma de Células Renales/cirugía , Neoplasias Renales/tratamiento farmacológico , Neoplasias Renales/cirugía , Antineoplásicos Inmunológicos/uso terapéutico , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Carcinoma de Células Renales/patología , Quimioterapia Adyuvante , Ensayos Clínicos Fase II como Asunto , Ensayos Clínicos Fase III como Asunto , Procedimientos Quirúrgicos de Citorreducción/métodos , Humanos , Neoplasias Renales/patología , Terapia Neoadyuvante , Metástasis de la Neoplasia , Inhibidores de Proteínas Quinasas/uso terapéutico , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
BACKGROUND: The role of retroperitoneal lymph node dissection (RPLND) as first-line treatment for testicular seminoma is less well defined than for testicular nonseminomatous germ-cell tumors. We describe utilization of primary RPLND in the United States and report on overall survival (OS) after surgery for these men. PATIENTS AND METHODS: Using 2004-2014 data from the National Cancer Data Base, we identified 62,727 men with primary testicular cancer, 31,068 of whom were diagnosed as having seminoma. After excluding men with benign, non-germ cell, and nonseminomatous germ-cell tumor histologies, those who did not undergo RPLND, those where clinical stage and survival data were unavailable, and those with testicular seminoma who underwent RPLND in the postchemotherapy setting (n = 47), 365 men comprised our final cohort. Descriptive statistics were used to summarize clinical and demographic factors. The Kaplan-Meier method was used to determine OS. RESULTS: A total of 365 men with testicular seminoma underwent primary RPLND. At a median follow-up of 4.1 years, there were 16 deaths in the entire cohort. Five-year OS was 94.2%. Subset analysis of men with stage I and IIA/B disease who underwent primary RPLND revealed 5-year OS rates of 97.3% and 92.0%, respectively (P = .035). OS did not significantly differ in patients with stage IIA versus IIB disease (91.8% vs. 92.3%, respectively, P = .907). CONCLUSION: Although RPLND is rarely used as primary therapy in testicular seminoma, OS rates appear to be comparable to rates reported in the literature for primary chemotherapy or radiotherapy. Ongoing prospective trials will clarify the role of RPLND in the management of testicular seminoma.
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Escisión del Ganglio Linfático/estadística & datos numéricos , Ganglios Linfáticos/cirugía , Espacio Retroperitoneal/cirugía , Seminoma/cirugía , Neoplasias Testiculares/cirugía , Adolescente , Adulto , Estudios de Seguimiento , Humanos , Estimación de Kaplan-Meier , Metástasis Linfática/prevención & control , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Orquiectomía , Sistema de Registros/estadística & datos numéricos , Estudios Retrospectivos , Seminoma/mortalidad , Seminoma/patología , Tasa de Supervivencia , Neoplasias Testiculares/mortalidad , Neoplasias Testiculares/patología , Testículo/patología , Testículo/cirugía , Resultado del Tratamiento , Estados Unidos/epidemiología , Adulto JovenRESUMEN
BACKGROUND: Preclinical and retrospective data suggest that cytoreductive radical prostatectomy may benefit a subset of men who present with metastatic prostate cancer (mPCa). Herein, we report the results of the first planned Phase 1 study on cytoreductive surgery. METHODS: From four institutions, 36 patients consented to the study. However, four did not complete surgery because of rapid disease progression (n = 3) and another because of an intraoperatively discovered pericolonic abscess. Men with newly diagnosed clinical mPCa to lymph nodes or bones were eligible. The primary endpoint was the rate of major perioperative complications (Clavien-Dindo Grade 3 or higher) occurring within 90 days of surgery. RESULTS: The mean age at surgery was 64.0 years. The 90-day overall complication rate was 31.2% (n = 10), of which two (6.25%) were considered major complications: one acute tubular necrosis requiring temporary dialysis and one death. In men with more than 6 months of follow-up, 67.9% had prostate specific antigen nadir ≤0.2 ng/mL, while one patient experienced a rapid rise in prostate specific antigen and another a widely disseminated disease that resulted in death 5 months after surgery. Altogether, these results demonstrate that cytoreductive radical prostatectomy is safe and surgically feasible in selected patients who present with mPCa . Yet, there may be a small subset of patients in whom surgery may cause a significant harm. CONCLUSION: Therefore, cytoreductive surgery in men with mPCa should be limited to clinical trials until robust data are available.
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The objective of this study is to report a benign mesenchymal neoplasm, cellular angiofibroma. We describe a 34-year-old male with a 4-month history of a painless right inguinal mass. CT scan of the abdomen and pelvis showed a 6.6 cm, oval-shaped mass without any distinguishing radiographical features. Surgical excision of the mass was performed. Tissue was extracted for immunohistochemical analysis, which stained positive for CD34 and Desmin, confirming cellular angiofibroma of the spermatic cord. Thus, this report highlights the importance of a challenging diagnostic case for providers due to the narrow range of imaging modalities and therefore limited treatment options.
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Angiofibroma , Neoplasias de los Genitales Masculinos , Cordón Espermático , Adulto , Angiofibroma/diagnóstico , Angiofibroma/cirugía , Neoplasias de los Genitales Masculinos/diagnóstico , Neoplasias de los Genitales Masculinos/cirugía , Humanos , Masculino , Enfermedades RarasRESUMEN
PURPOSE: Lymph node (LN) involvement in renal cell carcinoma (RCC) is associated with a poor prognosis. While lymph node dissection (LND) may provide diagnostic information, its therapeutic benefit remains controversial. Thus, the aim of our study is to analyze survival outcomes after LND for nonmetastatic RCC and to characterize contemporary practice patterns. MATERIALS AND METHODS: The National Cancer Database was queried for patients with nonmetastatic RCC who underwent either partial or radical nephrectomy from 2010 to 2014. A total of 11,867 underwent surgery and LND. Chi-square tests were used to examine differences in patient demographics. To minimize selection bias, propensity score matching (PSM) was used to select one control for each LND case (nâ¯=â¯19,500). Cox regression analyses were conducted to examine overall survival (OS) in patients who received LND compared to those who did not. RESULTS: Of all patients undergoing LND for RCC (nâ¯=â¯11,867), 5%, 23%, 31%, 47% were performed for tumors of clinical T stage 1, 2, 3, and 4, respectively. Proportions of LND have not significantly changed from 2010 to 2014. No significant improvement in median OS for patients undergoing LND compared to no LND was shown (34.7 vs. 34.9 months, respectively; Pâ¯=â¯0.98). Similarly, no significant improvement in median OS was found for clinically LN positive patients undergoing LND compared to no LND (Pâ¯=â¯0.90). On Cox regression analysis, LND dissection was not associated with an OS benefit (hazard ratio: 1.00; 95% confidence interval 0.97 to 1.04). CONCLUSIONS: Among all RCC patients, LNDs are often performed for low stage disease, suggesting a potential overutilization of LND. No OS benefit was seen in any subgroup of patients undergoing LND. Further investigation is needed to determine which patient populations may benefit most from LND.
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Carcinoma de Células Renales/cirugía , Bases de Datos Factuales/tendencias , Escisión del Ganglio Linfático/tendencias , Anciano , Carcinoma de Células Renales/patología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Puntaje de Propensión , Estados UnidosRESUMEN
Primary Ewing sarcoma of the kidney is an extremely rare and aggressive tumor affecting young adults. We present the case of a 22-year-old male with primary Ewing sarcoma/primitive neuroectodermal tumor (EWS/PNET) of the kidney who underwent right radical nephrectomy and adjuvant chemo-radiation.
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Prostate cancer metastases are commonly seen in the skeleton, lymph nodes, lungs, or liver, and are associated with a poor five-year survival rate. Renal pelvis and ureteral metastasis are exceedingly uncommon and can present with obstructive symptoms or as an asymptomatic mass on imaging. We report the case of a 60-year-old patient who was initially diagnosed with prostate adenocarcinoma and experienced eventual metastasis to the right renal pelvis and proximal ureter. Following the diagnosis, he was started on docetaxel and pembrolizumab as part of a clinical trial protocol. A high index of suspicion and thorough metastatic work-up is necessary when patients with prostate cancer present with symptoms of obstructive uropathy or new visceral disease is identified.
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BACKGROUND: Prostate cancer remains the second leading cause of cancer related death in men. Immune check point blocking antibodies have revolutionized treatment of multiple solid tumors, but results in prostate cancer remain marginal. Previous reports have suggested that local therapies, in particular cryoablation might increase tumor immunogenicity. In this work, we examine potential synergism between tumor cryoabalation and check point blocking antibodies. METHODS: FVB/NJ mice were injected subcutaneously into each flank with either 1 × 106 or 0.2 × 106 isogenic hormone sensitive Myc-Cap cells to establish synchronous grafts. Mice were treated with four intraperitoneal injections of anti-PD-1 (10 mg/kg), anti-CTLA-4 (1 mg/kg), or isotype control antibody with or without adjuvant cryoablation of the larger tumor graft and with or without neo-adjuvant androgen deprivation with degarelix (ADT). Mouse survival and growth rates of tumor grafts were measured. The immune dependency of observed oncological effects was evaluated by T cell depletion experiments. RESULTS: Treatment with anti-CTLA-4 antibody and cryoablation delayed the growth of the distant tumor by 14.8 days (p = 0.0006) and decreased the mortality rate by factor of 4 (p = 0.0003) when compared to cryoablation alone. This synergy was found to be dependent on CD3+ and CD8+ cells. Combining PD-1 blockade with cryoablation did not show a benefit over use of either treatment alone. Addition of ADT to anti-PD1 therapy and cryoablation doubled the time to accelerated growth in the untreated tumors (p = 0.0021) and extended survival when compared to cryoablation combined with ADT in 25% of the mice. Effects of combining anti-PD1 with ADT and cryoablation on mouse survival were obviated by T cell depletion. CONCLUSION: Trimodal therapy consisting of androgen deprivation, cryoablation and PD-1 blockade, as well as the combination of cryoablation and low dose anti-CTLA-4 blockade showed that local therapies with cryoablation could be considered to augment the effects of checkpoint blockade in prostate cancer.
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Antígeno CTLA-4/uso terapéutico , Neoplasias Hormono-Dependientes/inmunología , Neoplasias Hormono-Dependientes/terapia , Neoplasias de la Próstata/inmunología , Neoplasias de la Próstata/terapia , Animales , Linfocitos T CD8-positivos/inmunología , Antígeno CTLA-4/inmunología , Línea Celular Tumoral , Terapia Combinada , Criocirugía/métodos , Modelos Animales de Enfermedad , Humanos , Inmunoterapia/métodos , Estimación de Kaplan-Meier , Masculino , Ratones , Neoplasias Hormono-Dependientes/patología , Neoplasias Hormono-Dependientes/cirugía , Neoplasias de la Próstata/patología , Neoplasias de la Próstata/cirugíaRESUMEN
BACKGROUND: Radical cystectomy (RC) with ileal conduit (IC) or continent diversion (CD) is standard treatment for high-risk non-invasive and muscle-invasive bladder cancer. OBJECTIVE: Our aim is to study contemporary trends in the utilization of ICs and CDs in patients undergoing RC. METHODS: Using the National Inpatient Sample 2001-2012, we identified all patients diagnosed with a malignant bladder neoplasm who underwent RC followed by IC or CD. Patient demographics, comorbidities, length of stay (LOS), and in-hospital complications, mortality, and costs were compared. Multivariable logistic regression analysis, Chi square, and t-tests were used for analysis. RESULTS: Between 2001-2012, approximately 69,049 ICs and 6,991 CDs were performed. CDs increased from 2001 to 2008, but declined after 2008 (pâ<â0.0001). Patients of all ages received ICs at a higher rate than CDs (40-59 years: 79.5% vs. 20.5%; 60-69 years: 88.0% vs. 12.0%; pâ<â0.0001). There was a difference in males vs. females (10.2% vs. 4.0%; OR 2.36) and Caucasians vs. African Americans (9.0% vs. 6.7%; OR 1.49) when comparing CD rates. CD rates were highest in the West, urban teaching centers, and large hospitals (pâ<â0.001). ICs were associated with higher rates of overall postoperative complications (pâ=â0.0185) including infection (pâ=â0.002) and mortality (pâ<â0.0001). In-hospital costs were greater for the CD group. CONCLUSIONS: The number of CDs has declined recently. Patients of all ages are more likely to receive ICs than CDs. Gender, racial, and geographic disparities exist among those receiving CDs. CDs are associated with lower rates of in-hospital complications and mortality, but higher in-hospital costs.
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As we learn more about the molecular biology of genitourinary malignancies, novel therapeutic strategies can be developed. This is especially crucial for prostate, renal, and bladder cancer, where mortality rates remain high especially in advanced disease states. The androgen signaling axis and the androgen receptor (AR) are areas that are actively being explored for their role in these diseases. Although long been associated with prostate cancer development and progression, the role of AR in renal cell carcinoma (RCC) and bladder cancer is becoming recognized as well. This review will highlight the current research into the role of the androgen signaling axis in genitourinary malignancies and how this pathway is being used to expand our therapeutic armamentarium.