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Background: Partial cystectomy (PC) offers potential benefits for select patients with muscle-invasive bladder cancer (MIBC). However, the oncologic efficacy of PC may be compromised due to the underutilization of standard-of-care modalities, such as neoadjuvant chemotherapy (NAC) and pelvic lymph node dissection (PLND). We aimed to assess factors influencing the incorporation of NAC and PLND with PC and evaluate their impact on overall survival (OS). Methods: We identified 2,832 patients with cT2-4N0M0 bladder cancer (BCa) who underwent PC between 2004 and 2019 using the National Cancer Database (NCDB). The primary endpoint was OS. Kaplan-Meier analysis compared OS in treatment modalities in PC patients. Multivariate Cox Proportional Hazards (CPH) model assessed the impact of age, sex, race, insurance, income, Charlson-Deyo Index (CDI), clinical T-stage, facility type, histology, surgical margins, NAC, PLND adequacy [≥10 lymph node (LN) yield], and adjuvant radiation treatment on OS. Multivariate logistic regressions were performed to examine predictors of NAC and PLND receipt in PC patients. Results: Two hundred and thirty-one patients received multi-agent NAC with PC. NAC treatment with PLND was associated with significantly improved OS (P<0.001). Median OS was 43.9 months in patients treated with PC alone, while median OS was not reached in PC patients treated with NAC & PLND. Furthermore, patients who received NAC without any PLND had a median OS of 50.6 months, while those treated with PLND without NAC had a median OS of 76.5 months. This persisted in the adjusted CPH model, where private insurance, NAC, and PLND significantly improved OS, especially when PLND yielded ≥10 LN. Conversely, age >80 years old, CDI >2, cT3-4, positive margins, and adjuvant radiation all increased adjusted mortality risk. After controlling for clinicopathologic variables, females were less likely to receive PLND [odds ratio (OR) 0.719, P=0.005], while NAC was more likely administered to PC patients diagnosed from 2016-2019 (OR 5.295, P<0.001). PC patients who received NAC were more likely to have PLND performed as part of their treatment regimen (OR 2.189, P<0.001). Additionally, patients treated at academic centers were more likely to have NAC administered and PLND performed (OR 1.745, P=0.003; OR 2.465, P<0.001, respectively). Conclusions: Despite guideline recommendations, the utilization of NAC and PLND with PC remains insufficient. Our analysis underscores the significant OS benefit of these recommended treatments as part of MIBC care. Importantly, we highlight a gradual increase in NAC and PLND receipt in recent years, centered largely at academic facilities. Notably, gender disparities exist in PLND receipt, emphasizing the need for further investigation.
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In this case report, we describe a patient who developed metastatic liver cancer of unknown primary origin one year following the surgical removal of a retroperitoneal adenocarcinoma. The retroperitoneal adenocarcinoma is considered a malignant transformation of teratoma (MTT), given the patient's distant history of testicular tumor excised 25 years prior and treated with chemotherapy. Despite no primary tumor being identified, the leading primary hypothesis is that the liver metastasis stemmed from the resected retroperitoneal adenocarcinoma from one year prior. We theorize that the patient's cisplatin-based chemotherapy 25 years ago may have triggered the MTT, as documented in the existing literature. Using TEMPUS gene testing on both the retroperitoneal adenocarcinoma and the recently discovered liver metastasis, we identified several genes with variants of unknown significance (VUS) that could potentially be linked to cisplatin chemotherapy resistance. While we cannot conclude that this patient definitively underwent MTT, it remains the most plausible explanation. Future research should investigate both the validity of the genes we have uncovered with respect to cisplatin resistance, as well as other genes associated with cisplatin resistance to further understand the pathogenesis of cisplatin resistance for better prediction of treatment response. As the world of medicine shifts towards individualized therapies and precision medicine, reporting and analyzing genetic mutations derived from tumors remains imperative. Our case report aims to contribute to the growing database of defined mutations and underscores the immense potential of genetic analysis in directing personalized treatment options.
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INTRODUCTION: Nutritional status is an independent predictor of overall survival after radical cystectomy. Various biomarkers of nutritional status are proposed to predict postoperative outcome, including albumin, anemia, thrombocytopenia, and sarcopenia. Recently, a score comprising hemoglobin, albumin, lymphocyte, and platelet counts was postulated as an encompassing biomarker to predict overall survival post-radical cystectomy in a single-institution study. However, cutoffs for hemoglobin, albumin, lymphocyte, and platelet count are not well defined. In this study, we analyzed hemoglobin, albumin, lymphocyte, and platelet count thresholds predicting overall survival and examined the platelet-to-lymphocyte as an additional prognostic biomarker. METHODS: Fifty radical cystectomy patients were retrospectively evaluated from 2010-2021. American Society of Anesthesiologists classification, pathological data, and survival were extracted from our institutional registry. Univariable and multivariable Cox regression analysis was fit to the data to predict overall survival. RESULTS: Median follow-up was 22 (12-54) months. Hemoglobin, albumin, lymphocyte, and platelet count (continuous) was a significant predictor of overall survival on multivariable Cox regression analysis (HR 0.95, 95% CI: 0.90-0.99, P = .03), adjusting for Charlson Comorbidity Index, lymphadenopathy (pN >N0), muscle-invasive disease, and neoadjuvant chemotherapy. Optimal hemoglobin, albumin, lymphocyte, and platelet count cutoff was 25.0. Patients with hemoglobin, albumin, lymphocyte, and platelet count <25.0 had inferior overall survival (median, 33 months) vs with those with hemoglobin, albumin, lymphocyte, and platelet count ≥25.0 (median, not reached) (P = .03). CONCLUSIONS: Low hemoglobin, albumin, lymphocyte, and platelet count <25.0 was an independent predictor of inferior overall survival.