An Exploration of the Pillars of Leadership in Cancer Education.

Leadership plays a key role in cancer education (CE) and the success of its practices. Leaders in CE must effectively use their leadership skills to be able to communicate, collaborate, and educate their team members. There is a lack of formalized and standardized curriculums for institutions in developing leadership programs, including what themes to focus on in CE. In this article, the authors describe key pillars of leadership in CE that have presented themselves throughout their experience and within the literature. A search was conducted using the Ovid MEDLINE® database and articles were reviewed for eligibility. In this review, thirty articles were selected for their relevance to CE. With this literature search and the authors' reflections, four pillars of leadership in CE were identified: (1) leadership development, (2) collaboration, (3) diversity and equity, and (4) implementation. Within these themes, key areas of importance were discussed further, and barriers to CE leadership were identified. By reflecting upon pillars of leadership in CE, this article may be helpful for developing future leadership programs within CE. It is vital that initiatives continue to be held and barriers are addressed to increase leadership effectiveness within CE.

Association between early change in neutrophil-to-lymphocyte ratio after radical cystectomy and treatment outcomes.

OBJECTIVES: To evaluate the associations of peri-operative neutrophil-to-lymphocyte ratio (NLR) and change in NLR with survival after radical cystectomy. PATIENTS AND METHODS: We retrospectively reviewed a multicentre cohort of patients with bladder cancer who underwent radical cystectomy between 2010 and 2020. Preoperative NLR, postoperative NLR, delta-NLR (postoperative minus preoperative NLR) and NLR change (postoperative divided by preoperative NLR) were calculated. Patients were stratified based on elevation of preoperative and/ or postoperative NLR above the median values. Multivariable Cox regression models were used to evaluate the associations of peri-operative NLR and NLR change with survival. RESULTS: The study cohort included 346 patients with a median age of 69 years. The median (interquartile range) preoperative NLR, postoperative NLR, delta-NLR and NLR change were 2.55 (1.83, 3.90), 3.33 (2.21, 5.20), 0.43 (-0.50, 2.08) and 1.2 (0.82, 1.96), respectively. Both preoperative and postoperative NLR were elevated in 110 patients (32%), 126 patients (36%) had an elevated preoperative or postoperative NLR, and 110 patients (32%) did not have an elevated NLR. On multivariable analysis, increased preoperative and postoperative NLR were significantly associated with decreased survival. While delta-NLR and NLR change were not associated with outcome, patients with elevations in both preoperative and postoperative NLR had the worst overall (hazard ratio [HR] 2.97, 95% confidence interval [CI] 1.78, 4.95; P < 0.001) and cancer-specific survival rates (HR 2.41, 95% CI 1.3, 4.4; P = 0.004). CONCLUSIONS: Preoperative and postoperative NLR are significant predictors of survival after radical cystectomy; patients in whom both NLR measures were elevated had the worst outcomes. Future studies should evaluate whether an increase in NLR during long-term follow-up may precede disease recurrence.

Shock Wave Lithotripsy in Pediatric Stone Disease: A 15-Year Single-Center Experience with 2 Types of Lithotripters.

INTRODUCTION AND OBJECTIVES: We report our experience with pediatric shock wave lithotripsy (SWL) using two types of lithotripters: Dornier HM3 (HM3) and Dornier Lithotripter SII (DLS). STUDY DESIGN: We retrospectively reviewed the charts of children who underwent SWL between 2002 and 2016. Patients were divided into two groups based on the type of the lithotripter: during 2002-2009, we used the electrohydraulic HM3 lithotripter which was replaced in 2009 with the DLS electromagnetic lithotripter. Clinical and perioperative parameters were compared. RESULTS: Our cohort included 107 children who underwent SWL. Average age was 11.5 ± 5.1 years. Average stone size was 10.6 ± 4.9 mm. HM3 was used in 38% of children and DLS2 in 62% (n = 41 and 66, respectively). There were no significant differences in age, gender, stone size, or location between the groups. The total SFR did not differ statistically between HM3 and DLS (83% vs. 74%, p = 0.35). SFR after one SWL was higher with the HM3 (78% vs. 62%, p = 0.093). Re-treatment rate was 22% and 17% (HM3 vs. DLS, p = 0.61). Complication rates were low, with renal colic being the most common (HM3 10%, DLS 20%, NS). CONCLUSIONS: SWL in the pediatric population using the DLS showed good results with low complication rates that are equivalent to the gold standard HM3.

[GENDER-SPECIFIC MEDICINE IN UROLOGY].

INTRODUCTION: Gender-specific medicine seeks to identify and understand differences in the ways in which diseases manifest in men and women. This article claims that, in urology, gender awareness is crucial to providing female patients with apposite medical treatment. While the majority of urological patients are men and a number of urological diseases are male-specific, urologic practitioners must nevertheless be familiar with urologic issues in women. In particular, they must be aware of those which present with gender specific signs and symptoms, and thus require different clinical approaches and therapies. In urologic oncology, for example, most malignancies are more common among men, but women are also affected. In Transitional Cell Carcinoma (TCC) of the bladder, women are usually diagnosed at a later stage and their prognosis tends to be poorer. In contrary, in renal cell carcinoma, men are usually diagnosed with more progressive disease, and the prognosis for women was found to be better. In the field of endo-urology, nephrolithiasis is more common in men, although its prevalence in women is rising. In pregnant women, stones in the urinary tract present a diagnostic and treatment challenge because some of the diagnostic and therapeutic tools may put the mother and/or fetus at risk. Understanding this divergence between men and women in urologic disease is vital to treating patients appropriately. The impact of gender differences is addressed in many medical disciplines. This same perception is needed in urology. To provide women with optimal treatment, female urology must focus not only on urologic disorders specific to women, but also on disorders suffered by both genders, which manifest differently in women. Another step toward developing gender-awareness research and treatment in urology is increasing the number of women who choose to specialize in urology.

Modified colpocleisis for repair of pelvic organ prolapse post-radical cystectomy.

INTRODUCTION AND HYPOTHESIS: Since the era of neoadjuvant chemotherapy, complications of pelvic organ prolapse (POP) post-radical cystectomy have become more common; however, the exact incidence is not documented in the literature. The objective was to repair post-radical cystectomy POP, despite the lack of endopelvic fascia normally needed for this type of repair. METHODS: Three patients aged 60 to 80 had symptomatic POP (of all three compartments: apical, anterior, and posterior) following radical cystectomy and ileal conduit urinary diversion, and no interest in maintaining their coital abilities. Two of the three women were status post-hysterectomy. Colpocleisis, which is known to have a success rate of almost 100%, was performed on the first two patients, with a recurrence of the prolapse shortly after this correction (2-4 months), probably due to the lack of endopelvic fascia. Following the failure of the procedure, a side-to-side closure of the vagina was performed. The latter was the procedure of choice performed on the third patient. We present a video clip of the vaginal closure to demonstrate the procedure performed. RESULTS: Repair was successful in all three cases, with no relapse to date (4 months post-surgery). CONCLUSIONS: Closure of the vaginal canal successfully treated POP in our case series. There were no intra- or postoperative complications in any of the cases. Patients were discharged the following day and did not show any signs of recurrence at follow-up (3, 5, and 6 months post-surgery).

Tailoring Antibiotic Prophylaxis for Ureteroscopic Procedures Based on Local Resistance Profiles May Lead to Reduced Rates of Infections and Urosepsis.

INTRODUCTION AND OBJECTIVES: Urinary tract infections (UTI) following ureteroscopy (URS) occur in about 4% of patients. Due to the resistant bacterial strains we encounter in our institution, we retrospectively examined whether a double-drug antibiotic prophylactic treatment (APT) can reduce urosepsis after URS. MATERIALS AND METHODS: Between February 2015 and March 2016, we performed 344 URS for stone treatment. Starting from September 2015, we changed the APT. Exclusion criteria included procedures involving percutaneous nephrolithotomy, pediatric or pregnant patients, and patients with preoperative clinical UTI. RESULTS: Fifty-seven patients were excluded. Group 1 (n = 106) were the last to receive the conventional APT (oral ciprofloxacin), while the second group (n = 181) were the first to receive the new -regimen (intravenous gentamycin and ampicillin). A distinct percentage of both groups had a preoperative positive urine culture (29% in group 1 and 19% in group 2). Seven of 9 septic events developed in patients with preoperative positive urine culture (p < 0.001). Patients undergoing retrograde intrarenal surgery were at increased risk for sepsis when treated with conventional APT (p < 0.01). Post-URS sepsis was 7.5% using the conventional APT and 0.5% with the new APT (p < 0.0001). CONCLUSIONS: A distinct number of patients undergoing URS stone treatment have positive preoperative urine cultures. "One size fits all" APT is not sufficient according to our data. A regimen tailored to the local antibiotic resistance of the uropathogens can lower the rate of sepsis.

External Validation of Bladder Cancer Predictive Nomograms for Recurrence, Cancer-Free Survival and Overall Survival following Radical Cystectomy.

PURPOSE: We externally validated 3 previously published nomograms to predicting recurrence, and cancer specific and overall survival following radical cystectomy and pelvic lymph node dissection for urothelial carcinoma of the bladder. MATERIALS AND METHODS: Two surgeons from a single institution performed a total of 197 consecutive radical cystectomies and pelvic lymph node dissections for bladder cancer from January 2003 to September 2009. A total of 23 patients were excluded from analysis. Examined parameters were those used in the original nomograms, including patient age, gender, pathological T stage, N stage, tumor grade, presence of carcinoma in situ and lymphovascular invasion, neoadjuvant chemotherapy, adjuvant chemotherapy and adjuvant radiation therapy. Nomogram predictions were compared to actuarial outcomes and predictive accuracy was quantified using measures of discrimination and calibration. RESULTS: At the time of analysis 34 patients had experienced recurrence, of whom 28 died of disease and 6 were currently alive with disease. Discrimination at 2, 5 and 8 years was 0.776, 0.809 and 0.794 for recurrence, 0.822, 0.840 and 0.849 for cancer specific survival, and 0.812, 0.820 and 0.825, respectively, for overall survival. Calibration plots revealed nomogram overestimation of all 3 end points. CONCLUSIONS: Nomograms for bladder cancer recurrence, cancer specific survival and overall survival following radical cystectomy and pelvic lymph node dissection performed well in our series with accuracy comparable to that in the original series. The use of nomogram predictions should be further explored in clinical trials to assess the impact on patient care in clinical practice.

Usefulness of transurethral biopsy for staging the prostatic urethra before radical cystectomy.

PURPOSE: We determined the likelihood that transurethral resection biopsy of the prostatic urethra adjacent to the verumontanum would detect prostatic involvement of urothelial carcinoma in patients with bladder carcinoma. MATERIALS AND METHODS: We compared precystectomy transurethral resection biopsy specimens of the prostatic urethra with those of the matched radical cystoprostatectomy in 272 patients with urothelial carcinoma of the bladder. All prostates were evaluated by whole mount step sections. RESULTS: Prostatic involvement by urothelial carcinoma was detected by transurethral resection biopsy or radical cystoprostatectomy in 101 patients (37.1%). Transurethral resection biopsy detected urothelial carcinoma in 72 cases with 71.3% sensitivity and 100% specificity. The overall accuracy of transurethral resection biopsy to detect urothelial carcinoma of the prostate was 89% (positive and negative predictive values 100% and 86%, respectively). Invasive prostatic urothelial carcinoma arising from the prostatic urethra was detected by transurethral resection biopsy in 21 of 26 patients (81%) while prostatic carcinoma in situ was detected in 39 of 52 (75%). Transurethral resection biopsy detected prostatic invasive urothelial carcinoma resulting from transmural invasion of a bladder tumor in 4 of 15 patients. CONCLUSIONS: Prostatic involvement by urothelial carcinoma of the bladder was found in 37.1% of patients. Transurethral resection biopsy missed most tumors resulting from transmural invasion of the bladder primary lesion. Carcinoma in situ and invasive urothelial carcinoma arising from the prostatic urethra were detected in most cases. Transurethral resection biopsy of the prostatic urethra can complement staging and support clinical decision making with respect to neoadjuvant chemotherapy and planning for an orthotopic neobladder.

Alvimopan, a peripherally acting µ-opioid receptor antagonist, is associated with reduced costs after radical cystectomy: economic analysis of a phase 4 randomized, controlled trial.

PURPOSE: We evaluated the effect of alvimopan treatment vs placebo on health care utilization and costs related to gastrointestinal recovery in patients treated with radical cystectomy in a randomized, phase 4 clinical trial. MATERIALS AND METHODS: Resource utilization data were prospectively collected and evaluated by cost consequence analysis. Hospital costs were estimated from 2012 Medicare reimbursement rates and medication wholesale acquisition costs. Differences in base case mean costs between the study cohorts for total postoperative ileus related costs (hospital days, study drug, nasogastric tubes, postoperative ileus related concomitant medication and postoperative ileus related readmissions) and total combined costs (postoperative ileus related, laboratory, electrocardiograms, nonpostoperative ileus related concomitant medication and nonpostoperative ileus related readmission) were evaluated by probabilistic sensitivity analysis using a bootstrap approach. RESULTS: Mean hospital stay was 2.63 days shorter for alvimopan than placebo (mean±SD 8.44±3.05 vs 11.07±8.23 days, p=0.005). Use of medications or interventions likely intended to diagnose or manage postoperative ileus was lower for alvimopan than for placebo, eg total parenteral nutrition 10% vs 25% (p=0.001). Postoperative ileus related health care costs were $2,340 lower for alvimopan and mean total combined costs were decreased by $2,640 per patient for alvimopan vs placebo. Analysis using a 10,000-iteration bootstrap approach showed that the mean difference in postoperative ileus related costs (p=0.04) but not total combined costs (p=0.068) was significantly lower for alvimopan than for placebo. CONCLUSIONS: In patients treated with radical cystectomy alvimopan decreased hospitalization cost by reducing the health care services associated with postoperative ileus and decreasing the hospital stay.

Educational opportunities in bladder cancer: increasing cystoscopic adherence and the availability of smoking-cessation programs.

Cancer survivors who continue to smoke following diagnosis are at increased risk for recurrence. Yet, smoking prevalence among survivors is similar to the general population. Adherence to cystoscopic surveillance is an important disease-management strategy for non-muscle-invasive bladder cancer (NMIBC) survivors, but data from Surveillance, Epidemiology, and End Results program (SEER) suggest current adherence levels are insufficient to identify recurrences at critically early stages. This study was conducted to identify actionable targets for educational intervention to increase adherence to cystoscopic monitoring for disease recurrence or progression. NMIBC survivors (n = 109) completed telephone-based surveys. Adherence was determined by measuring time from diagnosis to interview date; cystoscopies received were then compared to American Urological Association (AUA) guidelines. Data were analyzed using non-parametric tests for univariate and logistic regression for multivariable analyses. Participants averaged 65 years (SD = 9.3) and were primarily white (95 %), male (75 %), married (75 %), and non-smokers (84 %). Eighty-three percent reported either Ta- or T1-stage bladder tumors. Forty-five percent met AUA guidelines for adherence. Compared to non-smokers, current smokers reported increased fear of recurrence and psychological distress (p < 0.05). In regression analyses, non-adherence was associated with smoking (OR = 33.91, p < 0.01), providing a behavioral marker to describe a survivor group with unmet needs that may contribute to low cystoscopic adherence. Research assessing survivorship needs and designing and evaluating educational programs for NMIBC survivors should be a high priority. Identifying unmet needs among NMIBC survivors and developing programs to address these needs may increase compliance with cystoscopic monitoring, improve outcomes, and enhance quality of life.

Prevention of Bladder Cancer Recurrence With the Botanical Formula LCS103: A Case Series Study.

Despite effective chemotherapy and other available oncology treatments, recurrence rates for non-muscle invasive bladder cancer (NMIBC) remain high, with as many as 60% of patients requiring repeat intravesical treatments with BCG or other agents within a 24-month period. The botanical formula LCS103 has displayed anti-cancer activity on bladder cancer cells, though its clinical efficacy remains to be proven. A consecutive series of 30 patients with bladder cancer was examined retrospectively, of which a cohort of 20 patients (18 with NMIBC, 2 with metastatic disease) was treated with LCS103 for between 14 months and 16 years, in addition to their conventional oncology care. Only 3 patients (15%) had a single tumor recurrence after initiation of the botanical treatment, as opposed to pre-treatment recurrence reported among 11 patients (55%; range, 1-5). The majority of LCS103-treated patients reported reduced severity for urological symptoms (pain, frequency, and urgency on urination; and nocturia), as well as for weakness and fatigue, and for general wellbeing. No adverse events were associated with use of the botanical formula. Further prospective randomized trials are needed to confirm and better understand these initial findings.

The Impact of PSMA PET/CT on Modern Prostate Cancer Management and Decision Making-The Urological Perspective.

Prostate-specific membrane antigen (PSMA) PET use in prostate cancer treatment has recently become a routinely used imaging modality by urologists. New, established data regarding its performance in different stages of prostate cancer, as well as gaining clinical knowledge with new tracers, drives the need for urologists and other clinicians to improve the utilization of this tool. While the use of PSMA PET/CT is more common in metastatic disease, in which it outperforms classical imaging modalities and drives treatment decisions and adjustments, recently, it gained ground in localized prostate cancer as well, especially in high-risk disease. Still, PSMA PET/CT might reveal lesions within the prostate or possibly locoregional or metastatic disease, not always representing true cancer when utilized in earlier stages of the disease, potentially adding diagnostic burden and changing treatment decisions. As urological treatment options advance toward focal treatments in localized organ-confined prostate cancer, recent reports suggest the utilization of PSMA PET/CT in treatment planning and follow-up and even when choosing active surveillance. This review aims to reveal the current perspective of urologists regarding its daily use.

Urine survivin as a diagnostic biomarker for bladder cancer: a systematic review.

What's known on the subject? and What does the study add? Although many tests for identifying patients with new or recurrent bladder cancer have been used, a reliable method has yet to be established. Recently, increasing attention has focused on the role of survivin in bladder cancer detection. Because urine survivin tests have better sensitivity than cytology, urine survivin could potentially replace routine cytology and might be used as an adjunct method for cystoscopy. However, the clinical utility of urine survivin as a bladder tumour marker identified in the present study remains to be elucidated. To determine the clinical utility of urine survivin as a bladder tumour marker we systematically reviewed the available evidence. A comprehensive literature review was performed, from August 1997 to March 2011, using three search engines in English including PubMed, Cochrane Library, and SCOPUS. Two reviewers independently evaluated both trial eligibility and methodological quality and data extraction. We included studies that evaluated urine survivin, used cystoscopy and/or histopathology as the reference standard, and allowed the construction of a 2 × 2 contingency table. Bivariate random effect meta-analyses were used to calculate the summary estimated of sensitivity and specificity and to construct a summary receiver-operating characteristics curve of urine survivin tests. In all, 14 studies were included in the present review; two studies had two subsets of data. There were 2051 subjects, including 1038 in the case group and 1013 in the control group, and heterogeneity was present among diagnostic studies. The pooled sensitivity and specificity for urine survivin tests were 0.772 (95% confidence interval [CI] 0.745-0.797) and 0.918 (95% CI 0.899-0.934), respectively. The area under the curve of urine survivin tests was 0.9392. When a subgroup analysis with six studies was performed, urine survivin tests had better sensitivity than cytology, but did not match cytology for specificity. The clinical utility of urine survivin as a bladder tumour marker identified in the present study remains to be elucidated.

Reported use of intravesical therapy for non-muscle-invasive bladder cancer (NMIBC): results from the Bladder Cancer Advocacy Network (BCAN) survey.

UNLABELLED: Study Type - Therapy (patterns of practice) Level of Evidence 2b. What's known on the subject? and What does the study add? Claims-based analyses suggest unexplained and potentially problematic variation in treatment intensity adherence to guidelines-recommended care in NMIBC. Previous physician surveys prior to the contemporary Clinical Practice Guidelines (CPGs) reported associations between variation in NMIBC care and practice type, years in practice, and other physician-related factors. In the largest physician survey addressing the management of NMIBC, and the first to examine these questions after the promulgation of contemporary CPGs, US urologists report grade-specific utilization consistent with CPG recommendations, at rates higher than suggested by recent claims-based analyses. As with prior studies, practice type and years in practice were significantly associated with variation in practices. Further research is needed to reconcile these findings with administrative claims data. OBJECTIVES: To determine self-reported practices of use of intravesical chemo- and immunotherapy for patients with non-muscle-invasive bladder cancer (NMIBC) • To evaluate the extent to which respondent characteristics were associated with any observed variation. Guidelines recommend intravesical therapy (IVT) in the management of NMIBC, but recent claims-based analyses suggest exceedingly low rates of use of some of these therapies. MATERIALS AND METHODS: An electronic survey was developed by members of the Bladder Cancer Advocacy Network (BCAN) to elicit self-reported use of management strategies for NMIBC. • The survey was circulated to urologists via the American Urological Association, Society for Urologic Oncology and Large Urology Group Practice Association distribution lists. • In all, 512 respondents completed the survey. RESULTS: In all, 63% reported routine perioperative mitomycin-c (MMC) after transurethral resection of bladder tumour (80% academic vs 54% private practice, P < 0.001). • Whereas 5% of respondents reported routine induction therapy with all new low-grade (LG) diagnoses, 99% reported routinely doing so in new high-grade (HG) cases; most commonly with single-agent bacille Calmette-Guérin (BCG) (94% vs 9% BCG/interferon and 5% MMC). • Reported induction therapy was higher in the setting of high-volume (77%) or frequently recurrent (44%) LG disease. • In all, 89% reported routinely using maintenance therapy for HG vs 29% for LG disease. • Routine biopsy after BCG, even with normal cystoscopy, was endorsed by 28% (39% academic vs 22% private practice, P < 0.001). CONCLUSIONS: Urologists report grade-specific use of IVT for NMIBC, at rates higher than suggested in some claims-based analyses. • Further study is needed to corroborate these self-reported patterns of care with lower rates of use suggested by claims-based analyses.

Racial/ethnic differences in upper-tract urothelial cancer.

OBJECTIVES: Information on clinical characteristics, pattern of initial treatment and survival in patient with upper-tract urothelial carcinomas (UTUC) is scarce. Our study examined the racial/ethnic differences in patients diagnosed with incident UTUC. DESIGN: Observational study. The data analyses included: proportion and ANOVA for categorical and continuous variables, respectively; Kaplan-Meier method for calculating overall survival; and Cox-proportional hazards models for obtaining adjusted hazard-ratios. SETTING: Regions of the Surveillance, Epidemiology and End Results (SEER). PATIENTS OR PARTICIPANTS: 16,702 incident UTUC patients identified from the SEER dataset 1988-2007 (14,192 White, 967 Hispanic, 718 African American and 825 Asian). INTERVENTIONS: None. MAIN OUTCOME MEASURES: Race/ethnicity-specific distributions of demographics, tumor characteristics, patterns of initial treatment, and survival. RESULTS: African American and Hispanic patients were diagnosed at a younger age than Whites and Asians (P = .001). Hispanics were more likely to be diagnosed with larger tumor size than Whites and Asians (P < .0001). Asians were more likely to be diagnosed with advanced stage and higher tumor grade. Cox-regression revealed that Whites and Asians were significantly less likely to die after UTUC diagnosis than African Americans (HR = .78, 95% Cl = .67-.91 and HR = .75, 95% CI = .61-.91, respectively; all P = < .01). CONCLUSIONS: Our study found that Asians had worse tumor characteristics at the initial presentation than the other groups in this study, but that their risk of dying was lower. Further research is needed to include a larger number of Asian patients to examine subgroup differences and to confirm the paradoxical finding of higher survival with poor clinical characteristics.

Association between Nuclear Morphometry Parameters and Gleason Grade in Patients with Prostatic Cancer.

Objective: Gleason scoring system remains the pathological method of choice for prostate cancer (Pca) grading. However, this method of tumor tissue architectural structure grading is still affected by subjective assessment and might succumb to several disadvantages, mainly inter-observer variability. These limitations might be diminished by determining characteristic cellular heterogeneity parameters which might improve Gleason scoring homogeneity. One of the quantitative tools of tumor assessment is the morphometric characterization of tumor cell nuclei. We aimed to test the relationship between various morphometric measures and the Gleason score assigned to different prostate cancer samples. Materials and Methods: We reviewed 60 prostate biopsy samples performed at a tertiary uro-oncology center. Each slide was assigned a Gleason grade according to the International Society of Urological Pathology contemporary grading system by a single experienced uro-pathologist. Samples were assigned into groups from grades 3 to 5. Next, the samples were digitally scanned (×400 magnification) and sampled on a computer using Image-Pro-Plus software©. Manual segmentation of approximately 100 selected tumor cells per sample was performed, and a computerized measurement of 54 predetermined morphometric properties of each cell nuclei was recorded. These characteristics were used to compare the pathological group grades assigned to each specimen. Results: Initially, of the 54 morphometric parameters evaluated, 38 were predictive of Gleason grade (p < 0.05). On multivariate analysis, 7 independent parameters were found to be discriminative of different Pca grades: minimum radius shape, intensity­minimal gray level, intensity­maximal gray level, character­gray level (green), character­gray level (blue), chromatin color, fractal dimension, and chromatin texture. A formula to predict the presence of Gleason grade 3 vs. grades 4 or 5 was developed (97.2% sensitivity, 100% specificity). Discussion: The suggested morphometry method based on seven selected parameters is highly sensitive and specific in predicting Gleason score ≥ 4. Since discriminating Gleason score 3 from ≥4 is essential for proper treatment selection, this method might be beneficial in addition to standard pathological tissue analysis in reducing variability among pathologists.

Can Endoscopic Appearance, Selective Cytology, and Pathological Sampling During Ureteroscopy Accurately Predict Tumor Grade of Upper-Tract Urothelial Carcinoma?

OBJECTIVE: This study examined the reliability of the various parameters obtained in diagnostic ureteroscopy for upper-tract urothelial carcinoma (UTUC) in predicting the degree of differentiation in the final pathological report after radical nephroureterectomy (RNU). METHODS: We conducted a retrospective review of patients undergoing RNU at a single tertiary hospital between 2000 and 2020. Only patients who underwent preoperative diagnostic ureteroscopy (URS) were included. The results of urine selective cytology, endoscopic appearance of the tumor, and biopsy taken during ureteroscopy were compared to the final pathological report. RESULTS: In total, 111 patients underwent RNU. A preliminary URS was performed in 54. According to endoscopic appearance, 40% of the "solid"-looking tumors were high grade (HG), while 52% of those with a papillary appearance were low grade (LG). Positive cytology predicted HG tumors in 86% of cases. However, 42% of patients with negative cytology had HG disease. The biopsies acquired during URS showed that HG disease findings matched the final pathology in 75% of cases. However, 25% of patients noted as being HG, based on URS biopsies, were noted to have LG disease based on nephroureterectomy biopsies. Full analyses revealed that 40% of the cases diagnosed as LG based on the URS biopsies actually had HG disease. CONCLUSIONS: Direct tumor observation of papillary lesions, negative cytology, and biopsies indicating LG disease are of low predictive value for classifying the actual degree of tumor differentiation. No single test can accurately rule out HG disease. In light of the rising use of neo-adjuvant chemotherapy in UTUC, a reliable predictive model should be developed that accurately discriminates between HG and LG disease.

Prognostic risk stratification of pathological stage T3N0 bladder cancer after radical cystectomy.

PURPOSE: Patients with pathological T3N0 stage urothelial carcinoma of the bladder show a range of outcomes after radical cystectomy. Given that nomograms have included heterogeneous groups of patients, we focused on and stratified patients with pT3N0 urothelial carcinoma of the bladder after radical cystectomy into prognostically different risk groups to facilitate the development of adjuvant therapy trials for those at high risk. MATERIALS AND METHODS: The study comprised a total of 578 patients from 9 centers worldwide with pT3N0 urothelial carcinoma of the bladder who underwent radical cystectomy without perioperative chemotherapy. We evaluated the effect of pT3 substage at radical cystectomy, age, grade, lymphovascular invasion, margin status and number of lymph nodes removed on recurrence-free survival using Cox regression analysis. A weighted prognostic model was devised. RESULTS: Median followup was 39.4 months (IQR 64). On multivariate analysis pT3 substage at radical cystectomy (pT3b vs pT3a HR 2.056, p <0.0001), lymphovascular invasion (positive vs negative HR 2.004, p <0.0001) and margin status (positive vs negative HR 2.503, p = 0.002) were associated with recurrence-free survival (concordance index 0.66) in the context of generally adequate lymph node dissection, that is with a median of 17 removed. Three risk groups were devised based on weighted variables with a 5-year recurrence-free survival rate of 79% (95% CI 70-84), 57% (95% CI 50-64) and 37% (95% CI 26-48) in the low, intermediate and high risk groups, respectively. CONCLUSIONS: We constructed a user friendly prognostic risk model for patients with pT3N0 urothelial carcinoma of the bladder treated with radical cystectomy based on pT3 substage at radical cystectomy, lymphovascular invasion and margin status. These data warrant validation and may enable tailored monitoring and selection of appropriate patients for adjuvant therapy trials.