ABSTRACT
BACKGROUND: The standard of care for patients with intermediate-to-high risk renal cell carcinoma is partial or radical nephrectomy followed by surveillance. We aimed to investigate use of nivolumab before nephrectomy followed by adjuvant nivolumab in patients with high-risk renal cell carcinoma to determine recurrence-free survival compared with surgery only. METHODS: In this open-label, randomised, phase 3 trial (PROSPER EA8143), patients were recruited from 183 community and academic sites across the USA and Canada. Eligible patients were aged 18 years or older with an Eastern Cooperative Oncology Group performance status of 0-1, with previously untreated clinical stage T2 or greater or Tany N+ renal cell carcinoma of clear cell or non-clear cell histology planned for partial or radical nephrectomy. Selected patients with oligometastatic disease, who were disease free at other disease sites within 12 weeks of surgery, were eligible for inclusion. We randomly assigned (1:1) patients using permuted blocks (block size of 4) within stratum (clinical TNM stage) to either nivolumab plus surgery, or surgery only followed by surveillance. In the nivolumab group, nivolumab 480 mg was administered before surgery, followed by nine adjuvant doses. The primary endpoint was investigator-reviewed recurrence-free survival in patients with renal cell carcinoma assessed in all randomly assigned patients regardless of histology. Safety was assessed in all randomly assigned patients who started the assigned protocol treatment. This trial is registered with ClinicalTrials.gov, NCT03055013, and is closed to accrual. FINDINGS: Between Feb 2, 2017, and June 2, 2021, 819 patients were randomly assigned to nivolumab plus surgery (404 [49%]) or surgery only (415 [51%]). 366 (91%) of 404 patients assigned to nivolumab plus surgery and 387 (93%) of 415 patients assigned to surgery only group started treatment. Median age was 61 years (IQR 53-69), 248 (30%) of 819 patients were female, 571 (70%) were male, 672 (88%) were White, and 77 (10%) were Hispanic or Latino. The Data and Safety Monitoring Committee stopped the trial at a planned interim analysis (March 25, 2022) because of futility. Median follow-up was 30·4 months (IQR 21·5-42·4) in the nivolumab group and 30·1 months (21·9-41·8) in the surgery only group. 381 (94%) of 404 patients in the nivolumab plus surgery group and 399 (96%) of 415 in the surgery only group had renal cell carcinoma and were included in the recurrence-free survival analysis. As of data cutoff (May 24, 2023), recurrence-free survival was not significantly different between nivolumab (125 [33%] of 381 had recurrence-free survival events) versus surgery only (133 [33%] of 399; hazard ratio 0·94 [95% CI 0·74-1·21]; one-sided p=0·32). The most common treatment-related grade 3-4 adverse events were elevated lipase (17 [5%] of 366 patients in the nivolumab plus surgery group vs none in the surgery only group), anaemia (seven [2%] vs nine [2%]), increased alanine aminotransferase (ten [3%] vs one [<1%]), abdominal pain (four [1%] vs six [2%]), and increased serum amylase (nine [2%] vs none). 177 (48%) patients in the nivolumab plus surgery group and 93 (24%) in the surgery only group had grade 3-5 adverse events due to any cause, the most common of which were anaemia (23 [6%] vs 19 [5%]), hypertension (27 [7%] vs nine [2%]), and elevated lipase (18 [5%] vs six [2%]). 48 (12%) of 404 patients in the nivolumab group and 40 (10%) of 415 in the surgery only group died, of which eight (2%) and three (1%), respectively, were determined to be treatment-related. INTERPRETATION: Perioperative nivolumab before nephrectomy followed by adjuvant nivolumab did not improve recurrence-free survival versus surgery only followed by surveillance in patients with high-risk renal cell carcinoma. FUNDING: US National Institutes of Health National Cancer Institute and Bristol Myers Squibb.
Subject(s)
Carcinoma, Renal Cell , Kidney Neoplasms , Nephrectomy , Nivolumab , Humans , Nivolumab/administration & dosage , Nivolumab/therapeutic use , Nivolumab/adverse effects , Carcinoma, Renal Cell/surgery , Carcinoma, Renal Cell/drug therapy , Carcinoma, Renal Cell/pathology , Carcinoma, Renal Cell/mortality , Male , Female , Kidney Neoplasms/surgery , Kidney Neoplasms/pathology , Kidney Neoplasms/drug therapy , Kidney Neoplasms/mortality , Middle Aged , Aged , Canada , Chemotherapy, Adjuvant , Neoplasm Staging , Antineoplastic Agents, Immunological/therapeutic use , Antineoplastic Agents, Immunological/adverse effects , Antineoplastic Agents, Immunological/administration & dosageABSTRACT
PURPOSE: CT-guided MWA is a safe and effective tool that should be utilized in the treatment of small renal masses (SRMs). We aim to clarify the utility of CT-guided MWA by examining patient outcomes such as recurrence, treatment success, changes in renal function, and complications. METHODS: A retrospective review of consecutive patients with SRMs who underwent same day renal mass biopsy (RMB) and CT-guided MWA between 2015 and 2022 was performed. Treatment safety was assessed by 30-day complications according to the Clavien-Dindo system and change in eGFR >30 days post-procedure. Treatment efficacy was defined by local recurrence and incomplete treatment rates and calculated using the Kaplan-Meier method. RESULTS: A total of 108 renal masses were found in 104 patients. The overall complication rate was 7.4% (8/108), of which 4 were major complications (3.7%). For those with renal function available >30 days post ablation, the median eGFR was 47.2 (IQR: 36.0, 57), compared to 52.3 (IQR: 43.7, 61.5) pre-ablation, p<0.0001. 5-year local recurrence free survival was 86%. Among those with biopsy proven malignancy (n= 66), there were five local recurrences (7.54%) occurring at a median of 25.1 months (IQR 19.9, 36.2) and one case (1.5%) of incomplete treatment. CONCLUSIONS: As the medical field continues to evolve towards less invasive interventions, MWA offers a valuable tool in the management of renal masses. With low major complication and recurrence rates, our findings support the utility of CT-guided MWA as a tool for treatment of SRMs.
Subject(s)
Ablation Techniques , Carcinoma, Renal Cell , Catheter Ablation , Kidney Neoplasms , Humans , Kidney Neoplasms/pathology , Carcinoma, Renal Cell/pathology , Microwaves/therapeutic use , Treatment Outcome , Ablation Techniques/adverse effects , Ablation Techniques/methods , Retrospective Studies , Catheter Ablation/methodsABSTRACT
BACKGROUND: The early diagnosis and treatment of depression are cancer care priorities. These priorities are critical for prostate cancer survivors because men rarely seek mental health care. However, little is known about the epidemiology of depression in this patient population. The goal of this study was to describe the prevalence and predictors of probable depression in prostate cancer survivors. METHODS: The data were from a population-based cohort of North Carolinian prostate cancer survivors who were enrolled from 2004 to 2007 in the North Carolina-Louisiana Prostate Cancer Project (n = 1031) and were prospectively followed annually from 2008 to 2011 in the Health Care Access and Prostate Cancer Treatment in North Carolina study (n = 805). Generalized estimating equations were used to evaluate an indicator of probable depression (Short Form 12 mental composite score ≤48.9; measured at enrollment and during the annual follow-up) as a function of individual-level characteristics within the longitudinal data set. RESULTS: The prevalence of probable depression fell from 38% in the year of the cancer diagnosis to 20% 6 to 7 years later. Risk factors for probable depression throughout the study were African American race, unemployment, low annual income, younger age, recency of cancer diagnosis, past depression, comorbidities, treatment decisional regret, and nonadherence to exercise recommendations. CONCLUSIONS: Depression is a major challenge for prostate cancer survivors, particularly in the first 5 years after the cancer diagnosis. To the authors' knowledge, this is the first study to demonstrate an association between treatment decisional regret and probable depression.
Subject(s)
Cancer Survivors/psychology , Depression/epidemiology , Prostatic Neoplasms/psychology , Quality of Life/psychology , Adult , Black or African American/psychology , Black or African American/statistics & numerical data , Age Factors , Aged , Aged, 80 and over , Cancer Survivors/statistics & numerical data , Decision Making , Depression/diagnosis , Depression/etiology , Depression/psychology , Emotions , Follow-Up Studies , Humans , Louisiana/epidemiology , Male , Middle Aged , North Carolina/epidemiology , Patient Compliance/psychology , Prevalence , Probability , Prospective Studies , Prostate , Prostatic Neoplasms/mortality , Prostatic Neoplasms/therapy , Psychiatric Status Rating Scales/statistics & numerical data , Risk Factors , Unemployment/psychology , Unemployment/statistics & numerical data , White People/psychology , White People/statistics & numerical dataABSTRACT
BACKGROUND: Supporting patients' decision making about clinical trials may enhance trial participation. To date, few theory-based interventions have been tested to address this issue. The objective of the current study was aimed to evaluate the effect of a multimedia psychoeducation (MP) intervention, relative to a print education (PE) intervention, on patients' decision support needs and attitudes about clinical trials. METHODS: Patients with cancer who were eligible for participation in a National Cancer Institute therapeutic cancer clinical trial were recruited through the nationwide University of Rochester Cancer Center National Cancer Institute Community Oncology Research Program from 2014 to 2016 and were randomized to the MP or PE intervention. Assessments at baseline (before intervention), postintervention, and at a 2-month follow-up visit included patients' decision support needs, attitudes regarding clinical trials, and clinical trial participation. RESULTS: In total, 418 patients with various types of cancer were recruited (ages 26-89 years). Relative to the PE intervention, the MP intervention did not significantly affect decision support needs. However, patients in the MP arm reported significantly more positive attitudes about clinical trials and were more likely to participate in a clinical trial than those in the PE arm (69% vs 62%; P = .01). Furthermore, an improvement in attitudes about clinical trials significantly mediated the effect of the intervention on participation in clinical trials. CONCLUSIONS: The MP intervention was able to improve patient attitudes toward clinical trials compared with the PE intervention, and this improvement led to increased rates of participation in trials. The MP intervention could be disseminated to improve attitudes about clinical trials among patients with cancer.
Subject(s)
Neoplasms/psychology , Patient Education as Topic/methods , Patient Participation/psychology , Aged , Decision Making , Female , Humans , Male , Middle Aged , Multimedia , National Cancer Institute (U.S.) , Pamphlets , United StatesABSTRACT
BACKGROUND: The aim of the study was to assess the morbidity and efficacy of repeat cryoablation (CA) in the treatment of localized prostate cancer. METHODS: Twenty-seven patients with median age of 71 years (range 48-80) who underwent repeat CA between April 2003 and April 2011 at a single institution were included. The median initial prostate-specific antigens (PSA) and Gleason values were 6.2 ng/ml (range 4-23.6) and 7 (range 6-9), respectively. Twenty-four patients underwent two CA treatments, and three patients underwent three CA treatments. Pre- and perioperative parameters and oncological and functional outcomes were evaluated. RESULTS: No intraoperative complications occurred. After the first CA, PSA was undetectable in 10 patients, and the median nadir PSA value was 0.65 ng/ml (range 0.1-4.9). After the second CA, 4 patients had undetectable PSA, and the median nadir PSA value was 1.25 ng/ml (range 0.2-7.9). For patients who underwent a third CA treatment, no patients had undetectable PSA, and the subsequent median nadir PSA value was 1.6 ng/ml (range 0.4-4.5). Two patients had incontinence (1 pad per day) following repeat CA. One patient had urinary retention after the third CA treatment, and one had urethral stricture. The mean hospitalization and follow-up periods were 1 day (range 0-2) and 51.5 months (range 11-96), respectively. CONCLUSIONS: Repeat CA successfully reduced PSA levels, and complications were modest. We conclude that repeat CA is a feasible, safe, and effective treatment option for localized prostate cancer.
Subject(s)
Cryosurgery/methods , Prostatic Neoplasms/surgery , Aged , Aged, 80 and over , Feasibility Studies , Female , Follow-Up Studies , Humans , Male , Middle Aged , Neoplasm Grading , Neoplasm Staging , Prognosis , Prostatic Neoplasms/pathology , Reoperation , Retrospective Studies , SafetyABSTRACT
BACKGROUND: The American Joint Committee on Cancer's (AJCC) 7th edition cancer staging manual reflects recent changes in cancer care practices. This report assesses changes from the AJCC 6th to the AJCC 7th edition stage distributions and the quality of site-specific factors (SSFs). METHODS: Incidence data for renal parenchyma and pelvis and ureter cancers from 18 Surveillance, Epidemiology, and End Results (SEER) registries were examined, including staging trends during 2004-2010, stage distribution changes between the AJCC 6th and 7th editions, and SSF completeness for cases diagnosed in 2010. RESULTS: From 2004 to 2010, the percentage of stage I renal parenchyma cancers increased from 50% to 58%, whereas stage IV and unknown stage cases decreased (18% to 15%, and 10% to 6%, respectively). During this period, the percentage of stage 0a renal pelvis and ureter cancers increased from 21% to 25%, and stage IV and unknown stage tumors decreased (20% to 18%, and 7% to 5%, respectively). Stage distributions under the AJCC 6th and 7th editions were about the same. For renal parenchymal cancers, 71%-90% of cases had known values for 6 required SSFs. For renal pelvis and ureter cancers, 74% of cases were coded as known for SSF1 (WHO/ISUP grade) and 47% as known for SSF2 (depth of renal parenchymal invasion). SSF values were known for larger proportions of cases with reported resections. CONCLUSIONS: Stage distributions between the AJCC 6th and 7th editions were similar. SSFs were known for more than two-thirds of cases, providing more detail in the SEER database relevant to prognosis.
Subject(s)
Carcinoma, Renal Cell/pathology , Carcinoma, Transitional Cell/pathology , Kidney Neoplasms/pathology , Kidney Pelvis , Lymph Nodes/pathology , Registries , Ureteral Neoplasms/pathology , Cohort Studies , Humans , Neoplasm Grading , Neoplasm Invasiveness , Neoplasm Staging/trends , Prognosis , Renal Veins , Retrospective Studies , SEER ProgramABSTRACT
OBJECTIVE: To evaluate the impact of microscopically positive vascular margins on recurrence and cancer-specific survival (CSS) in patients with renal cell carcinoma (RCC) with venous thrombus PATIENTS AND METHODS: We reviewed the records from the period 1993 to 2009 of consecutive patients treated surgically for RCC with venous tumour thrombus at the University of Texas MD Anderson Cancer Center. Patients with metastatic disease, positive soft tissue margins or gross residual disease at time of thrombectomy were excluded. The primary outcome measures were local or systemic disease recurrence, and CSS. Univariate and multivariate analysis were used to evaluate whether microscopically positive vascular margins were associated with RCC recurrence or CSS after nephrectomy with thrombectomy. RESULTS: A total of 256 patients with RCC were identified with a median (interquartile range) follow-up of 36.7 (18.4-63.5) months. Microscopic tumour was present at the margin of resection in 47 patients (18.4%). The median recurrence-free interval was significantly shorter in patients with positive vascular margins: 22.1 vs 70.2 months (P = 0.009). The rate of local recurrence was higher in patients with positive vein margins: 12.8 vs 4.3% (P < 0.01). Local recurrence without concomitant systemic recurrence was identified in only two of 256 (0.8%) patients. Patients with positive vascular margins had significantly worse CSS times compared with patients with negative vascular margins: 37.7 vs 93.0 months (P = 0.004). In multivariable analysis, positive vascular margins were found to be independently predictive of local recurrence but not of systemic recurrence or CSS. CONCLUSIONS: Complete surgical excision should always be attempted because positive vascular wall margins increase local recurrence rates. Invasion of RCC into the vein wall at the resection margin is associated with aggressive tumour biology, and the majority of patients with positive vascular wall margins experience systemic recurrence.
Subject(s)
Carcinoma, Renal Cell/pathology , Kidney Neoplasms/pathology , Thrombosis/pathology , Adult , Aged , Aged, 80 and over , Analysis of Variance , Carcinoma, Renal Cell/blood supply , Carcinoma, Renal Cell/surgery , Disease-Free Survival , Female , Humans , Kaplan-Meier Estimate , Kidney Neoplasms/blood supply , Kidney Neoplasms/surgery , Male , Middle Aged , Retrospective Studies , Thrombosis/surgeryABSTRACT
OBJECTIVE: We aim to determine the effect of region of residence (urban vs. rural) on the odds of receiving standard of care treatment for locally advanced BCa in Louisiana and its impact on survival outcomes. METHODS: Using the Louisiana Tumor Registry, we identified American Joint Committee on Cancer (AJCC) stage II or III, BCa diagnoses in Louisiana residents between 2010 and 2020. Treatment received was classified as standard or non-standard of care according to American Urological Association (AUA) guidelines and location of residence was determined using Rural Urban Commuting Area-Tract-level 2010 (RUCA). Multivariable logistic regression analyses and multivariate cox proportional hazard analyses were performed. RESULTS: Of 983 eligible patients, 85.6% (841/983) lived in urban areas. Overall, only 37.5% received standard-of-care (SOC) for the definitive management of locally advanced bladder cancer. Individuals living in rural areas (OR 0.53, 95% CI: 0.31-0.91, p = 0.02) were less likely to receive standard of care treatment. Both rural residence and receipt of non-standard of care therapy were associated with an increased risk of bladder cancer-specific (adj HR 1.53, 95% CI: 1.09-2.14, p = 0.01 and adj HR: 1.85, 95% CI: 1.43-2.39, <0.0001) and overall mortality (adj HR: 1.28, 95% CI: 1.01-1.61, p = 0.04 and adj HR: 1.73 95% CI: 1.44-2.07, p < 0.0001). CONCLUSIONS: Most patients with locally advanced bladder cancer in Louisiana do not receive SOC therapy. Individuals living in rural locations are more likely to receive non-standard of care therapy than individuals in urban areas. Nonstandard of care treatment and rural residence are both associated with worse survival outcomes for Louisiana residents with locally advanced bladder cancer.
Subject(s)
Rural Population , Standard of Care , Urinary Bladder Neoplasms , Humans , Urinary Bladder Neoplasms/therapy , Urinary Bladder Neoplasms/mortality , Urinary Bladder Neoplasms/pathology , Louisiana/epidemiology , Female , Male , Aged , Rural Population/statistics & numerical data , Middle Aged , Registries , Aged, 80 and over , Neoplasm Staging , Urban Population/statistics & numerical dataABSTRACT
BACKGROUND: Non-muscle invasive bladder cancer (non-MIBC) that is high-grade and confined to the lamina propria (HGT1) often has an aggressive clinical course. Currently, there is limited data on the comparative effectiveness of RT vs. CRT for HGT1 non-MIBC. We hypothesized that CRT would be associated with improved overall survival (OS) vs. RT in HGT1 bladder cancer. METHODS: Patients diagnosed with HGT1 non-MIBC, and treated with transurethral resection of bladder tumor followed by either treatment with RT alone or CRT, were identified in the National Cancer Database. Inverse probability of treatment weighting (IPTW) was employed and weight-adjusted multivariable analysis (MVA) using Cox regression modeling was used to compare overall survival (OS) hazard ratios. OS was the primary endpoint, and was estimated using the Kaplan-Meier method and log-rank tests. RESULTS: A total of 259 patients with HGT1 UC were treated with: (i) RT alone (n = 123) or (ii) CRT (n = 136). Propensity-weighted MVA showed that combined modality treatment with CRT was associated with improved OS relative to radiation alone (Hazard Ratio [HR]: 0.62, 95% Confidence Interval (95% CI): 0.44-0.88, P = .007). Four-year OS for the CRT vs. RT alone was 36% and 19%, respectively (log-rank P <.008). CONCLUSION: For patients with HGT1 bladder cancer, concurrent CRT was associated with improved OS compared with radiation alone in a retrospective cohort. These results are hypothesis-generating. The NRG is currently developing a phase II randomized clinical trial comparing CRT to other novel, bladder preservation strategies.
Subject(s)
Carcinoma, Transitional Cell , Urinary Bladder Neoplasms , Humans , Urinary Bladder Neoplasms/pathology , Carcinoma, Transitional Cell/therapy , Urinary Bladder/surgery , Urinary Bladder/pathology , Chemoradiotherapy/methods , Retrospective Studies , Treatment OutcomeABSTRACT
Trimodal therapy (TMT) for muscle invasive bladder cancer has become an accepted alternative to radical cystectomy and has become integrated into national guidelines as standard a treatment option. The urologist plays a critical role in proper patient selection, thorough transurethral resection, ongoing cystoscopic surveillance and management of local recurrences. There exists multiple patient related and tumor related factors, which contribute to the selection of TMT vs. radical cystectomy for a patient with muscle invasive bladder cancer. Although the ideal patient for TMT has a tumor which can undergo a visibly complete resection, has no associated hydronephrosis, does not invade the prostatic urethra and is not associated with diffuse carcinoma in situ throughout the bladder, select patients who do not meet all these criteria can still be successfully treated with this approach. A multidisciplinary approach including urology, radiation oncology and medical oncology is paramount with clear communication of tumor location, timing of chemoradiation and repeat cystoscopic resection followed by surveillance. Nonmuscle invasive bladder cancer recurrences can occur in up to 26% of patients after completion of TMT, with many being treated by routine and standard therapy for non-muscle invasive bladder cancer. However, in this population after TMT, early salvage cystectomy should be considered in those with adverse features, including T1 disease, tumor greater than 3 cm, CIS, or lymphovascular invasion. Salvage cystectomy can be performed for local recurrences with acceptable oncologic control and no clear evidence of any greater risk of early complications; however, there may be a slightly increased risk for late complications, namely small bowel obstruction, ureteral stricture, and parastomal hernia. An understanding of these surgical considerations is of utmost importance to the treating urologist in selecting and managing a patient through TMT.
Subject(s)
Urinary Bladder Neoplasms , Combined Modality Therapy , Cystectomy/adverse effects , Humans , Neoplasm Invasiveness/pathology , Organ Sparing Treatments , Treatment Outcome , Urinary Bladder/pathology , Urinary Bladder Neoplasms/pathology , Urinary Bladder Neoplasms/surgeryABSTRACT
PURPOSE: Patients with isolated regional nodal metastases from renal cell carcinoma are a distinct cohort for which resection of involved lymph nodes may be therapeutic. We assessed the outcomes of patients treated at our institution with pathological node positive renal cell carcinoma without concomitant metastatic disease (T(any)N+M0). MATERIALS AND METHODS: A total of 2,521 patients with nonmetastatic renal cell carcinoma (T(any)N(any)M0) of any histological subtype treated with nephrectomy were identified between 1995 and 2009. Pathological regional node positive disease in the absence of clinically detectable metastases (T(any)N(1-2)M0) was present in 68 patients (2.7%) and these patients formed our study cohort. Patients were assessed for timing and location of recurrence, disease specific survival and overall survival. Multivariate Cox regression analysis was performed to define factors predictive of recurrence and overall survival. RESULTS: Of the 68 patients with T(any)N(1-2)M0 renal cell carcinoma 22.1% were free of disease at a median followup of 43.5 months. In those patients experiencing recurrence, disease was detected within the first 4 months after surgery in 51% and was most commonly detected at multiple organ sites. The Kaplan-Meier estimated 5-year overall survival and disease specific survival was 37% and 39%, respectively. Predictors of a favorable outcome included an Eastern Cooperative Oncology Group performance status of 0, single node involvement, absence of sarcomatoid features and papillary histology. CONCLUSIONS: Nephrectomy with lymph node dissection can provide a durable disease-free survival in a proportion of patients with regionally advanced renal cell carcinoma and limited lymph node metastases.
Subject(s)
Carcinoma, Renal Cell/surgery , Disease-Free Survival , Kidney Neoplasms/surgery , Lymph Node Excision , Nephrectomy , Carcinoma, Renal Cell/mortality , Carcinoma, Renal Cell/pathology , Carcinoma, Renal Cell/secondary , Humans , Kidney Neoplasms/mortality , Kidney Neoplasms/pathology , Lymphatic Metastasis , Proportional Hazards Models , Survival RateABSTRACT
OBJECTIVE: The multimodality approach to treating both localized and metastatic renal cell carcinoma has led to a demand for improved imaging evaluation. We review the information needed from the radiologic studies used to determine treatment strategies. CONCLUSION: Adequate preoperative radiologic assessment provides the treating physician with information critical in determining the sequence of treatments, role of nephron-sparing surgery, surgical approach, and timing of systemic therapy for metastatic disease.
Subject(s)
Carcinoma, Renal Cell/diagnosis , Carcinoma, Renal Cell/therapy , Kidney Neoplasms/diagnosis , Kidney Neoplasms/therapy , Carcinoma, Renal Cell/pathology , Combined Modality Therapy , Humans , Kidney Neoplasms/pathology , Neoplasm Metastasis , Neoplasm Staging , Patient Care Planning , Practice Guidelines as TopicABSTRACT
Due to the relatively heterogeneous metastatic spread of renal cell carcinoma (RCC) through both hematogenous and lymphatogenous routes, the surgical extirpation of regional lymph nodes in the treatment of RCC has long been a controversial topic. Individual risk is dependent on multiple variables including tumor stage, grade, and histologic sub-type, in addition to many others. Controversy exists over whether lymph node dissection (LND) simply provides improved staging or whether removal of pathologic nodes offers a therapeutic advantage. Herein, we evaluate the available data regarding the use of LND in the treatment of RCC. While we believe that LND may provide an opportunity for cure in a select group of patients, there are many variables to consider when determining its applicability to an individual patient.
Subject(s)
Carcinoma, Renal Cell/secondary , Carcinoma, Renal Cell/surgery , Kidney Neoplasms/surgery , Lymph Node Excision/methods , Lymph Nodes/surgery , Carcinoma, Renal Cell/pathology , Humans , Kidney Neoplasms/pathology , Lymph Node Excision/mortality , Lymph Nodes/pathology , Lymphatic Metastasis , Neoplasm Staging , Nephrectomy , Prospective Studies , Retrospective StudiesABSTRACT
OBJECTIVE: To evaluate the effect of adding multiparametric magnetic resonance imaging (mpMRI) to pre-surgical planning on surgical decision making for the management of high-risk prostate cancer (HRPC). PATIENTS AND METHODS: A survey was designed to query multiple centers on surgical decisions of 41 consecutive HRPC cases seen from 2012 to 2015. HRPC was defined by the National Comprehensive Cancer Center Network guidelines. Six fellowship-trained urologic oncologists were asked for their surgical plan in regards to the degree of planned nerve-sparing and lymph node dissection. Two rounds of surveys were administered to six external urologic oncologists. The first survey included the case description only and the second included case description with mpMRI images and report. The correct surgical plan was analyzed by correlation of the degree of planned surgical excision and consistency with the final pathologic evaluation. A priori, an effect size of 20% change was used to determine statistical significance, at p < 0.05. RESULTS: All cases had at least one change to surgical planning after mpMRI review. Forty (98%) patients had a change in the degree of planned nerve sparing: wider excision in 32% and increased nerve sparing in 24%. After mpMRI the correct surgical plan change was made in 49% for the right and left 51%, decreasing the potential for positive margins. Lymph node dissection was altered from standard to extended lymph node dissection in 17%. CONCLUSIONS: Although mpMRI is not integrated in guidelines for preoperative planning in HRPC, its use may impact surgical planning, cancer control, and quality of life.
Subject(s)
Magnetic Resonance Imaging , Preoperative Care , Prostatic Neoplasms/diagnostic imaging , Prostatic Neoplasms/pathology , Clinical Decision-Making , Disease Management , Humans , Magnetic Resonance Imaging/methods , Male , Multiparametric Magnetic Resonance Imaging , Neoplasm Staging , Prognosis , Prostatectomy/methods , Prostatic Neoplasms/surgery , Risk AssessmentABSTRACT
PURPOSE OF REVIEW: To critically appraise the current literature on the benefits of lymphadenectomy in patients with renal cell carcinoma. Many questions exist including: What is a 'standard' versus 'extended' lymph node dissection (LND)? What is the morbidity of a LND? What type of patient may derive the most benefit from LND? On the basis of preoperative staging, what is the benefit (therapeutic versus staging) for an individual patient? How does the performance of a LND impact current and future adjuvant and neoadjuvant studies? RECENT FINDINGS: Results from the EORTC 30881 trial did not show a therapeutic benefit to performing a 'standard' LND in patients with renal cell carcinoma, but the population predominantly comprised patients at the lowest risk of harboring lymph node metastasis. There are no prospective randomized trials with sufficient statistical power to analyze the therapeutic or staging effects in high-risk patients. SUMMARY: This review provides a synopsis of the available data regarding the therapeutic and staging benefits of lympadenectomy in the setting of renal cell carcinoma and should assist the urologist in educating affected patients as well as providing the urologist with the current evidenced-based data regarding this longstanding unanswered question.
Subject(s)
Carcinoma, Renal Cell/surgery , Kidney Neoplasms/surgery , Lymph Node Excision , Evidence-Based Medicine , Humans , Lymph Node Excision/adverse effects , NomogramsABSTRACT
BACKGROUND: Appropriate depression care is a cancer-care priority. However, many cancer survivors live with undiagnosed and untreated depression. Prostate cancer survivors may be particularly vulnerable, but little is known about their access to depression care. The goal of this study was to describe patterns and predictors of clinical diagnosis and treatment of depression in prostate cancer survivors. METHODS: Generalized estimating equations were used to evaluate indicators of self-reported clinical diagnosis and treatment depression as a function of individual-level characteristics within a longitudinal dataset. The data were from a population-based cohort of North Carolinian prostate cancer survivors who were enrolled from 2004 to 2007 on the North Carolina-Louisiana Prostate Cancer Project (N = 1,031), and prospectively followed annually from 2008 to 2011 on the Health Care Access and Prostate Cancer Treatment in North Carolina (N = 805). RESULTS: The average rate of self-reported clinical diagnosis of depression was 44% (95% CI: 39%-49%), which declined from 60% to 40% between prostate cancer diagnosis and 5-7 years later. Factors associated with lower odds of self-reported clinical diagnosis of depression include African-American race, employment, age at enrollment, low education, infrequent primary care visits, and living with a prostate cancer diagnosis for more than 2 years. The average rate of self-reported depression treatment was 62% (95% CI: 55%-69%). Factors associated with lower odds of self-reported depression treatment included employment and living with a prostate cancer diagnosis for 2 or more years. CONCLUSION: Prostate cancer survivors experience barriers when in need of depression care.
Subject(s)
Cancer Survivors/psychology , Depression/epidemiology , Depression/etiology , Practice Patterns, Physicians' , Prostatic Neoplasms/complications , Prostatic Neoplasms/epidemiology , Adult , Aged , Depression/diagnosis , Depression/therapy , Disease Management , Humans , Male , Middle Aged , Patient Satisfaction , Prognosis , Public Health Surveillance , Self Report , Surveys and QuestionnairesABSTRACT
Retrospective observational studies support the utility of robotic-assisted radical cystectomy (RARC). Randomized controlled trials (RCTs) have shown that RARC with extracorporeal urinary diversion may lead to decreased estimated blood loss, decreased rate of transfusion, similar oncologic outcomes, cost-effectiveness, and variable increased operative times. Although RCTs comparing RARC with open radical cystectomy are currently ongoing, it may be several years before the utility of RARC is known. The discussion on the role of cystectomy, indications, outcomes, care pathways, access to high-volume care centers, and efforts to decrease complications may prove as important as the technique itself.
Subject(s)
Cystectomy/methods , Robotic Surgical Procedures , Urinary Bladder Neoplasms/surgery , Cystectomy/instrumentation , Cystectomy/statistics & numerical data , Humans , Learning Curve , Randomized Controlled Trials as Topic , Robotic Surgical Procedures/statistics & numerical dataABSTRACT
The S1602 Intergroup trial is a randomized phase III clinical trial that aims to test two important hypotheses: (1) priming with intradermal bacillus Calmette-Guérin (BCG) vaccine prior to standard intravesical BCG improves response to BCG in terms of recurrence-free survival and (2) Tokyo-172 BCG strain is non-inferior to TICE BCG in terms of time to high-grade recurrence. The study was approved by the Cancer Therapy Evaluation Program of the National Cancer Institute and activated in spring 2017. Here, we provide a synopsis of the study background, design, and update of the clinical trial.
Subject(s)
BCG Vaccine , Immunotherapy/methods , Injections, Intradermal/methods , T-Lymphocytes/immunology , Urinary Bladder Neoplasms , Adjuvants, Immunologic/administration & dosage , Adjuvants, Immunologic/adverse effects , Adjuvants, Immunologic/classification , Adjuvants, Immunologic/standards , BCG Vaccine/administration & dosage , BCG Vaccine/adverse effects , BCG Vaccine/classification , BCG Vaccine/standards , Female , Humans , Immunity, Cellular/drug effects , Male , Middle Aged , Neoplasm Invasiveness , Neoplasm Recurrence, Local/prevention & control , Neoplasm Staging , Progression-Free Survival , Treatment Outcome , Urinary Bladder Neoplasms/drug therapy , Urinary Bladder Neoplasms/pathologyABSTRACT
BACKGROUND: Positron emission tomography/computed tomography (PET/CT) has recently emerged as a promising diagnostic imaging platform for prostate cancer. Several radiolabelled tracers have demonstrated efficacy for cancer detection in various clinical settings. In this review, we aim to illustrate the diverse use of PET/CT with different tracers for the detection of prostate cancer. METHODS: We searched MEDLINE using the terms 'prostate cancer', 'PET', 'PET/CT' and 'PET/MR'). The current review was limited to 18F-NaF PET/CT, choline-based PET/CT, fluciclovine PET/CT and PSMA-targeted PET/CT, as these modalities have been the most widely adopted. RESULTS: NaF PET/CT has shown efficacy in detecting bone metastases with high sensitivity, but relatively low specificity. Currently, choline PET/CT has been the most extensively studied modality. Although having superior specificity, choline PET/CT suffers from low sensitivity, especially at low PSA levels. Nevertheless, choline PET/CT was found to significantly improve upon conventional imaging modalities (CIM) in the detection of metastatic lesions at biochemical recurrence (BCR). Newer methods using fluciclovine and PSMA-targeted radiotracers have preliminarily demonstrated great promise in primary and recurrent staging of prostate cancer. However, their superior efficacy awaits confirmation in larger series. CONCLUSIONS: PET/CT has emerged as a promising staging modality for both primary and recurrent prostate cancer. Newer tracers have increased detection accuracies for small, incipient metastatic foci. The clinical implications of these occult PET/CT detected disease foci require organized evaluation. Efforts should be aimed at defining their natural history as well as responsiveness and impact of metastasis-directed therapy.