Sarcopenia and systemic inflammation are associated with decreased survival after cytoreductive nephrectomy for metastatic renal cell carcinoma.

BACKGROUND: This study was aimed at assessing the associations of sarcopenia, muscle density, adiposity, and inflammation with overall survival (OS) after cytoreductive nephrectomy (CN) for metastatic renal cell carcinoma. METHODS: In all, 158 patients undergoing CN from 2001 to 2014 had digitized preoperative imaging for tissue segmentation via Slice-O-Matic software (version 5.0) at the mid-L3 level. The skeletal muscle index was calculated with the skeletal muscle area (cm2 ) normalized for height (m2 ), and the skeletal muscle density (SMD) was calculated with average Hounsfield units. Adiposity was measured with the cross-sectional area (cm2 ) of visceral, subcutaneous, and intramuscular adiposity compartments and was similarly normalized for height. The average fat density was obtained in Hounsfield units. OS was estimated with the Kaplan-Meier method. Associations between body composition, inflammation metrics, and relevant clinicopathology and OS were assessed with univariable and multivariate Cox analyses. RESULTS: Seventy-six of the 158 patients (48%) were sarcopenic. Sarcopenia was associated with elevated neutrophil to lymphocyte ratios (NLRs; P = .02), increased age (P = .001), lower body mass indices (P = .009), greater modified Motzer scores (P = .019), and lower SMD (P = .006). The median OS was 15.0 and 29.4 months for sarcopenic and nonsarcopenic patients, respectively (P = .04). Elevated inflammation (NLR or C-reactive protein), in addition to sarcopenia, was independently associated with OS, with an elevated NLR ≥ 3.5 and sarcopenia associated with the poorest OS at 10.2 months. No associations were observed between measurements of muscle density or adiposity and OS. CONCLUSIONS: Sarcopenia and measures of high systemic inflammation are additively associated with inferior OS after CN and may be of use in preoperative risk stratification. LAY SUMMARY: Body composition and sarcopenia (a deficiency in skeletal musculature) have been shown to affect outcomes in cancer. We found that sarcopenic patients had poor survival in comparison with nonsarcopenic patients in the setting of metastatic renal cell carcinoma (mRCC). Patients with both elevated inflammation and sarcopenia had the poorest survival. Sarcopenia is an objective measure of nutrition that can assist in therapeutic counseling and decision-making for individualized treatment in mRCC.

Adiposity may predict survival in patients with advanced stage cancer treated with immunotherapy in phase 1 clinical trials.

BACKGROUND: Body mass index (BMI) is used to define obesity, but it is an imperfect measure of body composition. In the current study, the authors explored the association between types of fat and survival in patients treated with immunotherapy. METHODS: A retrospective analysis of 90 patients who were treated with immunotherapy on phase 1 clinical trials at the Winship Cancer Institute in Atlanta, Georgia, from 2009 through 2017 was performed. Overall survival (OS) and progression-free survival (PFS) were used to measure clinical outcomes. Baseline BMI and radiographic images at the middle of the third lumbar vertebrae were obtained. Fat densities were calculated and converted to indices (subcutaneous fat index [SFI], intermuscular fat index [IFI], and visceral fat index [VFI]) after dividing by height in meters squared. Risk groups were created using recursive partitioning and the regression trees method for SFI and IFI, which were selected by stepwise variable selection among all fat-related variables. The Cox proportional hazards model and Kaplan-Meier method were used for the association with OS and PFS. RESULTS: The majority of patients (59%) were male and diagnosed with melanoma (33%) or gastrointestinal cancers (22%). The median BMI was 27.4 kg/m2 , the median SFI was 62.78, the median IFI was 4.06, and the median VFI was 40.53. Low-risk patients (those with an SFI ≥73) had a significantly longer OS (hazard ratio, 0.20; 95% CI, 0.09-0.46 [P < .001]) and PFS (hazard ratio, 0.38; 95% CI, 0.20-0.72 [P = .003]) compared with patients at intermediate risk (those with an SFI <73 and IFI <3.4) and poor risk (those with an SFI <73 and IFI ≥3.4). The Uno concordance statistics were found to be higher for fat risk groups than BMI in predicting OS (0.603 vs 0.574; P = .581) and PFS (0.602 vs 0.586; P = .71). CONCLUSIONS: Increased BMI, increased SFI, and decreased IFI may be associated with prolonged survival in patients with cancer who are treated with immunotherapy. Further studies are needed to elucidate the effect of adiposity on the host immune response to immunotherapy.

Endourological management of a rare radiopaque ritonavir-composed urinary calculus.

Protease inhibitors are a source of nephrolithiasis in HIV + patients, and these stones are described as not detected by CT. While urinary stones are commonly associated with certain protease inhibitors, stones composed of ritonavir are rare. We present the case of a 58-year-old female on ritonavir-boosted atazanavir who presented to our clinic complaining of gross hematuria and flank pain secondary to a ureteral stone. Surgical removal revealed the stone to be composed of 100% ritonavir with no usual urinary stone components. This is the first report of an HIV medicine stone being detectable by CT scan described as 100% ritonavir.

Use of Office Versus Ambulatory Surgery Center Setting and Associated Ancillary Services on Healthcare Cost Burden for Vasectomy Procedures.

OBJECTIVE: To analyze variation in total healthcare costs for vasectomies performed in the United States, based on procedure setting and use of ancillary pathology services. METHODS: We queried the MarketScan Commercial Claims database using CPT, ICD, and HCPCS codes to identify men who underwent vasectomy between 2009 and 2015, either in the office or ambulatory surgical center (ASC) setting, with or without use of pathology services. All payments for each treatment episode were calculated based on relevant claims. Patient out-of-pocket expenses were defined as the sum of copayments, coinsurance, and deductibles for each claim. Trends in vasectomy use, and differences in procedure costs by practice setting were compared over the study period. RESULTS: 453,492 men underwent a vasectomy between 2009 and 2015. The number of procedures decreased from 76,197 in 2009 to 37,575 in 2015 (P = .002). Average procedural costs increased from $870 in 2009 to $938 in 2015 (P = .001). Overall, 82.6% and 17.4% of procedures were performed in the office vs ASCs, respectively. In-office procedures were associated with lower total healthcare costs ($707 vs $1851) and lower patient out-of-pocket expenses ($173 vs $356) than those performed in ASCs. Vasal segments were submitted for pathologic evaluation in 40% of cases, which increased average payments by 55%. The use of ASCs and ancillary pathology services for vasectomies performed during the study period increased vasectomy-associated costs by $64 million. CONCLUSION: The unnecessary use of ASCs and ancillary pathology services for vasectomy may lead to tens of millions of dollars in potentially avoidable healthcare costs annually.

MRI quantitation of abdominal skeletal muscle correlates with CT-based analysis: implications for sarcopenia measurement.

Sarcopenia is associated with poor outcomes in a variety of conditions, including malignancy. Abdominal skeletal muscle area (SMA) segmentation using computed tomography (CT) has been shown to be an accurate surrogate for identifying sarcopenia. While magnetic resonance imaging (MRI) segmentation of SMA has been validated in cadaver limbs, few studies have validated abdominal SMA segmentation using MRI at lumbar level mid-L3. Our objective was to assess the reproducibility and concordance of CT and MRI segmentation analyses of SMA at mid-L3. This retrospective analysis included a random sample of 10 patients with renal cell carcinoma (RCC) and CT abdomen/pelvis, used to assess intra-observer variability of SMA measurements using CT. An additional sample of 9 patients with RCC and both CT and T2-weighted (T2w) MRI abdomen/pelvis was used to assess intra-observer variability of SMA using MRI and concordance of SMA between MRI and CT. SMA was segmented using Slice-O-Matic. SMA reproducibility was assessed using intraclass correlation coefficient (ICC). SMA concordance was analyzed using Bland-Altman plot and Pearson correlation coefficient. The intra-observer variability of CT and MRI SMA at mid-L3 was low, with ICC of 0.998 and 0.985, respectively. Bland-Altman analysis revealed bias of 0.74% for T2w MRI over CT. The Pearson correlation coefficient was 0.997 (p < 0.0001), demonstrating strong correlation between CT and T2w MRI. Abdominal SMA at mid-L3 is reproducibly segmented for both CT and T2w MRI, with strong correlation between the 2 modalities. T2w MRI can be used interchangeably with CT for assessment of SMA and sarcopenia. This finding has important clinical implications.

Surgical sterilization among US men and women with employer-based insurance: A claims data analysis.

OBJECTIVE: To assess variability in the use of surgical sterilization among privately insured U.S. men and women. STUDY DESIGN: We queried the MarketScan Commercial Claims database using CPT, ICD9, and HCPCS codes to identify 658,509 individuals between 18-65 years old (0.37% of total) who underwent male or female sterilization between 2009-2014. We examined annual trends using Cochran-Mantel-Haenszel test. We analyzed differences in age, geographic distribution, and family size using Wilcoxon sum-rank and generalized chi-squared tests. RESULTS: Between 2009-2014, 422,290 men (0.55% of total men) and 236,219 women (0.24% of total women) with employer-sponsored insurance underwent male and female sterilization, respectively. Annual male sterilizations decreased from 77,565 (0.60%) in 2009 to 61,436 (0.51%) in 2014 (p<.001), while annual female sterilizations decreased from 43,766 (0.26%) to 30,465 (0.19%) (p<.001) over the same time period. Median age at time of male or female sterilization was 38 and 37 years, respectively. The decision to undergo sterilization at age 35 or older was associated with family size of 4 or more individuals (p<.001). Sterilization was more common in urban areas, with 84% of male sterilizations and 79% of female sterilizations performed in urban areas. 79% of men compared to 60% of women who underwent sterilization were the primary policyholders of their employer-sponsored healthcare plans (p<.001). CONCLUSION: Male sterilization was twice as common as female sterilization in this privately insured cohort. Use of surgical sterilization was associated with increased age and larger family size. There was a decline in the annual number of male and female sterilizations during the study period. IMPLICATIONS: Male sterilization is more common among US men with employer-based insurance than among the general population. The decline in sterilization may reflect cultural factors and the rise of long-acting reversible contraception. Analyzing the sociodemographic factors impacting sterilization may provide insight into contraceptive choice and improve reproductive health services.

Granulomatous Inflammation of the Penis and Scrotum Following Application of Topical Cream.

Granulomas are collections of histiocytes that develop as an inflammatory response to bacterial and fungal infections, as well as foreign substances. We discuss here the case of a 49-year-old male who presented with a penile and scrotal mass with granulomatous inflammation, after application of a topical cream for enhancement of erectile function. While granuloma formation can often be seen with penile injections, this case presents the rare development of a foreign body granuloma after topical cream application on the penis and scrotum.