Primary Renal Carcinoid Tumor: Report of Two Cases.

INTRODUCTION: Primary renal carcinoid tumors are a rare subset of neuroendocrine tumors arising in the kidneys. Although carcinoid syndrome has occasionally been described, most patients are asymptomatic at presentation. CASE PRESENTATIONS: We present 2 cases of primary renal carcinoid tumor and describe the workup, immunohistochemical analysis, treatment, and surveillance of each female patient. The first patient was found to have a renal mass on imaging during a workup of chronic abdominal pain and subsequently underwent a robotic radical nephrectomy. The second patient was found to have an incidental renal mass on imaging and subsequently underwent renal biopsy, followed by robot-assisted laparoscopic partial nephrectomy. In both cases, a gallium dotatate Ga 68-enhanced positron emission tomography/computed tomography scan was used to further assess disease burden. DISCUSSION: This report describes 2 cases of primary renal carcinoid tumor with unique presentations and management in our regional health care system. Because primary renal carcinoid tumors are quite uncommon, there are no clear established guidelines on preoperative imaging or posttreatment surveillance in patients with these tumors. There remains a large amount of variability in the diagnosis, workup, immunohistochemical analysis, treatment, and surveillance of patients with primary renal carcinoid tumors. As we learn more about this disease, we hope to optimize patient outcomes and standardize pretreatment workup and posttreatment surveillance.

Safety and feasibility of outpatient robot-assisted radical prostatectomy.

Since its inception, robot-assisted radical prostatectomy (RARP) has developed into a familiar surgical modality with improved perioperative outcomes including decreased hospital stay for localized prostate cancer patients. Experience with outpatient RARP has been reported as early as 2010. In this study, we evaluate the safety and feasibility of outpatient RARP by comparing perioperative outcomes between patients undergoing outpatient RARP to patients discharged on the day following surgery. This is a single-institution retrospective cohort study. Patients with localized disease who underwent RARP without pelvic lymph node dissection from September 2017 to January 2018 were included. T tests and Chi-squared analysis were used to compare demographic and perioperative characteristics of patients who were discharged on the same day of surgery (outpatient RARP) to patients discharged on the day after surgery (inpatient RARP). Of the 51 patients included in the study, 26 underwent outpatient RARP while 25 underwent inpatient RARP. There was no significant difference in mean age (61.4 vs 65.8 years, p = 0.05), BMI (27.1 vs 28.3 kg/m2, p = 0.35), ethnicity, tobacco use (8 vs 15%, p = 0.41), PSA (8.7 vs 8.4 ng/dL, p = 0.77), biopsy Gleason score distribution, prostate size (51.8 vs 57.7 cc, p = 0.26) or preoperative hemoglobin (14.3 vs 13.4 g/dL, p = 0.06), respectively. There was no significant difference between operative time (95.3 vs 101 min, p = 0.16), EBL (52.8 vs 66.5 cc, p = 0.08), postoperative change in hemoglobin (- 1 vs - 1.1 g/dL, p = 0.62), pathologic stage distribution or complication rate (4 vs 8%, p = 0.58) between patients who underwent outpatient vs inpatient RARP, respectively. Outpatient RARP offers similar or improved perioperative outcomes when compared to inpatient RARP. We advocate outpatient RARP as a safe and feasible alternative to inpatient RARP for appropriately selected prostate cancer patients. Furthermore, we introduce an outpatient model that can be applied to other institutions seeking to implement outpatient RARP.

A natural language processing program effectively extracts key pathologic findings from radical prostatectomy reports.

INTRODUCTION AND OBJECTIVE: Natural language processing (NLP) software programs have been widely developed to transform complex free text into simplified organized data. Potential applications in the field of medicine include automated report summaries, physician alerts, patient repositories, electronic medical record (EMR) billing, and quality metric reports. Despite these prospects and the recent widespread adoption of EMR, NLP has been relatively underutilized. The objective of this study was to evaluate the performance of an internally developed NLP program in extracting select pathologic findings from radical prostatectomy specimen reports in the EMR. METHODS: An NLP program was generated by a software engineer to extract key variables from prostatectomy reports in the EMR within our healthcare system, which included the TNM stage, Gleason grade, presence of a tertiary Gleason pattern, histologic subtype, size of dominant tumor nodule, seminal vesicle invasion (SVI), perineural invasion (PNI), angiolymphatic invasion (ALI), extracapsular extension (ECE), and surgical margin status (SMS). The program was validated by comparing NLP results to a gold standard compiled by two blinded manual reviewers for 100 random pathology reports. RESULTS: NLP demonstrated 100% accuracy for identifying the Gleason grade, presence of a tertiary Gleason pattern, SVI, ALI, and ECE. It also demonstrated near-perfect accuracy for extracting histologic subtype (99.0%), PNI (98.9%), TNM stage (98.0%), SMS (97.0%), and dominant tumor size (95.7%). The overall accuracy of NLP was 98.7%. NLP generated a result in <1 second, whereas the manual reviewers averaged 3.2 minutes per report. CONCLUSIONS: This novel program demonstrated high accuracy and efficiency identifying key pathologic details from the prostatectomy report within an EMR system. NLP has the potential to assist urologists by summarizing and highlighting relevant information from verbose pathology reports. It may also facilitate future urologic research through the rapid and automated creation of large databases.

Cytoreductive nephrectomy for metastatic renal cell carcinoma with nonclear cell histology.

PURPOSE: To our knowledge the benefit of cytoreductive surgery for patients with metastatic renal cell carcinoma with nonclear cell histology is unknown. In this retrospective study we report our experience with cytoreductive nephrectomy for nonclear cell metastatic renal cell carcinoma at M. D. Anderson Cancer Center. We compared the outcomes with those in patients with clear cell metastatic renal cell carcinoma. MATERIALS AND METHODS: From 1991 to 2006, 606 patients with metastatic renal cell carcinoma underwent cytoreductive nephrectomy and they formed the basis of this report. Of these patients 92 had nonclear cell metastatic renal cell carcinoma. The remaining 514 patients had clear cell metastatic renal cell carcinoma and they formed a comparative group. Multivariate Cox regression analysis was performed to evaluate the relationship between clinical variables and histology (clear cell vs nonclear cell) on disease specific survival. RESULTS: Compared with patients with clear cell histology those with nonclear cell metastatic renal cell carcinoma were younger (p = 0.0001), and more likely to have nodal metastases (p <0.0001) and sarcomatoid features (23% vs 13%, p = 0.026). On multivariate analysis median disease specific survival in patients with nonclear cell histology was significantly worse than that in patients with clear cell metastatic renal cell carcinoma (9.7 vs 20.3 months, p = 0.0003) even after adjusting for T stage, grade, performance status, age and sarcomatoid features. Sarcomatoid features were a predictor of poor outcome in cases of clear and nonclear cell histology, although even in the absence of sarcomatoid features nonclear cell histology was associated with worse disease specific survival (p = 0.017). Interestingly although there was a significantly higher incidence of positive nodes in patients with nonclear histology (p <0.0001), this phenotype was not associated with a worse disease specific survival, as it was in those with clear cell histology (p = 0.0001). In fact, patients with node negative disease with nonclear cell histology had the worst prognosis overall in the entire group. CONCLUSIONS: Patients with nonclear cell metastatic renal cell carcinoma were younger and had a higher incidence of nodal metastases, a higher incidence of sarcomatoid features and a worse prognosis than those with clear cell histology who underwent cytoreductive surgery.

Cytoreductive nephrectomy for T4NxM1 renal cell carcinoma: the M.D. Anderson Cancer Center experience.

OBJECTIVES: Although cytoreductive nephrectomy may provide a survival benefit in metastatic renal cell carcinoma, patients with locally advanced lesions may be denied cytoreduction because of a perceived worse outcome and increased morbidity. We reviewed our experience with cytoreductive nephrectomy in patients with contiguous organ involvement (Stage T4NxM1) to evaluate the outcome and morbidity. METHODS: From 1993 to 2004, 498 patients underwent cytoreductive nephrectomy for renal cell carcinoma. Of those, 23 patients had Stage T4NxM1 disease. The analyzed variables included surgical complications, palliation of symptoms, and survival. RESULTS: The median patient age was 55 years (range 35 to 73), with a median tumor size of 15 cm (range 7 to 30). The median overall and disease-specific survival was 6.8 months (range 1.4 to 25.7). The distribution of the histologic type was conventional in 16, papillary in 2, and unclassified in 5. Sarcomatoid features were present in 9 patients. In 2 patients, surgery was aborted because of unresectable disease. Three patients developed postoperative complications (one wound dehiscence, one pancreatic collection, and one seizure). The median length of stay was 7 days (range 5 to 19). Of the 7 patients with local symptoms, 5 experienced postoperative palliation. Most patients (79%) received postoperative systemic therapy after a median of 39 days (range 24 to 114). Five patients did not receive systemic therapy because of disease progression. The median disease-specific survival for the patients who received systemic therapy was 7.1 months (range 1.4 to 25.7), but only 2.5 months (range 0 to 5.2) for those who had not (P = 0.003). CONCLUSIONS: Cytoreductive nephrectomy in Stage T4NxM1 renal cell carcinoma is feasible and provides significant palliation in symptomatic patients; however, the survival benefit is unclear. Our retrospective series has demonstrated that the prognosis in these patients is poor.