Epithelioid Hemangioma of the Popliteal Artery: A Case Report.

An epithelioid hemangioma (EH) is a rare benign vascular lesion that is usually seen in superficial small vessels within the dermis and subcutaneous tissue. Intravascular epithelioid hemangiomas of large and medium-sized vessels are rare, and only a handful of cases have been reported in the literature. Intravascular epithelioid hemangiomas are biologically benign and best treated by complete surgical excision. On occasion, lesions have been associated with aneurysmal changes in the affected vessel. Local recurrence may occur, and close clinical follow-up is advised. Herein, we report the second case in the literature of an EH originating from the popliteal artery. A 57-year-old male patient presented with a one-month history of knee pain without claudication. Imaging highlighted a right popliteal aneurysm, 5x5 cm, with partial distal thrombosis and inadequate outflow. The patient subsequently underwent popliteal artery ligation above and below the aneurysm, reconstructed with a superficial femoral artery (SFA) to distal anterior tibial artery (ATA) reverse saphenous vein bypass graft. Patient recovery was complicated by the development of a 5x5 cm right-sided mid-thigh hematoma, requiring evacuation under anesthesia. A post-one-year arterial duplex of the affected limb demonstrated a recurrent enlarging popliteal aneurysm measuring 5.7x4.8x9.1 cm. The aneurysm was reported to be mostly thrombosed with noted vascularity, but patency of the original bypass was noted. The patient underwent excision of the recurrent aneurysm with subsequent ligation of the feeding arteries. Pathology and histology confirmed the final diagnosis of EH of the popliteal artery. An 18-month follow-up after the excision procedure demonstrated no recurrence of vascular lesion and patency of the original bypass graft.

Complications and Surgeon Health: Resources for individuals and institutions.

The emotional impact of surgical complications on urologists is a significant yet historically under-addressed issue. Traditionally, surgeons have been expected to cope with complications and their psychological effects in silence, perpetuating a culture of perfectionism and 'silent suffering.' This has left many unprepared to handle the emotional toll of adverse events during their training and early careers. Recognizing the gap in structured education on this matter, there is a growing movement to openly address and educate on the emotional consequences of surgical complications. This article underscores the importance of such educational initiatives in the mid-career phase, proposing strategies to promote surgeon health, and psychological safety. It advocates for utilizing Morbidity and Mortality conferences as platforms for peer support, learning from 'near miss' events, and encourages at least annual department-wide discussions to raise awareness and normalize the emotional challenges faced by surgeons. Furthermore, it highlights the role of formal peer support programs, acceptance and commitment therapy, and resilience training as vital tools for promoting surgeon well-being. Resources from various organizations, including the American Urological Association and the American Medical Association, are now available to facilitate these critical conversations. By integrating these resources and encouraging a culture of openness and support, the article suggests that the surgical community can better manage the inevitable emotional ramifications of complications, thereby fostering resilience and reducing burnout among surgeons.

Late urinary toxicity and QOL with pelvic radiotherapy for high-risk prostate cancer: Dose-effect relations in the POP-RT randomized phase III trial.

PURPOSE: The POP-RT phase III randomized trial showed improved biochemical failure-free survival and metastasis-free survival with whole pelvic radiotherapy (WPRT) versus prostate-only radiotherapy (PORT) for high/very high-risk prostate cancer, albeit with worse RTOG late urinary toxicity. We report updated late urinary adverse effects and bladder dose-effect relations within this trial. MATERIALS/METHODS: Late urinary toxicity, and cumulative severity of each symptom over the follow-up period was graded using CTCAE v5.0. Bladder dosimetry in 5-Gy increments (V5, V10, V15...V65Gy, V68Gy) in the approved radiotherapy plans was compared for urinary symptoms and overall grade 2+ toxicity. Potential factors influencing urinary toxicity were tested using multivariable logistic regression analysis. Updated urinary quality of life (QOL) scores were compared between the trial arms. RESULTS: Complete combined data for late urinary symptoms and dosimetry was available for 193/224 patients. At a median follow-up of 75 months, cumulative late urinary CTCAE grade 3 toxicity was low and similar for WPRT and PORT (5.2% vs 4.1%, p=0.49), while grade 2 toxicity was 31.3% vs 22.7% respectively (p=0.12). Cumulative rates of each urinary symptom were similar between both arms. Multivariable analysis with age at diagnosis, known diabetes, tumor stage, trial arm, prior TURP, grade 2+ acute urinary toxicity, low bladder dose (V10Gy) and moderate bladder dose (V40Gy) did not identify any significant association with late urinary toxicity. Urinary QOL scores was similar between both the arms for all the symptoms. CONCLUSION: Over long term follow up, whole pelvic radiotherapy resulted in low (∼5%) and similar grade 3 cumulative urinary toxicity as prostate-only radiotherapy. The long term patient-reported QOL scores were similar. No causative factors affecting the late urinary toxicity were identified.

Diagnostic and Surgical Implications of Non-occlusive Mesenteric Ischemic Ileus Associated With Common Celiacomesenteric Trunk: A Case Report and Literature Review.

The celiacomesenteric trunk (CMT), an exceedingly rare anatomic variant uniting the celiac artery and superior mesenteric artery (SMA), holds significant clinical and surgical implications. Despite its rarity, understanding these implications is crucial for effective management. This report outlines the case of a 99-year-old female presenting with septic shock and abdominal pain, with imaging revealing an incidental CMT. This paper aims to elucidate the surgical implications associated with CMT through a comprehensive case review and literature search. A 99-year-old female with multiple cardiovascular comorbidities presented with altered mental status and right lower quadrant abdominal pain. Upon arrival, the patient exhibited disorientation, an inability to follow commands, hypoxia, and hypotension. Significant laboratory findings included a white count of 20.6 x 109/L, lactate of 6.1 mmol/L, glucose of 53 mg/dL, alanine transaminase (ALT)/aspartate aminotransferase (AST) of 186/336 U/L, and creatinine of 4.2 mg/dL. Immediate interventions involved high-flow oxygen, fluid resuscitation, intravenous antibiotics, and admission to the ICU for septic shock. A CT angiogram (CTA) revealed an incidental large common trunk comprising the celiac trunk and superior mesenteric artery (SMA). There was a high-grade stenosis at the origin of the SMA. However, all the vessels were widely patent distally, and acute mesenteric occlusion was ruled out. By day 12, the patient achieved clinical stability after conservative management and was discharged. Complications such as aneurysm, dissection, stenosis, thrombosis, or acute occlusion of a CMT may necessitate complex surgical interventions, including endovascular procedures or open hepatic surgery. Understanding these technical complexities is vital for avoiding surgical complications in critically ill patients.

Clinical Profile and Outcomes of Carcinoma Penis Patients Receiving Systemic Therapy at an Indian tertiary care Center: A Retrospective Observational Study.

BACKGROUND: Penile cancer is a rare malignancy with scant data on the impact of systemic therapy on outcomes. METHODS: Retrospective observational study of patients with a histological diagnosis of carcinoma penis treated with systemic therapy at the Tata Memorial Centre (Mumbai, India) between August 2010 and February 2018. Primary objective was overall survival (OS); secondary objectives included assessment of clinical characteristics, treatment approaches, and toxicity profiles. RESULTS: We included 91 patients with penile carcinoma who received systemic therapy at our center. Intent of therapy was curative in 71 patients (78%), and palliative in 20 (22%). Median age was 57 years (interquartile range [IQR], 50-65.5) for curatively treated patients and 58.5 years (IQR, 44-65.2) for those with advanced disease. Common presenting symptoms were lumps (70%), and pain (57%). Neoadjuvant chemotherapy (NACT) with paclitaxel + platinum was administered to 19 patients (20.9%), of which 7 (37%) attained complete or partial response. Six patients (31.5%) underwent R0 surgery post-NACT. All 71 patients underwent primary surgery; 47 (66.2%) undergoing partial penectomy. Of the 20 patients treated with palliative first-line chemotherapy, 4(20%) attained a partial response. Median OS of patients treated in curative and palliative settings was 33.8 months (95% CI, 17.2-not recorded) and 11.4 months (95% CI, 9.53-23.3), respectively. CONCLUSIONS: Patients with penile cancer treated with systemic therapy have poor outcomes. Little over a third of the patients respond to neoadjuvant chemotherapy and those with advanced disease have poor survival despite systemic therapy, emphasizing the need for early detection and optimum management of primary and nodal disease.

Prognostic Significance of Lymph Node Density in Pathological Node Positive Urothelial Carcinoma of the Bladder -Upfront Surgery and Post Neoadjuvant Chemotherapy Cohorts.

AIM: To validate the role of lymph node density as a prognostic marker in patients undergoing primary surgery and postneoadjuvant therapy in pathological node-positive urothelial bladder carcinoma. MATERIALS AND METHODS: Retrospective analysis of 503 patients who underwent radical cystectomy from 2006 to 2019 for muscle-invasive urothelial bladder carcinoma, of which 152 patients with pathological node-positive disease were analyzed. Demographic details, pathological findings, treatment details, disease-free, and overall survival were documented. X tile program analysis was used to divide patients with positive lymph nodes into 3 groups: LD1: <= 7, LD2 :>7 to <15, LD3: >15, and the optimal cut-off value obtained was 15%. To evaluate the impact of lymph node ratio, patients with positive lymph nodes into 3 categories for each cut-off point estimation method, the application generates the histogram, Kaplan-Meier plot and calculates hazard ratio, confidence intervals and P-values. Univariate and multivariate cox regression analysis was done with a P-value of <.05, considered significant. RESULTS: One hundred fifty-two patients (30.2%) had pathological nodal metastasis, with 87 of them having perinodal extension. Ninety-six underwent primary surgery, and 56 were postneoadjuvant chemotherapy. The median follow-up was 55.42 months. 68 of the 152 node-positive patients died of the disease. Median number of lymph nodes removed was 17.11. Lymph node density divided into tertiles were LD1 <7%, LD2 7-<15%, LD3 >15% showed 5-year RFS 40.5%,29.3%, 22.6% and 5 year OS was 55.5%, 42.4%,32.1% respectively. Cox regression analysis showed that age less than 55 years ,higher tumor stage, lymphovascular invasion, and higher lymph node ratio were significant in univariate and multivariate analysis. The lymph node density cut-off value of 15% was substantial among node-positive patients (P = .027), and subgroup analysis in upfront surgery with the adjuvant treatment group and postneoadjuvant chemotherapy group was also significant (P =.021). CONCLUSION: Pathological higher T stage, Age <55 years, Lymphovascular invasion, adjuvant chemotherapy , adjuvant radiation treatment and lymph node density had prognostic significance in both cohorts of patients who underwent upfront surgery and neoadjuvant chemotherapy. Lymph node density cut-off value of <15% was prognostically significant.

A Complicated Case of Strangulated Inguinal Hernia of the Sigmoid Colon With Secondary Ischemic-Compromise of Scrotal Tissue: A Multi-Disciplinary Surgical Approach.

Inguinal hernia is amongst the most common acute abdominal disease that presents in the Emergency Department (ED). Pathologically, it involves the displacement and herniation of abdominal, pelvic, or groin tissue through weaknesses in the abdominal wall. Many inguinal hernias are simple and asymptomatic, managed conservatively without the need for surgical intervention. However, under rare circumstances, hernias are susceptible to significant complications requiring emergent surgery. This report follows the case of a 61-year-old Hispanic-American male presenting to the ED with signs of a complex strangulated inguinal hernia and consequent infarction of the testis with Fournier's Gangrene. Clinical evaluation elucidated a one-week worsening abdominal pain, non-reducible painful inguinal hernia, nausea, vomiting, constipation, groin discoloration, dysuria, and a history of failed primary hernia repair during childhood. The patient underwent emergent surgery to excise ischemic-necrotic portions of the sigmoid colon, creation of end-colostomy, non-mesh repair of inguinal hernia, and right-sided complete orchiectomy with the removal of adjacent scrotal-Dartos tissues and spermatic cord due to Fournier's Gangrene. This report provides both a report for a potentially preventable consequence in one of the most common surgical presentations and a review of the multi-disciplinary expertise that is required in the surgical management of complex inguinal hernias.

Evaluation of post-chemotherapy residual seminomatous masses by 18F-fluorodeoxyglucose PET/CT using tumor-to-liver ratio - conundrum or solution?

OBJECTIVE: Assessment of diagnostic accuracy of FDG-PET/CT in the detection of viable disease in post-chemotherapy seminomatous residual masses using visual interpretation, SUVmax, and T/L ratio. METHODS: This is a retrospective study assessing the post-chemotherapy seminomatous residual masses of size >3 cm. The PET/CT scan findings were interpreted visually for presence of residual disease which were validated from histopathology reports or imaging follow-up for a maximum of 3 years. SUVmax and T/L ratios were also determined for all the residual lesions. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value NPV were calculated and compared for all three parameters along with ROC analysis to obtain an optimal cutoff value for SUVmax and T/L ratio, respectively. RESULTS: Sample size was 49. Out of these 49 patients, 8 had validation of PET results with histopathology. Rest was validated with imaging follow-up. FDG-PET was positive in 30 patients and negative in 19 patients by visual interpretation. The sensitivity, specificity, PPV, and NPV by this method were 100%, 62.5%, 73%, and 100%, respectively. The SUVmax and T/L ratios were also calculated for these lesions. The cutoff for these two variables was 4.56 and 1.21, respectively. The sensitivity, specificity, PPV, and NPV at these cutoffs were 76%, 87.5%, 86%, 77.7%, and 92%, 87.5%, 88%, 91%, respectively. CONCLUSION: FDG-PET has a favorable diagnostic value in predicting viable disease in post-chemotherapy seminomatous residual masses and using T/L ratio cutoff of 1.21 will increase the specificity of the test.

Surgical templates for inguinal lymph node dissection in cN0 penile cancer: A comparative study.

PURPOSE: Modified and superficial inguinal lymph node dissection (MILD and SILD) are the 2 widely used templates for surgical staging of clinically node negative (cN0) penile cancer (PeCa); however, no previous reports have compared their outcomes. We compared these 2 surgical templates for oncological outcomes and complications. MATERIALS AND METHODS: We retrospectively reviewed records of cN0 PeCa patients who underwent MILD/SILD at our cancer care center from January 2013 to December 2019. Patients who developed a penile recurrence during follow up were excluded from analysis of oncological outcomes. The 2 groups (MILD and SILD) were compared for baseline clinico-pathological characteristics. The primary outcome was the groin recurrence free survival (gRFS). Secondary outcomes included the false negative rate (FNR) and disease free survival (DFS) for both templates and also the post-operative wound related complication. RESULTS: Of the 146 patients with intermediate and high risk N0 PeCa, 74 (50.7%) and 72 (49.3%) underwent MILD and SILD respectively. The 2 groups were comparable with regards to the distribution of T stage, tumor grade and the proportion of intermediate and high-risk patients. At a median follow up of 34 months (47 for SILD and 23 for MILD), a total of 5 groin recurrences were encountered; all of them occurred in the MILD group. The gRFS and DFS for the MILD group was 93.2% and 91.8% respectively; while that for the SILD group was 100% and 94.4% respectively. Too few events had occurred to determine any statistically significant difference. The FNR for MILD and SILD was 26.3% and 0% respectively. The overall complication rate was significantly higher in the SILD group (46% vs 20.3%, p=0.001), especially for Clavien Dindo 3A complications. CONCLUSION: MILD can fail to pick up micro-metastatic disease in a small proportion of cN0 PeCa patients, while SILD provides better oncological clearance with no groin recurrences. This oncological superiority comes at the cost of a higher incidence of wound-related complications.

Patterns of Utilization and Outcomes of Perioperative Chemotherapy in Patients With Locally Advanced-urothelial Bladder Cancer (LABC)-Real World Data From an Indian Tertiary Care Cancer Center.

AIM: Optimal utilization of perioperative systemic therapy in locally advanced bladder cancer (LABC) holds the key in improving the survival outcomes. We aim to analyze the oncological outcomes of clinically locally advanced urothelial bladder cancer patients treated with neoadjuvant (NACT) or adjuvant chemotherapy or without any systemic therapy in the perioperative period of radical cystectomy. METHODS & MATERIAL: We retrospectively analyzed the medical records of patients with cancer of the urinary bladder diagnosed between 2012 and 2020. The demographic profile, and the treatment received, was recorded for all patients. Oncological outcomes of the patients based on these variables were analyzed. RESULTS: Two hundred and twenty nine (229) locally advanced bladder cancer patients were included in the study. Eighty eight (38%) of them underwent upfront radical cystectomy and 141 (62%) received neoadjuvant chemotherapy (NACT). With a median follow-up of 27 months, the 2-year DFS in either of the groups was 65.4% and 67.1% respectively (P - 0.373). In the multivariate analysis, the pathological lymph nodal status and lymph vascular invasion (LVI) status influenced the DFS. The initial modality of management chosen did not affect the outcome. (HR - 0.688; 95% CI: 0.38-1.21). The commonest reason for not receiving NACT was Cisplatin ineligibility due to malignant obstructive uropathy and a subgroup analysis of this set of patients also did not show any significant difference in 2 year DFS compared to those who received NACT. CONCLUSION: A significant proportion of patients with LABC are unable to receive the recommended neoadjuvant chemotherapy and obstructive uropathy is the commonest reason for this in our centre. In our single centre series upfront radical cystectomy followed by adjuvant platinum based therapy had an outcome similar to neoadjuvant chemotherapy in LABC patients, in patients who were unable to receive the same due to various reasons.

Variations in Penile Cancer Management: Results From the Global Society of Rare Genitourinary Tumors Survey.

INTRODUCTION: There is paucity of evidence and consensus on various aspects of management of penile cancer (PeCa), which is intuitive considering the rarity of this disease. We present here the details of an online survey conducted by the Global Society of Rare Genito-urinary Tumors (GSRGT) with the aim of capturing the variations in PeCa care across different regions of the world. MATERIALS AND METHODS: An online questionnaire was developed by experts within the GSRGT and then circulated via email in English and Spanish versions to clinicians dealing with PeCa. Respondents were allowed 8 weeks to reply. RESULTS: We received 102 responses; the majority of them were from South America (37.2%) followed by North America and Asia (17.6% each). Only 11.7% of the respondents treated more than 25 patients with PeCa annually. Total penectomy is performed by 21.5% of the respondents in >50% of their patients. Less than a fifth of the experts (19.6%) responded that >50% of their patients are clinically node-negative (cN0) at presentation. For intermediate-risk cN0 patients (T1 G2 cancer), about a third of the experts chose surveillance. For invasive inguinal staging, the options of Dynamic Sentinel Lymph Node Biopsy (DSNB), Modified Inguinal Lymph Node Dissection (MILD), Superficial Inguinal Lymph Node Dissection (SILD), and Video-Endoscopic Inguinal Lymphadenectomy (VEIL) were chosen by 28.4%, 26.4%, 31.3%, and 13.7% of the respondents respectively. Considerable variation was seen in the worldwide use of these techniques. For clinically node-positive patients, respondents were in favor of giving adjuvant chemotherapy instead of neoadjuvant chemotherapy, except for cN3 patients. CONCLUSION: The results of this questionnaire objectified the variations in global practices in the management of PeCa. This serves as the baseline information which can help prioritize research areas for multinational collaborative efforts, a key mission of the GSRGT.

Management of testicular tumours in patients with undescended testes- a challenging but rewarding task: experience from a tertiary care cancer centre in India.

Objective: Primary objective: To study patients' clinical profile and outcomes with germ cell tumours developing in undescended testes. Materials and methods: Case records of patients enlisted in the prospectively maintained 'testicular cancer database' at our tertiary cancer care hospital from 2014 to 2019 were retrospectively reviewed. Any patient who presented with testicular germ cell tumour with a documented history/diagnosis of undescended testes, whether surgically corrected or not, was considered for this study. The patients were managed along the standard lines of treatment for testicular cancer. We evaluated clinical features, difficulties and delays in diagnosis and complexities in management. We evaluated event-free survival (EFS) and overall survival (OS) using the Kaplan-Meier Method. Results: Fifty-four patients were identified from our database. The mean age was 32.4 years (median age 32, range: 15-56 years). Seventeen (31.4%) had developed cancer in orchidopexy testes, and 37 (68.6%) presented with testicular cancer in uncorrected cryptorchid testes. The median age at orchidopexy was 13.5 years (range: 2-32 years). The median time from symptom onset to diagnosis was 2 months (1-36 months). There was a delay in the initiation of treatment of more than 1 month in 13 patients, with the longest delay being 4 months. Two patients were initially misdiagnosed as gastrointestinal tumours. Thirty-two (59.25%) patients had seminoma, and 22 (40.7%) patients had non-seminomatous germ cell tumours (NSGCT). Nineteen patients had metastatic disease at presentation. Thirty (55.5%) patients underwent orchidectomy upfront while in 22 (40.7%) patients, orchidectomy was done after chemotherapy. The surgical approach included high inguinal orchidectomy, exploratory laparotomy or laparoscopic surgery per the clinical situation. Post-operative chemotherapy was offered as clinically indicated. At a median follow-up of 66 months (95% CI: 51-76), there were four relapses (all NSGCT) and one death. The 5-year EFS was 90.7% (95% CI: 82.9-98.7). The 5-year OS was 96.3% (95% CI: 91.2-100). Conclusions: The tumours in undescended testes, particularly those without prior orchiopexy, often presented late and with bulky masses, requiring complex multidisciplinary management. Despite the complexity and challenges, our patient's OS and EFS matched that of patients with tumours in normally descended testes. Orchiopexy may help in earlier detection. In the first such series from India, we show that testicular tumours in the cryptorchid are also as curable as the germ cell tumours developing in the descended testis.A multidisciplinary disease management group with expertise in managing complex cases is crucial for a favourable outcome in these groups of patients. We also found that orchiopexy done even later in life confers an advantage in terms of early detection in a subsequently developing testicular tumour.

Utilising alternative cystoscopic schedules to minimise cost and patient burden after trimodality therapy for muscle-invasive bladder cancer.

BACKGROUND: To assess urinary symptoms and urine cytology as screening tools for cystoscopic detection of local recurrence after bladder-preserving trimodality treatment (TMT). METHODS: Patients with muscle-invasive bladder cancer receiving definitive TMT follow-up three monthly for 2 years, six monthly for the next 3 years and then yearly, with a clinical review, urine cytology and cystoscopy at each visit (triple assessment, TA). Grade 2+ cystitis/haematuria absent/present was scored 0/1, and urine cytology reported negative/suspicious or positive was scored 0/1, respectively. The performance of these two parameters for predicting local recurrence in cystoscopic biopsy was tested. Other hypothetical surveillance schedules included cystoscopy on alternate visits (COAV), or suspected recurrence (COSR), six-monthly COSR and six-monthly TA. RESULTS: A total of 630 follow-up visits in 112 patients with 19 recurrences (7 muscle invasive, 12 non-muscle invasive) at a median follow-up of 19 months were analysed. The sensitivity and specificity of clinical symptoms were 47.4% and 92%, and for urine cytology 58% and 85%, respectively. The combination of clinical symptoms and cytology (COSR) was 95% sensitive and 78% specific for local recurrence but 100% sensitive for muscle-invasive recurrence. Both COAV and COSV schedules showed a high area under the curve (AUC) for detecting local recurrence (COAV = 0.84, COSR = 0.83), muscle-invasive recurrence (AUC = 0.848 each) and non-muscle-invasive recurrence (COAV = 0.82, COSR = 0.81); reducing the need for TAs by 64% and 67% respectively, and overall cost by 18% and 33%, respectively. CONCLUSION: Cystoscopy at suspected recurrence during follow-up is safe and the most cost-effective for detecting muscle-invasive local recurrences, while cystoscopy at alternate visits may be more optimal for detecting any local recurrence.

Plasmacytoid urothelial carcinoma - A clinicopathological case series of an aggressive variant of urothelial cancer.

Background: Many new morphological variants of urothelial carcinoma of urinary bladder have been described in the literature, plasmacytoid/signet ring cell/diffuse variant being one of the rare amongst these. Till date, no case series has been reported from India, describing this variant. Materials and Methods: We retrospectively analyzed the clinicopathological data of 14 patients diagnosed at our center with plasmacytoid urothelial carcinoma. Results: Seven cases (50%) were pure forms while the remaining 50% of cases had a concurrent conventional urothelial carcinoma component. Immunohistochemistry was performed to rule out other mimickers of this variant. Treatment-related data were available for seven patients, while follow-up was available for nine cases. Conclusion: Overall, plasmacytoid variant of urothelial carcinoma is considered to be an aggressive tumor with poor prognosis.

Pre-transplant Biomarkers of Immune Dysfunction Improve Risk Assessment of Post-transplant Mortality Compared to Conventional Clinical Risk Scores.

Introduction: There is a critical need to accurately stratify liver transplant (LT) candidates' risk of post-LT mortality prior to LT to optimize patient selection and avoid futility. Here, we compare previously described pre-LT clinical risk scores with the recently developed Liver Immune Frailty Index (LIFI) for prediction of post-LT mortality. LIFI measures immune dysregulation based on pre-LT plasma HCV IgG, MMP3 and Fractalkine. LIFI accurately predicts post-LT mortality, with LIFI-low corresponding to 1.4% 1-year post-LT mortality compared with 58.3% for LIFI-high (C-statistic=0.85). Methods: LIFI was compared to MELD, MELD-Na, MELD 3.0, D-MELD, MELD-GRAIL, MELD-GRAIL-Na, UCLA-FRS, BAR, SOFT, P-SOFT, and LDRI scores on 289 LT recipients based on waitlist data at the time of LT. Survival, hazard of early post-LT death, and discrimination power (C-statistic) were assessed. Results: LIFI showed superior discrimination (highest C-statistic) for post-LT mortality when compared to all other risk scores, irrespective of biologic MELD. On univariate analysis, the LIFI showed a significant correlation with mortality 6-months, as well as 1-, 3-, and 5-years. No other pre-LT scoring system significantly correlated with post-LT mortality. On bivariate adjusted analysis, African American race (p<0.05) and pre-LT cardiovascular disease (p=0.053) were associated with early- and long-term post-LT mortality. Patients who died within 1-yr following LT had a significantly higher incidence of infections, including 30-day and 90-day incidence of any infection, pneumonia, abdominal infections, and UTI (p<0.05). Conclusions: LIFI, which measures pre-LT biomarkers of immune dysfunction, more accurately predicts risk of post-LT futility compared with current clinical predictive models. Pre-LT assessment of immune dysregulation may be critical in predicting mortality after LT and may optimize selection of candidates with lowest risk of futile outcomes.

Updates in staging of penile cancer: the evolution, nuances, and issues.

Staging based on the tumor (T), node (N), and metastasis (M) schema of the American Joint Committee on Cancer (AJCC) is usually the most important prognostic factor for any tumor type. Although a rare tumor, in penile cancers, this staging has evolved rapidly in the last two editions of the AJCC Cancer Staging manuals. These changes and updates are largely based on the advancement in our knowledge of the complex anatomy of the penis, the role of histopathological variables in disease biology, and the results of multicentric studies comprising large data sets. In this review, we present the evolution of the AJCC staging model from its inception to the present day. The evidence and data that entailed these changes are also discussed. We highlight a few issues with the current staging model and also briefly discuss the future perspectives and the road map which, with the help of global efforts, can further refine the staging models.

Multimodal Management of Testicular Mesothelioma - A Retrospective Analysis From a Tertiary Cancer Care Centre.

The main modality of management of paratesticular mesothelioma remains orchiectomy while the use of adjuvant chemotherapy has not yet been explored. We aim to analyse the outcome of the multimodal management protocol in testicular mesothelioma We conducted a retrospective analysis of patients registered and treated for testicular mesothelioma between 2009 and 2019 in an oncology tertiary care hospital. Patients presenting with nodal, metastatic disease were treated with adjuvant, palliative chemotherapy respectively and their response to treatment was periodically monitored. Eight patients (3 early, 1 nodal, 4 metastatic) with median age of 58 years was included in the study. Patients who had limited (early, nodal) disease (n = 4) had overall survival ranging from 20 to 140 months while metastatic disease (n = 4) had poor outcomes with overall survival ranging from 2 to 13 months. Surgery remains to be an important modality of therapy that improves the local control and overall outcomes and the quality of life even in patients with metastatic disease at the time of diagnosis. Adjuvant chemotherapy might play a role in effective management of locoregional disease. The performance status, the extent of disease at the time of presentation are the important prognostic factors in deciding the outcome of the disease management.

Predictors of Pelvic Lymph Nodal Metastasis in Penile Squamous Cell Carcinoma- Results From a Matched-Pair Analysis.

INTRODUCTION: Pelvic lymph node (PLN) metastasis has a worse prognosis in penile squamous cell carcinoma. This study sought to determine the predictors of PLN metastasis in penile SCC. MATERIALS AND METHODS: This retrospective study included primary penile resections with inguinal lymph nodes (ILN) and PLN dissections over 10 years (2007-2017). A subset of treatment naïve cases with PLN metastasis was matched for age and tumor size with another subset of cases having metastatic ILN and negative PLN. The variables were correlated with the PLN metastasis using appropriate statistical tests. Internal validation of the multivariate model was conducted by using 2000 bootstraps on the same cohort. The optimum cut-off for the number of positive ILN was obtained by plotting a receiver operating characteristic curve and using the highest Youden's index as a discriminator. RESULTS: A total of 56 cases (28 in each subset) formed the study cohort. On unadjusted analysis the size of the largest ILN (p=0.038), number of positive ILN (p=0.001), percentage of positive ILN (p=0.001), and laterality of ILN involvement (p=0.007) had a significant correlation with PLN metastasis. On adjusted analysis, the number of positive ILN (p=0.011) was the only statistically significant variable. Bootstrapping results indicated that this multivariate model represented the dataset adequately. The maximum Youden's index was obtained when ≥5 ILN were positive. CONCLUSIONS: The number of metastatic ILN is the most important predictor of PLN metastasis. A higher threshold of metastatic ILN for addressing PLN dissection can be investigated, particularly in a high disease burden setup.

Optimizing Target Volume for Adjuvant Radiation Therapy in Penile Cancer.

PURPOSE: Recent studies have reported improved outcomes with adjuvant radiation therapy in penile cancer. However, the appropriate target volumes to be irradiated in this group of patients for optimal outcomes are still unclear. This study aims to report the patterns of failure and define target volumes to be irradiated in patients with pN3 penile cancer. METHODS AND MATERIALS: Patients with pT1-T4, pN3, cM0, and squamous cell carcinoma of the penis who received adjuvant radiation therapy (involved field or extended field), with or without concurrent chemotherapy were included in the study. Complete information on disease characteristics, radiation therapy target details, and patterns of failure were available for 75 patients. Disease-free (DFS) and overall survival (OS) were estimated using the Kaplan-Meier method, and log-rank test was used to compare survival outcomes between the involved field and extended field radiation therapy groups. Multivariate analysis was performed using the Cox proportional hazards model to analyze factors correlating with survival outcomes. RESULTS: At a median follow-up of 39 months, 38.6% (29/75) of patients had relapsed either locally, regionally, or at distant sites. Of the 24 patients who received extended field radiation therapy (EFRT), only 1 (4%) patient experienced relapse. Twenty-eight (55%) patients experienced relapse after involved-field radiation therapy (IFRT), of which 28.5% were regional-only relapses and 64% relapses were associated with a regional component. The 2-year DFS and OS of the entire cohort were 62.2% and 70.8%, respectively. The 2-year DFS was 67.9% in patients who received IFRT and 94.1% in those who received EFRT (P = .002), and the 2-year OS was 62.4% with IFRT and 91.1% with EFRT (P = .014). Extended field radiation therapy was associated with an improved DFS (hazard ratio, 12.2; 95% confidence interval, 1.5-97.4; P = .02) and OS (hazard ratio, 4.6; 95% confidence interval, 1-21.5; P = .05) on multivariate analysis. CONCLUSIONS: Extended field radiation therapy significantly improves clinical outcomes compared with involved-field radiation in patients with pN3 penile cancer.