Bilateral Pelvic Node Dissection Research Articles

Impact of comorbidities on recurrence rates and survival in patients with endometrial cancer.

e16528 Background: The aim was to determine the clinical characteristics, comorbidities, tumor features, and survival outcomes in patients with uterine carcinoma treated in our institution. Methods: Charecteristics of 410 patients underwent initial abdominal surgery for primary endometrial cancer in our institution between 2006 and 2012 were reviewed. Demographic features, histologic types, stage, type of surgery, comorbidities, treatment modalities and patient outcomes in terms of relapse-free survival (RFS) and overall survival (OS) were assessed. Results: Patient characteristics are shown in the Table. Nearly all patients (97%) were initially treated surgically with comprehensive staging, i.e. total abdominal hysterectomy, bilateral salphingooopherectomy, bilateral pelvic and paraaortic lymph node dissection and omentectomy. Median follow up was 26 mos. 3 year RFS was 90%. 3 year RFS was 97% at stage 1, 80% at stage 2, 62% at stage 3 and 4. 3 year OS was 91%. 3 year OS was 96% at stage 1, 85% at stage 2, 64% at stage 3-4. The only significant independent predictor of RFS was disease stage (HR 5.7, 95% CI 2.1-15.3, p<0.0001) while histologic grade also bordered significance (HR 2.3, 95% CI ,8-6.4, p=0.085). Independent predictors of OS was age (HR 4.5, 95% CI 1.5-13.7, p<0.007), presence of diabetes mellitus (HR 4.5, 95% CI %1.1-6.7, p=0.019) and stage (HR 5.2, 95% CI 2.2-12.6, p<0.0001). Conclusions: Our data shows that older age (>60 years) and advanced stage patients with endometrial cancer have significantly decreased overall survival. Presence of diabetes mellitus is not associated with recurrence rates but is associated with worse overall survival. Stage and grade are considered independent risk factors for recurrence [Table: see text]

Impact of treatment strategies on local control and survival in uterine carcinosarcomas.

e16526 Background: Carcinosarcoma is a biphasic neoplasm composed of a mixture of malignant epithelial and mesenchymal components. Uterine carcinosarcomas comprise only 3% of all uterine malignancies, however they account for a disproportionally higher rate of mortality from uterine cancer because of their agressive nature. No standardized treatment has yet been established. The purpose of this study was to determine the clinical characteristics, patterns of recurrence and survival outcomes in patients with uterine carcinosarcoma treated in our institution. Methods: Records of the patients with uterine carcinosarcoma were retrospectively evaluated and 29 pts with carcinosarcoma diagnosed between 2007 and 2012 were identified. All patients were initially treated surgically by the same surgeon with comprehensive staging, i.e. total abdominal hysterectomy, bilateral salphingooopherectomy , bilateral pelvic and paraaortic lymph node dissection and omentectomy. Demographic features, tumor characteristics, treatment regimens and patient outcomes in terms of relapse-free survival (RFS) and overall survival (OS) were analyzed. Results: Median age was 63 (range 43-78). 13 patients (45%) had stage I disease, 5 patients (17%) had stage III and 11 patients (38%) had stage IV disease at diagnosis. Median tumor size was 6 cm (range 1.7-20 cm) and lymphovascular invasion was present in 17 patients 59%). Twenty patients (69%) received chemotherapy (90% with paclitaxel and carboplatin) for 6 cycles. One patient received radiotherapy. Median follow up was 13 mos. Seventeen patients (59%) relapsed and 20 patients (69%) died on follow up. Two patients had vaginal cuff recurrence, 4 had pelvic, 4 had abdominal and 7 had distant recurrences. All recurrences were fatal. 3 year RFS was 31%. 3 year OS was 15%. Conclusions: Our data show that uterine carcinosarcomas tend to be more at more advanced stage at diagnosis and despite the use of chemotherapy and radiotherapy, overall prognosis is poor. Surgery remains the mainstay of treatment. More effective adjuvant strategies are needed to reduce relapse and death rates because recurrences are generally fatal.

Outcomes of patients with endometrial cancer and aggressive histology.

e16536 Background: To present patterns of practice and outcomes of patients with early stage poor histology endometrial cancer. Methods: Records of the patients with FIGO stage I-II serous papillary, clear cell, mixed or undifferentiated endometrial cancer were retrospectively evaluated. All patients were initially treated surgically by the same surgeon with comprehensive staging lymphadenectomy, i.e. total abdominal hysterectomy, bilateral salphingooopherectomy, bilateral pelvic and paraaortic lymph node dissection and omentectomy. Adjuvant chemotherapy was offered to all patients and given unless the patient refused. Results: 38 patients with early stage poor histology were identified Median age was 61 and 86.8 % of the patients were post menopausal. Median BMI was 31.2 kg/m2. 28 patients (73.7%) received chemotherapy (90% with paclitaxel and carboplatin for 6 cycles). 5 patients (13.2 %) received external radiotherapy 3 patients (7.9%) received brachytherapy. Median follow up was 19 mos. Totally 3 patients (7.9%) had relapse on follow up; Among those who received adjuvant chemotherapy, only one patient had recurrence on vaginal cuff and was treated with radiotherapy and currently disease free for 4 years. Among those who did not receive adjuvant chemotherapy, 2 patients had widespread abdominal and distal recurrence and died on follow up. 2 patients died without recurrence. Conclusions: Complete surgical staging and adjuvant chemotherapy results in excellent prognosis in our patient series. [Table: see text]

1283 LOWER URINARY TRACT SYMPTOMS (LUTS) AS A PRESENTING SYMPTOM FOR BLADDER CANCER IN A VETERAN POPULATION

You have accessJournal of UrologyBladder Cancer: Detection & Screening1 Apr 20131283 LOWER URINARY TRACT SYMPTOMS (LUTS) AS A PRESENTING SYMPTOM FOR BLADDER CANCER IN A VETERAN POPULATION Ryan Dobbs, John Petros, Usama Al-Qassab, Chad Ritenour, Muta Issa, and Daniel Canter Ryan DobbsRyan Dobbs Atlanta, GA More articles by this author , John PetrosJohn Petros Atlanta, GA More articles by this author , Usama Al-QassabUsama Al-Qassab Atlanta, GA More articles by this author , Chad RitenourChad Ritenour Atlanta, GA More articles by this author , Muta IssaMuta Issa Atlanta, GA More articles by this author , and Daniel CanterDaniel Canter Atlanta, GA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.2637AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Patients with bladder cancer usually present with either gross or microscopic hematuria. The incidence of lower urinary tract symptoms (LUTS) as the sole presenting symptom for bladder cancer has traditionally been reported to be low (1-2%). The objective of this study is to evaluate the prevalence, characteristics, and outcomes of patients with bladder cancer who originally presented with LUTS in the absence of hematuria. METHODS We queried our database of bladder cancer patients at the Atlanta Veteran Affairs Medical Center (VAMC) to identify patients who presented solely with LUTS and were subsequently diagnosed with bladder cancer. Demographic, clinical, and pathologic variables were examined. RESULTS 4.4% (14/321) of bladder cancer patients in our series presented solely with LUTS. All patients were males. Mean age was 66.4 years (range=52-83). 7.1% (n=1) were African-American (AA) with the remainder being non-African American. Mean Charlson Co-morbidity Index and tobacco use were 3 (range=0-7) and 34.4 (range=0-70) pack-years, respectively. The mean IPSS, Bother and Quality of Life scores at presentation were 24.0, 20.4, and 4.2. In our small cohort, 7 (50.0%), 4 (25.0%), and 1 (7.1%) patients presented with clinical stage Ta, CIS, and T2 disease, respectively. Two (14.3%) patients had unspecified non muscle-invasive bladder cancer. The incidence of low and high-grade disease was equal: 50.0% (n=7) and 50.0% (n=7), respectively. Median follow-up was 51.96 months (range=28 days-128.26 months). Recurrence occurred in 5 (35.7%) patients with progression occurring in 1 (7.1%) patient who refused further treatment despite multiple positive cytologies. The patient that presented with cT2 disease was managed definitively with a radical cystoprostatectomy and bilateral pelvic lymph node dissection. At last follow up, 11 (78.6%) patients were alive without bladder cancer recurrence, and 3 (21.4%) patients had died. Only 1 (5.9%) death was attributable to bladder cancer. CONCLUSIONS In contrast to prior reports, our database shows a greater percentage of patients with bladder cancer who present solely with LUTS. Furthermore, analysis of staging data at presentation demonstrates that a majority of patients with LUTS as their initial symptom did not have CIS at the time of tumor resection. Although this patient population is highly enriched with patients who are smokers and have a history of chemical exposure, this study suggests that urologists should have a low threshold for evaluating patients with irritative symptoms for underlying bladder cancer. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e525 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ryan Dobbs Atlanta, GA More articles by this author John Petros Atlanta, GA More articles by this author Usama Al-Qassab Atlanta, GA More articles by this author Chad Ritenour Atlanta, GA More articles by this author Muta Issa Atlanta, GA More articles by this author Daniel Canter Atlanta, GA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

241 DETERMINATION OF THE ACCURACY OF FDG-PET/CT IN THE PRIMARY STAGING OF BIOLOGICAL HIGH RISK PROSTATE CANCERS BEFORE LOCAL THERAPIES: INCREASED UPTAKE ASSOCIATED WITH HIGHLY AGGRESSIVE TUMORS

You have accessJournal of UrologyProstate Cancer: Staging (I)1 Apr 2013241 DETERMINATION OF THE ACCURACY OF FDG-PET/CT IN THE PRIMARY STAGING OF BIOLOGICAL HIGH RISK PROSTATE CANCERS BEFORE LOCAL THERAPIES: INCREASED UPTAKE ASSOCIATED WITH HIGHLY AGGRESSIVE TUMORS Annie-Claude Blouin, Goran Rimac, Frédéric Bouchard, Claude Lemay, Vincent Fradet, André Caron, Yves Fradet, Louis Lacombe, Thierry Dujardin, Rabi Tigert, Jean-Mathieu Beauregard, and Frédéric Pouliot Annie-Claude BlouinAnnie-Claude Blouin Québec, Canada More articles by this author , Goran RimacGoran Rimac Québec, Canada More articles by this author , Frédéric BouchardFrédéric Bouchard Québec, Canada More articles by this author , Claude LemayClaude Lemay Québec, Canada More articles by this author , Vincent FradetVincent Fradet Québec, Canada More articles by this author , André CaronAndré Caron Québec, Canada More articles by this author , Yves FradetYves Fradet Québec, Canada More articles by this author , Louis LacombeLouis Lacombe Québec, Canada More articles by this author , Thierry DujardinThierry Dujardin Québec, Canada More articles by this author , Rabi TigertRabi Tigert Québec, Canada More articles by this author , Jean-Mathieu BeauregardJean-Mathieu Beauregard Québec, Canada More articles by this author , and Frédéric PouliotFrédéric Pouliot Québec, Canada More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.1621AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Cancer staging with FDG-PET/CT is accurate for many cancers but not for prostate cancers (PCa) based on early studies on heterogeneous cohorts of patients. However, in more recent studies, FDG-PET/CT was shown to be as accurate as 18F-Choline-PET/CT in recurrent and metastatic PCa. Moreover, it was shown that glucose metabolism enzymes were overexpressed in high Gleason sum PCa. We therefore hypothesized that FDG-PET/CT might be useful in the initial staging of biological high risk PCa (Gleason ≥8) before local therapies. METHODS Last year, 54 patients with Gleason sum ≥8 at biopsy underwent a FDG-PET/CT and a bone scan as initial staging procedures. 41 patients then underwent radical prostatectomy (RP) and bilateral pelvic lymph node dissection, while 13 patients received androgen deprivation therapy (ADT) alone or a combination of ADT and radiation therapy. Increased FDG uptake for each organ was defined as our detection rate. RESULTS At biopsy, 73 and 27% of patients had Gleason sum 8 and 9, pre-operative PSA was 16 ng/mL (median = 7.5) and 34, 34, 26 and 6% of patients had clinical stages T1, T2, T3 or T4. Increased FDG uptake was found in the prostate, lymph nodes (LN) and bones of 44, 15 and 6% of patients. Bone scan was positive in the 3 patients that had bone FDG uptake. In the operated patients cohort, using RP pathological specimens, sensitivity, specificity, positive and negative predictive values were 27, 100, 100 and 78% for LN metastasis. On univariate analysis (RP group), higher clinical stage, pathological Gleason sum and pattern and the presence of perineural invasion were significantly associated with intraprostatic FDG uptake (all p < 0.037). Patients without FDG uptake in the prostate were downstaged to Gleason ≤ 7 in 72.4% of cases at RP (vs 18.4% for increased uptake, p=0.0001). None of the patients downstaged to Gleason 6(3+3) nor 7(3+4) at pathology had an increased FDG uptake in the prostate while 62,5 and 100% of patients with Gleason 8 or 9 did (p = 0.01). Moreover, FDG-PET/CT LN positivity was associated with higher pathological stage, Gleason sum, positive LN,LN density, and the presence of seminal vesicle invasion (all p < 0.044). CONCLUSIONS Our results suggest for the first time that FDG-PET/CT is highly specific for PCa metastasis and may identify intraprostatic pathological downstaging in biologically high risk patients. Therefore, we demonstrate a possible prognostic and staging role for FDG-PET/CT in high-risk prostate cancers imaged before primary therapies. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e99-e100 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Annie-Claude Blouin Québec, Canada More articles by this author Goran Rimac Québec, Canada More articles by this author Frédéric Bouchard Québec, Canada More articles by this author Claude Lemay Québec, Canada More articles by this author Vincent Fradet Québec, Canada More articles by this author André Caron Québec, Canada More articles by this author Yves Fradet Québec, Canada More articles by this author Louis Lacombe Québec, Canada More articles by this author Thierry Dujardin Québec, Canada More articles by this author Rabi Tigert Québec, Canada More articles by this author Jean-Mathieu Beauregard Québec, Canada More articles by this author Frédéric Pouliot Québec, Canada More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

Primary Cervical Choriocarcinoma: Case Report and the Review of Literatures

Background: Primary choriocarcinoma of the cervix is a very rare entity. Case: A 35-year-old patient had been admitted to our hospital with vaginal bleeding for 7 months. A cervical mass measured 4 × 4 cm was palpated on the anterior surface of the cervix. Biopsy of the lesion demonstrated extensive necrosis and was in favor of squamous cell carcinoma. Patient was accepted as FIGO stage Ib1-2 and underwent type II hysterectomy with bilateral salpingoopherectomy and bilateral pelvic lymph node dissection was carried out. Post operative pathologic evaluation of the surgical specimen evinced that the case was primary cervical choriocarcinoma. Conclusion: Primary choriocarcinoma of the cervix should be considered in patients in their reproductive years with cervical lesion and negative cervical cytology. Beta-hCG assay and transvaginal color Doppler sonography are useful for early diagnosis.

Learning curve analysis of robot-assisted radical hysterectomy for cervical cancer: initial experience at a single institution

ObjectiveThe aim of this study was to evaluate the learning curve and perioperative outcomes of robot-assisted laparoscopic procedure for cervical cancer.MethodsA series of 65 cases of robot-assisted laparoscopic radical hysterectomies with bilateral pelvic lymph node dissection for early stage cervical cancer were included. Demographic data and various perioperative parameters including docking time, console time, and total operative time were reviewed from the prospectively collected database. Console time was set as a surrogate marker for surgical competency, in addition to surgical outcomes. The learning curve was evaluated using cumulative summation method.ResultsThe mean operative time was 190 minutes (range, 117 to 350 minutes). Two unique phases of the learning curve were derived using cumulative summation analysis; phase 1 (the initial learning curve of 28 cases), and phase 2 (the improvement phase of subsequent cases in which more challenging cases were managed). Docking and console times were significantly decreased after the first 28 cases compared with the latter cases (5 minutes vs. 4 minutes for docking time, 160 minutes vs. 134 minutes for console time; p<0.001 and p<0.001, respectively). There was a significant reduction in blood loss during operation (225 mL vs. 100 mL, p<0.001) and early postoperative complication rates (28% vs. 8.1%, p=0.003) in phase 2. No conversion to laparotomy occurred.ConclusionImprovement of surgical performance in robot-assisted surgery for cervical cancer can be achieved after 28 cases. The two phases identified by cumulative summation analysis showed significant reduction in operative time, blood loss, and complication rates in the latter phase of learning curve.

Nail Toxicity Associated With Paclitaxel Treatment for Ovarian Cancer

A 57-year-old woman named C. B. began experiencing abdominal pain and bloating. She presented to her primary physician with these symptoms, and her physician palpated an adenexal mass on pelvic examination. That prompted a computed tomography (CT) scan of the abdomen and pelvis, which demonstrated omental thickening as well as a mildly enlarged left ovary. After initial consultation with a gynecologic oncologist, C. B. was taken to surgery and a total abdominal hysterectomy bilateral salpingo-oophorectomy omentectomy partial bowel resection, and pelvic and periaortic lymph node dissection were performed. C. B. was diagnosed with stage IV ovarian cancer involving the omentum, pelvic lymph nodes, and bowel wall and was subsequently referred for postoperative chemotherapy.

The Use of a Laparoscopic Bulldog Clamp to Control the Dorsal Vein Complex During Robot-Assisted Radical Prostatectomy: A Novel Technique

To describe a novel technique to control dorsal vein complex (DVC) during robot-assisted radical prostatectomy (RARP). We have been using a laparoscopic bulldog clamp to control DVC before apical dissection and urethral division. Data of 50 patients who underwent DVC control with laparoscopic bulldog clamp (group 1) were retrospectively compared with 50 consecutive patients in whom DVC was controlled with suture ligation (group 2). In the bulldog and suture groups, 30 and 31 patients underwent concomitant bilateral extended pelvic lymph node dissection (PLND), respectively. Operative and anastomosis time, estimated blood loss (EBL), apical surgical margin positivity, and early continence rates were evaluated. Patients in the bulldog group had significantly shorter operative time compared with patients in the suture group (146.8 vs 178.4 min, P=0.0005). Anastomosis time was significantly shorter in the bulldog group (12.3 vs 15.5 min, P=0.002). There was no difference in EBL between the groups (185 vs 184.2 mL). Immediate, postoperative first and third month continence rates were 62% vs 44%, 74% vs 60%, 90% vs 74% in groups 1 and 2, respectively. Although continence rates were better in favor of the bulldog group at each evaluation period, the difference did not reach statistical difference. None of the patients in both groups had apical surgical margin positivity. The use of a laparoscopic bulldog clamp to control DVC was associated with shorter operation and anastomosis time and a trend toward quicker recovery of continence. This technique provides clear vision during apical dissection and urethral division while potentially minimizing the external sphincteric trauma. Prospective randomized trials are needed for better evaluation of this technique.

Endocervical adenocarcinoma — Proposal for a new histopathologic pattern-based classification system with significant clinical implications: A multi-institutional study

Objectives: Lymph node (LN) involvement is an important prognostic factor in cervical adenocarcinoma (AC) and is associated with a need for adjuvant therapy. The standard of care for early stage (IA2, IB1, and IIA) adenocarcinoma is radical hysterectomy with bilateral pelvic lymph node dissection (PLND). Greater than 95% of LNs resected in AC, however, are negative and PLND has associated morbidity. The role of PLND in the management of cervical AC therefore remains controversial. Despite a variety of histopathologic markers that are correlated to LN metastases, there are no guidelines to suggest which patients with early stage disease may safely avoid lymphadenectomy.

Carboplatin Based Induction Chemotherapy for Nonorgan Confined Bladder Cancer—A Reasonable Alternative for Cisplatin Unfit Patients?

We investigated induction carboplatin based chemotherapy in patients with nonorgan confined urothelial carcinoma who were considered unfit for cisplatin. A comparison was made with patients who received induction cisplatin based combination chemotherapy. We identified 167 patients with nonorgan confined urothelial carcinoma who received induction cisplatin based combination chemotherapy (126) or gemcitabine and carboplatin (41) at our hospital between 1990 and 2010. Of the patients 124 completed 4 cycles of cisplatin based combination chemotherapy or gemcitabine and carboplatin. Clinical response (ycTNM) was evaluated according to RECIST (Response Evaluation Criteria in Solid Tumors) 1.1. Radical cystectomy and bilateral extended pelvic lymph node dissection were performed in 106 patients. A pathological complete response was defined as no evidence of disease (ypT0N0). Disease specific survival was analyzed using the Kaplan-Meier method. Multivariate analysis was performed. Complete clinical response rates did not differ significantly among the treatment groups. A pathological complete response was seen in 33.7% of specimens in the cisplatin based combination chemotherapy group vs 30.3% in the gemcitabine and carboplatin group (p = 0.808). We found no significant difference in disease specific survival between patients who started cisplatin based combination chemotherapy and those who started gemcitabine and carboplatin. For patients who completed 4 cycles and underwent radical cystectomy there was also no significant difference in disease specific survival between the groups. On multivariate analysis a pathological complete response was the only variable significantly associated with disease specific survival (p <0.045). Induction gemcitabine and carboplatin for nonorgan confined urothelial carcinoma achieves clinical and pathological response rates, and survival outcomes comparable to those of the cisplatin based combination chemotherapy schemes. Our data suggest that a carboplatin based regimen can be considered a reasonable alternative for cisplatin unfit patients in the preoperative setting.

A Prospective Single-Center Study of Sentinel Lymph Node Detection in Cervical Carcinoma: Is There a Place in Clinical Practice?

To establish the accuracy of sentinel lymph node (SLN) detection in early cervical cancer. Sentinel lymph node detection was performed prospectively over a 6-year period in 86 women undergoing surgery for cervical carcinoma by the combined method (Tc-99m and methylene blue dye). Further ultrastaging was performed on a subgroup of 26 patients who had benign SLNs on initial routine histological examination. The SLN was detected in 84 (97.7%) of 86 women by the combined method. Blue dye uptake was not seen in 8 women (90.7%). Sentinel lymph nodes were detected bilaterally in 63 women (73.3%), and the external iliac region was the most common anatomic location (48.8%). The median SLN count was 3 nodes (range, 1-7). Of the 84 women with sentinel node detection, 65 also underwent bilateral pelvic lymph node dissection, and in none of these cases was a benign SLN associated with a malignant non-SLN (100% negative predictive value). The median non-SLN count for all patients was 19 nodes (range, 8-35). Eighteen patients underwent removal of the SLN without bilateral pelvic lymph node dissection. Nine women (10.5%) had positive lymph nodes on final histology. One patient had bulky pelvic nodes on preoperative imaging and underwent removal of the negative bulky malignant lymph nodes and a benign SLN on the contralateral side. This latter case confirms the unreliability of the SLN method with bulky nodes. The remaining 8 patients had positive SLNs with negative nonsentinel lymph nodes. Fifty-nine SLNs from 26 patients, which were benign on initial routine histology, underwent ultrastaging, but no further disease was identified. Four patients (5%) relapsed after a median follow-up of 28 months (range, 8-80 months). Sentinel lymph node detection is an accurate and safe method in the assessment of nodal status in early cervical carcinoma.

Efficacy and tolerability of biweekly gemcitabine plus cisplatin (GEMCIS) or gemcitabine plus paclitaxel (GEMPAC) as neoadjuvant chemotherapy in patients with muscle invasive urothelial carcinoma of the bladder.

e15006 Background: Cisplatin, gemcitabine and paclitaxel are active chemotherapeutic agents for invasive urothelial carcinoma of the bladder (UCB). Biweekly administration of gemcitabine in combination with cisplatin (GEMCIS) or paclitaxel (GEMPAC) has been reported to have better tolerability than other schedules. Methods: Between 2009- 2011, we have treated 34 patients (median age 69 years, range 56-85) with muscle invasive UCB using gemcitabine (1500 mg/m2) in combination with cisplatin (50 mg/m2) or paclitaxel (150 mg/m2) given on days 1 and 15, every 4 weeks, for 3 cycles prior to radical cystectomy (RC) with bilateral pelvic lymph node dissection and urinary diversion. Patients deemed unsuitable for GEMCIS due to old age, frailty, multiple comorbidities or poor renal function received GEMPAC (n=9); all others received GEMCIS (n=25). Results: Clinical staging revealed T2, T3 and T4 disease in 20 (58.8 %), 8 (23.5 %) and 6 (17.6 %) patients, respectively. Patients were re-evaluated after 2 cycles with MRI or CT scans, which showed improvement in 21 (61.8 %) patients, no change in 12 (35.3 %) and progression in 1 patient (2.9%). Pathologic examination of the surgical specimens revealed T0, Tis, T2, T3 and T4 disease in 8 (23.5 %), 6 (17.6 %), 10 (29.4 %), 6 (17.6 %) and 4 (11.8 %) patients, respectively. Overall, pathologic downstaging was observed in 41.1% of patients. In the GEMCIS group, 12 patients (48%) had pT0 or pTis; in the GEMPAC group, 2 pts (22.2%) had pT0 disease. The most commonly observed toxicities are tabulated below. Conclusions: Biweekly GEMCIS or GEMPAC regimens were active and exceptionally well tolerated in the neoadjuvant setting in patients with muscle invasive UCB, producing favorable pathologic outcomes in an initial cohort of patients. To our knowledge, these data represent the first report detailing clinical results with these regimens in this setting. [Table: see text]

Neoadjuvant chemotherapy plus radical surgery followed by chemotherapy in locally advanced cervical cancer.

5093 Background: The aim of this study is to evaluate the efficacy, in terms of overall survival and progression free survival, and safety of adjuvant chemotherapy after neoadjuvant chemotherapy followed by radical surgery both in patients with and without node metastases. Methods: Between June 2000 to May 2007, all patients with diagnosis of locally advanced cervical cancer referred to the Division of Gynecologic Oncology of the University Campus Bio-Medico of Rome were elegible for this protocol.All enrolled patients received 3 cycles of platinum-based chemotherapy every 3 weeks according to the scheme cisplatin 100 mg/mq and paclitaxel 175 mg/mq. After neoadjuvant chemotherapy all patients with stable or progression to treatment were excluded from the protocol, all other were submitted classical radical hysterectomy and bilateral systematic pelvic lymph node dissection, and after to adjuvant treatment with 6 cycles of platinum based chemotherapy with cisplatin 100 mg/mq and paclitaxel 175 mg/mq. Results: 110 patients with local advanced cervical cancer received the treatment with neoadjuvant chemotherapy followed by radical surgery and adjuvant chemotherapy.Our study focused on clinical and operative data , in terms of overall survival and disease free survival at 5 and 3 years. 5-year OS of our series was 78% at five years and 86% at 3-years, with encouraging results also in subgroup with and without node mestastases. Conclusions: The adjuvant chemotherapy regimen after neoadjuvant chemotherapy and radical surgery rappresents a valid treatment option for patients with locally advanced cervical cancer without lymph node involvement, both in terms of overall survival than in terms of disease-free interval, the results have also confirmed the validity of this approach in lymph node metastases, with a complication rate lower than the standard radio-chemotherapy regime.

External-beam radiotherapy and/or HDR brachytherapy in postoperative endometrial cancer patients: clinical outcomes and toxicity rates

The objectives of this study were to evaluate local disease control, overall survival (OS), disease-free survival (DFS) and local relapse-free survival (LRFS) in patients with endometrial cancer undergoing adjuvant vaginal brachytherapy (VBT )± external-beam radiotherapy (EBRT). From September 2007 to February 2011, 40 patients with endometrial cancer were retrospectively analysed. Surgery consisted of total hysterectomy and bilateral salpingo-oophorectomy without node dissection (16 patients) or with bilateral pelvic node dissection (24 patients). The stage distribution was as follows: two IA, nine IB, 12 IC, five IIA, eight IIB, two IIIA and two IIIC. Thirty-four patients underwent EBRT and VBT. Six patients received VBT alone. Median follow-up was 26 months. The 5-year OS and DFS were 96.4% and 86.9%, respectively. No local recurrence was observed. Four patients presented distant disease (three had lung metastases and one had hepatic node metastases). Acute EBRT-related toxicities were seen in 15 (38%) patients. We recorded late toxicities in 14 patients (35%). There was no evidence of grade 3-4 toxicity. Adjuvant EBRT and/or VBT in patients with endometrial cancer showed good outcomes in terms of local disease control, with an acceptable toxicity profile.

Same-Day Discharge in Clinical Stage I Endometrial Cancer Patients Treated with Total Laparoscopic Hysterectomy, Bilateral Salpingo-Oophorectomy and Bilateral Pelvic Lymphadenectomy

Objectives: The purpose of this retrospective study was to evaluate the capacity for same-day discharge in clinical stage I endometrial cancer (EC) patients treated with total laparoscopic hysterectomy (TLH), bilateral salpingo-oophorectomy (BSO) and bilateral pelvic lymph node dissection (BPLND). Methods: We retrospectively reviewed the charts of stage I EC patients who were treated with TLH, BSO and BPLND and discharged on the same day. The intra- and postoperative clinical variables (e.g., age, complications, surgery time, patient hospital stay) were evaluated in an attempt to discern which factors may predispose a patient to same-day discharge. Results: Twenty-one patients were successfully discharged on the same day of surgery. Mean operative time was 1.48 h and length of hospital stay was 6.35 h. There were no intraoperative complications or hospital readmissions. Conclusions: We present a single, institutional experience solely assessing the capacity for same-day discharge in clinical stage I EC patients treated with TLH, BSO and BPLND. Since the postoperative complication rate was minimal with no hospital readmissions, we suggest that particularly selected stage I EC patients are amenable to outpatient management.

Malfunction of the da Vinci robotic system in urology

To analyze the incidence of malfunction of the da Vinci robotic system in a single center and to provide potential solutions. A total of 400 patients underwent da Vinci robotic urological surgery at Taichung Veterans General Hospital in Taichung, Taiwan, from December 2005 to April 2011. Episodes of malfunction of the robotic system were analyzed by period of operation, type of procedure, type of malfunction and management of the event. Overall, 14 cases of malfunction occurred (3.5% of the entire series). Among them, five (1.25%) occurred before the surgery and nine (2.25%) intraoperatively. Operative procedures included radical prostatectomy, bilateral pelvic lymph node dissection, dismembered pyeloplasty, partial nephrectomy, nephroureterectomy, and radical and partial cystectomies. Areas of malfunctions included the robotic arm system and joint (11/14), optical system (1/14), power system and connector (1/14), endoscopic instrument (1/14), and software (1/14). In 10 cases, the failure was recoverable, whereas in four cases there was a critical failure, requiring a conversion to standard laparoscopy in three of them, and the rescheduling of the surgery in one case. The da Vinci robotic system is extremely reliable for use in urology. Malfunction is rare and the risk of critical failure is very low. Managing mechanical failure before or during the surgery is the key to maintaining the safety of patients undergoing robotic surgical procedures.

Radical prostatectomy represents an effective treatment in patients with specimen‐confined high pathological Gleason score prostate cancer

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: To date, only a few studies have addressed the long-term oncological outcomes of radical prostatectomy (RP) in patients with pathological Gleason score ≥ 8 prostate cancer. According to these reports, some individuals with pathological Gleason score ≥ 8 may benefit from RP, with cancer-control outcomes comparable with those of patients with low- and intermediate-risk prostate cancer. The presence of pathological Gleason score 8-10 represents a poor prognostic factor in the outcome of men with prostate cancer. However, in patients with specimen-confined disease, RP and bilateral PLND provided long-term cancer-control outcomes similar to those of patients with more favourable disease characteristics. To evaluate the outcomes of patients with pathological Gleason score 8-10 prostate cancer subjected to radical prostatectomy (RP). To determine the prognostic factors associated with cancer-specific survival (CSS) in this subset of patients. The study included 580 consecutive patients with pathological Gleason sum 8-10 prostate cancer treated with RP and pelvic lymph node dissection (PLND) at a single European institution between July 1988 and April 2010. All patients had detailed pathological and follow-up data. Pathological Gleason score was determined by a single expert genitourinary pathologist. Biochemical recurrence (BCR) was defined PSA concentration of ≥ 0.2 ng/mL and rising. Kaplan-Meier plots were used to graphically explore BCR-free survival as well as CSS and overall survival (OS) rates. Moreover, univariable and multivariable Cox regression models were fitted to test the predictors of CSS. The mean (median, range) age at surgery was 66.1 (66.4, 41-85) years. The mean (median, range) total PSA concentration was 29.6 (11.1, 0.5-1710) ng/mL. Pathological Gleason score was 8 in 238 (41.0%), 9 in 330 (56.9%) and 10 in 12 (2.1%) patients. Overall, 119 (20.5%), 124 (21.4%), 281 (48.4%) and 56 (9.7%) patients had pT2, pT3a, pT3b and pT4 prostate cancer, respectively. Overall, 275 (47.4%) had LN invasion, while 150 (25.1%) patients had specimen-confined disease (defined as pT2cR0 pN0 or pT3aR0 pN0 prostate cancer). The mean (median, range) follow-up was 53 (47, 1-226) months. At 5 and 10 years after RP, BCR-free survival was 76.7% and 49.6%, respectively. Similarly, the 5- and 10-year CSS rates were 87.3% and 69.5%, respectively. Patients with specimen-confined disease (P < 0.001) and patients with negative LNs (P = 0.012) had significantly better CSS rates than their counterparts with less favourable pathological characteristics. In multivariable Cox regression models, only the presence of specimen-confined disease achieved independent predictor status (P = 0.001). Presence of high Gleason score at RP represents a poor prognostic factor in the outcome of patients with prostate cancer. However, RP provides excellent long-term cancer control outcomes in the subset of patients with specimen-confined disease.

V1885 ROBOTIC ASSISTED RADICAL CYSTECTOMY AND URINARY DIVERSION USING A MODIFIED PFANNENSTIEL INCISION

You have accessJournal of UrologyOncology, Bladder Oncology1 Apr 2012V1885 ROBOTIC ASSISTED RADICAL CYSTECTOMY AND URINARY DIVERSION USING A MODIFIED PFANNENSTIEL INCISION Devendar katkoori, Ahmed Eldefrawy, Rajinikanth Ayyathurai, and Murugesan Manoharan Devendar katkooriDevendar katkoori Miami, FL More articles by this author , Ahmed EldefrawyAhmed Eldefrawy Miami, FL More articles by this author , Rajinikanth AyyathuraiRajinikanth Ayyathurai Miami, FL More articles by this author , and Murugesan ManoharanMurugesan Manoharan Miami, FL More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.2040AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Robotic assisted laparoscopic radical cystectomy (RARC) is gaining popularity. A completely intracorporeal procedure is technically difficult and time consuming procedure. Most surgeons perform the diversion using small midline incision, which is also used for specimen retrieval. We report our technique of RARC with modified Pfannenstiel incision. METHODS Cystectomy is performed using da Vinci robotic platform in a standard fashion. Bilateral pelvic lymph node dissection (BPLND) is done and the robot is undocked; 8-10 cm transverse curvilinear incision is made along pubic hairline centered over symphysis pubis. V-shaped incision (limbs of V at 30° angle, prevents inadvertent entry into inguinal canal) is made in the anterior rectus sheath with midpoint 2 cm above symphysis pubis. Rectus sheath is reflected and V-incision is converted into Y-incision by vertical incision on the inferior leaflet of rectus sheath towards pubic symphysis. Rectus muscles are separated. Specimen is extracted, neobladder (NB) / ileal conduit (IC) is performed and diversion completed via the incision. RESULTS 30 patients underwent RARC since April 2008. Median age was 65 yr (44-85). All had extracorporeal urinary diversions. Ratio of IC vs. NB was 6.5:3.5. The EBL was 275 (175-375ml), mean operating time was 5±0.8 hr. No intraoperative visceral injuries were noted. Two patients had positive surgical margins. Mean number of lymph nodes removed was 12±3. No incision hernia noted. CONCLUSIONS RARC with modified Pfannenstiel incision is feasible, less time consuming, facilitates NB/IC reconstruction. The incision heals with a cosmetic scar and low risk of Incisional hernia. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e761 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Devendar katkoori Miami, FL More articles by this author Ahmed Eldefrawy Miami, FL More articles by this author Rajinikanth Ayyathurai Miami, FL More articles by this author Murugesan Manoharan Miami, FL More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

529 NEOADJUVANT GEMCITABINE PLUS CARBOPLATIN FOLLOWED BY IMMEDIATE RADICAL CYSTECTOMY IN PATIENTS WITH MUSCLE-INVASIVE BLADDER CANCER: A PROPENSITY SCORE ANALYSIS

You have accessJournal of UrologyUrothelial Cancer: Medical & Surgical Therapy1 Apr 2012529 NEOADJUVANT GEMCITABINE PLUS CARBOPLATIN FOLLOWED BY IMMEDIATE RADICAL CYSTECTOMY IN PATIENTS WITH MUSCLE-INVASIVE BLADDER CANCER: A PROPENSITY SCORE ANALYSIS Takuya Koie, Akiko Okamoto, Hayato Yamamoto, Yuki Tobisawa, Tohru Yoneyama, Kazuyuki Mori, Shingo Hatakeyama, Takahiro Yoneyama, Yasuhiro Hashimoto, Noritaka Kamimura, and Chikara Ohyama Takuya KoieTakuya Koie Hirosaki, Japan More articles by this author , Akiko OkamotoAkiko Okamoto Hirosaki, Japan More articles by this author , Hayato YamamotoHayato Yamamoto Hirosaki, Japan More articles by this author , Yuki TobisawaYuki Tobisawa Hirosaki, Japan More articles by this author , Tohru YoneyamaTohru Yoneyama Hirosaki, Japan More articles by this author , Kazuyuki MoriKazuyuki Mori Hirosaki, Japan More articles by this author , Shingo HatakeyamaShingo Hatakeyama Hirosaki, Japan More articles by this author , Takahiro YoneyamaTakahiro Yoneyama Hirosaki, Japan More articles by this author , Yasuhiro HashimotoYasuhiro Hashimoto Hirosaki, Japan More articles by this author , Noritaka KamimuraNoritaka Kamimura Hirosaki, Japan More articles by this author , and Chikara OhyamaChikara Ohyama Hirosaki, Japan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.602AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Standard neoadjuvant chemotherapy has not yet been established for patients with muscle-invasive bladder cancer. Our pervious phase II trial demonstrated the efficacy and safety of neoadjuvant gemcitabine plus carboplatin (GCarb) chemotherapy followed by immediate cystectomy in patients with muscle-invasive bladder cancer. In the present study, we conducted a propensity score analysis to elucidate clinical significance of the present treatment protocol. METHODS The cohort of neoadjuvant group consists of 120 patients with muscle-invasive bladder cancer. They received 2 courses of GCarb therapy consisting of 800 mg/m2 gemcitabine on days 1, 8, and 15 and carboplatin with an AUC of 4 on day 2 between March 2005 and June 2011. After the chemotherapy, radical cystectomy (RC) and bilateral pelvic lymph node dissection (PLND) were performed at an interval of 1 month. The cohort of RC alone group includes 155 patients with muscle-invasive bladder cancer treated with RC and bilateral PLND between May 1994 and December 2004. Propensity score matching was used to adjust for potential selection biases associated with treatment type. The endpoints were Overall (OS) and disease-free survival (DFS). RESULTS Of the 120 patients who received GCarb and RC, 28 (23.3%) RC specimens showed pT0. The mean interval from the time of diagnosis of muscle-invasive bladder cancer to RC was 61 days. Grade 3/4 neutropenia occurred in 40 patients (33.9%) and thrombocytopenia in 23 patients (19.8%). Propensity score-matched analysis indicated 112 matched pairs from both groups. The median follow-up period was 35.9 months. The 5-year OS rate was 91.5% for neoadjuvant GCarb versus 51.3% for RC alone group (P < 0.0001). The DFS rate was 83.8% for neoadjuvant GCarb versus 53.1% for RC alone (P < 0.0001). Multivariate analysis revealed that the neoadjuvant GCarb regimen was an extremely strong predictor of the improvement in OS and DFS. CONCLUSIONS Although the present study is not randomized, neoadjuvant gemcitabine plus carboplatin therapy followed by immediate RC achieved significantly longer OS and DFS comparing to surgery alone. The clinical usefulness of the present treatment for the patient with muscle-invasive bladder cancer should be verified by further trials. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e217-e218 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Takuya Koie Hirosaki, Japan More articles by this author Akiko Okamoto Hirosaki, Japan More articles by this author Hayato Yamamoto Hirosaki, Japan More articles by this author Yuki Tobisawa Hirosaki, Japan More articles by this author Tohru Yoneyama Hirosaki, Japan More articles by this author Kazuyuki Mori Hirosaki, Japan More articles by this author Shingo Hatakeyama Hirosaki, Japan More articles by this author Takahiro Yoneyama Hirosaki, Japan More articles by this author Yasuhiro Hashimoto Hirosaki, Japan More articles by this author Noritaka Kamimura Hirosaki, Japan More articles by this author Chikara Ohyama Hirosaki, Japan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...