Final Pathologic Analysis Research Articles

Surgical upstaging rates in patients meeting the eligibility for active surveillance trials.

Four clinical active surveillance trials including LORIS, COMET, LORD and LORETTA, are being conducted to assess whether women with low-risk ductal carcinoma in situ can safely avoid surgery. The present study aimed to determine the rate of upstaging to invasive cancer among patients with a preoperative diagnosis of ductal carcinoma in situ and to evaluate the incidence of upstaging in patients meeting the eligibility criteria for four active surveillance clinical trials. The present study initially enrolled 180 patients with 183 calcifications who received the diagnosis of ductal carcinoma in situ by biopsy. Patients were classified as eligible for four clinical trials according to the respective inclusion criteria. In total, 152 patients with 155 calcifications were analyzed. Of these, 32 (21%) were upstaged to invasive disease based on the final pathological analysis of surgical specimens. Of the 152 patients, 53 (35%), 90 (59%), 24 (16%) and 34 (22%) met the eligibility criteria for the LORIS, COMET, LORD and LORETTA trial, respectively. Among patients with low-risk ductal carcinoma in situ, 10 (19%), 14 (16%), 6 (25%) and 4 (12%) patients were upstaged to invasive disease in LORIS, COMET, LORD and LORETTA, respectively. The upstaging to pT1b or higher rates were 2% (1/53), 3% (3/90), 0% (0/24) and 3% (1/34) in LORIS, COMET, LORD and LORETTA, respectively. The upstaging rate in patients eligible for the clinical active surveillance trials was 12-25%. Although the rate of upstaging to pT1b or higher was low, further studies are required to determine the rates of upstaging to invasive cancer and the risk factors among patients with low-risk ductal carcinoma in situ.

Obesity, an independent predictor of pre and postoperative tumor grading disagreement in endometrial cancer

IntroductionObesity is a known independent risk factor for endometrial cancer (EC), and obese patients have a 4.7-fold increased risk compared to the general population to develop the neoplasm. To date, a general pre and postoperative tumor grading agreement from 53 % to 82 % is reported for endometrial analysis, and a consensus on which factors might influence the tumor grading discordance is still absent.Furthermore, although obesity alters the endometrial microenvironment, no studies investigated the role of obesity in the grading agreement of EC patients. This study aims to analyze the role of obesity in the pre and postoperative tumor grading agreement. Materials and methodsA retrospective analysis was conducted on EC cancer women subjected to surgical treatment. Upgrading discordance was defined as higher tumor grading on final pathological analysis compared to tumor grading on the preoperative examination. Downgrading discordance was defined as a lower tumor grading at the postoperative surgical specimen analysis compared to the preoperative biopsy. ResultsOf the 293 selected patients, 245 were included in the analysis. One hundred and forty nine (60.8 %) patients were tumor grade G1, 52 (21.2 %) G2, and 44 (18.0 %) G3. Grading agreement was 83.9 % for G1 patients, 51.9 % for G2 patients, and 83.3 % for G3 patients. The multivariate analysis showed obesity (BMI > 30 kg/m2) as significant factor influencing pre and postoperative grading agreement (p = 0.014, Odds Ratio 2.036, 95 % Confidence Interval 1.141–3.635). ConclusionsOur study for the first time showed obesity as the only factor in the multivariate analysis lowering the pre and postoperative tumor grading concordance. Grade 2 tumor was the factor that most frequently disagreed with the final surgical specimen analysis both in the general and in obese patients.

The effect of three-dimensional ultrasound and magnetic resonance imaging in the staging diagnosis of endometrial cancer with hepatitis B virus infection and construction of mathematical model

This paper was aimed to explore the effect of three-dimensional ultrasound and MRI (magnetic resonance imaging) in the staging diagnosis of endometrial cancer (EC) with hepatitis B virus infection and construction of mathematical model. The paper selected 31 patients with endometrial carcinoma with hepatitis B virus infection who were admitted to the hospital and who were diagnosed as endometrial carcinoma with hepatitis B virus infection. All patients underwent three-dimensional ultrasound and MRI. The results of the joint examination were compared with the final pathological diagnosis analysis, and the pathological diagnosis was used as the gold standard, and the detection rate and the coincidence rate of each examination result were calculated. The binary logistic regression mathematical model was established to analyze the fitting effect. The results of the study showed that the detection rates of 3D-TVUS (3-dimensional transvaginal ultrasound), MRI, and 3D-TVUS*MRI were 64.5%, 71%, and 96.8%, respectively. 3D-TVUS was statistically significant compared with 3D-TVUS*MRI results. MRI and the 3D-TVUS*MRI results were statistically significant. The difference between the three methods was statistically significant (P < 0.05). The coincidence rate of 3D-TVUS*MRI was higher than that of 3D-TVUS or MRI single examination. For Ia and Ib, the difference was statistically significant (P < 0.05), and in stage Ia. The staging results of MRI were compared with the staging results of 3D-TVUS*MRI, and the difference was statistically significant. Moreover, the fitting prediction effect of mathematical model was excellent. Clinical trials have verified that the diagnosis and staging of endometrial carcinoma with hepatitis B virus infection by 3D-TVUS*MRI is significantly better than 3D-TVUS or MRI single examination, which can better guide clinical treatment.

Multiparametric transvaginal ultrasound in the diagnosis of endometrial cancer in post-menopausal bleeding: diagnostic performance of a transvaginal algorithm and reproducibility amongst less experienced observers.

(a) To comparatively evaluate the performance of grayscale ultrasound features, power Doppler (PD) blood flow characteristics, and gel infusion sonography (GIS) in diagnosing endometrial cancer during real-time examination, (b) to compare the performance of real-time diagnosis of endometrial cancer by experienced observers with offline analysis by blinded observers using similar sonographic criteria during review of cine loop clips. 152 females with post-menopausal bleeding (PMB) had ET ≥ 4 mm at first-line ultrasound were included. Two experienced radiologists evaluated endometrial patterns at real-time evaluation (grayscale ultrasound, PD, and GIS), then examinations were stored as video clips for later evaluation by two less-experienced radiologists. The reference standard was hysteroscopy (HY) and/or hysterectomy with the histopathological examination. The area under (AUC) the receiver operating characteristic (ROC) curve was calculated to assess the diagnostic performance for the prediction of endometrial cancer. Among 152 females with ET ≥ 4 mm at first line TVUS, 88 (57.9%) patients had endometrial cancer on final pathologic analysis. Real-time ultrasound criteria (ET ≥ 5 mm with the presence of irregular branching endometrial blood vessels or multiple vessels crossing EM or areas with densely packed color-splash vessels with non-intact or interrupted EMJ at the grayscale ultrasound and/or GIS) correctly diagnosed 95% of endometrial cancers with 92% diagnostic efficiency.There is comparable accuracy of real-time evaluation (96%) and offline analysis (92%) after the exclusion of poor quality videos from the analysis. The diagnostic criteria showed good to an excellent agreement between real-time ultrasound and offline analysis. When real-time ultrasound is performed with good technique, utilizing multiple parameters, it is possible to diagnose endometrial cancer with a high degree of accuracy and reproducibility. when real-time ultrasound is performed with good technique, utilizing multiple parameters, it is possible to diagnose endometrial cancer with a high degree of accuracy and reproducibility.

Value of clinical parameters and MRI with PI-RADSV2 in predicting seminal vesicle invasion of prostate cancer

Objective To investigate the usefulness of magnetic resonance imaging (MRI) with Prostate Imaging Reporting and Data System version 2 (PI-RADSV2) and clinical parameters in predicting seminal vesicle invasion (SVI). Material and methods In this retrospective study, we identified 569 prostate cancer patients who underwent radical prostatectomy with MRI before surgery. SVI was interpreted with PI-RADSV2. Clinical parameters such as the prostate-specific antigen (PSA) and Gleason score (GS) were analyzed for the prediction of SVI. Logistic regression models and receiver operating characteristic (ROC) curves were used to evaluate SVI based on clinical parameters and MRI with PI-RADSV2. Results The median age at presentation was 67 years (43–85 years). The median PSA level was 6.1 ng/mL (2.2–72.8 ng/mL). There were 113 patients with a biopsy GS of ≥ 8. A total of 34 patients (6.0%) were interpreted to have SVI by MRI of which 20 were true positive, and 52 patients (9.1%) had true SVI in the final pathologic analysis. In multivariable analysis, PSA (HR: 1.03, 95% CI: 1.00–1.07), biopsy GS ≥ 8 (HR: 4.14, 95% CI: 2.12–8.09), and MRI with PI-RADSV2 (HR: 14.67, 95% CI: 6.34–33.93) were significantly associated with pathologic SVI. The area under the curve of the model based on the clinical parameters PSA and GS plus MRI (0.862) was significantly larger than that of the model based on clinical parameters alone (0.777, p < 0.001). Conclusions MRI with PI-RADSV2 using the clinical parameters PSA and GS was effective in predicting SVI.

Early Surgical and Long-term Oncological Outcomes of Totally Laparoscopic Near-total Gastrectomy in &gt;150 Cases

This study aimed to examine the early surgical outcomes and long-term oncological safety of totally laparoscopic near-total gastrectomy for the treatment of upper-third early gastric cancer. We retrospectively collected and analyzed the data of 167 consecutive patients who underwent totally laparoscopic near-total gastrectomy for upper-third early gastric cancer between January 2008 and May 2018. Data on clinical characteristics and surgical outcomes, including operation time, length of postoperative hospital stay, pathologic findings, and postoperative complications, were obtained. We also analyzed recurrence-free and overall survival rates to evaluate the oncological outcomes. The mean operation time was 149.44±37.59 minutes; none of the patients required conversion to laparotomy during surgery. The average postoperative hospital stay was 7.57±5.69 days. On final pathologic analysis, the mean proximal resection margin was 1.97±1.68 cm. No patients had an involved proximal resection margin. Twenty-seven patients (16.17%) had postoperative complications; of them, 6 patients (3.59%) had Clavien-Dindo classification grade 3 or higher complications, all within 1 month. The median follow-up duration was 54.35 months. The 3- and 5-year recurrence-free survival rates were 98.3% and 97.1%, respectively. The overall survival rate was 97.1% at both 3 and 5 years. Our study shows that totally laparoscopic near-total gastrectomy is a safe and feasible procedure for treating the upper-third early gastric cancer. Further, in the current study, the procedure demonstrated a favorable oncological outcome for a relatively long follow-up period and large sample size.

Computed Tomography in the Diagnosis of Ascites: The Role of Fluid Attenuation Values.

Intraperitoneal fluid accumulations are a common matter in current clinical practice, being encountered by most medical and surgical fields. To assess ascites fluid with attenuation values in the form of Hounsfield units (HU) in order to determine a non-invasive differentiation criterion for the diagnosis of intraperitoneal collections. Sixty patients with known intra-peritoneal collections who underwent computed tomography (CT) for reasons such as tumor staging, post-surgical follow-up or other indications, were retrospectively included in this study. All subjects had a final pathological analysis of the fluid collections. Two radiologists measured the attenuation values for each collection. The averaged values were used for comparing benign and malignancy-related ascites (MRA), bland and hemorrhagic ascites and infected and noninfected fluid collections by consuming the Mann-Whitney U test. Also, the receiver operating characteristic analysis was performed for the statistically significant results (P&lt;0.05), and the area under the curve (AUC) was calculated. Attenuation values could differentiate between benign and MRA (P=0.04; AUC=0.656; sensitivity, 65.52%; specificity, 71.43%) but failed to distinguish between bland ascites and ascites with hemorrhagic component (P=0.85), and between infected and noninfected fluid collections (P=0.47). Although the results are statistically significant, the substrate of differentiation between benign and MRA ascites cannot be clearly stated. As being the first study to investigate this issue, it opens the way for other researches in the field to determine the dynamics of imaging quantitative measurements according to the fluid's pathological features.

Elective Neck Dissection in T1N0M0 Oral Squamous Cell Carcinoma: When Is It Necessary?

Elective neck dissection (END) versus observation remains controversial for cT1N0M0 oral cavity squamous cell carcinoma (OSCC). The aim of this study was to determine whether neck dissection is indicated for cT1N0M0 OSCC versus observation when considering oral cavity subsites and depth of invasion (DOI) as predictors. A multicenter, ambispective cohort study of patients with cT1N0M0 OSCC treated at the University of Michigan and Beijing Stomatological Hospital from August 1998 to July 2017 with a follow-up end date of July 2019 was performed. Patients were excluded if follow-up was less than 2years and no neck disease had occurred or if the final pathologic analysis resulted in upstaging to T2 using American Joint Committee on Cancer criteria, eighth edition. A total of 283 patients met the criteria. The main outcome parameter was the 2-year neck metastatic rate. The total 2-year lymph node metastatic rate was 11.3%. Overall neck metastatic rates escalated consistently according to DOI: less than 2mm, 2.1%; 2 to 3mm, 9.4%; 3 to 4mm, 15.2%; and 4 to 5mm, 24.6%. On univariate Cox regression analysis, DOI greater than 3mm, tumor grade, and perineural invasion were statistically significant indicators of 2-year neck metastasis. On multivariate analysis, only DOI and tumor grade remained. On multivariate analysis of 2-year survival, no factors were independent predictors. Our proposed treatment strategy for END based both on statistically significant results for DOI and on review of the raw data using a 20% cutoff analysis showed cutoffs of 2mm for the tongue (18.2%), 3mm for the floor of the mouth (40.0%) and upper gingiva (20%), and 4mm for the lower gingiva (33.3%) and no cutoff for the hard palate (0.0%). The watch-and-wait approach remains a reasonable approach in selected patients with cT1N0M0 OSCC. Decision making for END in T1N0M0 patients should minimally consider tumor grade, DOI, and oral cavity subsite.

Preoperative Axillary Ultrasound Helps in the Identification of a Limited Nodal Burden in Breast Cancer Patients.

Since the Z0011 trial, the clinical evaluation of axillary status has been redirected to predicting nodal tumor burden rather than nodal metastases. Our study aimed to evaluate the value of clinicopathological factors and axillary ultrasound (US) for the prediction of a high nodal burden (≥3 metastatic lymph nodes) in breast cancer patients. A total of 532 consecutive patients who underwent preoperative axillary US and subsequent surgery for clinical T1-2 breast cancer with a final pathologic analysis were included. Clinical and pathologic variables were retrospectively evaluated. Univariate and multivariate statistical analyses were performed to identify the variables that were associated with a high nodal burden. Among the 532 patients, 110 (20.7%) had a high axillary nodal burden and 422 (79.3%) had a limited nodal burden. The multivariate analysis showed that suspicious axillary US findings (P < 0.001), clinical T2 stage (P = 0.011), the presence of lymphovascular invasion (P < 0.001), and estrogen receptor positivity (P < 0.001) were significantly associated with a high nodal burden. Patients with negative axillary US findings seldom had a high nodal burden, with a negative predictive value of 93.0% (294/316). Patients with suspicious axillary US findings, clinical T2 stage, lymphovascular invasion, and estrogen receptor positivity are more likely to have a high nodal burden, which may provide additional information for the treatment plan of breast cancer patients. Preoperative axillary US helps identify a limited nodal burden in breast cancer patients and has implications for axillary lymph node dissection and adjuvant treatment.

Retzius-sparing robotic-assisted laparoscopic radical prostatectomy: racial considerations for 250 consecutive cases.

Our objective is to report the functional and oncologic outcomes of a cohort of 250 consecutive prostate cancer patients undergoing a Retzius-sparing approach and to assess for racial differences in continence outcomes. This was a prospective, single-center, case series of 250 consecutive prostate cancer patients who underwent a Retzius-sparing robotic-assisted laparoscopic radical prostatectomy by a single surgeon between May 2015 and April 2019. Our primary objective was to report post-operative continence outcomes of patients undergoing this technique. Continence was defined as using zero or one precautionary pad per day. Median follow-up was 24.0months [interquartile range (IQR) 18.0-30.0months]. Median age and body mass index were 62.0years (IQR 57.0-67.0) and 29.0kg/m2 (IQR 26.0-33.0), respectively. Median PSA was 8.22ng/ml (IQR 5.74-13.31). 84.8% of patients were intermediate risk or high risk pre-operatively, as per AUA/ASTRO/SUO guidelines. 96.0% had Gleason Score 7 or worse disease on final pathologic analysis. Positive margin incidence was 18.1% and 44.4% in patients with pT2 and pT3 disease, respectively, of which 75.4% were unifocal. Immediate continence (i.e., continence achieved within 1month post-operatively) was achieved in 45.2% of patients. Three-month and 1-year continence rates were 70.0% and 92.0%, respectively. Caucasian patients experienced earlier return of continence (77% versus 65% at 3months) compared to African American patients. IPSS scores gradually improved from 8.0 pre-operatively to 4.0 1-year later. Median PSA level was 0.01ng/ml (IQR 0.01-9.01) post-operatively. Retzius-sparing robotic-assisted laparoscopic radical prostatectomy is an oncologically safe surgical technique with excellent short- and long-term continence outcomes. Caucasian patients may have earlier return of continence compared to African Americans.

Retzius-sparing robotic-assisted laparoscopic radical prostatectomy: Racial considerations for 250 consecutive cases.

e17546 Background: To report the functional and oncologic outcomes of a cohort of 250 consecutive prostate cancer patients undergoing a Retzius-sparing approach and to assess for racial differences in continence outcomes. Methods: This was a prospective, single-center, case series of 250 consecutive prostate cancer patients who underwent a Retzius-sparing robotic assisted laparoscopic radical prostatectomy by a single surgeon between May 2015 and April 2019.Our primary objective was to describe post-operative continence outcomes of patients undergoing this technique. Results: Median follow up was 24.0 months [Interquartile range (IQR) 18.0-30.0 months]. Median age and body mass index were 62.0 years (IQR 57.0-67.0) and 29.0 kg/m 2 (IQR 26.0-33.0), respectively. Median PSA was 8.22 ng/ml (IQR 5.74-13.31). 84.8% of patients were intermediate or high-risk pre-operatively. 96.0% had Gleason Score 7 or worse disease on final pathologic analysis. Positive margin incidence was 18.1% and 44.4% in patients with pT2 and pT3 disease, respectively. Immediate continence (i.e. continence achieved within one moth post-operatively) was achieved in 45.0% of patients. One-year continence rate was 92.0%. Caucasian patients experienced earlier return of continence (77% versus 65% at 3 months) compared to African American patients. IPSS scores gradually improved from 8.0 pre-operatively to 4.0 one year later. Median PSA level was 0.01 ng/ml (IQR 0.01-9.01) post-operatively. Conclusions: Retzius-sparing robotic assisted laparoscopic radical prostatectomy is an oncologically safe surgical technique with excellent short and long-term continence outcomes.

Ultrasound Findings of Breast Adenomas.

Breast adenomas are rare benign tumors. The aim of this study was to describe the ultrasound findings of breast adenomas, including less common worrisome features that can mimic malignancy. From November 2014 to November 2019, we performed 1605 core needle biopsies guided by ultrasound in our department. In all, 229 corresponded to fibroadenomas and 12 to breast adenomas. Breast adenomas represented 0.75% of all core needle biopsies; 50% (6 of 12) were tubular adenomas; 17% (2 of 12) were ductal adenomas; and 33% (4 of 12) were lactating adenomas. Tubular and lactating adenomas occurred in young women and ductal adenomas in postmenopausal women. Lactating adenomas occurred in pregnant or breastfeeding women and were larger than the other adenomas. Ultrasound showed a mass with an oval shape, a parallel orientation, circumscribed margins, and hypoechoic and homogeneous patterns in most cases. However, up to one-third of them presented with suspicious findings. Breast adenomas are rare benign entities with no specific clinical and radiologic features. Sometimes, they appear as suspicious tumors on radiologic modalities, requiring a histopathologic assessment to rule out malignancy. Radiologists need to be familiar with this entity to determine concordance between imaging and the final pathologic analysis.

MP62-03 IMPACT OF LYMPHOVASCULAR INVASION ON OVERALL SURVIVAL IN PATIENTS WITH PROSTATE CANCER FOLLOWING RADICAL PROSTATECTOMY STRATIFIED BY PATHOLOGICAL TUMOR STAGE

You have accessJournal of UrologyProstate Cancer: Staging I (MP62)1 Apr 2020MP62-03 IMPACT OF LYMPHOVASCULAR INVASION ON OVERALL SURVIVAL IN PATIENTS WITH PROSTATE CANCER FOLLOWING RADICAL PROSTATECTOMY STRATIFIED BY PATHOLOGICAL TUMOR STAGE Marcus Jamil*, Jacob Keeley, Akshay Sood, Deepansh Dalela, Sohrab Arora, Isaac Palma-Zamora, Natalija Kovacevic, Chandler Bronkema, Nikola Rakic, Alyssa Danno, James Peabody, Mani Menon, Craig Rogers, and Firas Abdollah Marcus Jamil*Marcus Jamil* More articles by this author , Jacob KeeleyJacob Keeley More articles by this author , Akshay SoodAkshay Sood More articles by this author , Deepansh DalelaDeepansh Dalela More articles by this author , Sohrab AroraSohrab Arora More articles by this author , Isaac Palma-ZamoraIsaac Palma-Zamora More articles by this author , Natalija KovacevicNatalija Kovacevic More articles by this author , Chandler BronkemaChandler Bronkema More articles by this author , Nikola RakicNikola Rakic More articles by this author , Alyssa DannoAlyssa Danno More articles by this author , James PeabodyJames Peabody More articles by this author , Mani MenonMani Menon More articles by this author , Craig RogersCraig Rogers More articles by this author , and Firas AbdollahFiras Abdollah More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000937.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The detrimental impact of lymphovascular invasion (LVI) in prostate cancer (PCa) on the risk of biochemical recurrence has been previously described. However, the impact of LVI on overall survival (OS) is not clear. The aim of this study was to evaluate the prognostic ability of LVI as a predictor of OS stratified by pathological tumor stage. METHODS: We examined all men with non-metastatic PCa who were treated with radical prostatectomy between 2004 and 2015 years within the National Cancer Database. Only those with information on the presence LVI on final pathological analysis were included (n=232,704). Patients were stratified according to final pathological T stage (pT2, pT3a and pT3b). Kaplan-Meier curves estimated survival in each individual sub-group based on LVI status. Moreover, Cox proportional hazards assessed the relationship between LVI and OS after adjusting for all available covariates. RESULTS: Median (IQR) age and PSA were 62 (56 – 67) years and 5.6 (4.3 - 8.2) ng/ml, respectively. Overall, 174,838 (75.1%), 40,281 (17.3%) and 17,585 (7.6%) of patients had pT2, pT3a and pT3b disease, respectively. Median follow-up was 42.7 months (27.1 – 58.7). At 10-years, the OS in LVI vs. non-LVI patients was 93.9% vs 95.0% in pT2 (0.0004), 92.7% vs 94.8% in pT3a (<0.0001), and 86.1% vs 91.6% in pT3b (<0.0001). On multivariable analysis, LVI status was not an independent predictor of OS in pT2 disease (hazard ratio [HR]: 1.11, 95% confidence interval [CI] 0.92 – 1.35, p = 0.2). Conversely, in pT3a and pT3b disease, presence of LVI had 1.2-fold (95%CI: 1.03–1.44, p=0.02) and 1.4-fold (95%CI: 1.22–1.61, p=<0.001) higher overall mortality than their counterparts without LVI. CONCLUSIONS: Our report is the first to demonstrate the detrimental impact of LVI on OS in locally advanced disease (pT3a and higher). This information may prove valuable when risk stratifying based on final pathology and in counseling patients regarding outcomes in addition to determining the necessity of further treatment. Source of Funding: HFHS © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e946-e946 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Marcus Jamil* More articles by this author Jacob Keeley More articles by this author Akshay Sood More articles by this author Deepansh Dalela More articles by this author Sohrab Arora More articles by this author Isaac Palma-Zamora More articles by this author Natalija Kovacevic More articles by this author Chandler Bronkema More articles by this author Nikola Rakic More articles by this author Alyssa Danno More articles by this author James Peabody More articles by this author Mani Menon More articles by this author Craig Rogers More articles by this author Firas Abdollah More articles by this author Expand All Advertisement PDF downloadLoading ...

MP11-17 ORIGIN OF GERM CELL TUMORS: SOMATIC TRANSFORMATION AND PRESENCE OF CANCER STEM-LIKE CELLS IN TERATOMA

You have accessJournal of UrologyPenile & Testicular Cancer: Penile & Testicular Cancer I (MP11)1 Apr 2020MP11-17 ORIGIN OF GERM CELL TUMORS: SOMATIC TRANSFORMATION AND PRESENCE OF CANCER STEM-LIKE CELLS IN TERATOMA Eric Umbreit*, Christopher Wood, Andrew McIntosh, Mary Beth Westerman, Daniel Shapiro, Aron Joon, Miao Zhang, Jose Karam, and Shi-ming Tu Eric Umbreit*Eric Umbreit* More articles by this author , Christopher WoodChristopher Wood More articles by this author , Andrew McIntoshAndrew McIntosh More articles by this author , Mary Beth WestermanMary Beth Westerman More articles by this author , Daniel ShapiroDaniel Shapiro More articles by this author , Aron JoonAron Joon More articles by this author , Miao ZhangMiao Zhang More articles by this author , Jose KaramJose Karam More articles by this author , and Shi-ming TuShi-ming Tu More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000831.017AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Controversy surrounds the genesis of germ cell-associated teratoma and the origin of its ability to transform into malignancy. It is unknown whether a teratoma dedifferentiates from a progeny cell into a progenitor cell or teratoma develops from cancer stem cells, enabling it to differentiate into multiple lineages. We hypothesize that somatic transformation occurs by differentiation of a progenitor stem-like cell embedded in the teratoma. METHODS: Two investigations where explored to further evaluate this hypothesis: (1) develop a post-chemotherapy teratoma primary culture and demonstrate a stem cell-like progenitor cell embedded within teratoma derived from surgically resected specimens, and (2) evaluate the genetic and molecular profiles of metastatic teratoma and corresponding malignant transformation. Flow cytometry was performed on live cells for cell-surface stem-ness markers to identify a potential cancer stem cell within teratoma. Second, archival tumor tissue from 7 patients with teratoma and its associated somatically transformed tumor was used for DNA and RNA sequencing. RESULTS: Teratoma cells were successfully grown in primary culture from two patients. Cells were confirmed as teratoma by final pathology and primary culture analysis for i12p, SALL4, OCT3 and NANOG. By flow cytometry, cell lines were found to have cells positive for the stem-ness markers CD24, CD26, CD34, CD44, CD90, CD117, Cripto-1, SSEA-1, and SSEA-4. In the second investigation arm using the T200 panel for DNA analysis, we identified 58 genes harboring mutations of which 24 genes indicated discordance between teratoma and somatic transformation. None of the 24 genes were consistently altered between patients, thus, teratoma and transformed tissue had similar genetic profiles. RNA analysis revealed 7 significant genes with increased expression in teratoma tissue compared to somatic transformation, suggesting a different epigenetic profile between tissue types. CONCLUSIONS: For the first time ever reported, we successfully created primary culture teratoma cell lines. In addition, we have begun to identify cancer stem-like cells within mature teratoma. By demonstrating that metastatic teratoma and their corresponding somatic transformations had similar if not identical genetic profiles, we hypothesize they have a common clonal origin. We propose an alternative hypothesis in which teratoma contains a stem-cell entity that could both differentiate into a teratoma or any other tumor phenotype. Source of Funding: None. © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e142-e142 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Eric Umbreit* More articles by this author Christopher Wood More articles by this author Andrew McIntosh More articles by this author Mary Beth Westerman More articles by this author Daniel Shapiro More articles by this author Aron Joon More articles by this author Miao Zhang More articles by this author Jose Karam More articles by this author Shi-ming Tu More articles by this author Expand All Advertisement PDF downloadLoading ...

V01-07 A RARE CASE OF PT3A CLEAR CELL RENAL CELL CARCINOMA IN A BIFID KIDNEY TREATED WITH ROBOTIC HEMINEPHRECTOMY

INTRODUCTION AND OBJECTIVE: Bifid, or divided-shaped kidney is relatively rare, with a reported incidence of 4%, of which 42% also demonstrate collecting system duplication. Malignant neoplasm accompanied by ureteral duplication is extremely rare with 24 cases reported in the literature. The majority of these reports were of urothelial carcinoma, and one case reported in the literature of a bifid kidney with papillary carcinoma. Here we present a case of a 42 year-old Hispanic female with the finding of a renal cell carcinoma involving only the upper pole of a bifid kidney with a completely duplicated collecting system. METHODS: The patient underwent a robotic-assisted laparoscopic left hemi-nephrectomy of the upper pole moiety of a bifid left kidney, with pathologic analysis demonstrating a 7.2 x 6.3 x 5.1cm clear cell renal cell carcinoma with invasion into a segmental branch of the renal vein. Intraoperative ultrasound was critical in the identification of the inferior border of the lesion to ensure complete excision along the isthmus dividing the upper and lower pole moieties. Indocyanine green was used to demonstrate re-perfusion and drainage of the remaining lower moiety of the bifid kidney at the completion of the procedure. RESULTS: There were no intraoperative or postoperative complications. Total robotic console time was 162 minutes. The intraoperative estimated blood loss was 400ml. Warm ischemia time was under 30 minutes. The patient was discharged home on postoperative day 2. Pre and post-operative eGFR were identical. Final pathologic analysis demonstrated a pT3a Fuhrman Grade 1 clear cell renal cell carcinoma with negative margins. CONCLUSIONS: Renal cell carcinoma of a bifid kidney with a duplicated collecting system is extremely rare. Here we demonstrate that a minimally invasive nephron sparing approach may be safely utilized in these cases. Pre-operative CT angiogram may be used in these cases delineate aberrant anatomy to minimize ischemia further. Further follow up to ensure oncologic outcome similar to partial nephrectomy in pT3a renal cell tumors will be necessary.Source of Funding: none

Retzius-sparing Robotic Radical Prostatectomy for Surgeons in the Learning Curve: A Propensity Score–matching Analysis

BackgroundSeveral authors claimed that the Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) needs a prolonged learning curve, and outcomes during this phase could be suboptimal. ObjectiveTo verify the safety and outcomes of RS-RARP performed by young surgeons during the learning curve. Design, setting, and participantsWe conducted a retrospective analysis of the pre-, intra-, and postoperative features of all the patients who underwent RS-RARP from 2013 to 2017. We divided our patients into two groups: patients operated by two experienced surgeons (ESs) with >100 procedures and patients operated on by five younger surgeons in the learning curve (LCSs). LCSs had no previous experience in radical prostatectomy, and the very first RS-RARP procedures of each LCS case are included in the analysis. Outcome measurements and statistical analysisPerioperative, oncological, and functional data were analyzed. Short-term oncological results were reported as positive surgical margins (PSMs) and 1-yr disease-free survival. Complications were graded according to the Clavien-Dindo system. Potency was defined as erections sufficient for intercourse; continence was defined as no pad or one safety liner. A propensity score–matching analysis was used to adjust the difference in baseline preoperative parameters between the groups. Results and limitationsWe obtained two homogeneous groups of 256 patients each. After the matching, preoperative variables were similar in the two groups. The mean console time was longer for younger surgeons (98 vs 122 min, p < 0.001). Postoperative course, complications, and functional results were similar in the two groups; the final pathological analysis showed a worse T stage in the ES group (p = 0.017). PSMs and 1-yr disease-free survival did not differ between the groups. ConclusionsRS-RARP can be safely performed by inexperienced surgeons who have received adequate training. Patient summarySurgeons in the learning curve can perform Retzius-sparing robot-assisted radical prostatectomy safely, with similar early oncological results and functional outcomes.

Does pathologic upstaging to PT3A portend a worsened prognosis when compared to non-upstaged PT3A renal cell carcinoma: Analysis of the National Cancer Database.

624 Background: Pathological T3a (pT3a) renal cell carcinoma (RCC) is often diagnosed at the time of final pathological analysis, though impact of lack pre-treatment detection on surgical outcomes is unclear. We sought to compare outcomes of pathologically upstaged pT3a RCC with pT3a RCC recognized clinically. Methods: We queried the National Cancer Database for incident cases of pT3a pN0/x pM0/x renal cell carcinoma (RCC) treated with radical (RN) or partial nephrectomy (PN) between 2009-2015. Tumors were staged using the AJCC staging system, 7th edition. Pathologically upstaged tumors were defined as those that had a clinical stage of T1 or T2. Non-upstaged tumors had a clinical stage of T3a. Multivariable Cox proportional hazards and Kaplan-Meier survival analysis were performed to study the impact of clinical to pathological upstaging in pT3a tumors on overall survival (OS) in patients treated with RN and PN. Results: A total of 19,538 pT3a tumors were identified of which 7,231 (37%) had concordant clinical stage (non-upstaged) and 12,307 (63%) had lower clinical stage (upstaged). Patients with upstaged tumors had longer time from diagnosis to surgery (31.5 vs. 23.8 days; p&lt;0.001), smaller tumor size (6.7 vs. 7.4 cm; p&lt;0.001), higher rates of treatment with partial nephrectomy (18% vs. 11%; p&lt;0.001), and higher rates of negative margins (92% vs. 89%; p&lt;0.001). On multivariate analysis, age (HR 1.06; p&lt;0.001), Charlson Comorbidity Index (HR 1.51; p=0.006) and positive margin status (HR 1.55; p&lt;0.001) were associated with worse OS. Pathological upstaging was an independent predictor of improved OS following both PN (HR 0.74; 95% CI 0.59-0.91; p=0.006) and RN (HR 0.87; 95% CI 0.82-0.93; p&lt;0.001). Kaplan-Meier analysis showed higher OS for tumors that were upstaged following both PN (5-year OS 73 vs. 70%; p=0.0083) and RN (5-year OS 67 vs. 64%; p&lt;0.001). Conclusions: Most pT3a RCC are pathologically upstaged. Pathological pT3a tumors that were correctly detected clinically were associated with worsened outcomes. While our findings require further confirmation, they call for consideration and refinement of risk stratification protocols in pT3a RCC.

Abstract P1-02-03: Our preliminary experience: Ultrasound guided localization of axillary lymph nodes using activated charcoal before neoadjuvant chemotherapy for guidance in axillary surgery in breast cancer patients

Abstract The study objective is to review the rate of identification of the biopsied lymph node during surgery by placing activated charcoal in patients with node-positive breast cancer prior to neoadjuvant chemotherapy (NAC). The secondary objective is to validate the concordance of tattooed lymph node with the sentinel nodes resected during surgery at the final pathological examination. Background: The SENTINA study concluded that for cN1 breast cancer patients that had neoadjuvant chemotherapy and afterwards had two or more sentinel node localization examined, the false negative rate (FNR) was above 10%. The ACOSOG Z1071 study showed that clipping the positive lymph node and its preoperative localization reduces the false negative rate (FNR) significantly. The use of charcoal suspension for tattooing positive nodes during the biopsy is an effective and minimal invasive technique. It avoids placing a clip and posteriorly marking it with wire or radioactive seed previous to surgery, reducing the number of procedures, costs and time. When correctly placed charcoal suspension does not affect the pathological examination. Methods: This is a retrospective pilot study form January 2016 to March 2019 that enrolled 13 cancer patients aged (26 -50 years) with clinical T1-4, N 1-2, M0 in which NAC was performed. Ultrasound axillary lymph node core biopsy and tattooing with 0,3 ml of activated charcoal suspension (Mamograf ™) in positive lymph nodes was performed prior to NAC. Patients after NAC had axillary surgery. The sentinel nodes (SN) were identified as the nodes that contained blue dye and technetium-99m. During surgery both the SN, and also the tattooed lymph nodes were removed. Evaluation of the final pathological analysis concordance between the sentinel nodes and the tattooed lymph node was performed. Results: The analysis showed that surgeons were able to successfully identify the biopsied lymph node marked with activated charcoal in 11 (84,6%) cases. The final pathology results showed concordance between the sentinel nodes and the tattooed lymph in 11 cases. There were no cases in which the tattooed lymph node did not correspond to the sentinel node. In 2 (15,4%) cases charcoal wasn´t identified neither during the surgery nor during the pathological examination. No charcoal migration to other lymph nodes was identified during surgery and in all of the cases pathological examination was not affected when the final pathology was analyzed. The final pathology results in tattooed lymph nodes was of metastases in 4 cases (36,4%), post NAC nodal fibrosis in 2 cases (18,2%) and reactive adenitis in 5 cases (45,4%). Conclusion: When visualized on ultrasound, placing activated charcoal in patients with node-positive breast cancer prior to NAC, had shown to be successful and have a high identification rate during axillary surgery. This subset analysis provides preliminary information that using charcoal suspension for tattooing positive lymph nodes before NAC has a high identification rate during axillary surgery. Larger prospective studies may probe that this new technique may change clinical approach when it comes to identifying positive lymph nodes in breast cancer patients after NAC by successfully targeting and removing them with the need of fewer radiological exams and reducing surgical times as well as overall costs. Citation Format: Africa Pineiro, Maria L Cosaka, Mora Amat, Federico Colo, Maria L Negri, Juliana Marulanda Salinas, Varela Alejandra, Loza Martin, Ponce Carolina, Victoria Constanzo, Adrian Nervo, Daniel C Mysler. Our preliminary experience: Ultrasound guided localization of axillary lymph nodes using activated charcoal before neoadjuvant chemotherapy for guidance in axillary surgery in breast cancer patients [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P1-02-03.

Colo-ovarian Fistula complicating acute diverticulitis: Two cases and literature review

IntroductionColonic diverticulosis is common in western world. Fistula formation occurs in 10–20 % of patients, usually as a consequence of an acute inflammatory process (diverticulitis). Fistulas from diverticulitis occur mainly to bladder, small bowel and uterus. Communication between colon and ovary occurred more frequently in the context of primary neoplasms of ovary, ovarian abscess or Crohn’s disease. However, colo-ovarian fistula after acute colonic diverticulitis is a rare entity with few cases reported in literature. Presentation of casesIn this article, we described two cases. We also performed a literature review. In both cases, an initial conservative management for acute diverticulitis was performed. The maintenance of symptoms dictated further investigation. The presence of left ovarian abscess was presented, suggesting the presence of fistula. DiscussionAlthough the distinct evolution during the initial treatment, which results in different timing for surgery, en bloc resection of colon and adnexa was performed, with favorable outcomes. Final pathological analysis confirmed the diagnosis. ConclusionColo-ovarian fistulas complicating acute diverticulitis are rare entities. In this article, we present our experience in the management of two cases, with different surgical approach but favorable outcomes.

Primary Fallopian Tube Carcinoma (PFTC), A Rare Malignancy of Female Genital Tract

Background: Primary fallopian tube carcinoma (PFTC) is one of the rarest malignancies of female genital tract. It represents &lt;1% of all gynecologic malignancies. Preoperative diagnosis is uncommon due to its rarity and non-specific symptoms. In most cases diagnosis is made during surgery or histological examination. Rarity of this type of carcinoma prompted us to report it as individual case. Case: A 40-yearold parous women presented with bilateral PFTC. The patient gave a history of lower abdominal and pelvic pain for 2 years on several occasions. An abdominal ultrasound finding showed an adnexal mass and her CA125 level was 30IU/ml (normal- &lt;35IU/ml). Clinically she was suspected as a case of pelvic inflammatory disease (PID). She underwent Total Abdominal Hysterectomy with bilateral salpingoophorectomy. Intraoperative findings were consistent with PID. Final pathologic analysis showed bilateral primary fallopian tube carcinoma —well differentiated serous adenocarcinoma. Post operatively she was referred for oncological management.&#x0D; Conclusion: Malignancy should be considered in the differential diagnosis of PID especially in premenopausal age and intraoperative frozen section biopsy is crucial to make correct diagnosis and to allow appropriate surgical staging.&#x0D; J Bangladesh Coll Phys Surg 2020; 38(1): 49-52