Higher Rate Of Positive Margins Research Articles

MP14-07 EFFECT OF HYPOGONADISM ON PROSTATE IMAGING AND CANCER DETECTION

You have accessJournal of UrologyProstate Cancer: Epidemiology & Natural History II1 Apr 2017MP14-07 EFFECT OF HYPOGONADISM ON PROSTATE IMAGING AND CANCER DETECTION Dordaneh Sugano, Abhinav Sidana, Brian Calio, Sonia Gaur, Mahir Maruf, Amit L. Jain, Maria Merino, Peter Choyke, Baris Turkbey, Bradford J. Wood, and Peter A. Pinto Dordaneh SuganoDordaneh Sugano More articles by this author , Abhinav SidanaAbhinav Sidana More articles by this author , Brian CalioBrian Calio More articles by this author , Sonia GaurSonia Gaur More articles by this author , Mahir MarufMahir Maruf More articles by this author , Amit L. JainAmit L. Jain More articles by this author , Maria MerinoMaria Merino More articles by this author , Peter ChoykePeter Choyke More articles by this author , Baris TurkbeyBaris Turkbey More articles by this author , Bradford J. WoodBradford J. Wood More articles by this author , and Peter A. PintoPeter A. Pinto More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.471AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Previous studies have demonstrated hypogonadism to be associated with higher grade prostate cancer (PCa) on prostate biopsy. However, there is a lack of literature on how hypogonadism (HG) affects prostate imaging on multiparametric MRI (mpMRI). Here, we aim to determine the impact of hypogonadism on PCa detection on MRI and subsequent detection on MRI-TRUS fusion biopsy (FBx). METHODS Clinical and pathologic data from a prospectively maintained, single-institution database were analyzed for patients who underwent FBx and standard biopsy (SBx) between 2007 and 2016. Patients with total testosterone (TT) measured within 90 days of mpMRI were included in the study. Patients were excluded if they received prior radiation or androgen deprivation therapy for prostate cancer. HG was determined by a TT level below 180 ng/dL. T2, DWI, and DCE scores were calculated from mpMRI and analyzed as binary variables. RESULTS In our cohort, 522 patients had testosterone measured within 90 days of mpMRI, of which 80 (15.3%) were deemed to be HG. Compared to normogonadal (NG) patients, HG patients had comparable age (62.0 years, IQR 8.8 vs 65.0 years, IQR 10.0; p = 0.519) and PSA (6.66 ng/ml, IQR 6.38 vs 6.86 ng/ml IQR 5.33; p=0.523). Median TT was 171 ng/dL (IQR 46) in the HG cohort, and 311 ng/dL (IQR 131) in the NG cohort (p<0.001). Imaging results were not significantly different between the HG and NG cohorts: prostate volume on MRI was 49.5 cc (IQR 40) vs. 50.0 cc (IQR 33), p=0.621; DWI was 95.0% vs 93.2% positive, p=0.542; DCE was 96.3% vs 91.4% positive, p=0.136. There was a lower detection rate of clinically significant cancer on SBx in the HG group compared to the NG group (28.8% vs 37.2%). However, FBx detection rates were similar between the HG and NG cohorts (40.4% vs 43.6%). In our cohort, 78 patients underwent radical prostatectomy. Of these, HG patients had higher rates of positive margins, lymph node invasion, seminal vesical invasion and Gleason score upgrade on pathology (22.2% vs 14.9%, 11.1% vs 7.5%, 11.1% vs 6.0%, and 22.2% vs 12.5%). CONCLUSIONS While SBx cancer detection rate (CDR) was lower in HG patients, FBx CDR was comparable in HG and NG cohorts, suggesting that FBx may provide an advantage in HG patients. In addition, HG patients seem to have higher adverse pathologic criteria in our MRI-screened cohort. Future larger, multi-institutional studies will be necessary to fully ascertain the impact of HG on PCa detection and staging by mpMRI. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e164 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Dordaneh Sugano More articles by this author Abhinav Sidana More articles by this author Brian Calio More articles by this author Sonia Gaur More articles by this author Mahir Maruf More articles by this author Amit L. Jain More articles by this author Maria Merino More articles by this author Peter Choyke More articles by this author Baris Turkbey More articles by this author Bradford J. Wood More articles by this author Peter A. Pinto More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Predictors of Positive Margins After Definitive Resection for Gastric Adenocarcinoma and Impact of Adjuvant Therapies

Positivemargins after definitive resection in gastric adenocarcinoma are associated with inferior outcomes. There are few randomized data to guide optimal adjuvant therapy after positive margins. Using the National Cancer Database, we identified 24,619 nonmetastatic gastric adenocarcinoma patients who received diagnoses from 2004 to 2013 and underwent definitive resection to analyze for predictors of positive surgical margins. Of these patients, 2754 had positive margins (11.2%). Multivariate prevalence ratios were used to determine predictors. Survival analyses were performed with a Cox proportional hazards model by use of several methods of propensity score analysis. Increasing T and/or N category, high grade, and lymphovascular invasion predicted higher rates of positive margins. Asian race, treatment at an academic center, and robotic surgery predicted lower rates of positive margins. Among positive-margin patients with adjuvant treatment (n=1021), with a median follow-up period of 55months, age, comorbidity score, nodal disease, and T4 disease predicted for worse overall survival (OS). Treatment at an academic center was associated with improved OS. Use of adjuvant concurrent chemoradiation therapy (CCRT) was associated with higher OS compared with chemotherapy alone after positive margins (hazard ratio, 0.72; 95% confidence interval, 0.58-0.91; P=.005) after propensity matching adjusting for predictors of OS. The 2-year and 3-year OS for positive-margin patients with chemotherapy alone was 43% and 29%, respectively, compared with 53% and 38%, respectively, with adjuvant CCRT. The log-rank P value for survival was .0015. Stage, race, treatment center, and surgery approach predict for margin status after resection. Adjuvant CCRT after positive margins is associated with improved OS after accounting for available clinical variables.

Abstract P1-11-08: Tumor and procedural factors associated with positive margins at lumpectomy in women undergoing breast conservation surgery

Abstract Background: Negative margins are important in decreasing risk of local recurrence after breast conservation surgery. Further, positive margins on final pathology require a second operation, burdening patients and increasing costs. We identified factors predicting positive margins at lumpectomy prompting intraoperative re-excision in a large referral center. Methods With IRB approval we reviewed all breast cancer lumpectomy cases from January 2012 to December 2013. Associations between rates of positive margin (defined as tumor at ink) and patient and tumor factors were assessed using chi square tests and univariate and adjusted multivariable logistic regression, overall and stratified by DCIS or invasive cancer. Results 385 patients (105 DCIS and 280 invasive disease) were identified. Overall positive margin rate at lumpectomy requiring intraoperative re-excision was 62.3% and was higher in DCIS than in invasive disease (78.1% vs 56.4%, OR=2.78, p=0.001). Positive margin rates did not vary by surgeon, patient age, ER, PR or HER2 status of the tumor. On univariate analysis higher tumor grade was associated with a higher margin positive rate (grade 3 vs grade 1, OR=1.71, p=0.049). Within the 105 DCIS cases, no factors had statistically significantly different odds of positive margins on univariate or multivariable analysis. Within the 280 cases of invasive breast cancer, factors independently associated with lower odds of margin positivity were neoadjuvant chemotherapy (OR 0.30, p=0.037, relative to no neoadjuvant therapy) and seed localized excision (OR 0.24, p=0.03, relative to no localization). Multivariable Logistic Regression* Modeling DCISInvasive DiseaseVariableOdds RatioP-valueOdds RatioP-valueAge 50+ vs Age &amp;lt;502.860.111.590.23Grade 2 vs Grade 10.940.921.500.21Grade 3 vs Grade 13.250.121.580.37Estrogen Receptor Positive vs Negative3.950.221.640.42Progesterone Receptor Positive vs Negative0.840.871.110.84Her2 Positive vs Negative 1.270.68Stage T2 vs T1 2.540.45Stage T3 vs T1 2.180.69Ki67 &amp;lt;15% vs 15%+ 0.570.09Neoadjuvant Chemotherapy vs None 0.300.04Seed Localization vs No Localization 0.240.03Wire Localization vs No Localization 0.330.13Intraoperative Ultrasound vs No Localization 0.670.53*adjusted for individual surgeons (all p &amp;gt;0.05) Conclusion DCIS was associated with higher rate of positive margins at lumpectomy than invasive breast cancer. Within invasive disease, neoadjuvant chemotherapy and seed localization were associated with lower rates of margin positivity. Strategies to decrease positive margins would be best employed in cases of lumpectomy for DCIS and for invasive disease treated without neoadjuvant chemotherapy. Seed localization may be one strategy to lower positive margin rates. Citation Format: Boughey JC, Keeney MG, Glasgow AE, Keeney GL, Habermann EB. Tumor and procedural factors associated with positive margins at lumpectomy in women undergoing breast conservation surgery [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-11-08.

Adenocarcinoma in situ of the Cervix – is Loop Electrosurgical Excision Procedure an Acceptable Alternative to Cold Knife Cone Biopsy?

Objective: To compare cone specimen size between loop electrosurgical excision procedure (LEEP) and cold knife cone (CKC), and evaluate the association between specimen size and margin status. Methods/materials: A retrospective review was performed of women with adenocarcinoma in situ (AIS) who underwent CKC or LEEP between 1998 and 2013. Specimen size, including length (distance from the external cervical os to the endocervical margin) and volume were compared between LEEP and CKC, and correlated with margin status. Results: Eighty-five patients underwent a total of 136 procedures, including 91 CKCs (67%) and 45 LEEPs (33%), with 27 removed as a single specimen (one-piece LEEP) and 18 as two specimens with an ectocervical specimen and a deeper endocervical top-hat specimen (two-piece LEEP). The two-piece LEEP specimen median length was significantly longer (2.1 cm) versus CKC (1.4 cm, p&lt;0.01) and one-piece LEEP (0.6 cm, p&lt;0.01). Median specimen volume was greater for two-piece LEEP (7.4 cm3) versus CKC (3.4 cm3, p&lt;0.01) and one-piece LEEP (1.6 cm3, p&lt;0.01). A higher rate of positive margins was noted when comparing all LEEP (67.6%) with CKC specimens (34.2%), p&lt;0.01. However, when the LEEP specimens were analysed separately, one-piece LEEPs had a higher rate of positive margins (81.0%) versus CKC (34.2%) (p&lt;0.01), but there were no significant differences between two-piece LEEP (50.0%) and CKC (34.2%), p=0.26. Conclusion: Our results suggest that a two-piece LEEP produces a larger specimen size with similar rates of positive margins compared with CKC. Given the decreased cost and morbidity compared with CKC, a two-piece LEEP should be considered in the management of women with AIS.

Myxofibrosarcoma of the extremity and trunk: a multidisciplinary approach leads to good local rates of LOCAL control.

Myxofibrosarcomas (MFSs) are malignant soft-tissue sarcomas characteristically presenting as painless slowly growing masses in the extremities. Locally infiltrative growth means that the risk of local recurrence is high. We reviewed our experience to make recommendations about resection strategies and the role of the multidisciplinary team in the management of these tumours. Patients with a primary or recurrent MFS who were treated surgically in our unit between 1997 and 2012 were included in the study. Clinical records and imaging were reviewed. A total of 50 patients with a median age of 68.4 years (interquartile range 61.6 to 81.8) were included. There were 35 men; 49 underwent surgery in our unit. The lower limb was the most common site (32/50, 64%). The mean size of the tumours was 8.95 cm (1.5 to 27.0); 26 (52%) were French Fédération Nationale des Centres de Lutte Contre le Cancer grade III. A total of 21 (43%) had positive margins after the initial excision; 11 underwent further excision. Histology showed microscopic spread of up to 29 mm beyond macroscopic tumour. Local recurrence occurred in seven patients (14%) at a mean of 21 months (3 to 33) and 15 (30%) developed metastases at a mean of 17 months (3 to 30) post-operatively. High rates of positive margins and the need for further excision makes this tumour particularly suited to management by multidisciplinary surgical teams. Microscopic tumour can be present up to 29 mm from the macroscopic tumour in fascially-based tumours. Cite this article: Bone Joint J 2016;98-B:1682-8.

Role of Radical Antegrade Modular Pancreatosplenectomy (RAMPS) and Pancreatic Cancer.

Conventional retrograde distal pancreatectomy and splenectomy for pancreatic adenocarcinoma of the body and tail have been associated with high rates of positive margins, low lymph node retrieval, and poor overall survival. Radical antegrade modular pancreatosplenectomy (RAMPS) was introduced in 2003 to overcome these limitations. A systematic literature search was performed and articles reviewed to determine if RAMPS or standard distal pancreatectomy and splenectomy offer better survival. The level of evidence was assessed using the Grades of Recommendation, Assessment, Development, and Evaluation system. Retrospective, single-institution series on RAMPS report mean lymph node counts as high as 24, and negative margin rates between 81 and 100%. Tangential margins are reportedly negative in 94% of patients undergoing RAMPS. Studies comparing RAMPS with standard distal pancreatectomy and splenectomy demonstrate significantly higher lymph node counts, but no improvement in overall survival with RAMPS. Despite the theoretic advantages of RAMPS over standard resection, high-level evidence that demonstrates a survival benefit with RAMPS does not currently exist.

A Phase 1 Study of Stereotactic Body Radiation Therapy Dose Escalation for Borderline Resectable Pancreatic Cancer After Modified FOLFIRINOX (NCT01446458)

A challenge in borderline resectable pancreatic cancer (BRPC) management is the high rate of positive posterior margins (PM). Stereotactic body radiation therapy (SBRT) allows for higher radiation delivery dose with conformity. This study evaluated the maximal tolerated dose with a dose escalation plan level up to 45Gy using SBRT in BRPC. A single-institution, 3+3 phase 1 clinical trial design was used to evaluate 4 dose levels of SBRT delivered in 3 fractions to the planning target volume (PTV) with a simultaneous in-field boost (SIB) to the PM. Dose level (DL) 1 was 30Gy to the PTV, and for dose levels 2 through 4 (DL2-DL4) the dose was 36Gy. The SIB dose to the PM was 6, 6, 7.5, and 9Gy for DL-1, DL-2, DL-3, and DL-4, respectively. All patients received 4 treatments of modified FOLFIRINOX (fluorouracil, leucovorin, irinotecan, oxaliplatin) before SBRT. Thirteen patients with a median age of 64years were enrolled. The median follow-up time was 18months. The locations of the cancer were head (n=12) and uncinate/neck (n=1). One patient did not undergo SBRT. There were no grade 3 or 4 toxicities. Five patients did not undergo resection because of disease progression (1 local, 4 distant); 8 had R0 resection in the PM, and 5 of 8 had vessel reconstruction. Two patients had disease downstaged to T1 and T2 from T3 disease. Four patients are still alive, and 3 are disease free. The median overall survival for resected patients was not reached (9.3: not reached). The SBRT dose of 36Gy with a 9-Gy SIB to the PM (total 45Gy) delivered in 3 fractions is safe and well tolerated. The dose-limiting toxicity for a 45-Gy dose was not reached, and further dose escalations are needed in future trials.

Radioactive Seed Localization for Nonpalpable Breast Lesions in a Community Hospital Setting

Purpose: To compare the positive margin rates for women with nonpalpable breast tumors whom had wire localization compared to radioactive seed localization in a small community hospital.Introduction: Wire localized (WL) breast biopsies have been performed on patients with nonpalpable breast lesions for many years. Radioactive seed localization (RSL) offers advantages of patient comfort and scheduling convenience.There is an extensive literature from large centers regarding the RSL technique. Little is known whether physicians performing these procedures in smaller community hospitals can achieve comparable negative margin rates as those performed with wire localization.Methods: The thirty-six patients who underwent wire localized breast conserving surgery between September 18, 2013 and December 10, 2014, were compared to the 48 radioactive seed localization patients resected between February 12, 2014 and December 18, 2014. The primary objective was to determine if the introduction of the radioactive seed localization technique significantly changed the positive margin rate.Results: Two of 36 wire localized breast biopsied patients had positive margins, compared to 5 of 48 radioactive seed localization patients, a difference which is not statistically different. The specimen weight was larger for the patients treated with the RSL technique. There was a trend toward a higher positive margin rate with older patients.Conclusion: The positive margin rate was similar between the wire localized and radioactive seed localized patients, and comparable to those in the published literature.

High Rate of Positive Circumferential Resection Margins Following Rectal Cancer Surgery: A Call to Action.

To identify predictors of positive circumferential resection margin following rectal cancer resection in the United States. Positive circumferential resection margin is associated with a high rate of local recurrence and poor morbidity and mortality for rectal cancer patients. Prior study has shown poor compliance with national rectal cancer guidelines, but whether this finding is reflected in patient outcomes has yet to be shown. Patients who underwent resection for stage I-III rectal cancer were identified from the 2010-2011 National Cancer Database. The primary outcome was a positive circumferential resection margin. The relationship between patient, hospital, tumor, and treatment-related characteristics was analyzed using bivariate and multivariate analysis. A positive circumferential resection margin was noted in 2859 (17.2%) of the 16,619 patients included. Facility location, clinical T and N stage, histologic type, tumor size, tumor grade, lymphovascular invasion, perineural invasion, type of operation, and operative approach were significant predictors of positive circumferential resection margin on multivariable analysis. Total proctectomy had nearly a 30% increased risk of positive margin compared with partial proctectomy (OR 1.293, 95%CI 1.185-1.411) and a laparoscopic approach had nearly 22% less risk of a positive circumferential resection margin compared with an open approach (OR 0.882, 95%CI 0.790-0.985). Despite advances in surgical technique and multimodality therapy, rates of positive circumferential resection margin remain high in the United States. Several tumor and treatment characteristics were identified as independent risk factors, and advances in rectal cancer care are necessary to approach the outcomes seen in other countries.

Abstract P2-13-16: Intraoperative ultrasound guided wire bracketing of nonpalpable breast lesions for excision

Abstract Background. Mammographic wire localization is the primary means of localizing nonpalpable breast lesions for excision. Unfortunately, that procedure is associated with patient discomfort and vasovagal responses, scheduling difficulties, and problems with inaccurate wire placement or wire displacement. In addition, the wires often enter far from the target and take an indirect course resulting in high positive margin rates. We reviewed our experience with intraoperative ultrasound guided bracketing of nonpalpable lesions to determine if the accuracy of the excision and patient factors could be improved. Methods. Patients that underwent intraoperative ultrasound guided wire bracketing were identified by electronic chart review. After the patient was anesthetized, high frequency linear array ultrasound was used to identify the target lesion. Under direct ultrasound visualization, the lesions were bracketed with 4 hook-wires placed perpendicular to the chest wall at the radial and antiradial margins of the lesion. Excision of the lesion was then performed with circumferential dissection around all 4 localization wires. Results. Intraoperative localization was planned on 80 patients. The lesion was identified by preoperative ultrasound in 76 of those patients (95%). The remaining patients required mammographic localization. In 67 patients (88%) the lesion was identified for bracketing, in the remaining 11 patients the biopsy clip was seen by ultrasound and bracketed. Only 2 patients had positive margins (no tumor touching ink) requiring re-excision (2.6%). Conclusions. The results of our experience show that intraoperative ultrasound guided wire bracketing is a reliable alternative to mammographic localization and is associated with a lower positive margin rate than reported for mammographic wire localization with a single wire. In addition, patient comfort is improved, cost is reduced, and there are no scheduling issues. The technique is especially useful for oncoplastic excisions where the incision is remote from the target lesion. Citation Format: David T Rock, Aimee L Stewart, Samith Sandadi. Intraoperative ultrasound guided wire bracketing of nonpalpable breast lesions for excision [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-13-16.

Surgical Options and Locoregional Recurrence in Patients Diagnosed with Invasive Lobular Carcinoma of the Breast.

Recent consensus guidelines on margins for breast-conserving surgery (BCS) recommend the use of "no ink on tumor" as the standard for an adequate margin. The recommendations extend to invasive lobular carcinoma (ILC), but the data on this subset are limited. We reviewed our modern dataset on margin status with outcomes of ILC. We performed a retrospective cohort study on 736 patients with a diagnosis of stage I-III ILC treated at our cancer center between May 1997 and December 2007. Clinicopathologic data were extracted from the Clinical Research Information Systems Database. Margin status was defined using the latest ASCO/ASTRO/SSO consensus guideline criteria. The initial surgery performed was mastectomy in 352 patients (48 %) and BCS in 384 patients (52 %). In multivariate analysis, tumor size and multifocality were significantly associated with high rates of mastectomy and positive surgical margins at initial BCS. After initial BCS, additional surgery was performed in 92 patients (24 %). During a 72-month median follow-up period, 12 (3.1 %) ipsilateral breast tumor recurrences (IBTR) and 5 (1.3 %) other locoregional recurrences (LRR) were observed. Patients with margins with ink on tumor who did not receive further surgery were found to have significantly increased LRR [odds ratio (OR) 5.5; p = 0.02] and IBTR (OR 8.5; p = 0.006), whereas patients with close margins (1-3 mm) and margins within 1 mm were not. Our study supports the validity of using "no ink on tumor" as the standard for a negative margin for pure and mixed ILC treated with multimodality therapy.

Pleomorphic Lobular Carcinoma In Situ: Radiologic-Pathologic Features and Clinical Management.

Pleomorphic lobular carcinoma in situ (PLCIS) is an unusual variant of LCIS for which optimal management remains unclear. We conducted a 15-year (2000-2014) retrospective chart review of the radiologic, pathologic, clinical management, and recurrence rates of patients with PLCIS on diagnostic biopsy. Fifty-one patients were found to have PLCIS either alone or with concomitant breast cancer. Of these, 23 were found to have pure PLCIS on diagnostic biopsy. Rates of upstaging after local excision, positive or close margins, mastectomy, and recurrence associated with pure pleomorphic lobular carcinoma in situ were examined. Of the 21 patients who underwent surgical excision following diagnostic biopsy, 33.3 % (7/21) were found to have invasive carcinoma, and 19 % (4/23) were found to have ductal carcinoma in situ. Extensive or multifocal PLCIS was present in 47.6 % (10/21) of patients, corresponding to at least one PLCIS-positive or close margin in 71.4 % (15/21). In total, there were 11 local re-excisions in nine patients, and 12 mastectomies. No ipsilateral breast cancer events have occurred, including in those with positive or close surgical margins (mean follow-up 4.1 years). Patients with isolated PLCIS on diagnostic biopsy are at high risk of upgrading to invasive cancer or ductal carcinoma in situ at diagnostic excision. PLCIS often is extensive, with high rates of positive or close surgical resection margins. If negative PLCIS margins are pursued, rates of successful breast conservation are low. In light of this and low recurrence rates, caution should be exercised in aggressively treating PLCIS with excision to clear margins.

MP6-05 THE ASSOCIATION OF PREOPERATIVE NEUTROPHIL TO LYMPHOCYTE RATIO WITH ONCOLOGIC OUTCOMES FOLLOWING RADICAL PROSTATECTOMY FOR PROSTATE CANCER

You have accessJournal of UrologyProstate Cancer: Markers II1 Apr 2015MP6-05 THE ASSOCIATION OF PREOPERATIVE NEUTROPHIL TO LYMPHOCYTE RATIO WITH ONCOLOGIC OUTCOMES FOLLOWING RADICAL PROSTATECTOMY FOR PROSTATE CANCER Vidit Sharma, Patrick A. Cockerill, Boyd R. Viers, Laureano J. Rangel, Rachel E. Carlson, R. Jeffrey Karnes, and Matthew K. Tollefson Vidit SharmaVidit Sharma More articles by this author , Patrick A. CockerillPatrick A. Cockerill More articles by this author , Boyd R. ViersBoyd R. Viers More articles by this author , Laureano J. RangelLaureano J. Rangel More articles by this author , Rachel E. CarlsonRachel E. Carlson More articles by this author , R. Jeffrey KarnesR. Jeffrey Karnes More articles by this author , and Matthew K. TollefsonMatthew K. Tollefson More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.252AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Elevated neutrophil-lymphocyte ratio (NLR) is a marker of systemic inflammation associated with adverse outcomes in multiple malignancies. Although NLR has prognostic value in the metastatic prostate cancer (PCa) setting, its prognostic role in localized PCa remains unclear. Here we evaluate the association of pre-operative NLR with long-term oncologic outcomes after radical prostatectomy (RP). METHODS A prospectively maintained institutional registry was queried for all men undergoing RP for PCa between 1990–2007. Men without an NLR within 90 days prior to RP and those receiving neoadjuvant therapy were excluded. Ten-year oncologic outcomes were compared between patients with an NLR > 5 and those with an NLR < 5 using univariate and multivariate models. RESULTS We identified 8350 patients with a median follow up of 9.7 years (IQR 6.7-14.1). Overall, 18.7% (1568/8350) of patients had a pre-RP NLR > 5. These patients were more likely to have: pT3/4 disease at RP (22% vs 17.1%, p<0.001), positive margins (33.2% vs 25.8%, p<0.001), adjuvant hormonal (13.8% vs 8.2%, p<0.001) and radiation therapy (4.7% vs 3.2%, p=0.006). Patients with NLR > 5 were also more likely to receive salvage hormonal therapy during follow up (14.0% 11.4%, p=0.004). Table 1 provides the univariate and multivariate hazard ratios comparing 10-year oncologic outcomes between the two NLR cohorts. After controlling for age, preoperative PSA, Gleason score, pathologic stage, and adjuvant hormonal or radiation therapy, NLR > 5 remained a significant predictor of biochemical recurrence (Hazard Ratio 1.13, p=0.02) and demonstrated a trend towards increased overall mortality (Hazard Ratio 1.12, p=0.06). CONCLUSIONS An elevated pre-operative NLR is significantly associated with locally advanced prostate cancer and is thereby associated with higher rates of positive margins and adjuvant therapy. NLR is also independently associated with an increased risk of biochemical recurrence. Further study is warranted to explore the implications of NLR on long term outcomes following radical prostatectomy for localized prostate cancer. Comparing 10 year Oncologic Outcomes between NLR > 5 and NLR < 5 10 year Outcome Univariate Hazard Ratio (95% CI) Univariate P-value Multivariate Hazard Ratio (95% CI) Multivariate P-value Biochemical recurrence 1.10 (0.99-1.22) P=0.07 1.13 (1.02-1.25) P=0.02 Systemic progression 0.92 (0.73-1.15) P=0.45 0.94 (0.74-1.18) P=0.59 Prostate cancer death 0.99 (0.71-1.37) P=0.93 0.98 (0.70-1.36) P=0.88 Death for any reason 1.13 (1.01-1.28) P=0.03 1.12 (1.00-1.26) P=0.06 Multivariate models accounted for age, preoperative PSA, Gleason score, pathologic stage, and adjuvant hormonal or radiation therapy © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e55-e56 Peer Review Report Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Vidit Sharma More articles by this author Patrick A. Cockerill More articles by this author Boyd R. Viers More articles by this author Laureano J. Rangel More articles by this author Rachel E. Carlson More articles by this author R. Jeffrey Karnes More articles by this author Matthew K. Tollefson More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP6-06 PROSTATE HEALTH INDEX PREDICTS UPGRADING OF MEN ON 5-ALPHA REDUCTASE INHIBITORS

RESULTS: We identified 8350 patients with a median follow up of 9.7 years (IQR 6.7-14.1). Overall, 18.7% (1568/8350) of patients had a pre-RP NLR > 5. These patients were more likely to have: pT3/ 4 disease at RP (22% vs 17.1%, p 5 were also more likely to receive salvage hormonal therapy during follow up (14.0% 11.4%, p1⁄40.004). Table 1 provides the univariate and multivariate hazard ratios comparing 10-year oncologic outcomes between the two NLR cohorts. After controlling for age, preoperative PSA, Gleason score, pathologic stage, and adjuvant hormonal or radiation therapy, NLR > 5 remained a significant predictor of biochemical recurrence (Hazard Ratio 1.13, p1⁄40.02) and demonstrated a trend towards increased overall mortality (Hazard Ratio 1.12, p1⁄40.06). CONCLUSIONS: An elevated pre-operative NLR is significantly associated with locally advanced prostate cancer and is thereby associated with higher rates of positive margins and adjuvant therapy. NLR is also independently associated with an increased risk of biochemical recurrence. Further study is warranted to explore the implications of NLR on long term outcomes following radical prostatectomy for localized prostate cancer.

A Multidisciplinary Approach for Abdominal Venous Involvement in Oncologic Resections

An aggressive surgical approach to locally advanced malignancy is being increasingly used in the absence of distant metastatic disease. This includes resection and reconstruction of major venous structures. We investigated the results of using a multidisciplinary surgical approach in these instances. The study data were obtained from a university-affiliated hospital from January 1, 2006, to December 31, 2012. All patients who underwent an oncologic resection using a multidisciplinary approach with vascular surgery consultation were included in the analysis. Primary outcomes analyzed included rate of margin positivity, postoperative venous patency, and survival. Secondary outcome measures included operative time, estimated blood loss, and length of hospital stay. A total of 23 patients met criteria for study. Venous involvement included the portal and/or superior mesenteric vein and inferior vena cava in 14 and 9 patients, respectively. Nine patients had clear vascular involvement before surgery and received preoperative consultation. Overall margins were positive in 56.5%, whereas the rate of vascular margin positivity was 30.4%. The postoperative venous patency rate was 65.0%. There were no perioperative mortalities, and median survival was 10 months (range, 4-80). Major venous resections and reconstructions in oncologic surgery are safe but associated with a high rate of positive margins. Future efforts should focus on identifying patients in the preoperative phase to provide opportunity for optimal multidisciplinary planning.

What is the appropriate role of minimally invasive vs. open surgery for small adrenocortical cancers?

The role of endoscopic adrenalectomy for adrenocortical carcinoma is the most controversial and debated points in adrenal surgery. We reviewed the most recent literature on this topic. From the amount of available data (even if not conclusive), the following could be extrapolated: first, for patients with apparently localized disease the adrenal gland should be removed en bloc with the entire retroperitoneal fat pad, which also includes some periadrenal lymph nodes, but no extended resection is necessary in absence of involvement of adjacent structures; second, in experienced centers, oncologic outcome for endoscopic adrenalectomy is not inferior to open adrenalectomy when strict selection criteria and the principles of oncologic surgery are respected. When performed by nonexperienced surgeons, endoscopic adrenalectomy may be associated with a higher rate of positive margin and local recurrence; third, patients observed at specialized referral centers receive a more accurate preoperative workup that allows a better operative planning and a more comprehensive postoperative treatment. Although waiting for further more exhaustive studies, we think that for suspected adrenocortical carcinoma, smaller than 8-10 cm and without pre or intraoperative evidence of local invasion, endoscopic adrenalectomy in a referral center seems to be an acceptable option.

A Strategy for the Successful Management of Dermatofibrosarcoma Protuberans

Dermatofibrosarcoma protuberans (DFSP) is a rare, locally invasive soft tissue sarcoma with extensive subclinical involvement. The National Comprehensive Cancer Network guidelines recommend immediate reconstruction in most cases. Our study reviewed the methods of treatment of DFSP at our institution, examined the types of closure used after surgical excision, and analyzed the prevalence of positive margins on permanent pathology after immediate closure after conventional non-Mohs excision of DFSP. The charts of 25 patients treated with surgical excision and 16 with Mohs surgery from 1990 to 2009 for lesions consistent with DFSP were reviewed for clinical variables including disease state, tumor site, closure type, permanent pathology margin status, disease recurrence/persistence, and excisional margin size. The trunk, followed by the head and neck, were the most common sites for DFSP. No patients had distant metastasis at diagnosis or experienced recurrence in either the surgical excision or the Mohs surgery group. Twelve (48%) patients were found to have positive margins after initial surgical resection. All lesions treated with Mohs surgery had clear histological margins at completion. Average margin size for surgical excision patients was 2.33 cm (range, 0.75-4.5 cm), and 1.36 cm (range, 0.74-2.55 cm) for Mohs excision. The average duration of follow-up was 107.9 months. The extent of DFSP is difficult to determine intraoperatively with traditional surgical excision, which leads to a higher rate of positive margins. Considering this difficulty and the complications of reconstruction with positive margins, we believe that reconstruction after tumor resection should be dependent on definitive pathologic clearance of the tumor.

Intraoperative narrow band imaging better delineates superficial resection margins during transoral laser microsurgery for early glottic cancer.

The high rate of positive margins after transoral laser microsurgery (TLM) remains a matter of debate. This study investigates the effect of intraoperative narrow band imaging (NBI) examination on the incidence of positive superficial surgical margins in early glottic cancer treated by TLM. Between January 2012 and October 2013, 82 patients affected by Tis-T1a glottic cancer were treated with TLM by type I or II cordectomies. Intraoperative NBI evaluation was performed using 0-degree and 70-degree rigid telescopes. Surgical specimens were oriented by marking the superior edge with black ink and sent to a dedicated pathologist. Comparison between the rate of positive superficial margins in the present cohort and in a matched historical control group treated in the same way without intraoperative NBI was calculated by chi-square test. At histopathological examination, all surgical margins were negative in 70 patients, whereas 7 had positive deep margins, 2 close, and 3 positive superficial margins. The rate of positive superficial margins was thus 3.6% in the present group and 23.7% in the control cohort (P<.001). Routine use of intraoperative NBI increases the accuracy of neoplastic superficial spreading evaluation during TLM for early glottic cancer.

Résultats carcinologiques et fonctionnels de l’abord interfascial de la prostatectomie robotique comparé avec l’abord intrafascial

Due to its technical ease and greater precision Robotic Assisted Laparoscopic radical Prostatectomy (RALP) allows a better preservation of the neurovascular bundles, thereby improving functional outcomes. The intrafascial dissection has been proposed to allow a more complete preservation of these bundles. However, this technique harbors a high rate of positive surgical margins, justifying another trend: the interfascial approach. To date, there are still few publications directly comparing these 2 techniques and our study is the first to offer a 2-year follow-up. Our study focused on a two-hundred patients population divided into two consecutive groups. All the patients were continent preoperatively and had a satisfactory IIEF5 score: (1) Group 1 consisted of 100 patients who underwent RALP with the intrafascial approach. They had a mean age of 60.3 years (45-70). The majority of cancers were of the low or moderate risk group of d'Amico. The mean PSA was 7.43ng/ml. Seventy-five patients had a pT2, 24 a pT3 and one patient had a pT4. (2) Group 2 included 100 patients who underwent RALP with the interfascial technique. Patients had a mean age of 61.6±5.96 years (45-72), and their cancers were mostly of the low or moderate risk groups of d'Amico. The mean PSA was 6.3ng/ml. Seventy-four patients had a pT2, 22 a pT3a, and 4 had a pT3b. All patients were evaluated after one and two years of follow-up. Rates of positive surgical margins were 45% and 19% respectively for groups 1 and 2 (P<0.0001). The rates of biochemical failure (PSA>0.2ng/ml) at 2 years were 10% and 3%, respectively for groups 1 and 2 (P=0.0447). At 2 years, 2 patients in group 1 and one patient in group 2 were using 2 or more urinary pads. Erection with or without oral medication was maintained in 65 (65%) and 31 (31%) patients respectively for groups 1 and 2 at one year. At 2 years 86 and 65 patients were having spontaneous erection, respectively in groups 1 and 2 (P=0.0006). In addition, 65 and 55 patients were also capable of sexual penetration, respectively in groups 1 and 2 (P=0.0045). The intrafascial approach exposed to a very high rate of positive surgical margins while offering only a little benefit in the erectile function preservation at 2 years compared to the interfascial variant. In our series, we did not notice any significant difference between the two techniques concerning the urinary continence. 5.

Squamous Neoplasia of the Scrotum

The current epidemiology and clinicopathologic features of squamous cell carcinoma (SCC) of the scrotum are largely unknown because of its low incidence. We describe the histopathologic features, immunohistochemistry, and human papillomavirus (HPV) status of 29 patients with scrotal SCC. The mean age at presentation was 55 years (range, 30 to 74 y). White to black ratio was 1.9:1. There was no predominant occupation, with the majority being white-collar professionals. Clinical history of condylomas was present in 5 patients, and 7 patients had a history of multiple skin cancers including melanoma, basal cell carcinoma, and other SCCs. Other comorbidities included human immunodeficiency virus infection (n=2), kidney transplant (n=1), leukemia/lymphoma (n=2), hidradenitis suppurativa (n=1), chronic scrotal infections with abscess (n=1), inflamed epidermal inclusion cyst (n=1), and lichen planus (n=1). One patient had a history of regular tanning bed use. Morphologically, the majority was usual type (n=17), followed by basaloid (n=7) and warty (n=5). Nineteen cases were in situ, and 10 were invasive. Three patients had inguinal lymphadenopathy; in 1, metastasis was confirmed. Suprabasal nuclear staining for Ki67 was considered positive. For p16, a continuous band of nuclear and cytoplasmic staining was considered positive, and a noncontinuous or absence of staining was considered negative. p16 was positive in 10 cases; high-risk HPV was confirmed in 7 cases. Ki67 was positive in 8/17 (47%) usual, 6/7 (85.7%) basaloid, and 3/5 (60%) warty type. p53 was positive in 5/17 (29.4%) usual, 2/7 (28.6%) basaloid, and 1/5 (20%) warty type. All patients were treated with local excision only; 13 had positive margins. Three patients were treated with imiquimod after local excision. The median follow-up was 30 months. Three patients recurred and were treated with re-excision; 1 patient received radiotherapy. Overall, the morphologic, immunohistochemical, and HPV studies show that, similar to SCC of the vulva or penis, the SCC of the scrotum can be divided into 2 major groups. Group 1 (38.5%): positive for p16 and elevated Ki67. This group is associated with HPV infection and displays predominantly a basaloid or warty morphology, although a number of them are of usual type. Group 2 (61.5%): negative for p16. This group has variable Ki67 expression, is consistently negative for HPV, and displays predominantly usual-type morphology. SCC of the scrotum in the United States currently affects primarily white-collar professionals. The majority present with in situ lesions, and the high rate of positive margins at first excision suggests that they are clinically ill-defined lesions. No longer are occupational exposures to carcinogens the major etiology of scrotal SCC. Rather in contemporary times, common risk factors include HPV infection, immunocompromised states, and chronic scrotal inflammatory conditions.