Multivariable Competing Risks Regression Research Articles

Retrospective Evaluation and Significance of Neutrophil-to-Lymphocyte Ratio Prior to and 1 month Following Microwave Ablation of Hepatocellular Carcinoma.

Neutrophil-to-lymphocyte ratio (NLR) recently demonstrated predictive value for hepatocellular carcinoma (HCC) recurrence after thermal ablation. Microwave ablation (MWA) has been shown to induce changes in the immune landscape after HCC treatment. This study aims at identifying predictors of local tumor progression (LTP) and post-treatment NLR kinetics after MWA. Data from 108 consecutive patients who underwent percutaneous MWA of 119 HCCs with a 2450Hz/100W generator in two institutions from October 2014 to September 2021 were retrospectively reviewed. Forty-five HCCs (42 patients) met inclusion criteria for analysis (technique efficacy, pre- and post-treatment NLR availability, follow-up > 6months, absence of complications). NLR was analyzed prior to therapy and at 1-month follow-up; difference between the two time points was defined as ΔNLR1stFU. After a median follow-up of 25months, LTP occurred in 18 HCCs (40%) and 18 patients (42.9%). Multivariate competing risk regression comprising ΔNLR1stFU > 0, cirrhosis etiology and subcapsular location showed that the only independent predictor of LTP was ΔNLR1stFU > 0, on both a per-patient (HR = 2.7, p = 0.049) and per-tumor (HR = 2.8, p = 0.047) analysis. ΔNLR1stFU > 0 occurred in 24/42 patients (57.1%). In this subgroup, higher rates of female patients (p = 0.026), higher mean baseline NLR (p < 0.0001) and lower mean energy/size (p = 0.006) were observed. Upon ROC curve analysis, energy/size < 1414J/mm predicted ΔNLR1stFU > 0 with 76% sensitivity and 70% specificity (AUC = 0.74). NLR increase after ablation was the only independent predictor of LTP, supporting the role of balance between systemic inflammation and immunity in recurrence after MWA. Ablation energy/tumor size predicted NLR increase, reinforcing the concept of immune ablation. III.

Potential significance of uncovered self-expandable metal stents for distal malignant biliary obstruction: A propensity score-adjusted competing risk regression analysis.

ObjectivesSelection criteria for self‐expandable metal stents (SEMSs) with or without cover during palliative treatment of distal malignant biliary obstruction (DMBO) remain unclear. We evaluated factors associated with time to recurrent biliary obstruction (TRBO) in fully covered SEMSs (FCSEMSs) and uncovered SEMSs (UCSEMSs).MethodsWe retrospectively analyzed consecutive patients with DMBO who received a SEMS. TRBO was determined using the Kaplan–Meier analysis, and complications were compared between the FCSEMS and UCSEMS groups. After TRBO‐associated factors were extracted using multivariate competing‐risks regression (CRR), propensity score‐adjusted CRRs were performed to verify their robustness.ResultsThere were 180 patients (66 FCSEMSs and 114 UCSEMSs) enrolled in this study. There was no significant difference between median TRBO in the FCSEMS and UCSEMS groups (275 vs. 255 days, p = 0.67). Complications were more frequent in the FCSEMS than UCSEMS group (21.2% vs. 8.8%; p = 0.023). Multivariate CRR for TRBO‐associated factors revealed that “pancreatic ductal carcinoma (PDAC) treated with UCSEMS” was the only independent predictor of TRBO (p = 0.03). Similarly, the propensity score‐adjusted CRRs showed no significant difference in TRBO in “FCSEMS” vs “UCSEMS” (p = 0.96); however, there was a significant difference in “PDAC using UCSEMS” vs “other” (p = 0.043). In the palliative care group including any DMBO without chemotherapy, the first quartile of the TRBO of UCSEMS was 100 days.ConclusionsUCSEMSs are a possible option for both patients with DMBO arising from PDAC and for patients with any DMBO receiving palliative care who should avoid SEMS‐related complications.

Investigation of risk factors for tunneled hemodialysis catheters dysfunction: competing risk analysis of a tertiary center data

BackgroundHemodialysis tunneled catheters are prone to failure due to infection or thrombosis. Prediction of catheter dysfunction chance and finding the predisposing risk factors might help clinicians to prolong proper catheter function. The multidimensional mechanism of failures following infection or thrombosis needs a multivariable and comprehensive analytic approach.MethodsA longitudinal cross-sectional study was implemented on 1048 patients admitted for the first hemodialysis tunneled catheterization attempt between 2013 and 2019 in Shahid Hasheminejdad hospital, Tehran, Iran. Patients’ information was extracted from digital and also paper records. Based on their criteria, single and multiple variable analyses were done separately in patients with catheter dysfunction due to thrombosis and infection. T-test and Chi-square test were performed in quantitative and categorical variables, respectively. Competing risk regression was performed under the assumption of proportionality for infection and thrombosis, and the sub-distributional hazard ratios (SHR) were calculated. All statistical inferences were made with a significance level of 0.05.ResultsFour hundred sixty-six patients were enrolled in the analysis based on study criteria. Samples’ mean (SD) age was 54(15.54), and 322 (69.1%) patients were female. Three hundred sixty-five catheter dysfunction cases were observed due to thrombosis 123(26.4%) and infection 242(52%). The Median (range) time to catheter dysfunction event was 243(36–1131) days.Single variable analysis showed a statistically significant higher proportion of thrombosis in females (OR = 2.66, 95% CI: 1.77–4.00) and younger patients, respectively. Multivariate competing risk regression showed a statistically significant higher risk of thrombosis in females (Sub-distributional hazard (SHR) = 1.81), hypertensive (SHR = 1.82), and more obese patients (BMI SHR = 1.037). A higher risk of infection was calculated in younger (Age SHR = 0.98) and diabetic (SHR = 1.63) patients using the same method.ConclusionFemale and hypertensive patients are considerably at higher risk of catheter thrombosis, whereas diabetes is the most critical risk factor for infectious catheter dysfunction. Competing risk regression analysis showed a comprehensive result in the assessment of risk factors of catheter dysfunction.

247.7: Trends and Risk Factors for Mortality While Awaiting Heart Transplantation: A UNOS Registry Analysis

Background: Orthotopic heart transplantation (OHT) remains the gold standard treatment of end-stage heart failure. In order to address organ scarcity, allocation systems aim to decrease waitlist mortality while maintaining acceptable post-transplant outcomes. The purpose of this study was to examine the characteristics of patients who suffered mortality on the waitlist versus those who underwent transplantation, as well as the impact of recent changes in the United States heart allocation policies on these outcomes. Methods: The United Network for Organ Sharing database was queried, and adult, isolated OHT candidates listed for transplant within the United States from 11/5/2015 to 9/30/2021 were analyzed. Baseline characteristics among candidates that either were transplanted, or had been removed from the waitlist due to death clinical deterioration were compared. Comparisons were also made between heart allocation policy (pre or post-10/18/2018) time eras. Multivariable competing risk regression was conducted to identify risk-adjusted predictors of transplantation from the waitlist. Additionally, predictors of the outcome of death or de-listing from the waitlist due to clinical decline were also modeled. Results: During the study period, a total of 13,575 recipients were transplanted (6,926 under the old policy and 6,649 under the new). A total of 1,875 candidates died or were de-listed (1,235 listed under the old policy and 640 listed under the new). In a comparison of baseline characteristics at time of listing, candidates that were transplanted differed significantly to those who were de-listed due to death or clinical decline with respect to age, heart failure etiology, mechanical circulatory support bridging, and baseline comorbidity (Table). In a multivariable model, waitlisting under the new allocation policy was associated with reduced hazards for death or de-listing (HR 0.57, 95% CI 0.51-0.63; P<0.001), and increased hazards for undergoing transplantation (HR 1.36; 95% CI 1.31-1.41; P<0.001). The two largest predictors of transplantation were bridging with an intra-aortic balloon pump (HR 2.13, 95% CI 1.97-2.31; P<0.001) and AB blood type (HR 1.43, 95% CI 1.30-1.57; P<0.001). The strongest predictors of death or de-listing were diagnosis of hypertrophic cardiomyopathy (HR 3.77, 95% CI 2.69-5.29; P<0.001) or biventricular hemodynamic support in the form of either extracorporeal membrane oxygenation (HR 2.59, 95% CI 1.96-3.42; P<0.001), total artificial heart (HR 2.36, 95% CI 1.28-4.35; P=0.006), or combined right and left ventricular assist device support (HR 2.45, 95% CI 1.71-3.50; P<0.001). Conclusions: Since the United States 2018 heart allocation policy change, waitlisted candidates are more likely to be transplanted and less likely be de-listed due to death or clinical decline. Need for biventricular mechanical circulatory support at time of waitlisting are associated with higher risk of death or falling too ill for transplantation.

Lymph node ratio predicts overall survival in patients with stage II non-small cell lung cancer: a population-based SEER analysis

BackgroundIn non-small-cell lung cancer (NSCLC), there are many factors that affect prognosis, and the lymph node ratio (LNR) may play a significant role. Our study aimed to confirm the value of the LNR in the prognosis of patients with stage II NSCLC.MethodsPatient data were obtained from the Surveillance, Epidemiology and End Results (SEER) database. The classification for the LNR was best determined using the X-tile method. The correlation between the LNR and overall survival (OS) was validated after the Kaplan–Meier analysis was performed. To determine the correlation between the LNR and survival, stratification and the Cox regression analysis were used.ResultsIn our study, 14,183 stage II NSCLC patients were included. Among them, 8303 patients had N1 disease. According to the X-tile analysis, the optimal critical points for the LNR in N1 patients with NSCLC was 0.21 and 0.38. We categorized the cohorts as low (LNR-L ≤ 0.21; n = 5158, 62.1%), medium (0.21 < LNR-M ≤ 0.38; n = 1736, 20.9%), and high (LNR-H > 0.38; n = 1409, 17.0%). According to the Kaplan–Meier analysis, the patients with a high LNR were considerably worse than those with a medium or low LNR (P < 0.001), which was also proven by stratified and multivariate analyses. The value of the LNR was reflected in all the subgroup analyses, especially in patients ages < 60 years. The multivariate competing risks regression analysis revealed that younger age, female sex, T1 disease, adenocarcinoma and N0 disease was associated with a better prognosis after controlling for potential confounders (P < 0.001).ConclusionsFor patients with stage II NSCLC, the LNR is valuable for assessing prognosis. A higher LNR indicates a worse prognosis.

Association between duration of gonadotrophin-releasing hormone agonist use and cardiovascular risks: A population-based competing-risk analysis.

Although androgen deprivation therapy has known cardiovascular risks, it is unclear if its duration is related to cardiovascular risks. This study thus aimed to investigate the associations between gonadotrophin-releasing hormone (GnRH) agonist use duration and cardiovascular risks. This retrospective cohort study included adult patients with prostate cancer receiving GnRH agonists in Hong Kong during 1999-2021. Patients who switched to GnRH antagonists, underwent bilateral orchidectomy, had <6 months of GnRH agonist, prior myocardial infarction (MI), or prior stroke was excluded. All patients were followed up until September 2021 for a composite endpoint of MI and stroke. Multivariable competing-risk regression using the Fine-Gray subdistribution model was used, with mortality from any cause as the competing event. In total, 4038 patients were analyzed (median age 74.9 years old, interquartile range (IQR) 68.7-80.8 years old). Over a median follow-up of 4.1 years (IQR 2.1-7.5 years), longer GnRH agonists use was associated with higher risk of the endpoint (sub-hazard ratio per year 1.04 [1.01-1.06], p = 0.001), with those using GnRH agonists for ≥2 years having an estimated 23% increase in the sub-hazard of the endpoint (sub-hazard ratio 1.23 [1.04-1.46], p = 0.017). Longer GnRH agonist use may be associated with greater cardiovascular risks.

Cancer-specific Mortality in T1a Renal Cell Carcinoma Treated with Local Tumor Destruction Versus Partial Nephrectomy

BackgroundLarge-scale analyses addressing cancer-specific mortality (CSM) in T1a renal cell carcinoma (RCC) patients treated with local tumor destruction (LTD), relative to partial nephrectomy (PN), are scarce. ObjectiveTo compare CSM after LTD versus PN. Design, setting, and participantsWithin the Surveillance, Epidemiology, and End Results (SEER) database (2004–2018), we identified patients with clinical T1a stage RCC treated with LTD or PN. Outcome measurements and statistical analysesAfter 1:1 ratio propensity score matching (PSM) between patients treated with LTD versus PN, competing risks regression (CRR) models addressed CSM, after adjustment for other-cause mortality (OCM) and other covariates (age, tumor size, tumor grade, and histological subtype). Results and limitationsRelative to the 35 984 PN patients, 5936 LTD patients were older and more frequently harbored unknown RCC histological subtype or unknown grade. After 1:1 PSM that resulted in 5352 LTD versus 5352 PN patients, the 10-yr CSM rate was 8.7% versus 5.5%. In multivariable CRR models, LTD was associated with higher CSM, relative to PN (hazard ratio [HR]: 1.58, p < 0.001). Subgroup analyses revealed invariably higher CSM after LTD versus PN in patients with tumor size ≤3 cm (10-yr CSM 7.2% vs 5.3%, multivariable HR: 1.47, p < 0.001) and in patients with tumor size 3.1–4 cm (10-yr CSM 11.4% vs 6.1%, multivariable HR: 1.72, p < 0.001). Lack of information regarding earlier cancer controls, retreatment, tumor location within the kidney, and type of surgery represented limitations. ConclusionsIn T1a RCC patients, LTD is invariably associated with higher CSM relative to PN, even after adjustment for OCM and all available patient and tumor characteristics, and regardless of tumor size considerations. However, the magnitude of CSM disadvantage was more pronounced in LTD patients with tumor size 3.1–4 cm than in those with tumor size ≤3 cm. Patient summaryIn patients with small renal masses, we observed higher cancer-specific death rates for local tumor destruction (LTD) than for partial nephrectomy. The LTD disadvantage was more pronounced for patients with tumor size 3.1–4 cm, but was also present in those with tumor size ≤3 cm.

P1323: PREDICTION OF NON-RELAPSE MORTALITY BY EASIX AND HCT-CI SCORES IN PATIENTS WITH CHRONIC MYELOMONOCYTIC LEUKEMIA UNDERGOING ALLOGENEIC STEM CELL TRANSPLANT

Background: The endothelial activation and stress index (EASIX) score has been shown as a predictor of non-relapse morality (NRM) after allogeneic stem cell transplantation (alloSCT) [Luft, et al. Bone Marrow Transplant. 2020;55(3):553–561]. However, data in patients with chronic myelomonocytic leukemia (CMML) is limited. Aims: Our goal was to study the risk of NRM and the impact on overall survival (OS) by EASIX and HCT-CI scores in patients with CMML undergoing alloSCT. Methods: We retrospectively evaluated patients with CMML who underwent alloSCT. We reviewed patient demographics, disease characteristics, and post-transplant outcomes. EASIX score was calculated using the formula: LDH (U/L) × Creatinine (mg/dL) / platelet count (10^9/L) and analyzed based on log2 transformed values. EASIX score was calculated within 45 days of alloSCT, but prior to starting conditioning therapy. The optimal log2 EASIX score cutoff was determined using maximally selected log-rank statistics. Patients with an HCT-CI score ≥ 3 were considered to have a high HCT-CI score. Results: Between, January 1992 to February 2019, a total of 70 CMML patients underwent alloSCT, 13 patients were excluded due to incomplete records and 57 patients (39 males and 18 females) were evaluated for the purposes of the study. CMML-0 was the most common subtype (21 patients, 36.8%), followed by CMML-2 (19 patients, 33.3%)) and CMML-1 (17 patients, 29.8%). Seventeen (29.8%) patients had progressed to CMML blast phase before alloSCT. Of the entire cohort, 18 (31.6%) patients were in complete remission at the time of alloSCT. Median age at transplant for the entire cohort was 58 years (range: 18 – 73 years). Median time of follow-up was 2 years (range: 11 days – 16 years). Median OS was 2 years, with a 3-year OS rate of 49.1%. Eighteen (31.6%) patients were alive at last follow-up. The median log2 EASIX score was 0.88 (range -2.29 to 5.91). The optimal log2 EASIX score cutoff using the maximally selected LogRank statistics was found to be 2.33. Patients with log2 EASIX score > 2.33 were considered to have a high EASIX score. Thirteen (22.8%) patients had a high EASIX score and 44 (77.2%) had a low EASIX score. The cumulative incidence of NRM among patients with high EASIX score was significantly higher compared to those with low EASIX score at 100 days (30.8% vs 0%, p < 0.001), at 1-year (46.2% vs 9.1%, p = 0.002) and at 3-years (53.8% vs 15.9%, p = 0.003) after alloSCT (Figure 1A). A total of 55 patients were evaluated for HCT-CI score, of whom 30 (54.54%) were found to have a low HCT-CI score, i.e., HCT-CI < 3, and 25 (45.45%) were found to have a high HCT-CI score. The median HCT-CI score was 2 (range: 0-7). NRM after alloSCT among patients with high HCT-CI score was not significantly different compared to those with low HCT-CI scores at 100 days (8% vs 6.7%, p = 0.85), at 1 year (24% vs 13.3%, p = 0.33), and at 3 years (24% vs 26.7%, p = 0.92) after alloSCT (Figure 1B). In multivariate competing risk regression analysis, a high EASIX score significantly increased NRM at 3 year (HR 4.14, 95% CI: 1.42 – 12.01, p = 0.009). Patients with a high log2 EASIX score had significantly worse OS at 3 years (median 8 months vs. NA, p = 0.007). OS at 3 years did not differ among patients with high vs. low HCT-CI scores (median 1.02 years vs. NA, p = 0.38). Image:Summary/Conclusion: In CMML, EASIX predicted NRM following alloSCT. EASIX was a better predictor of NRM compared to HCT-CI in this patient population. Larger patient cohort is required to confirm our findings.

Atrial fibrillation is an independent risk factor for heart failure hospitalization in heart failure with preserved ejection fraction.

Atrial fibrillation (AF) is a common comorbid condition in heart failure with preserved ejection fraction (HFpEF). The effect of AF on heart failure (HF) exacerbation in HFpEF has not been well described. This study investigated how AF modifies the clinical trajectory of HFpEF patients after hospitalization for decompensated HF. We stratified HFpEF subjects by AF diagnosis and performed longitudinal analysis to compare risk for HF hospitalization after index hospitalization for decompensated HF. All-cause mortality, 30day all-cause readmissions, and response to inpatient diuresis were also evaluated. Of 90 subjects enrolled, 35.6% (n=32) had AF. Subjects with AF were older (72.5 vs. 60.5years; P<0.01), more often male (46.9% vs. 24.1%; P=0.03), and had greater left atrial diameter (4.9 vs. 3.8cm; P<0.01) compared with those without AF. Subjects with AF had a higher risk for HF hospitalization than their counterparts without AF (P=0.02); this relationship remained significant following multivariable competing risk regression with propensity score weighting (hazard ratio 2.53, P=0.04 and hazard ratio 2.91, P=0.04, with overlap and inverse probability weighting, respectively). Although having AF appeared to increase the risk of all-cause hospital readmission within 30days of discharge (37.5% vs. 17.5%; P=0.036), this relationship failed to remain significant following propensity score adjustment for clinical covariates. Atrial fibrillation is an independent risk factor for HF rehospitalization in HFpEF. Further understanding of the interplay between AF and HFpEF will be critical to guide the selection of appropriate rhythm management strategies in this population.

Is lobectomy superior to sub-lobectomy in non-small cell lung cancer with pleural invasion? A population-based competing risk analysis

BackgroundPleural invasion (PL) has been regarded as an unfavorable prognostic factor for non-small cell lung cancer (NSCLC). But there was no agreement on the optimal surgical extent in NSCLC patients with PL. We aimed to compare the survival outcomes of lobectomy and sub-lobectomy in these patients.Method2717 patients were included in the Surveillance, Epidemiology, and End Results (SEER) database and divided into the lobectomy and sub-lobectomy groups. The propensity score matching (PSM) and competing risk analysis were implemented. Then the predictive nomogram was constructed and validated.Results2230 Patients received lobectomy while the other 487 patients underwent sub-lobectomy. After 1:1 PSM, the cumulative incidence of cancer-specific death (CSD) was lower in the lobectomy group compared with the sub-lobectomy group (1-year: 12% vs. 15%; 3-year: 30% vs. 37%, 5-year: 34% vs. 45%, P = 0.04). According to the subgroup analysis, the patients who underwent lobectomy suffered lower CSD in the N0–1 stage, adenocarcinoma, and PL-2 cohort (p < 0.05). And there was a significant relationship between the sub-lobectomy group and CSD in the multivariate competing risks regression analysis (HR, 1.26; 95%CI, 1.02–1.56; P = 0.034). Furthermore, a competing event nomogram was constructed to assess the 1-, 3-, and 5-year chances of CSD based on the variables from the multivariate analysis. The 1-, 3-, 5-year area under the receiver operating characteristic curve (AUC) values were 0.720, 0.706, and 0.708 in the training cohort, and 0.738, 0.696, 0.680 in the validation cohorts, respectively. And calibration curves demonstrated ideal consistency between the predicted and observed probabilities of CSD.ConclusionLobectomy should be considered the preferred surgery compared to sub-lobectomy for NSCLC patients with PL. The proposed nomograms presented great prediction ability for these patients.

Patterns of Failure and Optimal Treatment Paradigm for Large, Inoperable, Node-Negative Non–small Cell Lung Cancer

ObjectivesThe ideal non-operative treatment for patients with large, node-negative non–small cell lung cancer (NSCLC) is poorly defined. To inform optimal treatment paradigms for this cohort, we examined patterns of failure and the impact of radiation therapy (RT) and chemotherapy receipt. Materials and MethodsNode-negative NSCLC patients with 5+ cm primary tumors receiving definitive RT at our institution were identified. Sites of initial progression were analyzed. Local progression, regional/distant progression, progression-free survival, and overall survival were analyzed via cumulative incidence function and Kaplan-Meier. Associations between local vs. regional/distant progression with treatment and clinicopathologic variables were assessed via univariable and multivariable competing risks regression. Results and ConclusionWe identified 88 patients for analysis. Among patients with recurrent disease (N = 36), initial patterns of failure analysis showed that isolated distant (27.8%) and isolated regional progression (22.2%) were most common. Distant or regional failure as a component of initial failure was seen in 88.9% of patients who progressed, while isolated local failure was uncommon (11.1%). Univariable and multivariable competing risks regression showed that receipt of SBRT was associated with reduced risk of local progression (HR 0.23, P = .012), and receipt of chemotherapy was associated with reduced risk of regional/distant progression (HR 0.12, P = .040). In conclusion, patients with large, node-negative NSCLC treated with definitive RT are at high risk of regional and distant progression. SBRT correlates with a reduced risk of local failure while chemotherapy is associated with reduced regional/distant progression in this patient population. Ideal treatment may include SBRT when feasible with appropriate systemic therapy.

PD27-06 INCREASED AWARENESS OF SURGICAL OUTCOMES IMPROVES LONG-TERM FUNCTIONAL OUTCOMES AFTER ROBOT-ASSISTED RADICAL PROSTATECTOMY. A PROSPECTIVE ASSESSMENT FOLLOWING IMPLEMENTATION OF PROSPECTIVE DATA COLLECTION

PD27-06 INCREASED AWARENESS OF SURGICAL OUTCOMES IMPROVES LONG-TERM FUNCTIONAL OUTCOMES AFTER ROBOT-ASSISTED RADICAL PROSTATECTOMY. A PROSPECTIVE ASSESSMENT FOLLOWING IMPLEMENTATION OF PROSPECTIVE DATA COLLECTION

PD26-09 PRIMARY TA HIGH GRADE BLADDER TUMORS: DETERMINATION OF THE RISK OF PROGRESSION

You have accessJournal of UrologyCME1 May 2022PD26-09 PRIMARY TA HIGH GRADE BLADDER TUMORS: DETERMINATION OF THE RISK OF PROGRESSION Fahad Quhal, Keiichiro Mori, Ekaterina Laukhtina, Benjamin Pradere, Francesco Soria, Marco Moschini, Alberto Briganti, Pierre I. Karakiewicz, and Shahrokh F. Shariat Fahad QuhalFahad Quhal More articles by this author , Keiichiro MoriKeiichiro Mori More articles by this author , Ekaterina LaukhtinaEkaterina Laukhtina More articles by this author , Benjamin PradereBenjamin Pradere More articles by this author , Francesco SoriaFrancesco Soria More articles by this author , Marco MoschiniMarco Moschini More articles by this author , Alberto BrigantiAlberto Briganti More articles by this author , Pierre I. KarakiewiczPierre I. Karakiewicz More articles by this author , and Shahrokh F. ShariatShahrokh F. Shariat More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002574.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: TaG3 bladder cancer is an under-investigated disease and because of its rarity it is commonly studies together with T1G3 disease. We sought to exclusively study TaG3 disease and to determine the factors associated with disease progression. METHODS: Of 3505 patients with NMIBC, 285 patients had primary TaG3 and with no concomitant carcinoma in-situ. The median follow-up was 43 months; 70% of the patients received adjuvant BCG. RESULTS: Progression to ≥pT1 occurred in 21 patients (7.4%). In a multivariable competing-risk regression analysis, intravesical BCG was significantly associated with a lower risk of progression to ≥pT1 (HR 0.23, 95%CI 0.08-0.64, p=0.005). Recurrence in the first year of diagnosis was significantly associated with an increased risk of stage progression to ≥pT1 (HR 7.81, 95%CI 2.50-24.44, p<0.001). Progression to ≥T2 was observed in 9 patients (3.2%). In univariable competing-risk regression analyses, intravesical BCG was significantly associated with a lower risk of progression to ≥pT2 (HR 0.11, 95%CI 0.04-0.47, p=0.003). On the other hand, recurrence in the first year of diagnosis was significantly associated with an increased risk of stage progression to ≥T2 (HR 7.12, 95%CI 1.50-33.77, p=0.013). In a subgroup of 199 patients who were treated with BCG, there was no statistically significant association between tumor recurrence in the 1st year of diagnosis and stage progression to ≥pT1 (p=0.14) or ≥pT2 (p=0.19). CONCLUSIONS: Patients with TaG3 bladder cancer are considered high risk but if appropriately treated with BCG that risk is considerably mitigated. Our data support that TaG3 without concomitant CIS should not be considered as aggressive as T1G3 as it has a lower risk of progression to muscle-invasive bladder cancer (MIBC). Recurrence in the first year after diagnosis is the strongest predictor of progression to MIBC. Source of Funding: No funding © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e491 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Fahad Quhal More articles by this author Keiichiro Mori More articles by this author Ekaterina Laukhtina More articles by this author Benjamin Pradere More articles by this author Francesco Soria More articles by this author Marco Moschini More articles by this author Alberto Briganti More articles by this author Pierre I. Karakiewicz More articles by this author Shahrokh F. Shariat More articles by this author Expand All Advertisement PDF DownloadLoading ...

The role of chemotherapy in patients with stage IB gastric adenocarcinoma: a real-world competing risk analysis

BackgroundThis study aimed to investigate the potential effect of adjuvant chemotherapy in patients diagnosed with stage IB gastric adenocarcinoma (GAC).MethodA total of 1727 patients were included in the Surveillance, Epidemiology, and End Results (SEER) database from 2004 to 2015 and divided into the chemotherapy and no-chemotherapy groups. Then, the methods of Kaplan-Meier analysis, propensity score matching (PSM), and competing risk analysis were implemented.ResultsAfter PSM, no significant difference was found in the chemotherapy and no-chemotherapy groups in overall survival (OS) (p=0.4) and cancer-specific survival (CSS) (p=0.12) in survival curves. The competing risk analysis presented that the 5-year cumulative incidence of cancer-specific death (CSD) was significantly lower in patients receiving chemotherapy (11.5% vs. 20.8%, p=0.007), while no significant discrepancy was observed in other causes of death (OCD) in both groups (10.6% vs. 10.9%, p=0.474). Multivariable competing risks regression models presented a significant correlation between chemotherapy and CSD (HR, 0.51; 95%CI, 0.31–0.82; p=0.007).ConclusionThe stage IB GAC patients can benefit from adjuvant chemotherapy based on this competing risk analysis.

Risk factors for severe lower extremity ischemia following venoarterial extracorporeal membrane oxygenation: an analysis using a nationwide inpatient database

ObjectivesVenoarterial extracorporeal membrane oxygenation is increasingly being used as a life-saving modality in critically ill patients. Despite its necessity, severe lower extremity ischemia associated with venoarterial extracorporeal membrane oxygenation remains...

Survival benefit of chemotherapy in a contemporary cohort of metastatic urachal carcinoma.

We relied on the most contemporary Surveillance, Epidemiology, and End Results (SEER) database and tested the hypothesis that chemotherapy may improve survival in metastatic urachal carcinoma (m-UraC). Within the SEER database (2004-2016), we identified m-UraC patients aged ≥ 18 years. Propensity score matching (PSM: cystectomy status, age and sex), Kaplan-Meier plots, cumulative incidence plots, Cox regression models and competing risks regression (CRR) models addressed overall mortality (OM) and cancer-specific mortality (CSM). Overall, 274 m-UraC patients were identified with a median age of 70 years. Most were male (66%) and Caucasian (72%). Overall, 32% received chemotherapy. Chemotherapy-exposed patients were younger (62 vs. 73 years, p<0.001) and more frequently underwent cystectomy (19 vs. 8%, P = 0.014). In 274 m-UraC patients, median OM and CSM were 6 (4 -10) months and 8 (6 -14) months, respectively. After 1:1 PSM, chemotherapy-exposed patients exhibited lower OM (median 16 vs. 3 months; multivariable HR 0.38, P <0.001) and lower CSM (median 17 vs. 4 months; multivariable CRR HR 0.52, P = 0.001). The association between chemotherapy and better survival was even stronger in younger (≤70 years) patients (OM HR: 0.23, P <0.001; CSM CRR HR: 0.42, P = 0.001), but not in older (≥71 years) patients (OM HR: 0.61, P = 0.2; CSM CRR HR: 1.02, P = 1), after PSM and multivariable adjustments. Overall, we validated the very aggressive nature of UraC, when distant metastases are present, and observed that m-UraC patients exposed to chemotherapy exhibited lower OM and CSM.

Factors Associated with Treatment Outcomes Among Children and Adolescents Living with HIV Receiving Antiretroviral Therapy in Central Kenya.

Expanded access to HIV treatment services has improved outcomes for children and adolescents living with HIV in Kenya. Minimal data are available on these outcomes. We describe temporal trends in outcomes for children and adolescents initiating antiretroviral therapy (ART) from 2004 to 2014 at sites supported by Centre for Health Solutions—Kenya, in central Kenya. We retrospectively analyzed data from children 0–9 years of age (n = 3,519) and adolescents 10–19 years of age (n = 1,663) living with HIV, who newly initiated ART at 47 health facilities in central Kenya. Year cohorts were analyzed from the Comprehensive Patient Application Database (CPAD) and International Quality Care (IQCare) electronic medical databases, including temporal trends in outcomes and associated factors using multivariable competing risk regression analysis. There were more girls (2,453 [52.7%]) than boys, with most enrolled at World Health Organization (WHO) stage II (1,813 [37.7%]) or III disease (1,694 [35.1%]). Most of the children and adolescents (4,431 [96.4%]) did not have tuberculosis (TB) symptoms. Cumulative lost to follow-up (LTFU) incidence at 6, 12, 24, and 36 months were 5.0%, 9.9%, 22.9%, and 33.1%, respectively. Cumulative mortality incidence at 6, 12, 24, and 36 months were 0.7%, 1.0%, 1.2%, and 1.5%, respectively. The incidence of LTFU was higher among female children and adolescents, those initiated on tenofovir-based regimens, and those with presumptive TB symptoms. Mortality risk was higher among those with WHO stage III or IV disease, and children and adolescents on TB treatment or who had presumptive TB. Enrollment occurred at a young age and pediatric-friendly ART regimens were initiated at earlier WHO stages implying effective early infant diagnosis and treatment for all strategies, resulting in improved treatment outcomes. The higher retention rates in recent years as well as the lower retention after many years of follow-up underscore the importance of implementing longitudinal follow-up strategies targeting this population.

Predictors of thrombosis in children receiving therapy for acute lymphoblastic leukemia: Results from Dana‐Farber Cancer Institute ALL Consortium trial 05‐001

AbstractBackground/objectivesAlthough thromboembolism (TE) is a serious complication in patients with acute lymphoblastic leukemia (ALL), thromboprophylaxis is not commonly used due to the inherent bleeding risk in this population. Identifying prothrombotic risk factors will help target thromboprophylaxis to those at highest thrombotic risk. We aimed to define predictors and the impact of TE on ALL outcome in children (1‐18 years) treated on the Dana‐Farber Cancer Institute ALL 05‐001 trial.MethodsClinical and laboratory data including TE events were prospectively collected. PCR‐based allelic discrimination assay identified single‐nucleotide polymorphisms (SNP) for prothrombin G20210A (rs1799963) and Factor V G1691A (rs6025). Univariate and multivariable competing risk regression models evaluated the effect of diagnostic clinical (age, sex, body mass index, ALL‐immunophenotype, risk group) and laboratory variables (presenting leukocyte count, blood group, SNPs) on the cumulative incidence of TE. Cox regression modeling explored the impact of TE on survival.ResultsOf 794 patients [median age 4.97 (range, 1.04‐17.96) years; males 441], 100 developed TE; 25‐month cumulative incidence 13.0% (95% CI, 10.7%‐15.5%). Univariate analyses identified older age (≥10 years), presenting leucocyte count, T‐ALL, high‐risk ALL, and non‐O blood group as risk factors. Age and non‐O blood group were independent predictors of TE on multivariable regression; the blood group impact being most evident in patients 1‐5 years of age (P = 0.011). TE did not impact survival. Induction TE was independently associated with induction failure (OR 6.45; 95% CI, 1.64‐25.47; P = 0.008).ConclusionWe recommend further evaluation of these risk factors and consideration of thromboprophylaxis for patients ≥10 years (especially those ≥15 years) when receiving asparaginase.

Coronary Artery Calcium for Risk Stratification of Sudden Cardiac Death: The Coronary Artery Calcium Consortium

BackgroundCoronary artery calcium (CAC) is a marker of plaque burden. Whether CAC improves risk stratification for incident sudden cardiac death (SCD) beyond atherosclerotic cardiovascular disease (ASCVD) risk factors is unknown. ObjectivesSCD is a common initial manifestation of coronary heart disease (CHD); however, SCD risk prediction remains elusive. MethodsThe authors studied 66,636 primary prevention patients from the CAC Consortium. Multivariable competing risks regression and C-statistics were used to assess the association between CAC and SCD, adjusting for demographics and traditional risk factors. ResultsThe mean age was 54.4 years, 33% were women, 11% were of non-White ethnicity, and 55% had CAC >0. A total of 211 SCD events (0.3%) were observed during a median follow-up of 10.6 years, 91% occurring among those with baseline CAC >0. Compared with CAC = 0, there was a stepwise higher risk (P trend < 0.001) in SCD for CAC 100 to 399 (subdistribution hazard ratio [SHR]: 2.8; 95% CI: 1.6-5.0), CAC 400 to 999 (SHR: 4.0; 95% CI: 2.2-7.3), and CAC >1,000 (SHR: 4.9; 95% CI: 2.6-9.9). CAC provided incremental improvements in the C-statistic for the prediction of SCD among individuals with a 10-year risk <7.5% (ΔC-statistic = +0.046; P = 0.02) and 7.5% to 20% (ΔC-statistic = +0.069; P = 0.003), which were larger when compared with persons with a 10-year risk >20% (ΔC-statistic = +0.01; P = 0.54). ConclusionsHigher CAC burden strongly associates with incident SCD beyond traditional risk factors, particularly among primary prevention patients with low-intermediate risk. SCD risk stratification can be useful in the early stages of CHD through the measurement of CAC, identifying patients most likely to benefit from further downstream testing.

Radiation therapy after radical prostatectomy is associated with higher other-cause mortality

PurposeTo test the association between external beam radiotherapy (EBRT) after radical prostatectomy (RP) vs RP only on rates of other-cause mortality (OCM) in men with prostate cancer (PCa).Patients and methodsWithin the 2004–2016 Surveillance, Epidemiology, and End Results database, we identified 181,849 localized PCa patients, of whom 168,041 received RP only vs 13,808 who received RP + EBRT. Cumulative incidence plots displayed OCM between RP vs RP + EBRT after propensity score matching for age, PSA, clinical T- and N-stages, and biopsy Gleason scores. Multivariable competing risks regression models addressed OCM, accounting prostate cancer-specific mortality (CSM) as a competing event. Stratifications were made according to low- vs intermediate- vs high-risk groups and additionally according to age groups of ≤ 60, 61–70, and ≥ 71 years, within each risk group.ResultsIn low-, intermediate-, and high-risk patients, RP + EBRT rates were 2.7, 5.4 and 17.0%, respectively. After matching, 10-year OCM rates between RP and RP + EBRT were 7.7 vs 16.2% in low-, 9.4 vs 13.6% in intermediate-, and 11.4 vs 13.5% in high-risk patients (all p < 0.001), which, respectively, resulted in multivariable HR of 2.1, 1.3, and 1.2 (all p < 0.001). In subgroup analyses, excess OCM was recorded in low-risk RP + EBRT patients of all age groups (all p ≤ 0.03), but only in the older age group in intermediate-risk patients (61–70 years, p = 0.03) and finally, only in the oldest age group in high-risk patients (≥ 71 years, p = 0.02).ConclusionExcess OCM was recorded in patients exposed to RT after RP. Its extent was most pronounced in low-risk patients, decreased in intermediate-risk patients, and was lowest in high-risk patients.