Oncological Benefit Research Articles

Practice change: No benefit of extended lymphadenectomy at radical cystectomy in patients with muscle invasive bladder cancer

For many decades, extended pelvic lymph node dissection has been an integral part during radical cystectomy for patients with muscle invasive bladder cancer. This practice was based on large retrospective meta-analyses suggesting an oncologic benefit to an extended dissection. This mini review and meta-analysis includes the two available randomized trials in the current literature. Therefore, it can be considered as the strongest level of evidence regarding the prognostic benefit of an extended pelvic lymphadenectomy. Based on current randomized data, standard pelvic lymph node dissection up to the level of iliac bifurcation is sufficient, and extension of the dissection above this level does not provide any additional oncologic benefit.

Anaesthetic Techniques and Strategies: Do They Influence Oncological Outcomes?

Background: With the global disease burden of cancer increasing, and with at least 60% of cancer patients requiring surgery and, hence, anaesthesia over their disease course, the question of whether anaesthetic and analgesia techniques during primary cancer resection surgery might influence long term oncological outcomes assumes high priority. Methods: We searched the available literature linking anaesthetic-analgesic techniques and strategies during tumour resection surgery to oncological outcomes and synthesised this narrative review, predominantly using studies published since 2019. Current evidence is presented around opioids, regional anaesthesia, propofol total intravenous anaesthesia (TIVA) and volatile anaesthesia, dexamethasone, dexmedetomidine, non-steroidal anti-inflammatory medications and beta-blockers. Conclusions: The research base in onco-anaesthesia is expanding. There continue to be few sufficiently powered RCTs, which are necessary to confirm a causal link between any perioperative intervention and long-term oncologic outcome. In the absence of any convincing Level 1 recommending a change in practice, long-term oncologic benefit should not be part of the decision on choice of anaesthetic technique for tumour resection surgery.

Should Laparoscopic Complete Mesocolic Excision Be Offered to Elderly Patients to Treat Right-Sided Colon Cancer?

Despite its potential oncologic benefit, complete mesocolic excision (CME) has rarely been offered to elderly patients. The present study evaluated the effect of age on postoperative outcomes among patients undergoing laparoscopic right colectomies with CME for right-sided colon cancer (RCC). Data of patients undergoing laparoscopic right colectomies with CME for RCC between 2015 and 2018 were retrospectively analyzed. Selected patients were divided into two groups: the under-80 group and the over-80 group. Surgical, pathological, and oncological outcomes among the groups were compared. A total of 130 patients were selected (95 in the under-80 group and 35 in the over-80 group). No difference was found between the groups in terms of postoperative outcomes, except for median length of stay and adjuvant chemotherapy received, which were in favor of the under-80 group (5 vs. 8 days, p < 0.001 and 26.3% vs. 2.9%, p = 0.003, respectively). No difference between the groups was found regarding overall survival and disease free survival. Using multivariate analysis, only the ASA score > 2 (p = 0.01) was an independent predictor of overall complications. laparoscopic right colectomy with CME for RCC was safely performed in elderly patients ensuring similar oncological outcomes compared to younger patients.

O134 Does robotic anterior resection improve the outcomes for patients with rectal cancer over standard laparoscopic surgery?

Abstract Introduction Currently, laparoscopic anterior resection (L-AR) is the standard approach for rectal cancer (RC) treatment. Increasingly, AR procedures have been conducted robotically using the Da Vinci Surgical System (DVSS). Its design has the potential to improve upon the operative outcomes of L-AR. However, the DVSS's controversial price of $2,000,000 has slowed its clinical adoption. There has been speculation as to whether the clinical outcomes conferred by robotic-assisted AR (R-AR) merits the cost of the DVSS. Aims To review the literature on R-AR and L-AR surgery for RC, primarily comparing the clinical outcomes of each approach, with an auxiliary evaluation of cost-effectiveness. Methods A literature search was performed using the databases OVID Embase, MedLine, and Web of Science. The keywords ‘anterior resection’, ‘rectal neoplasm’, ‘robotics’, ‘robotic surgical procedures’, and ‘laparoscopy’ were entered into each database. 141 records were initially retrieved and screened for relevance. The remaining texts that were fully available and adhered to the eligibility criteria were included in this review. Results Ten studies were identified. R-AR resulted in higher quality TME specimens in three studies, (p=0.02, 0.03, 0.033). and in shorter hospital stays and longer operative times in four studies: (p=0.03, 0.0001&amp;lt;, 0.001&amp;lt;, 0.001). Overall, R-AR had lower rates of intraoperative complications. Conclusion Generally, R-AR seemed to deliver better outcomes, but there is insufficient evidence to establish its superiority over L-AR. Longitudinal studies with extended research periods are required to evaluate the long-term oncological benefits of R-AR.

Impact of newly diagnosed prostate cancer at time of evaluation for renal transplantation.

Systematic screening for prostate cancer is widely recommended in candidates for renal transplant at the time of listing. There are concerns that overdiagnosis of low-risk prostate cancer may result in reducing access to transplant without demonstrated oncological benefits. The objective of the study was to assess the outcome of newly diagnosed prostate cancer in candidates for transplant at the time of listing, and its impact on transplant access and transplant outcomes according to treatment options. This retrospective study was conducted over 10 years in 12 French transplant centers. Patients included were candidates for renal transplant at the time of prostate cancer diagnosis. Demographical and clinical data regarding renal disease, prostate cancer, and transplant surgery were collected. The primary outcome of the study was the interval between prostate cancer diagnosis and active listing according to treatment options. Overall median time from prostate cancer diagnosis to active listing was 25.0 months [16.4-40.2], with statistically significant differences in median time between the radiotherapy and the active surveillance groups (p=.03). Prostate cancer treatment modalities had limited impact on access and outcome of renal transplantation. Active surveillance in low-risk patients does not seem to compromise access to renal transplantation, nor does it impact oncological outcomes.

Surgical outcomes of gallbladder cancer: the OMEGA retrospective, multicentre, international cohort study.

Gallbladder cancer (GBC) is rare but aggressive. The extent of surgical intervention for different GBC stages is non-uniform, ranging from cholecystectomy alone to extended resections including major hepatectomy, resection of adjacent organs and routine extrahepatic bile duct resection (EBDR). Robust evidence here is lacking, however, and survival benefit poorly defined. This study assesses factors associated with recurrence-free survival (RFS), overall survival (OS) and morbidity and mortality following GBC surgery in high income countries (HIC) and low and middle income countries (LMIC). The multicentre, retrospective Operative Management of Gallbladder Cancer (OMEGA) cohort study included all patients who underwent GBC resection across 133 centres between 1st January 2010 and 31st December 2020. Regression analyses assessed factors associated with OS, RFS and morbidity. On multivariable analysis of all 3676 patients, wedge resection and segment IVb/V resection failed to improve RFS (HR 1.04 [0.84-1.29], p=0.711 and HR 1.18 [0.95-1.46], p=0.13 respectively) or OS (HR 0.96 [0.79-1.17], p=0.67 and HR 1.48 [1.16-1.88], p=0.49 respectively), while major hepatectomy was associated with worse RFS (HR 1.33 [1.02-1.74], p=0.037) and OS (HR 1.26 [1.03-1.53], p=0.022). Furthermore, EBDR (OR 2.86 [2.3-3.52], p<0.0010), resection of additional organs (OR 2.22 [1.62-3.02], p<0.0010) and major hepatectomy (OR 3.81 [2.55-5.73], p<0.0010) were all associated with increased morbidity and mortality. Compared to LMIC, patients in HIC were associated with poorer RFS (HR 1.18 [1.02-1.37], p=0.031) but not OS (HR 1.05 [0.91-1.22], p=0.48). Adjuvant and neoadjuvant treatments were infrequently used. In this large, multicentre analysis of GBC surgical outcomes, liver resection was not conclusively associated with improved survival, and extended resections were associated with greater morbidity and mortality without oncological benefit. Aggressive upfront resections do not benefit higher stage GBC, and international collaborations are needed to develop evidence-based neoadjuvant and adjuvant treatment strategies to minimise surgical morbidity and prioritise prognostic benefit. Cambridge Hepatopancreatobiliary Department Research Fund.

Central node dissection in papillary thyroid carcinoma in the era of near-infrared fluorescence.

The most common site of lymph node metastases in papillary thyroid carcinoma is the central compartment of the neck (level VI). In many patients, nodal metastases in this area are not clinically apparent, neither on preoperative imaging nor during surgery. Prophylactic surgical clearance of the level VI in the absence of clinically suspicious lymph nodes (cN0) is still under debate. It has been suggested to reduce local recurrence and improve disease-specific survival. Moreover, it helps to accurately diagnose the lymph node involvement and provides important staging information useful for tailoring of the radioactive iodine regimen and estimating the risk of recurrence. Yet, many studies have shown no benefit to the long-term outcome. Arguments against the prophylactic central lymph node dissection (CLND) cite minimal oncologic benefit and concomitant higher operative morbidity, with hypoparathyroidism being the most common complication. Recently, near-infrared fluorescence imaging has emerged as a novel tool to identify and preserve parathyroid glands during thyroid surgery. We provide an overview of the current scientific landscape of fluorescence imaging in thyroid surgery, of the controversies around the prophylactic CLND, and of fluorescence imaging applications in CLND. To date, only three studies evaluated fluorescence imaging in patients undergoing thyroidectomy and prophylactic or therapeutic CLND for thyroid cancer. The results suggest that fluorescence imaging has the potential to minimise the risk of hypoparathyroidism associated with CLND, while allowing to exploit all its potential benefits. With further development, fluorescence imaging techniques might shift the paradigm to recommend more frequently prophylactic CLND.

Neoadjuvant Androgen Receptor Signaling Inhibitors before Radical Prostatectomy for Non-Metastatic Advanced Prostate Cancer: A Systematic Review.

(1) Background: Several phase II studies, including randomized controlled trials (RCTs), assessed the efficacy of adding androgen receptor signaling inhibitors (ARSIs) to androgen deprivation therapy (ADT) as a neoadjuvant treatment in patients treated with radical prostatectomy (RP) for prostate cancer (PCa). Summarizing the early results of these studies could help in designing phase III trials and patient counseling. (2) Methods: We queried three databases in January 2023 for studies that included PCa patients treated with neoadjuvant ARSI-based combination therapy before RP. The outcomes of interest were oncologic outcomes and pathologic responses, such as pathologic complete response (pCR) and minimal residual disease (MRD). (3) Results: Overall, twenty studies (eight RCTs) were included in this systematic review. Compared to ADT or ARSI alone, ARSI + ADT was associated with higher pCR and MRD rates; this effect was less evident when adding a second ARSI or chemotherapy. Nevertheless, ARSI + ADT resulted in relatively low pCR rates (0-13%) with a high proportion of ypT3 (48-90%) in the resected specimen. PTEN loss, ERG positive, or intraductal carcinoma seem to be associated with worse pathologic response. One study that adjusted for the effects of possible confounders reported that neoadjuvant ARSI + ADT improved time to biochemical recurrence and metastasis-free survival compared to RP alone. (4) Conclusions: Neoadjuvant ARSI + ADT combination therapy results in improved pathologic response compared to either alone or none in patients with non-metastatic advanced PCa. Ongoing phase III RCTs with long-term oncologic outcomes, as well as biomarker-guided studies, will clarify the indication, oncologic benefits, and adverse events of ARSI + ADT in patients with clinically and biologically aggressive PCa.

Extended pelvic lymph node dissection in muscle invasive bladder cancer.

Bilateral pelvic lymph node dissection (PLND) at the time of radical cystectomy (RC) provides important staging information and oncologic benefit in patients with bladder cancer. The optimal extent of the PLND remains controversial. Our aim is to highlight nodal mapping studies and the data that guides optimization of both staging and oncologic outcomes. We then review contemporary randomized trials studying the extent of PLND. A recent randomized trial (RCT) powered for a 15% improvement in recurrence-free survival (RFS) of extended (e) over limited (l)PLND was completed but failed to identify this large difference in outcome. Concerns over study design limit the ability to interpret the oncologic results. Importantly, ePLND minimally changed surgical morbidity. An ongoing, similar RCT (SWOG S1011) powered to detect a 10% difference in RFS has completed accrual, but no published outcomes are available. RC and ePLND can provide cure in 33% of LN positive bladder cancer patients. Current data support a 5% improvement in RFS if ePLND is routinely used in MIBC patients. Two randomized trials powered to identify much larger (15 and 10%) improvements in RFS are unlikely to identify such an ambitious benefit by extending the PLND.

Strategies to Re-Sensitize Castration-Resistant Prostate Cancer to Antiandrogen Therapy

Since prostate cancer (PCa) was described as androgen-dependent, the androgen receptor (AR) has become the mainstay of its systemic treatment: androgen deprivation therapy (ADT). Although, through recent years, more potent drugs have been incorporated, this chronic AR signaling inhibition inevitably led the tumor to an incurable phase of castration resistance. However, in the castration-resistant status, PCa cells remain highly dependent on the AR signaling axis, and proof of it is that many men with castration-resistant prostate cancer (CRPC) still respond to newer-generation AR signaling inhibitors (ARSis). Nevertheless, this response is limited in time, and soon, the tumor develops adaptive mechanisms that make it again nonresponsive to these treatments. For this reason, researchers are focused on searching for new alternatives to control these nonresponsive tumors, such as: (1) drugs with a different mechanism of action, (2) combination therapies to boost synergies, and (3) agents or strategies to resensitize tumors to previously addressed targets. Taking advantage of the wide variety of mechanisms that promote persistent or reactivated AR signaling in CRPC, many drugs explore this last interesting behavior. In this article, we will review those strategies and drugs that are able to resensitize cancer cells to previously used treatments through the use of "hinge" treatments with the objective of obtaining an oncological benefit. Some examples are: bipolar androgen therapy (BAT) and drugs such as indomethacin, niclosamide, lapatinib, panobinostat, clomipramine, metformin, and antisense oligonucleotides. All of them have shown, in addition to an inhibitory effect on PCa, the rewarding ability to overcome acquired resistance to antiandrogenic agents in CRPC, resensitizing the tumor cells to previously used ARSis.

PD44-04 AGE ASSOCIATED CHANGES TO HEALTH RELATED QUALITY OF LIFE AFTER RADICAL CYSTECTOMY: A PROSPECTIVE STUDY

You have accessJournal of UrologyCME1 Apr 2023PD44-04 AGE ASSOCIATED CHANGES TO HEALTH RELATED QUALITY OF LIFE AFTER RADICAL CYSTECTOMY: A PROSPECTIVE STUDY Kelly R. Pekala, Daniel Sjoberg, New York, NY, Matthew B. Clements, MA Burlington, Benjamin Beech, Thomas Atkinson, Yuelin Li, Andrew Vickers, Harry Herr, S. Machele Donat, Amy Tin, Guido Dalbagni, and Bernard H. Bochner Kelly R. PekalaKelly R. Pekala More articles by this author , Daniel SjobergDaniel Sjoberg More articles by this author , New YorkNew York More articles by this author , NY NY More articles by this author , Matthew B. ClementsMatthew B. Clements More articles by this author , MA BurlingtonMA Burlington More articles by this author , Benjamin BeechBenjamin Beech More articles by this author , Thomas AtkinsonThomas Atkinson More articles by this author , Yuelin LiYuelin Li More articles by this author , Andrew VickersAndrew Vickers More articles by this author , Harry HerrHarry Herr More articles by this author , S. Machele DonatS. Machele Donat More articles by this author , Amy TinAmy Tin More articles by this author , Guido DalbagniGuido Dalbagni More articles by this author , and Bernard H. BochnerBernard H. Bochner More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003354.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: We previously documented the changes and recovery of Health Related Quality of Life (HR-QoL) after Radical Cystectomy (RC), the gold standard for high-risk invasive bladder cancer. The concern that elderly patients may have a poor QoL after RC may lead both patients and clinicians to avoid definitive surgery despite its oncologic benefits. Our objective was to examine post-RC HR-QoL and how it changes with increasing age. METHODS: To better characterize HR-QoL impacts of RC, we conducted a prospective study with 14 validated patient reported outcome measures of interest to invasive bladder cancer patients. Herein, we describe HR-QoL recovery after RC by patient age at surgery. Locally-weighted polynomial linear regression was utilized to estimate the relationship between age and subsequent QoL. QoL measures were assessed at 3 and 12 months after surgery to assess early and later effects on HRQOL and maximize the number of evaluable patients. RESULTS: We did not find any significant (>10 points) age-associated differences on the EORTC QLQ-C30 domains, which are rated on a 0-100 scale (i.e., global QoL, role functioning, cognitive functioning). (Figure 1) Of the differences that approached clinical significance, at 12 months, older patients reported slightly worse physical functioning and fatigue, with a mean physical functioning QoL score of 83 (95% CI 79-86) for a 80-year-old compared to 93 (95% CI 90-96) for a 60-year-old and a mean fatigue score of 28 (95% CI 23-33) for a 80-year-old compared to 18 (95% CI 14-23) for a 60-year old. Using the EORTC BLM-30, we found no major age-related differences in body image or urostomy issues, and a moderate difference in urinary functioning, which is only rated for continent diversions. Regardless of the age at RC, the satisfaction with life and mental health scores are stable at the 12-month time point. CONCLUSIONS: This prospective study demonstrates that older patients selected for RC do not report major decreases to HR-QoL after surgery compared to younger patients. While changes in activity levels and fatigue are mildly greater in the oldest group, overall QoL recovered in a similar fashion to younger patients. Geriatric patients selected for RC have a similar QoL post-RC compared to their younger counterparts and should not be counseled against RC based on QoL concerns alone. Source of Funding: This work was supported by the Sidney Kimmel Center for Prostate and Urologic Cancers, the National Cancer Institute Cancer Center Core grant number P30-CA008748, Ruth L. Kirschstein National Research Service Award T32CA082088, and the Pin Down Bladder Cancer Fund © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1125 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kelly R. Pekala More articles by this author Daniel Sjoberg More articles by this author New York More articles by this author NY More articles by this author Matthew B. Clements More articles by this author MA Burlington More articles by this author Benjamin Beech More articles by this author Thomas Atkinson More articles by this author Yuelin Li More articles by this author Andrew Vickers More articles by this author Harry Herr More articles by this author S. Machele Donat More articles by this author Amy Tin More articles by this author Guido Dalbagni More articles by this author Bernard H. Bochner More articles by this author Expand All Advertisement PDF downloadLoading ...

MP80-10 MANAGEMENT OF BIOCHEMICAL RECURRENCE AFTER PROSTATECTOMY WITHIN THE MUSIC COLLABORATIVE

You have accessJournal of UrologyCME1 Apr 2023MP80-10 MANAGEMENT OF BIOCHEMICAL RECURRENCE AFTER PROSTATECTOMY WITHIN THE MUSIC COLLABORATIVE David Gandham, Ji Qi, Stephanie Ferrante, Kevin Ginsburg, Brian Lane, Todd Morgan, Daniel Triner, Conrad Tobert, and Alice Semerjian David GandhamDavid Gandham More articles by this author , Ji QiJi Qi More articles by this author , Stephanie FerranteStephanie Ferrante More articles by this author , Kevin GinsburgKevin Ginsburg More articles by this author , Brian LaneBrian Lane More articles by this author , Todd MorganTodd Morgan More articles by this author , Daniel TrinerDaniel Triner More articles by this author , Conrad TobertConrad Tobert More articles by this author , and Alice SemerjianAlice Semerjian More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003357.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Although many men remain disease free following radical prostatectomy (RP), some men will develop biochemical recurrence (BCR). Treating (BCR) is challenging as various patient and cancer factors, balancing the oncological benefit, and potential morbidity of treatment must be considered. Herein, we evaluated the use of salvage therapy in men with BCR in diverse, real-world practices. METHODS: The MUSIC registry was queried for men undergoing RP between 3/2012 and 12/2021. Patients were included if they had an initial undetectable post-op PSA (<0.1) and then experienced BCR with PSA >=0.2. Time to salvage treatment after BCR and probability of undergoing treatment were estimated using the Kaplan-Meier method. Type of salvage therapy was summarized based on PSA value at time of treatment (0.1-0.19, 0.2-0.5, 0.51-1.0, and >1.0). Practice-level variation on time to salvage treatment was also assessed among those with at least ten patients. RESULTS: Of 17,755 patients who underwent RP in MUSIC, 2280 patients experienced BCR. Median time to BCR since RP was 9.0 months (IQR 1.7-23.8). Median length of follow up since BCR was 19.5 months (IQR 6.5-37.2). Probability of undergoing treatment sharply increased in the first 12 months following BCR, with 44% of patients getting treatment at 6 months, 52% at 12 months, and 61% at 24 months post-BCR (Figure 1). Among men receiving a salvage treatment, PSA before initiation of salvage therapy was 0.1-0.19 in 2.3% of patients, 0.2-0.5 in 58%, 0.51-1.0 in 15%, and >1.0 in 25%. Patients with higher PSA were more likely to receive systemic therapy (p<0.001). Significant practice-level variation was observed on time to salvage treatment after BCR, with the percent of patients undergoing treatment at 6 months ranging from 20% to 70% among 24 practices (p<0.001). CONCLUSIONS: The time from BCR and the PSA threshold used to trigger salvage treatment in men with BCR varies widely in MUSIC. This data may inform future quality improvement efforts aiming to decrease the variation in the PSA threshold used to initiate salvage therapy and the type of salvage therapy administered to men with BCR. Source of Funding: Blue Cross Blue Shield of Michigan © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1155 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information David Gandham More articles by this author Ji Qi More articles by this author Stephanie Ferrante More articles by this author Kevin Ginsburg More articles by this author Brian Lane More articles by this author Todd Morgan More articles by this author Daniel Triner More articles by this author Conrad Tobert More articles by this author Alice Semerjian More articles by this author Expand All Advertisement PDF downloadLoading ...

Robotic left apicoposterior bisegmentectomy for non–small cell lung cancer

Robotic left apicoposterior bisegmentectomy for non–small cell lung cancer

MP28-19 PATIENT PERCEPTIONS OF ADJUVANT THERAPY IN RENAL CELL CARCINOMA

You have accessJournal of UrologyCME1 Apr 2023MP28-19 PATIENT PERCEPTIONS OF ADJUVANT THERAPY IN RENAL CELL CARCINOMA Michael Staehler, Severin Rodler, Ulka Vaishampayan, Mark Ball, Ithaar Derweesh, Pavlos Msaouel, and Dena Battle Michael StaehlerMichael Staehler More articles by this author , Severin RodlerSeverin Rodler More articles by this author , Ulka VaishampayanUlka Vaishampayan More articles by this author , Mark BallMark Ball More articles by this author , Ithaar DerweeshIthaar Derweesh More articles by this author , Pavlos MsaouelPavlos Msaouel More articles by this author , and Dena BattleDena Battle More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003256.19AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Adjuvant pembrolizumab is currently considered the standard of care for patients with high-risk localized renal cell carcinoma (RCC). However, since approval, multiple trials testing checkpoint inhibitors in the adjuvant setting have failed to meet their primary endpoints, casting doubt on the oncological benefit of therapies that carry the risk of life-long toxicity. We sought to assess how patients perceive the benefits and risks of adjuvant therapy. METHODS: The survey was developed by the Kidney Cancer Research Alliance (KCCure), with multidisciplinary representation from urologic surgeons, medical oncologists and patient advocates. The survey was broadcast between 07/2022 and 09/2022 to patients via website, mailing lists and social media platforms. Multiple responses from the same patient were prohibited via anonymized IP address tracking. Out of 1,062 participants 639 patients self-identified with localized RCC and 223 patients had stage III RCC at initial diagnosis. RESULTS: Median age was 57 years (24-86). 113 patients were offered adjuvant therapy by their doctor, 74 patients were on or had adjuvant therapy (18% TKI, 82% IO). Patients with stage 3 disease assessed their average personal risk of recurrence to be 47% - 10% higher than what they reported their doctor assessed risk to be (37%). The most important factors related to adjuvant decision making, were Risk of Dying from Cancer (76%), severity of possible side effects (43%), chance of having side effects (35%), time required for treatment (24%), cost of treatment (7%). 49% of patients believe that treatment reduces the risk of recurrent disease by more than 30% and 25% believe it reduces risk by more than 50%. Adjuvant therapy was completed by 46%, 17% stopped early due to side effects and 14% recurred while on therapy. Side effects were asymptomatic or mild in 38%, moderate without invasive intervention or hospitalization in 48%, severe, requiring hospitalization in 8% and life-threatening in 7%. 18% of patients were told that their side effects would be life-long. CONCLUSIONS: Patients with high-risk localized disease estimate their risk significantly higher than what their doctors assess their risk to be. Thus, weighing decisions about adjuvant therapy, patients rank risk of dying from cancer over the risk of developing side effects and the severity of side effects. One quarter of patients believe that adjuvant therapy will reduce their risk of recurrence by 50 percent or more. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e378 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Michael Staehler More articles by this author Severin Rodler More articles by this author Ulka Vaishampayan More articles by this author Mark Ball More articles by this author Ithaar Derweesh More articles by this author Pavlos Msaouel More articles by this author Dena Battle More articles by this author Expand All Advertisement PDF downloadLoading ...

MP47-07 PATIENT-SPECIFIC PREDICTORS OF NEPHRECTOMY COMPLICATIONS IN T1B-T2 RENAL CELL CARCINOMA

You have accessJournal of UrologyCME1 Apr 2023MP47-07 PATIENT-SPECIFIC PREDICTORS OF NEPHRECTOMY COMPLICATIONS IN T1B-T2 RENAL CELL CARCINOMA Yash Shah, Rishabh Simhal, Kerith Wang, Hanan Goldberg, Costas Lallas, and Thenappan Chandrasekar Yash ShahYash Shah More articles by this author , Rishabh SimhalRishabh Simhal More articles by this author , Kerith WangKerith Wang More articles by this author , Hanan GoldbergHanan Goldberg More articles by this author , Costas LallasCostas Lallas More articles by this author , and Thenappan ChandrasekarThenappan Chandrasekar More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003293.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The decision between partial (PN) versus radical nephrectomy (RN) for localized T1b-T2 renal cell carcinoma (RCC) remains unclear, particularly in cases of oncologic equivalence. PN offers nephron-sparing benefits but has increased risk of complications. RN putatively maximizes oncologic benefit with complex tumors. We analyzed a new nephrectomy-specific database from the National Surgical Quality Improvement Program to determine if patient-specific factors may predict perioperative outcomes to facilitate treatment choice for T1b-T2 RCC. METHODS: We identified 2,094 localized T1b-T2 RCC patients undergoing nephrectomy from 2019-2020. Variables of interest include surgical procedure and approach, staging, comorbidities, prophylaxis, and 19 specific perioperative complications. 30-day reoperations and readmissions were also captured. Descriptive statistics were compared using Fisher’s exact test and Pearson’s chi-square test. Multivariable logistic regression models were generated to evaluate complication risks following correction for relevant factors. All statistical tests were two-tailed. p<0.05 was considered statistically significant. RESULTS: 816 patients received PN while 1,278 received RN. Reoperation rates were comparable; however, PN patients more commonly experienced 30-day readmissions (7.0% vs. 4.7%, p=0.026), bleeds (9.19% vs. 5.56%, p=0.001), renal failure requiring dialysis (1.23% vs. 0.31%, p=0.013) and urine leak or fistulae (1.10% vs. 0.31%, p=0.025). Rates of infectious, pulmonary, cardiac, and venothromboembolic events were comparable between the PN and RN cohorts. PN remained predictive of all four complications upon multivariable adjustment. Robotic surgery reduced incidence of several complications, readmissions, and reoperations. Several baseline comorbidities were found to increase risk of 11 separate complications, including bleeds and readmissions. CONCLUSIONS: This population-based cohort explicates perioperative outcomes following nephrectomy for pT1b-T2 RCC. In cases of oncologic equivalence, the findings may inform surgical decision making using patient-specific factors. Risk stratification may inform management to improve post-operative quality of life (QOL) and RCC outcomes. Source of Funding: AUA Summer Medical Student Fellowship: Herbert Brendler, MD Research Fund © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e646 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Yash Shah More articles by this author Rishabh Simhal More articles by this author Kerith Wang More articles by this author Hanan Goldberg More articles by this author Costas Lallas More articles by this author Thenappan Chandrasekar More articles by this author Expand All Advertisement PDF downloadLoading ...

MP11-09 SECOND LINE PSMA-TARGETED SALVAGE TREATMENT IN PATIENTS WITH miN1/M1a-b OLIGORECURRENT PCa

You have accessJournal of UrologyCME1 Apr 2023MP11-09 SECOND LINE PSMA-TARGETED SALVAGE TREATMENT IN PATIENTS WITH miN1/M1a-b OLIGORECURRENT PCa Lorenzo Bianchi, Eleonora Balestrazzi, Francesco Ceci, Francesco Costa, Matteo Droghetti, Alessandro Pissavini, Pietro Piazza, Andrea Farolfi, Riccardo Mei, Paolo Castellucci, Stefano Puliatti, Giorgio Gandaglia, Alessandro Larcher, Alexandre Mottrie, Alberto Briganti, Alessio Giuseppe Morganti, Stefano Fanti, Francesco Montorsi, Riccardo Schiavina, and Eugenio Brunocilla Lorenzo BianchiLorenzo Bianchi More articles by this author , Eleonora BalestrazziEleonora Balestrazzi More articles by this author , Francesco CeciFrancesco Ceci More articles by this author , Francesco CostaFrancesco Costa More articles by this author , Matteo DroghettiMatteo Droghetti More articles by this author , Alessandro PissaviniAlessandro Pissavini More articles by this author , Pietro PiazzaPietro Piazza More articles by this author , Andrea FarolfiAndrea Farolfi More articles by this author , Riccardo MeiRiccardo Mei More articles by this author , Paolo CastellucciPaolo Castellucci More articles by this author , Stefano PuliattiStefano Puliatti More articles by this author , Giorgio GandagliaGiorgio Gandaglia More articles by this author , Alessandro LarcherAlessandro Larcher More articles by this author , Alexandre MottrieAlexandre Mottrie More articles by this author , Alberto BrigantiAlberto Briganti More articles by this author , Alessio Giuseppe MorgantiAlessio Giuseppe Morganti More articles by this author , Stefano FantiStefano Fanti More articles by this author , Francesco MontorsiFrancesco Montorsi More articles by this author , Riccardo SchiavinaRiccardo Schiavina More articles by this author , and Eugenio BrunocillaEugenio Brunocilla More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003226.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: PSMA-PET is considered the imaging of choice in patients with recurrent prostate cancer (PCa) after primary treatments. Recurrent PCa includes various clinical settings. Thus, we aimed to explore the oncologic benefit of second-line salvage PSMA-guided MDT (metastases directed treatment) in PCa patients with recurrence after previous salvage treatments and oligo-recurrent N1/M1a-b disease at PSMA-PET. METHODS: We retrospectively analyzed patients underwent RP (radical prostatectomy) for PCa and PSMA-PET (from January 2016 to February 2021) performed for biochemical recurrence (BCR) after first-line salvage therapies for BCR after PR at 3 high volume European Centers. Oligo-recurrent (≤3 lesions) patients with N1/M1a-b disease at PSMA-PET and eligible for MDT were identified. MDT consist of salvage lymph node dissection (sLND) and stereotactic body radiotherapy (SBRT) or combination of both. Conventional approach includes observation or androgen deprivation therapy. Men were stratified according to treatment after PSMA-PET (MDT vs. conventional approach). Kaplan Meier curves were used to assess progression free survival (PFS), metastases free survival (MFS) and CRPC free survival (CRPC-FS) at 3 years of follow up after stratifying according to treatment after PSMA-PET. Multivariable Cox regression was performed to identify independent predictors of progression and metastases. RESULTS: Overall, 113 patients were enrolled: 91 patients were treated with MDT approach and 22 with conventional approach. The median (IQR) follow-up after PSMA-PET was 31 (19-42) months. Overall, no significant differences were found concerning 3-years PFS according to type of treatment (p=0.3). MFS and CRPC-FS estimates at 3 years were 73.5% and 94.7% in patients underwent MDT vs 30.5% and 79.5% in men treated with conventional approach, respectively (all p<0.001). At the multivariable Cox regression analysis, age (HR=0.96) and pT3b-pT4 (HR=2.02) were independent predictors of progression (all p≤0.03), while MDT (HR 0.37) was the only independent predictor of metastases (p= 0.02). CONCLUSIONS: In a selected population of oligo-recurrent N1/M1a-b Pca patients with limited therapeutic chances due to previous salvage treatments, the MDT targeted to PSMA-PET may represent a promising second-line salvage approach to delay further progression to CRPC status. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e126 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Lorenzo Bianchi More articles by this author Eleonora Balestrazzi More articles by this author Francesco Ceci More articles by this author Francesco Costa More articles by this author Matteo Droghetti More articles by this author Alessandro Pissavini More articles by this author Pietro Piazza More articles by this author Andrea Farolfi More articles by this author Riccardo Mei More articles by this author Paolo Castellucci More articles by this author Stefano Puliatti More articles by this author Giorgio Gandaglia More articles by this author Alessandro Larcher More articles by this author Alexandre Mottrie More articles by this author Alberto Briganti More articles by this author Alessio Giuseppe Morganti More articles by this author Stefano Fanti More articles by this author Francesco Montorsi More articles by this author Riccardo Schiavina More articles by this author Eugenio Brunocilla More articles by this author Expand All Advertisement PDF downloadLoading ...

Precision Surgery of Colorectal Liver Metastases in the Current Era: A Systematic Review

Liver resection for colorectal liver metastases (CRLM) is widely considered the treatment with the highest curative potential. However, not all patients derive the same oncological benefit, underlining the need for better patient stratification and treatment allocation. In this context, we performed a systematic review of the literature to determine the role of RAS status in selecting the optimal surgical strategy. Evidence comparing anatomical with non-anatomical resections depending on RAS mutational status was scarce and conflicting, with two studies reporting superiority in mutated RAS (mutRAS) patients and two studies reporting equivalent outcomes. The rate of incomplete microscopic resection (R1) was found to be increased among mutRAS patients, possibly due to higher micrometastatic spread lateral to the primary lesion. The impact of R1 resection margins was evaluated separately for mutRAS and wild-type patients in three studies, of which, two indicated an additive detriment to long-term survival in the former group. In the current era of precision surgery, RAS status can be utilized to predict the efficacy of liver resection in the treatment of CRLM, avoiding a potentially morbid operation in patients with adverse tumor profiles.

Oncological and physiological impact of thoracic duct resection in esophageal cancer.

Despite advances in multidisciplinary treatment, esophagectomy remains the main curative treatment for esophageal cancer. The advantages and disadvantages of thoracic duct (TD) resection have been controversial for decades. We have herein reviewed relevant published literature regarding 'thoracic duct,' 'esophageal cancer,' and 'esophagectomy' describing the anatomy and function of the TD, and incidence of thoracic duct lymph nodes (TDLN) and TDLN metastases, as well as the oncological and physiological effects of TD resection. The presence of lymph nodes around the TD, referred to as TDLN, has been reported previously. The delineation of TDLNs is clearly defined by a thin fascial structure covering the TD and the surrounding adipose tissue. Previous studies have examined the number of TDLNs and the percentage of patients with TDLN metastasis and revealed that each patient had approximately two TDLNs. The percentage of patients with TDLN metastasis was reported to be 6-15%. Several studies have been conducted to compare the survival after TD resection with that after TD preservation. However, no consensus has been reached because all studies were retrospective, precluding firm conclusions. Although the issue of whether the risk of postoperative complications is affected by TD resection is still unclear, resecting the TD has been shown to have a long-term impact on nutritional status after surgery. In summary, TDLNs are quite common and present in most patients, while metastasis in the TDLNs occurs in a minority. However, the oncological value of TD resection in esophageal cancer surgery remains controversial due to varying findings and methodological limitations of previous comparative studies. Considering the potential but unproven oncological benefits and possible physiological drawbacks of TD resection, including postoperative fluid retention and disadvantages in the long-term nutritional outcome, clinical stage, and nutritional status should be considered before deciding whether to perform TD resection or not.

Multivariable prediction model for both 90-day mortality and long-term survival for individual patients with perihilar cholangiocarcinoma: does the predicted survival justify the surgical risk?

The risk of death after surgery for perihilar cholangiocarcinoma is high; nearly one in every five patients dies within 90 days after surgery. When the oncological benefit is limited, a high-risk resection may not be justified. This retrospective cohort study aimed to create two preoperative prognostic models to predict 90-day mortality and overall survival (OS) after major liver resection for perihilar cholangiocarcinoma. Separate models were built with factors known before surgery using multivariable regression analysis for 90-day mortality and OS. Patients were categorized in three groups: favourable profile for surgical resection (90-day mortality rate below 10 per cent and predicted OS more than 3 years), unfavourable profile (90-day mortality rate above 25 per cent and/or predicted OS below 1.5 years), and an intermediate group. A total of 1673 patients were included. Independent risk factors for both 90-day mortality and OS included ASA grade III-IV, large tumour diameter, and right-sided hepatectomy. Additional risk factors for 90-day mortality were advanced age and preoperative cholangitis; those for long-term OS were high BMI, preoperative jaundice, Bismuth IV, and hepatic artery involvement. In total, 294 patients (17.6 per cent) had a favourable risk profile for surgery (90-day mortality rate 5.8 per cent and median OS 42 months), 271 patients (16.2 per cent) an unfavourable risk profile (90-day mortality rate 26.8 per cent and median OS 16 months), and 1108 patients (66.2 per cent) an intermediate risk profile (90-day mortality rate 12.5 per cent and median OS 27 months). Preoperative risk models for 90-day mortality and OS can help identify patients with resectable perihilar cholangiocarcinoma who are unlikely to benefit from surgical resection. Tailored shared decision-making is particularly essential for the large intermediate group.

Does a brief surgeon training in negotiation theory principles decrease rates of contralateral prophylactic mastectomy?

Despite the lack of any oncologic benefit, contralateral prophylactic mastectomy (CPM) use among women with unilateral breast cancer is increasing. This patient-driven trend is influenced by fear of recurrence and desire for peace of mind. Traditional educational strategies have been ineffective in reducing CPM rates. Here we employ training in negotiation theory strategies for counseling and determine the effect on CPM rates. In consecutive patients with unilateral breast cancer treated with mastectomy from 05/2017 to 12/2019, we examined CPM rates before and after a brief surgeon training in negotiation skills. This comprised a systematic framework for patient counseling utilizing early setting of the default option, leveraging social proof, and framing. Among 2144 patients, 925 (43%) were treated pre-training and 744 (35%) post-training. Those treated in the 6-month transition period were excluded (n = 475, 22%). Median patient age was 50years; most patients had T1-T2 (72%), N0 (73%), and estrogen receptor-positive (80%) tumors of ductal histology (72%). The CPM rate was 47% pre-training versus 48% post-training, with an adjusted difference of -3.7% (95% CI -9.4 to 2.1, p = 0.2). In a standardized self-assessment survey, all 15 surgeons reported a high baseline use of negotiation skills and no significant change in conversational difficulty with the structured approach. Brief surgeon training did not affect self-reported use of negotiation skills or reduce CPM rates. The choice of CPM is a highly individual decision influenced by patient values and decision styles. Further research to identify effective strategies to minimize surgical overtreatment with CPM is needed.