Rate Of Upstaging Research Articles

High-Risk of Adverse Pathologic Features in Patients With Clinical T1 High-Grade Bladder Cancer Undergoing Radical Cystectomy.

Radical cystectomy (RC) is used to treat select patients with T1 high-grade (T1HG) bladder cancer. However, population-level utilization trends and outcomes for these patients are not well-known. We sought to evaluate treatment patterns and clinicopathologic outcomes of RC for T1HG bladder cancer. Using the National Cancer Data Base (NCDB) for 1998-2012, we conducted a retrospective cohort study of patients with clinical T1HG bladder cancer. The prevalence of RC used to treat T1HG bladder cancer from 1998-2012 was determined. For years 2010-2012, demographic and cancer-related factors were described and regression analysis was used to examine associations with RC. Oncologic outcomes of RC were described and related to mortality using Cox proportional hazards regression. Treatment of T1HG bladder cancer with RC nearly doubled, from 5.5% during 1998-2000 to 9.9%, during 2010-2012. For 2010-2012, 18,277 patients with T1HG bladder cancer were analyzed. Patients who underwent RC were younger, had fewer comorbidities, and were more often treated at an academic center than those who did not undergo RC. At the time of RC, 41% of patients with T1HG bladder cancer were upstaged (pT2 or greater) and 12.7% had lymph node metastases. The 1- and 3-year survival rates were 0.89 and 0.68, respectively. Extravesical (T3+) disease at RC had the strongest independent hazard (hazard ratio [HR], 2.32; 95% CI, 1.72-3.11) of death other than age of 82 years or older (HR, 3.40; 95% CI, 2.28-5.07). The use of RC for T1HG bladder cancer has increased in prevalence in recent years but is still not widely used. There are concerning pathologic outcomes in patients with clinical T1HG bladder cancer treated with RC, including high rates of pathologic upstaging and nodal metastases. Future studies are necessary to better risk-stratify patients with T1HG bladder cancer to best select those who will benefit from aggressive therapy with RC.

Lobular carcinoma in situ of the breast - correlation between minimally invasive biopsy and final pathology.

IntroductionLobular carcinoma in situ (LCIS) is regarded as a non-obligate precursor of invasive breast cancer (IBC). Hence, the optimal management of LCIS found on minimally invasive breast biopsy remains a subject of debate. The aim of this study was to evaluate the correlation of biopsy findings with postoperative histology and to identify risk factors for upstaging to IBC.Material and methodsTwenty-seven patients with pure LCIS diagnosed on image-guided biopsy (vacuum-assisted or core-needle) underwent subsequent surgery. Clinical, radiological and histological features were compared to the final pathology after surgical excision.ResultsMedian age of patients was 56 years while median size of LCIS was 15 mm. Final examination demonstrated IBC foci in 29.6% of lesions. Upstaged patients were younger and had larger lesions but without statistical significance (p = 0.07 and p = 0.09, respectively). Palpable tumours (p = 0.0004), BIRADS 5 lesions (p = 0.0001), masses (p = 0.016) and pleomorphic LCIS (p = 0.0001) had a significantly increased rate of upstaging. Guidance of the procedure (ultrasound vs. stereotactic) was significantly associated with the upstaging risk (p = 0.016), while the importance of the biopsy technique (core-needle vs. vacuum-assisted) was not confirmed (p = 0.37). After excluding pleomorphic LCIS and mass-forming classic LCIS, there was no risk of upstaging for lesions with BIRADS 4 mammographic abnormalities.ConclusionsPleomorphic histology, mass formation and BIRADS 5 category reflect more aggressive behaviour of LCIS and identify patients who need subsequent surgery. For other patients, close follow-up could be a safe alternative.

Mucocele-Like Lesions of the Breast: Rate of Upstaging and Cancer Development.

Breast mucocele-like lesions (MLLs) are rare breast lesions. There is a paucity of literature on the rate of pathologic upstaging of MLL to insitu or invasive breast cancer. We sought to review our experience with MLL at a tertiary care center and review published literature. A retrospective review was undertaken of all patients with breast MLL at the Mayo Clinic, Rochester, from 1998 to 2016. Descriptive statistics were performed. Overall, 30 patients were diagnosed with MLL, with a mean age of 54.6years (range 51-58). Calcifications on screening mammogram were the most common method of MLL detection (n=26, 86.7%), with core needle biopsy (CNB) being performed in 29/30 patients. MLL with atypia was identified in 14 patients (48%), and surgical excision was performed in 26 patients. Disease was upstaged to invasive disease in one patient (3.8%) who presented with a palpable mass. With a median duration of follow up of 3.5years [interquartile range 1-7.1], two patients developed contralateral invasive breast cancer (both patients had a remote history of invasive breast cancer on that side), and one patient developed contralateral in situ disease. Review of the literature demonstrates a 2.9% upgrade rate of MLL without atypia on excisional biopsy. The upstage rate of MLL identified on CNB to invasive disease at surgical excision in this series was 3.8%. In cases with MLL presenting as calcifications, no cases were upstaged in this series. Across the literature, upstage rates of MLL without atypia on CNB are low, indicating excisional biopsy may be avoided in these cases.

Is Extensive Parenchymal Resection During Robotic Partial Nephrectomy Justified? A Match-Paired Comparison of Two Extirpative Surgical Modalities for Treatment of a Complex Renal Neoplasm.

To analyze the outcomes of robotic partial nephrectomy (RPN) in patients where nephron-sparing surgery would have mandated a large amount of renal volume resection. Patients undergoing RPN with extensive volume resection (≥30%), from 2006 to 2014, were identified. Pre- and postoperative CT/MRI-based volumetric assessment of the operated kidney was performed. To address the possible benefits of RPN, we matched this cohort to patients undergoing laparoscopic radical nephrectomy (LRN). The groups were matched for tumor size, R.E.N.A.L. nephrometry score, age-adjusted Charlson comorbidity index (ACCI), and preoperative estimated glomerular filtration rate (eGFR). Demographics, perioperative, functional, and oncologic outcomes were compared between the groups. Multivariable analysis of factors predicting chronic kidney disease (CKD) upstaging (type of surgery, R.E.N.A.L. score, ACCI, and baseline eGFR) was performed. In total, 52 patients undergoing RPN were matched to 52 LRN patients. The median R.E.N.A.L. score (interquartile range) was 9 (9-10) for both groups. Demographic variables were comparable between the groups. The median renal volume preservation in the RPN group was 57.0% (47.2-67.2). The rates of overall and major complications were comparable between RPN and LRN. The RPN group had higher overall eGFR preservation (75.8% vs 68.5%; p = 0.01) and a lower rate of CKD upstaging (26.9% vs 50.6%; p = 0.001). On multivariable analysis, LRN and baseline eGFR were significant predictors of CKD upstaging (odds ratio [OR] 4.26; 95% CI [1.80-10.12]; p = 0.001 and OR 0.98; 95% CI [0.96-0.99]; p = 0.03, respectively). During the median follow-up time of 21 (9-36) months, local recurrence, metastasis, and cancer-specific and overall survival were comparable between RPN and LRN. RPN requiring extensive volume resection provides renal functional preservation without significant increase in surgical complications or compromising short-term oncologic outcomes.

Survival After Sublobar Resection versus Lobectomy for Clinical Stage IA Lung Cancer: An Analysis from the National Cancer Data Base

Recent data have suggested possible oncologic equivalence of sublobar resection with lobectomy for early-stage non-small-cell lung cancer (NSCLC). Our aim was to evaluate and compare short-term and long-term survival for these surgical approaches. This retrospective cohort study utilized the National Cancer Data Base. Patients undergoing lobectomy, segmentectomy, or wedge resection for preoperative clinical T1A N0 NSCLC from 2003 to 2011 were identified. Overall survival (OS) and 30-day mortality were analyzed using multivariable Cox proportional hazards models, logistic regression models, and propensity score matching. Further analysis of survival stratified by tumor size, facility type, number of lymph nodes (LNs) examined, and surgical margins was performed. A total of 13,606 patients were identified. After propensity score matching, 987 patients remained in each group. Both segmentectomy and wedge resection were associated with significantly worse OS when compared with lobectomy (hazard ratio: 1.70 and 1.45, respectively, both p < 0.001), with no difference in 30-day mortality. Median OS for lobectomy, segmentectomy, and wedge resection were 100, 74, and 68 months, respectively (p < 0.001). Finally, sublobar resection was associated with increased likelihood of positive surgical margins, lower likelihood of having more than three LNs examined, and significantly lower rates of nodal upstaging. In this large national-level, clinically diverse sample of clinical T1A NSCLC patients, wedge and segmental resections were shown to have significantly worse OS compared with lobectomy. Further patients undergoing sublobar resection were more likely to have inadequate lymphadenectomy and positive margins. Ongoing prospective study taking into account LN upstaging and margin status is still needed.

Repeat transurethral resection for non-muscle-invasive bladder cancer: a contemporary series.

To evaluate the depth of transurethral resections of bladder tumour (TURBT), residual cancer rates and up-staging rates in a contemporary Australian series. Specimen reports from a single, major reporting pathology centre, servicing a group of urological oncologists in Sydney were obtained for TURBTs performed between October 2008 and February 2013. We examined the depth of TURBT, rates of repeat-TURBT (re-TUR) and residual cancer rates at the 3-6month check cystoscopy. One thousand and two hundred and nine transurethral resection specimens retrieved during this period were analysed. There were 162 (13.4%) T1 specimens and 631 (52.2%) Ta specimens, 218 (34.5%) of which were high grade. Muscularis propria was present in 506 (41.9%) specimens in total and in 151 (39.7%) of 380 high-risk specimens (high grade Ta, T1). Of the 380 high-risk non-muscle-invasive tumours, 85 (22.4%) proceeded to re-TUR. Of the 48 T1 specimens and 37 Ta high grade specimens that proceeded to re-TUR, 7 (14.6%) and 1 (2.7%) respectively were upstaged to muscle-invasive disease. Rates of residual disease/early recurrence at 3-6months was significantly better for those with re-TUR compared to those without 56.8% vs 82.5% (P < 0.001) for Ta high grade and 39.6% vs 84% (P = 0.028) for T1 tumours respectively. Re-TUR rates in high-risk non-muscle-invasive bladder cancer are low. However in a contemporary series, the upstaging rates are low, but residual cancer rates high, supporting the need for re-TUR in this population.

Nodal Upstaging During Lung Cancer Resection Is Associated With Surgical Approach

Recent reports indicate that thoracoscopic lobectomy for lung cancer may be associated with lower rates of surgical upstaging. We queried a statewide cancer registry for differences in upstaging rates and survival by surgical approach. The Kentucky Cancer Registry (KCR) collects data, including centralized pathology reporting, on cancer patients treated statewide. We performed a retrospective review from 2010 to 2012 to examine clinical and pathologic stage. We assessed rates of upstaging and whether the surgical approach, thoracotomy (THOR) versus minimally invasive techniques (video-assisted thoracic surgery; VATS), had an impact on final pathologic stage and survival. The KCR database from 2010 to 2012 contained information on 2830 lung cancer cases, 1964 having THOR procedure and 500 having VATS resections. Preoperatively, 36.4% of THOR were clinically stage 1a versus 47.4% VATS (p = 0.0002). Of these, final pathologic stage remained stage 1a in 30.5% of THOR procedures and 38.0% of VATS (p = 0.0002). The overall nodal upstaging rate for THOR was 9.9% and 4.8% for VATS (p = 0.002). Decreased nodal upstaging was found with VATS, independent of tumor size and extent of resection (odds ratio 0.6, 95% confidence interval [CI]: 0.387 to 0.985, p = 0.04). However, improved survival was found with VATS compared with THOR (hazard ratio 0.733, 95% CI: 0.592 to 0.907, p = 0.0042). Consistent with other reports, we report a lower upstaging rate with VATS. Nevertheless, there is a survival advantage in VATS patients. Although selection bias may play a role in these observed differences, the improved quality of life measures associated with VATS may explain survival improvement despite lower surgical upstaging.

A standardized technique of systematic mediastinal lymph node dissection by video-assisted thoracoscopic surgery (VATS) leads to a high rate of nodal upstaging in early-stage non-small cell lung cancer.

A substantial part of the oncologic surgical procedure in non-small cell lung cancer (NSCLC) is systematic lymph node dissection (sLND). However, controversies still exist regarding the quality of minimally invasive (video-assisted thoracoscopic surgery, VATS) sLND in oncologic resections. The rate of stage migration from clinical to pathological N-status has been discussed as one parameter for the quality of sLND. Between March 2011 and May 2014, seventy-seven patients (62 male, 15 female) were scheduled for anatomical lung resection and sLND by VATS for clinical stage I (UICC 7th edition) NSCLC. Preoperative staging was performed by [18F]-fluorodesoxyglucose positron emission tomography with computed tomography (FDG-PET/CT). Patient data were retrospectively analyzed with regard to divergence in clinical and pathological N-factor. FDG-PET/CTs of patients with lymph node (LN) upstaging after VATS resections were blindly re-evaluated by an experienced radiologist. In FDG-PET/CT, preoperative tumor stage was cT1N0M0 in 41 (53.2%) and cT2aN0M0 in 28 (36.4%) patients. In six (7.8%) patients the primary tumor was not suspicious for malignancy, and in two (2.6%) patients the tumor was not evaluable due to prior wedge resection before FDG-PET/CT. Thirty-one (40.3%) left-sided and 46 (59.7%) right-sided pulmonary resections with sLND were performed; 19.57 ± 0.99 LNs were dissected. In 13 (16.9%) patients a nodal stage migration from preoperative clinical to postoperative pathological N-stage was observed [cN0 to pN1 in 9 (11.7%) and cN0 to pN2 in 4 (5.2%) cases]. In correlation to the clinical T-factor, the rate of N-factor upstaging for cT1 was 12.2% and for cT2a was 28.6%, respectively. In 50% of the patients with postoperative nodal staging shift, no changes were observed on re-evaluation of the preoperative FDG-PET/CT. In this series of clinical stage I NSCLC patients, the rate of nodal stage migration after sLND by VATS is higher than previously reported. Prospective randomized controlled trials are needed to prove the oncologic quality of a sLND by VATS versus standard open approach.

MP53-04 SIGNIFICANT INTER-INSTITUTIONAL VARIATIONS IN RACIAL DISPARITIES AMONG AFRICAN-AMERICAN MEN ELIGIBLE FOR PROSTATE CANCER ACTIVE SURVEILLANCE

MP53-04 SIGNIFICANT INTER-INSTITUTIONAL VARIATIONS IN RACIAL DISPARITIES AMONG AFRICAN-AMERICAN MEN ELIGIBLE FOR PROSTATE CANCER ACTIVE SURVEILLANCE

Magnetic Resonance Imaging-Guided Core Needle Breast Biopsies Resulting in High-Risk Histopathologic Findings: Upstage Frequency and Lesion Characteristics

IntroductionThe purpose of the present study was to determine the malignancy upstage rates and imaging features of high-risk histopathologic findings resulting from magnetic resonance imaging (MRI)-guided core needle breast biopsies. These features include atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), flat epithelial atypia (FEA), and lobular carcinoma in situ (LCIS). Materials and MethodsA retrospective medical record review was performed on all MRI-guided core needle breast biopsies at a single institution from June 1, 2007 to December 1, 2013 to select biopsies yielding high-risk histopathologic findings. The patient demographics, MRI lesion characteristics, and histopathologic features at biopsy and surgical excision were analyzed. ResultsA total of 257 MRI-guided biopsies had been performed, and 50 yielded high-risk histopathologic features (19%). Biopsy site and surgical excision site correlation was confirmed in 29 of 50 cases. Four of 29 lesions (14%) were upstaged: 1 case to invasive ductal carcinoma and 3 cases to ductal carcinoma in situ. ADH alone had an overall upstage rate of 7% (1 of 14), mixed ADH/ALH a rate of 75% (3 of 4), ALH alone or with LCIS a rate of 0% (0 of 7), and FEA a rate of 0% (0 of 4). Only mixed ADH/ALH had a statistically significant upstage rate to malignancy compared with the other high-risk histopathologic subtypes combined. No specific imaging characteristics on MRI were associated with an upstage to malignancy on the statistical analysis. ConclusionMRI-guided breast biopsies yielding high-risk histopathologic features were associated with an overall upstage to malignancy rate of 14% at surgical excision. All upstaged lesions were associated with ADH. FEA and ALH alone or with LCIS were not associated with an upstage to malignancy.

Does 8-guage stereotactic core needle biopsy improve the accuracy over 11-gauge devices? Evaluation of pure DCIS on stereotactic biopsy and the rate of upstaging.

97 Background: Ductal carcinoma in situ (DCIS) accounts for 25% of newly diagnosed breast cancers. Core needle biopsy (CNB) has replaced open surgical biopsy for mammographic calcifications. We compare our experience with 8-gauge vs. 11-gauge vacuum assisted core needle biopsy in pure DCIS. We hypothesize that the diagnosis of DCIS with use of an 8-gauge vacuum-assisted core needle will lead to a lower rate of upstaging to invasive cancer at definitive surgical excision compared to 11-gauge vacuum-assisted core needle biopsy. Methods: A retrospective study was performed evaluating all patients who underwent a stereotactic core needle biopsy at our institution for DCIS during 2008-2012.We then compared the upstaging rates between patients biopsied using 8 or 11-gauge biopsy devices. Results: A total of 580 patients underwent STCNB during 2008-2012 at our institution, there were 461 patients excluded as they did not meet inclusion criteria and 119 patients were included. The most common mammographic finding was calcifications in 104/119 (87.4%) and a mammographic mass in 15/119 (12.60%). Biopsy with the 11 gauge needle was utilized in 60 patients and 59 patients with 8-G needle. Factors associated with upstaging were using a smaller 11 gauge needle and a mass on imaging, higher grade and more than four cores obtained on biopsy. There was an upstaging rate of 17/60 (28%) in patients who underwent stereotactic biopsy using a11-gauge needle versus upstaging rate of 7/59 (11.8%) in patients who underwent stereotactic biopsy using 8 gauge needle. We obtained a statistically significant p-value of 0.025. Conclusions: This is one of the few studies comparing upstaging rates from pure DCIS on STCNB using 8 and 11-gauge stereotactic vacuum assisted needles. Our results show that there is a statistically significant decrease in upstaging of pure DCIS to invasive malignancy at excision using the larger 8-gauge needle devices. The clinical implication is that SLNB need not be performed secondary to the low upstaging rate. We recommend that all stereotactic core needle biopsies be performed using the 8-gauge needle devices, and that SLNB generally be omitted for DCIS.

The Prevalence of Nodal Upstaging During Robotic Lung Resection in Early Stage Non-Small Cell Lung Cancer

Pathologic nodal upstaging can be considered a surrogate for completeness of nodal evaluation and quality of surgery. We sought to determine the rate of nodal upstaging and disease-free and overall survival with a robotic approach in clinical stage I NSCLC. We retrospectively reviewed patients with clinical stage I NSCLC after robotic lobectomy or segmentectomy at three centers from 2009 to 2012. Data were collected primarily based on Society of Thoracic Surgeons database elements. Robotic anatomic lung resection was performed in 302 patients. The majority were right sided (192; 63.6%) and of the upper lobe (192; 63.6%). Most were clinical stage IA (237; 78.5%). Pathologic nodal upstaging occurred in 33 patients (10.9% [pN1 20, 6.6%; pN2 13, 4.3%]). Hilar (pN1) upstaging occurred in 3.5%, 8.6%, and 10.8%, respectively, for cT1a, cT1b, and cT2a tumors. Comparatively, historic hilar upstage rates of video-assisted thoracoscopic surgery (VATS) versus thoracotomy for cT1a, cT1b, and cT2a were 5.2%, 7.1%, and 5.7%, versus 7.4%, 8.8%, and 11.5%, respectively. Median follow-up was 12.3 months (range, 0 to 49). Forty patients (13.2%) had disease recurrence (local 11, 3.6%; regional 7, 2.3%; distant 22, 7.3%). The 2-year overall survival was 87.6%, and the disease-free survival was 70.2%. The rate of nodal upstaging for robotic resection appears to be superior to VATS and similar to thoracotomy data when analyzed by clinical T stage. Both disease-free and overall survival were comparable to recent VATS and thoracotomy data. A larger series ofmatched open, VATS and robotic approaches is necessary.

Racial Variation in Prostate Cancer Upgrading and Upstaging Among Men with Low-risk Clinical Characteristics

BackgroundAfrican American (AA) men suffer a higher prostate cancer (PCa) burden than other groups. ObjectiveWe aim to determine the impact of race on the risk of upgrading, upstaging, and positive surgical margins (PSM) at radical prostatectomy (RP) among men eligible for active surveillance. Design, setting, and participantsWe studied men with low-risk PCa treated with RP at two centers. Low clinical risk was defined by National Comprehensive Cancer Network criteria. Outcome variables were upgrading, upstaging, and PSMs at surgery. Associations between race and the outcomes were evaluated with logistic regression adjusted for age, relationship status, diagnostic prostate-specific antigen level, percentage of positive biopsy cores, surgical approach, year of diagnosis, and clinical site. Results and limitationsOf 9304 men diagnosed with PCa, 4231 were low risk and underwent RP within 1 yr. Men were categorized as AA (n=273; 6.5%), Caucasian (n=3771; 89.1%), or other racial/ethnic group (Other; n=187; 4.4%). AA men had a significantly younger mean age (58.7 yr; standard deviation: ±7.06), and fewer (85%) were married or had a partner. Upgrading (34%) and upstaging (13%) rates did not significantly differ among the groups. The PSM rate was significantly higher in AA men (31%) than in the Caucasian (21%) and Other (20%) groups (p<0.01). We found an association between race group and PSM rate (p<0.03), with higher odds of PSMs in AA men versus Caucasian men (odds ratio [OR]: 1.64; 95% confidence interval [CI], 1.08–2.47). No statistically significant associations between race and rates of upgrading and upstaging were found. This study was limited by the relatively low proportion of AA men in the cohort. ConclusionsAmong clinically low-risk men who underwent RP, AA men had a higher likelihood of PSMs compared with Caucasian men. We did not find statistically significantly different rates of upgrading and upstaging between the race groups. Patient summaryWe analyzed two large groups of men with what appeared to be low-risk prostate cancer based on the initial biopsy findings. The likelihood of finding worse disease (higher grade or stage) at the time of surgery was similar across different racial groups.

Highlights from the canadian bladder cancer network.

It is an honour and privilege to introduce this issue of the CUAJ as the recently appointed Associate Editor for our journal. One of the important contributions in this issue includes that of Dr. Pouliot and colleagues from Universite Laval further defining the risk factors associated with renal deterioration after laparoscopic partial nephrectomy.1 The authors suggest that our surgical planning should focus more on limiting resection of normal tissue, careful closure of the collecting system and hemostasis, while paying less heed to early unclamping of vessels as long as warm ischemic time can be limited to 30 minutes. Also, Dr. Abdullah and Dr. Kapoor present a well-timed review of what is a mounting paradigm-shift around the management of castration-resistant prostate cancer (CRPC).2 This article should be required reading for all those who manage patients with prostate cancer. Finally, we are delighted to be able to highlight the recent work from the research team of the Canadian Bladder Cancer Network (CBCN).3 This consortium of Canadian investigators has evolved out of an unmet need due to traditionally underfunded urothelial cancer research. The network has so far compiled the clinical and pathologic data of 2287 contemporary patients who underwent cystectomy, implementing multiple strict quality control procedures to ensure accuracy and concordance of their data. This article focuses on patients who underwent cystectomy for high-grade T1 bladder cancer and confirms the ominous results recently demonstrated in other series.4,5 In this cohort of patients, local tumour upstaging to muscle invasive disease was evident in 48% of cases, with an alarming lymph node involvement of 19.9%. Although the treatment options for non-muscle invasive transitional cell carcinoma are well-described in many guidelines,6 including the recent CUA offering,7 there is little debate that the optimal management of high-grade T1 disease remains a common and vexing dilemma. Most recommendations for high-grade T1 disease include an initial attempt at bladder preservation (grade A) with the option of “early” cystectomy in those with high risk of progression (grade C). The extraordinarily high rates of pathologic upstaging and only modest disease-free survival demonstrated in this and other reports however would suggest the inadequacy of our clinical decision-making based on available tools for risk stratification and current treatment algorithms. Although the present study is limited by selection bias and the lack of certain clinical parameters, the results underscore the need to more effectively identify patients at high risk of progression. Given the propensity towards bladder sparing in Canada and the fact that randomized trials are unrealistic, it is apparent that the time has come to rally support and resources for future collaborative work embodied by the CBCN. Facilitating prospective, multi-institutional registry studies to further identify clinical, pathologic and molecular factors predicting progression is needed to inform us when we should “cut bait” and move on to definitive therapy for this invasive stage of disease.

226 INCREASED INCIDENCE OF PATHOLOGICALLY NON-ORGAN CONFINED PROSTATE CANCER IN AFRICAN-AMERICAN MEN ELIGIBLE FOR ACTIVE SURVEILLANCE

You have accessJournal of UrologyProstate Cancer: Epidemiology & Natural History (I)1 Apr 2013226 INCREASED INCIDENCE OF PATHOLOGICALLY NON-ORGAN CONFINED PROSTATE CANCER IN AFRICAN-AMERICAN MEN ELIGIBLE FOR ACTIVE SURVEILLANCE Yun-Sok Ha, Amirali Salmasi, Jeong Hyun Kim, Jae Young Joung, Dong Hyeon Lee, Wun-Jae Kim, and Isaac Yi Kim Yun-Sok HaYun-Sok Ha New Brunswick, NJ More articles by this author , Amirali SalmasiAmirali Salmasi New Brunswick, NJ More articles by this author , Jeong Hyun KimJeong Hyun Kim Chuncheon, Korea, Republic of More articles by this author , Jae Young JoungJae Young Joung Goyang, Korea, Republic of More articles by this author , Dong Hyeon LeeDong Hyeon Lee Seoul, Korea, Republic of More articles by this author , Wun-Jae KimWun-Jae Kim Cheongju, Korea, Republic of More articles by this author , and Isaac Yi KimIsaac Yi Kim New Brunswick, NJ More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.1606AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES African-American (AA) men have a relatively higher risk of developing prostate cancer (PCa) and dying of PCa compared to White-American (WA) men. For this reason, it is unclear whether the same active surveillance (AS) criteria should be applied to AA men. The aim of the present study is to compare the clinicopathologic findings of AA and WA men with prostate cancer who were candidates for active surveillance (AS) and underwent radical prostatectomy (RP). METHODS Prospectively maintained database of men who underwent RP from two academic centers were analyzed retrospectively. Post-operative pathologic characteristics of patients who met the AS inclusion criteria of the University of California, San Francisco (UCSF) and National Comprehensive Cancer Network (NCCN) were evaluated. After RP, the rate of pathological upstaging and Gleason upgrading were compared between AA and WA. RESULTS In the AA cohort, 196 and 124 met the UCSF and NCCN criteria for AS, respectively. With respect to WA patients, 191 and 148 fulfilled the AS criteria for UCSF and NCCN. AA men had higher percentage of maximum biopsy core than WA (15.3- 20.4% vs. 11.5-15.0%, P< 0.05, respectively) in both cohorts. In addition, a greater proportion of AA men had multiple positive biopsy cores compared to WA (45.2% vs. 33.1%, P= 0.046) under NCCN criteria. A higher proportion of AA men were upstaged compared to WA (19.4% vs. 10.1%, P= 0.037). A multivariate regression test revealed that age, preoperative PSA, and number of positive cores were independent predictors of more advanced disease (upstaging and/or upgrading) in AA men. CONCLUSIONS AA men who were candidates for AS criteria had worse clinicopathological features on final surgical pathology than WA men. These results suggest that a more stringent AS criteria should be considered in AA men with prostate cancer. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e93 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Yun-Sok Ha New Brunswick, NJ More articles by this author Amirali Salmasi New Brunswick, NJ More articles by this author Jeong Hyun Kim Chuncheon, Korea, Republic of More articles by this author Jae Young Joung Goyang, Korea, Republic of More articles by this author Dong Hyeon Lee Seoul, Korea, Republic of More articles by this author Wun-Jae Kim Cheongju, Korea, Republic of More articles by this author Isaac Yi Kim New Brunswick, NJ More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

2215 TRANSPERINEAL MAPPING TEMPLATE PROSTATE BIOPSY AFTER PREVIOUS TRANSRECTAL ULTRASOUND PROSTATE BIOPSY DETECTS WORSE DISEASE BURDEN

INTRODUCTION AND OBJECTIVES: Due to systematic sampling of the entire prostate, transperineal mapping template prostate biopsy (MTPB) has become a diagnostic tool in select patients. Current indications include 1) evaluation of persistently elevated PSA despite prior negative trans-rectal ultrasound guided (TRUS) prostate biopsy, and 2) patients initiating active surveillance (AS). However, the diagnostic utility of MTPB in these scenarios remains uncertain. As a result, we sought to determine the rate of new prostate cancer (PCa) diagnosis and Gleason upstaging (worse disease burden)with MTPB following previous TRUS biopsy. METHODS: Using a prospectively maintained institutional database, we identified 84 MTPB performed between 2008-2010 for persistently elevated PSA despite negative TRUS biopsy (32 patients) or as part of the evaluation for initiation of AS following a prior positive TRUS biopsy (52 patients). Previous TRUS biopsies were compared to MTPB results to determine if worse disease burden was identified. Patient characteristics including age, PSA, DRE, prostate volume, and number of prior TRUS biopsies were identified and evaluated for an association with worse disease burden on MTPB with univariable and multivariable logistic regression analyses. RESULTS: Despite a median of 2 (range 16) prior negative TRUS biopsies, MTPB diagnosed new PCa in 19/32 (59.4%) patients with persistently elevated PSA (9.3 ng/dL (IQR 6.9-12.6)), of which 13/19 (68.4%) were Gleason 7 disease (Table). Among patients with known PCa, Gleason score upgrading occurred in 13/52 (25.0%)patients following MTPB. Overall, MTPB identified worse disease burden in 32/84 (38.0%) patients. However, on univariable and multivariable analysis, no patient factors were significantly associated with detection of worse PCa disease burden on MTPB following previous TRUS biopsy. CONCLUSIONS: MTPB identifies worse PCa disease burden in a substantial portion of patients with previous TRUS biopsy, including detection of intermediateor high-grade disease in some patients with prior negative TRUS biopsies. Due to the inability to predict which patients are at risk for worse disease burden, MTPB is a valuable tool to detect biologically more aggressive disease.

Increased Incidence of Pathologically Nonorgan Confined Prostate Cancer in African-American Men Eligible for Active Surveillance

To compare the clinicopathologic findings of African-American (AA) and White-American (WA) men with prostate cancer (PCa) who were candidates for active surveillance (AS) and underwent radical prostatectomy (RP). Prospectively maintained database of men who underwent RP from 2 academic centers were analyzed retrospectively. Postoperative pathologic characteristics of patients who met the AS inclusion criteria of the University of California, San Francisco (UCSF) and National Comprehensive Cancer Network (NCCN) were evaluated. After RP, the rate of pathological upstaging and Gleason upgrading were compared between AA and WA men. In the AA cohort, 196 and 124 men met the UCSF and NCCN criteria for AS, respectively. With respect to WA patients, 191 and 148 fulfilled the AS criteria for UCSF and NCCN, respectively. AA men had a higher percentage of maximum biopsy core than WA men (15.3%-20.4% vs 11.5%-15.0%, P<.05, respectively) in both cohorts. In addition, a greater proportion of AA men had multiple positive biopsy cores compared to WA men (45.2% vs 33.1%, P= .046) under the NCCN criteria. A higher proportion of AA men were upstaged (≥pT3) compared to WA men (19.4% vs 10.1%, P= .037). A multivariate regression test revealed that age, preoperative PSA, and number of positive cores were independent predictors of more advanced disease (upstaging and/or upgrading) in AA men. AA men who were candidates for AS criteria had worse clinicopathological features on final surgical pathology than WA men. These results suggest that a more stringent AS criteria should be considered in AA men with prostate cancer.

Causes of false-negative sentinel node biopsy in patients with breast cancer

Sentinel lymph node (SLN) biopsy has replaced axillary lymph node dissection as the routine staging procedure in clinically node-negative breast cancer. False-negative SLN biopsy results in misclassification and may cause undertreatment of the disease. The aim of this study was to investigate whether serial sectioning of SLNs reveals metastases more frequently in patients with false-negative SLNs than in patients with true-negative SLNs. This was a case-control study. Tissue blocks from patients with false-negative SLNs, defined as tumour-positive lymph nodes excised at completion axillary dissection or a subsequent axillary tumour recurrence, were reassessed by serial sectioning and immunohistochemical staining. For each false-negative node, two true-negative SLN biopsies were analysed. Tumour and node characteristics in patients with false-negative SLNs were compared with those in patients with a positive SLN by univariable and multivariable regression analysis. Undiagnosed SLN metastases were discovered in nine (18 per cent) of 50 patients in the false-negative group and in 12 (11.2 per cent) of 107 patients in the true-negative group (P = 0.245). The metastases were represented by isolated tumour cells in 14 of these 21 patients. The risk of a false-negative SLN was higher in patients with hormone receptor-negative (odds ratio (OR) 2.50, 95 per cent confidence interval 1.17 to 5.33) or multifocal tumours (OR 3.39, 1.71 to 6.71), or if only one SLN was identified (OR 3.57, 1.98 to 6.45). SLN serial sectioning contributes to a higher rate of detection of SLN metastasis. The rate of upstaging of the tumour is similar in false- and true-negative groups of patients.

Pathologic Outcomes of Nonmalignant Papillary Breast Lesions Diagnosed at Imaging-guided Core Needle Biopsy

To determine the upstage rate from nonmalignant papillary breast lesions obtained at imaging-guided core needle biopsy (CNB) and if there are any clinical, imaging, or pathologic features that can be used to predict eventual upstaging to malignancy. This retrospective case review was institutional review board approved and HIPAA compliant, with a waiver of informed consent. A database search (from January 2001 to March 2010) was performed to find patients with a nonmalignant papillary breast lesion diagnosed at CNB. Of the resulting 128 patients, 86 (67%) underwent surgical excision; 42 (33%) patients were observed with imaging, for a median observation time of 4.1 years (range, 1.0-8.6 years). Chart review was performed to determine pertinent features of each case. Fourteen of 128 patients were subsequently found to have malignancy at excision, for an upstage rate of 11%. Nine (7%) of the 128 patients were subsequently found to have atypia at excision. Comparisons between patients with upstaged lesions and patients whose lesions were not upstaged demonstrated patients with upstaged lesions to be slightly older (65 vs 56 years, P=.01), more likely to have a mass than calcifications at imaging (P=.03), and to have had less tissue obtained at biopsy (three vs five cores obtained, P=.02; 14- vs 9-gauge needle used, P<.01; no vacuum assistance used, P<.01). Most strongly predictive of eventual malignancy, however, was whether the interpreting pathologist qualified the benign diagnosis at CNB with additional commentary (P<.01). Given the substantial upstage rate (11%) of papillary lesions diagnosed at imaging-guided CNB, surgical excision is an appropriate management decision; however, careful evaluation in concert with an expert breast pathologist may allow for observation in appropriately selected patients.

Excisional Biopsy of Borderline Lesions after Large Bore Vacuum-Assisted Core Needle Biopsy- Is It Necessary?

The current recommendation for borderline breast lesions after core needle biopsy is for surgical excision due to a high rate of pathologic underestimation. With the use of vacuum-assisted core needle (VACN) biopsy devices, upgrade rates have improved, but still average 20 per cent. We routinely use larger bore VACNs (7- and 8-gauge) than previously reported (9 to 11-gauge). The aim of this study is to evaluate the upgrade rate to malignancy in patients undergoing VACN using larger bore needles. VACN biopsies were performed in 902 patients. Of those, 87 were recommended excisional biopsy for borderline or noncorrelating lesions and 66 underwent the procedure. Two patients were upgraded to cancer, for an overall upstage rate of 3 per cent. Both of these underestimations were in patients that initially had atypical ductal hyperplasia. In the patients not excised, no patient developed further cancer. A 7- or 8-gauge needle was used in 57 per cent of patients, greater than 90 per cent removal of the initial lesion was accomplished in 53 per cent of cases, and there were no bleeding complications. This study suggests that upgrade rates decline with larger bore biopsy needles with near complete excision of the initial lesion, and that some borderline lesions may potentially be managed nonoperatively.