Lessons from the coronavirus disease 2019 pandemic: Will virtual patient management reshape uro-oncology in Germany?

The coronavirus disease 2019 (COVID-19) pandemic is challenging for physicians treating patients with genitourinary cancers as they are considered at high risk of severe events. The uro-oncology outpatient clinic at our academic institution was affected early by the outbreak owing to the widespread infection of healthcare personnel. Subsequently, we developed a strategy to ensure the patient's safety by efforts focused on strict quarantine observation, reduction of clinic visits and implementation of virtual patient management into the workflow. Furthermore, we analysed susceptibility to COVID-19 and its effects on patients with uro-oncological cancer treated with antitumoural agents. The goal is to warrant high-quality cancer care, despite being an academic centre on the front line of Germany's response to COVID-19.

Prognostic role of pretreatment derived neutrophil to lymphocyte ratio in urological cancers: A systematic review and meta-analysis

BACKGROUND

To investigate the possible prognostic role of pretreatment derived neutrophil-lymphocyte ratio (dNLR) in urological cancers, including renal cell carcinoma (RCC), prostate cancer (PCa), and urothelial cancer (UCa).

MATERIALS AND METHODS

Eligible studies were comprehensively searched from PubMed, Embase, Cochrane Library and Web of Science, up to April 2019. Pooled hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated to assess the relationships.

RESULTS

A total of 12 studies embracing 6585 patients were included in the meta-analysis. Our results indicated that a higher pretreatment dNLR was associated with a decreased cancer-specific survival (CSS, HR 2.67, 95% CI 1.06-6.71, P = 0.037) and disease-free survival (DFS, HR 2.02, 95% CI 1.03-3.94, P = 0.040) in RCC, but not for overall survival (OS, HR 1.05, 95% CI 0.71-1.53, P = 0.818). A higher dNLR was associated with an inferior biochemical recurrence-free survival (BRFS, HR 1.70, 95% CI 1.00-2.87, P = 0.049) and OS (HR 1.35, 95% CI 1.20-1.51, P < 0.001) in PCa. A higher dNLR was associated with a worse OS (HR 1.29, 95% CI 1.03-1.61, P = 0.029) and CSS (HR 1.51, 95% CI 1.06-2.15, P = 0.024) in UCa, but not for DFS (HR 1.44, 95% CI 0.89-2.34, P = 0.139).

CONCLUSION

A higher dNLR level was negatively associated with OS, CSS, DFS and BRFS, forecasting that it could be an independent prognosis predictor in urological cancers.

Multicenter prospective study validating the efficacy of a quantitative assessment tool for frailty in patients with urological cancers

We prospectively validate the efficacy of the frailty discriminant score (FDS) in individuals with urological cancers, as there has been growing importance in evaluating frailty in clinical practice. A prospective, multicenter study was conducted from February 2017 to April 2019. We enrolled 258 patients with urological cancers and 301 community-dwelling participants who were assessed for frailty. Frailty was assessed using FDS that includes ten items, such as physical, mental, and blood biochemical tests. The primary outcome was the non-inferiority (margin 5%) of FDS in discriminating patients with urological cancers from controls (Ctrl). The sensitivity, specificity, and area under the receiver operating characteristic (AUROC) curve for each predictive test were calculated. The secondary endpoints included the prediction of overall survival between patients with urological cancer who have high and low FDS. FDS was significantly higher in patients with urological cancers than that in the Ctrl. The AUROC curves for individuals with non-prostate cancers (such as bladder cancer, upper tract urothelial carcinoma, and renal cell carcinoma; 0.942) and those with prostate cancer (0.943) were within the non-inferior margin. The overall survival values were significantly lower in patients with higher FDS score than in those with lower FDS score. The study met its primary and secondary endpoints. The FDS is a reliable and valid tool for assessing frailty and prognosis in patients with urological cancers.

Science in the Heartland: Exploring determinants of offering cancer clinical trials in rural-serving community urology practices

OBJECTIVE

Engaging community urologists in referring patients to clinical trials could increase the reach of cancer trials and, ultimately, alleviate cancer disparities. We sought to identify determinants of referring patients to clinical trials among urology practices serving rural communities.

METHODS

We conducted semistructured qualitative interviews based on the Theoretical Domains Framework at nonmetropolitan urology practices located in communities offering urological cancer trials. Participants were asked to consider barriers and strategies that might support engaging their patients in discussions about urological cancer clinical trials and referring them appropriately. Recorded interviews were transcribed and coded using template analysis.

RESULTS

Most participants were not aware of available trials and had no experience with trial referral. Overall, participants held positive attitudes toward clinical trials and recognized their potential roles in accrual, but limited local resources reduced opportunities for offering trials. Most participants expressed a need for increased human, financial, and other resources to support this role. Many participants requested information and training to increase their knowledge of clinical trials and confidence in offering them to patients. Participants highlighted the need to build efficient pathways to identify available trials, match eligible patients, and facilitate communication and collaboration with cancer centers for patient follow-up and continuity of care.

CONCLUSIONS

With adequate logistical and informational support, community urology practices could play an important role in clinical trial accrual, advancing cancer research and increasing treatment options for rural cancer patients. Future studies should explore the effectiveness of strategies to optimize urology practices' role in clinical trial accrual.

Improving the Timely Detection of Bladder and Kidney Cancer in Primary Care

Bladder and kidney cancer are the 10th and 7th most common cancers in the United Kingdom (UK). They present with symptoms that are typically investigated via the same diagnostic pathway. However, diagnosing these cancers can be challenging, especially for kidney cancer, as many of the symptoms are non-specific and occur commonly in patients without cancer. Furthermore, the recognition and evaluation of these symptoms may differ because of the lack of supporting high-quality evidence to inform management, a problem also reflected in currently ambiguous guidelines. The majority of these two cancers are diagnosed following a referral from a general practitioner. In this article, we summarise current UK and United States (US) guidelines for investigating common symptoms of bladder and kidney cancer-visible haematuria, non-visible haematuria and urinary tract infections. Our article aims to support clinicians in recognising and investigating patients with symptoms of possible bladder and kidney cancer in a timely fashion. We discuss challenges during the diagnostic process and possible future interventions for improvement.

Malignancies of suprapubic catheter (SPC) tracts in spinal cord injury patients: a case series and review of literature

Introduction

Spinal cord injury (SCI) patients are at increased risk of bladder cancer. A rare variation of this is a malignancy arising or including the suprapubic catheter (SPC) tract.

Case series

We present the first case series of malignancy of the SPC tract in SCI patients, including a case of mucinous adenocarcinoma, squamous cell carcinoma and sarcoma. Presentation of patients ranged from bleeding at the site of the SPC to a rapidly growing mass. All three patients were thoroughly investigated, and management was bespoke to the extent of disease and their physiological state at the time of diagnosis. This ranged from extensive surgical intervention including cystectomy, partial sigmoidectomy, excision of the abdominal wall with reconstruction and ileal conduit formation to palliation.

Discussion

SCI patients represent 50% of all known published cases of malignancy of the SPC tract. Presentation and diagnosis can be challenging; however, prompt investigation and intervention are essential given the high degree of morbidity and mortality. Routine check of the SPC site may be indicated in those patients in whom the SPC has been present for more than 5 years.

Current and Future Applications of Novel Immunotherapies in Urological Oncology: A Critical Review of the Literature

CONTEXT

Immunotherapies promote anticancer responses with varying levels of success based on the tumor type.

OBJECTIVE

In this narrative review article, we searched the literature regarding immunotherapies in genitourinary malignancies to define the state of the field, explore future applications of immune checkpoint inhibitors, cytokines, vaccines, and cellular therapies in urological oncology and evaluate possible strategies to improve the selection of patients who might benefit from such approaches.

EVIDENCE ACQUISITION

We reviewed related literature, with a focus on recent studies about immunotherapies, predictors of response, and ongoing clinical trials.

EVIDENCE SYNTHESIS

Immunotherapies based on immune checkpoint blockade are approved as first- and second-line therapies for urothelial carcinoma (UC) and second-line therapies for renal cell carcinoma with limited success in prostate cancer. Programmed death-ligand 1 is the most commonly used predictive biomarker outside of UC; however, a substantial proportion of patients with tumors negative for programmed death-ligand 1 expression benefit from checkpoint inhibition, limiting its sensitivity. A high mutational load and molecular subtypes of UC are emerging as additional potential predictors. Genomic sequencing and gene expression analysis associate alterations of genes implicated in DNA repair pathways, such as BRCA1 and BRCA2, with immune checkpoint therapies. In prostate cancer, the vaccine, sipuleucel-T, is the only Food and Drug Administration-approved immunotherapy.

CONCLUSIONS

Immunotherapies are emerging as exciting new treatment options with a tolerable toxicity profile in urological cancers. Checkpoint inhibitors are effective only in a subset of patients, demanding personalized approaches that consider various clinical and molecular parameters to predict patient response. Clinical trials investigating the optimal timing, sequence, and combination of immunotherapies with standard of care and novel agents will guide therapy choices and improve patient outcome.

PATIENT SUMMARY

Clinical data supports the safety and efficacy of immune checkpoint inhibitors alone or in combination with other therapies in urological cancers.

Functioning metastatic paraganglioma of the urinary bladder in a 10-year-old child

Paragangliomas of the urinary bladder are very rare tumours representing less than 1% of bladder tumours. Preoperative diagnosis is essential to avoid perioperative complications related to catecholamine release. A high index of suspicion should be maintained when the classical symptoms of voiding-related paroxysms of headache, palpitation and dizziness are present. We present a rare case of malignant paraganglioma of the urinary bladder in a 10-year-old boy. The patient had the classic presentation. We review the radiological diagnostic tools and findings of this rare entity.

Systematic Review of Immune Checkpoint Inhibition in Urological Cancers

CONTEXT

In patients with advanced and metastatic urological cancers, clinical outcome may be improved by immune checkpoint inhibitors (ICIs).

OBJECTIVE

To systematically review relevant literature on efficacy and safety of ICIs in patients with advanced and metastatic urothelial cell cancer (UCC), renal cell cancer (RCC), and prostate cancer.

EVIDENCE ACQUISITION

Relevant databases, including Medline, Embase, and the Cochrane Library, were searched up to March 16, 2017. A narrative review of randomized clinical trials (RCTs) was performed.

EVIDENCE SYNTHESIS

Six RCTs were included for the systematic review. In platinum-pretreated UCC, efficacy of pembrolizumab was superior to chemotherapy, with longer median overall survival (OS; 10.3 vs 7.4 mo), a higher objective response rate (ORR; 21.1% vs 11.4%, p=0.001), and a lower adverse event rate (60.9% vs 90.2%). Three RCTs assessed the safety and efficacy of nivolumab in advanced RCC. The median OS (25.0 vs 19.6 mo) and the ORR (25% vs 5%) were higher in patients treated with nivolumab compared with second-line everolimus. In all three studies, the safety profile of nivolumab was favorable. In patients with metastatic castration-resistant prostate cancer, two RCTs were identified, which did not show significant benefits for ipilimumab over placebo. In UCC and RCC, there was no conclusive association between programmed cell death receptor ligand 1 (PD-L1) expression in tumor tissue and clinical outcome during pembrolizumab and nivolumab treatment, respectively.

CONCLUSION

In metastatic UCC and RCC, pembrolizumab and nivolumab have superior efficacy and safety to second-line chemotherapy and everolimus, respectively. No beneficial effect of ipilimumab was observed in prostate cancer patients. PD-L1 expression status is currently not suitable as a predictive marker for treatment outcome.

PATIENT SUMMARY

Immune checkpoint inhibitors are able to reactivate the immune system against tumor cells. In second-line setting, pembrolizumab and nivolumab are safe and confer survival benefit in advanced urothelial cell and renal cell cancer, respectively.

Vesical dermoid: a rare bladder tumour

Dermoid cysts are benign developmental lesions consisting of tissues of more than one germ cell lineage origin. The urinary bladder is a very rare location of dermoid cysts. We report a case of an 18-year-old woman who presented with suprapubic pain, dysuria and turbid urine. Blood and serum chemistry was normal. Contrast-enhanced CT revealed a heterogeneously enhancing mass of 2.5×2 cm within the urinary bladder infiltrating fundus of urinary bladder with extraluminal extension. At cystoscopy, an irregular mass arising from the dome of the urinary bladder with a covering of hair and whitish scales was seen. The patient was managed by transperitoneal laparoscopic partial cystectomy with left oophorectomy. Histology revealed dermoid cyst arising from the urinary bladder and simple serous cyst in the ovary. Postoperative course was uneventful.

Persistent fetal lobulation of kidney mimicking renal tumour

Renal pseudotumour is a term coined to describe conditions of renal anatomic variants that simulate focal renal pathology like a tumour on ultrasonography. These include persistent fetal lobulation, hypertrophy of Bertin columns and dromedary humps. We report a case of a 30-year-old nulliparous woman who was managed in gynaecology clinic for menorrhagia and was subsequently referred to us for management of recurrent urinary tract infections. The clinical examination was normal and on ultrasound scan, she was found to have multiple enlarged heterogeneous solid masses in both kidneys with significantly increased vascularity, suspicious for neoplastic lesions. She subsequently underwent a CT urogram and her case was discussed in uro-radiology meeting where a diagnosis of persistent fetal lobulation was made excluding other diagnoses. She was managed conservatively. We also present grey scale and Doppler ultrasound and CT urogram findings of this condition along with the literature review.

Urothelial papilloma: a rare cause of gross haematuria in childhood

Bladder urothelial papilloma is extremely rare in the paediatric population. It usually presents as painless gross haematuria and its diagnosis implies a high index of suspicion as other causes of haematuria predominate in this age range. We describe a 9-year-old boy with two episodes of gross haematuria occurring 1 year apart with spontaneous resolution after 2 days. Bladder ultrasound revealed an endovesical papillary lesion of 24×24 mm suggestive of bladder tumour. The diagnosis was confirmed by histopathological examination of the specimen obtained by cystoscopy with transurethral resection. After 3 years of follow-up with ultrasound and cystoscopy, there are no signs of recurrence. Due to the low prevalence of urothelial papilloma, paediatric guidelines for appropriate management and follow-up are unavailable, making this a challenging entity.

Atraumatic chylous ascites: an unusual presentation of bladder cancer

We describe a case of bladder cancer presenting with atraumatic chylous ascites, which remains an extremely rare presentation of this condition. A previously well, elderly ex-smoker with no prior history of abdominal surgery was referred for investigation of progressive dyspnoea, increasing peripheral oedema and new-onset ascites, on a background of long-standing alcohol consumption (four standard drinks daily). Liver biochemistry and coagulation profile were normal apart from marked hypoalbuminaemia. Doppler ultrasound of the liver demonstrated normal echotexture and patent vasculature. Abdominal paracentesis yielded 8 L of milk-coloured, triglyceride-rich fluid with abundant malignant cells. Urine cytology demonstrated malignant transitional cells, with radiological evidence of a large enhancing bladder mass, with evidence of adjacent lymphadenopathy and omental involvement. A diagnosis of metastatic stage IV transitional cell bladder cancer was made. The patient declined palliative chemotherapy and passed away 2 months after their initial presentation.

Migration of clips to the colon after laparoscopic partial nephrectomy

A 78-year-old man was treated with laparoscopic partial nephrectomy for a 4 cm tumour in the lower pole of the left kidney. The patient was discharged 2 days postoperatively. Preoperatively there was no sign of metastasis; the pathology indicated complete removal of the tumour, a renal cell carcinoma. 53 days postoperatively the patient had acute onset of rectal bleeding. A colonoscopy revealed necrosis and three clips on the wall of the colon corresponding to where the descending colon passes over the left kidney. The patient was treated conservatively. Clip migration has been reported previously, but to our knowledge we present the first case of clip migration to the colon after laparoscopic partial nephrectomy. Suggestions to avoid the presented complication are made.

Pulmonary metastasis from renal epithelioid angiomyolipoma in the setting of breast cancer

A 68-year-old woman presented with visible haematuria. Ultrasonography and triphasic CT revealed a 2.6 cm mass in the lower pole of the left kidney. A biopsy suggested low-grade renal cell carcinoma. Radical nephrectomy was performed and revealed an epithelioid angiomyolipoma. At year 3, the patient developed ductal carcinoma of the right breast and underwent a wide local excision and sentinel lymph node biopsy followed by chemotherapy and radiotherapy. 4 months later, she was noted to have a 1.6 cm nodule in the middle lobe of her right lung. The primary differential diagnosis was a breast cancer metastasis. Biopsy revealed a metastatic renal epithelioid angiomyolipoma. The patient elected to have stereotactic radiotherapy over surgical excision. Renal angiomyolipomata are generally regarded as benign tumours. In the present report, we describe the first case of pulmonary metastasis from renal epithelioid angiomyolipoma in the setting of breast cancer.

Paraneoplastic jaundice and prostate cancer

Cholestasis has numerous causes. We present the case of a 78-year-old man with a common diagnosis in this age group and gender but with an unusual presentation. There are only 11 articles published of patients with jaundice due to a paraneoplastic syndrome associated with prostate cancer. Interleukin 6 and other proinflammatory cytokines appear to contribute to the pathophysiology of this syndrome. Our patient remains symptom free 4 months after treatment initiation.

Molecular and Functional Diagnostic Tools in Precision Oncology for Urological Malignancies

Urological malignancies, represented mainly by prostate, bladder, and renal cancers, are some of the leading causes of cancer-related mortalities worldwide. Despite various efforts over decades to develop early detection tests and effective therapeutic paradigms, the response rate to the existing treatments remains low for both primary and late stage/recurrent phases of these cancers. The evolving landscape of molecular diagnostics, aiming to make the diagnosis and treatment more patient-driven, underpins precision oncology and particularly intends to rationally profile individual tumors and highlight the mechanistic insight and complexity of tumor microenvironment in order to develop biomarkers of toxicity risks and response prediction in a clinically oriented dynamical setting. The present review is an effort to capture some of the recent developments in the area of molecular diagnostics and functional testing platforms and their potential application in clinical decision making in the premises of precision oncology of urological malignancies.

Increased risk for urological cancer associated with anxiety disorder: a retrospective cohort study

BACKGROUND

Anxiety disorders (ADs) are common with a high rate of medical comorbidities. Although the association between ADs and the overall cancer risk remains controversial, patients with ADs were found to be more likely to develop specific cancer types. Herein, we estimated the risk of developing urological cancers among patients with ADs in a 5-year follow-up period using a population-based database.

METHODS

Two study cohorts were identified from the Taiwan Longitudinal Health Insurance Database 2005: patients with ADs, and comparison subjects selected by one-to-one matching for sex, age, and the year of recruitment. Follow-up was undertaken to determine whether sampled patients and comparison subjects had developed urological cancers in the subsequent 5 years.

RESULTS

We found that urological cancers occurred among 0.54% of patients with ADs and 0.13% of comparison subjects. After adjusting for sociodemographic characteristics, medical comorbidities, and alcohol and tobacco use disorder, the stratified Cox proportional hazard regression suggested that patients with ADs were more likely to develop urological cancers relative to comparison subjects (adjusted hazard ratio, 3.67; 95% confidence interval, 2.85 ~ 4.72). The adjusted HR for males with ADs was 3.82 (95% CI: 2.79 ~ 5.23) in comparison to males without ADs. In addition, the adjusted HR for females with ADs was 3.47 (95% CI: 2.26 ~ 5.31) than those females without ADs.

CONCLUSIONS

We concluded that during the 5-year follow-up period, there was a significantly increased risk of urological cancers among patients with ADs.

[Social medical/public health assessment of the ability to work regarding urological and urooncological diseases]

The primary objectives of modern urooncological treatment concepts are quality of life, reintegration and participation. Urological rehabilitation supports the overcoming of side effects of disease and treatment, which is necessary for the timely return to work life. Social medical assessment reflects the individual overall results of the entire treatment process concerning oncological prognosis, physical and mental capacity and resilience.

Update on advances in molecular PET in urological oncology

Integrated positron emission tomography/computed tomography (PET/CT) with 2-[(18)F]fluoro-2-deoxy-D-glucose ((18)F-FDG) has emerged as a powerful tool for the combined metabolic and anatomic evaluation of many cancers. In urological oncology, however, the use of (18)F-FDG has been limited by a generally low tumor uptake, and physiological excretion of FDG through the urinary system. (18)F-FDG PET/CT is useful when applied to specific indications in selected patients with urological malignancy. New radiotracers and positron emission tomography/magnetic resonance imaging (PET/MRI) are expected to further improve the performance of PET in uro-oncology.