Giant Renal Cell Carcinoma (RCC): A Case Report of Delayed Diagnosis and Management

Renal cell carcinoma (RCC) is the most common type of kidney cancer. It typically presents with macroscopic hematuria, weight loss, and or a palpable flank mass. Diagnosis of this disease involves imaging techniques such as abdominal ultrasound and CT scans. Care for RCC can consist of ablation, tumor removal, nephrectomy, and systemic treatment options. Herein, we present a case of a 50-year-old Hispanic male with complaints of rectal bleeding and hematuria. Prior to admission, the patient had been informed twice about high suspicion of renal malignancy. Due to low health literacy and barriers to communication, he failed to understand the magnitude of his diagnosis. Subsequently, he underwent a resection of a considerable 22 cm x 13 cm x 13 cm RCC of his left kidney. This case highlights the need for effective patient health education to prevent emotional distress in patients with low health literacy.

CD117⁺ cells in the circulation are predictive of advanced prostate cancer

Circulating tumor cells (CTCs) are associated with cancer progression, aggressiveness and metastasis. However, the frequency and predictive value of CTCs in patients remains unknown. If circulating cells are involved in tumor aggressiveness and metastasis, then cell levels should decline upon tumor removal in localized cancer patients, but remain high in metastatic patients. Accordingly, proposed biomarkers CD117/c-kit, CD133, CXCR4/CD184, and CD34-positive cell percentages in the blood of patients undergoing radical prostatectomy for localized cancer were assessed by flow cytometry prior to intervention and 1–3 months postoperatively. Only circulating CD117⁺ cell percentages decreased after radical prostatectomy, increased with cancer progression and correlated with high PSA values. Notably, postoperative CD117⁺ levels did not decrease in patients experiencing biochemical recurrence. In a xenograft model, CD117-enriched tumors were more vascularized and aggressive. Thus, CD117 expression on CTCs promotes tumor progression and could be a biomarker for prostate cancer diagnosis, prognosis, and/or response to therapy.

Resveratrol worsens survival in SCID mice with prostate cancer xenografts in a cell-line specific manner, through paradoxical effects on oncogenic pathways

BACKGROUND

Resveratrol increases lifespan and decreases the risk of many cancers. We hypothesized resveratrol will slow the growth of human prostate cancer xenografts.

METHODS

SCID mice were fed Western diet (40% fat, 44% carbohydrate, 16% protein by kcal). One week later, human prostate cancer cells, either LAPC-4 (151 mice) or LNCaP (94 mice) were injected subcutaneously. Three weeks after injection, LAPC-4 mice were randomized to Western diet (control group), Western diet plus resveratrol 50 mg/kg/day, or Western diet plus resveratrol 100 mg/kg/day. The LNCaP mice were randomized to Western diet or Western diet plus resveratrol 50 mg/kg/day. Mice were sacrificed when tumors reached 1,000 mm(3). Survival differences among groups were assessed using Cox proportional hazards. Serum insulin and IGF axis were assessed using ELISAs. Gene expression was analyzed using Affymetrix gene arrays.

RESULTS

Compared to control in the LAPC-4 study, resveratrol was associated with decreased survival (50 mg/kg/day--HR 1.53, P = 0.04; 100 mg/kg/day--HR 1.22, P = 0.32). In the LNCaP study, resveratrol did not change survival (HR 0.77, P = 0.22). In combined analysis of both resveratrol 50 mg/kg/day groups, IGF-1 was decreased (P = 0.05) and IGFBP-2 was increased (P = 0.01). Resveratrol induced different patterns of gene expression changes in each xenograft model, with upregulation of oncogenic pathways E2F3 and beta-catenin in LAPC-4 tumors.

CONCLUSION

Resveratrol was associated with significantly worse survival with LAPC-4 tumors, but unchanged survival with LNCaP. Based on these preliminary data that resveratrol may be harmful, caution should be advised in using resveratrol for patients until further studies can be conducted.

Intratumoral inflammation is associated with more aggressive prostate cancer

PURPOSE

Inflammation may play a role in the development and progression of many cancers, including prostate cancer. We sought to test whether histological inflammation within prostate cancer was associated with more aggressive disease.

METHODS

The slides of prostatectomy specimens were reviewed by a board-certified pathologist on 287 men from a Veterans Affairs Medical Center treated with radical prostatectomy from 1992 to 2004. The area with the greatest tumor burden was scored in a blinded manner for the degree of inflammation: absent, mild, or marked. We used logistic and Cox proportional hazards regression analysis to examine whether categorically coded inflammation score was associated with adverse pathology and biochemical progression, respectively.

RESULTS

No inflammation was found in 49 men (17%), while 153 (53%) and 85 (30%) had mild and marked inflammation. During a median follow-up of 77 months, biochemical recurrence occurred among 126 (44%) men. On multivariate analysis, more inflammation was associated with greater risk of positive margins, capsular penetration, and seminal vesicle invasion (all p < 0.05). Marked inflammation was associated with increased PSA recurrence risk when adjusting for preoperative features only (HR 2.08, 95% CI 1.02-4.24), but not after adjusting for pathologic features.

CONCLUSIONS

Inflammation within prostate cancer was associated with more advanced disease, although it is unclear whether aggressive disease caused increased inflammation or inflammation caused aggressive disease.

Tumor thrombus transection in renal cell carcinoma

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Background: Inferior vena cava (IVC) tumor thrombectomy with radical nephrectomy (RN) for renal cell carcinoma (RCC) is difficult when a large renal mass is present, but completing the RN by transecting the renal vein with tumor thrombus inside can facilitate dissection of the IVC for thrombectomy. We compared the outcomes of patients in whom the thrombus was purposely transected to those in whom the IVC thrombus was removed en bloc with the kidney. Methods: At our institution between 2000-2011, 152 patients with RCC and level II (N =53), III (N =52) or IV (N =47) IVC thrombus underwent RN and IVC thrombectomy. In 92 patients the kidney was removed prior to initiating the IVC thrombectomy. In 60 patients, the tumor thrombus and kidney were removed en bloc. Clinical information was obtained from an institutional database. Since thrombus level greatly affects surgical technique and complications, outcomes were analyzed within each level. Results: Thrombus level and clinical stage were higher in the transected group, but other baseline characteristics did not differ significantly. The primary endpoint, the overall rate of complications including intra-op and post-op events, was not statistically significantly different (all p >0.2) between the en bloc and transected groups for level 2 (8/37 vs. 6/16), level 3 (7/17 vs. 15/35), and level 4 (2/6 vs. 25/41). Operative times were similar within level 2 (300 vs. 300 minutes, p=0.2), level 3 (312 vs. 360, p=0.1), and level 4 (325 vs. 402, p=0.7). Units of blood products transfused were also similar within level 2 (3 vs 5, p=0.3), level 3 (5 vs. 9, p=0.06), and level 4 (6 vs. 14, p=0.4). Due to the low event numbers within each subgroup, multivariable analysis could not be reliably run on these outcomes. Three patients, all in the transected group, experienced intraoperative tumor thrombus embolization to the pulmonary artery requiring surgical embolectomy, but all 3 survived to discharge without any serious sequelae. Conclusions: Complications, operative time, and transfusion rates were similar between the en bloc and transected techniques when stratified by tumor thrombus level. Because of the rarity of this disease, statistical power of these comparisons is low, but our study suggests no evidence of advantage to either technique.

Defining heminephrectomy for cancer

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Background: The word heminephrectomy originally referred to the removal of half of a kidney with a duplicated collecting system. In the era of partial nephrectomies, heminephrectomy is sometimes used to describe the removal for tumor of >30% of the parenchyma of a non-duplicated kidney. We herein propose a new definition of heminephrectomy: excision of the upper or lower pole of the kidney, removing at least 30% of the parenchymal mass, cutting to hilar fat, and transecting the collecting system. Methods: Our institutional database of robotic and laparoscopic partial nephrectomies was queried for patients who underwent a partial nephrectomy for tumor between 2002 and 2011. Patients who had a heminephrectomy for obstruction in a duplicated collecting system were excluded. The patients who had a heminephrectomy by our strict definition were compared to the remainder of patients who had a partial nephrectomy. Logistic regression was used to compare outcomes between the two groups. Results: 61 patients met our strict definition of heminephrectomy out of 643 patients who underwent a partial nephrectomy for tumor. Heminephrectomy and non-heminephrectomy patients were similar in age, gender, BMI, ASA score, proportion of left- versus right-sided tumors, solitary kidney status, preoperative creatinine and GFR. (all p>0.1). The tumors in the heminephrectomy group were larger (5.1 vs. 2.8 cm, p<0.001) and had a higher R.E.N.A.L nephrometry score (8.5 vs. 6.5, p<0.001). Operative outcomes reflected the high complexity of performing a heminephrectomy. Estimated blood loss was greater (373 vs. 267 ml, p=0.04), operative time was longer (214 vs. 185 minutes, p<0.001), warm ischemia time was longer (25 vs. 20 minutes, p=0.002), and the rate of intra-operative complications was greater (11% vs. 4%, p=0.02) in the heminephrectomy group. On multivariable analysis adjusted for age, preoperative GFR, R.E.N.A.L. score, and warm ischemia time, heminephrectomy was a significant predictor of lower post-operative GFR (p<0.001). Conclusions: Our strict definition of heminephrectomy performed for tumor in a non-duplicated system will allow precise clinical and research communication about heminephrectomy patients and may aid in the prediction of outcomes after partial nephrectomy.

Patient-reported sexual and urinary function after open and robotic radical prostatectomy

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Background: Urinary continence (UC) and sexual function (SF) may be impacted differently after robotic-assisted laparoscopic (RALRP) versus open (ORP) radical prostatectomy. We compared UC and SF among patients treated by RALRP and ORP at a high-volume hospital who were enrolled in a prospective, longitudinal quality-of-life (QOL) protocol. Methods: Between 2007 and 2012, 516 patients treated by active surveillance, brachytherapy, cryotherapy, RALRP, and ORP were enrolled in a QOL protocol at our institution. The focus of this study is 361 patients who were treated by RALRP (N=190) and ORP (N=171). Functional outcomes were assessed at baseline and at 1, 3, 6, 12, and 24 months using a validated QOL instrument (Giesler RB et al. Qual Life Res 2000). SF was assessed by adding the scores from questions on the quality and frequency of erections. UC was assessed by adding the scores from three questions about the frequency and quantity of incontinence and pad usage. Wilcoxon rank sum test and linear regression multivariable analysis were used to assess SF and UC at each time point. Results: Treatment groups were similar in age, PSA, clinical stage, Gleason grade, BMI, baseline UC and SF scores and baseline PDE-5 inhibitor use (all P > 0.05), but the RALRP patients were slightly older (60 vs 61 years, p=0.04) and had larger prostates (38 vs 44 grams, p=0.001). On multivariate analysis, UC was worse in the RALRP cohort at 1 month (12.0 vs 10.9, P = 0.02), 3 months (9.9 vs 8.5, P = 0.01), and 6 months (8.1 vs 6.8, P=0.01) but was similar at 12 and 24 months (all P > 0.2). SF was similar between both RALRP and ORP at all time points (all P > 0.3). At 24 months, UC for RALRP and ORP was 7.1 vs. 6.4, respectively which was not significant in multivariable analysis (P = 0.5). Likewise, SF for RALRP and ORP was 5.3 vs. 6.2 (multivariable P = 0.9). On repeated measures analysis there was no difference between the groups in UC or SF (P=0.4 and 0.5, respectively). Conclusions: Prospectively collected, patient reported QOL endpoints for SF are similar after RALRP and ORP at all time points in a high-volume hospital. Final UC is similar between both techniques, although RALRP patients may experience a slightly slower return to continence.

Nomogram predicting treatment-related sexual dysfunction for men with localized prostate cancer treated by radical prostatectomy (RP), external-beam radiotherapy (EBRT), and brachytherapy (PI)

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Background: RP, EBRT, and PI for the treatment of clinically localized prostate cancer may negatively impact sexual function. Predictions of treatment-related sexual problems from patient-reported, prospective data may be useful in decision-making. Methods: Patient-reported data on treatment-related sexual problems was obtained from 4 prospective, longitudinal, health-related quality-of-life (HRQOL) protocols comprising 2,668 patients treated between 1999 and 2011 by RP (n = 1,294), EBRT (n = 630), and PI (n = 744). A single HRQOL instrument was not uniformly used for each study, although questions pertaining to the quality and frequency of erections were identical among the studies. Only those patients with quality of erections sufficient for intercourse were included in the model. The endpoint of the model was erections suitable for intercourse on at least half of attempts at 2 years after treatment, with or without the use of oral medications. Cox proportional hazards regression analysis was used to model the clinical information and follow-up data. Internal validation was performed using bootstrapping. Results: Overall, 931 (74%), 249 (42%), and 323 (45%) patients treated by RP, EBRT, and PI were considered to be potent at baseline. Significant differences in baseline characteristics such as patient age, ethnicity, and disease severity existed between the treatment groups. The potency rate at 2 years for 1,215 patients who were potent at baseline and had complete follow-up data was 38%, 51%, and 61% for patients treated by RP, EBRT, and PI, respectively (p < 0.001). In multivariable analysis, age (p < 0.001), baseline frequency of erections (p < 0.001), EBRT (p < 0.001), PI (p < 0.001), PSA (p = 0.001), and institution (p = 0.006), were associated with potency. A nomogram based on the predictive parameters had a concordance index of 0.72 and predictions were well-calibrated with observed outcome. Conclusions: An externally-validated nomogram that predicts 2-year potency after treatment for localized prostate cancer has been developed and may be useful for patient counseling regarding treatment options.

Nomogram predicting treatment-related bowel dysfunction for men with localized prostate cancer treated by radical prostatectomy (RP), external-beam radiotherapy (EBRT), and brachytherapy (PI)

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Background: RP, EBRT, and PI for treatment of clinically localized prostate cancer may negatively impact bowel function. Predictions of treatment-related bowel problems from patient-reported, prospective data may be useful in treatment decision-making. Methods: Patient-reported data on treatment-related bowel problems was obtained from 4 prospective, longitudinal, health-related quality-of-life (HRQOL) protocols comprising 2,668 patients treated between 1999 and 2011 by RP (n=1294), EBRT (n=630), and PI (n=744). A single HRQOL instrument was not uniformly used for each study, though all patients were asked if they experienced bother related to bowel problems using a similar 5-point scale. Patient responses were obtained at baseline and at 2 years after treatment. The endpoint of the model was bowel dysfunction, defined as bowel symptoms that were identified as a moderate-to-big problem. Cox proportional hazards regression analysis was used to model the clinical information and follow-up data. Internal validation was performed using bootstrapping. Results: Significant differences in baseline characteristics such as patient age, ethnicity, and disease severity existed between the treatment groups. Overall, 46 patients (2%) with complete data available had bowel dysfunction at baseline, including 11 (1%), 19 (4%), and 16 (3%) patients treated by RP, EBRT, and PI, respectively (p = 0.001). The overall rate of bowel dysfunction at 2 years in those patients with no bowel dysfunction at baseline was 2%, 10%, and 4% for patients treated by RP, EBRT, and PI, respectively (p < 0.001). In multivariable analysis, EBRT (p < 0.001), PI (p < 0.001), baseline bowel symptoms (p < 0.001), and institution (p = 0.04) were associated with bowel dysfunction. A nomogram based on the predictive parameters had a concordance index of 0.73 and predictions were well-calibrated with observed outcome. Conclusions: An externally validated nomogram that predicts 2-year incidence of bowel dysfunction after treatment for localized prostate cancer has been developed and may be useful for patient counseling regarding treatment options.

Nomogram predicting treatment-related urinary incontinence for men with localized prostate cancer treated by radical prostatectomy (RP), external-beam radiotherapy (EBRT), or brachytherapy (PI)

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Background: RP, EBRT, and PI for the treatment of clinically localized prostate cancer may negatively impact urinary continence. Predictions of treatment-related urinary problems from patient-reported, prospective data may be useful in treatment decision-making. Methods: Patient-reported data on treatment-related urinary incontinence was obtained from four prospective, longitudinal, health-related quality-of-life (HRQOL) protocols comprising 2,668 patients treated between 1999 and 2011 by RP (n = 1,294), EBRT (n = 630), and PI (n = 744). A single HRQOL instrument was not uniformly used for each study, although questions pertaining to the quantity (pad use) and frequency of urinary incontinence (“never” to “more than once per day”) were identical among the studies. Patient responses were obtained at baseline and at two years after treatment. The endpoint of the model was urinary continence defined as no pad use and leakage of urine less than once per day. Cox proportional hazards regression analysis was used to model the clinical information and follow-up data. Internal validation was performed using bootstrapping. Results: Overall, 1,937 (92%) of patients with complete data available were considered to be continent at baseline. Significant differences in baseline characteristics such as patient age, ethnicity, and disease severity existed between the treatment groups. The overall continence rate at two years was 66%, 88%, and 87% for patients treated by RP, EBRT, and PI, respectively (p < 0.001). In multivariable analysis, age (p = 0.001), baseline frequency of incontinence (p < 0.001), EBRT (p < 0.001), PI (p < 0.001), and ethnicity (p < 0.001) were associated with urinary continence. A nomogram based on the predictive parameters had a concordance index of 0.74 and predictions were well-calibrated with observed outcome. Conclusions: An externally-validated nomogram that predicts two-year urinary continence after treatment for localized prostate cancer has been developed and will be useful for patient counseling regarding treatment options.

Comparative outcomes of laparoscopic and open adrenalectomy for adrenocortical carcinoma: single, high-volume center experience

PURPOSE

Adrenocortical carcinoma (ACC) is a rare and clinically aggressive cancer. Previous studies reported increased recurrence rates associated with laparoscopic adrenalectomy (LA). We evaluated a single-center experience of LA versus open adrenalectomy (OA) for the management of ACC.

METHODS

Between 1993 and 2011, 44 consecutive patients with primary ACC were treated at our institution. Baseline patient characteristics and surgical and pathological outcomes were compared between OA and LA groups. Multivariable Cox proportional hazards analysis was used to estimate the association between OA versus LA with recurrence-free and overall survival.

RESULTS

Eighteen and 26 patients underwent LA and OA, respectively. Patients who underwent OA had larger tumors and more advanced clinical stage compared with LA group. During a median follow-up of 22 months, 22 recurrences and 26 deaths were observed. The 2-year, recurrence-free and overall survivals for OA and LA were 60 vs. 39 % (P = 0.7) and 54 vs. 58 % (P = 0.6), respectively. After adjusting for clinical stage, OA was associated with lower risk of recurrence (hazard ratio (HR) 0.4; 95 % confidence interval (CI) 0.2-1.2; P = 0.099) and improved overall survival (HR 0.5; 95 % CI 0.2-1.2; P = 0.122) compared with LA, although differences were not statistically significant.

CONCLUSIONS

A nonstatistically significant increase in recurrence and death was observed among patients undergoing LA versus OA after adjusting for clinical stage. The rarity of this disease limits the ability to assess for significant differences in a single-institution series. Patients with suspected ACC should be considered for OA.

High-grade prostatic intraepithelial neoplasia

High-grade prostatic intraepithelial neoplasia (HGPIN) has been established as a precursor to prostatic adenocarcinoma. HGPIN shares many morphological, genetic, and molecular signatures with prostate cancer. Its predictive value for the development of future adenocarcinoma during the prostate-specific antigen screening era has decreased, mostly owing to the increase in prostate biopsy cores. Nevertheless, a literature review supports that large-volume HGPIN and multiple cores of involvement at the initial biopsy should prompt a repeat biopsy of the prostate within 1 year. No treatment is recommended for HGPIN to slow its progression to cancer.

Cytoreductive radical nephrectomy (cRN) and level II-IV infereior vena cava (IVC) thrombectomy for metastatic renal cell carcinoma (mRCC)

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Background: cRN for mRCC is associated with a modest improvement in survival when combined with cytokine therapy in patients with good performance status. A level II-IV IVC thrombus renders cRN technically challenging with increased risks of perioperative morbidity and mortality. The outcome of these patients relative to the overall cRN population is poorly defined.

Methods: Clinical information and follow-up data were obtained from an institutional retrospective data base for patients who underwent cRN and IVC thrombectomy between 1990–2011.The operative outcomes, complications, and cancer outcomes were compared.

Results: cRN was performed on 56 patients with mRCC and level II (N =19), III (N =25) or IV (N =12) IVC thrombus. Age ranged from 23 to 84 years old and 36 (64%) were male. Predominant sites of metastases were: lung, 22 (39%); liver 3 (5%); mediastinum 3 (5%); multiple sites 17 (30%). Local clinical stage was T3a in 2 (3.6%), T3b in 38 (68%), T3c in 12 (21%), and T4 in 4 (7%). Twenty (36%) patients were clinical N1. Median tumor size was 10.2 cm (range, 1.4–21). Histologic classification was clear cell in 40 (71%), papillary in 4 (7%), and unclassified in 12 (21%). Intraoperatively, 2 patients had embolization of thrombus. Postoperatively, Clavien grade 3–5 complications occurred in 3 (5%) patients, including two (3.6%) mortalities. Follow-up information was available for 49 patients and the median follow-up was 13 months (IQR: 6–33). Of these patients, 31 (63%) received postoperative systemic therapy with cytokines (14), targeted agents (16), or both (1). The overall median survival was 13 months (95% CI: 10–16), and was similar before (median 12 months) and after (median 13 months) the introduction of targeted therapy.

Conclusions: Among patients with mRCC with level II–IV IVC thrombus managed at a high-volume kidney center, cRN and IVC thrombectomy is associated with acceptable perioperative morbidity and mortality. The median survival of patients in our cohort is similar to the overall population of patients managed with cRN and cytokine therapy though less than those managed with cRN and targeted therapy based on data from published randomized trials.

Prostate cancer–specific mortality and competing causes of mortality among elderly men after local therapy for prostate cancer

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Background: The benefit of definitive local therapy among elderly patients (> 65 years) with localized prostate cancer (PC) is uncertain, particularly for those with comorbid illness. Despite this uncertainty, the majority of these men currently receive local therapy. We analyzed the risk of prostate cancer-specific mortality (PCSM) relative to competing causes of mortality (CCM), stratified by disease severity and comorbidity, among contemporary men treated at two high-volume hospitals

Methods: Between 1995-2005, 4237 consecutive men aged 65 years or older were managed by radical prostatectomy (N = 1634), external-beam radiotherapy (N = 1570), or brachytherapy (N = 1033) at Cleveland Clinic or Barnes-Jewish Hospital. Clinical information was obtained from prospective data bases. Comorbidity was assessed using ACE-27 and Charlson Comorbidity indices. PC risk was classified according to D’Amico criteria. Fine and Gray competing risk analysis was used to assess PCSM and CCM at 10 years.

Results: Over a median follow-up of 72 months (IQR: 46-97), 88 and 748 PCSM and CCM events were observed. Among healthy men with low risk PC, 10 year PCSM was 2% and CCM was 19%. Among healthy men with high risk PC, PCSM was 11% and CCM was 27%. In the group with moderate-to-severe comorbidities, CCM was 49, 59%, and 58% and PCSM was 1%, 3%, and 21% among those with low-, intermediate- and high-risk PC, respectively. Among these unhealthy men, 26% were treated by radical prostatectomy, of whom 45% had low-risk PC and 16% had high-risk PC. Among healthy men, 41% were treated by radical prostatectomy, of whom 54% and 9% had low- and high-risk PC, respectively.

Conclusions: The risk of PCSM vs. CCM for older men is low, particularly for those with moderate-to-severe comorbidity; 49-59% had died from CCM within 10 years. Current evidence suggests that local therapy for PC is associated with a 25% reduction in PCSM, at best. Thus, with active surveillance, it is unlikely that PCSM would exceed 5-7% in those with low- and intermediate-risk PC. These results should inform elderly men and physicians about the risk of PCSM and CCM when deciding upon treatment for localized PC.

Can we predict malignancy in Bosniak III renal lesions identified on multiphasic CT scan?

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Background: To identify independent predictors of malignancy in Bosniak III (BIII) renal lesions and to build a prediction model based only on readily identifiable clinical and imaging variables.

Methods: In this IRB-approved retrospective study, radiology and hospital information systems were interrogated for BIII lesions in CT reports from January 1, 1994 to August 31, 2009. Patients with histopathology available were included. The following variables were recorded: age, gender, body mass index (BMI), race, symptoms at presentation, smoking history and history of renal cell carcinoma (RCC), presence of a co-existent BIII or BIV lesion. Univariate analyses were first performed using logistic regression analysis with generalized estimating equations and an exchangeable working correlation matrix to test each variable. Factors with univariate p-values <0.20 were considered in the multiple-variable analysis. The main effects of the factors were first evaluated. For the main effects with p-values <0.10, two-way interactions were assessed. Interactions with p-values <0.05 were included in the final model along with their main effects. The c-index was used to test accuracy of the models. Final model was chosen based on its parsimony and accuracy.

Results: Mean patient age was 58 years (range 27–80). There were 51 females and 50 males. Of the 107 BIII lesions in 101 patients (6 patients had two lesions each), 59 (55%) were malignant and 48 (45%) were benign. The strongest predictors of malignancy were race (p=0.04), history of RCC (p=0.03), co-existing III (p=0.03) or IV lesion (p=0.10) and BMI (p=0.10). In multiple-variable analysis, a history of RCC was the strongest independent predictor of malignancy (OR 12.7, 95% CI 1.8– 91, p=0.01) followed by BMI (OR 1.1, 95% CI 0.99–1.20, p=0.08). No other main effects or interactions had p-values <0.10. The model with these two predictors had an accuracy of 0.68. At >90% probability of malignancy, the model has a 77% sensitivity and 61% positive predictive value.

Conclusions: Clinical and imaging variables provide significant ability to predict malignancy for BIII renal lesions. A model encompassing history of RCC and BMI appears promising but merits refinement on an independent dataset.

Effect of intermittent fasting with or without caloric restriction on prostate cancer growth and survival in SCID mice

INTRODUCTION

Caloric restriction (CR) delays cancer growth in animals, though translation to humans is difficult. We hypothesized intermittent fasting (i.e., intermittent extreme CR), may be better tolerated and prolong survival of prostate cancer (CaP) bearing mice.

METHODS

We conducted a pilot study by injecting 105 male individually-housed SCID mice with LAPC-4 cells. When tumors reached 200 mm(3), 15 mice/group were randomized to one of seven diets and sacrificed when tumors reached 1,500 mm(3): Group 1: ad libitum 7 days/week; Group 2: fasted 1 day/week and ad libitum 6 days/week; Group 3: fasted 1 day/week and fed 6 days/week via paired feeding to maintain isocaloric conditions to Group 1; Group 4: 14% CR 7 days/week; Group 5: fasted 2 days/week and ad libitum 5 days/week; Group 6: fasted 2 day/week and fed 5 days/week via paired feeding to maintain isocaloric conditions to Group 1; Group 7: 28% CR 7 days/week. Sera from mice at sacrifice were analyzed for IGF-axis hormones.

RESULTS

There were no significant differences in survival among any groups. However, relative to Group 1, there were non-significant trends for improved survival for Groups 3 (HR 0.65, P = 0.26), 5 (0.60, P = 0.18), 6 (HR 0.59, P = 0.16), and 7 (P = 0.59, P = 0.17). Relative to Group 1, body weights and IGF-1 levels were significantly lower in Groups 6 and 7.

CONCLUSIONS

This exploratory study found non-significant trends toward improved survival with some intermittent fasting regimens, in the absence of weight loss. Larger appropriately powered studies to detect modest, but clinically important differences are necessary to confirm these findings.

Association between statins and prostate tumor inflammatory infiltrate in men undergoing radical prostatectomy

BACKGROUND

Cholesterol-lowering drugs known as statins have been reported to have significant anti-inflammatory properties. Given that inflammation may contribute to prostate cancer progression and that statins may reduce the risk for advanced prostate cancer, we investigated whether statin use was associated with reduced intratumoral inflammation in radical prostatectomy (RP) specimens.

METHODS

Inflammation within index tumors of 236 men undergoing RP from 1996 to 2004 was graded by a single pathologist as grade 0 (absent), 1 (mild: < or =10%), and 2 (marked: >10%). Preoperative statin use was analyzed by grouping subjects as statin users or nonusers. Type and dosage of statin was accounted for using dose equivalents with 20 mg simvastatin as reference. Logistic regression was used to determine the association between statin use and intratumoral inflammation controlling for age, race, body mass index, prostate-specific antigen, year of surgery, clinical stage, pathologic Gleason sum, surgical margin status, extracapsular extension, seminal vesicle invasion, prostate weight, time from prostate biopsy to RP, and nonsteroidal anti-inflammatory drug use.

RESULTS

Preoperative statin use was significantly associated with lower risk for any (grade > or =1) intratumoral inflammation (odds ratio, 0.31; 95% confidence interval, 0.10-0.98; P = 0.047) on multivariable analysis, with doses > or =20 mg simvastatin equivalents being more strongly associated (relative to nonuse; odds ratio, 0.22; 95% confidence interval, 0.06-0.79; P = 0.02).

CONCLUSION

In a cohort of men undergoing RP, statin use was associated with significantly lower risk of any inflammation within prostate tumors.

IMPACT

Given previous reports that inflammation is associated with advanced prostate cancer, and statin use is associated with decreased prostate cancer progression risk, our findings suggest that inhibition of inflammation within tumors may be a potential mechanism for purported anti-prostate cancer properties of statins.

Smooth muscle-specific expression of SV40 large TAg induces SMC proliferation causing adaptive arterial remodeling

To study the effects of enhanced smooth muscle cell (SMC) proliferation on arterial vessel geometry in the absence of vessel trauma, we developed a transgenic mouse model expressing SV40 large T antigen under control of the 2.3-kb smooth muscle-myosin heavy chain promoter. Transgenic mice studied at ages from 3 to 13 wk showed a 3.2-fold increase in arterial wall SMC density, with 28% of SMC exhibiting proliferative cell nuclear antigen staining, confirming enhanced SMC proliferation, which was accompanied by two- to threefold increases in arterial wall areas (P < 0.05). Remarkably, despite increased vessel wall mass, the lumen area was not compromised, but rather was increased. A tightly conserved linear relationship was found between arterial circumference and wall thickness with slopes of 0.036 for both transgenics (r = 0.93, P < 0.01) and controls (r = 0.77, P < 0.01), suggesting the hypothesis that the conservation of wall stress functions as a primary determinant of adaptive arterial remodeling. This establishes a new model of adaptive vessel remodeling occurring in response to a proliferative input in the absence of mechanical injury or primary flow perturbation.