PTEN loss in intraductal carcinoma of the prostate has low incidence in Japanese patients

Clinical and genomic features of prostate cancer (PCa) vary considerably between Asian and Western populations. PTEN loss is the most frequent abnormality in intraductal carcinoma of the prostate (IDC-P) in Western populations. However, its prevalence and significance in Asian populations have not yet been well studied. In the present study, we evaluated PTEN expression in IDC-P in a Japanese population and its association with ERG expression. This study included 45 and 59 patients with PCa with and without IDC-P, respectively, who underwent radical prostatectomy. PTEN loss was observed in 10 patients with PCa with IDC-P (22%) and nine patients with PCa without IDC-P (17%). ERG expression was relatively frequent in patients with PCa with PTEN loss, although a significant difference was not observed. The co-occurrence of PTEN loss and ERG expression was observed in four patients with PCa with IDC-P and one without IDC-P. PTEN loss and ERG expression did not affect progression-free survival, regardless of the presence of IDC-P. The frequency of PTEN loss in IDC-P is lower in Asian patients than in Western patients. Our results indicate that mechanisms underlying IDC-P in Asian populations are different from those of Western populations.

Creation of synthetic contrast-enhanced computed tomography images using deep neural networks to screen for renal cell carcinoma

In this study, we elucidate if synthetic contrast enhanced computed tomography images created from plain computed tomography images using deep neural networks could be used for screening, clinical diagnosis, and postoperative follow-up of small-diameter renal tumors. This retrospective, multicenter study included 155 patients (artificial intelligence training cohort [n = 99], validation cohort [n = 56]) who underwent surgery for small-diameter (≤40 mm) renal tumors, with the pathological diagnosis of renal cell carcinoma, during 2010-2020. We created a learned deep neural networks using pix2pix. We examined the quality of the synthetic enhanced computed tomography images created using this deep neural networks and compared them with real enhanced computed tomography images using the zero-mean normalized cross-correlation parameter. We assessed concordance rates between real and synthetic images and diagnoses according to 10 urologists by creating a receiver operating characteristic curve and calculating the area under the curve. The synthetic computed tomography images were highly concordant with the real computed tomography images, regardless of the existence or morphology of the renal tumor. Regarding the concordance rate, a greater area under the curve was obtained with synthetic computed tomography (area under the curve = 0.892) than with only computed tomography (area under the curve = 0.720; p < 0.001). In conclusions, this study is the first to use deep neural networks to create a high-quality synthetic computed tomography image that was highly concordant with a real computed tomography image. Our synthetic computed tomography images could be used for urological diagnoses and clinical screening.

Characteristics of uroflowmetry patterns in men with detrusor underactivity revealed by artificial intelligence

OBJECTIVES

To elucidate the characteristics of uroflowmetry (UFM) observed in men with detrusor underactivity (DU) using our developed artificial intelligence (AI) diagnostic algorithm to distinguish between DU and bladder outlet obstruction (BOO).

METHODS

Subjective and objective parameters, including four UFM parameters (first peak flow rate, time to first peak, gradient to first peak, and the ratio of first peak flow rate to maximum flow rate [Qmax ]) selected by analyzing the judgment basis of the AI diagnostic system, were compared in 266 treatment-naive men with lower urinary tract symptoms (LUTS). Patients were divided into the DU (70; 26.32%) and non-DU (196; 73.68%) groups, and the UFM parameters for predicting the presence of DU were determined by multivariate analysis and receiver operating characteristic (ROC) curve analysis. Detrusor underactivity was defined as a bladder contractility index <100 and a BOO index <40.

RESULTS

Most parameters on the first peak flow of UFM were significantly lower in the DU group. On multivariate analysis, lower first peak flow rate and lower ratio of first peak flow rate to Qmax were significant parameters to predict DU. In the ROC analysis, the ratio of the first peak flow rate to Qmax showed the highest area under the curve (0.848) and yielded sensitivities of 76% and specificities of 83% for DU diagnosis, with cutoff values of 0.8.

CONCLUSIONS

Parameters on the first peak flow of UFM, especially the ratio of the first peak flow rate to Qmax , can diagnose DU with high accuracy in men with LUTS.

Final efficacy and safety results and biomarker analysis of a phase 2 study of cabozantinib in Japanese patients with advanced renal cell carcinoma

BACKGROUND

Cabozantinib was established as the standard of care for the treatment of patients with renal cell carcinoma (RCC) whose disease had progressed after vascular endothelial growth factor receptor tyrosine kinase inhibitor (VEGFR-TKI) therapy in the global randomized trial METEOR. A phase 2 study was conducted to bridge the findings in METEOR to Japanese patients. Here, we report a biomarker analysis and update the efficacy and safety results of cabozantinib treatment.

METHODS

Japanese patients with RCC who received at least one prior VEGFR-TKI were enrolled and received cabozantinib 60 mg orally once daily. The primary endpoint was objective response rate. Secondary endpoints included progression-free survival, overall survival, and safety. Exploratory analyses included the relationship between plasma protein hepatocyte growth factor (HGF) levels and treatment responses.

RESULTS

In total, 35 patients were enrolled. The median treatment duration was 58.3 (range 5.1-131.4) weeks. The objective response rate was 25.7% (90% confidence interval [CI] 14.1-40.6). Kaplan-Meier estimate of median progression-free survival was 11.1 months (95% CI 7.4-18.4). The estimated progression-free survival proportion was 73.1% (95% CI 54.6-85.0) at 6 months. Median overall survival was not reached. Adverse events were consistent with those in METEOR and the safety profile was acceptable. Nonresponders to cabozantinib showed relatively higher HGF levels than responders at baseline.

CONCLUSIONS

Updated analyses demonstrate the long-term efficacy and safety of cabozantinib in Japanese patients with advanced RCC after at least one VEGFR-TKI therapy. Responders tended to show lower baseline HGF levels ClinicalTrials.gov Identifier: NCT03339219.

Impact of the coronavirus disease 2019 pandemic on the number of undergoing radical nephroureterectomy and postoperative adjuvant systematic therapy for upper tract urothelial carcinomas in Japan: A multicenter retrospective study

OBJECTIVES

The coronavirus disease 2019 pandemic has affected cancer management worldwide. For upper tract urothelial carcinomas, delays in treatments are not recommended even during the pandemic. We investigated the impact of the pandemic on patients with these carcinomas who underwent radical nephroureterectomy (RNU) and adjuvant systematic therapy before and after COVID-19 spread in Japan.

METHODS

This multicenter retrospective study included 304 patients who underwent RNU for upper tract urothelial carcinomas between May 1, 2019, and December 31, 2021, in Aichi, Japan. The patients were categorized into three groups based on whether they underwent surgery in the prepandemic (before infection spread in Japan), early pandemic (between confirmation of the first case and vaccination initiation), and late pandemic (after the start of vaccination in Japan) phases. The patient characteristics, diagnostic methods, pathological findings, and postoperative therapy were compared among the three phases.

RESULTS

Overall, 74, 152, and 78 patients underwent RNU in the prepandemic, early pandemic, and late pandemic phases, respectively. The number of patients who underwent preoperative ureteroscopy decreased significantly from the prepandemic phase to the late pandemic phase due to pandemic-related restrictions (p = 0.016). There was no difference in the time to the first visit or pathological findings. Among patients classified as high-risk according to existing clinical trials, the proportion receiving adjuvant systematic therapy after RNU decreased significantly from 52.3% to 19% (p = 0.003).

CONCLUSIONS

There was no difference in the pathological findings. The number of patients receiving appropriate adjuvant systematic therapy decreased during the pandemic.

Lenvatinib plus pembrolizumab versus sunitinib for advanced renal cell carcinoma: Japanese patients from the CLEAR study

BACKGROUND

The phase 3 CLEAR study demonstrated statistically significantly improved efficacy with lenvatinib plus pembrolizumab versus sunitinib, including progression-free survival and overall survival, in patients with previously untreated advanced renal cell carcinoma. This subset analysis investigated efficacy and safety in Japanese patients randomized to lenvatinib plus pembrolizumab or sunitinib in the CLEAR study.

METHODS

Progression-free survival, overall survival, tumor response, and safety were assessed in Japanese patients with previously untreated advanced renal cell carcinoma randomized to receive lenvatinib plus pembrolizumab (n = 42) or sunitinib (n = 31). Efficacy outcomes were analyzed by independent imaging review per Response Evaluation Criteria in Solid Tumors, version 1.1.

RESULTS

Progression-free survival was longer with lenvatinib plus pembrolizumab than with sunitinib (median, 22.1 vs. 10.9 months; hazard ratio, 0.39; 95% CI, 0.20-0.74). Median overall survival was not estimable in the lenvatinib plus pembrolizumab arm and 30.6 months in the sunitinib arm (HR, 1.20; 95% CI, 0.39-3.66). Overall survival adjusted for the imbalance of Memorial Sloan-Kettering Cancer Center prognostic risk group favored lenvatinib plus pembrolizumab (hazard ratio, 0.67; 95% CI, 0.18-2.39). Objective response rate (69.0% vs. 45.2%; odds ratio, 2.71; 95% CI, 1.03-7.10) was higher and median duration of response (20.3 vs. 9.1 months) was longer with lenvatinib plus pembrolizumab versus sunitinib. Grade ≥ 3 treatment-emergent adverse events occurred in 95.2% versus 87.1% of patients in the lenvatinib plus pembrolizumab versus sunitinib arms.

CONCLUSIONS

These findings support lenvatinib plus pembrolizumab as a potential first-line treatment for Japanese patients with advanced renal cell carcinoma.

Impact of Histological Variants on Clinical Responses to Pembrolizumab in Patients With Metastatic Urothelial Cancer

BACKGROUND

The efficacy of anti-programmed celldeath protein 1 treatment in patients with urothelial carcinoma (UC) with molecular subtypes of histological variants has not been investigated. This study aimed to examine the impact of histological variants classified according to molecular subtypes on clinical outcomes in patients with platinum-resistant metastatic UC treated with pembrolizumab.

PATIENTS AND METHODS

Data of 168 patients with metastatic UC who received intravenous pembrolizumab after platinum-based chemotherapy between December 2017 and November 2020 were retrospectively reviewed. Relationships between histological variant type (basal or luminal molecular subtypes) and survival outcome and response to immunotherapy were examined. Clinicopathological factors were analyzed using the Cox proportional hazards model.

RESULTS

UC with histological variants was identified in 19 (11.3%) cases (basal subtype in 12; luminal subtype in 7). The median age of the patients was 72.5 years (range=40-89 years). The performance status was 0-1 in 151 (89.9%) patients. Liver metastasis was detected in 44 (26.2%) patients. The median progression-free survival was 3.5 months (range=0.5-34.3 months). Treatment with immune checkpoint inhibitors resulted in an overall mean survival (from the start of treatment) of 8.1 months (range=1.2-34.3 months). Patients with basal-type UC had significantly shorter progression-free survival and cancer-specific survival than those with pure UC (p=0.010 and p=0.035, respectively). A complete response was observed in eight patients (seven with pure UC, one with basal type).

CONCLUSION

The basal histological variant might be a potential prognostic indicator in patients with platinum-resistant metastatic UC treated with pembrolizumab.

A case of metastatic prostate cancer treated with metastasectomy

In general, metastatic prostate cancer is managed medically. Here we present a patient with metastatic prostate cancer who was treated by surgical resection in addition to medical therapies. Local therapies should be considered if metastatic lesions are limited, also in cases of metastatic prostate cancer.

Imatinib mesylate inhibits androgen-independent PC-3 cell viability, proliferation, migration, and tumor growth by targeting platelet-derived growth factor receptor-α

AIM

The abnormal expression of oncogenic tyrosine kinase receptors such as platelet-derived growth factor receptors (PDGFRs) has been reported in cancer progression. However, the role of PDGFRs in the human androgen-independent prostate cancer PC-3 cell line is not well understood. Thus, this study examined the role of PDGFRs in androgen-independent PC-3 cells.

MAIN METHODS

PDGFR mRNA and protein expression was determined by quantitative real-time PCR and western blotting, respectively. The effects of the tyrosine kinase inhibitor imatinib (imatinib mesylate) and small interfering RNAs (siRNAs) were determined by a Cell Counting Kit-8 assay, bromodeoxyuridine assay, and Transwell migration assay. The in vivo effect of imatinib was analyzed using a tumor formation assay in nude mice.

KEY FINDINGS

PDGFRα was upregulated in androgen-independent PC-3 cells compared with normal prostate epithelial cells. PDGF-BB induced the phosphorylation of PDGFRα and downstream signaling molecules, including Akt, in a dose-dependent manner. Imatinib reduced the phosphorylation of the PDGFRα/Akt axis. Imatinib also suppressed the viability, proliferation, migration, and tumor growth of PC-3 cells. PDGFRα knockdown by siRNA decreased the viability and migration of PC-3 cells.

SIGNIFICANCE

These results demonstrated the distinct contribution of PDGFRα signaling to the proliferation and migration of PC-3 cells and suggested the potential for PDGFRα as a therapeutic target for metastatic and androgen-independent prostate cancer.

A case of renal cell carcinoma with microscopic pulmonary tumor embolism proven by surgical lung biopsy

Pulmonary tumor embolism (PTE) is difficult to diagnose before death. We report the case of a 75-year-old man with microscopic PTE of renal cell carcinoma who was diagnosed by surgical lung biopsy. He visited our hospital because of dyspnea on exertion. Chest computed tomography (CT) showed multiple micronodules and ground glass opacities. Steroid therapy was started as therapeutic diagnosis for IgG4-related pulmonary disease. However, he was admitted our hospital due to progressive respiratory failure. Pathological findings of a lung biopsy obtained by video-assisted thoracic surgery showed PTE of renal cell carcinoma without embolization of large pulmonary arteries. He received palliative medicine and died four months after the surgical lung biopsy. In cases of multiple micronodules in chest CT findings and worsened respiratory symptoms, PTE should be considered in the differential diagnosis.

Organ cross-sensitization mechanisms in chronic diseases related to the genitourinary tract

There are various refractory chronic inflammatory diseases related to the genitourinary tract, such as interstitial cystitis/bladder pain syndrome and chronic prostatitis/chronic pelvic pain syndrome. It has been reported that in the general population, these diseases are related to other chronic illnesses, such as irritable bowel syndrome or vulvodynia. Herein, we review papers regarding pelvic organ cross-sensitization, a factor which is considered to contribute to these relationships. Several other researchers and ourselves have reported that noxious stimuli from a diseased pelvic organ are transmitted to an adjacent normal structure via shared sensory neural pathways at the prespinal, spinal, and supraspinal levels, resulting in functional changes in the adjacent normal structure. In conclusion, since there are few treatments to cure interstitial cystitis/bladder pain syndrome and chronic prostatitis/chronic pelvic pain syndrome completely, further studies regarding organ cross-sensitization may provide new insights into the pathophysiology and treatment strategies for these diseases.

Impact of the objective response to and number of cycles of platinum-based first-line chemotherapy for metastatic urothelial carcinoma on overall survival of patients treated with pembrolizumab

OBJECTIVES

To investigate the impact of the number of cycles and objective response to chemotherapy on overall survival in patients with metastatic urothelial carcinoma treated with pembrolizumab.

METHODS

This multicenter, retrospective study included 755 patients from 59 institutions with advanced, chemoresistant urothelial carcinoma who received pembrolizumab. The associations of the overall survival with the number of cycles and best objective response were investigated using Cox multiple regression analysis.

RESULTS

Overall, 391 patients received standard first-line chemotherapy and pembrolizumab as a second-line treatment, and were included in the final analysis. Of the 391 patients, 185 received less than four cycles, 134 received four to six cycles and 72 received more than six cycles of first-line chemotherapy. An objective response (complete or partial response) to chemotherapy was observed in 145 patients (37.1%). Univariate analysis showed that the overall survival of patients who received more than six cycles or responded to chemotherapy (complete or partial response) was significantly longer than that of patients who received less than four cycles or did not respond to chemotherapy (stable or progressive disease). At multivariate levels, no correlations were observed between overall survival and the number of cycles of or the response to chemotherapy.

CONCLUSIONS

Therapeutic benefit of pembrolizumab can be expected irrespective of the objective response to and number of cycles of platinum-based first-line chemotherapy.

Development of an artificial intelligence diagnostic system for lower urinary tract dysfunction in men

OBJECTIVES

To establish an artificial intelligence diagnostic system for lower urinary tract function in men with lower urinary tract symptoms using only uroflowmetry data and to evaluate its usefulness.

METHODS

Uroflowmetry data of 256 treatment-naive men with detrusor underactivity, bladder outlet obstruction, or detrusor underactivity + bladder outlet obstruction were used for artificial intelligence learning and validation using neural networks. An optimal artificial intelligence diagnostic model was established using 10-fold stratified cross-validation and data augmentation. Correlations of bladder contractility index and bladder outlet obstruction index values for the artificial intelligence system and pressure flow study values were examined using Spearman's correlation coefficients. Additionally, diagnostic accuracy was compared between the established artificial intelligence system and trained urologists with uroflowmetry data of 25 additional patients by χ² -tests. Detrusor underactivity was defined as bladder contractility index ≤100 and bladder outlet obstruction index ≤40, bladder outlet obstruction was defined as bladder contractility index >100 and bladder outlet obstruction index >40, and detrusor underactivity + bladder outlet obstruction was defined as bladder contractility index ≤100 and bladder outlet obstruction index >40.

RESULTS

The artificial intelligence system's estimated bladder contractility index and bladder outlet obstruction index values showed significant positive correlations with pressure flow study values (bladder contractility index: r = 0.60, P < 0.001; bladder outlet obstruction index: r = 0.46, P < 0.001). The artificial intelligence system's detrusor underactivity diagnosis had a sensitivity and specificity of 79.7% and 88.7%, respectively, and those for bladder outlet obstruction diagnosis were 76.8% and 84.7%, respectively. The artificial intelligence system's average diagnostic accuracy was 84%, which was significantly higher than that of urologists (56%).

CONCLUSIONS

Our artificial intelligence diagnostic system developed using the uroflowmetry waveform distinguished between detrusor underactivity and bladder outlet obstruction with high sensitivity and specificity in men with lower urinary tract symptoms.

Comparable survival outcome between acquired cystic disease associated renal cell carcinoma and clear cell carcinoma in patients with end-stage renal disease: a multi-institutional central pathology study

Acquired cystic disease (ACD) associated renal cell carcinoma (RCC) is designated as a new subtype unique to patients with end-stage renal disease (ESRD) according to the 2016 World Health Organization (WHO) classification. However, the oncological outcomes of the prognostic factors for patients with this subtype are not fully understood. In the present study, we compared the survival of ACD associated RCC patients who underwent nephrectomy with that of patients with other histological subtypes who developed ESRD. Over 378 patients who underwent nephrectomy at three Japanese institutes between 1987 and 2016 were included in this study. A central pathologist reviewed the sections from all patients according to the 2016 WHO classification. The central pathological review showed a clear cell subtype in 165 patients (43.6%), ACD associated RCC in 112 (29.6%), papillary in 61 (16.1%), and others in 40 (10.7%). The proportion of patients with pathological stage 1 was extremely high in both clear cell and ACD associated RCC cohorts (86.6%, 85.7%). The cancer specific survival (CSS) and recurrence free survival rates of patients with ACD associated RCC were comparable with those with clear cell carcinoma and significantly better than those with the papillary subtype. The factors predictive of unfavourable outcomes were long dialysis duration, tumour size, pathological stage, grade 4 tumour, and the presence of lymphovascular invasion or a sarcomatoid component. Patients with a pre-operative dialysis duration of 20 years or longer showed a significantly worse CSS than other patients, probably owing to sarcomatoid differentiation and stage migration during the advanced stages. In conclusion, this study included the largest number of patients with ACD associated RCC, showing a survival similar to that of clear cell histology patients with ESRD, except for the rarity of late recurrence. ACD associated RCC was not as indolent as initially recognised when patients were on long term dialysis.

Pembrolizumab for treating advanced urothelial carcinoma in patients with impaired performance status: Analysis of a Japanese nationwide cohort

Background

The benefits of pembrolizumab in patients with advanced urothelial carcinoma (UC) and impaired performance status (PS) remain unknown. This study assessed the safety and efficacy of pembrolizumab in patients with platinum‐refractory UC and Eastern Cooperative Oncology Group PS ≥2 to identify which subgroups may benefit from this drug.

Methods

This retrospective nationwide cohort study collected clinicopathological information for 755 patients from 59 institutions. The overall response rate (ORR) and overall survival (OS) were compared among the patients with PS 0–1, 2, and 3–4. Multivariate analysis was conducted to identify factors predicting OS in patients with PS ≥2.

Results

The numbers of patients with PS 0–1, 2, and 3–4 were 602, 98, and 55, respectively; the ORRs in these groups were 29.5, 15.3, and 9.1%, respectively, and the median OS times were 14.3, 3.1, and 2.4 months, respectively. In multivariate Cox regression analysis, a neutrophil–lymphocyte ratio (NLR) ≥3.5 (hazard ratio [HR] = 1.897) and liver metastasis (HR = 2.072) were associated with OS in the PS ≥2 subgroup. The median OS of patients with PS ≥2 without either risk factor was 6.8 months, compared with 3.1 months for patients with one risk factor and 2.3 months for patients with both risk factors.

Conclusions

PS ≥2 portended worse ORR and OS than PS ≤1 despite a comparable safety profile. Among the patients with impaired PS, patients with NLR <3.5 and no liver metastasis may most greatly benefit from pembrolizumab therapy.

Urodynamic evaluation before and after to RARP to identify pre and intraoperative factors affecting postoperative continence

AIMS

To investigate factors contributing to pre and postoperative urethral function in male patients who underwent robot-assisted radical prostatectomy (RARP) using the urethral pressure profile (UPP).

METHODS

Study A A total of 313 patients who underwent RARP between April 2013 and March 2015 were prospectively investigated. UPP was performed preoperatively in all patients. Correlation and multiple regression analyses were performed to investigate predictive factors for low preoperative maximum urethral closure pressure (MUCP). Study B To validate the predictive factors for low preoperative MUCP obtained in Study A, 755 patients who underwent RARP between May 2010 and October 2017 were retrospectively examined. Relationships between the time to pad-free status and the following factors were investigated: number of predictive factors, nerve-sparing surgery, and vesicourethral anastomosis (VUA) methods (barbed vs. nonbarbed suture).

RESULTS

Study A A total of 187 patients were enrolled. Multivariate analysis revealed that older age, large prostate volume, low erectile function domain scores in International Index Erectile Function 15, and use of calcium channel blockers were significantly associated with low preoperative MUCP. Study B A total of 515 patients were included. Cox proportional hazard regression showed that the number of predictive factors and VUA method were significantly associated with the time to pad-free status.

CONCLUSIONS

Our study demonstrated that older age, larger prostate volume, poor erectile function, and calcium channel blocker use could be predictive markers for recovery from postprostatectomy urinary incontinence.

pT3 subclassification of renal pelvic cancer considering the tumor location improves the patients' prognostic accuracy

Whether pT3 urothelial carcinoma of the renal pelvis (UCRP) and urothelial carcinoma of the ureter (UCU) have the same prognosis is controversial, this study compared the prognosis of pT3 UCRP with that of pT3 UCU. We retrospectively evaluated 954 patients who underwent nephroureterectomy at our institutions between January 1983 and December 2017. All surgical specimens were reviewed by a single genitourinary pathologist. Cases of pT3 UCRP were subclassified as pT3a (urothelial carcinomas extending only to the renal medulla) and pT3b (urothelial carcinomas extending into the renal cortex and/or peripelvic adipose tissue). Fine and Gray's model was used to predict recurrence-free survival (RFS) and cancer-specific survival (CSS). A total of 493 (51.7%) had UCRP and 461 (48.3%) had UCU. Within this group, 202 patients had pT3 UCRP and 146 had pT3 UCU. The pT3 subclassification of UCRP resulted in 79 cases of pT3a and 120 of pT3b. The difference in 5-year CSS among the pT3a UCRP, pT2 UCRP, and pT2 UCU subgroups was not statistically significant (pT3a UCRP vs pT2 UCRP, HR = 0.69, p = 0.56; pT3a UCRP vs pT2 UCU, HR = 0.66, p = 0.31) However, RFS and CSS were significantly higher in the pT3a UCRP group than in the pT3b group (pT3a vs pT3b, HR = 2.59, p = 0.0038 and pT3a vs pT3b, HR = 3.10, p = 0.001). The results suggest that our proposed pT3 subclassification better predicts the prognosis of UCRP patients than does the pT3 of the current AJCC/UICC classification.

Characteristics of primary and repeated recurrent retroperitoneal liposarcoma: outcomes after aggressive surgeries at a single institution

OBJECTIVE

This study sought to investigate the characteristics of primary and repeated recurrent retroperitoneal liposarcoma.

METHODS

Patients treated with primary or recurrent retroperitoneal liposarcoma between 2005 and 2018 were retrospectively reviewed. Survival time analysis of recurrence-free survival and overall survival was conducted using Kaplan-Meier analysis and log-rank test.

RESULTS

Fifty-two patients with primary retroperitoneal liposarcoma were analysed. Amongst them, 46 patients (88%) had undergone surgery. Histologic grades included well-differentiated (n = 21), dedifferentiated (n = 21), myxoid (n = 3) and pleomorphic (n = 1) subtypes. The patients undergoing R0 resection in the first surgery had significantly higher recurrence-free survival rates compared with the patients undergoing non-R0 resection (3-year recurrence-free survival: 80 versus 38%; 5-year recurrence-free survival: 49 versus 29%, P = 0.033). Although overall survival rates tended to be higher in the patients undergoing R0 resection compared with the non-R0 resection, it did not reach to a statistical significant difference (5-year overall survival: 93 versus 75%; 10-year overall survival: 93 versus 59%, P = 0.124). The recurrence rates were 65, 67, 73 and 100%, and the median recurrence-free survival times were 46, 20, 9 and 3 months after the first, second, third and fourth surgeries, respectively. The 5-year overall survival rates were 82, 69, 40 and 0% after the first, second, third and fourth surgeries, respectively.

CONCLUSIONS

With repeated recurrence and surgeries, the time to recurrence decreased and the recurrence rate increased. R0 resection in the first surgery was considered the most important for longer recurrence-free survival and radical cure.

Presence of constipation predicts the therapeutic efficacy of pembrolizumab in metastatic urothelial cancer patients

OBJECTIVES

To study bowel function in urothelial cancer patients treated with pembrolizumab and to assess its association with treatment efficacy.

METHODS

This retrospective study was analyzed for patients with metastatic urothelial cancer who received immune checkpoint inhibitor treatment between December 2017 and June 2019 at Nagoya University and affiliated hospitals in Japan. The association between bowel dysfunction (defined as constipation or need for laxatives) and treatment efficacy was investigated.

RESULTS

We retrospectively enrolled 73 patients with metastatic urothelial cancer who received immune checkpoint inhibitor treatment. All patients received pembrolizumab at 200 mg per bodyweight administered intravenously every 3 weeks. Performance status was 0-1 in 58 patients (79.5%), and liver metastasis was detected in 22 patients (30.1%). The median age was 72 years (range 40-89 years). A total of 45 patients had constipation. The median progression-free survival and overall survival from the start of immune checkpoint inhibitor treatment was 4.0 months (95% confidence interval 1.0-17.3) and 6.6 months (95% confidence interval 1.0-18.0), respectively. Patients with constipation had a significantly higher risk of disease progression (P = 0.005). There was no significant association between constipation and overall survival (P = 0.131). However, complete response was observed among two patients treated with immune checkpoint inhibitor, both of whom did not present constipation.

CONCLUSION

The presence of constipation might be a prognostic factor for urothelial cancer patients undergoing immune checkpoint inhibitor treatment.

Retroperitoneal tumors: Review of diagnosis and management

Retroperitoneal tumors are extremely rare tumors occurring in the retroperitoneum. Retroperitoneal tumors are divided into benign tumors and malignant tumors, including retroperitoneal sarcoma. Approximately 70-80% of primary retroperitoneal soft-tissue tumors are malignant; however, these only account for 0.1-0.2% of all malignancies. Retroperitoneal sarcoma is an orphan malignant disease with a low incidence. The information on benign retroperitoneal tumors is limited. The American Joint Committee on Cancer/TNM classification updated to the 8th edition in 2017. In 2010, three new drugs for soft tissue sarcoma were approved based on the results of phase III trials, but the histological subtypes of the patients enrolled in the trials of each drug differed. Recently, in addition to surgery for retroperitoneal sarcoma, the effectiveness of perioperative radiation therapy has become interesting. For malignant retroperitoneal tumors and retroperitoneal sarcoma, survival improvement and locoregional recurrence prevention can be undertaken by carrying out surgery to secure negative margins with wide and combined resection of some adjacent organs, and cooperation with a trained medical team comprising of radiologists, pathologists and medical oncologists in centralized hospitals. Some clinical trials aimed at further improving treatment results by adding preoperative chemotherapy and radiation therapy based on histological confirmation using a correct needle biopsy are in progress. In recent years, molecular profiling has been used to select eligible patients for chemotherapy. In the future, precision medicine with next-generation sequencing technology will be expected among the diverse and potential future treatments for retroperitoneal sarcoma. In this review, we summarized the current state of retroperitoneal tumors and retroperitoneal sarcoma.

Cabozantinib in advanced renal cell carcinoma: A phase II, open-label, single-arm study of Japanese patients

Objectives

To evaluate the efficacy and safety of cabozantinib, through a bridging study to METEOR, in Japanese patients with advanced renal cell carcinoma who had progressed after prior tyrosine kinase inhibitor therapy.

Methods

This phase II, open‐label, single‐arm study (ClinicalTrials.gov registration number: NCT03339219) included adult Japanese patients with advanced renal cell carcinoma and measurable disease who had received one or more tyrosine kinase inhibitors. Patients received cabozantinib 60 mg orally once daily while there was clinical benefit, or until unacceptable toxicity or disease progression. The primary end‐point was objective response rate per Response Evaluation Criteria in Solid Tumors Version 1.1. Secondary end‐points included clinical benefit rate (complete or partial response, or ≥8‐week stable disease), progression‐free survival, overall survival and safety.

Results

Of the 35 patients enrolled, 68.6%, 22.9% and 8.6% had previously received one, two and three prior tyrosine kinase inhibitors, respectively. The median duration of cabozantinib exposure was 27.0 weeks (range 5.1–43.0 weeks). The objective response rate was 20.0% (90% confidence interval 9.8–34.3%), and the clinical benefit rate was 85.7% (95% confidence interval 69.7–95.2%). The 6‐month estimated progression‐free survival was 72.3% (95% confidence interval 53.3–84.6%); the median progression‐free survival and overall survival were not reached. All patients reported adverse events, which were manageable by supportive treatment or dose modification; two patients (5.7%) discontinued therapy due to adverse events.

Conclusions

The results showed that findings from METEOR can be extrapolated, and that cabozantinib 60 mg/day is a viable treatment option in Japanese patients with advanced renal cell carcinoma who had progressed after prior tyrosine kinase inhibitor therapy.

A pooled analysis of the efficacy and safety of cabozantinib post immunotherapy in patients with advanced renal cell carcinoma

5089

Background: While studies have demonstrated survival benefits of first-line regimens including immuno-oncology agents (IO) in advanced renal cell carcinoma (aRCC), optimal treatment following IO is unknown. In the phase 3 METEOR trial, cabozantinib improved progression-free survival (PFS), objective response rate (ORR), and overall survival (OS) versus everolimus in patients (pts) with aRCC, after VEGFR-TKI therapy. The Japanese phase II C2001 study (NCT03339219), targeting a population similar to that of METEOR, showed similar efficacy and safety results. Here, we present a post-hoc pooled analysis of pts who had received prior IO therapy from METEOR and C2001. Methods: A pooled analysis was performed in pts who received 60mg/day of oral cabozantinib once daily enrolled in the METEOR or C2001. Patients were divided into two groups with previous IO treatment (pre-w/ IO subgroup) or without previous IO treatment (pre-w/o IO subgroup). Analyses of ORR, PFS, OS, and safety were performed as measures of clinical outcome in each subgroup. Results: 365 pts (pre-w/ IO subgroup: 33 pts, pre-w/o IO subgroup:332 pts) were included for efficacy analysis and 366 pts (pre-w/ IO subgroup: 33 pts, pre-w/o IO subgroup:333 pts) for safety analysis. Minor differences in baseline characteristics were noted between the analysis subgroups but are not expected to substantially affect efficacy outcomes. The ORR was 21.2% (95% CI: 9.0-38.9%) for pre-w/ IO subgroup, and 17.2% (95% CI: 13.3-21.7%) for pre-w/o IO subgroup. PFS rate and OS rate at 6 months pre-w/ IO was 65.5%, 90.8% and pre-w/o IO was 58.3%, 90.6%, respectively. Although there were some differences in the safety profile, almost all AEs were manageable by dose modifications. There were no differences in AEs associated with IO treatment, such as pneumonitis, endocrinolopathy or infusion related reaction. No new safety signals were noted in any subgroups. Conclusions: Safety and treatment efficacy of cabozantinib were maintained in the pooled analysis of pts from METEOR and C2001 irrespective of prior IO treatment. Funded by Takeda Pharmaceutical Company Limited, Tokyo, Japan. Clinical trial information: NCT03339219, NCT01865747 .

Sunitinib Versus Sorafenib as Initial Targeted Therapy for mCC-RCC With Favorable/Intermediate Risk: Multicenter Randomized Trial CROSS-J-RCC

PURPOSE

The present study compared the efficacy of sunitinib and sorafenib as first-line treatment of metastatic clear cell renal cell carcinoma (mCC-RCC) with favorable or intermediate Memorial Sloan Kettering Cancer Center (MSKCC) risk.

PATIENTS AND METHODS

Treatment-naive patients with mCC-RCC were randomized to receive open-label sunitinib followed by sorafenib (SU/SO) or sorafenib followed by sunitinib (SO/SU). The primary endpoint was first-line progression-free survival (PFS). The secondary endpoints were total PFS and overall survival (OS).

RESULTS

Of the 124 patients enrolled at 39 institutions from February 2010 to July 2012, 120 were evaluated. The median first-line PFS duration was 8.7 and 7.0 months in the SU/SO and SO/SU groups, respectively (hazard ratio [HR], 0.67; 95% confidence interval [CI], 0.42-1.08). The total PFS and OS were not significantly different between the SU/SO and SO/SU groups (27.8 and 22.6 months; HR, 0.73; 95% CI, 0.428-1.246; and 38.4 and 30.9 months; HR, 0.934; 95% CI, 0.588-1.485, respectively). The subgroup analysis revealed that the total PFS with SU/SO was superior to the total PFS with SO/SU in the patients with favorable MSKCC risk and those with < 5 metastatic sites). SO/SU was superior to SU/SO for patients without previous nephrectomy.

CONCLUSIONS

No statistically significant differences were found in first-line PFS, total PFS, or OS between the 2 treatment arms (ClinicalTrials.gov identifier, NCT01481870).

Proposal of a new subcategory of the pT3 classification: Effects of tumor location and subclassification of renal pelvic pT3 to predict the prognosis of pelvic carcinoma more accurately than the current TNM classification

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Background: Whether pT3 urothelial carcinoma of the renal pelvis (UCRP) and urothelial carcinoma of the ureter (UCU) show the same prognosis or not remains controversial.This study aims to reveal whether the prognosis of pT3 UCRP shows similar to those of pT3 UCU. Methods: We retrospectively evaluated 954 patients who underwent nephroureterectomy between 1983 and 2017 at our institutions.None of the patients received neoadjuvant therapy.All HE slides for each patient were reviewed by a single genitourinary pathologist (TT).pT3 UCRP was subdivided pT3a (urothelial carcinomas that extend only to the renal medulla) and pT3b (urothelial carcinomas that extend to the renal cortex and/or peripelvic adipose tissue) according to the criteria previously we proposed.Fine and Gray model was developed to predict the reccurence-free survival (RFS) and cancer-specific survival (CSS). Results: Overall, 954 patients were eligible for this study, 493 of whom were pT3 with only renal pelvis and 461 of whom were pT3 with only ureter. A total of 202 cases were pT3 UCRP and 146 were pT3 UCU. The pT3 subclassification of UCRP resulted in 79 pT3a and 120 pT3b cases.No significant difference was found in the 5-yr RFS and 5-yr CSS between pT3a UCRP and pT2 UCRP and pT2 UCU. (RFS; pT3a UCRP vs pT2 UCRP: HR = 1.19 p = 0.74; pT3a UCRP vs pT2 UCU HR = 0.88, p = 0.72, CSS;pT3a UCRP vs. pT2 UCRP: HR = 0.69; p = 0.56; pT3a UCRP vs. pT2 UCU: HR = 0.66, p = 0.31) The RFS rate was significantly higher in the pT3a UCRP than that of pT3b, (pT3a vs pT3b: HR = 2.59, p = 0.0038) and so was the CSS rate. (pT3a vs. pT3b: HR = 3.1 p = 0.001) In fine and gray model analysis for RFS, pT stage, lymph node metastasis, WHO/ISUP grade, lymphovascular invasion were independently associated with tumor recurrence, whereas pT stage, lymph node metastasis, operation method, histologic type, lymphovascular invasion, gross type, adjuvant chemotherapy were independently associated with cancer mortality. Conclusions: Subclassifying pT3 UCRP into pT3a and pT3b was useful in determining the prognosis of different patients.The pT3b UCRP showed similar outcome compared to those of UCU.

Response of intraductal carcinoma of the prostate to androgen deprivation therapy predicts prostate cancer prognosis in radical prostatectomy patients

BACKGROUND

Intraductal carcinoma of the prostate (IDC-P) has a poor prognosis and is thought to be completely resistant to current therapies, including androgen deprivation therapy (ADT). However, to date, there are no data showing direct evidence of such resistance.

METHODS

We retrospectively evaluated 145 patients with high-risk prostate cancer who underwent radical prostatectomy (RP) with neoadjuvant ADT between 1991 and 2005. All patient data were collected from slides prepared from needle biopsy (NB) samples of prostate tissue and RP specimens. Data were analyzed in terms of serum level of prostate specific antigen (PSA), Gleason score of NB samples, clinical T stage, the positive cancer core rate, maximum cancer extension rate, presence of Gleason pattern 5, and presence of IDC-P in both NB samples and RP specimens.

RESULTS

The median initial PSA was 33.2 ng/mL (range, 2.4-296 ng/mL), and the median follow-up period was 109 months (range, 11-257 months). The preoperative median ADT period was 4 months (range, 1-20 months). IDC-P was present in 53 patients (37%) in NB samples and 65 (45%) in RP. The patients were divided into three groups based on the presence or absence of IDC-P in NB/RP samples (IDC-P-negative at biopsy: 92 cases, IDC-P-positive at biopsy with IDC-P disappearance: 15 cases, and IDC-P-positive at biopsy with IDC-P persistence: 38 cases). Overall, 28% of IDC-P-positive cases in NB samples showed the disappearance of IDC-P at RP. IDC-P persistence cases showed the poorest prognosis, while IDC-P disappearance cases had a similar prognosis to that of IDC-P-negative at biopsy cases in terms of disease-free survival, cancer-specific survival, and overall survival (P = .0018, P = .0087, and P = .0034, respectively).

CONCLUSIONS

Some cases with IDC-P responded to ADT and demonstrated favorable clinical outcomes similar to those of cases without IDC-P. These findings indicate that cases with IDC-P are heterogeneous.

Clinical characteristics and surgical outcomes of retroperitoneal tumors: a comprehensive data collection from multiple departments

BACKGROUND

There are only a limited number of comprehensive reports for retroperitoneal tumors (RPTs). The aim of this study was to perform an interdepartmental data collection for RPTs and to comprehensively clarify the clinical characteristics of this rare disease.

METHODS

All patients who were diagnosed with RPT from January 2005 to July 2018 in a single institution were included. The analyzed factors included demographics, clinical features, treatment methods, pathological diagnosis, and prognosis.

RESULTS

A total of 422 patients (215 males and 207 females) with primary RPTs were identified. Biopsy for RPT was performed in 180 patients (43%). Among the 422 patients, 239 (57%) underwent surgery. The most common tissue origin was mesodermal (n = 99, 41%), followed by neurogenic (n = 54, 23%), extragonadal (n = 27, 11%), and metastatic tumors (n = 13, 5%). Among the 99 resected mesodermal tumors, the most common pathological subtypes were liposarcoma (n = 55, 56%) and leiomyosarcoma (n = 16, 16%). The long-term outcomes after surgery were analyzed in patients with intermediate and malignant sarcomas (including liposarcoma, leiomyosarcoma, and others combined, n = 71). The 3- and 5-year disease-free survival rates in the intermediate tumors were 68.2% and 54.2%, respectively, whereas those in the malignant tumors were 48.6% and 28.9%, respectively. The 3- and 5-year overall survival rates in the intermediate tumors were 100% and 94.1%, respectively, whereas those in the malignant tumors were 78.4% and 72.8%, respectively (p = 0.009).

CONCLUSIONS

The clinical manifestations of RPTs were extremely variable. Recurrence after repeating resection is commonly observed in patients with malignant retroperitoneal sarcoma.

A case of advanced prostate cancer controlled for the long term by flutamide after bicalutamide failure

Currently, the early introduction of new antiandrogens is popular for castration-resistant prostate cancer (CRPC). However, adverse events can be severe and their costs are high. Here, we present a patient with CRPC in whom flutamide controlled disease progression for 10 years. This case report shows that conventional alternative antiandrogens are cost effective and are still an important option for the treatment for CRPC.

Precise estimation of renal vascular dominant regions using spatially aware fully convolutional networks, tensor-cut and Voronoi diagrams

This paper presents a new approach for precisely estimating the renal vascular dominant region using a Voronoi diagram. To provide computer-assisted diagnostics for the pre-surgical simulation of partial nephrectomy surgery, we must obtain information on the renal arteries and the renal vascular dominant regions. We propose a fully automatic segmentation method that combines a neural network and tensor-based graph-cut methods to precisely extract the kidney and renal arteries. First, we use a convolutional neural network to localize the kidney regions and extract tiny renal arteries with a tensor-based graph-cut method. Then we generate a Voronoi diagram to estimate the renal vascular dominant regions based on the segmented kidney and renal arteries. The accuracy of kidney segmentation in 27 cases with 8-fold cross validation reached a Dice score of 95%. The accuracy of renal artery segmentation in 8 cases obtained a centerline overlap ratio of 80%. Each partition region corresponds to a renal vascular dominant region. The final dominant-region estimation accuracy achieved a Dice coefficient of 80%. A clinical application showed the potential of our proposed estimation approach in a real clinical surgical environment. Further validation using large-scale database is our future work.

Influence of the Body Mass Index and its Effect on Tumor Characteristics and Survival among a Population with Access to Surgical Management of Upper Tract Urothelial Carcinoma

Objective

To examine the association between the body mass index (BMI) and the risk of survival, and to evaluate whether tumor characteristics differ by BMI in patients with upper tract urothelial carcinoma (UTUC) managed by surgery.

Methods

A clinical series on 876 patients with localized UTUC following nephroureterectomy with a bladder cuff, with data from Osaka Medical College registry (discovery cohort) and the Nagoya group (validation cohort) was examined. In addition to analyzing the overall survival and cancer-specific survival (CSS), the survival impact adjusted by pathological variables was also assessed by the BMI group.

Results

The percentage of high risk features including positive lymphovascular invasion was doubled in the discovery cohort compared to the validation cohort. The group of BMI ≥ 25 kg/m² was associated with improved CSS in the discovery cohort (p = 0.004), and this tendency was verified in the validation cohort (p = 0.006). Nonproportional hazards existed for the group of BMI ≥ 25 kg/m² and the BMI 18.5-25 kg/m² relative to the group of BMI < 18.5 kg/m², with a change in the CSS hazard. In multivariable Cox models, the BMI group had a superior predictive value compared with other pre-clinical factors both in the discovery cohort (HR = 3.85, p = 0.01; 95%CI: 0.09-0.73) and the validation cohort (HR = 1.56, p = 0.01; 95%CI: 0.45-0.91). When adjusted by lymphovascular invasion, the concordance of the model proposed by the discovery cohort (0.52) challenged in the validation cohort was 0.59.

Conclusions

We found a clinically relevant signature for high risk patients with BMI grouping. Further research is necessary on whether tailoring recommendations for weight and nutrition management to tumor characteristics will improve outcomes.

Abstract 4047: Tumor-infiltrating lymphocytes in renal cancer patients demonstrate a diverse PD-1 expression and characteristic Treg classification

Immunotherapy has been shown to be effective for a proportion of chemoradiotherapy-refractory cancer patients. In particular, immune checkpoint inhibitors such as anti-CTLA-4 and anti-PD-1 antibodies are more effective for patients with high tumor mutation burden (TMB) or high expression of immune checkpoint molecules. In this study, we investigated immune responses in patients with renal cancer (RCC). Previous studies have demonstrated that the clinical effect of immune checkpoint inhibitors was 20% to 30%, and TMB was moderate (high; melanoma and lung cancer, low: astrocytoma and acute lymphocytic leukemia). We performed immune profiling of lymphocytes in the tumor tissue, normal tissue, and peripheral blood from 13 RCC patients by flow cytometry. Firstly, we examined the difference of CD4+ T cells, CD8+ T cells, and regulatory T (Treg) cells among 3 individual sampling sites. The frequency of CD8+ T cells in the tumor and normal tissues was higher than that of CD4+ T cells in the peripheral blood. In contrast, the frequency of CD4+ T cells in the peripheral blood was the highest, and that of effector-Treg (eTreg) cells (defined by CD3+CD4+FOXP3highCD45RAlow) in the tumor tissue was the highest. Additionally, we found that the RCC patients were arbitrarily classified into three groups based on the frequency of eTreg cells (i.e. high: &gt; 10%, moderate: &gt; 5%, and low: &gt; 0%). Although this simple eTreg classification has not yet been shown to be associated with patient prognosis, this pattern is distinct from that of other cancer types. Secondly, we examined the expression of immune checkpoint molecules in the CD8+ T cells and eTreg cells. The CD8+ T cells in tumor tissue showed various degrees of PD-1 expression. An extremely high PD-1 expression in CD8+ cells was correlated with a moderate to high frequency of eTreg cells. The tumor-infiltrating CD8+ T cells showed a low expression of other checkpoint/accessory molecules such as LAG-3, CTLA-4, and TIGIT. In contrast, tumor-infiltrating eTreg cells showed high TIGIT and CTLA-4 expression, moderate PD-1 expression, and no LAG-3 expression. With regards to other immune-related molecules, the eTreg cells showed high CCR4 and low ICOS expression. These preliminary data implicate that the clinical benefit of immune checkpoint inhibitors for RCC patients could be associated with the high level of PD-1 expression in CD8+ T cells and the magnitude of eTreg cell infiltration into their tumor tissues. By analyzing the mechanism of high PD-1 expression in the CD8+ T cells and assessing the eTreg classification in RCC patients, we speculate that it is possible to develop a new treatment strategy by combining the anti-PD-1 antibody and Treg-depletion therapies. These data, along with additional measurements of samples from further patients, will be presented at the meeting.

Citation Format: Daisuke Sugiyama, Tomoaki Muramatsu, Yoichi Kobayashi, Naoto Sassa, Shoichi Maruyama, Momokazu Goto, Yoshiki Akatsuka, Hiroyoshi Nishikawa. Tumor-infiltrating lymphocytes in renal cancer patients demonstrate a diverse PD-1 expression and characteristic Treg classification [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 4047.

The influence of the presence of intraductal carcinoma of the prostate on the grade group system's prognostic performance

BACKGROUND

Although the presence of intraductal carcinoma of the prostate (IDC-P) influences biochemical failure in radical prostatectomy patients, no data are available regarding the impact of its integration into the classification grade group system. Thus, the aim of this study was to enhance the utility of the grade group system by integrating the presence of IDC-P.

METHODS

This study was a retrospective evaluation of 1019 patients with prostate cancer who underwent radical prostatectomy between 2005 and 2013 without neoadjuvant or adjuvant therapy. The data on age, prostate-specific antigen (PSA) level at diagnosis, pathological T stage (pT), presence of Gleason pattern 5 (GP5), presence of IDC-P, and surgical margin status were analyzed to predict PSA recurrence after prostatectomy.

RESULTS

The median patient age was 67 (range, 45-80) years and the median initial PSA level was 6.8 (range, 0.4-82) ng/mL. The median follow-up period was 82 (range, 0.7-148) months. IDC-P was detected in 157 patients (15.4%). Among these patients, the increase in the positive rate of IDC-P correlated with tumor upgrading. The grade groups (GGs) were as follows: GG1 without IDC-P, 16.0% (n = 163); GG2 without IDC-P, 46.1% (n = 470); GG3 without IDC-P, 15.7% (n = 160); GG4 without IDC-P, 2.6% (n = 27); GG5 without IDC-P, 4.1% (n = 42); any GG with IDC-P, 15.4% [n = 157; GG 2 (n = 29); GG3 (n = 60); GG4 (n = 13); GG5 (n = 55)]. Any grade Group with IDC-P showed significantly worse prognosis than any other group without IDC-P (P < 0.0001). In a multivariate analysis, integration of the IDC-P into the Grade Groups, the PSA level at diagnosis, and the surgical margin status were significant prognostic predictors (P < 0.0001, < 0.0001 and < 0.0001, respectively).

CONCLUSIONS

Integrating the presence of IDC-P into the grade group system will result in more accurate predictions of patient outcome.

Investigation of the relationship between bladder function and sarcopenia using pressure flow studies in elderly male patients

AIMS

Although detrusor underactivity is often encountered in elderly patients, the etiology remains unclear. We have hypothesized that sarcopenia was associated with impaired bladder contractility. Therefore, we have evaluated the relationship between bladder contractility and clinical parameters including sarcopenia markers in elderly male patients.

METHODS

This retrospective, single-centre study included male patients over 65 years of age who underwent a pressure flow study (PFS). We excluded patients with any previous medical histories that could affect bladder function, currently on urinary medication, and with no available data of abdominal CT scan. The psoas muscle area (PMA) (cm² /m² ) was measured as a surrogate for psoas muscle mass on computed tomography. PMA, serum CRP, and albumin are known as sarcopenia markers. Correlation and multiple regression analyses were performed to evaluate the association of bladder contractility index (BCI) with the following parameters: age, body mass index (BMI), prostate volume, bladder outlet obstruction index (BOOI), serum C-reactive protein (CRP), serum albumin, and PMA.

RESULTS

Out of 558 male patients identified in our PFS database, 119 patients were enrolled. In the correlation analysis, age, prostate volume, serum albumin, BOOI, and PMA significantly correlated with BCI. However, no significant correlation of BCI with CRP or BMI was observed. Multiple linear regression analysis showed that serum albumin, BOOI, and PMA were significantly associated with BCI.

CONCLUSIONS

We have demonstrated that serum albumin and PMA were significantly positively associated with detrusor contractility. It is possible that sarcopenia is associated with impaired detrusor contractility.

Diagnostic Utility of UroVysion Combined With Conventional Urinary Cytology for Urothelial Carcinoma of the Upper Urinary Tract

OBJECTIVES

We prospectively evaluated the utility of UroVysion in urothelial carcinomas of the upper urinary tract (UCUUTs).

METHODS

Ninety patients who received nephroureterectomy for UCUUT were enrolled. We performed urinary cytology and UroVysion before nephroureterectomy. We also performed the assays on 23 volunteers without a history of urothelial carcinoma.

RESULTS

Seventy-five high-grade urothelial carcinomas (HGUCs), 10 low-grade urothelial carcinomas, and five other conditions were enrolled. Sensitivity, specificity, positive predictive value, and negative predictive value for HGUC detection by urinary cytology were 28.0%, 100.0%, 100.0%, and 31.6%, respectively; for detection by fluorescence in situ hybridization, these values were 60.0%, 84.0%, 93.8%, and 41.2%, respectively. UroVysion detected the only deletion of 9p21 in eight of 23 samples negative for HGUC by urinary cytology and in three of 23 volunteers.

CONCLUSIONS

Combining urinary cytology and UroVysion can improve the diagnostic accuracy of UCUUT. Caution is advised in diagnosing UCUUT based only on deletion of 9p21.

Risk of recurrence in patients with positive surgical margin at apex only versus other locations after radical prostatectomy

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Background: Some reported that positive surgical margin at radical prostatectomy (RP) was a prognostic factor of clinical recurrence and prostate cancer death, and others showed that was not necessarily true. The prostatic apex is most popular location of positive surgical margin at RP and the frequency of apex is reported to be about 20-40% of all positive cases. Prostatic apex is also reported to lack a well-defined capsule and to be hardly retracted during operation. In this study, we evaluated the effect of positive surgical margin at apex-only on prognosis after RP in a large cohort. Methods: We retrospectively evaluated 1019 patients with prostate cancer who underwent radical prostatectomy without neoadjuvant or adjuvant therapy at the hospitals that the authors were affiliated with between 2005 and 2013. The operative approach (open, laparoscopic, or robotic) was decided by each institution. All prostatectomy specimen slides were reviewed by a single genitourinary pathologist according to ISUP 2014 criteria. Recurrence following RP was defined according to AUA guidelines. Results: The median patient age was 67 (range, 45–80) years. The median initial PSA was 6.8 ng/ml (range, 0.4–82 ng/ml). The median follow-up period was 69 (range, 0.7–135) months. Pathological T stage was in 72.5% of pT2 (n = 739), 23.4% of pT3a (n = 238), and 4.1% of pT3b (n = 42). There were 163 Grade Group (GG) 1 cases, 502 GG 2, 217 GG 3, 39 GG 4, and 98 GG 5 cases. 372 cases had positive surgical margin. Details were 201 (54%) apex only, 57 (15%) anterior, 43 (12%) posterior, 76 (20%) lateral, 40 (11%) bladder. Some patients showed multiple positive surgical margin. The patients with positive surgical margin at apex-only showed significantly better prognosis than other locations (P = 0.0001). This result was confirmed in each operative approach (open; P = 0.008, laparoscopic; P = 0.001, robotic; P = 0.01). Conclusions: Among surgical margin positive patients after RP, those at prostatic apex-only showed lower biochemical recurrence than other locations regardless of operative approach. Physician should follow such a patient carefully without adjuvant therapy.

The impact of tertiary Gleason pattern 5 in the grade group system on recurrence following radical prostatectomy in patients with prostate cancer

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Background: The current ISUP/WHO grade group system classified the Gleason grade into five groups. Although presence of tertiary Gleason pattern 5 (tG5) reported to be related with unfavorable tumor characteristic, only a few data is available about influences on the grade group system of tG5 so far. In this study, we evaluated the effect of tG5 on recurrence following radical prostatectomy in patients with prostate cancer. Methods: We retrospectively evaluated 1,020 patients with prostate cancer who underwent radical prostatectomy without neoadjuvant therapy at the hospitals that the authors were affiliated with between 2005 and 2013. After excluding the patients with missing data or slides, 1000 patients were enrolled in this study. All prostatectomy specimen slides were reviewed by a single genitourinary pathologist according to ISUP 2014. Recurrence following radical prostatectomy was defined according to European Association of Urology guidelines. The endpoint was defined as an increase in PSA level. Results: Patient median age was 67 years (range 49–77 years). The median serum PSA was 6.9 ng/mL (range 0.4–82 ng/mL). The median follow-up period was 69 months (range 0.7–134 months). All the patients showed Group1:163 cases (16.3%), Group2: 436 (43.6%), Group 2 with tG5: 54 (5.4%), Group 3:121 (12.1%), Group 3 with tG5: 89 (8.9%), Group 4: 39 (3.9%), and Group 5: 98 (9.8%). PSA progression-free survival was significantly different among the five groups (Group1-5) (p = 0.0001). As concerning tG5, it showed significant difference between Group 2 and Group 2 with tG5 by using log rank test (p < 0.0001). Similarly, there was significant difference between Group 3 and Group 3 with tG5 (p = 0.001). On the other hand, there was no difference between Group 2 with tG5 and Group 3 (p = 0.916), and in the same way, no difference between Group 3 with tG5 and Group 4 (p = 0.854). Conclusions: The Presence of tG5 on the grade group system increase PSA progression following radical prostatectomy in patients with prostate cancer. Especially, Group 2 and 3 showed upgrade by presence of tG5. Integrating tG5 into the grade group system will improve the accuracy of patient outcome predictions.

[A CASE WITH LATE RECURRENCE OF EXTRAGONADAL GERM CELL TUMOR]

A 61-year-old man had undergone resection of teratoma with a histological component of seminoma occurring in the anterior mediastinum at 26 years of age in 1978, followed by radiation treatment to the resected area. He had a recurrence tumor in the left retroperitoneum 2 years later, which was resected combined with left nephrectomy and was proved to be the same pathology as the initial tumor. At 36 years after the initial treatment, the tumor recurred in the right lung. Although he underwent surgical treatment after chemotherapy, he died due to the tumor recurrence 16 months later.

Prognostic parameter for high risk prostate cancer patients at initial presentation

BACKGROUND

High-risk prostate cancer can be defined by a patient's Gleason score (GS), prostate-specific antigen (PSA) level, and clinical T (cT) stage, but a novel marker is needed due to heterogeneity of the disease. In this study, we evaluated whether intraductal carcinoma of the prostate (IDC-P) confirmed by needle biopsy is an adverse prognostic parameter for progression-free survival (PFS) and cancer-specific survival (CSS) in patients with high-risk prostate cancer.

METHODS

We retrospectively evaluated 204 patients with high-risk prostate cancer treated by radical prostatectomy from 1991 to 2005 at Nagoya University and its affiliated hospitals. Data on each patient's PSA level, biopsy GS, cT stage, presence of Gleason pattern 5, presence of IDC-P, percentage of the core involved with cancer, and maximum percentage of the core involved with cancer were analyzed.

RESULTS

The median follow-up period was 108 months (range, 11-257 months). Forty-eight patients (24%) showed disease progression. Thirty-four patients (17%) died of the disease during follow-up. The IDC-P component was detected in 74 (36%) needle biopsy samples. The 5-, 10-, and 15-year CSS rates of the IDC-P-negative cases were 3.2%, 9.0%, and 23.7%; the corresponding rates of the IDC-P-positive cases were 23.9%, 33.7%, and 52.7%, respectively (P = 0.0001). In the Fine and Gray's model for PFS, IDC-P, maximum percentage of the core involved with cancer, and cT stage were significantly associated (P = 0.013, P = 0.003, P = 0.007). In the Fine and Gray's model for CSS, only IDC-P was significant (P = 0.027). In a multivariate Cox regression analysis, IDC-P (P = 0.04; hazard ratio [HR], 1.95) and maximum percentage of the core involved with cancer (P = 0.021; HR, 0.43) were significant factors in predicting overall survival (OS).

CONCLUSIONS

The presence of IDC-P in a needle biopsy was a prognostic factor for PFS, CSS, and OS in patients with high-risk prostate cancer who underwent radical prostatectomy. Multimodal pre-and/or post- surgical therapy may be needed when IDC-P is found in a needle biopsy specimen.

Causative factors for de novo inguinal hernia after robot-assisted radical prostatectomy

To determine causative factors for de novo inguinal hernia (IH), after robot-assisted radical prostatectomy (RARP). This was a retrospective, single-center study, which included patients undergoing RARP for prostate cancer at our institution, from February 2012 to January 2015. Cox proportional hazards models were used to determine the relationships between de novo IH and various factors. A total of 284 patients were included in the analysis. Forty-two (14.7%) patients developed IH at a median period of 8 months after RARP. On multivariate analysis, preoperative international prostate symptom score question 6 > 2, and a patent processus vaginalis were significantly correlated with de novo IH (hazard ratio (HR) 4.17, 95% confidence interval (CI) 2.07-8.37, p < 0.001; HR 3.67, 95% CI 2.36-5.69, p < 0.001). Preoperative urinary straining and a patent processus vaginalis were predictive of de novo IH after RARP.

Intravesical prostatic protrusion can predict therapeutic response to silodosin in male patients with lower urinary tract symptoms

OBJECTIVES

To investigate the predicting factors of therapeutic response to α1-blockers in patients with lower urinary tract symptoms associated with benign prostate enlargement based on a urodynamic study.

METHODS

This was a prospective study involving 125 outpatients with lower urinary tract symptoms associated with benign prostate enlargement. They received 8 mg of silodosin for 12 months. International Prostate Symptom Score, Overactive Bladder Symptom Score, International Prostate Symptom Score quality of life assessment, and urodynamic study were used to assess subjective and objective symptoms. Patient age, prostate-specific antigen level, prostate volume, International Prostate Symptom Score, Overactive Bladder Symptom Score, maximum flow rate and post-void residual urine volume, and intravesical prostatic protrusion were investigated as potential parameters to predict the therapeutic response. Baseline parameters that influenced the improvement of International Prostate Symptom Score and bladder outlet obstruction were statistically analyzed.

RESULTS

A total of 103 patients with mean age of 69.2 years and mean prostate volume of 46.8 mL were included in the analysis. A total of 39 patients (37.9%) showed insignificant improvement in International Prostate Symptom Score (<25%), whereas 36 patients (35.0%) showed insufficient improvement in bladder outlet obstruction index (less than 25%). Prostate volume, maximum flow rate and intravesical prostatic protrusion were independent predictors of ineffective treatment. On multivariate logistic regression analysis, intravesical prostatic protrusion was found to be the only factor related to improvement of both the International Prostate Symptom Score and bladder outlet obstruction. Additionally, multiple linear regression analysis showed that intravesical prostatic protrusion was the only significant factor for predicting improvement of the International Prostate Symptom Score (r = -0.56, P < 0.001) and bladder outlet obstruction (r = -0.59, P < 0.001).

CONCLUSIONS

Intravesical prostatic protrusion can be considered a useful predictor of therapeutic response to silodosin for subjective symptoms and bladder outlet obstruction in male patients with lower urinary tract symptoms associated with benign prostate enlargement.

Sunitinib versus sorafenib as first-line therapy followed by sorefenib and sunitinib for patients with metastatic renal cell carcinoma (RCC) with clear cell histology: A multicenter randomized trial, CROSS-J-RCC

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Background: SWITCH, a prospective, randomized sequential trial to evaluate SU/SO versus SO/SU, revealed no difference in first-line or total PFS or OS, but no direct comparison was obtained between 1st line sunitinib (SU) and sorafenib (SO) for clear cell (CC) metastatic renal cell carcinoma (mRCC). Methods: Treatment-naïve patients with CC mRCC, ECOG PS 0/1 and MSKCC favorable or intermediate risk were randomized to receive open-label SU/SO or SO/SU at the standard dosage and schedule. The primary endpoint was 1st line PFS, and secondary endpoints were total PFS and OS. The calculated sample size was 59 per group, with α = 0.05, β = 0.10, and a censoring rate of 15%. Results: Of 124 patients enrolled in this study from February 2010 to July 2012 from 39 institutions, 120 could be evaluated (SU/SO, 57 and SO/SU, 63). Baseline patients' characteristics in the SU/SO and SO/SU groups were as follows: favorable risk, 21% and 22%; and presence ofnephrectomy, 88% and 89%, respectively. First-line mPFS was 8.7 and 7.0 months in the SU/SO and SO/SU groups, respectively (HR, 0.67; 95% CI, 0.42–1.08; p= 0.095). There was no statistically significant difference in total (T)-PFS, 27.8 M, and 22.6 m (HR 0.73, CI 0.428-1.246; p=0.247), or OS 38.4 m and 30.9 m (HR 0.934, CI 0.588-1.485; p=0.773). Subgroup analyses showed that T-PFS was NR and 27.8 m (p=0.021) in the favorable risk, and 38.4 m and 16.1 m (p=0.009) in with less than 5 metastatic sites, 6.5 m and 13.6 m (p=0.025) without nephrectomy in the SU/SO and SO/SU groups, respectively. The most common adverse events (AEs) in case of first-line SU or SO (all grade, all cause) were hand–foot syndrome (71% vs. 86%), hypothyroidism (70% vs. 33%), fatigue (57% vs. 40%), hypertension (55% vs. 44%), and diarrhea (23% vs. 38%). AEs were generally lower during second-line therapy. Conclusions: There was no significant difference in first-line PFS, T-PFS, and OS between the two sequential treatments. Although fewer patients received second-line treatment in the SU/SO group, OS in this group was numerically longer than that in the SO/SU group. Clinical trial information: 01481870.

Effect of chemotherapy on survival for intraductal carcinoma of the prostate (IDC-P) in patients with castration-resistant prostate cancer

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Background: Several studies have reported that intraductal carcinoma of the prostate (IDC-P) was a pathological adverse prognostic factor in patients with prostate cancer; however, there have been no reports regarding the effect of chemotherapy on survival for this group of patients. This study assessed the effect of chemotherapy on survival in patients with IDC-P. Methods: We retrospectively evaluated 150 prostate cancer patients who were initially diagnosed with distant metastases from June 2002 to January 2014 at the authors’ affiliated hospitals. All needle biopsy slides were reviewed by a single genitourinary pathologist according to the 2014 International Society of Urological Pathology (ISUP) grading system. Exclusion criteria were patients with missing data and those receiving local treatment. Seventy-nine patients with castration-resistant prostate cancer (CRPC) were analyzed. Study endpoints included cancer-specific survival after starting chemotherapy and survival duration from diagnosis of CRPC to cancer-related death. Log-rank test and the Cox proportional hazard model were used for statistical analysis. Results: The patients’ median age was 70 years (range 50–85 years). The median serum prostate-specific antigen level at initial diagnosis was 495.0 ng/mL (range 12.6–10,000). IDC-P was found in 62 out of 79 cases. Forty-six patients received docetaxel-based chemotherapy. Patients received a median of seven chemotherapy courses (range 1–55 courses). The cancer-specific survival duration after starting chemotherapy was 16.7 months in patients with IDC-P and 23.4 months in patients without IDC-P (P = 0.068). Chemotherapy could significantly extend survival duration from diagnosis of CRPC in patients with IDC-P (18.4 months vs. 4.4 months, P = 0.001) Conclusions: Although the effect of chemotherapy may be limited in patients with IDC-P, it significantly extended the time from diagnosis of castration-resistant disease to cancer-related death.