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Rosen GH, Chakiryan NH, Murray KS. Re: Jim C. Hu, Melissa Assel, Mohamad E. Allaf, et al. Transperineal Versus Transrectal Magnetic Resonance Imaging-targeted and Systematic Prostate Biopsy to Prevent Infectious Complications: The PREVENT Randomized Trial. Eur Urol. In press. https://doi.org/10.1016/j.eururo.2023.12.015. Eur Urol 2024:S0302-2838(24)02316-9. [PMID: 38658308 DOI: 10.1016/j.eururo.2024.03.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 03/20/2024] [Indexed: 04/26/2024]
Affiliation(s)
- Geoffrey H Rosen
- Division of Urology, VA Portland Health Care, Portland, OR, USA; Department of Urology, Oregon Health & Science University, Portland, OR, USA.
| | - Nicholas H Chakiryan
- Division of Urology, VA Portland Health Care, Portland, OR, USA; Department of Urology, Oregon Health & Science University, Portland, OR, USA
| | - Katie S Murray
- Division of Urology, Bellevue Hospital, New York, NY, USA; Department of Urology, NYU Langone Health, New York, NY, USA
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Chou WH, Chakiryan NH. Editorial Comment. J Urol 2024; 211:572-573. [PMID: 38241207 DOI: 10.1097/ju.0000000000003836.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 12/20/2023] [Indexed: 01/21/2024]
Affiliation(s)
- Wesley H Chou
- Department of Urology, Oregon Health & Science University, Portland, Oregon
| | - Nicholas H Chakiryan
- Department of Urology, Oregon Health & Science University, Portland, Oregon
- Department of Urology, Portland VA Medical Center, Portland, Oregon
- Knight Cancer Institute, Translational Oncology Program, Portland, Oregon
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Grassauer J, Schmidt J, Cowan A, Gilbert SM, Chakiryan NH. Downstaging and Survival Associated with Neoadjuvant Immunotherapy Before Radical Cystectomy for Muscle-invasive Bladder Cancer. Eur Urol Oncol 2024; 7:139-146. [PMID: 37453853 DOI: 10.1016/j.euo.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 06/11/2023] [Accepted: 06/14/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Neoadjuvant cisplatin-containing chemotherapy before radical cystectomy is the standard of care for patients with localized muscle-invasive bladder cancer (MIBC). However, a large proportion of patients are ineligible for cisplatin. Single-arm phase 2 neoadjuvant immunotherapy trials have reported promising tumor response rates, but interpretation is limited owing to lack of a comparator arm. OBJECTIVE To compare rates of pathologic downstaging and overall survival between patients receiving neoadjuvant immunotherapy (NAI), neoadjuvant chemotherapy (NAC), or no neoadjuvant therapy (NNAT). DESIGN, SETTING, AND PARTICIPANTS We identified 18 483 patients in the National Cancer Data Base who were diagnosed with clinically localized MIBC and underwent radical cystectomy from 2014 to 2019. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Nearest-neighbor propensity-score caliper matching was used to create three demographically similar and equally sized cohorts stratified by NAT receipt. Logistic regression was used to examine the association of treatment received with pathologic downstaging to pT0N0 and pT < 2N0. Cox proportional-hazards regression was used to assess the association of treatment received with overall survival (OS). RESULTS AND LIMITATIONS Propensity score matching yielded three equally sized cohorts without significant differences in baseline characteristics (n = 840). The NAI group had a higher rate of pathologic downstaging to pT0N0 than the NNAT group and a similar rate to the NAC group (NNAT 6.7% vs NAC 26.4%, odds ratio 5.0, 95% confidence interval [CI] 2.9-8.3; NAI 22.5%, odds ratio 4.0, 95% CI 2.4-7.1). The NAI group had better OS than the NNAT group and similar OS to the NAC group (NAC: hazard ratio 0.62, 95% CI 0.42-0.92; NAI: hazard ratio 0.68, 95% CI 0.46-0.97, with NNAT as the reference). The primary limitation is selection bias from confounding by clinical indication. CONCLUSIONS NAI is a promising alternative to NAC for patients with clinically localized MIBC, as evidenced by similar pathologic downstaging rates and OS benefits in comparison to no NAT. Phase 3 trials should be conducted to test the noninferiority of NAI to NAC. PATIENT SUMMARY We compared outcomes for patients with muscle-invasive bladder cancer according to whether they received chemotherapy, immunotherapy, or no medical therapy before surgical removal of their bladder. We found that preoperative immunotherapy improved patient survival and regression of the cancer stage in comparison to no medical therapy, similar to the outcomes seen with preoperative chemotherapy. Randomized clinical trials are needed to confirm these findings.
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Affiliation(s)
- Jacob Grassauer
- Department of Urology, Oregon Health & Science University, Portland, OR, USA
| | - Jackson Schmidt
- Department of Urology, Oregon Health & Science University, Portland, OR, USA.
| | - Andrew Cowan
- Department of Urology, Oregon Health & Science University, Portland, OR, USA
| | - Scott M Gilbert
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Nicholas H Chakiryan
- Department of Urology, Oregon Health & Science University, Portland, OR, USA; Department of Urology, Portland VA Medical Center, Portland, OR, USA; Translational Oncology Program, Knight Cancer Institute, Portland, OR, USA
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Soupir AC, Hayes MT, Peak TC, Ospina O, Chakiryan NH, Berglund AE, Stewart PA, Nguyen J, Segura CM, Francis NL, Echevarria PMR, Chahoud J, Li R, Tsai KY, Balasi JA, Peres YC, Dhillon J, Martinez LA, Gloria WE, Schurman N, Kim S, Gregory M, Mulé J, Fridley BL, Manley BJ. Increased spatial coupling of integrin and collagen IV in the immunoresistant clear cell renal cell carcinoma tumor microenvironment. bioRxiv 2023:2023.11.16.567457. [PMID: 38014063 PMCID: PMC10680839 DOI: 10.1101/2023.11.16.567457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
Background Immunotherapy (IO) has improved survival for patients with advanced clear cell renal cell carcinoma (ccRCC), but resistance to therapy develops in most patients. We use cellular-resolution spatial transcriptomics in patients with IO naïve and IO exposed primary ccRCC tumors to better understand IO resistance. Spatial molecular imaging (SMI) was obtained for tumor and adjacent stroma samples. Spatial gene set enrichment analysis (GSEA) and autocorrelation (coupling with high expression) of ligand-receptor transcript pairs were assessed. Multiplex immunofluorescence (mIF) validation was used for significant autocorrelative findings and the cancer genome atlas (TCGA) and the clinical proteomic tumor analysis consortium (CPTAC) databases were queried to assess bulk RNA expression and proteomic correlates. Results 21 patient samples underwent SMI. Viable tumors following IO harbored more stromal CD8+ T cells and neutrophils than IO naïve tumors. YES1 was significantly upregulated in IO exposed tumor cells. The epithelial-mesenchymal transition pathway was enriched on spatial GSEA and the associated transcript pair COL4A1 - ITGAV had significantly higher autocorrelation in the stroma. Fibroblasts, tumor cells, and endothelium had the relative highest expression. More integrin αV+ cells were seen in IO exposed stroma on mIF validation. Compared to other cancers in TCGA, ccRCC tumors have the highest expression of both COL4A1 and ITGAV . In CPTAC, collagen IV protein was more abundant in advanced stages of disease. Conclusions On spatial transcriptomics, COL4A1 and ITGAV were more autocorrelated in IO-exposed stroma compared to IO-naïve tumors, with high expression amongst fibroblasts, tumor cells, and endothelium. Integrin represents a potential therapeutic target in IO treated ccRCC.
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Chakiryan NH. Nicholas H. Chakiryan, MD. J Urol 2023; 210:589. [PMID: 37249444 DOI: 10.1097/ju.0000000000003565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 05/18/2023] [Indexed: 05/31/2023]
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Hugar LA, Peak TC, Naqvi M, Kim Y, Bandini M, Pederzoli F, Marandino L, Albersen M, Roussel E, Zhu Y, Ye DW, Ornellas AA, Catanzaro M, Hakenberg OW, Heidenreich A, Haidl F, Watkin N, Ager M, Briganti A, Salvioni R, Chakiryan NH, Montorsi F, Necchi A, Spiess PE. Predicting Limited Survival Following Inguinal Lymph Node Dissection in Penile Cancer: Should We Revisit the Goals of Care? Urology 2023; 180:176-181. [PMID: 37467807 DOI: 10.1016/j.urology.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/26/2023] [Accepted: 07/03/2023] [Indexed: 07/21/2023]
Abstract
OBJECTIVE Patients with advanced penile squamous cell cancer have a poor prognosis and can benefit from early palliative care consultation. We built a model to identify those patients most likely to benefit. METHODS Patients with penile squamous cell cancer undergoing inguinal lymph node dissection were identified from the National Cancer Database (NCDB) and a multi-institutional international dataset (INT). A multivariable Cox proportional hazards model for overall survival (OS) was developed using the NCDB and applied to the INT dataset. Parameters were used to make receiver operating characteristic (ROC) curves. ROC-related criteria were optimized to identify a predictive probability cut point and dichotomize patients from INT into risk groups for limited OS of <6 and <12 months. RESULTS NCDB had 860 deaths; 105 (5%) at 6 months and 296 (15%) at 12 months. INT had 257 deaths; 56 (8%) at 6 months and 124 (18%) at 12 months. Limited OS was associated with older age, greater T and N stage, and fewer lymph nodes removed. Optimized ROC criteria using the OS <6 months curve best dichotomized INT patients into high-risk group with median OS of 24 months (95% CI 18-34) and low-risk group with median OS of 174 months (95% CI 120-NE). CONCLUSION We developed a simple model that could be used as a screening tool for early palliative care referral.
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Affiliation(s)
- Lee A Hugar
- Lexington Medical Center, Lexington Urology, Columbia, SC
| | - Taylor C Peak
- H Lee Moffitt Cancer Center, Department of Genitourinary Oncology, Tampa, FL.
| | - Mahrukh Naqvi
- H Lee Moffitt Cancer Center, Department of Biostatistics and Bioinformatics, Tampa, FL
| | - Youngchul Kim
- H Lee Moffitt Cancer Center, Department of Biostatistics and Bioinformatics, Tampa, FL
| | - Marco Bandini
- Urological Research Institute (URI), Unit of Urology, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | - Filippo Pederzoli
- Urological Research Institute (URI), Unit of Urology, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | - Laura Marandino
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | | | | | - Yao Zhu
- Fudan University Shanghai Cancer Center, Shanghai, China
| | - Ding-Wei Ye
- Fudan University Shanghai Cancer Center, Shanghai, China
| | - Antonio A Ornellas
- Hospital Mário Kröeff and Brazilian Cancer Institute, Rio de Janeiro, Brazil
| | - Mario Catanzaro
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | | | | | | | - Nick Watkin
- St. George's University Hospitals, NHS Foundation Trust, London, UK
| | - Michael Ager
- St. George's University Hospitals, NHS Foundation Trust, London, UK
| | - Alberto Briganti
- Urological Research Institute (URI), Unit of Urology, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | | | | | - Francesco Montorsi
- Urological Research Institute (URI), Unit of Urology, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | - Andrea Necchi
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Philippe E Spiess
- H Lee Moffitt Cancer Center, Department of Genitourinary Oncology, Tampa, FL
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Chakiryan NH, Kim Y, Berglund A, Chang A, Kimmel GJ, Hajiran A, Nguyen J, Moran-Segura C, Saeed-Vafa D, Katende EN, Lopez-Blanco N, Chahoud J, Rappold P, Spiess PE, Fournier M, Jeong D, Wang L, Teer JK, Dhillon J, Kuo F, Hakimi AA, Altrock PM, Mulé JJ, Manley BJ. Geospatial characterization of immune cell distributions and dynamics across the microenvironment in clear cell renal cell carcinoma. J Immunother Cancer 2023; 11:jitc-2022-006195. [PMID: 37185232 PMCID: PMC10151991 DOI: 10.1136/jitc-2022-006195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2023] [Indexed: 05/17/2023] Open
Abstract
INTRODUCTION In clear cell renal cell carcinoma (ccRCC), tumor-associated macrophage (TAM) induction of CD8+T cells into a terminally exhausted state has been implicated as a major mechanism of immunotherapy resistance, but a deeper biological understanding is necessary. METHODS Primary ccRCC tumor samples were obtained from 97 patients between 2004 and 2018. Multiplex immunofluorescence using lymphoid and myeloid markers was performed in seven regions of interest per patient across three predefined zones, and geospatial analysis was performed using Ripley's K analysis, a methodology adapted from ecology. RESULTS Clustering of CD163+M2 like TAMs into the stromal compartment at the tumor-stroma interface was associated with worse clinical stage (tumor/CD163+nK(75): stage I/II: 4.4 (IQR -0.5 to 5.1); stage III: 1.4 (IQR -0.3 to 3.5); stage IV: 0.6 (IQR -2.1 to 2.1); p=0.04 between stage I/II and stage IV), and worse overall survival (OS) and cancer-specific survival (CSS) (tumor/CD163+nK(75): median OS-hi=149 months, lo=86 months, false-discovery rate (FDR)-adj. Cox p<0.001; median CSS-hi=174 months, lo=85 months; FDR-adj. Cox p<0.001). An RNA-seq differential gene expression score was developed using this geospatial metric, and was externally validated in multiple independent cohorts of patients with ccRCC including: TCGA KIRC, and the IMmotion151, IMmotion150, and JAVELIN Renal 101 clinical trials. In addition, this CD163+ geospatial pattern was found to be associated with a higher TIM-3+ proportion of CD8+T cells, indicative of terminal exhaustion (tumor-core: 0.07 (IQR 0.04-0.14) vs 0.40 (IQR 0.15-0.66), p=0.05). CONCLUSIONS Geospatial clustering of CD163+M2 like TAMs into the stromal compartment at the tumor-stromal interface was associated with poor clinical outcomes and CD8+T cell terminal exhaustion.
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Affiliation(s)
- Nicholas H Chakiryan
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
- Translational Oncology, Oregon Health & Science University Knight Cancer Institute, Portland, Oregon, USA
| | - Youngchul Kim
- Biostatistics and Bioinformatics, H Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Anders Berglund
- Biostatistics and Bioinformatics, H Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Andrew Chang
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Gregory J Kimmel
- Integrated Mathematical Oncology Department, H Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Ali Hajiran
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Jonathan Nguyen
- Department of Pathology, H Lee Moffitt Cancer Center, Tampa, Florida, USA
| | | | | | - Esther N Katende
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Neale Lopez-Blanco
- Department of Pathology, H Lee Moffitt Cancer Center, Tampa, Florida, USA
| | - Jad Chahoud
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Phillip Rappold
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Philippe E Spiess
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Michelle Fournier
- Tissue Core, H Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Daniel Jeong
- Department of Radiology, H Lee Moffitt Cancer Center, Tampa, Florida, USA
| | - Liang Wang
- Department of Tumor Biology, H Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Jamie K Teer
- Biostatistics and Bioinformatics, H Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Jasreman Dhillon
- Department of Pathology, H Lee Moffitt Cancer Center, Tampa, Florida, USA
| | - Fengshen Kuo
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Abraham Ari Hakimi
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Philipp M Altrock
- Department of Evolutionary Theory, Max Planck Institute for Evolutionary Biology, Ploen, Germany
| | - James J Mulé
- Department of Immunology, H Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
- Radiation Oncology Program, H Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
- Cutaneous Oncology Program, H Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Brandon J Manley
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
- Integrated Mathematical Oncology Department, H Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
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Rappold PM, Vuong L, Leibold J, Chakiryan NH, Curry M, Kuo F, Sabio E, Jiang H, Nixon BG, Liu M, Berglund AE, Silagy AW, Mascareno A, Golkaram M, Marker M, Reising A, Savchenko A, Millholland J, Chen YB, Russo P, Coleman J, Reznik E, Manley BJ, Ostrovnaya I, Makarov V, DiNatale RG, Blum KA, Ma X, Chowell D, Li MO, Solit DB, Lowe SW, Chan TA, Motzer RJ, Voss MH, Hakimi AA. A Targetable Myeloid Inflammatory State Governs Disease Recurrence in Clear-Cell Renal Cell Carcinoma. Cancer Discov 2022; 12:2308-2329. [PMID: 35758895 PMCID: PMC9720541 DOI: 10.1158/2159-8290.cd-21-0925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 04/22/2022] [Accepted: 06/22/2022] [Indexed: 11/16/2022]
Abstract
It is poorly understood how the tumor immune microenvironment influences disease recurrence in localized clear-cell renal cell carcinoma (ccRCC). Here we performed whole-transcriptomic profiling of 236 tumors from patients assigned to the placebo-only arm of a randomized, adjuvant clinical trial for high-risk localized ccRCC. Unbiased pathway analysis identified myeloid-derived IL6 as a key mediator. Furthermore, a novel myeloid gene signature strongly correlated with disease recurrence and overall survival on uni- and multivariate analyses and is linked to TP53 inactivation across multiple data sets. Strikingly, effector T-cell gene signatures, infiltration patterns, and exhaustion markers were not associated with disease recurrence. Targeting immunosuppressive myeloid inflammation with an adenosine A2A receptor antagonist in a novel, immunocompetent, Tp53-inactivated mouse model significantly reduced metastatic development. Our findings suggest that myeloid inflammation promotes disease recurrence in ccRCC and is targetable as well as provide a potential biomarker-based framework for the design of future immuno-oncology trials in ccRCC. SIGNIFICANCE Improved understanding of factors that influence metastatic development in localized ccRCC is greatly needed to aid accurate prediction of disease recurrence, clinical decision-making, and future adjuvant clinical trial design. Our analysis implicates intratumoral myeloid inflammation as a key driver of metastasis in patients and a novel immunocompetent mouse model. This article is highlighted in the In This Issue feature, p. 2221.
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Affiliation(s)
- Phillip M. Rappold
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lynda Vuong
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Human Oncology and Pathogenesis Program, MSKCC, New York, NY, USA
| | - Josef Leibold
- Cancer Biology and Genetics Program, MSKCC, New York, NY, USA
- Department of Medical Oncology & Pneumology (Internal Medicine VIII), University Hospital Tuebingen, Tuebingen 72076, Germany
- DFG Cluster of Excellence 2180 Image-Guided and Functional Instructed Tumor Therapy (iFIT), University of Tuebingen, Tuebingen 72076, Germany
| | - Nicholas H. Chakiryan
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Michael Curry
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Fengshen Kuo
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Human Oncology and Pathogenesis Program, MSKCC, New York, NY, USA
| | - Erich Sabio
- Human Oncology and Pathogenesis Program, MSKCC, New York, NY, USA
| | - Hui Jiang
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Human Oncology and Pathogenesis Program, MSKCC, New York, NY, USA
| | - Briana G. Nixon
- Immunology Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ming Liu
- Legend Biotech USA Inc, NJ, USA
- Immunology Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anders E. Berglund
- Department of Biostatistics and Bioinformatics, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Andrew W. Silagy
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ankur Mascareno
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Human Oncology and Pathogenesis Program, MSKCC, New York, NY, USA
| | - Mahdi Golkaram
- Illumina, Inc., 5200 Illumina Way, San Diego, CA 92122, USA
| | | | | | | | | | | | - Paul Russo
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jonathan Coleman
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ed Reznik
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Brandon J. Manley
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA Integrated Mathematical Oncology Department, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Irina Ostrovnaya
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Vladimir Makarov
- Center for Immunotherapy and Precision Immuno-Oncology, Cleveland Clinic, Cleveland, OH, USA
| | - Renzo G. DiNatale
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kyle A. Blum
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Xiaoxiao Ma
- Center for Immunotherapy and Precision Immuno-Oncology, Cleveland Clinic, Cleveland, OH, USA
| | - Diego Chowell
- Department of Oncological Sciences, The Precision Immunology Institute, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ming O. Li
- Immunology Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David B. Solit
- Human Oncology and Pathogenesis Program, MSKCC, New York, NY, USA
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, MSKCC, New York, NY, USA
| | - Scott W. Lowe
- Cancer Biology and Genetics Program, MSKCC, New York, NY, USA
| | - Timothy A. Chan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Center for Immunotherapy and Precision Immuno-Oncology, Cleveland Clinic, Cleveland, OH, USA
| | - Robert J. Motzer
- Department of Medicine, Genitourinary Oncology, MSKCC, New York, NY, USA
| | - Martin H. Voss
- Department of Medicine, Genitourinary Oncology, MSKCC, New York, NY, USA
| | - A. Ari Hakimi
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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9
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Chang A, Chakiryan NH, Du D, Stewart PA, Zhang Y, Tian Y, Soupir AC, Bowers K, Fang B, Morganti A, Teer JK, Kim Y, Spiess PE, Chahoud J, Noble JD, Putney RM, Berglund AE, Robinson TJ, Koomen JM, Wang L, Manley BJ. Proteogenomic, Epigenetic, and Clinical Implications of Recurrent Aberrant Splice Variants in Clear Cell Renal Cell Carcinoma. Eur Urol 2022; 82:354-362. [PMID: 35718636 DOI: 10.1016/j.eururo.2022.05.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 04/24/2022] [Accepted: 05/24/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Alternative mRNA splicing can be dysregulated in cancer, resulting in the generation of aberrant splice variants (SVs). Given the paucity of actionable genomic mutations in clear cell renal cell carcinoma (ccRCC), aberrant SVs may be an avenue to novel mechanisms of pathogenesis. OBJECTIVE To identify and characterize aberrant SVs enriched in ccRCC. DESIGN, SETTING, AND PARTICIPANTS Using RNA-seq data from the Cancer Cell Line Encyclopedia, we identified neojunctions uniquely expressed in ccRCC. Candidate SVs were then checked for expression across normal tissue in the Genotype-Tissue Expression Project and primary tumor tissue from The Cancer Genome Atlas (TCGA), Clinical Proteomic Tumor Analysis Consortium (CPTAC), and our institutional Total Cancer Care database. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Clinicopathologic, genomic, and survival data were available for all cohorts. Epigenetic data were available for the TCGA and CPTAC cohorts. Proteomic data were available for the CPTAC cohort. The association of aberrant SV expression with these variables was examined using the Kruskal-Wallis test, pairwise t test, Spearman correlation test, and Cox regression analysis. RESULTS AND LIMITATIONS Our pipeline identified 16 ccRCC-enriched SVs. EGFR, HPCAL1-SV and RNASET2-SV expression was negatively correlated with gene-specific CpG methylation. We derived a survival risk score based primarily on the expression of five SVs (RNASET2, FGD1, PDZD2, COBLL1, and PTPN14), which was consistent and applicable across multiple cohorts on multivariate analysis. The splicing factor RBM4, which modulates splicing of HIF-1α, exhibited significantly lower expression at the protein level in the high-risk group, as defined by our SV-based score. CONCLUSIONS We describe 16 aberrant SVs enriched in ccRCC, many of which are associated with disease biology and/or clinical outcomes. This study provides a novel strategy for identifying and characterizing disease-specific aberrant SVs. PATIENT SUMMARY We describe a method to identify disease targets and biomarkers using transcriptomic analysis beyond somatic mutations or gene expression. Kidney tumors express unique splice variants that may provide additional prognostic information following surgery.
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Affiliation(s)
- Andrew Chang
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA.
| | - Nicholas H Chakiryan
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Dongliang Du
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Paul A Stewart
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Yonghong Zhang
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Yijun Tian
- Department of Tumor Biology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Alex C Soupir
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA; Department of Tumor Biology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Kiah Bowers
- Department of Molecular Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Bin Fang
- Department of Molecular Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Ashley Morganti
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Jamie K Teer
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Youngchul Kim
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Philippe E Spiess
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Jad Chahoud
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Jerald D Noble
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA; Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Ryan M Putney
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Anders E Berglund
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Timothy J Robinson
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - John M Koomen
- Department of Molecular Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Liang Wang
- Department of Tumor Biology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Brandon J Manley
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA; Department of Integrated Mathematical Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
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10
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Hayes M, Bassale S, Chakiryan NH, Boileau L, Grassauer J, Wagner M, Foster B, Coakley F, Isharwal S, Amling CL, Liu J. Selecting patients for magnetic resonance imaging cognitive versus ultrasound fusion biopsy of the prostate: A within‐patient comparison. BJUI Compass 2022; 3:443-449. [PMID: 36267201 PMCID: PMC9579877 DOI: 10.1002/bco2.172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/08/2022] [Accepted: 05/18/2022] [Indexed: 11/06/2022] Open
Abstract
Objectives To compare overall agreement between magnetic resonance imaging (MRI)–ultrasound (US) fusion biopsy (FB) and MRI cognitive fusion biopsy (CB) of the prostate and determine which factors affect agreement for prostate cancer (PCa) who underwent both modalities in a prospective within‐patient protocol. Patients and Methods From August 2017 to January 2021, patients with at least one Prostate Imaging Reporting & Data System (PI‐RADS) 3 or higher lesion on multiparametric MRI underwent transrectal FB and CB in a prospective within‐patient protocol. CB was performed for each region of interest (ROI), followed by FB, followed by standard 12 core biopsy. Patients who were not on active surveillance were analysed. The primary endpoint was agreement for any PCa detection. McNemar's test and kappa statistic were used to analyse agreement. Chi‐square test, Fisher's exact test and Wilcoxon rank sum test were used to analyse disagreement across clinical and MRI spatial variables. A multivariable generalized mixed‐effect model was used to compare the interaction between select variables and fusion modality. Statistics were performed using SAS and R. Results Ninety patients and 98 lesions were included in the analysis. There was moderate agreement between FB and CB (k = 0.715). McNemar's test was insignificant (p = 0.285). Anterior location was the only variable associated with a significant variation in agreement, which was 70% for anterior lesions versus 89.7% for non‐anterior lesions (p = 0.035). Discordance did not vary significantly across other variables. In a mixed‐effect model, the interaction between anterior location and use of FB was insignificant (p = 0.411). Conclusion In a within‐patient protocol of patients not on active surveillance, FB and CB performed similarly for PCa detection and with moderate agreement. Anterior location was associated with significantly higher disagreement, whereas other patient and lesion characteristics were not. Additional studies are needed to determine optimal biopsy technique for sampling anterior ROI.
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Affiliation(s)
- Mitch Hayes
- Department of Urology Oregon Health & Science University Portland Oregon USA
| | - Solange Bassale
- Knight Cancer Institute, Biostatistics Shared Resources Oregon Health and Science University Portland Oregon USA
| | | | - Luc Boileau
- Department of Urology Oregon Health & Science University Portland Oregon USA
| | - Jacob Grassauer
- Department of Urology Oregon Health & Science University Portland Oregon USA
| | - Matthew Wagner
- Department of Urology Kaiser Permanente Portland Oregon USA
| | - Bryan Foster
- Department of Radiology Oregon Health and Science University Portland Oregon USA
| | - Fergus Coakley
- Department of Radiology Oregon Health and Science University Portland Oregon USA
| | - Sudhir Isharwal
- Department of Urology Oregon Health & Science University Portland Oregon USA
| | | | - Jen‐Jane Liu
- Department of Urology Oregon Health & Science University Portland Oregon USA
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11
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Chakiryan NH, Gore LR, Reich RR, Dunn RL, Jiang DD, Gillis KA, Green E, Hajiran A, Hugar L, Zemp L, Zhang J, Jain RK, Chahoud J, Spiess PE, Manley BJ, Sexton WJ, Hollenbeck BK, Gilbert SM. Survival Outcomes Associated With Cytoreductive Nephrectomy in Patients With Metastatic Clear Cell Renal Cell Carcinoma. JAMA Netw Open 2022; 5:e2212347. [PMID: 35576003 PMCID: PMC9112069 DOI: 10.1001/jamanetworkopen.2022.12347] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE Level I evidence has failed to demonstrate an overall survival (OS) advantage for cytoreductive nephrectomy in patients with metastatic clear cell renal cell carcinoma (ccRCC) in the modern era, which is at odds with observational studies reporting a marked OS benefit associated with these operations. These observational studies were not designed to adjust for unmeasured confounding. OBJECTIVE To assess whether cytoreductive nephrectomy is associated with improved OS in patients with metastatic ccRCC. DESIGN, SETTING, AND PARTICIPANTS This cohort study identified patients with metastatic ccRCC in the National Cancer Database from January 1, 2006, to December 31, 2016, who received systemic targeted therapy. The analysis was finalized on July 23, 2021. EXPOSURES Receipt of cytoreductive nephrectomy. MAIN OUTCOMES AND MEASURES The primary outcome was OS from the date of diagnosis to death or censoring at last follow-up. Distance from the patients' zip code of residence to the treating facility was identified as a valid instrument and was used in a 2-stage residual inclusion instrumental variable analysis. Conventional adjustments for selection bias, multivariable Cox proportional hazards regression, and propensity score matching were performed for comparison. Measured covariates adjusted for in all analyses included age, sex, race, Charlson-Deyo score, facility type, year of diagnosis, clinical T stage, and clinical N stage. RESULTS The final study population included 12 766 patients (median age, 63 years; IQR, 56-70 years; 8744 [68%] male; 11 206 [88%] White). Cytoreductive nephrectomy was performed in 5005 patients (39%). Conventional adjustments for selection bias demonstrated a significant OS benefit associated with cytoreductive nephrectomy (multivariable Cox proportional hazards regression: hazard ratio [HR], 0.49; 95% CI, 0.47-0.51; propensity score matching: HR, 0.48; 95% CI, 0.46-0.50). Instrumental variable estimates did not demonstrate an association between cytoreductive nephrectomy and OS (HR, 0.92; 95% CI, 0.78-1.09). CONCLUSIONS AND RELEVANCE Instrumental variable analysis did not demonstrate a survival advantage associated with cytoreductive nephrectomy for patients with metastatic ccRCC. This discrepancy likely reflects the fact that surgical indication for cytoreductive nephrectomy is primarily driven by factors that are not commonly measured or available in observational data sets.
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Affiliation(s)
| | - L. Robert Gore
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Richard R. Reich
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Rodney L. Dunn
- Department of Urology, University of Michigan Medical School, Ann Arbor
| | - Da David Jiang
- Department of Urology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Kyle A. Gillis
- Department of Urology, University of Iowa Hospitals & Clinics, Iowa City
| | - Elizabeth Green
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Ali Hajiran
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Lee Hugar
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Logan Zemp
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Jingsong Zhang
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Rohit K. Jain
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Jad Chahoud
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Philippe E. Spiess
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Brandon J. Manley
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Wade J. Sexton
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | | | - Scott M. Gilbert
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
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12
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Chakiryan NH, Hajiran A, Kim Y, Aydin AM, Zemp L, Katende E, Nguyen J, Fan W, Cheng CH, Lopez-Blanco N, Chahoud J, Spiess PE, Fournier M, Dhillon J, Wang L, Moran-Segura C, Mulé J, Du D, Yoder SJ, Berglund A, Teer JK, Manley BJ. Correlating Immune Cell Infiltration Patterns with Recurrent Somatic Mutations in Advanced Clear Cell Renal Cell Carcinoma. Eur Urol Focus 2022; 8:784-793. [PMID: 33994165 DOI: 10.1016/j.euf.2021.04.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/24/2021] [Accepted: 04/15/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Clear cell renal cell carcinoma (ccRCC) tumors have low frequencies of genetic alterations compared with other malignancies, but very high levels of immune cell infiltration and favorable response rates to immunotherapy. Currently, the interplay between specific ccRCC somatic mutations and immune infiltration pattern is unclear. OBJECTIVE To analyze the associations between common ccRCC somatic mutations and immune cell infiltration patterns within the tumor immune microenvironment (TIME). DESIGN, SETTING, AND PARTICIPANTS The study included tumor samples (24 primary and 24 metastatic) from 48 patients with stage IV ccRCC. Targeted sequencing was performed for well-characterized recurrent somatic mutations in ccRCC, with the analysis focusing on the six most common ones: VHL, BAP1, PBRM1, SETD2, TP53, and KDM5C. For each sample, multiplex immunofluorescence (IF) was performed in lymphoid and myeloid panels, for seven regions of interest in three zones (tumor core, stroma, and tumor-stroma interface). IF-derived cellular densities were compared across patients, stratified by their somatic mutation status, using a linear mixed-model analysis. External validation was pursued using RNA-seq enrichment scoring from three large external data sources. RESULTS AND LIMITATIONS Tumors with SETD2 mutations demonstrated significantly decreased levels of FOXP3+ T cells in the tumor core, stroma, and tumor-stroma interface. PBRM1 mutations were associated with decreased FOXP3+ T cells in the tumor core. Primary KDM5C mutations were associated with significantly increased CD206+ macrophage tumor infiltration in the tumor core. A computational method estimating immune cell types in the TIME using bulk RNA-seq data, xCell scoring, failed to validate associations from the IF analysis in large external data sets. A major limitation of the study is the relatively small patient population studied. CONCLUSIONS This study provides evidence that common somatic mutations in ccRCC, such as SETD2, PBRM1, and KDM5C, are associated with distinct immune infiltration patterns within the TIME. PATIENT SUMMARY In this study, we analyzed tumor samples from patients with metastatic kidney cancer to determine whether common genetic mutations that arise from the cancer cells are associated with the density of immune cells found within those tumors. We found several distinct immune cell patterns that were associated with specific genetic mutations. These findings provide insight into the interaction between cancer genetics and the immune system in kidney cancer.
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Affiliation(s)
- Nicholas H Chakiryan
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA; Integrated Mathematical Oncology Department, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.
| | - Ali Hajiran
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA; Integrated Mathematical Oncology Department, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Youngchul Kim
- Department of Biostatistics and Bioinformatics, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA; Integrated Mathematical Oncology Department, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Ahmet M Aydin
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA; Integrated Mathematical Oncology Department, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Logan Zemp
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA; Integrated Mathematical Oncology Department, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Esther Katende
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA; Integrated Mathematical Oncology Department, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Jonathan Nguyen
- Department of Pathology, H Lee Moffitt Cancer Center, Tampa, FL, USA; Integrated Mathematical Oncology Department, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Wenyi Fan
- Biostatistics and Bioinformatics Shared Resource, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA; Integrated Mathematical Oncology Department, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Chia-Ho Cheng
- Biostatistics and Bioinformatics Shared Resource, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA; Integrated Mathematical Oncology Department, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Neale Lopez-Blanco
- Department of Pathology, H Lee Moffitt Cancer Center, Tampa, FL, USA; Integrated Mathematical Oncology Department, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Jad Chahoud
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA; Integrated Mathematical Oncology Department, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Philippe E Spiess
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA; Integrated Mathematical Oncology Department, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Michelle Fournier
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA; Integrated Mathematical Oncology Department, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Jasreman Dhillon
- Department of Pathology, H Lee Moffitt Cancer Center, Tampa, FL, USA; Integrated Mathematical Oncology Department, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Liang Wang
- Department of Tumor Biology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA; Integrated Mathematical Oncology Department, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Carlos Moran-Segura
- Department of Pathology, H Lee Moffitt Cancer Center, Tampa, FL, USA; Integrated Mathematical Oncology Department, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - James Mulé
- Immunology Department, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA; Integrated Mathematical Oncology Department, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Dongliang Du
- Department of Biostatistics and Bioinformatics, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA; Integrated Mathematical Oncology Department, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Sean J Yoder
- Molecular Genomics Shared Resource, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA; Integrated Mathematical Oncology Department, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Anders Berglund
- Department of Biostatistics and Bioinformatics, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA; Integrated Mathematical Oncology Department, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Jamie K Teer
- Department of Biostatistics and Bioinformatics, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA; Integrated Mathematical Oncology Department, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Brandon J Manley
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA; Department of Biostatistics and Bioinformatics, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA; Integrated Mathematical Oncology Department, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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13
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Chadha J, Adashek JJ, Jim H, Kim Y, Semaan A, Chakiryan NH, Safa H, Hajiran A, Sexton W, Gilbert SM, Manley BJ, Spiess PE, Chahoud J. Evaluation of Patient-Reported Outcomes (PROs) Protocol Content and Reporting for Clinical Trials that Lead to the approval of frontline Immune Checkpoint Blockade Combination for Patients with Advanced Renal Cell Carcinoma - The Patients' Voice or a Missed Opportunity. Clin Genitourin Cancer 2021; 20:e158-e165. [PMID: 34974985 DOI: 10.1016/j.clgc.2021.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 11/29/2021] [Accepted: 12/03/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Immune checkpoint blockade (ICB) is a rapidly emerging field of oncology that has revolutionized the metastatic renal cell carcinoma (mRCC) treatment. Four recent treatment regimens Nivolumab-Ipilimumab, Pembrolizumab-Axitinib, Nivolumab-Cabozantinib, and Pembrolizumab-Lenvatinib-have demonstrated improved clinical endpoints compared to standard of care and are endorsed by NCCN (2021). However, data on patient-reported outcomes (PROs) for patients receiving these regimens are limited. We conducted a comparative assessment of the quality and standardization of PROs endpoints and data reported for these randomized controlled trials (RCTs). PATIENTS AND METHODS We systematically identified all RCTs evaluating combination ICB for ccRCC. PROs-specific data were abstracted from the final version of 4 RCT protocols, as well as clinical and PROs specific manuscripts published between April 2018 and April 2021. We used 3 previously published guides standardizing PROs research to objectively score the data: (i) 24-point PROEAS; (ii) 12-point SPIRIT-PRO; and (iii) 14-point CONSORT-PRO. RESULTS The CheckMate 214, KEYNOTE 426, CheckMate 9ER, and CLEAR studies had PROEAS scores of 88% (21/24), 37% (9/24), 83% (20/24), and 16% (4/24), respectively, and SPIRIT-PRO scores of 50% (6/12), 75% (9/12), 66% (8/12), and 41% (5/12) respectively. The CONSORT-PRO scores were 86% (12/14) for CheckMate 214 and 43% (6/14) for CheckMate 9ER, but scores were not available for the CLEAR and KEYNOTE 426 studies because of a lack of sufficient data. The average SPIRIT-PRO score across the 4 RCTs was 58%, indicating a reasonable adoption of PROs research in data management and analysis. The CheckMate 214 trial had the longest follow-up and most comprehensive published PROs data. CONCLUSION Our analysis identified the limitations of current PROs data in combination ICB approved for mRCC. This analysis will enable clinicians to better interpret the current PROs results and emphasize the importance of better incorporation of PROs endpoints in future mRCC trial design.
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Affiliation(s)
- Juskaran Chadha
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Jacob J Adashek
- Department of Internal Medicine, University of South Florida, Tampa, FL
| | - Heather Jim
- Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Youngchul Kim
- Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Adele Semaan
- Participant Research, Interventions, and Measurements Core, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Nicholas H Chakiryan
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Houssein Safa
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Ali Hajiran
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Wade Sexton
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Scott M Gilbert
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Brandon J Manley
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Philippe E Spiess
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Jad Chahoud
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL.
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14
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Creed JH, Wilson CM, Soupir AC, Colin-Leitzinger CM, Kimmel GJ, Ospina OE, Chakiryan NH, Markowitz J, Peres LC, Coghill A, Fridley BL. spatialTIME and iTIME: R package and Shiny application for visualization and analysis of immunofluorescence data. Bioinformatics 2021; 37:4584-4586. [PMID: 34734969 PMCID: PMC8652029 DOI: 10.1093/bioinformatics/btab757] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 09/10/2021] [Accepted: 10/29/2021] [Indexed: 01/19/2023] Open
Abstract
Summary Multiplex immunofluorescence (mIF) staining combined with quantitative digital image analysis is a novel and increasingly used technique that allows for the characterization of the tumor immune microenvironment (TIME). Generally, mIF data is used to examine the abundance of immune cells in the TIME; however, this does not capture spatial patterns of immune cells throughout the TIME, a metric increasingly recognized as important for prognosis. To address this gap, we developed an R package spatialTIME that enables spatial analysis of mIF data, as well as the iTIME web application that provides a robust but simplified user interface for describing both abundance and spatial architecture of the TIME. The spatialTIME package calculates univariate and bivariate spatial statistics (e.g. Ripley’s K, Besag’s L, Macron’s M and G or nearest neighbor distance) and creates publication quality plots for spatial organization of the cells in each tissue sample. The iTIME web application allows users to statistically compare the abundance measures with patient clinical features along with visualization of the TIME for one tissue sample at a time. Availability and implementation spatialTIME is implemented in R and can be downloaded from GitHub (https://github.com/FridleyLab/spatialTIME) or CRAN. An extensive vignette for using spatialTIME can also be found at https://cran.r-project.org/web/packages/spatialTIME/index.html. iTIME is implemented within a R Shiny application and can be accessed online (http://itime.moffitt.org/), with code available on GitHub (https://github.com/FridleyLab/iTIME). Supplementary information Supplementary data are available at Bioinformatics online.
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Affiliation(s)
- Jordan H Creed
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, FL, USA
| | - Christopher M Wilson
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, FL, USA
| | - Alex C Soupir
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, FL, USA.,Department of Tumor Biology, Moffitt Cancer Center, Tampa, FL, USA
| | | | - Gregory J Kimmel
- Department of Integrated Mathematical Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Oscar E Ospina
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, FL, USA
| | | | - Joseph Markowitz
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Lauren C Peres
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, FL, USA
| | - Anna Coghill
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, FL, USA
| | - Brooke L Fridley
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, FL, USA
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15
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Chakiryan NH, Dahmen A, Bandini M, Pederzoli F, Marandino L, Albersen M, Roussel E, Zhu Y, Ye DW, Ornellas AA, Catanzaro M, Hakenberg OW, Heidenreich A, Haidl F, Watkin N, Ager M, Briganti A, Salvioni R, Montorsi F, Necchi A, Spiess PE. Risk factors and survival outcomes for upstaging after inguinal lymph node dissection for cN1 penile squamous cell carcinoma. Urol Oncol 2021; 39:838.e7-838.e13. [PMID: 34602362 DOI: 10.1016/j.urolonc.2021.08.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 08/02/2021] [Accepted: 08/30/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To identify incidence and risk factors for upstaging from cN1 to pN2/N3 at inguinal lymphadenectomy (ILND) for penile cancer (pSCC). Our secondary objective is to assess survival outcomes and associations for cN1 patients undergoing ILND. SUBJECTS/PATIENTS AND METHODS Patients with pT≥1cN1cM0 pSCC who underwent bilateral ILND and had complete data were identified in a multi-institutional international cohort from 8 referral centers in 7 countries diagnosed from 1980 to 2017. Upstaging was defined as pN2/N3 at ILND. Multivariable logistic regression analysis was used to determine associations with upstaging, and Cox multivariable logistic regression analysis to determine associations with overall survival (OS). RESULTS Of 144 patients were included in the final study population. 84 patients (58%) were upstaged from cN1 to pN2/N3, and 25 (17%) were down staged to pN0. Upstaging was associated with pT3/T4 (OR 4.1, 95%CI 1.5-11.7, P < 0.01) and pTX (OR 7.1, 95CI 1.6-51.1, P = 0.02). Age, smoking status, HPV status, and LVI were not associated with upstaging. Age (HR 1.03/y, 95%CI 1.01-1.06, P < 0.01) and upstaging (HR 2.8, 95%CI 1.3-5.9, P < 0.01) were associated with worse OS. Upstaged patients had a 5-year OS of 49%, compared with 86% for patients who were not upstaged. CONCLUSION The majority of cN1 pSCC patients harbor a higher-risk disease state than their clinical staging suggests, especially those with higher pT stages. More intensive pre-operative workup may be warranted for these patients to identify upstaging prior to ILND and potentially qualify them for neoadjuvant chemotherapy or clinical trials.
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Affiliation(s)
| | - Aaron Dahmen
- Department of Urology, University of South Florida, Tampa, FL.
| | - Marco Bandini
- Unit of Urology, IRCCS Ospedale San Raffaele, Urological Research Institute (URI), Vita-Salute San Raffaele University, Milan, Italy
| | - Filippo Pederzoli
- Unit of Urology, IRCCS Ospedale San Raffaele, Urological Research Institute (URI), Vita-Salute San Raffaele University, Milan, Italy
| | - Laura Marandino
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | | | | | - Yao Zhu
- Fudan University Shanghai Cancer Center, Shanghai, China
| | - Ding-Wei Ye
- Fudan University Shanghai Cancer Center, Shanghai, China
| | - Antonio A Ornellas
- Hospital Mário Kröeff and Brazilian Cancer Institute, Rio de Janeiro, Brazil
| | - Mario Catanzaro
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | | | | | | | - Nick Watkin
- St. George's University Hospitals, NHS Foundation Trust, London, UK
| | - Michael Ager
- St. George's University Hospitals, NHS Foundation Trust, London, UK
| | - Alberto Briganti
- Unit of Urology, IRCCS Ospedale San Raffaele, Urological Research Institute (URI), Vita-Salute San Raffaele University, Milan, Italy
| | | | - Francesco Montorsi
- Unit of Urology, IRCCS Ospedale San Raffaele, Urological Research Institute (URI), Vita-Salute San Raffaele University, Milan, Italy
| | - Andrea Necchi
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Philippe E Spiess
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center, Tampa, FL
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Chakiryan NH, Jiang DD, Gillis KA, Green E, Hajiran A, Hugar L, Zemp L, Zhang J, Jain R, Chahoud J, Li R, Sexton W, Manley BJ, Gilbert SM. Comparative effectiveness analysis of first-line immunotherapy versus chemotherapy in metastatic urothelial carcinoma of the bladder. Urol Oncol 2021; 40:107.e11-107.e17. [PMID: 34426068 DOI: 10.1016/j.urolonc.2021.07.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 07/06/2021] [Accepted: 07/29/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Clinical trials have not shown a significant overall survival (OS) difference between chemotherapy and immunotherapy as first-line agents in metastatic urothelial carcinoma (UC). However, the generalizability of these findings in a real-world setting has not yet been evaluated in comparative effectiveness studies. OBJECTIVE To assess the effectiveness of first-line immunotherapy compared with chemotherapy regimens on OS in patients with metastatic UC of the bladder. DESIGN, SETTING, AND PARTICIPANTS This retrospective propensity-matched study identified metastatic bladder UC patients in the National Cancer Database from 2014 to 2017 who received either first-line immunotherapy-monotherapy or multi-agent chemotherapy, and who were not treated on a clinical trial protocol. OUTCOME MEASURES AND ANALYSIS The primary outcome was OS from the date of diagnosis to date of death or censoring at last follow-up. Patients were stratified into first-line immunotherapy and chemotherapy treatment groups. After 1:1 nearest-neighbor caliper-matching of propensity scores, the survival analysis was conducted using Cox regression modeling and Kaplan-Meier estimates. RESULTS AND LIMITATIONS A total of 2,796 patients were included in the final study population, and 960 in the matched cohort (480 per treatment group). Utilization of immunotherapy increased over the time period studied as chemotherapy decreased (Immunotherapy: 3%-37%; Chemotherapy: 97%-63%; P < 0.001). In the overall cohort, patients who received first-line immunotherapy were older and more comorbid than those who received first-line chemotherapy (Age: 73 v. 67, respectively, P < 0.001; Charlson-Deyo score ≥2: 17% v. 11.5%, respectively, P < 0.001). In the matched cohort, patients who were treated with first-line immunotherapy had similar OS to those who were treated with first-line chemotherapy (HR: 0.91, 95CI 0.72-1.15). Due to the retrospective nature of the study, interpretation is limited by potential selection bias from unmeasured confounding. CONCLUSIONS AND RELEVANCE Metastatic bladder UC patients who received first-line immunotherapy had similar OS to those who received first-line chemotherapy.
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Affiliation(s)
| | - Da David Jiang
- Department of Urology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Kyle A Gillis
- Department of Urology, University of Iowa Hospitals & Clinics, Iowa City, IA
| | - Elizabeth Green
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center, Tampa, FL
| | - Ali Hajiran
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center, Tampa, FL
| | - Lee Hugar
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center, Tampa, FL
| | - Logan Zemp
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center, Tampa, FL
| | - Jingsong Zhang
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center, Tampa, FL
| | - Rohit Jain
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center, Tampa, FL
| | - Jad Chahoud
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center, Tampa, FL
| | - Roger Li
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center, Tampa, FL
| | - Wade Sexton
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center, Tampa, FL
| | - Brandon J Manley
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center, Tampa, FL
| | - Scott M Gilbert
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center, Tampa, FL
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Jiang DD, Chakiryan NH, Gillis KA, Hedges JC, Barry JM. Educational value of the transplant experience in urology residency. Can J Urol 2021; 28:10783-10787. [PMID: 34378516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
UNLABELLED INTRODUCTION To evaluate the educational value of transplant rotation in urology residency. In the United States, exposure to kidney transplantation during urology residency has declined significantly over the past few decades. At our institution, transplantation has been a core component of urology residency since its inception in 1959. MATERIALS AND METHODS A 15-question anonymous survey was developed. The first 8 questions queried demographics and the last 7 were a set of questions with a Likert Scale response. The survey was electronic- mailed to past and current urology residents who had completed the transplant rotation, dating back to 1972. RESULTS A total of 61 out of 98 (62%) individuals responded. The majority (59%) were general urologists, and one (2%) had completed a transplant fellowship. In their practices, 17% performed kidney transplants and 28% performed donor nephrectomies. Overall, 100% responded that the skills learned on the transplant rotation were beneficial for urology training, 100% had learned valuable vascular surgical techniques, and 93% felt that urology residents should have clinical transplant experience during their training. There was no statistical difference between the younger and older graduates in Likert scale responses. CONCLUSION The majority of graduates did not perform transplants in their practice, yet, all of responders agreed that the skills learned on the transplant rotation were beneficial and 93% expressed that urology residents should have clinical transplant experience during residency. Kidney transplantation should be an integral part of urology residency training.
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Affiliation(s)
- Da David Jiang
- Department of Urology, Oregon Health & Science University, Portland, Oregon, USA
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Chakiryan NH, Kimmel GJ, Kim Y, Johnson JO, Clark N, Hajiran A, Chang A, Aydin AM, Zemp L, Katende E, Chahoud J, Ferrall-Fairbanks MC, Spiess PE, Francis N, Fournier M, Dhillon J, Park JY, Wang L, Mulé JJ, Altrock PM, Manley BJ. Geospatial Cellular Distribution of Cancer-Associated Fibroblasts Significantly Impacts Clinical Outcomes in Metastatic Clear Cell Renal Cell Carcinoma. Cancers (Basel) 2021; 13:cancers13153743. [PMID: 34359645 PMCID: PMC8345222 DOI: 10.3390/cancers13153743] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/12/2021] [Accepted: 07/22/2021] [Indexed: 02/07/2023] Open
Abstract
Simple Summary Cancer-associated fibroblasts (CAFs) are highly prevalent cells in the clear cell renal cell carcinoma (ccRCC) tumor immune microenvironment. CAFs are thought to potentiate tumor proliferation primarily through paracrine interactions, as evidenced by laboratory-based studies. We sought to corroborate these findings using surgically removed tissue samples from 96 patients with metastatic ccRCC and associate geospatial relationships between CAFs and rapidly proliferating tumor cells with survival outcomes. We found that CAFs exhibited more geospatial clustering with proliferating tumor cells than with dying tumor cells, and patients whose samples exhibited higher tumor cell proliferation had worse overall survival and were more likely to be resistant to systemic tyrosine-kinase-inhibiting targeted therapies. Immunotherapy resistance was not associated with the geospatial metrics measured in this analysis. Overall, these findings suggest that close proximity to CAFs potentiates tumor cell proliferation, worsening survival and conferring resistance to targeted therapies. Abstract Cancer-associated fibroblasts (CAF) are highly prevalent cells in the tumor microenvironment in clear cell renal cell carcinoma (ccRCC). CAFs exhibit a pro-tumor effect in vitro and have been implicated in tumor cell proliferation, metastasis, and treatment resistance. Our objective is to analyze the geospatial distribution of CAFs with proliferating and apoptotic tumor cells in the ccRCC tumor microenvironment and determine associations with survival and systemic treatment. Pre-treatment primary tumor samples were collected from 96 patients with metastatic ccRCC. Three adjacent slices were obtained from 2 tumor-core regions of interest (ROI) per patient, and immunohistochemistry (IHC) staining was performed for αSMA, Ki-67, and caspase-3 to detect CAFs, proliferating cells, and apoptotic cells, respectively. H-scores and cellular density were generated for each marker. ROIs were aligned, and spatial point patterns were generated, which were then used to perform spatial analyses using a normalized Ripley’s K function at a radius of 25 μm (nK(25)). The survival analyses used an optimal cut-point method, maximizing the log-rank statistic, to stratify the IHC-derived metrics into high and low groups. Multivariable Cox regression analyses were performed accounting for age and International Metastatic RCC Database Consortium (IMDC) risk category. Survival outcomes included overall survival (OS) from the date of diagnosis, OS from the date of immunotherapy initiation (OS-IT), and OS from the date of targeted therapy initiation (OS-TT). Therapy resistance was defined as progression-free survival (PFS) <6 months, and therapy response was defined as PFS >9 months. CAFs exhibited higher cellular clustering with Ki-67+ cells than with caspase-3+ cells (nK(25): Ki-67 1.19; caspase-3 1.05; p = 0.04). The median nearest neighbor (NN) distance from CAFs to Ki-67+ cells was shorter compared to caspase-3+ cells (15 μm vs. 37 μm, respectively; p < 0.001). Multivariable Cox regression analyses demonstrated that both high Ki-67+ density and H-score were associated with worse OS, OS-IT, and OS-TT. Regarding αSMA+CAFs, only a high H-score was associated with worse OS, OS-IT, and OS-TT. For caspase-3+, high H-score and density were associated with worse OS and OS-TT. Patients whose tumors were resistant to targeted therapy (TT) had higher Ki-67 density and H-scores than those who had TT responses. Overall, this ex vivo geospatial analysis of CAF distribution suggests that close proximity clustering of tumor cells and CAFs potentiates tumor cell proliferation, resulting in worse OS and resistance to TT in metastatic ccRCC.
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Affiliation(s)
- Nicholas H. Chakiryan
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (A.H.); (A.C.); (A.M.A.); (L.Z.); (E.K.); (J.C.); (P.E.S.); (N.F.); (M.F.); (B.J.M.)
- Correspondence: ; Tel.: +1-813-745-3208; Fax: +1-813-745-8494
| | - Gregory J. Kimmel
- Integrated Mathematical Oncology Department, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (G.J.K.); (M.C.F.-F.); (P.M.A.)
| | - Youngchul Kim
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA;
| | - Joseph O. Johnson
- Analytic Microcopy Shared Resource, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA;
| | - Noel Clark
- Tissue Core Shared Resource, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA;
| | - Ali Hajiran
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (A.H.); (A.C.); (A.M.A.); (L.Z.); (E.K.); (J.C.); (P.E.S.); (N.F.); (M.F.); (B.J.M.)
| | - Andrew Chang
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (A.H.); (A.C.); (A.M.A.); (L.Z.); (E.K.); (J.C.); (P.E.S.); (N.F.); (M.F.); (B.J.M.)
| | - Ahmet M. Aydin
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (A.H.); (A.C.); (A.M.A.); (L.Z.); (E.K.); (J.C.); (P.E.S.); (N.F.); (M.F.); (B.J.M.)
| | - Logan Zemp
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (A.H.); (A.C.); (A.M.A.); (L.Z.); (E.K.); (J.C.); (P.E.S.); (N.F.); (M.F.); (B.J.M.)
| | - Esther Katende
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (A.H.); (A.C.); (A.M.A.); (L.Z.); (E.K.); (J.C.); (P.E.S.); (N.F.); (M.F.); (B.J.M.)
| | - Jad Chahoud
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (A.H.); (A.C.); (A.M.A.); (L.Z.); (E.K.); (J.C.); (P.E.S.); (N.F.); (M.F.); (B.J.M.)
| | - Meghan C. Ferrall-Fairbanks
- Integrated Mathematical Oncology Department, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (G.J.K.); (M.C.F.-F.); (P.M.A.)
| | - Philippe E. Spiess
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (A.H.); (A.C.); (A.M.A.); (L.Z.); (E.K.); (J.C.); (P.E.S.); (N.F.); (M.F.); (B.J.M.)
| | - Natasha Francis
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (A.H.); (A.C.); (A.M.A.); (L.Z.); (E.K.); (J.C.); (P.E.S.); (N.F.); (M.F.); (B.J.M.)
| | - Michelle Fournier
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (A.H.); (A.C.); (A.M.A.); (L.Z.); (E.K.); (J.C.); (P.E.S.); (N.F.); (M.F.); (B.J.M.)
| | - Jasreman Dhillon
- Department of Pathology, H. Lee Moffitt Cancer Center, Tampa, FL 33612, USA;
| | - Jong Y. Park
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center, Tampa, FL 33612, USA;
| | - Liang Wang
- Department of Tumor Biology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA;
| | - James J. Mulé
- Immunology Department, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA;
| | - Philipp M. Altrock
- Integrated Mathematical Oncology Department, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (G.J.K.); (M.C.F.-F.); (P.M.A.)
| | - Brandon J. Manley
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (A.H.); (A.C.); (A.M.A.); (L.Z.); (E.K.); (J.C.); (P.E.S.); (N.F.); (M.F.); (B.J.M.)
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Hajiran A, Azizi M, Aydin AM, Chakiryan NH, Peyton CC, Boulware DC, Manley BJ, Gilbert SM, Sexton WJ. Retroperitoneal Lymph Node Dissection Versus Surveillance for Adult Early Stage Pure Testicular Teratoma: A Nationwide Analysis. Ann Surg Oncol 2021; 28:3648-3655. [PMID: 33689081 PMCID: PMC9801512 DOI: 10.1245/s10434-021-09696-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 12/13/2020] [Indexed: 01/01/2023]
Abstract
PURPOSE Following radical orchiectomy, surveillance and primary retroperitoneal lymph node dissection (RPLND) are acceptable options for the management of early stage pure testicular teratoma in adult patients; however, there is no uniform consensus. The aim of this study was to investigate survival outcomes of adults with early stage pure testicular teratoma based on management strategy. METHODS Data was extracted from the National Cancer Database (NCDB) from testicular cancer patients diagnosed with clinical stage (CS) I pure teratoma (pT1-4N0M0S0) between 2004 and 2014. Kaplan-Meier and Cox regression analyses were used to assess clinical outcomes based on management strategy. RESULTS Of the 61,167 patients diagnosed with testicular cancer, 692 (1.1%) had pure teratoma. Only individuals with CS I disease were considered (n = 237). The median age was 28 (23-35) years. Overall, 43 (18%) patients underwent RPLND and 194 (82%) patients were managed with surveillance. There was an increase in surveillance for CS I teratoma during the study period. Increasing distance from residence to treatment facility was an unadjusted predictor for undergoing primary RPLND (p < 0.001). Median follow-up was 54 months and there was no significant difference in overall survival between CS I teratoma patients managed with RPLND and those managed with surveillance (p = 0.13). CONCLUSIONS There has been a trend toward increasing adoption of surveillance for the management of early stage pure testicular teratoma in adults. Our findings suggest that surveillance provides comparable survival outcomes to primary retroperitoneal lymph node dissection in this setting.
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Affiliation(s)
- Ali Hajiran
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Mounsif Azizi
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Ahmet M. Aydin
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Nicholas H. Chakiryan
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Charles C. Peyton
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - David C. Boulware
- Department of Biostatistics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Brandon J. Manley
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL,Department of Integrated Mathematical Oncology, H. Lee Moffitt Cancer Center and Research Institute Center, Tampa, FL
| | - Scott M. Gilbert
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Wade J. Sexton
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
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Jiang DD, Gillis KA, Chen Y, Hedges JC, Chakiryan NH. Perioperative stroke and myocardial infarction in urologic surgery. Can J Urol 2021; 28:10678-10684. [PMID: 34129461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
UNLABELLED INTRODUCTION Perioperative stroke and myocardial infarction are uncommon but devastating thromboembolic complications. There is no comprehensive study detailing these complications for urologic procedures. The primary aim of this study is to determine which urologic procedures and patients carry the highest risk of perioperative stroke and myocardial infarction. MATERIALS AND METHODS The National Surgical Quality Improvement Program data set was reviewed from 2008-2017. Procedures coded under the urology specialty were included and patients who had a perioperative stroke or myocardial infarction were identified. CPTs were stratified into clinically relevant procedure groups. Two multivariable logistic regression analyses were performed to determine preoperative and procedural risk factors for developing perioperative stroke or myocardial infarction. A multivariable logistic regression analysis was performed to determine the association between these complications and 30-day mortality. RESULTS A total of 281,744 cases were included, identifying 392 strokes (0.14%) and 1,016 myocardial infarctions (0.36%). Age ≥ 70, hypertension, and disseminated cancer were the strongest preoperative risk factors for perioperative stroke or myocardial infarction. Cystectomy was the highest risk urologic procedure (stroke: OR 3.3, 95%CI 2.3-4.8; MI: OR 7.2, 95%CI 5.6-9.1). Thirty-day mortality was dramatically worse for patients who had a perioperative stroke or myocardial infarction. CONCLUSIONS Perioperative stroke and myocardial infarction were confirmed to be uncommon but devastating complications of urologic surgery, with incidence of 0.14% and 0.36%, respectively. Cystectomy was the highest risk urologic procedure. Perioperative stroke and myocardial infarction were strongly associated with age ≥ 70, hypertension, and disseminated cancer.
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Affiliation(s)
- Da David Jiang
- Department of Urology, Oregon Health and Science University, Portland, Oregon, USA
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Chakiryan NH, Dahmen A, Bandini M, Pederzoli F, Marandino L, Albersen M, Roussel E, Zhu Y, Ye DW, Ornellas AA, Catanzaro M, Hakenberg OW, Heidenreich A, Haidl F, Watkin N, Ager M, Chahoud J, Briganti A, Salvioni R, Montorsi F, Necchi A, Spiess PE. Patterns of Recurrence following Inguinal Lymph Node Dissection for Penile Cancer: Optimizing Surveillance Strategies. J Urol 2021; 206:960-969. [PMID: 34032492 DOI: 10.1097/ju.0000000000001790] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Our primary objective is to detail the incidence, site, and timing of penile squamous cell carcinoma (pSCC) recurrence after inguinal lymph node dissection (ILND). MATERIALS AND METHODS We performed a retrospective analysis of 551 patients who underwent ILND for pSCC from 2000 to 2017. The primary outcome was pSCC recurrence after ILND. Recurrences were identified and stratified by site. Timing of recurrence was determined. Multivariable logistic regression analysis determined associations with recurrence. Multivariable Cox regression analysis determined associations with overall survival (OS). Sub-group analysis of the distant recurrences analyzed timing and OS by site of distant recurrence. RESULTS After ILND pSCC recurred in 176 (31.9%) patients. Median time to recurrence was 10 months for distant recurrences, 12 for inguinal, 10.5 for pelvic, and 44.5 for local. Greater than 95% of distant, inguinal, and pelvic recurrences occurred within 48 months of ILND, versus 127 months for local recurrences. Post-ILND recurrence was associated with pN2 (OR 1.99, 95% CI 1.0-4.1), and pN3 (OR 7.2, 95% CI 4.0-13.7). Patients who had local recurrence had similar OS to those without (HR 1.5, 95% CI 0.6-3.8), and worse OS was identified in patients with inguinal (HR 4.5, 95% CI 2.8-7.1), pelvic (HR 2.6, 95% CI 1.5-4.5), or distant (HR 4.0, 95% CI 2.7-5.8) recurrences. Patients with lung recurrences had worse OS than other sites (HR 2.2, 95% CI 1.1-4.3). CONCLUSIONS Of the patients 31.9% had post-ILND recurrence associated with high pN staging. Greater than 95% of distant, inguinal, and pelvic recurrences occurred within 48 months, suggesting surveillance beyond this is low yield. Local recurrences occurred over a longer timeline, emphasizing necessity of long-term surveillance of the primary site.
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Affiliation(s)
- Nicholas H Chakiryan
- H. Lee Moffitt Cancer Center, Department of Genitourinary Oncology, Tampa, Florida
| | - Aaron Dahmen
- University of South Florida, Department of Urology, Tampa, Florida
| | - Marco Bandini
- Urological Research Institute (URI), Unit of Urology, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | - Filippo Pederzoli
- Urological Research Institute (URI), Unit of Urology, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | - Laura Marandino
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | | | | | - Yao Zhu
- Fudan University Shanghai Cancer Center, Shanghai, China
| | - Ding-Wei Ye
- Fudan University Shanghai Cancer Center, Shanghai, China
| | - Antonio A Ornellas
- Hospital Mário Kröeff and Brazilian Cancer Institute, Rio de Janeiro, Brazil
| | - Mario Catanzaro
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | | | | | | | | | | | - Jad Chahoud
- H. Lee Moffitt Cancer Center, Department of Genitourinary Oncology, Tampa, Florida
| | - Alberto Briganti
- Urological Research Institute (URI), Unit of Urology, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | | | - Francesco Montorsi
- Urological Research Institute (URI), Unit of Urology, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | - Andrea Necchi
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Philippe E Spiess
- H. Lee Moffitt Cancer Center, Department of Genitourinary Oncology, Tampa, Florida
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Chakiryan NH, Jiang DD, Gillis KA, Green E, Hajiran A, Hugar L, Zemp L, Zhang J, Jain RK, Chahoud J, Spiess PE, Sexton W, Gilbert SM, Manley BJ. Real-World Survival Outcomes Associated With First-Line Immunotherapy, Targeted Therapy, and Combination Therapy for Metastatic Clear Cell Renal Cell Carcinoma. JAMA Netw Open 2021; 4:e2111329. [PMID: 34032854 PMCID: PMC8150693 DOI: 10.1001/jamanetworkopen.2021.11329] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Clinical trials have shown an overall survival (OS) benefit associated with first-line immunotherapy (IT) and combination targeted therapy (TT) and IT regimens compared with TT among patients with metastatic clear cell renal cell carcinoma (RCC). Generalizability of these findings in a real-world cohort outside of a clinical trial setting is unclear. OBJECTIVE To assess the association of first-line TT, IT, and combination TT and IT regimens with OS in a real-world cohort of patients with metastatic clear cell RCC. DESIGN, SETTING, AND PARTICIPANTS This retrospective propensity-matched cohort study identified 5872 patients with metastatic clear cell RCC in the National Cancer Database from January 1, 2015, to December 31, 2017, who received first-line TT, IT, or combination TT and IT and were not treated on a clinical trial protocol. Patients were stratified by first-line systemic treatment. Statistical analysis was conducted from October 1 to December 1, 2020. MAIN OUTCOMES AND MEASURES The primary outcome was OS from the date of diagnosis to death or censoring at last follow-up. After 1:1:1 nearest-neighbor caliper matching of propensity scores, survival analyses were conducted using Cox proportional hazards regression and Kaplan-Meier estimates. RESULTS The final study population included 5872 patients (TT group: n = 4755 [81%]; 3332 men [70%]; median age, 64 years [interquartile range, 57-71 years]; IT group: n = 638 [11%]; 475 men [74%]; median age, 61 years [interquartile range, 54-69 years]; and combination TT and IT group: n = 479 [8%]; 321 men [67%]; median age, 62 years [interquartile range, 55-69 years]), and the matched cohort included 1437 patients (479 per treatment group). Patients in the IT and combination TT and IT groups were younger than those in the TT group, had fewer comorbid conditions (Charlson-Deyo score of 0, 480 of 638 [75%] in the TT group, 356 of 479 [74%] in the IT group, and 3273 of 4755 [69%] in the combination TT and IT group), and were more often treated at academic centers (315 of 638 [49%], 216 of 479 [45%], and 1935 of 4755 [41%], respectively). Both first-line IT and combination TT and IT were associated with improved OS compared with first-line TT for patients with metastatic clear cell RCC (IT group: hazard ratio [HR], 0.60 [95% CI, 0.48-0.75]; P < .001; combination TT and IT group: HR, 0.74 [95% CI, 0.60-0.91]; P = .005). No survival difference was seen between the IT and combination TT and IT groups (combination TT and IT: HR, 1.24 [95% CI, 0.98-1.56]; P = .08). CONCLUSIONS AND RELEVANCE This study suggests that both first-line IT and combination TT and IT were associated with improved OS compared with first-line TT for patients with metastatic clear cell RCC. These findings are similar to those identified in recently reported clinical trials, lending confidence to the broader applicability of these findings outside of a clinical trial setting.
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Affiliation(s)
- Nicholas H. Chakiryan
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Da David Jiang
- Department of Urology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Kyle A. Gillis
- Department of Urology, University of Iowa Hospitals & Clinics, Iowa City
| | - Elizabeth Green
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Ali Hajiran
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Lee Hugar
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Logan Zemp
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Jingsong Zhang
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Rohit K. Jain
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Jad Chahoud
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Philippe E. Spiess
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Wade Sexton
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Scott M. Gilbert
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Brandon J. Manley
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
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Jiang DD, Chakiryan NH, Gillis KA, Acevedo AM, Chen Y, Austin JC, Seideman CA. Relative value units do not adequately account for operative time in pediatric urology. J Pediatr Surg 2021; 56:883-887. [PMID: 32732162 DOI: 10.1016/j.jpedsurg.2020.06.043] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/12/2020] [Accepted: 06/26/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Relative value units (RVUs) are the measure of value used in United States Medicare and Medicaid reimbursement. The Relative Update Committee (RUC) determines physician work RVU (wRVUs) based on operative time, technical skill and effort, mental effort and judgment, and stress. The primary aim of this study was to assess whether operative time is adequately accounted for in the wRVU system in pediatric urology. METHODS The American College of Surgeons National Surgical Quality Improvement Program Pediatric Participant User File (ACS-NSQIPP-PUF) was reviewed from 2012 to 2017. Most common single pediatric urology current procedural terminology (CPT) codes were included. The primary variable was wRVU per hour of operative time (wRVU/h). Linear regression analysis was used to assess the relative influence that operative time had on wRVU/h. RESULTS 25,432 cases were included in the final study population from 45 unique CPT codes. The median operative time was 79 min, and the median RVU/h was 12.2. Procedures with operative time less than 79 min had higher wRVU/h compared with procedures longer than 79 min (14.5 vs 10.5, p < 0.001). Procedures with higher than average incidence of any complications had a lower wRVU/h (9.0 vs. 14.6 p < 0.001). Linear regression analysis revealed that each additional hour of operative time was expected to decrease wRVU/h by 4.2 (-0.70 per 10 min, 95% CI: -0.71 to -0.69, p < 0.001; R2 = 0.39). CONCLUSION This analysis of contemporary large pediatric population national-level data suggests that the wRVU system significantly favors shorter and less complex procedures in Pediatric Urology. Pediatric urologists performing longer and more complex procedures are not adequately compensated for the increase in complexity. EVIDENCE LEVEL III Retrospective comparative study.
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Affiliation(s)
- Da David Jiang
- Oregon Health & Science University, Department of Urology, Portland, Oregon; O'Brien Research Group, Portland, Oregon.
| | - Nicholas H Chakiryan
- Oregon Health & Science University, Department of Urology, Portland, Oregon; O'Brien Research Group, Portland, Oregon
| | - Kyle A Gillis
- Oregon Health & Science University, Department of Urology, Portland, Oregon; O'Brien Research Group, Portland, Oregon
| | | | - Yiyi Chen
- Oregon Health & Science University, Department of Urology, Portland, Oregon
| | - J Christopher Austin
- Oregon Health & Science University, Department of Urology, Portland, Oregon; Doernbecher Children's Hospital, Department of Pediatric Urology, Portland, Oregon
| | - Casey A Seideman
- Oregon Health & Science University, Department of Urology, Portland, Oregon; Doernbecher Children's Hospital, Department of Pediatric Urology, Portland, Oregon
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Chakiryan NH, Kimmel GJ, Kim Y, Hajiran A, Aydin AM, Zemp L, Katende E, Nguyen J, Lopez-Blanco N, Chahoud J, Spiess PE, Fournier M, Dhillon J, Wang L, Moran-Segura C, El-Kenawi A, Mulé J, Altrock PM, Manley BJ. Spatial clustering of CD68+ tumor associated macrophages with tumor cells is associated with worse overall survival in metastatic clear cell renal cell carcinoma. PLoS One 2021; 16:e0245415. [PMID: 33882057 PMCID: PMC8059840 DOI: 10.1371/journal.pone.0245415] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 04/06/2021] [Indexed: 12/27/2022] Open
Abstract
Immune infiltration is typically quantified using cellular density, not accounting for cellular clustering. Tumor-associated macrophages (TAM) activate oncogenic signaling through paracrine interactions with tumor cells, which may be better reflected by local cellular clustering than global density metrics. Using multiplex immunohistochemistry and digital pathologic analysis we quantified cellular density and cellular clustering for myeloid cell markers in 129 regions of interest from 55 samples from 35 patients with metastatic ccRCC. CD68+ cells were found to be clustered with tumor cells and dispersed from stromal cells, while CD163+ and CD206+ cells were found to be clustered with stromal cells and dispersed from tumor cells. CD68+ density was not associated with OS, while high tumor/CD68+ cell clustering was associated with significantly worse OS. These novel findings would not have been identified if immune infiltrate was assessed using cellular density alone, highlighting the importance of including spatial analysis in studies of immune cell infiltration of tumors. Significance: Increased clustering of CD68+ TAMs and tumor cells was associated with worse overall survival for patients with metastatic ccRCC. This effect would not have been identified if immune infiltrate was assessed using cell density alone, highlighting the importance of including spatial analysis in studies of immune cell infiltration of tumors.
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Affiliation(s)
- Nicholas H. Chakiryan
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, United States of America
- * E-mail:
| | - Gregory J. Kimmel
- Integrated Mathematical Oncology Department, H Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, United States of America
| | - Youngchul Kim
- Department of Biostatistics and Bioinformatics, H Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, United States of America
| | - Ali Hajiran
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, United States of America
| | - Ahmet M. Aydin
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, United States of America
| | - Logan Zemp
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, United States of America
| | - Esther Katende
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, United States of America
| | - Jonathan Nguyen
- Department of Pathology, H Lee Moffitt Cancer Center, Tampa, Florida, United States of America
| | - Neale Lopez-Blanco
- Department of Pathology, H Lee Moffitt Cancer Center, Tampa, Florida, United States of America
| | - Jad Chahoud
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, United States of America
| | - Philippe E. Spiess
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, United States of America
| | - Michelle Fournier
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, United States of America
| | - Jasreman Dhillon
- Department of Pathology, H Lee Moffitt Cancer Center, Tampa, Florida, United States of America
| | - Liang Wang
- Department of Tumor Biology, H Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, United States of America
| | - Carlos Moran-Segura
- Department of Pathology, H Lee Moffitt Cancer Center, Tampa, Florida, United States of America
| | - Asmaa El-Kenawi
- Immunology Department, H Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, United States of America
| | - James Mulé
- Immunology Department, H Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, United States of America
| | - Philipp M. Altrock
- Integrated Mathematical Oncology Department, H Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, United States of America
| | - Brandon J. Manley
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, United States of America
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Jiang DD, Hayes M, Gillis KA, Korets R, Wagner AA, Hedges JC, Chakiryan NH. Misaligned Incentives in Benign Prostatic Enlargement Surgery: More Complex and Efficacious Procedures Are Earning Fewer Relative Value Units. J Endourol 2021; 35:835-839. [PMID: 33222524 DOI: 10.1089/end.2020.0941] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background: Relative value units (RVUs) are the measure of value used in US Medicare reimbursement. Medicare determines physician work RVUs (wRVUs) from the Relative Value Update Committee (RUC) for a procedure based on operative time, technical skill and effort, mental effort and judgment, and stress. In theory, work RVUs should account for the complexity and operative time involved in a procedure. The aim of this study was to assess whether major procedures for treatment of benign prostatic enlargement (BPE) are fairly compensated based on complexity and operative time in the RVU system and compare them with the intended reimbursement. Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database and the Centers for Medicare and Medicaid Services (CMS) Medicare Physician Fee Schedule were queried from 2015 to 2017. Single, current, procedural terminology codes associated with BPE treatments were included: transurethral resection of the prostate (TURP), photovaporization of the prostate (PVP), holmium laser enucleation of the prostate (HoLEP), retropubic simple prostatectomy (RSP), and suprapubic simple prostatectomy (SSP). The CMS operative times and the NSQIP real data were used in turn to calculate separate values for wRVUs per hour (wRVUs/hr) of operative time. The wRVUs/hr derived from CMS operative times represent RUC-estimated wRVUs/hr and wRVUs/hr derived from NSQIP represent actual wRVUs/hr. Results: A total of 27,664 cases were included from the NSQIP dataset. Median wRVU was 15.3 (interquartile range [IQR] 12.2-15.3), median operative time 50 minutes (IQR 33-74), and median wRVUs/hr 17.0 (IQR 11.6-26.2). RUC-estimated wRVUs/hr were TURP 12.2, PVP 12.2, RSP 9, SSP 9.3, and HoLEP 7.3. The actual wRVUs/hr were TURP 19.1, PVP 15.5, RSP 10.2, HoLEP 9.4, and SSP 7.6. Conclusions: Laser enucleation and simple prostatectomy are highly complex and efficacious procedures for treating BPE, yet the current payment schedule assigns these procedures the least amount of wRVUs/hr. Financial incentives for performing BPE surgeries are clearly misaligned.
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Affiliation(s)
- Da David Jiang
- Oregon Health and Science University, Portland, Oregon, USA.,O'Brien Research Group, Portland, Oregon, USA.,Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Mitchell Hayes
- Oregon Health and Science University, Portland, Oregon, USA
| | - Kyle A Gillis
- Oregon Health and Science University, Portland, Oregon, USA.,O'Brien Research Group, Portland, Oregon, USA.,University of Iowa Health Care, Iowa City, Iowa, USA
| | - Ruslan Korets
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Andrew A Wagner
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jason C Hedges
- Oregon Health and Science University, Portland, Oregon, USA
| | - Nicholas H Chakiryan
- Oregon Health and Science University, Portland, Oregon, USA.,O'Brien Research Group, Portland, Oregon, USA.,H. Lee Moffitt Cancer Center, Tampa, Florida, USA
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Kimmel GJ, Chakiryan NH, Kim Y, Hajiran AJ, Aydin AM, Nguyen JV, Moran-Segura CM, Dhillon J, Altrock P, Manley BJ. Abstract PO-034: Non-random spatial clustering of tumor associated macrophages is associated with poor survival in metastatic RCC patients receiving immunotherapy. Cancer Res 2020. [DOI: 10.1158/1538-7445.tumhet2020-po-034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
INTRODUCTION Tumor associated macrophages (TAM) stimulate tumor proliferation and facilitate immune escape via production of immunosuppressive cytokines. We hypothesize that non-random spatial clustering of TAMs within the tumor is associated with poor survival in RCC patients. METHODS Primary and metastatic tumor specimens were obtained from 39 patients with metastatic RCC who received immunotherapy (IT). 29 patients (74.3%) also received targeted therapy (TT) at some point during their disease course. Sections from the tumor compartment underwent immunohistochemical (IHC) staining for pan-macrophage marker CD68, and M2 markers CD163 and CD206. Digital pathologic analysis was used to convert the digital images to spatial point pattern plots (PPP). A probability density function (PDF) for the distance between cells was calculated under the assumption that cells can be located anywhere in the slide with equal probability. The PDF was then compared to empirical histograms of cells derived from the PPP. Deviations from the PDF, the expected random distribution, reveal evidence of cell clustering or dispersion. We assessed deviations with the Kolmogorov-Smirnov (KS) test. Patients were stratified by the median value into high and low KS groups, and survival outcomes were compared between the two groups using a Cox regression. A high KS statistic indicates a good fit between the two curves (in this case, randomness), and a low KS statistic indicates a poor fit (in this case, dispersion or clustering). RESULTS Among primary tumor specimens, spatial clustering of CD68+ cells was associated with worse overall survival (OS) (HR -1.7, p=0.015), worse OS from IT initiation (HR -1.5, p=0.025), and no difference in OS from TT initiation (HR -0.4, p=0.48). Among metastatic tumor specimens, spatial clustering of CD68+ cells was not associated with any of the three survival outcomes (OS: HR 0.9, p=0.11; OS from IT: HR 0.7, p=0.20; OS from TT: HR 0.0, p=0.97). Spatial clustering of CD163+ cells was not associated with any of the three survival outcomes for either primary and metastatic sites. Spatial clustering of CD206+ cells was not associated with any of the three survival outcomes for either primary and metastatic sites. CONCLUSION Non-random spatial clustering of CD68+ TAMs in the primary tumor specimen was associated with worse survival, driven primarily by worse survival from initiation of immunotherapy. These findings corroborate prior reports of TAMs eliciting an immunosuppressive effect on the tumor-immune microenvironment, introduce novel methodology for quantifying spatial heterogeneity, and demonstrate the novel finding of a clinically significant effect of TAM spatial clustering on overall survival.
Citation Format: Gregory J. Kimmel, Nicholas H. Chakiryan, Youngchul Kim, Ali J. Hajiran, Ahmet M. Aydin, Jonathan V. Nguyen, Carlos M. Moran-Segura, Jasreman Dhillon, Philipp Altrock, Brandon J. Manley. Non-random spatial clustering of tumor associated macrophages is associated with poor survival in metastatic RCC patients receiving immunotherapy [abstract]. In: Proceedings of the AACR Virtual Special Conference on Tumor Heterogeneity: From Single Cells to Clinical Impact; 2020 Sep 17-18. Philadelphia (PA): AACR; Cancer Res 2020;80(21 Suppl):Abstract nr PO-034.
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Aydin AM, Chakiryan NH, Spiess PE. Will Dynamic Sentinel Lymph Node Biopsy Become the New International Standard for Evaluating High-risk Penile Cancer in Patients with Clinically Negative Lymph Nodes? Eur Urol 2020; 78:873-874. [PMID: 33023773 DOI: 10.1016/j.eururo.2020.09.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 09/21/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Ahmet Murat Aydin
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Nicholas H Chakiryan
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Philippe E Spiess
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA.
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Chakiryan NH, Jiang DD, Gillis KA, Chen Y, Acevedo AM, Sajadi KP. RUC Operative Time Estimates are Inaccurate, Resulting in Decreased Work RVU Assignments for Longer Urologic Procedures. Urology 2020; 142:94-98. [DOI: 10.1016/j.urology.2020.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 03/02/2020] [Accepted: 05/03/2020] [Indexed: 11/30/2022]
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Jiang DD, Gillis KA, Chakiryan NH, Acevedo AM, Austin JC, Seideman CA. Work relative value units do not account for complexity and operative time in hypospadias surgery. J Pediatr Urol 2020; 16:459.e1-459.e5. [PMID: 32451244 DOI: 10.1016/j.jpurol.2020.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 04/22/2020] [Accepted: 04/29/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Relative value units (RVU) are the measure of value used in United States Medicare and Medicaid reimbursement. The Relative Update Committee (RUC) determine physician work RVU (wRVU) based on operative time, technical skill and effort, mental effort and judgement, and stress. In theory, wRVU should account for the complexity and operative time involved in a procedure. OBJECTIVE The primary aim of this study is to assess if operative time and complexity of hypospadias surgery is adequately accounted for by the current wRVU assignments. STUDY DESIGN The American College of Surgeons National Surgical Quality Improvement Program Participant User File (ACS-NSQIP PUF) database was utilized from 2012 to 2017. Single stage hypospadias current procedural terminology (CPT) codes (including acceptable secondary CPT codes) were extracted. Using total wRVU and total operative time, the primary variable of wRVU per hour was calculated (wRVU/hr). Multivariable linear regression analysis was used to assess the relative influence that wRVU and operative time had on the wRVU/hr variable. RESULTS 9810 cases were included in the final study population divided into four categories: simple distal (eg. MAGPI, V-Flap), single stage distal, single stage mid, single stage proximal. On analysis of variance, there was statistically significant different wRVU/hr for the four different types of hypospadias repairs with simple distal having the highest mean wRVU/hr of 19.5 and the lowest being proximal hypospadias repairs at 13.2. Simple distal, distal and midshaft hypospadias had statistically significantly higher wRVU/hr compared to proximal hypospadias (16.2, 95% CI: 15.8-16.5 vs. 13.2, 95% CI 10.9-15.5; p<0.001). Multivariable linear regression revealed that each additional hour of operative time was expected to decrease wRVU/hr by 10.5 (-10.5, 95% CI: -11.0 to -10.1, p < 0.001); total work wRVU had a statistically significant independent association with wRVU/hr (0.6, 95%CI: 0.5-0.7, p <0.001). DISCUSSION This the first objective assessment of the current wRVU assignments with regards to one stage hypospadias repairs. More complex and longer hypospadias procedures are not adequately compensated by wRVU. Most notably, simple distal procedures are reimbursed at a mean of 19.5 wRVU/hr compared to 13.2 wRVU/hr for one stage proximal repairs. CONCLUSION This analysis of national-level data suggests that the current wRVU assignments significantly favor shorter and simpler procedures in hypospadias surgery.
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Affiliation(s)
- Da David Jiang
- Department of Urology, Oregon Health & Sciences University, Portland, OR, USA; O'Brien Research Group, Portland, OR, USA.
| | - Kyle A Gillis
- Department of Urology, Oregon Health & Sciences University, Portland, OR, USA; O'Brien Research Group, Portland, OR, USA
| | - Nicholas H Chakiryan
- Department of Urology, Oregon Health & Sciences University, Portland, OR, USA; O'Brien Research Group, Portland, OR, USA
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Jiang DD, Chakiryan NH, Gillis KA, Acevedo AM, Austin JC, Seideman CA. Perioperative complications within 30 days of hypospadias surgery: Results from NSQIP-Pediatrics. J Pediatr Urol 2020; 16:316.e1-316.e7. [PMID: 32317234 DOI: 10.1016/j.jpurol.2020.03.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 03/29/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION There are no large multi-institutional studies reporting on perioperative complications of hypospadias repairs. We sought to determine perioperative complications of hypospadias repairs from the National Surgical Quality Improvement Program Pediatrics (NSQIP-P) to aid in patient counseling. STUDY DESIGN This cohort study from 2012 to 2017 was conducted using NSQIP-P database. Pediatric patients undergoing hypospadias surgery were identified and compared based on 4 major categories: distal/midshaft repair, one-stage repair proximal, stage one repair, and stage two repair. Baseline demographics between the four groups and perioperative parameters were compared. Multivariable logistic regression analysis models including type of repair was used to determine associations with overall complications, infectious complications, and dehiscence. DISCUSSION There were 11,292 patients identified in the study population. Overall, 78% underwent distal/midshaft hypospadias repair, 12% underwent one-stage proximal repair, 1.4% underwent proximal first stage repair and 9% underwent proximal second stage repair. Multivariable logistic regression analysis revealed that proximal first stage procedures had similar overall complications to distal/mid repairs but proximal one-stage and proximal second stage procedures were associated with significantly more overall complications, local infectious complications, and dehiscence. Age, race, operative time, prematurity were also independently associated with increased overall complications. As expected, complication rates are higher in those with proximal hypospadias. In staged hypospadias, first stage has a lower complication rate compared to second stage. All complications, especially of infectious and dehiscence are the highest in the one-stage proximal and proximal second stage repairs. CONCLUSION We report large multi-institutional analysis of 30-day peri-operative hypospadias repair complications; this information is useful for patient counseling and education.
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Affiliation(s)
- Da David Jiang
- Department of Urology, Oregon Health & Sciences University, Portland, OR, USA; O'Brien Research Group, Portland, OR, USA.
| | - Nicholas H Chakiryan
- Department of Urology, Oregon Health & Sciences University, Portland, OR, USA; O'Brien Research Group, Portland, OR, USA
| | - Kyle A Gillis
- Department of Urology, Oregon Health & Sciences University, Portland, OR, USA; O'Brien Research Group, Portland, OR, USA
| | | | | | - Casey A Seideman
- Department of Urology, Oregon Health & Sciences University, Portland, OR, USA
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Chakiryan NH, Acevedo AM, Garzotto MA, Chen Y, Liu JJ, Isharwal S, Amling CL, Kopp RP. Survival outcomes and practice trends for off-label use of adjuvant targeted therapy in high-risk locoregional renal cell carcinoma. Urol Oncol 2020; 38:604.e1-604.e7. [PMID: 32241693 DOI: 10.1016/j.urolonc.2020.02.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 02/18/2020] [Accepted: 02/26/2020] [Indexed: 01/20/2023]
Abstract
IMPORTANCE The appropriate use of adjuvant targeted therapy (TT) for high-risk locoregional renal cell carcinoma (RCC) after nephrectomy is currently unclear due to mixed results from the relevant randomized controlled trials. National-level survival outcomes and practice trends for the use of adjuvant TT in the United States have not been reported. OBJECTIVE To compare overall survival for patients who did and did not receive adjuvant TT after nephrectomy for high-risk locoregional RCC. DESIGN, SETTING, AND PARTICIPANTS This cohort study reviewed the National Cancer Database from 2006 to 2015. Patients with nonmetastatic clear cell RCC who underwent nephrectomy with either stage pT3a or greater or pN+ were included. MAIN OUTCOMES AND MEASURES Adjuvant TT was defined as receipt of TT within 3 months of nephrectomy. The primary end point was overall survival from initial diagnosis to date of death or censored at last follow-up. Baseline characteristics were described, and a multivariable analysis identified associations for receipt of adjuvant TT. Nearest-neighbor propensity matching was performed to create similar groups for comparison. A survival analysis was performed using Kaplan-Meier analysis and log-rank test. RESULTS The final study population included 41,127 patients. Two thousand seventy-one patients (5.04%) received off-label adjuvant TT. Younger age, white race, private insurance, positive margins, pT4, and pN+ were associated with receipt of adjuvant TT. After nearest-neighbor propensity matching for clinically and statistically relevant covariates, 1,604 patients remained in the matched cohort, with statistically nonsignificant differences between the groups for all baseline characteristics. Median overall survival was 52 months for patients in the Adjuvant TT group versus 79 months for those who did not receive adjuvant TT (P < 0.001). Decreased overall survival for patients receiving adjuvant therapy was also seen in pathologic subgroups with and without lymph node involvement. CONCLUSIONS The propensity matched survival analysis revealed significantly decreased overall survival in patients who received off-label adjuvant TT for high-risk locoregional RCC.
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Affiliation(s)
| | | | - Mark A Garzotto
- Oregon Health & Science University, Department of Urology, Portland, OR; Portland VA Healthcare System, Operative Care Division, Urology Section, Portland, OR
| | - Yiyi Chen
- Oregon Health & Science University, Knight Cancer Institute, Biostatistics Shared Resource, Portland, OR
| | - Jen-Jane Liu
- Oregon Health & Science University, Department of Urology, Portland, OR
| | - Sudhir Isharwal
- Oregon Health & Science University, Department of Urology, Portland, OR
| | | | - Ryan P Kopp
- Oregon Health & Science University, Department of Urology, Portland, OR; Portland VA Healthcare System, Operative Care Division, Urology Section, Portland, OR
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Clennon EK, Lam M, Manley A, Chakiryan NH, Acevedo M, Duty B, Sajadi KP. Patterns of Industry Payments to Urologists From 2014-2018. Urology 2020; 140:44-50. [PMID: 32165278 DOI: 10.1016/j.urology.2020.02.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 01/13/2020] [Accepted: 02/22/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To evaluate the patterns of financial transaction between industry and urologists in the first 5 years of reporting in the Open Payments Program (OPP) by comparing transactions over time, between academic and nonacademic urologists, and by provider characteristics among academic urologists. METHODS The Center for Medicare & Medicaid Services OPP database was queried for General Payments to urologists from 2014-2018. Faculty at ACGME-accredited urology training programs were identified and characterized via publicly available websites. Industry transfers were analyzed by year, practice setting (academic vs nonacademic), provider characteristics, and AUA section. Payment nature and individual corporate contributions were also summarized. RESULTS A total of 12,521 urologists - representing 75% of the urology workforce in any given year - received $168 million from industry over the study period. There was no significant trend in payments by year (P = .162). Urologists received a median of $1602 over the study period, though 14% received >$10,000. Payment varied significantly by practice setting (P <.001), with nonacademic urologists receiving more but smaller payments than academic urologists. Among academic urologists, gender (P <.001), department chair status (P <.001), fellowship training (P <.001), and subspecialty (P <.001) were significantly associated with amount of payment from industry. Annual payments from industry varied significantly by AUA section. CONCLUSION Reporting of physician-industry transactions has not led to a sustained decline in transactions with urologists. Significant differences in industry interaction exist between academic and nonacademic urologists, and values transferred to academic urologists varied by gender, chair status, subspecialty, and AUA section.
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Affiliation(s)
- Emily K Clennon
- Oregon Health & Science University, Department of Urology, Portland, OR.
| | - Michael Lam
- Oregon Health & Science University, Department of Urology, Portland, OR
| | - Annalise Manley
- Oregon Health & Science University, Department of Urology, Portland, OR
| | | | - Martinez Acevedo
- Oregon Health & Science University, Department of Urology, Portland, OR
| | - Brian Duty
- Oregon Health & Science University, Department of Urology, Portland, OR
| | - Kamran P Sajadi
- Oregon Health & Science University, Department of Urology, Portland, OR
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Chakiryan NH, Acevedo AM, Conlin MJ, Garzotto M, Chen Y, Liu JJ, Amling CL, Kopp RP. The estimated prevalence of missed positive lymph nodes based on extent of lymphadenectomy at radical prostatectomy. Urol Oncol 2019; 37:574.e1-574.e9. [DOI: 10.1016/j.urolonc.2019.06.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 05/29/2019] [Accepted: 06/09/2019] [Indexed: 11/30/2022]
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Winer AG, Chakiryan NH, Mooney RP, Verges D, Ghanaat M, Allaei A, Robinson L, Zinn H, Lang EK. Secondary pelvic congestion syndrome: description and radiographic diagnosis. Can J Urol 2014; 21:7365-7368. [PMID: 25171280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
INTRODUCTION Pelvic congestion syndrome (PCS) is a complex condition of the pelvic venous system leading to nonspecific pelvic pain that was initially described in females alone. The underlying abnormalities, though diverse, all result in increased pressure in the left gonadal vein which is transmitted retrograde into the pelvic venous system. Our primary aim was to describe our findings of secondary PCS as a distinct entity from primary PCS in that it has an identifiable vascular etiology and is gender nonspecific. We also aimed to assess the adequacy of late-arterial phase CT urography (CTU) as the initial imaging modality in diagnosing and evaluating secondary PCS. MATERIALS AND METHODS We retrospectively reviewed 59 patients with PCS, 36 males and 23 females ages 24 to 63, from 2000-2011. To maximize opacification, CTU images were taken in the late-arterial phase with a 35-50 second delay after contrast administration. RESULTS Review of our cases revealed multiple etiologies for PCS, including: Nutcracker syndrome (19 cases), cirrhosis (17), retroaortic left renal vein (11), tumor thrombosis of the IVC (5), portal vein thrombosis (4), renal cell carcinoma with left renal vein thrombosis (2), and left kidney AVF (1). The most common symptom was unexplained chronic pelvic pain. The patients in our series had clearly identifiable vascular flow abnormalities leading to the development of PCS, and were therefore diagnosed as having secondary PCS. All cases were easily identified utilizing CTU to visualize and measure dilation of the left gonadal vein and pelvic varices. This modality also proved valuable in the identification and management of the various underlying causes of secondary PCS. CONCLUSION Secondary PCS is distinct from primary PCS in that it arises from clearly identifiable vascular flow abnormalities and occurs in both males and females. The diverse set of underlying etiologies, as well as the resulting congested varices, can be reliably and adequately visualized using CTU as the initial imaging modality.
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