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Kümmerl L, Kraulich M, Lesyuk W, Binninger A, Goebell PJ, Kahlmeyer A. Sarcopenia assessments as predictors of overall survival in patients with metastatic renal cell carcinoma. Urol Oncol 2023; 41:392.e1-392.e9. [PMID: 37442742 DOI: 10.1016/j.urolonc.2023.06.011] [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: 01/09/2023] [Revised: 04/10/2023] [Accepted: 06/18/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND Sarcopenia represents an important prognostic marker in tumor patients. However, measurement methods and threshold values are not uniformly defined. The aim of this study is therefore to determine the prognostic value of current definitions of sarcopenia in patients with metastatic renal cell carcinoma treated with tyrosine-kinase-inhibitors (TKIs). METHODS In 93 patients with metastatic renal cell carcinoma, sarcopenia was assessed based on manually assisted software measurements of sarcopenia indices based on different muscle areas. Whole muscle area and psoas muscle area at L3 were estimated and adjusted to patient's height in routine CT imaging before the start of first-line TKI therapy. The correlation of different sarcopenia definitions to overall survival was investigated in a univariate analysis as well as in a multivariate analysis. RESULTS The mean patients' age at inclusion was 65.8 years (21-86 years). Median survival was 12.3 months (IQR: 5.7-29.8 months), and mean survival was 18.8 months (SD: 17.2 months). As the definitions of sarcopenia differ considerably, 7.6% to 96.7% of the patients were classified as sarcopenic. In univariate analysis, sarcopenia was significantly associated with overall survival. Multivariate analysis, taking into account the Memorial Sloan Kettering Cancer Center risk score, revealed that some sarcopenia-indices are additional and independent prognostic markers. The risk of death was approximately doubled in sarcopenic patients. CONCLUSIONS Sarcopenia is an important prognostic factor in patients with metastatic renal cell carcinoma treated with TKIs. Multivariate analysis demonstrates a doubling of the risk of death in sarcopenic patients. The assessment of sarcopenia can be performed by the analysis of routine staging imaging using indices of the total muscle area or the psoas muscle area.
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Affiliation(s)
- Luca Kümmerl
- Urologische und Kinderurologische Klinik, Universitätsklinikum Erlangen, Erlangen, Germany; Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.
| | - Matthias Kraulich
- Urologische und Kinderurologische Klinik, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Wladimir Lesyuk
- Radiologisches Institut, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Adrian Binninger
- Clinical Epidemiology and Health Economics, iOMEDICO, Freiburg, Germany
| | - Peter J Goebell
- Urologische und Kinderurologische Klinik, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Andreas Kahlmeyer
- Urologische und Kinderurologische Klinik, Universitätsklinikum Erlangen, Erlangen, Germany
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Manseck A, Piotrowski A, Butea-Bocu M, Foller S, Gleissner J, Kahlmeyer A, Karstedt H, Kirschner-Hermanns R, Liebald T, Linné C, Moll V, Otto U, Schorn A, Stein J, Wagner A, Wiedemann A. Qualifizierte Beratung für Inkontinenzhilfsmittel. ProCare 2022; 27:12-17. [PMID: 36161070 PMCID: PMC9484342 DOI: 10.1007/s00735-022-1581-0] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Eine Untersuchung der Stiftung Warentest im Jahr 2017 stellte wesentliche Schwachstellen bei der Beratung und nachfolgend ein massives Versorgungsdefizit bei Patienten mit Harninkontinenz heraus. Die Deutsche Gesellschaft für Urologie erstellte daraufhin federführend eine Leitlinie zur Beratung zur Hilfsmittelversorgung. Wesentliche Aspekte der Hilfsmittelberatung sind die Feststellung der Inkontinenzform und deren Ausprägung, sowie die Abklärung und Aufklärung hinsichtlich einer möglichen kurativen Therapieform. Im Mittelpunkt steht jedoch das Beratungsgespräch, das idealerweise von einer qualifizierten Person in einem möglichst separaten Raum, der Aspekte der Diskretion gewährleistet, und mit einem ausreichenden Zeitkontingent erfolgen sollte. Für eine optimale Versorgung, die anatomische Eigenheiten als auch Wünsche des Betroffenen berücksichtigt, kommt der ggf. mehrfachen Bemusterung mit verschiedenen auf die Inkontinenzform und -schwere angepassten Produkten eine hohe Bedeutung zu. Bei kommerziellen Leistungserbringern ist Transparenz hinsichtlich der finanziellen Auswirkungen beispielsweise bei Zuzahlungsprodukten geboten. Diese ist eigentlich auch von Seiten der Kostenträger vertraglich vorgesehen. Die neue Leitlinie zur Hilfsmittelberatung stellt einen Ansatz zur Prozessstrukturierung und damit zur Verbesserung der Versorgung von Patienten mit erforderlicher Hilfsmittelversorgung dar.
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Manseck A, Piotrowski A, Butea MC, Foller S, Gleissner J, Kahlmeyer A, Karstedt H, Kirschner-Hermanns R, Liebald T, Linné C, Moll V, Otto U, Schorn A, Stein J, Wagner A, Wiedemann A. [Guidelines for consultations regarding incontinence care products]. Urologe A 2022; 61:3-12. [PMID: 35006283 DOI: 10.1007/s00120-021-01721-3] [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: 11/05/2021] [Indexed: 10/19/2022]
Abstract
An investigation of the German consumer organisation "Stiftung Warentest" in 2017 confirmed significant deficiencies in the information, advice and supply of incontinence care products received by urinary incontinence patients. The German Society of Urology (DGU) thereupon drafted and later published guidelines concerning the consultation of patients in the context of incontinence care. Important aspects of the consultation process include the determination of the type of incontinence as well as its severity, clinical examination, and advice regarding possible curative treatments. However, the advice appointment takes centre stage and should ideally be conducted by a qualified person in a separate room granting sufficient privacy and time. Furthermore, repeated supply of a selection of samples for differing degrees and types of incontinence, accommodating the patient's individual preferences and anatomical features, is crucial in order to ensure optimal incontinence care. In the case of commercial health care service providers, transparency relating to the financial implications of e.g. expensive products is key, which is what has been intended by German health insurance providers. The new guidelines concerning urinary incontinence care consultation constitute a step towards the improvement and structuring of processes in the consultation regarding, and the supply of, incontinence care products.
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Affiliation(s)
- Andreas Manseck
- Urologischen Klinik, Klinikum Ingolstadt, Krumenauerstr. 25, 85049, Ingolstadt, Deutschland.
| | - A Piotrowski
- Urologische Klinik, Pyhrn-Eisenwurzen Klinikum Steyr, Steyr, Österreich
| | - M C Butea
- Urologisches Kompetenzzentrum für die Rehabilitation - UKR, Kliniken Hartenstein, Bad Wildungen, Deutschland
| | - S Foller
- Klinik und Poliklinik für Urologie, Universitätsklinikum Jena, Jena, Deutschland
| | - J Gleissner
- Urologische Praxis, Uro-Gyn-Zentrum, Wuppertal, Deutschland
| | - A Kahlmeyer
- Urologische Praxis, Urologie am Weinberg Kassel, Kassel, Deutschland
| | - H Karstedt
- Praxis für Urologie, Gelsenkirchen, Deutschland
| | - R Kirschner-Hermanns
- Neuro-Urologie, Universitätsklinikum Bonn, Bonn, Deutschland.,Neuro-Urologie, Neurologisches Rehabilitationszentrum Bonn-Godeshöhe, Bonn, Deutschland
| | - T Liebald
- Urologische Praxis, Dresden, Deutschland
| | - C Linné
- Urologische Praxis, Dresden, Deutschland
| | - V Moll
- Praxis für Urologie, Augsburg, Deutschland
| | - U Otto
- Urologisches Kompetenzzentrum für die Rehabilitation - UKR, Kliniken Hartenstein, Bad Wildungen, Deutschland
| | - A Schorn
- Praxis für Urologie, Saarburg, Deutschland
| | - J Stein
- Urologische Abteilung, Klinikum Großburgwedel, Großburgwedel, Deutschland
| | - A Wagner
- Praxis für Urologie, Limburgerhof, Deutschland
| | - A Wiedemann
- Urologische Abteilung, Evangelisches Krankenhaus Witten gGmbH, Lehrstuhl für Geriatrie, Universität Witten/Herdecke, Witten, Deutschland
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Kahlmeyer A, Fiebig C, Mueller M, Kraulich M, Brendel-Suchanek J, Kunath F, Wach S, Goebell PJ, Ritt M, Gassmann KG, Wullich B. Geriatric Assessments Can Predict Functional Outcome and Mortality after Urological Tumor Surgery. Urol Int 2021; 106:848-857. [PMID: 34537771 DOI: 10.1159/000518978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 03/17/2021] [Accepted: 08/05/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Older patients undergoing major urological tumor surgery are at severe risk of functional deterioration, complications, and mortality. We prospectively evaluated geriatric assessment tools and developed a novel easy-to-use assessment tool for clinical use. METHODS In 159 patients, geriatric assessment tools were used prior to cystectomy, prostatectomy, and renal tumor surgery, and their peri- and postoperative courses were recorded. Using all the tests, a short and easy-to-use assessment tool was developed, and nomograms were generated to predict functional outcomes and mortality. RESULTS Of all the patients, 13.8% underwent radical cystectomy, 37.7% underwent radical prostatectomy, and 48.4% underwent tumor surgery of the kidney at the age of 70 years or older. The average age was 75.6 years. Incomplete functional recovery at day 30 and day 180 was observed in 37.7% and 36.1% of the patients, respectively, and incomplete functional recovery was associated with impaired mobility, previous care dependency, frailty, comorbidities, and a high ASA score. The only predictor for high-grade complications was comorbidities, whereas mortality was associated with the geriatric screening tool scores, impaired mobility, preoperative care dependency, and comorbidities. The Erlangen Index (EI), a combination of the selected assessment tools, showed a good prediction of early (p = 0.002) and medium-term (p = 0.002) functional outcomes and mortality (p = 0.001). CONCLUSION Our prospective evaluation confirms the high risk of incomplete functional recovery, high-grade complications, and mortality in older patients undergoing major urological tumor surgery. The EI is an easy-to-use preoperative assessment tool and therefore should be used in preoperative patient counseling.
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Affiliation(s)
- Andreas Kahlmeyer
- Department of Urology and Pediatric Urology, University Hospital Erlangen, Friedrich Alexander-University Erlangen-Nuernberg, Erlangen, Germany
| | - Christian Fiebig
- Department of Urology and Pediatric Urology, University Hospital Erlangen, Friedrich Alexander-University Erlangen-Nuernberg, Erlangen, Germany
| | - Marco Mueller
- Department of Urology and Pediatric Urology, University Hospital Erlangen, Friedrich Alexander-University Erlangen-Nuernberg, Erlangen, Germany
| | - Matthias Kraulich
- Department of Urology and Pediatric Urology, University Hospital Erlangen, Friedrich Alexander-University Erlangen-Nuernberg, Erlangen, Germany
| | - Jonas Brendel-Suchanek
- Department of Urology and Pediatric Urology, University Hospital Erlangen, Friedrich Alexander-University Erlangen-Nuernberg, Erlangen, Germany
| | - Frank Kunath
- Department of Urology and Pediatric Urology, University Hospital Erlangen, Friedrich Alexander-University Erlangen-Nuernberg, Erlangen, Germany
| | - Sven Wach
- Department of Urology and Pediatric Urology, University Hospital Erlangen, Friedrich Alexander-University Erlangen-Nuernberg, Erlangen, Germany
| | - Peter J Goebell
- Department of Urology and Pediatric Urology, University Hospital Erlangen, Friedrich Alexander-University Erlangen-Nuernberg, Erlangen, Germany
| | - Martin Ritt
- Department of Internal Medicine III (Medicine of Ageing), Geriatrics Centre Erlangen, Malteser Waldkrankenhaus St. Marien gGmbH, Erlangen, Germany
| | - Karl-Guenter Gassmann
- Department of Internal Medicine III (Medicine of Ageing), Geriatrics Centre Erlangen, Malteser Waldkrankenhaus St. Marien gGmbH, Erlangen, Germany
| | - Bernd Wullich
- Department of Urology and Pediatric Urology, University Hospital Erlangen, Friedrich Alexander-University Erlangen-Nuernberg, Erlangen, Germany
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Keck B, Borkowetz A, Poellmann J, Jansen T, Fischer M, Fuessel S, Kahlmeyer A, Wirth M, Huber J, Cavallaro A, Hammon M, Platzek I, Hartmann A, Baretton G, Kunath F, Sikic D, Taubert H, Wullich B, Erdmann K, Wach S. Serum miRNAs Support the Indication for MRI-Ultrasound Fusion-Guided Biopsy of the Prostate in Patients with Low-PI-RADS Lesions. Cells 2021; 10:cells10061315. [PMID: 34070529 PMCID: PMC8226644 DOI: 10.3390/cells10061315] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/20/2021] [Accepted: 05/21/2021] [Indexed: 01/30/2023] Open
Abstract
Multiparametric MRI (mpMRI) and targeted biopsy of the prostate enhance the tumor detection rate. However, the prediction of clinically significant prostate cancer (PCa) is still limited. Our study tested the additional value of serum levels of selected miRNAs in combination with clinical and mpMRI information for PCa prediction and classification. A total of 289 patients underwent targeted mpMRI-ultrasound fusion-guided prostate biopsy complemented by systematic biopsy. Serum miRNA levels of miRNAs (miR-141, miR-375, miR-21-5p, miR-320b, miR-210-3p, let-7c, and miR-486) were determined by quantitative PCR. Detection of any PCa and of significant PCa were the outcome variables. The patient age, pre-biopsy PSA level, previous biopsy procedure, PI-RADS score, and serum miRNA levels were covariates for regularized binary logistic regression models. The addition of miRNA expression of miR-486 and let-7c to the baseline model, containing only clinical parameters, increased the predictive accuracy. Particularly in patients with PI-RADS ≤3, we determined a sensitivity for detecting significant PCa (Gleason score ≥ 7a corresponding to Grade group ≥2) of 95.2%, and an NPV for absence of significant PCa of 97.1%. This accuracy could be useful to support patient counseling in selected cases.
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Affiliation(s)
- Bastian Keck
- Department of Urology and Pediatric Urology, University Hospital Erlangen, Friedrich-Alexander Universität Erlangen, Krankenhausstrasse 12, 91054 Erlangen, Germany; (B.K.); (J.P.); (T.J.); (M.F.); (A.K.); (F.K.); (D.S.); (B.W.); (S.W.)
| | - Angelika Borkowetz
- Department of Urology, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany; (A.B.); (S.F.); (M.W.); (J.H.); (K.E.)
| | - Julia Poellmann
- Department of Urology and Pediatric Urology, University Hospital Erlangen, Friedrich-Alexander Universität Erlangen, Krankenhausstrasse 12, 91054 Erlangen, Germany; (B.K.); (J.P.); (T.J.); (M.F.); (A.K.); (F.K.); (D.S.); (B.W.); (S.W.)
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Östliche Stadtmauerstrasse 30, 91054 Erlangen, Germany; (A.C.); (A.H.)
| | - Thilo Jansen
- Department of Urology and Pediatric Urology, University Hospital Erlangen, Friedrich-Alexander Universität Erlangen, Krankenhausstrasse 12, 91054 Erlangen, Germany; (B.K.); (J.P.); (T.J.); (M.F.); (A.K.); (F.K.); (D.S.); (B.W.); (S.W.)
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Östliche Stadtmauerstrasse 30, 91054 Erlangen, Germany; (A.C.); (A.H.)
| | - Moritz Fischer
- Department of Urology and Pediatric Urology, University Hospital Erlangen, Friedrich-Alexander Universität Erlangen, Krankenhausstrasse 12, 91054 Erlangen, Germany; (B.K.); (J.P.); (T.J.); (M.F.); (A.K.); (F.K.); (D.S.); (B.W.); (S.W.)
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Östliche Stadtmauerstrasse 30, 91054 Erlangen, Germany; (A.C.); (A.H.)
| | - Susanne Fuessel
- Department of Urology, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany; (A.B.); (S.F.); (M.W.); (J.H.); (K.E.)
- Member of the Association of Scientists in Urological Research (UroFors) of the German Society of Urology, Martin-Buber-Straße 10, 14163 Berlin, Germany
| | - Andreas Kahlmeyer
- Department of Urology and Pediatric Urology, University Hospital Erlangen, Friedrich-Alexander Universität Erlangen, Krankenhausstrasse 12, 91054 Erlangen, Germany; (B.K.); (J.P.); (T.J.); (M.F.); (A.K.); (F.K.); (D.S.); (B.W.); (S.W.)
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Östliche Stadtmauerstrasse 30, 91054 Erlangen, Germany; (A.C.); (A.H.)
| | - Manfred Wirth
- Department of Urology, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany; (A.B.); (S.F.); (M.W.); (J.H.); (K.E.)
| | - Johannes Huber
- Department of Urology, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany; (A.B.); (S.F.); (M.W.); (J.H.); (K.E.)
| | - Alexander Cavallaro
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Östliche Stadtmauerstrasse 30, 91054 Erlangen, Germany; (A.C.); (A.H.)
- Department of Radiology, University Hospital Erlangen, Friedrich-Alexander Universität Erlangen, Maximiliansplatz 3, 91054 Erlangen, Germany;
| | - Matthias Hammon
- Department of Radiology, University Hospital Erlangen, Friedrich-Alexander Universität Erlangen, Maximiliansplatz 3, 91054 Erlangen, Germany;
| | - Ivan Platzek
- Department of Radiology and Interventional Radiology, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany;
| | - Arndt Hartmann
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Östliche Stadtmauerstrasse 30, 91054 Erlangen, Germany; (A.C.); (A.H.)
- Institute of Pathology, University Hospital Erlangen, Friedrich-Alexander Universität Erlangen, Krankenhausstrasse 8-10, 91054 Erlangen, Germany
| | - Gustavo Baretton
- Institute of Pathology, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany;
| | - Frank Kunath
- Department of Urology and Pediatric Urology, University Hospital Erlangen, Friedrich-Alexander Universität Erlangen, Krankenhausstrasse 12, 91054 Erlangen, Germany; (B.K.); (J.P.); (T.J.); (M.F.); (A.K.); (F.K.); (D.S.); (B.W.); (S.W.)
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Östliche Stadtmauerstrasse 30, 91054 Erlangen, Germany; (A.C.); (A.H.)
| | - Danijel Sikic
- Department of Urology and Pediatric Urology, University Hospital Erlangen, Friedrich-Alexander Universität Erlangen, Krankenhausstrasse 12, 91054 Erlangen, Germany; (B.K.); (J.P.); (T.J.); (M.F.); (A.K.); (F.K.); (D.S.); (B.W.); (S.W.)
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Östliche Stadtmauerstrasse 30, 91054 Erlangen, Germany; (A.C.); (A.H.)
| | - Helge Taubert
- Department of Urology and Pediatric Urology, University Hospital Erlangen, Friedrich-Alexander Universität Erlangen, Krankenhausstrasse 12, 91054 Erlangen, Germany; (B.K.); (J.P.); (T.J.); (M.F.); (A.K.); (F.K.); (D.S.); (B.W.); (S.W.)
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Östliche Stadtmauerstrasse 30, 91054 Erlangen, Germany; (A.C.); (A.H.)
- Correspondence: ; Tel.: +49-9131-8542658; Fax: +49-9131-8523374
| | - Bernd Wullich
- Department of Urology and Pediatric Urology, University Hospital Erlangen, Friedrich-Alexander Universität Erlangen, Krankenhausstrasse 12, 91054 Erlangen, Germany; (B.K.); (J.P.); (T.J.); (M.F.); (A.K.); (F.K.); (D.S.); (B.W.); (S.W.)
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Östliche Stadtmauerstrasse 30, 91054 Erlangen, Germany; (A.C.); (A.H.)
| | - Kati Erdmann
- Department of Urology, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany; (A.B.); (S.F.); (M.W.); (J.H.); (K.E.)
- Member of the Association of Scientists in Urological Research (UroFors) of the German Society of Urology, Martin-Buber-Straße 10, 14163 Berlin, Germany
- National Center for Tumor Diseases (NCT), Fetscherstrasse 74, 01307 Dresden, Germany
| | - Sven Wach
- Department of Urology and Pediatric Urology, University Hospital Erlangen, Friedrich-Alexander Universität Erlangen, Krankenhausstrasse 12, 91054 Erlangen, Germany; (B.K.); (J.P.); (T.J.); (M.F.); (A.K.); (F.K.); (D.S.); (B.W.); (S.W.)
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Östliche Stadtmauerstrasse 30, 91054 Erlangen, Germany; (A.C.); (A.H.)
- Member of the Association of Scientists in Urological Research (UroFors) of the German Society of Urology, Martin-Buber-Straße 10, 14163 Berlin, Germany
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Kunath F, Jensen K, Pinart M, Kahlmeyer A, Schmidt S, Price CL, Lieb V, Dahm P. Early versus deferred standard androgen suppression therapy for advanced hormone-sensitive prostate cancer. Cochrane Database Syst Rev 2019; 6:CD003506. [PMID: 31194882 PMCID: PMC6564091 DOI: 10.1002/14651858.cd003506.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Standard androgen suppression therapy (AST) using surgical or medical castration is considered a mainstay of advanced hormone-sensitive prostate cancer treatment. AST can be initiated early when disease is asymptomatic or deferred when patients suffer symptoms of disseminated prostate cancer. OBJECTIVES To assess the effects of early versus deferred standard AST for advanced hormone-sensitive prostate cancer. SEARCH METHODS For this Cochrane Review update, we performed a comprehensive search of multiple databases (CENTRAL, MEDLINE, Embase, Web of Science; last searched November 2018) and two clinical trial registers, with no restrictions on the language of publication or publication status. We also searched bibliographies of included studies and conference proceedings (last searched January 2019). SELECTION CRITERIA We included all randomised controlled trials (RCTs) with a direct comparison of early versus deferred standard AST. We excluded all other study designs. Participants included had advanced hormone-sensitive prostate cancer receiving surgical or medical castration. DATA COLLECTION AND ANALYSIS Two review authors independently classified studies and abstracted data. The primary outcomes were time to death of any cause and serious adverse events. Secondary outcomes were time to disease progression, time to death from prostate cancer, adverse events and quality of life. We performed statistical analyses using a random-effects model and assessed the certainty of evidence according to GRADE. We performed subgroup analyses for advanced but non-metastatic disease (T2-4/N+ M0), metastatic disease (M1), and prostate-specific antigen (PSA) relapse. MAIN RESULTS We identified seven new RCTs since publication of the original review in 2002. In total, we included 10 RCTs.Primary outcomesEarly AST probably reduces the risk of death from any cause over time (hazard ratio (HR) 0.82, 95% confidence interval (CI) 0.75 to 0.90; moderate-certainty evidence; 4767 participants). This corresponds to 57 fewer deaths (95% CI 80 fewer to 31 fewer) per 1000 participants at 5 years for the moderate risk group and 23 fewer deaths (95% CI 32 fewer to 13 fewer) per 1000 participants at 5 years in the low risk group. We downgraded for study limitations. Early versus deferred AST may have little or no effect on serious adverse events (risk ratio (RR) 1.05, 95% CI 0.95 to 1.16; low-certainty evidence; 10,575 participants) which corresponds to 6 more serious adverse events (6 fewer to 18 more) per 1000 participants. We downgraded the certainty of evidence for study limitations and selective reporting.Secondary outcomesEarly AST probably reduces the risk of death from prostate cancer over time (HR 0.69, 95% CI 0.57 to 0.84; moderate-certainty evidence). This corresponds to 62 fewer prostate cancer deaths per 1000 (95% CI 87 fewer to 31 fewer) at 5 years for the moderate risk group and 24 fewer death from prostate cancer (95% CI 34 fewer to 12 fewer) per 1000 men at 5 years in the low risk group. We downgraded the certainty of evidence for study limitations.Early AST may decrease the rate of skeletal events (RR 0.37, 95% CI 0.17 to 0.80; low-certainty evidence) corresponding to 23 fewer skeletal events per 1000 (95% CI 31 fewer to 7 fewer). We downgraded for study limitations and imprecision. It may also increase fatigue (RR 1.41, 95% CI 1.23 to 1.62; low-certainty evidence), corresponding to 31 more men with this complaint per 1000 (95% CI 18 more to 48 more). We downgraded for study limitations and imprecision. It may increase the risk of heart failure (RR 1.90, 95% CI 1.09 to 3.33; low-certainty evidence) corresponding to 27 more events per 1000 (95% CI 3 more to 69 more). We downgraded the certainty of evidence for study limitations and imprecision.Global quality of life is probably similar after two years as assessed with the EORTC QLQ-C30 (version 3.0) questionnaire (mean difference -1.56, 95% CI -4.50 to 1.38; moderate-certainty evidence) with higher scores reflecting better quality of life. We downgraded the certainty of evidence for study limitations. AUTHORS' CONCLUSIONS Early AST probably extends time to death of any cause and time to death from prostate cancer. It may slightly decrease the rate of skeletal events. Rates of serious adverse events and quality of life may be similar. It may increase fatigue and may increase the risk of heart failure. Better quality trials would be particularly important to better understand the outcomes related to possible treatment-related harm, for which we only found low-certainty evidence.
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Affiliation(s)
- Frank Kunath
- University Hospital ErlangenDepartment of UrologyKrankenhausstrasse 12ErlangenGermany91054
- UroEvidence@Deutsche Gesellschaft für UrologieBerlinGermany
| | - Katrin Jensen
- Heidelberg University HospitalInstitute of Medical Biometry and InformaticsMarsilius‐ArkadenIm Neuenheimer Feld 130.3, 12. OGHeidelbergBaden‐WürttembergGermany69120
| | - Mariona Pinart
- University Hospital ErlangenDepartment of UrologyKrankenhausstrasse 12ErlangenGermany91054
| | - Andreas Kahlmeyer
- University Hospital ErlangenDepartment of UrologyKrankenhausstrasse 12ErlangenGermany91054
| | | | - Carrie L Price
- Welch Medical Library, Johns Hopkins Medical InstitutionsClinical Informationist Services2024 E. Monument St.BaltimoreMarylandUSA21287
| | - Verena Lieb
- University Hospital ErlangenDepartment of UrologyKrankenhausstrasse 12ErlangenGermany91054
| | - Philipp Dahm
- Minneapolis VA Health Care SystemUrology SectionOne Veterans DriveMail Code 112DMinneapolisMinnesotaUSA55417
- University of MinnesotaDepartment of Urology420 Delaware Street SEMMC 394MinneapolisMinnesotaUSA55455
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7
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Grimm J, Zeuschner P, Janssen M, Wagenpfeil S, Hartmann A, Stöhr C, Keck B, Kahlmeyer A, Stöckle M, Junker K. Metastatic risk stratification of clear cell renal cell carcinoma patients based on genomic aberrations. Genes Chromosomes Cancer 2019; 58:612-618. [PMID: 30851148 DOI: 10.1002/gcc.22749] [Citation(s) in RCA: 5] [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: 01/03/2019] [Revised: 03/04/2019] [Accepted: 03/06/2019] [Indexed: 12/14/2022] Open
Abstract
Prognostic markers for the definition of the individual metastatic risk in renal cell carcinoma are still missing. The aim of our study was to establish a total number of specific aberrations (TNSA) genetic score as a new prognostic test for metastatic risk evaluation. Fluorescence in situ hybridization (FISH) was performed on isolated cell nuclei of 100 ccRCCs (50 M1/50 M0) and 100 FFPE sections (second cohort, 32 M1/68 M0). For each chromosomal region (1q21.3, 7q36.3, 9p21.3p24.1, 20q11.21q13.32) cut-off values were determined by receiver-operator curve (ROC)-curve analysis. TNSA was calculated based on the dichotomized specific CNVs. The prognostic significance of CNVs was proven by Cox and logistic regression. TNSA was the best predictor of metastasis and recurrence free survival in both cohorts. We derived an algorithm for risk stratification by combining TNSA and T-category, which increased the prognostic accuracy to 87% (specificity = 86%, sensitivity = 88%). This model divides patients into two risk groups with significantly different RFS, CSS, and OS (P = 3.8×10-5 , P = 5×10-6 and P = 3.57×10-8 respectively). The genetic risk model was superior to Leibovich score and was able to identify patients with metachronous metastatic spread which were incorrectly classified as "low" or "intermediate risk." We present a new tool for individual risk stratification by combining genetic alterations with clinico-pathologic parameters. Interphase FISH proves to be a dependable method for prognostic evaluation in primary tumor tissue on isolated cell nuclei as well as on FFPE sections. Especially in organ-confined tumors the genetic score seems to be an important tool to identify patients at high risk for metastatic disease.
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Affiliation(s)
- Julia Grimm
- Department of Urology and Pediatric Urology, Saarland University, Homburg, Germany
| | - Philip Zeuschner
- Department of Urology and Pediatric Urology, Saarland University, Homburg, Germany
| | - Martin Janssen
- Department of Urology and Pediatric Urology, Saarland University, Homburg, Germany
| | - Stefan Wagenpfeil
- Institute of Medical Biometry, Epidemiology and Medical Informatics, Saarland University, Homburg, Germany
| | - Arndt Hartmann
- Institute of Pathology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Christine Stöhr
- Institute of Pathology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Bastian Keck
- Department of Urology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Andreas Kahlmeyer
- Department of Urology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Michael Stöckle
- Department of Urology and Pediatric Urology, Saarland University, Homburg, Germany
| | - Kerstin Junker
- Department of Urology and Pediatric Urology, Saarland University, Homburg, Germany
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8
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Abstract
For the estimation of perioperative risks and mortality in the context of radical urological tumor surgery in elderly patients, the guidelines meanwhile require the use of geriatric assessments. The aim of this work is therefore to explain frequently used geriatric assessments and to give an overview of their predictive significance in radical urological tumor surgery. Comprehensive geriatric assessments provide a good description of the patient's state of health, but are hardly feasible in clinical routine due to their complexity. It is more reasonable to use screening tools with subsequent targeted examination of high-risk patients. Special tools allow the standardized assessment of functional status, mobility, cognition, mood, nutrition, frailty, comorbidities and polypharmacy and have different prognostic significance. Evidence on the predictive value of assessments prior to radical urological tumor surgery is mainly described for the systematic classification of comorbidities. In cystectomy, the Charlson Comorbidity Index (CCI) and the American Society of Anesthesiologists (ASA) score allow an estimation of the risk of complications and mortality. The focus of assessments prior to prostatectomy is to identify patients with sufficient life expectancy to benefit from radical surgery. CCI and ASA scores as well as the Eastern Co-operative Oncology Group (ECOG) score can help to assess the risk of perioperative complications in kidney tumor surgery.
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Affiliation(s)
- A Kahlmeyer
- Urologische und Kinderurologische Klinik, Universitätsklinikum Erlangen, Krankenhausstr. 12, 91054, Erlangen, Deutschland.
| | - P J Goebell
- Urologische und Kinderurologische Klinik, Universitätsklinikum Erlangen, Krankenhausstr. 12, 91054, Erlangen, Deutschland
| | - B Wullich
- Urologische und Kinderurologische Klinik, Universitätsklinikum Erlangen, Krankenhausstr. 12, 91054, Erlangen, Deutschland
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9
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Kunath F, Goebell PJ, Wullich B, Sikic D, Kahlmeyer A. Timing of androgen deprivation monotherapy and combined treatments in castration-sensitive and castration-resistant prostate cancer: a narrative review. World J Urol 2019; 38:601-611. [PMID: 30830274 DOI: 10.1007/s00345-019-02704-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 10/21/2018] [Accepted: 02/25/2019] [Indexed: 01/04/2023] Open
Abstract
PURPOSE Standard androgen deprivation therapy (ADT) can be initiated early at the time of diagnosis in asymptomatic castration-sensitive advanced prostate cancer. This definition has recently been expanded to also include an early combined treatment with standard ADT and new antihormonal drugs. We aimed to present the best available evidence for the timing of initiation of ADT monotherapy and combined treatments in castration-sensitive/-resistant prostate cancer. METHODS For this narrative review, we searched Cochrane reviews in the Cochrane Library, systematic reviews and randomized controlled trials in MEDLINE, phase III and ongoing trials in ClinicalTrials.gov and screened the reference lists to extract articles of interest. One author screened the references which were finally included after assessing their relevance through discussion with other experts in the field. RESULTS The identified references were grouped by medication (standard ADT, androgen biosynthesis inhibitor, androgen receptor antagonists or combined therapies) and tumor stage (castration sensitive or resistant). The evidence was narratively summarized and discussed in the context of the current therapeutic landscape. CONCLUSIONS Early standard ADT can reduce symptoms of disease progression and may extend progression-free and overall survival. The patient should be well informed about the higher rates of treatment-related side effects. Deferring standard ADT might be indicated only for well-informed or unfit patients. Early standard ADT is increasingly combined with new antihormonal drugs in castration-sensitive metastatic prostate cancer to gain additional survival and quality of life benefits. Combined treatment at the time of development of castration-resistant disease is well established.
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Affiliation(s)
- F Kunath
- Department of Urology and Pediatric Urology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Krankenhausstrasse 12, 91054, Erlangen, Germany. .,UroEvidence@Deutsche Gesellschaft für Urologie, Berlin, Germany.
| | - P J Goebell
- Department of Urology and Pediatric Urology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Krankenhausstrasse 12, 91054, Erlangen, Germany
| | - B Wullich
- Department of Urology and Pediatric Urology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Krankenhausstrasse 12, 91054, Erlangen, Germany.,UroEvidence@Deutsche Gesellschaft für Urologie, Berlin, Germany
| | - D Sikic
- Department of Urology and Pediatric Urology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Krankenhausstrasse 12, 91054, Erlangen, Germany
| | - A Kahlmeyer
- Department of Urology and Pediatric Urology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Krankenhausstrasse 12, 91054, Erlangen, Germany
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Stöhr CG, Steffens S, Polifka I, Jung R, Kahlmeyer A, Ivanyi P, Weber F, Hartmann A, Wullich B, Wach S, Taubert H. Piwi-like 1 protein expression is a prognostic factor for renal cell carcinoma patients. Sci Rep 2019; 9:1741. [PMID: 30741998 PMCID: PMC6370845 DOI: 10.1038/s41598-018-38254-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [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: 08/01/2018] [Accepted: 12/21/2018] [Indexed: 12/20/2022] Open
Abstract
The Piwi-like genes belong to the Argonaute gene family and are conserved in plants, animals and humans. In addition to their essential role in the germ line and as stem cell-associated genes, Piwi-like proteins play a role in different cancer types but have yet to be studied in renal cell carcinoma (RCC). We investigated tissue micro arrays (TMAs) with tumor samples of two independent cohorts of RCC patients (N = 265 and N = 345); we used immunohistochemistry to assess the protein expression of Piwi-like 1. Applying an immunoreactive score (IRS), we found Piwi-like 1 positivity (IRS > 0) in 28.3% and 14.8% of the tumors in cohorts 1 and 2, respectively. Piwi-like 1 positivity was correlated with Fuhrman grade, tumor stage and the presence of distant metastasis (P < 0.005). Moreover, in univariate and multivariate analyses (adjusted to Fuhrman grade and tumor stage), Piwi-like 1 positivity was associated with a shorter cancer-specific survival in the patients in the second cohort. In addition, Piwi-like 1 expression allowed to further distinguish the RCC patients with high Fuhrman grade, high tumor stage, distant metastasis or high pre-operative levels of C-reactive protein, as Piwi-like 1 positivity was associated with a shorter cancer-specific survival in both cohorts. Our data encourage further investigations to enlighten the role of Piwi-like 1 and its function as a marker of poor prognosis in RCC patients.
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Affiliation(s)
- Christine G Stöhr
- Institute of Pathology, University Hospital Erlangen, FAU Erlangen-Nürnberg, Erlangen, Germany
| | - Sandra Steffens
- Clinic for Urology, University Hospital Muenster, Muenster, Germany.,Department of Urology, Hannover Medical School, Hannover, Germany
| | - Iris Polifka
- Institute of Pathology, University Hospital Erlangen, FAU Erlangen-Nürnberg, Erlangen, Germany
| | - Rudolf Jung
- Institute of Pathology, University Hospital Erlangen, FAU Erlangen-Nürnberg, Erlangen, Germany
| | - Andreas Kahlmeyer
- Department of Urology and Pediatric Urology, University Hospital Erlangen, FAU Erlangen-Nürnberg, Erlangen, Germany
| | - Philipp Ivanyi
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Florian Weber
- Institute of Pathology, University Regensburg, Regensburg, Germany
| | - Arndt Hartmann
- Institute of Pathology, University Hospital Erlangen, FAU Erlangen-Nürnberg, Erlangen, Germany
| | - Bernd Wullich
- Department of Urology and Pediatric Urology, University Hospital Erlangen, FAU Erlangen-Nürnberg, Erlangen, Germany
| | - Sven Wach
- Department of Urology and Pediatric Urology, University Hospital Erlangen, FAU Erlangen-Nürnberg, Erlangen, Germany
| | - Helge Taubert
- Department of Urology and Pediatric Urology, University Hospital Erlangen, FAU Erlangen-Nürnberg, Erlangen, Germany.
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Schink K, Herrmann HJ, Schwappacher R, Meyer J, Orlemann T, Waldmann E, Wullich B, Kahlmeyer A, Fietkau R, Lubgan D, Beckmann MW, Hack C, Kemmler W, Siebler J, Neurath MF, Zopf Y. Effects of whole-body electromyostimulation combined with individualized nutritional support on body composition in patients with advanced cancer: a controlled pilot trial. BMC Cancer 2018; 18:886. [PMID: 30208857 PMCID: PMC6134788 DOI: 10.1186/s12885-018-4790-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 09/03/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Physical exercise and nutritional treatment are promising measures to prevent muscle wasting that is frequently observed in advanced-stage cancer patients. However, conventional exercise is not always suitable for these patients due to physical weakness and therapeutic side effects. In this pilot study, we examined the effect of a combined approach of the novel training method whole-body electromyostimulation (WB-EMS) and individualized nutritional support on body composition with primary focus on skeletal muscle mass in advanced cancer patients under oncological treatment. METHODS In a non-randomized controlled trial design patients (56.5% male; 59.9 ± 12.7 years) with advanced solid tumors (UICC III/IV, N = 131) undergoing anti-cancer therapy were allocated to a usual care control group (n = 35) receiving individualized nutritional support or to an intervention group (n = 96) that additionally performed a supervised physical exercise program in form of 20 min WB-EMS sessions (bipolar, 85 Hz) 2×/week for 12 weeks. The primary outcome of skeletal muscle mass and secondary outcomes of body composition, body weight and hand grip strength were measured at baseline, in weeks 4, 8 and 12 by bioelectrical impedance analysis and hand dynamometer. Effects of WB-EMS were estimated by linear mixed models. Secondary outcomes of physical function, hematological and blood chemistry parameters, quality of life and fatigue were assessed at baseline and week 12. Changes were analyzed by t-tests, Wilcoxon signed-rank or Mann-Whitney-U-tests. RESULTS Twenty-four patients of the control and 58 of the WB-EMS group completed the 12-week trial. Patients of the WB-EMS group had a significantly higher skeletal muscle mass (0.53 kg [0.08, 0.98]; p = 0.022) and body weight (1.02 kg [0.05, 1.98]; p = 0.039) compared to controls at the end of intervention. WB-EMS also significantly improved physical function and performance status (p < 0.05). No significant differences of changes in quality of life, fatigue and blood parameters were detected between the study groups after 12 weeks. CONCLUSIONS Supervised WB-EMS training is a safe strength training method and combined with nutritional support it shows promising effects against muscle wasting and on physical function in advanced-stage cancer patients undergoing treatment. TRIAL REGISTRATION ClinicalTrials.gov NCT02293239 (Date: November 18, 2014).
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Affiliation(s)
- Kristin Schink
- Department of Medicine 1 – Gastroenterology, Pneumology and Endocrinology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Ulmenweg 18, 91054 Erlangen, Germany
| | - Hans J. Herrmann
- Department of Medicine 1 – Gastroenterology, Pneumology and Endocrinology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Ulmenweg 18, 91054 Erlangen, Germany
| | - Raphaela Schwappacher
- Department of Medicine 1 – Gastroenterology, Pneumology and Endocrinology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Ulmenweg 18, 91054 Erlangen, Germany
| | - Julia Meyer
- Department of Medicine 1 – Gastroenterology, Pneumology and Endocrinology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Ulmenweg 18, 91054 Erlangen, Germany
| | - Till Orlemann
- Department of Medicine 1 – Gastroenterology, Pneumology and Endocrinology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Ulmenweg 18, 91054 Erlangen, Germany
| | - Elisabeth Waldmann
- Institute of Medical Informatics, Biometry and Epidemiology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Universitätsstraße 22, 91054 Erlangen, Germany
| | - Bernd Wullich
- Department of Urology and Pediatric Urology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Rathsberger Straße 57, 91054 Erlangen, Germany
| | - Andreas Kahlmeyer
- Department of Urology and Pediatric Urology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Rathsberger Straße 57, 91054 Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Universitätsstraße 27, 91054 Erlangen, Germany
| | - Dorota Lubgan
- Department of Radiation Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Universitätsstraße 27, 91054 Erlangen, Germany
| | - Matthias W. Beckmann
- Department of Obstetrics and Gynaecology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Universitätsstraße 21/23, 91054 Erlangen, Germany
| | - Carolin Hack
- Department of Obstetrics and Gynaecology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Universitätsstraße 21/23, 91054 Erlangen, Germany
| | - Wolfgang Kemmler
- Institute of Medical Physics, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Henkestraße 91, 91052 Erlangen, Germany
| | - Jürgen Siebler
- Department of Medicine 1 – Gastroenterology, Pneumology and Endocrinology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Ulmenweg 18, 91054 Erlangen, Germany
| | - Markus F. Neurath
- Department of Medicine 1 – Gastroenterology, Pneumology and Endocrinology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Ulmenweg 18, 91054 Erlangen, Germany
| | - Yurdagül Zopf
- Department of Medicine 1 – Gastroenterology, Pneumology and Endocrinology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Ulmenweg 18, 91054 Erlangen, Germany
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Narayan V, Kahlmeyer A, Dahm P, Skoetz N, Risk MC, Bongiorno C, Patel N, Hwang EC, Jung JH, Gartlehner G, Kunath F. Pembrolizumab monotherapy versus chemotherapy for treatment of advanced urothelial carcinoma with disease progression during or following platinum-containing chemotherapy. A Cochrane Rapid Review. Cochrane Database Syst Rev 2018; 7:CD012838. [PMID: 30036453 PMCID: PMC6513246 DOI: 10.1002/14651858.cd012838.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND The use of systemic immunotherapy targets is emerging as an important treatment option for metastatic urothelial carcinoma, particularly for patients who cannot tolerate or who fail cisplatin-based chemotherapy. One such target is the inhibition of the checkpoint protein programmed cell death-1 (PD-1) receptor and its ligand (PD-L1) by monoclonal antibodies. OBJECTIVES To assess the effects of pembrolizumab monotherapy versus chemotherapy for treatment of advanced urothelial carcinoma with disease progression during or following platinum-containing chemotherapy. SEARCH METHODS We performed a Cochrane Rapid Review, limiting our search to published studies in the English language. We searched databases of the medical literature, including the Cochrane Central Register of Controlled Trials and MEDLINE, as well as trial registries including ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP). Our search extended from January 2000 to June 2018. SELECTION CRITERIA We included randomised controlled trials except cross-over trials and cluster randomised trials. We excluded all other study designs. Participants included had locally advanced or metastatic urothelial carcinoma of the bladder, with disease progression during or following platinum-containing chemotherapy (synonymous with second-/third-/fourth-line therapy). This review focused on pembrolizumab (synonyms: MK-3475, lambrolizumab, Keytruda). DATA COLLECTION AND ANALYSIS Two review authors independently classified and abstracted data from the included study. The certainty of evidence was rated according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS We identified one randomised controlled trial that included 542 participants, which compared the use of pembrolizumab monotherapy versus chemotherapy for the treatment of advanced urothelial carcinoma with disease progression during or following platinum-containing chemotherapy. Results were reported after a median follow-up of 14.1 months (range 9.9 to 22.1 months).Primary outcomesPembrolizumab probably reduces the risk of death from any cause (hazard ratio (HR) 0.73, 95% confidence interval (CI) 0.59 to 0.90; moderate certainty evidence). This corresponds to 115 fewer deaths (191 fewer to 38 fewer) per 1000 participants with pembrolizumab at 12 months. We downgraded the certainty of evidence one level for imprecision.Pembrolizumab may slightly improve quality of life (change from baseline to week 15 assessed with the Core Quality of Life Questionnaire; higher value reflects better quality of life; scale 0 to 100) with a mean difference (MD) of 9.05, 95% CI 4.61 to 13.50; low certainty evidence). We downgraded the certainty of evidence two levels for study limitations and imprecision.Secondary outcomesPembrolizumab may have little or no effect on disease progression (HR 0.98, 95% CI 0.81 to 1.19; low certainty evidence). This corresponds to three fewer patients (42 fewer to 24 more) whose disease progressed per 1000 participants at 12 months. We downgraded the certainty of evidence two levels for study limitations and imprecision.Pembrolizumab probably improves treatment response (based on complete or partial radiologic response) with a risk ratio (RR) of 1.85, 95% CI 1.24 to 2.77; moderate certainty evidence). This corresponds to 97 more respondents (27 more to 202 more) per 1000 participants with pembrolizumab. We downgraded the certainty of evidence one level for imprecision.Pembrolizumab may have little or no effect on treatment-related mortality (RR 0.96, 95% CI 0.24 to 3.79; low certainty evidence). This corresponds to one fewer (12 fewer to 44 more) treatment-related deaths per 1000 participants with pembrolizumab. We downgraded the certainty of evidence two levels for study limitations and imprecision.Pembrolizumab may have little or no effect on discontinuations due to adverse events (RR 0.66, 95% CI 0.39 to 1.10). This corresponds to 54 fewer discontinuations per 1000 participants (95% CI 79 fewer to 7 more). We downgraded the certainty of evidence for study limitations and imprecision.Pembrolizumab may reduce serious adverse events (RR 0.83, 95 CI 0.72 to 0.97; low certainty evidence). This corresponds to 107 fewer serious averse events per 1000 participants (95% CI 19 fewer to 176 fewer). We downgraded two levels for study limitations and imprecision. AUTHORS' CONCLUSIONS The use of pembrolizumab in men with advanced urothelial carcinoma with disease progression during or following platinum-containing chemotherapy probably improves overall survival when compared with chemotherapy alone. At 12 months follow-up about 70% of those in the chemotherapy group had died, compared with 59% of those treated with pembrolizumab. We are very uncertain about the effects of pembolizumab on quality of life. Pembolizumab may also improve treatment response rates, and reduce the risk of serious adverse events, but may make little or no difference to discontinuations of treatment due to adverse events. These conclusions are based on a single trial that was sponsored by the producer of pembrolizumab.
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Affiliation(s)
- Vikram Narayan
- University of MinnesotaDepartment of UrologyMinneapolisMinnesotaUSA
| | | | - Philipp Dahm
- Minneapolis VA Health Care SystemUrology SectionOne Veterans DriveMail Code 112DMinneapolisMinnesotaUSA55417
| | - Nicole Skoetz
- University Hospital of CologneCochrane Haematological Malignancies Group, Department I of Internal MedicineKerpener Str. 62CologneGermany50937
| | - Michael C Risk
- Minneapolis VA Health Care SystemUrology SectionOne Veterans DriveMail Code 112DMinneapolisMinnesotaUSA55417
| | | | - Neil Patel
- Minneapolis VA Health Care SystemMinneapolisMinnesotaUSA
| | - Eu Chang Hwang
- Chonnam National University Medical School, Chonnam National University Hwasun HospitalDepartment of UrologyHwasunKorea, South
| | - Jae Hung Jung
- Yonsei University Wonju College of MedicineDepartment of Urology20 Ilsan‐roWonjuGangwonKorea, South26426
| | - Gerald Gartlehner
- Danube University KremsCochrane AustriaDr.‐Karl‐Dorrek‐Strasse 30KremsAustria3500
| | - Frank Kunath
- University Hospital ErlangenDepartment of UrologyErlangenGermany
- UroEvidence@Deutsche Gesellschaft für UrologieBerlinGermany
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Kahlmeyer A, Losensky W, Sikic D, Keck B, Goebell PJ, Wullich B. Prospective evaluation of geriatric assessments as predictors of complications and functional outcome after major urologic tumor surgery in the older population. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.6_suppl.597] [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: 11/20/2022] Open
Abstract
597 Background: Old patients undergoing major urologic tumor surgery are at severe risk of functional deterioration. In this study we prospectively performed a comprehensive geriatric assessment to identify potential risk predictors for early functional outcome. Methods: Since January 2016, 75 patients undergoing elective cystectomy, prostatectomy or nephrectomy at the age of 70 or older have been enrolled prospectively. A selection of geriatric assessment tools was applied before surgery. Follow up data including standardized peri- and postoperative parameters were obtained at discharge and at day 30 and 180 after surgery (DRKS-ID: DRKS00009825). Results: 14.7% had radical cystectomy, 33.3% had radical prostatectomy and 52.0% had kidney surgery due to malignant tumor. The average age was 75.7 (70-88) years. Within hospital stay, 20.3% had major complications (Clavien-Dindo > = 3) and 25% showed incomplete functional recovery at day 30 after surgery. The average reduction in activities of daily living (ADL) was -34.71. Major complications were significantly associated with impaired mobility (TUG, OR 7.350, p = 0.002), frailty (FrailScale, OR 5.007, p = 0.019) and ASA-Score (ASA, OR 4.400, p = 0.015). Incomplete functional recovery was strongly associated with preoperative impaired mobility (TUG, OR 11.524, p < 0.001) but correlation with ASA-Score (ASA, OR 3.288, p = 0.070) and comorbidities (CCI, OR 3.833, p = 0.106) missed statistical significance. No correlation of functional deterioration was found with age and functional status at admission. The combination of selected assessment tools showed good prediction of early functional recovery (ErlangerIndex, OR 4.400, p = 0.019). Conclusions: Major urologic tumor surgery has a high risk of severe complications and incomplete recovery in old patients. Fast and easy-to-do preoperative assessment tools may predict functional outcome more precisely than age or preoperative functional status alone. Clinical trial information: DRKS00009825.
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Affiliation(s)
| | | | - Danijel Sikic
- University Medical Center Erlangen, Erlangen, Germany
| | - Bastian Keck
- University Medical Center Erlangen, Erlangen, Germany
| | | | - Bernd Wullich
- University Medical Center Erlangen, Erlangen, Germany
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Hautmann RE, de Petriconi R, Kahlmeyer A, Enders M, Volkmer B. Preoperatively Dilated Ureters are a Specific Risk Factor for the Development of Ureteroenteric Strictures after Open Radical Cystectomy and Ileal Neobladder. J Urol 2017; 198:1098-1106. [DOI: 10.1016/j.juro.2017.05.069] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2017] [Indexed: 10/19/2022]
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Sikic D, Keck B, Wach S, Taubert H, Wullich B, Goebell PJ, Kahlmeyer A, Olbert P, Isfort P, Nimphius W, Hartmann A, Giedl J. Immunohistochemiocal subtyping using CK20 and CK5 can identify urothelial carcinomas of the upper urinary tract with a poor prognosis. PLoS One 2017. [PMID: 28632777 PMCID: PMC5478149 DOI: 10.1371/journal.pone.0179602] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose Genome-wide analyses revealed basal and luminal subtypes of urothelial carcinomas of the bladder. It is unknown if this subtyping can also be applied to upper tract urothelial carcinomas. Materials and methods Tumor samples from 222 patients with upper tract urothelial carcinomas who were treated with radical nephroureterectomy were analyzed for the expression of seven basal/luminal immunohistochemical markers (CK5, EGFR, CD44, CK20, p63, GATA3, FOXA1). Results Hierarchical clustering revealed a basal-like subtype (enrichment of CK5, EGFR and CD44) in 23.9% and a luminal-like subtype (enrichment of CK20, GATA3, p63 and FOXA1) in 13.1% of the patients. In 60.8%, little to no markers were expressed, whereas markers of both subtypes were expressed in 2.2%. By using CK5 and CK20 as surrogate markers for the basal and luminal subtypes, we defined four subtypes of upper tract urothelial carcinomas: (i) exclusively CK20 positive and CK5 negative (CK20+/CK5-), (ii) exclusively CK5 positive and CK20 negative (CK20-/ CK5+), (iii) both markers positive (CK20+/CK5+) and (iv) both markers negative (CK20-/CK5-). A receiver-operator analysis provided the optimal cut-off values for this discrimination. An immunoreactive score >1 for CK5 and >6 for CK20 were defined as positive. In multivariate Cox’s regression analysis, the CK20+/CK5- subtype was an independent negative prognostic marker with a 3.83-fold increased risk of cancer-specific death (p = 0.02) compared to the other three subtypes. Conclusions Immunohistochemical subgrouping of upper tract urothelial carcinomas by analyzing CK5 and CK20 expression can be performed in a routine setting and can identify tumors with a significantly worse cancer-specific survival prognosis.
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Affiliation(s)
- Danijel Sikic
- Department of Urology and Pediatric Urology, University Hospital Erlangen, Erlangen, Germany
- * E-mail:
| | - Bastian Keck
- Department of Urology and Pediatric Urology, University Hospital Erlangen, Erlangen, Germany
| | - Sven Wach
- Department of Urology and Pediatric Urology, University Hospital Erlangen, Erlangen, Germany
| | - Helge Taubert
- Department of Urology and Pediatric Urology, University Hospital Erlangen, Erlangen, Germany
| | - Bernd Wullich
- Department of Urology and Pediatric Urology, University Hospital Erlangen, Erlangen, Germany
| | - Peter J. Goebell
- Department of Urology and Pediatric Urology, University Hospital Erlangen, Erlangen, Germany
| | - Andreas Kahlmeyer
- Department of Urology and Pediatric Urology, University Hospital Erlangen, Erlangen, Germany
| | - Peter Olbert
- Department of Urology and Pediatric Urology, Philipps University of Marburg, Marburg, Germany
| | - Philipp Isfort
- Department of Urology and Pediatric Urology, Philipps University of Marburg, Marburg, Germany
| | - Wilhelm Nimphius
- Institute of Pathology, Philipps University of Marburg, Marburg, Germany
| | - Arndt Hartmann
- Institute of Pathology, University Hospital Erlangen, Erlangen, Germany
| | - Johannes Giedl
- Institute of Pathology, University Hospital Erlangen, Erlangen, Germany
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Volkmer B, Kahlmeyer A, Enders M, Czeloth K, Stredele R, Hautmann R. PD12-02 SPECIFIC PREDISPOSING RISK FACTORS FOR THE DEVELOPMENT OF URETEROENTERIC STRICTURES AFTER OPEN RADICAL CYSTECTOMY AND ILEAL NEOBLADDER DIVERSION. J Urol 2016. [DOI: 10.1016/j.juro.2016.02.897] [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] [Indexed: 11/29/2022]
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Volkmer B, Kahlmeyer A, Petervari M, Pechoel M. Entwicklung des G-DRG-Systems 2014. Urologe A 2014; 53:27-32. [DOI: 10.1007/s00120-013-3397-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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