Prostate Cancer, Version 3.2024

The NCCN Guidelines for Prostate Cancer include recommendations for staging and risk assessment after a prostate cancer diagnosis and for the care of patients with localized, regional, recurrent, and metastatic disease. These NCCN Guidelines Insights summarize the panel's discussions for the 2024 update to the guidelines with regard to initial risk stratification, initial management of very-low-risk disease, and the treatment of nonmetastatic recurrence.

Prostate Cancer, Version 4.2023, NCCN Clinical Practice Guidelines in Oncology

The NCCN Guidelines for Prostate Cancer provide a framework on which to base decisions regarding the workup of patients with prostate cancer, risk stratification and management of localized disease, post-treatment monitoring, and treatment of recurrence and advanced disease. The Guidelines sections included in this article focus on the management of metastatic castration-sensitive disease, nonmetastatic castration-resistant prostate cancer (CRPC), and metastatic CRPC (mCRPC). Androgen deprivation therapy (ADT) with treatment intensification is strongly recommended for patients with metastatic castration-sensitive prostate cancer. For patients with nonmetastatic CRPC, ADT is continued with or without the addition of certain secondary hormone therapies depending on prostate-specific antigen doubling time. In the mCRPC setting, ADT is continued with the sequential addition of certain secondary hormone therapies, chemotherapies, immunotherapies, radiopharmaceuticals, and/or targeted therapies. The NCCN Prostate Cancer Panel emphasizes a shared decision-making approach in all disease settings based on patient preferences, prior treatment exposures, the presence or absence of visceral disease, symptoms, and potential side effects.

Recruiting African American Prostate Cancer Survivors for a Population-based Biobank Study

BACKGROUND

Prostate cancer affects African American men disproportionately compared with men of other racial/ethnic groups. To identify biological bases for this health disparity, we sought to create a state-wide biobank of African American prostate cancer survivors in Florida.

METHODS

African American men diagnosed with prostate cancer between 2013 and 2017 and living in Florida at diagnosis were identified through the State of Florida's cancer registry. Individuals were approached via mail and telephone, assessed for eligibility, and asked for informed consent. χ2 and t tests were conducted to identify differences between eligible and reachable individuals (i.e., had valid contact information) versus consented participants.

RESULTS

Of the 5,960 eligible and reachable individuals, 3,904 were eligible and contacted at least once, and 578 consented [overall consent rate = 10% (578/5,960); adjusted consent rate = 15% (578/3,904)]. Statistically significant (Ps < 0.05) but small differences in demographic and clinical variables were observed. Consented participants were less likely to be older than 64 (35% vs. 41%) and less likely to have received radiotherapy (36% vs. 41%) and hormone therapy (16% vs. 21%), but more likely to have regional prostate cancer (13% vs. 11%) and have undergone surgery (44% vs. 39%). Consented participants did not differ from reachable individuals on other demographic and clinical factors (Ps > 0.05).

CONCLUSIONS

Recruiting African American prostate cancer survivors to biobanking research through a cancer registry is feasible. However, the consent rate was low, and existing challenges limit consent and participation.

IMPACT

Strategies for overcoming barriers to informed consent and increasing participation in biospecimen research are needed to address cancer disparities.

NCCN Guidelines® Insights: Prostate Cancer, Version 1.2023

The NCCN Guidelines for Prostate Cancer address staging and risk assessment after a prostate cancer diagnosis and include management options for localized, regional, recurrent, and metastatic disease. The NCCN Prostate Cancer Panel meets annually to reevaluate and update their recommendations based on new clinical data and input from within NCCN Member Institutions and from external entities. These NCCN Guidelines Insights summarizes much of the panel's discussions for the 4.2022 and 1.2023 updates to the guidelines regarding systemic therapy for metastatic prostate cancer.

Substantial Gleason reclassification in Black men with national comprehensive cancer network low-risk prostate cancer - A propensity score analysis

BACKGROUND

Emerging evidence suggests that a subset of Black men with National Comprehensive Cancer Network (NCCN) low-risk prostate cancer (PCa) may harbor high volume and genomically aggressive disease. However, limited, and ambiguous research exist to evaluate the risk of extreme Gleason reclassification in Black men with low-risk PCa.

METHODS

This retrospective cohort study included 45,674 low-risk PCa patients who underwent prostatectomy and were not on active surveillance, from National Cancer Database (NCDB). A propensity score matched-pair design was employed, and the final cohort was limited to 1:1 matched 12,340 patients. Gleason score reclassification was used as primary endpoint. As such, any migration to pathologic Gleason score ≥7(3 + 4) was identified as overall, whereas migration to ≥7(4 + 3) was defined as extreme reclassification. A conditional Poisson regression model was used to estimate the risk of reclassification. Whereas spline model was used to estimate the impact of increasing time to treatment as a non-linear function on Gleason reclassification between race group.

RESULTS

Upon matching there were no differences in the baseline characteristics between race groups. In a matched cohort, higher proportion of low-risk Black men (6.6%) reported extreme reclassification to pathologic Gleason score than White men (5.0%), p < 0.001. In a conditional Poisson regression model adjusted for time to treatment, the risk of overall (RR = 1.09, 95% CI, 1.05-1.13, p < 0.001) and extreme (RR = 1.30, 95% CI, 1.12-1.50, p = 0.004) reclassification was significantly higher in Black men as compared to their White counterpart. In spline model, the probability of Gleason reclassification in Black men was elevated with increasing time to treatment, especially after 180 days (53% vs. 43% between Black and White men).

CONCLUSION

Risk of Gleason score reclassification is disparately elevated in Black men with low-risk PCa. Furthermore, time to treatment can non-linearly impact Gleason reclassification in Black men.

Preliminary results from phase Ib/II neoadjuvant CG0070 and nivolumab (N) for cisplatin (C)-ineligible muscle invasive bladder cancer (MIBC)

4574

Background: CG0070 is a replication-competent oncolytic adenovirus engineered to target RB deficient tumor cells and to express GM-CSF. CG0070 has previously demonstrated safety and efficacy against BCG-exposed high risk non-muscle invasive bladder cancer through tumor lysis and anti-tumor immune activation. We tested the safety and efficacy of CG0070 in combination with N as neoadjuvant therapy for MIBC in C-ineligible patients in this study (NCT04610671). Methods: C-ineligible pts with MIBC (cT2-4a, N≤1) were enrolled. Pts received 6 weekly intravesical CG0070 (1x1012vp) and 2 doses of N at wks 2 and 6, followed by radical cystectomy (RC). The primary objective is safety of CG0070+N as measured by CTCAEv5.0. Secondary objective is to assess pathologic response (PaR) (pT0N0). Exploratory objectives include the assessment of correlation between PaR with baseline 1) E2F expression; 2) immune infiltration; 3) PD-L1 expression; and 4) TLS expression. Results from a prespecified interim analysis following accrual of 15 patients is reported herein. Results: Between Nov 2020 and Jan 2022, 15 pts were enrolled with median age 75.5yrs, 73% male, 47% > cT2; 1 patient refused RC but was included in the ITT population. No DLTs were encountered. The overall rate of grade 3-4 AEs was 10/15 (75%), and the vast majority were related to RC (90%). Immune related AEs were seen in one pt, who had grade 2 autoimmune thyroiditis. There was no delay in time to RC and no unexpected surgical complications from treatment. PaR was observed in 6/13 (46%) evaluable pts, and an additional pt had negative post-treatment biopsy but refused RC. Conclusions: Neoadjuvant CG0070+N is safe and effective in C-ineligible pts with MIBC. This combination was well tolerated without any delays in RC and induced an overall response rate of 54%. Clinical trial information: NCT04610671. [Table: see text]

Management of Patients With Nonmetastatic Prostate Cancer

Localized prostate cancer is a heterogeneous disease. However, some diagnostic features are helpful in categorizing patients into risk groups for adverse outcomes, such as pathology, imaging, and genetic profiling. Risk‐specific management options, including active surveillance, can be tailored to individual patients based on their risk profile. Clinicians should discuss the risks and benefits of each of these options with patients for informed decision-making.

Novel Transcriptomic Interactions Between Immune Content and Genomic Classifier Predict Lethal Outcomes in High-grade Prostate Cancer

Grade group 4 and 5 (GG-45) prostate cancer (PCa) patients are at the highest risk of lethal outcomes, yet lack genomic risk stratification for prognosis and treatment selection. Here, we assess whether transcriptomic interactions between tumor immune content score (ICS) and the Decipher genomic classifier can identify most lethal subsets of GG-45 PCa. We utilized whole transcriptome data from 8071 tumor tissue (6071 prostatectomy and 2000 treatment-naïve biopsy samples) to derive four immunogenomic subtypes using ICS and Decipher. When compared across all grade groups, GG-45 samples had the highest proportion of most aggressive subtype-ICS^High/Decipher^High. Subsequent analyses within the GG-45 patient samples (n = 1420) revealed that the ICS^High/Decipher^High subtype was associated with increased genomic radiosensitivity. Additionally, in a multivariable model (n = 335), ICS^High/Decipher^High subtype had a significantly higher risk of distant metastasis (hazard ratio [HR] = 5.41; 95% confidence interval [CI], 2.76-10.6; p ≤  0.0001) and PCa-specific mortality (HR = 10.6; 95% CI, 4.18-26.94; p ≤  0.0001) as compared with ICS^Low/Decipher^Low. The novel immunogenomic subtypes establish a very strong synergistic interaction between ICS and Decipher in identifying GG-45 patients who experience the most lethal outcomes. PATIENT SUMMARY: In this analysis, we identified a novel interaction between the total immune content of prostate tumors and genomic classifier to identify the most lethal subset of patients with grade groups 4 and 5. Our results will aid in the subtyping of aggressive prostate cancer patients who may benefit from combined immune-radiotherapy modalities.

A prospective validation of the genomic classifier to define high-metastasis risk in a subset of African American men with early localized prostate cancer: VanDAAM study

5005

Background: Risk stratification of prostate cancer (PC) using routine clinical variables remains suboptimal as they do not account for underlying tumor biology. The genomic classifier provides information on underlying biology and independently predicts an individual patient’s risk of metastasis. Although the performance of the genomic classifier has been tested across different cohorts primarily comprised of White men, its validation as an optimal genomic risk classifier for African American men (AAM) is thus far lacking in a prospective trial. We report the initial results on the prospective validation of the genomic classifier in a matched cohort of AAM and non-AAM (NAAM). Methods: This was a multisite, prospective validation trial of the genomic classifier i.e. Decipher score in AAM. Participants were recruited on a 1:1 enrollment ratio of AAM to NAAM diagnosed with low-intermediate risk PC. Patient on active surveillance were ineligible. NAAM were matched to AAM on PSA, age, biopsy Gleason score, clinical stage, and percent positive biopsy cores. Diagnostic biopsy specimens were processed at a CLIA certified laboratory and Decipher score was assessed using whole transcriptome profiling platform. Total target accrual was 250 men treated for low-intermediate PC over three years. Statistical analyses include categorical comparison of race dependent risk group migration between NCCN risk group and genomic classifier. Relative risk of metastasis was estimated using negative binomial model. Results: Final analytical cohort included 207 evaluable cases (AAM = 102 and NAAM = 107) with comprehensive genomic information. Risk of metastasis was determined based on pretreatment biopsy Decipher score, and patients were classified as low, favorable-, and unfavorable intermediate risk. Despite achieving a robustly matched clinical cohort, we observed significant genomic heterogeneity between AAM and NAAM across NCCN risk groups. In a comparative analysis, 49% of low-favorable intermediate risk AAM harbored high genomic risk tumors as compared to only 10% NAAM, p = 0.02. Similarly, using the modified clinico-genomic risk classifier (cGC), comprised of both Decipher score and clinical variables, AAM experienced an extreme deviation of risk status (difference [δ] between cGC and NCCN ≥ 2) as compared to NAAM (26.8% vs 8.1%, p = 0.03). In a binomial model, low-favorable NCCN risk AAM were 3.9 times more likely to be reclassified as high genomic risk for distant metastasis compared to NAAM (RR = 3.99, 95% CI, 1.15 – 13.86, p = 0.02). Conclusions: Clinical NCCN risk classification is an inadequate surrogate of tumor biology and offers suboptimal risk stratification for AAM with PC. Integration of patient specific genomic classifier into standard of care will improve accuracy in disease risk classification and treatment recommendations for AAM. Clinical trial information: NCT02723734.

Effectiveness and Safety of Prostatic Artery Embolization for the Treatment of Lower Urinary Tract Symptoms from Benign Prostatic Hyperplasia in Men with Concurrent Localized Prostate Cancer

PURPOSE

To assess the effectiveness and safety of prostatic artery embolization (PAE) on lower urinary tract symptoms (LUTS) in the setting of localized prostate cancer (PCa).

MATERIALS AND METHODS

This was a retrospective, single-center, institutional review board-approved study from December 2016 to June 2020 of 21 patients (median age, 72; range, 63-83 years) with moderate LUTS and localized PCa. Clinical effectiveness was evaluated at 6 and 12 weeks using International Prostate Symptom Score (IPSS) and quality of life (QoL) improvement. Seventeen patients were scheduled to receive definitive radiotherapy (RT) after PAE; 13 patients completed RT. Short-term imaging signs of oncologic progression were evaluated at 6 and 12 weeks defined by at least one of the following on magnetic resonance imaging: increased Prostate Imaging-Reporting and Data System score of index lesion(s) to at least 4, new extracapsular extension, seminal vesicle involvement, or pelvic lymphadenopathy. Nonparametric Wilcoxon signed-rank test was used for analysis.

RESULTS

IPSS improved by a median of 12 (n = 19, P < .0001) and 14 (n = 14, P < .0001) at 6 and 12 weeks, respectively. QoL improved by a median of 2 (n = 19, P < .0001) and 3 (n = 3, P < .0001) at 6 and 12 weeks. Prostate volume decreased by a median of 24% (n = 19, P < .0001) and 36% (n = 12, P = .015) at 6 and 12 weeks. No patients demonstrated disease progression at 6 (n = 16) or 12 (n = 8) weeks by imaging. No patients experienced increased prostate-specific antigen after RT, grade ≥3 adverse events, or greater genitourinary toxicity.

CONCLUSIONS

PAE is effective and safe for the treatment of men with LUTS from benign prostatic hyperplasia in the setting of concomitant, localized, non-obstructive PCa.

Budget Impact of Adaptive Abiraterone Therapy for Castration-Resistant Prostate Cancer

BACKGROUND

The use of a novel strategy known as adaptive abiraterone therapy based on mathematical modeling of evolutionary dynamics of tumor subpopulations was shown in a clinical trial to extend the time to disease progression in patients with metastatic castration-resistant prostate cancer (CRPC) and reduced the use of abiraterone therapy. Although the clinical impact of adaptive abiraterone treatment is clear, the economic impact of this strategy has not been investigated.

OBJECTIVE

To compare the cost of care with adaptive abiraterone therapy versus standard continuous abiraterone therapy in patients with metastatic CRPC, using patient billing data.

METHODS

We performed a retrospective review of billing data for patients with metastatic CRPC who received abiraterone treatment at a large cancer center between June 1, 2012, and August 31, 2018. Patients were divided into 2 groups based on whether they received adaptive abiraterone therapy (N = 15) or continuous abiraterone therapy (N = 21). All patients with refractory, metastatic prostate cancer after castration that was indicated for abiraterone therapy were eligible for this study. Each patient in the adaptive abiraterone therapy cohort received abiraterone plus prednisone treatment until the patient reached a target threshold of 50% or more reduction in prostate-specific antigen (PSA) level compared with his PSA level before abiraterone therapy; treatment was then suspended until the PSA level rose above the 50% of PSA before abiraterone therapy target threshold. The continuous therapy cohort received abiraterone plus prednisone daily until radiographic progression. The primary outcomes were the mean annual cost of care per patient, including and excluding the cost of abiraterone, and the cost of care, by clinical category.

RESULTS

The median time to disease progression was 25.8 months for patients who received adaptive abiraterone therapy compared with 12.1 months for patients who received continuous abiraterone therapy. Overall, the mean total, including the cost of drug, annual cost per patient who received adaptive abiraterone therapy was $79,093 compared with $146,782 for patients who received continuous abiraterone therapy (P <.0001). The annual cost of care per patient, excluding the cost of abiraterone, was $13,883 for those who received adaptive therapy versus $22,322 for those who received continuous abiraterone therapy (P = .2757), which was not statistically significant.

CONCLUSION

Practical precision medicine strategies, such as adaptive abiraterone treatment or pharmacogenomics-targeted dosing, can use known biomarkers, such as PSA, to tailor therapy, generate improved outcomes, and reduce costs without the need for novel drug and diagnostic discovery and development. The results of this study suggest that a large clinical study of adaptive abiraterone therapy is warranted to validate the potential of this strategy to extend the time to disease progression and reduce costs of treatment of metastatic CRPC.

TMPRSS2-ERG fusion impacts anterior tumor location in men with prostate cancer

BACKGROUND

In prostate cancer (PCa), lack of androgen receptor (AR) regulated TMPRSS2-ETS-related gene (ERG) gene fusion (ERG^negative ) status has been associated with African American race; however, the implications of ERG status for the location of dominant tumors within the prostate remains understudied.

METHODS

An African American-enriched multiinstitutional cohort of 726 PCa patients consisting of both African American men (AAM; n = 254) and European American men (EAM; n = 472) was used in the analyses. Methods of categorical analysis were used. Messenger RNA (mRNA) expression differences between anterior and posterior tumor lesions were analyzed using Wilcoxon rank-sum tests with multiple comparison corrections.

RESULTS

Anti-ERG immunohistochemistry staining showed that the association between ERG status and anterior tumors is independent of race and is consistently robust for both AAM (ERG^negative 81.4% vs. ERG^positive 18.6%; p = .005) and EAM (ERG^negative 60.4% vs. ERG^positive 39.6%; p < .001). In a multivariable model, anterior tumors were more likely to be IHC-ERG^negative (odds ratio [OR]: 3.20; 95% confidence interval [CI]: 2.14-4.78; p < .001). IHC-ERG^negative were also more likely to have high-grade tumors (OR: 1.73; 95% CI: 1.06-2.82; p = .02). In the exploratory genomic analysis, mRNA expression of location-dependent genes is highly influenced by ERG status and African American race. However, tumor location did not impact the expression of AR or the major canonical AR-target genes (KLK3, AMACR, and MYC).

CONCLUSIONS

ERG^negative tumor status is the strongest predictor of anterior prostate tumors, regardless of race. Furthermore, AR expression and canonical AR signaling do not impact tumor location.

NCCN Guidelines Insights: Prostate Cancer, Version 1.2021

The NCCN Guidelines for Prostate Cancer address staging and risk assessment after a prostate cancer diagnosis and include management options for localized, regional, and metastatic disease. Recommendations for disease monitoring and treatment of recurrent disease are also included. The NCCN Prostate Cancer Panel meets annually to reevaluate and update their recommendations based on new clinical data and input from within NCCN Member Institutions and from external entities. This article summarizes the panel’s discussions for the 2021 update of the guidelines with regard to systemic therapy for metastatic castration-resistant prostate cancer.

Abstract 3520: Immunogenomic landscape of grade group 5 prostate cancer predicts risk of lethal outcomes and may inform treatment response

Introduction

Prognostic and therapeutic implications of the immunogenomic landscape in poorly differentiated Grade Group 5 (GG5) prostate cancer (PCa) remains largely unknown. While novel treatment strategies including immuno-radiotherapy have been hypothesized to attenuate disease progression in advanced PCa, limited data exist to show underlying mechanisms related to immunogenomcis and its role in the management of GG5 PCa.

Method

This retrospective analysis includes 822 PCa patients who underwent radical prostatectomy (RP) with pathologic GG5 disease. Immunogenomic interaction between the immune content score (ICS) and Decipher score was used to predict the metastasis and Prostate cancer specific mortality (PCSM). Immunogenomic interaction categories were used to assess patient response to radiation therapy, measured by the PORTOS score. Additionally, 135 biopsy based tumor samples were also used to validate the immunogenomic correlation between ICS and Decipher as well as the association with PORTOS score. A Kruskal-Wallis test was used to compare median scores whereas methods of survival analysis were used for time dependent endpoints. Principal component analysis (PCA) was used to show sample clustering based on PORTOS score.

Results

Among GG5 patients 64.8% had high Decipher risk score (&gt; 0.60) whereas 35.5% had low-average risk score (≤ 0.60). When comparing Decipher risk categories with ICS, a linear association was observed with the highest ICS quartile showing the highest Decipher score (Spearman's correlation 0.23, p &lt; 2.4e−11). In a multivariable model, high Decipher score was associated with risk metastasis (HR = 1.63, 95% CI: 1.12 - 2.37, p = 0.01) and PCSM (HR = 1.61, 95% CI: 0.93 – 2.78, p = 0.08) whereas high ICS did not show significant effect on lethal outcomes. However, in the interaction model, effect of decipher on lethal outcomes was augmented in relation with higher ICS. Patients with ICSHigh and DecipherHigh showed significantly higher risk of metastasis (HR = 3.29, 95% CI: 1.53 - 7.07, p = 0.002) and PCSM (HR = 4.15, 95% CI: 1.55 - 11.0, p = 0.004). Additionally, ICSHigh and DecipherHigh also showed higher PORTOS score compared to those with ICSLow and DecipherLow (p &lt; 2.2e−16). Similar to RP cases, in the validation biopsy data Decipher score and ICS were associated (p = 0.01). Likewise, the association of immunogenomic categories with PORTOS score was also consistent in the validation dataset (p = 0.0002). PCA in both RP and validation data using other T cells (i.e. CD4+, CD8+ and Treg) along with ICS, showed separation of high and low PORTOS score categories in relation to immune cells.

Conclusions

The immunogenomic landscape of GG5 disease has major prognostic and therapeutic implications in aggressive PCa. Immunogenomic interaction between immune content and genomic risk classifiers can be used to identify subsets of patients who are at increased risk of metastasis and PCSM, and may have enhanced response to radiotherapy.

Citation Format: Kosj Yamoah, Shivanshu Awasthi, Brandon Mahal, Shuang G. Zhao, Julieta Abraham-Miranda, Travis A. Gerke, Elai Davicioni, Robert J. Rounbehler, Anders E. Berglund, Daniel G. Grass, Jong Y. Park, Julio M. Pow-Sang, Daniel Fernandez, Rohit K. Jain, Edward M. Schaeffer, Stephen Freedland, Daniel E. Spratt, Robert B. Den, Manish Kohli, Timothy R. Rebbeck, Felix Y. Fang. Immunogenomic landscape of grade group 5 prostate cancer predicts risk of lethal outcomes and may inform treatment response [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 3520.

Prostate Cancer, Version 2.2019, NCCN Clinical Practice Guidelines in Oncology

The NCCN Guidelines for Prostate Cancer include recommendations regarding diagnosis, risk stratification and workup, treatment options for localized disease, and management of recurrent and advanced disease for clinicians who treat patients with prostate cancer. The portions of the guidelines included herein focus on the roles of germline and somatic genetic testing, risk stratification with nomograms and tumor multigene molecular testing, androgen deprivation therapy, secondary hormonal therapy, chemotherapy, and immunotherapy in patients with prostate cancer.

Focal bipolar radiofrequency ablation for localized prostate cancer: Safety and feasibility

OBJECTIVES

To evaluate the safety and feasibility of focal bipolar radiofrequency ablation in men with localized prostate cancer.

METHODS

A review of 10 patients treated with a novel bipolar radiofrequency ablation probe integrated in a coil design (Encage; Trod Medical, Bradenton, FL, USA) between 2011 and 2017 in two prospective pilot trials. All men had clinical stage T1c prostate cancer, prostate-specific antigen <10 ng/mL and Gleason score ≤7. Ablation was carried out under general anesthesia, and bipolar probes were inserted transperineally under transrectal ultrasound guidance. Treatment-related adverse events, quality of life and negative biopsy rate were evaluated at 6 months after ablation. The Wilcoxon signed-rank test was used to compare baseline and post-treatment symptom scores.

RESULTS

The median age was 58 years (range 50-64 years) and the median prostate volume was 49.65 cc (range 21-68 cc). Prostate cancer with a Gleason score of 6 (3 + 3) and 7 (3 + 4) was noted in seven and three patients, respectively. The median number of radiofrequency ablation cycles was 2.5 (range 2-5). All patients were catheter-free and able to void the day of surgery. Within 6 months after ablation, all adverse events were low grade, with the exception of one grade 3 hematuria that required cystoscopy without coagulation. Six months after ablation bowel, urinary and hormonal functions, and overall satisfaction remained stable. Erectile dysfunction occurred in two out of four patients who had normal sexual function before the procedure. Neither urinary incontinence nor urinary infection was noted.

CONCLUSIONS

This first report on focal bipolar radiofrequency ablation documents a safe and feasible treatment option for selected patients with localized prostate cancer.

Proof-of-principle Phase I results of combining nivolumab with brachytherapy and external beam radiation therapy for Grade Group 5 prostate cancer: safety, feasibility, and exploratory analysis

BACKGROUND

To determine whether combining brachytherapy with immunotherapy is safe in prostate cancer (PCa) and provides synergistic effects, we performed a Phase I/II trial on the feasibility, safety, and benefit of concurrent delivery of anti-PD-1 (nivolumab) with high-dose-rate (HDR) brachytherapy and androgen deprivation therapy (ADT) in patients with Grade Group 5 (GG5) PCa.

METHODS

Eligible patients were aged 18 years or older with diagnosis of GG5 PCa. Patients received ADT, nivolumab every two weeks for four cycles, with two cycles prior to first HDR, and two more cycles prior to second HDR, followed by external beam radiotherapy. The primary endpoint was to determine safety and feasibility. This Phase I/II trial is registered with ClinicalTrials.gov (NCT03543189).

RESULTS

Between September 2018 and June 2019, six patients were enrolled for the Phase I safety lead-in with a minimum observation period of 3 months after nivolumab administration. Overall, nivolumab was well tolerated in combination with ADT and HDR treatment. One patient experienced a grade 3 dose-limiting toxicity (elevated Alanine aminotransferase and Aspartate aminotransferase) after the second cycle of nivolumab. Three patients (50%) demonstrated early response with no residual tumor detected in ≥4 of 6 cores on biopsy post-nivolumab (4 cycles) and 1-month post-HDR. Increase in CD8+ and FOXP3+/CD4+ T cells in tissues, and CD4+ effector T cells in peripheral blood were observed in early responders.

CONCLUSION

Combination of nivolumab with ADT and HDR is well tolerated and associated with evidence of increased immune infiltration and antitumor activity.

Association of positive Ki-67 and PD-L1 expressions in post neoadjvuant chemotherapy (NAC) radical cystectomy samples with lack of tumor downstaging (TD) and shorter overall survival (OS) in patients with muscle-invasive bladder cancer (MIBC)

554

Background: Previous chart review studies have reported that adjuvant chemotherapy after NAC did not clearly increase OS in MIBC cases characterized by a lack of TD. There is an unmet need to develop biomarkers to guide adjuvant therapy for this patient population. High levels of expression of cell proliferation marker Ki-67 are associated with poor outcome in chemotherapy naïve bladder cancer. Expression of PD-L1 has been studied as a potential predictive biomarker for anti-PD1 or PD-L1 therapies in metastatic MIBC. We therefore studied Ki-67 and PD-L1 expression in post NAC radical cystectomy samples at Moffitt Cancer Center and correlate them with TD and OS. Methods: Tissue microarrays (TMAs) were constructed from 116 post NAC cystectomy samples. The expressions of Ki-67 were evaluated with immunohistochemistry (IHC) and considered positive if any of the cores per sample were stained positive for Ki-67. The Dako 22C3 assay was used for PD-L1 IHC and the combined positive score of 10 or above was considered positive for PD-L1. Results: The median survival of this cohort of 116 patients was 33.4 months (range: 1.13 -127 months). 40 patients (35%) had TD and 21 patients (18%) achieved pathological complete response. Using Cox regression for OS, positive Ki-67 expression in post NAC radical cystectomy sample was associated with poorer OS (hazard ratio=2.412, 95% CI:1.076-5.408, p=0.033), independent of the pathological N stage. Patients with Ki67/PD-L1 double-negative tumors had a significantly longer median OS of 98.2 months versus 29.9 and 26.9 months in PD-L1-/Ki67+ and PD-L1+/Ki67+ tumors respectively (Log-rank test, p=0.0361). Lack of TD was significantly associated with positive Ki-67 (P<0.001) and positive PD-L1 (p=0.003) in the post NAC samples with a multi-variable logistic regression model. Conclusions: Positive Ki-67 and PD-L1 expressions in post NAC radical cystectomy samples were associated with inferior OS and absence of TD. Adjuvant anti-PD1 therapy either alone or in combination with chemotherapy would be indicated for this subset of patients.

Radiological semantics discriminate clinically significant grade prostate cancer

Background

Identification of imaging traits to discriminate clinically significant prostate cancer is challenging due to the multi focal nature of the disease. The difficulty in obtaining a consensus by the Prostate Imaging and Data Systems (PI-RADS) scores coupled with disagreements in interpreting multi-parametric Magnetic Resonance Imaging (mpMRI) has resulted in increased variability in reporting findings and evaluating the utility of this imaging modality in detecting clinically significant prostate cancer. This study assess the ability of radiological traits (semantics) observed on multi-parametric Magnetic Resonance images (mpMRI) to discriminate clinically significant prostate cancer.

Methods

We obtained multi-parametric MRI studies from 103 prostate cancer patients with 167 targeted biopsies from a single institution. The study was approved by our Institutional Review Board (IRB) for retrospective analysis. The biopsy location had been identified and marked by a clinical radiologist for targeted biopsy based on initial study interpretation. Using the target locations, two study radiologists independently re-evaluated the scans and scored 16 semantic traits on a point scale (up to 5 levels) based on mpMRI images. The semantic traits describe size, shape, and border characteristics of the prostate lesion, as well as presence of disease around lymph nodes (lymphadenopathy). We built a linear classifier model on these semantic traits and related to pathological outcome to identify clinically significant tumors (Gleason Score ≥ 7). The discriminatory ability of the predictors was tested using cross validation method randomly repeated and ensemble values were reported. We then compared the performance of semantic predictors with the PI-RADS predictors.

Results

We found several semantic features individually discriminated high grade Gleason score (ADC-intensity, Homogeneity, early-enhancement, T2-intensity and extraprostatic extention), these univariate predictors had an average area under the receiver operator characteristics (AUROC) ranging from 0.54 to 0.68. Multivariable semantic predictors with three features (ADC-intensity; T2-intensity, enhancement homogenicity) had an average AUROC of 0.7 [0.43, 0.94]. The PI-RADS based predictor had average AUROC of 0.6 [0.47, 0.75].

Conclusion

We find semantics traits are related to pathological findings with relatively higher reproducibility between radiologists. Multivariable predictors formed on these traits shows higher discriminatory ability compared to PI-RADS scores.

The effect of clinical pathways utilization on total cost of care for the treatment of prostate cancer

20

Background: Moffitt Cancer Center (MCC) has developed evidence-based cancer care pathways which are integrated into the Electronic Health Record (EHR). We retrospectively compared the 1 year (yr) total cost of care in patients (pts) with newly diagnosed prostate cancer (PCA) treated at MCC based on EHR tool utilization and pathway alignment. Methods: Using existing Cancer Registry data, we retrospectively identified all pts presenting with newly diagnosed PCA between 7/1/2015-6/30/2017 who received all 1st course treatment (tx) at MCC. Pts direct costs were tracked for 1 yr from the Cancer Registry “date of 1st contact.” Tx was categorized as either radiation (RT) +/- hormone tx (HT), surgery (S) +/- HT, active surveillance only (ASO), HT only, palliative care, chemotherapy (CT), or mixed (a combination of S, RT, or CT). Pathway alignment was either electronically tracked through the EHR pathway tool or determined through manual chart review for pts tx’ed off the pathway tool. Results: 477 pts met inclusion criteria, including men with: low or favorable intermediate (n=259); unfavorable intermediate, high, or very high (n=186); and metastatic (n=32) risk group PCA. The majority (n=396, 83%) had tx in alignment with a pathway. The major tx modalities on pathway were S-HT (n=139), RT-HT (n=113), or ASO (n=110) and off pathway were RT-HT (n=52, 64%), S-HT (n=10), or ASO (n=9). Overall, treatment in alignment with a pathway was significantly associated with lower 1 yr total cost compared to off pathway tx (p <0.001) with a mean difference of $5,500 per pt yr. Conclusions: Clinical pathway alignment was significantly associated with less aggressive therapy and lower 1 yr cost of care for PCA pts treated at MCC. Cost of care was highly associated with tx modality selected. Further analyses are needed to understand the association between pathway alignment, patient risk factors and tx modality selection.

Abstract 2632: Increased recurrence and clinical grade in renal cell carcinomas associated with novel EGFR splice variants

Background: It is well established that alterations of epidermal growth factor receptor (EGFR) are associated with the development and progression of epithelial tumors across several cancer types. Alternative splicing and alterations of EGFR splice sites can cause translational changes and EGFR alterations have historically demonstrated associations with clinical and therapeutic outcomes in lung cancer.

Objectives: To evaluate the prevalence and clinical significance of recently identified novel ΔEGFR-TKF splice variant in 102 renal cell carcinoma (RCC) tumors

Methods: The majority of the RCC samples were RNA sequenced through the Orien AVATAR™ pipeline, and 7 additional cases were analyzed through Moffitt STAR™. Moffitt STAR™ and AVATAR™ are next generation targeted sequencing assay that include both DNA and RNA analyses. Frequency tables were generated using the data collected. The Grehan-Breslow-Wilcoxon test was used to compare recurrence free survival (RFS) due to the higher weight given to survival difference at earlier time points. The rationale being that the majority of recurrence events occurred earlier than 25 months in EGFR ≥5% cases and 50 months in the EGFR &lt;5% cases compared to the follow-up times of 75 months and 125 months in the study cohort.

Results: We identified a EGFR gene splice variant, predominantly c.2470-188_c.2470-2, between exons 20 and 21 in RCCs subjected to the sequencing assay. Of 1075 solid tumors analyzed, the presence of the EGFR gene splice variant was observed, in any amount, within 74 of 102 RCC cases (72.5%), with the only exceptions being one multiple myeloma and sarcoma case. Using an EGFR slice variant cutoff of ≥5%, 33 of 102 (32.4%) RCC were chosen to be further investigated. Upon further analysis, 32 EGFR slice variant tumors were clear cell RCC, while 1 was papillary type II RCC. Thirty cases involving ≥5% slice variants were clinically staged revealed 6 T1, 8 T2, and 16 T3/4 cases compared to tumors with &lt;5% of the splice variants which were staged 28 T1, 10 T2, 21 T3/4, and 8 Tx (p=.011). The RFS curve trended to worse outcomes for patients with ≥5% EGFR splice variants compared to &lt;5% EGFR splice variants (p=.0315). All variants were identified at the RNA level without obvious corresponding DNA alterations. There was an average of 106 unique reads (average of 7.7% of all reads) for these cases supporting this variant.

Conclusion: EGFR splice variants in RCC are a relatively frequent and specific molecular alteration. This novel splice variant may prove to be significant as a druggable target or as part of a kidney cancer screening protocol.

Citation Format: George A. Coba, Saif Zaman, Jamie K. Teer, Timothy Robinson, Roger Li, Jingsong Zhang, Todd C. Knepper, Philippe E. Spiess, Wade Sexton, Matthew A. Smith, Mayer N. Fishman, Julio M. Pow-Sang, Michael A. Poch, Scott M. Gilbert, Anthony M. Magliocco, Theresa A. Boyle, Brandon J. Manley. Increased recurrence and clinical grade in renal cell carcinomas associated with novel EGFR splice variants [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 2632.

Economic benefits of adaptive abiraterone therapy for advanced prostate cancer

e18343

Background: We recently completed a study showing that adaptive abiraterone therapy (AT) led to more than a doubling of the time to radiographic progression (TTP) compared to continuous therapy (CT) in patients with metastatic castration resistant prostate cancer (mCRPC), [Nat Commun. 2017; 1816]. This study compared the cost of care in the AT cohort versus the standard of care CT cohort. Methods: We conducted a retrospective economic analysis of mCRPC patients receiving intermittent AT compared to patients receiving CT abiraterone. The study followed the adaptive therapy trial protocol (NCT02415621). The primary endpoints were costs of care per patient per year and cost per treatment month. We used itemized billing data and standardized to Medicare reimbursement rates to determine the pharmacy, lab, and imaging costs. Results: Patients receiving adaptive abiraterone therapy (N = 15) had a mean annual cost of care of $80,668 compared to a mean annual cost of care of $132,631 for CT patients. The cost of treatment per month was $6,713 for the AT versus $11,088 for the CT. The economic benefits persisted even after taking into account the cost of abiraterone (Table). Conclusions: The reduction in cost of care in patients with mCRPC with nearly an additional year of TTP from adaptive abiraterone therapy demonstrates the potential value of novel precision medicine approaches. If confirmed by other, larger scale studies, AT may provide significant economic value from far more effective therapy. [Table: see text]

AA9int: SNP interaction pattern search using non-hierarchical additive model set

Motivation

The use of single nucleotide polymorphism (SNP) interactions to predict complex diseases is getting more attention during the past decade, but related statistical methods are still immature. We previously proposed the SNP Interaction Pattern Identifier (SIPI) approach to evaluate 45 SNP interaction patterns/patterns. SIPI is statistically powerful but suffers from a large computation burden. For large-scale studies, it is necessary to use a powerful and computation-efficient method. The objective of this study is to develop an evidence-based mini-version of SIPI as the screening tool or solitary use and to evaluate the impact of inheritance mode and model structure on detecting SNP-SNP interactions.

Results

We tested two candidate approaches: the 'Five-Full' and 'AA9int' method. The Five-Full approach is composed of the five full interaction models considering three inheritance modes (additive, dominant and recessive). The AA9int approach is composed of nine interaction models by considering non-hierarchical model structure and the additive mode. Our simulation results show that AA9int has similar statistical power compared to SIPI and is superior to the Five-Full approach, and the impact of the non-hierarchical model structure is greater than that of the inheritance mode in detecting SNP-SNP interactions. In summary, it is recommended that AA9int is a powerful tool to be used either alone or as the screening stage of a two-stage approach (AA9int+SIPI) for detecting SNP-SNP interactions in large-scale studies.

Availability and implementation

The 'AA9int' and 'parAA9int' functions (standard and parallel computing version) are added in the SIPI R package, which is freely available at https://linhuiyi.github.io/LinHY_Software/.

Supplementary information

Supplementary data are available at Bioinformatics online.

Predicting clinically significant prostate cancer using DCE-MRI habitat descriptors

Prostate cancer diagnosis and treatment continues to be a major public health challenge. The heterogeneity of the disease is one of the major factors leading to imprecise diagnosis and suboptimal disease management. The improved resolution of functional multi-parametric magnetic resonance imaging (mpMRI) has shown promise to improve detection and characterization of the disease. Regions that subdivide the tumor based on Dynamic Contrast Enhancement (DCE) of mpMRI are referred to as DCE-Habitats in this study. The DCE defined perfusion curve patterns on the identified tumor habitat region are used to assess clinical significance. These perfusion curves were systematically quantified using seven features in association with the patient biopsy outcome and classifier models were built to find the best discriminating characteristics between clinically significant and insignificant prostate lesions defined by Gleason score (GS). Multivariable analysis was performed independently on one institution and validated on the other, using a multi-parametric feature model, based on DCE characteristics and ADC features. The models had an intra institution Area under the Receiver Operating Characteristic (AUC) of 0.82. Trained on Institution I and validated on the cohort from Institution II, the AUC was also 0.82 (sensitivity 0.68, specificity 0.95).

Optimizing Time to Treatment to Achieve Durable Biochemical Disease Control after Surgery in Prostate Cancer: A Multi-Institutional Cohort Study

BACKGROUND

The impact of treatment delays on prostate cancer-specific outcomes remains ill-defined. This study investigates the effect of time to treatment on biochemical disease control after prostatectomy.

METHODS

This retrospective study includes 1,807 patients who received a prostatectomy as a primary treatment at two large tertiary referral centers from 1987 to 2015. Multivariate cox model with restricted cubic spline was used to identify optimal time to receive treatment and estimate the risk of biochemical recurrence.

RESULTS

Median follow-up time of the study was 46 (interquartile range, 18-86) months. Time to treatment was subcategorized based on multivariate cubic spline cox model. In multivariate spline model, adjusted for all the pertinent pretreatment variables, inflection point in the risk of biochemical recurrence was observed around 3 months, which further increased after 6 months. Based on spline model, time to treatment was then divided into 0 to 3 months (61.5%), >3 to 6 months (31.1%), and 6 months (7.4%). In the adjusted cox model, initial delays up to 6 months did not adversely affect the outcome; however, time to treatment >6 months had significantly higher risk of biochemical recurrence (HR, 1.84; 95% confidence interval, 1.30-2.60; P < 0.01).

CONCLUSIONS

The initial delays up to 6 months in prostate cancer primary treatment may be sustainable without adversely affecting the outcome. However, significant delays beyond 6 months can unfavorably affect biochemical disease control.

IMPACT

Time to treatment can aid clinicians in the decision-making of prostate cancer treatment recommendation and educate patients against unintentional treatment delays.

Epidural anesthesia and cancer outcomes in bladder cancer patients: is it the technique or the medication? A matched-cohort analysis from a tertiary referral center

BACKGROUND

The perioperative period can be a critical period with long-term implications on cancer-related outcomes. In this study, we evaluate the influence of regional anesthesia on cancer-specific outcomes in a radical cystectomy (RC) cohort of patients.

METHODS

We performed a retrospective analysis of patients with clinically-nonmetastatic urothelial carcinoma of the bladder who underwent RC at our institution from 2008 to 2012. Patients were retrospectively registered and stratified based on two anesthetic techniques: perioperative epidural analgesia with general anesthesia (epidural) versus general anesthesia alone (GA). Epidural patients received a sufentanil-based regimen (median intraoperative sufentanil dose 50 mcg (45,85). Propensity-score was used to make 1:1 case-control matching. Cumulative risk of recurrence with competing risks was calculated based on anesthetic technique. Kaplan-Meier curves were used to compare recurrence-free (RFS) and cancer-specific survival (CSS). Univariable and multivariable analyses were performed with Cox proportional hazard regression models for RFS and CSS.

RESULTS

Only patients with complete data on anesthetic technique were included. Out of 439 patients, 215-pair samples with complete follow-up were included in the analysis. Median follow-up was 41.4 months (range: 0.20-101). Patients with epidurals received higher median total intravenous morphine equivalents (ivMEQ) versus those in the GA group (75 (11-235) vs. 50 ivMEQ (7-277), p < 0.0001). Cumulative risk of recurrence at two years was 25.2% (19.6, 31.2) for epidural patients vs. 20.0% (15.0, 25.7) for GA patients (Gray test p = 0.0508). Epidural analgesic technique was a significant predictor of worse RFS (adjusted HR = 1.67, 1.14-2.45; p = 0.009) and CSS (HR = 1.53, 1.04-2.25; p = 0.030) on multivariable analyses.

CONCLUSIONS

Epidural anesthesia using sufentanil was associated with worse recurrence and disease-free survival in bladder cancer patients treated with surgery. This may be due use of epidural sufentanil or due to the increased total morphine equivalents patient received as a consequence of this drug.

Downstaging and Survival Outcomes Associated With Neoadjuvant Chemotherapy Regimens Among Patients Treated With Cystectomy for Muscle-Invasive Bladder Cancer

Importance

Neoadjuvant chemotherapy (NAC) followed by radical cystectomy improves survival compared with cystectomy alone for patients with bladder cancer. Although gemcitabine with cisplatin has become a standard NAC regimen, a dose-dense combination of methotrexate, vinblastine, doxorubicin, and cisplatin (ddMVAC) is being adopted at some institutions.

Objective

To assess the association of neoadjuvant ddMVAC vs standard regimens with downstaging and overall survival among patients treated with radical cystectomy for bladder cancer.

Design, Setting, and Participants

Cross-sectional analysis of data extracted from the medical records of a consecutive sample, after exclusions, of 1113 patients with bladder cancer of whom 824 had disease stage T2 or greater, who were treated with cystectomy at the Moffitt Cancer Center in Tampa, Florida, a tertiary care cancer center, between January 1, 2007, and May 31, 2017. Data were collected between November 14, 2016, and July 21, 2017, and analyzed between August 21, 2017, and December 8, 2017. Patients were compared based on type of NAC. Those who did not receive NAC were included as controls.

Main Outcomes and Measures

Comparative rates and the association of any downstaging, complete response, and overall survival with ddMVAC and other NAC regimens and surgery alone. Outcomes were examined using Kaplan-Meier, adjusted logistic, Cox regression, and propensity-weighted models.

Results

Of the 1113 patients who underwent cystectomy for bladder cancer, 861 (77.4%) were male, the median (interquartile range) age was 67 (60-74) years, 1051 (94.4%) were white, 27 (2.4%) black, 37 (3.3%) Hispanic/Latino, and 35 (3.1%) other race/ethnicity. Of 824 patients with muscle-invasive bladder cancer, 332 (40%) received NAC. Downstaging rates were 52.2% for ddMVAC, 41.3% for gemcitabine-cisplatin, and 27.0% for gemcitabine with carboplatin, and complete response (pT0N0) rates were 41.3% for ddMVAC, 24.5% for gemcitabine-cisplatin, and 9.4% for gemcitabine-carboplatin (2-sided P < .001). Adjusted analysis comparing ddMVAC with gemcitabine-cisplatin demonstrated a higher likelihood of downstaging (odds ratio [OR], 1.84; 95% CI, 1.10-3.09) and complete response (OR, 2.67; 95% CI, 1.50-4.77) with ddMVAC. Similar results were achieved with propensity score matching (OR, 1.52; 95% CI, 0.99-2.35). Patients who received ddMVAC had better overall survival than those treated with other chemotherapy regimens, although the observed survival benefit did not reach statistical significance in adjusted or propensity-matched models (hazard ratio, 0.44; 95% CI, 0.14-1.38; P = .16).

Conclusions and Relevance

This study suggest that neoadjuvant ddMVAC followed by cystectomy is associated with a higher complete response (ypT0N0) rate than standard NAC. These data highlight and suggest the need to further investigate ddMVAC vs standard NAC in a prospective, randomized fashion.

Prostate cancer mortality rates in Peru and its geographical regions

OBJECTIVE

To evaluate the mortality rates for prostate cancer according to geographical areas in Peru between 2005 and 2014.

MATERIALS AND METHODS

Information was extracted from the Deceased Registry of the Peruvian Ministry of Health. We analysed age-standardised mortality rates (world population) per 100 000 men. Spatial autocorrelation was determined according to the Moran Index. In addition, we used Cluster Map to explore relations between regions.

RESULTS

Mortality rates increased from 20.9 (2005-2009) to 24.1 (2010-2014) per 100 000 men, an increase of 15.2%. According to regions, during the period 2010-2014, the coast had the highest mortality rate (28.9 per 100 000), whilst the rainforest had the lowest (7.43 per 100 000). In addition, there was an increase in mortality in the coast and a decline in the rainforest over the period 2005-2014. The provinces with the highest mortality were Piura, Lambayeque, La Libertad, Callao, Lima, Ica, and Arequipa. Moreover, these provinces (except Arequipa) showed increasing trends during the years under study. The provinces with the lowest observed prostate cancer mortality rates were Loreto, Ucayali, and Madre de Dios. This study showed positive spatial autocorrelation (Moran's I: 0.30, P = 0.01).

CONCLUSION

Mortality rates from prostate cancer in Peru continue to increase. These rates are higher in the coastal region compared to those in the highlands or rainforest.

Expansion of tumor infiltrating lymphocytes (TIL) from bladder cancer

Advanced bladder cancer patients have limited therapeutic options resulting in a median overall survival (OS) between 12 and 15 months. Adoptive cell therapy (ACT) using tumor infiltrating lymphocytes (TIL) has been used successfully in treating patients with metastatic melanoma, resulting in a median OS of 52 months. In this study, we investigated the feasibility of expanding TIL from the tumors of bladder cancer patients. Primary bladder tumors and lymph node (LN) metastases were collected. Tumor specimens were minced into fragments, placed in individual wells of a 24-well plate, and propagated in high dose IL-2 for four weeks. Expanded TIL were phenotyped by flow cytometry and anti-tumor reactivity was assessed after co-culture with autologous tumor digest and IFN-gamma ELISA. Of the 28 transitional cell bladder or LN tumors collected, 14/20 (70%) primary tumors and all of the LN metastases demonstrated TIL expansion. Expanded TIL were predominantly CD3⁺ (median 63%, range 10-87%) with a median of 30% CD8 + T cells (range 5-70%). TIL secreted IFN-gamma in response to autologous tumor. Addition of agonisitic 4-1BB antibody improved TIL expansion from primary bladder tumors regardless of pre-treatment with chemotherapy. This study establishes the practical first step towards an autologous TIL therapy process for therapeutic testing in patients with bladder cancer.

Prognostic Value of Neutrophil-to-Lymphocyte Ratio in Penile Squamous Cell Carcinoma Patients Undergoing Inguinal Lymph Node Dissection

BACKGROUND

Further biomarkers are warranted to improve prognostic stratification of penile squamous cell carcinoma (PSCC) patients undergoing inguinal lymph node dissection (ILND).

OBJECTIVE

To assess the prognostic value of pretreatment neutrophil-to-lymphocyte ratio (NLR) in PSCC patients undergoing ILND and to investigate its role in predicting pathologic node-positive (pN+) disease.

DESIGN, SETTING, AND PARTICIPANTS

In total, 84 consecutive patients undergoing ILND for PSCC at our institution between 1994 and 2014 were identified. Sixty-eight patients with a complete blood count and differential prior to surgery were included. Median follow-up was 35.5 mo.

OUTCOMES MEASUREMENTS AND STATISTICAL ANALYSIS

Cut-off point analysis of NLR was performed using the Contal and O'Quigley method. Estimates of overall survival (OS), cancer-specific survival, and recurrence-free survival stratified by NLR were provided by the Kaplan-Meier method. Cox regression models were performed to determine predictors of survival and recurrence. Logistic regression models were used to identify factors associated with pathologic node-positivity.

RESULTS AND LIMITATIONS

The cut-off point value was determined to be 3. Median OS was significantly shorter for patients with NLR ≥3 than those with NLR <3 (30 vs 158 mo, p<0.001). NLR ≥3 was an independent predictor of worse OS (hazard ratio=2.48; 95% confidence interval [CI]: 1.02-6.06, p=0.046). On univariable analysis, NLR ≥3 was associated with an increased risk of pN+ disease (odds ratio [OR]=3.75; 95% CI: 1.30-10.81, p=0.014). However, on multivariable analysis adjusted for primary tumor grade, lymphovascular invasion, clinical N stage, and neoadjuvant treatment receipt, the association between NLR and pN+ disease was no longer significant (OR=3.66; 95% CI: 0.82-16.42, p=0.091). The retrospective design and limited size of the study are acknowledged limitations.

CONCLUSIONS

Pretreatment NLR is an independent predictor of OS in PSCC patients undergoing ILND and highlights the association between systemic inflammation and survival. Our data suggests that a simple biomarker of inflammation can serve as a prognosticator in PSCC.

PATIENT SUMMARY

Penile cancer is a rare malignancy in North America and Europe. Therefore, there is a lack of prognostic parameters to help predict oncologic and survival outcomes. In this report, patients with an elevated neutrophil-to-lymphocyte ratio had an increased risk of mortality.

Evaluating the accuracy of intraoperative frozen section during inguinal lymph node dissection in penile cancer

INTRODUCTION

Inguinal lymph node dissection is an integral part in the management of invasive penile tumors with intraoperative assessment often aiding decision-making during dissection. In this study, we evaluate the diagnostic value of intraoperative frozen section (FS) and analyze clinicopathologic factors that affect its accuracy.

MATERIAL AND METHODS

We, retrospectively, reviewed 84 patients with squamous cell carcinoma of the penis who underwent inguinal lymph node dissection at our institution. Intraoperative FS from the superficial inguinal nodes was available in 65 patients and compared with correspondent permanent sections (pathologic node staging [pN]). Sensitivity and specificity were calculated and factors associated with a false negative event were analyzed using logistic regression.

RESULTS

The total positive node rate was 60% (39/65). Of 39 pN+ cases, 10 (25.6%) had false-negative FS, whereas the remaining 29 were concordant intraoperatively. Sensitivity and specificity were 0.74 and 1, respectively. On univariable analysis, higher body mass index was associated with a false negative event although there was no association with age, receipt of neoadjuvant therapy, or clinical node stage.

CONCLUSION

Intraoperative FS is highly specific and moderately sensitive for the detection of positive superficial inguinal lymph nodes in penile cancer. Its use can help guide intraoperative surgical planning while limiting its reliance for patients with higher body mass index.

Laparoscopic Surgery in Urologic Oncology

Background

Techniques in genitourinary oncologic surgery have evolved over the past several years, shifting from traditional open approaches toward minimally invasive routes by laparoscopy.

Methods

We reviewed the literature on laparoscopic surgery for genitourinary cancer, with emphasis on contemporary indications, complications, and oncologic outcome of laparoscopic surgery for urologic malignancies.

Results

All urologic oncology procedures have been performed laparoscopically. Laparoscopic radical nephrectomy is becoming the preferred approach for managing kidney cancer. The initial experience with nephroureterectomy is encouraging. Laparoscopic radical prostatectomy is rapidly becoming the standard in Europe and is the procedure of choice in many centers in the United States.

Conclusions

When following the open oncologic principles for the surgical treatment of malignancies, laparoscopy offers similar oncologic clinical outcomes, less morbidity, improved operative precision, and reduced convalescence time.

Laparoscopic Retroperitoneal Lymph Node Dissection in the Management of Testis Cancer

BACKGROUND

The surgical approach to management of testis cancer has been traditionally through an open incision, but in the last decade, several centers have reported their experience with laparoscopic retroperitoneal lymph node dissection (LRPLND).

METHODS

We reviewed the English literature, summarized the outcomes, and included our initial experience with the LRPLND procedure.

RESULTS

Improvements in operative time, complications, and morbidity have occurred as surgical experience has increased. The procedure is more challenging in postchemotherapy patients. Outcomes at our institute are comparable to reported series from other institutions, and LRPLND is our current procedure of choice for RPLND.

CONCLUSIONS

LRPLND has been shown to be a safe, effective, minimally invasive procedure in the management of testicular cancer patients who require surgery to address the retroperitoneal lymph nodes.

Delay to Inguinal Lymph Node Dissection Greater than 3 Months Predicts Poorer Recurrence-Free Survival for Patients with Penile Cancer

PURPOSE

To our knowledge it is unknown whether concomitant inguinal lymph node dissection at the time of penectomy improves outcomes in patients with penile cancer. We analyzed predictors of regional recurrence as well as disease specific survival based on time of inguinal lymph node dissection. We also determined an optimal time to perform inguinal lymph node dissection.

MATERIALS AND METHODS

We reviewed the records of 84 consecutive patients with available nodal pathology findings. Recurrence-free and disease specific survival was estimated using the Kaplan-Meier method. Optimal time to inguinal lymph node dissection was assessed by ROC curves and used for dichotomization. Cox proportional HRs were used to identify predictors of regional recurrence after inguinal lymph node dissection.

RESULTS

A total of 47 (56%) and 37 patients (44%) presented with cN0 and cN+ disease, respectively, during a median followup of 21 months. A cutoff point of 3 months to perform inguinal lymph node dissection was used to dichotomize the cohort into early vs delayed groups. Early dissection in 51 men demonstrated 5-year recurrence-free survival of 77% vs 37.8% in 33 who underwent delayed dissection. Positive node disease (HR 23.2, 95% CI 2.98-181.2) and early inguinal lymph node dissection (HR 0.48, 95% CI 0.21-0.98) were predictors of regional recurrence. Five-year disease specific survival was 64.1% and 39.5% in the early and late dissection groups, respectively.

CONCLUSIONS

Three months appears to be an optimal window for performing inguinal lymph node dissection. While prospective trials are needed to define the role of upfront groin dissection, our results may help delineate patterns of referral and timing of inguinal lymph node dissection in patients with penile cancer.

Does Implementing an Enhanced Recovery After Surgery Protocol Increase Hospital Charges? Comparisons From a Radical Cystectomy Program at a Specialty Cancer Center

OBJECTIVE

To compare perioperative charges induced at the initial phase of a standardized enhanced recovery after surgery (ERAS) program from a tertiary referral center.

METHODS

A multidisciplinary ERAS protocol was implemented in our department on July 2015. During the subsequent year, all patients were treated according to this protocol (ERAS group). The patients were compared in terms of real in-hospital charges per surgical episode with a control group consisting of consecutive patients before the start of ERAS. Individual charges were analyzed per sample population and compared with the Wilcoxon rank-sum test or t test. Additionally, cost variances for each group were evaluated.

RESULTS

A total of 257 consecutive patients were evaluated of which the last 112 were ERAS patients. The median length of stay for each group was 6 days (P = .748). ERAS patients incurred higher medication charges ($1939 vs $1729, P = .036). Control patients incurred higher supplies ($861 vs $692), treatment ($90 vs $72), and miscellaneous charges ($537 vs $388) (all, P < .001). The median total charges per patient were $59,539 for the control group and $60,655 for the ERAS group (P = .175). ERAS adoption significantly reduced variance in billed charges (P < .001).

CONCLUSION

ERAS implementation did not significantly increase expenditure for cystectomy patients. ERAS showed decreased variance in charges likely due to standardization of care while eliciting savings in supplies, treatment, and miscellaneous costs.