Active surveillance in favorable intermediate-risk prostate cancer: A single-center experience

PURPOSE

To report the long-term oncological outcomes of active surveillance (AS) in selected patients with favorable intermediate-risk (IR) prostate cancer (PCa).

METHODS

A retrospective database review of two academic centers was conducted to identify favorable IR PCa patients initially managed by AS between 2014 and 2022. Favorable IR PCa was defined by the presence of one single element of IR disease (i.e., PSA 10-20ng/mL, Gleason Grade Group [GG] 2, or cT2b). All patients were diagnosed and followed up according to a contemporary scheme, including MRI and image-guided biopsies. The primary endpoint was metastasis-free survival.

RESULTS

A total of 57 patients met our inclusion criteria and the median follow-up was 56months. During follow-up, there were no cases of metastasis or death due to PCa, but 6 deaths due to competing causes. A total of 25 (44%) and 6 patients (11%) had definitive treatment and GG 3 reclassification during follow-up, respectively. In multivariable Cox hazard regression analysis, the risk of undergoing definitive treatment was significantly associated with PSA density>0.15 (HR: 4.82, 95% CI: 1.47 to 15; P=0.01) and PI-RADS 4-5 lesions on mpMRI (HR: 2.48, 95% CI: 1.06 to 5.19; P=0.006). Interestingly, tumor burden (P=0.3) and GG (P=0.7) on biopsy were not associated with definitive treatment.

CONCLUSIONS

AS is a safe and valuable strategy for well-selected patients with favorable IR prostate cancer, with excellent oncological outcomes after five years' follow-up.

LEVEL OF EVIDENCE: 4

POS0393 ASSOCIATION BETWEEN GENETICALLY PREDICTED EXPRESSION OF TPMT AND AZATHIOPRINE ADVERSE EVENTS IN PATIENTS WITH INFLAMMATORY CONDITIONS

Background

Azathioprine is a widely used immunosuppressant for the treatment of inflammatory conditions such as systemic lupus erythematosus (SLE), systemic vasculitis, dermatomyositis, and inflammatory bowel disease. However, its use is often limited by myelotoxicity. Variants in the gene encoding thiopurine-S-methyltransferase (TPMT), an enzyme in the metabolic pathway of azathioprine, increase the risk for myelotoxicity1. We know little about the relationship between the genetically predicted expression of TPMT and side effects of azathioprine.

Objectives

To examine whether genetically predicted expression of TPMT in liver tissue is associated with azathioprine adverse effects.

Methods

We assembled a retrospective cohort of new users taking azathioprine for inflammatory conditions at a tertiary care center. We performed genotyping with Illumina Infinium Expanded Multi-Ethnic Genotyping Array plus custom content data, and we then used Michigan Imputation servers for genetic imputation and PrediXcan models trained with GTEx/Genotype-Tissue Expression Project version 8 data to impute TPMT expression in liver tissue. We prespecified nine groups of phecodes (comprised of ICD9 and ICD10 codes) corresponding to known adverse effects of azathioprine. We then tested the association between the predicted expression of TPMT and these adverse events; for outcomes significant in the Wilcoxon ranksum tests (p<0.05), each case was reviewed in clinical records for confirmation. Finally, we grouped the predicted expression of TPMT in liver tissue into tertiles and conducted logistic regressions to assess the associations between predicted expression and side effects. We conducted a sensitivity analysis restricted to patients with EHR-reported White race.

Results

The cohort included 1034 patients (Table 1). Phecodes for 3 side effects—leukopenia (n=29), skin cancer (n=13), and rash (n=52)—were identified as associated with predicted TPMT expression in liver tissue. Of these, cases of side effects attributed to azathioprine were validated by chart review: leukopenia (96.6%; n=28), skin cancer (92.3%; n=12), and rash (9.6%; n=5) and used for analysis. When assessed by tertile of predicted TPMT expression, patients in the highest tertile had lower odds of having leukopenia (OR=0.35, 95%CI: 0.12-0.98, p=0.045) and a trend towards higher odds for skin cancer, but the number of cases was small (OR=3.56, 95%CI: 0.73-17.27, p=0.115). Confirmed cases of rash attributed to azathioprine were too few for meaningful analysis. We found similar results when restricted to patients with reported White race.

Table 1.

Characteristics of patients by TPMT expression

Lowest TertileMiddle TertileHighest TertileN=345N=345N=344Female sex, n (%)228 (66.1)244 (70.7)238 (69.2)EHR-reported White race, n (%)306 (88.7)293 (84.9)290 (84.3)Age, median [IQR]42 [29-58]43 [30-55]46 [30-56]Indication, n (%)Systemic lupus erythematosus38 (11.0)42 (12.2)38 (11.0)Inflammatory bowel disease191 (55.3)185 (53.6)190 (55.2)Other connective tissue disorder/autoimmune92 (26.7)96 (27.8)100 (29.1)Other24 (7.0)22 (6.4)16 (4.7)Verified leukopenia attributed to azathioprine, n (%)14 (4.1)9 (2.6)5 (1.5)Verified skin cancer attributed to azathioprine, n (%)2 (0.6)3 (0.9)7 (2.0)Verified rash attributed to azathioprine, n (%)2 (0.6)3 (0.9)0 (0)

Conclusion

This analysis suggests that PrediXcan may be useful for examining the association between gene expression and side effects of medications. Moreover, this approach successfully identified leukopenia as a side effect associated with predicted TPMT expression.

Acknowledgements

None to declare.

Disclosure of Interests

None declared.

POS1444 FLT1 AND EPHB2 ARE NOVEL GENETIC MARKERS ASSOCIATED WITH PANCREATITIS IN PATIENTS TAKING AZATHIOPRINE FOR IMMUNE-MEDIATED CONDITIONS: INTEGRATING GENOME- AND TRANSCRIPTOME-WIDE ASSOCIATION STUDIES

Background

Azathioprine (AZA) is a thiopurine immunosuppressant medication used to treat a variety of immune-mediated diseases. Unfortunately, its use is limited by adverse effects. Pancreatitis, a potentially severe, life-threatening side effect is independent of dose and necessitates AZA discontinuation given the high risk of recurrent pancreatitis with continued use or re-challenge. The mechanisms driving pancreatitis are unclear. While classic thiopurine-induced acute pancreatitis (TIAP) has been associated with HLA haplotypes, most patients taking AZA and presenting with pancreatitis do not fulfill the stringent criteria for TIAP.

Objectives

To identify genetic risk factors for pancreatitis in patients taking azathioprine for immune-mediated conditions.

Methods

Using a biobank linked to electronic health records (EHR) from a tertiary center, we identified new users of AZA. Patients were excluded if the primary indication for AZA was organ transplant or if there was a history of pancreatitis prior to AZA use. The analysis was restricted to patients with EHR-reported race as White due to insufficient case counts for the non-White group. We then identified patients with amylase or lipase values that exceeded twice the upper limit of normal (“>2x ULN”) or with ICD-9/ICD-10 codes for acute pancreatitis. Each record was manually reviewed to confirm the timing of AZA use in relation to laboratory derangements or ICD coding, as well as to further classify patients into three increasingly strict, but not exclusive categories: 1) pancreatic injury (amylase or lipase >2x ULN); 2) acute pancreatitis1, or 3) TIAP2. We completed genotyping with Illumina Infinium Expanded Multi-Ethnic Genotyping Array plus custom content data, employed Michigan Imputation servers for genetic imputation, and used PrediXcan (GTEx v8) to impute gene expression. We then conducted genome-wide association and transcriptome-wide association studies (GWAS, TWAS). Acknowledging the relatively small overall cohort, and possible imbalance of cases vs controls, we used the Firth logistic regression method, which is a penalized likelihood-based method.

Results

We studied 2127 AZA users (35.4% male; mean 44.5+/-17.2 years). The median AZA dose was 100mg/day (IQR: 50-125mg/day). Rheumatologic conditions (56.9%) and inflammatory bowel disease (40.4%) comprised the most common primary indications for AZA. Pancreatic injury, pancreatitis, and TIAP were diagnosed in 42 (2.0%), 16 (0.8%), and 9 (0.4%) patients, respectively. GWAS identified several significantly associated genes, many with overlapping TWAS findings in the pancreas and liver (Figure 1). From these, the two protein-encoding genes Fms Related Receptor Tyrosine Kinase-1 (FLT1) and Ephrin type-B receptor-2 (EPHB2) overlapped in two or more pancreatitis phenotypes in the TWAS and GWAS, respectively. EPHB2 was associated with a 8.6-fold (P=1.84 x 10-8) and a 31.4-fold (P=2.87x 10-8) higher likelihood of pancreatic injury and TIAP, respectively.

Figure 1.

Conclusion

FLT1—a gene that encodes a receptor tyrosine kinase and is a member of the vascular endothelial growth factor receptor (VEGFR) family—and EPHB2—a gene that encodes a member of the Eph receptor family, which is the largest subgroup of the receptor tyrosine kinase family—are novel genetic markers associated with pancreatitis in patients taking AZA. VEGF can potentiate inflammation and the pancreas microenvironment is known to promote VEGF expression, which has been linked to pancreatic cancer development; anti-VEGF treatments have been investigated both for mitigating inflammation and also anti-pancreatic cancer treatment. Future studies validating our findings in AZA-induced pancreatitis are warranted.

References

[1]Crockett et al. Gastroenterology (2018). 154(4):1096-1101.

[2]Heap et al. Nature Genetics (2014). 46:1131-1134

Disclosure of Interests

Shailja Shah Consultant of: ad hoc consultant for Phathom pharmaceuticals, Tyler Reese: None declared, Jacy Zanussi: None declared, Alyson Dickson: None declared, Laura Daniel: None declared, Ran Tao: None declared, Tyne Miller-Fleming: None declared, Peter Straub: None declared, Adriana Hung: None declared, Puran Nepal: None declared, Wei-Qi Wei: None declared, Elizabeth Phillips: None declared, Nancy Cox: None declared, Charles M. Stein: None declared, QiPeng Feng: None declared, Cecilia P. Chung: None declared

[HLA-B58.01 and allopurinol hypersensitivity renal vasculitis in a Chinese patient]

INTRODUCTION

Allopurinol, widely used in the treatment of hyperuricemia and gout, has been shown to cause severe cutaneous reactions, including Stevens-Johnson syndrome and toxic epidermal necrolysis, as well as systemic reactions such as DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms). The HLA-B*5801 allele is known to be a risk factor for severe cutaneous manifestations of hypersensitivity to allopurinol, mostly in Asian populations.

OBSERVATION

We report the observation of a 47-year-old Chinese patient, with no previous medical history, carrying the HLA-B*5801 allele, who developed an isolated allopurinol hypersensitivity necrotizing renal vasculitis without cutaneous manifestations.

DISCUSSION

. The identification of this allele should be proposed before prescribing allopurinol in patients originating from certain regions of Asia, and the imputability of allopurinol should be evoked in case of necrotizing renal vasculitis, even without associated cutaneous involvement.

[Minimal change nephropathy and IgA deposits associated with a Sezary syndrome]

INTRODUCTION

The Sézary syndrome (SS) is an aggressive form of cutaneous T-cell lymphoma (CTCL) requiring a rapid diagnosis due to its poor prognosis.

CASE REPORT

We report the first case of an eighty-nine-year-old woman who presented with concomitant Sezary syndrome and anasarca, revealing a nephrotic syndrome caused by a minimal change nephropathy associated with immunoglobulin A (IgA) deposits. Scarce literature described rare cases associating these two entities (nephrotic syndrome and nephropathy). However, the nephrotic syndrome was delayed from disease onset, secondary to immunosuppressive treatment of SS, or due to the weaning of SS therapy. Thus, the direct link between the glomerular lesion and the cutaneous lymphoma was difficult to establish. However, the synchronous occurrence of both SS and glomerulopathy in our patient, along with Sezary cells in both urines (urinary cytology) and biopsy, and resolution of nephropathy after treatment of SS, support the likely attributability of SS in glomerulopathy.

CONCLUSION

Practitioners must acknowledge the possible occurrence of glomerular involvement in SS.

Continuous saline bladder irrigation after blue light transurethral resection of bladder tumor increases recurrence-free survival in low- to intermediate-risk non-muscle invasive bladder cancer

OBJECTIVES

To evaluate the efficacy of Continuous Saline Bladder Irrigation (CSBI) after blue light transurethral resection of bladder tumor (TURBT) to prevent recurrence of low- to intermediate-risk Non-Muscle Invasive Bladder Cancer (NMIBC).

PATIENTS AND METHODS

We conducted a retrospective study including patients with low- to intermediate-risk NMIBC who underwent TURBT in two urological centers between January 2017 and December 2018. Each TURBT was performed using blue light after intravesical instillation of hexaminolaevulinic acid. The experimental group included patients who received CSBI while the control group included patients without CSBI. When practice, CSBI was started immediately after the surgery and was interrupted 24 hours thereafter. Low-risk NMIBC had a surveillance while intermediate NMIBC had 8 adjuvant endovesical instillations of Mitomycin. The primary endpoint was bladder tumor recurrence free-survival which was defined as the time between the initial TURBT and the date of TURBT for bladder recurrence.

RESULTS

A total of 167 patients (median age: 71 years) were included: 20% female, 15% low-risk, 85% intermediate-risk NMIBC. CSBI was performed in 95 cases (57%). No complication related to irrigation was reported. Bladder recurrence was observed in 55 cases (32.9%): 22 (23.1%) in the CSBI group vs. 33 (45.8%) in the control group (P=0.002). Multivariate stepwise logistic regression analysis with backward selection revealed that CSBI (HR 0.47 [0.27-0.81]; P=0.006) and MMC (HR 0.55 [0.31-0.95]; P=0.034) were significantly associated with reduced risk of bladder recurrence.

CONCLUSIONS

Continuous saline bladder irrigation reduced the risk of bladder recurrence after blue light TURBT in patients with low- to intermediate-risk NMIBC while being safe. Prospective randomized study is needed to confirm these results.

LEVEL OF EVIDENCE

3.

[Evolution of followed renal oncocytomas]

INTRODUCTION

Oncocytomas are primitive kidney tumours, considered benign but their evolution is not fully established. The local progression is generally admitted but few data explain what makes a oncocytoma to grow more or less quickly. The objective of our study is to analyse the evolution of followed renal oncocytomas after histologic confirmation and to identify factors that can influence their growth.

MATERIAL AND METHODS

This is a retrospective study in two centers (North Hospital and Hospital of the Conception of Marseille). All patients with renal oncocytoma diagnosed with percutaneous biopsy from September 2010 to April 2016 and followed for more than one year were included. Epidemiological, histological, and morphological data were collected at diagnosis, during follow-up and in case of strategy change (intervention). Statistical analysis of factors influencing oncocytomes growth was based on the Pearson correlation test.

RESULTS

Fifty-three patients were included. The median age for diagnosis was 65 years [39-85]. The sex ratio H/F was 6/5. The median follow-up was 34 months [12-180]. The average diagnosis size was 29 mm [12-90]. Thirteen patients (25%) were treated secondarily, including 70% by conservative treatment. The average growth was 0.25 (±0.23) cm/yr. The patients treated were younger and had a higher growth rate than the untreated (0.48±0.23cm/yr versus 0.18±0.18cm/yr, P<0,001). According to Pearson's analysis, there was a positive linear relationship (R=0.27, P=0.047) between velocity and initial size and a negative linear relationship (ρ=-0.44, P<0.001) between velocity and age at diagnosis. So tumor growth was faster if the patients were young and the tumor voluminous at diagnosis.

DISCUSSION

Rapid growth often leads to a cessation of surveillance in favour of an intervention strategy. For young patients, conservative treatment (partiel nephrectomy or ablative treatment) in the medium term is likely to be preferred, but for elderly patients or with important comorbidities follow-up is an alternative to an invasive attitude.

LEVEL OF EVIDENCE

3.

Geographic disparities in bladder cancer incidence among women in the department of Bouches-du-Rhône

Key messages

We identify for the first time a cluster of bladder cancers in women in France. Practitioners need to think about bladder cancers in women with urinary signs because this cancer will become a public health issue in the future.

[Thymic disease associated with nephrotic syndrome: a new case with membranous nephropathy and literature review]

INTRODUCTION

Malignant thymoma or thymic hyperplasia is associated with various autoimmune diseases. Renal disease has rarely been reported in this condition. We report a new case with improvement of renal disease after thymectomy.

CASE REPORT

A 77-year-old-women with nephritic syndrome was found to have associated thymic mass. Renal pathology showed membranous nephropathy. The thymic mass pathology showed a B2 type thymoma. After thymectomy the nephrotic syndrome improved.

CONCLUSION

Glomerulopathy can be secondary to an acquired thymic disease. Membranous nephropathy but also other glomerular diseases can be observed often presenting with nephritic syndrome. Despite the rarity of this association this clinical observation underlines that a thymoma should be searched in the presence of a glomerulopathy. The glomerulopathy can be improved by the treatment of the thymoma.

[Treatment by radiofrequency ablation for a renin-secreting juxtaglomerular tumour: a case report]

Juxtaglomerular cell tumors are rare and benign tumors, occurring in young patients. The standard treatment is partial nephrectomy. We report the case of a young 22-year-old patient with a renin-secreting tumor diagnosed during an exploration of severe hypertension associated with hypokalemia that we treated by radiofrequency ablation.

[Comparative study of radical prostatectomy versus external beam radiotherapy (75.6 Gy) combined with hormone therapy for prostate cancer of intermediate D'Amico risk classification]

INTRODUCTION

Thirty-three percent of the localized cancers belongs initially to the group of intermediate risk of D'Amico. The standard treatments validated by the French Association of Urology are the radical prostatectomy and the external beam radiotherapy.

OBJECTIVES

We retrospectively compared the carcinologic results of the radical prostatectomy±adjuvant treatment (RP) and the external beam radiotherapy combining high dose (75.6 Gy) and short hormonotherapy (RH), in the treatment of intermediate risk prostate cancer. The series consisted of 143 patients treated between 2000 and 2006 in the department of Urology and Kidney transplantation of the Conception Hospital, Marseilles. The main assessment criteria was the survival without biological recurrence (SBR).

RESULTS

The median follow-up was 90 months [59-51]. The 5 years and 8 years SBR were 85% and 73% in the RH group, versus 74% and 65% with RP (P=0.196). There was a significant difference between the series: on the age of diagnosis (63.9 versus 73.3 years, P<0.001), the Charlson score of comorbidity (2 versus 3, P<0.001) and the number of intermediate criteria per patients (one intermediate criteria: RP 74% versus 57%, P<0.01).

CONCLUSION

According to our study, there was no superiority of the radical prostatectomy±adjuvant treatment or the external radiotherapy combining high dose and concomitant short hormonotherapy on the survival without biological recurrence at 5 and 8 years. Many studies confirm that a concomitant hormonotherapy increases the carcinologic control, even with a high rate external beam radiotherapy.

Evaluation of hepatic steatosis in dogs with congenital portosystemic shunts using Oil Red O staining

The aims of this prospective study were to quantify steatosis in dogs with congenital portosystemic shunts (CPS) using a fat-specific stain, to compare the amount of steatosis in different lobes of the liver, and to evaluate intra- and interobserver variability in lipid point counting. Computer-assisted point counting of lipid droplets was undertaken following Oil Red O staining in 21 dogs with congenital portosystemic shunts and 9 control dogs. Dogs with congenital portosystemic shunts had significantly more small lipid droplets (<6 μ) than control dogs (P = .0013 and .0002, respectively). There was no significant difference in steatosis between liver lobes for either control dogs and CPS dogs. Significant differences were seen between observers for the number of large lipid droplets (>9 μ) and lipogranulomas per tissue point (P = .023 and .01, respectively). In conclusion, computer-assisted counting of lipid droplets following Oil Red O staining of liver biopsy samples allows objective measurement and detection of significant differences between dogs with CPS and normal dogs. This method will allow future evaluation of the relationship between different presentations of CPS (anatomy, age, breed) and lipidosis, as well as the impact of hepatic lipidosis on outcomes following surgical shunt attenuation.

[Pathological features of radiofrequency ablation (RFA) renal scar CT-imaging in a swine model]

PURPOSE

To analyze the changes in vicinal kidney parenchyma after percutaneous RFA.

MATERIALS AND METHODS

[corrected] Twenty-four CT-guided RFA procedures were performed on six pigs using 2 cm LeVeen coaxial needles. We studied volume, morphology, cavitation and enhancement of the ablation zones (AZ) before and after the procedure on contrast-injected CT-scans. The kidneys were removed four weeks later and studied in the path lab.

RESULTS

All the procedures were successfully completed. Four weeks later, the CT-scans showed AZ that were either clearly circumscribed or with unclear borders, heterogenous areas associating necrosis and infarct tissue and mesenchyma showing a process of apoptosis around the edges. A treatment considered as incomplete on the CT-scan (presenting as an enhancement) was always associated with necrosis on the histology slides, although the necrotic areas behaved in various different ways on the CT-scan after injection of contrast medium: an enhancement of more than 10 HU did not mean that no necrotic tissue was present.

CONCLUSION

RFA causes heterogenous tissue changes, associating necrotic and ischemic zones and an apoptotic reaction. The mechanisms of these changes and their therapeutic significance should be studied. CT-scans performed immediately after RFA procedure and one month later are not predictive of the efficacy of the treatment because an enhancement of the AZ does not mean that it is not necrotic. The value of a CT-scan performed one month after the procedure is debatable, because the tissue remodeling that occurs in the kidneys is not definitive at this time-point.

Noble gas (argon and xenon)-saturated cold storage solutions reduce ischemia-reperfusion injury in a rat model of renal transplantation

BACKGROUND

Following kidney transplantation, ischemia-reperfusion injury contributes to adverse outcomes. The purpose of this study was to determine whether a cold-storage solution saturated with noble gas (xenon or argon) could limit ischemia-reperfusion injury following cold ischemia.

METHODS

Sixty Wistar rats were randomly allocated to 4 experimental groups. Kidneys were harvested and then stored for 6 h before transplantation in cold-storage solution (Celsior®) saturated with either air, nitrogen, xenon or argon. A syngenic orthotopic transplantation was performed. Renal function was determined on days 7 and 14 after transplantation. Transplanted kidneys were removed on day 14 for histological and immunohistochemical analyses.

RESULTS

Creatinine clearance was significantly higher and urinary albumin significantly lower in the argon and xenon groups than in the other groups at days 7 and 14. These effects were considerably more pronounced for argon than for xenon. In addition, kidneys stored with argon, and to a lesser extent those stored with xenon, displayed preserved renal architecture as well as higher CD-10 and little active caspase-3 expression compared to other groups.

CONCLUSION

Argon- or xenon-satured cold-storage solution preserved renal architecture and function following transplantation by reducing ischemia-reperfusion injury.

[IgG4-related systemic disease: emergence of a new systemic disease? Literature review]

Hyper-IgG4 syndrome, or IgG4-related systemic disease (IgG4-RSD), has been recently characterized by the association of a focal or diffuse enlargement in one or more organs, elevated levels of serum IgG4 and histopathological findings including "storiform" fibrosis and prominent infiltration of lymphocytes and IgG4-positive plasma cells. Pancreas was the first organ involved with sclerosing pancreatitis (or autoimmune pancreatitis). Since this first description, many extrapancreatic lesions have been described, even in the absence of pancreatitis and include sialadenitis, lacrimal gland inflammation, lymphadenopathy, aortitis, sclerosing cholangitis, tubulointerstitial nephritis, retroperitoneal fibrosis or inflammatory pseudotumors. Multiorgan lesions can occur synchronously or metachronously in a same patient, usually after 50 years of age. They all share common histopathological findings. The disease often responds well to corticosteroid therapy. In this literature review on IgG4-RSD, we present historical, epidemiological and clinical characteristics, and we review the biological and histological diagnostic criteria. To date there is no international validated diagnostic criteria. Pathophysiological hypothesis and therapeutic approaches are also discussed.