Publications by authors named "Alexander Kutikov"

284 Publications

Estradiol-secreting adrenal oncocytoma in a 31-year old male.

Urol Case Rep 2022 Sep 22;44:102138. Epub 2022 Jun 22.

Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA.

Oncocytic adrenocortical tumors (OAT) are rare and often are non-functional. We report a unique case of an estradiol-secreting adrenal oncocytoma in a 31-year-old male discovered upon an infertility and gynecomastia work-up. After resection of the 9 cm adrenal mass, the patient's estradiol levels normalized from 83.2 pg/ml to 19.0 pg/ml. Gonadotropins and serum dehydroepiandrosterone sulfate also normalized.
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http://dx.doi.org/10.1016/j.eucr.2022.102138DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9241131PMC
September 2022

Association of tumor size and surgical approach with oncological outcomes and overall survival in patients with adrenocortical carcinoma.

Urol Oncol 2022 Jun 17. Epub 2022 Jun 17.

Department of Surgical Oncology, Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA.

Objectives: To investigate the association of surgical approach with outcomes in patients with adrenocortical carcinomas smaller and larger than 6 cm in size.

Methods: We reviewed the national cancer database for patients undergoing minimally invasive adrenalectomy (MIA) and open adrenalectomy (OA) from 2010 to 2017. To adjust for differences between patients undergoing MIA and OA, we performed propensity score matching within each size strata of ≤6 cm, 6.1 to 10 cm, and 10.1 to 20 cm. We fit generalized estmiating equations with a logit link function to assess for the association of surgical approach with positive surgical margins and a Cox proportional hazards model to assess for the association of surgical approach with overall survival.

Results: We identified 364 patients that underwent MIA (182) and OA (182) in the matched cohort.  We noted 21% and 18% of patients undergoing MIA and OA had a positive surgical margin, respectively. We did not identify a significant association between surgical approach and positive surgical margins in the cohort as a whole or within each of strata. Furthermore, we did not appreciate a significant association between surgical approach and overall survival in the cohort as a whole or within each size strata.

Conclusion: In the National Cancer Database, patients undergoing MIA had similar positive surgical margins and overall survival compared with OA for masses ≤6 cm, 6.1 to 10cm, and >10 cm in size. Patients undergoing MIA should be carefully selected with surgical oncologic integrity being the primary determinants of surgical approach.
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http://dx.doi.org/10.1016/j.urolonc.2022.05.021DOI Listing
June 2022

The Power of Hashtags in Social Media: Lessons Learnt from the Urology Tag Ontology Project.

Eur Urol Focus 2022 Jun 3. Epub 2022 Jun 3.

Urology Unit, Santa Maria della Misericordia University Hospital, Udine, Italy.

Standardisation of hashtags for urologic diseases in the Urology Tag Ontology (UTO) project has facilitated more efficient filtering of social media content. Hashtags must be recognisable and easy to understand. The UTO list should be expanded to include hashtags for urologic procedures and the hashtags could be used on social media platforms other than Twitter to reach a wider audience.
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http://dx.doi.org/10.1016/j.euf.2022.05.002DOI Listing
June 2022

Association of Surgical Approach With Treatment Burden, Oncological Effectiveness, and Perioperative Morbidity in Adrenocortical Carcinoma.

Clin Genitourin Cancer 2022 Apr 29. Epub 2022 Apr 29.

Department of Surgical Oncology, Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia PA.

Microabstract: In the National Cancer Database (NCDB), patients treated with minimally invasive adrenalectomy (MIA) for adrenocortical carcinoma (ACC) had similar oncological outcomes and cumulative treatment burden with less morbidity compared with open adrenalectomy (OA). Although OA remains the standard of care for adrenal lesions concerninge for malignancy, MIA in appropriately selected patients may offer equivalent oncological outcomes.

Introduction/background: We investigated the cumulative treatment burden, oncological effectiveness, and perioperative morbidity in patients undergoing MIA compared with (OA) for patients with ACC.

Patients And Methods: We reviewed the NCDB for patients undergoing surgical resection (MIA vs. OA) for ACC from 2010 to 2017. Inverse probability of treatment weighted logistic regression, negative binomial, and Cox proportional hazards models were fit to assess for an association of surgical approach with cumulative treatment burden (any adjuvant therapy, radiation therapy [RT], and systemic therapy), oncological effectiveness (positive surgical margins [PSM], lymph node yield [LNY], and overall survival [OS]), and perioperative morbidity (length of stay [LOS] and readmission) as appropriate.

Results: We identified 776 patients that underwent adrenalectomy for ACC, of which 307 underwent MIA. We noted patients with larger tumors (OR 0.82, 95% CI 0.78-0.86, P < .001) were less likely to have MIA prior to IPTW. We did not appreciate a significant association of MIA with cumulative treatment burden or the use of any adjuvant therapy (OR 0.85, 95% CI 0.60-1.21, P = .375), adjuvant RT (OR 0.94, 95% CI 0.59-1.50, P = .801), or adjuvant systemic therapy (OR 0.84, 95% CI 0.58-1.21, P = .352). Patients undergoing MIA had similar oncological effectiveness of surgery and OS when compared with patients which underwent OA. Patients that underwent MIA had a significantly shorter LOS (IRR: 0.74, 95% CI 0.62-0.88, P = .001) and lower odds of readmission (OR 0.46, 95% CI 0.23-0.91, P = .026).

Conclusions: Although the standard of care for adrenal lesions suspicious for ACC remains OA, in appropriately selected patients, MIA may offer similar oncological effectiveness and cumulative treatment burden, with less morbidity, than OA.
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http://dx.doi.org/10.1016/j.clgc.2022.04.011DOI Listing
April 2022

Contemporary Staging for Muscle-Invasive Bladder Cancer: Accuracy and Limitations.

Eur Urol Oncol 2022 Aug 14;5(4):403-411. Epub 2022 May 14.

MD Anderson Cancer Center, Houston, TX, USA. Electronic address:

Context: Bladder cancer prognosis and treatment are heavily dependent on accurate staging. Traditional imaging and pathologic evaluation of transurethral resection (TUR) specimens have been associated with high rates of clinical understaging at the time of radical cystectomy (RC).

Objective: We describe current components and limitations of bladder cancer staging for muscle-invasive bladder cancer (MIBC), and discuss the rationale for inclusion of novel biomarkers and imaging modalities to improve diagnostic accuracy.

Evidence Acquisition: We summarize the data informing MIBC staging accuracy using a nonsystematic review of published literature and provide expert opinion on current and emerging standards in MIBC staging.

Evidence Synthesis: Nearly 50% of patients undergoing RC are clinically understaged preoperatively. Components of clinical staging include TUR specimen evaluation, bimanual examination under anesthesia (EUA), and cross-sectional imaging of the chest, abdomen, and pelvis. Complete endoscopic resection of visible disease with sampling of muscularis propria is indicated. While histologic features such as tumor size, focality, variant histologic differentiation, and lymphovascular invasion have prognostic utility, insufficient evidence exists to incorporate them into current staging paradigms. For primary tumor staging, conventional computed tomography (CT) has limited accuracy in differentiating non-MIBC from MIBC. Magnetic resonance imaging (MRI) has exhibited superior pT staging accuracy with the validated Vesical Imaging Reporting and Data System. Positron emission tomography (PET)/CT does not increase clinical nodal staging accuracy beyond CT or MRI, and there exists no consensus role for the use of PET in routine clinical staging.

Conclusions: In the absence of reliable biomarkers to serve as staging adjuncts, we continue to rely heavily on basic clinical staging components-TUR with accurate pathologic evaluation, EUA, and standard cross-sectional imaging modalities. MRI shows promising accuracy and interobserver reliability for primary tumor staging.

Patient Summary: Effective clinical staging for muscle-invasive bladder cancer estimates local and systemic disease burden and can dictate eligibility for systemic therapy and/or radical cystectomy. Herein, we review the accuracy and limitations of current and emerging staging modalities.
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http://dx.doi.org/10.1016/j.euo.2022.04.008DOI Listing
August 2022

A Seat at the Table: The Correlation Between Female Authorship and Urology Journal Editorial Board Membership.

Eur Urol Focus 2022 May 6. Epub 2022 May 6.

Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA.

Background: Gender disparities in editorial board composition exist across a variety of surgical subspecialties.

Objective: To investigate temporal variation in gender representation on the editorial boards of urology journals and assess the relationship between editorial board composition and female authorship.

Design, Setting, And Participants: We analyzed female authorship and editorial board composition between 2002 and 2020 among eight high-impact urology journals. Female publication status was assessed using publication records retrieved from PubMed. Editorial board information was manually extracted and titles were grouped for comparison as Editor-in-Chief, mid-level editor, and consulting editors.

Outcome Measurements And Statistical Analysis: Female representation across different editorial levels was analyzed via hierarchical logistic regression with additional terms to test for between-journal differences in overall representation and change over time. The relationship between representation on editorial boards and as publication authors was assessed at the journal level via correlation.

Results And Limitations: Eight journals and 49 412 articles were analyzed. No female has held the title of Editor-in-Chief for any of these eight journals in 18 yr. Significant growth was seen for mid-level editors, whereas no growth was seen for consulting editors. Neurourology and Urodynamics and Journal of Sexual Medicine had significantly higher than average female editorial board representation (p < 0.05). Across the eight journals, there was a statistically significant correlation between the proportion of overall female authors and female editors (r = 0.93, 95% confidence interval 0.65-0.99). For all journals, the proportion of female contributing authors is greater than the proportion of female editorial board members.

Conclusions: Women in urology represent a small but increasing presence as editorial board members. Clear differences exist between journals, potentially attributable to specialty-specific demographics. Despite increasing representation, no female has ever been appointed Editor-in-Chief for any of the eight journals evaluated. At the journal-specific level, a positive correlation was observed between female editorial staff and female authorship. Given the implication of both academic authorship and editorial board assignment on academic advancement, actionable changes are outlined to guide improvement in gender diversity at the journal level.

Patient Summary: Females are under-represented on the editorial boards for urology journals, although some roles have seen growth over time. Moreover, female editorial board membership is associated with representation of females among article authors. Gender disparities in both are noteworthy because they affect career paths and contribute to the gender gap in urology.
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http://dx.doi.org/10.1016/j.euf.2022.04.009DOI Listing
May 2022

Pathological and genetic markers improve recurrence prognostication with the University of California Los Angeles Integrated Staging System for patients with clear cell renal cell carcinoma.

Eur J Cancer 2022 06 20;168:68-76. Epub 2022 Apr 20.

Institute of Urologic Oncology at the Department of Urology, David Geffen School of Medicine at University of California, Los Angeles, USA.

Purpose: To elucidate which patients with clear cell renal cell carcinoma have the highest risk for disease relapse after curative nephrectomy is challenging but is acutely relevant in the era of approved adjuvant therapies. Pathological and genetic markers were used to improve the University of California Los Angeles Integrated Staging System (UISS) for the risk stratification and prognostication of recurrence free survival (RFS).

Patients And Methods: Necrosis, sarcomatoid features, Rhabdoid features, chromosomal loss 9p, combined chromosomal loss 3p14q and microvascular invasion (MVI) were tested in univariable and multivariable analyses for their ability to improve the discriminatory ability of the UISS.

Results: In the development cohort, during the median follow-up time of 43.4 months (±SD 54.1 months), 50/240 (21%) patients developed disease recurrence. MVI (HR: 2.22; p = 0.013) and the combined loss of chromosome 3p/14q (HR: 2.89; p = 0.004) demonstrated independent association with RFS and were used to improve the assignment to the UISS risk category. In the current UISS high-risk group, only 7/50 (14%) recurrence cases were correctly identified; while in the improved system, 23/50 (45%) were correctly prognosticated. The concordance index meaningfully improved from 0.55 to 0.68 to distinguish patients at intermediate risk versus high risk. Internal validation demonstrated a robust prognostication of RFS. In the external validation cohort, there was no case with disease recurrence in the low-risk group, and the mean RFS times were 13.2 (±1.8) and 8.2 (±0.8) years in the intermediate and high-risk groups, respectively.

Conclusions: Adding MVI and combined chromosomal loss3p/14q to the UISS improves the ability to define the patient group with clear cell renal cell carcinomawho are at the highest risk for disease relapse after surgical treatment.
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http://dx.doi.org/10.1016/j.ejca.2022.03.023DOI Listing
June 2022

Predictors of Positive Surgical Margins after Robot-Assisted Partial Nephrectomy for Localized Renal Tumors: Insights from a Large Multicenter International Prospective Observational Project (The Surface-Intermediate-Base Margin Score Consortium).

J Clin Med 2022 Mar 23;11(7). Epub 2022 Mar 23.

Unit of Oncologic Minimally-Invasive Urology and Andrology, Department of Experimental and Clinical Medicine, Careggi Hospital, 50134 Florence, Italy.

Background: To explore predictors of positive surgical margins (PSM) after robotic partial nephrectomy (PN) in a large multicenter international observational project, harnessing the Surface-Intermediate-Base (SIB) margin score to report the resection technique after PN in a standardized way.

Methods: Data from consecutive patients with cT1-2N0M0 renal masses treated with PN from September 2014 to March 2015 at 16 tertiary referral centers and included in the SIB margin score International Consortium were prospectively collected. For the present study, only patients treated with robotic PN were included. Uni- and multivariable analysis were fitted to explore clinical and surgical predictors of PSMs after PN.

Results: Overall, 289 patients were enrolled. Median (IQR) preoperative tumor size was 3.0 (2.3-4.2) cm and median (IQR) PADUA score was 8 (7-9). SIB scores of 0-2 (enucleation), 3-4 (enucleoresection) and 5 (resection) were reported in 53.3%, 27.3% and 19.4% of cases, respectively. A PSM was recorded in 18 (6.2%) patients. PSM rate was 4.5%, 11.4% and 3.6% in case of enucleation, enucleoresection and resection, respectively. Patients with PSMs had tumors with a higher rate of contact with the urinary collecting system (55.6% vs. 27.3%; < 0.001) and a longer median warm ischemia time (22 vs. 16 min; = 0.02) compared with patients with negative surgical margins, while no differences emerged between the two groups in terms of other tumor features (i.e., pathological diameter, PADUA score). In multivariable analysis, only enucleoresection (SIB score 3-4) versus enucleation (SIB score 0-2) was found to be an independent predictor of PSM at final pathology (HR: 2.68; 95% CI: 1.25-7.63; = 0.04), while resection (SIB score 5) was not. In our experience, enucleoresection led to a higher risk of PSMs as compared to enucleation. Further studies are needed to assess the differential impacts of resection technique and surgeon's experience on margin status after robotic PN.
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http://dx.doi.org/10.3390/jcm11071765DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8999836PMC
March 2022

Impact of Trifecta definition on rates and predictors of "successful" robotic partial nephrectomy for localized renal masses: results from the Surface-Intermediate-Base Margin Score International Consortium.

Minerva Urol Nephrol 2022 Apr;74(2):186-193

Department of Urology, University of Florence, Florence, Italy -

Background: Over the years, five different Trifecta score definitions have been proposed to optimize the framing of "success" in partial nephrectomy (PN) field. However, such classifications rely on different metrics. The aim of the present study was to explore how the success rate of robotic PN, as well as its drivers, vary according to the currently available definitions of Trifecta.

Methods: Data from consecutive patients with cT1-2N0M0 renal masses treated with robotic PN at 16 referral centers from September 2014 to March 2015 were prospectively collected. Trifecta rate was defined for each of the currently available definitions. Multivariable logistic regression analysis was used to evaluate possible predictors of "Trifecta failure" according to the different adopted formulation.

Results: Overall, 289 patients met the inclusion criteria. Among the definitions, Trifecta rates ranged between 66.4% and 85.9%. Multivariable analysis showed that predictors for "Trifecta failure" were mainly tumor-related (i.e. tumor's nephrometry) for those Trifecta scores relying on WIT as a surrogate metric for postoperative renal function deterioration (definitions 1,2), while mainly surgery-related (i.e. ischemia time and excision strategy) for those including the percentage change in postoperative eGFR as the functional cornerstone of Trifecta (definitions 3-5).

Conclusions: There was large variability in rates and predictors of "unsuccessful PN" when using different Trifecta scores. Further research is needed to improve the value of the Trifecta metrics, integrating them into routine patient counseling and standardized assessment of surgical quality across institutions.
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http://dx.doi.org/10.23736/S2724-6051.21.04601-2DOI Listing
April 2022

Novel Imaging Methods for Renal Mass Characterization: A Collaborative Review.

Eur Urol 2022 05 22;81(5):476-488. Epub 2022 Feb 22.

Urology Associates and UPMC Western Maryland, Cumberland, MD, USA; Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. Electronic address:

Context: The incidental detection of localized renal masses has been rising steadily, but a significant proportion of these tumors are benign or indolent and, in most cases, do not require treatment. At the present time, a majority of patients with an incidentally detected renal tumor undergo treatment for the presumption of cancer, leading to a significant number of unnecessary surgical interventions that can result in complications including loss of renal function. Thus, there exists a clinical need for improved tools to aid in the pretreatment characterization of renal tumors to inform patient management.

Objective: To systematically review the evidence on noninvasive, imaging-based tools for solid renal mass characterization.

Evidence Acquisition: The MEDLINE database was systematically searched for relevant studies on novel imaging techniques and interpretative tools for the characterization of solid renal masses, published in the past 10 yr.

Evidence Synthesis: Over the past decade, several novel imaging tools have offered promise for the improved characterization of indeterminate renal masses. Technologies of particular note include multiparametric magnetic resonance imaging of the kidney, molecular imaging with targeted radiopharmaceutical agents, and use of radiomics as well as artificial intelligence to enhance the interpretation of imaging studies. Among these, Tc-sestamibi single photon emission computed tomography/computed tomography (CT) for the identification of benign renal oncocytomas and hybrid oncocytic chromophobe tumors, and positron emission tomography/CT imaging with radiolabeled girentuximab for the identification of clear cell renal cell carcinoma, are likely to be closest to implementation in clinical practice.

Conclusions: A number of novel imaging tools stand poised to aid in the noninvasive characterization of indeterminate renal masses. In the future, these tools may aid in patient management by providing a comprehensive virtual biopsy, complete with information on tumor histology, underlying molecular abnormalities, and ultimately disease prognosis.

Patient Summary: Not all renal tumors require treatment, as a significant proportion are either benign or have limited metastatic potential. Several innovative imaging tools have shown promise for their ability to improve the characterization of renal tumors and provide guidance in terms of patient management.
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http://dx.doi.org/10.1016/j.eururo.2022.01.040DOI Listing
May 2022

The Role of Cytoreductive Nephrectomy in Metastatic Renal Cell Carcinoma: A Real-World Multi-Institutional Analysis.

J Urol 2022 07 25;208(1):71-79. Epub 2022 Feb 25.

Department of Urology, Fox Chase Cancer Center, Philadelphia, Pennsylvania.

Purpose: The role of cytoreductive nephrectomy (CN) in metastatic renal cell carcinoma (mRCC) was challenged by the results of the CARMENA trial. Here we evaluate the role of CN in mRCC patients, including those receiving modern therapies.

Materials And Methods: We included patients with synchronous mRCC between 2011-2020 from the de-identified nationwide Flatiron Health database. We evaluated 3 groups: systemic therapy alone, CN followed by systemic therapy (up-front CN [uCN]) and systemic therapy followed by CN (deferred CN [dCN]). The primary outcome was median overall survival (mOS) in patients receiving systemic therapy alone vs uCN. Secondary outcome was overall survival in patients receiving uCN vs dCN. First-treatment, landmark and time-varying covariate analyses were conducted to overcome immortal time bias. Weighted Kaplan-Meier curves, log-rank tests and Cox proportional hazards regressions were used to assess the effect of therapy on survival.

Results: Of 1,910 patients with mRCC, 972 (57%) received systemic therapy, 605 (32%) received uCN, 142 (8%) dCN and 191 (10%) CN alone; 433 (23%) patients received immunotherapy-based therapy. The adjusted mOS was significantly improved in first-treatment, landmark and time-varying covariate analysis (mOS 26.6 vs 14.6 months, 36.3 vs 21.1 months and 26.1 vs 12.2 months, respectively) in patients undergoing CN. Among patients receiving CN and systemic therapy, the timing of systemic therapy relative to CN was not significantly related to overall survival (HR=1.0, 95% CI 0.76-1.32, p=0.99).

Conclusions: Our findings support an oncologic role for CN in select mRCC patients. In patients receiving both CN and systemic therapy, the survival benefit compared to systemic alone was similar for up-front and deferred CN.
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http://dx.doi.org/10.1097/JU.0000000000002495DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9187610PMC
July 2022

The Delayed Nephrogram: Point-of-care Quantitative Measurement, Validation as an Indicator of Obstruction, and Novel Use as a Predictor of Renal Functional Impairment.

Eur Urol Focus 2022 Feb 15. Epub 2022 Feb 15.

Division of Urology, Department of Surgery, Fox Chase Cancer Center, Philadelphia, PA, USA.

Background: The diagnostic value of delayed nephrograms on contrast-enhanced computed tomography has not been studied rigorously.

Objective: To develop a method for quantitatively assessing delayed and diminished nephrograms (DDNs) easily at the point of care and to assess the association of DDNs with renal obstruction and renal function.

Design, Setting, And Participants: Data were reviewed from 76 patients who underwent a contrast-enhanced computed tomography scan within 30 days of a technetium-99m mercaptoacetyltriglycine diuretic renal scintigraphy (MAG3-DRS) which showed at least one kidney to have normal drainage (T1/2 <10 min) between 2010 and 2021 at a tertiary academic center.

Outcome Measurements And Statistical Analysis: Attenuations of the renal cortex and medulla were measured using circular regions of interest. These attenuations were compared between kidneys to compute several measures of DDN in the kidney with a greater concern for obstruction. Renal parenchymal volume and anterior-posterior renal pelvis diameter (APD) were estimated using simple linear measurements. Inter-rater reliability was computed using the intraclass correlation coefficient (ICC), correlations were computed using Spearman's R, and the relationships between DDN, APD, and renal function of the subject kidney were estimated using linear regression.

Results And Limitations: Measures of DDN were highly reliable between raters (ICC 0.71-0.87). DDN was almost always associated with prolonged drainage on MAG3-DRS (90-100%); however, 33-52% of patients with prolonged drainage on MAG3-DRS had no appreciable DDN, depending on the measure of the DDN chosen. All measures of DDN were associated with decreased renal function (<0.001). APD did not significantly predict renal function when controlling for a DDN.

Conclusions: DDNs on contrast-enhanced computed tomography are associated with renal obstruction and can easily and accurately be quantified at the point of care. A DDN is more closely associated with renal dysfunction than renal pelvic dilation and therefore may be useful in assessing the severity of upper tract obstruction.

Patient Summary: In this report, we confirm that a "delayed nephrogram", a classic x-ray finding thought to be associated with kidney blockage, is associated with blockage of the affected kidney. Furthermore, we show that a delayed nephrogram indicates that the affected kidney is not functioning as well as we would expect for a normal kidney of the same size. Since the severity of a delayed nephrogram predicts this decreased function better than the degree of dilation of the kidney, which is a different measurement often used to measure the severity of kidney blockage, the delayed nephrogram may be a better way of measuring the severity of kidney blockage in clinical practice.
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http://dx.doi.org/10.1016/j.euf.2022.01.019DOI Listing
February 2022

Ischemia Time Has Little Influence on Renal Function Following Partial Nephrectomy: Is It Time for Urology to Stop the Tick-Tock Dance?

Eur Urol 2022 05 12;81(5):501-502. Epub 2022 Feb 12.

Department of Surgical Oncology, Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA.

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http://dx.doi.org/10.1016/j.eururo.2022.01.036DOI Listing
May 2022

Optimal Dissemination of Scientific Manuscripts via Social Media: A Prospective Trial Comparing Visual Abstracts Versus Key Figures in Consecutive Original Manuscripts Published in European Urology.

Eur Urol 2022 Feb 9. Epub 2022 Feb 9.

Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA.

Visual abstracts (VAs) are graphical representations of the key findings in manuscripts and have been adopted by many journals to improve content dissemination via social media. We sought to assess whether VAs, compared to key figures (KFs), increased reader engagement via social media using articles published in European Urology. We prospectively randomized 200 consecutive new publications to representation on Twitter and Instagram using either a VA (n = 99) or a KF (n = 101). Randomization was stratified by prostate cancer content. The primary outcome was Twitter impressions. Secondary outcomes included Twitter total engagements, link clicks, likes, and retweets, as well as Instagram likes. Analysis of covariance was conducted using the stratification variable as a covariate. We found that Twitter impressions were greater for tweets containing VAs compared to KFs (8385 vs 6882; adjusted difference 1480, 95% confidence interval [CI] 434-2526; p = 0.006). VA use was also associated with more retweets and likes (p < 0.002), but fewer full-article link clicks than KFs (60 vs 105, adjusted difference 45, 95% CI 21-70; p = 0.0004). The choice between VA and KF should depend on the relative value given to impressions versus full-article link clicks. PATIENT SUMMARY: We found that use of a visual abstract increases the social media reach of new urology articles when compared to key figures from the manuscript, but was associated in a significantly lower click-through rate. In the increasingly virtual world of academic medicine, these findings may assist authors, editors, and publishers with dissemination of new research.
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http://dx.doi.org/10.1016/j.eururo.2022.01.041DOI Listing
February 2022

Predictive Models for Patients with a Renal Mass in the Clinical Trenches Continue to be a Muddy Proposition.

Eur Urol 2022 Jun 9;81(6):586-587. Epub 2022 Feb 9.

Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA, USA.

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http://dx.doi.org/10.1016/j.eururo.2022.01.034DOI Listing
June 2022

Stereotactic ablative radiation therapy for renal cell carcinoma with inferior vena cava tumor thrombus.

Urol Oncol 2022 04 8;40(4):166.e9-166.e13. Epub 2022 Feb 8.

University of Texas Southwestern Medical Center, Dallas, TX. Electronic address:

Background: Inferior vena cava tumor thrombus (IVC-TT) is a rare yet deadly sequel of renal cell carcinoma (RCC) with limited treatment options. The standard treatment is extirpative surgery, which has high rates of morbidity and mortality. As a result, many patients are unfit or unwilling to undergo surgery and face poor prognosis. This stresses the need for alternative options for local disease control. Our study aims to assess the feasibility and oncological outcomes of stereotactic ablative radiation (SAbR) for IVC-TT.

Methods: A retrospective study reviewing six leading international institutions' experience in treating RCC with IVC-TT with SAbR. Primary end point was overall survival using Kaplan-Meier.

Results: Fifteen patients were included in the cohort. Over 50% of patients had high level IVC-TT (level III or IV), 66.7% had metastatic disease. Most eschewed surgery due to high surgical risk (7/15) or recurrent thrombus (3/15). All patients received SAbR to the IVC-TT with a median biologically equivalent dose (BED) of 72 Gy (range: 37.5-100.8) delivered in a median of 5 fractions (range 1-5). Median overall survival was 34 months. Radiographic response was observed in 58% of patients. Symptom palliation was recorded in all patients receiving SAbR for this indication. Only grade 1 to 2 adverse events were noted.

Conclusions: SAbR for IVC-TT appears feasible and safe. In patients who are not candidates for surgery, SAbR may palliate symptoms and improve outcomes. SAbR may be considered as part of a multimodal treatment approach for patients with RCC IVC-TT.
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http://dx.doi.org/10.1016/j.urolonc.2021.12.018DOI Listing
April 2022

Propensity-score matched oncological outcomes and patterns of recurrence following open and minimally-invasive partial nephrectomy for renal cell carcinoma.

Urol Oncol 2022 03 6;40(3):111.e19-111.e25. Epub 2022 Feb 6.

Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY. Electronic address:

Background: Oncological equivalency of minimally-invasive partial nephrectomy compared to open partial nephrectomy (OPN) continues to be challenged by proponents of open urologic oncology surgery.

Objective: To compare patterns of recurrence, recurrence-free survival, cancer-specific survival, and overall survival between patients who underwent open or minimally-invasive partial nephrectomy.

Materials And Methods: Data from prospectively maintained databases from 2 urban quaternary referral centers was retrospectively collected from 2003 to 2018. Patients who underwent either open or minimally-invasive (laparoscopic or robotic-assisted) partial nephrectomy and found to have malignant pathology were included. The groups subsequently underwent propensity-score matching to ensure homogeneity prior to analysis. The primary outcomes were incidence of recurrence, time to recurrence, time from recurrence to death, location of recurrence, and recurrence-free survival. Secondary outcomes included overall survival and cancer-specific survival.

Results: A total of 190 patients underwent OPN and 190 underwent minimally-invasive partial nephrectomy. Recurrence was more common in patients undergoing OPN (10% vs. 3.2%, P = 0.01), but surgical approach was not predictive of location of recurrence (P = 1) or time to recurrence (23.8 vs. 26.3 months, P = 0.73). All-cause mortality was more common in the OPN group (10.5% vs. 2.6%, P = 0.003). On multivariable analysis, only surgical approach was associated with increased risk for recurrence (OR 3.88, P = 0.009).

Conclusion: This propensity-score matched analysis of patients undergoing partial nephrectomy suggests that minimally invasive surgical approach is resulted in decreased risk of recurrence and overall survival, and does not increase the risk for atypical sites of recurrence.
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http://dx.doi.org/10.1016/j.urolonc.2021.12.011DOI Listing
March 2022

A Point-of-Care Resource to Improve Care of Patients with Adrenal Mass: www.AdrenalMass.org.

Eur Urol 2022 04 14;81(4):434. Epub 2022 Jan 14.

Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA.

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http://dx.doi.org/10.1016/j.eururo.2021.12.025DOI Listing
April 2022

Redefining the Gender Gap in Urology Authorship: An 18-Year Publication Analysis.

Eur Urol Focus 2021 Dec 30. Epub 2021 Dec 30.

Fox Chase Cancer Center, Division of Urologic Oncology, Philadelphia, PA, USA.

Background: Academic authorship is a critical productivity metric used for academic promotion.

Objective: To characterize temporal changes in female representation in academic authorship in ten primary urology journals as the complement of female urologists is increasing.

Design, Setting, And Participants: Publication records were retrieved from 2002 to 2020 for the ten urology journals with the highest impact factor. The names of all authors were gathered and gender was inferred using first names.

Outcome Measurements And Statistical Analysis: Trends in first and last/senior authorship by gender were evaluated overall, within journals, and by geographic region.

Results: A total of 59,375 articles were analyzed, of which 94.1% had gender information for the first author and 94.2% had gender information for the last author. The percentage of overall female authors increased positively from 17.2% (95% highest density interval [HDI] 12.9-21.4%) in 2002 to 27.2% (HDI 21.7-33.6%; p < 0.01) in 2020. Overall female first authorship increased from 15.2% (95% HDI 11.0-19.5%) to 28.5% (95% HDI 21.8-35.6%; p < 0.01). There was also significant growth for female senior authors from 10.4% (95% HDI 7.6-13.5%) to 18.6% (95% HDI 13.6-23.8%; p < 0.01). Assessment of journal-specific changes revealed that Neurourology and Urodynamics (12.6%, 95% HDI 9.9-15.1%) and The Journal of Sexual Medicine (16.2%, 95% HDI 13.6-19.0%) had significantly higher growth in female authorship when compared to Journal of Endourology (7.2%, 95% HDI 5.5-8.7%) and Urologic Oncology (4.5%, 95% HDI 2.0-6.8%; p < 0.05).

Conclusions: Although overall female authorship increased between 2002 and 2020, women remain underrepresented in urology authorship. The percentage of females in senior (last) author positions is less than the percentage of females in first author positions. Journal-specific differences can probably be attributed to gender-based differences in subspecialized fields.

Patient Summary: In this study, we characterized the underrepresentation of women as authors in urology journals and analyzed the change in female authorship for ten academic urology journals over the course of 18 years. Although the proportion of female authors has increased over that time, the percentage of females in senior authorship roles is less than the percentage of females in first author positions.
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http://dx.doi.org/10.1016/j.euf.2021.12.001DOI Listing
December 2021

Management of SHDB positive patient with metastatic bilateral giant retroperitoneal paragangliomas.

Urol Case Rep 2022 Jan 26;40:101950. Epub 2021 Nov 26.

Division of Urologic Oncology, Department of Surgery, Fox Chase Cancer Center-Temple University Health System, Philadelphia, PA, USA.

Paragangliomas are rare neuroendocrine tumors that can vary in size and metabolic activity. We report a case of giant bilateral malignant retroperitoneal paragangliomas (PGL) in a patient with germline succinate dehydrogenase B (SDHB) mutation. This patient, who presented in an emaciated and debilitated state, was managed with adrenergic blockade followed by radical primary surgery. After being metabolically and radiographically disease free for 4 years, he underwent salvage resection for recurrent retroperitoneal disease and palliative radiation to a site of solidary vertebral metastasis. We review incidence and prognosis of metastatic PGL.
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http://dx.doi.org/10.1016/j.eucr.2021.101950DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8649644PMC
January 2022

Re: Adjuvant Pembrolizumab After Nephrectomy in Renal-cell Carcinoma.

Eur Urol 2022 03 9;81(3):317-318. Epub 2021 Dec 9.

Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA, USA. Electronic address:

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http://dx.doi.org/10.1016/j.eururo.2021.11.026DOI Listing
March 2022

Harnessing choice architecture in urologic practice: Implementation of an opioid-sparing protocol grounded in cognitive behavioral theory.

Urol Oncol 2022 03 6;40(3):95-102. Epub 2021 Dec 6.

Division of Urologic Oncology and Urology, Fox Chase Cancer Center, Philadelphia, PA.

Purpose: Opioids are prescribed excessively following surgery. As many urologic oncology procedures are performed minimally invasively, an opportunity exists to push forward initiatives to minimize postoperative opioid use.

Materials And Methods: A quality improvement initiative to reduce inpatient opioid prescribing was launched at a tertiary cancer center. In Phase I (December 2019-July 2020), providers were instructed to start standing acetaminophen. In Phase II (beginning August 2020), education was provided to the entire care team and ordersets were modified to an opioid sparing protocol (OSP). We analyzed the proportion of minimally invasive surgery (MIS) prostatectomy and nephrectomy patients that adhered to an OSP during each phase and compared them to controls from the preceding 2 years.

Results: A total of 303, 153, and 839 patients underwent MIS during the Phase I, Phase II, and control periods respectively. The proportion of patients adhering to an OSP increased from 16% at the beginning of Phase I to 76% at the end of Phase II (p-trend < 0.001). The median total oral morphine equivalents for oral opioids declined from 20 mg and 40 mg at baseline for prostatectomy and nephrectomy patients respectively to 0 mg for both groups (p-trends < 0.001). Multivariable analysis found that patients received 22% and 81% less oral morphine equivalents during Phase I and II respectively compared to the control period (P < 0.001).

Conclusions: Adherence to an OSP is most effective when initiatives incorporate the entire team and are supported by nudge theory-based structural changes. Using these strategies, most patients following urologic MIS can dramatically reduce opioid use postoperatively.
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http://dx.doi.org/10.1016/j.urolonc.2021.10.011DOI Listing
March 2022

Impact of surgical approach and resection technique on the risk of Trifecta Failure after partial nephrectomy for highly complex renal masses.

Eur J Surg Oncol 2022 Mar 27;48(3):687-693. Epub 2021 Nov 27.

Department of Urology, University of Florence, Florence, Italy, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy. Electronic address:

Introduction: We aimed to compare the outcomes of open vs robotic partial nephrectomy (PN), focusing on predictors of Trifecta failure in patients with highly complex renal masses.

Patients And Methods: We queried the prospectively collected database from the SIB International Consortium, including 507 consecutive patients with cT1-2N0M0 renal masses treated at 16 high-volume referral centres, to select those with highly complex (PADUA score ≥10) tumors undergoing PN. RT was classified as enucleation, enucleoresection or resection according to the SIB score. Trifecta was defined as achievement of negative surgical margins, no acute kidney injury and no Clavien-Dindo grade ≥2 postoperative surgical complications. Multivariable logistic regression analysis was used to assess independent predictors of Trifecta failure.

Results: 113 patients were included. Patients undergoing open PN (n = 47, 41.6%) and robotic PN (n = 66, 58.4%) were comparable in baseline characteristics. RT was classified as enucleation, enucleoresection and resection in 46.9%, 34.0% and 19.1% of open PN, and in 50.0%, 40.9% and 9.1% of robotic PN (p = 0.28). Trifecta was achieved in significantly more patients after robotic PN (69.7% vs. 42.6%, p = 0.004). On multivariable analysis, surgical approach (open vs robotic, OR: 2.62; 95%CI: 1.11-6.15, p = 0.027) and tumor complexity (OR for each additional unit of the PADUA score: 2.27; 95%CI: 1.27-4.06, p = 0.006) were significant predictors of Trifecta failure, while RT was not. The study is limited by lack of randomization; as such, selection bias and confounding cannot be entirely ruled out.

Conclusions: Tumor complexity and surgical approach were independent predictors of Trifecta failure after PN for highly complex renal masses.
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http://dx.doi.org/10.1016/j.ejso.2021.11.126DOI Listing
March 2022

Multiple brain metastases in a patient with ypT0N0 micropapillary urothelial carcinoma of the bladder.

Urol Case Rep 2021 Nov 13;39:101838. Epub 2021 Sep 13.

Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA.

Radical cystectomy (RC) after neoadjuvant chemotherapy (NAC) is the gold standard for management of muscle-invasive bladder cancer (MIBC). Patients without residual tumor at the time of extirpative surgery (ypT0) have excellent prognosis. Distant metastases in this population are rare. We present a unique case of a patient with ypT0N0 urothelial carcinoma (UC) with rapid development of metastasis to the brain.
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http://dx.doi.org/10.1016/j.eucr.2021.101838DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8488483PMC
November 2021

Feasibility and Outcomes of Renal Mass Biopsy for Anatomically Complex Renal Tumors.

Urology 2021 12 8;158:125-130. Epub 2021 Aug 8.

The Department of Surgery, Division of Urologic Oncology, Fox Chase Cancer Center - Temple Health, Philadelphia, PA. Electronic address:

Objective: To compare the feasibility and outcomes of renal mass biopsies (RMB) of anatomically complex vs non-complex renal masses.

Methods: Our institutional renal tumor database was queried for patients who underwent RMB between 2005 and 2019 and with available nephrometry score. Complex masses were: (1) small (<2 cm), (2) entirely endophytic (nephrometry E=3), (3) hilar (h) or (4) partially endophytic (E=2) and anterior. Demographic and pathologic data were compared. Biopsies were deemed adequate if they resulted in a diagnosis. Concordance with surgical pathology was assessed. These were both presented using proportions. Factors associated with biopsy outcomes were identified using multivariable logistic regression. RMB sensitivity and specificity were calculated using contingency methods.

Results: A total of 306 RBMs were included, 179 complex and 127 non-complex. A total of 199 (65%) had an extirpative procedure. Complex lesions were less likely to have an adequate biopsy (89% vs 96%, P = .03), and to be concordant with final surgical pathology from an oncologic standpoint (89% vs 97%, P = .03). There was no significant difference in concordance of histology (76% vs 86%, P = .10) or grade (48 vs 51%, P = .66). On multivariable analyses, only male gender was associated with biopsy adequacy (OR 3.31, 95% CI 1.28-8.55, P = .01). Our overall sensitivity was 93%, specificity 93%, and accuracy 93%. There were no significant differences over time in biopsy outcomes during the study period.

Conclusion: RMB of complex lesions is associated with excellent diagnostic yield, albeit lower than non-complex lesions. RMB should not be deferred in cases of anatomically complex lesions where additional data could improve clinical decision-making.
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http://dx.doi.org/10.1016/j.urology.2021.07.026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9039834PMC
December 2021

Papillary Renal Neoplasm With Reverse Polarity Is Often Cystic: Report of 7 Cases and Review of 93 Cases in the Literature.

Am J Surg Pathol 2022 03;46(3):336-343

Departments of Pathology.

Papillary renal neoplasm with reverse polarity (PRNRP) is a newly proposed entity with distinct histology and frequent KRAS mutations. To date, 93 cases of PRNRPs have been reported. In this study, we present 7 new cases of PRNRP and review the literature. Most of the pathologic features in our 7 cases are similar to those previously reported cases. However, all 7 of our cases showed at least partial cystic changes, which was not stressed in prior studies. Single-nucleotide polymorphism-microarray based chromosomal analysis demonstrated no trisomy or other alteration of chromosomes 7 or 17; and no loss or other alteration of chromosome Y was detected in all 7 cases. Next-generation sequencing detected KRAS missense mutations in 4 of 7 cases. No fusion genes were detected. In summary, PRNRP is a small, well-circumscribed often encapsulated and cystic neoplasm with loose papillary formations. Cuboidal tumor cells always have eosinophilic cytoplasm and nuclei located at the pole opposite the basement membrane with a low World Health Organization (WHO)/International Society of Urologic Pathologists (ISUP) nuclear grade. The fibrovascular cores can be hyalinized or edematous. Macrophage aggregates and intracellular hemosiderin are uncommon, and no psammoma bodies or necrosis should be seen. Immunophenotypically, this tumor is always positive for CK7 and GATA3, and negative for CD117 and vimentin. CD10 and AMACR can be positive, but often weakly and focally. PRNRP often has KRAS mutations, however, only 32% of cases have chromosomal abnormalities in chromosomes 7, 17, and Y. No recurrences, metastases, or tumor-related deaths have been reported following complete resection.
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http://dx.doi.org/10.1097/PAS.0000000000001773DOI Listing
March 2022

Genetic risk assessment for hereditary renal cell carcinoma: Clinical consensus statement.

Cancer 2021 Nov 3;127(21):3957-3966. Epub 2021 Aug 3.

Massachusetts General Hospital Cancer Center, Boston, Massachusetts.

Background: Although renal cell carcinoma (RCC) is believed to have a strong hereditary component, there is a paucity of published guidelines for genetic risk assessment. A panel of experts was convened to gauge current opinions.

Methods: A North American multidisciplinary panel with expertise in hereditary RCC, including urologists, medical oncologists, clinical geneticists, genetic counselors, and patient advocates, was convened. Before the summit, a modified Delphi methodology was used to generate, review, and curate a set of consensus questions regarding RCC genetic risk assessment. Uniform consensus was defined as ≥85% agreement on particular questions.

Results: Thirty-three panelists, including urologists (n = 13), medical oncologists (n = 12), genetic counselors and clinical geneticists (n = 6), and patient advocates (n = 2), reviewed 53 curated consensus questions. Uniform consensus was achieved on 30 statements in specific areas that addressed for whom, what, when, and how genetic testing should be performed. Topics of consensus included the family history criteria, which should trigger further assessment, the need for risk assessment in those with bilateral or multifocal disease and/or specific histology, the utility of multigene panel testing, and acceptance of clinician-based counseling and testing by those who have experience with hereditary RCC.

Conclusions: In the first ever consensus panel on RCC genetic risk assessment, 30 consensus statements were reached. Areas that require further research and discussion were also identified, with a second future meeting planned. This consensus statement may provide further guidance for clinicians when considering RCC genetic risk assessment.

Lay Summary: The contribution of germline genetics to the development of renal cell carcinoma (RCC) has long been recognized. However, there is a paucity of guidelines to define how and when genetic risk assessment should be performed for patients with known or suspected hereditary RCC. Without guidelines, clinicians struggle to define who requires further evaluation, when risk assessment or testing should be done, which genes should be considered, and how counseling and/or testing should be performed. To this end, a multidisciplinary panel of national experts was convened to gauge current opinion on genetic risk assessment in RCC and to enumerate a set of recommendations to guide clinicians when evaluating individuals with suspected hereditary kidney cancer.
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http://dx.doi.org/10.1002/cncr.33679DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8711633PMC
November 2021

Early Prostate-Specific Antigen Kinetics for Low- and Intermediate-Risk Prostate Cancer Treated With Definitive Radiation Therapy.

Pract Radiat Oncol 2022 Jan-Feb;12(1):60-67. Epub 2021 Jul 21.

Departments of Radiation Oncology. Electronic address:

Purpose: This study used a patient-specific model to characterize and compare ideal prostate-specific antigen (PSA) kinetics for low- and intermediate-risk prostate cancer after definitive radiation treatment with conventionally fractionated, hypofractionated, stereotactic body radiation therapy, or brachytherapy, both high-dose and low-dose rate.

Methods And Materials: This retrospective analysis includes low- and intermediate-risk patients with prostate cancer treated between 1998 and 2018 at an National Cancer Institute-designated comprehensive cancer center. Demographics and treatment characteristics were prospectively collected. Patients had at least 2 PSA measurements within 24 months of treatment and were free from biochemical recurrence. The incidence of, time to, and risk factors for PSA nadir (nPSA) and bounce (bPSA) were analyzed at 24 months after radiation therapy. Ideal PSA kinetics were characterized for each modality and compared.

Results: Of 1042 patients, 45% had low-risk cancer, 37% favorable intermediate risk, and 19% unfavorable intermediate risk. nPSAs were higher for ablative modalities, both as absolute nPSA and relative to initial PSA. Median time to nPSA ranged from 14.8 to 17.1 months. Over 50% treated with nonablative therapy (conventionally fractionated, hypofractionated, and low-dose rate) reached an nPSA threshold of ≤0.5 ng/mL compared with 23% of stereotactic body radiation therapy and 33% of high-dose rate cohorts. The incidence of bPSA was 13.3% and not affected by treatment modality, Gleason score, or prostate volume. PSA decay rate was faster for ablative therapies in the 6- to 24-month period.

Conclusions: Analysis of PSA within 24 months after radiation therapy revealed ablative therapies are associated with a latent PSA response and higher nPSA. Multivariable logistics modeling revealed younger age, initial PSA above the median, presence of bPSA, and ablative therapy as predictors for not achieving nPSA ≤0.5 ng/mL. PSA decay rate appears to be faster in ablative therapies after a latent period. Understanding the different PSA kinetic profiles is necessary to assess treatment response and survey for disease recurrence.
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http://dx.doi.org/10.1016/j.prro.2021.07.003DOI Listing
January 2022

Identification of oncological characteristics associated with improved overall survival in patients with adrenocortical carcinoma treated with adjuvant radiation therapy: Insights from the National Cancer Database.

Urol Oncol 2021 11 21;39(11):791.e1-791.e7. Epub 2021 Jul 21.

Department of Surgical Oncology, Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia PA. Electronic address:

Objectives: To test for an association between oncological risk factors and overall survival in patients with non-metastatic adrenocortical carcinoma treated with adjuvant radiation therapy at high-risk for recurrence per NCCN guidelines.

Materials And Methods: We analyzed data from patients undergoing surgical resection with or without aRT in the NCDB from 2004 to 2017. A multivariable Cox proportional hazards model was fit to assess for an association of aRT and OS. To determine whether aRT was associated with improved OS in patients with specific NCCN risk factors, we fit three multivariable Cox proportional hazard models with an interaction term between NCCN risk factors and the use of aRT.

Results: We identified 1,433 patients treated surgically for adrenocortical carcinoma with at least one risk factor. 259 patients received adjuvant radiation therapy (18%) while 1,174 (82%) patients did not. After adjustment, we noted a significant association between adjuvant radiation therapy and overall survival in the entire cohort in the multivariable Cox proportional hazards model (HR 0.68, 95% CI 0.55-0.85, P = 0.001). Adjuvant radiation therapy was associated with increased overall survival in patients with positive surgical margins (HR 0.47, 95% CI 0.35-0.65, P < 0.001), large tumor size ≥6 cm (HR 0.69, 95% CI 0.55-0.87, P = 0.002), and high-grade disease (HR 0.61, 95% CI 0.37-0.99, P = 0.046).

Conclusions: Patients with ACC at high-risk for recurrence were associated with improved overall survival when treated with adjuvant radiation therapy. These data may help identify which patients should consider aRT after resection of clinically localized ACC.
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http://dx.doi.org/10.1016/j.urolonc.2021.06.019DOI Listing
November 2021
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