Publications by authors named "Darrel E Drachenberg"

35 Publications

The Association Between Income Status and Treatment Selection for Prostate Cancer in a Universal Healthcare System: A Population-Based Analysis.

J Urol 2021 Jun 28:101097JU0000000000001942. Epub 2021 Jun 28.

Section of Urology, University of Manitoba, Winnipeg, MB, Canada.

Purpose: Treatment selection for localized prostate cancer is guided by risk stratification and patient preferences. While socioeconomic status (SES) disparities exist for access to care, less is known on the effect of SES on treatment decision making. We sought to evaluate whether income status was associated with the treatment selected (radical prostatectomy (RP) versus radiation therapy (RT)) for nonmetastatic prostate cancer in a universal health care system.

Materials And Methods: All men from Manitoba, Canada who were diagnosed with nonmetastatic prostate cancer between 2005 and 2016 and subsequently treated with RP or RT were identified using a provincial cancer database. SES was defined as neighbourhood income by postal code and divided into income quintiles (Q1-Q5, with Q1 the lowest quintile and Q5 the highest). Multivariable logistic regression nested models were used to compare whether SES was associated with treatment type received.

Results: We identified 3,966 individuals who were diagnosed with nonmetastatic prostate cancer and were treated with RP (n=2,354) or RT (n=1,612). After adjusting for demographic and clinicopathologic characteristics, as income quintile increased, men were incrementally more likely to undergo RP than RT (range: Q2 vs. Q1: aOR 1.40, 95% CI 1.01-1.93; Q5 vs. Q1: aOR 2.30, 95% CI 1.70-3.12).

Conclusions: As income levels increased there was a stepwise incremental increase in the odds of receiving RP over RT for localized prostate cancer. These results may inform initiatives to better understand the values, priorities and barriers that patients experience when making treatment decisions in a universal health care system.
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http://dx.doi.org/10.1097/JU.0000000000001942DOI Listing
June 2021

Adrenalectomy During Radical Nephrectomy- Incidence and Oncologic Outcomes From the Canadian Kidney Cancer Information System (CKCis) -A Modern Era, Nationwide, Multicenter Cohort.

Urology 2021 Jun 12. Epub 2021 Jun 12.

Urology Division, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada. Electronic address:

Objective: To characterize proportion of patients receiving adrenalectomy, adrenal involvement prevalence and oncologic outcomes of routine adrenalectomy in contemporary practice. Ipsilateral adrenalectomy was once standard during radical nephrectomy. However, benefit of routine adrenalectomy has been questioned because adrenal involvement of renal cell carcinoma (RCC) is low.

Methods: All patients receiving radical nephrectomy in the Canadian Kidney Cancer information system, a collaborative prospective cohort populated by 14 major Canadian centers, between January 2011 to February 2020 were included. Patients were excluded if they had non-RCC histology, multiple tumors, contralateral tumors, metastatic disease or previous history of RCC. Patient demographic, clinical, and surgical information were summarized and compared. Cox-proportional hazards was used for multivariable analysis.

Results: During study period, 2759 patients received radical nephrectomy, of these, 831(30.1%) had concomitant adrenalectomy. Pathological adrenal involvement was identified in 102 (3.7%overall; 12.3%of adrenalectomy). Median follow-up was 21.6months (Interquartile range 7.0-46.5). Patients with adrenalectomy had higher venous tumor thrombus (30.3% vs 9.6%; P <.0001), higher T stage (71.1% vs 43.4% pT3/4; P <.0001), lymph node metastases (17.6% vs 10.7%; P = .0035), Fuhrman grades (71.4% of Fuhrman grades 3/4 vs 56.2%; P <.0001) and increased proportion of clear cell histology (79.3% vs 74.5%; P = .0074) compared to the no adrenalectomy group. Adrenalectomy patients had higher risk of recurrence (HR 1.23; 95% CI 1.04-1.47; P = .019) and no difference in survival (HR 1.09, 95% CI 0.86-1.38, P = .48).

Conclusion: Adrenalectomy is not associated with better oncological outcome of recurrence/survival. Adrenalectomy should be reserved for patients with radiographic adrenal involvement and/or intra-operative adrenal involvement.
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http://dx.doi.org/10.1016/j.urology.2021.05.053DOI Listing
June 2021

Lymph node dissection during radical nephrectomy: A Canadian multi-institutional analysis.

Urol Oncol 2021 Jun 27;39(6):371.e17-371.e25. Epub 2021 Mar 27.

The University of Texas MD Anderson Cancer Center, Houston, TX. Electronic address:

Objectives: To determine the association between lymph node dissection (LND) at the time of radical nephrectomy and survival in a large, multi-institutional cohort using a propensity score matching design.

Subjects And Methods: The Canadian Kidney Cancer information system was used to identify patients undergoing radical nephrectomy for nonmetastatic renal cell carcinoma. Associations between LND with overall survival , recurrence free survival and cancer specific survival were determined using various propensity score techniques in the overall cohort and in patients with varying probabilities of pN1. Cox models were used to determine association of lymph node removed with outcomes.

Results: Of the 2,699 eligible patients, 812 (30%) underwent LND. Of the LND patients, 88 (10.8%) had nodal metastases. There was no association between LND and improved overall survival, recurrence free survival or cancer specific survival using various propensity score techniques (stratification by propensity score quintile, matched pairs, inverse treatment probability weighting and adjusted for propensity score quintile). There was no association between LND and a therapeutic benefit in patients with increased threshold probabilities of nodal metastases. Increased number of lymph nodes removed was not associated with improved survival outcomes.

Conclusions: LND at the time of radical nephrectomy for renal cell carcinoma is not associated with improved outcomes. There was no benefit in patients at high risk for nodal metastases, and the number of nodes removed did not correlate with survival. Further studies are needed to determine which high risk patients may benefit from LND.
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http://dx.doi.org/10.1016/j.urolonc.2021.02.025DOI Listing
June 2021

Comparing Perspectives of Canadian Men Diagnosed With Prostate Cancer and Health Care Professionals About Active Surveillance.

J Patient Exp 2020 Dec 11;7(6):1122-1129. Epub 2020 Jun 11.

Institut du cancer de Montréal and Centre de recherche du Centre hospitalier de l'Université de Montréal, Quebec, Canada.

Active surveillance (AS) has gained acceptance as a primary management approach for patients diagnosed with low-risk prostate cancer (PC). In this qualitative study, we compared perspectives between patients and health care professionals (HCP) to identify what may contribute to patient-provider discordance, influence patient decision-making, and interfere with the uptake of AS. We performed a systematic comparison of perspectives about AS reported from focus groups with men eligible for AS (7 groups, N = 52) and HCP (5 groups, N = 48) who engaged in conversations about AS with patient. We used conventional content analysis to scrutinize separately focus group transcripts and reached a consensus on similar or divergent viewpoints between them. Patients and clinicians agreed that AS was appropriate for low grade PC and understood the low-risk nature of the disease. They shared the perspective that disease status was a critical factor to pursue or discontinue AS. However, men expressed a greater emphasis on quality of life in their decisions related to AS. Patients and clinicians differed in their perspectives on the clarity, availability, and volume of information needed and offered; clinicians acknowledged variations between HCP when presenting AS, while patients were often compelled to seek additional information beyond what was provided by physicians and experienced difficulty in finding or interpreting information applicable to their situation. A greater understanding of discordant perspectives about AS between patients and HCP can help improve patient engagement and education, inform development of knowledge-based tools or aids for decision-making, and identify areas that require standardization across the clinical practice.
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http://dx.doi.org/10.1177/2374373520932735DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7786672PMC
December 2020

Determining generalizability of the Canadian Kidney Cancer information system (CKCis) to the entire Canadian kidney cancer population.

Can Urol Assoc J 2020 Oct;14(10):E499-E506

Department of Medicine and Urology, Dalhousie University, Halifax, NS, Canada.

Introduction: The Canadian Kidney Cancer information system (CKCis) has prospectively collected data on patients with renal tumors since January 1, 2011 from 16 sites within 14 academic centers in six provinces. Canadian kidney cancer experts have used CKCis data to address several research questions. The goal of this study was to determine if the CKCis cohort is representative of the entire Canadian kidney cancer population, specifically regarding demographic and geographic distributions.

Methods: The CKCis prospective cohort was analyzed up to December 31, 2018. Baseline demographics and tumor characteristics were analyzed, including location of patients' residence at the time of CKCis entry. Geographic data is presented by province, rural vs. urban via postal code information (2 digit=0) and by Canadian urban boundary files. To determine the proportion of renal cell carcinoma (RCC) patients that CKCis captures, CKCis accruals were compared to projected Canadian Cancer Society RCC incidence in 2016-2017 and the incidence from the 2016 Canadian Cancer Registry. To determine if the CKCis baseline data is representative, it was compared to registry data and other published data when registry data was not available.

Results: This CKCis cohort includes 10 298 eligible patients: 66.6% male, median age 62.6 years; 14.6% had metastatic disease at the time of diagnosis and 70.4% had clear-cell carcinomas. The CKCis cohort captures about 1250 patients per year, which represents approximately 20% of the total kidney cancer incidence. The proportion of patients captured per province did vary from 13-43%. Rural patients make up 17% of patients, with some baseline differences between rural and urban patients. There appears to be no major differences between CKCis patient demographics and disease characteristics compared to national data sources. Canadian heat maps detailing patient location are presented.

Conclusions: CKCis contains prospective data on >10 000 Canadian kidney cancer patients, making it a valuable resource for kidney cancer research. The baseline demographic and geographic data do appear to include a broad cross-section of patients and seem to be highly representative of the Canadian kidney cancer population. Moving forward, future projects will include determining if CKCis cancer outcomes are also representative of the entire Canadian kidney cancer population and studying variations across provinces and within rural vs. urban areas.
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http://dx.doi.org/10.5489/cuaj.6716DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7716824PMC
October 2020

Small Renal Mass Surveillance: Histology-specific Growth Rates in a Biopsy-characterized Cohort.

Eur Urol 2020 09 14;78(3):460-467. Epub 2020 Jul 14.

Division of Urology, Department of Surgery, Princess Margaret Cancer Centre and the University Health Network, University of Toronto, Toronto, ON, Canada.

Background: Most reports of active surveillance (AS) of small renal masses (SRMs) lack biopsy confirmation, and therefore include benign tumors and different subtypes of renal cell carcinoma (RCC).

Objective: We compared the growth rates and progression of different histologic subtypes of RCC SRMs (SRM) in the largest cohort of patients with biopsy-characterized SRMs on AS.

Design, Setting, And Participants: Data from patients in a multicenter Canadian trial and a Princess Margaret cohort were combined to include 136 biopsy-proven SRM lesions managed by AS, with treatment deferred until progression or patient/surgeon decision.

Outcome Measurements And Statistical Analysis: Growth curves were estimated from serial tumor size measures. Tumor progression was defined by sustained size ≥4 cm or volume doubling within 1 yr.

Results And Limitations: Median follow-up for patients who remained on AS was 5.8 yr (interquartile range 3.4-7.5 yr). Clear cell RCC SRMs (SRM) grew faster than papillary type 1 SRMs (0.25 and 0.02 cm/yr on average, respectively, p =  0.0003). Overall, 60 SRM lesions progressed: 49 (82%) by rapid growth (volume doubling), seven (12%) increasing to ≥4 cm, and four (6.7%) by both criteria. Six patients developed metastases, and all were of clear cell RCC histology. Limitations include the use of different imaging modalities and a lack of central imaging review.

Conclusions: Tumor growth varies between histologic subtypes of SRM and among SRM, which likely reflects individual host and tumor biology. Without validated biomarkers that predict this variation, initial follow-up of histologically characterized SRMs can inform personalized treatment for patients on AS.

Patient Summary: Many small kidney cancers are suitable for surveillance and can be monitored over time for change. We demonstrate that different types of kidney cancers grow at different rates and are at different risks of progression. These results may guide better personalized treatment.
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http://dx.doi.org/10.1016/j.eururo.2020.06.053DOI Listing
September 2020

Canadian Update on Surgical Procedures (CUSP) Urology Group consensus for intraoperative hemostasis during minimally invasive partial nephrectomy.

Can Urol Assoc J 2020 Sep;14(9):E387-E393

Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada.

Introduction: Partial nephrectomy remains the gold standard in the management of small renal masses. However, minimally invasive partial nephrectomy (MIPN) is associated with a steep learning curve, and optimal, standardized techniques for time-efficient hemostasis are poorly described. Given the relative lack of evidence, the goal was to describe a set of actionable guiding principles, through an expert working panel, for urologists to approach hemostasis without compromising warm ischemia or oncological outcomes.

Methods: A three-step modified Delphi method was used to achieve expert agreement on the best practices for hemostasis in MIPN. Panelists were recruited from the Canadian Update on Surgical Procedures (CUSP) Urology Group, which represent all provinces, academic and community practices, and fellowship-and non-fellowship-trained surgeons. Thirty-two (round 1) and 46 (round 2) panellists participated in survey questionnaires, and 22 attended the in-person consensus meeting.

Results: An initial literature search of 945 articles (230 abstracts) underwent screening and yielded 24 preliminary techniques. Through sequential survey assessment and in-person discussion, a total of 11 strategies were approved. These are temporally distributed prior to tumor resection (five principles), during tumor resection (two principles), and during renorrhaphy (four principles).

Conclusions: Given the variability in tumor size, depth, location, and vascularity, coupled with limitations of laparoscopic equipment, achieving consistent hemostasis in MIPN may be challenging. Despite over two decades of MIPN experience, limited evidence exists to guide clinicians. Through a three-step Delphi method and rigorous iterative review with a panel of experts, we ascertained a guiding checklist of principles for newly beginning and practicing urologists to reference.
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http://dx.doi.org/10.5489/cuaj.6579DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7492033PMC
September 2020

Real-world evidence in patient-reported outcomes (PROs) of metastatic castrate-resistant prostate cancer (mCRPC) patients treated with abiraterone acetate + prednisone (AA+P) across Canada: Final results of COSMiC.

Can Urol Assoc J 2020 Dec;14(12):E616-E620

Trillium Health Partners, Toronto, ON, Canada.

Introduction: Abiraterone acetate plus prednisone (AA+P) has shown to significantly improve survival. COSMiC, a Canadian Observational Study in Metastatic Cancer of the Prostate, set out to prospectively amass real-world data on metastatic castration-resistant prostate cancer (mCRPC) patients managed with AA+P in Canada. Herein, we report their patient-reported outcomes (PROs).

Methods: After a median followup of 67.1 weeks, 254 patients were enrolled across 39 sites. Functional Assessment of Cancer Therapy-Prostate (FACT-P), Montreal Cognitive Assessment (MoCA), Brief Pain Inventory-Short Form (BPI-SF), Brief Fatigue Inventory (BFI), and Current Health Satisfaction in Prostate Cancer (CHS-PCa) were evaluated at baseline, as well as at weeks 12, 24, 48, and 72 after AA+P initiation. Descriptive analysis was used with continuous variables. Changes from baseline were summarized using mean (standard deviation [SD]).

Results: At a median age of 76.6 (8.94), baseline FACT-P total score was 111.3 (19.56) with no significant change in their functional status observed from baseline over time. The median baseline MoCA score was 25.2 (4.52), yet subsequent assessments showed an absence of cognitive decline while under treatment. Similarly, no meaningful changes were detected in BPI, BFI, and CHS-PCa during the 72-week study period, thus suggesting that patients' PROs were well-maintained throughout AA+P treatment. Prostate-specific antigen (PSA) response with >50% decline was 66.4%. Safety profile was consistent with the known side effect of AA+P.

Conclusions: COSMiC represents the largest Canadian mCRPC cohort treated with AA+P with real-world, prospective evaluation of PROs. This data demonstrated the maintenance in quality of life and cognitive status over the course of the study and underscores the importance of PRO use in this complex patient population.
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http://dx.doi.org/10.5489/cuaj.6388DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7704085PMC
December 2020

The Comparative Outcomes of Radical Prostatectomy versus Radiotherapy for Non-metastatic Prostate Cancer: A Longitudinal, Population-Based Analysis.

J Urol 2020 Feb 18:101097JU0000000000000805. Epub 2020 Feb 18.

Section of Urology, University of Manitoba, Winnipeg, Manitoba, Canada.

Introduction: The comparative effectiveness of radical prostatectomy (RP) versus radiation therapy (RT) for prostate cancer remains a largely debated topic. Utilizing a provincial population-based linked dataset from an equal-access, universal health care system, we sought to compare outcomes among patients treated with either radiation or prostatectomy for non-metastatic prostate cancer.

Methods: We performed a retrospective cohort study by linking several administrative datasets to identify patients who were diagnosed with prostate cancer between 2004-2016 in Manitoba, Canada, and who were subsequently treated with either RP or RT. Cox proportional hazard models with inverse probability of treatment weighting (IPTW) were used to compare rates of all-cause mortality, as well as prostate cancer specific mortality (PCSM) between patients who underwent RP vs. RT.

Results: During the study period, 2,540 patients underwent RP and 1,895 underwent RT for prostate cancer. Unadjusted overall survival (OS) was higher for RP vs. RT (5-year OS 95.52% for RP compared with 84.55% for RT, p<0.0001). In IPTW-adjusted Cox regression analysis, compared to patients in the RP groups, patients in the RT group had an increased rate of all-cause mortality (HR 1.93, 95% CI 1.65-2.26, p<0.0001), and PCSM (HR 3.98, 95% CI 2.89-5.49; p<0.0001).

Conclusions: RT was associated with higher all-cause mortality and PCSM rates compared with RP. These findings highlight the importance of comparative effectiveness research to identify treatment disparities and warrant further investigation.
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http://dx.doi.org/10.1097/JU.0000000000000805DOI Listing
February 2020

Outcomes and prognosticators of stage 4 renal cell carcinoma with pathological T4 primary lesion using a large, Canadian, multi-institutional database.

Can Urol Assoc J 2020 Feb 23;14(2):24-30. Epub 2019 Jul 23.

Section of Urology, University of Manitoba, Winnipeg, MB, Canada.

Introduction: The primary objective of this study was to evaluate outcomes and prognosticators in patients who underwent radical nephrectomy (RN) or cytoreductive nephrectomy (CN), depending on the clinical stage of disease preoperatively, with a pathological T4 (pT4) renal cell carcinoma (RCC) outcome. There is little data on the outcome of this specific subset of patients.

Methods: From 2009-2016, we identified patients in the Canadian Kidney Cancer information system (CKCis) who underwent RN or CN and were found to have pT4 RCC. Clinical, operative, and pathological variables were analyzed with univariable and multivariable Cox proportional hazard models to identify factors associated with overall survival (OS). Survival curves were created using Kaplan-Meier methods and compared using the log-rank test.

Results: A total of 82 patients were included in the study cohort. Median patient age was 62 years (interquartile range [IQR] 55, 70). Fifty (61%) patients had clear-cell histology and 14 (17%) had sarcomatoid characteristics. Median followup was 12 months (IQR 3, 24). At last followup, eight (10%) patients are alive with no evidence of disease, 27 (33%) are alive with disease, four (5%) were lost to followup, 36 (44%) died of disease, and seven (8%) died of other causes. Tumor histological subtype (clear-cell vs. non-clear-cell) (p=0.0032), larger tumor size (cm) (p=0.012), and Fuhrman grade (G4 vs. G2-G3) (p=0.045) were significantly associated with mortality in a multivariable Cox regression model.

Conclusions: For patients with pT4 RCC after RN or CN, survival is poor. Sarcomatoid features, non-clear-cell histology, and presence of systemic symptoms were associated with worse OS.
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http://dx.doi.org/10.5489/cuaj.5941DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7012283PMC
February 2020

Development and Acceptability Testing of a Patient Decision Aid for Urinary Diversion with Radical Cystectomy.

J Urol 2019 11 9;202(5):1001-1007. Epub 2019 Oct 9.

Division of Urology, University of Ottawa, Ottawa, Canada.

Purpose: The choice of urinary diversion at cystectomy is a life altering decision. Patient decision aids are clinical tools that promote shared decision making by providing information about management options and helping patients communicate their values. We sought to develop and evaluate a patient decision aid for individuals undergoing cystectomy with urinary diversion.

Materials And Methods: We used the IPDAS (International Patient Decision Aids Standards) to guide a systematic development process. A literature review was performed to determine urinary diversion options and the incidence of outcomes. We created a prototype using the Ottawa Decision Support Framework. A 10-question survey was used to assess patient decision aid acceptability among patients, allied health professionals and urologists. The primary outcome was acceptability of the patient decision aid.

Results: Ileal conduit and orthotopic neobladder were included as primary urinary diversion options because they had the most evidence and are most commonly performed. Continent cutaneous diversion was identified as an alternative option. Outcomes specific to ileal conduit were stomal stenosis and parastomal hernia. Outcomes specific to neobladder were daytime and nighttime urinary incontinence and urinary retention. Acceptability testing was completed by 8 urologists, 9 patients and 1 advanced practice nurse. Of the respondents 94% reported that the language was appropriate, 94% reported that the length was adequate and 83% reported that option presentation was balanced. The patient decision aid met all 6 IPDAS defining criteria, all 6 certification criteria and 21 of 23 quality criteria.

Conclusions: We created a novel patient decision aid to improve the quality of decisions made by patients when deciding among urinary diversion options. Effectiveness testing will be performed prospectively.
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http://dx.doi.org/10.1097/JU.0000000000000341DOI Listing
November 2019

Long-Term Surveillance of Complex Cystic Renal Masses and Heterogeneity of Bosniak 3 Lesions.

J Urol 2019 Feb 7. Epub 2019 Feb 7.

University of Texas Health San Antonio, San Antonio, TX UNITED STATES.

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http://dx.doi.org/10.1097/JU.0000000000000144DOI Listing
February 2019

Case - Combined endoscopic cautery and over-the-scope-clip closure of an acquired rectourethral fistula: A novel surgical repair technique.

Can Urol Assoc J 2019 May 15;13(5):E151-E153. Epub 2018 Oct 15.

Department of Surgery, Section of General Surgery, University of Manitoba, Winnipeg, MB, Canada.

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http://dx.doi.org/10.5489/cuaj.5624DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6520061PMC
May 2019

Long-Term Surveillance of Complex Cystic Renal Masses and Heterogeneity of Bosniak 3 Lesions.

J Urol 2018 12 1;200(6):1192-1199. Epub 2018 Aug 1.

Department of Urology, University of Manitoba, Winnipeg, Manitoba, Canada.

Purpose: We sought to better characterize the frequency of Bosniak cyst class changes, identify predictors of change and progression, determine the average growth rate of cysts and validate the safety of active surveillance.

Materials And Methods: Consecutive patients referred for the management of complex cysts (Bosniak 2F or greater) were included in analysis. All imaging studies were reevaluated and any stage change was reviewed with a blinded genitourinary radiologist. Bosniak 3 cysts were subclassified as 3s-septated enhancing Bosniak cysts and 3n-cysts with wall or septation-only nodularity. A multivariate Cox proportional hazards model was used to identify predictors of the Bosniak classification change. Kaplan-Meier curves were applied to analyze Bosniak cyst progression and regression.

Results: A total 140 lesions were included in study, necessitating review of a total of 1,011 abdominal scans in 111 patients. Median followup was 46 months (IQR 23-65.5) and patients underwent a mean of 6.8 diagnostic scans. On multivariate analysis nodular cysts progressed (HR 6.16, 95% CI 2.58-14.72, p <0.00004) and entirely endophytic cysts were less likely to progress (HR 0.21, 95% CI 0.05-0.85, p = 0.028). On Kaplan-Meier analysis Bosniak 3s cysts were more likely to regress while Bosniak 3n cysts were more likely to progress than 3s cysts (p = 0.0178 and 0.0002, respectively). The growth rate of 3n and 2F cysts was 0.19 and 0.11 cm per year (p = 0.0493 and 0.0327, respectively). Locally advanced or metastatic disease did not develop in any patient.

Conclusions: A diagnostic change in Bosniak 3s and 2F cysts is common and Bosniak 3n cysts behave more like Bosniak 4 cysts. Most complex kidney cysts can be safely monitored without intervention and the interval between serial imaging procedures should be increased.
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http://dx.doi.org/10.1016/j.juro.2018.07.063DOI Listing
December 2018

Describing perspectives of health care professionals on active surveillance for the management of prostate cancer.

BMC Health Serv Res 2018 06 8;18(1):430. Epub 2018 Jun 8.

Institut du cancer de Montréal and Centre de recherche du Centre hospitalier de l'Université de Montréal, 900, St Denis St, Montréal, QC, Canada.

Background: Over the last decade, active surveillance has proven to be a safe approach for patients with low-risk prostate cancer. Although active surveillance presents several advantages for both patients and the health care system, all eligible patients do not adopt this approach. Our goal was to evaluate the factors that influence physicians to recommend active surveillance and the barriers that impact adherence to this approach.

Methods: Focus groups (n = 5) were held with physicians who provided care for men with low-risk prostate cancer and had engaged in conversations with men and their families about active surveillance. The experience of health care professionals (HCPs) was captured to understand their decisions in proposing active surveillance and to reveal the barriers and facilitators that affect the adherence to this approach. A content analysis was performed on the verbatim transcripts from the sessions.

Results: Although physicians agreed that active surveillance is a suitable approach for low-risk prostate cancer patients, they were concerned about the rapidly evolving and non-standardized guidelines for patient follow-up. They pointed out the need for additional tools to appropriately identify proper patients for whom active surveillance is the best option. Urologists and radiation-oncologists were keen to collaborate with each other, but the role of general practitioner remained controversial once patients were referred to a specialist.

Conclusions: Integration of more reliable tools and/or markers in addition to more specific guidelines for patient follow-up would increase the confidence of both patients and physicians in the choice of active surveillance.
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http://dx.doi.org/10.1186/s12913-018-3273-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5994022PMC
June 2018

Surveillance guidelines based on recurrence patterns for upper tract urothelial carcinoma.

Can Urol Assoc J 2018 Aug 12;12(8):243-251. Epub 2018 Apr 12.

University of British Columbia, Vancouver, BC, Canada.

Introduction: Upper tract urothelial carcinoma (UTUC) accounts for 5% of all urothelial tumours. Due to its rarity, evidence regarding postoperative surveillance is lacking. The objective of this study was to develop a post-radical nephroureterectomy (RNU) surveillance protocol based on recurrence patterns in a large, multi-institutional cohort of patients.

Methods: Retrospective clinical and pathological data were collected from 1029 patients undergoing RNU over a 15-year period (1994-2009) at 10 Canadian academic institutions. A multivariable model was used to identify prognostic clinicopathological factors, which were then used to define risk categories. Risk-based surveillance guidelines were proposed based on actual recurrence patterns.

Results: Overall, 555 (49.9%) patients developed recurrence, including 289 (25.9%) in the urothelium and 266 (23.9%) with loco-regional and distant recurrences. Based on multivariable analysis, three risk groups were identified: 1) low-risk patients with pTa-T1, pN0 disease, and no adverse histological features (high tumour grade, lymphovascular invasion [LVI], tumour multifocality); 2) intermediate-risk patients with pTa-T1, pN0 disease with one or more of the adverse histological features; and 3) high-risk patients with a ≥pT2 tumour and/or nodal involvement. Low-, intermediate-, and high-risk patients were free of urothelial recurrence at three years in 72%, 66%, and 63%, respectively, and free of regional/distant recurrence in 93%, 87%, and 62%, respectively. The risks of loco-regional and distant recurrences (p<0.0001) and time to death (p<0.0001) were significantly different between the low-, intermediate-, and high-risk patients.

Conclusions: Based on recurrence patterns in a large, multicentre patient cohort, we have proposed an evidence-based, risk-adapted post-RNU surveillance protocol.
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http://dx.doi.org/10.5489/cuaj.5377DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6114151PMC
August 2018

Canadian Men's perspectives about active surveillance in prostate cancer: need for guidance and resources.

BMC Urol 2017 Oct 27;17(1):98. Epub 2017 Oct 27.

Institut du cancer de Montréal and Centre de recherche du Centre hospitalier de l'Université de Montréal, 900 St Denis St, Montreal, QC, Canada.

Background: In prostate cancer, men diagnosed with low risk disease may be monitored through an active surveillance. This research explored the perspectives of men with prostate cancer regarding their decision-making process for active surveillance to identify factors that influence their decision and assist health professionals in having conversations about this option.

Methods: Focus group interviews (n = 7) were held in several Canadian cities with men (N = 52) diagnosed with prostate cancer and eligible for active surveillance. The men's viewpoints were captured regarding their understanding of active surveillance, the factors that influenced their decision, and their experience with the approach. A content and theme analysis was performed on the verbatim transcripts from the sessions.

Results: Patients described their concerns of living with their disease without intervention, but were reassured by the close monitoring under AS while avoiding harmful side effects associated with treatments. Conversations with their doctor and how AS was described were cited as key influences in their decision, in addition to availability of information on treatment options, distrust in the health system, personality, experiences and opinions of others, and personal perspectives on quality of life.

Conclusions: Men require a thorough explanation on AS as a safe and valid option, as well as guidance towards supportive resources in their decision-making.
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http://dx.doi.org/10.1186/s12894-017-0290-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5658971PMC
October 2017

A Multicentered, Propensity Matched Analysis Comparing Laparoscopic and Open Surgery for pT3a Renal Cell Carcinoma.

J Endourol 2017 07;31(7):645-650

1 Section of Urology, University of Manitoba , Winnipeg, Canada .

Introduction: To compare outcomes following laparoscopic renal surgery (LRS) and open renal surgery (ORS) in the treatment of pathologic T3a (pT3a) renal cell carcinoma (RCC) using a propensity matched analysis.

Materials And Methods: The Canadian Kidney Cancer Information System is a prospectively maintained database for patients diagnosed with RCC from 15 Canadian institutions. Patients treated for nonmetastatic pT3a RCC between 2008 and 2015 were included. Propensity score matching for age, gender, tumor size, grade, histology, and surgical approach was performed to compare laparoscopic radical and partial nephrectomy (LRN or LPN) with open radical or partial nephrectomy (ORN or OPN). The primary endpoint was recurrence-free survival (RFS).

Results: Two hundred twenty-six (45%) patients underwent LRS (88% LRN and 12% LPN), and 275 (55%) underwent ORS (75% ORN and 25% OPN). After a median follow-up of 21.1 months, 155 (72 LRS and 83 ORS) patients experienced recurrence. The 3-year RFS was 63% and 50% for the LRS and ORS groups, respectively, p = 0.36. On subgroup analysis, there was no significant difference in RFS among patients who underwent radical nephrectomy (3-year RFS 61% in LRN compared with 46% in ORN group, p = 0.32) or partial nephrectomy (77% in LPN compared with 79% in OPN group, p = 0.82).

Conclusions: This study is the largest matched analysis comparing LRS and ORS for pT3a RCC. In matched patients, LRS showed no difference in oncologic outcomes compared with ORS and should be considered when technically feasible.
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http://dx.doi.org/10.1089/end.2016.0787DOI Listing
July 2017

Disease progression and kidney function after partial vs. radical nephrectomy for T1 renal cancer.

Urol Oncol 2016 11 14;34(11):486.e17-486.e23. Epub 2016 Jul 14.

Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada. Electronic address:

Purpose: Partial nephrectomy (PN) for early stage renal cancer preserves renal function better than radical nephrectomy (RN) and is generally considered oncologically similar. The Intergroup European Organisation for Research and Treatment of Cancer trial comparing outcomes after PN vs. RN, however, showed reduced overall survival in the PN group. Our aim was to evaluate recurrence, death, and renal function after PN vs. RN for T1 tumors in a Canadian population.

Materials And Methods: From 2000 to 2015, 2,358 patients with a first occurrence of a clinical T1 renal cancer who underwent PN or RN were identified from the Canadian Kidney Cancer Information System. Clinical, surgical, and pathologic parameters were analyzed. Time to progression was compared after PN vs. RN using a Cox proportional hazards model, adjusted for pertinent variables.

Results: Inclusion criteria were met in 1,615 PN and 743 RN. Preoperative characteristics appeared similar in both groups. Time to progression was not different after PN vs. RN, adjusted for potential confounders (hazard ratio = 1.17 [95% CI: 0.8-1.72, P = 0.42]). Postoperative estimated glomerular filtration rate at 1 and 3 years was significantly greater for PN vs. RN in a linear regression model, accounting for preoperative estimated glomerular filtration rate.

Conclusions: These results suggest that progression-free survival after PN and RN in patients with T1 renal cancer was similar, but that there was better preservation of renal function after PN. This suggests that both PN and RN have similar oncological efficiency, and that selection of surgical approach should be based on other factors such as technical feasibility, potential complications, and preservation of renal function.
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http://dx.doi.org/10.1016/j.urolonc.2016.05.034DOI Listing
November 2016

Pathological Upstaging of Clinical T1 to Pathological T3a Renal Cell Carcinoma: A Multi-institutional Analysis of Short-term Outcomes.

Urology 2016 Aug 31;94:154-60. Epub 2016 Mar 31.

Section of Urology, Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada. Electronic address:

Objective: To determine the oncological impact of pathological upstaging among patients with clinical T1 (cT1) disease treated by partial nephrectomy or radical nephrectomy.

Methods: The Canadian Kidney Cancer Information System comprises a prospectively maintained multi-institutional database for patients with renal cell carcinoma. Nonmetastatic, cT1 renal cell carcinoma cases were evaluated. Upstaging was defined as pathological T3a disease. Multivariate Cox regression analysis identified predictors for recurrence (local recurrence and/or metastatic disease) whereas logistic regression identified predictors of pathological upstaging. Kaplan-Meier methods estimated survival.

Results: Of 1448 eligible cT1 patients, upstaging was observed in 134 (9%). One thousand fifty-eight (73%) were treated by partial nephrectomy. After a median follow-up of 23 months, the 3-year recurrence-free survival was 76% in upstaged patients compared with 93% in those not upstaged (P < .001). Controlling for age, gender, year of surgery, histology, tumor size, surgical approach, and margin status, pathological upstaging was independently associated with disease recurrence (hazard ratio 2.03, 95% confidence interval [CI] 1.12-3.68). Increasing age (odds ratio [OR] 1.02, 95% CI 1.00-1.05), Fuhrman grade (OR 2.47, 95% CI 1.47-4.14), and tumor size (OR 1.16, 95% CI 1.00-1.36) were independently associated with a risk of pathological upstaging.

Conclusion: Pathological upstaging confers a negative prognosis and highlights the importance of accurate clinical staging. A number of factors have been identified, including some attainable by renal biopsy, which may predict upstaging and provide valuable adjunct information to inform risk stratification and management decisions among patients with cT1 renal masses.
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http://dx.doi.org/10.1016/j.urology.2016.03.029DOI Listing
August 2016

A primer on tumour immunology and prostate cancer immunotherapy.

Can Urol Assoc J 2016 Jan-Feb;10(1-2):60-5

Department of Urology, Queen's University, Kingston, ON, Canada;; Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada;

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http://dx.doi.org/10.5489/cuaj.3418DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4771561PMC
March 2016

Clinical outcomes following laparoscopic management of pT3 renal masses: A large, multi-institutional cohort.

Can Urol Assoc J 2015 Nov-Dec;9(11-12):397-402. Epub 2015 Dec 14.

Section of Urology, University of Manitoba, Winnipeg, MB;

Introduction: We described the clinical and oncological outcomes of patients treated by laparoscopic surgery for non-metastatic pT3 renal cell carcinoma (RCC).

Methods: We queried a multi-institutional database for patients diagnosed with non-metastatic pathological T3 RCC from 13 Canadian centres treated laparoscopically (radical or partial nephrectomy) between 2008 and 2014. Clinical and pathological outcomes were evaluated. Progression was defined as the development of recurrence or metastatic disease. Log-rank testing and Kaplan-Meier statistical methods assessed for differences and estimated progression-free survival (PFS).

Results: In total, 176 patients were identified with a median age of 64 years. The median tumour size was 7.0 cm. Pre-clinical stage was cT1 to cT4 in 39%, 28%, 30% and 3%, respectively. The median blood loss was 150 mL (range: 0-6000) and the median operative time was 124 minutes (range: 60-360). Most lesions were clear cell RCC (80%). After a median follow-up of 17.6 months (range: 0.2-75.0), disease progression occurred in 26% (46/176) of patients, consisting of local recurrence in 7% (3/46), and metastatic disease in 93% (43/46). The 3-year PFS was 67%, with a median PFS of 49 months. Of those who progressed, the median time to progression was 10.3 months.

Conclusions: This study is the largest cohort of pT3 RCC patients treated laparoscopically in the literature and suggests that for properly selected patients, laparoscopic management of locally advanced renal masses yields acceptable short-term oncological outcomes.
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http://dx.doi.org/10.5489/cuaj.2848DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4707891PMC
January 2016

Small Cell Cancer of the Bladder and Prostate: A Retrospective Review from a Tertiary Cancer Center.

Cureus 2015 Aug 7;7(8):e296. Epub 2015 Aug 7.

Urology, St. Boniface Hospital, University of Manitoba, Canada.

Background:  Genitourinary small cell cancer (GUSCC) is a rare malignancy. Most of the published data on how to manage this malignancy is based on institutional experience. We undertook the current retrospective review to determine the outcome of the patients with GUSCC treated at CancerCare Manitoba, Canada over a period of 18 years.

Methods: The Manitoba Cancer Registry was used to identify patients with a confirmed pathological diagnosis of small cell cancer (SCC) of the bladder or prostate between January 1, 1995, and October 31, 2013.

Results:  There were 42 patients identified, 28 bladder SCC (17 limited, 11 extensive stage) and 14 prostate SCC (one limited, 12 extensive, and one unknown stage). The median age was 70.7 years. There were 22 patients who were treated with chemotherapy and radiation, five received radiation only, four received chemo only, nine did not receive any treatment, one patient had surgery only, and one had surgery and radiation. The median and one-year overall survival for all patients was 10.7 months and 43%. The median and one-year overall survival of SCC of the bladder was 55.1 months and 71% for the limited stage and 10.1 months and 36% for the extensive stage. The median and one-year overall survival for extensive stage SCC of the prostate was 4.1 months and 17%. There was only one patient with limited stage SCC of the prostate who did not receive any treatment and died of progressive disease 11 months from diagnosis.

Conclusions:  Our findings suggest that patients with limited stage SCC of the bladder can have a surprisingly good outcome with multimodality treatment. The outcome of the patients with extensive stage SCC of the bladder and prostate remains dismal and optimal therapeutic options have yet to be determined.
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http://dx.doi.org/10.7759/cureus.296DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4529331PMC
August 2015

Surgical management of stage T1 renal tumours at Canadian academic centres.

Can Urol Assoc J 2015 Mar-Apr;9(3-4):99-106

Division of Urology, University of Ottawa, Ottawa, ON; ; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON;

Introduction: The proportion of patients with stage 1 renal tumours receiving partial nephrectomy is considered a quality of care indicator. The objective of this study was to characterize surgical practice patterns at Canadian academic institutions for the treatment of these tumours.

Methods: The Canadian Kidney Cancer Information System (CKCis) is a multicentre collaboration of 13 academic institutions in Canada. All patients with pathologic stage T1 renal tumours in CKCis were identified. Descriptive statistics were performed to characterize practice patterns over time. Associations between patient, tumour, and treatment factors with the use of partial nephrectomy were determined.

Results: From 1988 to April 2014, 1453 patients with pathologic stage 1 renal tumours were entered in the CKCis database. Of these, 977 (67%) patients had pT1a tumours; of these, 765 (78%) received partial nephrectomy. Of the total number of patients (1453), 476 (33%) had pT1b tumours; of these, 204 (43%) received partial nephrectomy. The use of partial nephrectomy increased over time from 60% to 90% for pT1a tumours and 20% to 60% for pT1b tumours. Stage pT1b (relative risk [RR] 0.56, 95% confidence interval [CI] 0.50-0.63) and minimally invasive surgical approach (RR 0.78, 95% CI 0.73-0.84 for pT1a and RR 0.23, 95% CI 0.17-0.30 for pT1b) were associated with decreased use of partial nephrectomy. Most patient factors including age, gender, body mass index, hypertension, and renal function were not significantly associated with use of partial nephrectomy (p > 0.05).

Conclusion: Almost all pT1a and most pT1b renal tumours managed surgically at academic centres in Canada receive partial nephrectomy. The use of partial versus radical nephrectomy appears to occur independently of patient age and comorbid status, which may indicate that urologists are performing partial nephrectomy whenever technically feasible based on tumour factors. Although the ideal proportion patients receiving partial nephrectomy cannot be determined, treatment distribution observed in this cohort may indicate an achievable case distribution among experienced surgeons.
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http://dx.doi.org/10.5489/cuaj.2598DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4455632PMC
June 2015

The impact of fellowship training on pathological outcomes following radical prostatectomy: a population based analysis.

BMC Urol 2014 Oct 23;14:82. Epub 2014 Oct 23.

CancerCare Manitoba, Winnipeg, Manitoba, Canada.

Background: Radical prostatectomy (RP) is a common treatment for prostate cancer (PCa). Morbidity, mortality and pathological outcomes may be superior in academic institutions. One explanation may be the involvement of oncology fellowship trained urologists within academic institutions. The literature examining pathological outcomes often lacks individual surgeon data. The objective of this study was to compare pathological outcomes following RP between fellowship trained and non-fellowship trained urologists.

Methods: Population-based, retrospective chart review of men diagnosed with PCa between 2003 and 2008, the majority treated with open approach RP (>99%). Pathological outcomes were compared between oncology fellowship trained academic (FTA), non-fellowship trained academic (NFTA) and non-academic (NA) urologists. Relationships with pathological outcomes were examined utilizing multivariable logistic regression.

Results: 83.1% of eligible patients were included in our analysis resulting in 1075 patients. In multivariable analysis, surgeon group was an independent predictor of positive surgical margin (PSM) (p < 0.0001). NFTA and NA urologists were more likely to have PSM compared to FTA urologists (OR 2.50; 95% CI: 1.44-4.35 and OR 2.10; 95% CI: 1.53-2.88, respectively). However, the proportion of PSM between NFTA and NA urologists was not significant (p = 0.492). In addition, pathological stage (p = 0.0004), Gleason sum (p < 0.0001), and surgeon volume (p = 0.017) were associated with PSM. Limitations include retrospective design and lack of clinical and functional outcomes.

Conclusions: Uro-oncology fellowship trained surgeons had significantly lower rates of PSM than non-fellowship trained surgeons in this population based cohort. This study demonstrates the importance of surgeon-related variables on pathological outcomes and highlights the value of additional urologic oncology fellowship training.
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http://dx.doi.org/10.1186/1471-2490-14-82DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4216843PMC
October 2014

Angiomyolipoma with caval extension and regional nodal involvement: Aggressive behaviour or just rare natural history? Case report and review of literature.

Can Urol Assoc J 2014 Mar;8(3-4):E276-8

Department of Surgery, Section of Urology, University of Manitoba, Winnipeg, MB;

Renal angiomyolipoma (AML) is predominantly a non-aggressive benign tumour. Cases of more aggressive AMLs are present in the literature. We present 2 cases of aggressive AML behaviour. The first case is an AML with vascular extension in a young female and the second case is of AML found in regional lymph nodes in a female with a left renal AML and renal cell carcinoma.
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http://dx.doi.org/10.5489/cuaj.1781DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4001661PMC
March 2014

Age ≥ 80 years is independently associated with survival outcomes after radical cystectomy: results from the Canadian Bladder Cancer Network Database.

Urol Oncol 2012 Nov-Dec;30(6):825-32. Epub 2011 Sep 1.

University of Alberta, Edmonton, Alberta, Canada.

Objectives: The role of advanced age as an independent prognostic factor for clinical outcomes after radical cystectomy is controversial. The objective of the current study was to assess the associations between age and clinical outcomes in a large, multi-institutional series of patients treated with radical cystectomy for bladder cancer.

Materials And Methods: Institutional radical cystectomy databases containing detailed information on bladder cancer patients treated between 1993 and 2008 were obtained from 8 academic centers in Canada. Data were collected on 2,287 patients and combined into a relational database formatted with patient characteristics, pathologic characteristics, recurrence status, and survival status. Patient age was coded as <60 years, 60-69 years, 70-79 years, or ≥ 80 years. Clinical outcomes were 30-day mortality, 90-day mortality, overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS). Logistic regression and Cox proportional hazards regression analysis were used to analyze survival data.

Results: Five hundred fifty-seven (24.6%), 679 (30.0%), 846 (37.4%), and 181 (8.0%) patients were <60 years, 60-69 years, 70-79 years, and ≥ 80 years, respectively. Increased age was associated with decreased utilization rates of neoadjuvant chemotherapy (P = 0.0143), adjuvant chemotherapy (P < 0.0001), and continent urinary diversion (P < 0.0001) as well as advanced pathologic tumor stage (P = 0.0003), increased positive surgical margins (P < 0.0001), and lymphovascular invasion (P = 0.0335). Compared with patients < 60 years, multivariate regression analysis showed that age ≥ 80 years was independently associated with 90-day mortality (OR 2.98, 95% CI 1.22-7.30), OS (HR 2.03, 95% CI 1.51-2.75), DSS (HR 1.56, 95% CI 1.09-2.24), and RFS (HR 2.06, 95% CI 1.57-2.70).

Conclusions: Age ≥ 80 years at the time of radical cystectomy was independently associated with adverse survival outcomes. These data suggest that increased chronologic age should be considered in clinical trial design and in nomograms predicting survival.
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http://dx.doi.org/10.1016/j.urolonc.2011.07.014DOI Listing
July 2013

Active surveillance of small renal masses: progression patterns of early stage kidney cancer.

Eur Urol 2011 Jul 1;60(1):39-44. Epub 2011 Apr 1.

Division of Urology, Department of Surgery and of Surgical Oncology, Princess Margaret Hospital and the University Health Network, University of Toronto, Toronto, Ontario, Canada.

Background: Most early stage kidney cancers are renal cell carcinomas (RCCs), and most are diagnosed incidentally by imaging as small renal masses (SRMs). Indirect evidence suggests that most small RCCs grow slowly and rarely metastasize.

Objective: To determine the progression and growth rates for newly diagnosed SRMs stratified by needle core biopsy pathology.

Design, Setting, And Participants: A multicenter prospective phase 2 clinical trial of active surveillance of 209 SRMs in 178 elderly and/or infirm patients was conducted from 2004 until 2009 with treatment delayed until progression.

Intervention: Patients underwent serial imaging and needle core biopsies.

Measurements: We measured rates of change in tumor diameter (growth measured by imaging) and progression to ≥ 4 cm, doubling of tumor volume, or metastasis with histology on biopsy.

Results And Limitations: Local progression occurred in 25 patients (12%), plus 2 progressed with metastases (1.1%). Of the 178 subjects with 209 SRMs, 127 with 151 SRMs had>12 mo of follow-up with two or more images, with a mean follow-up of 28 mo. Their tumor diameters increased by an average of 0.13 cm/yr. Needle core biopsy in 101 SRMs demonstrated that the presence of RCC did not significantly change growth rate. Limitations included no central review of imaging and pathology and a short follow-up.

Conclusions: This is the first SRM active surveillance study to correlate growth with histology prospectively. In the first 2 yr, the rate of local progression to higher stage is low, and metastases are rare. SRMs appear to grow very slowly, even if biopsy proven to be RCC. Many patients with SRMs can therefore be initially managed conservatively with serial imaging, avoiding the morbidity of surgical or ablative treatment.
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http://dx.doi.org/10.1016/j.eururo.2011.03.030DOI Listing
July 2011
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