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Characterizing Tumor Thrombus Arising from Non-Clear Cell Renal Cell Carcinoma

Rabinowitz, Matthew J; Esfandiary, Tina; Cheaib, Joseph; Patel, Sunil H; Alam, Ridwan; Metcalf, Meredith; Enikeev, Dmitry; Pierorazio, Phillip M; Ged, Yasser M A; Allaf, Mohamad E; Singla, Nirmish
Background/UNASSIGNED:Renal cell carcinoma (RCC) can exhibit a unique vascular tropism that enables tumor thrombus extension into the inferior vena cava (IVC). While most RCC subtypes that form tumor thrombi are of clear cell (cc) histology, non-clear cell (ncc) subtypes can also exhibit this unique growth pattern. Objective/UNASSIGNED:To characterize clinicopathologic differences and survival outcomes among patients with IVC tumor thrombus arising from ccRCC versus nccRCC. Design setting and participants/UNASSIGNED:Patients diagnosed with IVC tumor thrombus secondary to RCC in our institutional experience from 2003 to 2021 were identified. Outcome measurements and statistical analysis/UNASSIGNED:Clinicopathologic characteristics were compared by histology. Perioperative and oncologic outcomes including recurrence-free (RFS), overall (OS), and cancer-specific (CSS) survival were assessed using multivariable Cox regression analyses. Results and limitations/UNASSIGNED: = 0.1). There was no significant difference in OS or CSS. This study was limited by its small sample size. Conclusions/UNASSIGNED:Patients with IVC tumor thrombus arising from ccRCC and nccRCC exhibit similar perioperative and oncologic outcomes. While surgical appropriateness was not impacted by histologic subtype, multimodal strategies are needed to improve outcomes for patients with tumor thrombus. Patient summary/UNASSIGNED:Renal cell carcinoma (RCC) can uniquely invade vasculature and form a tumor thrombus. This study examined the difference in outcomes of patients with tumor thrombus based on RCC subtype (clear cell vs non-clear cell). We found that patients exhibited similar surgical and survival outcomes regardless of RCC type.
PMID: 36353070
ISSN: 2666-1683
CID: 5357382

Safety and Efficacy of Reproductive Organ-Sparing Radical Cystectomy in Women With Variant Histology and Advanced Stage

Patel, Sunil H; Wang, Shirley; Metcalf, Meredith R; Gupta, Natasha; Gabrielson, Andrew; Lee, Esther; Rostom, Mary; Pierorazio, Phil; Smith, Armine; Hahn, Noah; Schoenberg, Mark; Kates, Max; Hoffman-Censits, Jean; Bivalacqua, Trinity J
PURPOSE:Muscle invasive bladder cancer surgical management has been historically a radical cystoprostatectomy in males and an anterior exenteration in females. Uterine, ovarian, and vaginal preservation are utilized, but raise concerns regarding risk to oncologic control, especially in variant histopathology or advanced stage. MATERIALS AND METHODS:A retrospective single institutional analysis identified radical cystectomies performed in women, including those with variant histology, which were defined as reproductive organ sparing (uterine, vaginal, and ovary sparing) or nonorgan sparing. The Kaplan-Meier method was used for recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) in patients with advanced disease. RESULTS:From 2000 to 2020, 289 women were identified, 188 underwent reproductive organ-sparing cystectomy. No statistical differences were noted for clinical parameters or presence of variant histology for organ-sparing (ROS) and nonorgan-sparing (non-ROS). Positive margin rates did not differ for ROS and non-ROS; 4.3% vs. 7.9%, P = .19, respectively. Median RFS was not statistically significantly different for ROS vs. non-ROS (26.1 vs. 15.3 months) P = .937 hazard ratio (HR) 1.024. CSS was not statistically different for ROS vs. non-ROS (36.3 vs. 28.6 months), P = .755 HR 0.9. OS was not statistically different for ROS vs. non-ROS (25.8 vs. 23.8 months), P = .5 HR = 1.178. Variant histology did not change survival (HR 1.1, P = .643). CONCLUSION:In this analysis, ROS in women with advanced disease did not increase positive margin rates or decrease RFS, CSS, or OS compared to non-ROS. Variant histology did not decrease survival odds. Based on preoperative assessment and intraoperative findings, ROS in patients with variant histology and advanced disease should be considered.
PMID: 34896022
ISSN: 1938-0682
CID: 5404572

Evidence-Based Recommendations for Opioid Prescribing after Endourological and Minimally Invasive Urological Surgery

Koo, Kevin; Winoker, Jared S; Patel, Hiten; Faisal, Farzana; Gupta, Natasha; Metcalf, Meredith; Mettee, Lynda; Meyer, Alexa; Pavlovich, Christian; Pierorazio, Philip; Matlaga, Brian R
INTRODUCTION/BACKGROUND:Procedure-specific guidelines for postsurgical opioid use can decrease overprescribing and facilitate opioid stewardship. Initial recommendations were based on feasibility data from limited pilot studies. This study aims to refine opioid prescribing recommendations for endourological and minimally invasive urological procedures by integrating emerging clinical evidence with a panel consensus. METHODS:A multistakeholder panel was convened with broad subspecialty expertise. Primary literature on opioid prescribing after 16 urological procedures was systematically assessed. Using a modified Delphi technique, the panel reviewed and revised procedure-specific recommendations and opioid stewardship strategies based on additional evidence. All recommendations were developed for opioid-naïve adult patients after uncomplicated procedures. RESULTS:Seven relevant studies on postsurgical opioid prescribing were identified: four studies on ureteroscopy, two studies on robotic prostatectomy including a combined study on robotic nephrectomy, and one study on transurethral prostate surgery. The panel affirmed prescribing ranges to allow tailoring quantities to anticipated need. The panel noted that zero opioid tablets would be potentially appropriate for all procedures. Following evidence review, the panel reduced the maximum recommended quantities for 11 of the 16 procedures; the other 5 procedures were unchanged. Opioids were no longer recommended following diagnostic endoscopy and transurethral resection procedures. Finally, data on prescribing decisions supported expanded stewardship strategies for first-time prescribing and ongoing quality improvement. CONCLUSION/CONCLUSIONS:Reductions in initial opioid prescribing recommendations are supported by evidence for most endourological and minimally invasive urological procedures. Shared decision-making prior to prescribing and periodic reevaluation of individual prescribing patterns are strongly recommended to strengthen opioid stewardship.
PMID: 34107778
ISSN: 1557-900x
CID: 4952002

Editorial Comment

Metcalf, Meredith R
PMID: 34284617
ISSN: 1527-3792
CID: 4952012

Volume-outcome relationships for kidney cancer may be driven by disparities and patient risk

Wainger, Julia J; Cheaib, Joseph G; Patel, Hiten D; Huang, Mitchell M; Biles, Michael J; Metcalf, Meredith R; Canner, Joseph K; Singla, Nirmish; Trock, Bruce J; Allaf, Mohamad E; Pierorazio, Phillip
PURPOSE:Provider and hospital factors influence healthcare quality, but data are lacking to assess their impact on renal cancer surgery. We aimed to assess factors related to surgeon and hospital volume and study their impact on 30-day outcomes after radical nephrectomy. MATERIALS AND METHODS:Renal surgery data were abstracted from Maryland's Health Service Cost Review Commission from 2000 to 2018. Patients ≤18 years old, without a diagnosis of renal cancer, and concurrently receiving another major surgery were excluded. Volume categories were derived from the mean annual cases distribution. Multivariable logistic and linear regression models assessed the association of volume on length of stay, intensive care days, cost, 30-day mortality, readmission, and complications. RESULTS:7,950 surgeries, completed by 573 surgeons at 48 hospitals, were included. Demographic, surgical, and admission characteristics differed between groups. Radical nephrectomies performed by low volume surgeons demonstrated increased post-operative complication frequency, mortality frequency, length of stay, and days spent in intensive care relative to other groups. However, after logistic regression adjusting for clinical risk and socioeconomic factors, only increased length of stay and ICU days remained associated with lower surgeon volume. Similarly, after adjusted logistic regression, hospital volume was not associated with the studied outcomes. CONCLUSIONS:Surgeons and hospitals differ in regards to patient demographic and clinical factors. Barriers exist regarding access to high-volume care, and thus some volume-outcome trends may be driven predominantly by disparities and case mix.
PMID: 34078583
ISSN: 1873-2496
CID: 4951992

Gender Differences in the Clinical Management of clinical T1a Renal Cell Carcinoma

Metcalf, Meredith R; Cheaib, Joseph G; Wainger, Julia; Peña, Vanessa N; Patel, Hiten D; Singla, Nirmish; Pierorazio, Phillip M
OBJECTIVE:To evaluate gender differences in the management of clinical T1a (cT1a) renal cell carcinoma (RCC) before and after release of the AUA guidelines for management in 2009, which prioritized nephron-sparing approaches. METHODS:Patients aged ≥66 years diagnosed with cT1a RCC from 2004 to 2013 in Surveillance, Epidemiology, and End Results-Medicare were analyzed. Multivariable mixed-effects logistic regression models were used to evaluate factors associated with radical nephrectomy (RN) for cT1a RCC before (2004 to 2009) and after (2010 to 2013) guidelines release. Predictors of pathologic T3 upstaging and high grade pathology in the postguidelines period were examined using multivariable logistic regression among patients who underwent RN or partial nephrectomy. RESULTS:Twelve thousand four hundred and two patients with cT1a RCC were identified, 42% of whom were women. Overall, the likelihood of RN decreased postguidelines (odds ratio [OR] = 0.44, P <.001), but women were at increased odds of undergoing RN both before and after guideline release (OR = 1.27, P <.001 and OR = 1.37, P <.001, respectively) upon multivariable mixed-effects logistic regression. Tumor size >2 cm was also associated with increased likelihood of RN before and after guidelines (OR = 2.61, P <.001 and OR = 2.51, P <.001, respectively). In the postguidelines period, women had significantly lower odds of pathologic upstaging (OR = 0.75, P = .024) and harboring high grade pathology (OR = 0.71, P <.001) compared to men. CONCLUSION/CONCLUSIONS:Gender differences persist in the management of cT1a RCC, with women having higher odds of undergoing RN, even after release of AUA guidelines and despite having lower odds of pathologic upstaging and high-grade disease.
PMID: 32890618
ISSN: 1527-9995
CID: 4951922

Outcomes of Active Surveillance for Young Patients with Small Renal Masses: Prospective Data from the DISSRM Registry

Metcalf, Meredith R; Cheaib, Joseph G; Biles, Michael J; Patel, Hiten D; Peña, Vanessa N; Chang, Peter; Wagner, Andrew A; McKiernan, James M; Pierorazio, Phillip M
PURPOSE/OBJECTIVE:A paradigm shift in the management of small renal masses has increased utilization of active surveillance. However, questions remain regarding safety and durability in younger patients. MATERIALS AND METHODS/METHODS:and Fisher's exact tests, and Kruskal-Wallis and Wilcoxon signed-rank tests. Survival outcomes were calculated using the Kaplan-Meier method and compared with the log-rank test. RESULTS:Of 224 patients with median followup of 4.9 years 30.4% chose surveillance. There were 20 (29.4%) surveillance progression events, including 4 elective crossovers, and 13 (19.1%) patients underwent delayed intervention. Among patients with initial tumor size ≤2 cm, 15.1% crossed over, compared to 33.3% with initial tumor size 2-4 cm. Overall survival was similar in primary intervention and surveillance at 7 years (94.0% vs 90.8%, log-rank p=0.2). Cancer-specific survival remained at 100% for both groups. There were no significant differences between primary and delayed intervention with respect to minimally invasive or nephron-sparing interventions. Recurrence-free survival at 5 years was 96.0% and 100% for primary and delayed intervention, respectively (log-rank p=0.6). CONCLUSIONS:Active surveillance is a safe initial strategy in younger patients and can avoid unnecessary intervention in a subset for whom it is durable. Crucially, no patient developed metastatic disease on surveillance or recurrence after delayed intervention. This study confirms active surveillance principles can effectively be applied to younger patients.
PMID: 33356478
ISSN: 1527-3792
CID: 4951972

Reply by Authors [Comment]

Metcalf, Meredith R; Cheaib, Joseph G; Biles, Michael J; Patel, Hiten D; Peña, Vanessa N; Chang, Peter; Wagner, Andrew A; McKiernan, James M; Pierorazio, Phillip M
PMID: 33635089
ISSN: 1527-3792
CID: 4951982

Testis-sparing Surgery: A Single Institution Experience

Egan, Jillian; Cheaib, Joseph G; Biles, Michael J; Huang, Mitchell M; Metcalf, Meredith; Matoso, Andres; Pierorazio, Phillip
OBJECTIVE:To demonstrate the safety and efficacy of testis-sparing surgery (TSS) in 2 specific circumstances: small, nonpalpable masses suspected to be benign and masses suspicious for germ cell tumor in a solitary or functionally solitary testicle or bilateral disease. METHODS:Our institutional review board-approved testicular cancer registry was reviewed for men who underwent inguinal exploration with intent for TSS (2013-2020). The attempted TSS and completed TSS groups were evaluated for differences using Student's t test for normally-distributed variables, chi-squared and Fisher's exact tests for proportions, and Wilcoxon rank-sum test for nonparametric variables. RESULTS:TSS was attempted in 28 patients and completed in 14. TSS was completed only if intraoperative frozen section demonstrated benign disease, except for 1 patient with stage I seminoma and solitary testicle. Sensitivity and specificity of frozen section analysis was 100% and 93%, respectively. There were no significant differences in demographics between attempted vs completed TSS cohorts. Median tumor size was significantly smaller in the completed TSS cohort (1.0 cm vs 1.7 cm, P = .03). In patients with unilateral masses without history of testis cancer, the testis was successfully spared in 9 of 22 cases (41%). In patients with bilateral disease or germ cell tumor in solitary testis, the testis was spared in 5 of 6 cases (83%). At a median follow up of 12.2 months, all patients were alive, and 27 of 28 had no evidence of disease (96%). CONCLUSION/CONCLUSIONS:TSS is safe and effective for small, benign masses and in the setting of bilateral disease or tumor in a solitary testis.
PMID: 33137349
ISSN: 1527-9995
CID: 4951952

Feasibility of a Weight Management Program Tailored for Overweight Men with Localized Prostate Cancer - A Pilot Study

Hamilton-Reeves, Jill M; Johnson, Chelsea N; Hand, Lauren K; Bechtel, Misty D; Robertson, Hilary L; Michel, Carrie; Metcalf, Meredith; Chalise, Prabhakar; Mahan, Nicholas J; Mirza, Moben; Lee, Eugene K; Sullivan, Debra K; Klemp, Jennifer R; Befort, Christie A; Parker, William P; Gibbs, Heather D; Demark-Wahnefried, Wendy; Thrasher, J Brantley
BACKGROUND/UNASSIGNED:Overweight men with prostate cancer are more likely to suffer from recurrence and death following prostatectomy compared with healthy weight men. This study tested the feasibility of delivering a comprehensive program to foster weight loss before and weight maintenance after surgery in overweight men with localized prostate cancer. METHODS/UNASSIGNED: = 5). Anthropometrics, biomarkers, diet quality, nutrition literacy, quality of life, and long-term follow-up were assessed in both groups. RESULTS/UNASSIGNED:The intervention led to 5.55 kg of weight loss including 3.88 kg of fat loss from baseline to surgery (mean = 8.3 weeks). The intervention significantly increased fiber, protein, fruit, nut, and vegetable intake; and decreased trans fats intake during weight loss. The intervention significantly reduced insulin, C-peptide, systolic blood pressure, leptin:adiponectin ratio, and visceral adiposity compared to the nonintervention. Post-surgically, weight loss was maintained. Changes in lipid profiles, nutrition literacy, and follow-up were not statistically significant in either group. CONCLUSION/UNASSIGNED:Significant weight loss (≥5%) is feasible with a coaching intervention in overweight men preparing for prostatectomy and is associated with favorable cardiometabolic effects. This study is registered under NCT02252484 (
PMID: 33295204
ISSN: 1532-7914
CID: 4951962