Urological Survey Urological Oncology: Adrenal, Renal, Ureteral and Retroperitoneal Tumors Re: Risk Stratification for Bladder Recurrence of Upper Urinary Tract Urothelial Carcinoma after Radical Nephroureterectomy J. Ishioka, K. Saito, T. Kijima, Y. Nakanishi, S. Yoshida, M. Yokoyama, Y. Matsuoka, N. Numao, F. Koga, H. Masuda, Y. Fujii, Y. Sakai, C. Arisawa, T. Okuno, K. Nagahama, S. Kamata, M. Sakura, J. Yonese, S. Morimoto, A. Noro, T. Tsujii, S. Kitahara, S. Gotoh, Y. Higashi and K. Kihara Departments of Urology, Tokyo Medical and Dental University Graduate School, East Tokyo Metropolitan Hospital, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo Metropolitan Ohtsuka Hospital and Tama-Nanbu Chiiki Hospital, Tokyo, National Cancer Centre Hospital East and Kounodai Hospital, National Centre for Global Health and Medicine, Chiba, JA Toride Medical Centre and Tsuchiura Kyodo General Hospital, Ibaraki, Soka Municipal Hospital, Saitama Red Cross Hospital and Saitama Cancer Centre, Saitama and Hamamatsu Medical Centre, Shizuoka, Japan BJU Int 2015; 115: 705e712.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.09.008 available at http://jurology.com/ Editorial Comment: After nephroureterectomy for primary upper urinary tract urothelial carcinoma up to 50% of patients will eventually manifest bladder recurrence. Due to the low prevalence of the primary condition most of the literature on the risk of systemic or bladder recurrence is retrospective. The authors reviewed 745 patients with primary upper urinary tract urothelial carcinoma without prior or concurrent bladder carcinoma who were treated with nephroureterectomy at 13 Japanese institutions. Primary outcome was bladder recurrence. Based on multivariate analysis, the authors constructed a risk stratification model that included papillary tumor architecture, stage pT2 or higher, absence of lymphovascular invasion and male gender. Patients were stratified into 3 groups, ie low (0 to 1), intermediate (2 to 3) and high risk (4 risk factors), with increasing incidence of bladder cancer varying from 8% to 24% at 5 years and 10% to 44% at 10 years. Probability of recurrence was depicted in a mathematical nomogram. The risk stratification model and the nomogram exhibited similar c-index of 0.60 and 0.62, respectively. In addition to its originality, the simplicity of including exclusively categorical variables makes such a risk prognostic system attractive. Furthermore, the model offers the hypothetical possibility of adapting bladder surveillance schedules to risk of recurrence and even driving prophylactic postoperative administration of intravesical therapy. However, the predictive ability of the presented risk stratification model and nomogram seems insufficient to support its clinical use, and one cannot avoid questioning the value of the model in counseling or designing a specific followup. Nonetheless, the model represents a first step in the effort to identify clinicopathological prognosticators of bladder recurrence that may well be complemented by genetic signatures in the future. M. Pilar Laguna, MD, PhD
Suggested Reading Saito K, Kawakami S, Fujii Y et al: Lymphovascular invasion is independently associated with poor prognosis in patients with localized upper urinary tract urothelial carcinoma treated surgically. J Urol 2007; 178: 2291.
0022-5347/15/1946-1582/0 THE JOURNAL OF UROLOGY® Ó 2015 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
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Krabbe LM, Lotan Y, Bagrodia A et al: Prospective comparison of molecular signatures in urothelial cancer of the bladder and the upper urinary tractdis there evidence for discordant biology? J Urol 2014; 191: 926. Fajkovic H, Cha EK, Jeldres C et al: Prognostic value of extranodal extension and other lymph node parameters in patients with upper tract urothelial carcinoma. J Urol 2012; 187: 845. Ishikawa S, Abe T, Shinohara N et al: Impact of diagnostic ureteroscopy on intravesical recurrence and survival in patients with urothelial carcinoma of the upper urinary tract. J Urol 2010; 184: 883. Wu WJ, Ke HL, Yang YH et al: Should patients with primary upper urinary tract cancer receive prophylactic intravesical chemotherapy after nephroureterectomy? J Urol 2010; 183: 56. Catto JW, Yates DR, Rehman I et al: Behavior of urothelial carcinoma with respect to anatomical location. J Urol 2007; 177: 1715.
Imaging Re: Incompletely Characterized Incidental Renal Masses: Emerging Data Support Conservative Management S. G. Silverman, G. M. Israel and Q.-D. Trinh Division of Abdominal Imaging and Intervention, Department of Radiology and Division of Urology, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, and Department of Radiology, Yale University School of Medicine, New Haven, Connecticut Radiology 2015; 275: 28e42.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.09.012 available at http://jurology.com/ Editorial Comment: This article addresses some trends in renal mass management that include not imaging small renal lesions at all that are likely benign cysts and delay of imaging small solid lesions in selected patients. Masses that are homogeneously of low (20 HU or less) or high attenuation (70 HU or greater) are likely benign. Active surveillance has been used for indeterminate renal cysts and is discussed in detail in this article for the small solid renal neoplasm. Cases managed by active surveillance for renal mass with a linear growth rate of 8 mm yearly and a volumetric growth rate of 27 cm3 were associated with the strongest predictor for progression to metastatic disease. Percutaneous biopsy may provide information to stratify patients on the basis of risk. This article discusses the accuracy of renal mass biopsy for subtype and tumor grade. Renal masses too small to characterize or small enough that their imaging features cannot be confidently assessed are usually 1 cm or smaller. Magnetic resonance imaging might perform better with sub cm renal mass characterization. The article gives management recommendations for incompletely characterized incidental masses. Cary Siegel, MD
Urological Oncology: Bladder, Penis and Urethral Cancer, and Basic Principles of Oncology Re: SUCCINCT: An Open-Label, Single-Arm, Non-Randomised, Phase 2 Trial of Gemcitabine and Cisplatin Chemotherapy in Combination with Sunitinib as First-Line Treatment for Patients with Advanced Urothelial Carcinoma T. Geldart, J. Chester, A. Casbard, S. Crabb, T. Elliott, A. Protheroe, R. A. Huddart, G. Mead, J. Barber, R. J. Jones, J. Smith, R. Cowles, J. Evans and G. Griffiths
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.09.008 available at http://jurology.com/ Editorial Comment: After nephroureterectomy for primary upper urinary tract urothelial carcinoma up to 50% of patients will eventually manifest bladder recurrence. Due to the low prevalence of the primary condition most of the literature on the risk of systemic or bladder recurrence is retrospective. The authors reviewed 745 patients with primary upper urinary tract urothelial carcinoma without prior or concurrent bladder carcinoma who were treated with nephroureterectomy at 13 Japanese institutions. Primary outcome was bladder recurrence. Based on multivariate analysis, the authors constructed a risk stratification model that included papillary tumor architecture, stage pT2 or higher, absence of lymphovascular invasion and male gender. Patients were stratified into 3 groups, ie low (0 to 1), intermediate (2 to 3) and high risk (4 risk factors), with increasing incidence of bladder cancer varying from 8% to 24% at 5 years and 10% to 44% at 10 years. Probability of recurrence was depicted in a mathematical nomogram. The risk stratification model and the nomogram exhibited similar c-index of 0.60 and 0.62, respectively. In addition to its originality, the simplicity of including exclusively categorical variables makes such a risk prognostic system attractive. Furthermore, the model offers the hypothetical possibility of adapting bladder surveillance schedules to risk of recurrence and even driving prophylactic postoperative administration of intravesical therapy. However, the predictive ability of the presented risk stratification model and nomogram seems insufficient to support its clinical use, and one cannot avoid questioning the value of the model in counseling or designing a specific followup. Nonetheless, the model represents a first step in the effort to identify clinicopathological prognosticators of bladder recurrence that may well be complemented by genetic signatures in the future. M. Pilar Laguna, MD, PhD
Suggested Reading Saito K, Kawakami S, Fujii Y et al: Lymphovascular invasion is independently associated with poor prognosis in patients with localized upper urinary tract urothelial carcinoma treated surgically. J Urol 2007; 178: 2291.
0022-5347/15/1946-1582/0 THE JOURNAL OF UROLOGY® Ó 2015 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
1582
j
www.jurology.com
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2015.09.008 Vol. 194, 1582-1586, December 2015 Printed in U.S.A.
IMAGING
1583
Krabbe LM, Lotan Y, Bagrodia A et al: Prospective comparison of molecular signatures in urothelial cancer of the bladder and the upper urinary tractdis there evidence for discordant biology? J Urol 2014; 191: 926. Fajkovic H, Cha EK, Jeldres C et al: Prognostic value of extranodal extension and other lymph node parameters in patients with upper tract urothelial carcinoma. J Urol 2012; 187: 845. Ishikawa S, Abe T, Shinohara N et al: Impact of diagnostic ureteroscopy on intravesical recurrence and survival in patients with urothelial carcinoma of the upper urinary tract. J Urol 2010; 184: 883. Wu WJ, Ke HL, Yang YH et al: Should patients with primary upper urinary tract cancer receive prophylactic intravesical chemotherapy after nephroureterectomy? J Urol 2010; 183: 56. Catto JW, Yates DR, Rehman I et al: Behavior of urothelial carcinoma with respect to anatomical location. J Urol 2007; 177: 1715.
Imaging Re: Incompletely Characterized Incidental Renal Masses: Emerging Data Support Conservative Management S. G. Silverman, G. M. Israel and Q.-D. Trinh Division of Abdominal Imaging and Intervention, Department of Radiology and Division of Urology, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, and Department of Radiology, Yale University School of Medicine, New Haven, Connecticut Radiology 2015; 275: 28e42.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.09.012 available at http://jurology.com/ Editorial Comment: This article addresses some trends in renal mass management that include not imaging small renal lesions at all that are likely benign cysts and delay of imaging small solid lesions in selected patients. Masses that are homogeneously of low (20 HU or less) or high attenuation (70 HU or greater) are likely benign. Active surveillance has been used for indeterminate renal cysts and is discussed in detail in this article for the small solid renal neoplasm. Cases managed by active surveillance for renal mass with a linear growth rate of 8 mm yearly and a volumetric growth rate of 27 cm3 were associated with the strongest predictor for progression to metastatic disease. Percutaneous biopsy may provide information to stratify patients on the basis of risk. This article discusses the accuracy of renal mass biopsy for subtype and tumor grade. Renal masses too small to characterize or small enough that their imaging features cannot be confidently assessed are usually 1 cm or smaller. Magnetic resonance imaging might perform better with sub cm renal mass characterization. The article gives management recommendations for incompletely characterized incidental masses. Cary Siegel, MD
Urological Oncology: Bladder, Penis and Urethral Cancer, and Basic Principles of Oncology Re: SUCCINCT: An Open-Label, Single-Arm, Non-Randomised, Phase 2 Trial of Gemcitabine and Cisplatin Chemotherapy in Combination with Sunitinib as First-Line Treatment for Patients with Advanced Urothelial Carcinoma T. Geldart, J. Chester, A. Casbard, S. Crabb, T. Elliott, A. Protheroe, R. A. Huddart, G. Mead, J. Barber, R. J. Jones, J. Smith, R. Cowles, J. Evans and G. Griffiths
