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Ofer Yossepowitch

Publications and source records attributed to Ofer Yossepowitch.

At least 19 recordsLinked to original sources
PubMed2006

The natural history of noncastrate metastatic prostate cancer after radical prostatectomy.

OBJECTIVES: To characterise the natural history of metastatic prostate cancer after radical prostatectomy (RP) in patients followed expectantly for rising prostate-specific antigen (PSA) (noncastrate metastases). METHODS: Cox proportional hazards analyses were used to assess predictors of survival among 95 patients who developed clinically detectable noncastrate metastases after RP. The initial metastatic phenotype was characterised as minimal (nodal or axial skeletal involvement) or extensive (appendicular skeletal involvement or visceral metastases). Estimates of survival after diagnosis of metastases were generated with the Kaplan-Meier method. RESULTS: Median disease-specific survival from diagnosis of noncastrate metastases was 6.6 yr (95% confidence interval [CI], 5.2, 7.9). The initial site of metastatic disease was bone, lymph node, and viscera in 63%, 36%, and 6% of patients, respectively. Thirteen patients (14%) had extensive disease at their first metastatic manifestation. Longer PSA doubling time in the rising PSA state (hazard ratio [HR] 0.8 for each month increase in doubling time; 95%CI, 0.67-0.94) and the initial metastatic phenotype (HR 0.3 for minimal vs. extensive disease; 95%CI, 0.1-0.6) were associated with improved survival. The prostatectomy Gleason score, lymph node status at RP, PSA level at diagnosis of metastases, and interval from surgery to diagnosis of metastases did not correlate with outcome. CONCLUSION: Men who develop noncastrate metastases after RP may have a durable survival. Favourable prognostic indicators include longer PSA doubling time preceding diagnosis of metastases and initial involvement of axial skeleton or lymph nodes.

Adult↗
PubMed2006

Renal cell carcinoma recurrence after nephrectomy for localized disease: predicting survival from time of recurrence.

PURPOSE: Prognostic factors for patients with metastatic renal cell carcinoma (RCC) are well established. However, the risk profile is unknown for patients with recurrent RCC after a nephrectomy for localized disease. PATIENTS AND METHODS: From January 1989 to July 2005, we identified patients with localized RCC treated by nephrectomy who subsequently developed recurrent disease. We applied a validated prognostic scoring system previously developed for patients with metastatic RCC. Each patient was given a total risk score of 0 to 5, with one point for each of five prognostic variables (recurrence < 12 months after nephrectomy, serum calcium > 10 mg/dL, hemoglobin < lower limit of normal, lactate dehydrogenase > 1.5x upper limit of normal, and Karnofsky performance status < 80%). Patients were categorized into low- (score = 0), intermediate- (score = 1 to 2), and high-risk subgroups (score = 3 to 5). RESULTS: Our final cohort included 118 patients, with a median survival time of 21 months from the time of recurrence. Median follow-up time for survivors was 27 months. Overall survival was strongly associated with risk group category (P < .0001). Low-risk, intermediate-risk, and high-risk criteria were fulfilled in 34%, 50%, and 16% of patients, respectively. Median survival time for low-risk, intermediate-risk, and high-risk patients was 76, 25, and 6 months, respectively. Two-year overall survival rates for low-risk, intermediate-risk, and high-risk patients were 88% (95% CI, 77% to 99%), 51% (95% CI, 37% to 65%), and 11% (95% CI, 0% to 24%), respectively. CONCLUSION: At disease recurrence after nephrectomy for localized disease, a scoring system based on objective clinical and laboratory data provides meaningful risk stratification for both patient counseling and clinical trial entry.

Aged↗
PubMed2006

Safety and efficacy of intravesical bacillus Calmette-Guerin instillations in steroid treated and immunocompromised patients.

PURPOSE: We assessed the safety and efficacy of intravesical bacillus Calmette-Guerin instillations in steroid treated and immunocompromised patients. MATERIALS AND METHODS: We retrospectively reviewed the charts of 697 patients treated with bacillus Calmette-Guerin instillations at our institution from 1991 to 2004. In 24 patients (3.5%) an underlying comorbidity directly affecting the immune system was diagnosed before bacillus Calmette-Guerin administration or steroids were administered at least 6 weeks before and at the time of bacillus Calmette-Guerin instillations. The immunosuppressive effect of steroids was assessed by the percent of lymphocytes. End points were the bacillus Calmette-Guerin response at 6 months, defined as normal cystoscopy, cytology and biopsy when available, and treatment related toxicity. RESULTS: Four patients (17%) had active lymphoma or chronic lymphocytic leukemia during bacillus Calmette-Guerin administration and 21 (88%) had a concurrent condition for which oral steroids (11), inhaled steroids (14) or oral and inhaled steroids (4) were administered. Patients treated with oral steroids had a lower percent of lymphocytes than patients treated with inhaled steroids and 15 age matched patients with high risk superficial bladder cancer and no steroid treatment (12.3% vs 17.5% and 18.6%, respectively). The overall bacillus Calmette-Guerin response rate at 6 months was 58%. Ten of the 24 patients had disease recurrence and 3 had disease progression at a median followup of 63.5 months (IQR 19.5, 89). One patient treated with oral steroids had self-limited febrile disease and worsening of myalgia 48 hours after his third bacillus Calmette-Guerin cycle. No other systemic adverse event following bacillus Calmette-Guerin therapy was recorded and all patients completed scheduled treatments. CONCLUSIONS: Intravesical bacillus Calmette-Guerin is a viable therapeutic option in patients with high risk superficial bladder cancer and concomitant lymphoma or chronic lymphocytic leukemia, treatment with low dose oral steroids or treatment with inhaled steroids. The bacillus Calmette-Guerin response rate at 6 months and the side effects profile associated with bacillus Calmette-Guerin therapy in these patients were comparable to those in patients with no evidence of immunosuppression. Further studies are warranted to assess the safety and efficacy of bacillus Calmette-Guerin instillations in critically immunocompromised patients.

Adjuvants, Immunologic↗
PubMed2006

Prediagnosis prostate specific antigen velocity is associated with risk of prostate cancer progression following brachytherapy and external beam radiation therapy.

PURPOSE: Prostate specific antigen velocity 2.0 ng/ml per year or greater in the year before prostate cancer diagnosis is associated with cancer specific survival following radical prostatectomy and radiation therapy. We evaluated the relationship between prediagnosis prostate specific antigen velocity and cancer progression following primary radiation therapy. MATERIALS AND METHODS: We analyzed the records of 24,893 men from a community based prostate cancer screening study and identified 237 with clinically localized prostate cancer who elected primary radiation therapy. Our final cohort consisted of 130 men, including 83 treated with external beam radiation and 47 treated with brachytherapy. Patient specific variables at diagnosis were analyzed for their value in predicting biochemical progression using American Society for Therapeutic and Radiation Oncology criteria. RESULTS: Mean followup +/- SD was 64 +/- 35 months. Prostate specific antigen at diagnosis, family history of prostate cancer and prediagnosis prostate specific antigen velocity 2.0 ng/ml per year or greater were associated with cancer progression following brachytherapy or external beam radiation. Of men with prostate specific antigen velocity 2.0 ng/ml per year or greater 38% had cancer progression compared to 12% with prostate specific antigen velocity less than 2.0 ng/ml per year (OR 4.3, p = 0.003). The 6-year progression-free survival estimate was 57% in men with prostate specific antigen velocity 2.0 ng/ml per year or greater and 82% in men with prostate specific antigen velocity less than 2.0 ng/ml per year (p < 0.001). On multivariate analysis absolute prostate specific antigen at diagnosis and prostate specific antigen velocity 2.0 ng/ml per year or greater were independently associated with cancer progression in men treated with external beam radiation therapy or brachytherapy. CONCLUSIONS: Men with a prediagnosis prostate specific antigen velocity of 2.0 ng/ml per year or greater are at increased risk for cancer progression following brachytherapy or external beam radiation compared to men with a prostate specific antigen velocity of less than 2.0 ng/ml per year.

Adult↗
PubMed2006

Temporary renal ischemia during nephron sparing surgery is associated with short-term but not long-term impairment in renal function.

PURPOSE: The emergence of laparoscopic nephron sparing surgery has rekindled interest in the impact of warm renal ischemia on renal function. To provide data with which warm renal ischemia can be compared we analyzed short-term and long-term changes in the glomerular filtration rate after temporary cold renal ischemia. MATERIALS AND METHODS: In patients undergoing open nephron sparing surgery the estimated glomerular filtration rate was assessed preoperatively, early in the postoperative hospital stay, and 1 and 12 months after surgery using the abbreviated Modification of Diet in Renal Disease Study equation. We separately analyzed 70 patients with a solitary kidney and 592 with 2 functioning kidneys. The end point was the percent change from the baseline glomerular filtration rate. A linear regression model was used to test the association between the glomerular filtration rate change, and ischemia time, patient age, tumor size, estimated blood loss and intraoperative fluid administration. RESULTS: Median cold ischemia time was 31 minutes in patients with a solitary kidney and 35 minutes in those with 2 kidneys. Compared to patients with 2 kidneys those with a solitary kidney had a significantly lower preoperative estimated glomerular filtration rate (p < 0.001), which decreased a median of 30% during the early postoperative period, and 15% and 32% 1 and 12 months after surgery, respectively. In patients with 2 kidneys the corresponding glomerular filtration rate decreases were 16%, 13% and 14%, respectively. On multivariate analyses in each group cold ischemia duration and intraoperative blood loss were significantly associated with early glomerular filtration rate changes. However, 12 months after surgery age was the only independent predictor of a glomerular filtration rate decrease in patients with 2 kidneys. CONCLUSIONS: Cold renal ischemia during nephron sparing surgery is a significant determinant of the short-term postoperative glomerular filtration rate. Longer clamping time is particularly detrimental in patients with a solitary kidney but it does not appear to influence long-term renal function. Patients of advanced age may be less likely to recover from acute ischemic renal injury.

Aged↗
PubMed2006

Distribution of nodal metastases after chemotherapy in nonseminomatous testis cancer: a possible indication for limited dissection.

OBJECTIVE: To assess the clinical and pathological findings of patients treated by bilateral retroperitoneal lymph node dissection (RPLND) after chemotherapy, to identify a subset for whom modified template nodal resection might be contemplated, as bilateral RPLND is the treatment of choice in patients with residual retroperitoneal disease after chemotherapy for nonseminomatous germ-cell tumour (GCT). PATIENTS AND METHODS: The medical records were reviewed of 50 consecutive patients who had RPLND after chemotherapy between 1996 and 2005. Bilateral template RPLND was performed uniformly. Extracted lymph nodes were surgically stratified into three distinct anatomical zones by two sagittal planes running in front of the aorta and the inferior vena cava. The pathological findings were correlated with the side of the primary lesion and the extent of metastatic disease before chemotherapy. RESULTS: Pathological assessment of the resected lymph nodes revealed teratoma in 28 patients (56%), viable carcinoma in three (6%), and necrosis or fibrosis in 19 (38%). All clinical stage Is, IIA and IIB left-sided primary tumours followed a predictable pattern of spread constricted to a modified left-sided template. Patients with clinical stage IIC and III, or right-sided primary tumour, had a less predictable metastatic pattern, having crossover metastases to the contralateral template. CONCLUSION: Bilateral RPLND should be considered as the reference standard in patients with metastatic GCT and residual retroperitoneal mass after completing chemotherapy. However, the present data suggest that a modified template dissection might be considered even after chemotherapy in patients with left-sided primary tumours and limited nodal involvement at presentation.

Adolescent↗
PubMed2005

Ureterosigmoidostomy and obstructive uropathy.

BACKGROUND: A 19-year-old mentally retarded man with failed exstrophy repair and ureterosigmoidostomy urinary diversion presented with high fever, vomiting and right-flank pain of 2 days' duration. Past medical history was notable for a left nephrectomy to treat an infected staghorn calculus in a poorly functioning kidney. Physical examination revealed pyrexia and right-flank tenderness. INVESTIGATIONS: Physical examination, renal function tests, electrolyte and metabolic assessment, urine and blood cultures, abdominal CT, ANTEGRADE PYELOURETEROGRAPHY, sigmoidoscopy and histopathology. DIAGNOSIS: Ureterosigmoidostomy complicated by acute pyelonephritis, obstructive uropathy, recurrent urinary tract infections, renal impairment and the development of renal stones and metabolic acidosis. MANAGEMENT: Fluids, intravenous antibiotics, bicarbonate and potassium supplementation, and rediversion of ureterosigmoidostomy to an ileal conduit.

Adult↗
PubMed2005

Assessment of vesicoureteral reflux in patients with self-retaining ureteral stents: implications for upper urinary tract instillation.

PURPOSE: Conservative treatment of upper urinary tract tumors has been popularized during the last decade. Like in bladder cancer management, localized adjuvant therapy has been advocated to reduce the risk of disease recurrence or progression. In this study we tested the feasibility of creating vesicoureteral reflux (VUR) using a Double-J stent (Medical Engineering Corp., New York, New York) as a measure of efficacy for intravesical adjuvant treatment of the ureter and renal collecting system. MATERIALS AND METHODS: The cohort included 100 consecutive patients in whom a Double-J stent was inserted for renal obstruction. All the patients underwent cystography in the supine position by retrograde filling of the bladder with a 50% dilute solution of 300 mgI/ml iopromide in serial increments of 50 ml up to a maximum of 350 ml. A total of 41 patients underwent cystography immediately following stent insertion (early group) and 59 patients with indwelling stents underwent cystography before further endourological intervention (late group). The presence of VUR and the level along the ureter and renal collecting system were assessed fluoroscopically. RESULTS: Overall VUR was detected in 56 patients (56%), specifically 11 of the 41 (27%) in the early group and 45 of the 59 (76%) in the late group (p <0.001). There was no correlation between stent diameter or length and VUR, or between patient sex, age or particular side and the likelihood of reflux. Mean minimal intravesical volume required to obtain reflux was 171 +/- 11 ml, which was significantly higher in the early (255 +/- 21 ml) than in the late (146 +/- 11 ml) cystogram group. In 24 of the 56 patients (43%) with VUR, there was complete visualization of the entire ureter and renal collecting system. However, 15 patients (26%) had opacified renal pelves and calices without concomitant visualization of the ureters, whereas 7 patients (31%) had reflux to the ureter without opacification of the renal pelvis. CONCLUSIONS: VUR is not a guaranteed consequence of Double-J stent placement. Therefore, when upper urinary tract instillation with the Double-J technique is considered, a cystogram should be performed first to confirm the occurrence of reflux, determine the intravesical volume required to induce reflux and ascertain that the pertinent section of the ureter or pelvicaliceal system from which the tumor was initially removed is opacified during study. An interval that remains to be defined should be allowed between stent insertion and VUR assessment.

Administration, Intravesical↗
PubMed2004

Deleted-in-colon-cancer protein expression in patients with adenocarcinoma of the urinary tract and a history of colorectal cancer.

OBJECTIVES: To assess whether immunostaining for deleted-in-colon-cancer (DCC) protein, a previously established prognostic marker in colon and bladder cancer, may assist in resolving the uncommon differential diagnostic dilemma of distinguishing primary from secondary urothelial adenocarcinoma. METHODS: The study group consisted of 12 patients with adenocarcinoma involving the bladder or ureter and previously resected colorectal carcinoma between 1988 and 2002. All patients were initially considered to have primary urothelial transitional cell carcinoma, and the management strategy was conducted accordingly. The clinical data were recorded from the charts, and immunohistochemical staining for DCC was performed on formalin-fixed paraffin-embedded tissues containing the primary colorectal cancer and ensuing urinary tract tumor. Staining was defined as positive when at least 25% of the tumor cells were immunoreactive for DCC. RESULTS: Of the 12 patients, 10 presented with bladder and 2 with ureteral adenocarcinoma. All secondary tumors originated from a primary carcinoma invariably located along the left colon or rectum. The overall 5-year disease-specific survival rate from the time of colectomy was 31% at a median follow-up of 50 +/- 8 months. Of the 12 patients, 5 (41%) had positive DCC immunoreactivity. In all cases, concordant expression of DCC was found in the primary colorectal cancer and the ensuing tumor in the urinary tract. The survival time from colectomy was significantly longer for the DCC-positive subgroup (median 59 months, 95% confidence interval 41 to 77) than in the DCC-negative subgroup (median 23 months, 95% confidence interval 13 to 37). Likewise, the time lag between colectomy and tumor recurrence in the urinary tract was significantly longer in the patients with DCC-positive tumors (median 35 months) than in those with DCC-negative tumors (median 10 months). CONCLUSIONS: DCC immunoreactivity was consistently observed in secondary bladder or ureteral adenocarcinoma when the primary colorectal lesion expresses DCC, and thus may serve to establish the origin of the tumor. Positive DCC protein expression in secondary urinary tract adenocarcinoma of colorectal origin may identify a subset of patients with a relatively favorable prognosis. Additional studies are required to confirm our results.

Adenocarcinoma↗
PubMed2004

Urological injuries during cesarean section: intraoperative diagnosis and management.

PURPOSE: We report a single center experience with emergency urological consultations and interventions during cesarean sections, and provide several guidelines for the intraoperative diagnosis and management of urological trauma in this specific clinical setting. MATERIALS AND METHODS: From 1996 to 2003 urological consultations were required in 29 of 10,439 abdominal deliveries (0.3%). Patient files were reviewed for obstetric, surgical and followup data. RESULTS: In 20 patients (69%) cesarean section was done on an emergency basis for fetal distress or placental abruption. Of the 29 urological consults 12 (42%) were for inadvertent cystotomy and 17 (58%) were for suspected injuries to the ureter. Patients with inadvertent cystotomy underwent concomitant assessment of ureteral patency by direct insertion of ureteral catheters through the ureteral orifice. Ureteral obstruction was identified in 1 case and promptly repaired by dissecting the ureter and releasing offending sutures that were angulating the ureter and occluding the lumen. Patients with suspected ureteral damage and an intact bladder were studied by endoscopic means (14) or direct surgical dissection and exposure of the ureter (3). Endoscopic assessment was performed by cystoscopic inspection of stained urine flow from the orifices following the administration of intravenous dye (indigo carmine) or by retrograde ureteral catheterization. One patient was found to have incomplete ureteral transection, which was repaired primarily over a self-retaining ureteral stent. CONCLUSIONS: Key factors to obtain optimal results in the management of urological injuries during cesarean sections are the early recognition and immediate repair of damage. Ureteral catheterization via a cystoscope or directly through the orifices should be considered the modality of choice to assess ureteral intactness. Algorithms for urological assessment in this clinical setting are provided.

Adult↗
PubMed2003

Orthotopic urinary diversion after cystectomy for bladder cancer: implications for cancer control and patterns of disease recurrence.

PURPOSE: The impact of orthotopic urinary diversion on the quality of cystectomy and ensuing cancer control has not been adequately studied. We analyzed our experience with this clinical problem. MATERIALS AND METHODS: The records of 214 patients who underwent cystectomy and orthotopic diversion for bladder cancer were retrospectively evaluated and compared with those of 269 treated with an ileal conduit. Analyzed end points included overall and cancer specific survival. We specifically assessed the patterns of relapse and their association with pathological findings at cystectomy in the neobladder group. RESULTS: No cancer specific survival difference was identified in the neobladder and ileal conduit cohorts when adjusting for pathological stage. Patterns of relapse in 62 of the 214 patients with a neobladder (29%) included local recurrence in 23 (11%), distant recurrence in 19 (9%), and combined local and distant recurrence in 18 (8%). Urethral recurrence was rare (2%). Of 10 patients (4.6%) diagnosed with upper tract recurrence 6 and 4 initially had relapse in the ureteroenteric anastomosis and renal pelvis, respectively. Five of the 6 patients with anastomotic relapse had evidence of disease in the intramural or juxtavesical ureter that was removed en bloc with the cystectomy specimen. Only 1 patient required neobladder takedown after such anastomotic recurrence. CONCLUSIONS: These results indicate that neobladders do not compromise the quality of preceding cystectomy or interfere with management in the presence of local or distant disease relapse. Our data suggest that involvement of the intramural or juxtavesical ureteral segment at cystectomy irrespective of surgical margin status may identify patients at higher risk for anastomotic recurrence, which is associated with an ominous prognosis.

Aged↗
PubMed2003

Transitional cell carcinoma in a fused crossed ectopic kidney.

Nephroureterectomy is considered the reference standard treatment for invasive transitional cell carcinoma of the ureter. When this malignancy occurs in a patient with renal fusion anomaly, separating the involved kidney from its conjoint mate becomes a challenging task for the surgeon. We report a unique case in which a patient with an L-shaped left-to-right crossed ectopic kidney was diagnosed with invasive ureteral transitional cell carcinoma. The preoperative assessment in these uncommon cases should include renal angiography or computed tomography angiography to provide key information about the renal vasculature, which is essential for planning the surgical dissection and line of separation between the kidneys.

Aged↗
PubMed2003

Carcinoma in a bladder diverticulum: presentation and treatment outcome.

PURPOSE: In this retrospective review we characterize the outcomes of patients treated for transitional cell carcinoma in a bladder diverticulum. MATERIALS AND METHODS: Between 1986 and 2001, 39 patients were treated for tumors in a bladder diverticulum. All patients underwent initial transurethral resection of the tumor. Based on cystoscopic evaluation, bimanual examination and computerized tomography findings, tumors were classified as superficial (Ta, Tis), superficially invasive confined to diverticulum (T1) or extra diverticular (T3+). Patients with superficial or superficially invasive disease were treated either conservatively with repeat transurethral resection, or with partial or radical cystectomy. Patients with extra diverticular extension were treated with partial or radical cystectomy when amenable to surgical extirpation. Predictors of outcome were assessed by univariate and multivariate analyses. End point was overall and disease-specific survival. RESULTS: Of our cohort of 39 patients 13 (33%) presented with superficial disease, 13 (33%) with superficially invasive tumors and 13 (33%) with invasive (extra diverticular) disease. Actuarial 5-year disease specific survival for the cohort was 72 +/- 5.4%. Significant differences in 5-year disease specific survival were observed among patients presenting with superficial tumors (83 +/- 9%), superficially invasive tumors (67 +/- 7%) and extra diverticular disease (45 +/- 14%). Of the patients presenting with T1 tumors the primary mode of treatment did not correlate with outcome. In a multivariate model clinical staging was the only independent predictor of outcome and concomitant carcinoma in situ reached borderline significance. CONCLUSIONS: Our data support a conservative approach for tumors confined to the bladder diverticulum, provided complete removal is feasible and close surveillance ensues.

Adult↗
PubMed2002

Bladder neck involvement in pathological stage pT4 radical prostatectomy specimens is not an independent prognostic factor.

PURPOSE: Bladder neck invasion by prostate cancer in radical prostatectomy specimens is uncommon and, thus, its influence on disease recurrence has not been well defined. Consequently the classification of bladder neck invasion in the TNM staging system is controversial. We studied our cohort of patients with stage pT4 disease and bladder neck invasion to clarify the true clinical behavior and prognostic significance of bladder neck invasion in radical prostatectomy specimens. MATERIALS AND METHODS: The study group consisted of 4,090 consecutive patients treated with radical prostatectomy at one of our institutions between 1983 and 2001. Median followup was 53.1 months (range 1 to 189). After excluding from analysis patients treated with neoadjuvant androgen withdrawal or preoperative irradiation 72 of the remaining 2,571 (2.8%) with bladder neck invasion were classified with stage pT4 disease and their specimens were reviewed. Progression-free probability was determined by Kaplan-Meier analysis. Using the Cox proportional hazards model the independent prognostic significance of bladder neck invasion was assessed after controlling for pretreatment prostate specific antigen, final Gleason sum, extracapsular extension, surgical margins status, seminal vesicle invasion and lymph node involvement. RESULTS: Of the 72 patients categorized with stage pT4 disease 14 (19%) had poorly differentiated Gleason sum 8 to 10 cancer, 38 (53%) had established extracapsular extension, 24 (33%) had seminal vesicle invasion and 8 (11%) had lymph node involvement. However, 26 patients (36%) had cancer confined to the prostate and 28 (39%) had negative surgical margins except for the bladder neck site. The mean 5-year progression-free probability plus or minus SD in all stage pT4 cases was 68% +/- 7%, which was better than in cases of seminal vesicle invasion (52% +/- 5%, log rank test p = 0.0156) but worse than in those of extracapsular extension (84% +/- 4.1%). Univariate analysis of the stage pT4 cohort revealed that higher prostatectomy Gleason sum, more extensive extracapsular extension and seminal vesicle invasion were significantly associated with an adverse prognosis. However, in a multivariate model that included all radical prostatectomy cases the finding of bladder neck invasion or stage pT4 disease did not independently predict prostate specific antigen recurrence. CONCLUSIONS: Stage pT4 disease comprises a heterogeneous group of tumors with various pathological features and inconsistent outcomes. Assigning the pT4 stage to cases of microscopic bladder neck invasion provides no independent ability for predicting disease progression after adjusting for other adverse disease features. Due to this and previously reported data the definition of stage pT4 disease should be modified in the next version of the TNM staging system.

Adult↗
PubMed2002

Partial nephrectomy for renal cortical tumors: pathologic findings and impact on outcome.

OBJECTIVES: To review the experience with partial nephrectomy for the diagnosis and treatment of renal cortical tumors at the Memorial Sloan-Kettering Cancer Center with a particular focus on the histologic findings at the time of surgery. METHODS: The results of 292 consecutive partial nephrectomies were reviewed. Demographic data, perioperative complications, and disease status were recorded. The specimens were reviewed for histologic subtyping in accordance with the Heidelberg classification for renal cortical tumors. The probabilities of recurrence and disease-specific death were assessed with the cumulative incidence estimate. RESULTS: The median follow-up was 25.3 months (range 1 to 155). A total of 246 patients (87%) were diagnosed with a renal cortical tumor, 1 patient (less than 1%) was diagnosed with another cancer, and 34 (12%) were diagnosed with benign lesions. The most frequent histologic finding among the renal cortical tumor subgroup was conventional clear cell carcinoma in 148 cases (51%), followed by papillary carcinoma in 54 (18%), oncocytoma in 32 (11%), and chromophobe carcinoma in 21 (7%). Bilateral disease and multifocality were most prevalent in the conventional and papillary subtypes, respectively. The 5-year probability of recurrence and disease-specific death was 12% and 8%, respectively, for the conventional clear cell type. No local or distant disease recurrence was observed in any other renal cortical tumor subtypes. CONCLUSIONS: Partial nephrectomy should be considered a diagnostic and therapeutic surgical approach for renal cortical masses. Conventional clear cell carcinoma is the most frequent histologic subtype and is associated with a less favorable outcome compared with papillary carcinoma and chromophobe carcinoma. Radical nephrectomy for renal lesions that could be removed by partial nephrectomy will risk renal impairment in a substantial proportion of patients with benign disease.

Adult↗
PubMed2002

Comparisons of nomograms and urologists' predictions in prostate cancer.

When applying nomograms to a clinical setting it is essential to know how their predictions compare with clinicians'. Comparisons exist outside of the prostate cancer literature. We reviewed these comparisons and conducted 2 experiments comparing predictions of clinicians with prostate cancer nomograms. By using Medline, we searched studies from January 1966 to July 1999 that compared human predictions with nomogram predictions. Next, we conducted 2 experiments: (1) 17 urologists were presented with 10 case vignettes and asked to predict the 5-year recurrence-free probabilities for each patient; (2) case presentations of 63 prostate cancer patients (including full clinical histories with complete diagnostic data and surgical findings) were made to a group of 25 clinicians who were asked to predict organ-confined disease. We found 22 published studies comparing human experts with nomograms, greater than half (13 of 22) showed the nomogram performing above the level of the human expert. Our first experiment showed urologist modification of 165 nomogram predictions led to a decrease in prediction accuracy (c-index decreased from.67 to.55, P <.05). In our second experiment, clinician predictions of organ-confined disease were comparable to the nomogram (area under the receiver operating characteristic curve [AUC] 0.78 and 0.79, respectively). A mixed-model suggests the nomogram did not augment clinician prediction accuracy (doctor excess error 1.4%, P =.75, 95% confidence interval [CI]: -10.9% to 8.2%). Our data suggest that nomograms do not seem to diminish predictive accuracy and they may be of significant benefit in certain clinical decision making settings.

Carcinoma↗