Oncologic outcomes in men with metastasis to the prostatic anterior fat pad lymph nodes: a multi-institution international study

BackgroundThe presence of lymph nodes (LN) within the prostatic anterior fat pad (PAFP) has been reported in several recent reports. These PAFP LNs rarely harbor metastatic disease, and the characteristics of patients with PAFP LN metastasis are not well-described in the literature. Our previous study suggested that metastatic disease to the PAFP LN was associated with less severe oncologic outcomes than those that involve the pelvic lymph node (PLN). Therefore, the objective of this study is to assess the oncologic outcome of prostate cancer (PCa) patients with PAFP LN metastasis in a larger patient population.MethodsData were analyzed on 8800 patients from eleven international centers in three countries. Eighty-eight patients were found to have metastatic disease to the PAFP LNs (PAFP+) and 206 men had isolated metastasis to the pelvic LNs (PLN+). Clinicopathologic features were compared using ANOVA and Chi square tests. The Kaplan-Meier method was used to calculate the time to biochemical recurrence (BCR).ResultsOf the eighty-eight patients with PAFP LN metastasis, sixty-three (71.6%) were up-staged based on the pathologic analysis of PAFP and eight (9.1%) had a low-risk disease. Patients with LNs present in the PAFP had a higher incidence of biopsy Gleason score (GS) 8-10, pathologic N1 disease, and positive surgical margin in prostatectomy specimens than those with no LNs detected in the PAFP. Men who were PAFP+ with or without PLN involvement had more aggressive pathologic features than those with PLN disease only. However, there was no significant difference in BCR-free survival regardless of adjuvant therapy. In 300 patients who underwent PAFP LN mapping, 65 LNs were detected. It was also found that 44 out of 65 (67.7%) nodes were located in the middle portion of the PAFP.ConclusionsThere was no significant difference in the rate of BCR between the PAFP LN+ and PLN+ groups. The PAFP likely represents a landing zone that is different from the PLNs for PCa metastasis. Therefore, the removal and pathologic analysis of PAFP should be adopted as a standard procedure in all patients undergoing radical prostatectomy

Laparoscopic partial nephrectomy: state of the art review

Izak Faiena, Christopher Sejong Han, Ephrem O Olweny Division of Urology, Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA Introduction: The surgical management of small renal masses (<4 cm) has greatly evolved over the last few decades, with the paradigm shifting from radical to partial nephrectomy. Laparoscopic partial nephrectomy (LPN) is increasingly utilized, and has achieved similar outcomes to open partial nephrectomy with decreased patient morbidity in experienced hands. The aim of this review was to examine the current status and future direction of LPN. Materials and methods: We performed a nonsystematic review of the literature using a free-text protocol in the PubMed database, using the terms “laparoscopic partial nephrectomy”, “robot-assisted partial nephrectomy”, “robotic partial nephrectomy”, and “laparoscopic partial nephrectomy oncologic and functional outcomes”. Only English language articles were selected. Evidence synthesis: Our search results yielded 1,136. Three authors reviewed the results, and articles with information on patient and tumor selection, surgical techniques, and oncologic and functional outcomes were included. With regard to outcomes, only series with the largest cohorts and longest follow-up were selected. Conclusion: LPN has evolved rapidly over the past 2 decades, and advances in technique as well as innovations in surgical technologies have facilitated its increased adoption in urologic practice. However, limitations remain, such as inadequacy of techniques to achieve cold ischemia laparoscopically, high technical demands of intracorporeal suturing, and limited ability to assess surgical anatomy beyond the field of view. These comprise goals of research aimed at improving future surgical precision and outcomes, while further decreasing the invasiveness of LPN. Keywords: nephrectomy, robotics, kidne

Durvalumab: an investigational anti-PD-L1 monoclonal antibody for the treatment of urothelial carcinoma

Izak Faiena,1,2 Amy L Cummings,3 Anna M Crosetti,3 Allan J Pantuck,1,2 Karim Chamie,1,2 Alexandra Drakaki1–3 1Department of Urology, 2Institute of Urologic Oncology, 3Department of Medicine, Division of Hematology and Oncology, David Geffen School of Medicine at University of California, Los Angeles, CA, USA Abstract: Our expanding knowledge of immunotherapy for solid tumors has led to an explosion of clinical trials aimed at urothelial carcinoma. The primary strategy is centered on unleashing the immune system by releasing the inhibitory signals propagated by programmed cell death-1 (PD-1) and its ligand programmed cell death ligand-1 (PD-L1). Many antibody constructs have been developed to block these interactions and are used in clinical trials. The Food and Drug Administration has already approved a number of checkpoint inhibitors such as anti-cytotoxic T-lymphocyte-associated protein 4 (CTLA4) monoclonal antibodies including ipilimumab; anti-PD-1 monoclonal antibodies including nivolumab and pembrolizumab; anti-PD-L1 antibodies including atezolizumab, avelumab, and durvalumab. One of the latest inhibitors is durvalumab, which is a high-affinity human immunoglobulin G1 kappa monoclonal antibody and blocks the interaction of PD-L1 with PD-1 and CD80. Currently, there are a number of ongoing trials in advanced urothelial carcinoma both using durvalumab monotherapy and in combination with other targeted therapies. In addition, durvalumab is being investigated in the non-muscle-invasive urothelial carcinoma, which is centered around intravenous formulations. These exciting developments have added a significant number of therapies in a previously limited treatment landscape. Keywords: durvalumab, checkpoint inhibitors, metastatic urothelial carcinom