Rare Histological Variants of Prostate Adenocarcinoma (PCa): NCDB Analysis

Introduction and Objective: American Joint Committee on Cancer (AJCC) recognizes five rare histological variants of prostate adenocarcinoma (PCa). Our aim was to describe the contemporary presentation and overall survival (OS) of these rare variants. Methods: From 2004-2015, we selected cases of mucinous, ductal, signet ring cell (SRC), Adenosquamous, and neuroendocrine (NEC) variants of PCa from the National Cancer Database. Characteristics at presentation for each variant were compared with nonvariant PCa. Cox regression was used to study the effect of histological subtype on overall mortality. Results: Less than 1 percent (5062/1345561; 0.38%) patients presented with rare-variant PCa. All variants had a higher clinical T stage at presentation than nonvariant PCa (all p\u3c0.001; Table 1). Metastatic disease was most common with NEC (62.9%), followed by adenosquamous (31.1%), SRC (10.3%), and ductal (9.8%) variants, compared to 4.2% in nonvariant PCa (all p\u3c0.001). Metastatic disease in mucinous (3.3%) was similar to nonvariant PCa (p = 0.15). SRC, mucinous, and ductal variants presented with a significantly higher PSA (Median 9.0, 6.7, and 6.6, respectively vs. 6.2 ng/ml in nonvariant PCa; all p \u3c 0.001), and higher biopsy grade (Grade group ≥ 4 (34.7%, 11.2%, and 27%, respectively vs. 8.6% in nonvariant PCa; all p \u3c 0.001). Estimated 5-year OS was highest in mucinous variant (89.3%), followed by nonvariant (87.2%), ductal (76.4%), SRC (67.0%), adenosquamous (20.5%), and NEC PCa (13.4%). After adjusting for covariates—compared to nonvariant PCa—mortality was significantly higher in ductal, SRC, adenosquamous, and NEC variants (Table 2) Conclusions: There are differences in the presentation and OS among rare variants of PCa. NEC, adenosquamous, signet ring cell, and ductal variants more commonly present with metastatic disease. All variants present with a higher local stage than nonvariant PCa. NEC variant is associated with the worst, and mucinous variant with the best OS.https://scholarlycommons.henryford.com/merf2019basicsci/1004/thumbnail.jp

Use of ultra-low dose computed tomography versus abdominal plain film for assessment of stone-free rates after shock-wave lithotripsy: implications on emergency room visits, surgical procedures, and cost-effectiveness

The aims of this investigation were: (1) to compare residual stone-fragment (RSF) detection rates of ultra-low dose computed tomography (ULD-CT) and abdominal plain film (KUB) in urolithiasis patients undergoing shock-wave lithotripsy (SWL), and (2) to evaluate the downstream sequelae of utilizing these two disparate imaging pathways of differing diagnostic fidelity. A retrospective chart-review of patients undergoing SWL at two high-volume surgical centers was undertaken (2013-2016). RSF diagnostic rates of ULD-CT and KUB were assessed, and the impact of imaging modality used on subsequent emergency room (ER) visits, unplanned procedures, and cost-effectiveness was investigated. Adjusted analyses examined association between imaging modality used and outcomes, and Markov decision-tree analysis was performed to identify a cost advantageous scenario for ULD-CT over KUB. Of 417 patients studied, 57 (13.7%) underwent ULD-CT while the remaining 360 underwent KUB. The RSF rates were 36.8% and 22.8% in the ULD-CT and KUB groups, respectively (p = 0.019). A 5.6% and 18% of the patients deemed stone-free on ULD-CT and KUB, respectively, returned to the ER (p = 0.040). Similarly, 2.8% and 15.1% needed an unplanned surgery (p = 0.027). These findings were confirmed on multivariable analyses, Odds ratios CT-ULD versus KUB: 0.19 and 0.10, respectively, p \u3c 0.05. With regards to cost-effectiveness, at low ULD-CT charges, the ULD-CT follow-up pathway was economically more favorable, but with increasing ULD-CT charges, the KUB follow-up pathway superseded. ULD-CT seems to provide a more \u27true\u27 estimate of stone-free status, and in consequence mitigates unwanted emergency and operating room visits by reducing untimely stent removals and false patient reassurances. Further, at low ULD-CT costs, it may also be economically more favorable

Impact of Hospital Teaching Status on Healthcare Utilization, Length of Stay (LOS), and Cost of Hospitalization of Radiation Cystitis (RC) in the United States

Background: Limited data exist regarding in-hospital use of resources, LOS, and cost of RC-associated admissions in teaching hospital (TH) versus nonteaching hospital (NTH) settings. The goal of this study was to address the above void in literature. Methods:We focused on 13,272 admissions for RC between 2008-2014 within the National Inpatient Sample. Patients with concurrent diagnosis of other bladder conditions (n=914) were excluded. ICD-9 diagnosis and procedure codes were used to study inpatient procedures performed during admission. Type of admissions, receipt of a procedure, type of procedures performed, LOS, and total inflation-adjusted cost were then compared between TH and NTH. Complex survey chi-squared test and analysis of variance procedures were used to account for the NIS sampling design. Results: Of the 12,358 assessable records, 49% were at THs. Patients were more commonly admitted to emergency department at NTH (85%) compared to TH (80%; p\u3c0.001). Weekend admissions were more common at NTH (24%) compared to TH (21%) (p=0.004). Receipt of a procedure during admission was higher in TH (65%) compared to NTH (60%; p\u3c0.001). Number of procedure codes recorded was higher in TH (\u3e= 2 codes; 28.9% in TH vs 24.5% in NTH; p \u3c0.001. More complex procedures like cystectomy were almost exclusively performed at TH (cystectomy 2.4% in TH vs 0.4% in NTH admissions; p \u3c0.001), whereas there was no difference in procedures like blood transfusion (TH 34%; NTH 33%; p=0.3), suprapubic cystostomy (TH 1.3%; NTH 1.4%; p=0.8), and transurethral procedures (TH 14%; NTH 16%; p=0.06). Despite statistically significant difference in LOS between the two groups (Median days (IQR): TH 5 (3-9); NTH 5 (3-8); p\u3c0.001) the difference was not clinically significant. Cost of admission was higher in TH (10,377$TH; 8504$ NTH; p\u3c0.001). Conclusions: In the United States, patients with RC are more frequently admitted to the emergency department in NTH. Patients admitted to TH receive a procedure more often, receive a higher number of procedures, and more complex procedures, compared to NTH. This explains higher cost of admission in TH. Further research is needed to study the readmission rates and outcomes of patients treated in both types of health systems to know the best practices that can reduce morbidity and readmissions.https://scholarlycommons.henryford.com/merf2019qi/1021/thumbnail.jp

Inpatient morbidity and cost of cytoreductive radical prostatectomy in the United States

INTRODUCTION AND OBJECTIVES: Clinical trials are currently examining the role of local therapy in metastatic prostate cancer (mPCa). While the safety of RP in localized disease is proven, few studies have looked at perioperative complications and cost of cytoreductive RP (cRP). We used the National Inpatient Sample (NIS) to study the inpatient morbidity, and cost of cRP in the United States (US). METHODS: Analyzing the NIS dataset from 2008-2014, we identified 90,662 patients (weighted estimate 449,025 in the US) who underwent RP for non-metastatic disease, and 1,173 patients (weighted estimate 5,835) who underwent cRP for mPCa (see Fig. 1). Outcomes of interest were inpatient complications, individual complications, hospital stay, and total cost. Covariates included age, race, Charlson Comorbidity score, insurance status, rural/semi-urban/urban location, income, hospital location (rural/urban), teaching status, geographical location of hospital, and hospital volume. Multivariable logistic regression was used to evaluate the effect of metastatic disease on morbidity after adjusting for covariates. RESULTS: Inpatient complication rates were 14.9% (13,688/91,835) overall, 14.9% (13,464/90,662) in the non-metastatic group, and 19.1% (224/1,173) in the cRP group (p = 0.01). On multivariable analysis, metastasis was an independent predictor of inpatient complications (OR 1.329; 95% CI: 1.077-1.640; p = 0.01). The cRP group also had higher rates of blood transfusion (6.9% [82/1,173] vs 4.3% [3,869/90,662]; p \u3c 0.001), longer hospital stay (median 1.25 vs 0.97 days; p \u3c 0.001), and higher cost (median $14,123 vs$11,591; p \u3c 0.001) compared to the non-metastatic group (see table 1). Majority of cRP was performed in urban teaching hospitals. CONCLUSIONS: cRP is associated with higher inpatient morbidity, longer hospital stay, and higher cost compared to RP for non-metastatic disease. This information may be valuable for informed decision-making in practice and before recruiting patients in clinical trials on this subject. Source of Funding: Nonehttps://scholarlycommons.henryford.com/merf2019hvc/1006/thumbnail.jp

Long-term risk of recurrence in surgically treated intermediate-high risk renal cell carcinoma: a post-hoc analysis of the Eastern Cooperative Oncology Group - American College of Radiology Imaging Network E2805 Trial cohort

Background: Surgical resection remains the gold standard treatment modality for clinically localized renal cell carcinoma (RCC). However, the optimal follow-up period in these individuals is controversial, and the current recommendations are based on retrospective data, which inevitably contain attrition bias. Our objective was to re-visit the recurrence rate of surgically treated intermediate-high risk RCC patients using randomized clinical trial data. MethodsWe performed a post-hoc analysis of all the patients that were included in the ECOG-ACRIN E2805 Trial. We assessed post-operative recurrence rates using the cumulative incidence method. Conditional estimates of a 36-month recurrence for patients whom did not have recurrence at set intervals following surgery was performed. Assessment of routinely available clinical and pathological features in predicting disease recurrence at time 0-months after surgery was compared it to that of the same features at 60-months after surgery.ResultsThe original cohort consisted of 1943 patients . Median follow-up for the 1508 patients whom were alive at the end of the study was 67.9 months (IQR 56.7 – 82.0). 730 patients developed disease recurrence. The 36-month cumulative incidence of recurrence was found to be 31.1% (IQR 29.3 – 33.6) for the entire cohort at 0-months from surgery. The rate changed to 26.0% (IQR 23.7 – 28.2), 18.8% (IQR 16.5 – 21.1), 16.1% (IQR 13.6 – 18.8), 18.9% (IQR 15.0 – 23.1) and 20.3% (IQR 12.5 – 28.1) for patients whom did not have recurrence at 12-, 24-, 36-, 48- and 60-months from surgery, respectively. At time 0-month from surgery, age (hazard ratio [HR]: 1.01, 95% confidence interval [CI]: 1.00-1.02), pathologic T3/4 stage (HR: 1.557, 95%CI: 1.17 - 2.07), pathologic N1/2 stage (HR: 2.38, 95%CI: 1.85 - 3.07), Fuhrman grade 3 (HR: 1.36, 95%CI: 1.14 - 1.62) and Fuhrman grade 4 (HR: 2.41, 95%CI: 1.96 - 2.96) were independent predictors of recurrence. Conversely, none of the aforementioned covariates were predictors of disease recurrence at 60-months following surgery. Conclusions: Long-term follow-up, beyond 5-years, is supported by the findings within the present study. Also, the usual independent predictors that are frequently used to guide patient follow-up demonstrated validity immediately following surgery however lose their predictive power at 5 years from surgery.https://scholarlycommons.henryford.com/merf2019clinres/1028/thumbnail.jp

Impact of treatment modality on overall survival in localized ductal prostate adenocarcinoma: A National Cancer Database analysis

INTRODUCTION AND OBJECTIVE: Ductal adenocarcinoma is considered a rare histological variant of prostate adenocarcinoma (PCa). Given the rarity of this subtype, optimal treatment strategies for men with nonmetastatic ductal PCa is largely unknown. We aimed to describe the impact of surgery, radiotherapy, and systemic therapy on overall survival (OS) in men with nonmetastatic ductal PCa. METHODS: We retrospectively selected 2209 cases of ductal PCa, diagnosed between 2004 and 2015, within the National Cancer Database (NCDB). Exclusion of metastatic patients yielded a total sample of 1993 individuals. Cox regression analysis tested the impact of treatment (surgery, radiotherapy, systemic therapy and no treatment) on OS. Covariates included age, race, Charlson comorbidity score (CCI), clinical T stage, biopsy Gleason score, serum prostate specific antigen (PSA), and income. Adjusted Kaplan-Meier estimates were used to visualize the impact of treatment modality on OS. RESULTS: In men with nonmetastatic ductal PCa, median (IQR) age and PSA were 67 (61-74) years and 6.3 (4.3-10.8) ng/mL, respectively. Further, 9.8% (n=195) of patients presented with cT3 disease or higher, 3.4% (n=68) presented a CCI score ≥ 4, and 40.6% (808) presented with a Gleason biopsy score ≥ 4. Further, 1212 (60.8%) patients were treated surgically, 406 (20.4%) with radiotherapy, 102 (5.1%) with systemic therapies, and 273 (13.7%) received no treatment. Multivariable analysis showed that in comparison to men treated surgically, OS was significantly lower for patients receiving radiotherapy (HR 2.6; 95% CI 1.7-4.0) and systemic therapies (HR 9.1; 95% CI 5.0-16.5). Adjusted Kaplan-Meier curves are shown in the associated figure. CONCLUSIONS: Our findings show that in the rare ductal PCa variant, starting treatment with surgery offers more favorable long-term OS outcomes than radiotherapy and systemic therapies. While residual selection bias might persist after adjustment, the rarity of this disease precludes the possibility of a future trial, and the presented data represents the best available level of evidence on this topic