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Accuracy of clinical nodal staging and factors associated with receipt of lymph node dissection at the time of surgery for nonmetastatic renal cell carcinoma
© 2019 Elsevier Inc. Introduction: The benefit of lymph node dissection (LND) in renal cell carcinoma (RCC) remains poorly defined. Despite this uncertainty, the American Urological Association (AUA) guideline on localized renal cancer recommends that LND be performed for staging purposes when there is suspicion of regional lymphadenopathy on imaging. Using the National Cancer Database (NCDB), we sought to determine how much of a departure the new AUA guideline is from current practice. We hypothesized that practice patterns would reflect the “Expert Opinion” recommendation and that patients who are clinical lymph node (cLN) positive would receive a LND more often than those who are cLN negative. Additionally, we sought to determine factors that would trigger a LND as well the accuracy of clinical staging by examining the relationship between cLN and pathologic lymph node (pLN) status of patients who received a LND. Materials and methods: The NCDB was queried for patients with nonmetastatic RCC who underwent partial nephrectomy or nephrectomy from 2010 to 2014. Patient sociodemographic and clinical characteristics were extracted. Frequency distributions were calculated for patients with both cLN and pLN status available. Of patients who received a LND, sensitivity, specificity, and positive/negative predictive values (PPV/NPV) of cLN status for pLN positivity were calculated. Logistic regression models were used to examine association between clinical and socioeconomic factors and receipt of LND. Propensity score matching was used in sensitivity analyses to examine potential for reporting bias in NCDB data. Results: We identified 110,963 patients who underwent surgery for RCC, of whom 11,867 (11%) had LND performed at the time of surgery. cLN and pLN information were available in 11,300 patients, of which 1,725 were preoperatively staged as having positive cLN. More LNDs were performed per year for patients who were cLN negative than cLN positive. Of patients who received a LND, the majority of patients were cLN negative across all clinical T (cT) stages. Multivariable analysis showed that all patients who had care at an academic/research institution (odds ratio [OR]: 1.58, 95% confidence interval [CI]: 1.43–1.74) and had to travel \u3e12.5 to 31.0 miles and \u3e31.0 miles to a treatment center (OR: 1.08, 95%CI: 1.01–1.15 and OR: 1.28, 95%CI: 1.20–1.36, respectively) were more likely to get a LND. As cT stage increased from cT2-4, the risk of LND increased (OR range: 4.7–7.90, respectively). Patients who were cLN positive were more likely to receive a LND at the time of surgery (OR: 18.68, 95%CI: 16.62–21.00). Of the patients who received a LND, clinical staging was more specific than sensitive. Conclusion: More patients received a LND who were cLN negative compared to patients who were cLN positive. Patients who were cLN positive were more likely to receive a LND. Treatment center type, distance to treatment center, cT stage, and cLN positivity were factors associated with LND receipt
Outcomes of Patients With Double-Hit Lymphoma Who Achieve First Complete Remission
PurposePatients with double-hit lymphoma (DHL) rarely achieve long-term survival following disease relapse. Some patients with DHL undergo consolidative autologous stem-cell transplantation (autoSCT) to reduce the risk of relapse, although the benefit of this treatment strategy is unclear.MethodsPatients with DHL who achieved first complete remission following completion of front-line therapy with either rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) or intensive front-line therapy, and deemed fit for autoSCT, were included. A landmark analysis was performed, with time zero defined as 3 months after completion of front-line therapy. Patients who experienced relapse before or who were not followed until that time were excluded.ResultsRelapse-free survival (RFS) and overall survival (OS) rates at 3 years were 80% and 87%, respectively, for all patients (n = 159). Three-year RFS and OS rates did not differ significantly for autoSCT (n = 62) versus non-autoSCT patients (n = 97), but 3-year RFS was inferior in patients who received R-CHOP compared with intensive therapy (56% v 88%; P = .002). Three-year RFS and OS did not differ significantly for patients in the R-CHOP or intensive therapy cohorts when analyzed by receipt of autoSCT. The median OS following relapse was 8.6 months.Conclusion In the largest reported series, to our knowledge, of patients with DHL to achieve first complete remission, consolidative autoSCT was not associated with improved 3-year RFS or OS. In addition, patients treated with R-CHOP experienced inferior 3-year RFS compared with those who received intensive front-line therapy. When considered in conjunction with reports of patients with newly diagnosed DHL, which demonstrate lower rates of disease response to R-CHOP compared with intensive front-line therapy, our findings further support the use of intensive front-line therapy for this patient population.Curis (Inst); TG Therapeutics (Inst); AbbVie (Inst); Acerta Pharma (Inst); Regeneron (Inst); DTRM (Inst); Portola Pharmaceuticals (Inst); Pharmacyclics (Inst); Karyopharm Therapeutics (Inst); Spectrum Pharmaceuticals (Inst); Seattle Genetics; Merck; Celgene; Bristol-Myers Squibb; Janssen; Novartis; Takeda; Seattle Genetics (Inst); Gilead Sciences (Inst); Merck (Inst); Incyte (Inst); Pfizer (Inst)6 month embargo; Published Online: May 5, 2017.This item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]