A population-based comparison of cancer-control rates between radical and partial nephrectomy for T1A renal cell carcinoma.

OBJECTIVES: To complement existing data with population-based cancer control outcomes that account for the effect of other-cause mortality (OCM). Cancer control rates are virtually equivalent between partial (PN) and radical nephrectomy (RN) for patients with T1aN0M0 renal cell carcinoma (RCC). To date, only 6 studies from centers of excellence examined cancer control rates after PN vs RN for T1aN0M0 RCC. OCM was unaccounted for in those studies, which may introduce a bias. We relied on the surveillance, epidemiology, and end results (SEER) database and assessed cancer-specific mortality (CSM) after either PN or RN for T1aN0M0 RCC, in competing-risks models. METHODS: Between 1988 and 2004, the SEER-9 database identified 1622 PN (22.3%) and 5658 RN (77.7%) T1aN0M0 RCC. Competing-risks regression models, controlling for OCM and matched for age, year of surgery, tumor size, and Fuhrman grade, addressed the effect of nephrectomy type (PN vs RN) on CSM. RESULTS: At 5 years, in a PN and RN matched-population controlling for OCM, CSM after PN and RN was respectively 1.8% vs 2.5% (P = .5). The CSM rates in this cohort for patients aged ≥ 70 years were respectively 1.0% and 3.4% (P = .7). CONCLUSIONS: This competing-risks population-based analysis confirmed the CSM equivalence between PN and RN for T1aN0M0 RCC and showed virtually perfect CSM-free rates (97.5% or better) even in older patients.

The rate of secondary malignancies after radical prostatectomy versus external beam radiation therapy for localized prostate cancer: a population-based study on 17,845 patients.

PURPOSE: External-beam radiation therapy (EBRT) may predispose to secondary malignancies that include bladder cancer (BCa), rectal cancer (RCa), and lung cancer (LCa). We tested this hypothesis in a large French Canadian population-based cohort of prostate cancer patients. METHODS AND MATERIALS: Overall, 8,455 radical prostatectomy (RP) and 9,390 EBRT patients treated between 1983 and 2003 were assessed with Kaplan-Meier and Cox regression analyses. Three endpoints were examined: (1) diagnosis of secondary BCa, (2) LCa, or (3) RCa. Covariates included age, Charlson comorbidity index, and year of treatment. RESULTS: In multivariable analyses that relied on incident cases diagnosed 60 months or later after RP or EBRT, the rates of BCa (hazard ratio [HR], 1.4; p = 0.02), LCa (HR, 2.0; p = 0.004), and RCa (HR 2.1; p <0.001) were significantly higher in the EBRT group. When incident cases diagnosed 120 months or later after RP or EBRT were considered, only the rates of RCa (hazard ratio 2.2; p = 0.003) were significantly higher in the EBRT group. In both analyses, the absolute differences in incident rates ranged from 0.7 to 5.2% and the number needed to harm (where harm equaled secondary malignancies) ranged from 111 to 19, if EBRT was used instead of RP. CONCLUSIONS: EBRT may predispose to clinically meaningfully higher rates of secondary BCa, LCa and RCa. These rates should be included in informed consent consideration.

A comparative population-based analysis of the rate of partial vs radical nephrectomy for clinically localized renal cell carcinoma.

STUDY TYPE: Prevalence (prospective cohort with good follow up). LEVEL OF EVIDENCE: 1a. OBJECTIVE: To examine contemporary (1989-2004) trends in partial nephrectomy (PN) within the Surveillance, Epidemiology and End Results (SEER) database, as among other considerations, a survival benefit due to avoidance of surgically induced renal insufficiency distinguishes PN from radical nephrectomy (RN). PATIENTS AND METHODS: Diagnostic, stage and surgical codes of patients with T1-2N0M0 renal cell carcinoma treated with either PN or RN were assessed. Proportions, trends and multivariable logistic regression models tested the predictors of the use of PN. RESULTS: Of 19 733 assessable patients, 2614 (13.2%) and 17 119 (86.8%), respectively, had PN or RN. The use of PN decreased with increasing tumour size, was more frequent in younger patients and increased with more contemporary years of surgery (all P < 0.001). Intriguingly, there was important geographical variability (P < 0.001), e.g. in the San Francisco-Oakland Metropolitan Area the absolute PN rate was 16.4%, vs 7.6% in New Mexico (P < 0.001). In multivariable analyses, tumour size, age, year of surgery, gender and SEER registries were independent predictors of PN use. CONCLUSION: Although as expected the rate of PN use increased over time, unexplained variability remained. For example, gender and SEER registries affected the likelihood of PN. These variables warrant further analyses to reduce unnecessary variability and to maximize PN use and its benefit.

Nephron-sparing surgery is equally effective to radical nephrectomy for T1BN0M0 renal cell carcinoma: a population-based assessment.

OBJECTIVES: To test the effect of nephron-sparing surgery (NSS) vs radical nephrectomy (RN) on cancer-specific mortality (CSM) in patients with T1bN0M0 renal cell carcinoma (RCC) in a population-based cohort. To date, only few series from tertiary care centers supported the use of NSS for T1bN0M0 (range 4-7 cm) RCC. METHODS: The Surveillance, Epidemiology, and End Results database allowed us to identify 275 NSS (5.3%) and 4866 RN (94.7%) patients treated for T1bN0M0 RCC between 1988 and 2004. Analyses matched for age, year of surgery, tumor size, and Fuhrman grade addressed the effect of nephrectomy type (NSS vs RN) on CSM. RESULTS: Five years after surgery, the surviving proportions of NSS and RN patients matched for age, tumor size, and year of surgery were respectively 91.4 and 95.3% and 90.1 and 93.8% in the cohort, where additional matching for Fuhrman grade was performed. Neither of the matched analyses resulted in statistically significant CSM difference (P = .1 and .4) between NSS and RN. Similarly, competing-risks regression analyses based on both matching schemes also failed to reveal statistically significant CSM differences (P = .3 and .3). CONCLUSIONS: Our study represents the largest and the only population-based analysis of cancer control efficacy of NSS vs RN in T1bN0M0 RCC. It indicates that NSS does provide equivalent cancer control relative to RN. In consequence, based on cancer control equivalence, NSS should be given equal consideration to RN in patients with T1bN0M0 lesions.

A critical appraisal of the value of lymph node dissection at nephroureterectomy for upper tract urothelial carcinoma.

OBJECTIVES: To perform a population-based analysis of the potential staging or prognostic value (or both) of lymph node dissection (LND) in patients without nodal metastases vs no LND. In several previous reports, LND in patients with upper tract urothelial carcinoma (UTUC) treated with nephroureterectomy (NU) was associated with better survival relative to no LND (pN(x)), even in the absence of pathologically confirmed nodal metastases (pN(0)). METHODS: Within the surveillance, epidemiology, and end results database, we identified 2824 patients treated with NU for UTUC between 1988 and 2004. CSM rates after NU were graphically explored using Kaplan-Meier plots. Univariable and multivariable Cox regression models tested the effect of N(0) vs N(x) stage on CSM, after adjusting for T stage, tumor grade, age, gender, primary tumor location, type, and year of surgery. RESULTS: The CSM-free survival rate at 5 years after NU was 81.2% and 77.8% respectively for pN(0) and pN(x) patients. In univariable analyses pN(x) vs pN(0) status was not associated with worse survival (HR: 1.19; P = .09). After adjustment for all covariates, pN(x) vs pN(0) status still failed to achieve independent predictor status (HR: 0.99; P = .9). CONCLUSIONS: We found no survival benefit related to the performance of LND in pN(0) patients, relative to pN(x) patients. Lack of standardized criteria for patients' selection for LND and for pathological lymph node specimen evaluation represents some of the explanation for the observed discrepancy between the current finding and previous findings.

Temporal stage and grade migration in surgically treated patients with upper tract urothelial carcinoma.

STUDY TYPE: Therapy (individual cohort). LEVEL OF EVIDENCE: 2b. OBJECTIVE: To examine the temporal trends in stage and grade at presentation, as well as cancer-specific mortality (CSM) rates, in surgically treated patients with upper tract urothelial carcinoma (UTUC), as few population-based studies addressed contemporary cancer-control outcomes in patients with UTUC. PATIENTS AND METHODS: Within the Surveillance, Epidemiology and End Results (SEER) database, we identified 4915 patients diagnosed with UTUC between 1983 and 2004, who had either a nephroureterectomy (NU) or a segmental ureterectomy (SU). Patients were divided into four groups according to the year-of-surgery quartiles. The chi-square test and the chi-square trend test were used for comparison of proportions and trends over time. Kaplan-Meier plots were used to graphically depict CSM rates. Multivariable Cox regression models were used to test the effect of the year-of-surgery quartiles on CSM. Covariates consisted of SEER stage, tumour grade, age, race, primary tumour site, type of surgery, and SEER registries. RESULTS: Of 4915 assessable patients, 1316, 1328, 1146 and 1125 were, respectively, treated in 1983-1988, 1989-94, 1995-99 and 2000-2004. Of those, 4430 had a NU and 485 had a SU. The rates of non-localized stage and of grade III-IV disease at surgery increased, respectively, from 49.8% to 69.5% (P < 0.001) and 45.7 to 70.2% (P < 0.001) during the study period. CSM rates at 4 years after surgery reflected the temporal stage and grade differences, and increased from 18.2 to 23.9% (P = 0.03) between 1983-1988 and 2000-2004. In multivariable analyses, when stage and grade were taken into account, most contemporary patients showed more favourable CSM rates than their historic counterparts (hazard ratio 0.7, P = 0.02). CONCLUSIONS: We report a stage and grade migration at NU or SU towards more aggressive disease among surgically treated patients between 1983 and 2004. Despite this observation, the CSM rates of contemporary patients have not worsened, which validates the role of NU and SU as effective treatments for UTUC.

A population-based assessment of perioperative mortality after nephroureterectomy for upper-tract urothelial carcinoma.

OBJECTIVES: To examine the perioperative mortality rates at 90 days (90 dM) after nephroureterectomy (NU) and to devise a model capable of identifying individuals at an elevated 90 dM risk. NU represents the surgical standard of care for patients with invasive, nonmetastatic upper-tract urothelial carcinoma. However, this major abdominal surgery may be associated with a nonnegligible rate of perioperative mortality. METHODS: We identified 6078 upper-tract urothelial carcinoma patients treated with NU from 17 registries of the Surveillance, Epidemiology, and End Results database, between 1988 and 2006. Stratified analyses quantified 90 dM rates according to age, gender, race, year of diagnosis, tumor location, surgery type, T stage, tumor grade, and lymph node status. Subsequently, multivariable logistic regression models identified predictors of 90 dM within the development cohort (n = 3039). The accuracy and calibration of the model were tested in an independent validation cohort (n = 3039). RESULTS: The overall 90 dM rate was 4.4%. Continuously coded age and T and N stages achieved an independent predictor status in multivariable logistic regression models and represented key variables for prediction of individual 90 dM risk after NU, with 73.4% accuracy. Excellent correlation between predicted and observed 90 dM rates after NU was recorded. CONCLUSIONS: In this large-scale population-based analysis of perioperative mortality after NU, age and T and N stages emerged as the most informative predictor of 90 dM. We recommend the use of this tool in individual decision-making and in informed consent considerations.

Prognostic significance of lymph node invasion in patients with metastatic renal cell carcinoma: a population-based perspective.

BACKGROUND: Virtually all staging schemes aimed at predicting the prognosis of surgically treated patients diagnosed with metastatic renal cell carcinoma (MRCC) omit the use of lymph node stage. In the current study, the authors tested the prognostic significance of lymph node stage in patients with MRCC within a population-based cohort of patients treated with cytoreductive nephrectomy to assess whether the inclusion of lymph node stage could improve the accuracy of cancer-specific mortality predictions. METHODS: Within the Surveillance, Epidemiology, and End Results database, the authors identified 1153 patients who were treated with cytoreductive nephrectomy for MRCC, with (negative lymph nodes [N0] vs positive lymph nodes [N1-2]) or without (unknown lymph node stage [Nx]) lymphadenectomy. Of 797 patients treated with lymphadenectomy, 42.9% were found to have lymph node metastases. Kaplan-Meier plots and univariate and multivariate Cox regression analyses tested the statistical significance and the independent predictor status of lymph node stage, Fuhrman grade, tumor size, year of surgery, race, sex, and age in patients who underwent lymphadenectomy at the time of cytoreductive nephrectomy. RESULTS: At 3 years after cytoreductive nephrectomy, the cancer-specific mortality-free rates of N1-2 versus N0 versus Nx patients were 14.4% versus 34.7% versus 34.0%, respectively. Lymph node stage represented the most informative variable and achieved independent predictor status in all multivariate models (P<.001). Consideration of lymph node stage added 3.2% accuracy to other predictors of cancer-specific mortality. CONCLUSIONS: The findings of the current study indicate that lymph node stage should be considered in prognostic models. The TNM staging of MRCC patients also should rely on the stage of locoregional lymph nodes, because the 3-year cancer-specific mortality rates of lymph node-negative and lymph node-positive MRCC patients differ by as much as 20%.

Location of the primary tumor is not an independent predictor of cancer specific mortality in patients with upper urinary tract urothelial carcinoma.

PURPOSE: The prognostic significance of renal pelvis vs ureteral upper urinary tract urothelial carcinoma tumor location is controversial. We assessed the prognostic significance of upper urinary tract urothelial carcinoma tumor location in a large, population based data set. MATERIALS AND METHODS: Our analyses relied on 2,824 patients treated with nephroureterectomy for upper urinary tract urothelial carcinoma within 9 SEER registries between 1988 and 2004. Univariable and multivariable models tested the effect of tumor location on cancer specific mortality rates. Covariates consisted of age, race, SEER registry, gender, type of surgery (nephroureterectomy with vs without bladder cuff removal), pT stage, pN stage, grade and year of surgery. RESULTS: Relative to ureteral tumors renal pelvis tumors were of higher stage (T3/T4 disease 38.4% vs 57.9%, p <0.001) and had a higher rate of lymph node metastases (6.0% vs 9.8%, p = 0.003) at nephroureterectomy. The respective 5-year cancer specific mortality-free survival estimates were 81.0% vs 75.5% (p = 0.007). However, after multivariable adjustment tumor location failed to reach independent predictor status of cancer specific mortality (p = 0.8). CONCLUSIONS: To our knowledge this is the largest cohort in which the impact of upper urinary tract urothelial carcinoma tumor location on cancer specific mortality was examined. At nephroureterectomy renal pelvis tumors had significantly more advanced T and N stages compared to ureteral tumors. However, after adjustment for stage, grade and other covariates tumor location did not independently predict cancer specific mortality. Thus, the biological behavior of renal pelvis vs ureteral tumors is the same after nephroureterectomy as long as stage, grade, and other patient and tumor characteristics are accounted for.

Tumor size is a determinant of the rate of stage T1 renal cell cancer synchronous metastasis.

PURPOSE: A recent multi-institutional analysis of 995 patients treated for renal cell cancer questioned the relationship between tumor size and the synchronous metastasis rate. We revisited the hypothesis that metastatic potential is unrelated to tumor size. MATERIALS AND METHODS: We tested the relationship between tumor size and synchronous metastasis in 22,204 patients with T1a and T1b renal cell cancer diagnosed and/or treated with nephrectomy for clear cell, papillary or chromophobe histological subtypes in 1 of 9 Surveillance, Epidemiology and End Results registries between 1988 and 2004. RESULTS: In the study population the synchronous metastasis rate was 9.6%, including 5.6% vs 14.2% for T1a vs T1b. Stratification by 1 cm tumor size intervals revealed that the rate increased with increasing tumor size, that is 4.8% at 1.0 cm or less, 4.2% at 1.1 to 2.0 cm, 4.9% at 2.1 to 3.0 cm, 7.1% at 3.1 to 4.0 cm, 12.1% at 4.1 to 5.0 cm, 13.3% at 5.1 to 6.0 cm and 18.4% 6.1 to 7.0 cm (chi-square trend p <0.001). Cubic spline analysis showed that tumor size was virtually linearly related to the synchronous metastasis rate. Stratification by histological subtype in patients treated with nephrectomy revealed that clear cell renal cell cancer was most frequently associated with synchronous metastasis. Finally, tumor size was an independent predictor of synchronous metastasis in multivariate regression models adjusted for age, gender, histological subtype and year of diagnosis quartiles. CONCLUSIONS: Our study confirms that tumor size is an important determinant of the likelihood of synchronous metastasis in patients with T1a and T1b renal cell cancer. The synchronous metastasis rate directly increases with increasing tumor size. Even patients with small renal masses are at risk for synchronous metastasis and patients with clear cell renal cell cancer are at highest risk.

A proposal for reclassification of the Fuhrman grading system in patients with clear cell renal cell carcinoma.

BACKGROUND: The conventional Fuhrman grading system, which categorizes renal cell carcinoma (RCC) with grades I, II, III, and IV, is the most widely used predictor assessment of RCC cancer-specific mortality (CSM). OBJECTIVES: The aim of this study was to test the prognostic ability of simplified Fuhrman grading schemes (FGSs) that rely on two- or three-tiered classifications. DESIGN, SETTING, AND PARTICIPANTS: The current study addressed a population of 14064 patients with clear cell RCC who were treated with partial or radical nephrectomy between 1988-2004, within nine Surveillance, Epidemiology, and End Results (SEER) cancer registries. MEASUREMENTS: Univariable and multivariable analyses as well as prognostic accuracy analyses were performed for various FGSs to test their ability to predict CSM rates. The conventional four-tiered FGS was compared to a modified two-tiered FGS in which grades I and II and grades III and IV were combined. A second simplified three-tiered FGS in which grades I and II were combined but grades III and IV were kept separate was also tested. RESULTS AND LIMITATIONS: The overall 5-yr CSM-free rate was 81.5%. All three FGSs achieved independent predictor status in multivariable analyses. Prognostic accuracy of multivariable models that relied on various FGSs was 83.6% for the modified two-tiered FGS and 83.8% for both the conventional four-tiered and the modified three-tiered FGS. CONCLUSIONS: Our findings indicate that the simplified FGSs perform equally as well as the conventional four-tiered FGS. The use of simplified grading schemes may represent an advantage for pathologists as well as for clinicians caring for patients with RCC.

Nephroureterectomy and segmental ureterectomy in the treatment of invasive upper tract urothelial carcinoma: a population-based study of 2299 patients.

PURPOSE: The TNM staging system represents the cornerstone for classifying patients with upper tract urothelial carcinoma (UTUC). We tested the prognostic impact of pT and pN stages on cancer-specific mortality (CSM) in a large population-based cohort of surgically treated patients with UTUC. METHODS: Our analyses relied on 2299 patients treated with nephroureterectomy (NU) or segmental ureterectomy (SU) for UTUC within nine Surveillance, Epidemiology and End Results registries between 1988 and 2004. CSM rates after surgery were graphically explored using Kaplan-Meier plots. Univariable and multivariable Cox regression models tested the effect of pT and pN stages on CSM, after adjusting for tumour grade, age, gender, primary tumour location, type and year of surgery. RESULTS: Five years after surgery, the overall CSM-free survival rate was 77.6%. The 5-year CSM-free survival rates of pT(1)N(0) (n=739), pT(2)N(0) (n=422), pT(3)N(0) (n=691), pT(4)N(0) (n=190) and any T N(1-3) (n=257) were, respectively, 93.5 versus 86.2 versus 64.5 versus 54.7 versus 35.0%. The 5-year CSM-free survival rates of pT(1-2)N(1-3) (n=41) and pT(3-4)N(1-3) (n=216) patients were, respectively, 68.9% and 28.7% (p=0.006). In multivariable analyses, pT and pN stages (p<0.001), as well as tumour grade (p<0.001), achieved independent predictor status. Advanced age adversely affected CSM-free survival (p=0.001). Conversely, tumour location, gender, year and type of surgery did not exert independent predictor status. CONCLUSION: Durable cancer control can be expected in patients treated with NU or SU for organ-confined (pT(1-2)) UTUC. Conversely, the presence of non-organ-confined (pT(3-4)) disease and/or of nodal metastases (pN(1-3)) exerts a profound detrimental effect on CSM-free survival.

Does histologic subtype affect oncologic outcomes after nephron-sparing surgery?

OBJECTIVES: To test whether renal cell carcinoma (RCC) histologic subtypes (HSs) affect cancer-specific mortality after nephron-sparing surgery (NSS). HSs are considered of prognostic value in RCC. For example, the papillary HS might confer a worse prognosis, and, at some centers, only radical nephrectomy is performed for the papillary HS. METHODS: We used univariate and multivariate Cox regression models to study patients with Stage T1N0M0 RCC treated with NSS (n = 1205) from 1988 to 2004. The data were taken from 9 Surveillance, Epidemiology, and End Results registries. RESULTS: At 36 months after NSS, the cancer-specific mortality rate was 97.8%, 100%, and 97.4% for a clear cell, chromophobe, and papillary RCC HS, respectively. On univariate and multivariate analyses, no statistically significant differences were recorded with regard to the HS. CONCLUSIONS: Despite the suggested more aggressive phenotype of the papillary HS, we found no difference among the papillary, chromophobe, and clear cell variants. Thus, the diagnosis of one HS vs another HS should not deter from the use of NSS when cancer-specific mortality is considered as an endpoint.

Population-based study of perioperative mortality after retroperitoneal lymphadenectomy for nonseminomatous testicular germ cell tumors.

OBJECTIVES: To determine whether retroperitoneal lymphadenectomy (RPLND) perioperative mortality (PM) rates reported from a center of excellence (Indiana University: 0% for primary and 0.8% for postchemotherapy RPLND) are applicable to institutions at large. METHODS: We used the data from 882 assessable patients with nonseminomatous testicular germ cell tumor treated with RPLND from 1988 to 1997 accessed from the Surveillance, Epidemiology, and End Results (SEER) database. These data did not include data from Indiana University. The observed PM rates were stratified according to age and SEER stage. RESULTS: The median age at RPLND was 29 years. Of the 882 cases, 435 (49.3%) were performed for localized (Stage I), 380 (43.1%) for regional (Stage II), and 67 (7.6%) for metastatic (Stage III) SEER stage. Of the 882 patients, 7 patients died during the initial 90 days after RPLND, for a 0.8% PM rate. PM increased with increasing age: < or =29 years, 0.0%; 30-39 years, 1.3%; and > or =40 years, 2.7% (chi(2) trend test, P = .002). PM also increased with increasing stage: 0.0% for localized, 0.8% for regional, and 6.0% for metastatic disease (chi(2) trend test, P < .001). CONCLUSIONS: RPLND is associated with virtually no or low PM in patients with localized and regional disease. The PM rates for these 2 groups replicated those of Indiana University. In contrast, the PM rate of 6% for patients with distant metastases implies that RPLND for these higher risk patients should ideally be performed at centers of excellence, with the intent of reducing the PM rate.

External validation of a nomogram predicting mortality in patients with adrenocortical carcinoma.

OBJECTIVE: To develop nomograms predicting cancer-specific and all-cause mortality in patients managed with either surgery or no surgery for adrenocortical carcinoma (ACC). PATIENTS AND METHODS: The models were developed in 205 patients with ACC and externally validated using 207 other patients with ACC, identified in the 1973-2004 Surveillance, Epidemiology and End Results database. The predictors comprised age, gender, race, stage and surgery status. Nomograms based on Cox regression model-derived coefficients were used for predicting the cancer-specific and all-cause mortality, and were tested using area under the receiver operating characteristics (ROC) curve. RESULTS: In cancer-specific analyses, the median survival of patients within the development cohort was 26 months, vs 71 months in the external validation cohort (P < 0.001). In overall survival analyses, the median values were 21 vs 32 months for, respectively, the development and the external validation cohort (P < 0.001). Three variables (age, stage and surgical status) were included in the nomograms predicting cancer-specific and all-cause mortality. In the external validation cohort, the nomograms achieved between 72 and 80% accuracy for prediction of cancer-specific or all-cause mortality at 1-5 years after either surgery or diagnosis of ACC for non-surgical patients. CONCLUSION: Our models are the first standardized and individualized prognostic tools for patients with ACC. Their accuracy was confirmed within a large external population-based cohort of patients with ACC.

Nephrectomy improves survival in patients with invasion of adjacent viscera and absence of nodal metastases (stage T4N0 renal cell carcinoma).

OBJECTIVE: To examine the cancer-specific mortality (CSM) of patients with T4N0-2M0 renal cell carcinoma (RCC) treated with either nephrectomy (RN) or no surgery (NS). PATIENTS AND METHODS: Of 43 143 patients with RCC identified in the Surveillance, Epidemiology and End Results database, 310 had tumours involving adjacent organs with no evidence of distant metastases (T4NanyM0) and had RN (246, 79.4%) or NS (64, 20.6%). Kaplan-Meier analyses, Cox regression and competing-risks regression models were used to compare the effect of RN vs NS on CSS. RESULTS: In patients with T4N0 disease the median survival benefit associated with RN vs NS was 42 months (48 vs 6 months, P < 0.001). Conversely, the median survival in patients T4N1-2 was no different between RN and NS (9.3 vs 9.1 months, P = 0.9). Multivariable analyses in T4N0 cases indicated a substantial survival disadvantage for patients having NS vs RN (hazard ratio 4.8, P < 0.001). Conversely, in patients with N1-2 stages, the CSS was virtually the same for NS and RN (hazard ratio 0.9, P = 0.9). Competing-risks regression models confirmed the benefit of RC in patients with T4N0 and the lack of benefit in those with T4N1-2 disease, after controlling for other-cause mortality. CONCLUSION: Our data suggest a survival benefit in patients with T4N0 RCC treated with RC. By contrast, RN seems to have no effect on survival in patients with evidence of nodal metastases.

Population-based analysis of normal Total PSA and percentage of free/Total PSA values: results from screening cohort.

OBJECTIVES: To examine the distribution of total prostate-specific antigen (tPSA) and percentage of free/total PSA (%f/tPSA) values in patients undergoing prostate cancer screening in Canada. METHODS: The data from 4 consecutive annual prostate cancer screening events held in Montreal, Canada were examined with respect to age, tPSA, and %f/tPSA in 3222 men. RESULTS: Within the entire cohort, the median PSA level was 1.0 ng/mL and the median %f/tPSA was 26%. Using the interquartile range around the median, the upper bound for tPSA was situated at 1.9 ng/mL and the lower bound for %f/tPSA was at 19%. The 90th percentile for the median tPSA was 3.8, and the 10th percentile for the median %f/tPSA was 14. PSA and %f/tPSA showed a relation with age. The 75th percentile for the median tPSA level in the age category 40-49, 50-59, 60-69, and 70-79 years was 1.1, 1.4, 2.6, and 3.6 ng/mL, respectively. The 25th percentile for the median %f/tPSA level in the age category 40-49, 50-59, 60-69, and 70-79 years was 19, 21, 18 and 19 ng/mL, respectively. CONCLUSIONS: Our results can guide clinicians regarding the population-based distribution of serum tPSA and %f/tPSA values. Those values can be used for the purpose of counseling, as well as in the informed consent process before prostate biopsy.

A simple and accurate model for prediction of cancer-specific mortality in patients treated with surgery for primary penile squamous cell carcinoma.

PURPOSE: Cancer-specific mortality (CSM) of patients with primary penile squamous cell carcinoma (PPSCC) may be quite variable. Recently, a nomogram was developed to provide standardized and individualized mortality predictions. Unfortunately, it relies on a large number (n = 8) of specific variables that are unavailable in routine clinical practice. We attempted to develop a simpler prediction rule with at least equal accuracy in predicting CSM after surgical removal of PPSCC. EXPERIMENTAL DESIGN: The predictive rule was developed on a cohort of 856 patients identified in the 1988 to 2004 Surveillance, Epidemiology and End Results (SEER) database. The predictors consisted of age, race, SEER stage (localized versus regional versus metastatic), tumor grade, type of surgery (excisional biopsy, partial penectomy, and radical penectomy), and of lymph node status (pN0 versus pN1-3 versus pNx). A look-up table based on Cox regression model-derived coefficients was used for prediction of 5-year CSM. The predictive rule accuracy was tested using the Harrell's modification of the area under the receiver operating characteristics curve. RESULTS: SEER stage and histologic grade achieved independent predictor status and qualified for inclusion in the model. The model achieved 73.8% accuracy for prediction of CSM at 5 years after surgery. Both predictors achieved independent predictor status in competing risk regression models addressing CSM, where other cause mortality was controlled for. CONCLUSION: Despite equivalent accuracy, our predictive rule predicting 5-year CSM in patients with PPSCC is substantially less complex (2 versus 8 variables) than the previously published model.

A population-based comparison of survival after nephrectomy vs nonsurgical management for small renal masses.

OBJECTIVE: To examine population-based rates of cancer-specific and other-cause mortality after either non-surgical management (NSM) or nephrectomy, in patients with small renal masses, as several reports from selected institutions support the applicability of surveillance in patients with small renal masses, but there are no population-based studies confirming the general applicability of this therapy. PATIENTS AND METHODS: Of 43 143 patients with renal cell carcinoma identified in the 1988-2004 Surveillance, Epidemiology and End Results database, 10 291 had localized small renal masses (

External validation of the updated partin tables in a cohort of French and Italian men.

PURPOSE: To test the discrimination and calibration properties of the newly developed 2007 Partin Tables in two European cohorts with localized prostate cancer. METHODS: Data on clinical and pathologic characteristics were obtained for 1,064 men treated with radical prostatectomy at the Creteil University Health Center in France (n = 839) and at the Milan University Vita-Salute in Italy (n = 225). Overall discrimination was assessed with receiver operating characteristic curve analysis, which quantified the accuracy of stage predictions for each center. Calibration plots graphically explored the relationship between predicted and observed rates of extracapsular extension (ECE), seminal vesicle invasion (SVI) and lymph node invasion (LNI). RESULTS: The rates of ECE, SVI, and LNI were 28%, 14%, and 2% in the Creteil cohort vs. 11%, 5%, and 5% in the Milan cohort. In the Creteil cohort, the accuracy of ECE, SVI, and LNI prediction was 61%, 71%, and 82% vs. 66%, 92% and 75% for the Milan cohort. Important departures were recorded between Partin Tables' predicted and observed rates of ECE, SVI, and LNI within both cohorts. CONCLUSIONS: The 2007 Partin Tables demonstrated worse performance in European men than they originally did in North American men. This indicates that predictive models need to be externally validated before their implementation into clinical practice.