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Purpose: Clinical staging is vital for treatment decision-making by renal cell carcinoma (RCC) patients. Some RCCs clinically appear T1 on CT, but are actually T3a due to extension into fat or renal vein, causing the tumor to be pathologically upstaged. The objective of this study to determine the rate, survival, and predictors of RCC upstaging, for patients with cT1 disease treated surgically., Methods: Using the National Cancer Data Base Participant User File for RCC from 2004 to 2013, we selected AJCC cT1 patients, who underwent surgical resection and whose AJCC pathological T stage (pT) was available. Upstaging was characterized dichotomously-overall (any pT > T1) and pT3a-specific upstaging. Patient and tumor characteristics of those upstaged and not were compared using Chi-squared analyses. Multivariable logistic regression was used to analyze predictors of upstaging, and Cox proportional hazards regression was used to estimate overall survival hazards ratios., Results: Overall upstaging (pT > T1) was observed in 8252 (7.1%) patients, and T3a-specific upstaging was observed in 3380 (5.4%) patients. Patients who were older, male, and had comorbidities, and tumors that were cT1b, underwent RN, and had high Fuhrman grade were at a higher risk of pathological upstaging. Upstaging led to a 40% increased risk of death compared to patients who were not upstaged., Conclusion: The rate of upstaging is not negligible (5-7% of the time), negatively impacts survival, and various patient and tumor characteristics can be used to predict upstaging.

Purpose: Local therapy for prostate cancer (PCa) includes radical prostatectomy (RP) and radiotherapy (XRT), both of which share a complication of urinary incontinence. Post-treatment incontinence has been reported to occur 6-69%, yet no truly patient-centered report has been compiled. We evaluated patient-reported incontinence rates and bother scores after treatment for prostate cancer., Methods: The NHANES database was queried for all men who reported a diagnosis and treatment of PCa from 2001 to 2010. A control arm of men without a diagnosis of PCa age 60-80 years was constructed for baseline incontinence rates. Incontinence was patient-reported and obtained through questionnaires. Three additional cohorts were created for patients treated with RP, XRT or combination RP and XRT., Results: We identified 316 men treated for prostate cancer, of which 136 reported RP and 125 reported XRT, who were compared to 3534 controls. Men that underwent RP experience significant incontinence rates of 23% compared to 12% of those patients treated with XRT, whereas those patients with combined therapy had incontinence rates of 52% (p < 0.0001). Bother scores did not significantly vary, but were increased compared to baseline. Urge incontinence did not differ between treatment groups, but stress incontinence was significantly higher in surgical patients., Conclusion: These data from a nationwide sample of patient-reported urinary outcomes have limited interviewer bias and report significantly higher incontinence rates, which may impact prostate cancer discussions. This further underscores the importance of patient-reported outcomes in the evaluation of treatment success and counseling for patients with prostate cancer.

Objective: To provide updated treatment trends, determinants, and survival of partial nephrectomy (PN) and radical nephrectomy (RN) across the USA., Data Sources: Secondary data from the National Cancer Data Base (NCDB) participant user file from 2004 to 2013. The NCDB captures approximately 70% of all newly diagnosed cancer cases each year., Study Design: Multivariable logistic regression was used to estimate odds ratios for RN overall. Kaplan-Meier, multivariable Cox regression, and log-rank test were used to characterize patient survival., Data Collection: Patients diagnosed with clinical stage I RCC who received either RN or PN as the primary surgical treatment were included., Principle Findings: The study consisted of 121,386 cases (PN = 57,016; RN = 64,370). The overall use of PN for stage I RCC increased by 24.2% over 9 years. An overall 5- and 10-year survival advantage was estimated following PN compared to RN; estimated overall risk of death was higher with RN., Conclusions: The use of PN for stage I RCC has continued to increase and is associated with an overall survival advantage. Multivariable analysis showed that disparities exist among sociodemographic groups that are also associated with treatment type and survival.

Objective: To identify renal function outcomes after robotic multiplex partial nephrectomy (RMxPNx), we reviewed our institutional database at the National Institutes of Health, National Cancer Institute. To our knowledge, we present the largest series of RMxPNx renal function outcomes to date. Robotic partial nephrectomy has been employed for oncologic control and to prevent dialysis dependence in hereditary multifocal renal cell carcinoma conditions. We have termed robotic surgery on a single kidney with three or more lesions a RMxPNx., Materials and Methods: We evaluated patients from a prospectively maintained database at a single institution (NIH/NCI) that underwent RMxPNx from 2007 to 2013. Demographic and operative data were compiled with statistical analysis with T test performed to determine renal function outcomes., Results: A total of 54 patients underwent RMxPNx. Mean number of tumors removed was 8.63 (range 3-52). Mean preoperative creatinine and eGFR were 1.02 ± 0.26 mg/dL and 85.4 ± 21.5 mL/min, respectively. Postoperatively, creatinine increased from baseline by 0.45 mg/dL (p < 0.001). Similarly, a mean decrease in eGFR by 24.6 mL/min was observed (p < 0.001). At 3-month follow-up, the creatinine increase from baseline was 0.05 mg/dL (p = 0.10) and mean decrease in eGFR was 3.01 mL/min (p = 0.21). When stratifying based on preoperative CKD stages I-III, similar results were observed., Conclusion: Robotic multiplex partial nephrectomy is a safe and feasible approach to patients with multifocal renal masses. These complex surgeries have a demonstrated learning curve, but this minimally invasive approach for nephron-sparing surgery allows patients to preserve renal function where they would otherwise require open surgery or a radical nephrectomy.

Objective: To identify the risk factors associated with development of postoperative elevation of creatine kinase (CK) and study its effect on renal function in patients who underwent complex multifocal partial nephrectomy (PN)., Methods: Patients who underwent PN at National Cancer Institute between January 2007 and December 2012 were included in the study. Elevated serum CK was defined as >2000 U/L. Kidney function was assessed using serum creatinine and estimated glomerular filtration rate (eGFR). Changes were reported as percent change from preoperative values and compared using the Wilcoxon test. Regression analysis was performed to identify the predictors of elevation in CK and decline in eGFR., Results: From 407 total cases, 207 had adequate CK data for analysis. Median number of tumors removed was 3 (1-70). Median peak CK was 1458 (82-36,788). Forty-two percent developed CK elevation >2000 U/L. Factors associated with postoperative elevation of CK > 2000 were young age (p = 0.009), high BMI (p = 0.003) and operating room time (p < 0.001). Although CK > 2000 was associated with significantly greater decline in eGFR (37.4 vs. 20.3 %, p < 0.001) in immediate postoperative period, this change largely resolved to a much less clinically relevant (9.2 vs 3.3 %, p = 0.040) change after 3 months. On multivariate analysis, postoperative elevation in CK was not found to be an independent factor determining renal function at 3 months., Conclusion: In our cohort, a significant proportion of patients developed CK elevations >2000 U/L. While patients with elevated CK had more decline in eGFR in immediate postoperative period, postoperative elevations of CK did not appear to impact overall long-term renal function in patients undergoing PN.

Background: Carbonic anhydrase IX (CA-IX) is a potential imaging biomarker of clear cell renal cell carcinoma (ccRCC). Here, we report the results of a phase II clinical trial of a small molecule radiotracer targeting CA-IX ((18)F-VM4-037) in ccRCC., Methods: Between October 2012 and May 2013, 11 patients with kidney masses underwent (18)F-VM4-037 PET/CT prior to surgery. Dynamic imaging was performed for the first 45 min post injection and whole-body imaging was obtained at 60 min post injection. Tumors were surgically excised or biopsied within 4 weeks of imaging., Results: All patients tolerated the radiotracer well with no adverse events. Ten of the 11 patients had histologically confirmed malignancy. One patient had a Bosniak Type 3 cyst with no tumor found at surgery. Two patients had extrarenal disease and 9 had tumors only in the kidney. Primary ccRCC lesions were difficult to visualize on PET alone due to high uptake of the tracer in the adjacent normal kidney parenchyma, however when viewed in conjunction with CT, the tumors were easily localized. Metastatic lesions were clearly visible on PET. Mean SUV for primary kidney lesions was 2.55 in all patients; in patients with histologically confirmed ccRCC, the mean SUV was 3.16. The time-activity curves (TAC) are consistent with reversible ligand binding with peak activity concentration at 8 min post injection followed by washout. Distribution Volume Ratio (DVR) of the lesions was measured using the Logan graphical analysis method. The mean DVR value across the 9 kidney lesions was 5.2 ± 2.8, (range 0.68-10.34)., Conclusion: 18F-VM4-037 is a well-tolerated PET agent that allows same day imaging of CA-IX expression. The agent demonstrated moderate signal uptake in primary tumors and excellent visualization of CA-IX positive metastases. While the evaluation of primary ccRCC lesions is challenging due to high background activity in the normal kidney parenchyma, 18F-VM4-037 may be most useful in the evaluation of metastatic ccRCC lesions.