AUA 2011 Washington D C OUTLINE Prostate cancer

AUA 2011 Washington, D. C

OUTLINE • • • Prostate cancer Urothelial, testis and other Renal Discussion and break The PIVOT trial video Discussion

PROSTATE CANCER • PIVOT trial a major highlight • Large number of abstracts on RALRP • >70% of all RP in USA • Most interesting abstracts focused on other aspects of the disease • http: //www. aua 2011. org/index. cfm

ACTIVE SURVEILLANCE • #1292 Fleshner- role of MRI at start • • Concept of ‘TDF’ in 22% Largely anterior and may be predicted by PSA density • #1638 Baltimore- role of 5�R inhibitors • Retrospective cohort=> progression • No independent association with unfavourable biopsy at 2 years

PROSTATE CANCER • #1298 Paris HIFU 5 yr data • • 260 pts at 5 yr Secondary therapy free 84%, 72%, 45% 56% biopsy, only 55% negative at 3 yrs Should only be offered to low risk pts • #997 North Carolina • 921 VA pts with RP, looked at lipid profile and risk factors • Chol assoc with increased BCR

PROSTATE CANCER MSKCC – cohort showed decreased BCR, mets and death

PROSTATE CANCER • 706 Van Poppel, Milan • • a. RT vs early salvage multiinstitutional 420 pts 75% a. RT, 25% early salvage PSA <0. 5 • Matched case control design • Significant advantage in BCR for a. RT • HR 0. 38 p<0. 001 • Maintained if earlier salvage, higher dosage 66 Gy

INTERMITTENT ADT • #716 Phase III intermittent vs continous • • Lisbon, median f/u 6 yrs Induction course, randomised if >80% drop or <4 ng/ml • No change in OS (HR 0. 96, p=0. 61) • Non sig increase in Ca death offset by CVD death

ABIRATERONE • #705 Molina, Montreal • RCT, double blind, placebo controlled • N=1195 m. CRPC, progressed post docetaxel • Vs placebo and prednisone • Significant effect on OS, TTP, r. PFS, PSA response • Objective response in 14%, and improved OS 14. 8 vs 10. 9 months

LYMPH NODE DISSECTION • #473 and #474 • D’Amico low risk does not benefit from (limited) LND • Norfolk, n=211, retrospective • Scardino n=13000 multiinstitutional 1987 -2006, median fu 4 yrs • Assoc of LNN with ACM, PCSM • Adjusted for age, yr, Ca characteristics • No assoc in any D’Amico risk group

PROSTATE CANCER • #1783 Vickers • Analysis of Holmberg trial • 4. 6% reduction in death at 10 yrs is an amalgam • Young, high risk up to 17%

UPPER TRACT UROTHELIAL • #665 Tolley, Scotland • N=62 over 10 yrs • More ureteric tumours in open group • No difference in any oncological parameter

NMI BLADDER • #1648 Romania • Hexaminolevulinate Blue light cystoscopy • Prospective RCT 362 pts • BL=> higher detection and worse disease • 10% reduction in recurrence at 1 and 2 years • Largely ‘other site recurrence’

MI BLADDER CANCER • Genetic evaluation/ profiles important • Selection for neoadjuvant therapy • Increasing trend for high risk disease

MI BLADDER CA • #1599 St Louis • 181 pts median age 81 • Retrospectively compared RC vs other • No diff in tumor or comorbidity b/w groups • Univariate RC median survival 48 vs 16 months • Multivariate OS HR 0. 47 (0. 25 -0. 89)

PENILE CANCER • #836 Munich • Prospective study of PET in assessing LNs • Specificity 98%, sens 88% • #975 Hungary • • Dynamic SNB using gamma probe All SNs identified n=36 No recurrence if SNB –ve ? Ideal in medium risk patients

GERM CELL CANCER • #586 Durham, NC • Radiation exposure by stage and treatment modality • 10 yr period NCCN guidelines • SGCT – s 369 m. Sv (23 AP CT), chemo 1. 2, radiation 22 • NSGCT- s 339 m. Sv (21 AP CT), chemo 114 • Guidelines need revision

RENAL • Nephron sparing evolving to ‘zero ischaemia’ • Novel techiques • Hilar microdissection #940 • Temporary vascular occlusion Lumagel #1214 (animal model) • Wet monopolar knife #1217

CVD∞GFR- an explanation • Diastolic dysfunction/ LVH • Renal • • • Abnormal calcium handling 200 mg/d excretion=>25 mg day Extra load from catabolic bone Massive vascular depositon Also positive phosphorous balance

RENAL • http: //www. siattend. com/My. Account. asp x • Gill • Vascular and tumor anatomy 0. 5 cm cuts with 3 D recons • Hilar microdissection and micro bulldogs • Intraoperative ultrasound

SURVEILLANCE SRM • #1663 Philadelphia • • Pooled analysis of 18 series, n=936 2% mets 33% zero growth with no mets Mets assoc with faster growth, older pt and higher tumour size • If objective competing risks, then delayed intervention can be performed without negative sequelae

NEPHROMETRY • #1271 • RENAL Nephrometry score to describe size/location/diffculty • Help decision making and comparison • NS is an independent predictor of ischaemia time • Esp 3 components of RNL

RENAL BIOPSY • • • #704 Boston 1997 -2010 N=277/899 - correlation with surg path Not all core biopsy PPV= 0. 98 NPV= 0. 31 Grade concordance 78%

CYTOREDUCTION • #1776 San Diego • N=35 retrospective review of initial nephrectomy vs planned Nx post TKI • Groups similar • Non response to TKI (7/18) portends the worst prognosis • Nephrectomy post neoadj TKI did better than adj group

CYTOREDUCTION • #1998 Wood, Madison WI • 75 pts with sunitinib with RCC in situ • >10% reduction in 90 dd = early response and correlates with OS HR 0. 18 (0. 05 -0. 62) • May be a group to offer cytoreductive nehrectomy to?

PIVOT • http: //webcasts. prous. com/AUA 2011/ht ml/1 en/template. aspx? section=20&idl=1810 8&idcl=1

PIVOT • Randomised, ITT, low contamination, minimised ascertainment bias • N=731, up to 75 yrs (mean 67) • Median f/u 10 yrs (1994 -2002) • Excluded c. T 3 • 50% palpable, 21% high risk, 70% <=Gl 6 • 40% low risk

PIVOT • All comers • No diff in OM or PCSM • D’Amico high risk (a priori? ) • PCSM 8% ARR (HR 0. 4) • PSA >10 • OM 13. 2% ARR • PCSM 7. 2%ARR (HR 0. 38)

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