AUA 2011AUA 2011Washington, D.CWashington, D.C

OUTLINEOUTLINE

• Prostate cancerProstate cancer• Urothelial, testis and otherUrothelial, testis and other• RenalRenal• Discussion and breakDiscussion and break• The PIVOT trial videoThe PIVOT trial video• DiscussionDiscussion

PROSTATE CANCERPROSTATE CANCER

• PIVOT trial a major highlightPIVOT trial a major highlight• Large number of abstracts on Large number of abstracts on

RALRPRALRP• >70% of all RP in USA>70% of all RP in USA

• Most interesting abstracts focused Most interesting abstracts focused on other aspects of the diseaseon other aspects of the disease

• http://www.aua2011.org/index.cfmhttp://www.aua2011.org/index.cfm

ACTIVE SURVEILLANCEACTIVE SURVEILLANCE

• #1292 Fleshner- role of MRI at start#1292 Fleshner- role of MRI at start• Concept of ‘TDF’ in 22% Concept of ‘TDF’ in 22% • Largely anterior and may be predicted by Largely anterior and may be predicted by

PSA densityPSA density

• #1638 Baltimore- role of 5R #1638 Baltimore- role of 5R inhibitorsinhibitors• Retrospective cohort=> progressionRetrospective cohort=> progression• No independent association with No independent association with

unfavourable biopsy at 2 yearsunfavourable biopsy at 2 years

PROSTATE CANCERPROSTATE CANCER

• #1298 Paris HIFU 5yr data#1298 Paris HIFU 5yr data• 260 pts at 5yr260 pts at 5yr• Secondary therapy free 84%, 72%, 45%Secondary therapy free 84%, 72%, 45%• 56% biopsy, only 55% negative at 3 yrs56% biopsy, only 55% negative at 3 yrs• Should only be offered to low risk ptsShould only be offered to low risk pts

• #997 North Carolina#997 North Carolina• 921 VA pts with RP, looked at lipid profile 921 VA pts with RP, looked at lipid profile

and risk factorsand risk factors• Chol assoc with increased BCRChol assoc with increased BCR

PROSTATE CANCERPROSTATE CANCERMSKCC – cohort showed decreased BCR, MSKCC – cohort showed decreased BCR,

mets and deathmets and death

PROSTATE CANCERPROSTATE CANCER

• 706 Van Poppel, Milan706 Van Poppel, Milan• aRT vs early salvage multiinstitutionalaRT vs early salvage multiinstitutional• 420 pts 75% aRT, 25% early salvage 420 pts 75% aRT, 25% early salvage

PSA <0.5PSA <0.5• Matched case control designMatched case control design• Significant advantage in BCR for aRT Significant advantage in BCR for aRT

• HR 0.38 p<0.001HR 0.38 p<0.001• Maintained if earlier salvage, higher Maintained if earlier salvage, higher

dosage 66Gydosage 66Gy

INTERMITTENT ADTINTERMITTENT ADT

• #716 Phase III intermittent vs #716 Phase III intermittent vs continouscontinous• Lisbon, median f/u 6yrsLisbon, median f/u 6yrs• Induction course, randomised if >80% Induction course, randomised if >80%

drop or <4ng/mldrop or <4ng/ml• No change in OS (HR 0.96, p=0.61)No change in OS (HR 0.96, p=0.61)• Non sig increase in Ca death offset by Non sig increase in Ca death offset by

CVD deathCVD death

ABIRATERONEABIRATERONE

• #705 Molina, Montreal#705 Molina, Montreal• RCT, double blind, placebo controlledRCT, double blind, placebo controlled

• N=1195 mCRPC, progressed post docetaxelN=1195 mCRPC, progressed post docetaxel• Vs placebo and prednisoneVs placebo and prednisone

• Significant effect on OS, TTP, rPFS, PSA responseSignificant effect on OS, TTP, rPFS, PSA response• Objective response in 14%, and improved OS 14.8 vs Objective response in 14%, and improved OS 14.8 vs

10.9 months10.9 months

•

LYMPH NODE LYMPH NODE DISSECTIONDISSECTION

• #473 and #474#473 and #474• D’Amico low risk does not benefit from D’Amico low risk does not benefit from

(limited) LND(limited) LND• Norfolk, n=211, retrospectiveNorfolk, n=211, retrospective

• Scardino n=13000 multiinstitutional Scardino n=13000 multiinstitutional 1987-2006, median fu 4 yrs1987-2006, median fu 4 yrs• Assoc of LNN with ACM, PCSMAssoc of LNN with ACM, PCSM• Adjusted for age, yr, Ca characteristicsAdjusted for age, yr, Ca characteristics• No assoc in any D’Amico risk groupNo assoc in any D’Amico risk group

PROSTATE CANCERPROSTATE CANCER

• #1783 Vickers#1783 Vickers• Analysis of Analysis of

Holmberg trialHolmberg trial• 4.6% reduction 4.6% reduction

in death at 10yrs in death at 10yrs is an amalgamis an amalgam

• Young, high risk Young, high risk up to 17%up to 17%

UPPER TRACT UPPER TRACT UROTHELIALUROTHELIAL

• #665 Tolley, #665 Tolley, ScotlandScotland

• N=62 over 10yrsN=62 over 10yrs• More ureteric More ureteric

tumours in open tumours in open groupgroup

• No difference in No difference in any oncological any oncological parameterparameter

NMI BLADDERNMI BLADDER

• #1648 Romania#1648 Romania• Hexaminolevulinate Blue light Hexaminolevulinate Blue light

cystoscopycystoscopy• Prospective RCT 362 ptsProspective RCT 362 pts• BL=> higher detection and worse BL=> higher detection and worse

diseasedisease• 10% reduction in recurrence at 1 and 2 10% reduction in recurrence at 1 and 2

yearsyears• Largely ‘other site recurrence’Largely ‘other site recurrence’

MI BLADDER CANCERMI BLADDER CANCER

• Genetic evaluation/ profiles Genetic evaluation/ profiles importantimportant

• Selection for neoadjuvant therapySelection for neoadjuvant therapy• Increasing trend for high risk diseaseIncreasing trend for high risk disease

MI BLADDER CAMI BLADDER CA

• #1599 St Louis#1599 St Louis• 181 pts median age 81181 pts median age 81• Retrospectively compared RC vs otherRetrospectively compared RC vs other

• No diff in tumor or comorbidity b/w groupsNo diff in tumor or comorbidity b/w groups

• Univariate RC median survival 48 vs Univariate RC median survival 48 vs 16 months16 months

• Multivariate OS HR 0.47 (0.25-0.89)Multivariate OS HR 0.47 (0.25-0.89)

PENILE CANCERPENILE CANCER

• #836 Munich#836 Munich• Prospective study of PET in assessing Prospective study of PET in assessing

LNsLNs• Specificity 98%, sens 88%Specificity 98%, sens 88%• #975 Hungary#975 Hungary

• Dynamic SNB using gamma probeDynamic SNB using gamma probe• All SNs identified n=36All SNs identified n=36• No recurrence if SNB –veNo recurrence if SNB –ve• ?Ideal in medium risk patients?Ideal in medium risk patients

GERM CELL CANCERGERM CELL CANCER

• #586 Durham, NC#586 Durham, NC• Radiation exposure by stage and Radiation exposure by stage and

treatment modalitytreatment modality• 10yr period NCCN guidelines10yr period NCCN guidelines

• SGCT – s369mSv (23 AP CT), chemo 1.2, SGCT – s369mSv (23 AP CT), chemo 1.2, radiation 22radiation 22

• NSGCT- s 339mSv (21 AP CT), chemo 114NSGCT- s 339mSv (21 AP CT), chemo 114

• Guidelines need revisionGuidelines need revision

RENALRENAL

• Nephron sparing evolving to ‘zero Nephron sparing evolving to ‘zero ischaemia’ischaemia’

• Novel techiquesNovel techiques• Hilar microdissection #940Hilar microdissection #940• Temporary vascular occlusion Temporary vascular occlusion

Lumagel #1214 (animal model)Lumagel #1214 (animal model)• Wet monopolar knife #1217Wet monopolar knife #1217

CVD∞GFR- an CVD∞GFR- an explanationexplanation

• Diastolic dysfunction/ LVHDiastolic dysfunction/ LVH• Renal Renal

• Abnormal calcium handlingAbnormal calcium handling• 200mg/d excretion=>25mg day200mg/d excretion=>25mg day• Extra load from catabolic boneExtra load from catabolic bone• Massive vascular depositonMassive vascular depositon• Also positive phosphorous balanceAlso positive phosphorous balance

RENALRENAL

• http://www.siattend.com/MyAccount.aspx

• GillGill• Vascular and tumor anatomy 0.5 Vascular and tumor anatomy 0.5

cm cuts with 3D reconscm cuts with 3D recons• Hilar microdissection and micro Hilar microdissection and micro

bulldogsbulldogs• Intraoperative ultrasoundIntraoperative ultrasound

SURVEILLANCE SRMSURVEILLANCE SRM

• #1663 Philadelphia#1663 Philadelphia• Pooled analysis of 18 series, n=936Pooled analysis of 18 series, n=936• 2% mets2% mets• 33% zero growth with no mets33% zero growth with no mets• Mets assoc with faster growth, older pt Mets assoc with faster growth, older pt

and higher tumour sizeand higher tumour size• If objective competing risksIf objective competing risks, then , then

delayed intervention can be performed delayed intervention can be performed without negative sequelaewithout negative sequelae

NEPHROMETRYNEPHROMETRY• #1271#1271

• RENAL Nephrometry score RENAL Nephrometry score to describe to describe size/location/diffcultysize/location/diffculty• Help decision making and Help decision making and

comparisoncomparison

• NS is an independent NS is an independent predictor of ischaemia predictor of ischaemia timetime• Esp 3 components of RNLEsp 3 components of RNL

RENAL BIOPSYRENAL BIOPSY

• #704 Boston 1997-2010#704 Boston 1997-2010• N=277/899- correlation with surg N=277/899- correlation with surg

pathpath• Not all core biopsyNot all core biopsy• PPV= 0.98PPV= 0.98• NPV= 0.31NPV= 0.31• Grade concordance 78% Grade concordance 78%

CYTOREDUCTIONCYTOREDUCTION

• #1776 San Diego#1776 San Diego• N=35 retrospective review of initial N=35 retrospective review of initial

nephrectomy vs planned Nx post TKInephrectomy vs planned Nx post TKI• Groups similarGroups similar

• Non response to TKI (7/18) portends Non response to TKI (7/18) portends the worst prognosisthe worst prognosis

• Nephrectomy post neoadj TKI did Nephrectomy post neoadj TKI did better than adj groupbetter than adj group

CYTOREDUCTIONCYTOREDUCTION

• #1998 Wood, Madison WI#1998 Wood, Madison WI• 75 pts with sunitinib with RCC in 75 pts with sunitinib with RCC in

situsitu• >10% reduction in 90dd = early >10% reduction in 90dd = early

response and correlates with OS HR response and correlates with OS HR 0.18 (0.05-0.62)0.18 (0.05-0.62)

• May be a group to offer May be a group to offer cytoreductive nehrectomy to?cytoreductive nehrectomy to?

PIVOTPIVOT

• http://webcasts.prous.com/AUA2011/html/1-en/template.aspx?section=20&idl=18108&idcl=1

PIVOTPIVOT

• Randomised, ITT, low contamination, Randomised, ITT, low contamination, minimised ascertainment biasminimised ascertainment bias

• N=731, up to 75 yrs (mean 67)N=731, up to 75 yrs (mean 67)• Median f/u 10yrs (1994-2002)Median f/u 10yrs (1994-2002)• Excluded cT3Excluded cT3• 50% palpable, 21% high risk, 70% 50% palpable, 21% high risk, 70%

<=Gl6<=Gl6• 40% low risk40% low risk

PIVOTPIVOT

• All comersAll comers• No diff in OM or PCSMNo diff in OM or PCSM

• D’Amico high risk (a priori?)D’Amico high risk (a priori?)• PCSM 8% ARR (HR 0.4)PCSM 8% ARR (HR 0.4)

• PSA >10PSA >10• OM 13.2% ARROM 13.2% ARR• PCSM 7.2%ARR (HR 0.38)PCSM 7.2%ARR (HR 0.38)

THANK YOUTHANK YOU