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Background The tumor stage, size, grade, and necrosis (SSIGN) score was originally defined using patients treated with radical nephrectomy (RN) between 1970 and 1998 for clear cell renal cell carcinoma (ccRCC), excluding patients treated with partial nephrectomy (PN). Objective To characterize the original SSIGN score cohort with longer follow-up and evaluate a contemporary series of patients treated with RN and PN. Design, setting, and participants Retrospective single-institution review of 3600 consecutive surgically treated ccRCC patients grouped into three cohorts: original RN, contemporary (1999–2010) RN, and contemporary PN. Intervention RN or PN. Outcome measurements and statistical analysis The association of the SSIGN score with risk of death from RCC was assessed using a Cox proportional hazards regression model, and predictive ability was summarized with a C-index. Results and limitations The SSIGN scores differed significantly between the original RN, contemporary RN, and contemporary PN cohorts (p < 0.001), with SSIGN ≥4 in 53.5%, 62.7%, and 4.7%, respectively (p < 0.001). The median durations of follow-up for these groups were 20.1, 9.2, and 7.6 yr, respectively. Each increase in the SSIGN score was predictive of death from RCC (hazard ratios [HRs]: 1.41 for original RN, 1.37 for contemporary RN, and 1.70 for contemporary PN; all p < 0.001). The C-indexes for these models were 0.82, 0.84, and 0.82 for original RN, contemporary RN, and contemporary PN, respectively. After accounting for an era-specific improvement in survival among RN patients (HR: 0.53 for contemporary vs original RN; p < 0.001), the SSIGN score remained predictive of death from RCC (HR: 1.40; p < 0.001). Conclusions The SSIGN score remains a useful prediction tool for patients undergoing RN with 20-yr follow-up. When applied to contemporary RN and PN patients, the score retained strong predictive ability. These results should assist in patient counseling and help guide surveillance for ccRCC patients treated with RN or PN. Patient summary We evaluated the validity of a previously described tool to predict survival following surgery in contemporary patients with kidney cancer. We found that this tool remains valid even when extended to patients significantly different than were initially used to create the tool.

Complete surgical metastasectomy for metastatic renal cell carcinoma is associated with improved survival compared with incomplete surgical metastasectomy based on meta-analysis of observational data. Consideration should be given to performing complete surgical metastasectomy, when technically feasible, in patients with metastatic renal cell carcinoma who are surgical candidates.

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Background Management of recurrent prostate cancer (CaP) after radiotherapy (RT) is dependent on accurate localization of the site of recurrent disease. Objective To describe the anatomic patterns and clinical features associated with CaP recurrence following RT identified on advanced imaging. Design, setting, and participants Retrospective review of 184 patients with a rising prostate-specific antigen (PSA) after RT for CaP. Intervention C-11 choline positron emission tomography/computed tomography (CholPET). Outcome measurements and statistical analysis Recurrence patterns were classified as pelvic soft tissue only (as a surrogate for potentially salvageable disease) versus any extrapelvic disease, and clinical features were compared between patterns. Multivariable logistic regression was used to generate a predictive nomogram for extrapelvic recurrence. Discrimination was assessed with a c-index. Results and limitations Recurrence site was identified in 161 (87%) patients, with 95 (59%) sites histologically confirmed. Factors associated with the detection of recurrence included the difference between PSA nadir and PSA at CholPET (odds ratio: 1.30, p < 0.01) and National Comprehensive Cancer Network high-risk classification (odds ratio: 10.83, p = 0.03). One hundred (54.3%) patients recurred in the pelvic soft tissue only, while 61 (33%) had extrapelvic recurrence. Of 21 patients who underwent CholPET prior to meeting the Phoenix criteria of biochemical failure, 15 (71%) had recurrence identified on CholPET with 11 localized to the pelvis. On multivariable analysis, PSA at CholPET, time from RT, and National Comprehensive Cancer Network risk group were predictive of recurrence outside of the pelvis, and a nomogram was generated with a c-index of 0.79. Conclusions CholPET identified the site of recurrence in 87% of patients with a rising PSA after RT; most commonly within the pelvis in potentially salvageable locations. A predictive nomogram was generated, and pending external validation, this may aid in assessing the risk of disease beyond the pelvis. These findings underscore the importance of advanced imaging when considering management strategies for patients with a rising PSA following primary RT. Patient summary We identified anatomic patterns of recurrence in patients with a rising prostate-specific antigen after radiotherapy using C-11 choline positron emission tomography/computed tomography. Most recurrences were localized to the pelvis and we were able to generate a tool to aid in disease localization prior to evaluation with advanced imaging.

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Purpose To evaluate C-11 choline PET/CT (CholPET) in staging and determining patterns of recurrence in prostate cancer patients with rising PSA post prostatectomy radiotherapy (RT). Materials and Methods The study includes patients with biochemical failure following post-prostatectomy RT who underwent CholPET between 2008 and 2015. Patient and disease characteristics were examined in relation to sites of recurrence. All RT dosimetry records were reviewed, and recurrences were mapped on a representative CT dataset with their relationship relative to the irradiated fossa field as out-of-field (OOF), edge-of-field (EOF; recurrence within <45Gy isodose lines), or in-field (IF; recurrence within ≥45 Gy isodose lines). Results Forty-one patients were identified with 121 sites of recurrence (median 2 sites; IQR 1-4). The median PSA at CholPET was 3.1 (IQR 1.9-5.6) ng/mL. Median interval from RT to biochemical failure was 24 (IQR: 10-46) months, with recurrence identified on CholPET at a median of 15 (IQR 7-28) months from biochemical failure. Histologic confirmation of recurrence was obtained in 20 (49%) patients; with the remainder confirmed by treatment response. Five patients (12%) had IF recurrences, 10 patients (24%) had EOF recurrences (median dose 10 Gy; IQR 5-30 Gy), and 36 patients (88%) had OOF recurrences. Ten patients had combination failures: 6 (15%) EOF/OOF and 4 (10%) IF/OOF. Fifty-seven (47%) of recurrences were pelvic nodal sites inferior to the L5-S1 interspace of which 52 (43%) are within a pelvic RT field. Eighty-one (67%) of recurrences were nodal and inferior to the aortic bifurcation. Conclusions Using CholPET, we found that the majority of patients evaluated for biochemical failure recurred outside of the post-prostatectomy RT field. Furthermore, most recurrence sites were nodal and inferior to the aortic bifurcation. These results provide data which may be useful for examining strategies that include elective lymph node irradiation in post-prostatectomy patients.

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