Robert Houston Thompson

Mayo Clinic - Rochester, Рочестер, Minnesota, United States

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Publications (8)25.96 Total impact

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    ABSTRACT: Evidence supporting surveillance guidelines after radical cystectomy (RC) are lacking. Herein, we evaluate the ability of the National Comprehensive Cancer Network (NCCN) guidelines and the European Association of Urology (EAU) guidelines to capture recurrences and provide an alternative approach that balances risks of recurrence with non-bladder cancer death. We identified 1,797 patients who had M0 urothelial carcinoma who underwent RC at our institution between 1980 and 2007. The success of current guidelines to capture recurrences was assessed by calculating the percentage of recurrences detected during the recommended follow-up time: the NCCN-2 years and the EAU-5 years. An alternative protocol was created using Weibull distributions, which estimate when a patient׳s risk of non-bladder cancer death exceeds their risk of recurrence. At a median follow-up of 10.6 years (interquartile range : 6.8-15.2), a total of 714 patients recurred. Of these, 491 (68.7%) would have been detected by the NCCN guidelines and 642 (89.8%) by the EAU guidelines. Using a risk-adapted approach, vastly different surveillance durations were appreciated. For example, for patients older than 80 years with pT0Nx-0 or pTa/CIS/1Nx-0 disease, recurrence risk to any location never exceeded their risk of non-bladder cancer death, whereas for patients aged 60 years and younger with pT3/4Nx-0 or pTanyN+disease, risk of abdominal/pelvis recurrence remained greater than their risk of non-bladder cancer death for>20 years. The duration of post-RC follow-up recommended by the NCCN and the EAU does not comprehensively capture recurrences. A surveillance algorithm based on the interaction between recurrence risk and competing health factors individualizes recommendations and may improve capture of recurrences and resource allocation. Copyright © 2015 Elsevier Inc. All rights reserved.
    Urologic Oncology 05/2015; DOI:10.1016/j.urolonc.2015.04.017 · 3.36 Impact Factor
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    ABSTRACT: Surgical resection for renal cell carcinoma (RCC) with suprahepatic inferior vena cava tumor thrombus is associated with significant morbidity, yet there are currently no tools for preoperative prognostic evaluation. Our goal was to develop a preoperative multivariable model for prediction of survival and risk of major complications in patients with suprahepatic thrombi. We identified patients who underwent surgery for RCC with suprahepatic tumor thrombus extension from 2000 to 2013 at 4 tertiary centers. A Cox proportional hazard model was used for analysis of overall survival (OS) and logistic regression was used for major complications within 90 days of surgery (Clavien≥3A). Nomograms were internally calibrated by bootstrap resampling method. A total of 49 patients with level III thrombus and 83 patients with level IV thrombus were identified. During median follow-up of 24.5 months, 80 patients (60.6%) died and 46 patients (34.8%) experienced major complication. Independent prognostic factors for OS included distant metastases at presentation (hazard ratio = 2.52, P = 0.002) and Eastern Cooperative Oncology Group (ECOG) performance status (hazard ratio = 1.84, P<0.0001). Variables associated with increased risk of major complications on univariate analysis included preoperative systemic symptoms, level IV thrombus, and elevated preoperative alkaline phosphatase and aspartate transaminase levels; however, only systemic symptoms (odds ratio = 8.45, P<0.0001) was an independent prognostic factor. Preoperative nomograms achieved a concordance index of 0.72 for OS and 0.83 for major complications. We have developed and internally validated multivariable preoperative models for the prediction of survival and major complications in patients with RCC who have a suprahepatic inferior vena cava thrombus. If externally validated, these tools may aid in patient selection for surgical intervention. Copyright © 2015 Elsevier Inc. All rights reserved.
    Urologic Oncology 04/2015; 193(4):e763-e764. DOI:10.1016/j.juro.2015.02.2234 · 3.36 Impact Factor
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    ABSTRACT: Objective: To evaluate outcomes of percutaneous ablation of small renal tumors in the elderly population. Patients and Methods: Utilizing our tumor ablation database, we searched for percutaneous ablation procedures for clinical T1a renal masses in octogenarians and nonagenarians between June 2001 and May 2012. Altogether 105 tumors from 99 procedures among 95 patients (mean age 84.0 ± 3.0 years, range 80-92) were identified. Oncologic outcomes and major complications were evaluated. Assessment also included patient hospital stays and renal functional outcomes. Results: Technical success was achieved in 60/61 (98.4%) tumors treated with cryoablation and 43/44 (97.7%) after radiofrequency ablation (RFA). Of 87 renal tumors with at least 3 months imaging follow up, 2 (5.4%) tumors progressed at 1.2 and 2.2 years following RFA. None recurred following cryoablation. Estimated progression-free survival rates at 1, 3, and 5 years following ablation were 99%, 97%, and 97%, respectively. Thirty-four patients died at a mean of 3.7 years following ablation (median 3.7; range 0.4-9.6). Estimated overall survival rates were 98%, 83%, and 61%, respectively. Among 33 patients with sporadic, biopsy-proven renal cell carcinoma, estimated cancer-specific survival rates were 100%, 100%, and 86%, respectively. Five (8.6%) major complications developed after renal cryoablation with no (0%) major complication after RFA. Mean decrease in serum creatinine within one week following ablation was 0.1 mg/dL. Mean hospitalization was 1.2 days. Conclusion: Percutaneous thermal ablation is safe and effective in the active management of clinical T1a renal masses in elderly patients. These results should help urologists appropriately assess expected outcomes when counseling octogenarian and nonagenarian patients.
    Journal of endourology / Endourological Society 11/2014; 29(6). DOI:10.1089/end.2014.0733 · 2.10 Impact Factor
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    ABSTRACT: Objectives The neutrophil-lymphocyte ratio (NLR) is an indicator of the systemic inflammatory response. An increased pretreatment NLR has been associated with adverse outcomes in other malignancies, but its role in localized (M0) clear cell renal cell carcinoma (ccRCC) remains unclear. As such, we evaluated the ability of preoperative NLR to predict oncologic outcomes in patients with M0 ccRCC undergoing radical nephrectomy (RN). Methods and materials From 1995 to 2008, 952 patients underwent RN for M0 ccRCC. Of these, 827 (87%) had pretreatment NLR collected within 90 days before RN. Metastasis-free, cancer-specific, and overall survival was estimated using the Kaplan-Meier method and compared using the log-rank test. Multivariate models were used to analyze the association of NLR with clinicopathologic outcomes. Results At a median follow-up of 9.3 years, 302, 233, and 436 patients had distant metastasis, death from ccRCC, and all-cause mortality, respectively. Higher NLR was associated with larger tumor size, higher nuclear grade, histologic tumor necrosis, and sarcomatoid differentiation (all, P<0.001). A NLR≥4.0 was significantly associated with worse 5-year cancer-specific (66% vs. 85%) and overall survival (66% vs. 85%). Finally, after controlling for clinicopathologic features, NLR remained independently associated with risks of death from ccRCC and all-cause mortality (hazard ratio for 1-unit increase: 1.02, P< 0.01). Conclusions Our results suggest that NLR is independently associated with increased risks of cancer-specific and all-cause mortality among patients with M0 ccRCC undergoing RN. Accordingly, NLR, an easily obtained marker of biologically aggressive ccRCC, may be useful in preoperative patient risk stratification.
    Urologic Oncology 11/2014; 32(8). DOI:10.1016/j.urolonc.2014.05.014 · 3.36 Impact Factor
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    ABSTRACT: Grading of renal cell carcinoma (RCC) has prognostic significance, and there is recent consensus by the International Society of Urological Pathology (ISUP) that for clear cell and papillary RCC, grading should primarily be based on nucleolar prominence. Microscopic tumor necrosis also predicts outcome independent of tumor grading. This study was undertaken to assess whether the incorporation of microscopic tumor necrosis into the ISUP grading system provides survival information superior to ISUP grading alone. Data on 3017 patients treated surgically for clear cell RCC, 556 for papillary RCC, and 180 for chromophobe RCC were retrieved from the Mayo Clinic Registry. Median follow-up periods were 8.9, 9.7, and 8.5 years, respectively. Four proposed grades were defined: grade 1: ISUP grade 1+ISUP grade 2 without necrosis; grade 2: ISUP grade 2 with necrosis+ISUP grade 3 without necrosis; grade 3: ISUP grade 3 with necrosis+ISUP grade 4 without necrosis; grade 4: ISUP grade 4 with necrosis or sarcomatoid/rhabdoid tumors. There was a significant difference in survival between each of the grades for clear cell RCC, and the concordance index was superior to that of ISUP grading. The proposed grading system also outperformed the ISUP grading system when cases were stratified according to the TNM stage. Similar results were not obtained for papillary RCC or chromophobe RCC. We conclude that grading for clear cell RCC should be based on nucleolar prominence and necrosis, that ISUP grading should be used for papillary RCC, and that chromophobe RCC should not be graded.
    The American journal of surgical pathology 01/2013; 37(3). DOI:10.1097/PAS.0b013e318270f71c · 4.59 Impact Factor
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    ABSTRACT: It has been reported that Fuhrman grading is not appropriate for chromophobe renal cell carcinoma (RCC). The objective of this study was to determine whether nucleolar grading and the recently described chromophobe RCC grading system by Paner and colleagues provide prognostic information. Pathologic features of 185 patients with chromophobe RCC treated surgically between 1970 and 2006 were reviewed, including nucleolar grade, chromophobe RCC grade, the 2010 TNM groupings, sarcomatoid differentiation, and coagulative tumor necrosis. Cancer-specific (CS) survival was estimated using the Kaplan-Meier method, and associations with CS survival were evaluated using Cox proportional hazard regression models. Twenty-three patients died from RCC at a mean of 3.0 years after surgery (median 1.3; range 0 to 16) with estimated CS rates (95% confidence interval) of 89% (84 to 94), 86% (81 to 92), and 85% (78 to 91) at 5, 10, and 15 years after surgery. Univariate associations with CS survival included the 2010 TNM stage groupings, sarcomatoid differentiation, coagulative tumor necrosis, chromophobe RCC grade, and nucleolar grade (all P<0.001). These last 4 features remained significantly associated with CS survival after adjusting for the 2010 TNM stage groupings. When the analysis was restricted to the 155 patients with nonsarcomatoid TNM stage groupings I and II chromophobe RCC, only stage grouping (I vs. II) was significantly associated with CS survival (P=0.03). Although the chromophobe RCC grading system described by Paner and colleagues and nucleolar grade are associated with CS survival in chromophobe RCC, they add no additional prognostic information once TNM stage and sarcomatoid differentiation are assessed.
    The American journal of surgical pathology 02/2012; 36(6):851-6. DOI:10.1097/PAS.0b013e3182496895 · 4.59 Impact Factor
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    ABSTRACT: Prior studies suggest that the renal sinus permits early tumor spread in otherwise localized renal cell carcinoma (RCC) tumors. We hypothesized that renal sinus fat invasion may be unrecognized in pT1 patients who subsequently die from RCC. Between 1985 and 2002, we identified 577 patients who underwent radical nephrectomy for localized pT1 clear cell RCC as reviewed by a single urologic pathologist (J.C.C.). Among these patients, 49 died from RCC including 33 who had their original nephrectomy specimen stored in formalin. These specimens were then resectioned with thin cuts of the renal sinus and reviewed by the same pathologist. For comparison, 33 patients who did not die from RCC (controls) also had their original nephrectomy specimen resectioned. Among the 33 patients who died from seemingly localized RCC, 14 (42%) had previously unrecognized renal sinus fat invasion compared with 2 (6%) of the controls (P<0.001). In addition, 19 (58%) patients who died from RCC had renal sinus small vein (microscopic venous) invasion, a pathologic feature not currently incorporated into the TNM staging system for RCC. This feature was present in 7 (21%) of the controls (P=0.003). In total, 22 (67%) patients who died from RCC had unrecognized renal sinus fat or small vein invasion compared with 7 (21%) of the controls (P<0.001). We conclude that renal sinus fat invasion is an important adverse pathologic feature that is clearly underreported in the literature. Appropriate assessment of nephrectomy specimens should include proper sampling of the renal sinus even for seemingly localized tumors.
    American Journal of Surgical Pathology 07/2007; 31(7):1089-93. DOI:10.1097/PAS.0b013e31802fb4af · 4.59 Impact Factor