Outcomes after adjuvant chemotherapy in the treatment of high-risk urothelial carcinoma of the upper urinary tract (UUT-UC): results from a large multicenter collaborative study

The role of perioperative chemotherapy for upper tract urothelial carcinoma patients treated with radical nephroureterectomy

PURPOSE

To summarize evidence regarding the use of neoadjuvant (NAC) and adjuvant chemotherapy (AC) among patients treated with radical nephroureterectomy (RNU).

METHODS

A comprehensive literature search of PubMed (MEDLINE), EMBASE and the Cochrane library was performed to identify any original or review article on the role of perioperative chemotherapy for UTUC patients treated with RNU.

RESULTS

With regards to NAC, retrospective studies consistently suggested that it may be associated with better pathological downstaging (pDS) ranging from 10.8 to 80% and complete response (pCR) ranging from 4.3 to 15%, while decreasing the risk of recurrence and death as compared to RNU alone. Even higher pDS ranging from 58 to 75% and pCR ranging from 14 to 38% were observed in single-arm phase II trials. With regards to AC, retrospective studies provided conflicting results although the largest report from the National Cancer Database suggested an overall survival benefit in pT3-T4 and/or pN + patients. In addition, a phase III randomized controlled trial showed that the use of AC was associated with a disease-free survival benefit (HR = 0.45; 95% CI = [0.30-0.68]; p = 0.0001) in pT2-T4 and/or pN + patients with acceptable toxicity profile. This benefit was consistent in all subgroups analyzed.

CONCLUSIONS

Perioperative chemotherapy improves oncological outcomes associated with RNU. Given the impact of RNU on renal function, the rational is stronger for the use of NAC which impacts final pathology and potentially prolongs survival. However, the level of evidence is stronger for the use of AC that has been proven to decrease the risk of recurrence after RNU with a potential survival benefit.

The prognostic impact of lymph node dissection for clinically node-negative upper urinary tract urothelial carcinoma in patients who are treated with radical nephroureterectomy

BACKGROUND

To evaluate the prognostic impact of lymph node dissection (LND) in patients who underwent radical nephroureterectomy (RNU) with bladder cuff excision (BCE) for clinically node-negative (cN0) upper urinary tract urothelial carcinoma (UTUC).

METHODS

We retrospectively enrolled 520 patients with cN0 UTUC in a single tertiary referral center from 2000 to 2015. The patients were divided into three groups: patients with and without pathologically proved lymph node metastasis (pN1-3 and pN0, respectively) and patients without LND (pNx). We analyzed associations between overall survival (OS)/ disease-free survival (DFS)/ cancer-specific survival (CSS) and clinical characteristics.

RESULTS

The patients were divided into three groups (pN1-3, pN0 and pNx with 20, 303, and 197 patients, respectively). OS/DFS/CSS in the pN1-3 group were significantly worse (all p<0.001) compared with the pN0 group. However, there were no significant differences between the pNx and pN0 groups. In the multivariate analyses, CSS was only affected by age [(hazard ratio (HR) = 1.03, p = 0.008]), positive surgical margin (HR = 3.38, p<0.001) and pathological T3-4 stages (HR = 4.07, p<0.001). In the subgroup analyses for patients with LND, locally advanced disease (pT3 and pT4) had significantly more metastases [T3-4: 13.91% (16/115) vs. T0-2: 1.92% (4/208), p<0.001].

CONCLUSIONS

In the pN0 group, LND for cN0 UTUC did not show therapeutic benefits in terms of DFS, CSS, and OS. However, LND with RNU allowed optimal tumor staging, through patients still had a poor prognosis. Clinically occult LN metastases were found in 6.2% of our patients.

Prognostic Significance of Organ-Specific Metastases in Patients with Metastatic Upper Tract Urothelial Carcinoma

Background: Existing data on metastatic upper tract urothelial carcinoma (mUTUC) are limited. In this study, we investigated the prognostic value of site-specific metastases in patients with mUTUC and its association with survival outcomes. Methods: We retrospectively collected data from the Surveillance, Epidemiology and End Results (SEER) database between 2004 and 2016. Kaplan−Meier analysis with a log-rank test was used for survival comparisons. Multivariate Cox regression was employed to predict overall survival (OS) and cancer-specific survival (CSS). Results: 633 patients were selected in this study cohort. The median follow-up was 6 months (IQR 2−13) and a total of 584 (92.3%) deaths were recorded. Within the population presenting with a single metastatic organ site, the most common metastatic sites were distant lymph nodes, accounting for 36%, followed by lung, bone and liver metastases, accounting for 26%, 22.8% and 16.2%, respectively. In patients with a single metastatic organ site, the Kaplan−Meier curves showed significantly worse OS for patients with liver metastases vs. patients presenting with metastases in a distant lymph node (p < 0.001), bone (p = 0.023) or lung (p = 0.026). When analyzing CSS, statistically significant differences were detectable only between patients presenting with liver metastases vs. distant lymph node metastases (p < 0.001). Multivariate analyses showed that the presence of liver (OS: HR = 1.732, 95% CI = 1.234−2.430, p < 0.001; CSS: HR = 1.531, 95% CI = 1.062−2.207, p = 0.022) or multiple metastatic organ sites (OS: HR = 1.425, 95% CI = 1.159−1.753, p < 0.001; CSS: HR = 1.417, 95% CI = 1.141−1.760, p = 0.002) was an independent predictor of poor survival. Additionally, survival benefits were found in patients undergoing radical nephroureterectomy (RNU) (OS: HR = 0.675, 95% CI = 0.514−0.886, p = 0.005; CSS: HR = 0.671, 95% CI = 0.505−0.891, p = 0.006) and chemotherapy (CHT) (OS: HR = 0.405, 95% CI = 0.313−0.523, p < 0.001; CSS: HR = 0.435, 95% CI = 0.333−0.570, p < 0.001). Conclusions: A distant lymph node was the most common site of single-organ metastases for mUTUC. Patients with liver metastases and patients with multiple organ metastases exhibited worse survival outcomes. Lastly, CHT administration and RNU were revealed to be predictors of better survival outcomes in the mUTUC cohort.

Clinical Efficacy of Adjuvant Chemotherapy in Advanced Upper Tract Urothelial Carcinoma (pT3-T4): Real-World Data from the Taiwan Upper Tract Urothelial Carcinoma Collaboration Group

The clinical efficacy of adjuvant chemotherapy in upper tract urothelial carcinoma (UTUC) is unclear. We aimed to assess the therapeutic outcomes of adjuvant chemotherapy in patients with advanced UTUC (pT3-T4) after radical nephroureterectomy (RNU). We retrospectively reviewed the data of 2108 patients from the Taiwan UTUC Collaboration Group between 1988 and 2018. Comprehensive clinical features, pathological characteristics, and survival outcomes were recorded. Univariate and multivariate Cox proportional hazards models were used to evaluate overall survival (OS), cancer-specific survival (CSS), and disease-free survival (DFS). Of the 533 patients with advanced UTUC included, 161 (30.2%) received adjuvant chemotherapy. In the multivariate analysis, adjuvant chemotherapy was significantly associated with a reduced risk of overall death (hazard ratio (HR), 0.599; 95% confidence interval (CI), 0.419–0.857; p = 0.005), cancer-specific mortality (HR, 0.598; 95% CI, 0.391–0.914; p = 0.018), and cancer recurrence (HR, 0.456; 95% CI, 0.310–0.673; p < 0.001). The Kaplan–Meier survival analysis revealed that patients receiving adjuvant chemotherapy had significantly better five-year OS (64% vs. 50%, p = 0.002), CSS (70% vs. 62%, p = 0.043), and DFS (60% vs. 48%, p = 0.002) rates compared to those who did not receive adjuvant chemotherapy. In conclusion, adjuvant chemotherapy after RNU had significant therapeutic benefits on OS, CSS, and DFS in advanced UTUC.

Perioperative chemotherapy in the management of high risk upper tract urothelial cancers

Radical nephroureterectomy (RNU) remains the gold-standard in the treatment of invasive urothelial cancers of the upper tract (>pT2). However, there are stage-related, postoperative recurrence and cancer-specific death rates that are unacceptably high. Multimodality treatment regimens including neoadjuvant and adjuvant cisplatin-based systemic chemotherapy have been studied. While there is a paucity of Level 1 evidence to support either regimen, both have advantages and disadvantages. The provision of chemotherapy in the neoadjuvant setting is supported by extensive bladder cancer literature, but randomized controlled trials in the upper tract have not been completed. Neoadjuvant chemotherapy also risks overtreatment of patients due to the lack of accurate pre-operative staging modalities. On the other hand, adjuvant chemotherapy is supported by the findings of one prospective randomized trial, and eliminates the need for patient selection based on imperfect pre-operative modalities. However, the rigors of surgery and the renal function loss related to nephrectomy, may preclude the provision of adjuvant chemotherapy in a significant subset of patients. One may conclude that multimodal therapy is desirable for oncologic control, but the best means of providing such therapy requires further study.

Association between lymphovascular invasion and oncological outcome in node-negative upper tract urothelial carcinoma with different stage

OBJECTIVES

To evaluate the prognostic impact of lymphovascular invasion (LVI) on node-negative upper tract urothelial carcinoma (UTUC) in patients treated with radical nephroureterectomy (RNU).

MATERIALS AND METHODS

A retrospective study was performed in single tertiary referral center of middle Taiwan between 2001 and 2015. Seven hundred and twenty-eight patients were diagnosed of UTUC and underwent RNU with ipsilateral bladder cuff excision including 303 and 195 patients with N0 and Nx status respectively. LVI status was assessed as a prognostic factor for cancer-specific (CSS) and overall survival (OS) using univariate and multivariate Cox regression analysis.

RESULTS

LVI was observed in 82 patients (16.5%). LVI presentation associated with smoking status, advanced tumor stage, high tumor grade, positive surgical margin, and consequence lung/liver/bone metastasis. In the multivariate analysis, LVI was failed to predict CSS, OS, and disease-free survival (DFS) (hazard ratio [HR] [95% confidence interval [CI]: 1.07 [0.55-2.09], 1.05 [0.62-1.79], 1.15 [0.69-1.92], in CSS, OS, DFS, respectively). In the subgroup analysis of pT1-2 disease, the CSS, OS, and DFS were associated with LVI status (HR [95% CI]: 2.29 [0.44-11.84], 3.17 [1.16-8.67], 2.66 [1.04-6.79], in CSS, OS, DFS, respectively). In contrast, there was no difference in pT3 disease.

CONCLUSION

In conclusion, LVI status was not associated with survival outcomes of node-negative UTUC in our study. The subgroup analysis showed different prognostic impacts of LVI status in node-negative UTUC with T1-2 and T3 stage. Further evidence to clarify the prognostic effect is needed to make LVI became a practical factor in clinical decision-making.

The effectiveness of chemotherapy for patients with pT3N0M0 renal pelvic urothelial carcinomas: An inverse probability of treatment weighting comparison using Surveillance, Epidemiology, and End Results data

Introduction

Unlike the established evidence to use chemotherapy for urothelial carcinoma of the bladder, presently there are insufficient data to inform a recommendation on upper urinary tract urothelial carcinoma treatment. The prognosis for patients with stage T4 and positive lymph nodes is poor; however, primary tumors in the renal pelvis are associated with favorable prognoses compared to those located in the ureter. Our study aimed at investigating the effectiveness of chemotherapy in patients with pT3N0M0 renal pelvic urothelial carcinomas (RPUC) who have relative favorable prognosis.

Methods

Patients with pT3N0M0 tumors who underwent radical nephroureterectomy combined with bladder cuff excision between 2005 and 2014 and registered in the Surveillance, Epidemiology, and End Results database were eligible for inclusion (n = 939). Baseline characteristics between the chemotherapy and observation groups were controlled for with inverse probability of treatment weighting (IPTW)‐adjusted analysis.

Results

After the IPTW‐adjusted analysis, the 5‐year IPTW‐adjusted rates of overall survival (OS) for the chemotherapy and observation groups were 53.1% and 44.9%, respectively. The IPTW‐adjusted Kaplan‐Meier curves suggested that chemotherapy was associated with increased OS compared with observation (P = .028). In the IPTW‐adjusted Cox proportional hazards regression model, chemotherapy was associated with favorable survival benefits compared with observation (hazard ratio [HR] 0.71, 95% CI 0.52‐0.92, P = .031), and this was maintained after bootstrapping (HR 0.72, 95% CI 0.49‐0.93). Chemotherapy had a protective effect on OS benefits, which were found in a majority of the results of the subgroup analysis and were consistent with the main results (all P‐interactions > 0.05).

Conclusion

Chemotherapy may provide significant OS benefits for patients with pT3N0M0 RPUC. The results of our study could strengthen the evidence for using adjuvant chemotherapy in this rare group of patients.

Nomograms to predict overall and cancer-specific survival in patients with upper tract urothelial carcinoma: a large population-based study

Background

To develop and validate survival nomograms for predicting the overall survival (OS) and cancer-specific survival (CSS) in upper tract urothelial carcinoma (UTUC) patients.

Method

Patients diagnosed with UTUC from 2010 to 2015 in the Surveillance, Epidemiology, and End Results (SEER) database were retrospectively enrolled. Clinical characteristics and survival outcomes were respectively collected from the included patients. Then, eligible patients were divided into the training cohort and the validation cohort. Additionally, survival nomograms were developed based on the results of multivariate Cox analysis in the training cohort. Furthermore, Kaplan-Meier (KM) survival curves were generated to assess the actual effect of each variable. Lastly, the nomograms were validated using the concordance index (C-index), the area under the receiver operating characteristic (ROC) curve and calibration curves.

Results

Totally, 3,556 patients were included, with 2,492 in the training cohort and 1,064 in the validation cohort. No significant differences were detected in comparisons in clinical characteristics between two cohorts. Based on the results of uni- and multivariate Cox regression analysis, seven factors (age, TNM stage, use of surgery/radiation and marital status) for OS and six factors (age, TNM stage and use of surgery/radiation) for CSS were selected to develop the survival nomograms. The C-index for OS and CSS was 0.763 and 0.793 in the training cohort, and 0.759 and 0.784 in the validation cohort. Additionally, the 3- and 5-year AUCs for OS were 0.808 and 0.780 in the training cohort, and 0.785 and 0.778 in the validation group. As for CSS, it was 0.833 and 0.803 in the training cohort, and 0.815 and 0.810 in the validation cohort. Lastly, the calibration curves indicated a good consistency between the actual survival and the predictive survival.

Conclusions

It was the first time to conduct survival models for UTUC patients with predictive performance. It might be valuable of clinical application and further exploration with more studies in the future.

Prognostic Value of Lymphovascular Invasion in Node-Negative Upper Urinary Tract Urothelial Carcinoma Patients Undergoing Radical Nephroureterectomy

PURPOSE

This study aimed to evaluate the prognostic impact of lymphovascular invasion (LVI) in patients treated with radical nephroureterectomy (RNU) for upper urinary tract urothelial carcinoma (UTUC).

MATERIALS AND METHODS

We collected data from 180 patients who were treated with RNU from 2005 to 2013 at our institution. The Kaplan-Meier method with log-rank test and Cox proportional hazards regression models were used for univariate and multivariate analyses.

RESULTS

LVI was present in 28 patients (15.6%), which was associated with higher pathological tumor stage (p<0.001), tumor necrosis (p=0.012), lymph node metastasis (p=0.017) and multifocality (p=0.012). On multivariate analysis, LVI was an independent prognostic factor of recurrence-free survival [RFS: hazard ratio (HR)=2.954; 95% confidence interval (CI)=1.539-5.671; p=0.001] and cancer-specific survival (CSS: HR=3.530; 95% CI=1.701-7.325; p=0.001) in all patients. In patients with node-negative UTUC, LVI was also a significant predictor of RFS (HR=3.732; 95% CI 1.866-7.464; p<0.001) and CSS (HR=3.825; 95% CI=1.777-8.234; p=0.001).

CONCLUSION

LVI status was an independent predictor in patients with UTUC who underwent RNU. The estimate of LVI could help physicians identify high-risk patients and make a better medication regimen of adjuvant chemotherapy.

Outcomes of stage II-IV upper-tract urothelial carcinoma and adjuvant chemotherapy for locally advanced cancer

The present retrospective study aimed to examine the outcomes of stage II-IV upper-tract urothelial carcinoma (UTUC) and determine whether adjuvant chemotherapy is a beneficial treatment for patients with locally advanced UTUC (specifically, stage III-IV). The analysis included 126 patients with muscle-invasive UTUC who were treated between June 2003 and June 2012. All patients underwent laparoscopic or open nephroureterectomy and bladder cuff excision. Overall survival (OS), disease-free survival (DFS), distant metastasis-free survival (DMFS) and locoregional recurrence-free survival (LRFS) were assessed. Outcomes were compared between groups of patients with stage II (high-stage localized) disease, stage III-IV (high-stage locally advanced) disease treated with chemotherapy, and stage III-IV disease not treated with chemotherapy. Among patients with high-stage locally advanced UTUC (stage III-IV), those who received adjuvant chemotherapy had significantly better rates of OS (67.1 vs. 33.7%; P=0.004), DFS (70.2 vs. 46.0%; P=0.030) and DMFS (86.3 vs. 65.2%; P=0.048) at 5-years compared with those who did not undergo adjuvant chemotherapy. However, there was no significant difference between the 5-year LRFS rates in these two groups (78.2 vs. 62.5%; P=0.525). Importantly, the survival curve of patients with high-stage UTUC who received adjuvant chemotherapy was similar to that of patients with low-stage UTUC who underwent surgery only. Multivariate analysis revealed that adjuvant chemotherapy was an independent risk factor for OS [without adjuvant chemotherapy vs. with adjuvant chemotherapy: Hazard ratio (HR), 0.29; 95% confidence interval (CI), 0.129-0.654; P=0.003] and DFS (without adjuvant chemotherapy vs. with adjuvant chemotherapy: HR, 0.381; 95% CI, 0.168-0.865; P=0.021). In conclusion, adjuvant chemotherapy may improve the outcome for patients with high-stage locally advanced UTUC.

Survival effect of perioperative systemic chemotherapy on overall mortality in locally advanced and/or positive regional lymph node non-metastatic urothelial carcinoma of the upper urinary tract

OBJECTIVES

To analyze the potential survival benefit of perioperative chemotherapy (CHT) in patients treated with nephroureterectomy (NU) for non-metastatic locally advanced upper tract urothelial carcinoma.

METHODS

Within the Surveillance, Epidemiology, and End Results database (2004-2014), we identified 1286 patients with T3 or T4, N 0-3 M0 UTUC. Kaplan-Meier plots, as well as multivariable Cox regression models (MCRMs) relying on inverse probability after treatment weighting (IPTW) and landmark analyses, were used to test the effect of CHT vs no CHT on overall mortality (OM) in the overall population (n =1286), as well as after stratification according to lymph node invasion (LNI).

RESULTS

Overall, 37.4% patients received CHT. The CHT rate was higher with LNI (62.2% vs 35.2%, p < 0.001). In MCRMs, testing for OM in the overall population, CHT was associated with lower rates of OM (HR 0.71, CI 0.58-0.87; p = 0.001). Similarly, in MCRMs testing for OM in patients with LNI, CHT achieved independent predictor status for lower OM (HR 0.61, CI 0.48-0.78; p < 0.001). Conversely, in MCRMs testing for OM in patients without LNI, no CHT effect was recorded (HR 0.72, CI 0.52-1.01; p = 0.05). All results were confirmed after IPTW adjustment and in landmark analyses.

CONCLUSIONS

Our results represent a contemporary North American report indicating lower OM after CHT for patients with locally advanced non-metastatic upper tract urothelial carcinoma, specifically in patients with T3-T4, N1-N3, M0 disease. Validation of the current and of the previous study is required within a randomized prospective design.

Perioperative chemotherapy for urothelial carcinoma of the upper urinary tract: A systematic review and meta-analysis

INTRODUCTION

Upper tract urothelial carcinomas are rare malignancies with differences in anatomy and biology requiring therapeutic strategies that differ from bladder cancer. The role of perioperative systemic therapy in this disease remains uncertain with limited data to support its use. A systematic review of the literature and meta-analysis was therefore undertaken to provide more information and guide clinical practice.

METHODS

A literature search was performed using Embase and Medline databases with additional searches performed manually using terms associated with upper tract urothelial malignancies. Data was extracted from studies of patients that underwent nephrouretectomy for the management of upper tract urothelial carcinoma and received either neoadjuvant or adjuvant systemic therapy. Overall survival (OS), disease-free survival (DFS), and cancer-specific survival (CSS) were summated and analyzed using Cochrane Revman software Version 5.3.

RESULTS

There were 13 comparative studies and no randomized studies identified for data extraction; 11 adjuvant and 2 neoadjuvant with 1170 patients receiving perioperative systemic therapy and 3472 controls that did not. Perioperative chemotherapy was associated with improved OS (HR 0.75, 95%CI 0.57-0.99), DFS (HR 0.54, 95%CI 0.32-0.92), and CSS (HR 0.69, 95%CI 0.42-1.15).

CONCLUSIONS

The available data suggests that perioperative systemic therapy is associated with improved survival in patients with upper tract urothelial cancer.

Does perioperative chemotherapy improve survival in upper tract urothelial carcinoma? A population based analysis

Objectives

To evaluate the utilization and outcomes of perioperative chemotherapy in non-metastatic UTUC patients over the past decade using a large national database.

Methods

All patients aged 18 and older diagnosed with non-metastatic UTUC between 2004 and 2013 were identified within the Surveillance, Epidemiology and End Results (SEER) database. Relevant clinical data was collected and predictors of cancer specific mortality (CSM) and other cause mortality (OCM) were analyzed.

Results

The total cohort included 8,762 patients. Of these, 1,402 (16%) patients received chemotherapy, including only 35% of high-risk patients (>pT2 or N1). Treated patients had higher CSM (21.3% vs. 13.1%, p<0.001). Predictors of chemotherapy utilization included residence in Midwest states, tumor located in the ureter, higher stage and grade. Predictors of CSM included older age, residence in southern states, receipt of chemotherapy (HR = 1.151, 95% CI: 1.003-1.32, p=0.044), higher stage and grade. OCM was predicted by male gender, older age, ureteral tumor, and higher stage. A subset analysis of patients younger than 65 showed similar predictors, while an analysis of high risk patients demonstrated that chemotherapy receipt did not predict CSM or OCM.

Conclusions

In this large contemporary non-metastatic UTUC cohort, chemotherapy utilization was found to be quite infrequent, but increasing steadily. Perioperative chemotherapy had no effect on CSM in high-risk patients, while correlated to higher CSM in the younger patients.

Prognostic importance of lymphovascular invasion in urothelial carcinoma of the renal pelvis

BACKGROUND

The current study was conducted to assess the impact of lymphovascular invasion on the survival of patients with urothelial carcinoma of the renal pelvis.

METHODS

Patients with urothelial carcinoma of the renal pelvis who underwent radical nephroureterectomy from 2010 through 2015 were identified in the National Cancer Data Base. Patients were characterized according to demographic and clinical factors, including pathologic tumor stage and lymphovascular invasion. Associations with overall survival were assessed through proportional hazards regression analysis.

RESULTS

A total of 4177 patients were identified; 1576 had lymphovascular invasion. Patients with T3 disease and lymphovascular invasion had 5-year survival that was significantly worse than that of patients with T3 disease without lymphovascular invasion (34.7% vs 52.6; P < .001 by the log-rank test), and approached that of patients with T4 disease without lymphovascular invasion (34.7% vs 26.5%; P = .002). On multivariate analysis controlling for age, comorbidities, grade, lymph node status, surgical margin status, race, sex, and chemotherapy administration, patients with T3 disease and lymphovascular invasion also were found to have significantly worse survival compared with patients with T3 disease without lymphovascular invasion (hazard ratio, 1.7; 95% confidence interval, 1.4-1.91).

CONCLUSIONS

Lymphovascular invasion status is a key prognostic marker that can stratify the risk of patients with pT3 upper tract urothelial carcinoma further. Patients with this pathologic feature should be carefully considered for clinical trials exploring existing and novel therapies. Cancer 2018;124:2507-14. © 2018 American Cancer Society.

Perioperative treatments for resected upper tract urothelial carcinoma: a network meta-analysis

BACKGROUND

Perioperative treatments have been used to improve prognosis in patients with upper tract urothelial carcinoma (UTUC). However, optimal management remains unestablished.

METHODS

We searched the Embase, Web of Science and Cochrane databases for studies published before June 20, 2015. All included studies were categorised into three groups on the basis of the outcome reported (overall survival (OS), disease-specific survival (DSS) and recurrence-free survival (RFS)). Relative hazard ratios (HRs) for death were calculated using random-effects Bayesian network meta-analysis methods. We also ranked the three different treatments in terms of three outcomes.

RESULTS

A total of 31 trials with 8100 patients were included. Compared with the control, adjuvant chemotherapy (AC) could improve OS, DSS and RFS by 32% (HR 0.68, 95% CI 0.51-0.89), 29% (HR 0.71, 95% CI 0.54-0.89) and 51% (HR 0.49, 95% CI 0.23-0.85), respectively. We noted a marked prolongation of RFS in both intravesical chemotherapy (HR 0.32, 95% CI 0.09-0.69) as well as concurrent radiotherapy and intravesical chemotherapy (HR 0.32, 95% CI 0.03-0.97) than in the control. Neoadjuvant chemotherapy (NAC) showed a significant improvement in DSS relative to the control (HR 0.25, 95% CI 0.06-0.61) and a distinct advantage over AC (HR 0.36, 95% CI 0.08-0.90) or AR (HR 6.89, 95% CI 1.25-18.66).

CONCLUSIONS

Our results showed that AC; intravesical chemotherapy; and concurrent radiotherapy and intravesical chemotherapy could improve the prognosis of UTUC patients. NAC was found to be more favourable for UTUC than AC in terms of DSS.

Urothelial carcinomas of the upper urinary tract – how does UK practice compare with European guidelines: is there a difference?

Upper urinary tract urothelial carcinomas (UUT-UCs) are relatively rare tumours that present a challenge to urologists, both in terms of diagnosis and treatment. The diagnostic pathway is often complex and the surgical options continue to generate controversy. The outcomes of treatment are mixed, with invasive tumours having a particularly poor prognosis. In this article we compare UK practice with the most recent European Association of Urology (EAU) guidelines for the management of UUT-UCs.

Percutaneous Nephrostomy Infusion: Nursing Considerations for Treatment of Upper Urinary Tract Urothelial Carcinoma

An intrarenal approach using a percutaneous nephrostomy tube is a novel method to deliver chemotherapy and biotherapy to patients with upper urinary tract urothelial carcinoma. A paucity of evidence exists regarding basic nursing implications for this unique treatment option. This column will provide suggested guidelines to administer intrarenal treatment via a percutanous nephrostomy tube.
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Prognostic factors and outcomes of primary transitional cell carcinoma of the ureter: a population-based study

Objective

This study investigated the prognostic factors and outcomes of a large observational cohort of patients with primary transitional cell carcinoma of the ureter, which was obtained from the Surveillance, Epidemiology, and End Results database.

Methods

We used the Surveillance, Epidemiology, and End Results program to identify 1910 patients who had available clinical and follow-up information and were diagnosed for primary transitional cell carcinoma of the ureter between 2004 and 2013. Descriptive statistics were used to explore the epidemiology, treatment practices, and tumor characteristics of the patients. Univariate and multivariable Cox regression models were used to analyze the patient data.

Results

The median overall survival (OS) was 46 months, and the 5-year OS rate was 41.8%. The median CSS was 78 months, and the 5-year CSS rate was 54.3%. Multivariate analysis identified tumor grade, tumor size, AJCC stage, M stage, cancer-directed surgical procedure and radiation as independent factors of primary transitional cell carcinoma of the ureter. For early stage patients, the surgical procedure was associated with fairly longer survival and additional radiation may cause more harm than benefit. Meanwhile, for advanced stage patients, the impact of surgery on OS and CSS greatly decreased. Radiation exerted a very limited impact on clinical outcomes. Patients with bad tumor differentiation or a large tumor size were more likely to have advanced stage disease.

Conclusion

Durable cancer control can be expected in patients treated with surgery for early stage UTUC. The presence of advanced stage disease exerts a profound detrimental effect on the survival of patients.

The renal safety and efficacy of combined gemcitabine plus cisplatin and gemcitabine plus carboplatin chemotherapy in Chinese patients with a solitary kidney after nephroureterectomy

PURPOSE

The renal safety of cisplatin-based chemotherapy has not been investigated in patients with urothelial carcinoma of the upper urinary tract (UUT-UC) who retain a solitary kidney after nephroureterectomy. This study aimed to assess and compare the renal safety and efficacy of gemcitabine-cisplatin (GP) and gemcitabine-carboplatin (GC) in these patients.

METHODS

The medical records of patients diagnosed with urothelial carcinoma at the Sun Yat-Sen University Cancer Center between January 2005 and December 2015 were retrospectively reviewed. The creatinine clearance (CrCl) and estimated glomerular filtration rate (eGFR) were used to assess renal function and were calculated using different formulas.

RESULTS

A total of 71 patients were enrolled in this study; 48 patients were on GP, and 23 were on GC. The renal function indicators (CrCl and eGFR) were all significantly lower after GP chemotherapy than at baseline, a phenomenon that was not observed in the GC group. Severe nephrotoxicities (SNTs) were reported in 12 patients on GP (25%) and zero on GC. SNT risk factors included a more than 20% decrease in eGFR after one GP cycle and the presence of diabetes (all p < 0.05). Among patients treated with first-line palliative chemotherapy (n = 32), GC (n = 13) patients had an ORR of 46.2%, which was not significantly different from GP patients (36.8%, n = 19), whereas GC patients tended to have a shorter OS than GP patients (9.2 vs. 29 months, p = 0.200).

CONCLUSIONS

Our results confirm that GP has an adverse impact on the renal function of patients with UUT-UC who retain a solitary kidney, but it can be safely administered to the majority of these patients without inducing SNT. In specific patients, GC is an alternative to GP that has comparable efficacy and favourable renal toxicity.

Efficacy of post-nephroureterectomy cisplatin-based adjuvant chemotherapy for locally advanced upper tract urothelial carcinoma: a multi-institutional retrospective study

PURPOSE

To evaluate the efficacy of adjuvant systemic chemotherapy for locally advanced (pT3-4pN0/xM0) upper tract urothelial carcinoma (UTUC).

MATERIALS AND METHODS

We retrospectively reviewed the medical records of 109 patients with pT3-4pN0/xM0 UTUC who had undergone radical nephroureterectomy between 1996 and 2013 at our four institutions. The patients were divided into two groups: those who received adjuvant chemotherapy (AC group) and those who did not (surgery-alone: SA group). All chemotherapy regimens were cisplatin-based. Cox proportional hazards regression models addressed the associations between clinicopathological factors and recurrence-free survival (RFS) and cancer-specific survival (CSS).

RESULTS

Forty-three (39.5%) out of the 109 patients underwent one to four cycles of adjuvant chemotherapy after nephroureterectomy. Median follow-up was 46.5 months. There were no significant differences in the background characteristics of the two groups, except for age. Recurrence developed in 11 (25.6%) and 29 (43.9%) patients in the AC and SA groups, respectively. Ultimately, six (14.0%) and 18 (27.3%) patients in the AC and SA groups, respectively, died of disease progression. On univariate analysis, hydronephrosis, nuclear grade, lymphovascular invasion, and adjuvant chemotherapy were significantly associated with both RFS and CSS. Charlson comorbidity index was associated only with CSS. On multivariate analysis, adjuvant chemotherapy was the only independent factor associated with improved RFS (p = 0.0178, HR = 0.41). Moreover, adjuvant chemotherapy (p = 0.0375, HR = 0.33), lower nuclear grade (p = 0.0070), and the absence of hydronephrosis (p = 0.0493) were independently associated with better CSS.

CONCLUSION

Locally advanced (pT3-4pN0/xM0) UTUC patients who underwent cisplatin-based adjuvant chemotherapy demonstrated better RFS and CSS than those without adjuvant chemotherapy.

Can lymphovascular invasion replace the prognostic value of lymph node involvement in patients with upper tract urothelial carcinoma after radical nephroureterectomy?

INTRODUCTION

This study aimed to evaluate whether lymphovascular invasion (LVI) can replace lymph node (LN) involvement as a prognostic marker in patients who do not undergo lymph node dissection (LND) during surgery in patients with upper tract urothelial carcinoma (UTUC).

METHODS

A total of 505 patients who underwent radical nephroureterectomy (RNU) were recruited from four academic centres and divided into four groups: node negative (N0, Group 1); node positive (N+, Group 2); no LND without LVI (NxLVI-, Group 3); and no LND with LVI (NxLVI+, Group 4).

RESULTS

Patients in Group 2 had larger tumours, a higher incidence of left-sided involvement, more aggressive T stage and grade, and a higher positive surgical margin rate than patients in other groups. Pathological features (T stage and grade) were poorer in Group 4 than in Groups 1 and 3. Compared to other groups, Group 2 had the worst prognostic outcomes regarding locoregional/distant metastasis-free survival (MFS), cancer-specific survival (CSS), and overall survival (OS). LVI and LN status in Group 4 was not associated with MFS in multivariate analysis. Among Nx diseases, LVI was not an independent predictor of MFS or CCS. The small number of cases in Groups 2 and 4 is a major limitation of this study.

CONCLUSIONS

Clinical outcomes according to LVI did not correlate with those outcomes predicted by LN involvement in patients with UTUC. Therefore, LVI may not be used as a substitute for nodal status in patients who do not undergo LND at the time of surgery.

Perioperative chemotherapy in upper tract urothelial carcinoma: a comprehensive review

PURPOSE

To evaluate the role of neoadjuvant (NAC) and adjuvant chemotherapy (AC) in patients with upper tract urothelial carcinoma (UTUC) treated with radical nephroureterectomy (RNU).

METHODS

A comprehensive review of the current literature was performed searching for all studies investigating NAC and AC in UTUC in MEDLINE and https://clinicaltrials.gov , prior to April 2016. The following keywords were used: "ureteral neoplasms," "urothelium," "ureter," "upper tract urothelial," "chemotherapy," "adjuvant," "neoadjuvant" and relevant variants.

RESULTS

No randomized trials investigated the role of AC or NAC for UTUC. There was one prospective study with n = 36 patients investigating AC with carboplatin-paclitaxel. We included 14 retrospective studies (four in the NAC and ten in the AC setting), with a total of 694 patients receiving cisplatin-based or non-cisplatin-based AC after RNU and 1437 patients undergoing RNU alone. We found that the current literature, mainly based on retrospective studies, suggests significant overall and cancer-specific survival benefits for AC in UTUC. NAC appears promising, with favorable pathologic response rates up to 14%.

CONCLUSIONS

Evidence is scarce for both NAC and AC use in UTUC. This comprehensive review suggests promising response rates for NAC and a survival benefit for patients treated with AC. Prospective randomized trials are needed to establish the role of AC and NAC in UTUC.

External validation of the pathological nodal staging score in upper tract urothelial carcinoma: A population-based study

OBJECTIVES

To externally validate our previously developed pathological nodal staging model (pNSS) that allows quantification of the likelihood that a patient with pathologic node-negative status has, indeed, no lymph node metastasis (LNM).

PATIENTS AND METHODS

We analyzed data from 2,768 patients treated with radical nephroureterectomy (RNU) and lymph node dissection (LND) using the Surveillance, Epidemiology, and End Results database from 1988 to 2010. We estimated the sensitivity of pathologic nodal staging using a beta-binomial model and developed a new pNSS. Then, we compared these findings with those of the initial cohort.

RESULTS

The mean and median numbers of lymph node (LN) removed were 5 and 2, respectively (interquartile range = 5) in the validation cohort, though 66.5% of the patients (n = 1814) were pN0. Similar to the development cohort, the probability of missing a LNM decreased as the number of nodes examined increased in the validation cohort. If only a single node was examined, 35% of patients would be misclassified as pN0 while harboring LNM. Even when 5 nodes were examined, 8% would be misclassified. The probability of having a positive node increased with advancing pathological T stage in both the cohorts. Patients with pT0-Ta-Tis-T1 disease in both cohorts would have more than a 95% chance of a correct pathologic nodal staging with 2 examined nodes. However, if a patient has pT3-T4 disease, more than 12 examined LNs are needed to reach 95% accuracy.

CONCLUSIONS

We confirmed that the number of examined nodes needed for adequate staging depends on pT category. We externally validated our previous pNSS in a population-based database, which could help in the clinical decision-making regarding adjuvant chemotherapy administration.

Why are upper tract urothelial carcinoma two different diseases?

In the last few years growing evidence highlighted the differences between upper tract urothelial carcinoma (UTUC) and urothelial bladder carcinoma (UBC) which cannot be explained solely by their different anatomical location. The aim of this review was to summarize current progress in UTUC research and to underline the differences and similarities between UTUC and UBC by focusing on epidemiology, etiology, staging and risk factors as well as on surgical and medical management. UBC and UTUC sharing common risk factors such as smoking and aromatic amines, while aristolochic acid exposure or familiar Lynch syndrome are rather specific for UTUC. The grading of UBC and UTUC are identical, but inherent from their different anatomical locations, there are some differences between their stage classifications. As an example, in contrast to UBC where a clear recommendation for pT3 subclassification exists, in UTUC current research aims to define an adequate subclassification for pelvic pT3 cases aiming to provide a better risk stratification. The primary treatment for both UBC and UTUC is surgery. Similarly to UBC, UTUC patients at high risk of disease progression are treated by radical surgery. However, because of the inaccurate preoperative or transurethral staging of UTUC, many radical nephroureterectomies are performed unnecessarily. Preoperative prediction of pathological stage or patients' prognosis may reduce this overtreatment by selecting patients for nephron-sparing surgery. To this end, predictive models combining histological and molecular features together with imaging data may be used. The antegrade or retrograde instillation of BCG or mitomycin C, as topical agents is feasible after conservative treatment of UTUC or for the treatment of CIS. However, the prognostic significance of lymph node positivity in UTUC seems to be similar to that of UBC, the therapeutic benefit of lymph node dissection (LND) in UTUC has not been firmly established yet. In addition, the number of lymph nodes to be removed and the sequence of lymphadenectomy also remain to be defined. Systemic neoadjuvant and adjuvant chemotherapies appear to have beneficial effect on UTUC survival, however, this has to be confirmed by large prospective studies. Due to the intensive research of the last few years, our knowledge on UTUC has been largely improved, but many questions remained to be answered. Further research on the molecular background of UTUC holds the potential to identify prognostic or predictive markers which, together with imaging and histologic data, may help to overcome the inaccuracy of ureteroscopic endoscopy and may therefore help to improve therapeutic decision-making. Further, prospective studies should confirm the benefit of LND and adjuvant chemotherapy. Considering the low incidence of UTUC, conduction of such studies is difficult and may only be performed in a multicenter setting.

Adjuvant chemotherapy for locally advanced upper tract urothelial carcinoma: updated results of the Seoul National University Hospital experience

Objectives:

The objective of this study was to update the long-term outcome in the treatment of locally advanced upper tract urothelial carcinoma (UTUC) after radical nephroureterectomy (RNU) regarding the role of adjuvant chemotherapy.

Materials and methods:

Clinical data from 138 patients who underwent RNU for locally advanced UTUC (pT3/4 or pN+) were analyzed.

Results:

The adjuvant chemotherapy group comprised 66 patients, and other 72 patients did not receive adjuvant chemotherapy. Cisplatin-based chemotherapy was the most common regimen, depending on the patient's eligibility and renal function. The median follow-up period was 48.7 months (interquartile range: 29.2-96.9 months). The 3-and 5-year disease-specific survival (DSS) rates were 76.0% and 69.9% for the non-adjuvant chemotherapy group versus 74.6% and 54.5% for the adjuvant chemotherapy group (p=0.301, log-rank test). Overall survival (OS) rates for the same time period were 70.1% and 62.9% for the non-adjuvant chemotherapy group versus 73.8% and 53.2% for the adjuvant chemotherapy group (p=0.931, log-rank test). On multivariate analysis, adjuvant chemotherapy could not predict DSS and OS after surgery. When patients who received cisplatin-based adjuvant chemotherapy (n=59) were compared to those who did not receive adjuvant chemotherapy, similar results were found.

Conclusions:

There does not appear to be a significant DSS or OS benefit associated with adjuvant chemotherapy. Prospective randomized clinical trials are necessary to verify the effect of adjuvant chemotherapy on locally advanced UTUC.

Upper urinary tract disease: what we know today and unmet needs

Purpose

Upper tract urothelial carcinoma (UTUC) is a rare and poorly investigated disease. Intense collaborative efforts have increased our knowledge and improved the management of the disease. The objective of this review was to discuss recent advances and unmet needs in UTUC.

Methods

A non-systematic Medline/PubMed literature search was performed on UTUC using the terms “upper tract urothelial carcinoma” with different combinations of keywords. Original articles, reviews and editorials in English language were selected based on their clinical relevance.

Results

UTUC is a disease with specific epidemiologic and risk factors different to urothelial carcinoma of the bladder (UCB). Similarly to UCB, smoking increases the risk of UTUC and worsens its prognosis, whereas aristolochic acid (AA) exposure and mismatch repair genes abnormality are UTUC specific risk factors. A growing understanding of biological pathways involved in the tumorigenesis of UTUC has led to the identification of promising prognostic/predictive biomarkers. Risk stratification of UTUC is difficult due to limitations in staging and grading. Modern imaging and endoscopy have improved clinical decision-making, and allowed kidney-sparing management and surveillance in favorable-risk tumors. In high-risk tumors, radical nephroureterectomy (RNU) remains the standard. Complete removal of the intramural ureter is necessary with inferiority of endoscopic management. Post-RNU intravesical instillation has been shown to decrease bladder cancer recurrence rates. While the role of neoadjuvant cisplatin based combination chemotherapy and lymphadenectomy are not clearly established, the body of evidence suggests a survival benefit to these. There is currently no evidence for adjuvant chemotherapy (AC) in UTUC.

Conclusions

Despite growing interest and understanding of UTUC, its management remains challenging, requiring further high quality multicenter collaborations. Accurate risk estimation is necessary to avoid unnecessary RNUs while advances in technology are still required for optimal kidney-sparing approaches.

OUTCOMES AFTER SURGICAL TREATMENT OF UPPER TRACT UROTHELIAL CARCINOMA

(Objectives) We retrospectively investigated the prognostic factors and the role of adjuvant chemotherapy against upper tract urothelial carcinoma (UTUC) after surgery. (Materials and methods) 343 patients of UTUC who underwent radical nephroureterectomy at Jikei University Hospital and affiliated institutions between January 2004 and February 2012 were retrospectively analyzed. A chi-squared test was used for categorical variables. Survival probabilities after surgery were estimated using the Kaplan-Meier method. Multivariate Cox regression models addressed overall survival and cancer-specific survival after surgery. (Results) The 5-year overall and cancer-specific survival rates were 64.6% and 74.6%, respectively. On multivariate analysis, higher age, male, higher pT-stage and lymphovascular invasion (LVI) were associated with worse overall survival and higher pT-stage and LVI were associated with worse cancer-specific survival. 44 patients (G3 and ≥pT3) who received cisplatin-based adjuvant chemotherapy had improved overall survival (P=0.044). (Conclusions) Higher pT-stage, LVI were important prognostic variables associated with oncologic outcomes. Cisplatin-based adjuvant chemotherapy offered a significant benefit to overall survival in high risk UTUC (G3 and ≥pT3), but more investigations are needed to confirm its utility.

Therapeutic role of template-based lymphadenectomy in urothelial carcinoma of the upper urinary tract

Lymphadenectomy for urothelial carcinoma of the upper urinary tract has attracted the attention of physicians. The mapping study of lymphatic spread has shown that a relatively wide area should comprise the regional nodes for tumors of the right renal pelvis or the right upper two-thirds of the ureter. A prospective study showed that an anatomical template-based lymphadenectomy significantly improved patient survival in tumors of the renal pelvis. This benefit was more evident for patients with pT2 stage tumors or higher. The risk of regional node recurrence is significant reduced by template-based lymphadenectomy, which is likely to be associated with improved patient survival. The removal of lymph node micrometastases is assumed to be the reason for therapeutic benefit following lymphadenectomy. The number of resected lymph nodes can be used to assess the quality of lymphadenectomy, but not to determine the extent of lymphadenectomy. The guidelines currently recommend lymphadenectomy for patients with muscle-invasive disease, even though the current recommendation grades are still low. The present limitation of lymphadenectomy is the lack of standardization of the extent of lymphadenectomy and the randomized trials. Further studies are warranted to collect the evidence to support lymphadenectomy.

Tumor necrosis predicts poor clinical outcomes in patients with node-negative upper urinary tract urothelial carcinoma

OBJECTIVE

Tumor necrosis has been indicated as a factor for the poor clinical outcome in human cancers. We aim to disclose the association between tumor necrosis and overall survival and recurrence-free survival in node-negative upper urinary tract urothelial carcinoma patients treated with radical nephroureterectomy.

METHODS

A retrospective cohort of 100 patients with upper urinary tract urothelial carcinoma from January 1990 to June 2011 was enrolled in this study. Univariate analysis with Log-rank test and multivariate analysis with Cox proportional hazards regression models were conducted to determine the correlations of tumor necrosis with overall survival and recurrence-free survival.

RESULTS

Tumor necrosis was presented in 48 patients with upper urinary tract urothelial carcinoma and was significantly associated with the advanced pathological stage (P < 0.001), high tumor grade (P < 0.001), subsequent bladder tumor (P = 0.018), vascular invasion (P < 0.001) and lymph node metastasis (P = 0.026). Multivariate analysis revealed tumor necrosis as an independent unfavorable predictor of overall survival in node-negative upper urinary tract urothelial carcinoma patients by multivariate analysis (hazard ratio = 9.23, 95% confidence interval = 1.05-80.89, P = 0.045).

CONCLUSIONS

Tumor necrosis was an independent factor of adverse clinical outcomes in node-negative upper urinary tract urothelial carcinoma patients who received radical nephroureterectomy. Evaluation of tumor necrosis might be of clinical significance to determine whether patients with node-negative upper urinary tract urothelial carcinoma should be given further therapy after radical nephroureterectomy.

European Association of Urology Guidelines on Upper Urinary Tract Urothelial Cell Carcinoma: 2015 Update

CONTEXT

The European Association of Urology (EAU) guidelines panel on upper urinary tract urothelial cell carcinoma (UTUC) has prepared updated guidelines to aid clinicians in the current evidence-based management of UTUC and to incorporate recommendations into clinical practice.

OBJECTIVE

To provide a brief overview of the EAU guidelines on UTUC as an aid to clinicians.

EVIDENCE ACQUISITION

The recommendations provided in the current guidelines are based on a thorough review of available UTUC guidelines and articles identified following a systematic search of Medline. Data on urothelial malignancies and UTUC were searched using these keywords: urinary tract cancer; urothelial carcinomas; upper urinary tract, carcinoma; renal pelvis; ureter; bladder cancer; chemotherapy; nephroureterectomy; adjuvant treatment; instillation; neoadjuvant treatment; recurrence; risk factors; and survival. References were weighted by a panel of experts.

EVIDENCE SYNTHESIS

Due to the rarity of UTUC, there are insufficient data to provide strong recommendations (ie, grade A). However, the results of recent multicentre studies are now available, and there is a growing interest in UTUC. The 2009 TNM classification is recommended. Recommendations are given for diagnosis and risk stratification as well as radical and conservative treatment, and prognostic factors are discussed. A single postoperative dose of intravesical mitomycin after nephroureterectomy reduces the risk of bladder tumour recurrence. Recommendations are also provided for patient follow-up after different therapeutic strategies.

CONCLUSIONS

These guidelines contain information on the management of individual patients according to a current standardised approach. Urologists should take into account the specific clinical characteristics of each patient when determining the optimal treatment regimen, based on the proposed risk stratification of these tumours.

PATIENT SUMMARY

Urothelial carcinoma of the upper urinary tract is rare, but because 60% of these tumours are invasive at diagnosis, an appropriate diagnosis is most important. A number of known risk factors exist.

Patterns of Lymphatic Metastases in Upper Tract Urothelial Carcinoma and Proposed Dissection Templates

PURPOSE

Information on patterns of lymph node metastases for upper tract urothelial carcinoma is sparse. We investigated patterns of lymph node metastases in upper tract urothelial carcinoma.

MATERIALS AND METHODS

We performed a retrospective multi-institutional study of 73 patients with N+M0 upper tract urothelial carcinoma who underwent template lymphadenectomy during nephroureterectomy. Anatomical locations of tumor, and number of lymph nodes removed and positive lymph nodes were analyzed and descriptive statistics were performed.

RESULTS

On the right side the 20 renal pelvis tumors had lymph node metastases to the hilum in 22.1% of cases, and to paracaval, retrocaval and interaortocaval regions in 44.1%, 10.3% and 20.6%, respectively. The 10 proximal ureter tumors had lymph node metastases to the hilum in 46.2% of cases, and to paracaval and retrocaval regions in 46.2% and 7.7%, respectively. The 2 distal ureter tumors had lymph node metastases equally to the paracaval and pelvic regions. On the left side the 24 renal pelvis tumors had lymph node metastases to the hilum region in 50.0% of cases and to the para-aortic region in 30.0%. The 8 proximal ureter tumors had lymph node metastases to the hilum region in 36.4% of cases and the para-aortic region in 63.6%. The 5 mid ureter tumors had lymph node metastases to the para-aortic, common iliac and internal iliac regions in 40%, 40% and 20% of cases, respectively. The 4 distal ureter tumors had lymph node metastases to the para-aortic, common iliac, external iliac and internal iliac regions in 33.3%, 33.3%, 16.7% and 16.7% of cases, respectively. Interaortocaval involvement from both sides as well as out of field lymph node metastases appeared to occur secondarily. Consolidated templates were constructed based on the available data.

CONCLUSIONS

Upper tract urothelial carcinoma has characteristic patterns of lymph node metastases depending on the side and anatomical location of the primary tumor, including right-to-left migration and involvement of interaortocaval nodes in the setting of proximal disease. Standardized dissection templates should be prospectively evaluated in multicenter trials to assess morbidity and potential clinical benefit.

Clinical Value of 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in Upper Tract Urothelial Carcinoma: Impact on Detection of Metastases and Patient Management

OBJECTIVE

To determine the diagnostic accuracy of 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) for detecting metastasis and its impact on patient management with upper tract urothelial carcinoma (UTUC).

PATIENTS AND METHODS

Consecutive patients with UTUC underwent 18F-FDG PET/CT after CT for initial staging (n = 47) and for restaging at recurrence (n = 9). Diagnostic accuracy for detecting metastases with PET/CT and CT was compared statistically. The impact of PET/CT on patient management was assessed by comparing questionnaires that were completed by the attending physicians before and after PET/CT.

RESULTS

In the lesion-based analysis, 142 lesions were diagnosed as metastases. The sensitivity of PET/CT was significantly better than that of CT (85 vs. 50%, p = 0.0001). In the patient-based analysis, 22 patients were diagnosed as having metastases. The sensitivity/specificity/accuracy of PET/CT tended to be superior to those of CT, but these values were not significantly different (95, 91, and 93% vs. 82, 85, and 84%; p = 0.25, 0.50, and 0.063, respectively). The clinicians changed their assessments of disease extent and management plans in 18 (32%) and 11 (20%) patients, respectively, based on the PET/CT results.

CONCLUSIONS

The diagnostic accuracy of PET/CT for detecting metastasis was superior to that of CT. PET/CT provided additional information to the CT-based staging, which had an impact on patient management.

Extraurothelial recurrence after radical nephroureterectomy: preoperative predictors and survival

OBJECTIVE

To identify the preoperative predictors of extraurothelial recurrence (EUR) after radical nephroureterectomy (RNU) in patients with upper tract urothelial carcinoma (UTUC).

METHODS

A single-center series of 238 consecutive patients who were treated with RNU for UTUC was evaluated. Recurrence-free probabilities and cancer-specific survival (CSS) were estimated using the Kaplan-Meier method. Multivariate Cox proportional hazards regression models were used to evaluate the association between various clinicopathological factors and EUR.

RESULTS

The median time to EUR was 17.6 months (range 3-73 months). EUR-free survival rates at 1, 3, 5, and 7 years were 87.8, 75.2, 73.5, and 72.6%, respectively. In multivariate Cox regression analyses, tumor stage (HR 27.4; 95% CI 7.83-95.8; p = 0.0001) and lymphovascular invasion (LVI) (HR 1.53; 95% CI 1.22-3.12; p = 0.01) were independently associated with EUR. In patients with EUR, 5-year CSS estimate was 29.2%. Tumor stage (HR 14.3; 95% CI 4.55-45.2; p < 0.001) and EUR (HR 2.7; 95% CI 1.54-4.73; p = 0.001) were the only independent predictors associated with worse CSS.

CONCLUSIONS

EUR significantly affected the prognosis in patients with UTUC managed by RNU. Patient with EUR had a greater probability of having higher tumor stages, higher tumor grades, and positive LVI. Tumor stage and LVI were independently associated with a worse EUR-free survival.