Cancer-specific survival after radical nephroureterectomy for upper urinary tract urothelial carcinoma: proposal and multi-institutional validation of a post-operative nomogram

High Infiltration of CD163-Positive Macrophages in Intratumor Compartment Predicts Poor Prognosis in Patients With Upper Urinary Tract Urothelial Carcinoma and Radical Nephroureterectomy

OBJECTIVES

To investigate the prognostic value of CD68- and CD163-positive macrophages in patients with upper urinary tract urothelial carcinoma (UTUC).

PATIENTS AND METHODS

This retrospective study enrolled 50 patients (34 men and 16 women) with UTUC who received radical nephroureterectomy (RNU). We evaluated the expression of CD68 and CD163 in the intratumor compartment by immunohistochemistry. The Kaplan-Meier method and Cox proportional hazards regression model were used to evaluate overall survival (OS), cancer-specific survival (CSS), recurrence-free survival (RFS), and bladder recurrence-free survival (BRFS).

RESULTS

High infiltration of CD163-positive macrophages in patients with UTUC was significantly correlated with worse OS, CSS, and RFS (P < .05 for all). Multivariate analysis showed that high infiltration of CD163-positive macrophages was an independent negative prognostic factor of OS and CSS in patients with UTUC who received RNU. Lymphovascular invasion was an independent negative prognostic factor of RFS, and high infiltration of CD68-positive macrophages was an independent positive prognostic factor of BRFS.

CONCLUSION

This study indicated that high infiltration of CD163-positive macrophages in the intratumor compartment might be a useful prognostic marker for survival in patients with UTUC who receive RNU. Further, high infiltration of CD68-positive macrophages in the intratumoral compartment might be a useful prognostic marker for bladder recurrence in these patients.

A dynamic nomogram integrated with blood inflammation markers for predicting overall survival in patients with upper tract urothelial carcinoma

Background

Upper tract urothelial carcinoma (UTUC) is a relatively rare disease with a poor prognosis. A growing body of evidence demonstrates that inflammation and the inflammatory microenvironment play a crucial role in tumorigenesis and tumor progression. Our aim was to evaluate the prognostic value of blood inflammation markers and develop a prediction model that incorporates inflammation markers in order to predict overall survival (OS) of UTUC.

Methods

We included 304 localized UTUC patients from two medical institutions who had undergone radical nephroureterectomy (RNU) (167 in the training cohort, 137 in the validation cohort). Univariate and multivariate Cox regression analyses were performed to screen the prognostic factors, and a nomogram and a web-based calculator were generated based on these predictors. The Harrell's concordance index (C-index), the area under the receiver operating characteristic (ROC) curve, the calibration curve, and decision curve analysis (DCA) were used to evaluate the performance of the nomogram.

Results

Independent predictors incorporated in the nomogram were pathological stage, surgical margin, albumin-to-globulin ratio (AGR), and hemoglobin-to-red cell distribution width ratio (HRR). The c-index value was 0.726 in the training cohort and 0.761 in the validation cohort. The area under the ROC of the nomogram at 1-, 3- and 5-year in the training and validation sets were 0.765, 0.755, 0.763, and 0.791, 0.833, 0.802, respectively. Both the internal and external validation calibration plots showed a subtle distinction between the predicted and the actual probabilities. And it appears to provide incremental benefits for clinical decision-making in comparison to the American Joint Committee of Cancer (AJCC) staging system.

Conclusions

In patients with UTUC after RNU, lower preoperative AGR and HRR were independent predictors of inferior survival. In addition, we created a novel blood inflammation marker-based dynamic nomogram that may be useful for surgeons or oncologists in risk stratification and patient selection for more intensive therapy and closer follow-up.

French AFU Cancer Committee Guidelines - Update 2022-2024: Upper urinary tract urothelial cancer (UTUC)

INTRODUCTION

The aim was to propose an update of the French Urology Association Cancer Committee (ccAFU) Recommendations on the management of upper urinary tract urothelial carcinomas (UUT-UC).

METHODS

A systematic Medline search was performed between 2020 and 2022, taking account of the diagnosis, treatment options and follow-up of UUT-UC, while evaluating the references with their levels of evidence.

RESULTS

The diagnosis of this rare pathology is based on CTU acquisition during excretion and flexible ureterorenoscopy with histological biopsies. Radical nephroureterectomy (RNU) remains the gold standard for surgical treatment. Nevertheless conservative treatment can be discussed for low risk lesions: tumour of low-grade, with no infiltration on imaging, unifocal<2cm, eligible for full treatment therefore requiring close endoscopic surveillance by flexible ureteroscopy in compliant patients. After RNU, postoperative instillation of chemotherapy is recommended to reduce the risk of recurrence in the bladder. Adjuvant chemotherapy has shown clinical benefits compared to surveillance after RNU for tumours (pT2-T4 N0-3 M0).

CONCLUSION

These updated recommendations should contribute to improving not only patients' level of care, but also the diagnosis and decision-making concerning treatment for UUT-UC.

A Systematic Review and Meta-Analysis of Prognostic Nomograms After UTUC Surgery

Background

Current guidelines recommend assessing the prognosis in high-risk upper tract urothelial carcinoma patients (UTUC) after surgery. However, no specific method is endorsed. Among the various prognostic models, nomograms represent an easy and accurate tool to predict the individual probability for a specific event. Therefore, identifying the best-suited nomogram for each setting seems of great interest to the patient and provider.

Objectives

To identify, summarize and compare postoperative UTUC nomograms predicting oncologic outcomes. To estimate the overall performance of the nomograms and identify the most reliable predictors. To create a reference tool for postoperative UTUC nomograms, physicians can use in clinical practice.

Design

A systematic review was conducted following the recommendations of Cochrane’s Prognosis Methods Group. Medline and EMBASE databases were searched for studies published before December 2021. Nomograms were grouped according to outcome measurements, the purpose of use, and inclusion and exclusion criteria. Random-effects meta-analyses were performed to estimate nomogram group performance and predictor reliability. Reference tables summarizing the nomograms’ important characteristics were created.

Results

The systematic review identified 26 nomograms. Only four were externally validated. Study heterogeneity was significant, and the overall Risk of Bias (RoB) was high. Nomogram groups predicting overall survival (OS), recurrence-free survival (RFS), and intravesical recurrence (IVR) had moderate discrimination accuracy (c-Index summary estimate with 95% confidence interval [95% CI] and prediction interval [PI] > 0.6). Nomogram groups predicting cancer-specific survival (CSS) had good discrimination accuracy (c-Index summary estimate with 95% CI and PI > 0.7). Advanced pathological tumor stage (≥ pT3) was the most reliable predictor of OS. Pathological tumor stage (≥ pT2), age, and lymphovascular invasion (LVI) were the most reliable predictors of CSS. LVI was the most reliable predictor of RFS.

Conclusions

Despite a moderate to good discrimination accuracy, severe heterogeneity discourages the uninformed use of postoperative prognostic UTUC nomograms. For nomograms to become of value in a generalizable population, future research must invest in external validation and assessment of clinical utility. Meanwhile, this systematic review serves as a reference tool for physicians choosing nomograms based on individual needs.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=282596, identifier PROSPERO [CRD42021282596].

Construction and Verification of Immunohistochemistry Parameters-Based Classifier to Predict Local-Recurrence of Upper Tract Urothelial Carcinoma After Kidney-Sparing Surgery

Background

Kidney-sparing surgery (KSS) for upper tract urothelial carcinomas (UTUCs) has been gradually performed in selected patients beyond the recommendation of guidelines. However, there is still a lack of tools to evaluate postoperative local recurrence. Herein, a new nomogram was established to predict the local recurrence risk after KSS.

Methods

Patients were randomly divided into two cohorts (training: testing cohorts = 7:3). Cancer samples after KSS were used for immunohistochemical tests to detect molecules missing in previous pathology reports. Then, the total number of molecules were screened by the least absolute shrinkage and selection operator (LASSO) method to construct an IHCscore, which was further tested in the validation cohort. Finally, the IHCscore and other clinicopathologic parameters were combined to develop a more accurate model using univariate and multivariate Cox regression methods.

Results

In total, 200 patients were included. The Kaplan-Meier test showed that high Ki-67 and loss of Uroplakin III and E-cadherin were correlated with poor recurrence-free survival. The individual IHCscore was calculated based on the expression levels of Ki-67, Her2 and E-cadherin. Based on the IHC score, patients were further classified as low- or high-risk, and a significant difference in the recurrence-free survival was observed between the two groups. Then, the nomogram was developed based on Gender, surgical margin and IHCscore; this nomogram had a higher AUC (0.847) in predicting 3-year recurrence-free survival than the IHCscore alone (0.788).

Conclusions

This easy-to-use nomogram shows better prediction accuracy in recurrence-free survival after KSS and may guide individualized intravesical chemotherapy. However, a larger sample is required for external validation.

Influence of American Society of Anesthesiologists Score on Oncologic Outcomes in Patients With Upper Tract Urothelial Carcinoma After Radical Nephroureterectomy: A Large-Sample Study in Two Institutions

Introduction

As a research team of urologists and an anesthetist, we sought to investigate the prognostic significance of American Society of Anesthesiologists (ASA) score in patients with upper tract urothelial cancer (UTUC) after radical nephroureterectomy (RNU). ASA physical status (ASA-PS) classification not only was found to be associated with increased comorbidities but also independently factors for predicting morbidity and mortality. Accurate risk assessment was being particularly important for patients being considered for surgery.

Methods

Records for 958 patients with UTUC who underwent RNU were reviewed. Clinicopathologic variables, including ASA-PS, were assessed at two institutions. Overall survival (OS), cancer-specific survival (CSS), intravesical recurrence-free survival (IRFS), and metastasis-free survival (MFS) were estimated using the Kaplan–Meier method and Cox regression analyses. We measured the independent predictive value of ASA-PS for mortality by multivariate regression. Association of ASA-PS and clinicopathologic variables was assessed.

Results

The group of patients with ASA = 2/3 had a shorter 5-year OS (67.6% and 49.9%), CSS (72.9% and 58.1%), and MFS (75.1% and 58.5%). The median follow-up time was 39 months. Kaplan–Meier curves showed that the group with ASA = 2/3 had significantly poorer OS, CSS, and MFS. Adjusting for multiple potential confounding factors, multivariate analyses suggested that ASA score was an independent predictor of OS, CSS, and MFS (p = 0.004, p = 0.005, p < 0.001).

Conclusion

Higher ASA scores were independently associated with lower survival rate. This capability, along with its simplicity, makes it a valuable prognostic metric. It should be seriously referenced in UTUC patients being considered for RNU.

[French ccAFU guidelines - update 2020-2022: upper urinary tract urothelial carcinoma]

INTRODUCTION

-The purpose was to propose an update of the French guidelines from the national committee ccAFU on upper tract urothelial carcinomas (UTUC).

METHODS

- A systematic Medline search was performed between 2018 and 2020, as regards diagnosis, options of treatment and follow-up of UTUC, to evaluate different references with levels of evidence.

RESULTS

- The diagnosis of this rare pathology is based on CT-scan acquisition during excretion and ureteroscopy with histological biopsies. Radical nephroureterectomy (RNU) remains the gold standard for surgical treatment, nevertheless a conservative endoscopic approach can be proposed for low risk lesion: unifocal tumor, possible complete resection and low grade and absence of invasion on CT-scan. Close monitoring with endoscopic follow-up (flexible ureteroscopy) in compliant patients is therefore necessary. After RNU, bladder instillation of chemotherapy is recommended to reduce risk of bladder recurrence. A systemic chemotherapy is recommended after RNU in pT2-T4 N0-3 M0 disease.

CONCLUSION

- These updated guidelines will contribute to increase the level of urological care for diagnosis and treatment for UTUC.

A Novel Nomogram for Predicting the Survival of Patients with Invasive Upper Tract Urothelial Carcinoma

Purpose: Available tools for the prediction of the prognosis of patients with upper tract urothelial carcinoma (UTUC) are unified. We determined whether a novel nomogram is effective in estimating the survival of patients with invasive UTUC.

Methods: From January 2004 to December 2015, 4796 invasive UTUC patients in the Surveillance, Epidemiology and End Results database underwent radical nephroureterectomy (RNU) for invasive UTUC. The medical records of the patients were randomly (7:3) divided into the training and validation cohorts. The independent factors included in the nomogram were selected by multivariate analyses. The nomogram was developed based on the training cohort. Bootstrap validation was applied to validate the nomogram, whereas external validation was performed using the validation cohort. The accuracy and discrimination of the nomogram were assessed using concordance indices (C-indices) and calibration curves.

Results: The multivariate Cox regression model identified that age, tumor stage, node stage, metastasis stage and grade were associated with survival. In the training set, the nomogram, which included the above factors, exhibited discrimination power superior to that of the 8th American Joint Committee on Cancer (AJCC) TNM classification (Harrell's C-index, 0.74 vs. 0.71; P < 0.001). The nomogram showed better probability of survival agreement with the C-index than the AJCC-TNM staging system in the bootstrap validation (0.74 vs. 0.70; P < 0.001) and validation set (Harrell's C-index, 0.77 vs. 0.73; P < 0.001). The validation revealed that this nomogram exhibited excellent discrimination and calibration capacities.

Conclusion: An accurate novel nomogram that is superior to the current AJCC-TNM staging system was established for the prediction of CSS after RNU for invasive UTUC.

Outcome prediction following radical nephroureterectomy for upper tract urothelial carcinoma

OBJECTIVE

To predict overall survival, cancer, and metastasis specific survival in upper tract urothelial carcinoma (UTUC) following radical nephroureterectomy (RNU).

MATERIALS AND METHODS

All nonmetastatic UTUC patients who underwent RNU with a curative intent at 1 institution between December 1998 and January 2017 were included.  Detailed data were collected. End points for this study included OS, CCS, and MFS. Univariate and multivariate analysis were conducted. Log Rank tests and Kaplan-Meier curves were generated. Backward elimination and boot strapping was used to identify the most parsimonious model with the smallest number of variables in order to predict the outcomes of interest. A separate second institution data base was used for external validation.

RESULTS

There were 218 patients in the development cohort. Mean follow-up was 42 months (±39.6). There was 99 (45.4%) deaths, 28 (12.8%) cancer related deaths, 72 (33%) recurrences, and 54 (24.8%) metastases. The c-index for our model was 0.71 for OS, 0.72 for MFS and 0.74 for CSS. The nomograms did not show significant deviation from actual observations using our calibration plots. We divided the patient into 3 different groups (low, intermediate and high risk) based on their final total score for each outcome and compared them. On external validation our accuracy was 78.4%, 71.4%, and 75.3% for OS, CSS, and MFS survival respectively.

CONCLUSION

We designed a predictive model for survival outcomes following RNU in UTUC. This model uses simple, readily available data for patients without the need for expensive or additional testing.

Diagnostic challenges and treatment strategies in the management of upper-tract urothelial carcinoma

Upper-tract urothelial carcinoma (UTUC) is a rare disease, posing many challenges for the treating physician due to the lack of strong evidence-based recommendations. However, novel molecular discoveries and a better understanding of the clinical behavior of the disease lead to a continuous evolution of therapeutic landscape in UTUC. The aim of the review is to provide a comprehensive update of the current diagnostic modalities and treatment strategies in UTUC with a special focus on recent developments and challenges. A comprehensive literature search including relevant articles up to August 2020 was performed using the MEDLINE/PubMed database. Despite several technological improvements, accurate staging and outcome prediction remain major challenges and hamper appropriate risk stratification. Kidney-sparing surgery can be offered in low risk UTUC; however, physician and patient must be aware of the high rate of recurrence and risk of progression due to tumor biology and understaging. The value and efficacy of intracavitary therapy in patients with UTUC remains unclear due to the lack of high-quality data. In high-risk diseases, radical nephroureterectomy with bladder cuff excision and template lymph node dissection is the standard of care. Perioperative systemic chemotherapy is today accepted as a novel standard for advanced cancers. In metastatic or unresectable disease, the therapeutic landscape is rapidly changing due to several novel agents, such as checkpoint inhibitors. While several diagnostic and treatment challenges remain, progress in endoscopic technology and molecular knowledge have ushered a new age in personalized management of UTUC. Novel accurate molecular and imaging biomarkers are, however, still needed to guide decision making as tissue acquisition remains suboptimal. Next generation sequencing and novel agents are promising to rapidly improve patient outcomes.

Survival nomogram for patients with upper tract recurrence after resection for localized bladder urothelial carcinoma

Aim: To develop a survival nomogram for patients with upper tract recurrence (UTR) after resection for localized bladder urothelial carcinoma (BUC). Methods: The data of 361 patients with UTR after resection for BUC registered in the Surveillance, Epidemiology, and End Results database were retrospectively analyzed. The nomogram was established using the Fine and Gray method and its predictive accuracy was assessed using the concordance index. The nomogram was calibrated by comparing the predicted and actual survival. Results: The concordance index of the nomogram was 0.746 (95% CI: 0.733-0.759). Excellent agreement was observed between the predicted and actual survival in all calibration plots. Conclusion: This study describes the first survival nomogram for patients experienced UTR after resection for BUC.

European Association of Urology Guidelines on Upper Urinary Tract Urothelial Carcinoma: 2020 Update

CONTEXT

The European Association of Urology (EAU) Guidelines Panel on Upper Urinary Tract Urothelial 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 an 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 the following keywords: urinary tract cancer, urothelial carcinomas, upper urinary tract carcinoma, renal pelvis, ureter, bladder cancer, chemotherapy, ureteroscopy, nephroureterectomy, neoplasm, adjuvant treatment, instillation, recurrence, risk factors, and survival. References were weighted by a panel of experts.

EVIDENCE SYNTHESIS

Owing to the rarity of UTUC, there are insufficient data to provide strong recommendations. The 2017 tumour, node, metastasis (TNM) classification is recommended. Recommendations are given for diagnosis and risk stratification as well as for 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. Kidney-sparing management should be offered as a primary treatment option to patients with low-risk tumour and two functional kidneys. After radical nephroureterectomy, cisplatin-based chemotherapy is indicated in locally advanced UTUC.

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.

Optimal Management of Upper Tract Urothelial Carcinoma: Current Perspectives

INTRODUCTION

Upper tract urothelial carcinoma (UTUC) is a relatively uncommon urologic malignancy for which there has not been significant improvement in survival over the past few decades, highlighting the need for optimal multi-modality management.

METHODS

A non-systematic review of the latest literature was performed to include relevant articles up to June 2019. It summarizes the epidemiologic risk factors associated with UTUC, including smoking, carcinogenic aromatic amines, arsenic, aristolochic acid, and Lynch syndrome. Molecular pathways underlying UTUC and potential druggable targets are outlined.

RESULTS

Surgical management for UTUC includes kidney-sparing surgery (KSS) for low-risk disease and radical nephroureterectomy (RNU) for high-risk disease. Endoscopic management of UTUC may include ureteroscopic or percutaneous resection. Topical instillation therapy post-KSS aims to reduce recurrence, progression and to treat carcinoma-in-situ; this may be achieved retrogradely (via ureteric catheterization), antegradely (via percutaneous nephrostomy) or via reflux through double-J stent. RNU, which may be performed via open, laparoscopic or robot-assisted approaches, is the gold standard treatment for high-risk UTUC. The distal cuff may be dealt with extravesical, transvesical or endoscopic techniques. Peri-operative chemotherapy and immunotherapy are increasingly utilized; level 1 evidence exists for adjuvant chemotherapy, but neoadjuvant chemotherapy is favored as kidney function is better prior to RNU. Immunotherapy is primarily reserved for metastatic UTUC but is currently being investigated in the perioperative setting.

CONCLUSION

The optimal management of UTUC includes a firm understanding of the epidemiological factors and molecular pathways. Surgical management includes KSS for low-risk disease and RNU for high-risk disease. Peri-operative immunotherapy and chemotherapy may be considered as evidence mounts.

Significant clinicopathologic prognostic factors for bladder recurrence, progression, and cancer-specific survival after surgery among patients with upper urinary tract urothelial carcinoma

Purpose

This study aimed to identify prognostic factors for outcomes after radical nephroureterectomy among patients with upper urinary tract urothelial carcinoma (UTUC).

Materials and Methods

We retrospectively reviewed 184 nonmetastatic cases of UTUC after radical nephroureterectomy, bladder cuffing, and/or partial cystectomy (2004-2016). Bladder recurrence-free survival (BRFS), disease progression-free survival (DPFS), and cancer-specific survival (CSS) were estimated. The prognostic values of clinicopathologic parameters were evaluated by using Cox logistic regression analysis.

Results

The median BRFS, DPFS, and CSS values were 19.0 months, 38.5 months, and 67.0 months, respectively. We identified cases of bladder recurrence (64 cases, 34.8%), disease progression (54 cases, 29.3%), and cancer-specific death (23 cases, 12.5%). BRFS was independently associated with lymphovascular invasion (hazard ratio [HR], 0.421); DPFS was associated with intravesical instillation (HR, 0.290), active smoking (HR, 0.367), synchronous bladder lesions (HR, 2.355), and pT2 (HR, 5.199) and pT3 and pT4 (HR, 13.281) stages; and CSS was associated with alkaline phosphatase levels (HR, 0.966). Among 123 cases without previous bladder cancer, DPFS was associated with intravesical instillation (HR, 0.264), multifocal ureteral tumors (HR, 4.823), and pT3 and pT4 stages (HR, 10.899), whereas CSS was associated with pTis (HR, 32.071).

Conclusions

Patients with the factors we identified should receive adjuvant intravesical/systemic chemotherapy and intensive surveillance.

[French ccAFU guidelines - Update 2018-2020: Upper tract urothelial carcinoma]

INTRODUCTION

To propose an update of the French guidelines from the national committee ccAFU on upper tract urothelial carcinomas (UTUC).

METHODS

A systematic Medline search was performed between 2016 and 2018, with regards to the diagnosis, the options of treatment and the follow-up of UTUC, to evaluate the different studies with levels of evidence.

RESULTS

The diagnosis of this rare disease is based on CT-scan acquisition during excretion and ureteroscopy with histological biopsies. Radical nephroureterectomy (RNU) remains the gold standard for surgical treatment, nevertheless a conservative endoscopic approach can be proposed for low-risk diseases: unifocal tumour, possible complete resection low-grade and lack of invasion on CT-scan. Close monitoring with endoscopic follow-up (flexible ureteroscopy) in compliant patients is therefore necessary. After RNU, bladder instillation of chemotherapy is recommended in order to reduce the risk of bladder recurrence. An adjuvant chemotherapy is recommended after RNU in pT2-T4 N0-3 M0 disease.

CONCLUSION

These updated guidelines will contribute to increase the level of urological care for diagnosis and treatment of UTUC.

A Novel Risk-based Approach Simulating Oncological Surveillance After Radical Nephroureterectomy in Patients with Upper Tract Urothelial Carcinoma

BACKGROUND

The current guideline lacks evidence for creating individualized surveillance strategies for upper tract urothelial carcinoma (UTUC) patients after radical nephroureterectomy (RNU).

OBJECTIVE

To create a novel risk model and to simulate individualized surveillance duration that dynamically illustrates the changing risk relationship of UTUC-related death and non-UTUC death, considering the impact of cigarette smoking.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter cohort study comprised 714 pTa-T4N0M0 UTUC patients, with a median follow-up duration of 65mo. There were 279 (39.1%) nonsmokers, 260 (36.4%) current smokers, and 175 (24.5%) ex-smokers.

INTERVENTION

All patients underwent RNU.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The risks of UTUC death and non-UTUC death over time were estimated using parametric models for time to failure with Weibull distributions. Age-specific, stage-specific, and smoking status-specific surveillance durations were simulated based upon Weibull estimates.

RESULTS AND LIMITATIONS

The hazard rate (HR) of non-UTUC death gradually increased over time in all age groups regardless of the smoking status, whereas that of UTUC-related death decreased markedly according to the pathological T (pT) stage and was affected by the smoking status. Among current smokers, the baseline HR of UTUC-related death in pT3/4 was higher than that of pT ≤2 and remained high even 10yr after RNU. Among heavy smokers, the HR of UTUC-related death in all pT stages was highest at baseline and remained high after RNU, compared with nonsmokers, current smokers, or ex-smokers. We simulated specific time points when the risk of non-UTUC death was greater than that of UTUC-related death. Among patients ≥80yr of with pT3N0M0, the risk of non-UTUC death was greater than that of UTUC-related death 1yr after RNU in nonsmokers, but 7yr for heavy smokers.

CONCLUSIONS

Our result revealed that smokers bear a long-term risk burden of UTUC-related death more than the risk of non-UTUC death. For UTUC smokers, longer-term surveillance duration is recommended even in elderly stage.

PATIENT SUMMARY

In the present study, we evaluated the risk transition of upper tract urothelial carcinoma (UTUC)-related death and non-cancer-related death over time. We found that smoking weighed a huge impact upon UTUC-related death compared with death from other cause, and therefore, we created a more individualized surveillance duration model.

Developing a prediction model for disease-free survival from upper urinary tract urothelial carcinoma in the Korean population

Background

In this study, we aimed to propose a validated prediction model for disease‐free survival (DFS) after radical nephroureterectomy (RNU) in a Korean population with upper urinary tract urothelial carcinoma (UTUC).

Methods

We performed a retrospective review of 1561 cases of UTUC who underwent either open RNU (ONU, n = 906) or laparoscopic RNU (LNU, n = 615) from five tertiary Korean institutions between January 2000 and December 2012. Data were used to develop a prediction model using the Cox proportional hazards model. Prognostic factors were selected using the backward variable selection method. The prediction model performance was investigated using Harrell's concordance index (C‐index) and Hosmer‐Lemeshow type 2 statistics. Internal validation was performed using a bootstrap approach, and the National Cancer Center data set (n = 128) was used for external validation.

Results

A best‐fitting prediction model with seven significant factors was developed. The C‐index and two Hosmer‐Lemeshow type statistics of the prediction model were 0.785 (95% CI, 0.755‐0.815), 4.810 (P = 0.8506), and 5.285 (P = 0.8088). The optimism‐corrected estimate through the internal validation was 0.774 (95% CI, 0.744‐0.804) and the optimism‐corrected calibration curve was close to the ideal line with mean absolute error = 0.012. In external validation, the discrimination was 0.657 (95% CI, 0.560‐0.755) and the two calibration statistics were 0.790 (P = 0.9397) and 3.103 (P = 0.5408), respectively.

Conclusion

A validated prediction model based on a large Korean RNU cohort was developed with acceptable performance to estimate DFS in patients with UTUC.

Identification of Significant Prognostic Tissue Markers Associated with Survival in Upper Urinary Tract Urothelial Carcinoma Patients Treated with Radical Nephroureterectomy: A Retrospective Immunohistochemical Analysis Using Tissue Microarray

Purpose

The purpose of this study was to identify prognostic tissue markers for several survival outcomes after radical nephroureterectomy among patients with upper urinary tract urothelial carcinoma using tissue microarray and immunohistochemistry.

Materials and Methods

Retrospectively, data of 162 non-metastatic patients with upper urinary tract urothelial carcinoma after radical nephroureterectomy between 2004 and 2016 were reviewed to determine intravesical recurrence-free survival (IVRFS), disease-free survival (DFS), and overall survival (OS). The expression of 27 tissue markers on a tissue microarray of radical nephroureterectomy samples and prognostic values of clinicopathological parameters were evaluated using immunohistochemistry and Cox proportional hazard models after adjusting for significant prognostic clinicopathological variables. The expression of all tissue markers was categorized into a binary group with continuous H-scores (0-300).

Results

Median follow-up was 53.4 months (range, 3.6 to 176.5 months); and, 58 (35.8%), 48 (29.6%), and 19 (11.7%) bladder recurrence, disease progression, and all cause death, respectively, were identified. After adjusting for significant clinicopathological factors including intravesical instillation for bladder recurrence-free survival, pathologic T category and intravesical instillation for disease progression-free survival, and pathologic T category for OS (p < 0.05), IVRFS was associated with epithelial cadherin (hazard ratio [HR], 0.49), epidermal growth factor receptor/erythroblastosis oncogene B (c-erb) (HR, 2.59), and retinoblastoma protein loss (HR, 1.85); DFS was associated with cyclin D1 (HR, 2.16) and high-molecular-weight cytokeratin (HR, 0.42); OS was associated with E-cadherin (HR, 0.34) and programmed cell death 1 ligand (HR, 13.42) (p < 0.05).

Conclusion

Several significant tissue markers were associated with survival outcomes in upper urinary tract urothelial carcinoma patients treated with radical nephroureterectomy.

Contemporary best practice in the management of urothelial carcinomas of the renal pelvis and ureter

Upper tract urothelial carcinoma (UTUC) accounts for 5% of urothelial carcinomas (UCs), the estimated annual incidence being 1-2 cases per 100,000 inhabitants. Similarly to bladder UC, divergent differentiations and histologic variants confer an adverse risk factor in comparison with pure UTUC. Molecular and genomic characterization studies on UTUC have shown changes occurring at differing frequencies from bladder cancer, with unique molecular and clinical subtypes, potentially with different responses to treatment. Systemic chemotherapy is the standard approach for patients with inoperable locally advanced or metastatic UCs. Although initial response rates are high, the median survival with combination chemotherapy is about 15 months. In first-line chemotherapy several cisplatin-based regimens have been proposed. For patients with advanced UC who progress to first-line treatment, the only product licensed in Europe is vinflunine, a third-generation, semisynthetic, vinca alkaloid. Better response rates (15-60%), with higher toxicity rates and no overall survival (OS) benefit, are generally achieved in multidrug combinations, which often include taxanes and gemcitabine. The US FDA has recently approved five agents targeting the programmed death-1 and programmed death ligand-1 pathway as a second-line therapy in patients with locally advanced or metastatic UC with disease progression during or following platinum-containing chemotherapy. Potential therapeutic targets are present in 69% of tumours analyzed. Specific molecular alterations include those involved in the RTK/Ras/PI(3)K, cell-cycle regulation and chromatin-remodeling pathways, many of them have either targeted therapies approved or under investigation. Angiogenic agents, anti-epidermal growth factor receptor therapy, phosphoinositide 3-kinase (PI3K) and mammalian target of rapamycin (mTOR) pathway inhibitors and immunotherapeutic drugs are being successfully investigated.

Upper urinary tract urothelial carcinoma and its variants: transition from morphology to personalized molecular characterization in diagnosis, prognosis, and therapy

INTRODUCTION

Upper tract urothelial carcinoma (UTUC) accounts for 5% of urothelial carcinomas (UCs), the estimated annual incidence being 1-2 cases per 100,000 inhabitants. The aim of this review was to summarize the main morphologic features of UTUC as well as the current status and future role of its molecular characterization in diagnosis, prognosis, and therapy. Areas covered: Several studies on the UTUCs have shown the diagnostic, prognostic, and therapeutic significance of standard pathological features, such as tumor stage, grade, and lymph node metastasis. Investigations have also identified novel factors, in particular, variant histologies, and molecular biomarkers. Based on these, predictive tools have been developed. Expert commentary: The morphology of the UTUC has been considered to be the same as that of Bladder Urothelial carcinoma (BUC). Molecular characterization studies, including genomics, have shown changes in UTUC occurring at differing frequencies in comparison with BUC, the former with unique molecular subtypes and different responses to treatment.

RETRACTED: Recommandations françaises du Comité de Cancérologie de l’AFU — Actualisation 2018—2020 : tumeurs de la voie excrétrice supérieure French ccAFU guidelines — Update 2018—2020: Upper tract urothelial carcinoma

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). Cet article est retiré de la publication à la demande des auteurs car ils ont apporté des modifications significatives sur des points scientifiques après la publication de la première version des recommandations. Le nouvel article est disponible à cette adresse: doi:10.1016/j.purol.2019.01.005. C’est cette nouvelle version qui doit être utilisée pour citer l’article. This article has been retracted at the request of the authors, as it is not based on the definitive version of the text because some scientific data has been corrected since the first issue was published. The replacement has been published at the doi:10.1016/j.purol.2019.01.005. That newer version of the text should be used when citing the article.

Risk Stratification of Upper Urinary Tract Urothelial Carcinoma Patients for Survival Prediction: A Simple Summation Scoring Method

Purpose: To stratify upper urinary tract urothelial carcinoma (UTUC) patients into risk groups in terms of 5-year survival.

Methods and materials: All potential UTUC patients recorded in our cancer registry database from 1997 to 2011 were evaluated for authentic presence of UTUC. Age at diagnosis, sex, organ involvement, dialysis, renal transplantation status, clinical stage, survival to the last follow-up, and the cause of death of each patient were recorded. All patients were randomized into a developmental set or a validation set at a 1:1 ratio. Survival prediction models and scores were developed using the developmental set and validated in terms of discrimination and calibration using the validation set. Patients were stratified into risk groups using the summed risk scores and their survival compared by the log rank test.

Results: We enrolled 1,120 authentic UTUC patients. In the developmental set, older age, male sex, and higher clinical staging were significant predictors of 5-year death after controlling for other variables. Based on these three clinical variables, patients were stratified into low-, intermediate-, high-, and very high-risk groups using the summed risk scores. The 5-year all-cause and cancer-specific survivals of UTUC patients in the low-, intermediate-, high-, and very high-risk groups were 83.0% and 85.0%, 57.7% and 70.9%, 16.8% and 26.3%, and 2.2% and 7.5%, respectively (p < 0.001). Both discrimination and calibration were good for the validation set (overall concordance index = 0.762).

Conclusions: Stratification of UTUC patients using summed risk scores was a simple and useful way to estimate survivals and to select appropriate treatments.

Predictive value of gene methylation for second recurrence following surgical treatment of first bladder recurrence of a primary upper-tract urothelial carcinoma

The clinical relevance of aberrant DNA promoter methylation is being increasingly recognized in urothelial carcinoma. The present study was conducted to explore the methylation status of patients with upper-tract urothelial carcinoma (UTUC) who experienced bladder recurrence, and to evaluate the predictive value of gene methylation for second bladder recurrence and tumor progression. A total of 85 patients with primary UTUC, who experienced bladder recurrence after radical nephroureterectomy, were enrolled between January 2001 and December 2013. Using methylation-sensitive polymerase chain reaction, the promoter methylation statuses of 10 genes were analyzed in the bladder tumor specimens. Among the patient group, 32 patients experienced second bladder recurrence, and bladder progression was detected in 16. With the exception of BRCA1, the methylation rate of the majority of genes tended to gradually increase to varying extents with the number of recurrences; a smaller proportion of primary tumors exhibited gene methylation when compared with the first recurrent tumors and second recurrent tumors. Univariate and multivariate Cox regression analyses revealed that unmethylated GDF15 [hazard ratio (HR)=0.36; 95% confidence interval (CI), 0.14-0.92] and methylated VIM (HR=2.91; 95% CI, 1.11-7.61) in the first recurrent bladder tumor, as well as male gender (HR=2.28; 95% CI, 1.06-4.87), first recurrence interval <8 months (HR=2.34; 95% CI, 1.15-4.78) and primary UTUC tumor size ≥5 cm (HR=3.48; 95% CI, 1.43-8.45) were independent risk factors for a second bladder recurrence after surgery for the first bladder recurrence; the Harrell's concordance index (c-index) for the related nomogram was 0.71 (95% CI: 0.61-0.81). Furthermore, methylated CDH1 (HR=2.91; 95% CI, 1.08-7.77) and VIM (HR=4.91; 95% CI, 1.11-21.7) in the first recurrent bladder tumor, male gender (HR=3.6; 95% CI, 1.1-11.73), and primary tumor stage T2-T4 (HR=4.57; 95% CI, 1.22-17.13), multifocality (HR=3.64; 95% CI, 1.19-11.16) and size ≥5 cm (HR=3.1; 95% CI, 1.91-10.54) for the primary UTUC were considered to be predictors of tumor progression; the c-index for the nomogram was 0.88 (95% CI, 0.69-0.92). The present findings demonstrated that promoter methylation of cancer-related genes was frequently observed in patients with urothelial carcinoma, and that the gene methylation rate of certain genes tended to gradually increase with the number of bladder recurrences. This may be used as a predictive factor for a second bladder recurrence and tumor progression after the surgical treatment of the first bladder recurrence.

Surveillance guidelines based on recurrence patterns for upper tract urothelial carcinoma

INTRODUCTION

Upper tract urothelial carcinoma (UTUC) accounts for 5% of all urothelial tumours. Due to its rarity, evidence regarding postoperative surveillance is lacking. The objective of this study was to develop a post-radical nephroureterectomy (RNU) surveillance protocol based on recurrence patterns in a large, multi-institutional cohort of patients.

METHODS

Retrospective clinical and pathological data were collected from 1029 patients undergoing RNU over a 15-year period (1994-2009) at 10 Canadian academic institutions. A multivariable model was used to identify prognostic clinicopathological factors, which were then used to define risk categories. Risk-based surveillance guidelines were proposed based on actual recurrence patterns.

RESULTS

Overall, 555 (49.9%) patients developed recurrence, including 289 (25.9%) in the urothelium and 266 (23.9%) with loco-regional and distant recurrences. Based on multivariable analysis, three risk groups were identified: 1) low-risk patients with pTa-T1, pN0 disease, and no adverse histological features (high tumour grade, lymphovascular invasion [LVI], tumour multifocality); 2) intermediate-risk patients with pTa-T1, pN0 disease with one or more of the adverse histological features; and 3) high-risk patients with a ≥pT2 tumour and/or nodal involvement. Low-, intermediate-, and high-risk patients were free of urothelial recurrence at three years in 72%, 66%, and 63%, respectively, and free of regional/distant recurrence in 93%, 87%, and 62%, respectively. The risks of loco-regional and distant recurrences (p<0.0001) and time to death (p<0.0001) were significantly different between the low-, intermediate-, and high-risk patients.

CONCLUSIONS

Based on recurrence patterns in a large, multicentre patient cohort, we have proposed an evidence-based, risk-adapted post-RNU surveillance protocol.

Preoperative serum pre-albumin as an independent prognostic indicator in patients with localized upper tract urothelial carcinoma after radical nephroureterectomy

Purpose

To investigate the prognostic value of preoperative pre-albumin and albumin level in patients with localized upper tract urothelial carcinoma (UTUC) undergoing radical nephroureterectomy.

Methods and Materials

Between January 2003 and June 2013, we evaluated data on 425 patients with nonmetastatic UTUC (Ta-4N0/+M0) who underwent radical nephroureterectomy at our institution. Low pre-albumin level was defined as <20 mg/dl, while hypoalbuminemia was defined as albumin <35 g/L. The associations of preoperative low pre-albumin level and hypoalbuminemia with clinical and pathologic variables were assessed. Univariable and multivariable analyses using the Cox regression model were performed to determine prognostic factors that were associated with cancer specific survival (CSS) and overall survival (OS). The Harrell concordance index with variables only or combined pre-albumin data were used to evaluate the prognostic accuracy.

Results

Compared with patients with high pre-albumin level, patients with low pre-albumin level were more likely to have older age, higher tumor stage, higher rate of diabetes, regional lymph node metastasis and lymphovascular invasion. Meanwhile, hypoalbuminemia was only associated with diabetes. Multivariate analysis identified decreased preoperative pre-albumin level as an independent prognostic factor for CSS (HR 1.85, 95% CI 1.14-3.00, p=0.013) and OS (HR 1.73, 95% CI 1.12-2.70, p=0.015), but not preoperative hypoalbuminemia. The estimated c-index of the multivariate model for CSS and OS increased from 0.771 and 0.760 without pre-albumin to 0.775 and 0.765 when pre-albumin added.

Conclusions

Low preoperative pre-albumin level but not preoperative hypoalbuminemia is a negative independent prognostic factor for survival outcome in patients with UTUC undergoing radical nephroureterectomy.

A New Approach to Predict Progression-free Survival in Stage IV EGFR-mutant NSCLC Patients with EGFR-TKI Therapy

Purpose: We established a CT-derived approach to achieve accurate progression-free survival (PFS) prediction to EGFR tyrosine kinase inhibitors (TKI) therapy in multicenter, stage IV EGFR-mutated non-small cell lung cancer (NSCLC) patients.Experimental Design: A total of 1,032 CT-based phenotypic characteristics were extracted according to the intensity, shape, and texture of NSCLC pretherapy images. On the basis of these CT features extracted from 117 stage IV EGFR-mutant NSCLC patients, a CT-based phenotypic signature was proposed using a Cox regression model with LASSO penalty for the survival risk stratification of EGFR-TKI therapy. The signature was validated using two independent cohorts (101 and 96 patients, respectively). The benefit of EGFR-TKIs in stratified patients was then compared with another stage-IV EGFR-mutant NSCLC cohort only treated with standard chemotherapy (56 patients). Furthermore, an individualized prediction model incorporating the phenotypic signature and clinicopathologic risk characteristics was proposed for PFS prediction, and also validated by multicenter cohorts.Results: The signature consisted of 12 CT features demonstrated good accuracy for discriminating patients with rapid and slow progression to EGFR-TKI therapy in three cohorts (HR: 3.61, 3.77, and 3.67, respectively). Rapid progression patients received EGFR TKIs did not show significant difference with patients underwent chemotherapy for progression-free survival benefit (P = 0.682). Decision curve analysis revealed that the proposed model significantly improved the clinical benefit compared with the clinicopathologic-based characteristics model (P < 0.0001).Conclusions: The proposed CT-based predictive strategy can achieve individualized prediction of PFS probability to EGFR-TKI therapy in NSCLCs, which holds promise of improving the pretherapy personalized management of TKIs. Clin Cancer Res; 24(15); 3583-92. ©2018 AACR.

Positive urinary fluorescence in situ hybridization indicates poor prognosis in patients with upper tract urothelial carcinoma

Here, we evaluated the potential contribution of fluorescent in situ hybridization (FISH) as a prognostic risk factor of bladder recurrence and survival in patients with upper tract urothelial carcinoma (UTUC). A total of 159 UTUC patients were enrolled in this study from January 2012 to May 2016. The 159 voided urine samples before surgery were analyzed using the UroVysion^® kit to detect the copy numbers of chromosomes 3, 7, 17 and 9p21 (p16). Patients were classified using an optimal cutoff value of chromosomes 3, 7, 17, and 9p21. Cox's proportional hazards regression model was used to assess the prognostic value of FISH for bladder recurrence and survival. We found that 27 (17.6%) patients experienced bladder recurrence and 26 (16.4%) patients died from cancer, with a median follow-up of 27 months. The patients with positive FISH result were more likely to present bladder recurrence (p = 0.077). However, positive FISH was not associated with cancer specific-free survival (CSS) (p = 0.944). Tumor multifocality, the percentage of abnormal chromosome 3 > 5%, chromosome 7 > 6%, chromosome 17 > 11% and deletion of p16 > 4% were significant prognostic risk factors for BRFS in univariate analysis. In multivariate analysis, only tumor multifocality (hazard ratio [HR] = 3.487, 95%CI: 1.605–7.576, p = 0.002) and the percentage of p16 loss > 4% were both prognostic risk factors for bladder recurrence (HR = 3.487, 95%CI: 1.605–7.576, p = 0.002). These data consider that the urinary FISH test could be a powerful tool in predicting the risk of bladder recurrence in patients with UTUC.

Preoperative Pyuria Is a Poor Prognostic Factor in Patients With Urothelial Carcinoma of the Upper Urinary Tract After Surgery

INTRODUCTION

The purpose of this study was to determine the prognostic significance of preoperative pyuria in patients with upper urinary tract urothelial carcinoma after surgery.

PATIENTS AND METHODS

We retrospectively evaluated data on 157 patients with nonmetastatic upper urinary tract urothelial carcinoma who had undergone surgery at our institution. The associations between clinical features and advanced pathological findings were evaluated using a logistic regression model. Recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) were assessed with the Kaplan-Meier method and Cox regression analysis. The influence of pyuria on the predictive accuracy of the multivariate model was assessed using the concordance index.

RESULTS

The median postoperative follow-up among patients who survived was 48.1 months. Preoperative pyuria was significantly correlated with worse RFS, CSS, and OS (P < .001 each). Pyuria was also associated with significantly increased risk of a high pathological T stage (≥ pT3; odds ratio, 2.99; P = .003), high tumor Grade (G3; odds ratio, 2.25; P = .038), and lymphovascular invasion (odds ratio, 2.25; P = .008). Moreover, multivariate Cox regression analyses showed that pyuria was an independent prognostic factor for RFS (hazard ratio, 3.02; P < .001), CSS (hazard ratio, 2.15; P = .043), and OS (hazard ratio, 2.10; P = .019). For CSS, the addition of pyuria to the multivariate model increased its predictive accuracy from 0.87 to 0.90.

CONCLUSION

Preoperative pyuria is significantly associated with CSS, OS, and increased risk of locally advanced disease and subsequent disease recurrence in patients with upper urinary tract urothelial carcinoma who undergo surgery.

[CCAFU french national guidelines 2016-2018 on upper tract tumors]

INTRODUCTION

The purpose was to propose an update of the french guidelines from the national committee CCAFU on upper tract urothelial carcinomas (UTUC).

METHODS

A systematic Medline search was performed between 2013 and 2016, as regards diagnosis, options of treatment and follow-up of UTUC, to evaluate different references with levels of evidence.

RESULTS

The diagnosis of this rare pathology is based on CT-scan acquisition during excretion and ureteroscopy with histological biopsies. Radical nephroureterectomy (RNU) remains the gold standard for surgical treatment, nevertheless a conservative endoscopic approach can be proposed for low risk lesion: unifocal tumour, possible complete resection and low grade and absence of invasion on CT-scan. Close monitoring with endoscopic follow-up (flexible ureteroscope) in compliant patients is therefore necessary. After RNU, bladder instillation of chemotherapy is recommended to reduced risk of baldder recurrence. The place of systemic therapy (adjuvant and neoadjuvant chemotherapy) remains to define.

CONCLUSION

These updated guidelines will contribute to increase the level of urological care for diagnosis and treatment for UTUC. © 2016 Elsevier Masson SAS. All rights reserved.

Predictive models and prognostic factors for upper tract urothelial carcinoma: a comprehensive review of the literature

In the context of customized patient care for upper tract urothelial carcinoma (UTUC), decision-making could be facilitated by risk assessment and prediction tools. The aim of this study was to provide a critical overview of existing predictive models and to review emerging promising prognostic factors for UTUC. A literature search of articles published in English from January 2000 to June 2016 was performed using PubMed. Studies on risk group stratification models and predictive tools in UTUC were selected, together with studies on predictive factors and biomarkers associated with advanced-stage UTUC and oncological outcomes after surgery. Various predictive tools have been described for advanced-stage UTUC assessment, disease recurrence and cancer-specific survival (CSS). Most of these models are based on well-established prognostic factors such as tumor stage, grade and lymph node (LN) metastasis, but some also integrate newly described prognostic factors and biomarkers. These new prediction tools seem to reach a high level of accuracy, but they lack external validation and decision-making analysis. The combinations of patient-, pathology- and surgery-related factors together with novel biomarkers have led to promising predictive tools for oncological outcomes in UTUC. However, external validation of these predictive models is a prerequisite before their introduction into daily practice. New models predicting response to therapy are urgently needed to allow accurate and safe individualized management in this heterogeneous disease.

Promising role of preoperative neutrophil-to-lymphocyte ratio in patients treated with radical nephroureterectomy

Objective

Several retrospective studies with small cohorts reported neutrophil-to-lymphocyte ratio (NLR) as a prognostic marker in upper tract urothelial carcinoma (UTUC) following radical nephroureterectomy (RNU). We aimed at validating the predictive and prognostic role of NLR in a large multi-institutional cohort.

Methods

Preoperative NLR was assessed in a multi-institutional cohort of 2477 patients with UTUC treated with RNU. Altered NLR was defined by a ratio >2.7. Logistic regression analyses were performed to assess the association between NLR and lymph node metastasis, muscle-invasive and non-organ-confined disease. The association of altered NLR with recurrence-free survival (RFS) and cancer-specific survival (CSS) was evaluated using Cox proportional hazards regression models.

Results

Altered NLR was observed in 1428 (62.8 %) patients and associated with more advanced pathological tumor stage, lymph node metastasis, lymphovascular invasion, tumor necrosis and sessile tumor architecture. In a preoperative model that included age, gender, tumor location and architecture, NLR was an independent predictive factor for the presence of lymph node metastasis, muscle-invasive and non-organ-confined disease (p < 0.001). Within a median follow-up of 40 months (IQR 20–76 months), 548 (24.1 %) patients experienced disease recurrence and 453 patients (19.9 %) died from their cancer. Compared to patients with normal NLR, those with altered NLR had worse RFS (0.003) and CSS (p = 0.002). In multivariable analyses that adjusted for the effects of standard clinicopathologic features, altered NLR did not retain an independent value. In the subgroup of patients treated with lymphadenectomy in addition to RNU, NLR was independently associated with CSS (p = 0.03).

Conclusion

In UTUC, preoperative NLR is associated with adverse clinicopathologic features and independently predicts features of biologically and clinically aggressive UTUC such as lymph node metastasis, muscle-invasive or non-organ-confined status. NLR may help better risk stratify patients with regard to lymphadenectomy and conservative therapy.

Upper Tract Urothelial Carcinomas Accompanied by Previous or Synchronous Nonmuscle-Invasive Bladder Cancer and Preoperative Hydronephrosis Might Have Worse Oncologic Outcomes After Radical Nephroureterectomy

BACKGROUND

The purpose of the study was to identify predictors of clinicopathologic features and oncologic outcomes in patients with upper tract urothelial carcinoma treated with radical nephroureterectomy (RNU).

PATIENTS AND METHODS

The medical records of 172 patients treated with RNU from January 2001 to September 2014 were retrospectively reviewed. Logistic regression and survival analysis methodology were respectively used to evaluate predictors of clinicopathologic features and oncologic outcomes.

RESULTS

Of the enrolled 172 patients, 80 (46.5%) had renal pelvic tumors, 67 (39%) had ureteral tumors, and the remaining 25 (14.5%) patients had multifocal tumors. Compared with patients with renal pelvic tumors, those with ureteral and multifocal tumors were more likely to have previous or synchronous nonmuscle-invasive bladder cancer (NMIBC) and severe hydronephrosis (P = .001 and P < .001, respectively). Logistic regression analysis showed that previous or synchronous NMIBC was significantly associated with worse renal function and high grade (P = .034 and P = .014, respectively), and severe hydronephrosis independently predicted worse renal function and positive lymph node or lymphovascular invasion status (P = .001 and P = .007, respectively). Moreover, severe hydronephrosis was an independent risk factor for overall survival and cancer-specific survival in multivariate analysis (P = .025 and P = .045, respectively). Multifocality and previous or synchronous NMIBC were significantly associated with bladder-recurrence-free survival (P = .023 and P = .001, respectively).

CONCLUSION

Upper tract urothelial carcinoma accompanied by previous or synchronous NMIBC and preoperative severe hydronephrosis could have worse oncologic outcomes after RNU. These common accompanied diagnoses could be valuable for guiding preoperative planning and postoperative adjuvant therapy.

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.

Impact of p53, MIB-1 and PECAM-1 expression on the prognosis of urothelial carcinoma of the renal pelvis

OBJECTIVE

Determine whether the overexpression p53, MIB-1 and PECAM-1 of protein levels is of interest in predicting the prognosis of transitional cell carcinoma of the upper urinary tract (TCC-UUT) with the primary seat in the renal pelvis.

MATERIAL AND METHOD

A univariate and multivariate analysis was conducted for prognosis prediction in a series of 82 patients with TCC-UUT of the renal pelvis who had no metastases at diagnosis (N0/Nx M0) and were treated exclusively with nephroureterectomy. We assessed clinicopathological parameters (age, gender, tumor grade and extent, histological variety, growth pattern, vascular invasion, infiltration of the renal parenchyma, tumor necrosis) and the immunohistochemical expression of p53, MIB-1 (ki-67) and PECAM-1 (CD31) in sections performed with tissue microarray (TMA).

RESULTS

A total of 47.6% of the patients had high-grade lesions according to the USIP-WHO classification. The growth pattern was flat in 15.85%. The distribution by T category was: 3.7% pTa, 51.2% pT1, 11% pT2, 29.3% pT3 and 4.9% pT4. The mean follow-up was 46.8+38.5 (range, 4-172) months. The median survival was reached at 57 (95% CI 44-63) months. The univariate analysis revealed that survival in these patients is associated with tumor size (P=.028), histological variety (P<.0001), growth pattern (P<.0001), grade (P<.0001), pT (P=.01), vascular invasion (P=.025), necrosis (P=.004) and overexpression of p53 (P=.0006), PECAM-1 (P=.0036) and MIB-1 (P=.0038). The Cox regression model showed that high-grade (HR, 4.2; 95% CI 1.28-13.79; P=.018), flat growth pattern (HR, 2.52; 95% CI 1.05-6.03; P=.038) and p53 overexpression (HR, 2.8; 95% CI 1.22-6.44; P=.015) were independent predictors.

CONCLUSION

Histological grade, tumor growth pattern and p53 overexpression were established as the primary predictors of prognosis for primary TCC-UUT of the renal pelvis. The independent value of MIB-1 observed in other studies was not reproduced in this study.