Oncologic outcomes following radical nephroureterectomy for upper tract urothelial carcinoma: a literature review

Impact of Histological Subtypes/Divergent Differentiation on Clinicopathological and Oncological Outcomes for Patients with Upper Tract Urothelial Carcinoma Treated with Radical Nephroureterectomy: A Comprehensive Updated Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVE

Upper tract urothelial carcinoma (UTUC) is associated with poor survival. Recent studies have evaluated whether the presence of histological subtypes or divergent differentiation (HS/DD) is associated with worse UTUC prognosis. Our aim was to assess the relationship between HS/DD and clinicopathological features and oncological outcomes for patients with UTUC undergoing radical nephroureterectomy (RNU) without investigating causal pathways.

METHODS

A literature search was conducted in September 2024. Patients with UTUC who underwent RNU were included. The main outcomes were differences in clinicopathological features and oncological outcomes between HS/DD and pure urothelial carcinoma (PUC) groups.

KEY FINDINGS AND LIMITATIONS

We included 22 studies involving 14 407 patients in our review. HS/DD was present in 14% of tumours. In comparison to PUC, the HS/DD group had significantly higher rates of ≥pT3 stage, high-grade tumours, lymph node invasion (LNI), lymphovascular invasion (LVI), and receipt of adjuvant chemotherapy. Pooled results revealed that the HS/DD group had significantly worse cancer-specific survival (CSS) (hazard ratio [HR] 1.65, 95% confidence interval CI] 1.39-1.96), overall survival (OS; HR 1.84, 95% CI 1.52-2.22) ,and recurrence-free survival (RFS; HR 1.64, 95% CI 1.43-1.87). Intravesical RFS (IVRFS) and urothelial RFS (URFS) were comparable between the groups.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Our findings suggest that UTUC with HS/DD is associated with more advanced/aggressive features, such as higher pathological stage and grade, LNI, and LVI. HS/DD is associated with significantly worse CSS, OS, and RFS, but does not predict worse IVRFS or URFS. Therefore, HS/DD detection should prompt extensive treatment and closer follow-up. To improve the quality of recommendations and patient care, well-designed studies with central pathological review are needed.

Trends, outcomes, and predictors of open conversion during minimally invasive radical nephroureterectomy for upper tract urothelial carcinoma: a national analysis from 2010 to 2020

We evaluated trends, predictors, and outcomes of unplanned open conversion for patients with upper tract urothelial carcinoma (UTUC) undergoing robotic radical nephroureterectomy (R-RNU) or laparoscopic RNU (L-RNU). The National Cancer Database was queried from 2010 to 2020 for patients with non-metastatic UTUC treated with RNU. Trends in surgical approach and conversion were evaluated. Demographics and outcomes including lymph node dissection, lymph node yield, positive surgical margins (PSM), prolonged length of stay (PLOS) (≥ 90th percentile), unplanned readmission (UR), and 30- and 90-day mortality were compared between converted and unconverted cases. Multivariate logistic regression evaluated predictors of conversion and whether conversion predicted adverse clinical outcomes. 25,523 cases were included (robotic = 40.4%, laparoscopic = 36.9%, open = 22.7%), where 3.2% and 9.2% of R-RNU and L-RNU cases were converted, respectively. From 2010 to 2020, robotic cases increased while open and laparoscopic approaches decreased, p < 0.001. A higher T-stage and a ureteral tumor site predicted conversion while a higher R-RNU and L-RNU facility volume, respectively, were protective against conversion, all p < 0.05. Compared to unconverted cases, conversion generally resulted in a higher rate of all adverse outcomes, and was predictive of 30-day mortality, PLOS, UR, and PSM, all p < 0.05. Conversion to open RNU is becoming less frequent but is more common with a laparoscopic approach. Oncologic complexity and facility surgical volume influence conversion rates which in turn are associated with higher rates of morbidity, mortality, and greater resource utilization when compared to unconverted cases.

Primary Adenocarcinoma of the Upper Urinary Tract: A Systematic Review of the Literature on a Rare Entity

Background: Only a few published cases of primary adenocarcinoma of the upper urinary tract have been described in the literature. The aim of this systematic review was to collect all published cases of primary adenocarcinoma of the upper UT and identify prognostic factors and useful diagnostic modalities for their optimal treatment. Methods: Systematic research in the PubMed/Medline and Scopus databases concerning primary adenocarcinoma of the upper urinary tract was performed by two independent investigators. A total of 85 studies were included in the review. Results: In total, 84 patients were included, consisting of 54 males (64.29%) and 30 females (35.71%). Out of the available data, 24.71% reported a history of lithiasis, 16.47% episodes of pyelonephritis and 10.59% a history of hydronephrosis. Concerning histologic findings on excised tumors, 52.44% of neoplasms were mucinous, 19.51% tubulovilous, 18.29% papillary, 4.88% mixed mucinous-papillary and 4.88% poorly differentiated. Concerning anatomical origin, 62.34% of tumors were found in the renal pelvis, 22.08% in the ureter and 12.99% in both the renal pelvis and the ureter. Surgical treatment was the preferred therapeutic option and was performed in 96.39% of the included patients. In multivariable analysis, a statistically significant relationship was found between a clinical cure and ureter origin of the lesion (OR: 0.17, 95% CI: 0.00-0.22, p = 0.002), the presence of an abdominal mass (OR: 0.08, 95% CI: 0.01-0.63, p: 0.034) and a poorly differentiated histological type (OR: 0.02, 95% CI: 0.00-0.91). In multivariable time-to-event analysis, the male sex (HR: 0.12, 95% CI: 0.02-1.01, p: 0.019) and poorly differentiated histological type (HR: 91.06, 95% CI: 7.31-1134.32, p: 0.002) had statistically significant impacts on overall survival. Conclusions: Selection of the optimal surgical management, via either nephrectomy or nephroureterectomy, depends on the origin of the primary lesion and represents the mainstay of treatment. A suspicion from the urologist is needed for the identification and optimal treatment of these rare tumors.

Novel Preoperative Immune Prognostic Index for Predicting Outcomes in Patients Undergoing Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma

BACKGROUND/AIM

The lung immune prognostic index (LIPI), which is determined by assessing the derived neutrophil-to-lymphocyte ratio in conjunction with the level of lactate dehydrogenase, predicts outcomes in various cancers. Its utility as a preoperative biomarker in upper tract urothelial carcinoma (UTUC) patients remains unexplored.

PATIENTS AND METHODS

This is a retrospective study of UTUC patients who underwent radical nephroureterectomy. Patients were stratified into favorable, intermediate, and poor LIPI groups. Non-urothelial tract recurrence-free survival (NUTRFS) was evaluated using Kaplan-Meier analysis, and Cox regression analyses were performed to identify risk factors for NUTRFS.

RESULTS

A total of 567 UTUC patients were included, with 46.4% in the favorable, 44.6% in the intermediate, and 9.0% in the poor (9.0%) LIPI groups. The median participant age was 74 years, with a median follow-up of 26 months. Kaplan-Meier curves demonstrated that NUTRFS was significantly worse in patients with poor and intermediate LIPI scores than in those with favorable LIPI scores. Furthermore, combining LIPI status with pathological stages (pT3-4/ypT2-4) and lymph node metastasis status improved postoperative non-urothelial tract recurrence prognosis assessment.

CONCLUSION

The preoperative LIPI is a prognostic indicator for patients with UTUC undergoing nephroureterectomy. Its predictive accuracy improves when combined with advanced pathological stages and lymph node metastasis status.

Challenges in diagnosing and managing sarcomatoid urothelial carcinoma of the renal pelvis: a case report

Sarcomatoid urothelial carcinoma of the renal pelvis is an extremely rare malignant tumor with a high risk of recurrence and metastasis and a poor prognosis. This case reports a 61-year-old male patient with renal pelvic sarcomatoid urothelial carcinoma who developed extensive lymph node metastasis 26 days after posterior laparoscopic radical nephrectomy for renal carcinoma, and the patient died on the 45th postoperative day, with the cause of death being advanced malignancy of the tumor. This case highlights the rapid progression of sarcomatoid urothelial carcinoma, and sarcomatoid variants should be identified as early as possible, with active multidisciplinary adjuvant therapy and closer follow-up when feasible. Retrospective analysis of this patient's treatment regimen and admission provides lessons for recognizing and aggressively managing this rare and fatal variant of urothelial carcinoma.

Significant association between systemic inflammation response index and prognosis in patients with urological malignancies

Background

The systemic inflammation response index (SIRI) as an immune marker, is associated with prognosis of urological malignancies(UM). However, the conclusion remains controversial. Therefore, the objective of this study was to conduct a meta-analysis to comprehensively evaluate the predictive value of SIRI in patients with UM.

Methods

A comprehensive search of PubMed, Web of Science, and EMBASE databases was performed for articles investigating the association between SIRI and UM. The search deadline was August 28, 2024. Survival outcome such as overall survival (OS), disease-free survival (DFS), progression-free survival (PFS), and recurrence-free survival (RFS) were analyzed.

Results

15 studies from 13 articles involving 4985 patients were included in the meta-analysis. The results showed that increased SIRI was associated with poorer OS (HR: 2.16, 95% CI: 1.61-2.89) and DFS/PFS/RFS (HR: 3.56, 95% CI: 1.41-8.99). Subgroup analysis further confirmed the prognostic value of SIRI in urinary system cancer.

Robot-assisted nephroureterectomy: surgical and mid-term oncological outcomes in over 1100 patients (ROBUUST 2.0 collaborative group)

OBJECTIVE

To analyse surgical, functional, and mid-term oncological outcomes of robot-assisted nephroureterectomy (RANU) in a contemporary large multi-institutional setting.

PATIENTS AND METHODS

Data were retrieved from the ROBotic surgery for Upper tract Urothelial cancer STtudy (ROBUUST) 2.0 database, an international, multicentre registry encompassing data of patients with upper urinary tract urothelial carcinoma undergoing curative surgery between 2015 and 2022. The analysis included all consecutive patients undergoing RANU except those with missing data in predictors. Detailed surgical, pathological, and postoperative functional data were recorded and analysed. Oncological time-to-event outcomes were: recurrence-free survival (RFS), metastasis-free survival (MFS), cancer-specific survival (CSS), and overall survival (OS). Survival analysis was performed using the Kaplan-Meier method, with a 3-year cut-off. A multivariable Cox proportional hazard model was built to evaluate predictors of each oncological outcome.

RESULTS

A total of 1118 patients underwent RANU during the study period. The postoperative complications rate was 14.1%; the positive surgical margin rate was 4.7%. A postoperative median (interquartile range) estimated glomerular filtration rate decrease of -13.1 (-27.5 to 0) mL/min/1.73 m2 from baseline was observed. The 3-year RFS was 59% and the 3-year MFS was 76%, with a 3-year OS and CSS of 76% and 88%, respectively. Significant predictors of worse oncological outcomes were bladder-cuff excision, high-grade tumour, pathological T stage ≥3, and nodal involvement.

CONCLUSIONS

The present study contributes to the growing body of evidence supporting the increasing adoption of RANU. The procedure consistently offers low surgical morbidity and can provide favourable mid-term oncological outcomes, mirroring those of open NU, even in non-organ-confined disease.

GLPp16 gene amplification induces susceptibility to high-grade urothelial carcinoma

Background

Urothelial carcinoma is a common malignant tumor of the urinary system, with prognosis linked to pathological grade and TNM stage. Alterations in chromosomes 3, 7, and 17, along with the P16 locus on chromosome 9 (CSP3, CSP7, CSP17, and GLPp16), are associated with cancer progression and may serve as important biomarkers. This study aimed to explore the relationships between these chromosomal factors and the pathological grade and TNM stage of UCC, potentially leading to a novel diagnostic approach that enhances patient stratification and treatment planning.

Methods

A retrospective analysis was conducted on 149 patients to evaluate the correlation between CSP3, CSP7, CSP17, GLPp16, TNM stage, and pathological grade using chi-square tests and logistic regression. Immunohistochemistry was employed to assess the associated changes.

Results

Univariate analysis indicated that only CSP7 and GLPp16 were significantly associated with pathological grade. Logistic regression linked GLPp16 and gender to pathological grade in urothelial carcinoma. A nomogram model incorporating these factors demonstrated reliable calibration in the training set (non-significant Hosmer-Lemeshow test, P = 0.436; AUC = 0.785, 95% CI: 0.707 - 0.863) and effective discrimination in the test set (AUC = 0.740, 95% CI: 0.559 - 0.920). Immunohistochemistry revealed P16 gene deletion in low-grade urothelial carcinoma and amplification in high-grade urothelial carcinoma.

Conclusion

Mutations at the GLPp16 were significantly correlated with the pathological grade of urothelial carcinoma. Additionally, the amplification of GLPp16 was recognized as a contributing factor to the development of high-grade urothelial carcinoma.

Open versus Minimally Invasive Nephroureterectomy: Contemporary Analysis from a Wide National Population-Based Database

BACKGROUND

It is generally perceived that minimally invasive nephroureterectomy (MINU), especially in the form of robotic-assisted laparoscopy, is gaining an increasing role in many institutions.

OBJECTIVE

The aim of our study was to investigate contemporary trends in the adoption of MINU in the United States compared with open nephroureterectomy (ONU).

METHODS

Patients who underwent ONU or MINU between 2011 and 2021 were retrospectively analyzed using PearlDiver Mariner, an all-payer insurance claims database. International Classification of Diseases diagnosis and procedure codes were used to identify the type of surgical procedure, patients' characteristics, social determinants of health (SDOH), and perioperative complications. The primary objective assessed different trends and costs in NU adoption, while secondary objectives analyzed factors influencing the postoperative complications, including SDOH. Outcomes were compared using multivariable regression models.

RESULTS

Overall, 15,240 patients underwent ONU (n = 7675) and MINU (n = 7565). Utilization of ONU declined over the study period, whereas that of MINU increased from 29 to 72% (p = 0.01). The 60-day postoperative complication rate was 23% for ONU and 19% for MINU (p < 0.001). At multivariable analysis, ONU showed a significantly higher risk of postoperative complications (odds ratio 1.33, 95% CI 1.20-1.48). Approximately 5% and 9% of patients reported at least one SDOH at baseline for both ONU and MINU (p < 0.001).

CONCLUSIONS

Contemporary trend analysis of a large national dataset confirms that there has been a significant shift towards MINU, which is gradually replacing ONU. A minimally invasive approach is associated with lower risk of complications. SDOH are non-clinical factors that currently do not have an impact on the outcomes of nephroureterectomy.

If not now, then when? The need for new evidence in the robotic management of upper tract urothelial carcinoma

Current guidelines recommend radical nephroureterectomy with bladder cuff excision as the standard surgical treatment for high-risk upper tract urothelial carcinoma (UTUC). While large evidence is available regarding open and laparoscopic nephroureterectomy, data focusing on robotic nephroureterectomy (RNU) in UTUC are mostly limited with mixed results, especially in locally advanced disease. In light of the recent introduction of new robotic platforms, it is of utmost importance to further investigate oncologic outcomes associated with RNU. Moreover, stronger data exploring different operative settings (i.e. robotic arms and trocars placement) for the new robotic systems are eagerly warranted. To give an answer to such open clinical questions, the Junior ERUS/Young Academic Urologist Working Group on Robot-assisted Surgery designed a multicentric project involving different high-volume centers across the world. The aim of the study will be exploring surgical and oncologic outcomes of RNU, specifically focusing on several clinical unmet needs, such as best operative setting for new robotic platforms, lymph node dissection (LDN) template and robotic bladder cuff management.

Radiomics-Based Computed Tomography Urogram Approach for the Prediction of Survival and Recurrence in Upper Urinary Tract Urothelial Carcinoma

Upper tract urothelial carcinoma (UTUC) is a rare and aggressive malignancy with a poor prognosis. The accurate prediction of survival and recurrence in UTUC is crucial for effective risk stratification and guiding therapeutic decisions. Models combining radiomics and clinicopathological data features derived from computed tomographic urograms (CTUs) can be a way to predict survival and recurrence in UTUC. Thus, preoperative CTUs and clinical data were analyzed from 106 UTUC patients who underwent radical nephroureterectomy. Radiomics features were extracted from segmented tumors, and the Least Absolute Shrinkage and Selection Operator (LASSO) method was used to select the most relevant features. Multivariable Cox models combining radiomics features and clinical factors were developed to predict the survival and recurrence. Harrell's concordance index (C-index) was applied to evaluate the performance and survival distribution analyses were assessed by a Kaplan-Meier analysis. The significant outcome predictors were identified by multivariable Cox models. The combined model achieved a superior predictive accuracy (C-index: 0.73) and higher recurrence prediction (C-index: 0.84). The Kaplan-Meier analysis showed significant differences in the survival (p < 0.0001) and recurrence (p < 0.002) probabilities for the combined datasets. The CTU-based radiomics models effectively predicted survival and recurrence in the UTUC patients, and enhanced the prognostic performance by combining radiomics features with clinical factors.

Decisional and prognostic impact of diagnostic ureteroscopy in high-risk upper tract urothelial carcinoma: A multi-institutional collaborative analysis (ROBUUST collaborative group)

BACKGROUND

Diagnostic ureteroscopy (URS) with or without biopsy remains a subject of contention in the management of upper tract urothelial carcinoma (UTUC), with varying recommendations across different guidelines. The study aims to analyse the decision-making and prognostic role of diagnostic ureteroscopy (URS) in high-risk UTUC patients undergoing curative surgery.

MATERIALS AND METHODS

In this retrospective multi-institutional analysis of high-risk UTUC patients from the ROBUUST dataset, a comparison between patients who received or not preoperative URS and biopsy before curative surgery was carried out. Logistic regression analysis evaluated differences between patients receiving URS and its impact on treatment strategy. Survival analysis included 5-year recurrence-free survival (RFS), metastasis-free survival (MFS), cancer-specific survival (CSS) and overall survival (OS). After adjusting for high-risk prognostic group features, Cox proportional hazard model estimated significant predictors of time-to-event outcomes.

RESULTS

Overall, 1,912 patients were included, 1,035 with preoperative URS and biopsy and 877 without. Median follow-up: 24 months. Robot-assisted radical nephroureterectomy was the most common procedure (55.1%), in both subgroups. The 5-year OS (P = 0.04) and CSS (P < 0.001) were significantly higher for patients undergoing URS. The 5-year RFS (P = 0.6), and MFS (P = 0.3) were comparable between the 2 groups. Preoperative URS and biopsy were neither a significant predictor of worse oncological outcomes nor of a specific treatment modality.

CONCLUSIONS

The advantage in terms of OS and CSS in patients undergoing preoperative URS could derive from a better selection of candidates for curative treatment. The treatment strategy is likely more influenced by tumor features than by URS findings.

Increased Apolipoprotein A1 Expression Correlates with Tumor-Associated Neutrophils and T Lymphocytes in Upper Tract Urothelial Carcinoma

An increased neutrophil-to-lymphocyte ratio (NLR) is a poor prognostic biomarker in various types of cancer, because it reflects the inhibition of lymphocytes in the circulation and tumors. In urologic cancers, upper tract urothelial carcinoma (UTUC) is known for its aggressive features and lack of T cell infiltration; however, the association between neutrophils and suppressed T lymphocytes in UTUC is largely unknown. In this study, we examined the relationship between UTUC-derived factors and tumor-associated neutrophils or T lymphocytes. The culture supernatant from UTUC tumor tissue modulated neutrophils to inhibit T cell proliferation. Among the dominant factors secreted by UTUC tumor tissue, apolipoprotein A1 (Apo-A1) exhibited a positive correlation with NLR. Moreover, tumor-infiltrating neutrophils were inversely correlated with tumor-infiltrating T cells. Elevated Apo-A1 levels in UTUC were also inversely associated with the population of tumor-infiltrating T cells. Our findings indicate that elevated Apo-A1 expression in UTUC correlates with tumor-associated neutrophils and T cells. This suggests a potential immunomodulatory effect on neutrophils and T cells within the tumor microenvironment, which may represent therapeutic targets for UTUC treatment.

Narrative review of nephron-sparing surgical management of upper tract urothelial carcinoma: is there a role for distal ureterectomy, segmental ureterectomy, and partial nephrectomy

Background and Objective

Upper tract urothelial carcinoma (UTUC) is a relatively rare malignancy and radical nephroureterectomy (RNU) with bladder cuff excision (BCE) is considered as the standard of care for high-risk non-metastatic disease. Loss of the renal unit secondary to RNU, especially in elderly patients, causes significant decline in overall renal function which in turn negatively impacts the overall survival (OS). Such radical surgeries can be spared in a select group of the patients with segmental ureterectomy (SU) or distal ureterectomy to salvage the ipsilateral kidney. In this article, we will review the oncological and renal function outcomes following such procedures. This review excludes endourologic procedures.

Methods

This is a non-systematic review of the published literature focusing on the nephron-sparing surgical alternatives for the management of UTUCs. The following texts were used for literature search: "nephron-sparing surgery", "segmental ureterectomy", "total ureterectomy", "partial nephrectomy", and "ileal ureter". We included the articles indexed in PubMed, written in English language, and published within the last 15 years.

Key Content and Findings

The main argument against the utilization of these procedures is the lack of high quality, level I evidence, which is due to the rarity of this disease and the rates of ipsilateral recurrences. Despite that, the evidence in support of these nephron-sparing surgical alternatives is increasing over time. Published literature including single/multi-centric studies & systematic reviews, suggests comparable oncological outcomes and significantly improved renal function preservation. Lymph node dissection (LND) at the time of nephron-sparing surgical alternatives is largely underutilized. Similarly, the role of neoadjuvant or adjuvant systemic chemotherapy following such procedures is also not established currently.

Conclusions

With comparable oncological outcomes while preserving renal function, the nephron-sparing surgical alternatives to RNU are gaining momentum. These options can be offered to patients with low volume, localized UTUC with imperative indication for renal preservation such as solitary kidney, compromised baseline, and expected significant decline in post-RNU renal function without compromising oncological principles during surgery.

Atypical presentations of UTUC: a case report of three patients

Background

Upper tract urothelial carcinoma (UTUC) is a rare clinical condition primarily characterized by symptoms such as gross or microscopic hematuria, flank pain, and renal colic. Although computed tomography urography (CTU) is currently the most accurate imaging modality for diagnosis, atypical presentations and physical examination findings can sometimes obscure lesions, posing diagnostic challenges.

Case presentation

In this report, three patients exhibited atypical symptoms, sharing a common complaint of flank pain. Notably, the first patient, who had recently undergone laparoscopic right duplex nephrectomy, presented with microscopic hematuria, whereas the other two did not show any gross or microscopic hematuria. Computed tomography urography revealed hydronephrosis and infection without significant renal pelvic space-occupying lesions, with persistently elevated white blood cell (WBC) counts, but no fever. These atypical clinical presentations confounded clinicians, delaying the diagnosis of upper tract urothelial carcinoma until postoperative pathological examination for the first two patients and resulting in advanced-stage diagnosis for the third patient. Postoperative pathology confirmed high-grade invasive upper tract urothelial carcinoma in all three patients.

Conclusion

Upper tract urothelial carcinoma can manifest atypically without hematuria and may be challenging to visualize on computed tomography urography, potentially leading to misdiagnosis. Therefore, clinicians should maintain a high level of suspicion for malignant tumors when patients exhibit hydronephrosis, infection on imaging, and persistently elevated white blood cell counts without fever, even in the absence of typical signs of upper urothelial carcinoma on computed tomography urography.

Imaging-based adipose biomarkers for predicting clinical outcomes of cancer patients treated with immune checkpoint inhibitors: a systematic review

Background

Since the application of Immune checkpoint inhibitors (ICI), the clinical outcome for metastatic cancer has been greatly improved. Nevertheless, treatment response varies in patients, making it urgent to identify patients who will receive clinical benefits after ICI therapy. Adipose body composition has proved to be associated with tumor response. In this systematic review, we aimed to summarize the current evidence on imaging adipose biomarkers that predict clinical outcomes in patients treated with ICI in various cancer types.

Methods

Embase and PubMed were searched from database inception to 1st February 2023. Articles included investigated the association between imaging-based adipose biomarkers and the clinical outcomes of patients treated with ICI. The methodological quality of included studies was evaluated through Newcastle- Ottawa Quality Assessment Scale and Radiomics Quality Score tools.

Results

Totally, 22 studies including 2256 patients were selected. Non-small cell lung cancer (NSCLC) had the most articles (6 studies), followed by melanoma (5 studies), renal cell carcinoma (RCC) (3 studies), urothelial carcinoma (UC) (2 studies), head and neck squamous cell carcinoma (HNSCC) (1 study), gastric cancer (1 study) and liver cancer (1 study). The remaining 3 studies investigated metastatic solid tumors including various types of cancers. Adipose biomarkers can be summarized into 5 categories, including total fat, visceral fat, subcutaneous fat, intramuscular fat and others, which exerted diverse correlations with patients' prognosis after being treated with ICI in different cancers. Most biomarkers of body fat were positively associated with survival benefits. Nevertheless, more total fat was predictable of worse outcomes in NSCLC, while inter-muscular fat was associated with poor clinical benefits in UC.

Conclusion

There is relatively well-supported evidence for imaging-based adipose biomarkers to predict the clinical outcome of ICI. In general, most of the studies show that adipose tissue is positively correlated with clinical outcomes. This review summarizes the significant biomarkers proven by researches for each cancer type. Further validation and large independent prospective cohorts are needed in the future. The protocol of this systematic review has been registered at the International Prospective Register of Systematic Reviews (http://www.crd.york.ac.uk/PROSPERO, registration no: CRD42023401986).

Minimally Invasive Radical Nephroureterectomy: 5-Year Update of Techniques and Outcomes

The gold standard treatment for non-metastatic upper tract urothelial cancer (UTUC) is represented by radical nephroureterectomy (RNU). The choice of surgical technique in performing UTUC surgery continues to depend on several factors, including the location and extent of the tumor, the patient's overall health, and very importantly, the surgeon's skill, experience, and preference. Although open and laparoscopic approaches are well-established treatments, evidence regarding robot-assisted radical nephroureterectomy (RANU) is growing. Aim of our study was to perform a critical review on the evidence of the last 5 years regarding surgical techniques and outcomes of minimally invasive RNU, mostly focusing on RANU. Reported oncological and function outcomes suggest that minimally invasive RNU is safe and effective, showing similar survival rates compared to the open approach.