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

Prevalence and oncologic impact of chronic kidney disease for upper tract urothelial carcinoma in endemic area

OBJECTIVE

This study aimed to assess the impact of preoperative chronic kidney disease (CKD) on the oncological outcomes of patients with upper tract urothelial carcinoma (UTUC) who underwent standard radical nephroureterectomy (RNU).

METHODS

A total of 1172 UTUC patients who received RNU at a single center in Taiwan between February 2005 and August 2019 were included. The patients were categorized into two groups based on their preoperative CKD stage: CKD stage ≤3 (811 patients) and CKD stage >3 (361 patients). The estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease (MDRD) formula. The study investigated the oncological outcomes, including intravesical recurrence, non-urothelial recurrence, and cancer-specific mortality, stratified by preoperative CKD status.

RESULTS

The main findings indicated that UTUC patients with CKD stage >3 in Taiwan exhibited a higher proportion of females (p < 0.001), a greater history of concurrent bladder cancer (p = 0.003), more multifocal tumor behavior (p < 0.001), a higher incidence of carcinoma in situ (p = 0.008), increased rates of intravesical recurrence (p < 0.001), a lower prevalence of smoking history (p = 0.003), lower utilization of adjuvant chemotherapy (p < 0.001), reduced occurrence of non-urothelial recurrence (p < 0.001), and lower cancer-specific mortality (p = 0.006) compared to patients with CKD stage ≤3. Multivariate Cox regression analysis revealed significant differences in intravesical recurrence (p = 0.014) and non-urothelial recurrence (p = 0.006) between the CKD stage >3 and CKD stage ≤3 groups. The study also demonstrated that patients with concurrent bladder cancer and variant histology had higher rates of intravesical recurrence, non-urothelial recurrence, and cancer-specific mortality. The CKD stage >3 group exhibited lower rates of intravesical recurrence (p = 0.0014), higher rates of non-urothelial recurrence (p < 0.0001), and increased cancer-specific mortality (p = 0.0091) compared to the CKD stage ≤3 group in the 5-year free survival analysis.

CONCLUSION

In Taiwan, UTUC patients with CKD stage >3 exhibit distinct characteristics compared to the general population with urothelial carcinoma. They are associated with a non-smoking status, a higher proportion of females, and less aggressive pathological features. Additionally, CKD stage >3 can serve as a clinical indicator for intravesical and non-urothelial recurrence. Further investigation into molecular aspects and treatment modifications for these patients is warranted.

The impact of histological variants in patients with upper tract urothelial carcinoma treated with radical nephroureterectomy

OBJECTIVE

To investigate the impact of histological variants (HV) in patients with upper tract urothelial carcinoma (UTUC) and analyze the potential association between HV and postoperative bladder recurrence.

MATERIALS AND METHODS

The medical records of UTUC patients treated with RNU at our center from January 2012 to December 2019 were retrospectively analyzed. Patients were grouped according to the types of HV. Clinicopathological features and prognostic factors were compared among groups.

RESULTS

A total of 629 patients were included in the study: 458 (73%) patients had pure urothelial carcinoma (PUC) and 171 (27%) patients had UTUC with HV. Squamous differentiation was the most common type (124 cases, 19%), followed by glandular differentiation (29 cases, 5.0%). Patients with HV had a higher proportion of T3 and T4 pathologic stages (P < 0.001) as well as high-grade disease (P = 0.002). In the univariate analysis, squamous differentiation and glandular differentiation were significantly associated with worse cancer-specific survival (CSS) (HR 2.22, 95% CI 1.62-3.04, P < 0.001; HR 1.90, 95% CI 1.13-3.20, P = 0.016). However, the multivariate analysis showed that this association became non-significant. We found that HV were associated with recurrent muscle-invasive bladder cancer (MIBC) after RNU and all patients had T2 and T3 initial tumor stages (P = 0.008, P < 0.001).

CONCLUSION

We found that UTUC patients with HV were associated with biologically aggressive disease and recurrent MIBC after RNU. The detection of bladder recurrence following surgery needs to be given more attention in advanced UTUC patients with HV.

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.

The prognostic value of tumor architecture in patients with upper tract urothelial carcinoma treated with radical nephroureterectomy: A systematic review and meta-analysis

BACKGROUND AND PURPOSE

There is a lack of consensus regarding the prognostic value of tumor architecture (sessile vs. papillary) in upper tract urothelial carcinoma (UTUC) treated with radical nephroureterectomy (RNU). The aim of the present study was to analyze the current evidence regarding the prognostic role of tumor architecture in patients undergoing RNU for UTUC through a systematic review and meta-analysis.

METHODS

According to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, a literature search in PubMed, Web of Science, Wanfang, and China National Knowledge Infrastructure (CNKI) databases was performed for citations published prior to February 2020. Cumulative analyses of hazard ratios (HRs) and their corresponding 95% confidence intervals (95% CIs) were conducted for the survival outcomes by Stata 12.0 software.

RESULTS

We retrieved 17 studies (including 8,146 patients) evaluating the effect of tumor architecture on oncologic outcomes in patients treated with RNU. According to our final results, sessile tumor architecture had a significant correlation with worse cancer-specific survival (CSS) (HR = 1.43, 95% CI: 1.31-1.55, P < .001), overall survival (OS) (HR = 1.40, 95% CI: 1.24-1.58, P < .001), recurrence-free survival (RFS) (HR = 1.43, 95% CI: 1.35-1.53, P < .001), and progression-free survival (PFS) (HR = 1.27, 95% CI: 1.11-1.45, P = 0.001). The funnel plot test indicated that there was no significant publication bias in the meta-analysis. Besides, the findings of this study were found to be reliable by our sensitivity and subgroup analysis.

CONCLUSIONS

Sessile tumor architecture correlates with a significantly worse survival outcome compared with papillary tumor architecture, and it can be used as a valuable biomarker for monitoring prognoses of UTUC patients.

Albumin-to-alkaline phosphatase ratio serves as a prognostic indicator in unresectable pancreatic ductal adenocarcinoma: a propensity score matching analysis

BACKGROUND

Recent evidence suggests that albumin-to-Alkaline Phosphatase Ratio (AAPR) functions as a novel prognostic marker in several malignancies. However, whether it can predict the prognosis of unresectable pancreatic ductal adenocarcinoma (PDAC) remains unclear. Herein, we seek to investigate this possibility by a propensity score matching (PSM) analysis.

METHODS

This was a retrospective cohort study in which 419 patients diagnosed with unresectable PDAC and receiving chemotherapy were recruited. Patients were stratified based on the cutoff value of AAPR. The PSM analysis was performed to identify 156 well-balanced patients in each group for overall survival (OS) comparison and subgroup analysis. Univariate and multivariate analyses were carried out to examine the potential of AAPR to indicate the prognosis of unresectable PDAC. The prediction performance of conventional model and combined model including AAPR was compared using the Akaike Information Criterion (AIC) and concordance index (C-index).

RESULTS

We identified an AAPR of 0.4 to be the optimal cutoff for OS prediction. Patients with AAPR≤0.4 had significantly shorter OS compared with patients with AAPR> 0.4 (6.4 versus 9.3 months; P < 0.001). Based on the PSM cohort and entire cohort, multivariate Cox analysis revealed that high pretreatment for AAPR was an independent marker predicting favorable survival in unresectable PDAC (hazard ratio, 0.556; 95% confidence interval, 0.408 to 0.757; P < 0.001). Significant differences in OS were observed in all subgroups except for the group of patients age ≤ 60. Combined prognostic model including AAPR had lower AIC and higher C-index than conventional prognostic model.

CONCLUSIONS

Pretreatment AAPR servers as an independent prognostic indicator for patients with unresectable PDAC. Inclusion of AAPR improved the prediction performance of conventional prognostic model, potentially helping clinicians to identify patients at high risk and guide individualized treatment.