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MeSH term: Carcinoma, Transitional Cell
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Predominant global glomerulosclerosis in patients of upper urinary tract urothelial carcinoma with pre-existing renal function impairment is a predictor of poor renal outcomes.
BMC Cancer. 2019; 19(1):337 [PubMed] Free Access to Full Article Related Publications
METHODS: Totally 193 renal cancer patients, including 132 UTUC and 61 RCC, were studied to clarify whether the pathological changes of the kidney remnant removed from nephrectomy and the clinical factors might predict the risk of ESRD. Renal tubulointerstitial (TI) score and global glomerulosclerosis (GGS) rate were examined by one pathologist and two nephrologists independently under same histopathological criteria.
RESULTS: The glomerular filtration rates at the time of surgery were lower in UTUC than RCC groups (p < 0.001). Average GGS score and average TI rate were higher in UTUC than in RCC groups (p < 0.001; p < 0.001). Competitive risk factor analysis revealed that abnormal GGS rate not related to age, predominant in UTUC with pre-existing renal function impairment, was a histopathological predictor of poor renal outcomes (creatinine doubling or ESRD) within 5 years in UTUC patients.
CONCLUSION: Pre-existing renal function and pathological change of kidney remnant in both UTUC and RCC have the value for prediction of renal outcomes.
Optimizing the Sequence of Chemotherapy for Upper Tract Urothelial Carcinoma with Clinically Positive Regional Lymph Nodes.
J Urol. 2019; 202(1):76-82 [PubMed] Related Publications
MATERIALS AND METHODS: We identified 1,658 patients in the NCDB (National Cancer Database) who had cN+M0 upper tract urothelial carcinoma. Patients were stratified into treatment groups. We compared baseline patient and tumor characteristics between the groups, and completed survival analysis using a multivariate Cox regression model.
RESULTS: There were 1,658 patients in the final study population. Preoperative chemotherapy was the least performed treatment. That group comprised 6.8% of the overall population and was associated with the highest median overall survival of 36 months compared to 21 months for adjuvant chemotherapy, 14 for chemotherapy only, 10 for surgery without perioperative chemotherapy and 5 for no treatment. On multivariate analysis preoperative chemotherapy was associated with improved median overall survival compared to that in the adjuvant chemotherapy group (HR 0.58, 95% CI 0.38-0.87). There was no statistically significant difference in survival between the chemotherapy only and the surgery only groups. Of patients in the preoperative chemotherapy group 34.6% achieved pN0 status compared to 10.3% of those who underwent surgery as initial therapy.
CONCLUSIONS: Preoperative chemotherapy was the least performed treatment strategy in the management of cN+M0 upper tract urothelial carcinoma but it was associated with the highest median overall survival. There was no difference in survival between the chemotherapy only and the surgery only groups. Overall these results suggest that initial chemotherapy is appropriate in this population when feasible.
Cutaneous toxicity associated with enfortumab vedotin treatment of metastatic urothelial carcinoma.
Dermatol Online J. 2019; 25(2) [PubMed] Related Publications
Effect of neoadjuvant chemotherapy on locally advanced upper tract urothelial carcinoma: A systematic review and meta-analysis.
Crit Rev Oncol Hematol. 2019; 135:59-65 [PubMed] Related Publications
METHODS: Systematic literature searches were conducted in PubMed/Medline and Embase for all studies that examined the role of chemotherapy for UTUC. We performed this study according to the Preferred Reported Items for Systematic Reviews and Meta-analysis guidelines. Endpoints were overall survival (OS), cancer-specific survival (CSS), and progression-free survival (PFS).
RESULTS: A total of four trials on 318 patients were included in this study. Each of the included studies was retrospective. Compared to controls, NAC improved OS, CSS, and PFS by 57% (95% confidence interval [CI], 0.25-0.73; p = 0.002), 59% (95% CI, 0.27-0.57; p < 0.00001), and 45% (95% CI, 0.50-0.60; p < 0.00001), respectively. The absolute increases in OS, CSS, and PFS were 11%, 18%, and 13%, respectively, and these increases are equivalent to numbers-needed-to-treat of 9, 5.5, and 7.6, respectively. Pooled odds ratio for the effect of NAC on downstaging was 0.21 (95% CI, 0.09-0.60; p = 0.004), which indicates that NAC group had a 4.76-fold higher probability of having pathologic N stage 0 than control group.
CONCLUSIONS: NAC treatment before radical nephroureterectomy might provide better survival outcomes in patients with locally advanced UTUC. Prospective randomized studies are needed to confirm the benefits of NAC in locally advanced UTUC patients.
8-armed octopus: Evaluation of clinicopathologic prognostic factors of urothelial carcinoma of the upper urinary system
Turk J Med Sci. 2019; 49(1):153-161 [PubMed] Related Publications
Materials and methods: A total of 74 cases of UUSUC were included, from three different centers. Demographic data and histopathological features such as tumor localization, concomitant tumor in the urinary system, distant metastasis with overall survival and disease-free survival obtained from the hospital records were evaluated retrospectively. Histopathologic prognostic features such as grade, perineural invasion, lymphovascular invasion, tumor necrosis, and surgical margin status were also evaluated.
Results: Seventy cases (94.6%) underwent open nephroureterectomy whereas 4 cases (5.4%) had laparoscopic nefroureterectomy. Thirty-eight (51.4%) cases were located in the pelvis, 7 (9.5%) in the ureter, 29 (39.2%) both in the pelvis and ureter. Fifty-six (75.7%) cases were alive; however, 18 (24.3%) patients were found to be dead. pTa, pT1, pT2, pT3, and pT4 tumors were reported in 16 (21.6%), 13 (17.6%), 4 (5.4%), 28 (37.8%), and 13 (17.6%) patients, respectively. Histopathologically, 17 cases (23%) were low-grade, 57 cases (77%) were high-grade. Statistically significant correlation was observed between overall survival and lymph node metastasis, distant metastasis, tumor necrosis, and differentiation by univariate analysis. Only distant metastasis was statistically associated with overall survival by multivariate analysis. We found no significant relationship between disease-free survival and all parameters.
Conclusion: Differentiation and necrosis of tumor, lymph node involvement, and presence of distant metastasis is associated with the overall survival of urothelial carcinoma of the upper urinary system.
Serum Hepcidin and GDF-15 levels as prognostic markers in urothelial carcinoma of the upper urinary tract and renal cell carcinoma.
BMC Cancer. 2019; 19(1):74 [PubMed] Free Access to Full Article Related Publications
METHODS: In this retrospective study n = 38 patients suffering from UUTUC, n = 94 patients suffering from RCC and n = 21 patients without infections or cancer, all hospitalized at the University Hospital Muenster, were included. Serum samples of patients were retrospectively analyzed. Serum hepcidin and GDF-15 levels were measured and correlated to aggressiveness and progression of the disease as well as patient's outcome.
RESULTS: For both entities, UUTUC and RCC, serum hepcidin levels as well as serum GDF-15 levels were increased compared to sera of controls. High serum hepcidin and GDF-15 levels were associated with metastases and cancer relapse. Also, in both entities, the overall survival was decreased in patients with increased serum hepcidin and GDF-15 levels. Hence, high serum hepcidin and GDF-15 levels correlated with patient's outcome.
CONCLUSION: To conclude, the data of this study show a correlation of high serum hepcidin and GDF-15 levels with aggressiveness and progression of the disease and demonstrate potential prognostic properties of serum hepcidin and GDF-15 levels. The data support the further assessment of serum hepcidin and GDF-15 as prognostic markers in RCC and UUTUC.
Clinico-pathological characteristics and outcome of upper urinary tract urothelial carcinoma presenting to a tertiary care urology unit in Sri Lanka
Ceylon Med J. 2018; 63(3):129-132 [PubMed] Related Publications
Methods: A retrospective analysis of all patients who underwent nephroureterectomy for upper urinary tract urothelial cancer at the Urology Unit at National Hospital of Sri Lanka between January1997 and December 2016 was carried out.
Results: There were 43 patients. Male: female=1.87. Median age was 65 years (range:42-83). Macroscopic haematuria was the commonest presentation (n=29; 67.4%). Median duration of symptoms was 3 months (range 0.5-6). In the majority (n=20;46.5%) the tumour was confined to the ureter. Thirty-three (75.6%) were papillary tumours. Twenty-one had non-muscle invasive tumours (pTa: n=6(14%), pT1: n=15(34.9%) and others had invasive cancers (pT2: n=11(25.6%), pT3: n=7(16.3%) and pT4: n=4(9.3%)). Majority were low grade tumours (n=23;53.5%). Twelve (27.9%) had preceding urothelial bladder cancer. Nineteen (44.2%) were lost to follow up after surgery. Median follow up duration of the rest was 40 months (range:4-224months). Of them, 9(20.9%) developed metachronous bladder tumours. Nine had recurrence free survival of ≥5years and 15 had overall survival of ≥5 years. Of them, 4 patients survived ≥10 years. Older age (p=0.015) and presence of necrosis(p=0.05) were the only clinico-pathological parameters predictive of tumour recurrence.
Conclusions: A relatively higher number females and high number of ureteric tumours were noted compared to similar studies from Asia.
Diagnostic pathway efficacy for urinary tract cancer: population-based outcome of standardized evaluation for macroscopic haematuria.
Scand J Urol. 2018; 52(4):237-243 [PubMed] Related Publications
METHODS: The outcome of the first 11 months was evaluated in 1697 individuals referred to a standardized care pathway for urinary tract cancer compared with 174 patients with conventionally diagnosed urothelial carcinoma.
RESULTS: Among the referred individuals, 317 (19%) were diagnosed with cancer, 1034 (61%) had a benign diagnosis and 345 (20%) had a negative evaluation. Bladder cancer was the most common malignant diagnosis [262/317 (83%)]. Cancers were diagnosed in 23% of males and 13% of females, and showed a strong correlation with age: cancer diagnosis in 2% aged <50 years and in 44% aged ≥90 years. Results were affected by bacteriuria but not by anticoagulant medication, with 12%/22% and 19%/19% cancer detection, respectively. The standardized care pathway shortened the diagnostic delay to a median of 25 days compared to 35 days for regular referral (p = .01). However, median time to treatment was unchanged: 39 days from referral to transurethral resection, 42 days from primary resection to re-resection for stage TaG3/T1 disease and 100 days from referral to curative treatment for muscle-invasive disease.
CONCLUSIONS: Macroscopic haematuria had a cancer capture rate of 19%, with higher predictive values in men and at older age, whereas anticoagulant therapy did not influence the diagnostic yield. The demonstrated lack of effect on time to treatment underscores the need to consider the entire patient process when initiating healthcare reforms to improve outcome.
Recent advances in upper tract urothelial carcinomas: From bench to clinics.
Int J Urol. 2019; 26(2):148-159 [PubMed] Related Publications
Predictive ability of renal cortex enhancement in dynamic computed tomography for residual renal function after nephroureterectomy: Comparison with
Int J Urol. 2019; 26(2):266-272 [PubMed] Related Publications
METHODS: A total of 47 patients who received radical nephroureterectomy and underwent both preoperative dynamic computed tomography and renography were the model-development cohort; and 109 patients who underwent dynamic computed tomography alone were the validation cohort. Postoperative renal function of the unremoved kidney was estimated using the following formulas: preoperative estimated glomerular filtration rate × the percentage of total renal cortex radiodensity for the intact kidney in Hounsfield units obtained from corticomedullary phase images in the computed tomography-based model, or the percentage of the total glomerular filtration rate measured by renography in the nuclear model. The correlation between observed and estimated postoperative renal function was determined. The computed tomography-based prediction model derived from linear regression analysis was validated externally.
RESULTS: The correlation of computed tomography-based split renal function with the observed postoperative estimated glomerular filtration rate (r = 0.80) was equivalent to that of nuclear split renal function (r = 0.78). In the validation cohort, the computed tomography-based prediction model showed an equivalently strong correlation (r = 0.78).
CONCLUSIONS: The present study showed that the percentage of total renal cortex radiodensity for the intact kidney is a useful tool for predicting unremoved kidney function in upper tract urothelial carcinoma patients, thereby allowing appropriate patient selection for perioperative cisplatin-based combination chemotherapy.
MicroRNA Expression Profiles in Upper Tract Urothelial Carcinoma Differentiate Tumor Grade, Stage, and Survival: Implications for Clinical Decision-Making.
Urology. 2019; 123:93-100 [PubMed] Related Publications
METHODS: miRNA was isolated from 157 radical nephroureterectomy specimens from 2 institutions. The relative expression of miRNA was examined for high grade vs low grade tumors as well as muscle invasive vs nonmuscle invasive tumors. Recurrence free survival (RFS) and overall survival (OS) were also stratified using relative expression of specific miRNA.
RESULTS: The optimized model to identify high grade UTUC included miR-29b-2-5p, miR-18a-5p, miR-223-3p, and miR-199a-5p, generating a sensitivity of 83%, specificity of 85%, and generated a receiver operating characteristic (ROC) curve with area-under-the-curve of 0.86. Similarly, the model classifier for predicting ≥pT2 disease incorporated miR-10b-5p, miR-26a-5p-5p, miR-31-5p, and miR-146b-5p, producing a sensitivity of 64%, specificity of 96%, and area-under-the-curve of 0.90. RFS was best reflected by a combination of miR-10a-5p, miR-30c-5p, and miR-10b-5p, while OS was best predicted by miR-10a-5p, miR-199a-5p, miR-30c-5p, and miR-10b-5p.
CONCLUSION: High-grade vs low-grade as well as muscle invasive vs nonmuscle invasive UTUC can be reliable distinguished with unique miRNA signatures. Furthermore, differential expression of UTUC miRNA produces robust classifiers for predicting RFS and OS that may help identify patients who would most benefit from adjuvant therapies.
Evaluation of upper tract urothelial carcinomas by contrast-enhanced ultrasound.
Radiologia. 2018 Nov - Dec; 60(6):496-503 [PubMed] Related Publications
MATERIAL AND METHODS: We reviewed our hospital's database over a period of 45 months to identify patients diagnosed with upper tract urothelial carcinomas. We reviewed the findings on mode B-ultrasound, contrast-enhanced ultrasound (location and qualitative assessment of intensity and washout of enhancement), and made a comparison with other techniques (computed tomography or magnetic resonance), and with the surgical specimen.
RESULTS: We found 42 patients with a diagnosis of upper tract urothelial carcinoma confirmed with surgery over the period reviewed. Twenty-eight (67%) patients underwent contrast-enhanced ultrasound. Baseline ultrasound showed hydronephrosis with or without ureteral dilatation with echogenic content occupying the renal calyx (6), pelvis (10) or ureter (12). After injection of contrast, enhancement was noticed in 100% of the lesions, with similar intensity to the cortex in 23, and less in 5. Twenty-four lesions showed early washout, before the cortex, between 40 and 55seconds after the injection. The diagnosis was correct in 27 cases. Localisation coincided with the histological specimen in 28 cases, and 3 patients had additional distal carcinoma foci.
CONCLUSION: Contrast-enhanced ultrasound is a useful technique for diagnosing upper tract urothelial tumours that increases confidence in the diagnosis.
Impact of Neoadjuvant Chemotherapy on Pathologic Response in Patients With Upper Tract Urothelial Carcinoma Undergoing Extirpative Surgery.
Clin Genitourin Cancer. 2018; 16(6):e1237-e1242 [PubMed] Related Publications
PATIENTS AND METHODS: A total of 6174 patients with nonmetastatic, high-grade UTUC who underwent extirpative surgery from 2006 to 2014 were identified from the National Cancer Database. Patients were stratified by NAC status. PR was defined as pathologic stage less than clinical stage. Univariate and multivariable logistic regression analysis was employed to identify predictors of PR.
RESULTS: Two hundred sixty (4.2%) patients received NAC. A higher incidence of PR was observed in patients receiving NAC (25.2% vs. 1.8%; P < .001), with complete PR observed in 6.1% of patients receiving NAC and 0.4% of patients undergoing surgery alone. NAC (odds ratio [OR], 19.8; 95% confidence interval [CI], 11.8-33.5), nonwhite race (OR, 3.2; 95% CI, 1.7-6.3), and ureteral tumor location (OR, 1.6; 95% CI, 1.02-2.6) were independently associated with PR.
CONCLUSIONS: Examining a large national cancer registry, we observed a higher incidence of PR in patients with UTUC receiving NAC, validating findings of prior studies. Our findings support consideration of NAC in high grade UTUC. Prospective trials will better define the impact of NAC on pathologic and survival outcomes.
Immune checkpoint inhibitors for urothelial carcinoma.
Investig Clin Urol. 2018; 59(5):285-296 [PubMed] Free Access to Full Article Related Publications
The significance of the initial symptom in Chinese patients with upper tract urothelial carcinoma: Regular health examination is still underutilized.
Kaohsiung J Med Sci. 2018; 34(9):511-521 [PubMed] Related Publications
Perioperative outcomes and complication predictors associated with open and minimally invasive nephroureterectomy.
Can J Urol. 2018; 25(4):9395-9400 [PubMed] Related Publications
MATERIAL AND METHODS: Using the National Surgical Quality Improvement Program (NSQIP) database, 912 patients were identified that underwent radical nephroureterectomy for UTUC between 2005 and 2013. Logistic regression and contingency table methods used preoperative covariates to predict rates of major (Clavien-Dindo grade ≥ 3) and 16 common perioperative complications. Additional comparisons between treatment groups were performed using unpaired t-tests, Wilcoxon rank-sum tests, or Fisher's Exact tests. P values were adjusted to maintain an experiment-wise p < 0.05.
RESULTS: A total of 625 (69%) and 287 (31%) patients underwent MINU and ONU, respectively. ONU was associated with a higher rate of major complications (OR: 2.5, CI: 1.2-5.1, p < 0.03). The incidence of pulmonary embolism (bias adjusted OR: 24, CI: 1.3-441, p < 0.003), postoperative pneumonia (OR: 4.9, CI: 1.7-16, p < 0.0016), and transfusion (OR: 2.7, CI: 1.8-4.0, p < 0.0001) was higher for ONU compared to MINU. There were no significant differences in the incidence of other complications. MINU took longer on average (median 223 versus 213 mins, p < 0.02). Time to discharge was longer for ONU (median 5 versus 4 days, p < 0.0001). No other covariates were independent predictors of major complications regardless of surgical approach.
CONCLUSIONS: Occurrence of major complications were higher for ONU compared to MINU. These data suggest that MINU is an acceptable surgical option with lower morbidity compared to ONU for the management of UTUC.
Prognostic role of the preoperative serum albumin : globulin ratio after radical nephroureterectomy for upper tract urothelial carcinoma.
Int J Urol. 2018; 25(10):871-878 [PubMed] Related Publications
METHODS: We retrospectively reviewed 124 consecutive patients with upper tract urothelial carcinoma who underwent radical nephroureterectomy at Chiba Cancer Center, Chiba, Japan between 2002 and 2015. The albumin : globulin ratio was defined: albumin / (total protein - albumin). Associations between preoperative clinicopathological factors, including the albumin : globulin ratio, and recurrence-free survival, cancer-specific survival and overall survival were assessed. The log-rank test and Cox proportional hazards models were used for univariate and multivariable analyses, respectively. The study cohort was separated into two groups based on the optimal albumin : globulin ratio cut-off value determined using receiver operating characteristic curve analysis.
RESULTS: The median survival time was 55 months (interquartile range 28-76 months), and 31 patients died during follow up. A low preoperative albumin : globulin ratio <1.40 was associated with tumor grade and surgical margin status. Kaplan-Meier analyses showed that a low albumin : globulin ratio was more significantly correlated with worse recurrence-free survival, cancer-specific survival and overall survival. Multivariate analyses showed that a low albumin : globulin ratio was an independent predictive factor associated with poor recurrence-free survival (hazard ratio 3.758; P = 0.0028), cancer-specific survival (hazard ratio 5.687; P = 0.0044) and overall survival (hazard ratio 3.124; P = 0.0030).
CONCLUSIONS: A low albumin : globulin ratio is an independent predictive factor associated with poor prognosis in upper tract urothelial carcinoma patients treated with radical nephroureterectomy.
Femoral neuropathy following a psoas hitch vesicopexy.
BMJ Case Rep. 2018; 2018 [PubMed] Related Publications
Preoperative Low Lymphocyte-to-Monocyte Ratio Predicts Poor Clinical Outcomes for Patients with Urothelial Carcinoma of the Upper Urinary Tract.
Urol J. 2018; 15(6):348-354 [PubMed] Related Publications
MATERIALS AND METHODS: A historical cohort of 100 UUTUC patients was recruited from January 1990 to June 2011. The counts of peripheral lymphocyte and monocyte were retrieved, and the LMR was calculated by dividing lymphocyte count by monocyte count. Receiver operating characteristic curve (ROC) analysis, Log-rank test and Cox proportional hazards regression models were used for univariate and multivariate analyses to evaluate theassociations of LMR with overall survival (OS) and disease-free survival (DFS).
RESULT: Univariate analysis revealed that low level of LMR (? 3.0) was significantly associated with worse OS (P = .024) but not DFS (P = .993). Multivariate Cox proportional hazard analysis showed that low level of LMR was a significantly independent predictor for worse OS (hazard ratio = 0.366, 95% confident interval: 0.180-0.744). Based on the results of multivariate analysis, the rates of OS at 5 years developed by the prognostic model were asfollows: low risk, 88.0%, intermediate risk, 44.0%, and high risk, 13.0%, respectively.
CONCLUSION: The pre-operative LMR serves an independent prognostic biomarker in UUTUC. The prognostic model based on the LMR and pathologic factors can be available in selection of high risk patients for further aggressive therapy.
Does urinary cytology have a role in haematuria investigations?
BJU Int. 2019; 123(1):74-81 [PubMed] Free Access to Full Article Related Publications
PATIENT AND METHODS: The DETECT I study (clinicaltrials.gov NCT02676180) recruited patients presenting with haematuria following referral to secondary case at 40 hospitals. All patients had a cystoscopy and upper tract imaging (renal bladder ultrasound [RBUS] and/ or CT urogram [CTU]). Patients, where urine cytology were performed, were sub-analysed. The reference standard for the diagnosis of bladder cancer and UTUC was histological confirmation of cancer. A positive urine cytology was defined as a urine cytology suspicious for neoplastic cells or atypical cells.
RESULTS: Of the 3 556 patients recruited, urine cytology was performed in 567 (15.9%) patients from nine hospitals. Median time between positive urine cytology and endoscopic tumour resection was 27 (IQR: 21.3-33.8) days. Bladder cancer was diagnosed in 39 (6.9%) patients and UTUC in 8 (1.4%) patients. The accuracy of urinary cytology for the diagnosis of bladder cancer and UTUC was: sensitivity 43.5%, specificity 95.7%, positive predictive value (PPV) 47.6% and negative predictive value (NPV) 94.9%. A total of 21 bladder cancers and 5 UTUC were missed. Bladder cancers missed according to grade and stage were as follows: 4 (19%) were ≥ pT2, 2 (9.5%) were G3 pT1, 10 (47.6%) were G3/2 pTa and 5 (23.8%) were G1 pTa. High-risk cancer was confirmed in 8 (38%) patients. There was a marginal improvement in sensitivity (57.7%) for high-risk cancers. When urine cytology was combined with imaging, the diagnostic performance improved with CTU (sensitivity 90.2%, specificity 94.9%) superior to RBUS (sensitivity 66.7%, specificity 96.7%). False positive cytology results were confirmed in 22 patients, of which 12 (54.5%) had further invasive tests and 5 (22.7%) had a repeat cytology. No cancer was identified in these patients during follow-up.
CONCLUSIONS: Urine cytology will miss a significant number of muscle-invasive bladder cancer and high-risk disease. Our results suggest that urine cytology should not be routinely performed as part of haematuria investigations. The role of urine cytology in select cases should be considered in the context of the impact of a false positive result leading to further potentially invasive tests conducted under general anaesthesia.
Prognostic Impact of Preoperative Albumin-Globulin Ratio on Oncologic Outcomes in Upper Tract Urothelial Carcinoma Treated With Radical Nephroureterectomy.
Clin Genitourin Cancer. 2018; 16(5):e1059-e1068 [PubMed] Related Publications
PATIENTS AND METHODS: We retrospectively reviewed medical records of 620 patients treated with RNU for UTUC at our institution. Logistic regression analysis was used to evaluate the relation between low AGR (<1.45) and adverse pathologic features. Kaplan-Meier curves were used to estimate recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) probabilities between 2 groups. Univariable and multivariable Cox regression models were performed to address prognostic factors related to RFS, CSS, and OS.
RESULTS: Of the 620 patients, 323 (52.1%) had AGR < 1.45. During a median follow-up of 50.0 months (interquartile range, 28-78 months), 277 (44.7%) experienced disease recurrence and 194 (31.3%) died of disease. The results showed that low AGR was significantly associated with adverse pathologic features (all P < .05). Kaplan-Meier analysis showed that compared to those with high AGR (≥1.45), patients with low AGR had poorer RFS, CSS, and OS (P < .001). After adjusting for the confounding clinicopathologic factors, multivariate analyses showed that AGR < 1.45 independently predicted poor RFS (hazard ratio [HR] = 1.321, P = .029), CSS (HR = 1.503, P = .010) and OS (HR = 1.403, P = .015).
CONCLUSION: Low preoperative AGR is an independent predictor of worse pathologic and oncologic outcomes in patients with UTUC after RNU. The application of AGR as an easily assessed blood-based biomarker in predicting the prognosis of patients with UTUC is promising.
Ureteroscopic Management of Large ≥2 cm Upper Tract Urothelial Carcinoma: A Comprehensive 23-Year Experience.
Urology. 2018; 121:66-73 [PubMed] Related Publications
RESULTS: In total, 86 unique lesions ≥2cm were identified in the 80 qualifying patients; mean tumor size was 3.04 cm. Median follow-up was 43.6 months. During follow-up of patients treated curatively, 90.5% of tumors had ipsilateral recurrence and 31.7% progressed in grade at a median of 26.3 months. RNU was performed in 16 patients (20%); mean time to surgery was 23.2 months. Overall survival was 75%, and cancer specific survival was 84% at 5-year follow-up.
CONCLUSION: Under strict surveillance, ureteroscopic management of large (≥ 2cm) UTUC lesions is a viable treatment alternative to RNU. While recurrence is common, URS can potentially preserve renal units in patients with large lesions.
Robotic-Assisted Surgery for Upper Tract Urothelial Carcinoma: A Comparative Survival Analysis.
Ann Surg Oncol. 2018; 25(9):2550-2562 [PubMed] Related Publications
MATERIALS AND METHODS: Patients diagnosed with non-metastatic UTUC undergoing removal of the kidney and/or ureter were identified using Medicare-linked Surveillance, Epidemiology, and End Results Program data (2004-2013). Patients aged 65-85 years were categorized based on surgical approach (open, laparoscopic, or robotic-assisted). Kaplan-Meier methods were used to determine survival (overall and cancer-specific) and intravesical recurrence rates, the former using a propensity score-weighted model. Independent predictors of survival were determined using multivariable Cox proportional hazards regression analysis.
RESULTS: We identified a total of 3801 patients meeting the final inclusion criteria: open (n = 1862), laparoscopic (n = 1624), and robotic (n = 315). Robotic surgery was associated with the shortest length of hospital stay (p < 0.001) but highest in-hospital charges (p < 0.001), with no difference in readmission rates (p = 0.964). No difference was found in overall or cancer-specific survival in the robotic cohort when compared with open or laparoscopic surgery. In addition, no difference in the rate of intravesical recurrence was noted in robotic-assisted laparoscopy compared with the other groups. The sole predictor of improved survival was extent of lymphadenectomy, which was highest in the robotic cohort.
CONCLUSIONS: Using a large, population-based cancer database, there was no survival difference when a robotic-assisted approach was utilized in patients undergoing surgery for UTUC. These findings are important with the increased use of robotic surgery in the management of UTUC.
The prognostic value of preoperative neutrophil-to-lymphocyte ratio in patients with upper tract urothelial carcinoma.
Clin Chim Acta. 2018; 485:26-32 [PubMed] Related Publications
METHODS: A total of 717 patients were identified between 2003 and 2016. The cutoff value of NLR was set as 2.5. Kaplan-Meier method and Cox's proportional hazards regression models were utilized to analyze the association between NLR and oncological outcomes.
RESULTS: The median follow-up was 42 months. The results suggested that preoperative elevated NLR was associated with worse pathological features. Also, patients with NLR ≥ 2.5 had worse survival outcomes than those with NLR <2.5 (all P < .001). Multivariate cox analysis revealed that NLR ≥ 2.5 was an independent predictor of worse cancer-specific survival, disease recurrence-free survival, metastasis-free survival and overall survival (HR 1.95, 95%CI: 1.42-2.69, P < .001; HR 1.70, 95%CI: 1.31-2.20, P < .001; HR 1.67, 95%CI: 1.22-2.31, P = .002; and HR 1.88, 95%CI: 1.42-2.50, P < .001; respectively). Notably, NLR was ascertained to be a useful prognostic predictor in patients with high-grade disease, but not in those with low-grade UTUC.
CONCLUSIONS: Preoperative elevated NLR was associated with worse outcomes in patients with UTUC. Subgroup analysis affirmed that NLR was a useful predictor in patients with high-grade disease, but not in those with low-grade UTUC.
Salvage topical therapy for upper tract urothelial carcinoma.
World J Urol. 2018; 36(12):2027-2034 [PubMed] Article available free on PMC after 01/12/2019 Related Publications
METHODS: A single-center retrospective review on patients receiving salvage TT via percutaneous nephrostomy tube or cystoscopically placed ureteral catheters was performed. Primary outcome was response to therapy based on International Bladder Cancer Group criteria.
RESULTS: 51 patients with 58 renal units (RUs) received TT. Of these, 17 patients with 18 RUs received the second-line TT, with a median follow-up of 36.5 months (IQR 24.5-67 months). 44% (8/18) received salvage TT for refractory disease and 56% (10/18) as reinduction. 5 RUs with CIS were unresponsive to initial TT and went on to receive salvage TT, of which 20% (1/5) responded. 13 RUs recurred or relapsed following initial TT and received salvage TT for papillary tumors, with 62% (8/13) responding.
CONCLUSION: Our data provide preliminary clinical rationale for the second-line TT for refractory and recurrent, endoscopically managed papillary UTUC in patients ineligible for or refusing nephroureterectomy. However, refractory upper tract CIS appears to have poor response to salvage TT.
A Rare Case of Ureteral IgG4 Disease Masquerading as Urothelial Carcinoma.
Urology. 2018; 118:e1-e2 [PubMed] Related Publications
Coincidental Bladder Cuff Transitional Cell Carcinoma in Nephroureterectomy Specimens: Risk Factors, Prognosis and Clinical Implementation.
Urol J. 2018; 15(5):256-260 [PubMed] Related Publications
MATERIALS AND METHODS: The study was retrospective, from 1983-2013 on 305 patients who had diagnosed with UTUC. Patients were managed by radical open/ laparoscopic nephroureterectomy with bladder cuff excision. The tumor was staged using 1997 TNM classification and the 3-tiered WHO grading system was used for grading. Patients who found to have a malignant bladder cuff on the final pathology were further analyzed for the risk factors for such disease and its effect on survivaltheir outcomes.
RESULTS: 13/ 281 (4.6%) cases were found to have malignant bladder cuff. Regarding tumor stage; one case was diagnosed with Tis, eight had T1 and four cases had T2 malignant bladder cuff. All cases were with pure ureteric or multifocalcentric tumors, and none had pure pelvicalyceal tumors (p = .001).Local recurrence at the surgical site and distant metastasis were significantly higher among patients with malignant bladder cuff (p = .001 and .002 respectively), and the last sustained its significance in multivariate analysis. Those patients had a poor prognosis when compared to non-malignant bladder cuff cases (Log Rank test, p = .001)Conclusion: Ureteric tumor is the only independent risk factor for malignant bladder cuff at the final pathology and is associated with increased risks for invasive bladder tumor, distant metastasis and poor survival in comparison with non-malignant bladder cuff. In a clinical implementation, BCE is considered as a mandatory step in management of ureteric tumors, while it could be omitted in pure and low grade renal pelvis tumors.
Perioperative Immunotherapy in Muscle-Invasive Bladder Cancer and Upper Tract Urothelial Carcinoma.
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Endoscopic Approaches to Upper Tract Urothelial Carcinoma.
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Adjuvant Therapy in Muscle-Invasive Bladder Cancer and Upper Tract Urothelial Carcinoma.
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