Discordance Between Clinical and Pathological Staging and Grading in Upper Tract Urothelial Carcinoma.

Keiichiro Mori,Nico C Grossmann,Benjamin Pradere,Mohammad Abufaraj,Reza Sari Motlagh,Shahrokh F Shariat,Victor M Schuettfort,Hadi Mostafaei,Fahad Quhal,Satoshi Katayama,Morgan Rouprêt,Ekaterina Laukhtina,Dmitry V Enikeev,Pawel Rajwa,Kristin Zimmermann,Harun Fajkovic,Shin Egawa,Pierre I Karakiewicz,Vitaly Margulis

doi:10.1016/j.clgc.2021.10.002

Abstract

This study aimed to evaluate the concordance in tumor stage and grade between ureteroscopic (URS) biopsy and radical nephroureterectomy (RNU) in patients with upper tract urothelial carcinoma (UTUC). Records of 1,214 UTUC patients who had undergone URS biopsy followed by RNU were included. Univariable and multivariable logistic regression analyses were performed to identify factors contributing to the pathological upstaging. The concordance between URS biopsy-based clinical and RNU pathological staging was 34.5%. Clinical understaging occurred in 59.5% patients. Upstaging to muscle-invasive disease occurred in 240 (41.7%) of 575 patients diagnosed with ≤cT1 disease. Of those diagnosed with muscle-invasive disease on final pathology, 89.6% had been clinically diagnosed with ≤cT1 disease. In the univariable analyses, computed tomography urography (CTU)-based invasion, ureter location, hydronephrosis, high-grade cytology, high-grade biopsy, sessile architecture, age, and women sex were significantly associated with pathological upstaging (P < .05). In the multivariable analyses, CTU-based invasion and hydronephrosis remained associated with pathological upstaging (P < .05). URS biopsy-based clinical and pathological gradings were concordant in 634 (54.2%) patients. Clinical undergrading occurred in 496 (42.4%) patients. Clinical understaging/undergrading and upstaging to muscle-invasive disease occurred in a high proportion of UTUC patients undergoing RNU. Despite the inherent selection bias, these data underline the challenges of accurate UTUC staging and grading. In daily clinical practice, URS biopsy and CTU offer the most accurate preoperative information albeit with limited predictive value when used alone. These findings should be considered when utilizing preoperative, risk-adapted strategies.

Highlights

This study aimed to evaluate the concordance in tumor stage and grade between ureteroscopic (URS) biopsy and radical nephroureterectomy (RNU) in patients with upper tract urothelial carcinoma (UTUC)
In biopsy-based clinical T staging, high grade on cytology, high grade on biopsy, and sessile architecture were shown to be associated with higher clinical T stages (Supplementary Table 2)
In imaging-based clinical T staging, hydronephrosis, high grade on biopsy, sessile architecture, multifocality of tumor, and larger tumor size were shown to be associated with higher clinical T stages (Supplementary Table 3)

Summary

Introduction

This study aimed to evaluate the concordance in tumor stage and grade between ureteroscopic (URS) biopsy and radical nephroureterectomy (RNU) in patients with upper tract urothelial carcinoma (UTUC). To improve oncological outcomes in patients with UTUC, preoperative predictive models have been developed to guide clinical decision-making and patient counseling [2, 3] These models stratify tumors into low- and high-risk categories based on their multifocality, size, biopsy- and cytology-derived grade, hydronephrosis, and imaging findings; thereby facilitating the decision-making regarding kidney-sparing therapy versus radical nephroureterectomy (RNU), with or without lymphadenectomy and perioperative chemotherapy [1, 4, 5]. The European Association of Urology (EAU) UTUC guidelines recommend the consideration of URS biopsy when additional information is likely to affect treatment decisions 1 Despite this recommendation, accurate preoperative predictions of pathological features remain difficult because of the limited tissue available from biopsy specimens 13.

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