Abstract
Purpose: Discordance between pre-operative biopsy and final pathology for Upper Tract Urothelial Carcinoma (UTUC) is high and optimal management remains controversial. The aim of this study is to evaluate the accuracy of pre-operative biopsy, to identify prognostic factors and to evaluate the effect of adjuvant chemotherapy on survival and oncologic outcome in UTUC.Methods: We analyzed records of patients receiving surgical treatment for UTUC. Pathology of pre-operative biopsy was compared to surgical specimen. We used Kaplan-Meier method to estimate survival probabilities and Cox's proportional hazards models to estimate the association between covariates and event times. Primary endpoint was overall survival (OS). A matched-pair analysis was performed to evaluate the effect of adjuvant chemotherapy.Results: 151 patients underwent surgical treatment (28% open, 36% laparoscopic, 17% robotic radical nephroureterectomy; 14% segmental ureteral resections and 5% palliative nephrectomy) for UTUC and were included in the analysis. Upstaging from <pT1 in endoscopic biopsy to ≥pT1 in final pathology occurred in 61% of patients and upgrading from low-grade to high-grade occurred in 30% of patients. Five-year OS was 59.5%. In the univariate Cox-regression model pathological stage, grade, lymphovascular invasion and positive surgical margins were associated with OS. Matched pair analysis for stage (<pT3; ≥pT3; pN+) and age revealed a significant survival benefit for adjuvant chemotherapy (HR 0.40, 0.14–0.77, p < 0.018) in this cohort.Conclusion: UTUC is often underestimated in pre-operative biopsy, and it is associated with significant mortality. Pathological stage and grade, lymphovascular invasion and lymph node metastases are predictors of oncologic outcome and survival.
Highlights
Upper urinary tract urothelial carcinoma (UTUC) is a rare disease that accounts for around 5% of all urothelial cancers [1]
The standard of care for invasive UTUC is radical nephroureterectomy (RNU) with excision of an ipsilateral bladder-cuff, and lymph node dissection (LND) [3], which can be performed as open, laparoscopic or robotic surgery
We aimed to evaluate the influence of perioperative chemotherapy on overall survival (OS) and disease-free survival (DFS)
Summary
Upper urinary tract urothelial carcinoma (UTUC) is a rare disease that accounts for around 5% of all urothelial cancers [1]. At the time of diagnosis around 60% of UTUC are invasive tumors [2]. The standard of care for invasive UTUC is radical nephroureterectomy (RNU) with excision of an ipsilateral bladder-cuff, and lymph node dissection (LND) [3], which can be performed as open, laparoscopic or robotic surgery. Because of high recurrence rates, mostly retrospective studies have investigated perioperative chemotherapy. While studies on neoadjuvant chemotherapy (NAC) only consist of small cohorts leading to insufficient survival data, adjuvant chemotherapy has stronger evidence to improve survival in locally advanced or lymph node (LN) positive disease and is recommended by the EAU-Guidelines [3, 8,9,10]
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