Prognostication of Upper Tract Urothelial Carcinoma: What Do We Really Need?

Abstract

Zigeuner et al reported on the prognostic significance of tumor necrosis in patients undergoing nephroureterectomy for urothelial carcinoma [1]. This large, multi-institutional study represents one of the more thorough attempts to identify prognostic factors for poor clinical outcome in upper tract tumors. Such studies have clinical value if they allow us to direct interventions to the patients who aremost likely to benefit. One way to accomplish this would be recommending adjuvant chemotherapy for patients with high-risk tumors. However, there are two arguments against adjuvant chemotherapy in upper tract urothelial cancer. The first argument is the lack of evidence of efficacy. Several retrospective studies of chemotherapy after nephroureterectomy have yielded variable results. Kwak et al reported on 43 patients with pT2 or greater disease and no evidence of distant metastases [2]. Thirty-two patients received cisplatin-based chemotherapy while 11 were not treated. After a median follow-up of 31 mo, disease-free survival was higher in the chemotherapy group than in the nonchemotherapy group. In a multivariate analysis, the use of adjuvant chemotherapy and node-negative status were strongly associatedwith survival. In contrast, Lee et al could not demonstrate any difference in recurrence-free survival between adjuvant and nonadjuvant groups [3]. This study was a retrospective review of 27 patients with pT3 urothelial cancer and node-negative disease. Sixteen patients received chemotherapy while 11 were observed. Five of the 16 patients in the adjuvant group had recurrence, compared with 4 of 11 patients in the surveillance group, and the disease-specific survival rates for the two groups were 75% and 71%, respectively. Similarly, Hellenthal et al could not identify any effect of adjuvant chemotherapy in patients with upper tract cancer [4]. In a retrospective analysis of an international database, the authors identified