Abstract
To report the outcomes of patients with pathologic T4 UTUC and investigate the potential impact of peri-operative chemotherapy combined with radical nephroureterectomy (RNU) and regional lymph node dissection (LND) on oncologic outcomes. Patients with pathologic T4 UTUC were identified from the cohort of 1464 patients treated with RNU at 13 academic centers between 1987 and 2007. Oncologic outcomes were stratified according to utilization of perioperative systemic chemotherapy and regional LND as an adjunct to RNU. The study included 69 patients, 42 males (61%) with median age 73 (range 43-98). Median follow-up was 17 months (range: 6-88). Lymphovascular invasion was found in 47 (68%) and regional lymph node metastases were found in 31 (45%). Peri-operative chemotherapy was utilized in 29 (42%) patients. Patients treated with peri-operative chemotherapy and RNU with LND demonstrated superior oncologic outcomes compared to those not treated by chemotherapy and/or LND during RNU (3Y-DFS: 35% vs. 10%; P = 0.02 and 3Y-CSS: 28% vs. 14%; P = 0.08). In multivariate Cox regression analysis, administration of peri-operative chemotherapy and utilization of LND during RNU was associated with lower probability of recurrence (HR: 0.4, P = 0.01), and cancer specific mortality (HR: 0.5, P = 0.06). Pathological T4 UTUC is associated with poor prognosis. Peri-operative chemotherapy combined with aggressive surgery, including lymph node dissection, may improve oncological outcomes. Our findings support the use of aggressive multimodal treatment in patients with advanced UTUC.
Highlights
Upper tract urothelial carcinoma (UTUC) is an uncommon genitourinary malignancy accounting for only 5% of urothelial cancers and 7-8% of all renal tumors [1]
Given biologic similarities between upper and lower tract urothelial cancer, we sought to assess the potential impact of peri-operative systemic chemotherapy and lymph node dissection (LND) as an adjunct to radical Radical nephroureterectomy (RNU) in patients with advanced UTUC
The poor prognosis of T4 UTUC was confirmed with short time to systemic relapse and nearly 75% of patients dying from their disease within 3 years after RNU
Summary
Upper tract urothelial carcinoma (UTUC) is an uncommon genitourinary malignancy accounting for only 5% of urothelial cancers and 7-8% of all renal tumors [1]. Radical nephroureterectomy (RNU) with excision of an ipsilateral bladder cuff remains the gold standard treatment for ibju | Radical nephroureterectomy for pathologic T4 upper tract urothelial cancer patients with invasive UTUC. Pathological stage is the most important predictor of oncologic outcomes in UTUC with dismal survival rates despite radical surgery for patients harboring T4 tumors [2,3,4]. Experience with urothelial carcinoma of the urinary bladder (UCB) highlights that adequate lymph node dissection (LND) in conjunction with systemic chemotherapy ( neoadjuvant cisplatin-based regimens), comprise a fundamental part of the contemporary multi-modal therapeutic strategy. Given biologic similarities between upper and lower tract urothelial cancer, we sought to assess the potential impact of peri-operative systemic chemotherapy and LND as an adjunct to radical RNU in patients with advanced UTUC
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