Adjuvant Chemotherapy With Paclitaxel and Carboplatin in Patients With Advanced Carcinoma of the Upper Urinary Tract: A Study by the Hellenic Cooperative Oncology Group

Comparing lymphadenectomy during radical nephroureterectomy: open versus laparoscopic

OBJECTIVES

Laparoscopic nephroureterectomy (LNU) is an accepted treatment for tumors of the ureter and renal pelvis, although the ability to perform a regional lymphadenectomy has been criticized. We compared the quality of lymphadenectomy with LNU with that involving open nephroureterectomy (ONU) to determine whether oncologic principles are maintained.

METHODS

We searched our institutional database for patients who had undergone ONU from 1990 to 2005. These were compared with a series of patients from January 2003 to April 2007 who underwent LNU. From each patient's medical records, we assessed the number of lymph nodes removed, the number of positive nodes removed, and the density of positive nodes. The differences between groups were analyzed using the Wilcoxon rank sum statistical test.

RESULTS

We identified 106 patients who underwent ONU with lymphadenectomy and 28 who underwent LNU with lymphadenectomy. The median number of nodes removed, median number of positive nodes, and median density of positive nodes were, respectively, 3, 0, and 0 for the ONU group; and 6, 0, and 0, for the LNU group. There was a statistically significant difference between groups with respect to the number of nodes removed (P = 0.01) but not with respect to the number of positive nodes removed (P = 0.61) or the lymph node density (P = 0.42).

CONCLUSIONS

Offsetting the benefits of laparoscopy could be a flawed oncologic technique. We have demonstrated that lymphadenectomy, which is a potentially important component of nephroureterectomy, can be performed as well during LNU as it is with ONU when a dedicated effort is made.

Clinical significance of lymphovascular invasion in upper urinary tract urothelial cancer

OBJECTIVES

To clarify the significance of lymphovascular invasion (LVI) in patients with pT3N0M0 upper urinary tract (UUT) urothelial carcinoma (UC) relative to prognosis in terms of disease-specific survival, as LVI, which implies both blood vessel and lymph vessel involvement, is reportedly a poor prognostic factor in patients with UUT-UC.

PATIENTS AND METHODS

The clinical records of 90 patients who had surgery for UUT-UC were reviewed retrospectively. The median patient age was 71 years and the median follow-up was 42 months. The prognostic significances of LVI (with vs without), T stage (< 1 vs 2-4), grade (1-2 vs 3), N stage (0 vs 1-2), age (< or = 70 vs > 70 years), gender and tumour location (renal pelvis vs ureter) for survival time were evaluated.

RESULTS

LVI of UUT-UC was found in 34 patients (37.8%). There were significantly higher frequencies of LVI with advancing stage and lymph node metastasis. Kaplan-Meier analysis showed that LVI was strongly associated with disease-specific survival in all patients (P < 0.001) and in patients with pT3N0M0 disease (P < 0.001). Univariate analyses showed that LVI, T stage, N stage and tumour grade were significantly related to disease-specific survival in all patients (P < 0.001, < 0.001, 0.003 and 0.007, respectively). Multivariate analysis using Cox proportional hazards model showed that LVI was the only prognostic factor with independent significance for disease-specific survival (P < 0.001).

CONCLUSIONS

LVI appears to be an important and independent prognostic factor for UUT-UC in patients treated by nephroureterectomy. Our data suggest that the LVI status might be a predictive marker for disease-specific survival in patients with T3N0M0 UTT-UC.

DNA repair gene polymorphisms may be associated with prognosis of upper urinary tract transitional cell carcinoma

Upper urinary tract transitional cell carcinoma (UUT-TCC) is quite an uncommon disease, and its prognosis differs among individuals irrespective of tumor stage. DNA repair gene polymorphisms are reported to result in the modulation of the repair capacity and might influence the prognosis of UUT-TCC. We examined the associations between functional polymorphisms in five DNA repair genes, and the prognosis of UUT-TCC in 103 UUT-TCC patients. Variant alleles in xeroderma pigmentosum complementation group C, more than three total variant alleles in all DNA repair genes studied and more than two total variant alleles in three nucleotide excision repair genes were independently associated with improved overall and disease-specific survival of UUT-TCC patients in multivariate analysis (P = .0063 and P = .0005 for xeroderma pigmentosum complementation group C, P = .016 and P = .0016 for all genes, and P = .0053 and P = .018 for nucleotide excision repair genes, respectively). These results suggest that some DNA repair gene polymorphisms may preoperatively be valuable as prognostic factors for UUT-TCC beyond tumor stage and grade, helping to provide optimal treatment strategies for individual patients.

Urothelial carcinoma of the upper urinary tract: surgical approach and prognostic factors

OBJECTIVES

Open radical nephroureterectomy (O-RNU) has been the gold standard for the treatment of upper urinary tract urothelial carcinoma (UUT-UC) for decades. With the advances in laparoscopic techniques and endourologic procedures, this concept has been increasingly challenged. Oncologic outcome prediction is mainly based on stage and grade. With progress in medical treatment, adjuvant therapies may gain importance in the future. This review assesses the values of the variety of available treatments as well as prognostic factors that may become relevant regarding patient selection for future adjuvant treatment trials.

METHODS

We performed a systematic literature research using MEDLINE with emphasis on open surgical, laparoscopic, and endourologic (ureteroscopic or percutaneous) techniques and prognostic contents.

RESULTS

Overall, no evidence level 1 information from prospective randomised trials is available for treatment of UUT-UC. Laparoscopic radical nephroureterectomy (L-RNU) is increasingly challenging open surgery. Currently, L-RNU should be reserved for low-stage, low-grade tumours. Ureteroscopy and percutaneous nephron-sparing techniques show favourable survival data but high local recurrence rates. Regarding prognosis, estimation of outcome still relies mainly on stage and grade because no additional parameters have been introduced in a routine clinical setting.

CONCLUSIONS

O-RNU still represents the gold standard for the treatment of UUT-UC. The laparoscopic approach is not yet standard of care and should be reserved for low-stage, low-grade tumours. Endourologic nephron-sparing treatments are still experimental in elective indications due to high local recurrence rates. For prognosis, no parameters in addition to stage and grade have been standardised.

The atypical urothelial cancer patient: management of bladder cancers of non-transitional cell histology and cancers of the ureters and renal pelvis

Non-transitional cell neoplasms of the bladder and upper tract transitional cell carcinomas (ureter and renal pelvis) represent only a small fraction of urothelial carcinomas. Clinicians faced with the rare case are always confronted with management dilemmas complicated by the scarcity of published experience to guide decisions. The current review brings together the best of the limited published data in an attempt to provide some reasonable context to help in the management of these difficult neoplasms.

Evaluation of regional lymph node dissection in patients with upper urinary tract urothelial cancer

OBJECTIVE

The role of the lymph node dissection (LND) in conjunction with nephroureterectomy (NU) in upper tract urothelial cell carcinoma (UT-UCC) remains undefined. We evaluated the manner in which the LND was applied at NU, the patterns of lymph node (LN) involvement and the preoperative variables that could identify patients at high risk for lymph node metastasis (LNM).

METHODS

We examined clinical, radiological and pathological records of patients who underwent NU for UT-UCC between 1985 and 2004. The central pathology laboratory reviewed all specimens and graded tumors using the 2002 World Health Organization/International Society of Urologic Pathologists grading system.

RESULTS

Of the NU performed in 252 patients for UT-UCC, 105 (42%) were N0, 28 (11%) N+ and 119 (47%) Nx. Some form of LN resection was performed with NU in 53% of patients, with a median of four LN sampled (interquartile range, 2-10). After adjustment for tumor and patient characteristics, surgeon remained a significant predictor of LN resection (P < 0.0005). Of the evaluated variables, suspicious LN on preoperative computed tomography, present in 60% of N+ patients, was the only preoperative variable associated with the pathological finding of LNM (P < 0.0005).

CONCLUSIONS

LND in patients with UT-UCC is surgeon-dependent. Given the prognostic importance of LN status and the limited accuracy of preoperative staging of the regional LN, surgeons should perform a regional LND at the time of NU.

An unusual case of transitional cell carcinoma of renal pelvis presenting with brain metastases

We report a rare case, who had presented with a constellation of neurological symptoms (due to multiple brain metastases), but without any urological symptoms, to the department of neurosurgery. The patient was managed with gamma knife stereotactic radiosurgery for the metastatic lesions. During an evaluation for primary, he was found to be having transitional cell carcinoma (TCC) of right renal pelvis, for which palliative radical nephroureterectomy was performed, following which he received four cycles of paclitaxel and carboplatin chemotherapy. The patient is alive with stable disease at 22-months follow-up.

Gemcitabine and cisplatin after radical cystectomy for bladder cancer in an adjuvant setting: feasibility study from the Genito-Urinary Group of the French Federation of Cancer Centers

The impact of adjuvant chemotherapy in locally advanced bladder cancer is still not fully established. Between January 2000 and November 2001, 30 patients entered the trial to receive four cycles of a combination of gemcitabine 1,250 mg/m on day 1 and day 8 and cisplatin 70 mg/m on day 1, repeated every 3 weeks. Histologic diagnoses included pT2-pT3-pT4 tumors and/or pN1-pN2. Combination treatment with gemcitabine and cisplatin was considered feasible if 70% of the patients received a relative dose intensity of each drug of more than 90%. Twenty-seven patients received four cycles of combination treatment. The relative dose intensity of cisplatine and gemcitabine was 96 and 88%, respectively. No toxic death occurred. We conclude that giving four cycles of the gemcitabine-cisplatin regimen in the adjuvant setting after cystectomy is feasible with a manageable toxicity and a high relative dose intensity. Whether this approach may increase survival is currently assessed in a randomized trial.

Evaluation of Calvert's Formula for Dosage Adjustment of Carboplatin in Japanese Patients with Hormone Refractory Prostate Cancer

For hormone refractory prostate carcinoma, a combination therapy of paclitaxel and carboplatin is used to expect life extension. We investigated the pharmacokinetics of carboplatin in Japanese prostate cancer patients (n=10, 55-72 years), and evaluated the usefulness of Calvert's formula in the individualized dosing adjustment. They were intravenously administered carboplatin (area under the free plasma concentration versus time curve (AUC)=5 mg.min/ml), following the intravenous administration of paclitaxel (175 mg/m(2)). The dosage of carboplatin for each patient was determined with Calvert's formula using individual creatinine clearance values. Plasma concentration of total platinum was measured sequentially and the pharmacokinetic parameters of carboplatin were determined in each patient. Plasma concentration of total carboplatin after intravenous infusion well fitted the two-compartment model. Carboplatin clearance was 62.0+/-12.7 ml/min (mean+/-S.D.), and linearly related to the individual creatinine clearance (r(2)=0.64, p<0.01). The actual AUC for total carboplatin was 8.20+/-1.11 mg.min/ml, and its inter-individual variability was decreased to 65% of that in carboplatin clearance, indicating the effectiveness of Calvert's formula for dosage adjustment of carboplatin. Leucopenia of grade 4 according to the National Cancer Institute's Common Toxicity Criteria was found in one patient, but no patient demonstrated thrombocytopenia. In conclusion, determining carboplatin dosage based on Calvert's formula decreased the inter-individual variability in the actual AUC compared with that in the carboplatin clearance, and a target AUC of 5 mg.min/ml of carboplatin was comparatively safe for Japanese patients with prostate cancer.

["Second line" polychemotherapy in metastatic urothelial cancer of the renal pelvis. Persisting partial remission by 18 treatment cycles of gemcitabine/paclitaxel after 24 treatment cycles gemcitabine/cisplatin "stable disease"]

Moderate activity of systemic chemotherapy for advanced urothelial cancer has been reported for more than 30 years. Only with the advent of potent combination therapy in the mid-1980s have clinically significant response rates and prolonged survival been documented. Due to the small number of cases and poor prognosis, knowledge is scant about the therapeutic effect of "second-line" polychemotherapy in metastatic upper tract urothelial cancer. We report an interesting case of a 59-year-old man suffering from urothelial cancer of the renal pelvis with pulmonary, lymphogenous, and bone metastases who had an unexpected response to "second-line" chemotherapy with only 2 treatment cycles of gemcitabine/paclitaxel (partial remission) after 24 treatment cycles of gemcitabine/cisplatin in "stable disease" with progression between the therapeutic intervals.