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Dłubak A, Karwacki J, Logoń K, Tomecka P, Brawańska K, Krajewski W, Szydełko T, Małkiewicz B. Lymph Node Dissection in Upper Tract Urothelial Carcinoma: Current Status and Future Perspectives. Curr Oncol Rep 2023; 25:1327-1344. [PMID: 37801187 PMCID: PMC10640513 DOI: 10.1007/s11912-023-01460-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2023] [Indexed: 10/07/2023]
Abstract
PURPOSE OF REVIEW This narrative review aims to evaluate the role of lymph node dissection (LND) in upper tract urothelial carcinoma (UTUC) and its implications for staging and management outcomes, as well as future perspectives. RECENT FINDINGS Multiple studies have demonstrated the limitations of conventional imaging techniques in accurately localizing lymph node metastasis (LNM) in UTUC. While 18F-fluorodeoxyglucose positron emission tomography with computed tomography (18FDG-PET/CT) shows promise for preoperative LNM detection, its specificity is low. Alternative methods such as choline PET/CT and sentinel lymph node detection are under consideration but require further investigation. Additionally, various preoperative factors associated with LNM hold potential for predicting nodal involvement, thereby improving nodal staging and oncologic outcomes of LND. Several surgical approaches, including segmental ureterectomy and robot-assisted nephroureterectomy, provide a possibility for LND, while minimizing morbidity. LND remains the primary nodal staging tool for UTUC, but its therapeutic benefit is still uncertain. Advances in imaging techniques and preoperative risk assessment show promise in improving LNM detection. Further research and multi-center studies are needed to comprehensively assess the advantages and limitations of LND in UTUC, as well as the long-term outcomes of alternative staging and treatment strategies.
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Affiliation(s)
- Andrzej Dłubak
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-556, Wroclaw, Poland
| | - Jakub Karwacki
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-556, Wroclaw, Poland
| | - Katarzyna Logoń
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-556, Wroclaw, Poland
| | - Paulina Tomecka
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-556, Wroclaw, Poland
| | - Kinga Brawańska
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-556, Wroclaw, Poland
| | - Wojciech Krajewski
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-556, Wroclaw, Poland
| | - Tomasz Szydełko
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-556, Wroclaw, Poland
| | - Bartosz Małkiewicz
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-556, Wroclaw, Poland.
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Peyrottes A, Califano G, Ouzaïd I, Lainé-Caroff P, Long Depaquit T, Hermieu JF, Xylinas E. Lymph Node Dissection During Radical Nephro-Ureterectomy for Upper Tract Urothelial Carcinoma: A Review. Front Surg 2022; 9:852969. [PMID: 35402485 PMCID: PMC8987284 DOI: 10.3389/fsurg.2022.852969] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 02/08/2022] [Indexed: 02/03/2023] Open
Abstract
Although lymphonodal dissection is well-accepted for muscle-invasive bladder cancer management, its role is still debated during radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). The aim of this study was to summarize the current knowledge concerning the indication, anatomical template, prognostic, and therapeutic roles of lymph node dissection (LND) performed at the time of RNU. Quality control markers, such as the number of lymph nodes (LN) removed, lymph node density, and safety of the different surgical approaches, were assessed. We performed a narrative review using the PubMed and ClinicalTrials.gov databases. We identified and analyzed articles based on the practice and the role of lymph node dissection for non-metastatic UTUC. There are no clear guidelines regarding the indication of LND for UTUC, but aggressive tumors may beneficiate from lymphadenectomy since lymph node invasion is a clear independent poor prognostic factor, allowing for adjuvant treatments. It seems that an extended lymphadenectomy may provide therapeutic advantages as a higher number of nodes removed may be related to the removal of undetected LNs micrometastases and a subsequent improvement in recurrence rate and cancer-specific survival. Clear anatomical templates are thus needed based on the location and the laterality of the primary tumor.
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Affiliation(s)
- Arthur Peyrottes
- Department of Urology, Bichat-Claude Bernard Hospital, Assistance-Publique Hôpitaux de Paris, Paris University, Paris, France
| | - Gianluigi Califano
- Urology Unit, Department of Neurosciences, Reproductive Sciences and Odontostomatology, Federico II University of Naples, Naples, Italy
| | - Idir Ouzaïd
- Department of Urology, Bichat-Claude Bernard Hospital, Assistance-Publique Hôpitaux de Paris, Paris University, Paris, France
| | - Paul Lainé-Caroff
- Department of Urology, Bichat-Claude Bernard Hospital, Assistance-Publique Hôpitaux de Paris, Paris University, Paris, France
| | - Thibaut Long Depaquit
- Urology Unit, Military Teaching Hospital Sainte Anne, French Military Health Service, Toulon, France
| | - Jean-François Hermieu
- Department of Urology, Bichat-Claude Bernard Hospital, Assistance-Publique Hôpitaux de Paris, Paris University, Paris, France
| | - Evanguelos Xylinas
- Department of Urology, Bichat-Claude Bernard Hospital, Assistance-Publique Hôpitaux de Paris, Paris University, Paris, France
- *Correspondence: Evanguelos Xylinas
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3
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Huang J, Qian H, Yuan Y, Cai X, Chen Y, Zhang J, Kong W, Wu X, Cao M, Huang Y, Chen H, Xue W. Prospective Clinical Trial of the Oncologic Outcomes and Safety of Extraperitoneal Laparoscopic Extended Retroperitoneal Lymph Node Dissection at Time of Nephroureterectomy for Upper Tract Urothelial Carcinoma. Front Oncol 2022; 12:791140. [PMID: 35280720 PMCID: PMC8907892 DOI: 10.3389/fonc.2022.791140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 01/26/2022] [Indexed: 11/26/2022] Open
Abstract
Purpose To determine the safety and feasibility of extraperitoneal laparoscopic extended lymph node dissection (LND) at the time of extraperitoneal laparoscopic radical nephroureterectomy (RNU). Materials and Methods Between May 2018 and March 2019, 39 patients with upper tract urothelial carcinoma (UTUC) received extraperitoneal laparoscopic RNU and concomitant extraperitoneal laparoscopic extended LND. All patients were followed for at least 90 days. Perioperative and pathological data including nodal status and perioperative complications were collected. Results Among all 39 patients, 12 patients had pT1, 6 had pT2, 20 had pT3 disease, and 1 had T4 disease. The median (range) lymph node count was 10 (5–22), with 8 patients having pathologically proven lymph node metastasis. The median (range) operating time was 225 (165–430) min, and the median estimated blood loss was 200 (60–800) ml. The median postoperative hemoglobin loss was 1.6 (0–4.2) g/dl. The median (range) postoperative hospital stays were 6 (3–26) days. Overall, 7 patients experienced minor (Clavien Grade I–II) postoperative complications with five patients having Clavien Grade I complications and two patients having Clavien Grade II complications. No major complication (Clavien grade III–IV) occurred. With a median follow-up of 38 months, a total of 8 patients (20.5%) developed local or distant recurrence and no regional LNs where extended LND were performed had recurrence. Conclusions The present prospective study demonstrated that extraperitoneal laparoscopic extended LND during extraperitoneal laparoscopic RNU for UTUC is a feasible and safe procedure which provides minimal invasion, rapid recovery, and potentially lower risk of regional LN recurrence. Larger prospective clinical trials with survival endpoints are needed to further determine its potential therapeutic benefits. Trial Registration ClinicalTrials.gov identifier NCT 03544437 www.clinicaltrials.gov
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Affiliation(s)
- Jiwei Huang
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Hongyang Qian
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yichu Yuan
- Department of Urology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xingyun Cai
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yonghui Chen
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jin Zhang
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Wen Kong
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaorong Wu
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ming Cao
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yiran Huang
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Haige Chen
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Wei Xue
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Morselli S, Vitelli FD, Verrini G, Sebastianelli A, Campi R, Liaci A, Spatafora P, Barzaghi P, Ferrari G, Gacci M, Serni S, Brausi M. Comparison of Tumor Seeding and Recurrence Rate After Laparoscopic vs. Open Nephroureterectomy for Upper Urinary Tract Transitional Cell Carcinoma. Front Surg 2022; 8:769527. [PMID: 35004836 PMCID: PMC8732869 DOI: 10.3389/fsurg.2021.769527] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 11/15/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction: Laparoscopic surgery for Upper Urinary Tract Urothelial Cell Carcinoma (UTUC) is still debated for its possible seeding risk and thus consequent oncological recurrences, especially for atypical ones. The aim of the study is to compare recurrence and survival after Laparoscopic vs. Open Radical Nephroureterectomy (RNU) for Upper Urinary Tract Urothelial Cancer (UTUC). Method: A retrospective evaluation of UTUC consecutive surgeries from 2008 to 2019 was conducted, including pT ≥ 2, High Grade UTUC who underwent RNU with bladder cuff excision without concomitant lymphadenectomy in three urological tertiary centers. Statistical analyses compared recurrence and cancer specific survival, based on surgical approach, while logistic multivariate analyses and Kaplan Meyer survival curve analyzed possible risk factors for recurrence and survival. Results: One hundred seven cases of RNU, 47 (43.9%) laparoscopic and 60 (56.1%) open, were included in this report. Preoperative characteristics were comparable between groups. However, tumor stage was higher in the Open arm [T3–T4 in 44 (73.3%) vs. 20 (43.4%) in Laparoscopic]. Mean follow-up was 91.6 months in laparoscopy RNU vs. 93.5 months in open RNU. Recurrence rate (RR) was comparable between groups (p = 0.594), and so was the site, although 3 (6.3%) peritoneal recurrences were found only in laparoscopic group (p = 0.057). At multivariate logistic regression, tumor stage and surgical approach were independent predictors of recurrence (p < 0.05), while only tumor stage was predictor of cancer specific death (p = 0.029). Conclusion: Surgical approach has no impact on recurrence site, overall survival, and RR. Still, according to our data peritoneal carcinomatosis was present only in laparoscopic arm, despite how it didn't reach statistical significance.
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Affiliation(s)
- Simone Morselli
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Unit of Urological Minimally Invasive Robotic Surgery and Renal Transplantation, Careggi Hospital, University of Florence, Florence, Italy
| | | | | | - Arcangelo Sebastianelli
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Unit of Urological Minimally Invasive Robotic Surgery and Renal Transplantation, Careggi Hospital, University of Florence, Florence, Italy
| | - Riccardo Campi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Unit of Urological Minimally Invasive Robotic Surgery and Renal Transplantation, Careggi Hospital, University of Florence, Florence, Italy
| | - Andrea Liaci
- Unit of Urological Minimally Invasive Robotic Surgery and Renal Transplantation, Careggi Hospital, University of Florence, Florence, Italy
| | - Pietro Spatafora
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Unit of Urological Minimally Invasive Robotic Surgery and Renal Transplantation, Careggi Hospital, University of Florence, Florence, Italy
| | - Paolo Barzaghi
- Unit of Urological Minimally Invasive Robotic Surgery and Renal Transplantation, Careggi Hospital, University of Florence, Florence, Italy
| | | | - Mauro Gacci
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Unit of Urological Minimally Invasive Robotic Surgery and Renal Transplantation, Careggi Hospital, University of Florence, Florence, Italy
| | - Sergio Serni
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Unit of Urological Minimally Invasive Robotic Surgery and Renal Transplantation, Careggi Hospital, University of Florence, Florence, Italy
| | - Maurizio Brausi
- Department of Urology, Cure Hesperia Hospital, Modena, Italy.,Department of Urology, AUSL Modena, Modena, Italy
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5
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Olson KM, Faraj KS, Singh P, Tyson MD. Treatment of Upper Tract Urothelial Carcinoma. Urol Oncol 2022. [DOI: 10.1007/978-3-030-89891-5_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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6
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McIntosh AG, Umbreit EC, Wood CG, Matin SF, Karam JA. Role of lymph node dissection at the time of open or minimally invasive nephroureterectomy. Transl Androl Urol 2021; 10:2233-2245. [PMID: 34159106 PMCID: PMC8185683 DOI: 10.21037/tau.2019.11.34] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Unlike urothelial carcinoma of the bladder, there is no guideline-based consensus on whether a lymph node dissection (LND) should be performed at the time of radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). Variable lymphatic drainage based on primary tumor location, lack of prospective trials, and difficulties in developing a risk-adapted approach to LND for UTUC are all challenges to the development of an established approach. The UTUC literature consists of an evidence pool that has historically been limited to single-institution series with heterogenous inclusion criteria for LND and variable LND templates. Areas of controversy exist regarding migration to the great vessel LN beds for mid and distal tumors. A lack of template standardization limits the interpretation of studies relative to one another and a lack of uniformity in reporting templates may lead to inaccuracies in the estimation of lymph node metastasis landing sites. Most clinicians agree that there is a staging benefit to LND for UTUC. Although the data is somewhat heterogenous, it demonstrates a prognostic and staging benefit to LND in higher stages of UTUC. Unlike the staging benefits provided by LND for UTUC, the therapeutic benefits are not as clearly established. Several studies have evaluated differences in cancer-specific survival (CSS) and demonstrated LND to be an independent predictor of CSS when compared to patients not undergoing LND. However, this finding is not consistent across all studies and the literature is again limited by inclusion heterogeneity and inconsistent or lack or template-based resections. LND for UTUC at the time of RNU is a safe and feasible procedure that seems to especially benefit patients with muscle-invasive or locally advanced disease. Prospective, randomized studies with strict inclusion criteria and defined anatomic templates are needed to definitely characterize the role of LND for UTUC.
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Affiliation(s)
- Andrew G McIntosh
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eric C Umbreit
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christopher G Wood
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Surena F Matin
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jose A Karam
- Department of Urology and Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Abstract
The cornerstone for diagnosis and treatment of bladder and upper tract urothelial carcinoma involves surgery. Transurethral resection of bladder tumors forms the basis of further management. Radical cystectomy for invasive bladder carcinoma provides good oncologic outcomes. However, it can be a morbid procedure, and advances such as minimally invasive surgery and early recovery after surgery need to be incorporated into routine practice. Diagnostic ureteroscopy for upper tract carcinoma is needed in cases of doubt after cytology and imaging studies. Low-risk cancers can be managed with conservative endoscopic surgery without compromising oncological outcomes; however, high-risk disease necessitates radical nephroureterectomy.
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8
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Lec PM, Venkataramana A, Lenis AT, Fero KE, Sharma V, Golla V, Gollapudi K, Blumberg J, Chamie K. Trends in management of ureteral urothelial carcinoma and effects on survival: a hospital-based registry study. Urol Oncol 2020; 39:194.e17-194.e24. [PMID: 33012575 DOI: 10.1016/j.urolonc.2020.08.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/11/2020] [Accepted: 08/23/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND High-risk ureteral tumors represent an understudied subset of upper tract urothelial carcinoma, whose surgical management can range from a radical nephroureterectomy (NU) to segmental ureterectomy (SU). OBJECTIVES To evaluate contemporary trends in the management of high-risk ureteral tumors, the utilization of lymphadenectomy and peri-operative chemotherapy, and their impact on overall survival (OS). DESIGN, SETTING, AND PARTICIPANTS We performed a retrospective cohort study of patients in the National Cancer Database from years 2006 to 2013 with clinically localized high-risk ureteral tumors treated with NU or SU. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Chi-squared tests were utilized to assess differences in clinicodemographic features and peri-operative treatment delivery between SU and NU cohorts. Cochran-Armitage tests and linear regressions were performed to evaluate temporal trends in treatment utilization. Multivariable logistic regression models were employed to assess predictors of treatment delivery. Multivariable Cox proportional hazards models evaluated associations with OS. RESULTS Of the 1,962 patients included, NU was more commonly performed than SU (72.4%, 1,421/1,962 vs. 27.6%, 541/1,962). Only 22.7% (446/1,962) of the population underwent lymphadenectomy, and 24.8% (271/1,092) of those with advanced pathology (≥pT2 or pN+) received adjuvant chemotherapy. Lymphadenectomy was associated with improved OS in NU patients when more than 3 nodes were removed (hazard ratio [HR] 0.58, 95% confidence interval [CI] 0.39-0.89). Receipt of adjuvant chemotherapy for advanced pathology had no impact OS in both the NU (HR 1.10, 95% CI 0.84-1.44) and SU (HR 0.94, 95% CI 0.61-1.46) cohorts. Performance of SU was not associated with poorer OS on multivariable analysis (HR 1.02, 95% CI 0.89-1.21, P = 0.83). CONCLUSION Our study suggests that SU may be an appropriate alternative to NU for the management of high-risk ureteral tumors. Further, lymphadenectomy may play an important role at the time of NU, and adjuvant chemotherapy is infrequently utilized in patients with advanced pathology.
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Affiliation(s)
- Patrick M Lec
- Institute of Urologic Oncology (IUO), Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, CA.
| | - Abhishek Venkataramana
- Institute of Urologic Oncology (IUO), Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Andrew T Lenis
- Institute of Urologic Oncology (IUO), Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Katherine E Fero
- Institute of Urologic Oncology (IUO), Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Vidit Sharma
- Institute of Urologic Oncology (IUO), Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Vishnukamal Golla
- Institute of Urologic Oncology (IUO), Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Kiran Gollapudi
- Division of Urology, Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA
| | - Jeremy Blumberg
- Division of Urology, Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA
| | - Karim Chamie
- Institute of Urologic Oncology (IUO), Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, CA
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Goltzman ME, Gogoj A, Ristau BT. The role of lymphadenectomy at the time of radical nephroureterectomy for upper tract urothelial carcinoma. Transl Androl Urol 2020; 9:1860-1867. [PMID: 32944550 PMCID: PMC7475672 DOI: 10.21037/tau.2019.11.29] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The role of lymphadenectomy (LND) at the time of radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC) is controversial. The National Comprehensive Cancer Network guidelines recommend performing a template-based LND for high-risk primary tumors while the European guidelines state that it is not feasible to determine indication or extent of LND at the time of surgery for UTUC. Herein, we review the anatomic rationale for template-based LND, examine when a LND should be considered, and discuss the impact of LND on staging and survival outcomes.
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10
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Grimes N, McKay A, Lee SM, Aboumarzouk OM. Lymph node dissection during nephroureterectomy: Establishing the existing evidence based on a review of the literature. Arab J Urol 2019; 17:167-180. [PMID: 31489232 PMCID: PMC6711077 DOI: 10.1080/2090598x.2019.1596401] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 02/18/2019] [Accepted: 02/26/2019] [Indexed: 12/14/2022] Open
Abstract
Abstract Objective: To determine the role of lymph node dissection (LND) in the treatment of upper tract transitional cell carcinoma (UTTCC), as the role of LND along with nephroureterectomy in treating UTTCC is unclear and several retrospective studies have been published on this topic with conflicting results. Methods: The Medical Literature Analysis and Retrieval System Online (MEDLINE), the Excerpta Medica dataBASE (EMBASE), Cochrane Central Register of Controlled Trials database (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Clinicaltrials.gov, Google Scholar, and individual urological journals, were searched for all studies investigating the role of LND in the treatment of UTTCC. Of the studies identified, those that met inclusion criteria were included in this review. Results: In all, 27 studies were included in this review, with 9303 patients who underwent LND. No randomised controlled trials (RCTs) were identified. Tumours were located in the renal pelvis in 62% of patients, in the ureter in 35.5%, and multifocal in 2.3%. In total: 77.1% were LN-negative and 22.9% had LN metastasis. For all patients undergoing LND, the 5-year recurrence-free survival (RFS) and cancer-specific survival (CSS) rates were 27–65.4% and 32.3–95%, respectively. For patients who underwent a LND in accordance with a standardised anatomical template, the 5-year RFS and CSS rates were 84.3–93% and 83.5–94%, respectively. Conclusion: LND may provide a survival benefit in patients undergoing nephroureterectomy for UTTCC, particularly if following a standardised anatomical template and in those patients with muscle-invasive disease; however, a prospective RCT is required to confirm this. Abbreviations: CSS: cancer-specific survival; LN(D): lymph node (dissection); MeSH: Medical Subject Headings; OS: overall survival; pT: pathological T stage; RCT: randomised controlled trial; RFS: recurrence-free survival; UTTCC: upper tract TCC
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Affiliation(s)
- Nathan Grimes
- Department of Urology, Monklands Hospital, Airdrie, UK
| | - Alastair McKay
- Department of Urology, Glasgow Royal Infirmary, Glasgow, UK
| | - Su-Min Lee
- Department of Urology, Weston Area Health NHS Trust, Weston-super-Mare, UK
| | - Omar M Aboumarzouk
- Department of Urology, Queen Elizabeth University Hospital, Glasgow, UK.,University of Glasgow, Glasgow, UK
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11
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Duquesne I, Ouzaid I, Loriot Y, Moschini M, Xylinas E. Lymphadenectomy for Upper Tract Urothelial Carcinoma: A Systematic Review. J Clin Med 2019; 8:jcm8081190. [PMID: 31398895 PMCID: PMC6722659 DOI: 10.3390/jcm8081190] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 07/15/2019] [Accepted: 08/05/2019] [Indexed: 12/20/2022] Open
Abstract
Background: The role of lymphonodal dissection during surgery for a tumor of the urinary tract remains controversial. Objective: To analyze anatomical bases of lymphonodal dissection in tumors of the upper urinary tract and analyze its impact on survival, recurrence, and staging. Acquisition of data: A web-based search for scientific articles using Medline/Pubmed was carried out to identify and analyze articles on the practice and the role of lymphonodal dissection in this indication. Data Synthesis: The lymphatic drainage of the upper urinary tract has rarely been studied and is poorly understood. The lymphonodal metastatic extension is the most common extension in upper urinary tract urothelial carcinoma. Lymphnode invasion is a clear independent poor prognostic factor. Therefore, it seems legitimate to offer an extended lymphonodal dissection to patients undergoing surgery to cure these tumors. When lymphnodes dissection respects clear anatomical principles based on the location of the primary tumor and its extension, it improves both survival and recurrence rates. This result could be secondary to the treatment of subclinical metastatic disease. Conclusion: An extended lymphadenectomy during surgery for upper urinary tract urothelial carcinoma following strict anatomical pattern improves staging with a highly probable therapeutic benefit.
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Affiliation(s)
- Igor Duquesne
- Department of Urology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris Descartes University, 75014 Paris, France
- Department of Cancer Medicine, Gustave Roussy Institute, Cancer Campus, Grand Paris, University of Paris-Sud, 94800 Villejuif, France
| | - Idir Ouzaid
- Department of Urology, Bichat-Claude Bernard Hospital, Assistance Publique-Hôpitaux de Paris, Paris Diderot University, 75018 Paris, France
| | - Yohann Loriot
- Department of Cancer Medicine, Gustave Roussy Institute, Cancer Campus, Grand Paris, University of Paris-Sud, 94800 Villejuif, France
| | - Marco Moschini
- Klinik für Urologie, Luzerner Kantonsspital, 6004 Lucerne, Switzerland
| | - Evanguelos Xylinas
- Department of Urology, Bichat-Claude Bernard Hospital, Assistance Publique-Hôpitaux de Paris, Paris Descartes University, 75006 Paris, France.
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12
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13
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Potential Benefit of Lymph Node Dissection During Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma: A Systematic Review by the European Association of Urology Guidelines Panel on Non–muscle-invasive Bladder Cancer. Eur Urol Focus 2019; 5:224-241. [DOI: 10.1016/j.euf.2017.09.015] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 08/15/2017] [Accepted: 09/21/2017] [Indexed: 01/26/2023]
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Tamhankar AS, Patil SR, Ahluwalia P, Gautam G. Current Status of Lymphadenectomy During Radical Nephroureterectomy for Upper Tract Urothelial Cancer-Yes, No or Maybe? Indian J Surg Oncol 2018; 9:418-426. [PMID: 30288011 DOI: 10.1007/s13193-018-0807-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 07/26/2018] [Indexed: 01/30/2023] Open
Abstract
While pelvic lymphadenectomy during radical cystectomy for bladder cancer is a well-established standard of care, the same does not hold true for upper tract urothelial carcinoma (UTUC). Indeed, a template-based lymphadenectomy is rarely, if ever, performed in conjunction with radical nephroureterectomy at most centres across the globe. While multiple studies have explored the staging and therapeutic role of lymphadenectomy in cases of UTUC, there remain large gaps in our understanding of the indications, extent and safety of this procedure as an adjunct to nephroureterectomy. This article elucidates the current knowledge on outcomes, benefits and complications of template-based lymphadenectomy during radical nephroureterectomy for UTUC. We also explore the current evidence-based guidelines on this controversial topic.
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Affiliation(s)
- Ashwin Sunil Tamhankar
- Section of Urologic Oncology, Department of Surgical Oncology, Max Institute of Cancer Care, New Delhi, India
| | - Saurabh Ramesh Patil
- Section of Urologic Oncology, Department of Surgical Oncology, Max Institute of Cancer Care, New Delhi, India
| | - Puneet Ahluwalia
- Section of Urologic Oncology, Department of Surgical Oncology, Max Institute of Cancer Care, New Delhi, India
| | - Gagan Gautam
- Section of Urologic Oncology, Department of Surgical Oncology, Max Institute of Cancer Care, New Delhi, India
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Guo R, Zhu Y, Xiong G, Li X, Zhang K, Zhou L. Role of lymph node dissection in the management of upper tract urothelial carcinomas: a meta-analysis. BMC Urol 2018; 18:24. [PMID: 29636103 PMCID: PMC5894184 DOI: 10.1186/s12894-018-0336-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 03/13/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Lymph node dissection (LND) is not routinely performed during radical nephroureterectomy (RNU) in upper tract urothelial carcinomas (UTUC) and the role of LND has been controversial. We aim to investigate whether patients with LND had improved survival in UTUC patients. METHODS We performed a systematic literature search of PubMed, Embase, and Cochrane library for citations published prior to January 2016, describing LND performed among UTUC patients and conducted a standard meta-analysis of survival outcomes. RESULTS Eleven eligible studies containing 7516 patients satisfied the inclusion criteria. Pooled HRs for cancer-specific survival (CSS) and recurrence-free survival (RFS) were 1.17 (P = 0.18) and 1.33 (P = 0.19) respectively. However, the patients in the LND group had more advanced tumour stages and grades (P < 0.001). Further subgroup analysis showed that among muscle-invasive UTUC patients, the pooled HR for CSS and RFS were 1.10 (P = 0.42) and 0.92 (P = 0.72) respectively. Besides, no difference was found in CSS and RFS between pN0 and pNx individuals in overall populations and in patients with muscle-invasive UTUC, while pN+ patients had significantly worse prognosis when compared to pN0 patients. CONCLUSIONS LND during RNU allows more accurate staging and prediction of survival, but it remains uncertain whether LND independently improves survival in patients with UTUC. However, standard use of LND should be further investigated in a multi-center, prospective evaluation to obtain a definitive statement regarding this matter.
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Affiliation(s)
- Runqi Guo
- Department of Urology, Peking University First Hospital and Institute of Urology, National Research Center for Genitourinary Oncology, Beijing, 100034, China
| | - Yuze Zhu
- Department of Urology, Peking University First Hospital and Institute of Urology, National Research Center for Genitourinary Oncology, Beijing, 100034, China
| | - Gengyan Xiong
- Department of Urology, Peking University First Hospital and Institute of Urology, National Research Center for Genitourinary Oncology, Beijing, 100034, China
| | - Xuesong Li
- Department of Urology, Peking University First Hospital and Institute of Urology, National Research Center for Genitourinary Oncology, Beijing, 100034, China
| | - Kai Zhang
- Department of Urology, Peking University First Hospital and Institute of Urology, National Research Center for Genitourinary Oncology, Beijing, 100034, China.
| | - Liqun Zhou
- Department of Urology, Peking University First Hospital and Institute of Urology, National Research Center for Genitourinary Oncology, Beijing, 100034, China.
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Margolin EJ, Matulay JT, Li G, Meng X, Chao B, Vijay V, Silver H, Clinton TN, Krabbe LM, Woldu SL, Singla N, Bagrodia A, Margulis V, Huang WC, Bjurlin MA, Shah O, Anderson CB. Discordance between Ureteroscopic Biopsy and Final Pathology for Upper Tract Urothelial Carcinoma. J Urol 2018; 199:1440-1445. [PMID: 29427584 DOI: 10.1016/j.juro.2018.02.002] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2018] [Indexed: 10/18/2022]
Abstract
PURPOSE We evaluated the discordance between ureteroscopic biopsy and surgical pathology findings for grading and staging upper tract urothelial carcinoma. We also sought to establish preoperative predictors of aggressive tumors. MATERIALS AND METHODS We retrospectively reviewed the records of 314 patients who underwent ureteroscopic biopsy followed by surgical management of upper tract urothelial carcinoma from 2000 to 2016 at a total of 3 institutions. Our primary outcomes were muscle invasive (pT2 or greater) disease at surgical pathology and upgrading of clinical low grade tumors to pathological high grade. RESULTS At biopsy 61% of the patients had clinical high grade tumors and 21% had subepithelial connective tissue invasion (cT1+). On final pathology 79% of the patients had pathological high grade tumors and 45% had stage pT2 or greater. On multivariate analysis advanced patient age, clinical high grade and cT1+ were independently associated with pT2 or greater. The combined presence of clinical high grade and cT1+ had 86% positive predictive value for muscle invasion while the combined absence of clinical high grade and cT1+ had 80% negative predictive value. The likelihood of missing invasion on biopsy in patients with muscle invasive disease was increased when biopsy fragments were limited to 1 mm or less. Of clinical low grade cases on biopsy 51% were upgraded at surgery. The presence of positive urine cytology was associated with an increased risk of upgrading but this was not statistically significant. CONCLUSIONS Clinical high grade, cT1+ on biopsy and advanced patient age are independent risk factors for muscle invasive upper tract urothelial carcinoma. There is a significant risk of upgrading in patients with clinical low grade tumors on biopsy, especially when urine cytology is positive. The predictive value of biopsy can likely be improved by more extensive ureteroscopic sampling.
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Affiliation(s)
- Ezra J Margolin
- Department of Urology, Columbia University Medical Center, New York, New York
| | - Justin T Matulay
- Department of Urology, Columbia University Medical Center, New York, New York
| | - Gen Li
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York
| | - Xiaosong Meng
- Department of Urology, New York University Langone Medical Center, New York, New York
| | - Brian Chao
- Department of Urology, New York University Langone Medical Center, New York, New York
| | - Varun Vijay
- Department of Urology, New York University Langone Medical Center, New York, New York
| | - Hayley Silver
- Department of Urology, New York University Langone Medical Center, New York, New York
| | - Timothy N Clinton
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Laura-Maria Krabbe
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Solomon L Woldu
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Nirmish Singla
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Aditya Bagrodia
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Vitaly Margulis
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - William C Huang
- Department of Urology, New York University Langone Medical Center, New York, New York
| | - Marc A Bjurlin
- Department of Urology, New York University Langone Medical Center, New York, New York
| | - Ojas Shah
- Department of Urology, Columbia University Medical Center, New York, New York
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Tamhankar AS, Patil SR, Ahluwalia P, Gautam G. Robot-assisted radical nephroureterectomy with extended template lymphadenectomy for upper tract urothelial carcinoma: An outcome analysis. Indian J Urol 2018; 34:212-218. [PMID: 30034133 PMCID: PMC6034406 DOI: 10.4103/iju.iju_30_18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Introduction Robot-assisted radical nephroureterectomy (RANU) with extended template lymphadenectomy (E-LND) is the leading treatment option for nonmetastatic upper tract urothelial carcinoma. Due to the rarity of this disease, there is a lack of consensus regarding the best approach and the extent of lymphadenectomy. We report our technique and its initial outcomes from the retrospective evaluation of a prospectively maintained database of 11 consecutive cases of RANU + E-LND. To the best of our knowledge, our series represents the first published experience of this procedure from India. Materials and Methods RANU was performed in 11 patients (including two patients with simultaneous radical cystectomy) with the da Vinci Xi system. Pelvic and upper ureteric tumors were operated without re-docking or repositioning, using the port hopping feature. For the lower ureteric tumors, the patient was repositioned and the robot was re-docked to ensure completeness of pelvic lymphadenectomy. E-LND was performed in all the patients as per the templates described in previous studies. Results Median age was 67.5 years (range 52-71). Median console time and blood loss were 170 min (range 156-270) and 150 cc (range 25-500), respectively. Median hospital stay was 3 days (range 2-8). One patient developed paralytic ileus in the postoperative period (Clavien Dindo Grade 1). None had a positive surgical margin and the median lymph node yield was 22.5 (range 7-47). Median follow-up was 9 months during which one patient developed metastatic systemic recurrence. All other patients were disease free at the last follow-up. Conclusions A robotic approach to radical nephroureterectomy with E-LND is feasible and safe and does not appear to compromise the short-term oncological outcomes as defined by lymph node yields and margin positivity. At the same time, it offers the benefits of minimal invasion and results in swifter patient recovery from this extensive surgery.
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Affiliation(s)
| | | | - Puneet Ahluwalia
- Department of Uro-oncology, Max Institute of Cancer Care, New Delhi, India
| | - Gagan Gautam
- Department of Uro-oncology, Max Institute of Cancer Care, New Delhi, India
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Li P, Tao J, Deng X, Qin C, Cheng Y, Li P, Zhang J, Cao Y, Yang X, Yang C, Lu Q. Extraperitoneal Laparoscopic Radical Nephroureterectomy and Lymph Node Dissection in Modified Supine Position. Urology 2017; 107:126-131. [DOI: 10.1016/j.urology.2017.05.048] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 05/07/2017] [Accepted: 05/30/2017] [Indexed: 11/25/2022]
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Furuse H, Matsushita Y, Yajima T, Kato T, Suzuki T, Matsumoto R, Motoyama D, Sugiyama T, Otsuka A, Ozono S. Systematic regional lymph node dissection for upper tract urothelial carcinoma improves patient survival. Jpn J Clin Oncol 2017; 47:239-246. [PMID: 27920099 DOI: 10.1093/jjco/hyw179] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 11/20/2016] [Indexed: 11/13/2022] Open
Abstract
Objective Unlike for bladder cancer, the impact of regional lymph node dissection for upper tract urothelial carcinoma is unclear. We explored whether patient survival was influenced by systematic regional lymph node dissection, using resection templates according to the main tumor location, during radical nephroureterectomy for upper tract urothelial carcinoma. Methods The systematic regional lymph node dissection group was defined as cases in which the dissection of nodes and surrounding tissues followed the established template, and the non-systematic regional lymph node dissection group as cases undergoing limited or no lymph node dissection. We performed radical nephroureterectomy on 98 consecutive patients with various stages of upper tract urothelial carcinoma from May 1994 to September 2014 at our institution. Of these, 77 patients with cTanyN0M0 of upper tract urothelial carcinoma undergoing radical nephroureterectomy were grouped into systematic regional lymph node dissection or non-systematic regional lymph node dissection cohorts according to the extent of dissection, and their outcomes compared. Results Forty-four patients were categorized as systematic regional lymph node dissection and 33 as non-systematic regional lymph node dissection, including 17 with more limited nodal dissection and 16 with no nodal dissection. Five-year recurrence-free survival and cancer-specific survival were significantly higher in the systematic regional lymph node dissection (93% and 94%, respectively) than in the non-systematic regional lymph node dissection group (75% and 77% recurrence-free survival and cancer-specific survival, respectively). Further, 5-year recurrence-free survival and cancer-specific survival of muscle-invasive upper tract urothelial carcinoma (pT2-4) were significantly higher in the systematic regional lymph node dissection (87% and 91%, respectively) than in the non-systematic regional lymph node dissection group (59% and 62%, respectively) (P = 0.0237 and P = 0.0224). Neither recurrence-free survival nor cancer-specific survival was significantly prolonged by systematic dissection in patients with pTis-1 histology. Conclusions Systematic regional lymph node dissection during radical nephroureterectomy for cTanyN0M0 upper tract urothelial carcinoma patients has a significantly beneficial impact on survival compared with patients undergoing more limited dissection, especially in the cases involving muscle invasion.
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Affiliation(s)
- Hiroshi Furuse
- Department of Urology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yuto Matsushita
- Department of Urology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Takashi Yajima
- Department of Urology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Taiki Kato
- Department of Urology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Takahisa Suzuki
- Department of Urology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Rikiya Matsumoto
- Department of Urology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Daisuke Motoyama
- Department of Urology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Takayuki Sugiyama
- Department of Urology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Atsushi Otsuka
- Department of Urology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Seiichiro Ozono
- Department of Urology, Hamamatsu University School of Medicine, Hamamatsu, Japan
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20
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Ikeda M, Matsumoto K, Sakaguchi K, Ishii D, Tabata KI, Kurosawa K, Urakami S, Okaneya T, Iwamura M. Effect of Lymphadenectomy During Radical Nephroureterectomy in Locally Advanced Upper Tract Urothelial Carcinoma. Clin Genitourin Cancer 2017; 15:556-562. [PMID: 28501481 DOI: 10.1016/j.clgc.2017.04.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 03/29/2017] [Accepted: 04/03/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND The role of lymph node dissection (LND) for upper tract urothelial carcinoma (UTUC) patients remains controversial. The aim of this study was to evaluate the effect of LND on clinical outcomes during radical nephroureterectomy (RNU) and to determine prognostic factors of survival. PATIENTS AND METHODS From 1985 to 2013, 404 patients with UTUC underwent RNU; 5 patients who received neoadjuvant chemotherapy were excluded. Among them, 182 (46%) were pathologically negative for lymph node metastasis (pN0), 177 (44%) were non-LND (pNx), and 40 (10%) were positive for lymph nodes metastasis (pN1/2). RESULTS The 5-year disease-free survival (DFS) and cancer-specific survival (CSS) rate were higher in pN0 patients than in pNx patients and in pN1/2 patients. According to multivariate analysis, non-LND was an independent predictive factor of DFS (hazard ratio [HR], 1.91; P = .004) and CSS (HR, 2.28; P = .003). In the subgroup with muscle-invasive UTUC, the 5-year DFS and CSS rates were higher in pN0 patients than in pNx patients. However, there was no statistical difference between pN0 and pNx groups in terms of DFS and CSS in the pT2 cases. DFS and CSS times were significantly prolonged in the pN0 group in the locally advanced UTUC patients (≥pT3). CONCLUSION In the ≥pT3 subgroup, the 5-year DFS and CSS were significantly prolonged in the pN0 group, but there were no statistical differences between pN0 and pNx groups in terms of DFS and CSS in the pT2 subgroup. LND for patients with locally advanced UTUC might improve disease prognosis.
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Affiliation(s)
- Masaomi Ikeda
- Department of Urology, Kitasato University School of Medicine, Kaanagawa, Japan.
| | - Kazumasa Matsumoto
- Department of Urology, Kitasato University School of Medicine, Kaanagawa, Japan
| | - Kazushige Sakaguchi
- Department of Urology, Toranomon Hospital and Okinaka Memorial Institute for Medical Research, Tokyo, Japan
| | - Daisuke Ishii
- Department of Urology, Kitasato University School of Medicine, Kaanagawa, Japan
| | - Ken-Ichi Tabata
- Department of Urology, Kitasato University School of Medicine, Kaanagawa, Japan
| | - Kazuhiro Kurosawa
- Department of Urology, Toranomon Hospital and Okinaka Memorial Institute for Medical Research, Tokyo, Japan
| | - Shinji Urakami
- Department of Urology, Toranomon Hospital and Okinaka Memorial Institute for Medical Research, Tokyo, Japan
| | - Toshikazu Okaneya
- Department of Urology, Toranomon Hospital and Okinaka Memorial Institute for Medical Research, Tokyo, Japan
| | - Masatsugu Iwamura
- Department of Urology, Kitasato University School of Medicine, Kaanagawa, Japan
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Campi R, Minervini A, Mari A, Hatzichristodoulou G, Sessa F, Lapini A, Sessa M, Gschwend JE, Serni S, Roscigno M, Carini M. Anatomical templates of lymph node dissection for upper tract urothelial carcinoma: a systematic review of the literature. Expert Rev Anticancer Ther 2017; 17:235-246. [PMID: 28103449 DOI: 10.1080/14737140.2017.1285232] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Indications and techniques of lymph node dissection (LND) for upper tract urothelial carcinoma (UTUC) are still controversial. Areas covered: In this study, a systematic review of the English-language literature was performed up to 1 July 2016 using the Medline, Scopus, Cochrane Library and Web of Sciences databases to provide a detailed overview of the most commonly dissected surgical templates of LND for UTUC according to laterality and location of the tumor. Overall, sixteen studies were analyzed. Based on the shared experiences in the scientific literature, the LND template typically included: for right-sided tumors of the renal pelvis, upper third and middle third of the ureter, the renal hilar, paracaval, precaval and retrocaval nodes, while for left-sided tumors the renal hilar, paraaortic and preaortic nodes. For tumors of the lower ureter, an extended pelvic LND was performed in most cases; however, the paracaval, paraaortic or presacral nodes were dissected in selected series. Expert commentary: LND is not routinely performed at the time of surgery for UTUC and both indication and extent of LND vary among surgeons and institutions. Future high-quality studies are needed to define the most accurate LND templates and to assess their oncological efficacy and surgical morbidity.
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Affiliation(s)
- Riccardo Campi
- a Department of Urology , Careggi Hospital, University of Florence , Florence , Italy
| | - Andrea Minervini
- a Department of Urology , Careggi Hospital, University of Florence , Florence , Italy
| | - Andrea Mari
- a Department of Urology , Careggi Hospital, University of Florence , Florence , Italy
| | - Georgios Hatzichristodoulou
- b Department of Urology , Klinik und Poliklinik für Urologie, Technische Universität München (TUM), Klinikum rechts der Isar , Munich , Germany
| | - Francesco Sessa
- a Department of Urology , Careggi Hospital, University of Florence , Florence , Italy
| | - Albero Lapini
- a Department of Urology , Careggi Hospital, University of Florence , Florence , Italy
| | - Maurizio Sessa
- c Department of Experimental Medicine , Section of Pharmacology 'L. Donatelli', II University of Naples , Naples , Italy
| | - Jurgen Erich Gschwend
- b Department of Urology , Klinik und Poliklinik für Urologie, Technische Universität München (TUM), Klinikum rechts der Isar , Munich , Germany
| | - Sergio Serni
- a Department of Urology , Careggi Hospital, University of Florence , Florence , Italy
| | - Marco Roscigno
- d Department of Urology , AO Papa Giovanni XXIII , Bergamo , Italy
| | - Marco Carini
- a Department of Urology , Careggi Hospital, University of Florence , Florence , Italy
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Winer AG, Vertosick EA, Ghanaat M, Corradi RB, Carlsson S, Sjoberg DD, Sankin AI, Sfakianos JP, Cha EK, Dalbagni G, Coleman JA. Prognostic value of lymph node yield during nephroureterectomy for upper tract urothelial carcinoma. Urol Oncol 2016; 35:151.e9-151.e15. [PMID: 27932270 DOI: 10.1016/j.urolonc.2016.11.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 10/07/2016] [Accepted: 11/04/2016] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Lymph node dissection (LND) performed during radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC) remains controversial and difficult to evaluate. The aim of this study was to investigate whether removal of more lymph nodes during RNU is safe and improves oncologic outcomes. METHODS We evaluated 422 patients who underwent RNU with concomitant LND for upper tract urothelial carcinoma between 1976 and 2015, assessing for an association between total nodes removed, recurrence-free survival, and cancer-specific survival using Cox proportional hazards models. We also investigated the relationship between nodal yield and perioperative metrics and intersurgeon variability using linear regression. RESULTS In our cohort of 442 patients, 239 developed recurrences and 94 patients died of disease. Median follow-up among survivors was 3.7 years (interquartile range: 1.2, 7.4). The median nodal yield was 9 (interquartile range: 4, 16). Among patients with node-positive disease (pN1), we observed a significant improvement in recurrence-free survival (hazard ratio = 0.84 per 5 nodes removed, P = 0.039) and a nonsignificant improvement in cancer-specific survival with an increase in the nodal yield (hazard ratio = 0.90 per 5 nodes removed, P = 0.2). There was no evidence of an association between node yield and operative time, estimated blood loss, or 30-day complications on multivariable analysis. There was significant heterogeneity among surgeons regarding the extent of LND (P<0.0001). CONCLUSIONS We found that a more extensive node dissection may improve oncologic outcomes in a subset of high-risk patients without significantly increasing operative time or serious complications. Additionally, we identified considerable intersurgeon heterogeneity regarding the extent of LND furthering the notion of surgeon variability as a nonstandardized factor.
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Affiliation(s)
- Andrew G Winer
- SUNY Downstate College of Medicine and Kings County Hospital Center, Brooklyn, NY
| | - Emily A Vertosick
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York City, NY
| | - Mazyar Ghanaat
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, NY
| | - Renato B Corradi
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, NY
| | - Sigrid Carlsson
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York City, NY; Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, NY; Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Daniel D Sjoberg
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York City, NY
| | - Alexander I Sankin
- Department of Urology, Montefiore Medical Center and Albert Einstein College of Medicine, New York City, NY
| | - John P Sfakianos
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York City, NY
| | - Eugene K Cha
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, NY
| | - Guido Dalbagni
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, NY
| | - Jonathan A Coleman
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, NY.
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Szarvas T, Módos O, Horváth A, Nyirády P. Why are upper tract urothelial carcinoma two different diseases? Transl Androl Urol 2016; 5:636-647. [PMID: 27785420 PMCID: PMC5071198 DOI: 10.21037/tau.2016.03.23] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
In the last few years growing evidence highlighted the differences between upper tract urothelial carcinoma (UTUC) and urothelial bladder carcinoma (UBC) which cannot be explained solely by their different anatomical location. The aim of this review was to summarize current progress in UTUC research and to underline the differences and similarities between UTUC and UBC by focusing on epidemiology, etiology, staging and risk factors as well as on surgical and medical management. UBC and UTUC sharing common risk factors such as smoking and aromatic amines, while aristolochic acid exposure or familiar Lynch syndrome are rather specific for UTUC. The grading of UBC and UTUC are identical, but inherent from their different anatomical locations, there are some differences between their stage classifications. As an example, in contrast to UBC where a clear recommendation for pT3 subclassification exists, in UTUC current research aims to define an adequate subclassification for pelvic pT3 cases aiming to provide a better risk stratification. The primary treatment for both UBC and UTUC is surgery. Similarly to UBC, UTUC patients at high risk of disease progression are treated by radical surgery. However, because of the inaccurate preoperative or transurethral staging of UTUC, many radical nephroureterectomies are performed unnecessarily. Preoperative prediction of pathological stage or patients' prognosis may reduce this overtreatment by selecting patients for nephron-sparing surgery. To this end, predictive models combining histological and molecular features together with imaging data may be used. The antegrade or retrograde instillation of BCG or mitomycin C, as topical agents is feasible after conservative treatment of UTUC or for the treatment of CIS. However, the prognostic significance of lymph node positivity in UTUC seems to be similar to that of UBC, the therapeutic benefit of lymph node dissection (LND) in UTUC has not been firmly established yet. In addition, the number of lymph nodes to be removed and the sequence of lymphadenectomy also remain to be defined. Systemic neoadjuvant and adjuvant chemotherapies appear to have beneficial effect on UTUC survival, however, this has to be confirmed by large prospective studies. Due to the intensive research of the last few years, our knowledge on UTUC has been largely improved, but many questions remained to be answered. Further research on the molecular background of UTUC holds the potential to identify prognostic or predictive markers which, together with imaging and histologic data, may help to overcome the inaccuracy of ureteroscopic endoscopy and may therefore help to improve therapeutic decision-making. Further, prospective studies should confirm the benefit of LND and adjuvant chemotherapy. Considering the low incidence of UTUC, conduction of such studies is difficult and may only be performed in a multicenter setting.
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Affiliation(s)
- Tibor Szarvas
- Department of Urology, Semmelweis University, Budapest, Hungary; ; Department of Urology, University Hospital of Essen, University of Duisburg-Essen, Essen, Germany
| | - Orsolya Módos
- Department of Urology, Semmelweis University, Budapest, Hungary
| | - András Horváth
- Department of Urology, Semmelweis University, Budapest, Hungary
| | - Péter Nyirády
- Department of Urology, Semmelweis University, Budapest, Hungary
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Chappidi MR, Kates M, Johnson MH, Hahn NM, Bivalacqua TJ, Pierorazio PM. Lymph node yield and tumor location in patients with upper tract urothelial carcinoma undergoing nephroureterectomy affects survival: A U.S. population-based analysis (2004-2012). Urol Oncol 2016; 34:531.e15-531.e24. [PMID: 27476032 DOI: 10.1016/j.urolonc.2016.06.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 06/15/2016] [Accepted: 06/18/2016] [Indexed: 12/20/2022]
Abstract
PURPOSE The purpose of the study was to characterize the contemporary trends in lymphadenectomy for the treatment of upper tract urothelial carcinoma in a population-based cohort and to determine if number of lymph nodes removed and tumor location are predictors of cancer-specific survival in patients undergoing nephroureterectomy. MATERIALS AND METHODS Individuals with upper tract urothelial carcinoma undergoing nephroureterectomy in the Surveillance, Epidemiology, and End Results program from 2004 to 2012 were identified. Linear regression was used to assess trends in lymphadenectomy. Patients were stratified based on nodal status, quartiles of nodes removed, and tumor location. Kaplan-Meier analysis, log-rank tests, and Cox proportional hazards models were used to compare cancer-specific survival and overall survival among groups. RESULTS In the cohort, 25% (721/2,862) of all patients and 27% (566/2,079) of grade 3/4 patients underwent lymphadenectomy. The percentage of patients undergoing lymphadenectomy increased from 20% (60/295) in 2004 to 33% (106/320) in 2012 (P = 0.02). Patients with the highest quartile of lymph nodes removed had improved the 5-year cancer-specific survival of 78% (95% CI: 69%-85%) compared to the second quartile (60%; 95% CI: 51%-67%; P = 0.003) and the third quartile (60%; 95% CI: 51%-68%; P = 0.002) of nodes removed. This trend held for node-negative and node-positive patients. In multivariable modeling, a lower number of lymph nodes dissected (hazard ratio = 0.94, 95% CI: 0.91-0.98) and ureteral tumors (hazard ratio = 1.29, 95% CI: 1.07-1.56) were predictors of worse cancer-specific survival. CONCLUSIONS In patients with upper tract urothelial carcinoma undergoing nephroureterectomy, rates of lymphadenectomy have increased from 2004 to 2012 in the United States. In this contemporary cohort, an increase in the number of nodes removed and renal pelvis tumors are associated with improved cancer-specific survival, which highlights the importance of intentional lymph node dissection with adequate lymph node yield in these patients.
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Affiliation(s)
- Meera R Chappidi
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Max Kates
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael H Johnson
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Noah M Hahn
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Trinity J Bivalacqua
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Phillip M Pierorazio
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
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Template-based lymphadenectomy reduces the risk of regional lymph node recurrence among patients with upper/middle ureteral cancer. Int J Clin Oncol 2016; 22:145-152. [DOI: 10.1007/s10147-016-1024-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 07/12/2016] [Indexed: 01/26/2023]
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Fiuk JV, Schwartz BF. Upper tract urothelial carcinoma: Paradigm shift towards nephron sparing management. World J Nephrol 2016; 5:158-165. [PMID: 26981440 PMCID: PMC4777787 DOI: 10.5527/wjn.v5.i2.158] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 09/10/2015] [Accepted: 01/29/2016] [Indexed: 02/06/2023] Open
Abstract
Upper tract urothelial carcinoma (UTUC) is relatively rare compared to urothelial carcinoma of the lower tract, comprising only 5%-10% of all urothelial cancers. Although both entities share histologic properties, UTUC tends to be more invasive at diagnosis and portend a worse prognosis, with a 5 year overall mortality of 23%. To date, the gold standard management of UTUC has been radical nephroureterectomy (RNU), with nephron sparing techniques reserved for solitary kidneys or cases where the patient could not tolerate radical surgery. Limited data from these series, as well as select series where nephron-sparing endoscopic management has been offered to a broader patient base, suggest that minimally invasive, nephron sparing techniques can offer comparable oncologic and survival outcomes to RNU in appropriately selected patients. We review the current literature on the topic and discuss long term outcomes and sequelae of the gold standard treatment, RNU. We also discuss the oncologic outcomes of minimally invasive, endoscopic management of UTUC. Our goal is to provide the reader a comprehensive overview of the current state of the field in order to inform and guide their treatment decisions.
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The effect of surgical approach on performance of lymphadenectomy and perioperative morbidity for radical nephroureterectomy. Urol Oncol 2016; 34:121.e15-21. [DOI: 10.1016/j.urolonc.2015.09.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 09/13/2015] [Accepted: 09/16/2015] [Indexed: 11/18/2022]
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Mathieu R, Bensalah K, Lucca I, Mbeutcha A, Rouprêt M, Shariat SF. Upper urinary tract disease: what we know today and unmet needs. Transl Androl Urol 2016; 4:261-72. [PMID: 26816829 PMCID: PMC4708228 DOI: 10.3978/j.issn.2223-4683.2015.05.01] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Purpose Upper tract urothelial carcinoma (UTUC) is a rare and poorly investigated disease. Intense collaborative efforts have increased our knowledge and improved the management of the disease. The objective of this review was to discuss recent advances and unmet needs in UTUC. Methods A non-systematic Medline/PubMed literature search was performed on UTUC using the terms “upper tract urothelial carcinoma” with different combinations of keywords. Original articles, reviews and editorials in English language were selected based on their clinical relevance. Results UTUC is a disease with specific epidemiologic and risk factors different to urothelial carcinoma of the bladder (UCB). Similarly to UCB, smoking increases the risk of UTUC and worsens its prognosis, whereas aristolochic acid (AA) exposure and mismatch repair genes abnormality are UTUC specific risk factors. A growing understanding of biological pathways involved in the tumorigenesis of UTUC has led to the identification of promising prognostic/predictive biomarkers. Risk stratification of UTUC is difficult due to limitations in staging and grading. Modern imaging and endoscopy have improved clinical decision-making, and allowed kidney-sparing management and surveillance in favorable-risk tumors. In high-risk tumors, radical nephroureterectomy (RNU) remains the standard. Complete removal of the intramural ureter is necessary with inferiority of endoscopic management. Post-RNU intravesical instillation has been shown to decrease bladder cancer recurrence rates. While the role of neoadjuvant cisplatin based combination chemotherapy and lymphadenectomy are not clearly established, the body of evidence suggests a survival benefit to these. There is currently no evidence for adjuvant chemotherapy (AC) in UTUC. Conclusions Despite growing interest and understanding of UTUC, its management remains challenging, requiring further high quality multicenter collaborations. Accurate risk estimation is necessary to avoid unnecessary RNUs while advances in technology are still required for optimal kidney-sparing approaches.
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Affiliation(s)
- Romain Mathieu
- 1 Department of Urology, Rennes University Hospital, Rennes, France ; 2 Department of Urology, General Hospital, Medical University Vienna, Vienna, Austria ; 3 Department of Urology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland ; 4 Academic Department of Urology, La Pitié-Salpetrière Hospital, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Pierre et Marie Curie, University Paris 6, Paris, France ; 5 Department of Urology, University of Texas Southwestern Medical Center, Dallas, USA ; 6 Department of Urology, Weill Cornell Medical College, New York, USA
| | - Karim Bensalah
- 1 Department of Urology, Rennes University Hospital, Rennes, France ; 2 Department of Urology, General Hospital, Medical University Vienna, Vienna, Austria ; 3 Department of Urology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland ; 4 Academic Department of Urology, La Pitié-Salpetrière Hospital, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Pierre et Marie Curie, University Paris 6, Paris, France ; 5 Department of Urology, University of Texas Southwestern Medical Center, Dallas, USA ; 6 Department of Urology, Weill Cornell Medical College, New York, USA
| | - Ilaria Lucca
- 1 Department of Urology, Rennes University Hospital, Rennes, France ; 2 Department of Urology, General Hospital, Medical University Vienna, Vienna, Austria ; 3 Department of Urology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland ; 4 Academic Department of Urology, La Pitié-Salpetrière Hospital, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Pierre et Marie Curie, University Paris 6, Paris, France ; 5 Department of Urology, University of Texas Southwestern Medical Center, Dallas, USA ; 6 Department of Urology, Weill Cornell Medical College, New York, USA
| | - Aurélie Mbeutcha
- 1 Department of Urology, Rennes University Hospital, Rennes, France ; 2 Department of Urology, General Hospital, Medical University Vienna, Vienna, Austria ; 3 Department of Urology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland ; 4 Academic Department of Urology, La Pitié-Salpetrière Hospital, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Pierre et Marie Curie, University Paris 6, Paris, France ; 5 Department of Urology, University of Texas Southwestern Medical Center, Dallas, USA ; 6 Department of Urology, Weill Cornell Medical College, New York, USA
| | - Morgan Rouprêt
- 1 Department of Urology, Rennes University Hospital, Rennes, France ; 2 Department of Urology, General Hospital, Medical University Vienna, Vienna, Austria ; 3 Department of Urology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland ; 4 Academic Department of Urology, La Pitié-Salpetrière Hospital, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Pierre et Marie Curie, University Paris 6, Paris, France ; 5 Department of Urology, University of Texas Southwestern Medical Center, Dallas, USA ; 6 Department of Urology, Weill Cornell Medical College, New York, USA
| | - Shahrokh F Shariat
- 1 Department of Urology, Rennes University Hospital, Rennes, France ; 2 Department of Urology, General Hospital, Medical University Vienna, Vienna, Austria ; 3 Department of Urology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland ; 4 Academic Department of Urology, La Pitié-Salpetrière Hospital, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Pierre et Marie Curie, University Paris 6, Paris, France ; 5 Department of Urology, University of Texas Southwestern Medical Center, Dallas, USA ; 6 Department of Urology, Weill Cornell Medical College, New York, USA
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Miyazaki J, Nishiyama H, Fujimoto H, Ohyama C, Koie T, Hinotsu S, Kikuchi E, Sakura M, Inokuchi J, Hara T. Laparoscopic Versus Open Nephroureterectomy in Muscle-Invasive Upper Tract Urothelial Carcinoma: Subanalysis of the Multi-Institutional National Database of the Japanese Urological Association. J Endourol 2016; 30:520-5. [PMID: 26669358 DOI: 10.1089/end.2015.0757] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Open nephroureterectomy (ONU) is the current standard for muscle-invasive upper tract urothelial carcinoma (UTUC) in the European Association of Urology/Japanese Urological Association (JUA) guidelines. In this study, we compared the postsurgical survival of muscle-invasive UTUC patients treated with ONU or with laparoscopic nephroureterectomy (LNU), using the multi-institutional national database of the JUA. METHODS The 1509 patients with UTUC who were diagnosed at 348 Japanese institutions in 2005 were registered. We collected the clinical data of the patients in 2011. The muscle-invasive UTUC patients who underwent ONU or LNU were identified, and survival curves were estimated using the Kaplan-Meier method. RESULTS Overall, 749 pT2≥cNxM0 patients underwent a nephroureterectomy (ONU, n = 527 and LNU, n = 222). The overall survival and cause-specific survival rates were not significantly different between the ONU and LNU groups (p = 0.1263 and p = 0.0893, respectively). In addition, 459 of the 749 (61.3%) patients experienced disease recurrence (bladder recurrence, local recurrence, or distant metastasis), with no significant difference between the ONU and LNU groups. Even when patients were stratified by pT3/pT4 and/or pN+, overall survival was not significantly different between the ONU and LNU groups (p = 0.2876). The results of a univariate analysis showed that lymphovascular invasion was an independent prognostic factor for overall survival, but the surgical approaches were not found to be associated with overall survival. CONCLUSIONS Our data suggest that there is no evidence that the oncologic outcome of LNU is inferior to that of ONU in muscle-invasive UTUC, when the appropriate patients are selected.
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Affiliation(s)
- Jun Miyazaki
- 1 Department of Urology, Faculty of Medicine, University of Tsukuba , Ibaraki, Japan
| | - Hiroyuki Nishiyama
- 1 Department of Urology, Faculty of Medicine, University of Tsukuba , Ibaraki, Japan
| | | | - Chikara Ohyama
- 3 Department of Urology, Hirosaki University Graduate School of Medicine , Hirosaki, Japan
| | - Takuya Koie
- 3 Department of Urology, Hirosaki University Graduate School of Medicine , Hirosaki, Japan
| | - Shiro Hinotsu
- 4 Center for Innovative Clinical Medicine, Okayama University Hospital , Okayama, Japan
| | - Eiji Kikuchi
- 5 Department of Urology, Keio University School of Medicine , Tokyo, Japan
| | - Mizuaki Sakura
- 6 Department of Urology, Cancer Institute Hospital , Japanese Foundation of Cancer Research, Tokyo, Japan
| | - Junichi Inokuchi
- 7 Department of Urology, Graduate School of Medical Sciences, Kyushu University , Fukuoka, Japan
| | - Tomohiko Hara
- 2 Urology Division, National Cancer Center Hospital , Tokyo, Japan
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Contemporary role of lymph node dissection at the time of radical nephroureterectomy for upper tract urothelial carcinoma. World J Urol 2016; 35:535-548. [PMID: 26809456 DOI: 10.1007/s00345-016-1764-z] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2015] [Accepted: 01/05/2016] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To review the contemporary data on the role of lymph node dissection (LND) at the time of radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). METHODS A computerized bibliographic search using the following protocol ("Nephroureterectomy") AND ("Lymphadenectomy" OR "Lymph node" OR "Lymphatic") was performed in MEDLINE to identify all original and review articles that addressed the role of LND for UTUC. RESULTS Regional lymph node (LN) boundaries of UTUC have been recently investigated in mapping studies to propose anatomic templates of LND according to the laterality and location of primary tumor. Although these anatomic templates remained poorly described, most reports supported the staging benefit of LND that allowed for risk stratification of patients with (pN+) or without (pN0) LN metastases from those who did not undergo such a procedure (pNx). In addition, the therapeutic benefit of LND at the time of RNU was supported by better oncological outcomes obtained after complete LND when compared to incomplete or no LND, especially in the group of patients with advanced disease. The number of LNs removed was also correlated with both, more accurate staging and greater cancer-specific survival after LND, whose feasibility and safety have been validated in prospective studies. CONCLUSIONS Despite mostly based on data with level of evidence 3, our comprehensive review of the literature supports the staging and therapeutic benefits of LND at the time of RNU for UTUC, which are particularly significant for patients with muscle-invasive or locally advanced disease.
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OUTCOMES AFTER SURGICAL TREATMENT OF UPPER TRACT UROTHELIAL CARCINOMA. Nihon Hinyokika Gakkai Zasshi 2016; 107:79-86. [PMID: 28442674 DOI: 10.5980/jpnjurol.107.79] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
(Objectives) We retrospectively investigated the prognostic factors and the role of adjuvant chemotherapy against upper tract urothelial carcinoma (UTUC) after surgery. (Materials and methods) 343 patients of UTUC who underwent radical nephroureterectomy at Jikei University Hospital and affiliated institutions between January 2004 and February 2012 were retrospectively analyzed. A chi-squared test was used for categorical variables. Survival probabilities after surgery were estimated using the Kaplan-Meier method. Multivariate Cox regression models addressed overall survival and cancer-specific survival after surgery. (Results) The 5-year overall and cancer-specific survival rates were 64.6% and 74.6%, respectively. On multivariate analysis, higher age, male, higher pT-stage and lymphovascular invasion (LVI) were associated with worse overall survival and higher pT-stage and LVI were associated with worse cancer-specific survival. 44 patients (G3 and ≥pT3) who received cisplatin-based adjuvant chemotherapy had improved overall survival (P=0.044). (Conclusions) Higher pT-stage, LVI were important prognostic variables associated with oncologic outcomes. Cisplatin-based adjuvant chemotherapy offered a significant benefit to overall survival in high risk UTUC (G3 and ≥pT3), but more investigations are needed to confirm its utility.
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Kondo T, Takagi T, Tanabe K. Therapeutic role of template-based lymphadenectomy in urothelial carcinoma of the upper urinary tract. World J Clin Oncol 2015; 6:237-51. [PMID: 26677437 PMCID: PMC4675909 DOI: 10.5306/wjco.v6.i6.237] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 08/14/2015] [Accepted: 10/01/2015] [Indexed: 02/06/2023] Open
Abstract
Lymphadenectomy for urothelial carcinoma of the upper urinary tract has attracted the attention of physicians. The mapping study of lymphatic spread has shown that a relatively wide area should comprise the regional nodes for tumors of the right renal pelvis or the right upper two-thirds of the ureter. A prospective study showed that an anatomical template-based lymphadenectomy significantly improved patient survival in tumors of the renal pelvis. This benefit was more evident for patients with pT2 stage tumors or higher. The risk of regional node recurrence is significant reduced by template-based lymphadenectomy, which is likely to be associated with improved patient survival. The removal of lymph node micrometastases is assumed to be the reason for therapeutic benefit following lymphadenectomy. The number of resected lymph nodes can be used to assess the quality of lymphadenectomy, but not to determine the extent of lymphadenectomy. The guidelines currently recommend lymphadenectomy for patients with muscle-invasive disease, even though the current recommendation grades are still low. The present limitation of lymphadenectomy is the lack of standardization of the extent of lymphadenectomy and the randomized trials. Further studies are warranted to collect the evidence to support lymphadenectomy.
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Zhang XK, Zhang ZL, Yang P, Cai MY, Hu WM, Yun JP, Zhou FJ, Qian CN, Cao Y. Tumor necrosis predicts poor clinical outcomes in patients with node-negative upper urinary tract urothelial carcinoma. Jpn J Clin Oncol 2015; 45:1069-75. [PMID: 26355163 DOI: 10.1093/jjco/hyv127] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 07/30/2015] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE Tumor necrosis has been indicated as a factor for the poor clinical outcome in human cancers. We aim to disclose the association between tumor necrosis and overall survival and recurrence-free survival in node-negative upper urinary tract urothelial carcinoma patients treated with radical nephroureterectomy. METHODS A retrospective cohort of 100 patients with upper urinary tract urothelial carcinoma from January 1990 to June 2011 was enrolled in this study. Univariate analysis with Log-rank test and multivariate analysis with Cox proportional hazards regression models were conducted to determine the correlations of tumor necrosis with overall survival and recurrence-free survival. RESULTS Tumor necrosis was presented in 48 patients with upper urinary tract urothelial carcinoma and was significantly associated with the advanced pathological stage (P < 0.001), high tumor grade (P < 0.001), subsequent bladder tumor (P = 0.018), vascular invasion (P < 0.001) and lymph node metastasis (P = 0.026). Multivariate analysis revealed tumor necrosis as an independent unfavorable predictor of overall survival in node-negative upper urinary tract urothelial carcinoma patients by multivariate analysis (hazard ratio = 9.23, 95% confidence interval = 1.05-80.89, P = 0.045). CONCLUSIONS Tumor necrosis was an independent factor of adverse clinical outcomes in node-negative upper urinary tract urothelial carcinoma patients who received radical nephroureterectomy. Evaluation of tumor necrosis might be of clinical significance to determine whether patients with node-negative upper urinary tract urothelial carcinoma should be given further therapy after radical nephroureterectomy.
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Affiliation(s)
- Xin-Ke Zhang
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou Department of Pathology, Sun Yat-sen University Cancer Center, Guangzhou
| | - Zhi-Ling Zhang
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Ping Yang
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou Department of Pathology, Sun Yat-sen University Cancer Center, Guangzhou
| | - Mu-Yan Cai
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou Department of Pathology, Sun Yat-sen University Cancer Center, Guangzhou
| | - Wan-Ming Hu
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou Department of Pathology, Sun Yat-sen University Cancer Center, Guangzhou
| | - Jing-Ping Yun
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou Department of Pathology, Sun Yat-sen University Cancer Center, Guangzhou
| | - Fang-Jian Zhou
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Chao-Nan Qian
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou
| | - Yun Cao
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou Department of Pathology, Sun Yat-sen University Cancer Center, Guangzhou
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Lucca I, Leow JJ, Shariat SF, Chang SL. Diagnosis and Management of Upper Tract Urothelial Carcinoma. Hematol Oncol Clin North Am 2015; 29:271-88, ix. [DOI: 10.1016/j.hoc.2014.10.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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A contemporary review of management and prognostic factors of upper tract urothelial carcinoma. Cancer Treat Rev 2015; 41:310-9. [DOI: 10.1016/j.ctrv.2015.02.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 02/09/2015] [Accepted: 02/11/2015] [Indexed: 01/02/2023]
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Abe T, Takada N, Matsumoto R, Osawa T, Sazawa A, Maruyama S, Tsuchiya K, Harabayashi T, Minami K, Nagamori S, Hatanaka KC, Tanaka Y, Shinohara N, Nonomura K. Outcome of regional lymphadenectomy in accordance with primary tumor location on laparoscopic nephroureterectomy for urothelial carcinoma of the upper urinary tract: a prospective study. J Endourol 2014; 29:304-9. [PMID: 25255401 DOI: 10.1089/end.2014.0369] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
PURPOSE To determine the appropriate template of regional lymph node dissection (LND) at the time of laparoscopic nephroureterectomy (LNU) for patients with clinically node- negative urothelial carcinoma of the upper urinary tract. PATIENTS AND METHODS This prospective study included 45 patients undergoing LND with LNU in accordance with our prospective rules regarding the area of LND. Perioperative, pathologic, and follow-up data were collected. Micrometastasis in lymph nodes (LNs) was later evaluated by immunohistochemistry (IHC). Recurrence-free survival (RFS) was calculated with the Kaplan-Meier method. RESULTS The median number of LNs removed was 14 (range 1-33). One patient with pT3 disease had node metastasis based on routine pathologic examination, and IHC revealed micrometastases in two additional patients (pT2 in one and pT3 in one). Therefore, 15% (3/20) of patients with ≥pT2 disease had node disease. After surgery, six patients experienced minor complications (Grade 1 or 2), and Grade 5 gastrointestinal bleeding after aspiration pneumonia developed in one elderly male patient on the 45th postoperative day, which was not considered to be associated with LND. At the last follow-up, lung metastasis developed in four patients (pT1 in one, pT2 in one, and pT3 in two), and presacral lymph node metastasis developed in one patient with a lower ureteral tumor (pT2), which was not included in our prospective template for a lower ureteral tumor. LN recurrence within/ near the LND area was not observed in patients with pelvic/upper ureteral carcinoma. The 2-year nonurothelial RFS rate was 84%. CONCLUSIONS We consider that the present template represents regional LNs for patients with clinically node-negative pelvic/upper ureteral carcinoma, while presacral LNs may be incorporated into the regional LND template for patients with clinically node-negative lower ureteral carcinoma.
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Affiliation(s)
- Takashige Abe
- 1 Department of Urology, Hokkaido University Graduate School of Medicine , Sapporo, Japan
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Neuzillet Y, Colin P, Phé V, Shariat S, Rouprêt M. Traitement chirurgical des tumeurs de la voie excrétrice supérieure par néphro-urétérectomie totale : état-de-l’art pour le rapport annuel de l’Association française d’urologie. Prog Urol 2014; 24:1021-9. [DOI: 10.1016/j.purol.2014.07.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 06/27/2014] [Accepted: 07/16/2014] [Indexed: 01/18/2023]
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Kondo T, Hara I, Takagi T, Kodama Y, Hashimoto Y, Kobayashi H, Iizuka J, Omae K, Ikezawa E, Yoshida K, Tanabe K. Possible role of template-based lymphadenectomy in reducing the risk of regional node recurrence after nephroureterectomy in patients with renal pelvic cancer. Jpn J Clin Oncol 2014; 44:1233-8. [PMID: 25271269 DOI: 10.1093/jjco/hyu151] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE It remains unclear whether lymphadenectomy alters regional node recurrence after nephroureterectomy in patients with urothelial carcinoma of the renal pelvis. The predictive factors for regional node recurrence are still unclear. In this study, we retrospectively examined how the extent of lymphadenectomy influences regional node recurrence in patients with urothelial carcinoma of the renal pelvis. METHODS From January 1988 through July 2013, we performed nephroureterectomy in 180 patients with non-metastatic (cN0M0) urothelial carcinoma of the renal pelvis at two Japanese institutes. Regional nodes were determined according to our previous mapping study: complete lymphadenectomy designates that all regional sites were dissected; incomplete lymphadenectomy that all sites were not dissected. A third group included those without lymphadenectomy. RESULTS The 5-year cancer-specific and recurrence-free survival was significantly higher in the complete lymphadenectomy group than in the incomplete lymphadenectomy or without lymphadenectomy groups (P = 0.03). The incidence of regional node recurrence was significantly lower in the complete lymphadenectomy group at 2.9% (2/67) than in the incomplete lymphadenectomy at 18.1% (4/22) or without lymphadenectomy at 10.9% (10/91) groups (P = 0.03). In patients with incomplete lymphadenectomy, 75% of regional node recurrence occurred outside of the dissected sites. Complete lymphadenectomy is shown to be a likely predictive factor of reduced risk of recurrence at the regional nodes by multivariate analysis, after adjusting for patient age, pathological T stage, and pathological nodal metastases. CONCLUSIONS This study shows that template-based lymphadenectomy reduced the risk of regional node recurrence in patients with urothelial carcinoma of the renal pelvis and appears to result in improved survival.
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Affiliation(s)
- Tsunenori Kondo
- Department of Urology, Tokyo Women's Medical University, Tokyo
| | - Isao Hara
- Department of Urology, Wakayama Medical University, Wakayama, Japan
| | - Toshio Takagi
- Department of Urology, Tokyo Women's Medical University, Tokyo
| | - Yoshiki Kodama
- Department of Urology, Wakayama Medical University, Wakayama, Japan
| | | | | | - Junpei Iizuka
- Department of Urology, Tokyo Women's Medical University, Tokyo
| | - Kenji Omae
- Department of Urology, Tokyo Women's Medical University, Tokyo
| | - Eri Ikezawa
- Department of Urology, Tokyo Women's Medical University, Tokyo
| | | | - Kazunari Tanabe
- Department of Urology, Tokyo Women's Medical University, Tokyo
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Yang D, Chen Q, Song X, Wang J, Che X, Zhu Z, Zheng W, Wang L. Effect of lymph node dissection on the outcomes of upper tract urothelial carcinomas: a meta-analysis. Expert Rev Anticancer Ther 2014; 14:667-75. [PMID: 24673605 DOI: 10.1586/14737140.2014.895670] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A systematic search was conducted in PubMed, Cochrane Library. 6032 patients were included. There was no significant difference in survival between LND and NLND (non-lymph node dissection) among the patients. However, the patients in the LND group had more advanced tumour stages and grades (p < 0.001). In addition, among the muscle-invasive patients, LND demonstrated remarkable CSS improvement compared with NLND (HR: 2.19; 95% CI: 1.26-3.80; p = 0.005). Moreover, subgroup analyses found that patients with muscle-invasive UTUC had better CSS (HR: 1.22; 95% CI: 1.02-1.45; p < 0.001) than those patients with pN0 compared to pNx (NLND). In terms of RFS, the results showed no difference in the survival rates between pN0 and pNx patients in the subgroup of patients with muscle-invasive UTUC (HR: 1.40; 95% CI: 0.84-2.23; p = 0.19). Our meta-analysis supports that LND may prolong the CSS and RFS of UTUC, especially for patients with muscle-invasive UTUC.
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Affiliation(s)
- Deyong Yang
- Department of Urology, First Affiliated Hospital of Dalian Medical University , 222 Zhong Shan Road, Dalian, Liaoning 116011 , P.R. China
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40
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Sun M, Abdo A, Abdollah F, Schmitges J, Thuret R, Jeldres C, Shariat SF, Perrotte P, Karakiewicz PI. Management of upper urinary tract urothelial carcinoma. Expert Rev Anticancer Ther 2014; 10:1955-65. [DOI: 10.1586/era.10.194] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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41
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Kondo T, Hara I, Takagi T, Kodama Y, Hashimoto Y, Kobayashi H, Iizuka J, Omae K, Yoshida K, Tanabe K. Template-based lymphadenectomy in urothelial carcinoma of the renal pelvis: A prospective study. Int J Urol 2013. [DOI: 10.1111/iju.12338] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Tsunenori Kondo
- Department of Urology; Tokyo Women's Medical University; Tokyo Japan
| | - Isao Hara
- Department of Urology; Wakayama Medical University; Wakayama Japan
| | - Toshio Takagi
- Department of Urology; Tokyo Women's Medical University; Tokyo Japan
| | - Yoshiki Kodama
- Department of Urology; Wakayama Medical University; Wakayama Japan
| | | | | | - Junpei Iizuka
- Department of Urology; Tokyo Women's Medical University; Tokyo Japan
| | - Kenji Omae
- Department of Urology; Tokyo Women's Medical University; Tokyo Japan
| | - Kazuhiko Yoshida
- Department of Urology; Tokyo Women's Medical University; Tokyo Japan
| | - Kazunari Tanabe
- Department of Urology; Tokyo Women's Medical University; Tokyo Japan
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Williams AK, Kassouf W, Chin J, Rendon R, Jacobsen N, Fairey A, Kapoor A, Black P, Lacombe L, Tanguay S, So A, Lattouf JB, Bell D, Fradet Y, Saad F, Matsumoto E, Drachenberg D, Cagiannos I, Izawa JI. Multifocality rather than tumor location is a prognostic factor in upper tract urothelial carcinoma. Urol Oncol 2013; 31:1161-5. [DOI: 10.1016/j.urolonc.2011.12.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Revised: 12/03/2011] [Accepted: 12/04/2011] [Indexed: 11/28/2022]
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43
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Youssef RF, Yair L, Sagalowsky AI, Shariat SF, Wood CG, Raman JD, Cord L, Richard Z, Marco R, Francesco M, Christian B, Wassim K, Vitaly M. Radical nephroureterectomy for pathologic T4 upper tract urothelial cancer: can oncologic outcomes be improved with multimodality therapy? Int Braz J Urol 2013; 39:614-21. [DOI: 10.1590/s1677-5538.ibju.2013.05.02] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Accepted: 09/09/2013] [Indexed: 12/30/2022] Open
Affiliation(s)
- Ramy F. Youssef
- UT Southwestern Medical Center (RFY, YL, AIS, VM), United States
| | - Lotan Yair
- UT Southwestern Medical Center (RFY, YL, AIS, VM), United States
| | | | | | | | - Jay D. Raman
- UT Southwestern Medical Center (RFY, YL, AIS, VM), United States
| | - Langner Cord
- UT Southwestern Medical Center (RFY, YL, AIS, VM), United States
| | - Zigeuner Richard
- UT Southwestern Medical Center (RFY, YL, AIS, VM), United States
| | - Roscigno Marco
- UT Southwestern Medical Center (RFY, YL, AIS, VM), United States
| | | | - Bolenz Christian
- UT Southwestern Medical Center (RFY, YL, AIS, VM), United States
| | - Kassouf Wassim
- UT Southwestern Medical Center (RFY, YL, AIS, VM), United States
| | - Margulis Vitaly
- UT Southwestern Medical Center (RFY, YL, AIS, VM), United States
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44
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Chen XP, Xiong GY, Li XS, Matin SF, Garcia M, Fang D, Wang TY, Yu W, Gong K, Song Y, He ZS, He Q, Zhou LQ. Predictive factors for worse pathological outcomes of upper tract urothelial carcinoma: experience from a nationwide high-volume centre in China. BJU Int 2013; 112:917-24. [PMID: 23905945 DOI: 10.1111/bju.12238] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To analyse the predictive factors for worse pathological outcome (muscle invasive pT2+, non-organ-confined pT3+ or N+ and histological Grade 3) of upper tract urothelial carcinoma (UTUC) in a Chinese population from a nationwide high-volume centre in China. PATIENTS AND METHODS Predictors were studied by retrospectively reviewing the clinicopathological data of 729 consecutive patients with UTUC treated in our centre from January 2002 to December 2010. Univariate and multivariate logistic regression analyses were used. RESULTS There were more female patients (56.4%) than males and more tumours were located in the ureter (52.7%) than in the pelvis. In multivariate analysis, male gender (hazard ratio [HR] 1.898, P = 0.001), sessile architecture (HR 3.249, P < 0.001), high grade (HR 5.007, P < 0.001), ipsilateral hydronephrosis (HR 4.768, P < 0.001), renal pelvis location (HR 2.620, P < 0.001) and tumour without multifocality (HR 1.639, P = 0.028) were predictive factors for muscle-invasive UTUC. Male gender (HR 2.132, P < 0.001), renal pelvis location (HR 3.466, P < 0.001), tumour without multifocality (HR 2.532, P = 0.001), sessile tumour architecture (HR 3.274, P < 0.001), and high grade (HR 3.019, P < 0.001) were predictive factors for non-organ-confined disease. Chronological old age (HR 1.047, P < 0.001), sessile tumour architecture (HR 25.192, P < 0.001), ipsilateral hydronephrosis (HR 1.689, P = 0.024), and positive urinary cytology (HR 1.997, P = 0.006) were predictive factors for histological Grade 3 UTUC. CONCLUSIONS There was a predominance of female patients and ureteric tumours in UTUCs of this Chinese population. Male gender, sessile architecture, tumour location, tumour without multifocality, high histological grade and preoperative ipsilateral hydronephrosis were independent predictive factors for worse pathological outcome of UTUCs.
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Affiliation(s)
- Xiao-Peng Chen
- Department of Urology, Peking University First Hospital, Institute of Urology, National Urological Cancer Center, Peking University, Beijing, China
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45
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The impact of lymph node status and features on oncological outcomes in urothelial carcinoma of the upper urinary tract (UTUC) treated by nephroureterectomy. World J Urol 2012; 31:189-97. [PMID: 23229227 DOI: 10.1007/s00345-012-0983-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2012] [Accepted: 10/29/2012] [Indexed: 01/13/2023] Open
Abstract
PURPOSE Prognostic impact of lymphadenectomy during radical nephroureterectomy (RNU) for urothelial carcinoma of the upper urinary tract (UTUC) is controversial. Our aim was to assess the impact of lymph node status (LNS) on survival in patients treated by RNU. METHODS In our multi-institutional, retrospective database, 714 patients with non-metastatic UTUC had undergone RNU between 1995 and 2010. LNS was tested as prognostic factor for survivals through univariate and multivariable Cox regression analysis. RESULTS Median age was 70 years [interquartile range (IQR), 60-75] with median follow-up of 27 months (IQR, 10-50). Overall, lymphadenectomy was performed in 254 patients (35.5 %). Among these patients, 204 (80 %) had negative lymph nodes (pN0) and 50 (20 %) had positive lymph nodes (pN1/2). The 5-year cancer-specific survival (CSS) was 81 % [95 % confidence interval (CI), 73-88 %] for pN0 patients, 85 % (95 % CI, 80-90 %) for pNx patients and 47 % (95 % CI, 24-69 %) for pN1/2 patients (p < 0.001). Metastasis-free survival (MFS) and overall survival (OS) rates were significantly lower in pN1/2 patients than in pN0 and pNx patients (p < 0.05). On multivariable analysis, LNS did not appear as an independent prognostic factor for CSS, OS or MFS (p > 0.05). In case of lymph node involvement, extra-nodal extension was marginally associated with worse CSS (log rank p = 0.07). The retrospective design was the main limitation. CONCLUSION LNS is helpful for survival stratification in patients treated with RNU for UTUC. However, LNS did not appear as an independent predictor of survival in this retrospective series and needs to be investigated in a large multicentre, prospective evaluation.
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Rink M, Sjoberg D, Comploj E, Margulis V, Xylinas E, Lee RK, Hansen J, Cha EK, Raman JD, Remzi M, Bensalah K, Novara G, Matin SF, Chun FK, Kikuchi E, Kassouf W, Martinez-Salamanca JI, Lotan Y, Seitz C, Pycha A, Zigeuner R, Karakiewicz PI, Scherr DS, Vickers AJ, Shariat SF. Risk of cancer-specific mortality following recurrence after radical nephroureterectomy. Ann Surg Oncol 2012; 19:4337-44. [PMID: 22805867 PMCID: PMC3576920 DOI: 10.1245/s10434-012-2499-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Indexed: 12/26/2022]
Abstract
PURPOSE To describe the natural history and identify predictors of cancer-specific survival in patients who experience disease recurrence after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). METHODS Of 2,494 UTUC patients treated with RNU without neoadjuvant chemotherapy, 597 patients experienced disease recurrence. A total of 148 patients (25 %) received adjuvant chemotherapy before disease recurrence. Multivariable Cox regression model addressed time to cancer-specific mortality after disease recurrence. RESULTS The median time from RNU to disease recurrence was 12 months (interquartile range 5-22). A total of 491 (82 %) of 597 patients died from UTUC, and 8 patients (1.3 %) died from other causes. The median time from disease recurrence to death of UTUC was 10 months. Actuarial cancer-specific survival estimate at 12 months after disease recurrence was 35 %. On multivariable analysis that adjusted for the effects of standard clinicopathologic characteristics, higher tumor stages [hazard ratio (HR) pT3 vs. pT0-T1: 1.66, p = 0.001; HR pT4 vs. pT0-T1: 1.90, p = 0.002], absence of lymph node dissection (HR 1.28, p = 0.041), ureteral tumor location (HR 1.44, p < 0.0005) and a shorter interval from surgery to disease recurrence (p < 0.0005) were significantly associated with cancer-specific mortality. The adjusted 6-, 12- and 24-month postrecurrence cancer-specific mortality was 73, 60 and 57 %, respectively. CONCLUSIONS Approximately 80 % of patients who experience disease recurrence after RNU die within 2 years after recurrence. Patients with non-organ-confined stage, absence of lymph node dissection, ureteral tumor location and/or shorter time to disease recurrence died of their tumor more quickly than their counterparts. These factors should be considered in patient counseling and risk stratification for salvage treatment decision making.
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Affiliation(s)
- Michael Rink
- Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA.
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Allard CB, Alamri A, Dason S, Farrokhyar F, Matsumoto ED, Kapoor A. The method of bladder cuff excision during laparoscopic radical nephroureterectomy does not affect oncologic outcomes in upper tract urothelial carcinoma. World J Urol 2012; 31:175-81. [PMID: 22843075 DOI: 10.1007/s00345-012-0915-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Accepted: 07/13/2012] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To determine whether the method of bladder cuff excision (BCE) during laparoscopic radical nephroureterectomy for upper urinary tract urothelial carcinoma is associated with rates of disease recurrence or metastases. METHODS We performed a retrospective review of all laparoscopic radical nephroureterectomies performed at our institution over 10 years. Three methods of BCE were used: transurethral incision (TUI) with Collins knife and a single intravesical port, open extravesical, and open intravesical via cystotomy. Logistic regression analyses were performed to determine whether BCE method was associated with recurrence or metastases. RESULTS Laparoscopic radical nephroureterectomy was performed in 110 patients. BCE was performed via TUI in 61 patients, open extravesical in 29, and open intravesical in 20. After a median follow-up of 22 months, 36 patients (32.7 %) developed recurrences. Metastases were observed in 18 patients (16.4 %). Recurrence rates were 32.8, 27.6, and 40.0 % in the TUI, extravesical, and intravesical groups, respectively (p = 0.69). Positive surgical margins occurred in nine patients with no significant difference between groups. Factors associated with recurrence or metastases in a multivariate regression analysis were stage, positive surgical margins and carcinoma in situ (CIS). The method of BCE was not associated with oncologic outcomes. CONCLUSIONS The three methods of bladder cuff excision (TUI, extravesical, and intravesical) are oncologically valid with similar recurrence and metastases rates when performed during laparoscopic radical nephroureterectomy. Stage, positive margin status and CIS are predictive of adverse oncologic outcomes and can facilitate postoperative prognostication.
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Affiliation(s)
- Christopher B Allard
- Institute of Urology at St. Joseph's Healthcare, 3rd Floor Rm G344, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada.
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48
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Upper tract urothelial carcinoma: current treatment and outcomes. Urology 2012; 79:749-56. [PMID: 22469572 DOI: 10.1016/j.urology.2011.12.024] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Revised: 11/26/2011] [Accepted: 12/15/2011] [Indexed: 01/12/2023]
Abstract
The reference standard treatment of upper tract urothelial carcinoma is open radical nephroureterectomy. Many centers have advocated less-invasive treatment modalities. We reviewed contemporary treatments of upper tract urothelial carcinoma and their outcomes. A MEDLINE search was conducted for all relevant published data during the past 15 years. Endoscopic management is feasible for low-grade disease with strict surveillance protocols. Radical nephroureterectomy remains the reference standard for upper tract urothelial carcinoma. The intermediate-term oncologic outcomes are similar between the laparoscopic and open approaches. Controversies still exist regarding the optimal management of the distal ureter, the utility of topical therapy, and the role of lymphadenectomy.
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Prognostic Factors in Upper Urinary Tract Urothelial Carcinomas: A Comprehensive Review of the Current Literature. Eur Urol 2012; 62:100-14. [DOI: 10.1016/j.eururo.2012.02.030] [Citation(s) in RCA: 307] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2011] [Accepted: 02/14/2012] [Indexed: 12/12/2022]
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50
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Rao SR, Correa JJ, Sexton WJ, Pow-Sang JM, Dickinson SI, Lin HY, Spiess PE. Prospective clinical trial of the feasibility and safety of modified retroperitoneal lymph node dissection at time of nephroureterectomy for upper tract urothelial carcinoma. BJU Int 2012; 110:E475-80. [PMID: 22564727 DOI: 10.1111/j.1464-410x.2012.11170.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
UNLABELLED What's known on the subject? and What does the study add? Very little is known about the safety and potential oncological benefit of performing a retroperitoneal lymph node dissection at time of nephroureterectomy for upper tract tumours. This study is the first clinical trial to prospectively validate the safety and feasibility of a retroperitoneal lymph node dissection at time of nephroureterectomy for upper tract tumours. The onus is now on the scientific community at large to conduct adequately powered multicentre clinical trials to evaluate the potential oncological benefit it may impart to patients with upper tract tumours. OBJECTIVE • To determine the safety and feasibility of modified retroperitoneal lymph node dissection (RPLND) at the time of radical nephroureterectomy (RNU). PATIENTS AND METHODS • Between 2009 and 2011, 20 patients with suspected upper urinary tract urothelial carcinoma (UUT-UC) underwent open (n= 10), laparoscopic (n= 4), or robot-assisted (n= 6) RNU with modified RPLND. • Demographic, clinical and pathological data, histological nodal status, peri-operative complications and recurrence data were collected. RESULTS • On histopathological review, one patient had a benign angioma and was excluded from the final data analysis. Of the remaining 19 patients, 10 had pTa, five had pT1, one had pT2, and three pT3 disease. • The mean (range) lymph node count was 7 (2-17), with one patient having pathologically proven lymph node metastasis. The mean (range) operating time was 279 (146-500) min. The mean EBL was 396 (100-1100) mL, with the mean (range) hospital stay 7.1 (4-18) days. The mean (range) duration of follow-up after surgery was 12 (2-24) months. • Overall, nine patients developed postoperative complications, which included eight minor (Clavien Grade I-II) and one major complication (Clavien grade IIIb). The major complication was a postoperative chylous lymphatic leak requiring surgical exploration. CONCLUSION • The present results indicate that modified RPLND during RNU for UUT-UC is a feasible procedure with acceptable morbidity. A larger prospective clinical trial is needed to adequately assess its potential therapeutic benefit.
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Affiliation(s)
- Sandhya R Rao
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA
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