The Predictive Value of C-reactive Protein for Prognosis in Patients with Upper Tract Urothelial Carcinoma Treated with Radical Nephroureterectomy: A Multi-institutional Study

Prognostic factors for overall survival in clinical node-positive patients with upper tract urothelial carcinoma

BACKGROUND

There is sparse evidence regarding optimal management and prognosticators for oncologic outcomes in patients with clinical node-positive (cN+) upper tract urothelial carcinoma (UTUC).

METHODS

We retrospectively analyzed the data from 105 UTUC patients with cN1-2M0 between June 2010 and June 2022 at multiple institutions affiliated with our university. At the time of diagnosis, all patients received standard-of-care treatment including radical nephroureterectomy (RNU), chemotherapy, and/or palliative care. We employed a Cox regression model to analyze the prognostic importance of various factors on overall survival (OS).

RESULTS

Of 105 patients, 54 (51%) underwent RNU, while 51 (49%) did not. RNU was likely to be selected in patients with younger and higher G8 score, resulting in better median OS in patients who underwent RNU than in those who did not (42 months vs. 15 months, p < 0.001). Multivariable analysis among the entire cohort revealed that low G8 score (≤14) (hazard ratio [HR]: 2.07, 95% confidence interval [CI]: 1.08-3.99), elevated pretreatment C-reactive protein (CRP) (HR: 3.35, 95%CI: 1.63-6.90), and failure to perform RNU (HR: 2.16, 95%CI: 1.06-4.42) were independent prognostic factors for worse OS. In the subgroup analyses of cohorts who did not undergo RNU, elevated pretreatment CRP was the only independent prognostic factor for worse OS in cN+ UTUC patients.

CONCLUSIONS

RNU seems to be a reasonable treatment option in cN+ UTUC patients where applicable. Elevated pretreatment CRP appears to be a reliable prognosticator of worse OS and may be helpful in optimizing candidate selection for intensified treatment in this setting.

Preoperative fibrinogen/CRP score predicts survival in upper urothelial tract carcinoma patients undergoing radical curative surgery

PURPOSE

Upper tract urothelial carcinoma (UTUC) represents an often aggressive malignancy associated with poor prognosis. Therefore, finding reliable prognostic biomarkers in patients undergoing curative surgery for improved risk stratification is crucial. We evaluated the prognostic value of the Fibrinogen/C-reactive protein (FC)-score in a cohort of surgically treated UTUC patients.

METHODS

170 patients with radiologically and histologically verified UTUC who underwent radical curative surgery between 1990 and 2020, were included. The FC-score was calculated for each patient, with patients receiving 1 point each if Fibrinogen and/or CRP levels were elevated above the 25th or 75th percentile, respectively. Patients were divided into three subgroups according to their FC-score of 0, 1 or 2 point(s). Kaplan-Meier analysis, uni- and multivariable Cox proportional hazard models were implemented. We determined cancer-specific survival (CSS) as primary endpoint, whereas overall survival (OS) and recurrence-free survival (RFS) were considered secondary endpoints.

RESULTS

High FC-score (2 points) was significantly associated with adverse histological features such as vascular invasion (OR = 4.08, 95%CI 1.18-14.15, p = .0027) and tumour necrosis (OR = 6.67, 95%CI 1.35-32.96, p = 0.020). Both, uni- and multivariable Cox proportional hazard models showed the FC-score as a significant predictor for CSS (univariable analysis: FC-score = 1: HR = 1.90, 95%CI 0.92-3.93, p = 0.085 | FC-score = 2: HR = 2.86, 95%CI 1.22-6.72, p = 0.016). Furthermore, in univariable analysis, patients with higher FC-score had significantly shorter OS (FC-score = 1: HR = 1.32, 95%CI 0.70-2.49, p = 0.387 | FC-score = 2: HR = 2.19, 95%CI 1.02-4.67, p = 0.043). However, this did not prevail in multivariable analysis.

CONCLUSION

The FC-score represents a novel potential biomarker in patients with UTUC undergoing radical curative surgery.

The tumour-associated stroma correlates with poor clinical outcomes and immunoevasive contexture in patients with upper tract urothelial carcinoma: results from a multicenter real-world study (TSU-01 Study)

BACKGROUND

In this real-world study, we aimed to elucidate the predictive value of tumour-associated stroma for clinical prognostic and therapeutic response in upper tract urothelial carcinoma (UTUC) by reviewing the clinicopathologic characteristics of 1015 UTUC patients through a nationwide multicenter analysis.

METHODS

The tumour-stroma ratio (TSR) was assessed based on tissue sections stained for hematoxylin and eosin (H&E), and patients were further stratified into stroma-high (>50% stroma) and stroma-low group (≤50% stroma). Kaplan-Meier curve and Cox regression hazard analysis were conducted to assess the survival outcomes of UTUC patients. Bioinformatics analysis and immunostaining analysis were applied to portray the tumour microenvironment (TME).

RESULTS

Stroma-high UTUC was significantly associated with poorer survival outcomes and inferior chemotherapeutic responsiveness. Our established nomogram achieved a high prognostic accuracy in predicting overall survival and cancer-specific survival in both of the discovery cohort (area under the curve [AUC] 0.663 and 0.712) and the validation cohort (AUC 0.741 and 0.747). Moreover, stroma-high UTUC was correlated with immunoevasive TME accompanied by increased cancer-associated fibroblasts, tumour-associated macrophages and, conspicuously a cluster of highly exhausted CD8+ T cells.

CONCLUSION

Our results showed stroma-high UTUC was associated with an inferior prognosis and an immunoevasive TME with exhausted CD8+ T cells in UTUC patients. Our TSR-based nomogram could be used to refine prognosis and inform treatment decisions of patients with UTUC.

Effectiveness and safety profile of pembrolizumab for metastatic urothelial cancer: A retrospective single-center analysis in Japan

BACKGROUND

The paradigm of medical treatment for metastatic urothelial carcinoma is dramatically changing through the introduction of pembrolizumab.

AIM

We investigated the treatment effectiveness, the safety profile, and the prognostic factors of pembrolizumab in Japanese real-world clinical practice.

METHODS AND RESULTS

The medical records of 74 consecutive Japanese patients with metastatic urothelial cancer (UC), who started pembrolizumab as a second- or later-line treatment at our institution between January 2018 and March 2020, were reviewed and statistically analyzed. The median follow-up period after initiation of pembrolizumab was 8.5 (interquartile range: 3.5-15.7) months. The objective response rate was 30.2%, the median progression-free survival period was 4.9 months, and the median overall survival (OS) period was 13.3 months. Evaluation revealed that 39 (52.9%) patients experienced adverse events (AEs), among whom eight patients (10.9%) had severe AEs (grade 3 or more), including grade 5 hemophagocytic syndrome. Multivariate analysis indicated that the presence of liver metastasis, worse performance status (≥2), elevated serum lactate dehydrogenase, and increased C-reactive protein were predictive of shorter OS.

CONCLUSION

We studied the effectiveness and safety profile of pembrolizumab therapy in Japanese UC patients. We believe that the data presented here will be useful for clinical physicians.

Blood-based protein biomarkers in bladder urothelial tumors

Bladder cancer (BC) is the fifth most common cancer with a high prevalence rate. It is classically classified in two groups, namely non-muscle invasive (NMIBC) and muscle invasive (MIBC). NMIBC accounts for 75% of cases and has a better prognosis than MIBC. However, 30-50% of the NMIBC patients will show recurrences throughout their lives, and about 10-20% of them will progress to MIBC, with frequent metastasis and a reduced survival rate. The diagnosis of bladder cancer is confirmed by direct visualization of the tumour and other mucosal abnormalities with endoscopic excision using cystoscopy and transurethral resection of the bladder (TURBT). An adequate TURBT requires complete resection of all visible tumour with appropriate sampling of the bladder to assess the depth of invasion. However, for many years, researchers have attempted to identify and utilise urinary markers for bladder cancer detection. Voided urine cytology has been the mainstay of urine-based diagnosis of bladder cancer since originally described by Papanicolau and Marshall. Nonetheless, urine cytology has several drawbacks, including a poor sensitivity for low-grade/stage tumours, a lack of interobserver consistency and a variable range of readings (e.g., atypical, atypical-suspicious, non-diagnostic). These shortcomings have inspired the search for more sensitive bladder cancer biomarkers. To bring precision medicine to genitourinary oncology, the analysis of the plasma/serum wide genome and proteome offers promising possibilities.

Cytoreductive Nephrectomy Promoted Abscopal Effect of Camrelizumab Combined With Radiotherapy for Metastatic Renal Cell Carcinoma: A Case Report and Review of the Literature

There is little evidence around Camrelizumab combined with cytoreductive nephrectomy (CN) and radiotherapy (RT) as a treatment option for metastatic renal cell carcinoma (mRCC). The influence of CN on immune responses and the abscopal effect are not well understood. In this paper, we report a case of anti-programmed cell death-1 (PD-1) treated with combined RT once CN reduced the primary tumor burden (TB). This patient also encountered an increased response to targeted radiotherapy after immune resistance. We also observed a macrophage-to-lymphocyte ratio (MLR) peak, which may be correlated with subsequent pseudoprogression after thoracic radiotherapy. Consequently, even with the disease, this patient has remained stable. This peculiar instance suggests there is a need to investigate the underlying mechanisms of CN in promoting the abscopal effect during immunotherapy when combined with RT. It also suggests that there is a need for further investigation into the role of RT in overcoming immune resistance, and the value of MLR in predicting pseudoprogression. We hypothesize that a heavy tumor burden might suppress the abscopal effect, thereby ensuring that CN promotes it. However, radiotherapy may overcome immune resistance during oligoprogression.

Impact of cachexia on oncologic outcomes of sarcopenic patients with upper tract urothelial carcinoma after radical nephroureterectomy

Objectives

To investigate the prognostic significance of sarcopenic cachexia compared to sarcopenia without cachexia in the outcomes of upper urinary tract urothelial carcinoma (UTUC) patients treated with radical nephroureterectomy (RNU).

Materials and methods

Between 2011 and 2016, 163 patients with UTUC who received RNU at a tertiary medical center were included. Pre-operatively clinical data, history, and abdominal computer tomography scans were analyzed retrospectively. The diagnosis of sarcopenia was based on abdominal computed tomography data on the patient’s skeletal muscles. Outcomes of relapse-free, cancer-specific, and overall survival were analyzed by multivariate Cox regression.

Results

After adjusting for age, sex, pre-operatively estimated glomerular filtration rate, body mass index, underlying diseases, tumor grade, and tumor stage, cachexia was a significant poor prognostic factor for relapse-free survival (hazard ratio [HR]: 18.5, 95% confidence interval [CI]: 2.87–118, p = 0.002) and cancer-specific survival (HR: 26.6, 95% CI: 4.04–175, p = 0.001). In contrast, sarcopenia without cachexia was not a significant predictor of cancer outcomes.

Conclusions

To date, this is the first study to investigate the effect of cachexia among sarcopenic patients with UTUC treated with RNU. We identified the prognostic significance of cachexia on outcomes. Indeed, when UTUC is treated with RNU, we should evaluate not only sarcopenia status but also cachexia. The low survival rate among patients with UTUC complicated with cachexia deserves attention.

Postoperative C-reactive protein-to-albumin ratio predicts poor prognosis in patients with bladder cancer undergoing radial cystectomy

The purpose of the present study was to investigate the prognostic value of the postoperative C-reactive protein/albumin ratio (CAR) in patients with bladder cancer undergoing radial cystectomy. The present study retrospectively reviewed 102 patients who underwent radical cystectomy and were followed for ≥6 months postoperatively at our institution, and evaluated clinicopathological factors and laboratory parameters for cancer-specific survival (CSS) and extraurothelial recurrence-free survival (ERFS). Multivariate analysis using the Cox proportional hazards model revealed that only postoperative CAR ≥0.27 [hazard ratio (HR), 3.368; 95% confidence interval (CI), 1.674-6.731; P<0.001] was an independent factor for poor CSS rate. Higher postoperative CAR was also the only significant factor for shortened ERFS time (HR, 2.401; 95% CI, 1.196-4.684; P=0.015). No significant association was identified between postoperative CAR ≥0.27 and any pathological factors or postoperative laboratory markers besides postoperative neutrophil-to-lymphocyte ratio. Furthermore, postoperative CAR (≥0.27) was an independent factor for poor CSS and ERFS rates in 48 patients with advanced pT stage (≥pT3) in the multivariate analysis (P=0.026 and P=0.036, respectively). A higher postoperative CAR value can provide additional information about the possibility of poor CSS and ERFS rates in patients with bladder cancer undergoing radical cystectomy.

Pretreatment elevated fibrinogen level predicts worse oncologic outcomes in upper tract urothelial carcinoma

This study aimed to further validate the prognostic role of fibrinogen in upper tract urothelial carcinoma (UTUC) in a large Chinese cohort. A total of 703 patients who underwent radical nephroureterectomy were retrospectively identified. Fibrinogen levels of ≥4.025 g l⁻¹ were defined as elevated. Logistic regression analysis was performed to determine the association between fibrinogen and adverse pathological features. Kaplan–Meier analysis and Cox regression models were used to assess the associations of fibrinogen with cancer-specific survival (CSS), disease recurrence-free survival (RFS), and overall survival (OS). Harrell c-index and decision curve analysis were used to assess the clinical utility of multivariate models. The median follow-up duration was 42 (range: 1–168) months. Logistic regression analysis revealed that elevated fibrinogen was associated with higher tumor stage and grade, lymph node involvement, lymphovascular invasion, sessile carcinoma, concomitant variant histology, and positive surgical margins (all P < 0.05). Multivariate Cox regression analysis demonstrated that elevated fibrinogen was independently associated with decreased CSS (hazard ratio [HR]: 2.33; P < 0.001), RFS (HR: 2.09; P < 0.001), and OS (HR: 2.09; P < 0.001). The predictive accuracies of the multivariate models were improved by 3.2%, 2.0%, and 2.8% for CSS, RFS, and OS, respectively, when fibrinogen was added. Decision curve analysis showed an added benefit for CSS prediction when fibrinogen was added to the model. Preoperative fibrinogen may be a strong independent predictor of worse oncologic outcomes in UTUC; therefore, it may be valuable to apply this marker to the current risk stratification in UTUC.

Identification of Mutated Peptides in Bladder Cancer From Exomic Sequencing Data Reveals Negative Correlation Between Mutation-Specific Immunoreactivity and Inflammation

Introduction and Objective

Neoantigen-based immunotherapy is one of the breakthroughs in cancer immunotherapy. Benefit from the Cancer Genome Atlas database, we intended to identify mutant peptides with neoantigen property in bladder cancer (BC). Correlations between the immunoreactivity of candidate neoantigens and clinical manifestations were further analyzed.

Methods

HLA-A*02:01 restricted mutant (MT) and wildtype (WT) peptides were predicted by using whole exome sequencing data of 412 BC patients in the TCGA database. Binding affinity to HLA-A2 molecules was determined by using T2 cell-based binding assay. The immunoreactivity to WT and MT peptides in HLA-A2⁺ BC patients was determined by using an ELISPOT assay upon in vitro stimulation with MT and WT peptides individually. Clinical relevance to peptide-specific immunoreactivity was analyzed by Pearson correlation analysis. The disease free survival (DFS) curves were plotted using the Kaplan–Meier method in BC patients with or without mutations and compared using the log-rank test online.

Results

Fifty-seven HLA-A*02:01 restricted WT and MT peptides were selected based on predicted high affinity and expression frequency, among which 12 MT peptides from 12 individual genes exhibited strong affinity to HLA-A2 molecules when compared to WT counterparts. MT peptides induced more peptide-specific IFNγ spot forming units (SFUs) than WT counterparts in HLA-A2⁺ BC patients upon in vitro stimulation. They were negatively correlated to the counts of peripheral leukocytes and platelets. Patients with higher C-reactive protein level exhibited lower immunoreactivity to MT peptides. Combination of MT peptides from 6 genes, including CDKN1A^G61V, RHOB^P75L, DDB1^S25L, AHNAK^D4855Y, ANP32A^S56L and MKI67^H84L covered 47.5% of the patients under investigation. Patients harboring combinational mutations in these genes were associated with a longer DFS according to the cBioportal online analysis.

Conclusion

Twelve HLA-A*02:01 restricted MT peptides have been identified exhibiting higher binding affinity to HLA-A2 molecules and stronger immunoreactivity than WT counterparts in BC patients. Combination of MT peptides from six genes might be potential as neoantigen candidates in cancer immunotherapy against BC in the future. Inflammatory modulation is inclined to be a strategy to enhance the efficacy of neoantigen-based immunotherapy.

Risk stratification for upper tract urinary carcinoma

Upper tract urinary carcinoma (UTUC) is a heterogeneous group of rare tumors. The aim of this article is to critically review current therapeutic strategies and to propose a change in the risk-stratification of the disease. A non-systematic review of the literature was performed using the Medline database with the search terms: “upper tract urothelial carcinoma” together with “prognostic factor”, “risk stratification”, “risk factor”, “recurrence”, “predictive tool”, “nomograms” and “treatment”. Preoperative risk factors can be viewed as patient-related risk factors (gender, age, ethnicity, body mass index, smoking status, or genetic factors), or tumor-related risk factors (stage, grade, size, architecture, multifocality, ureteric obstruction). Several biomarkers, available either in blood, urine, or the tumor itself have also been proposed. However, many of these prognostic factors lack accuracy and validation in predicting oncological outcomes, despite their use in predictive tools. After risk stratification, kidney-sparing strategies should be considered (endoscopic management and segmental ureterectomy) and could benefit from new diagnostic tools and technical improvements in in situ adjuvant endocavitary instillations. Radical nephroureterectomy remains the first choice therapy for high-grade disease and will probably be associated with other treatments in the future (lymphadenectomy, perioperative chemotherapy, or immunotherapy). In view of the major recent improvements in UTUC treatment strategies, a new classification should be proposed, including low-, intermediate-, high- and very high-risk disease. Subgroup analysis of good quality trials and better understanding of UTUC risk factors will help validate this new approach toward more personalized medicine.

Role of Systemic Inflammatory Response Markers in Urothelial Carcinoma

Urothelial carcinoma (UC) can occur in various parts of the urinary tract and occurs in different stages and grades. The disease recurs frequently and is monitored through a series of invasive tests, such as cystoscopy or ureteroscopy, over the lifetime of an individual. Although many researchers have attempted to stratify the risks of UC, with the majority being based on cancer characteristics and host factors such as performance status, a risk classification system has yet to be fully developed. Cancer affects various parts of the body through the systemic immune response, including changes in hormones, the number and ratio of white blood cells and platelets, and C-reactive protein (CRP) or albumin levels under the influence of neuroendocrine metabolism, hematopoietic function, and protein and energy metabolism, respectively. Herein, we reviewed various systemic inflammatory response markers (SIRs) related to UC, including CRP, albumin-globulin ratio, albumin, Glasgow prognostic score (GPS), modified GPS, neutrophil-lymphocyte ratio, and platelet-lymphocyte ratio. Our aim was to summarize the role of various SIRs in the treatment of patients with UC.

Neoadjuvant and Adjuvant Chemotherapy for Upper Tract Urothelial Carcinoma: A 2020 Systematic Review and Meta-analysis, and Future Perspectives on Systemic Therapy

CONTEXT

To improve the prognosis of upper tract urothelial carcinoma (UTUC), clinicians have used neoadjuvant chemotherapy (NAC) or adjuvant chemotherapy (AC) before or after radical nephroureterectomy (RNU). Despite some new data, the evidence remains mixed on their efficacy.

OBJECTIVE

To update the current evidence on the role of NAC and AC for UTUC.

EVIDENCE ACQUISITION

We searched for all studies investigating NAC or AC for UTUC in Medline, Embase, the Cochrane Central Register of Controlled Trials, and abstracts from the American Society of Clinical Oncology meetings up to February 2020. A systematic review and meta-analysis was performed.

EVIDENCE SYNTHESIS

For NAC, the pooled pathologic complete response rate (≤ypT0N0M0) was 11% (n = 811) and pathologic partial response rate (≤ypT1N0M0) was 43% (n = 869), both across 14 studies. Across six studies, the pooled hazard ratios (HRs) were 0.44 (95% confidence interval [CI]: 0.32-0.59, p <  0.001) for overall survival (OS) and 0.38 (95% CI: 0.24-0.61, p <  0.001) for cancer-specific survival (CSS) in favor of NAC. The evidence for NAC is at best level 2. As for AC, there was a benefit in OS (pooled HR 0.77; 95% CI: 0.64-0.92, p =  0.004 across 14 studies and 7983 patients), CSS (pooled HR 0.79; 95% CI: 0.69-0.91, p =  0.001 across 18 studies and 5659 patients), and disease-free survival (DFS; pooled HR 0.52; 95% CI: 0.38-0.70 across four studies and 602 patients). While most studies were retrospective (level 2 evidence), there were two prospective randomized trials providing level 1 evidence. There are currently four phase 2 trials on neoadjuvant immunotherapy and three phase 2 trials on adjuvant immunotherapy for UTUC.

CONCLUSIONS

NAC for UTUC confers a favorable pathologic response and tumor downstaging rate, and an OS and CSS benefit compared with RNU alone. AC confers an OS, CSS, and DFS benefit compared with RNU alone. Currently, the evidence for AC appears stronger (with positive level 1 evidence) than that for NAC (at best level 2 evidence). Limited data are available for chemoimmunotherapy approaches, but preliminary data support an active research investment.

PATIENT SUMMARY

After a comprehensive search of the latest studies examining the role of neoadjuvant and adjuvant chemotherapy for upper tract urothelial cancer, the pooled evidence shows that perioperative chemotherapy was beneficial for prolonging survival; however, the evidence for adjuvant chemotherapy was stronger than that for neoadjuvant chemotherapy.

Prognostic outcomes and safety in patients treated with pembrolizumab for advanced urothelial carcinoma: experience in real-world clinical practice

BACKGROUND

Prognostic outcomes and safety following treatment with pembrolizumab in patients with advanced urothelial carcinoma (UC) have not been fully elucidated in clinical practice. The aim of this study was to evaluate the oncological efficacy and safety of pembrolizumab after failure of platinum-based chemotherapy in Japanese patients with advanced UC in a routine clinical setting.

METHODS

This retrospective study included 41 consecutive Japanese patients with advanced UC treated with pembrolizumab as second-line or greater therapy at Iwate Medical University Hospital from January 2018 to April 2019.

RESULTS

The mean follow-up period was 6.2 months. The objective response rate, median progression-free survival, and median overall survival were 15%, 2.5 months, and 11.9 months, respectively. Univariate analysis identified poor performance status (> 1), liver metastasis, two or more metastatic organs, low hemoglobin levels, two or more prior regimens, high baseline C-reactive protein levels, higher relative C-reactive protein level change after 6 weeks, and higher relative neutrophil-to-lymphocyte ratio change after 6 weeks as significant predictors of overall survival. Among these factors, poor performance status (> 1), two or more metastatic organs, and higher relative neutrophil-to-lymphocyte ratio change after 6 weeks were identified as independent predictors of overall survival in multivariate analysis.

CONCLUSIONS

The introduction of pembrolizumab can result in favorable cancer control outcomes in Japanese patients with advanced UC, and the prognosis of these patients can be stratified according to three potential parameters, including poor performance status, high number of metastatic organs, and higher relative neutrophil-to-lymphocyte ratio change.

Preoperative sterile pyuria as a prognostic biomarker for intravesical recurrence in upper urinary tract urothelial carcinoma

Purpose

To evaluate if preoperative sterile pyuria can be a prognostic factor for intravesical recurrence (IVR) and overall survival (OS)in patients with upper tract urothelial carcinoma (UTUC) undergoing surgery.

Materials and Methods

We retrospectively reviewed the medical records of patients who were diagnosed with UTUC from October 2003 to December 2016 at Korea University Medical Center. Sterile pyuria was defined as urine containing five or more white blood cells per high-power field in the absence of bacteria in urine culture. We used a stepwise multivariable Cox proportional hazards model to assess the independent effects of the prognostic factors for IVR and OS.

Results

We investigated a total of 176 patients who were diagnosed with UTUC. Among them, 91 (51.7%) patients had preoperative sterile pyuria. There were no significant differences in the baseline characteristics between the pyuria and non-pyuria groups concerning tumor grade, T stage, tumor multiplicity, and recurrence history. However, there was a significant difference in the IVR between the two groups. In the multivariable analysis, preoperative sterile pyuria, diabetes mellitus, high-grade tumor, and lymphovascular invasion were revealed as independent risk factors for IVR, and only lymphovascular invasion was identified as an independent risk factor for OS.

Conclusions

Preoperative sterile pyuria is significantly associated with IVR in patients with UTUC undergoing surgery, but it is not associated with OS. Furthermore, diabetes mellitus, high-grade tumor, and lymphovascular invasion are also independent prognostic factors for these patients.

Preoperative albumin-to-globulin ratio as a significant prognostic indicator in urologic cancers: a meta-analysis

Background

Emerging studies reported that preoperative albumin-to-globulin ratio (AGR) correlated with tumor progression and prognosis in several types of cancer. The aim of this study was to systematically explore the association between preoperative AGR and clinical outcomes in cancers of the urinary system.

Methods

Relevant articles were searched in PubMed, Embase and Web of Science by two independent investigators from inception to June 1, 2018. Eligible studies were selected based on predetermined selection criteria. Summarized HRs or ORs and 95% CIs were calculated for prognosis and clinicopathologic features with the fixed-effects or random-effects models.

Results

Eight cohort studies comprising 2,668 patients were included for analysis. The pooled results showed that a low AGR significantly correlated with poor OS (HR: 0.38, 95% CI: 0.27-0.48, P<0.001), worse cancer-specific survival (CSS) (HR: 0.36, 95% CI: 0.22-0.50, P<0.001) and inferior event-free survival (EFS) (HR: 0.36, 95% CI: 0.25-0.48, P<0.001) in urologic cancers. In addition, patients in low and high AGR groups showed significant differences in lymphovascular invasion (P<0.001), pT status (P<0.001) and pN status (P<0.001).

Conclusion

Preoperative AGR might be a valuable, cheap and reproducible prognostic bio-marker in urologic cancers following surgical resection.

Outcome and prognostic factors in metastatic urothelial carcinoma patients receiving second-line chemotherapy: an analysis of real-world clinical practice data in Japan

Objectives

The objective of the present study was to investigate the survival outcome and prognostic factors of metastatic urothelial carcinoma patients treated with second-line systemic chemotherapy in real-world clinical practice.

Methods

Overall, 114 patients with metastatic urothelial carcinoma undergoing second-line systemic chemotherapy were included in this retrospective analysis. The dominant second-line chemotherapy was a paclitaxel-based combination regimen (60%, 68/114). We assessed the progression-free survival and overall survival times using the Kaplan–Meier method. The Cox proportional hazards model was applied to identify the factors affecting overall survival.

Results

The median progression-free survival and overall survival times were 4 and 9 months, respectively. In the multivariate analysis, an Eastern Cooperative Oncology Group performance status score greater than 0 at presentation, C-reactive protein level ≧1 mg/dl and poor response to prior chemotherapy were adverse prognostic indicators. Patients with 0, 1, 2 and 3 of those risk factors had a median overall survival of 17, 12, 7 and 3 months, respectively.

Conclusions

The Eastern Cooperative Oncology Group performance status at presentation, C-reactive protein level and response to prior chemotherapy were prognostic factors for metastatic urothelial carcinoma patients undergoing second-line chemotherapy. In the future, this information might help guide the choice of salvage treatment, such as second-line chemotherapy or immune checkpoint inhibitors, after the failure of first-line chemotherapy.

Is preoperative serum lactate dehydrogenase useful in predicting the outcomes of patients with upper tract urothelial carcinoma?

Background

Lactate dehydrogenase (LDH) has been proved to be associated with clinical outcomes in various carcinomas; however, limited evidence was available in upper urinary tract urothelial carcinoma (UTUC). Thus, the aim of this study was to evaluate the prognostic impact of LDH in UTUC.

Patients and methods

A cohort of 668 patients WERE retrospectively included between 2003 and 2016. Kaplan‐Meier method and Cox proportional hazards regression models were used to evaluate the association of LDH with overall survival (OS), cancer‐specific survival (CSS), disease recurrence‐free survival (RFS), and metastasis‐free survival (MFS). The cutoff level of LDH was set at 220 U/L for the upper limit of normal.

Results

Kaplan‐Meier plots showed the group with elevated LDH had significant poor OS (P = 0.003), CSS (P = 0.005), and RFS (P = 0.005), but not MFS (P = 0.099). However, multivariate Cox analysis suggested that LDH was not an independent predictor for CSS (HR 1.50, 95%CI: 0.87‐2.59), OS (HR 1.56, 95%CI: 0.94‐2.58), RFS (HR 1.33, 95%CI: 0.83‐2.12), or MFS (HR 1.16, 95%CI: 0.79‐1.71). Albumin, globulin, and HBDH were also not related to survival outcomes of UTUC patients in multivariate analysis, while higher alkaline phosphatase was associated with worse CSS and OS, and higher white blood cells contributed to poor CSS and RFS. In subgroup analysis, results found higher LDH was associated with poor OS in patients with localized disease (pT ≤ 2) (HR 4.03, 95%CI: 1.37‐11.88).

Conclusion

The preoperative LDH was not an independent prognostic factor for patients with UTUC, while elevated LDH was proved to be correlated with worse OS in patients with localized disease.

Can preoperative neutrophil lymphocyte ratio predict malignancy in patients undergoing partial nephrectomy because of renal mass?

Purpose:

To evaluate the importance of preoperative neutrophil lymphocyte ratio (NLR) predicting malignancy in patients who undergo partial nephrectomy due to renal mass.

Materials and Methods:

Seventy nine patients who underwent open partial nephrectomy for renal masses were included in this retrospective study. In preoperative routine blood tests, renal ultrasonography and contrast-enhanced computed tomography were performed for all patients. Preoperative neutrophil lymphocyte ratio were compared in patients with clear cell renal cell carcinoma (Group1, 65 patients) and benign lesions (Group 2, 14 patients). The predictive ability of NLR was analyzed by ROC curves and Youden Index method was used to identify the cut-off value for NLR.

Results:

The mean age of patients was 59.8±11.7 years in Group1 and 57.4±12.6 years in Group 2 (p=0.493). The mean tumor size was 3.8±1.2 cm in Group 1 and 3.3±1.0 cm in Group 2 (p=0.07). The median NLR was 2.48 (1.04) in Group 1 and 1.63 (0.96) in Group 2 (p<0.001). The area under a ROC curve was 0.799 (p<0.001).

Conclusions:

Preoperative neutrophil lymphocyte ratio may predict renal masses that can not be distinguished radiologically. Our results must be confirmed by large and properly designed prospective, randomized trials.

The systemic inflammation-based Glasgow Prognostic Score as a powerful prognostic factor in patients with upper tract urothelial carcinoma

Introduction and Objective

The combination of C-reactive protein and albumin, the Glasgow Prognostic Score (GPS), had independent prognostic value in patients with varying cancers, except for upper tract urothelial carcinoma (UTUC). The aim of this study was to describe the relationship between GPS and survival in patients with UTUC after adjustment for other prognostic factors.

Materials and Methods

We queried 2 UTUC databases. Retrospective clinical series on patients with localized UTUC managed by nephroureterectomy with bladder cuff, for whom data from the Yamaguchi Uro-Oncology Group and Osaka Medical College registry, including age, presence of bladder cancer, pT stage, lymphovascular invasion, C-reactive protein (CRP) and albumin, were analyzed. The GPS was constructed by combining CRP and albumin. Cancer specific survival (CSS) and overall survival (OS) and relative excess risk of death were estimated by GPS categories after adjusting for gender, age, ECOG performance status (PS), grade, and lymphovascular invasion (LVI).

Results

Seven hundred and twenty four UTUC patients were identified. Our final cohort included 574 patients; of these, 29.2% died during a maximum follow up of 16.7 years. The estimated mean 10-year CSS of patients with GPS of scre-0, -1, and -2 was 99.5, 95.1, and 75.9 months, respectively. Patients with GPS of score-2 had poorest 10-year estimated mean OS of 67.6 months (57.2–77.9). Raised GPS also had a significant association with excess risk of cancer death at 10 years (GPS 2: Relative Excess Risk = 1.74, 95% CI 1.20–2.54) after adjusting for gender, patients’ age, ECOG PS, and tumor focality. C-index of GPS both for CSS and OS were superior to patients’ age and tumor focality, and comparable to grade.

Conclusions

The GPS is an independent prognostic factor for CSS and OS after surgery with curative intent for localized UTUC. It significantly increases the accuracy of established prognostic factors. The GPS may provide a meaningful adjunct for patient counseling and clinical trial design.

Preoperative controlling nutritional status (CONUT) score as a novel predictive biomarker of survival in patients with localized urothelial carcinoma of the upper urinary tract treated with radical nephroureterectomy

OBJECTIVE

The purpose of this study was to investigate the correlation between the controlling nutritional status (CONUT) score and survival of patients with localized urothelial carcinoma of the upper urinary tract treated with radical nephroureterectomy (RNU).

METHODS AND MATERIALS

We retrospectively enrolled 107 patients. CONUT score was calculated based on the serum albumin concentration, lymphocyte count, and total cholesterol concentration. Patients were classified into 2 groups based on CONUT score. Relapse-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) after RNU were compared between the 2 groups, and predictors of survival were analyzed using Cox proportional hazards regression models.

RESULTS

For CONUT score, the area under the curve was 0.588 and the optimal cutoff value was 3. Twenty-four patients (22.4%) had high CONUT scores. The patients with high CONUT scores had significantly shorter 5-year RFS, CSS, and OS than did those with low CONUT scores (RFS: 50.1% vs. 66.0%; CSS: 28.1% vs. 71.7%; OS: 26.4% vs. 66.8%; all P<0.05). Results of the multivariable analysis, after adjustment for factors such as pT stage, pN stage, tumor grade, presence of lymphovascular invasion, and C-reactive protein level, revealed that CONUT score was an independent predictor of CSS (hazard ratio [HR] = 5.44, P = 0.0016) and OS (HR = 2.90, P = 0.0214) and showed marginal significance for predicting RFS (HR = 2.26, P = 0.0581).

CONCLUSIONS

Preoperative CONUT score helps predict survival in patients with localized urothelial carcinoma of the upper urinary tract treated with RNU.

Prognostic implications of preoperative anemia in urothelial carcinoma: A meta-analysis

The prognostic significance of preoperative anemia (PA) has been identified in various malignancies. However, its predictive role in urothelial carcinoma (UC) remains controversial. The aim of this study was to investigate the prognostic value of PA in UC patients. We performed a meta-analysis of the association between PA and survival outcome in UC patients. Electronic databases were searched up to June 30, 2016. Study characteristics and prognostic data were extracted from each included study. Cancer-specific survival (CSS), recurrence-free survival (RFS), and overall survival (OS) were pooled using hazard ratio (HR) with corresponding 95% confidence intervals (CI). Herein, 12 studies comprising 3815 patients were included in the meta-analysis. There were 1593 (41.76%) patients in the PA group and 2222 (58.24%) in the control group. The overall pooled HRs of PA for CSS, RFS, and OS were significant at 2.21, (95% CI: 1.83-2.65, Pheterogeneity = 0.49, I2 = 0%), 1.87 (95% CI: 1.59-2.20, Pheterogeneity = 0.22, I2 = 28%), and 2.04(95% CI: 1.76-2.37, Pheterogeneity = 0.36, I2 = 9%) respectively. Stratified analyses indicated that PA was a predictor of poor prognosis based on ethnicity, sample size, tumor T stage, G grade, lymphovascular invasion (LVI), concomitant carcinoma in situ (CIS), and follow-up values. Our findings show that PA has negative prognostic effects on the survival outcome (CSS, RFS, and OS) in UC patients and can serve as a useful and cost-effective marker to aid prognosis prediction.

Preoperative Pyuria Is a Poor Prognostic Factor in Patients With Urothelial Carcinoma of the Upper Urinary Tract After Surgery

INTRODUCTION

The purpose of this study was to determine the prognostic significance of preoperative pyuria in patients with upper urinary tract urothelial carcinoma after surgery.

PATIENTS AND METHODS

We retrospectively evaluated data on 157 patients with nonmetastatic upper urinary tract urothelial carcinoma who had undergone surgery at our institution. The associations between clinical features and advanced pathological findings were evaluated using a logistic regression model. Recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) were assessed with the Kaplan-Meier method and Cox regression analysis. The influence of pyuria on the predictive accuracy of the multivariate model was assessed using the concordance index.

RESULTS

The median postoperative follow-up among patients who survived was 48.1 months. Preoperative pyuria was significantly correlated with worse RFS, CSS, and OS (P < .001 each). Pyuria was also associated with significantly increased risk of a high pathological T stage (≥ pT3; odds ratio, 2.99; P = .003), high tumor Grade (G3; odds ratio, 2.25; P = .038), and lymphovascular invasion (odds ratio, 2.25; P = .008). Moreover, multivariate Cox regression analyses showed that pyuria was an independent prognostic factor for RFS (hazard ratio, 3.02; P < .001), CSS (hazard ratio, 2.15; P = .043), and OS (hazard ratio, 2.10; P = .019). For CSS, the addition of pyuria to the multivariate model increased its predictive accuracy from 0.87 to 0.90.

CONCLUSION

Preoperative pyuria is significantly associated with CSS, OS, and increased risk of locally advanced disease and subsequent disease recurrence in patients with upper urinary tract urothelial carcinoma who undergo surgery.

Risk stratification for kidney sparing procedure in upper tract urothelial carcinoma

Risk stratification for kidney sparing procedures (KSP) to treat upper tract urothelial carcinoma (UTUC) is a major issue. A non-systematic Medline/PubMed literature search was performed using the terms “upper tract urothelial carcinoma” with different combinations of keywords to review the current knowledge on this topic. Original articles, reviews and editorials in English language were selected based on their clinical relevance. Available techniques for KSP include segmental ureterectomy and endoscopic resection through a percutaneous or flexible ureteroscopic access. These approaches were traditionally restricted to patients with imperative indications. Current recommendations suggest that selected patients with normal contralateral kidney should also be candidates for such treatments. Modern imaging and endoscopy have improved to accurately stage and grade the tumor while various prognostic clinical factors and biomarkers have been proposed to identify tumor with aggressive features and worse outcomes. Several predictive models using different combinations of such baseline characteristics may help clinicians in clinical decision making. However, risk-adapted based approach that has been proposed in recent guidelines to identify patients who are more likely to benefit from KSP only relies on few clinical and pathological factors. Despite growing understanding of the disease, treatment of UTUC remains challenging. Further efforts and collaborative multicenter studies are mandatory to improve risk stratification to decide and promote optimal KSP in UTUC. These efforts should focus on the integration of promising biomarkers and predictive tools in clinical decision making.

Changes in oncological outcomes after radical nephroureterectomy in patients with upper urinary tract urothelial carcinoma treated in the last two decades: a retrospective analysis based on a multicenter collaborative study

OBJECTIVE

We investigated chronological changes in the outcomes of patients with upper urinary tract urothelial carcinoma treated in the past two decades, during which there was an important change in treatment paradigm.

METHODS

A retrospective review was conducted of 1180 urinary tract urothelial carcinoma patients who underwent radical nephroureterectomy in multicenter collaborative institutions between 1996 and 2015. The patients were divided into four groups according to the year when radical nephroureterectomy was performed, as follows: 1996-2000 (period 1; P1), 2001-05 (P2), 2006-10 (P3) and 2011-15 (P4). Variables including tumor grade, T and N categories, administration of perioperative chemotherapy and treatment outcomes were compared among the four groups.

RESULTS

There were 146 (12%), 312 (27%), 459 (39%) and 263 (22%) patients in the P1, P2, P3 and P4 groups, respectively. The proportion of patients harboring pT2/3 and Grade 3 tumors increased gradually from 42% (P1) to 58% (P4) and from 49% (P1) to 65% (P4), respectively. The 5-year disease-free survival rates were 74%, 74%, 73% and 75%, and the 5-year overall survival rates were 74%, 65%, 67% and 72% for the P1, P2, P3, and P4 groups, respectively. Multivariate analysis with adjustment for possible confounding factors revealed no significant differences in disease-specific survival, overall survival or intravesical recurrence-free survival among the four groups.

CONCLUSIONS

Despite advances in diagnostic instruments, surgery and systemic chemotherapy, the clinical outcome of urinary tract urothelial carcinoma after radical surgery has not significantly improved over the last two decades, and further research is therefore required.

Prognostic significance of sarcopenia in upper tract urothelial carcinoma patients treated with radical nephroureterectomy

We investigated the prognostic significance of sarcopenia in upper tract urothelial carcinoma (UTUC) patients treated with radical nephroureterectomy (RNU). The skeletal muscle index (SMI) was calculated from computed tomography images. Sarcopenia was defined as SMI <43 cm²/m² for males with body mass index <25 kg/m², <53 cm²/m² for males with BMI ≥25 kg/m², and <41 cm²/m² for females. Associations of sarcopenia with cancer‐specific survival (CSS) and overall survival (OS) were evaluated in 81 consecutive UTUC patients who underwent RNU. Forty‐seven (58%) out of 81 patients had sarcopenia. Multivariate analyses identified sarcopenia as a significant and independent poor prognostic factor for both CSS (hazard ratio [HR] 8.58, 95% confidence interval [CI]: 1.63–158.1, P = 0.008) and OS (HR 6.05, 95%CI 2.00–26.21, P < 0.001). In patients with locally advanced disease (pT3/4 or pN+), those with sarcopenia showed significantly worse CSS and OS than those without (5‐year CSS rate 55% vs. 100%, P = 0.014; 5‐year OS rate 40% vs. 86%, P = 0.007). In contrast, no prognostic difference was observed between patients with and without sarcopenia in those with organ‐confined disease (pTa‐2pN0/x). Sarcopenia is an independent poor prognostic factor for UTUC patients treated with RNU, particularly for those with locally advanced disease.

Prognostic serum markers in patients with high-grade upper tract urothelial carcinoma

INTRODUCTION

The role of preoperative serum-based markers in predicting survival outcomes of patients has been reported for several cancer types; however, their association with upper tract urothelial carcinoma (UTUC) prognosis is unclear. We evaluated the role of systemic serum-based markers in predicting adverse pathological features and survival outcomes in patients surgically treated for high-grade (HG) UTUC.

METHODS

We retrospectively reviewed all patients undergoing surgery for HG UTUC between June 2006 and July 2013 at our institution. Comprehensive clinicopathologic data and preoperative serum-based markers including hemoglobin, white blood cell count, platelet count, serum albumin, calcium, and liver function tests were recorded. Associations of serum markers with pathologic features and recurrence-free survival (RFS) were determined by logistic and Cox regression analyses, respectively. The concordance index for the oncologic outcomes model was determined.

RESULTS

In total, 101 patients were identified with a median follow-up of 18.5 months (range: 1-74mo). In all, 60% of patients had pT2 or less and 11% had nodal metastases. Preoperative elevated alkaline phosphatase (ALP) (≥116IU/l) was associated with multiple adverse pathologic features including advanced T stage, lymphovascular invasion, and histologic necrosis. On univariate analysis, serum markers independently associated with RFS included hemoglobin≤12.9 (hazards ratio [HR] = 2.51; 95% CI: 1.17-5.36, P = 0.018), albumin≤4g/dl (HR = 4.4; 95% CI: 2.04-9.30; P<0.0001), ALP≥116U/l (HR = 13.3; 95% CI: 5.3-33.52, P<0.0001), alanine transaminase≥27 (HR = 2.63, 95% CI: 1.11-6.21, P = 0.028), serum aspartate transaminase≥20 (HR = 2.21, 95% CI: 1.04-4.69, P = 0.038), and corrected calcium≥9.3 (HR = 2.45, 95% CI: 1.01-5.93, P = 0.047). The 2 strongest predictors, albumin and ALP, were combined to form an AA score (range: 0-2), which improved the baseline preoperative clinical model concordance index for prediction of RFS from 0.626 to 0.799.

CONCLUSION

In HG UTUC, elevated preoperative ALP was associated with adverse pathologic features. Additionally, elevated ALP and low albumin were independently associated with worse RFS and overall survival. These serum-based markers are often measured in the preoperative workup of UTUC, and thus they can be included in future prognostic models to risk stratify patients.

Preoperative risk factors for extraurothelial recurrence in N0M0 patients with renal pelvic cancer treated by radical nephroureterectomy

The prediction of extraurothelial recurrence (EUR) before radical nephroureterectomy (RNU) is difficult for patients with upper tract urothelial carcinoma. If EUR can be predicted preoperatively, it may be possible to determine the need for neoadjuvant chemotherapy or the surgical strategy. Our previous study identified preoperative risk factors for EUR in ureteral cancer, while the present study identified preoperative risk factors for EUR in renal pelvic cancer (RPC). The preoperative factors were reviewed in 71 N0M0 patients with RPC treated by RNU between 1999 and 2013. Preoperative clinical background data, laboratory test results, including inflammatory indices, lactate dehydrogenase (LDH), and estimated glomerular filtration rate, and radiological findings were subjected to multivariate analyses to identify independent predictive factors for EUR. The 3-year EUR-free survival (EURFS) rate was 81.9%, and univariate analysis showed that clinical T (cT) stage ≥3, white blood cell counts ≥7600/µl, neutrophil counts ≥4,500/µl, neutrophil-to-lymphocyte ratio ≥2.0, and LDH ≥210 IU/l were significantly associated with EURFS. Additionally, a cT stage ≥3 (P=0.0244) and LDH ≥210 IU/l (P=0.0322) were independent predictors for EUR. When patients were stratified into three groups according to the number of risk factors, the 3-year EURFS rates were 94.5, 76.3, and 33.3% for the low-, intermediate-, and high-risk patient groups, respectively. In conclusion, cT stage ≥3 and LDH ≥210 IU/l were preoperative predictive factors of EUR in patients with RPC. High-risk patients may be candidates for neoadjuvant chemotherapy and low-risk patients may be candidates for RNU without lymph node dissection.

Prognostic model to predict survival in patients with metastatic upper tract urothelial carcinoma treated with cisplatin-based chemotherapy

OBJECTIVES

To create a novel prognostic model to predict survival in metastatic upper tract urothelial carcinoma patients treated with cisplatin-based chemotherapy.

METHODS

After institutional review board approval, patients who had metastatic upper tract urothelial carcinoma and were treated with cisplatin based chemotherapy from 2000 to 2012 at Kaohsiung Chang Gung Memorial Hospital were retrospectively reviewed. Significantly predictive factors were identified by multivariate Cox regress analyses. Kaplan-Meier curves were plotted to estimate overall survival. Several prognostic models were validated by using our cohort, and Harrell's c-index was calculated to evaluate their predicting performances.

RESULTS

The present study consisted of 136 patients with a median age of 62 years and a median follow-up visit of 13.6 months. Multivariate analyses showed that renal function, performance status, liver metastasis and number of metastatic sites was independently related to survival. Based on these four variables, we constructed a prognostic model "renal function, performance status, liver metastasis, number of metastatic sites" with significantly different survival (P < 0.001). C-index results were renal function, performance status, liver metastasis, number of metastatic sites model 0.80 (0.69-0.90), Bajorin model 0.72 (0.61-0.83), Taguchi model 0.77 (0.67-0.87) and Tanaka model 0.78 (0.69-0.88). Our renal function, performance status, liver metastasis, number of metastatic sites prognostic model achieved the highest c-index in this study.

CONCLUSIONS

Our renal function, performance status, liver metastasis, number of metastatic sites prognostic model could be useful for providing prognostic information on survival in patients with metastatic upper tract urothelial carcinoma.

Plasma fibrinogen level: an independent prognostic factor for disease-free survival and cancer-specific survival in patients with localised renal cell carcinoma

OBJECTIVES

To investigate the impact of perioperative plasma fibrinogen level as a biomarker of oncological outcome in localised renal cell carcinoma (RCC).

PATIENTS AND METHODS

We consecutively identified 601 patients with localised RCC who underwent curative surgery at a single institution. Subsequent disease recurrence and cancer-specific survival (CSS) were assessed using the Kaplan-Meier method. To evaluate the independent prognostic impact of plasma fibrinogen level, multivariate analysis was performed for these outcomes.

RESULTS

Using the defined threshold level of preoperative plasma fibrinogen of ≥420 mg/dL as elevated, we found 56 patients (9.3%) with an elevated plasma fibrinogen level preoperatively. In Kaplan-Meier analysis, there was a significant difference in disease-free survival and CSS rates between patients with and without preoperative plasma fibrinogen levels of ≥420 mg/dL. Multivariate analysis showed that elevated preoperative plasma fibrinogen level was an independent predictor of subsequent disease recurrence and cancer-specific mortality. In a subgroup analysis of the elevated preoperative plasma fibrinogen level group, postoperative normalisation of plasma fibrinogen level was significantly associated with CSS, showing that patients with non-normalised plasma fibrinogen levels tended to have a higher incidence of cancer-specific mortality after surgery.

CONCLUSION

Patients with elevated preoperative plasma fibrinogen levels could be significantly predicted to have subsequent tumour metastasis and cancer-specific mortality, while there was a significant difference in CSS between patients in the normalised and non-normalised postoperative plasma fibrinogen groups. While these are hypothesis generating results, plasma fibrinogen levels may be a useful biomarker due to its low cost and ease of assessment.

Systemic Inflammatory Response Based on Neutrophil-to-Lymphocyte Ratio as a Prognostic Marker in Bladder Cancer

A growing body of evidence suggests that systemic inflammatory response (SIR) in the tumor microenvironment is closely related to poor oncologic outcomes in cancer patients. Over the past decade, several SIR-related hematological factors have been extensively investigated in an effort to risk-stratify cancer patients to improve treatment selection and to predict posttreatment survival outcomes in various types of cancers. In particular, one readily available marker of SIR is neutrophil-to-lymphocyte ratio (NLR), which can easily be measured on the basis of absolute neutrophils and absolute lymphocytes in a differential white blood cell count performed in the clinical setting. Many investigators have vigorously assessed NLR as a potential prognostic biomarker predicting pathological and survival outcomes in patients with urothelial carcinoma (UC) of the bladder. In this paper, we aim to present the prognostic role of NLR in patients with UC of the bladder through a thorough review of the literature.

Impaction of ureteral stones into the ureteral wall: Is it possible to predict?

To determine the possible predictive value of certain acute phase reactants CRP and ESR as well as radiologic parameters on the degree of impaction in ureteral stones. A total of 80 adult patients with a single opaque proximal ureteral stone were evaluated. A non-contrast CT was performed in all cases and all possible radiologic predictive parameters calculated. Additionally, to outline the degree of impaction at the stone site, two serum acute phase reactants namely CRP and ESR levels were also assessed. Patients were divided into two groups as follows; Group 1 (n:42) patients with normal CRP levels and Group 2 (n:38) patients with elevated levels of CRP. The data obtained in the subgroups were first comparatively evaluated with radiological parameters and the possible correlation between CRP values and these parameters was well evaluated. While the serum CRP levels were normal in 42 cases, they were elevated in 38 cases. Evaluation of the data from CRP subgroups and radiologic parameters showed that elevated levels of serum CRP were closely related with mean values of ureteral wall thickness (UWT) as well as mean level of hydronephrosis with a statistically significant difference. Additionally, a correlation analysis between serum CRP levels and all other parameters mentioned above demonstrated a statistically significant correlation between UWT, degree of hydronephrosis and serum ESR values. Evaluation of serum CRP and ESR values could let us to predict the UWT, a parameter which is closely related with the degree of stone impaction.

Preoperative Underweight Patients with Upper Tract Urothelial Carcinoma Survive Less after Radical Nephroureterectomy

The prognostic impact of body mass index (BMI) in patients with upper tract urothelial carcinoma (UTUC) is an ongoing debate. Our study aimed to investigate the prognostic role of BMI in patients treated with radical nephroureterectomy (RNU) for UTUC from a multi-institutional Korean collaboration. We retrospectively reviewed data from 440 patients who underwent RNU for UTUC at four institutions in Korea. To avoid biasing the survival estimates, patients who had previous or concomitant muscle-invasive bladder tumors were excluded. BMI was categorized into approximate quartiles with the lowest quartile assigned to the reference group. Kaplan-Meier and multivariate Cox regression analyses were performed to assess the influence of BMI on survival. The lower quartile BMI group showed significantly increased overall mortality (OM) and cancer specific mortality (CSM) compared to the 25%-50% quartiles and upper quartile BMI groups. Kaplan-Meier estimates showed similar results. Based on multivariate Cox regression analysis, preoperative BMI as a continuous variable was an independent predictor for OM and CSM. In conclusion, preoperative underweight patients with UTUC in Korea survive less after RNU. Preoperative BMI may provide additional prognostic information to establish risk factors.

A novel risk stratification model, involving preoperative lymphocyte-monocyte ratio and standard pathological factors, for overall survival in patients with bladder cancer undergoing radical cystectomy

OBJECTIVE

To evaluate the ability of preoperative lymphocyte-monocyte ratio to predict prognosis and determine post-operative risk stratification in patients with bladder cancer undergoing radical cystectomy.

METHODS

A retrospective review of the 210 patients who had undergone radical cystectomy for bladder cancer from 2006 to 2013 identified 181 patients with sufficient data to evaluate the prognostic significance of the lymphocyte-monocyte ratio. Overall survival was assessed by the Kaplan-Meier method. The association of clinicopathological findings with overall survival was evaluated by a multivariate Cox proportional model, and a novel risk stratification model to predict prognosis was established.

RESULTS

Median follow-up after radical cystectomy was 6.0 years. The 5-year overall survival rate was significantly lower for patients with low than high lymphocyte-monocyte ratio (27.6 vs 80.7%, P < 0.001). Multivariable analyses showed that pT ≥2, pN ≥1, positive margins and low lymphocyte-monocyte ratio were independent predictors of overall survival. A post-operative risk stratification model using these factors showed significant differences among the three subgroups (low, intermediate and high risk) with a concordance index of 0.84. The 5-year overall survival rates in patients at low, intermediate and high risk were 85.4, 45.5 and 0%, respectively (P < 0.001).

CONCLUSIONS

Preoperative lymphocyte-monocyte ratio, pathological tumor and lymph node stage and positive margins are significantly associated with overall survival in patients who have undergone radical cystectomy for bladder cancer.

Prognostic Role of C-Reactive Protein In Urological Cancers: A Meta-Analysis

Growing evidence suggests serum C-reactive protein (CRP) can serve as a prognostic marker in urological cancers. However, some studies yield contradictory results. Our objective was to determine the relationship between baseline serum CRP and survival outcome in urological cancers. We searched PubMed and EMBASE databases until October 2014 without language restrictions. 44 independent studies investigating the association between baseline serum CRP and cancer-specific survival (CSS) or overall survival (OS) were selected. High CRP yielded a worse survival in renal cell carcinoma, prostate cancer, bladder cancer, and upper urinary tract urothelial carcinoma. Combined results of meta-analyses indicated that CRP was a prognostic factor in urological cancers (CSS: p < 0.01; OS: p < 0.01). Subgroup analyses confirmed the significant association between CRP and prognosis, regardless of race and cutoff value of CRP. Specifically, prognostic impact of CRP was also noted in patients with localized RCC treated with nephrectomy (CSS: p < 0.01) and metastatic RCC treated with molecular-targeted therapy (OS: p < 0.01). In conclusion, serum CRP is an independent prognostic factor in urological cancers and risk stratification by serum CRP level could be helpful for prognostic assessment.

High expression of KPNA2 defines poor prognosis in patients with upper tract urothelial carcinoma treated with radical nephroureterectomy

BACKGROUND

To analyze the expression of karyopherin alpha 2 (KPNA2) in upper tract urothelial carcinoma (UTUC) and to investigate whether the KPNA2 expression provides additional prognostic information following radical nephroureterectomy (RNU).

METHODS

A tissue microarray (TMA) containing samples from 176 patients with UTUC who underwent RNU at our institute was analyzed for KPNA2 expression using immunohistochemistry. KPNA2 expression in normal urothelial cell line and urothelial carcinoma cell lines was evaluated by western blot analysis. Using RNA interference in vitro, the effects of KPNA2 inhibition on cellular viability, migration and apoptosis were determined.

RESULTS

KPNA2 expression was significantly upregulated in the UTUC samples compared with the adjacent normal urothelial tissues. High KPNA2 immunoreactivity was identified as a predictor of bladder recurrence (hazard ratio [HR]: 2.017, 95% CI 1.13-3.61, p = 0.018), poor disease-free survival (DFS, HR: 2.754, 95% CI 1.68-4.51, p = 0.001) and poor overall survival (OS, HR: 4.480, 95% CI 1.84-10.89, p = 0.001) for patients with UTUC after RNU. Furthermore, high KPNA2 immunoreactivity was independent of the conventional predictive factors in a multivariate analysis. Additional in vitro experiments revealed that KPNA2 expression was higher in urothelial carcinoma cell lines than in normal urothelial cell line. KPNA2 inhibition with a specific siRNA decreased cell viability and migration and increased apoptosis in urothelial carcinoma cell lines.

CONCLUSIONS

KPNA2 is a novel independent prognostic marker for bladder recurrence, DFS and OS of UTUC patients who have undergone RNU. Moreover, these data suggest that KPNA2 may be a promising therapeutic target for UTUC.

C-reactive protein in urologic cancers

C-reactive protein is an acute-phase reactant that is elevated in the setting of systemic infections, trauma, and malignancies. Urologic cancers have been shown to promote changes in c-reactive protein levels. Pre-treatment serum levels can predict disease characteristics, extent of disease, and prognosticate survival after intervention in renal cell carcinoma, prostate cancer, bladder cancer, upper tract urothelial carcinoma, and penile cancer. Changes in post-treatment serum levels have also shown promise in determining survival. As a result, c-reactive protein has been incorporated into various survival nomograms to improve predictive accuracy. While the association between c-reactive protein and survival in testicular cancer has not been studied, elevated serum levels may correlate with treatment side effects, such as cardiovascular disease and chronic cancer-related fatigue. Understanding the relationship between c-reactive protein and urologic cancers can help physicians determine the appropriate course of treatment and improve patient care.