Predictors of Upper Tract Urothelial Cell Carcinoma After Primary Bladder Cancer: A Population Based Analysis

Impact of an optimized surveillance protocol based on the European Association of Urology substratification on surveillance costs in patients with primary high-risk non-muscle-invasive bladder cancer

OBJECTIVES

The optimal frequency and duration of surveillance in patients with high-risk non-muscle-invasive bladder cancer (NMIBC) remain unclear. The aim of the present study is to develop an optimal surveillance protocol based on the European Association of Urology (EAU) substratification in order to improve surveillance costs after transurethral resection of bladder tumor (TURBT) in patients with primary high-risk NMIBC.

MATERIALS AND METHODS

We retrospectively evaluated 428 patients with primary high-risk NMIBC who underwent TURBT from November 1993 to April 2019. Patients were substratified into the highest-risk and high-risk without highest-risk groups based on the EAU guidelines. An optimized surveillance protocol that enhances cost-effectiveness was then developed using real incidences of recurrence after TURBT. A recurrence detection rate ([number of patients with recurrence / number of patients with surveillance] × 100) of ≥ 1% during a certain period indicated that routine surveillance was necessary in this period. The 10-year total surveillance cost was compared between the EAU guidelines-based protocol and the optimized surveillance protocol developed herein.

RESULTS

Among the 428 patients with primary high-risk NMIBC, 97 (23%) were substratified into the highest-risk group. Patients in the highest-risk group had a significantly shorter recurrence-free survival than those in the high-risk without highest-risk group. The optimized surveillance protocol promoted a 40% reduction ($394,990) in the 10-year total surveillance cost compared to the EAU guidelines-based surveillance protocol.

CONCLUSION

The optimized surveillance protocol based on the EAU substratification could potentially reduce over investigation during follow-up and improve surveillance costs after TURBT in patients with primary high-risk NMIBC.

Clinical features and prognostic indicators in upper-tract urothelial carcinoma with bone metastasis

Purpose

With the gradual increase in the incidence of upper-tract urothelial carcinoma (UTUC), its metastatic disease has attracted much attention. The prognosis of UTUC patients with bone metastasis is worse than that of UTUC patients with other metastases. Therefore, the current study is performed to analyze the clinicopathologic features and survival predictors among UTUC patients with bone metastasis.

Patients and methods

We reviewed the Surveillance, Epidemiology, and End Results (SEER) database to select cases diagnosed with UTUC and bone metastasis at present from 2010 to 2016. Overall survival (OS) and cancer-specific survival (CSS) were first performed by applying univariate Cox regression analysis. Then we performed multivariate Cox analysis to determine independent predictors of survival. Forest plots were drawn by GraphPad 8.0.1 and used to visually display the results of multivariate analysis. Kaplan-Meier method was applied to intuitively show the prognosis difference of each independent risk factor.

Results

We finally identified 380 UTUC patients with bone metastasis for survival analysis, of which 230 males (60.5%) and 150 females (39.5%). The mean and median age at diagnosis were 71 and 72 years, respectively. Simultaneous lung metastasis (33.4%) and liver metastasis (31.1%) were more common in UTUC patients with bone metastasis. The 1-year OS and CSS rates of this research population were 23.8% and 26.6%, respectively. Multivariate Cox proportional hazards modeling controlling for surgery, chemotherapy, brain metastasis, liver metastasis, lung metastasis, and marital status, revealed that surgery, chemotherapy, no liver metastasis, no lung metastasis, and married status predicted for better OS and CSS.

Conclusion

Surgery and chemotherapy are optimal management of UTUC patients with bone metastasis. Active treatments on lung and liver metastases should be performed. The prognosis of patients with unmarried status or others should be further improved.

Prognostic values of distal ureter involvement and survival outcomes in bladder cancer at T1 and T2 stages: a propensity score matching study

PURPOSE

To study prognostic values of distal ureter involvement (DUI) and survival outcomes in bladder cancer at T1 and T2 stages.

METHODS

The national Surveillance, Epidemiology, and End Results database (2004-2015) was applied to obtain bladder cancer patients. We used the Kaplan-Meier method with the log-rank test, subgroup analyses, the multivariable Cox proportional hazard model and propensity score matching (PSM).

RESULTS

A total of 490 patients with DUI and 28,498 patients with non-DUI (non-involvement) were enrolled in our study. After 1:1 PSM, 490 matched pairs were picked out. The multivariable Cox regression before and after PSM revealed that the DUI group had a high risk of overall mortality (HR = 1.374, P < 0.001 before PSM; HR = 1.513, P < 0.001 after PSM) and cancer-specific mortality (HR = 1.632, P < 0.001 before PSM; HR = 1.699, P < 0.001 after PSM). The results of survival analyses showed that patients in the DUI group had lower survival probability in OS (P = 0.0011) and CSS (P < 0.0001) analyses. Nevertheless, in the subgroup analysis, significant differences were only observed in the T1 stage in terms of CSS and T2a stage in terms of OS and CSS (all P < 0.05).

CONCLUSION

The prognosis of DUI was poorer than that of non-DUI. DUI was an independent risk factor for OM and CSM in bladder cancer at T1 and T2 stages especially for those at T1 and T2a stages.

Management of hydronephrosis after radical cystectomy and urinary diversion for bladder cancer: A single tertiary center experience

OBJECTIVES

To clarify the incidence of postoperative hydronephrosis and verify the validity of diagnostic and therapeutic approaches for hydronephrosis after cystectomy and urinary diversion for bladder cancer.

METHODS

Totally, 290 patients receiving urinary diversion from 2005 through 2017 with complete data were enrolled, including 258 (89.0%) with an ileal conduit and 32 (11.0%) with an ileal neobladder. Postoperative radiographic images were reviewed. In patients with postoperative hydronephrosis, antegrade pyelography and ureteroscopy were performed to exclude malignant etiology. Balloon dilation and open surgical revision were performed according to the conditions.

RESULTS

Forty-six patients (58 renal units) developed postoperative hydronephrosis. The cumulative incidence was 11.4% by a median follow-up of 59.5 months. Ureteral recurrence was detected by antegrade examinations in two patients, whereas malignant strictures were subsequently revealed in three patients. Thus, malignant etiology was found in hydronephrosis in five renal units (12.8%) of five patients (16.1%). The median times to diagnosis of hydronephrosis were 0 (interquartile range [IQR] 0-4) and 14 months (IQR 9-12) for benign and malignant strictures, respectively (p = 0.003). Of them, 31 patients (39 renal units) received interventions. Balloon dilation was performed in 13 renal units with benign strictures, and was successful in two (15.4%). Open surgical revision was performed in eight patients (11 renal units), including two with failed balloon dilation, all of which was successful.

CONCLUSIONS

Postoperative hydronephrosis is potentially associated with recurrent disease. Accurate differential diagnosis is challenging although antegrade procedures may be helpful in some cases. Open surgical revision is highly effective to treat benign strictures.

Retrograde Pyelography in the Presence of Urothelial Bladder Cancer Does Not Affect the Risk of Upper Tract Urothelial Cancer: A Retrospective Analysis of a Single-Centre Cohort

OBJECTIVE

Patients with bladder cancer (BC) are at risk of developing upper tract urothelial carcinoma (UTUC). Therefore, CT urography is recommended for follow-up. To avoid intravenous contrast agents, retrograde pyelography (RPG) is an alternative. However, it is still unclear whether RPG increases the incidence of UTUC. The aim of this study was to investigate the impact of RPG in the presence of BC on the risk of developing UTUC.

PATIENTS AND METHODS

Retrospectively analysing a total of 3,680 RPGs between 2009 and 2016, all patients with simultaneous BC (group 1) and those without synchronous BC (group 2) during RPG were compared. All patients were risk stratified according to the EORTC bladder calculator. In patients without BC during RPG, risk stratification was based on the worst prior tumour characteristics.

RESULTS

A total of 145 patients with a history of BC were analysed. Of these, 112 patients underwent RPG with simultaneous BC. UTUC developed in 6 of 112 patients (5.4%) and 58.9% (66/112) had high-risk BC according to the EORTC bladder calculator. In the control group, one out of 33 (3%) patients with metachronous high-risk BC developed UTUC.

CONCLUSIONS

Using RPG in the presence of BC did not increase the risk of UTUC. Due to the predominant number of high-risk/high-grade tumours, individual tumour biology appears to be the primary driver for the development of UTUC.

The incidence and prevalence of upper tract urothelial carcinoma: a systematic review

BACKGROUND

Upper tract urothelial carcinoma (UTUC) is a rare urological cancer that is still an important public health concern in many areas around the world. Although UTUC has been linked to a number of risk factors, to our knowledge no systematic review has been published on the overall incidence and prevalence of de-novo UTUC. This review aimed to examine the global epidemiology of UTUC to provide clinicians and public health specialists a better understanding of UTUC.

METHODS

A systematic search was conducted on MEDLINE, Embase, and the Web of Science using a detailed search strategy. Observational epidemiological studies describing the incidence and prevalence of de-novo UTUC in adults were included, and the Joanna Briggs Institute checklist was used for critical appraisal and data extraction of the studies selected.

RESULTS

The systematic search identified 3506 papers, of which 59 papers were included for qualitative synthesis. The studies selected included data ranging from the years 1943 to 2018. A comprehensive qualitative synthesis of the data was performed. UTUC incidence generally varied according to age (higher with increasing age), sex (unclear), race (unclear), calendar time (increased, stable, or decreased according to region), geographical region (higher in Asian countries), occupation (higher in seamen and printers), and other population characteristics. Prevalence was only reported by one study, which showed UTUC to have the highest incidence of the rare urogenital cancers in Europe.

CONCLUSION

This systematic review highlights an increased incidence of UTUC in certain groups, including increasing age and certain occupations such as seamen. The incidence of UTUC also varies between certain geographical regions. The trend of UTUC incidence for sex, race, and calendar time is less clear due to a wide variety of metrics used by the studies identified. More studies are also required on the prevalence of UTUC to understand its disease burden. Trial registration This review was registered on PROSPERO (registration number CRD42019134255).

Stratifying risk for multiple, recurrent, and large (≥3 cm) Ta, G1/G2 tumors in non-muscle-invasive bladder cancer

Purpose

The current stratification of risk groups regarding recurrence and progression of non-muscle-invasive bladder cancer (NMIBC) is problematic. We aimed to assess the long-term outcome and risk of multiple, recurrent, and large (≥3 cm) Ta, G1/G2 tumors after transurethral resection of the bladder tumor (TURBT).

Materials and Methods

We categorized 1,621 patients with NMIBC who underwent TURBT into four risk groups according to the European Association of Urology (EAU) guidelines as follows: low-risk, intermediate-risk, high-risk, and study group. The overall, cancer-specific, disease recurrence-free, and disease progression-free survival rates were estimated by using the Kaplan–Meier method. Then, the impact of risk group was assessed by using a multivariable Cox regression model.

Results

The study group comprised 52 patients (3.2%) within a mean follow-up of 64.8 months. The disease recurred and progressed in 41 (78.8%) and 7 (13.5%) patients, respectively. Among the four groups, the study group showed the highest risk for 10-year recurrence after TURBT. The disease progression risk in the study group was between that of the intermediate- and high-risk groups. Cancer-specific and all-cause deaths occurred in one and four patients in the study group, respectively. The study group had a higher risk for disease recurrence than did the high-risk group; however, it did not have a higher risk for disease progression than in the high-risk group.

Conclusions

Multiple, recurrent, and large (≥3 cm) Ta, G1/G2 tumors carry a higher risk for disease recurrence, but not progression, than in the EAU high-risk group of NMIBC.

Nephron-sparing management of upper tract urothelial carcinoma

Urothelial carcinoma of the upper urinary tract is uncommon and presents unique challenges for diagnosis and management. Nephroureterectomy has been the preferred management option, but it is associated with significant morbidity. Nephron-sparing treatments are a valuable alternative and provide similar efficacy in select cases. A PubMed literature review was performed in English language publications using the following search terms: urothelial carcinoma, upper tract, nephron-sparing, intraluminal and systemic therapy. Contemporary papers published within the last 10 years were primarily included. Where encountered, systematic reviews and meta-analyses were given priority, as were randomized controlled trials for newer treatments. Core guidelines were referenced and citations reviewed for inclusion. A summary of epidemiological data, clinical diagnosis, staging, and treatments focusing on nephron-sparing approaches to upper tract urothelial carcinoma (UTUC) are outlined. Nephron-sparing management strategies are viable options to consider in patients with favorable features of UTUC. Adjunctive therapies are being investigated but the data remains mixed. Protocol variability and dosage differences limit statistical interpretation. New mechanisms to improve treatment dwell times in the upper tracts are being designed with promising preliminary results. Studies investigating systemic therapies are ongoing but implications for nephron-sparing management are uncertain. Nephron-sparing management is an acceptable treatment modality best suited for favorable disease. More work is needed to determine if intraluminal and/or systemic therapies can further optimize treatment outcomes beyond resection alone.

Oncologic outcomes of radical nephroureterectomy (RNU)

Radical nephroureterectomy is the mainstay of surgical treatment for upper tract urothelial carcinoma (UTUC), a disease which comprises approximately 5% of urothelial malignancies. Minimally-invasive and nephron-sparing interventions have been explored, although thus far have not shown comparable oncologic outcomes except in a relatively narrow set of patients. Due to the relative rarity of the disease, it has taken decades and multi-disciplinary efforts to sufficiently identify prognostic factors of oncologic outcomes. Despite these efforts, however, oncologic outcomes of nephroureterectomy have remained remarkably stable over the past 30 years. New techniques, such as laparoscopic and robotic surgery, have been applied to this procedure. High level evidence regarding equivalent oncologic outcomes is lacking and open surgery remains the standard of care for high-stage disease, although there is a role for laparoscopic and robotic nephroureterectomy. The importance of bladder cuff removal in improving oncologic outcomes has been broadly accepted, although there is no consensus as to the most oncologically appropriate technique. There does appear to be evidence that endoscopic techniques confer worse oncologic control. The role of lymphadenectomy remains controversial, although there is evidence that increased nodal yield could have oncologic benefit. Given disease heterogeneity and varied technical approaches to the procedure, no consensus standardized template has been identified. There is level 1 evidence for the use of intravesical chemotherapy peri-operatively and that this intervention can improve the risk of intravesical recurrence. Advances in systemic neoadjuvant and adjuvant chemotherapy have yielded promising results and are likely to become standard of care for patients without contraindications. Immunotherapy and targeted biologic agents are also likely to improve the surgical efficacy of radical nephroureterectomy as well. Ultimately, more high level evidence is needed to identify successful surgical and medical approaches to UTUC and multi-institutional collaboration is critical to this progress.

Impact of double J stenting or nephrostomy placement during transurethral resection of bladder tumour on the incidence of metachronous upper urinary tract urothelial cancer

Background

Whether or not double J (DJ) stenting during transurethral resection of a bladder tumour (TURBT) harms patients with regard to possible metachronous upper urinary tract urothelial cancer (UUTUC) development remains controversial. This study evaluated the impact of DJ compared to nephrostomy placement during TURBT for bladder cancer (BCa) on the incidence of metachronous UUTUCs.

Methods

We retrospectively analysed 637 patients who underwent TURBT in our department between 2008 and 2016. BCa, UUTUC and urinary drainage data (retrograde/anterograde DJ and percutaneous nephrostomy) were assessed, along with the prevalence of hydronephrosis, and mortality. Chi-square and Fisher’s exact test was performed for univariate analyses. Survival analysis was performed by the Kaplan-Meier method and log-rank tests.

Results

UUTUC was noted in 28 out of 637 patients (4.4%), whereas only eight (1.3%) developed it metachronously to BCa. Out of these, four patients received DJ stents, while four patients received no urinary drainage of the upper urinary tract. Placement of urinary drainage significantly correlated with UUTUC (50.0% vs. 17.9%; p = 0.041). DJ stenting significantly correlated with UUTUC (50.0% vs. 11%; p <  0.01), while no patient with a nephrostomy tube developed UUTUC. UUTUC-free survival rates were significantly lower for patients with DJ stents than for all other patients (p = 0.001). Patients with or without DJ stents had similar overall survival (OS) rates (p = 0.73), whereas patients with nephrostomy tubes had significantly lower OS rates than all other patients (p <  0.001).

Conclusions

Patients with DJ stenting during TURBT for BCa might have an increased risk of developing metachronous UUTUC. This study indicated advantages in placing nephrostomy tubes rather than DJ stents; however, confirmation requires investigation of a larger cohort. Even so, the increased mortality rate in the nephrostomy group reflected hydronephrosis as an unfavourable prognostic factor.

Risk factors for upper tract urothelial recurrence following local excision of bladder cancer

The mechanism of upper tract recurrence after local excision of bladder cancer remains unknown. This study was designed to identify risk factors for upper tract urothelial recurrence following local tumor excision of bladder cancer. To identify 76 597 bladder cancer patients, comprising 76 537 nonrecurrence and 60 recurrence patients, the Surveillance, Epidemiology, and End Results database was used. Kaplan‐Meier analysis and univariate and multivariate Cox proportional hazards regression models were used to determine the risk factors. Compared with the nonrecurrence group, the recurrence group was associated with older age, higher grade, high T stage, and higher proportional squamous cell carcinomas. Univariate Cox proportional hazards regression model showed that age, grades III and IV, T stage, and pathology were significantly associated with worse upper tract urothelial recurrence (UTUR) survival. However, after adjusting for prognostic factors, grade was no longer an independent prognostic factor in multivariate analysis. This study demonstrates that clinical prognosis of UTUR after local bladder tumor excision has significant independent risk factors that include age ≥60 years, T1 and T2 stage, and squamous cell carcinoma, and will require more careful consideration during follow‐up.

Long-term Bladder and Upper Urinary Tract Follow-up Recurrence and Progression Rates of G1-2 Non-muscle-invasive Urothelial Carcinoma of the Bladder

OBJECTIVE

To evaluate the risk of long-term tumor recurrence and progression in patients with low- and intermediate-risk non-muscle-invasive bladder cancers, which could facilitate optimization in the follow-up schedules.

MATERIALS AND METHODS

A single-institution, retrospective analysis of 704 patients with primary TaG1, TaG2, T1G1, and T1G2 urothelial carcinomas of the bladder without concomitant carcinoma in situ, treated with transurethral resection, was performed. Response was determined and monitored by routine periodic urine cytology, cystoscopy, and upper tract imaging.

RESULTS

The median follow-up was 64.9 months (maximum, 120 months). Among all of the tumors, 59.3% did not relapse, 36.6% recurred in the bladder during the first 5 years of surveillance, and only 3.6% recurred after 5 years of follow-up. Eight urothelial bladder cancers (1.1%) progressed in stage, and 87.5% of the progressions occurred during the first 5 years of surveillance. An upper urinary tract recurrence was detected in 2.4% of the patients; 94.1% were diagnosed within the upper urinary tract during the first 5 years of follow-up and 5.9% occurred after 5 years of surveillance.

CONCLUSION

G1-2 urothelial bladder cancers recur and progress uncommonly in the long-term period. Although limited by its retrospective nature, the present study provides potential grounds for re-examination of the follow-up schedule for patients with primary non-muscle-invasive bladder cancer G1-2 tumors who remain asymptomatic and disease-free for at least 5 years.

Management of non-muscle invasive bladder cancer: A comprehensive analysis of guidelines from the United States, Europe and Asia

Bladder cancer is the 8th most common cancer with 74,000 new cases in the United States in 2015. Non-muscle invasive bladder cancer (NMIBC) accounts for 75% of all bladder cancer cases. Transurethral resection and intravesical treatments remain the main treatment modality. Up to 31-78% of cases recur, hence the need for intensive treatment and surveillance protocols which makes bladder cancer one of the most expensive cancers to manage. The purpose of this review is to compare contemporary guidelines from Europe, (European Association of Urology), the United States (National Comprehensive Cancer Network), the United Kingdom (National Institute for Health and Care Excellence), Japan (Japanese Urological Association) and the International Consultation on Bladder Cancer (ICUD). We compare and contrast the different guidelines and the evidence on which their recommendations are based.

Prognostic value of prior history of urothelial carcinoma of the bladder in patients with upper urinary tract urothelial carcinoma: results from a retrospective multicenter study

BACKGROUND

Patients with urothelial carcinoma (UC) often develop multifocal metachronous tumors throughout the genitourinary tract. In the present study, we evaluated the prognostic value of prior history of UC of the bladder (UCB) in patients with upper tract urothelial carcinoma (UTUC) in an international multi-institutional cohort.

PATIENTS AND METHODS

Data from 785 patients who underwent radical nephroureterectomy (RNU) with ipsilateral bladder cuff resection at nine academic institutions in Europe and the USA between 1987 and 2008 were reviewed. Log-rank tests and Cox proportional hazards regression models were used for univariable and multivariable analyses.

RESULTS

The median follow-up of the whole cohort was 34 months (interquartile range 15-66 months). Five hundred and fifty-eight (72 %) patients had no UCB before the diagnosis of UTUC; a prior history of non-muscle-invasive and muscle-invasive UCB before the UTUC was found in 179 (23 %) and 36 (5 %), respectively. History of UCB before RNU was an independent predictor of both recurrence-free survival (p = 0.012; no UCB vs. non-muscle-invasive UCB: hazard ratio (HR) 1.4, p = 0.082; no UCB vs. muscle-invasive UCB: HR 2.1, p = 0.007) and cancer-specific survival (p = 0.008; no UCB vs. non-muscle-invasive UCB: HR 1.2, p = 0.279; no UCB vs. muscle-invasive UCB: HR 2.3, p = 0.008) on multivariable Cox regression analyses that included age, gender, surgical type, stage, grade, presence of concomitant carcinoma in situ, presence of lymphovascular invasion, and lymph node status.

CONCLUSIONS

Prior history of muscle-invasive UCB was significantly associated with an increased risk of disease recurrence and cancer-specific death in patients with UTUC.

[How to apply follow-up in relation to risk group]

The term 'Non-muscle invasive bladder cancer' identifies a heterogeneous disease due to different natural history of its various appearances. T1 stage represents a non-predictable population, which might respond to non-operative treatment strategies or to the need of a more aggressive treatment, in order to avoid the progression to invasive, and possibly to metastatic stages. In the first year following transurethral resection of bladder (TURB), tumor recurrence is seen in up to 45% of the population; of this, 15% may progress to muscle invasive or metastatic disease, or both. In order to control the recurrence and progression and identify invasive tumors at the earliest possible stage, it is strongly necessary to define individual patient risk assessment follow-up. To obtain exact staging, besides a proper transurethral resection of bladder, a restaging transurethral resection of bladder should be performed in T1 patients. Data from literature support the immediate postoperative intravesical instillation of different chemotherapeutic agents in low-risk patients. Multifocal papillary lesions might require a more intensive adjuvant regimen, whereas intravesical immunotherapy using Bacillus Calmette-Guérin is recommended in patients at high risk of progression. Early cystectomy should be considered in patients with recurrent T1 tumors or refractory carcinoma in situ to avoid unfavorable tumor progression.

Resection of ureteral orifice during transurethral resection of bladder tumor: functional and oncologic implications

PURPOSE

We assessed the risk of upper urinary tract obstruction and tumor recurrence following ureteral orifice resection during transurethral resection of bladder tumor.

MATERIALS AND METHODS

We reviewed the medical records of patients treated with transurethral resection of bladder tumors involving the ureteral orifice from 2008 to 2011. Patients with preoperative hydronephrosis or prior ipsilateral nephrectomy and those in whom a ureteral stent was placed during the procedure were excluded from analysis. Study end points were clinical or radiographic evidence of upper urinary tract obstruction and disease recurrence.

RESULTS

The study group included 65 men (82%) and 14 women (18%) in whom a total of 84 orifice resections were performed. Hydronephrosis was observed in 11 patients (13%) during a median followup of 15 months (IQR 7-26). Hydronephrosis was secondary to muscle invasive disease in 5 patients (6%) and it resolved spontaneously in 3 (4%). In the remaining 3 patients (4%) overt stricture was detected at the ureterovesical junction, requiring endoscopic intervention. One patient was diagnosed with recurrent tumor in the upper urinary tract. The estimated bladder disease recurrence rate was 28% at 1 year and 54% at 2 years. Corresponding disease progression rates were 4% and 12%, respectively.

CONCLUSIONS

Ureteral orifice resection during transurethral resection of bladder tumor is rarely associated with detrimental renal obstruction or an increased risk of tumor recurrence in the upper urinary tract. New onset hydronephrosis is mostly attributable to muscle invasive disease or temporary obstruction. However, the few cases of overt stricture underscore the importance of meticulous followup with imaging.

Monitoring of the upper urinary tract in patients with bladder cancer

Upper urinary tract (UUT) transitional cell carcinoma (TCC) is relatively rare tumor. Approximately 0.7-4% of patients with primary bladder cancer develops UUT-TCC. The symptoms related to an UUT-TCC often occur with an advanced stage which leads one to emphasize a surveillance strategy to monitor the UUT to allow for an earlier diagnosis. Although the risk of UUT-TCC after bladder cancer is well established, there is a paucity of recommendations suggesting the optimal method and frequency of monitoring the UUT and there is no consensus among them. This article reviews the recommendations on monitoring the UUT in patients with bladder cancer.

Urothelial carcinoma at the uretero-enteric junction: multi-center evaluation of oncologic outcomes after radical nephroureterectomy

OBJECTIVE

The natural history of urothelial carcinoma arising at the uretero-enteric junction (UEJ) is poorly defined, and the data guiding clinical management of these patients is limited. Therefore, we evaluated oncologic outcomes of patients treated for urothelial carcinoma at the UEJ.

METHODS

Utilizing a multi-institutional database of patients treated with radical nephroureterectomy (RNU), we assessed the clinicopathologic parameters and oncologic outcomes of UEJ tumors compared with other upper tract urothelial carcinomas (UTUC). Survival analyses were performed to determine independent predictors of disease recurrence and cancer-specific mortality after RNU.

RESULTS

The study included 1,363 patients, 921 men and 442 women with 36 months median follow-up after RNU. Compared with UTUC in the kidney or ureter, UEJ tumors (n = 22) were more likely to demonstrate features of advanced disease, which were proved to be independent predictors of disease recurrence and cancer-specific mortality after RNU. The 5 year disease-free survival (DFS) and cancer-specific survival (CSS) rates were 25% and 39% in those with UEJ tumors vs. 69% and 73% in those with UTUC in the kidney or ureter (P = 0.001 and P = 0.008, respectively).

CONCLUSIONS

UEJ tumors harbor features of locally advanced disease associated with high risk of systemic recurrence and death from cancer after RNU. Our findings suggest the need for integration of systemic therapy into the management paradigm of these patients.

Prognostic effect of urinary bladder carcinoma in situ on clinical outcome of subsequent upper tract urothelial carcinoma

OBJECTIVES

To evaluate the effect of a history of bladder carcinoma in situ (CIS) on relapse and survival after surgical management of metachronous upper tract urothelial carcinoma (UTUC). Urinary bladder CIS was previously reported to be among the independent risk factors for the development of UTUC.

METHODS

Using a multi-institutional database of patients treated with radical nephroureterectomy (RNU) for UTUC, we compared the clinicopathologic parameters and clinical outcomes of patients with and without a history of bladder CIS. Multivariate Cox regression analysis was performed to determine the independent predictors of disease recurrence and cancer-specific mortality after RNU.

RESULTS

The study included 1316 patients, 884 men and 432 women, with median follow-up of 36 months after RNU. The patients with a history of bladder CIS (n = 91) were more likely to have high-grade and sessile UTUC (P < .05). The 5 year disease-free survival and cancer-specific survival rate was 53% and 59% in those with a history of bladder CIS and 71% and 75% in those without a history of bladder CIS, respectively (P = .031 and P = .045, respectively). On multivariate Cox regression analysis, a history of bladder CIS was an independent predictor of disease recurrence and cancer-specific mortality after RNU (P = .006 and P = .045, respectively).

CONCLUSIONS

The results of our study have shown that patients with a history of bladder CIS are more likely to develop aggressive UTUC and demonstrate a greater risk of recurrence and death from cancer after RNU. Our findings suggest the need for aggressive surveillance regimens and multimodal management strategies for patients who develop UTUC in the setting of previous bladder CIS.

[Renal pelvic carcinoma: a different urothelial tumor?]

Urothelial tumors of the renal pelvis and the ureter do not differ from those of the urinary bladder concerning histopathological phenotypes. However, with respect to tumor biology there are relevant differences between the two tumor locations. The originating tissue (urothelium) of the bladder and of the upper urinary tract varies significantly with respect to developmental origin, morphology and physiological function. Specific pathways of tumorigenesis (e.g. hereditary non-polyposis colorectal cancer, HNPCC) and tumor propagation (seeding) are described for tumors of the upper urinary tract. Clinical epidemiological data indicate specific correlations between the two tumor locations.