Bilan et prise en charge d’une tumeur de la voie excrétrice urinaire supérieure en 2010 : mise au point du comité de cancérologie de l’Association francaise d’urologie

Multidetector CT imaging features of invasive renal parenchyma urothelial carcinoma

OBJECTIVE

To characterize the multidetector CT imaging features of invasive renal parenchyma urothelial carcinoma (IRPUC).

METHODS

29 patients with IRPUC were retrospectively evaluated. Tumour location, density, cystic or solid appearance, calcification, capsule sign, enhancement pattern and metastases were assessed.

RESULTS

IRPUC involved the right kidney in 82.7% of patients. Medullary involvement was observed in 93.1% of patients. In 89.6% of patients, the reniform contour of the kidney was preserved. Tumours showed an infiltrative appearance (100%) with a poorly defined margin (100%), but an expansile component was also present (20.7%). Linear calcification was present (20.7%). Evidence of intra-abdominal metastatic disease (in 37.9% of cases) and regional lymphadenopathy (in 27.5% of cases) was present. Tumour attenuation was less or equal compared with the renal cortex or medulla on unenhanced CT (p-value> 0.05), after i.v. contrast administration; 100% were of homogeneous low attenuation compared with the normal renal cortex and medulla (p-value< 0.05).

CONCLUSION

IRPUC tends to be more prevalent in the right kidney, poorly defined margin, medullary involvement, with homogeneous enhancement less than the cortex and medulla in all phases.

ADVANCES IN KNOWLEDGE

IRPUC was more prevalent in the right kidney. IRPUC enhancement was less than that of the cortex and medulla on all phases. IRPUC showed poorly defined margin with medullary involvement and preserved reniform contour.

Validation of pretreatment neutrophil-lymphocyte ratio as a prognostic factor in a European cohort of patients with upper tract urothelial carcinoma

OBJECTIVE

To investigate the potential prognostic significance of the neutrophil-lymphocyte ratio (NLR) in a large European cohort of patients with upper urinary tract urothelial cell carcinoma (UUT-UCC).

PATIENTS AND METHODS

We retrospectively evaluated data from 202 consecutive patients with non-metastatic upper urinary tract urothelial cell carcinoma (UUT-UCC), who underwent surgery between 1990 and 2012 at a single tertiary academic centre. Patients' cancer-specific survival (CSS) and overall survival (OS) were assessed using the Kaplan-Meier method. To evaluate the independent prognostic significance of the NLR, multivariate proportional Cox regression models were applied for both endpoints.

RESULTS

A higher NLR was significantly associated with shorter CSS (P = 0.002, log-rank test), as well as with shorter OS (P < 0.001, log-rank test). Multivariate analysis identified a high NLR as an independent prognostic factor for patients' CSS (hazard ratio 2.72, 95% CI 1.25-5.93, P = 0.012), and OS (hazard ratio 2.48, 95% CI 1.31-4.70, P = 0.005).

CONCLUSIONS

In the present cohort, patients with a high preoperative NLR had higher cancer-specific and overall mortality after radical surgery for UUT-UCC, compared with those with a low preoperative NLR. This easily identifiable laboratory measure should be considered as an additional prognostic factor in UUT-UCC in future.

Tumours of the bladder: what does the urologist expect from imaging?

Cancer of the bladder is the seventh most common of all cancers observed in France, and is the second urological cancer after prostate cancer. It is mainly related to nicotine addiction. When doing the initial tests, ultrasound examination of the bladder can enable the clinician to diagnose a polypoid tumour and thus avoid his having to organise diagnostic fibroscopy. When the bladder tumour infiltrates the detrusor muscle, the situation becomes life-threatening for the patient and radical treatment is envisaged. Uro-CT is the standard examination to characterise the lesion and describe its relationship with neighbouring organs. It is essential, and must be performed before endoscopic resection of the tumour, to be correctly interpreted. It is imperative for imaging to look for a synchronous lesion in the upper urinary tract (ureters, renal pelvis), because the presence of such a lesion changes the prognosis of the disease and the sequence of therapy, which is decided by the urologist in a multidisciplinary consultation.

[European guidelines for the diagnosis and management of upper urinary tract urothelial cell carcinomas: 2011 update. European Association of Urology Guideline Group for urothelial cell carcinoma of the upper urinary tract]

CONTEXT

The European Association of Urology (EAU) Guideline Group for urothelial cell carcinoma of the upper urinary tract (UUT-UCC) has prepared new guidelines to aid clinicians in assessing the current evidence-based management of UUT-UCC and to incorporate present recommendations into daily clinical practice.

OBJECTIVE

This paper provides a brief overview of the EAU guidelines on UUT-UCC as an aid to clinicians in their daily practice.

EVIDENCE ACQUISITION

The recommendations provided in the current guidelines are based on a thorough review of available UUT-UCC guidelines and papers identified using a systematic search of Medline. Data on urothelial malignancies and UUT-UCCs in the literature were searched using Medline with the following keywords: urinary tract cancer, urothelial carcinomas, upper urinary tract, carcinoma, transitional cell, renal pelvis, ureter, bladder cancer, chemotherapy, nephroureterectomy, adjuvant treatment, neoadjuvant treatment, recurrence, risk factors, and survival. A panel of experts weighted the references.

EVIDENCE SYNTHESIS

There is a lack of data in the current literature to provide strong recommendations due to the rarity of the disease. A number of recent multicentre studies are now available, whereas earlier publications were based only on limited populations. However, most of these studies have been retrospective analyses. The TNM classification 2009 is recommended. Recommendations are given for diagnosis as well as for radical and conservative treatment; prognostic factors are also discussed. Recommendations are provided for patient follow-up after different therapeutic options.

CONCLUSIONS

These guidelines contain information for the diagnosis and treatment of individual patients according to a current standardised approach. When determining the optimal treatment regimen, physicians must take into account each individual patient's specific clinical characteristics with regard to renal function including medical comorbidities; tumour location, grade and stage; and molecular marker status.

[Urothelial carcinoma of the upper urinary tract: clinical and pathological criteria and their predictive implications after radical nephroureterectomy]

Recent multicentric studies contributed significantly to the understanding of clinical and pathological criteria and their implications as prognosticators of the upper urinary tract urothelial carcinoma. They demonstrated a large variety of prognosticators influencing the course of this rare disease. The influence of gender and age and the presence of symptoms and renal obstruction in addition to pathologic criteria such as staging, tumor architecture, lymphnode invasion, localization and the presence of CIS or tumor necrosis on prognosis and disease recurrence after radical nephroureterectomy were investigated. Additional multicentric, ideally prospective studies are warranted to validate current findings.

Prognostic factors for upper urinary tract urothelial carcinoma

Upper urinary tract urothelial carcinoma (UTUC) is a rare disease, which means there are little evidence-based data available to guide clinical decision-making. Although diagnosis and treatment of UTUC have improved significantly over the last 5 years, accurate risk stratification remains a challenge owing to the difficulty of clinical staging. A number of potential prognostic factors have been identified, encompassing clinical characteristics, pathological factors and molecular markers. Tumor stage and lymph node status are the most important predictors of survival in patients with UTUC. Preoperative evaluation for hydronephrosis can identify patients at risk of non-organ-confined disease. In the subgroup of patients with stage ≥pT2 disease, a longer interval between diagnosis and radical nephroureterectomy is associated with a higher risk of disease recurrence and cancer-specific mortality. Extensive tumor necrosis, sessile tumor architecture and lymphovascular invasion are independent predictors of clinical outcomes for patients with UTUC treated with radical nephroureterectomy. The incorporation of such prognosticators into clinical prediction models might help to guide decision-making with regard to timing of surveillance, type of treatment, performance of lymphadenectomy, and consideration of neoadjuvant or adjuvant systemic therapies.

Predictive factors of recurrence and survival of upper tract urothelial carcinomas

OBJECTIVE

UTUCC is a rare tumor, and most reports on prognostic factors come from small single-center series. The objective of this article was to provide an updated overview of current clinical, pathological and biological prognostic factors of UTUC.

METHODS

PubMed was searched for records from 2002 to 2010 using the terms "prognostic factors", "recurrence", "survival", and "upper tract urothelial carcinoma". Among identified citations, papers were selected based on their clinical relevance.

RESULTS

Classical clinical factors that influence UTUC prognosis include age, presence of symptoms, hydronephrosis, and interval from diagnosis. Many biomarkers have shown promises to better appraise the natural course of UTUC although none is currently used in clinical practice. Stage, grade, lymph node metastases, lymphovascular invasion, tumor necrosis, and tumor architecture are strong pathological parameters. RNU is the standard treatment of localized UTUC. Both laparoscopic and open approaches seem to offer similar cancer control. Lymph node dissection increases staging accuracy and might confer a survival benefit.

CONCLUSION

RNU is the standard treatment for most patients with UTUC. Recent multicenter studies confirmed the prognostic value of classical prognostic parameters. Better survival prediction might be obtained with prognostic systems including clinical data and new biomarkers.

[New concepts in the management of upper tract urinary carcinoma in 2010]

The aim of this article is to make a synthesis of news headlines concerning the management of upper tract urinary carcinoma. For non muscle-invasive upper tract urinary tumors, ureteroscopy with biopsies is a part of the systematic diagnostic assessment in case of suspicious imaging. For muscle-invasive upper tract urinary tumors, there is low level of evidence of expert's opinion guidelines about neoadjuvant or adjuvant chemotherapy. These therapeutic strategies can be sometimes discussed, by arguing analogy with bladder tumors.

European guidelines for the diagnosis and management of upper urinary tract urothelial cell carcinomas: 2011 update

CONTEXT

The European Association of Urology (EAU) Guideline Group for urothelial cell carcinoma of the upper urinary tract (UUT-UCC) has prepared new guidelines to aid clinicians in assessing the current evidence-based management of UUT-UCC and to incorporate present recommendations into daily clinical practice.

OBJECTIVE

This paper provides a brief overview of the EAU guidelines on UUT-UCC as an aid to clinicians in their daily practice.

EVIDENCE ACQUISITION

The recommendations provided in the current guidelines are based on a thorough review of available UUT-UCC guidelines and papers identified using a systematic search of Medline. Data on urothelial malignancies and UUT-UCCs in the literature were searched using Medline with the following keywords: urinary tract cancer, urothelial carcinomas, upper urinary tract, carcinoma, transitional cell, renal pelvis, ureter, bladder cancer, chemotherapy, nephroureterectomy, adjuvant treatment, neoadjuvant treatment, recurrence, risk factors, and survival. A panel of experts weighted the references.

EVIDENCE SYNTHESIS

There is a lack of data in the current literature to provide strong recommendations due to the rarity of the disease. A number of recent multicentre studies are now available, whereas earlier publications were based only on limited populations. However, most of these studies have been retrospective analyses. The TNM classification 2009 is recommended. Recommendations are given for diagnosis as well as for radical and conservative treatment; prognostic factors are also discussed. Recommendations are provided for patient follow-up after different therapeutic options.

CONCLUSIONS

These guidelines contain information for the diagnosis and treatment of individual patients according to a current standardised approach. When determining the optimal treatment regimen, physicians must take into account each individual patient's specific clinical characteristics with regard to renal function including medical comorbidities; tumour location, grade and stage; and molecular marker status.