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Lai HY, Wu LC, Kong PH, Tsai HH, Chen YT, Cheng YT, Luo HL, Li CF. High Level of Aristolochic Acid Detected With a Unique Genomic Landscape Predicts Early UTUC Onset After Renal Transplantation in Taiwan. Front Oncol 2022; 11:828314. [PMID: 35071023 PMCID: PMC8770835 DOI: 10.3389/fonc.2021.828314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 12/13/2021] [Indexed: 11/25/2022] Open
Abstract
Background The unusual high dialysis prevalence and upper urinary tract urothelial carcinoma (UTUC) incidence in Taiwan may attribute to aristolochic acid (AA), which is nephrotoxic and carcinogenic, exposure. AA can cause a unique mutagenic pattern showing A:T to T:A transversions (mutational Signature 22) analyzed by whole exome sequencing (WES). However, a fast and cost-effective tool is still lacking for clinical practice. To address this issue, we developed an efficient and quantitative platform for the quantitation of AA and tried to link AA detection with clinical outcomes and decipher the genomic landscape of UTUC in Taiwan. Patients and Methods We recruited 61 patients with de novo onset of UTUC after kidney transplantation who underwent radical nephroureterectomy. A liquid chromatography-tandem mass spectrometry (LC-MS/MS) platform was developed for the quantitation of AA. Pearson’s chi-square test, Kaplan–Meier method, and Cox proportional hazard model were utilized to assess the correlations among AA detection, clinicopathological characteristics, and clinical outcomes. Seven tumors and seven paired normal tissues were sequenced using WES (approximately 800x sequencing depth) and analyzed by bioinformatic tool. Results We found that high level of 7-(deoxyadenosin-N6-yl)aristolactam I (dA-AL-I) detected in paired normal tissues was significantly correlated with fast UTUC initiation times after renal transplantation (p = 0.035) and with no use of sirolimus (p = 0.046). Using WES analysis, we further observed that all tumor samples were featured by Signature 22 mutations, apolipoprotein B mRNA-editing enzyme, catalytic polypeptide (APOBEC)-associated gene mutations, p53 mutations, no fibroblast growth factor receptor 3 (FGFR3) mutation, and high tumor mutation burden (TMB). Especially, mammalian target of rapamycin (mTOR) activation predominated in dA-AL-I-detected samples compared with those without dA-AL-I detection and might be associated with UTUC initiation through cell proliferation and suppression of UTUC progression via autophagy inhibition. Conclusion Accordingly, dA-AL-I detection can provide more direct evidence to AA exposure and serve as a more specific predictive and prognostic biomarker for patients with de novo onset of UTUC after kidney transplantation.
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Affiliation(s)
- Hong-Yue Lai
- Center for Precision Medicine, Chi Mei Medical Center, Tainan, Taiwan.,Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Li-Ching Wu
- Center for Precision Medicine, Chi Mei Medical Center, Tainan, Taiwan.,Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Po-Hsin Kong
- Center for Precision Medicine, Chi Mei Medical Center, Tainan, Taiwan.,Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Hsin-Hwa Tsai
- Center for Precision Medicine, Chi Mei Medical Center, Tainan, Taiwan.,Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Yen-Ta Chen
- Department of Urology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yuan-Tso Cheng
- Department of Urology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hao-Lun Luo
- Department of Urology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Center for Shockwave Medicine and Tissue Engineering, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chien-Feng Li
- Center for Precision Medicine, Chi Mei Medical Center, Tainan, Taiwan.,Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan.,Department of Clinical Pathology, Chi Mei Medical Center, Tainan, Taiwan.,National Institute of Cancer Research, National Health Research Institutes, Tainan, Taiwan.,Institute of Precision Medicine, National Sun Yat-Sen University, Kaohsiung, Taiwan.,Department of Pathology, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Tumor distribution affects bladder recurrence but not survival outcome of multifocal upper tract urothelial carcinoma treated with radical nephroureterectomy. Sci Rep 2021; 11:19059. [PMID: 34561545 PMCID: PMC8463529 DOI: 10.1038/s41598-021-98696-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 09/14/2021] [Indexed: 11/25/2022] Open
Abstract
Tumor multifocality and location are prognostic factors for upper tract urothelial carcinoma (UTUC). However, confounding effects can appear when these two factors are analyzed together. Therefore, we aimed to investigate the impact of tumor distribution on the outcomes of multifocal UTUC after radical nephroureterectomy. From the 2780 UTUC patients in the Taiwan UTUC Collaboration Group, 685 UTUC cases with multifocal tumors (defined as more than one tumor lesion in unilateral upper urinary tract) were retrospectively included and divided into three groups: multiple renal pelvic tumors, multiple ureteral tumors, and synchronous renal pelvic and ureteral tumors included 164, 152, and 369 patients, respectively. We found the prevalence of carcinoma in situ was the highest in the synchronous group. In multivariate survival analyses, tumor distribution showed no difference in cancer-specific and disease-free survival, but there was a significant difference in bladder recurrence-free survival. The synchronous group had the highest bladder recurrence rate. In summary, tumor distribution did not influence the cancer-specific outcomes of multifocal UTUC, but synchronous lesions led to a higher rate of bladder recurrence than multiple renal pelvic tumors. We believe that the distribution of tumors reflects the degree of malignant involvement within the urinary tract, but has little significance for survival or disease progression.
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3
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Risk Stratification of Upper Tract Urothelial Carcinoma for Kidney-Sparing Surgery. Bladder Cancer 2021. [DOI: 10.1007/978-3-030-70646-3_34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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4
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Tam AW, Liaw C, Li E, Katims AB, Say RK, Gul Z, Winoker JS, Martini A, Audenet F, Sfakianos JP. The effect of tumor location on overall survival for pT2-4 bladder and upper tract urothelial carcinoma following radical surgery. Can Urol Assoc J 2020; 15:E248-E255. [PMID: 33119498 DOI: 10.5489/cuaj.6698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Historically, staging and treatment for upper tract urothelial carcinoma were extrapolated from bladder urothelial carcinoma literature. However, embryological, genetic, and anatomical differences exist between them. We sought to explore the relationship between location of urothelial cancer and overall survival (OS). METHODS Data was culled from the National Cancer Database from 2004-2015. Patients with pT2-pT4 treated with definitive surgery were included; those with metastatic disease or who received neoadjuvant or adjuvant treatment were excluded. Patients were stratified by tumor location and pathological stage. The primary outcome was OS. Secondary outcomes were predictors of mortality in each pT stage stratum. RESULTS A total of 11 330 patients with bladder, 954 patients with ureteral, and 1943 patients with renal pelvis urothelial carcinoma were analyzed. Mean followup was 43.3, 39.4, and 41.4 months for bladder, ureteral, and renal pelvis, respectively. On univariable analysis, ureteral pT2 was associated with worse OS compared to both bladder (61.3 vs. 80.4 months, p=0.007) and renal pelvis (61.3 vs. 80.5 months, p=0.014). Renal pelvis pT3 was associated with improved OS compared to both bladder (42.5 vs. 28.6 months, p=0.003) and ureteral (42.5 vs. 25.7 months, p<0.001). Renal pelvis pT4 had decreased survival compared to bladder (11.4 vs. 17.7 months, p<0.001). On multivariable Cox regression, only renal pelvis pT3 was associated with a 20% decreased risk of mortality compared to bladder pT3 (hazard ratio 0.80, 95% confidence interval 0.72-0.88, p<0.001). CONCLUSIONS Renal pelvis pT3 is associated with lower mortality. Mutational and embryological differences may play a role in this disparity.
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Affiliation(s)
- Andrew W Tam
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Christine Liaw
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Eric Li
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Andrew B Katims
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Rollin K Say
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Zeynep Gul
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Jared S Winoker
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Alberto Martini
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Francois Audenet
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - John P Sfakianos
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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5
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European Association of Urology Guidelines on Upper Urinary Tract Urothelial Carcinoma: 2020 Update. Eur Urol 2020; 79:62-79. [PMID: 32593530 DOI: 10.1016/j.eururo.2020.05.042] [Citation(s) in RCA: 473] [Impact Index Per Article: 118.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 05/28/2020] [Indexed: 12/12/2022]
Abstract
CONTEXT The European Association of Urology (EAU) Guidelines Panel on Upper Urinary Tract Urothelial Carcinoma (UTUC) has prepared updated guidelines to aid clinicians in the current evidence-based management of UTUC and to incorporate recommendations into clinical practice. OBJECTIVE To provide an overview of the EAU guidelines on UTUC as an aid to clinicians. EVIDENCE ACQUISITION The recommendations provided in the current guidelines are based on a thorough review of available UTUC guidelines and articles identified following a systematic search of Medline. Data on urothelial malignancies and UTUC were searched using the following keywords: urinary tract cancer, urothelial carcinomas, upper urinary tract carcinoma, renal pelvis, ureter, bladder cancer, chemotherapy, ureteroscopy, nephroureterectomy, neoplasm, adjuvant treatment, instillation, recurrence, risk factors, and survival. References were weighted by a panel of experts. EVIDENCE SYNTHESIS Owing to the rarity of UTUC, there are insufficient data to provide strong recommendations. The 2017 tumour, node, metastasis (TNM) classification is recommended. Recommendations are given for diagnosis and risk stratification as well as for radical and conservative treatment, and prognostic factors are discussed. A single postoperative dose of intravesical mitomycin after nephroureterectomy reduces the risk of bladder tumour recurrence. Kidney-sparing management should be offered as a primary treatment option to patients with low-risk tumour and two functional kidneys. After radical nephroureterectomy, cisplatin-based chemotherapy is indicated in locally advanced UTUC. CONCLUSIONS These guidelines contain information on the management of individual patients according to a current standardised approach. Urologists should take into account the specific clinical characteristics of each patient when determining the optimal treatment regimen, based on the proposed risk stratification of these tumours. PATIENT SUMMARY Urothelial carcinoma of the upper urinary tract is rare, but because 60% of these tumours are invasive at diagnosis, an appropriate diagnosis is most important. A number of known risk factors exist.
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Medunjanin D, Sonicki Z, Vena JE, Cvitkovic A, Robb SW. Geographic distribution and risk of upper urothelial carcinomas in Croatia, 2001-2011. BMC Cancer 2019; 19:950. [PMID: 31615453 PMCID: PMC6792263 DOI: 10.1186/s12885-019-6160-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 09/13/2019] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Strong associations exist between Balkan endemic nephropathy (BEN) and upper urothelial carcinomas (UUCs). However, the common etiology between the two remains unclear and there are no studies to date that visualize UUC risks in Croatia. In Croatia, 14 villages in the southwestern part of Brod-Posavina County are considered endemic for BEN. The aim of this ecological study is to map cancer risks and describe the case distribution of UUCs in Croatia at the county level during 2001-2011. METHODS A total of 608 incident cases from the Croatian National Cancer Registry were identified. Indirect standardization was employed to compute standardized incidence ratios (SIRs). RESULTS Counties with SIRs greater than 1 were concentrated around the agricultural region of Slavonia and the coastal region of Dalmatia. However, only Brod-Posavina County and Vukovar-Srijem County had a statistically significant risk of UUC development, where there were 390 and 210% more UUC cases observed than expected, respectively. Only unique to Brod-Posavina County, females were at higher risk (SIR 4.96; 95% CI 3.59-6.34) of developing UUCs than males (SIR 3.03; 95% CI 2.04-4.01) when compared to their Croatian counterparts. Although Brod-Posavina County only made up 3.7% of the total Croatian population (as of 2011), it had the highest frequency of incident UUC cases after the capital City of Zagreb. No elevated cancer risks were noted in the City of Zagreb, even after stratifying by sex. CONCLUSION Our findings suggest that Brod-Posavina County had the highest cancer risk for UUCs, especially among females, when compared to Croatia as a whole during 2001-2011. Given that a majority of BEN patients develop associated UUCs, concurrent screening programs for UUCs and BEN should be considered not only in endemic areas of BEN but also the surrounding rural areas and amongst at-risk groups such as those undergoing hemodialysis, who frequently develop UUCs, to help clarify BEN-UUC associations by identifying common risk factors while standardizing disease estimates across endemic regions for BEN.
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Affiliation(s)
- Danira Medunjanin
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA.
| | - Zdenko Sonicki
- University of Zagreb, School of Medicine, Andrija Stampar School of Public Health, Zagreb, Croatia
| | - John E Vena
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Ante Cvitkovic
- Institute for Public Health, Brodsko Posavska County, Slavonski Brod, Croatia.,Josip Juraj Strossmayer University of Osijek, Faculty of Medicine, Osijek, Croatia.,Josip Juraj Strossmayer University of Osijek, Faculty of Dental Medicine and Health, Osijek, Croatia
| | - Sara Wagner Robb
- Department of Public Health Sciences, Clemson University, Clemson, SC, USA
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7
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Kardoust Parizi M, Glybochko PV, Enikeev D, Rouprêt M, Fajkovic H, Seebacher V, Shariat SF. Risk stratification of upper tract urothelial carcinoma: A Review of the Current Literature. Expert Rev Anticancer Ther 2019; 19:503-513. [DOI: 10.1080/14737140.2019.1621753] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Mehdi Kardoust Parizi
- Department of Urology, Medical University of Vienna, Vienna, Austria
- Department of Urology, Shariati Hospital, Tehran University of Medical Sciences, Teheran, Iran
| | - Petr V. Glybochko
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Dmitry Enikeev
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Morgan Rouprêt
- Sorbonne Université, GRC no. 5, ONCOTYPE-URO, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Harun Fajkovic
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Veronika Seebacher
- Department for Gynecology and Gynecologic Oncology, Gynecologic Cancer Unit, Comprehensive Cancer Centre, Medical University of Vienna, Vienna, Austria
| | - Shahrokh F. Shariat
- Department of Urology, Medical University of Vienna, Vienna, Austria
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
- Department of Urology, Weill Cornell Medical College, New York, NY, USA
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria
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8
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[Organ preservation in cancer of the upper urinary tract]. Urologe A 2019; 58:22-24. [PMID: 30649581 DOI: 10.1007/s00120-018-0831-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Urothelial carcinoma of the upper urinary tract is a rare disease. Tumor biology is comparable to transitional cell carcinomas of the bladder. Local tumor control is much more difficult to achieve in the upper urinary tract than in the bladder. Radical nephroureterectomy is often performed due to carcinomas with low grade histology. Progression rates in these cases are rare; overtreatment has to be discussed. The current article uses the available published data to discuss whether local treatment is an option for tumors of the upper urinary tract. Summarizing the available data, it is indicated that if complete resectability is possible organ preservation is equivalent to radical nephroureterectomy independent of the T‑ and G‑category of the tumor.
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9
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Krabbe LM, Woldu SL, Sanli O, Margulis V. Metastatic Surgery in Advanced Renal Cell Carcinoma. Urol Oncol 2019. [DOI: 10.1007/978-3-319-42623-5_65] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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10
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Shao IH, Chang YH, Pang ST. Recent advances in upper tract urothelial carcinomas: From bench to clinics. Int J Urol 2018; 26:148-159. [PMID: 30372791 DOI: 10.1111/iju.13826] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 09/10/2018] [Indexed: 12/16/2022]
Abstract
Urothelial carcinoma in the upper tract is rare and often discussed separately. Many established risk factors were identified for the disease, including genetic and external risk factors. Radiographic survey, endoscopic examination and urine cytology remained the most important diagnostic modalities. In localized upper tract urothelial carcinomas, radical nephroureterectomy with bladder cuff excision are the gold standard for large, high-grade and suspected invasive tumors of the renal pelvis and proximal ureter, whereas kidney-sparing surgeries should be considered in patients with low-risk disease. Advances in technology have given endoscopic surgery an important role, not only in diagnosis, but also in treatment. Although platinum-based combination chemotherapy is efficacious in advanced or metastatic disease, current established chemotherapy regimens are toxic and lack a sustained response. Immune checkpoint inhibitors have led to a new era of treatment for advanced or metastatic urothelial carcinomas. The remarkable results achieved thus far show that immunotherapy will likely be the future treatment paradigm. The combination of immune checkpoint inhibitors and other agents is another inspiring avenue to explore that could benefit even more patients. With respect to the high incidence rate and different clinical appearance of upper tract urothelial carcinomas in Taiwan, a possible correlation exists between exposure to certain external risk factors, such as arsenic in drinking water and aristolochic acid in Chinese herbal medicine. As more gene sequencing differences between upper tract urothelial carcinomas and various disease causes are detailed, this has warranted the era of individualized screening and treatment for the disease.
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Affiliation(s)
- I-Hung Shao
- Division of Urology, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ying-Hsu Chang
- Division of Urology, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - See-Tong Pang
- Division of Urology, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
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11
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Locke JA, Hamidizadeh R, Kassouf W, Rendon RA, Bell D, Izawa J, Chin J, Kapoor A, Shayegen B, Lattouf JB, Saad F, Lacombe L, Fradet Y, Fairey AS, Jacobson NE, Drachenberg DE, Cagiannos I, So AI, Black PC. Surveillance guidelines based on recurrence patterns for upper tract urothelial carcinoma. Can Urol Assoc J 2018; 12:243-251. [PMID: 29688881 DOI: 10.5489/cuaj.5377] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Upper tract urothelial carcinoma (UTUC) accounts for 5% of all urothelial tumours. Due to its rarity, evidence regarding postoperative surveillance is lacking. The objective of this study was to develop a post-radical nephroureterectomy (RNU) surveillance protocol based on recurrence patterns in a large, multi-institutional cohort of patients. METHODS Retrospective clinical and pathological data were collected from 1029 patients undergoing RNU over a 15-year period (1994-2009) at 10 Canadian academic institutions. A multivariable model was used to identify prognostic clinicopathological factors, which were then used to define risk categories. Risk-based surveillance guidelines were proposed based on actual recurrence patterns. RESULTS Overall, 555 (49.9%) patients developed recurrence, including 289 (25.9%) in the urothelium and 266 (23.9%) with loco-regional and distant recurrences. Based on multivariable analysis, three risk groups were identified: 1) low-risk patients with pTa-T1, pN0 disease, and no adverse histological features (high tumour grade, lymphovascular invasion [LVI], tumour multifocality); 2) intermediate-risk patients with pTa-T1, pN0 disease with one or more of the adverse histological features; and 3) high-risk patients with a ≥pT2 tumour and/or nodal involvement. Low-, intermediate-, and high-risk patients were free of urothelial recurrence at three years in 72%, 66%, and 63%, respectively, and free of regional/distant recurrence in 93%, 87%, and 62%, respectively. The risks of loco-regional and distant recurrences (p<0.0001) and time to death (p<0.0001) were significantly different between the low-, intermediate-, and high-risk patients. CONCLUSIONS Based on recurrence patterns in a large, multicentre patient cohort, we have proposed an evidence-based, risk-adapted post-RNU surveillance protocol.
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Affiliation(s)
| | | | | | | | - David Bell
- Dalhousie University, Halifax, NS, Canada
| | | | - Joseph Chin
- University of Western Ontario, London, ON, Canada
| | | | | | | | - Fred Saad
- University of Montreal, Montreal, QC, Canada
| | | | | | | | | | | | | | - Alan I So
- University of British Columbia, Vancouver, BC, Canada
| | - Peter C Black
- University of British Columbia, Vancouver, BC, Canada
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12
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Joshi SS, Quast LL, Chang SS, Patel SG. Effects of tumor size and location on survival in upper tract urothelial carcinoma after nephroureterectomy. Indian J Urol 2018; 34:68-73. [PMID: 29343916 PMCID: PMC5769253 DOI: 10.4103/iju.iju_216_17] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Introduction: Upper Tract Urothelial Carcinoma (UTUC) is a rare disease with few prognostic determinants. We sought to evaluate the impact of tumor size and location on patient survival following nephroureterectomy for UTUC. Materials and Methods: Data on 8284 patients treated with radical nephroureterectomy for UTUC in the United States between 1998 and 2011 were analyzed from the National Cancer Data Base. Univariable survivorship curves were generated based on pT stage, pN stage, grade, tumor size, and tumor site (renal pelvis vs. ureter). A Cox proportional hazards model was used to evaluate the effect of age, comorbidity, T stage, lymph node involvement, tumor site, and tumor size on survival. Results: The median follow-up time was 46 months. A majority of the patients were male (55.4%) with a tumor size of ≥3.5 cm (52.0%) and pT stage <T2 (47.8%). The overall 5 years survival overall survival (OS) for the entire cohort was 51.6%. When stratified by tumor size <3.5 cm or ≥3.5 cm the 5-year OS was 45.9% and 58.5%, respectively. On multivariable analysis controlling for age, Charlson comorbidity index, grade, and tumor stage, tumor size ≥3.5 cm was independently predictive of worse OS (odds ratio: 1.13 [95% confidence interval: 1.02–1.26], P = 0.023). Conclusions: Using the largest series of patients with UTUC undergoing nephroureterectomy, we demonstrated a worse survival in patients with larger tumor sizes (≥3.5 cm) but no difference in survival based on tumor location while controlling for other pathologic characteristics. Incorporation of tumor size into perioperative risk modeling may help with patient stratification and provide further prognostic information for patient counseling.
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Affiliation(s)
- Shreyas S Joshi
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Laura L Quast
- Department of Urologic Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Sam S Chang
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sanjay G Patel
- Department of Urology, University of Oklahoma Health Sciences Center, Norman, OK, USA
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13
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Rouprêt M, Babjuk M, Compérat E, Zigeuner R, Sylvester RJ, Burger M, Cowan NC, Gontero P, Van Rhijn BWG, Mostafid AH, Palou J, Shariat SF. European Association of Urology Guidelines on Upper Urinary Tract Urothelial Carcinoma: 2017 Update. Eur Urol 2017; 73:111-122. [PMID: 28867446 DOI: 10.1016/j.eururo.2017.07.036] [Citation(s) in RCA: 553] [Impact Index Per Article: 79.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 07/26/2017] [Indexed: 02/06/2023]
Abstract
CONTEXT The European Association of Urology (EAU) Guidelines Panel on Upper Urinary Tract Urothelial Carcinoma (UTUC) has prepared updated guidelines to aid clinicians in the current evidence-based management of UTUC and to incorporate recommendations into clinical practice. OBJECTIVE To provide an overview of the EAU guidelines on UTUC as an aid to clinicians. EVIDENCE ACQUISITION The recommendations provided in the current guidelines are based on a thorough review of available UTUC guidelines and articles identified following a systematic search of Medline. Data on urothelial malignancies and UTUC were searched using the following keywords: urinary tract cancer; urothelial carcinomas; upper urinary tract, carcinoma; renal pelvis; ureter; bladder cancer; chemotherapy; ureteroscopy; nephroureterectomy; adjuvant treatment; instillation; recurrence; risk factors; and survival. References were weighted by a panel of experts. EVIDENCE SYNTHESIS Owing to the rarity of UTUC, there are insufficient data to provide strong recommendations (ie, grade A). However, the results of recent multicentre studies are now available, and there is a growing number of retrospective articles in UTUC. The 2017 tumour, node, metastasis (TNM) classification is recommended. Recommendations are given for diagnosis and risk stratification, as well as for radical and conservative treatment; prognostic factors are also discussed. A single postoperative dose of intravesical mitomycin after radical nephroureterectomy reduces the risk of bladder tumour recurrence. Kidney-sparing management should be offered as a primary treatment option to patients with low-risk tumours and two functional kidneys. CONCLUSIONS These guidelines contain information on the management of individual patients according to a current standardised approach. Urologists should take into account the specific clinical characteristics of each patient when determining the optimal treatment regimen, based on the proposed risk stratification of these tumours. PATIENT SUMMARY Urothelial carcinoma of the upper urinary tract is rare, but because 60% of these tumours are invasive at diagnosis; appropriate diagnosis and management is most important. We present recommendations based on current evidence for optimal management.
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Affiliation(s)
- Morgan Rouprêt
- AP-HP, Hôpital La Pitié-Salpétrière, Service d'Urologie, Paris, France; UPMC University Paris 06, GRC5, ONCOTYPE-Uro, Institut Universitaire de Cancérologie, Paris, France.
| | - Marko Babjuk
- Department of Urology, Hospital Motol, Second Faculty of Medicine, Charles University, Praha, Czech Republic
| | - Eva Compérat
- Department of Pathology, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, UPMC Paris VI, Paris, France
| | - Richard Zigeuner
- Department of Urology, Medical University of Graz, Graz, Austria
| | | | - Maximilian Burger
- Department of Urology, Caritas St. Josef Medical Centre, University of Regensburg, Regensburg, Germany
| | - Nigel C Cowan
- Department of Radiology, Queen Alexandra Hospital, Portsmouth, UK
| | - Paolo Gontero
- Division of Urology, Department of Surgical Sciences, Molinette Hospital, University of Studies of Torino, Turin, Italy
| | - Bas W G Van Rhijn
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - A Hugh Mostafid
- Department of Urology, Royal Surrey County Hospital, Guildford, UK
| | - Joan Palou
- Department of Urology, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Shahrokh F Shariat
- Department of Urology, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
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14
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Yamashita R, Watanabe R, Ito I, Shinsaka H, Nakamura M, Matsuzaki M, Niwakawa M. Risk factors for intravesical recurrence after nephroureterectomy in patients with upper urinary tract urothelial carcinoma. Int Urol Nephrol 2017; 49:425-430. [DOI: 10.1007/s11255-017-1510-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 01/06/2017] [Indexed: 10/20/2022]
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15
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Metastatic Surgery in Advanced Renal Cell Carcinoma. Urol Oncol 2017. [DOI: 10.1007/978-3-319-42603-7_65-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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16
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Mbeutcha A, Mathieu R, Rouprêt M, Gust KM, Briganti A, Karakiewicz PI, Shariat SF. Predictive models and prognostic factors for upper tract urothelial carcinoma: a comprehensive review of the literature. Transl Androl Urol 2016; 5:720-734. [PMID: 27785429 PMCID: PMC5071205 DOI: 10.21037/tau.2016.09.07] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
In the context of customized patient care for upper tract urothelial carcinoma (UTUC), decision-making could be facilitated by risk assessment and prediction tools. The aim of this study was to provide a critical overview of existing predictive models and to review emerging promising prognostic factors for UTUC. A literature search of articles published in English from January 2000 to June 2016 was performed using PubMed. Studies on risk group stratification models and predictive tools in UTUC were selected, together with studies on predictive factors and biomarkers associated with advanced-stage UTUC and oncological outcomes after surgery. Various predictive tools have been described for advanced-stage UTUC assessment, disease recurrence and cancer-specific survival (CSS). Most of these models are based on well-established prognostic factors such as tumor stage, grade and lymph node (LN) metastasis, but some also integrate newly described prognostic factors and biomarkers. These new prediction tools seem to reach a high level of accuracy, but they lack external validation and decision-making analysis. The combinations of patient-, pathology- and surgery-related factors together with novel biomarkers have led to promising predictive tools for oncological outcomes in UTUC. However, external validation of these predictive models is a prerequisite before their introduction into daily practice. New models predicting response to therapy are urgently needed to allow accurate and safe individualized management in this heterogeneous disease.
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Affiliation(s)
- Aurélie Mbeutcha
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna General Hospital, Vienna, Austria; ; Department of Urology, University of Nice Sophia-Antipolis, Hôpital Pasteur 2, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Romain Mathieu
- Department of Urology, Rennes University Hospital, Rennes, France
| | - Morgan Rouprêt
- Department of Urology, Pitié-Salpêtrière, APHP, University Paris VI, Paris, France
| | - Kilian M Gust
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Alberto Briganti
- Unit of Urology, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Ospedale S. Raffaele, Milan, Italy
| | | | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna General Hospital, Vienna, Austria; ; Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA; ; Department of Urology, Weill Cornell Medical College, New York, NY, USA
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Patterns of Recurrence in Upper Tract Transitional Cell Carcinoma: Imaging Surveillance. AJR Am J Roentgenol 2016; 207:789-796. [PMID: 27382922 DOI: 10.2214/ajr.16.16064] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The objective of our study was to evaluate recurrence patterns of upper tract transitional cell carcinomas (UT-TCCs) after radical nephroureterectomy (RNU). MATERIALS AND METHODS Sixty-eight patients (mean age, 78 years; 34 men and 34 women) with UT-TCC after having undergone RNU from 2001 to 2008 were included in this study. Radiologic examinations and clinical notes were reviewed to record tumor location, tumor morphology, histologic T stages and grades, lymphovascular invasion (LVI) status, and surgical procedures. Five-year imaging and clinical follow-up (2001-2013) findings were noted at 3, 6, 12, 18, 24, 36, 48, 60, and more than 60 months after RNU for recurrence pattern and tumor-free survival. Kaplan-Meier survival curves and Cox regression models were used to assess tumor-free survival and to perform a multivariate analysis. RESULTS Forty-one postoperative recurrences were noted in 20 patients. The mean time to relapse was 16 months, and time to relapse ranged from 1 to 66 months. Tumor site (multifocal lesions involving both renal collecting system and ureter), tumor morphology (mass), T stage (muscle invasion [T2-T4]), histologic grade (grade 3), and the presence of LVI were identified as risk factors for postoperative recurrence in UT-TCC. T stage was the only independent risk factor. CONCLUSION Urinary tract, lymph node, liver, bone, and lung recurrences were common in patients with UT-TCC and were detected most frequently at 3-24 months. Tumor site, tumor morphology, T stage, grade, and LVI status were associated with recurrence after RNU. T stage was the only independent predictor of tumor-free survival. Close surveillance for extra-urinary tract recurrences in high-risk groups and a shorter-interval follow-up of the urinary tract in low-risk patients with adjuvant chemotherapy are recommended. Identifying recurrence patterns in UT-TCC can aid in planning an effective tailored imaging surveillance strategy.
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Strijbos WE, van der Heij B. Percutaneous resection of upper tract urothelial cell carcinoma: When, how, and is it safe? Asian J Urol 2016; 3:134-141. [PMID: 29264181 PMCID: PMC5730826 DOI: 10.1016/j.ajur.2016.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 04/27/2016] [Accepted: 04/28/2016] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION In the management of upper tract urothelial cell carcinoma (UTUC) endoscopic, nephron sparing procedures like ureterorenoscopy (URS) or percutaneous tumour resection (PCTR) still play a very limited role. This could lead to possible unnecessary radical nephroureterectomies (RNU), still being the gold standard treatment. The risk of chronic kidney disease (CKD) later in life is important. In this study we present the results of 24-year experience with PCTR in a single institution. METHODS We identified 44 patients who underwent PCTR between 1992 and 2015. Radical resection was achieved in 40 patients who were included in this study. Demographic and clinical data, including tumour recurrence, progression to RNU, tumour grade and overall survival (OS) were retrospectively acquired. An outcome analysis was conducted. RESULTS Median age at diagnosis was 68 years (range 42-94 years). Low grade tumours were found in 37 patients (92.5%) and high grade tumours in three patients (7.5%). Median follow-up was 53 months during which 20 patients developed upper tract recurrences (50.0%). The longest time to recurrence was 97 months. At follow-up 11 patients (27.5%) underwent an RNU and two patients died from UTUC. RNU could be avoided in 29 patients (72.5%). In this study we found that multifocality is a significant risk factor for recurrence, but not for stage progression to RNU. CONCLUSION PCTR is a surgically and oncologically safe procedure. Renal preservation in patients with UTUC who are eligible for percutaneous resection can be achieved in the majority of patients. Selection criteria for PCTR should be further refined, leading to a wider application of PCTR in the future. Follow-up needs invasive procedures and should be long term.
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Affiliation(s)
- Willem E. Strijbos
- Department of Urology, Zuyderland Medical Centre, Heerlen, The Netherlands
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Elawdy MM, Taha DE, Elbaset MA, Abouelkheir RT, Osman Y. Histopathologic Characteristics of Upper Tract Urothelial Carcinoma With an Emphasis on Their Effect on Cancer Survival: A Single-Institute Experience With 305 Patients With Long-Term Follow-Up. Clin Genitourin Cancer 2016; 14:e609-e615. [PMID: 27262370 DOI: 10.1016/j.clgc.2016.04.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 04/18/2016] [Accepted: 04/22/2016] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Tumor stage and grade represent the best established predictors for the prognosis of upper tract urothelial carcinoma (UTUC). However, controversies still exist regarding the role of tumor necrosis, location, and multifocality in the prognosis of UTUC. We share our experience with 305 patients, reporting on the pathologic features in detail, cancer characteristics, and survival. MATERIALS AND METHODS We retrospectively reviewed the data from patients who had undergone surgery for UTUC from 1983 to 2013. The tumors were staged according to the 1997 TNM classification and the 3-tiered World Health Organization grading system. Cancer-specific survival (CSS) was estimated using the Kaplan-Meier method. RESULTS A total of 305 patients were eligible for analysis. The 5-year CSS for grade 1, 2, and 3 was 88%, 84%, and 60%, respectively. The CSS for stage pT1, T2, T3, and T4 was 82%, 70%, 62%, and 0%, respectively. On univariate analysis, tumor stage, tumor grade, positive lymph node status, and micropapillary invasion had adverse effects on survival (P = .006, P = .045, P = .01, and P = .005, respectively). On multivariate analysis, only stage and micropapillary variant maintained significance (P = .01). Multicentricity and tumor location affected CSS in the early follow-up period but did not in the late follow-up period. Neither carcinoma in situ nor adverse pathologic variants affected survival. CONCLUSION The tumor stage and presence of a micropapillary variant are of paramount prognostic significance for survival in patients with UTUC. The tumor grade and lymph node status are also good predictors. In our series, multifocality and tumor location affected early and mid-term survival with no significant effects on late survival.
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Affiliation(s)
| | - Diaa E Taha
- Department of Urology, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Mohamed A Elbaset
- Department of Urology, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Rasha T Abouelkheir
- Department of Radiology, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Yasser Osman
- Department of Urology, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
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Prognostic factors and predictive tools for upper tract urothelial carcinoma: a systematic review. World J Urol 2016; 35:337-353. [DOI: 10.1007/s00345-016-1826-2] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Accepted: 04/04/2016] [Indexed: 01/12/2023] Open
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21
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Motamedinia P, Keheila M, Leavitt DA, Rastinehad AR, Okeke Z, Smith AD. The Expanded Use of Percutaneous Resection for Upper Tract Urothelial Carcinoma: A 30-Year Comprehensive Experience. J Endourol 2015; 30:262-7. [PMID: 26630130 DOI: 10.1089/end.2015.0248] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
INTRODUCTION The gold standard treatment for upper tract urothelial carcinoma (UTUC) is radical nephroureterectomy (RNU). The role of endoscopic resection is limited to low-risk patients. In this study, we present our 30-year experience in the endoscopic management of UTUC. METHODS In this retrospective study, we identified 141 patients who underwent percutaneous UTUC resection. Demographic and clinical data were collected, including tumor characteristics, bacillus Calmette-Guérin (BCG) and mitomycin use, tumor recurrence, progression to RNU, and overall survival (OS), and compared in univariate and multivariate analyses. RESULTS Median follow-up was 66 months. Recurrence occurred in 37% of low-grade patients and 63% of high-grade (HG) patients, with a median time to recurrence of 71.4 vs 36.4 months, respectively. Grade was the only predictor of recurrence (HR 2.12, p = 0.018). The latest time to recurrence occurred after 116 months of surveillance. RNU was avoided by 87% of patients. Age, imperative indications for endoscopy, a history of bladder cancer, and tumor stage and grade were predictors of OS; however, in multivariate analysis, grade and stage lost significance. BCG and mitomycin did not protect against recurrence, progression to RNU, or death over resection alone. CONCLUSION Percutaneous management of UTUC allows for renal preservation in the majority of patients with resectable disease. Patients with HG tumors are more likely to experience recurrence, but are not at an increased risk of death. Intraluminal BCG and mitomycin continue to have a limited adjuvant role to resection. Recurrence may occur many years following initial resection and therefore prolonged surveillance is advised.
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Affiliation(s)
- Piruz Motamedinia
- 1 Arthur Smith Institute for Urology, North Shore-Long Island Jewish Medical Center, New Hyde Park, New York.,2 Department of Urology, Yale University, New Haven, Connecticut
| | - Mohamed Keheila
- 1 Arthur Smith Institute for Urology, North Shore-Long Island Jewish Medical Center, New Hyde Park, New York
| | - David A Leavitt
- 1 Arthur Smith Institute for Urology, North Shore-Long Island Jewish Medical Center, New Hyde Park, New York.,3 Vattikuti Urology Institute, Henry Ford Health System, Detroit, Michigan
| | | | - Zeph Okeke
- 1 Arthur Smith Institute for Urology, North Shore-Long Island Jewish Medical Center, New Hyde Park, New York
| | - Arthur D Smith
- 1 Arthur Smith Institute for Urology, North Shore-Long Island Jewish Medical Center, New Hyde Park, New York
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Waseda Y, Saito K, Ishioka J, Matsuoka Y, Numao N, Fujii Y, Sakai Y, Koga F, Okuno T, Arisawa C, Kamata S, Nagahama K, Masuda H, Yonese J, Kageyama Y, Noro A, Tsujii T, Morimoto S, Gotoh S, Kihara K. Ureteral Involvement Is Associated with Poor Prognosis in Upper Urinary Tract Urothelial Carcinoma Patients Treated by Nephroureterectomy: A Multicenter Database Study. Eur Urol Focus 2015; 2:296-302. [PMID: 28723376 DOI: 10.1016/j.euf.2015.10.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 09/29/2015] [Accepted: 10/21/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND The prognostic significance of tumor location for patients with upper urinary tract urothelial carcinoma (UUT-UC) has been disputed. Several papers have reported that ureteral cancer is associated with worse prognosis. OBJECTIVE To investigate the prognostic significance of the presence of ureteral tumors in UUT-UC patients who underwent radical nephroureterectomy (RNU). DESIGN, SETTING, AND PARTICIPANTS In this multicenter retrospective study, 1068 eligible patients (median follow-up: 40 mo [interquartile range: 17-77 mo]) were divided into three groups based on tumor location: renal pelvic, ureteral, and both-regional (having both renal pelvic and ureteral tumors). The ureteral and both-regional groups were subsequently integrated into the ureteral involvement group to evaluate its prognostic impact. INTERVENTION All patients underwent RNU. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The prognostic impact of tumor location on survival was analyzed. RESULTS AND LIMITATIONS The renal pelvic, ureteral, and both-regional groups consisted of 507 (47.5%), 430 (40.3%), and 131 (12.3%) patients, respectively. The ureteral and both-regional groups had a higher rate of lymphovascular invasion and lymph node metastasis compared with the renal pelvic group. The renal pelvic and both-regional tumors presented more frequently with locally advanced stages (pT3/T4) compared with the ureteral tumors. The 5-yr cancer-specific survival (CSS) and progression-free survival (PFS) rates of patients in the ureteral (70.5% and 66.7%, respectively) and both-regional groups (64.8% and 57.8%, respectively) were significantly worse than those in the renal pelvic group (81.9% and 78.1%, respectively). In a multivariate analysis, the presence of ureteral involvement was a significant prognostic factor for CSS (hazard ratio [HR]: 1.50; p=0.006) and PFS (HR: 1.35; p=0.023). This study is inherently limited by the biases associated with its retrospective and multicenter design. CONCLUSIONS The presence of ureteral involvement had a significant impact on the survival of surgically treated UUT-UC patients associated with a poor prognosis. PATIENT SUMMARY We demonstrated that the ureteral involvement was associated with poor survival compared with patients with renal pelvic tumor only in upper urinary tract urothelial patients treated by nephroureterectomy.
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Affiliation(s)
- Yuma Waseda
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazutaka Saito
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Junichiro Ishioka
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoh Matsuoka
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Noboru Numao
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yasuhisa Fujii
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yasuyuki Sakai
- Department of Urology, National Cancer Center Hospital East, Chiba, Japan
| | - Fumitaka Koga
- Department of Urology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Tetsuo Okuno
- Department of Urology, Toride Medical Center, Ibaraki, Japan
| | | | | | - Katsuji Nagahama
- Department of Urology, National Center for Global Health and Medicine, Konodai Hospital, Chiba, Japan
| | - Hitoshi Masuda
- Department of Urology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Junji Yonese
- Department of Urology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yukio Kageyama
- Department of Urology, Saitama Cancer Center, Saitama, Japan
| | - Akira Noro
- Department of Urology, Saitama Red Cross Hospital, Saitama, Japan
| | - Toshihiko Tsujii
- Department of Urology, Tokyo Metropolitan Otsuka Hospital, Tokyo, Japan
| | - Shinji Morimoto
- Department of Urology, Tsuchiura Kyodo Hospital, Ibaraki, Japan
| | - Shuichi Gotoh
- Department of Urology, Hamamatsu Medical Center, Shizuoka, Japan
| | - Kazunori Kihara
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
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23
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Rouprêt M, Babjuk M, Compérat E, Zigeuner R, Sylvester RJ, Burger M, Cowan NC, Böhle A, Van Rhijn BWG, Kaasinen E, Palou J, Shariat SF. European Association of Urology Guidelines on Upper Urinary Tract Urothelial Cell Carcinoma: 2015 Update. Eur Urol 2015; 68:868-79. [PMID: 26188393 DOI: 10.1016/j.eururo.2015.06.044] [Citation(s) in RCA: 392] [Impact Index Per Article: 43.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 06/23/2015] [Indexed: 01/03/2023]
Abstract
CONTEXT The European Association of Urology (EAU) guidelines panel on upper urinary tract urothelial cell carcinoma (UTUC) has prepared updated guidelines to aid clinicians in the current evidence-based management of UTUC and to incorporate recommendations into clinical practice. OBJECTIVE To provide a brief overview of the EAU guidelines on UTUC as an aid to clinicians. EVIDENCE ACQUISITION The recommendations provided in the current guidelines are based on a thorough review of available UTUC guidelines and articles identified following a systematic search of Medline. Data on urothelial malignancies and UTUC were searched using these keywords: urinary tract cancer; urothelial carcinomas; upper urinary tract, carcinoma; renal pelvis; ureter; bladder cancer; chemotherapy; nephroureterectomy; adjuvant treatment; instillation; neoadjuvant treatment; recurrence; risk factors; and survival. References were weighted by a panel of experts. EVIDENCE SYNTHESIS Due to the rarity of UTUC, there are insufficient data to provide strong recommendations (ie, grade A). However, the results of recent multicentre studies are now available, and there is a growing interest in UTUC. The 2009 TNM classification is recommended. Recommendations are given for diagnosis and risk stratification as well as radical and conservative treatment, and prognostic factors are discussed. A single postoperative dose of intravesical mitomycin after nephroureterectomy reduces the risk of bladder tumour recurrence. Recommendations are also provided for patient follow-up after different therapeutic strategies. CONCLUSIONS These guidelines contain information on the management of individual patients according to a current standardised approach. Urologists should take into account the specific clinical characteristics of each patient when determining the optimal treatment regimen, based on the proposed risk stratification of these tumours. PATIENT SUMMARY Urothelial carcinoma of the upper urinary tract is rare, but because 60% of these tumours are invasive at diagnosis, an appropriate diagnosis is most important. A number of known risk factors exist.
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Affiliation(s)
- Morgan Rouprêt
- Department of Urology, Hospital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, University Pierre et Marie Curie, Institut Universitaire de Cancérologie, Paris, France.
| | - Marko Babjuk
- Department of Urology, Hospital Motol and 2nd Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Eva Compérat
- Department of Pathology, Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, University Pierre et Marie Curie, Institut Universitaire de Cancérologie, Paris, France
| | - Richard Zigeuner
- Department of Urology, Medizinische Universität Graz, Graz, Austria
| | - Richard J Sylvester
- EAU Guidelines Office Board, European Association of Urology, The Netherlands
| | - Maximilian Burger
- Department of Urology, Caritas St. Josef Medical Centre, University of Regensburg, Regensburg, Germany
| | - Nigel C Cowan
- Department of Radiology, Queen Alexandra Hospital, Portsmouth, UK
| | | | - Bas W G Van Rhijn
- Department of Urology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Eero Kaasinen
- Department of Surgery, Hyvinkää Hospital, Hyvinkää, Finland
| | - Joan Palou
- Department of Urology, Universitat Autònoma de Barcelona-Fundació Puigvert, Barcelona, Spain
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Centre, Medical University of Vienna, Vienna General Hospital, Vienna, Austria; Department of Urology, Weill Medical College of Cornell University, New York, NY, USA; Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Kapoor A, Dason S, Allard CB, Shayegan B, Lacombe L, Rendon R, Jacobsen NE, Fairey A, Izawa J, Black P, Tanguay S, Chin J, So A, Lattouf JB, Bell D, Saad F, Drachenberg D, Cagiannos I, Fradet Y, Alamri A, Kassouf W. The impact of method of distal ureter management during radical nephroureterectomy on tumour recurrence. Can Urol Assoc J 2014; 8:E845-52. [PMID: 25485014 DOI: 10.5489/cuaj.1985] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTON Radical nephroureterectomy for upper tract urothelial carcinoma (UTUC) must include some form of distal ureter management to avoid high rates of tumour recurrence. It is uncertain which distal ureter management technique has the best oncologic outcomes. To determine which distal ureter management technique resulted in the lowest tumour recurrence rate, we analyzed a multi-institutional Canadian radical nephroureterectomy database. METHODS We retrospectively analyzed patients who underwent radical nephroureterectomy with distal ureter management for UTUC between January 1990 and June 2010 at 10 Canadian tertiary hospitals. Distal ureter management approaches were divided into 3 categories: (1) extravesical tenting for ureteric excision without cystotomy (EXTRAVESICAL); (2) open cystotomy with intravesical bladder cuff excision (INTRAVESICAL); and (3) extravesical excision with endoscopic management of ureteric orifice (ENDOSCOPIC). Data available for each patient included demographic details, distal ureter management approach, pathology and operative details, as well as the presence and location of local or distant recurrence. Clinical outcomes included overall recurrence-free survival and intravesical recurrence-free survival. Survival analysis was performed with the Kaplan-Meier method. Multivariable Cox regression analysis was also performed. RESULTS A total of 820 patients underwent radical nephroureterectomy with a specified distal ureter management approach at 10 Canadian academic institutions. The mean patient age was 69.6 years and the median follow-up was 24.6 months. Of the 820 patients, 406 (49.5%) underwent INTRAVESICAL, 316 (38.5%) underwent EXTRAVESICAL, and 98 (11.9%) underwent ENDOSOPIC distal ureter management. Groups differed significantly in their proportion of females, proportion of laparoscopic cases, presence of carcinoma in situ and pathological tumour stage (p < 0.05). Recurrence-free survival at 5 years was 46.3%, 35.6%, and 30.1% for INTRAVESICAL, EXTRAVESICAL and ENDOSCOPIC, respectively (p < 0.05). Multivariable Cox regression analysis confirmed that INTRAVESICAL resulted in a lower hazard of recurrence compared to EXTRAVESICAL and ENDOSCOPIC. When looking only at intravesical recurrence-free survival (iRFS), a similar trend held up with INTRAVESICAL having the highest iRFS, followed by ENDOSCOPIC and then EXTRAVESICAL management (p < 0.05). At last follow-up, 406 (49.5%) patients were alive and free of disease. CONCLUSION Open intravesical excision of the distal ureter (INTRAVESICAL) during radical nephroureterectomy was associated with improved overall and intravesical recurrence-free survival compared with extravesical and endoscopic approaches. These findings suggest that INTRAVESICAL should be considered the gold standard oncologic approach to distal ureter management during radical nephroureterectomy. Limitations of this study include its retrospective design, heterogeneous cohort, and limited follow-up.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Peter Black
- University of British Columbia, Vancouver, BC
| | | | | | - Alan So
- University of British Columbia, Vancouver, BC
| | | | | | - Fred Saad
- University of Montreal, Montreal, QC
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Colin P, Irani J, Drouin S, Shariat S, Rouprêt M. Facteurs pronostiques des tumeurs de la voie excrétrice supérieure et impact sur la survie : une revue systématique pour le rapport annuel de l’Association française d’urologie. Prog Urol 2014; 24:1000-10. [DOI: 10.1016/j.purol.2014.07.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 07/16/2014] [Accepted: 07/22/2014] [Indexed: 02/02/2023]
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26
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Lee HY, Li CC, Huang CN, Ke HL, Li WM, Liang PI, Yang SF, Tu HP, Wu WJ, Yeh HC. Prognostic significance of lymphovascular invasion in upper urinary tract urothelial carcinoma is influenced by tumor location. Ann Surg Oncol 2014; 22:1392-400. [PMID: 25239005 DOI: 10.1245/s10434-014-4103-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND To examine the prognostic value of lymphovascular invasion (LVI) in different tumor locations (i.e., renal pelvis and ureter) of upper urinary tract urothelial carcinoma (UTUC). METHODS Data from a total of 250 patients with nonmetastatic UTUC who received radical nephroureterectomy between 2004 and 2010 at our institution were analyzed retrospectively. The significance of LVI and other relevant factors on cancer-specific survival (CSS), metastasis-free survival (MFS), and intraluminal recurrence-free survival (IRFS) were evaluated. RESULTS Lymphovascular invasion was present in 60 patients (24 %) and was related to advanced pathological T stage (P < 0.001), higher tumor grade (P < 0.001), lymph node metastasis (P = 0.005), and pyelocaliceal tumor location (P = 0.002). By Kaplan-Meier analysis, LVI was found to be significantly correlated with worse CSS and MFS but not with IRFS. Multivariate analysis showed that high pathological T stage and regional lymph node involvement were significant prognostic factors for CSS and MFS, and LVI was an independent predictor for MFS (hazard ratio 1.71, 95 % confidence interval 1.00-2.93, P = 0.049). In patients with ureteral tumors, LVI represented the only significant prognosticator for both CSS and MFS in multivariate analysis. The prognostic value of LVI was not observed in pyelocaliceal tumors. CONCLUSIONS The implication of LVI on prognosis, particularly in ureteral tumors but not in pyelocaliceal tumors, may imply diverse disease characteristics between different tumor locations among UTUC. LVI is essential to identify patients at high risk for metastasis/mortality and can facilitate treatment planning and surveillance strategies, especially in patients with ureteral tumors.
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Affiliation(s)
- Hsiang-Ying Lee
- Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
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Hurel S, Rouprêt M, Seisen T, Comperat E, Phé V, Droupy S, Audenet F, Pignot G, Cathelineau X, Guy L, Cussenot O, Ouzzane A, Bozzini G, Nison L, Ruffion A, Colin P. Influence of preoperative factors on the oncologic outcome for upper urinary tract urothelial carcinoma after radical nephroureterectomy. World J Urol 2014; 33:335-41. [DOI: 10.1007/s00345-014-1311-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 04/22/2014] [Indexed: 11/28/2022] Open
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Kapoor A, Allard CB, Black P, Kassouf W, Morash C, Rendon R. Canadian guidelines for postoperative surveillance of upper urinary tract urothelial carcinoma. Can Urol Assoc J 2013; 7:306-11. [PMID: 24319507 DOI: 10.5489/cuaj.1578] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Anil Kapoor
- Division of Urology, McMaster University, Hamilton, ON
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