Management of patients with upper urinary tract transitional cell carcinoma

Overview, Diagnosis, and Perioperative Systemic Therapy of Upper Tract Urothelial Carcinoma

Upper tract urothelial carcinoma comprises 5-10% of all urothelial carcinoma cases. This disease tends to have a more aggressive course than its lower urinary tract counterpart, with 60% of patients presenting with invasive disease and 30% of patients presenting with metastatic disease at diagnosis. The diagnostic workup of UTUC involves imaging with CT urogram, urine cytology, and direct visualization and biopsy of suspected lesions via ureteroscopy. Standard treatment of high-grade UTUC involves radical nephroureterectomy (RNU) and excision of the ipsilateral bladder cuff. Both the NCCN and EAU Guidelines include neoadjuvant chemotherapy as a treatment option for select patients with UTUC; however, there are no strict guidelines. Much of the rationale for neoadjuvant chemotherapy is based on extrapolation from data from muscle-invasive bladder cancer, which has demonstrated a 5-year OS benefit of 5-8%. Retrospective studies evaluating the use of NACT in urothelial carcinoma have yielded pathologic objective response rates of 48% in UTUC cohorts. The randomized Phase III POUT study noted a DFS advantage with adjuvant platinum-based chemotherapy, compared with surveillance in UTUC, of 70% vs. 51% at 2 years. Though not the standard of care, multiple studies have explored the use of perioperative immunotherapy or chemoimmunotherapy in the management of invasive urothelial carcinoma. The PURE-02 study explored the use of neoadjuvant pembrolizumab in patients with high-risk UTUC. A small study of 10 patients, it showed no significant signals of activity with neoadjuvant pembrolizumab. Another Phase II study of neoadjuvant ipilimumab and nivolumab in cisplatin-ineligible UTUC yielded more promising findings, with 3/9 patients attaining a pathologic CR and the remaining six pathologically downstaged. The ABACUS trial found a 31% pathologic complete response rate amongst cisplatin-ineligible MIBC patients treated with neoadjuvant atezolizumab. The use of adjuvant immunotherapy has been explored over three phase III trials. The CheckMate-274 trial found a DFS benefit with the addition of one year of adjuvant nivolumab in patients with high-risk urothelial carcinoma. The IMvigor-010 study of adjuvant atezolizumab was a negative study. The AMBASSADOR trial of adjuvant pembrolizumab is pending results. With the FDA approval of erdafitinib in metastatic urothelial carcinoma, similar targets have been explored for use in perioperative use in invasive urothelial carcinoma, as with adjuvant infigratinib in the PROOF-302 trial. As the treatment paradigm for urothelial carcinoma evolves, further prospective studies are needed to expand the perioperative treatment landscape of UTUC.

Current laser therapy options for endoscopic treatment of upper tract urothelial carcinoma

Endoscopic management via retrograde ureteroscopic laser ablation of upper tract urothelial carcinoma (UTUC) has become the preferred treatment modality for low-risk tumors. The most popular ablative lasers over the past 15-20 years have been the holmium:yttrium-aluminum-garnet (Ho:YAG) and neodymium (Nd:YAG) lasers, but recently the thulium (Th:YAG) laser has emerged as a potential alternative. This review compares the mechanism of action, physiological properties and effects, and oncologic outcomes of Ho:YAG/Nd:YAG lasers versus the Th:YAG laser for UTUC treatment. Potential advantages of the Th:YAG laser over existing technologies are outlined, followed by a discussion of emerging laser technologies in UTUC management.

Hypomethylated RRBP1 Potentiates Tumor Malignancy and Chemoresistance in Upper Tract Urothelial Carcinoma

Ribosome-binding protein 1 (RRBP1) is a potential oncogene in several cancer types. However, the correlation between RRBP1 expression and the prognosis of patients with upper tract urothelial carcinoma (UTUC) remains unclear. In this study, we identified that RRBP1 is associated with carcinogenesis and metastasis in UTUC using a methylation profiling microarray. High correlations between RRBP1 and cancer stages, nodal metastasis status, molecular subtypes, and prognosis in bladder urothelial cancer (BLCA) were found. Aberrant DNA methylation in the gene body region of RRBP1 was determined in UTUC tissues by methylation-specific PCR. RRBP1 expression was significantly increased in UTUC tissues and cell lines, as determined by real-time PCR and immunohistochemistry. RRBP1 depletion significantly reduced BFTC909 cell growth induced by specific shRNA. On the other hand, molecular subtype analysis showed that the expression of RRBP1 was associated with genes related to cell proliferation, epithelial-mesenchymal transition, and basal markers. A patient-derived organoid model was established to analyze patients' responses to different drugs. The expression of RRBP1 was related to chemoresistance. Taken together, these results provide the first evidence that RRBP1 gene body hypomethylation predicts RRBP1 high expression in UTUC. The data highlight the importance of RRBP1 in UTUC malignancy and chemotherapeutic tolerance.

Role of lymph node dissection at the time of open or minimally invasive nephroureterectomy

Unlike urothelial carcinoma of the bladder, there is no guideline-based consensus on whether a lymph node dissection (LND) should be performed at the time of radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). Variable lymphatic drainage based on primary tumor location, lack of prospective trials, and difficulties in developing a risk-adapted approach to LND for UTUC are all challenges to the development of an established approach. The UTUC literature consists of an evidence pool that has historically been limited to single-institution series with heterogenous inclusion criteria for LND and variable LND templates. Areas of controversy exist regarding migration to the great vessel LN beds for mid and distal tumors. A lack of template standardization limits the interpretation of studies relative to one another and a lack of uniformity in reporting templates may lead to inaccuracies in the estimation of lymph node metastasis landing sites. Most clinicians agree that there is a staging benefit to LND for UTUC. Although the data is somewhat heterogenous, it demonstrates a prognostic and staging benefit to LND in higher stages of UTUC. Unlike the staging benefits provided by LND for UTUC, the therapeutic benefits are not as clearly established. Several studies have evaluated differences in cancer-specific survival (CSS) and demonstrated LND to be an independent predictor of CSS when compared to patients not undergoing LND. However, this finding is not consistent across all studies and the literature is again limited by inclusion heterogeneity and inconsistent or lack or template-based resections. LND for UTUC at the time of RNU is a safe and feasible procedure that seems to especially benefit patients with muscle-invasive or locally advanced disease. Prospective, randomized studies with strict inclusion criteria and defined anatomic templates are needed to definitely characterize the role of LND for UTUC.

Predictors of Locoregional Recurrence and Delineation of Adjuvant Radiation Therapy Fields for Patients With Upper Tract Urothelial Carcinoma Receiving Nephroureterectomy

PURPOSE

To identify factors predictive of locoregional recurrence (LRR) in upper tract urothelial carcinoma (UTUC) treated with nephroureterectomy and to propose adjuvant radiation therapy (ART) fields.

METHODS AND MATERIALS

Clinical and pathologic variables for patients receiving nephroureterectomy for UTUC between 1995 and 2009 were analyzed for associations with outcomes. Sites of LRR from all patients with available imaging (39) were contoured on computed tomography image sets of patients with representative anatomy, and ART fields were proposed based on these distributions.

RESULTS

A total of 279 patients with a median follow-up of 13.0 years were analyzed. The 5-year cumulative incidence of LRR was 16.7% (95% CI, 12.2-21). Pathologic risk factors (PRFs) associated with increased risk of LRR included tumor in both the renal pelvis and ureter, T stage ≥2, lymph node involvement, grade 3 histology, and positive surgical margins (P < .05). Patients with an increased number of PRFs had a significantly greater risk of LRR. The 5-year cumulative incidence estimates of LRR were 5.3% (95% CI, 1.8%-16.0%), 15.6% (95% CI, 9.5%-25.7%), and 43.9% (95% CI, 31.1%-62.1%) for those with 1, 2, and ≥3 PRFs, respectively. ART fields covering the renal fossa and retroperitoneal lymph nodes from the superior border of L1 through the aortic bifurcation would encompass all sites of LRR for 33 of 46 patients (72%). Non-LRR bladder and distant failure occurred in 101 (36.2%) and 73 (26.2%) of the patients, respectively. The 5-year cumulative incidence estimate of distant failure was 22.5% (95% CI, 17.4%-27.3%).

CONCLUSIONS

In patients receiving nephroureterectomy for UTUC, LRR is significantly increased in patients with 2 or more PRFs. These data provide clinically valuable insight into the selection of candidates for ART and the design of ART fields.

Neoadjuvant chemotherapy for upper tract urothelial carcinoma

Upper tract urothelial carcinoma (UTUC) is a very uncommon disease that occupies for <5% of all urothelial cancers. Radical nephroureterectomy (RNU) remains the standard-of-care for UTUC; however, when patients with locally advanced UTUC are treated with RNU only, the recurrence rate is high. Therefore, perioperative chemotherapy has been proposed given the high systemic recurrence rate. Moreover, there is growing evidence that neoadjuvant chemotherapy (NAC) plays an important role in the treatment of UTUC. Several studies and meta-analyses have reported the beneficial effect of NAC on survival outcomes and pathologic downstaging of patients with UTUC. However, the recommendation of NAC for UTUC is primarily based on level 1 evidence that demonstrated a beneficial effect on survival outcomes in patients with bladder cancer. The chemotherapy regimen for patients with UTUC is also based on that used for patients with bladder cancer. Nevertheless, the use of NAC for UTUC has some limitations, including the possibility of overtreatment. Therefore, selection criteria for NAC are needed, as are further trials to identify the most suitable patients and validate its use in daily clinical practice.

Perioperative chemotherapy in the management of high risk upper tract urothelial cancers

Radical nephroureterectomy (RNU) remains the gold-standard in the treatment of invasive urothelial cancers of the upper tract (>pT2). However, there are stage-related, postoperative recurrence and cancer-specific death rates that are unacceptably high. Multimodality treatment regimens including neoadjuvant and adjuvant cisplatin-based systemic chemotherapy have been studied. While there is a paucity of Level 1 evidence to support either regimen, both have advantages and disadvantages. The provision of chemotherapy in the neoadjuvant setting is supported by extensive bladder cancer literature, but randomized controlled trials in the upper tract have not been completed. Neoadjuvant chemotherapy also risks overtreatment of patients due to the lack of accurate pre-operative staging modalities. On the other hand, adjuvant chemotherapy is supported by the findings of one prospective randomized trial, and eliminates the need for patient selection based on imperfect pre-operative modalities. However, the rigors of surgery and the renal function loss related to nephrectomy, may preclude the provision of adjuvant chemotherapy in a significant subset of patients. One may conclude that multimodal therapy is desirable for oncologic control, but the best means of providing such therapy requires further study.

Nephroureterectomy vs. segmental ureterectomy of clinically localized, high-grade, urothelial carcinoma of the ureter: Practice patterns and outcomes

BACKGROUND

Nephroureterectomy (NU) remains the gold-standard for upper-tract urothelial carcinoma (UTUC). However, nephron-sparing management (NSM), specifically segmental ureterectomy (SU) for urothelial tumors distal to the renal pelvis may offer decreased risk of renal insufficiency and equivalent cancer control.

OBJECTIVES

To identify patient-specific and facility-related factors that are associated with the selection of SU vs. NU for patients with clinically localized, high-grade, ureteral UTUC.

DESIGN, SETTING, PARTICIPANTS

We searched the National Cancer Database between 2004 and 2015 for patients with high-grade, clinically localized, primary ureteral UTUC managed by either NU or SU.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Univariate and multivariate analysis was performed to assess patient, disease-specific, facility and treatment-related factors associated with SU vs. NU. Since surgical approach was only indexed after 2010, separate multivariable logistic regressions were performed including and excluding surgical approach in order to capture patients treated between 2004 and 2009. Survival analysis utilized Kaplan-Meier methods and Cox proportional hazards regression.

RESULTS AND LIMITATIONS

Multivariate analysis including surgical approach demonstrated that among other factors, higher clinical stage (P = 0.034), larger tumor size (P < 0.001), the addition of neoadjuvant chemotherapy (P = 0.002), and the utilization of minimally invasive surgery (P < 0.05) decreased the likelihood of patients receiving SU. In this same cohort, institutions with larger facility volumes (P = 0.038) and performing intraoperative lymph node dissection (P < 0.001) were associated with a higher probability of SU. Excluding surgical approach, once again more advanced clinical stage (P = 0.005), larger tumor size (P < 0.001), and neoadjuvant chemotherapy (P = 0.003) decreased the probability of patients receiving SU, while increasing age (P = 0.049) and intraoperative lymph node dissection (P < 0.001) were more closely associated with SU compared to NU. No differences were noted in pathological T stage (P > 0.05), 30-day readmission (P = 0.7), 30-day mortality (P = 0.09), and 90-day mortality (P = 0.157) on multivariate analysis between SU and NU. Additionally, no significant differences were seen in median overall survival between patients receiving SU or NU (53 vs. 50 months; P = 0.143).

CONCLUSIONS

Comparable outcomes suggest segmental ureterectomy for high-grade ureteral UTUC is appropriate in well-selected patients. Practice patterns appear consistent with guideline recommendations (decreased tumor size and lower clinical stage favor SU), but treatment disparities may exist based on a multitude of patient, pathologic- and facility-related factors. Improved dissemination of knowledge regarding practice patterns and outcomes of SU for UTUC of the ureter has the potential to improve delivery of NSM in appropriate patients.

PATIENT SUMMARY

In this study, we examined factors associated with different surgical procedures for cancer of the ureter. We found that smaller tumor sizes, a less advanced clinical stage, intraoperative lymph dissection higher facility volumes tended to favor kidney-sparing treatment, while survival outcomes appear comparable to renal extirpation.

Role of Microtubule-Associated Protein 1b in Urothelial Carcinoma: Overexpression Predicts Poor Prognosis

We sought to examine the relationship between microtubule-associated proteins (MAPs) and the prognosis of urothelial carcinoma by assessing the microtubule bundle formation genes using a reappraisal transcriptome dataset of urothelial carcinoma (GSE31684). The result revealed that microtubule-associated protein 1b (MAP1B) is the most significant upregulated gene related to cancer progression. Real-time reverse-transcription polymerase chain reaction was used to measure MAP1B transcription levels in urothelial carcinoma of the upper tract (UTUC) and the bladder (UBUC). Immunohistochemistry was conducted to detect MAP1B protein expression in 340 UTUC and 295 UBUC cases. Correlations of MAP1B expression with clinicopathological status, disease-specific survival, and metastasis-free survival were completed. To assess the oncogenic functions of MAP1B, the RTCC1 and J82 cell lines were stably silenced against their endogenous MAP1B expression. Study findings indicated that MAP1B overexpression was associated with adverse clinical features and could independently predict unfavorable prognostic effects, indicating its theranostic value in urothelial carcinoma.

Significant clinicopathologic prognostic factors for bladder recurrence, progression, and cancer-specific survival after surgery among patients with upper urinary tract urothelial carcinoma

Purpose

This study aimed to identify prognostic factors for outcomes after radical nephroureterectomy among patients with upper urinary tract urothelial carcinoma (UTUC).

Materials and Methods

We retrospectively reviewed 184 nonmetastatic cases of UTUC after radical nephroureterectomy, bladder cuffing, and/or partial cystectomy (2004-2016). Bladder recurrence-free survival (BRFS), disease progression-free survival (DPFS), and cancer-specific survival (CSS) were estimated. The prognostic values of clinicopathologic parameters were evaluated by using Cox logistic regression analysis.

Results

The median BRFS, DPFS, and CSS values were 19.0 months, 38.5 months, and 67.0 months, respectively. We identified cases of bladder recurrence (64 cases, 34.8%), disease progression (54 cases, 29.3%), and cancer-specific death (23 cases, 12.5%). BRFS was independently associated with lymphovascular invasion (hazard ratio [HR], 0.421); DPFS was associated with intravesical instillation (HR, 0.290), active smoking (HR, 0.367), synchronous bladder lesions (HR, 2.355), and pT2 (HR, 5.199) and pT3 and pT4 (HR, 13.281) stages; and CSS was associated with alkaline phosphatase levels (HR, 0.966). Among 123 cases without previous bladder cancer, DPFS was associated with intravesical instillation (HR, 0.264), multifocal ureteral tumors (HR, 4.823), and pT3 and pT4 stages (HR, 10.899), whereas CSS was associated with pTis (HR, 32.071).

Conclusions

Patients with the factors we identified should receive adjuvant intravesical/systemic chemotherapy and intensive surveillance.

Identification of Significant Prognostic Tissue Markers Associated with Survival in Upper Urinary Tract Urothelial Carcinoma Patients Treated with Radical Nephroureterectomy: A Retrospective Immunohistochemical Analysis Using Tissue Microarray

Purpose

The purpose of this study was to identify prognostic tissue markers for several survival outcomes after radical nephroureterectomy among patients with upper urinary tract urothelial carcinoma using tissue microarray and immunohistochemistry.

Materials and Methods

Retrospectively, data of 162 non-metastatic patients with upper urinary tract urothelial carcinoma after radical nephroureterectomy between 2004 and 2016 were reviewed to determine intravesical recurrence-free survival (IVRFS), disease-free survival (DFS), and overall survival (OS). The expression of 27 tissue markers on a tissue microarray of radical nephroureterectomy samples and prognostic values of clinicopathological parameters were evaluated using immunohistochemistry and Cox proportional hazard models after adjusting for significant prognostic clinicopathological variables. The expression of all tissue markers was categorized into a binary group with continuous H-scores (0-300).

Results

Median follow-up was 53.4 months (range, 3.6 to 176.5 months); and, 58 (35.8%), 48 (29.6%), and 19 (11.7%) bladder recurrence, disease progression, and all cause death, respectively, were identified. After adjusting for significant clinicopathological factors including intravesical instillation for bladder recurrence-free survival, pathologic T category and intravesical instillation for disease progression-free survival, and pathologic T category for OS (p < 0.05), IVRFS was associated with epithelial cadherin (hazard ratio [HR], 0.49), epidermal growth factor receptor/erythroblastosis oncogene B (c-erb) (HR, 2.59), and retinoblastoma protein loss (HR, 1.85); DFS was associated with cyclin D1 (HR, 2.16) and high-molecular-weight cytokeratin (HR, 0.42); OS was associated with E-cadherin (HR, 0.34) and programmed cell death 1 ligand (HR, 13.42) (p < 0.05).

Conclusion

Several significant tissue markers were associated with survival outcomes in upper urinary tract urothelial carcinoma patients treated with radical nephroureterectomy.

Laparoscopy versus Open Nephroureterectomy in Prognostic Outcome of Patients with Advanced Upper Tract Urothelial Cancer: A Retrospective, Multicenter, Propensity-Score Matching Analysis

Purpose

The purpose of this study was to compare oncologic outcomes between open nephroureterectomy (ONU) and laparoscopic nephroureterectomy (LNU) in patients with upper tract urothelial carcinoma.

Materials and Methods

The medical records of consecutive ONU and LNU cases from five tertiary institutions were retrospectively analyzed between 2000 and 2012. The propensity-score matching methodology was used to compare the two surgical approaches in terms of age, body mass index, American Society of Anesthesiologists score, tumor location, grade, pathologic T and N categories, the presence of lymphovascular invasion, and follow-up duration. The Kaplan-Meier with log-rank tests and clustered Cox regression were used to compare the estimated rates of survival for each surgical approach and to investigate the effect of the surgical approach on each prognostic outcome.

Results

Six hundred thirty-eight propensity-score matching pairs (n=1,276) were compared; LNU was significantly better than ONU in all types of survival, including intravesical recurrence-free survival (IVRFS), disease-free survival, overall survival (OS), and cancer-specific survival (CSS) (p < 0.05). The 3-year OS and CSS rates were significantly higher with LNU than with ONU (p < 0.05). Compared with ONU, LNU had significantly better 3-year OS and CSS rates (82.9% and 86.2% vs. 78.3% and 81.8%); there were no differences at 5 years. In subgroup analysis of the early-staged group, advanced-stage group, lymph node–positive group, and lymph node–negative group, the two approaches did not significantly affect prognostic outcomes, except LNU improved the IVRFS in the lymph node–negative or no history of previous bladder cancer group.

Conclusion

LNU had a significantly better prognostic outcome than ONU after propensity-score matching.

Salvage topical therapy for upper tract urothelial carcinoma

PURPOSE

Topical therapy (TT) for upper tract urothelial carcinoma (UTUC) has been explored as a kidney sparing approach to treat carcinoma in situ (CIS) and as adjuvant for endoscopically treated Ta/T1 tumors. In bladder cancer, data support use of salvage TT for repeat induction. We investigate the outcomes of salvage TT for UTUC in patients ineligible for or refusing nephroureterectomy.

METHODS

A single-center retrospective review on patients receiving salvage TT via percutaneous nephrostomy tube or cystoscopically placed ureteral catheters was performed. Primary outcome was response to therapy based on International Bladder Cancer Group criteria.

RESULTS

51 patients with 58 renal units (RUs) received TT. Of these, 17 patients with 18 RUs received the second-line TT, with a median follow-up of 36.5 months (IQR 24.5-67 months). 44% (8/18) received salvage TT for refractory disease and 56% (10/18) as reinduction. 5 RUs with CIS were unresponsive to initial TT and went on to receive salvage TT, of which 20% (1/5) responded. 13 RUs recurred or relapsed following initial TT and received salvage TT for papillary tumors, with 62% (8/13) responding.

CONCLUSION

Our data provide preliminary clinical rationale for the second-line TT for refractory and recurrent, endoscopically managed papillary UTUC in patients ineligible for or refusing nephroureterectomy. However, refractory upper tract CIS appears to have poor response to salvage TT.

Validation of the Pretreatment Neutrophil-to-Lymphocyte Ratio as a Prognostic Factor in a Large Cohort of Chinese Patients with Upper Tract Urothelial Carcinoma

BACKGROUND

The pretreatment neutrophil-to-lymphocyte ratio (NLR) has been reported to be a prognostic factor in various types of carcinomas. The aim of this study was to investigate the prognostic value of pretreatment NLR in a large cohort of Chinese patients with upper tract urothelial carcinoma (UTUC).

METHODS

We retrospectively analyzed the medical data of 656 UTUC patients who underwent radical nephroureterectomy (RNU) from 2001 to 2011 at Peking University First Hospital. Receiver operating characteristic (ROC) curve analysis was performed to calculate the optimal cutoff point of pretreatment NLR. Uni- and multi-variate analyses were used to identify the prognostic factors for cancer-specific survival (CSS) and intravesical recurrence-free survival (IVRFS).

RESULTS

The optimal cutoff point of pretreatment NLR was 2.40 by ROC curves, by which patients with high NLR (NLR ≥2.40) and low NLR (NLR <2.40) accounted for 314 (47.9%) and 342 (52.1%) patients, respectively. Patients with a high pretreatment NLR tended to have high tumor grades (χ2 = 15.725, P< 0.001), high tumor stages (χ2 = 25.416, P< 0.001), tumor sizes >5 cm (χ2 = 8.213, P= 0.005), ipsilateral hydronephrosis (χ2 = 4.624, P= 0.033), and concomitant carcinoma in situ(CIS) (χ2 = 9.517, P= 0.003). A high pretreatment NLR (hazard ratio [HR] = 1.820, P= 0.001), main tumor diameter >5 cm (HR = 1.789, P= 0.009), lymph node metastasis (HR = 1.863, P= 0.024), and high tumor stage (HR = 1.745, P< 0.001) independently predicted poor CSS after surgery, while only concomitant carcinoma in situ(CIS) (HR = 2.164, P= 0.034), ureteroscopy before surgery (HR = 1.701, P= 0.015), and high tumor grade (HR = 1.645, P= 0.018) were independent predictors of IVRFS after RNU.

CONCLUSIONS

The pretreatment NLR was related to some adverse clinicopathological features and was an independent predictor of CSS, although not IVRFS, in Chinese UTUC patients.

Adjuvant chemotherapy after radical nephroureterectomy does not improve survival in patients with upper tract urothelial carcinoma: a joint study by the European Association of Urology-Young Academic Urologists and the Upper Tract Urothelial Carcinoma Collaboration

OBJECTIVE

To analyse the outcomes of adjuvant chemotherapy vs observation in a multicentre cohort of patients with upper tract urothelial carcinoma (UTUC) in order to clarify whether such patients benefit from adjuvant chemotherapy after radical nephroureterectomy (RNU).

PATIENTS AND METHODS

Data from 15 centres were collected for a total of 1544 patients, treated between 2000 and 2015. Criteria for patient selection included pT2-4N0/x stage, or lymph node-positive disease, and prior RNU. The standardized difference approach was used to compare subgroup characteristics. Overall survival (OS) was the primary endpoint. The primary analysis used 1:1 propensity score matching, with inverse probability of treatment weighting in addition to this in the secondary analysis. The latter was also performed with the inclusion of covariates, i.e. with 'doubly robust' estimation. A 6-month landmark analysis was performed to exclude early events.

RESULTS

A total of 312 patients received adjuvant chemotherapy and 1232 underwent observation. Despite differences between the two groups, the standardized difference was generally <10% after matching. In the matched analysis no difference was observed in OS between adjuvant chemotherapy and observation (hazard ratio [HR] 1.14, 95% confidence inverval [CI] 0.91-1.43; P = 0.268). In the doubly robust estimate-adjusted comparison, adjuvant chemotherapy was significantly associated with shorter OS (HR 1.26, 95% CI 1.02-1.54; P = 0.032). Similar findings were confirmed in subgroup analyses stratified by pathological stage, and after landmark analysis. Results should be interpreted with consideration given to the inherent limitations of retrospective studies.

CONCLUSION

Adjuvant chemotherapy did not improve OS compared with observation in the present study. These results contribute to the uncertainties regarding postoperative chemotherapy in UTUC, and suggest dedicated prospective trials, new more potent therapies, and the identification of enhanced patient selection criteria are required.

Why are upper tract urothelial carcinoma two different diseases?

In the last few years growing evidence highlighted the differences between upper tract urothelial carcinoma (UTUC) and urothelial bladder carcinoma (UBC) which cannot be explained solely by their different anatomical location. The aim of this review was to summarize current progress in UTUC research and to underline the differences and similarities between UTUC and UBC by focusing on epidemiology, etiology, staging and risk factors as well as on surgical and medical management. UBC and UTUC sharing common risk factors such as smoking and aromatic amines, while aristolochic acid exposure or familiar Lynch syndrome are rather specific for UTUC. The grading of UBC and UTUC are identical, but inherent from their different anatomical locations, there are some differences between their stage classifications. As an example, in contrast to UBC where a clear recommendation for pT3 subclassification exists, in UTUC current research aims to define an adequate subclassification for pelvic pT3 cases aiming to provide a better risk stratification. The primary treatment for both UBC and UTUC is surgery. Similarly to UBC, UTUC patients at high risk of disease progression are treated by radical surgery. However, because of the inaccurate preoperative or transurethral staging of UTUC, many radical nephroureterectomies are performed unnecessarily. Preoperative prediction of pathological stage or patients' prognosis may reduce this overtreatment by selecting patients for nephron-sparing surgery. To this end, predictive models combining histological and molecular features together with imaging data may be used. The antegrade or retrograde instillation of BCG or mitomycin C, as topical agents is feasible after conservative treatment of UTUC or for the treatment of CIS. However, the prognostic significance of lymph node positivity in UTUC seems to be similar to that of UBC, the therapeutic benefit of lymph node dissection (LND) in UTUC has not been firmly established yet. In addition, the number of lymph nodes to be removed and the sequence of lymphadenectomy also remain to be defined. Systemic neoadjuvant and adjuvant chemotherapies appear to have beneficial effect on UTUC survival, however, this has to be confirmed by large prospective studies. Due to the intensive research of the last few years, our knowledge on UTUC has been largely improved, but many questions remained to be answered. Further research on the molecular background of UTUC holds the potential to identify prognostic or predictive markers which, together with imaging and histologic data, may help to overcome the inaccuracy of ureteroscopic endoscopy and may therefore help to improve therapeutic decision-making. Further, prospective studies should confirm the benefit of LND and adjuvant chemotherapy. Considering the low incidence of UTUC, conduction of such studies is difficult and may only be performed in a multicenter setting.

Complications Following Radical Nephroureterectomy

Radical nephroureterectomy (RNU) is the gold standard treatment strategy for bulky, high-grade, or muscle-invasive upper tract urothelial carcinoma (UTUC). Many patients with UTUC who require RNU are elderly, comorbid, and at risk for perioperative complications. Recognition of likelihood and extent of such complications guides preoperative counseling, decision-making process for major surgery, and perioperative care. A critical review of such data is essential, given the inevitable impact of complications on hospital duration, need for readmission, resource utilization, and costs associated with management.

Preoperative nomogram to predict the likelihood of complications after radical nephroureterectomy

OBJECTIVES

To construct a nomogram based on preoperative variables to better predict the likelihood of complications occurring within 30 days of radical nephroureterectomy (RNU).

PATIENTS AND METHODS

The charts of 731 patients undergoing RNU at eight academic medical centres between 2002 and 2014 were reviewed. Preoperative clinical, demographic and comorbidity indices were collected. Complications occurring within 30 days of surgery were graded using the modified Clavien-Dindo scale. Multivariate logistic regression determined the association between preoperative variables and post-RNU complications. A nomogram was created from the reduced multivariate model with internal validation using the bootstrapping technique with 200 repetitions.

RESULTS

A total of 408 men and 323 women with a median age of 70 years and a body mass index of 27 kg/m² were included. A total of 75% of the cohort was white, 18% had an Eastern Cooperative Oncology Group (ECOG) performance status ≥2, 20% had a Charlson comorbidity index (CCI) score >5 and 50% had baseline chronic kidney disease (CKD) ≥ stage III. Overall, 279 patients (38%) experienced a complication, including 61 events (22%) with Clavien grade ≥ III. A multivariate model identified five variables associated with complications, including patient age, race, ECOG performance status, CKD stage and CCI score. A preoperative nomogram incorporating these risk factors was constructed with an area under curve of 72.2%.

CONCLUSIONS

Using standard preoperative variables from this multi-institutional RNU experience, we constructed and validated a nomogram for predicting peri-operative complications after RNU. Such information may permit more accurate risk stratification on an individual cases basis before major surgery.

De Ritis (aspartate transaminase/alanine transaminase) ratio as a significant predictor of recurrence-free survival in patients with upper urinary tract urothelial carcinoma following nephroureterectomy

BACKGROUND

To evaluate the prognostic significance of preoperatively assessed aspartate aminotransaminase (AST), alanine aminotransaminase (ALT), and the AST/ALT (De Ritis) ratio in patients with upper urinary tract urothelial carcinoma (UUTUC).

METHODS

This study included a total of 109 consecutive patients with clinically localized UUTUC who underwent nephroureterectomy. Effects of preoperative levels of AST, ALT, and the De Ritis ratio in addition to conventional clinicopathological parameters on the extravesical recurrence-free survival (eRFS) in these 109 patients were retrospectively analyzed.

RESULTS

Despite the lack of a significant correlation of AST or ALT with any of the factors examined in this study, the elevation of the De Ritis ratio was significantly correlated with several unfavorable parameters, including elderly age, high pathological stage, high tumor grade, and lymphovascular invasion. During the observation period of this series (median = 40.8mo), extravesical disease recurrence developed in 39 (35.8%) of the 109 patients, with a 5-year eRFS rate of 56.8%. Of several factors examined, the tumor location, De Ritis ratio, pathological stage, lymph node metastasis, tumor grade, lymphovascular invasion, surgical margin status, and adjuvant chemotherapy were shown to be significantly correlated with eRFS by univariate analysis. Of these, the De Ritis ratio, pathological stage, lymph node metastasis, and tumor grade were identified as independent predictors of eRFS on multivariate analysis.

CONCLUSIONS

These findings suggest that preoperative assessment of the De Ritis ratio may provide useful information with respect to the clinical course of patients with clinically localized UUTUC who are scheduled to be treated with nephroureterectomy.

Clinicopathological prognostic factors for upper tract urothelial carcinoma

INTRODUCTION

The aim of the present study was to evaluate the influence of clinicopathological factors including age, gender, tumor grade, tumor stage, lymphovascular invasion (LVI), tumor necrosis and previous history of non-muscle invasive bladder cancer on outcomes of patients with upper tract urothelial carcinoma (UTUC) treated with radical nephroureterectomy (RNU).

MATERIAL AND METHODS

A total of 60 patients who underwent radical nephroureterectomy for upper tract urothelial carcinoma at our institute between 2005 to 2012 were included in our study. Univariate and multivariate analysis was performed using the Kaplan-Meier method, log rank statistics, the chi-square test and Cox regression models.

RESULTS

The mean length of follow-up time was 33.3 months. There were 27 (45%) patients alive with the disease, whereas 33 (55%) were dead. In 19 cases (31.7%) the tumor grade was low, while in 41 cases (68.3%) it was high. Lymphovascular invasion was observed in 28 (46.7%) cases. Tumor necrosis was registered in 14 patients (23.3%). From the patients with LVI, 3 (9.6%) were alive, whereas from the patients negative for LVI, 75% were alive. Significant relationship was found between gender and grading and between positive LVI and low grading.

CONCLUSIONS

Day case Variables such as gender, grading, tumor stage, LVI and tumor necrosis were all demonstrated to be significant independent prognostic factors for the overall survival. On the multivariate analysis only LVI remained statistically significant, which may explain the different clinical course in patients and could be considered as a part of pathological reporting and treatment planning for the future.

Extraurothelial recurrence after radical nephroureterectomy: preoperative predictors and survival

OBJECTIVE

To identify the preoperative predictors of extraurothelial recurrence (EUR) after radical nephroureterectomy (RNU) in patients with upper tract urothelial carcinoma (UTUC).

METHODS

A single-center series of 238 consecutive patients who were treated with RNU for UTUC was evaluated. Recurrence-free probabilities and cancer-specific survival (CSS) were estimated using the Kaplan-Meier method. Multivariate Cox proportional hazards regression models were used to evaluate the association between various clinicopathological factors and EUR.

RESULTS

The median time to EUR was 17.6 months (range 3-73 months). EUR-free survival rates at 1, 3, 5, and 7 years were 87.8, 75.2, 73.5, and 72.6%, respectively. In multivariate Cox regression analyses, tumor stage (HR 27.4; 95% CI 7.83-95.8; p = 0.0001) and lymphovascular invasion (LVI) (HR 1.53; 95% CI 1.22-3.12; p = 0.01) were independently associated with EUR. In patients with EUR, 5-year CSS estimate was 29.2%. Tumor stage (HR 14.3; 95% CI 4.55-45.2; p < 0.001) and EUR (HR 2.7; 95% CI 1.54-4.73; p = 0.001) were the only independent predictors associated with worse CSS.

CONCLUSIONS

EUR significantly affected the prognosis in patients with UTUC managed by RNU. Patient with EUR had a greater probability of having higher tumor stages, higher tumor grades, and positive LVI. Tumor stage and LVI were independently associated with a worse EUR-free survival.

Prognostic value of systemic inflammatory responses in patients with upper urinary tract urothelial carcinoma

PURPOSE

To determine the utility of systemic inflammatory response and develop a model based on serum inflammatory indices to aid prognostication in patients with upper urinary tract urothelial carcinoma (UTUC).

METHODS

The study population comprised 277 patients with non-metastatic UTUC who underwent nephroureterectomy between 1999 and 2010. Multivariate survival analysis was performed using Cox's proportional hazards model, and a new model was developed to predict recurrence-free (RFS) and disease-specific survival (DSS). The factors considered, in relation to systemic inflammatory responses, were as follows: albumin, white blood cell count, neutrophil count, lymphocyte count, red blood cell count, serum creatinine level, platelet count, prognostic nutritional index, platelet/lymphocyte ratio, neutrophil/lymphocyte ratio (NLR), and derived NLR.

RESULTS

The final model consisted of bladder cuffing, pathologic T stage, lymphovascular invasion, and derived NLR. The bootstrap-concordance indices of the model were 0.778 [95 confidence interval (CI) 0.730-0.826] for RFS and 0.802 (95 % CI 0.752-0.851) for DSS, respectively, and integrated area under the curve value for time to RFS and DSS for patients was 0.738 and 0.760, respectively. When we generated calibration curves, the nomograms were reasonably calibrated.

CONCLUSIONS

Derived NLR may be used in combination with conventional staging techniques and other clinicopathological parameters to improve the prediction of survival in patients with UTUC.

Risk factors associated with ineligibility of adjuvant cisplatin-based chemotherapy after nephroureterectomy

PURPOSE

Radical nephroureterectomy (RNU) is a standard treatment for upper urinary tract urothelial carcinoma. However, RNU can result in decreased renal function and cannot be treated with adjuvant chemotherapy. We performed a risk group stratification analysis to determine the preoperative factors that are predictive of diminished renal function after RNU.

MATERIALS AND METHODS

We retrospectively evaluated the medical records of all patients who underwent nephroureterectomy for upper urinary tract urothelial carcinoma at the Chang Gung Memorial Hospital from 2001 to 2008. We analyzed the association between perioperative glomerular filtration rate and preoperative parameters including cancer characteristics, serum creatinine level, and kidney size measured on computed tomographic images.

RESULTS

A total of 242 patients fulfilled the inclusion criteria. The average decrease in renal function 1 month after RNU was 19.7%. Using 60 mL/min/1.73 m(2) as the eligibility cutoff for cisplatin-based chemotherapy, 42.1% of the population was eligible prior to nephroureterectomy, whereas following surgery only 15.2% remained eligible. Using a cutoff of 45 mL/min/1.73 m(2), 59.9% of the cohort was eligible for fractionated cisplatin dosing preoperatively, whereas only 32.6% remained above the cutoff postoperatively. The most significant predictors of poor postoperative renal function were body mass index >25 kg/m(2), age >65 years, contralateral kidney length less than 10 cm, and absence of ipsilateral hydronephrosis.

CONCLUSION

Our results suggest that older age, higher body mass index, smaller contralateral renal length, and absence of ipsilateral hydronephrosis are predictive of decreased renal function after RNU.

Nephron-sparing management vs radical nephroureterectomy for low- or moderate-grade, low-stage upper tract urothelial carcinoma

OBJECTIVE

To compare overall and cancer-specific outcomes between patients with upper tract urothelial carcinoma (UTUC) managed with either radical nephroureterectomy (RNU) or nephron-sparing measures (NSM) using a large population-based dataset.

PATIENTS AND METHODS

Using Surveillance, Epidemiology, and End Results (SEER) data, patients diagnosed with low- or moderate-grade, localised non-invasive UTUC were stratified into two groups: those treated with RNU or NSM (observation, endoscopic ablation, or segmental ureterectomy). Cancer-specific mortality (CSM) and other-cause mortality (OCM) rates were determined using cumulative incidence estimators. Adjusting for clinical and pathological characteristics, the associations between surgical type, all-cause mortality and CSM were tested using Cox regressions and Fine and Gray regressions, respectively.

RESULTS

Of 1227 patients [mean (sd) age 70.2 (11.00) years, 63.2% male] meeting inclusion criteria, 907 (73.9%) and 320 (26.1%) patients underwent RNU and NSM for low- or moderate-grade, low-stage UTUC from 1992 to 2008. Patients undergoing NSM were older (mean age 71.6 vs 69.7 years, P < 0.01) with a greater proportion of well-differentiated tumours (26.3% vs 18.0%, P = 0.001). While there were differences in OCM between the groups (P < 0.01), CSM trends were equivalent. After adjustment, RNU treatment was associated with improved non-cancer cause survival [hazard ratio (HR) 0.78, confidence interval [CI] 0.64-0.94) while no association with CSM was demonstrable (HR 0.89, CI 0.63-1.26).

CONCLUSIONS

Patients with low- or moderate-grade, low-stage UTUC managed through NSM are older and are more likely to die of other causes, but they have similar CSM rates to those patients managed with RNU. These data may be useful when counselling patients with UTUC with significant competing comorbidities.

Rationale and timing of perioperative chemotherapy for upper-tract urothelial carcinoma

Radical surgery alone for high-risk upper-tract urothelial carcinoma (UTUC) is often inadequate for long-term cancer control. Numerous studies implicate failure presumably attributable to metastatic disease. Therefore, multimodal therapy by way of perioperative chemotherapy is integral to improve cancer outcomes and disease-specific survival. Despite this apparent reality, there is lack of consensus regarding which patients will need additional therapy, optimal timing for delivery of agents, and specific regimens to be utilized. Progress is being made, however, to explore these issues both by extrapolation from the bladder cancer literature as well as studying outcomes from retrospective UTUC series. Prospectively accruing studies for both neoadjuvant and adjuvant chemotherapy will likely mature in the next 5 years thereby providing higher level data to better guide standard of care.

Mitomycin C instillation following ureterorenoscopic laser ablation of upper urinary tract carcinoma

Introduction:

Instillation of Mitomycin C (MMC) should prevent implantation of cancer cells released during endoscopic treatment and prevent recurrences as seen in carcinoma of the bladder.

Aim:

To develop and evaluate a protocol for a single dose MMC instillation following Holmium: YAG laser ablation of upper urinary tract transitional cell carcinoma (UUT-TCC).

Setting and Design:

A single institute prospective study.

Materials and Methods:

MMC instillations protocol was designed and offered to patients between August 2005 and April 2011. Following tumor ablation, MMC was instilled into upper urinary tract (UUT) over 40 minutes. All the patients were regularly followed up.

Results:

Twenty UUT units (19 patients) were managed for UUT-TCCs using our MMC protocol. Two UUT units had G1pTa tumors, 14 had G2pTa, 2 had G3pTa, and 2 had G3pT1. At a mean follow-up of 24 months (range 1-72 months), 13/20 (65%) of the UUT units remained cancer-free, 3 (15%) UUT units developed stricture and were treated with endoscopic dilatation, only 1 (5%) of these developed long-term complications. None of the patients developed postoperative renal impairment or systemic side-effects.

Conclusions:

Using a set standard protocol, MMC can safely be instilled into the UUT after TCC ablation with minimal complications or side effects, good preservation of renal function, and with a low recurrences rate comparable to the literature.

Upper tract urothelial carcinoma

Upper tract urothelial carcinoma (UTUC) accounts for approximately 5% of all urothelial carcinoma. There are many risk factors for UTUC, including environmental and genetic risk factors, some of which are in common with bladder cancer. The gold standard surgical management of UTUC is radical nephroureterectomy (RNU) with excision of bladder cuff, which is increasingly being performed laparoscopically or robotically with various methods used for the distal ureter. There are increasing numbers of patients being treated endoscopically, with excellent oncological outcomes in low-grade disease. The use of topical BCG and chemotherapy agents has been extrapolated from bladder cancer and may be an adjunct to endoscopic management in those patients in whom it is imperative to avoid RNU.

Post-operative urothelial recurrence in patients with upper urinary tract urothelial carcinoma managed by radical nephroureterectomy with an ipsilateral bladder cuff: Minimal prognostic impact in comparison with non-urothelial recurrence and other clinical indicators

Upper urinary tract urothelial carcinoma (UTUC) is a rare disease, and novel prognostic factors for patients who have undergone a radical nephroureterectomy (RNU) for UTUC have been studied intensely. To the best of our knowledge, the prognostic value of urothelial recurrence in patients with UTUC has not been previously described in studies. The present study compared the prognostic value of urothelial and non-urothelial recurrence in patients with UTUC of the kidney and ureter managed by surgery. The inclusion criteria consisted of a diagnosis of non-metastatic UTUC (any T stage, N0–1 and M0) and receipt of an RNU with an ipsilateral bladder cuff as the primary treatment. Of the 153 patients that were screened for the study, comprehensive clinical and pathological data was available for 103 patients, who were consequently included in the analysis. Overall survival (OS) and cancer-specific survival (CSS) times were estimated. A multivariate analysis was performed using the Cox regression model. The median follow-up period was 29 months (interquartile range, 14–63 months). The patient population was comprised of 71 males (68.9%) and 32 females (31.1%). A total of 32 patients (31.1%) showed non-urothelial recurrence, while 38 patients (36.9%) exhibited urothelial recurrence and 33 patients (32.0%) exhibited no recurrence. When comparing the risk parameters between the non-urothelial recurrence categories, the factors of pathological grade, microvascular invasion, lymphatic invasion and pT classification showed significant differences. However, there were no significant differences between the urothelial recurrence categories. No significant difference was observed between the OS and CSS times within the urothelial recurrence categories (P=0.3955 and P=0.05891, respectively), but significant differences were identified in the non-urothelial recurrence categories (P<0.0001 and P<0.0001, respectively). Among the other relevant descriptive pre-operative characteristics in the multivariate analysis, only non-urothelial recurrence remained associated with a worse CSS [P=0.002; hazard ratio (HR) 9.512]. The results show that urothelial recurrence has a minimal prognostic value in patients with UTUC managed by RNU with an ipsilateral bladder cuff.

Endoscopic management of upper urinary tract urothelial carcinoma

Upper urinary tract urothelial carcinoma (UTUC) is relatively uncommon. Radical nephroureterectomy with an ipsilateral bladder cuff excision has been the gold standard treatment for UTUC. However, recent advances in technology have made possible the increased use of endoscopic management for the treatment of UTUC. The definitive goal of endoscopic management of UTUC is cancer control while maintaining renal function and the integrity of the urinary tract. Endoscopic management includes both the retrograde ureteroscopic and antegrade percutaneous approaches. The endoscopic management of UTUC is a reasonable alternative for patients with renal insufficiency or a solitary functional kidney, bilateral disease, or a significant comorbidity that precludes radical surgery. Select patients with a functional contralateral kidney who have low-grade, low-stage tumors may also be candidates for endoscopic management. The careful selection of patients is the most important point for the successful endoscopic management of UTUC. It is crucial that patients are compliant and motivated, because a lifetime protocol of strict surveillance is necessary. Adjuvant topical therapy with Bacillus Calmette-Guerin or mitomycin C can be used after endoscopic management of UTUC in an attempt to reduce recurrence. In this article, we review current endoscopic techniques, indications for endoscopic treatment, clinical outcomes of endoscopic management, adjuvant topical therapy, and surveillance in patients with UTUC.

Prognostic impact of the expression of ALDH1 and SOX2 in urothelial cancer of the upper urinary tract

Aldehyde dehydrogenase 1 (ALDH1) and sex determining region-Y-related high mobility group box 2 (SOX2) have been identified as putative cancer stem-like cell/tumor-initiating cell markers in various cancer tissues. The aim of this study was to elucidate the prognostic impact of these putative cancer stem-like cell/tumor-initiating cell markers in upper urinary tract urothelial cell carcinoma. Immunohistochemical staining for ALDH1 and SOX2 was carried out on archival specimens from 125 patients with upper urinary tract urothelial cell carcinoma who underwent radical nephroureterectomy. The prognostic value of ALDH1 and SOX2 expression and other clinicopathological features was evaluated. On univariate analysis, tumor grade, pathological T stage, pathological N stage, lymphovascular invasion, ALDH1 expression and SOX2 expression were associated with a poor prognosis. On multivariate analysis, the independent factors of prognosis were tumor grade (P=0.014), pathological N stage (P=0.005) and ALDH1 expression (P=0.002). In subgroup analysis, those subgroups with no positive, one positive or two positive results in immunohistochemistry for ALDH1 and SOX2 expression had estimated 5-year cancer-specific survival rates of 80%, 49% and 22%, respectively (P<0.001). Neither ALDH1 nor SOX2 expression correlated with intravesical recurrence after radical nephroureterectomy. These findings suggest that cancer stem-like cells/tumor-initiating cells are linked to more aggressive behavior of upper urinary tract urothelial cell carcinoma, supporting the current cancer stem cell hypothesis. Thus, therapeutic targeting of cancer stem-like cells/tumor-initiating cells in upper urinary tract urothelial cell carcinoma is a future possibility.

[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.

Endoscopic management of upper tract transitional cell carcinoma

Upper urinary tract transitional cell carcinoma (TCC) accounts for up to 10% of cases of neoplasm of the upper urinary tract. The “gold standard” management of upper tract TCC is nephroureterectomy. Technological innovations, miniaturisations and increased availability of energy sources such as Holmium laser fibers have improved the armamentarium of endoscopic management of upper tract TCC. Endoscopic management of upper tract TCC includes the percutaneous (antegrade) and retrograde approaches. Modern flexible ureterorenoscopy allows retrograde approach to small (<1.5cm), low grade and noninvasive tumors, which is inaccessible to standard rigid ureteroscopes without breaching the urothelial barrier. In patients with large tumors or in whom retrograde access is difficult, the percutaneous approach to the renal pelvis, although more invasive, provides an alternative access and control. Both retrograde and percutaneous approaches allow instillation of various chemotherapeutic agents. Careful selection of patients is the key point in the successful endoscopic management of upper tract TCC. Patient selection is based on tumor size, grade and multifocality and other patient factors such as comorbidities, single kidney, post kidney transplant and patient choice. Both motivation and compliance of patients are needed for long-term successes. However, until large randomized trials with long term follow-up are available, endoscopic management of upper tract TCC should be reserved for only selected group of patients. This review summarizes the current techniques, indications, contraindications and outcomes of endoscopic management of UTTCC and the key published data.

Radiotherapy may improve overall survival of patients with T3/T4 transitional cell carcinoma of the renal pelvis or ureter and delay bladder tumour relapse

BACKGROUND

Since transitional cell carcinoma (TCC) of the upper urinary tract is a relatively uncommon malignancy, the role of adjuvant radiotherapy is unknown.

METHODS

We treated 133 patients with TCC of the renal pelvis or ureter at our institution between 1998 and 2008. The 67 patients who received external beam radiotherapy (EBRT) following surgery were assigned to the radiation group (RT). The clinical target volume included the renal fossa, the course of the ureter to the entire bladder, and the paracaval and para-aortic lymph nodes, which were at risk of harbouring metastatic disease in 53 patients. The tumour bed or residual tumour was targeted in 14 patients. The median radiation dose administered was 50 Gy. The 66 patients who received intravesical chemotherapy were assigned to the non-radiation group (non-RT).

RESULTS

The overall survival rates for the RT and non-RT groups were not significantly different (p = 0.198). However, there was a significant difference between the survival rates for these groups based on patients with T3/T4 stage cancer. A significant difference was observed in the bladder tumour relapse rate between the irradiated and non-irradiated bladder groups (p = 0.004). Multivariate analysis indicated that improved overall survival was associated with age < 60 years, T1 or T2 stage, absence of synchronous LN metastases, and EBRT. Acute gastrointestinal and bladder reactions were the most common symptoms, but mild non-severe (> grade 3) hematologic symptoms also occurred.

CONCLUSION

EBRT may improve overall survival for patients with T3/T4 cancer of the renal pelvis or ureter and delay bladder tumour recurrence in all patients.