Perioperative chemotherapy for upper tract urothelial cancer

Influence of American Society of Anesthesiologists Score on Oncologic Outcomes in Patients With Upper Tract Urothelial Carcinoma After Radical Nephroureterectomy: A Large-Sample Study in Two Institutions

Introduction

As a research team of urologists and an anesthetist, we sought to investigate the prognostic significance of American Society of Anesthesiologists (ASA) score in patients with upper tract urothelial cancer (UTUC) after radical nephroureterectomy (RNU). ASA physical status (ASA-PS) classification not only was found to be associated with increased comorbidities but also independently factors for predicting morbidity and mortality. Accurate risk assessment was being particularly important for patients being considered for surgery.

Methods

Records for 958 patients with UTUC who underwent RNU were reviewed. Clinicopathologic variables, including ASA-PS, were assessed at two institutions. Overall survival (OS), cancer-specific survival (CSS), intravesical recurrence-free survival (IRFS), and metastasis-free survival (MFS) were estimated using the Kaplan–Meier method and Cox regression analyses. We measured the independent predictive value of ASA-PS for mortality by multivariate regression. Association of ASA-PS and clinicopathologic variables was assessed.

Results

The group of patients with ASA = 2/3 had a shorter 5-year OS (67.6% and 49.9%), CSS (72.9% and 58.1%), and MFS (75.1% and 58.5%). The median follow-up time was 39 months. Kaplan–Meier curves showed that the group with ASA = 2/3 had significantly poorer OS, CSS, and MFS. Adjusting for multiple potential confounding factors, multivariate analyses suggested that ASA score was an independent predictor of OS, CSS, and MFS (p = 0.004, p = 0.005, p < 0.001).

Conclusion

Higher ASA scores were independently associated with lower survival rate. This capability, along with its simplicity, makes it a valuable prognostic metric. It should be seriously referenced in UTUC patients being considered for RNU.

Impact of the ASA Physical Status Score on Adjuvant Chemotherapy Eligibility and Survival of Upper Tract Urothelial Carcinoma Patients: a Multicenter Study

The aim of the present multi-institutional study was to assess the influence of the American Society of Anesthesiologists Physical Status (ASA-PS) classification on adjuvant chemotherapy eligibility and survival in a multi-institutional cohort of patients treated with radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). We retrospectively reviewed data from 416 patients who underwent RNU for UTUC at four Korean institutions between 2001 and 2013. The ASA-PS classification was obtained from the anesthesia chart. Locally advanced UTUC was defined as ≥ pT3 and/or pN1 disease. The influence of ASA-PS score on survival was evaluated by Kaplan-Meier analyses and a multivariate Cox regression model. Patients with a higher ASA-PS class were less likely to be eligible for adjuvant chemotherapy in locally advanced UTUC (P = 0.016). Kaplan-Meier estimates showed that the high-risk ASA-PS group has a poorer overallsurvival (OS) and cancer-specific survival (CSS) compared to low risk ASA-PS groups in both the total and locally advanced UTUC cohorts. Based on multivariate Cox regression analysis, the high-risk ASA-PS category was an independent predictor for overall mortality (OM) (hazard ratio [HR], 1.919; 95% confidence interval [CI], 1.017-3.619; P = 0.044) and cancer-specific mortality (CSM) (HR, 2.120; 95% CI, 1.023-4.394; P = 0.043). In conclusion, high-risk ASA-PS score was independently associated with a lower survival rate in patients with UTUC after RNU. However, the influence of ASA-PS classification on survival was limited to locally advanced UTUC. The lower eligibility of patients in the high-risk ASA category for adjuvant chemotherapy may contribute to the lower survival rate in this group.

The effect of contralateral kidney volume on renal function after radical nephroureterectomy: Implications for eligibility for neoadjuvant chemotherapy for upper tract urothelial cancer

PURPOSE

We investigated the effect of preoperative contralateral kidney (CK) volume on renal function after radical nephroureterectomy (RNU).

METHODS

We reviewed 630 patients who underwent RNU between September 1994 and December 2013. Of these 630 patients, 135 patients with advanced upper tract urothelial cancer were ultimately included. Preoperative CK volume was measured from computed tomography images of the venous phase using a specialized volumetric program. Glomerular filtration rate (GFR) was calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations and checked preoperatively, 7 days, 1, 3, and 12 months postoperatively.

RESULTS

The mean age at surgery was 62.1 (10.1) years and the mean CKD-EPI GFR was 73.8 (75.5) ml/min/1.73m². After RNU, new-onset CKD was identified in 69 (51.1%) patients. On multivariate logistic regression analysis, high body mass index (95% CI: 1.08-1.51, P = 0.005), low preoperative CKD-EPI GFR (95% CI: 0.92-0.98, P = 0.037), and low CK volume (95% CI: 0.96-0.99, P<0.001) were associated with new-onset CKD at 1 month after RNU. There was a positive correlation between CK volume and CKD-EPI GFR at 1 month after RNU (Spearman ρ = 0.495, P<0.001). When stratified according to CK volume, CK volume less than 150ml was significantly associated with new-onset CKD after RNU (95% CI: 2.49-26.29, P = 0.001).

CONCLUSIONS

High body mass index, low preoperative CKD-EPI GFR, and low CK volume are significantly associated with new-onset CKD. Therefore, they could be used to identify patients eligible for neoadjuvant chemotherapy in upper tract urothelial cancer.

Expression of Estrogen Receptor Beta Predicts Oncologic Outcome of pT3 Upper Urinary Tract Urothelial Carcinoma Better Than Aggressive Pathological Features

Upper urinary tract urothelial carcinoma (UT-UC) is rare and treatment options or prognostic markers are limited. There is increasing evidence indicating that urothelial carcinoma may be an endocrine-related cancer. The aim of this study was to analyze the prognostic effect of estrogen receptor beta (ERβ) on the outcome of UT-UC. From 2005 to 2012, this study included 105 patients with pT3 UT-UC. Perioperative factors, pathological features, and ERβ immunostaining were reviewed and prognostic effects were examined by multivariate analysis. This study divided patients into either the ERβ-high (n = 52) or ERβ-low (n = 53) group and analyzed their oncologic outcomes. All pathological features except infiltrating tumor architecture (significantly higher incidence in ERβ-low group, p = 0.004) are symmetric in both groups. Low ERβ expression was significantly correlated with local recurrence and distant metastasis in univariate analysis (p = 0.035 and 0.004, respectively) and multivariate analysis (p = 0.05 and 0.008, respectively). Cell line study also proved that knock down of ERβ cause less UTUC proliferation and migration. In addition, ERβ agonist also enhanced the cytotoxic and migration inhibition effect of cisplatin and ERβ antagonist cause the UTUC cell more resistant to cisplatin. This result may help identify patients in need of adjuvant therapy or develop potential targeted therapy.

Annexin A4 induces platinum resistance in a chloride-and calcium-dependent manner

Platinum resistance has long been a major issue in the treatment of various cancers. We previously reported that enhanced annexin A4 (ANXA4) expression, a Ca²⁺-regulated phospholipid-binding protein, induces chemoresistance to platinum-based drugs. In this study, we investigated the role of annexin repeats, a conserved structure of all the annexin family, responsible for platinum-resistance as well as the effect of knockdown of ANXA4. ANXA4 knockdown increased sensitivity to platinum-based drugs both in vitro and in vivo. To identify the domain responsible for chemoresistance, ANXA4 deletion mutants were constructed by deleting annexin repeats one by one from the C terminus. Platinum resistance was induced both in vitro and in vivo in cells expressing either full-length ANXA4 or the deletion mutants, containing at least one intact annexin repeat. However, cells expressing the mutant without any calcium-binding sites in the annexin repeated sequence, which is essential for ANXA4 translocation from the cytosol to plasma membrane, failed to acquire platinum resistance. After cisplatin treatment, the intracellular chloride ion concentration, whose channel is partly regulated by ANXA4, significantly increased in the platinum-resistant cells. These findings indicate that the calcium-binding site in the annexin repeat induces chemoresistance to the platinum-based drug by elevating the intracellular chloride concentration.

Sequential chemotherapy using gemcitabine + carboplatin followed by gemcitabine + carboplatin + docetaxel for advanced upper-tract urothelial cancer

BACKGROUND

Retrospective evaluation of the effectiveness and adverse events (AEs) of a sequential chemotherapy regimen using gemcitabine + carboplatin (GCarbo) followed by GCarbo + docetaxel (GCarboD) for advanced upper-tract urothelial carcinoma (UTUC).

METHODS

We treated 56 patients with advanced UTUC. Mean patient age was 68.9 years, creatinine clearance was 51.2 mL/min, and the observation period was 20 months. Patients received two courses of GCarbo comprising 800 mg/m(2) gemcitabine on days 1, 8, and 15, and carboplatin at an area under the curve of four on day 2. If this regimen was effective, we administered two more courses of GCarbo; if the regimen was ineffective, we switched to two courses of GCarboD (70 mg/m(2)).

RESULTS

Complete (n = 3) and partial response (PR; n = 25) were achieved after GCarbo. Mean response duration was 9.7 months. Two of 17 cases achieved PR after GCarboD treatment (mean duration, 31.5 months). Median survival was 14.0 months with the GCarbo/GCarboD regimen. Responders to GCarbo therapy survived significantly longer. AEs with the GCarbo regimen included 31 instances of G3/4 blood toxicity and 8 instances of G3/4 urticaria; however, there were only 6 instances of G3/4 gastrointestinal complications. AEs with the GCarboD regimen included 16 instances of blood toxicity and 8 instances of gastrointestinal complications. Neither regimen resulted in G3/4 renal toxicity.

CONCLUSIONS

GCarbo and GCarboD chemotherapy may be administered safely to patients with advanced UTUC, with or without renal dysfunction. Response to GCarbo was high (50.0 %) whereas GCarboD was of limited effectiveness for non-responders to GCarbo.

Are urothelial carcinomas of the upper urinary tract a distinct entity from urothelial carcinomas of the urinary bladder? Behavior of urothelial carcinoma after radical surgery with respect to anatomical location: a case control study

BACKGROUND

To compare the prognosis of upper urinary tract (UUT)-urothelial carcinoma (UC) and UC of the bladder (UCB) by pathological staging in patients treated with radical surgeries.

METHODS

The study population comprised 335 and 302 consecutive radical surgery cases performed between 1991 and 2010 for UUT-UC and UCB, respectively. Five-year recurrence-free survival (RFS) and cancer-specific survival (CSS) rates were analyzed. The median follow-up period of all subjects was 59.3 months (range, 0.1-261.0 months).

RESULTS

No difference was observed in median patient age, distribution of pathologic T stage, or rates of positive surgical margin between the two groups. The UUT-UC group had significantly more frequent hydronephrosis than the USB group (48.1% vs. 20.2%, p < 0.001). However, the UUT-UC group showed significantly less frequent grade III tumors (28.1% vs. 58.6%, p < 0.001), lymphovascular invasion (18.8% vs. 35.8%, p < 0.001), and associated carcinoma in situ (9.0% vs. 21.9%, p < 0.001) than the UCB group. Five year RFS rates in the UUT-UC and UCB groups were 77.0% and 75.9%, respectively (p = 0.546). No significant difference in RFS rate was observed between pathological T stage subgroups. Five year CSS rates in the UUT-UC and UCB groups were 76.1% and 76.2%, respectively (p = 0.462). No significant difference was observed in CSS rate between the pathologic T stage subgroups.

CONCLUSIONS

UUT-UC and UCB showed comparable prognosis at identical stages. However, our results should be verified in a prospective study due to the retrospective study design in this study.

Evidenced-based clinical practice guideline for upper tract urothelial carcinoma (summary--Japanese Urological Association, 2014 edition)

Upper tract urothelial carcinoma is more rare than bladder cancer, although they are both categorized as urothelial carcinoma. Because of the low incidence, little clinical evidence is available regarding the treatment of the former. However, recently such evidence has slowly begun to accumulate. The guideline presented herein was compiled for the purpose of ensuring proper diagnosis and treatment by physicians involved in the treatment of upper tract urothelial carcinoma. We carefully selected 16 clinical questions essential for daily clinical practice and grouped them into four major categories: epidemiology, diagnosis, surgery and systemic chemotherapy/other matters. Related literature was searched using PubMed and Japan Medical Abstracts Society databases for articles published between 1987 and 2013. If the judgment was made on the basis of insufficient or inadequate evidence, the grade of recommendation was determined on the basis of committee discussions and resultant consensus statements. Here, we present a short English version of the original guideline, and overview its key clinical issues.

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.

Annexin A4 is a promising therapeutic target for the treatment of platinum-resistant cancers

INTRODUCTION

Platinum drugs are widely used for the treatment of testicular, bladder, ovarian, colorectal, lung and prostate cancers. With regard to ovarian cancer in particular, the prognosis is poor for tumours that are (or have become) platinum-resistant. Determining the mechanism underlying platinum resistance may aid in the identification of therapeutic targets for the treatment of platinum-resistant tumours.

AREAS COVERED

This review gives an overview of the characteristics and functions of Annexin (Anx) A4, the mechanism of Anx A4-induced platinum resistance, the association between platinum resistance and platinum transporters, recent reports that Anx A4 overexpression promotes the efflux of platinum drugs via platinum transporters and the association between other Anxs and chemoresistance. The reader will gain an understanding of recent studies on the mechanism of Anx A4-induced chemoresistance. Anx A4 represents a therapeutic target for the treatment of Anx A4-overexpressing platinum-resistant tumours.

EXPERT OPINION

Anx A4 is overexpressed in ovarian clear cell carcinoma (CCC), and enhanced Anx A4 expression induces platinum resistance. Recent studies showed that Anx A4 is also associated with platinum resistance in cancers other than ovarian CCC. Furthermore, other Anxs are reportedly associated with chemoresistance, suggesting a relationship between the Anx family and chemoresistance.