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Qu Y, Yao Z, Xu N, Shi G, Su J, Ye S, Chang K, Li K, Wang Y, Tan S, Pei X, Chen Y, Qin Z, Feng J, Lv J, Zhu J, Ma F, Tang S, Xu W, Tian X, Anwaier A, Tian S, Xu W, Wu X, Zhu S, Zhu Y, Cao D, Sun M, Gan H, Zhao J, Zhang H, Ye D, Ding C. Plasma proteomic profiling discovers molecular features associated with upper tract urothelial carcinoma. Cell Rep Med 2023; 4:101166. [PMID: 37633276 PMCID: PMC10518597 DOI: 10.1016/j.xcrm.2023.101166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 05/16/2023] [Accepted: 08/01/2023] [Indexed: 08/28/2023]
Abstract
Upper tract urothelial carcinoma (UTUC) is often diagnosed late and exhibits poor prognosis. Limited data are available on potential non-invasive biomarkers for disease monitoring. Here, we investigate the proteomic profile of plasma in 362 UTUC patients and 239 healthy controls. We present an integrated tissue-plasma proteomic approach to infer the signature proteins for identifying patients with muscle-invasive UTUC. We discover a protein panel that reflects lymph node metastasis, which is of interest in identifying UTUC patients with high risk and poor prognosis. We also identify a ten-protein classifier and establish a progression clock predicting progression-free survival of UTUC patients. Finally, we further validate the signature proteins by parallel reaction monitoring assay in an independent cohort. Collectively, this study portrays the plasma proteomic landscape of a UTUC cohort and provides a valuable resource for further biological and diagnostic research in UTUC.
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Affiliation(s)
- Yuanyuan Qu
- Department of Urology, Fudan University Shanghai Cancer Center, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Institutes of Biomedical Sciences, and Human Phenome Institute, Fudan University, Shanghai 200433, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai Genitourinary Cancer Institute, Shanghai 200032, China
| | - Zhenmei Yao
- Department of Urology, Fudan University Shanghai Cancer Center, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Institutes of Biomedical Sciences, and Human Phenome Institute, Fudan University, Shanghai 200433, China
| | - Ning Xu
- Department of Urology, Fudan University Shanghai Cancer Center, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Institutes of Biomedical Sciences, and Human Phenome Institute, Fudan University, Shanghai 200433, China
| | - Guohai Shi
- Department of Urology, Fudan University Shanghai Cancer Center, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Institutes of Biomedical Sciences, and Human Phenome Institute, Fudan University, Shanghai 200433, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai Genitourinary Cancer Institute, Shanghai 200032, China
| | - Jiaqi Su
- Department of Urology, Fudan University Shanghai Cancer Center, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Institutes of Biomedical Sciences, and Human Phenome Institute, Fudan University, Shanghai 200433, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai Genitourinary Cancer Institute, Shanghai 200032, China
| | - Shiqi Ye
- Department of Urology, Fudan University Shanghai Cancer Center, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Institutes of Biomedical Sciences, and Human Phenome Institute, Fudan University, Shanghai 200433, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai Genitourinary Cancer Institute, Shanghai 200032, China
| | - Kun Chang
- Department of Urology, Fudan University Shanghai Cancer Center, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Institutes of Biomedical Sciences, and Human Phenome Institute, Fudan University, Shanghai 200433, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai Genitourinary Cancer Institute, Shanghai 200032, China
| | - Kai Li
- Department of Urology, Fudan University Shanghai Cancer Center, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Institutes of Biomedical Sciences, and Human Phenome Institute, Fudan University, Shanghai 200433, China
| | - Yunzhi Wang
- Department of Urology, Fudan University Shanghai Cancer Center, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Institutes of Biomedical Sciences, and Human Phenome Institute, Fudan University, Shanghai 200433, China
| | - Subei Tan
- Department of Urology, Fudan University Shanghai Cancer Center, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Institutes of Biomedical Sciences, and Human Phenome Institute, Fudan University, Shanghai 200433, China
| | - Xiaoru Pei
- Department of Urology, Fudan University Shanghai Cancer Center, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Institutes of Biomedical Sciences, and Human Phenome Institute, Fudan University, Shanghai 200433, China
| | - Yijiao Chen
- Department of Urology, Fudan University Shanghai Cancer Center, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Institutes of Biomedical Sciences, and Human Phenome Institute, Fudan University, Shanghai 200433, China
| | - Zhaoyu Qin
- Department of Urology, Fudan University Shanghai Cancer Center, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Institutes of Biomedical Sciences, and Human Phenome Institute, Fudan University, Shanghai 200433, China
| | - Jinwen Feng
- Department of Urology, Fudan University Shanghai Cancer Center, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Institutes of Biomedical Sciences, and Human Phenome Institute, Fudan University, Shanghai 200433, China
| | - Jiacheng Lv
- Department of Urology, Fudan University Shanghai Cancer Center, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Institutes of Biomedical Sciences, and Human Phenome Institute, Fudan University, Shanghai 200433, China
| | - Jiajun Zhu
- Department of Urology, Fudan University Shanghai Cancer Center, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Institutes of Biomedical Sciences, and Human Phenome Institute, Fudan University, Shanghai 200433, China
| | - Fahan Ma
- Department of Urology, Fudan University Shanghai Cancer Center, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Institutes of Biomedical Sciences, and Human Phenome Institute, Fudan University, Shanghai 200433, China
| | - Shaoshuai Tang
- Department of Urology, Fudan University Shanghai Cancer Center, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Institutes of Biomedical Sciences, and Human Phenome Institute, Fudan University, Shanghai 200433, China
| | - Wenhao Xu
- Department of Urology, Fudan University Shanghai Cancer Center, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Institutes of Biomedical Sciences, and Human Phenome Institute, Fudan University, Shanghai 200433, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai Genitourinary Cancer Institute, Shanghai 200032, China
| | - Xi Tian
- Department of Urology, Fudan University Shanghai Cancer Center, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Institutes of Biomedical Sciences, and Human Phenome Institute, Fudan University, Shanghai 200433, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai Genitourinary Cancer Institute, Shanghai 200032, China
| | - Aihetaimujiang Anwaier
- Department of Urology, Fudan University Shanghai Cancer Center, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Institutes of Biomedical Sciences, and Human Phenome Institute, Fudan University, Shanghai 200433, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai Genitourinary Cancer Institute, Shanghai 200032, China
| | - Sha Tian
- Department of Urology, Fudan University Shanghai Cancer Center, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Institutes of Biomedical Sciences, and Human Phenome Institute, Fudan University, Shanghai 200433, China
| | - Wenbo Xu
- Department of Urology, Fudan University Shanghai Cancer Center, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Institutes of Biomedical Sciences, and Human Phenome Institute, Fudan University, Shanghai 200433, China
| | - Xinqiang Wu
- Department of Urology, Fudan University Shanghai Cancer Center, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Institutes of Biomedical Sciences, and Human Phenome Institute, Fudan University, Shanghai 200433, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai Genitourinary Cancer Institute, Shanghai 200032, China
| | - Shuxuan Zhu
- Department of Urology, Fudan University Shanghai Cancer Center, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Institutes of Biomedical Sciences, and Human Phenome Institute, Fudan University, Shanghai 200433, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai Genitourinary Cancer Institute, Shanghai 200032, China
| | - Yu Zhu
- Department of Urology, Fudan University Shanghai Cancer Center, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Institutes of Biomedical Sciences, and Human Phenome Institute, Fudan University, Shanghai 200433, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai Genitourinary Cancer Institute, Shanghai 200032, China
| | - Dalong Cao
- Department of Urology, Fudan University Shanghai Cancer Center, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Institutes of Biomedical Sciences, and Human Phenome Institute, Fudan University, Shanghai 200433, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai Genitourinary Cancer Institute, Shanghai 200032, China
| | - Menghong Sun
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai Genitourinary Cancer Institute, Shanghai 200032, China; Tissue Bank & Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Hualei Gan
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai Genitourinary Cancer Institute, Shanghai 200032, China; Tissue Bank & Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Jianyuan Zhao
- Institute for Development and Regenerative Cardiovascular Medicine, MOE-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China.
| | - Hailiang Zhang
- Department of Urology, Fudan University Shanghai Cancer Center, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Institutes of Biomedical Sciences, and Human Phenome Institute, Fudan University, Shanghai 200433, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai Genitourinary Cancer Institute, Shanghai 200032, China.
| | - Dingwei Ye
- Department of Urology, Fudan University Shanghai Cancer Center, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Institutes of Biomedical Sciences, and Human Phenome Institute, Fudan University, Shanghai 200433, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai Genitourinary Cancer Institute, Shanghai 200032, China.
| | - Chen Ding
- Department of Urology, Fudan University Shanghai Cancer Center, State Key Laboratory of Genetic Engineering, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Institutes of Biomedical Sciences, and Human Phenome Institute, Fudan University, Shanghai 200433, China.
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Hsieh HC, Wang CL, Chen CS, Yang CK, Li JR, Wang SS, Cheng CL, Lin CY, Chiu KY. The prognostic impact of lymph node dissection for clinically node-negative upper urinary tract urothelial carcinoma in patients who are treated with radical nephroureterectomy. PLoS One 2022; 17:e0278038. [PMID: 36454803 PMCID: PMC9714942 DOI: 10.1371/journal.pone.0278038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 11/08/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND To evaluate the prognostic impact of lymph node dissection (LND) in patients who underwent radical nephroureterectomy (RNU) with bladder cuff excision (BCE) for clinically node-negative (cN0) upper urinary tract urothelial carcinoma (UTUC). METHODS We retrospectively enrolled 520 patients with cN0 UTUC in a single tertiary referral center from 2000 to 2015. The patients were divided into three groups: patients with and without pathologically proved lymph node metastasis (pN1-3 and pN0, respectively) and patients without LND (pNx). We analyzed associations between overall survival (OS)/ disease-free survival (DFS)/ cancer-specific survival (CSS) and clinical characteristics. RESULTS The patients were divided into three groups (pN1-3, pN0 and pNx with 20, 303, and 197 patients, respectively). OS/DFS/CSS in the pN1-3 group were significantly worse (all p<0.001) compared with the pN0 group. However, there were no significant differences between the pNx and pN0 groups. In the multivariate analyses, CSS was only affected by age [(hazard ratio (HR) = 1.03, p = 0.008]), positive surgical margin (HR = 3.38, p<0.001) and pathological T3-4 stages (HR = 4.07, p<0.001). In the subgroup analyses for patients with LND, locally advanced disease (pT3 and pT4) had significantly more metastases [T3-4: 13.91% (16/115) vs. T0-2: 1.92% (4/208), p<0.001]. CONCLUSIONS In the pN0 group, LND for cN0 UTUC did not show therapeutic benefits in terms of DFS, CSS, and OS. However, LND with RNU allowed optimal tumor staging, through patients still had a poor prognosis. Clinically occult LN metastases were found in 6.2% of our patients.
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Affiliation(s)
- Hsiang-Chen Hsieh
- Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chun-Li Wang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Family Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chuan-Shu Chen
- Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Cheng-Kuang Yang
- Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Jian-Ri Li
- Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Medicine and Nursing, Hungkuang University, Taichung, Taiwan
| | - Shian-Shiang Wang
- Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Medicine and Nursing, Hungkuang University, Taichung, Taiwan
| | - Chen-Li Cheng
- Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Chia-Yen Lin
- Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- * E-mail: (CYL); (KYC)
| | - Kun-Yuan Chiu
- Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Applied Chemistry, National Chi Nan University, Nantou, Taiwan
- * E-mail: (CYL); (KYC)
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Piontkowski AJ, Corsi N, Morisetty S, Majdalany S, Rakic I, Li P, Arora S, Jamil M, Rogers C, Autorino R, Abdollah F. Benefit of lymph node dissection in cN+ patients in the treatment of upper tract urothelial carcinoma: Analysis of NCDB registry. Urol Oncol 2022; 40:409.e9-409.e17. [DOI: 10.1016/j.urolonc.2022.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 04/05/2022] [Accepted: 04/25/2022] [Indexed: 11/25/2022]
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4
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Peyrottes A, Califano G, Ouzaïd I, Lainé-Caroff P, Long Depaquit T, Hermieu JF, Xylinas E. Lymph Node Dissection During Radical Nephro-Ureterectomy for Upper Tract Urothelial Carcinoma: A Review. Front Surg 2022; 9:852969. [PMID: 35402485 PMCID: PMC8987284 DOI: 10.3389/fsurg.2022.852969] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 02/08/2022] [Indexed: 02/03/2023] Open
Abstract
Although lymphonodal dissection is well-accepted for muscle-invasive bladder cancer management, its role is still debated during radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). The aim of this study was to summarize the current knowledge concerning the indication, anatomical template, prognostic, and therapeutic roles of lymph node dissection (LND) performed at the time of RNU. Quality control markers, such as the number of lymph nodes (LN) removed, lymph node density, and safety of the different surgical approaches, were assessed. We performed a narrative review using the PubMed and ClinicalTrials.gov databases. We identified and analyzed articles based on the practice and the role of lymph node dissection for non-metastatic UTUC. There are no clear guidelines regarding the indication of LND for UTUC, but aggressive tumors may beneficiate from lymphadenectomy since lymph node invasion is a clear independent poor prognostic factor, allowing for adjuvant treatments. It seems that an extended lymphadenectomy may provide therapeutic advantages as a higher number of nodes removed may be related to the removal of undetected LNs micrometastases and a subsequent improvement in recurrence rate and cancer-specific survival. Clear anatomical templates are thus needed based on the location and the laterality of the primary tumor.
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Affiliation(s)
- Arthur Peyrottes
- Department of Urology, Bichat-Claude Bernard Hospital, Assistance-Publique Hôpitaux de Paris, Paris University, Paris, France
| | - Gianluigi Califano
- Urology Unit, Department of Neurosciences, Reproductive Sciences and Odontostomatology, Federico II University of Naples, Naples, Italy
| | - Idir Ouzaïd
- Department of Urology, Bichat-Claude Bernard Hospital, Assistance-Publique Hôpitaux de Paris, Paris University, Paris, France
| | - Paul Lainé-Caroff
- Department of Urology, Bichat-Claude Bernard Hospital, Assistance-Publique Hôpitaux de Paris, Paris University, Paris, France
| | - Thibaut Long Depaquit
- Urology Unit, Military Teaching Hospital Sainte Anne, French Military Health Service, Toulon, France
| | - Jean-François Hermieu
- Department of Urology, Bichat-Claude Bernard Hospital, Assistance-Publique Hôpitaux de Paris, Paris University, Paris, France
| | - Evanguelos Xylinas
- Department of Urology, Bichat-Claude Bernard Hospital, Assistance-Publique Hôpitaux de Paris, Paris University, Paris, France
- *Correspondence: Evanguelos Xylinas
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Koll FJ, Meisenzahl E, Haller B, Maisch P, Kirchhoff F, Horn T, Gschwend JE, Schmid SC. Evaluation of Pre-operative Biopsy, Surgical Procedures and Oncologic Outcomes in Upper Tract Urothelial Carcinoma (UTUC). Front Surg 2021; 8:790738. [PMID: 34901146 PMCID: PMC8655158 DOI: 10.3389/fsurg.2021.790738] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 10/29/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose: Discordance between pre-operative biopsy and final pathology for Upper Tract Urothelial Carcinoma (UTUC) is high and optimal management remains controversial. The aim of this study is to evaluate the accuracy of pre-operative biopsy, to identify prognostic factors and to evaluate the effect of adjuvant chemotherapy on survival and oncologic outcome in UTUC. Methods: We analyzed records of patients receiving surgical treatment for UTUC. Pathology of pre-operative biopsy was compared to surgical specimen. We used Kaplan-Meier method to estimate survival probabilities and Cox's proportional hazards models to estimate the association between covariates and event times. Primary endpoint was overall survival (OS). A matched-pair analysis was performed to evaluate the effect of adjuvant chemotherapy. Results: 151 patients underwent surgical treatment (28% open, 36% laparoscopic, 17% robotic radical nephroureterectomy; 14% segmental ureteral resections and 5% palliative nephrectomy) for UTUC and were included in the analysis. Upstaging from <pT1 in endoscopic biopsy to ≥pT1 in final pathology occurred in 61% of patients and upgrading from low-grade to high-grade occurred in 30% of patients. Five-year OS was 59.5%. In the univariate Cox-regression model pathological stage, grade, lymphovascular invasion and positive surgical margins were associated with OS. Matched pair analysis for stage (<pT3; ≥pT3; pN+) and age revealed a significant survival benefit for adjuvant chemotherapy (HR 0.40, 0.14-0.77, p < 0.018) in this cohort. Conclusion: UTUC is often underestimated in pre-operative biopsy, and it is associated with significant mortality. Pathological stage and grade, lymphovascular invasion and lymph node metastases are predictors of oncologic outcome and survival.
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Affiliation(s)
- Florestan J Koll
- Department of Urology, Rechts der Isar Medical Center, Technical University of Munich, School of Medicine, Munich, Germany.,Department of Urology, University Hospital Frankfurt, Frankfurt, Germany
| | - Eva Meisenzahl
- Department of Urology, Rechts der Isar Medical Center, Technical University of Munich, School of Medicine, Munich, Germany
| | - Bernhard Haller
- Institute of Medical Informatics, Statistics and Epidemiology, Technical University of Munich, Munich, Germany
| | - Philipp Maisch
- Department of Urology, Rechts der Isar Medical Center, Technical University of Munich, School of Medicine, Munich, Germany.,Department of Urology, University of Ulm, Ulm, Germany
| | - Florian Kirchhoff
- Department of Urology, Rechts der Isar Medical Center, Technical University of Munich, School of Medicine, Munich, Germany
| | - Thomas Horn
- Department of Urology, Rechts der Isar Medical Center, Technical University of Munich, School of Medicine, Munich, Germany
| | - Jürgen E Gschwend
- Department of Urology, Rechts der Isar Medical Center, Technical University of Munich, School of Medicine, Munich, Germany
| | - Sebastian C Schmid
- Department of Urology, Rechts der Isar Medical Center, Technical University of Munich, School of Medicine, Munich, Germany
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König F, Shariat SF, Karakiewicz PI, Mun DH, Rink M, Pradere B. Quality indicators for the management of high-risk upper tract urothelial carcinoma requiring radical nephroureterectomy. Curr Opin Urol 2021; 31:291-296. [PMID: 33973537 DOI: 10.1097/mou.0000000000000895] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW The purpose of this article was to identify quality indicators for an optimized management of high-risk upper tract urothelial carcinoma (UTUC) requiring radical nephroureterectomy (RNU). RECENT FINDINGS RNU with bladder cuff resection is the standard treatment of high-risk UTUC. For the bladder cuff resection, two main approaches are accepted: transvesical and extravesical. Lymph node dissection following a dedicated template should be performed in all high-risk patients undergoing RNU as it improves tumour staging and possibly survival. Postoperative bladder instillation of single-dose chemotherapy should be administered after RNU to decrease the risk of intravesical tumour recurrence. Perioperative systemic chemotherapy should always be considered for advanced cancers. Although level-1 evidence is available for adjuvant platinum-based chemotherapy, neoadjuvant regimens are still being evaluated. SUMMARY Optimal management of high-risk UTUC requires evidence-based reproducible quality indicators in order to allow guidance and frameworks for clinical practices. Adherence to quality indicators allows for the measurement and comparison of outcomes that are likely to improve prognosis. Based on the literature, we found four evidence-based accepted quality indicators that are easily implementable to improve the management of high-risk UTUC patients treated with RNU: adequate management of the distal ureter/ bladder cuff, template-based lymph node dissection, single-shot postoperative intravesical chemotherapy, and perioperative systemic treatment.
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Affiliation(s)
- Frederik König
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Department of Urology, Weill Cornell Medical College, New York, New York
- Department of Urology, University of Texas Southwestern, Dallas, Texas, USA
- Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic
- Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan
- Institute for Urology and Reproductive Health, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Pierre I Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Centre, Montreal, Canada
| | - Dong-Ho Mun
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Michael Rink
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Benjamin Pradere
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
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7
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McIntosh AG, Umbreit EC, Wood CG, Matin SF, Karam JA. Role of lymph node dissection at the time of open or minimally invasive nephroureterectomy. Transl Androl Urol 2021; 10:2233-2245. [PMID: 34159106 PMCID: PMC8185683 DOI: 10.21037/tau.2019.11.34] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
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.
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Affiliation(s)
- Andrew G McIntosh
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eric C Umbreit
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christopher G Wood
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Surena F Matin
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jose A Karam
- Department of Urology and Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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8
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Li Z, Li X, Li Y, Liu Y, Du P, Liu Z, Xiao K. A Novel Nomogram for Predicting the Survival of Patients with Invasive Upper Tract Urothelial Carcinoma. J Cancer 2021; 12:790-798. [PMID: 33403036 PMCID: PMC7778545 DOI: 10.7150/jca.50419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 10/30/2020] [Indexed: 11/06/2022] Open
Abstract
Purpose: Available tools for the prediction of the prognosis of patients with upper tract urothelial carcinoma (UTUC) are unified. We determined whether a novel nomogram is effective in estimating the survival of patients with invasive UTUC. Methods: From January 2004 to December 2015, 4796 invasive UTUC patients in the Surveillance, Epidemiology and End Results database underwent radical nephroureterectomy (RNU) for invasive UTUC. The medical records of the patients were randomly (7:3) divided into the training and validation cohorts. The independent factors included in the nomogram were selected by multivariate analyses. The nomogram was developed based on the training cohort. Bootstrap validation was applied to validate the nomogram, whereas external validation was performed using the validation cohort. The accuracy and discrimination of the nomogram were assessed using concordance indices (C-indices) and calibration curves. Results: The multivariate Cox regression model identified that age, tumor stage, node stage, metastasis stage and grade were associated with survival. In the training set, the nomogram, which included the above factors, exhibited discrimination power superior to that of the 8th American Joint Committee on Cancer (AJCC) TNM classification (Harrell's C-index, 0.74 vs. 0.71; P < 0.001). The nomogram showed better probability of survival agreement with the C-index than the AJCC-TNM staging system in the bootstrap validation (0.74 vs. 0.70; P < 0.001) and validation set (Harrell's C-index, 0.77 vs. 0.73; P < 0.001). The validation revealed that this nomogram exhibited excellent discrimination and calibration capacities. Conclusion: An accurate novel nomogram that is superior to the current AJCC-TNM staging system was established for the prediction of CSS after RNU for invasive UTUC.
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Affiliation(s)
- Zaishang Li
- Department of Urology, Shenzhen People's Hospital, The Second Clinic Medical College of Jinan University 518060, Shenzhen, Guangdong, P. R. China.,Department of Urology, First Affiliated Hospital of Southern University of Science and Technology, 518060, Shenzhen, Guangdong, P. R. China.,Department of Urology, Shenzhen Engineering and Technology Center of minimally Invasive Urology, Shenzhen People's Hospital, 518060, Shenzhen, Guangdong, P. R. China
| | - Xueying Li
- Department of Oncology, The Seventh Affiliated Hospital Sun Yat-sen University, 518107, Shenzhen, Guangdong, P. R. China
| | - Yonghong Li
- Department of Urology, Sun Yat-sen University Cancer Center, 510060, Guangzhou, Guangdong, P. R. China.,State Key Laboratory of Oncology in South China, 510060, Guangzhou, Guangdong, P. R. China.,Collaborative Innovation Center of Cancer Medicine, 510060, Guangzhou, Guangdong, P. R. China
| | - Ying Liu
- Department of Urology, Shenzhen People's Hospital, The Second Clinic Medical College of Jinan University 518060, Shenzhen, Guangdong, P. R. China.,Department of Urology, First Affiliated Hospital of Southern University of Science and Technology, 518060, Shenzhen, Guangdong, P. R. China.,Department of Urology, Shenzhen Engineering and Technology Center of minimally Invasive Urology, Shenzhen People's Hospital, 518060, Shenzhen, Guangdong, P. R. China
| | - Peng Du
- Gynecology Department, Long-gang District Maternal and Child Healthcare Hospital, 518172, Shenzhen, Guangdong, P. R. China
| | - Zenqing Liu
- Department of Urology, Shenzhen People's Hospital, The Second Clinic Medical College of Jinan University 518060, Shenzhen, Guangdong, P. R. China.,Department of Urology, First Affiliated Hospital of Southern University of Science and Technology, 518060, Shenzhen, Guangdong, P. R. China.,Department of Urology, Shenzhen Engineering and Technology Center of minimally Invasive Urology, Shenzhen People's Hospital, 518060, Shenzhen, Guangdong, P. R. China
| | - Kefeng Xiao
- Department of Urology, Shenzhen People's Hospital, The Second Clinic Medical College of Jinan University 518060, Shenzhen, Guangdong, P. R. China.,Department of Urology, First Affiliated Hospital of Southern University of Science and Technology, 518060, Shenzhen, Guangdong, P. R. China.,Department of Urology, Shenzhen Engineering and Technology Center of minimally Invasive Urology, Shenzhen People's Hospital, 518060, Shenzhen, Guangdong, P. R. China
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9
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Lec PM, Venkataramana A, Lenis AT, Fero KE, Sharma V, Golla V, Gollapudi K, Blumberg J, Chamie K. Trends in management of ureteral urothelial carcinoma and effects on survival: a hospital-based registry study. Urol Oncol 2020; 39:194.e17-194.e24. [PMID: 33012575 DOI: 10.1016/j.urolonc.2020.08.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/11/2020] [Accepted: 08/23/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND High-risk ureteral tumors represent an understudied subset of upper tract urothelial carcinoma, whose surgical management can range from a radical nephroureterectomy (NU) to segmental ureterectomy (SU). OBJECTIVES To evaluate contemporary trends in the management of high-risk ureteral tumors, the utilization of lymphadenectomy and peri-operative chemotherapy, and their impact on overall survival (OS). DESIGN, SETTING, AND PARTICIPANTS We performed a retrospective cohort study of patients in the National Cancer Database from years 2006 to 2013 with clinically localized high-risk ureteral tumors treated with NU or SU. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Chi-squared tests were utilized to assess differences in clinicodemographic features and peri-operative treatment delivery between SU and NU cohorts. Cochran-Armitage tests and linear regressions were performed to evaluate temporal trends in treatment utilization. Multivariable logistic regression models were employed to assess predictors of treatment delivery. Multivariable Cox proportional hazards models evaluated associations with OS. RESULTS Of the 1,962 patients included, NU was more commonly performed than SU (72.4%, 1,421/1,962 vs. 27.6%, 541/1,962). Only 22.7% (446/1,962) of the population underwent lymphadenectomy, and 24.8% (271/1,092) of those with advanced pathology (≥pT2 or pN+) received adjuvant chemotherapy. Lymphadenectomy was associated with improved OS in NU patients when more than 3 nodes were removed (hazard ratio [HR] 0.58, 95% confidence interval [CI] 0.39-0.89). Receipt of adjuvant chemotherapy for advanced pathology had no impact OS in both the NU (HR 1.10, 95% CI 0.84-1.44) and SU (HR 0.94, 95% CI 0.61-1.46) cohorts. Performance of SU was not associated with poorer OS on multivariable analysis (HR 1.02, 95% CI 0.89-1.21, P = 0.83). CONCLUSION Our study suggests that SU may be an appropriate alternative to NU for the management of high-risk ureteral tumors. Further, lymphadenectomy may play an important role at the time of NU, and adjuvant chemotherapy is infrequently utilized in patients with advanced pathology.
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Affiliation(s)
- Patrick M Lec
- Institute of Urologic Oncology (IUO), Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, CA.
| | - Abhishek Venkataramana
- Institute of Urologic Oncology (IUO), Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Andrew T Lenis
- Institute of Urologic Oncology (IUO), Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Katherine E Fero
- Institute of Urologic Oncology (IUO), Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Vidit Sharma
- Institute of Urologic Oncology (IUO), Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Vishnukamal Golla
- Institute of Urologic Oncology (IUO), Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Kiran Gollapudi
- Division of Urology, Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA
| | - Jeremy Blumberg
- Division of Urology, Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA
| | - Karim Chamie
- Institute of Urologic Oncology (IUO), Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, CA
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10
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Kaag MG. Perioperative chemotherapy in the management of high risk upper tract urothelial cancers. Transl Androl Urol 2020; 9:1881-1890. [PMID: 32944552 PMCID: PMC7475667 DOI: 10.21037/tau.2020.03.48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Matthew G Kaag
- Division of Urology, Department of Surgery, The Pennsylvania State College of Medicine, Hershey, PA, USA
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11
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Goltzman ME, Gogoj A, Ristau BT. The role of lymphadenectomy at the time of radical nephroureterectomy for upper tract urothelial carcinoma. Transl Androl Urol 2020; 9:1860-1867. [PMID: 32944550 PMCID: PMC7475672 DOI: 10.21037/tau.2019.11.29] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The role of lymphadenectomy (LND) at the time of radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC) is controversial. The National Comprehensive Cancer Network guidelines recommend performing a template-based LND for high-risk primary tumors while the European guidelines state that it is not feasible to determine indication or extent of LND at the time of surgery for UTUC. Herein, we review the anatomic rationale for template-based LND, examine when a LND should be considered, and discuss the impact of LND on staging and survival outcomes.
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12
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Chen CS, Lin CY, Wang CL, Wang SS, Li JR, Yang CK, Cheng CL, Chiu KY, Yang SF. Association between lymphovascular invasion and oncological outcome in node-negative upper tract urothelial carcinoma with different stage. Urol Oncol 2020; 39:132.e13-132.e26. [PMID: 32900630 DOI: 10.1016/j.urolonc.2020.08.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 07/29/2020] [Accepted: 08/03/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To evaluate the prognostic impact of lymphovascular invasion (LVI) on node-negative upper tract urothelial carcinoma (UTUC) in patients treated with radical nephroureterectomy (RNU). MATERIALS AND METHODS A retrospective study was performed in single tertiary referral center of middle Taiwan between 2001 and 2015. Seven hundred and twenty-eight patients were diagnosed of UTUC and underwent RNU with ipsilateral bladder cuff excision including 303 and 195 patients with N0 and Nx status respectively. LVI status was assessed as a prognostic factor for cancer-specific (CSS) and overall survival (OS) using univariate and multivariate Cox regression analysis. RESULTS LVI was observed in 82 patients (16.5%). LVI presentation associated with smoking status, advanced tumor stage, high tumor grade, positive surgical margin, and consequence lung/liver/bone metastasis. In the multivariate analysis, LVI was failed to predict CSS, OS, and disease-free survival (DFS) (hazard ratio [HR] [95% confidence interval [CI]: 1.07 [0.55-2.09], 1.05 [0.62-1.79], 1.15 [0.69-1.92], in CSS, OS, DFS, respectively). In the subgroup analysis of pT1-2 disease, the CSS, OS, and DFS were associated with LVI status (HR [95% CI]: 2.29 [0.44-11.84], 3.17 [1.16-8.67], 2.66 [1.04-6.79], in CSS, OS, DFS, respectively). In contrast, there was no difference in pT3 disease. CONCLUSION In conclusion, LVI status was not associated with survival outcomes of node-negative UTUC in our study. The subgroup analysis showed different prognostic impacts of LVI status in node-negative UTUC with T1-2 and T3 stage. Further evidence to clarify the prognostic effect is needed to make LVI became a practical factor in clinical decision-making.
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Affiliation(s)
- Chuan-Shu Chen
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan; Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chia-Yen Lin
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan; Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan; Division of Surgical Critical Care, Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chun-Li Wang
- Department of Family Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shian-Shiang Wang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan; Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan; Department of Applied Chemistry, National Chi Nan University, Nantou, Taiwan
| | - Jian-Ri Li
- Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chun-Kuang Yang
- Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chen-Li Cheng
- Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Kun-Yuan Chiu
- Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan; Department of Applied Chemistry, National Chi Nan University, Nantou, Taiwan.
| | - Shun-Fa Yang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan; Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan.
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13
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Survival Benefits Based on the Number of Lymph Nodes Removed during Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma: Systematic Review and Meta-Analysis. J Clin Med 2020; 9:jcm9061933. [PMID: 32575801 PMCID: PMC7357082 DOI: 10.3390/jcm9061933] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/09/2020] [Accepted: 06/19/2020] [Indexed: 12/24/2022] Open
Abstract
The role of lymph node dissection (LND) is still controversial for upper tract urothelial carcinoma (UTUC), and there are no guidelines regarding its use. This study was conducted to find a higher level of evidence for the survival benefits based on the number of LNs removed during radical nephroureterectomy (RNUx) through a systematic review and meta-analysis. We included studies comparing patients who underwent LND during RNUx for UTUC. We searched the major electronic databases (Pubmed, Embase®, and Scopus®) and conducted manual searches of the electronically available abstracts of the major international urology cancer meetings [American Society of Clinical Oncology (ASCO), American Urological Association (AUA), and Eropean Association of Urology (EAU)] prior to April 2019 using grouped terms of nephroureterectomy (nephroureterectom*) and lymph node excision (lymphadenectomy; lymph + node*; lymph* + metasta*) with variations in the terms. Study selection, data collection, and risk of bias assessment were performed by two independent authors (A and B). Six retrospective case-control studies included a total of 33,944 patients who underwent RNUx for UTUC, 5071 of whom underwent LND and were finally included in the meta-analysis. The pooled hazard ratio (HR) in these studies revealed that an increased number of LNs removed during RNUx was associated with improved cancer-specific survival (CSS) in patients with UTUC (HR = 0.95, 95% CI: 0.91–0.99; p = 0.07). In addition, increased numbers of LNs removed were associated with improved overall survival (OS) in pN0 patients. However, in pN+ patients, the number of LNs removed showed no survival benefit on CSS, overall survival (OS), or progression-free survival (PFS). Higher numbers of LNs removed during RNUx were associated with improved survival outcomes in patients with UTUC. This study confirmed that LND also has oncological benefits in UTUC patients. Although still a controversial topic, meticulous LND must be considered, and efforts should be made to eliminate as many LNs as possible when administering RNUx for UTUC, especially in patients without clear evidence of LN metastasis.
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14
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Grimes N, McKay A, Lee SM, Aboumarzouk OM. Lymph node dissection during nephroureterectomy: Establishing the existing evidence based on a review of the literature. Arab J Urol 2019; 17:167-180. [PMID: 31489232 PMCID: PMC6711077 DOI: 10.1080/2090598x.2019.1596401] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 02/18/2019] [Accepted: 02/26/2019] [Indexed: 12/14/2022] Open
Abstract
Abstract Objective: To determine the role of lymph node dissection (LND) in the treatment of upper tract transitional cell carcinoma (UTTCC), as the role of LND along with nephroureterectomy in treating UTTCC is unclear and several retrospective studies have been published on this topic with conflicting results. Methods: The Medical Literature Analysis and Retrieval System Online (MEDLINE), the Excerpta Medica dataBASE (EMBASE), Cochrane Central Register of Controlled Trials database (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Clinicaltrials.gov, Google Scholar, and individual urological journals, were searched for all studies investigating the role of LND in the treatment of UTTCC. Of the studies identified, those that met inclusion criteria were included in this review. Results: In all, 27 studies were included in this review, with 9303 patients who underwent LND. No randomised controlled trials (RCTs) were identified. Tumours were located in the renal pelvis in 62% of patients, in the ureter in 35.5%, and multifocal in 2.3%. In total: 77.1% were LN-negative and 22.9% had LN metastasis. For all patients undergoing LND, the 5-year recurrence-free survival (RFS) and cancer-specific survival (CSS) rates were 27–65.4% and 32.3–95%, respectively. For patients who underwent a LND in accordance with a standardised anatomical template, the 5-year RFS and CSS rates were 84.3–93% and 83.5–94%, respectively. Conclusion: LND may provide a survival benefit in patients undergoing nephroureterectomy for UTTCC, particularly if following a standardised anatomical template and in those patients with muscle-invasive disease; however, a prospective RCT is required to confirm this. Abbreviations: CSS: cancer-specific survival; LN(D): lymph node (dissection); MeSH: Medical Subject Headings; OS: overall survival; pT: pathological T stage; RCT: randomised controlled trial; RFS: recurrence-free survival; UTTCC: upper tract TCC
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Affiliation(s)
- Nathan Grimes
- Department of Urology, Monklands Hospital, Airdrie, UK
| | - Alastair McKay
- Department of Urology, Glasgow Royal Infirmary, Glasgow, UK
| | - Su-Min Lee
- Department of Urology, Weston Area Health NHS Trust, Weston-super-Mare, UK
| | - Omar M Aboumarzouk
- Department of Urology, Queen Elizabeth University Hospital, Glasgow, UK.,University of Glasgow, Glasgow, UK
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15
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Duquesne I, Ouzaid I, Loriot Y, Moschini M, Xylinas E. Lymphadenectomy for Upper Tract Urothelial Carcinoma: A Systematic Review. J Clin Med 2019; 8:jcm8081190. [PMID: 31398895 PMCID: PMC6722659 DOI: 10.3390/jcm8081190] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 07/15/2019] [Accepted: 08/05/2019] [Indexed: 12/20/2022] Open
Abstract
Background: The role of lymphonodal dissection during surgery for a tumor of the urinary tract remains controversial. Objective: To analyze anatomical bases of lymphonodal dissection in tumors of the upper urinary tract and analyze its impact on survival, recurrence, and staging. Acquisition of data: A web-based search for scientific articles using Medline/Pubmed was carried out to identify and analyze articles on the practice and the role of lymphonodal dissection in this indication. Data Synthesis: The lymphatic drainage of the upper urinary tract has rarely been studied and is poorly understood. The lymphonodal metastatic extension is the most common extension in upper urinary tract urothelial carcinoma. Lymphnode invasion is a clear independent poor prognostic factor. Therefore, it seems legitimate to offer an extended lymphonodal dissection to patients undergoing surgery to cure these tumors. When lymphnodes dissection respects clear anatomical principles based on the location of the primary tumor and its extension, it improves both survival and recurrence rates. This result could be secondary to the treatment of subclinical metastatic disease. Conclusion: An extended lymphadenectomy during surgery for upper urinary tract urothelial carcinoma following strict anatomical pattern improves staging with a highly probable therapeutic benefit.
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Affiliation(s)
- Igor Duquesne
- Department of Urology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris Descartes University, 75014 Paris, France
- Department of Cancer Medicine, Gustave Roussy Institute, Cancer Campus, Grand Paris, University of Paris-Sud, 94800 Villejuif, France
| | - Idir Ouzaid
- Department of Urology, Bichat-Claude Bernard Hospital, Assistance Publique-Hôpitaux de Paris, Paris Diderot University, 75018 Paris, France
| | - Yohann Loriot
- Department of Cancer Medicine, Gustave Roussy Institute, Cancer Campus, Grand Paris, University of Paris-Sud, 94800 Villejuif, France
| | - Marco Moschini
- Klinik für Urologie, Luzerner Kantonsspital, 6004 Lucerne, Switzerland
| | - Evanguelos Xylinas
- Department of Urology, Bichat-Claude Bernard Hospital, Assistance Publique-Hôpitaux de Paris, Paris Descartes University, 75006 Paris, France.
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16
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Guo R, Zhu Y, Xiong G, Li X, Zhang K, Zhou L. Role of lymph node dissection in the management of upper tract urothelial carcinomas: a meta-analysis. BMC Urol 2018; 18:24. [PMID: 29636103 PMCID: PMC5894184 DOI: 10.1186/s12894-018-0336-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 03/13/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Lymph node dissection (LND) is not routinely performed during radical nephroureterectomy (RNU) in upper tract urothelial carcinomas (UTUC) and the role of LND has been controversial. We aim to investigate whether patients with LND had improved survival in UTUC patients. METHODS We performed a systematic literature search of PubMed, Embase, and Cochrane library for citations published prior to January 2016, describing LND performed among UTUC patients and conducted a standard meta-analysis of survival outcomes. RESULTS Eleven eligible studies containing 7516 patients satisfied the inclusion criteria. Pooled HRs for cancer-specific survival (CSS) and recurrence-free survival (RFS) were 1.17 (P = 0.18) and 1.33 (P = 0.19) respectively. However, the patients in the LND group had more advanced tumour stages and grades (P < 0.001). Further subgroup analysis showed that among muscle-invasive UTUC patients, the pooled HR for CSS and RFS were 1.10 (P = 0.42) and 0.92 (P = 0.72) respectively. Besides, no difference was found in CSS and RFS between pN0 and pNx individuals in overall populations and in patients with muscle-invasive UTUC, while pN+ patients had significantly worse prognosis when compared to pN0 patients. CONCLUSIONS LND during RNU allows more accurate staging and prediction of survival, but it remains uncertain whether LND independently improves survival in patients with UTUC. However, standard use of LND should be further investigated in a multi-center, prospective evaluation to obtain a definitive statement regarding this matter.
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Affiliation(s)
- Runqi Guo
- Department of Urology, Peking University First Hospital and Institute of Urology, National Research Center for Genitourinary Oncology, Beijing, 100034, China
| | - Yuze Zhu
- Department of Urology, Peking University First Hospital and Institute of Urology, National Research Center for Genitourinary Oncology, Beijing, 100034, China
| | - Gengyan Xiong
- Department of Urology, Peking University First Hospital and Institute of Urology, National Research Center for Genitourinary Oncology, Beijing, 100034, China
| | - Xuesong Li
- Department of Urology, Peking University First Hospital and Institute of Urology, National Research Center for Genitourinary Oncology, Beijing, 100034, China
| | - Kai Zhang
- Department of Urology, Peking University First Hospital and Institute of Urology, National Research Center for Genitourinary Oncology, Beijing, 100034, China.
| | - Liqun Zhou
- Department of Urology, Peking University First Hospital and Institute of Urology, National Research Center for Genitourinary Oncology, Beijing, 100034, China.
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Campi R, Minervini A, Mari A, Hatzichristodoulou G, Sessa F, Lapini A, Sessa M, Gschwend JE, Serni S, Roscigno M, Carini M. Anatomical templates of lymph node dissection for upper tract urothelial carcinoma: a systematic review of the literature. Expert Rev Anticancer Ther 2017; 17:235-246. [PMID: 28103449 DOI: 10.1080/14737140.2017.1285232] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Indications and techniques of lymph node dissection (LND) for upper tract urothelial carcinoma (UTUC) are still controversial. Areas covered: In this study, a systematic review of the English-language literature was performed up to 1 July 2016 using the Medline, Scopus, Cochrane Library and Web of Sciences databases to provide a detailed overview of the most commonly dissected surgical templates of LND for UTUC according to laterality and location of the tumor. Overall, sixteen studies were analyzed. Based on the shared experiences in the scientific literature, the LND template typically included: for right-sided tumors of the renal pelvis, upper third and middle third of the ureter, the renal hilar, paracaval, precaval and retrocaval nodes, while for left-sided tumors the renal hilar, paraaortic and preaortic nodes. For tumors of the lower ureter, an extended pelvic LND was performed in most cases; however, the paracaval, paraaortic or presacral nodes were dissected in selected series. Expert commentary: LND is not routinely performed at the time of surgery for UTUC and both indication and extent of LND vary among surgeons and institutions. Future high-quality studies are needed to define the most accurate LND templates and to assess their oncological efficacy and surgical morbidity.
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Affiliation(s)
- Riccardo Campi
- a Department of Urology , Careggi Hospital, University of Florence , Florence , Italy
| | - Andrea Minervini
- a Department of Urology , Careggi Hospital, University of Florence , Florence , Italy
| | - Andrea Mari
- a Department of Urology , Careggi Hospital, University of Florence , Florence , Italy
| | - Georgios Hatzichristodoulou
- b Department of Urology , Klinik und Poliklinik für Urologie, Technische Universität München (TUM), Klinikum rechts der Isar , Munich , Germany
| | - Francesco Sessa
- a Department of Urology , Careggi Hospital, University of Florence , Florence , Italy
| | - Albero Lapini
- a Department of Urology , Careggi Hospital, University of Florence , Florence , Italy
| | - Maurizio Sessa
- c Department of Experimental Medicine , Section of Pharmacology 'L. Donatelli', II University of Naples , Naples , Italy
| | - Jurgen Erich Gschwend
- b Department of Urology , Klinik und Poliklinik für Urologie, Technische Universität München (TUM), Klinikum rechts der Isar , Munich , Germany
| | - Sergio Serni
- a Department of Urology , Careggi Hospital, University of Florence , Florence , Italy
| | - Marco Roscigno
- d Department of Urology , AO Papa Giovanni XXIII , Bergamo , Italy
| | - Marco Carini
- a Department of Urology , Careggi Hospital, University of Florence , Florence , Italy
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Winer AG, Vertosick EA, Ghanaat M, Corradi RB, Carlsson S, Sjoberg DD, Sankin AI, Sfakianos JP, Cha EK, Dalbagni G, Coleman JA. Prognostic value of lymph node yield during nephroureterectomy for upper tract urothelial carcinoma. Urol Oncol 2016; 35:151.e9-151.e15. [PMID: 27932270 DOI: 10.1016/j.urolonc.2016.11.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 10/07/2016] [Accepted: 11/04/2016] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Lymph node dissection (LND) performed during radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC) remains controversial and difficult to evaluate. The aim of this study was to investigate whether removal of more lymph nodes during RNU is safe and improves oncologic outcomes. METHODS We evaluated 422 patients who underwent RNU with concomitant LND for upper tract urothelial carcinoma between 1976 and 2015, assessing for an association between total nodes removed, recurrence-free survival, and cancer-specific survival using Cox proportional hazards models. We also investigated the relationship between nodal yield and perioperative metrics and intersurgeon variability using linear regression. RESULTS In our cohort of 442 patients, 239 developed recurrences and 94 patients died of disease. Median follow-up among survivors was 3.7 years (interquartile range: 1.2, 7.4). The median nodal yield was 9 (interquartile range: 4, 16). Among patients with node-positive disease (pN1), we observed a significant improvement in recurrence-free survival (hazard ratio = 0.84 per 5 nodes removed, P = 0.039) and a nonsignificant improvement in cancer-specific survival with an increase in the nodal yield (hazard ratio = 0.90 per 5 nodes removed, P = 0.2). There was no evidence of an association between node yield and operative time, estimated blood loss, or 30-day complications on multivariable analysis. There was significant heterogeneity among surgeons regarding the extent of LND (P<0.0001). CONCLUSIONS We found that a more extensive node dissection may improve oncologic outcomes in a subset of high-risk patients without significantly increasing operative time or serious complications. Additionally, we identified considerable intersurgeon heterogeneity regarding the extent of LND furthering the notion of surgeon variability as a nonstandardized factor.
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Affiliation(s)
- Andrew G Winer
- SUNY Downstate College of Medicine and Kings County Hospital Center, Brooklyn, NY
| | - Emily A Vertosick
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York City, NY
| | - Mazyar Ghanaat
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, NY
| | - Renato B Corradi
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, NY
| | - Sigrid Carlsson
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York City, NY; Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, NY; Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Daniel D Sjoberg
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York City, NY
| | - Alexander I Sankin
- Department of Urology, Montefiore Medical Center and Albert Einstein College of Medicine, New York City, NY
| | - John P Sfakianos
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York City, NY
| | - Eugene K Cha
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, NY
| | - Guido Dalbagni
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, NY
| | - Jonathan A Coleman
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, NY.
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Szarvas T, Módos O, Horváth A, Nyirády P. Why are upper tract urothelial carcinoma two different diseases? Transl Androl Urol 2016; 5:636-647. [PMID: 27785420 PMCID: PMC5071198 DOI: 10.21037/tau.2016.03.23] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
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.
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Affiliation(s)
- Tibor Szarvas
- Department of Urology, Semmelweis University, Budapest, Hungary; ; Department of Urology, University Hospital of Essen, University of Duisburg-Essen, Essen, Germany
| | - Orsolya Módos
- Department of Urology, Semmelweis University, Budapest, Hungary
| | - András Horváth
- Department of Urology, Semmelweis University, Budapest, Hungary
| | - Péter Nyirády
- Department of Urology, Semmelweis University, Budapest, Hungary
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The effect of surgical approach on performance of lymphadenectomy and perioperative morbidity for radical nephroureterectomy. Urol Oncol 2016; 34:121.e15-21. [DOI: 10.1016/j.urolonc.2015.09.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 09/13/2015] [Accepted: 09/16/2015] [Indexed: 11/18/2022]
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21
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Mathieu R, Bensalah K, Lucca I, Mbeutcha A, Rouprêt M, Shariat SF. Upper urinary tract disease: what we know today and unmet needs. Transl Androl Urol 2016; 4:261-72. [PMID: 26816829 PMCID: PMC4708228 DOI: 10.3978/j.issn.2223-4683.2015.05.01] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Purpose Upper tract urothelial carcinoma (UTUC) is a rare and poorly investigated disease. Intense collaborative efforts have increased our knowledge and improved the management of the disease. The objective of this review was to discuss recent advances and unmet needs in UTUC. Methods A non-systematic Medline/PubMed literature search was performed on UTUC using the terms “upper tract urothelial carcinoma” with different combinations of keywords. Original articles, reviews and editorials in English language were selected based on their clinical relevance. Results UTUC is a disease with specific epidemiologic and risk factors different to urothelial carcinoma of the bladder (UCB). Similarly to UCB, smoking increases the risk of UTUC and worsens its prognosis, whereas aristolochic acid (AA) exposure and mismatch repair genes abnormality are UTUC specific risk factors. A growing understanding of biological pathways involved in the tumorigenesis of UTUC has led to the identification of promising prognostic/predictive biomarkers. Risk stratification of UTUC is difficult due to limitations in staging and grading. Modern imaging and endoscopy have improved clinical decision-making, and allowed kidney-sparing management and surveillance in favorable-risk tumors. In high-risk tumors, radical nephroureterectomy (RNU) remains the standard. Complete removal of the intramural ureter is necessary with inferiority of endoscopic management. Post-RNU intravesical instillation has been shown to decrease bladder cancer recurrence rates. While the role of neoadjuvant cisplatin based combination chemotherapy and lymphadenectomy are not clearly established, the body of evidence suggests a survival benefit to these. There is currently no evidence for adjuvant chemotherapy (AC) in UTUC. Conclusions Despite growing interest and understanding of UTUC, its management remains challenging, requiring further high quality multicenter collaborations. Accurate risk estimation is necessary to avoid unnecessary RNUs while advances in technology are still required for optimal kidney-sparing approaches.
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Affiliation(s)
- Romain Mathieu
- 1 Department of Urology, Rennes University Hospital, Rennes, France ; 2 Department of Urology, General Hospital, Medical University Vienna, Vienna, Austria ; 3 Department of Urology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland ; 4 Academic Department of Urology, La Pitié-Salpetrière Hospital, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Pierre et Marie Curie, University Paris 6, Paris, France ; 5 Department of Urology, University of Texas Southwestern Medical Center, Dallas, USA ; 6 Department of Urology, Weill Cornell Medical College, New York, USA
| | - Karim Bensalah
- 1 Department of Urology, Rennes University Hospital, Rennes, France ; 2 Department of Urology, General Hospital, Medical University Vienna, Vienna, Austria ; 3 Department of Urology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland ; 4 Academic Department of Urology, La Pitié-Salpetrière Hospital, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Pierre et Marie Curie, University Paris 6, Paris, France ; 5 Department of Urology, University of Texas Southwestern Medical Center, Dallas, USA ; 6 Department of Urology, Weill Cornell Medical College, New York, USA
| | - Ilaria Lucca
- 1 Department of Urology, Rennes University Hospital, Rennes, France ; 2 Department of Urology, General Hospital, Medical University Vienna, Vienna, Austria ; 3 Department of Urology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland ; 4 Academic Department of Urology, La Pitié-Salpetrière Hospital, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Pierre et Marie Curie, University Paris 6, Paris, France ; 5 Department of Urology, University of Texas Southwestern Medical Center, Dallas, USA ; 6 Department of Urology, Weill Cornell Medical College, New York, USA
| | - Aurélie Mbeutcha
- 1 Department of Urology, Rennes University Hospital, Rennes, France ; 2 Department of Urology, General Hospital, Medical University Vienna, Vienna, Austria ; 3 Department of Urology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland ; 4 Academic Department of Urology, La Pitié-Salpetrière Hospital, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Pierre et Marie Curie, University Paris 6, Paris, France ; 5 Department of Urology, University of Texas Southwestern Medical Center, Dallas, USA ; 6 Department of Urology, Weill Cornell Medical College, New York, USA
| | - Morgan Rouprêt
- 1 Department of Urology, Rennes University Hospital, Rennes, France ; 2 Department of Urology, General Hospital, Medical University Vienna, Vienna, Austria ; 3 Department of Urology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland ; 4 Academic Department of Urology, La Pitié-Salpetrière Hospital, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Pierre et Marie Curie, University Paris 6, Paris, France ; 5 Department of Urology, University of Texas Southwestern Medical Center, Dallas, USA ; 6 Department of Urology, Weill Cornell Medical College, New York, USA
| | - Shahrokh F Shariat
- 1 Department of Urology, Rennes University Hospital, Rennes, France ; 2 Department of Urology, General Hospital, Medical University Vienna, Vienna, Austria ; 3 Department of Urology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland ; 4 Academic Department of Urology, La Pitié-Salpetrière Hospital, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Pierre et Marie Curie, University Paris 6, Paris, France ; 5 Department of Urology, University of Texas Southwestern Medical Center, Dallas, USA ; 6 Department of Urology, Weill Cornell Medical College, New York, USA
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22
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Contemporary role of lymph node dissection at the time of radical nephroureterectomy for upper tract urothelial carcinoma. World J Urol 2016; 35:535-548. [PMID: 26809456 DOI: 10.1007/s00345-016-1764-z] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2015] [Accepted: 01/05/2016] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To review the contemporary data on the role of lymph node dissection (LND) at the time of radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). METHODS A computerized bibliographic search using the following protocol ("Nephroureterectomy") AND ("Lymphadenectomy" OR "Lymph node" OR "Lymphatic") was performed in MEDLINE to identify all original and review articles that addressed the role of LND for UTUC. RESULTS Regional lymph node (LN) boundaries of UTUC have been recently investigated in mapping studies to propose anatomic templates of LND according to the laterality and location of primary tumor. Although these anatomic templates remained poorly described, most reports supported the staging benefit of LND that allowed for risk stratification of patients with (pN+) or without (pN0) LN metastases from those who did not undergo such a procedure (pNx). In addition, the therapeutic benefit of LND at the time of RNU was supported by better oncological outcomes obtained after complete LND when compared to incomplete or no LND, especially in the group of patients with advanced disease. The number of LNs removed was also correlated with both, more accurate staging and greater cancer-specific survival after LND, whose feasibility and safety have been validated in prospective studies. CONCLUSIONS Despite mostly based on data with level of evidence 3, our comprehensive review of the literature supports the staging and therapeutic benefits of LND at the time of RNU for UTUC, which are particularly significant for patients with muscle-invasive or locally advanced disease.
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23
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Badani KK, Rothberg MB, Bergman A, Silva MV, Shapiro EY, Nieder A, Patel T, Bhandari A. Robot-Assisted Nephroureterectomy and Bladder Cuff Excision Without Patient or Robot Repositioning: Description of Modified Port Placement and Technique. J Laparoendosc Adv Surg Tech A 2014; 24:647-50. [DOI: 10.1089/lap.2013.0251] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ketan K. Badani
- Department of Urology, Columbia University Medical Center, New York, New York
| | - Michael B. Rothberg
- Department of Urology, Columbia University Medical Center, New York, New York
| | - Ari Bergman
- Department of Urology, Columbia University Medical Center, New York, New York
| | - Mark V. Silva
- Department of Urology, Columbia University Medical Center, New York, New York
| | - Edan Y. Shapiro
- Department of Urology, Columbia University Medical Center, New York, New York
| | - Alan Nieder
- Division of Urology, Mount Sinai Medical Center, Miami, Florida
| | - Trushar Patel
- Department of Urology, Columbia University Medical Center, New York, New York
| | - Akshay Bhandari
- Division of Urology, Mount Sinai Medical Center, Miami, Florida
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24
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Sun M, Abdo A, Abdollah F, Schmitges J, Thuret R, Jeldres C, Shariat SF, Perrotte P, Karakiewicz PI. Management of upper urinary tract urothelial carcinoma. Expert Rev Anticancer Ther 2014; 10:1955-65. [DOI: 10.1586/era.10.194] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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25
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Intermediate-Term Outcomes of Robot-Assisted Laparoscopic Nephroureterectomy in Upper Urinary Tract Urothelial Carcinoma. Clin Genitourin Cancer 2013; 11:515-21. [DOI: 10.1016/j.clgc.2013.04.027] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Revised: 04/06/2013] [Accepted: 04/22/2013] [Indexed: 11/19/2022]
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26
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Lim SK, Shin TY, Kim KH, Han WK, Chung BH, Hong SJ, Choi YD, Rha KH. Laparoendoscopic single-site (LESS) robot-assisted nephroureterectomy: comparison with conventional multiport technique in the management of upper urinary tract urothelial carcinoma. BJU Int 2013; 114:90-7. [PMID: 24053174 DOI: 10.1111/bju.12356] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To compare the peri-operative, pathological and oncological outcomes of laparoendoscopic single-site (LESS) robot-assisted nephroureterectomy (LESS-RALNU) with those of multiport robot-asssisted nephroureterectomy (M-RALNU). PATIENTS AND METHODS A total of 38 patients with upper urinary tract urothelial carcinoma underwent LESS-RALNU (n = 17) or M-RALNU (n = 21) by a single surgeon at a tertiary institution. Data were obtained from a prospectively maintained database. RESULTS Patients' demographics and tumour characteristics were similar between the M-RALNU and LESS-RALNU groups. The mean follow-up was 48.4 months for M-RALNU and 30.9 months for LESS-RALNU (P = 0). The mean operating time, estimated blood loss and length of hospitalization for M-RALNU and LESS-RALNU were 251 min, 192 mL, 6.5 days and 247 min, 376 mL and 5.4 days, respectively (P > 0.05). Overall, there were no significant differences in complication rates, although three patients in the LESS-RALNU group required blood transfusion, whereas no patient in the M-RALNU group did (P = 0.081). The proportion of patients with bladder recurrence, local recurrence and distant metastases was similar between the two groups. There were no significant differences in the recurrence-free survival, cancer-specific survival and overall survival rates between the two groups. CONCLUSIONS Although the oncological and peri-operative outcomes of patients who underwent LESS-RALNU compared well with those who underwent M-RALNU and with series of other surgical approaches, LESS-RALNU might result in greater intra-operative blood loss. We suggest careful selection of patient for this technique.
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Affiliation(s)
- Sey Kiat Lim
- Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, South Korea
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27
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Takahara K, Inamoto T, Komura K, Watsuji T, Azuma H. 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. Oncol Lett 2013; 6:1015-1020. [PMID: 24137456 PMCID: PMC3796430 DOI: 10.3892/ol.2013.1485] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Accepted: 06/20/2013] [Indexed: 12/29/2022] Open
Abstract
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.
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The impact of lymph node status and features on oncological outcomes in urothelial carcinoma of the upper urinary tract (UTUC) treated by nephroureterectomy. World J Urol 2012; 31:189-97. [PMID: 23229227 DOI: 10.1007/s00345-012-0983-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2012] [Accepted: 10/29/2012] [Indexed: 01/13/2023] Open
Abstract
PURPOSE Prognostic impact of lymphadenectomy during radical nephroureterectomy (RNU) for urothelial carcinoma of the upper urinary tract (UTUC) is controversial. Our aim was to assess the impact of lymph node status (LNS) on survival in patients treated by RNU. METHODS In our multi-institutional, retrospective database, 714 patients with non-metastatic UTUC had undergone RNU between 1995 and 2010. LNS was tested as prognostic factor for survivals through univariate and multivariable Cox regression analysis. RESULTS Median age was 70 years [interquartile range (IQR), 60-75] with median follow-up of 27 months (IQR, 10-50). Overall, lymphadenectomy was performed in 254 patients (35.5 %). Among these patients, 204 (80 %) had negative lymph nodes (pN0) and 50 (20 %) had positive lymph nodes (pN1/2). The 5-year cancer-specific survival (CSS) was 81 % [95 % confidence interval (CI), 73-88 %] for pN0 patients, 85 % (95 % CI, 80-90 %) for pNx patients and 47 % (95 % CI, 24-69 %) for pN1/2 patients (p < 0.001). Metastasis-free survival (MFS) and overall survival (OS) rates were significantly lower in pN1/2 patients than in pN0 and pNx patients (p < 0.05). On multivariable analysis, LNS did not appear as an independent prognostic factor for CSS, OS or MFS (p > 0.05). In case of lymph node involvement, extra-nodal extension was marginally associated with worse CSS (log rank p = 0.07). The retrospective design was the main limitation. CONCLUSION LNS is helpful for survival stratification in patients treated with RNU for UTUC. However, LNS did not appear as an independent predictor of survival in this retrospective series and needs to be investigated in a large multicentre, prospective evaluation.
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Lee Z, Cadillo-Chavez R, Lee DI, Llukani E, Eun D. The technique of single stage pure robotic nephroureterectomy. J Endourol 2012; 27:189-95. [PMID: 22876964 DOI: 10.1089/end.2012.0394] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
PURPOSE To describe a novel technique for a single setup approach for robotic radical nephroureterectomy (RANU) that does not require patient repositioning, port reassignment, or redocking of the robotic arms. MATERIALS AND METHODS Twenty consecutive patients underwent RANU at a single institution between January 2009 and January 2012. We implemented a unique port placement strategy based on a modified paramedian line (MPL), which allowed sufficient access to both the upper abdomen and the deep pelvis for radical NU with bladder cuff excision and concomitant lymphadenectomy. RESULTS The mean operative time was 161.3 minutes (range 91-330 minutes), mean estimated blood loss was 98.8 (range 50-200), and the mean hospital stay was 3 days (median 2 days, range 1-16 days). None of the procedures were converted to open or required blood transfusions. Lymphadenectomy was performed on 16 out of 20 patients, and the mean number of lymph nodes removed per patient when lymphadenectomy was performed was 14.1 (range 2-35). Three patients had positive lymph nodes. One patient had prolonged postoperative ileus, and one had a hospital course that was complicated by pneumonia. Mean patient follow-up was 13.5 months (range 1-24 months); one patient was found to have a recurrence at 3 month follow-up. CONCLUSION The use of our MPL line for novel port placement allows for an effective, efficient, and reproducible method for RANU without the need for repositioning of the patient or the robot.
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Affiliation(s)
- Ziho Lee
- Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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30
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Pérez-Utrilla Pérez M, Aguilera Bazán A, Alonso Dorrego JM, Vitón Herrero R, Cisneros Ledo J, de la Peña Barthel J. Simultaneous Cystectomy and Nephroureterectomy due to Synchronous Upper Urinary Tract Tumors and Invasive Bladder Cancer: Open and Laparoscopic Approaches. Curr Urol 2012; 6:76-81. [PMID: 24917718 DOI: 10.1159/000343514] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Accepted: 04/10/2012] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION It is not unusual for bladder tumors to appear following transitional cell carcinoma of the upper urinary tract (UUT), with involvement of the UUT, following invasive bladder cancer, being less common. The synchronous presence of transitional cell carcinoma of the bladder and of the UTT is exceptional. METHODS Fifteen simultaneous cystectomies with nephroureterectomies were performed due to synchronous UUT and invasive bladder cancers (1997-2009). Surgery was performed using an open approach in 10 patients, while the last 5 procedures were performed laparoscopically. RESULTS The mean age was 68.7 years. Mean surgery time was 348.6 minutes. Mean blood loss was 816 ml. Acute renal failure was the most frequent postoperative complication being present in 5 patients (33%). There was 1 case of a leak in the ureter-intestinal anastomosis (open approach), which required placement of a left-sided percutaneous nephrostomy. There were 2 cases of postoperative mortality, both in the open approach series and with intestinal neobladder. Mean follow-up time for the whole series was 21.25 months. Eight cases experienced metastatic progression of the disease (mean follow-up 17 months). CONCLUSION Though multi-site studies with longer follow-up and a greater numbers of patients are needed, the moment at which urothelial tumors appear seems to influence their prognosis, with lower survival rates for tumors that synchronically appear.
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Affiliation(s)
| | | | | | - Rebeca Vitón Herrero
- Hospital General Universitario Ciudad Real, Servicio de Cirugía General, Ciudad Real, Spain
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31
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Rao SR, Correa JJ, Sexton WJ, Pow-Sang JM, Dickinson SI, Lin HY, Spiess PE. Prospective clinical trial of the feasibility and safety of modified retroperitoneal lymph node dissection at time of nephroureterectomy for upper tract urothelial carcinoma. BJU Int 2012; 110:E475-80. [PMID: 22564727 DOI: 10.1111/j.1464-410x.2012.11170.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
UNLABELLED What's known on the subject? and What does the study add? Very little is known about the safety and potential oncological benefit of performing a retroperitoneal lymph node dissection at time of nephroureterectomy for upper tract tumours. This study is the first clinical trial to prospectively validate the safety and feasibility of a retroperitoneal lymph node dissection at time of nephroureterectomy for upper tract tumours. The onus is now on the scientific community at large to conduct adequately powered multicentre clinical trials to evaluate the potential oncological benefit it may impart to patients with upper tract tumours. OBJECTIVE • To determine the safety and feasibility of modified retroperitoneal lymph node dissection (RPLND) at the time of radical nephroureterectomy (RNU). PATIENTS AND METHODS • Between 2009 and 2011, 20 patients with suspected upper urinary tract urothelial carcinoma (UUT-UC) underwent open (n= 10), laparoscopic (n= 4), or robot-assisted (n= 6) RNU with modified RPLND. • Demographic, clinical and pathological data, histological nodal status, peri-operative complications and recurrence data were collected. RESULTS • On histopathological review, one patient had a benign angioma and was excluded from the final data analysis. Of the remaining 19 patients, 10 had pTa, five had pT1, one had pT2, and three pT3 disease. • The mean (range) lymph node count was 7 (2-17), with one patient having pathologically proven lymph node metastasis. The mean (range) operating time was 279 (146-500) min. The mean EBL was 396 (100-1100) mL, with the mean (range) hospital stay 7.1 (4-18) days. The mean (range) duration of follow-up after surgery was 12 (2-24) months. • Overall, nine patients developed postoperative complications, which included eight minor (Clavien Grade I-II) and one major complication (Clavien grade IIIb). The major complication was a postoperative chylous lymphatic leak requiring surgical exploration. CONCLUSION • The present results indicate that modified RPLND during RNU for UUT-UC is a feasible procedure with acceptable morbidity. A larger prospective clinical trial is needed to adequately assess its potential therapeutic benefit.
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Affiliation(s)
- Sandhya R Rao
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA
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Remzi M, Shariat S, Huebner W, Fajkovic H, Seitz C. Upper urinary tract urothelial carcinoma: what have we learned in the last 4 years? Ther Adv Urol 2011; 3:69-80. [PMID: 21869907 DOI: 10.1177/1756287211403349] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
In the last 4 years many studies have been published on the topic of upper urinary tract urothelial carcinoma (UTUC). This is a recent review of the available literature of the last 3 years. A systematic Medline/PubMed search on UTUC including limits for clinical trials and randomized, controlled trials was performed for English-language articles using the keywords 'upper urinary tract carcinoma', 'nephroureterectomy', 'laparoscopic', 'ureteroscopy', 'percutaneous', 'renal pelvis', 'ureter' and their combinations from January 2008 to December 2010. Additional selected reports from 2007 were included. Case reports and non-English literature were excluded. Publications were mostly retrospective, including some large, multicentre studies from the Upper Tract Urothelial Carcinoma Collaboration (UTUCC). The authors of this article are members of the UTUCC. Altogether, 92 original articles dealing with UTUC were identified and summarized. The vast majority of the available literature has a low level of evidence (level IV), although many multicentre studies tried to overcome the problem of low numbers by pooling data. It was concluded that in the last 3 years our knowledge regarding UTUC has increased dramatically, although new study concepts allowing us to increase the level of evidence are needed.
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Affiliation(s)
- Mesut Remzi
- Landeskrankenhaus Weinviertel-Korneuburg, Wiener-Ring 3-5, 2100 Korneuburg, Austria
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Weight CJ, Gettman MT. The emerging role of lymphadenectomy in upper tract urothelial carcinoma. Urol Clin North Am 2011; 38:429-37, vi. [PMID: 22045174 DOI: 10.1016/j.ucl.2011.07.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Within the last decade, there has been an increased focus on lymphadenectomy or lymph node dissection (LND) in patients with upper tract urothelial carcinoma (UTUC). Although the data with regards to LND in UTUC are sparse, investigators are beginning to evaluate the role and define the anatomy to understand how LND may affect outcomes in patients with UTUC. This article reviews the history of LND for UTUC, outlines the relative anatomy, and evaluates the arguments and evidence for, and against, LND in patients with UTUC.
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Roscigno M, Brausi M, Heidenreich A, Lotan Y, Margulis V, Shariat SF, Van Poppel H, Zigeuner R. Lymphadenectomy at the time of nephroureterectomy for upper tract urothelial cancer. Eur Urol 2011; 60:776-83. [PMID: 21798659 DOI: 10.1016/j.eururo.2011.07.009] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2011] [Accepted: 07/04/2011] [Indexed: 11/26/2022]
Abstract
CONTEXT The role of lymph node dissection (LND) in patients treated with radical nephroureterectomy (RNU) for upper tract urothelial cancer (UTUC) is still controversial. OBJECTIVE To analyze the impact of lymph node invasion on the outcome of patients, the staging, and the possible therapeutic role of LND in UTUC. EVIDENCE ACQUISITION A Medline search was conducted to identify original articles, review articles, and editorials addressing the role of LND in UTUC. Keywords included upper tract urothelial neoplasms, lymphadenectomy, lymph node excision, lymphatic metastases, nephroureterectomy, imaging, and survival. EVIDENCE SYNTHESIS Regional nodes are frequently involved in UTUC and represent the most common metastatic site. Regional nodal status is a significant predictor of patient outcomes, especially in invasive disease. Therefore, select patients treated with RNU at high risk for regional nodal metastases should undergo LND to improve disease staging, which would identify those who could benefit from adjuvant systemic therapy. Several retrospective studies suggested the potential therapeutic role of LND in UTUC. An accurate LND could remove some nodal micrometastases not identified on routine pathologic examination, thus improving local control and cancer-specific survival. Radical surgery and LND might be curative in a subpopulation with limited nodal disease, as described in bladder cancer. A clear knowledge of the limits of LND and a template of LND for UTUC are still needed. CONCLUSIONS An extended LND can provide better disease staging and may be curative in patients with limited nodal disease. However, current evidence is based on retrospective studies, which limits the ability to standardize either the indication or the extent of LND. Prospective trials are required to determine the impact of LND on survival in patients with UTUC and identify patients for a risk-adapted approach such as close follow-up or adjuvant chemotherapy.
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Affiliation(s)
- Marco Roscigno
- Department of Urology, Ospedali Riuniti di Bergamo, Bergamo, Italy.
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Messer J, Lin YK, Raman JD. The role of lymphadenectomy for upper tract urothelial carcinoma. Nat Rev Urol 2011; 8:394-401. [DOI: 10.1038/nrurol.2011.78] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Kaag MG, O'Malley RL, O'Malley P, Godoy G, Chen M, Smaldone MC, Hrebinko RL, Raman JD, Bochner B, Dalbagni G, Stifelman MD, Taneja SS, Huang WC. Changes in renal function following nephroureterectomy may affect the use of perioperative chemotherapy. Eur Urol 2010; 58:581-7. [PMID: 20619530 DOI: 10.1016/j.eururo.2010.06.029] [Citation(s) in RCA: 201] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2010] [Accepted: 06/16/2010] [Indexed: 11/25/2022]
Abstract
BACKGROUND Nephroureterectomy alone fails to adequately treat many patients with advanced upper tract urothelial carcinoma (UTUC). Perioperative platinum-based chemotherapy has been proposed but requires adequate renal function. OBJECTIVE Our aim was to determine whether the ability to deliver platinum-based chemotherapy following nephroureterectomy is affected by postoperative changes in renal function. DESIGN, SETTINGS, AND PARTICIPANTS We retrospectively reviewed data on 388 patients undergoing nephroureterectomy for UTUC between 1991 and 2009. Four institutions were included. INTERVENTION All patients underwent nephroureterectomy. MEASUREMENTS All patients had serum creatinine measured before and after surgery. The value closest to 3 mo after surgery was taken as the postoperative value (range: 2-52 wk). Estimated glomerular filtration rate (eGFR) was calculated using the abbreviated Modification of Diet in Renal Disease study equation. eGFR values before and after surgery were compared using the paired t test. We chose an eGFR of 45 and 60 ml/min per 1.73 m(2) as possible cut-offs for chemotherapy eligibility and compared eligibility before and after surgery using the chi-square test. RESULTS AND LIMITATIONS Our cohort of 388 patients included 233 men (60%) with a median age of 70 yr. Mean eGFR decreased by 24% after surgery. Using a cut-off of 60 ml/min per 1.73 m(2), 49% of patients were eligible for chemotherapy before surgery, but only 19% of patients remained eligible postoperatively. Using a cut-off of 45 ml/min per 1.73 m(2), 80% of patients were eligible preoperatively, but only 55% remained eligible after surgery. This distribution persisted when we limited the analysis to patients with advanced pathologic stage (T3 or higher). Patients older than the median age of 70 yr were more likely to be ineligible for chemotherapy both pre- and postoperatively by either definition, and they were significantly more likely to have an eGFR <45 ml/min per 1.73 m(2) postoperatively, regardless of their starting eGFR. This study is limited by its retrospective nature, and there was some variability in the timing of postoperative serum creatinine measurements. CONCLUSIONS eGFR is significantly diminished after nephroureterectomy, particularly in elderly patients. These changes in renal function likely affect eligibility for adjuvant cisplatin-based therapy. Accordingly, we suggest strong consideration of neoadjuvant regimens.
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Affiliation(s)
- Matthew G Kaag
- Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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Kim DS, Lee YH, Cho KS, Cho NH, Chung BH, Hong SJ. Lymphovascular invasion and pT stage are prognostic factors in patients treated with radical nephroureterectomy for localized upper urinary tract transitional cell carcinoma. Urology 2010; 75:328-32. [PMID: 20018349 DOI: 10.1016/j.urology.2009.07.1350] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2009] [Revised: 07/08/2009] [Accepted: 07/12/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To investigate the prognostic significance of lymphovascular invasion (LVI) in patients with localized upper urinary tract transitional cell carcinoma (UUT-TCC) after radical nephroureterectomy. METHODS The clinical records of 271 patients with UUT-TCC who underwent radical nephroureterectomy between 1986 and 2006 were reviewed. Patients with pT4 stage, lymph node involvement, or distant metastasis were excluded. A total of 238 patients with pTa-3N0M0 were eligible. The prognostic significance of various clinicopathologic factors was analyzed using univariate and multivariate analysis. The mean age was 64.1 years (range, 25-91 years) and the median follow-up duration was 53.4 months (range, 3-240 months). RESULTS LVI was present in 31 patients (13%). LVI was related to higher pT stage, high tumor grade, sessile architecture, and squamous differentiation. On univariate analysis, tumor architecture, squamous differentiation, LVI, tumor grade, and pT stage influenced disease-specific survival. On multivariate analysis, LVI (hazards ratio [HR], 2.33; P = .014) and pT stage (HR, 2.07; P = .021) showed significantly different rates of disease-specific survival. Patients were classified according to pT stage and LVI. The high-risk group (pT3 and LVI+) showed significantly worse disease-specific survival than the low- (pT < or = 2 and LVI-) or intermediate-risk groups (pT3 and LVI-, pT < or = 2 and LVI+) (P <.001 and P = .032, respectively). CONCLUSIONS LVI and pT stage are significant prognostic factors for recurrence-free and cancer-specific survivals in patients with localized UUT-TCC. LVI and pT stage would be helpful for selecting patients who are appropriate for postoperative adjuvant chemotherapy.
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Affiliation(s)
- Dong Suk Kim
- Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
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Fugita OE. Editorial comment. Urology 2010; 75:124-5; author reply 125. [PMID: 20109707 DOI: 10.1016/j.urology.2009.07.1297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2009] [Revised: 07/29/2009] [Accepted: 07/31/2009] [Indexed: 10/20/2022]
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Prognostic role of lymphovascular invasion in patients with urothelial carcinoma of the upper urinary tract: an international validation study. Eur Urol 2010; 57:1064-71. [PMID: 20071073 DOI: 10.1016/j.eururo.2009.12.029] [Citation(s) in RCA: 144] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2009] [Accepted: 12/24/2009] [Indexed: 11/22/2022]
Abstract
BACKGROUND Lymphovascular invasion (LVI) identified following pathologic slide review has been shown to be an independent predictor of recurrence-free survival (RFS) and cancer-specific survival (CSS) in a multicenter series of patients undergoing radical nephroureterectomy (RNU) for upper urinary tract urothelial carcinoma (UTUC). However, the validity of LVI in everyday practice, where pathologic re-review of all slides is uncommon, has not been assessed. OBJECTIVE Our aim was to evaluate the prognostic role of LVI in an international cohort of patients treated with RNU for UTUC without pathologic slide review. DESIGN, SETTING, AND PARTICIPANTS Data from 762 patients treated with RNU for UTUC without neoadjuvant chemotherapy were collected at nine centers located in Europe, Asia, and Canada. MEASUREMENTS We evaluated patients' characteristics, RFS, and CSS. RESULTS AND LIMITATIONS LVI was present in 148 patients (19.4%). At a median follow-up of 34 mo, 23.5% of the patients developed disease recurrence and 19.8% died of UTUC. The 5-yr RFS and CSS rates were 79.3% and 82.1%, respectively, in the absence of LVI compared with 45.1% and 45.8%, respectively, in the presence of LVI (p values <0.0001). On multivariable Cox regression analyses, LVI was an independent predictor of RFS (hazard ratio [HR]: 3.3; p=0.005) and CSS (HR: 5.9; p<0.0001). Similarly, among patients with pN0/Nx disease, LVI was an independent predictor of RFS (HR: 2.1; p=0.001) and CSS (HR: 2.3; p<0.0001). CONCLUSIONS In a large multicenter series of patients treated with RNU for UTUC and for which no pathologic slide review was performed, LVI was present in approximately 20% and was an independent predictor of both RFS and CSS. LVI status should always be included in the pathologic report of RNU specimens, and patients with LVI should be considered for adjuvant therapy studies.
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Roscigno M, Shariat SF, Freschi M, Margulis V, Karakiewizc P, Suardi N, Remzi M, Zigeuner R, Bolenz C, Kikuchi E, Weizer A, Bensalah K, Sagalowsky A, Koppie TM, Raman J, Fernández M, Ströbel P, Kabbani W, Langner C, Wheat J, Guo CC, Kassouf W, Haitel A, Wood CG, Montorsi F. Assessment of the minimum number of lymph nodes needed to detect lymph node invasion at radical nephroureterectomy in patients with upper tract urothelial cancer. Urology 2009; 74:1070-4. [PMID: 19883824 DOI: 10.1016/j.urology.2009.04.084] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2009] [Revised: 04/01/2009] [Accepted: 04/06/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To determine whether a minimum number of lymph nodes (LNs) exist to detect lymph node invasion (LNI) in patients undergoing radical nephroureterectomy (RNU) for upper tract urothelial carcinoma. METHODS The study included 551 consecutive patients, from 13 centers worldwide, who underwent RNU and lymphadenectomy (LND) between 1992 and 2006. LND was performed at the discretion of the surgeon. All pathological slides were re-reviewed by uropathologists according to strict criteria. Receiver-operating characteristic curve coordinates were used to determine the probability of diagnosing LNI according to the total number of nodes removed. Additionally, the relationship between the number of nodes removed and the rate of positive LNs was tested in univariate and multivariate logistic regression models. RESULTS Median patient age was 68 years (range: 27-97). Of 551 patients, 140 (25.4%) had positive lymph nodes. Median number of lymph nodes removed was 5 (mean 6.7, range 1-41). The Receiver-operating characteristic coordinates plot indicated that the removal of 13 nodes yielded a 90% probability to detect >or=1 positive LNs. The removal of 8 nodes resulted in a 75% probability of finding >or=1 positive nodes. Removal of >8 LNs (P = .03; odds ratio 1.49) was independently associated with LNI after adjusting for pathological stage and grade. CONCLUSIONS Our data indicate that 8 LNs need to be removed at radical nephroureterectomy to achieve a 75% probability of finding >or=1 positive nodes. Further improvement of the specificity of LND will require the removal of more lymph nodes.
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Affiliation(s)
- Marco Roscigno
- Department of Urology and Pathology, Vita-Salute University, Milan, Italy.
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Aguilera A, Pérez-Utrilla M, Giron M, Cansino R, Gil A, de la Peña J. Nefroureterectomía abierta y laparoscópica en tumores uroteliales del tracto urinario superior: experiencia inicial. Actas Urol Esp 2009; 33:1078-82. [DOI: 10.1016/s0210-4806(09)73184-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Lughezzani G, Jeldres C, Isbarn H, Shariat SF, Sun M, Pharand D, Widmer H, Arjane P, Graefen M, Montorsi F, Perrotte P, Karakiewicz PI. A critical appraisal of the value of lymph node dissection at nephroureterectomy for upper tract urothelial carcinoma. Urology 2009; 75:118-24. [PMID: 19864000 DOI: 10.1016/j.urology.2009.07.1296] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2009] [Revised: 06/30/2009] [Accepted: 07/09/2009] [Indexed: 01/26/2023]
Abstract
OBJECTIVES To perform a population-based analysis of the potential staging or prognostic value (or both) of lymph node dissection (LND) in patients without nodal metastases vs no LND. In several previous reports, LND in patients with upper tract urothelial carcinoma (UTUC) treated with nephroureterectomy (NU) was associated with better survival relative to no LND (pN(x)), even in the absence of pathologically confirmed nodal metastases (pN(0)). METHODS Within the surveillance, epidemiology, and end results database, we identified 2824 patients treated with NU for UTUC between 1988 and 2004. CSM rates after NU were graphically explored using Kaplan-Meier plots. Univariable and multivariable Cox regression models tested the effect of N(0) vs N(x) stage on CSM, after adjusting for T stage, tumor grade, age, gender, primary tumor location, type, and year of surgery. RESULTS The CSM-free survival rate at 5 years after NU was 81.2% and 77.8% respectively for pN(0) and pN(x) patients. In univariable analyses pN(x) vs pN(0) status was not associated with worse survival (HR: 1.19; P = .09). After adjustment for all covariates, pN(x) vs pN(0) status still failed to achieve independent predictor status (HR: 0.99; P = .9). CONCLUSIONS We found no survival benefit related to the performance of LND in pN(0) patients, relative to pN(x) patients. Lack of standardized criteria for patients' selection for LND and for pathological lymph node specimen evaluation represents some of the explanation for the observed discrepancy between the current finding and previous findings.
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Affiliation(s)
- Giovanni Lughezzani
- Cancer Prognosis and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada
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Cai G, Liu X, Wu B. Treatment of upper urinary tract urothelial carcinoma. Surg Oncol 2009; 20:43-55. [PMID: 19854042 DOI: 10.1016/j.suronc.2009.10.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2009] [Revised: 09/28/2009] [Accepted: 10/02/2009] [Indexed: 11/28/2022]
Abstract
Upper urinary tract urothelial carcinoma (UUTUC) is relatively rare, occurring in only 5% of all urothelial cancers. It has not been as extensively studied and reviewed as carcinoma of the bladder. UUTUC has a propensity for multifocality, local recurrence, and development of metastases, which argues for an aggressive treatment approach. Open radical nephroureterectomy (ORNU) with removal of an ipsilateral bladder cuff still remains the gold standard treatment for patients with UUTUC and a normal contralateral kidney, which, however, is being challenged by minimally invasive approaches, such as endoscopic and laparoscopic approaches. They are rapidly evolving as reasonable alternatives of care depending on grade and stage of disease. Adjuvant therapy seems to be safe, although its efficacy is debatable. Immunotherapy appears to be most effective in patients with upper-tract carcinoma in situ. Chemotherapy and radiotherapy also show some improvement in recurrence rates, but there have been no randomized, prospective trials. Gene and molecular-targeted therapy is expected. Several controversies remain in our management, including a selection of endoscopic versus laparoscopic approaches, management strategies on the distal ureter, the role of lymphadenectomy, and the value of immunotherapy, chemotherapy, radiotherapy and genetics and molecular markers in UUTUC. Aims of this paper are to critically review the treatment of UUTUC.
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Affiliation(s)
- Guiyang Cai
- Department of Urology, Shengjing Hospital of China Medical University, Shenyang 110004, People's Republic of China
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Dalbagni G. Editorial Comment on: The Extent of Lymphadenectomy Seems to Be Associated with Better Survival in Patients with Nonmetastatic Upper-Tract Urothelial Carcinoma: How Many Lymph Nodes Should Be Removed? Eur Urol 2009; 56:519. [DOI: 10.1016/j.eururo.2009.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Cho KS, Choi HM, Koo K, Park SJ, Rha KH, Choi YD, Chung BH, Cho NH, Yang SC, Hong SJ. Clinical significance of lymph node dissection in patients with muscle-invasive upper urinary tract transitional cell carcinoma treated with nephroureterectomy. J Korean Med Sci 2009; 24:674-8. [PMID: 19654951 PMCID: PMC2719212 DOI: 10.3346/jkms.2009.24.4.674] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2008] [Accepted: 09/26/2008] [Indexed: 11/20/2022] Open
Abstract
We investigated the value of lymph node dissection in patients with cN0 muscle-invasive transitional cell carcinoma of the upper urinary tract (UUT-TCC). Medical records of 152 patients with cN0 muscle-invasive UUT-TCC, who underwent nephroureterectomy between 1986 and 2005, were reviewed. Sixty-three patients (41.4%) underwent lymph node dissection. The median number of lymph nodes harvested was 6 (range, 1 to 35), and from these, lymph node involvement was confirmed in 9 patients (14.3%). Locoregional recurrence (LR) and disease-recurrence (DR) occurred in 29 patients and 63 patients, respectively. Fifty-five patients (36.2%) had died of cancer at the last follow-up. The number of lymph nodes harvested was associated with the reduction of LR (chi(2)(trend)=6.755, P=0.009), but was not associated with DR (chi(2)(trend)=1.558, P=0.212). In the survival analysis, N stage (P=0.0251) and lymph node dissection (P=0.0073) had significant influence on LR, but not on DR or disease-specific survival. However, the number of lymph nodes harvested did not affect LR-free, DR-free, or disease-specific survival. We conclude that lymph node dissection may improve the control of locoregional cancer, as well as staging accuracy, in cN0 muscle-invasive UUT-TCC, but that it does not clearly influence survival.
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Affiliation(s)
- Kang Su Cho
- Department of Urology, the Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Min Choi
- Department of Urology, the Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Kyochul Koo
- Department of Urology, the Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Jin Park
- Department of Urology, the Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Koon Ho Rha
- Department of Urology, the Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Young Deuk Choi
- Department of Urology, the Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Ha Chung
- Department of Urology, the Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Nam Hoon Cho
- Department of Pathology, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Choul Yang
- Department of Urology, the Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Joon Hong
- Department of Urology, the Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
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Margulis V, Shariat SF, Matin SF, Kamat AM, Zigeuner R, Kikuchi E, Lotan Y, Weizer A, Raman JD, Wood CG. Outcomes of radical nephroureterectomy: a series from the Upper Tract Urothelial Carcinoma Collaboration. Cancer 2009; 115:1224-33. [PMID: 19156917 DOI: 10.1002/cncr.24135] [Citation(s) in RCA: 795] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND The literature on upper tract urothelial carcinoma (UTUC) has been limited to small, single center studies. A large series of patients treated with radical nephroureterectomy for UTUC were studied, and variables associated with poor prognosis were identified. METHODS Data on 1363 patients treated with radical nephroureterectomy at 12 academic centers were collected. All pathologic slides were re-reviewed by genitourinary pathologists according to strict criteria. RESULTS Pathologic review revealed renal pelvis location (64%), necrosis (21.6%), lymphovascular invasion (LVI) (24.8%), concomitant carcinoma in situ (28.7%), and high-grade disease (63.7%). A total of 590 patients (43.3%) underwent concurrent, lymphadenectomy and 135 (9.9%) were lymph node (LN) -positive. Over a mean follow-up of 51 months, 379 (28%) patients experienced disease recurrence outside of the bladder and 313 (23%) died of UTUC. The 5-year recurrence-free and cancer-specific survival probabilities (+/-SD) were 69%+/-1% and 73%+/-1%, respectively. On multivariate analysis, high tumor grade (hazards ratio [HR]: 2.0, P<.001), advancing pathologic T stage (P-for-trend<.001), LN metastases (HR: 1.8, P<.001), infiltrative growth pattern (HR: 1.5, P<.001), and LVI (HR: 1.2, P=.041) were associated with disease recurrence. Similarly, patient age (HR: 1.1, P=.001), high tumor grade (HR: 1.7, P=.001), increasing pathologic T stage (P-for-trend<.001), LN metastases (HR: 1.7, P<.001), sessile architecture (HR: 1.5, P=.002), and LVI (HR: 1.4, P=.02) were independently associated with cancer-specific survival. CONCLUSIONS Radical nephroureterectomy provided durable local control and cancer-specific survival in patients with localized UTUC. Pathologic tumor grade, T stage, LN status, tumor architecture, and LVI were important prognostic variables associated with oncologic outcomes, which could potentially be used to select patients for adjuvant systemic therapy.
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Affiliation(s)
- Vitaly Margulis
- Department of Urology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
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Retroperitoneal lymph nodes in transitional cell carcinoma of the kidney and ureter. Adv Urol 2009:181927. [PMID: 19190765 PMCID: PMC2630418 DOI: 10.1155/2009/181927] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2008] [Accepted: 11/03/2008] [Indexed: 11/18/2022] Open
Abstract
The incidence of transitional cell carcinoma of the kidney and ureter is
low and for that reason limited data exists regarding the appropriate management of
regional retroperitoneal lymph nodes. Lymph node metastases have consistently
been associated with an adverse prognosis. However, five-year cancer-specific survival
following nephroureterectomy and lymphadenectomy for patients with lymph node involvement ranges
from 0–39%, suggesting a therapeutic benefit. This review covers the primary tumor characteristics
associated with lymph node involvement, imaging of the lymph nodes, as well as the rationale,
role, patient selection, suggested anatomic templates, and technical
considerations for lymphadenectomy.
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Bolenz C, Shariat SF, Fernández MI, Margulis V, Lotan Y, Karakiewicz P, Remzi M, Kikuchi E, Zigeuner R, Weizer A, Montorsi F, Bensalah K, Wood CG, Roscigno M, Langner C, Koppie TM, Raman JD, Mikami S, Michel MS, Ströbel P. Risk stratification of patients with nodal involvement in upper tract urothelial carcinoma: value of lymph-node density. BJU Int 2008; 103:302-6. [PMID: 18990164 DOI: 10.1111/j.1464-410x.2008.07988.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the risk factors associated with clinical outcome in patients with lymph node (LN)-positive urothelial carcinoma of the upper urinary tract (UTUC) treated with radical nephroureterectomy (RNU) and lymphadenectomy, focusing on the concept of LN density (LND). PATIENTS AND METHODS Patients undergoing RNU with regional lymphadenectomy were identified through multi-institutional databases. All pathology slides were re-evaluated by genitourinary pathologists unaware of the clinical data. The exposure variable used was LND (continuously coded and that of all possible thresholds) with recurrence-free and disease-specific survival (DSS) serving as the outcome measures. RESULTS Of 432 patients undergoing RNU with lymphadenectomy, 135 (31%) had LN metastases. Within a median follow-up of 4.1 years, 90 of the 135 patients with LN metastases (68%) had disease recurrence and 76 (58%) died from UTUC. The mean (sem) 5-year recurrence-free and DSS probabilities were 27 (4)% and 33 (5)%, respectively. The median (range) LND was 50 (3-100)%. The most informative threshold for LND in relation to outcome was 30%. In multivariable analyses that adjusted for the effects of tumour stage and grade, patients with a LND of > or =30% were at greater risk of both cancer recurrence, with 5-year rates of 25 (5)% vs 38 (8)% (hazard ratio 1.8, P = 0.021) and mortality, with 5-year rates of 30 (6)% vs 48 (9)% (1.7, P = 0.032) compared to those with a LND of <30%. Our results are primarily limited by a lack of standardization in the lymphadenectomy template. CONCLUSION We evaluated the concept of LND for the first time in UTUC. LND provides additional prognostic information in patients with node-positive disease after RNU. The use of LND in clinical trials might provide an additional insight into the value of LN dissection in patients undergoing RNU.
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Bolenz C, Fernández MI, Trojan L, Herrmann E, Becker A, Weiss C, Alken P, Ströbel P, Michel MS. Lymphovascular Invasion and Pathologic Tumor Stage Are Significant Outcome Predictors for Patients With Upper Tract Urothelial Carcinoma. Urology 2008; 72:364-9. [DOI: 10.1016/j.urology.2008.04.032] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2008] [Revised: 04/11/2008] [Accepted: 04/17/2008] [Indexed: 11/26/2022]
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