35 research outputs found
Radical nephroureterectomy for pathologic T4 upper tract urothelial cancer: can oncologic outcomes be improved with multimodality therapy?
Purpose To report the outcomes of patients with pathologic T4 UTUC and investigate the potential impact of peri-operative chemotherapy combined with radical nephroureterectomy (RNU) and regional lymph node dissection (LND) on oncologic outcomes. Materials and Methods Patients with pathologic T4 UTUC were identified from the cohort of 1464 patients treated with RNU at 13 academic centers between 1987 and 2007. Oncologic outcomes were stratified according to utilization of perioperative systemic chemotherapy and regional LND as an adjunct to RNU. Results The study included 69 patients, 42 males (61%) with median age 73 (range 43-98). Median follow-up was 17 months (range: 6-88). Lymphovascular invasion was found in 47 (68%) and regional lymph node metastases were found in 31 (45%). Peri-operative chemotherapy was utilized in 29 (42%) patients. Patients treated with peri-operative chemotherapy and RNU with LND demonstrated superior oncologic outcomes compared to those not treated by chemotherapy and/or LND during RNU (3Y-DFS: 35% vs. 10%; P = 0.02 and 3Y-CSS: 28% vs. 14%; P = 0.08). In multivariate Cox regression analysis, administration of peri-operative chemotherapy and utilization of LND during RNU was associated with lower probability of recurrence (HR: 0.4, P = 0.01), and cancer specific mortality (HR: 0.5, P = 0.06). Conclusions Pathological T4 UTUC is associated with poor prognosis. Peri-operative chemotherapy combined with aggressive surgery, including lymph node dissection, may improve oncological outcomes. Our findings support the use of aggressive multimodal treatment in patients with advanced UTUC
Prognostic role of ECOG performance status in patients with urothelial carcinoma of the upper urinary tract: an international study.
OBJECTIVE: To evaluate the prognostic role of ECOG Performance status (ECOG-PS)
in a large multi-institutional international cohort of patients treated with
radical nephroureterectomy for upper tract urothelial carcinoma.
MATERIALS AND METHODS: Data of 427 patients treated with radical
nephroureterectomy at five international institutions in Asia, Europe and
Northern America were collected retrospectively from 1987 to 2008. Logistic and
Cox regression models were used for univariable and multivariable analyses.
RESULTS: ECOG-PS was 0 in 272 of 427 (64%) patients. The median follow-up of the
whole cohort was 32 months. The five-year recurrence-free (RFS), cancer-specific
(CSS) and overall (OS) survival estimates were 71.7%, 74.9% and 68.5%,
respectively, in patients with ECOG-PS 0 compared with 60.1%, 67.8%, and 51.4%
respectively, in patients with ECOG-PS 651 (P value 0.08 for RFS, 0.43 for CSS,
and <0.001 for OS, respectively). On multivariable Cox regression analyses,
ECOG-PS was not an independent predictor of either RFS (hazard ratio 1.4; P =
0.107) or CSS (hazard ratio 1.2; P = 0.426) but was an independent predictor of
OS (hazard ratio 1.5; P = 0.03).
CONCLUSIONS: In this large multicentre international study, ECOG-PS was not
significantly associated with RFS and CSS. Conversely we find a strong
association with survival 1-month after surgery and OS. Further research is
needed to ascertain the additive prognostic role of ECOG-PS in well-designed
prospective multicentre studies
Multicenter validation of the prognostic value of patient age in patients treated with radical cystectomy.
PURPOSE: Small studies have suggested that older patients have worse outcomes
following radical cystectomy (RC) for urothelial carcinoma of the bladder (UCB).
We evaluated the association of patient age with clinical outcomes in a large
multi-institutional RC series. METHODS: Data were collected from 4,429 patients
treated with RC and lymphadenectomy for UCB without neoadjuvant chemotherapy. Age
at RC was analyzed both as a continuous and categorical variable. RESULTS: Higher
age at RC, analyzed as a continuous or categorical variable, was associated with
advanced pathologic stage (PÂ <Â 0.001), higher tumor grade (PÂ =Â 0.045), presence
of lymphovascular invasion (PÂ =Â 0.018), and positive soft-tissue surgical margin
status (PÂ =Â 0.004). Elderly patients were less likely to receive postoperative
chemotherapy (PÂ <Â 0.001). In multivariable analyses, higher age was associated
with disease recurrence, cancer-specific, and overall mortality (PÂ <Â 0.001).
Patients â„80Â years had a significantly greater risk of cancer-specific mortality
than patients <50Â years (HR 1.763, PÂ <Â 0.001). Age minimally improved the
accuracy of a base model that included standard pathologic features for
prediction of disease recurrence (+0.2-0.3%) and cancer-specific survival
(+0.3%). Conversely, age improved the predictive accuracy for overall survival by
a sizeable margin (+4.2-4.5%). CONCLUSIONS: This large external validation study
confirms that advanced patient age is minimally but significantly associated with
worse prognosis after RC. Nevertheless, a large proportion of elderly patients
benefitted from RC with curative intent. We need to improve our understanding of
the reasons for the worse UCB outcomes in this growing segment of the population
and to develop strategies to improve cancer care in the elderly
The impact of tumor multifocality on outcomes in patients treated with radical nephroureterectomy.
BACKGROUND: The prognostic impact of multifocal upper-tract urothelial carcinoma
(UTUC) is poorly understood.
OBJECTIVE: To investigate the association between tumor multifocality and
clinicopathologic features and outcomes of UTUC in patients managed by radical
nephroureterectomy (RNU).
DESIGN, SETTING, AND PARTICIPANTS: The study included 2492 patients treated with
either open or laparoscopic RNU. Tumor and patient characteristics included tumor
stage, tumor grade, lymph node status, lymphovascular invasion (LVI), tumor
architecture, tumor location, unifocal or multifocal disease, gender, age,
history of bladder cancer (BCa), Eastern Cooperative Oncology Group (ECOG)
performance status (PS), and adjuvant chemotherapy. tumor multifocality of UTUC
was defined as the synchronous presence of multiple tumors in the renal pelvis or
ureter.
INTERVENTION: All patients were treated with either open or laparoscopic RNU.
MEASUREMENTS: Univariable and multivariable models tested the effect of tumor
multifocality on disease progression and cancer-specific mortality.
RESULTS AND LIMITATIONS: Five hundred ninety patients (23.7%) had tumor
multifocality at the time of RNU. The median follow-up was 45 mo (interquartile
range [IQR]: 0-101). Tumor multifocality was significantly associated with a
history of previous BCa (p=0.032), lymph node involvement (p=0.036), tumor
location in the ureter (p=0.003), higher tumor stage (p<0.001), higher tumor
grade (p<0.001), sessile tumor architecture (p=0.003), and LVI (p=0.001). In
organ-confined patients, tumor multifocality was an independent predictor of both
disease progression (hazard ratio [HR]: 1.43; p=0.019) and cancer-specific
mortality (HR: 1.46; p=0.027). When assessed in all patients, tumor multifocality
was associated with both disease progression and cancer-specific mortality in
univariable (p=0.005 and p=0.006, respectively) but not in multivariable analyses
(p=0.468 and p=0.798, respectively). The main limitation is the retrospective
design of the study.
CONCLUSIONS: Tumor multifocality is an independent prognosticator of disease
progression and cancer-specific mortality in patients with organ-confined UTUC
treated with RNU. Multifocal organ-confined patients with UTUC may need closer
follow-up. Integration of tumor multifocality with other factors may help
identify those patients who would benefit from multimodal therapy
International validation of the prognostic value of subclassification for AJCC stage pT3 upper tract urothelial carcinoma of the renal pelvis.
Study Type - Prognosis (inception cohort) Level of Evidence\u20032a What's known on
the subject? and What does the study add? Tumour stage is a powerful predictor of
clinical outcomes and the most important factor driving clinical decision-making
after radical nephroureterectomy (RNU) in upper tract urothelial carcinoma
(UTUC). It has been suggested that renal pelvic pT3 subclassification into
microscopic infiltration of the renal parenchyma (pT3a) versus macroscopic
infiltration or invasion of peripelvic adipose tissue (pT3b) has strong
prognostic value. This is an external validation study of the prognostic value of
pT3 subclassification of renal pelvic UTUC in a large international cohort of
patients treated with RNU. pT3b UTUC is associated with features of aggressive
tumour biology, disease recurrence and cancer-specific mortality. However, pT3
subclassification is not an independent predictor of clinical outcomes.
OBJECTIVE: \u2022\u2002 To externally validate the prognostic value of subclassification of
pT3 renal pelvic upper tract urothelial carcinoma (UTUC) in a large international
cohort of patients treated with radical nephroureterectomy (RNU). PATIENTS AND
METHODS: \u2022\u2002 The RNU specimens with pT3 UTUC of the renal pelvis from 284 patients
at 11 centres located in Asia, North America and Europe were retrospectively
evaluated. All specimens were reviewed by genitourinary pathologists at each
institution. Tumours were categorized as pT3a (microscopic infiltration of the
renal parenchyma) or pT3b (macroscopic infiltration of the renal parenchyma
and/or infiltration of peripelvic adipose tissue). RESULTS: \u2022\u2002 Overall, 148 (52%)
tumours were classified as pT3a and 136 (48%) as pT3b. Patients with pT3b disease
were more likely to have high-grade tumours and sessile tumour architecture (all
P 64 0.02). Patients with pT3b tumours were at increased risk of disease recurrence
(5-year estimates: 55% versus 42%, P= 0.012) and cancer-specific mortality (CSM)
(5-year estimates: 48% versus 40%, P= 0.04). Lymph node status, tumour
architecture and tumour grade were independently associated with disease
recurrence, whereas lymph node status, tumour architecture and lymphovascular
invasion were independently associated with CSM. Subclassification of pT3 tumours
was not associated with recurrence or CSM in multivariable analyses. CONCLUSION:
\u2022\u2002 Patients with pT3b UTUC were more likely to have tumours with aggressive
pathological features and were at higher risk of disease recurrence and CSM after
RNU compared with patients with pT3a disease. However, the pT3 subclassification
did not remain an independent predictor of disease recurrence or CSM after
controlling for tumour grade, lymph node status, tumour architecture and
lymphovascular invasion
Chronological age is not an independent predictor of clinical outcomes after radical nephroureterectomy.
Purpose: Higher chronological age has been suggested to confer worse prognosis in patients with upper tract urothelial carcinoma (UTUC). The aim of the current study was to test this hypothesis in a large multicenter external validation cohort of patients treated with radical nephroureterectomy (RNU) while controlling for patient performance status. Materials and methods: We retrospectively reviewed the data from 1,169 patients treated with RNU for UTUC. Age at RNU was analyzed both as a continuous and categorical variable ( 0.001). Conclusions: We confirmed that advanced patient age at the time of RNU is associated with worse clinical outcomes after surgery. However, ECOG performance status abrogated the association. Furthermore, a large proportion of elderly patients were cured with RNU. This suggests that chronological age alone is an inadequate indicator criterion to predict response of older UTUC patients to RNU