Optimizing the Sequence of Chemotherapy for Upper Tract Urothelial Carcinoma with Clinically Positive Regional Lymph Nodes
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Abstract
Purpose:
Upper tract urothelial carcinoma with clinically positive regional lymph nodes is an aggressive disease state with a high propensity for metastasis and death. The current literature is limited regarding national practice patterns and outcomes in this patient population.
Materials and Methods:
We identified 1,658 patients in the NCDB (National Cancer Database) who had cN+M0 upper tract urothelial carcinoma. Patients were stratified into treatment groups. We compared baseline patient and tumor characteristics between the groups, and completed survival analysis using a multivariate Cox regression model.
Results:
There were 1,658 patients in the final study population. Preoperative chemotherapy was the least performed treatment. That group comprised 6.8% of the overall population and was associated with the highest median overall survival of 36 months compared to 21 months for adjuvant chemotherapy, 14 for chemotherapy only, 10 for surgery without perioperative chemotherapy and 5 for no treatment. On multivariate analysis preoperative chemotherapy was associated with improved median overall survival compared to that in the adjuvant chemotherapy group (HR 0.58, 95% CI 0.38-0.87). There was no statistically significant difference in survival between the chemotherapy only and the surgery only groups. Of patients in the preoperative chemotherapy group 34.6% achieved pN0 status compared to 10.3% of those who underwent surgery as initial therapy.
Conclusions:
Preoperative chemotherapy was the least performed treatment strategy in the management of cN+M0 upper tract urothelial carcinoma but it was associated with the highest median overall survival. There was no difference in survival between the chemotherapy only and the surgery only groups. Overall these results suggest that initial chemotherapy is appropriate in this population when feasible.
References
- 1. : Outcomes of radical nephroureterectomy: a series from the upper tract urothelial carcinoma collaboration. Cancer 2009; 115: 1224. Google Scholar
- 2. : Bladder cancer, version 5.2017, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2017; 15: 1240. Google Scholar
- 3. : European Association of Urology guidelines on upper urinary tract urothelial cell carcinoma: 2015 update. Eur Urol 2015; 68: 868. Google Scholar
- 4. : Time to define an international standard of postoperative care for resected upper urinary tract transitional cell carcinoma (TCC)—opening of the peri-operative chemotherapy versus surveillance in upper tract urothelial cancer (POUT) Trial. BJU Int 2012; 110: 919. Google Scholar
- 5. : Results of POUT: a phase III randomized trial of perioperative chemotherapy versus surveillance in upper tract urothelial cancer (UTUC). J Clin Oncol, suppl., 2018; 36: abstract 407. Google Scholar
- 6. : Conventional CT signs in staging transitional cell tumors of the upper urinary tract. Eur Urol 1999; 35: 318. Google Scholar
- 7. : Platinum-based neoadjuvant chemotherapy improves oncological outcomes in patients with locally advanced upper tract urothelial carcinoma. Eur Urol Focus 2017. Google Scholar
- 8. : Neoadjuvant chemotherapy for locally advanced urothelial cancer of the upper urinary tract. Urol Int 1995; 55: 74. Google Scholar
- 9. : Neoadjuvant chemotherapy improves survival of patients with upper tract urothelial carcinoma. Cancer 2014; 120: 1794. Google Scholar
- 10. : Upper urinary tract urothelial carcinoma with loco-regional nodal metastases: insights from the Upper Tract Urothelial Carcinoma Collaboration. BJU Int 2011; 108: 1286. Google Scholar
- 11. : Neoadjuvant chemotherapy plus cystectomy compared with cystectomy alone for locally advanced bladder cancer. N Engl J Med 2003; 349: 859. Google Scholar
- 12. : Incidence of downstaging and complete remission after neoadjuvant chemotherapy for high-risk upper tract transitional cell carcinoma. Cancer 2010; 116: 3127. Google Scholar
- 13. : Changes in renal function following nephroureterectomy may affect the use of perioperative chemotherapy. Eur Urol 2010; 58: 581. Google Scholar
- 14. : Impact of renal function on eligibility for chemotherapy and survival in patients who have undergone radical nephro-ureterectomy. BJU Int 2013; 112: 453. Google Scholar
- 15. : Limitations of computed tomography in the preoperative staging of upper tract urothelial carcinoma. Urology 2000; 56: 930. Google Scholar
- 16. : Computerized tomography for detection and staging of localized and pathologically defined upper tract urothelial tumors. J Urol 1991; 146: 1500. Link, Google Scholar
The corresponding author certifies that, when applicable, a statement(s) has been included in the manuscript documenting institutional review board, ethics committee or ethical review board study approval; principles of Helsinki Declaration were followed in lieu of formal ethics committee approval; institutional animal care and use committee approval; all human subjects provided written informed consent with guarantees of confidentiality; IRB approved protocol number; animal approved project number.
No direct or indirect commercial, personal, academic, political, religious or ethical incentive is associated with publishing this article.
Editor's Note: This article is the third of 5 published in this issue for which category 1 CME credits can be earned. Instructions for obtaining credits are given with the questions on pages 174 and 175.
