Chronic kidney disease after nephroureterectomy for upper tract urothelial carcinoma and implications for the administration of perioperative chemotherapy

Abstract

BACKGROUND:The prevalence of chronic kidney disease (CKD) in patients with upper tract urothelial carcinoma (UTUC) is poorly defined, both before and after nephrouretectomy. Although multimodal treatment paradigms for UTUC are under‐developed, this has important implications on patients' ability to receive cisplatin‐based combination chemotherapy (CBCC).METHODS:Estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease formula in 336 patients with UTUC, who were treated at the Cleveland Clinic by nephroureterectomy since 1992. An eGFR cutoff of 60 mL/min/1.73 m2 was used to determine the presence of CKD and eligibility for CBCC.RESULTS:Median age was 72 years and median preoperative eGFR was 59 mL/min/1.73m2. Before nephroureterectomy, only 48% of patients were eligible to receive CBCC and this decreased to 22% postoperatively (P < .001). In the 144 patients with pT2‐pT4 and/or pN1‐pN3 disease who are suitable to receive CBCC, these proportions were 40% and 24%, respectively (P = .009). Although 50 patients overall received some form of perioperative chemotherapy, only 3 and 11 patients received neoadjuvant and adjuvant CBCC, respectively.CONCLUSIONS:CKD is prevalent in the UTUC population and a minority of patients has an optimal eGFR to receive neoadjuvant CBCC. Nephrouretectomy may eliminate CBCC as a therapeutic option in 49% of high‐risk patients if it is deferred to the adjuvant setting. Multimodal treatment strategies for UTUC should focus on neoadjuvant chemotherapy, as few patients are eligible for adjuvant CBCC because of the substantial decline in eGFR caused by nephroureterectomy. Cancer 2010. © 2010 American Cancer Society.

Effect of preoperative chemotherapy on survival of patients with upper urinary tract urothelial carcinoma clinically involving regional lymph nodes

“…7,8,13,14 Several retrospective studies and the meta-analysis of those studies suggested the efficacy of neoadjuvant chemotherapy in patients with locally advanced or high-grade UTUC. [15][16][17] In patients with node-positive UTUC, only a few retrospective studies reported the impact of preoperative chemotherapy on the oncological outcomes.…”

Invasive Upper Urinary Tract Urothelial Carcinoma With Atypical Clinic: Case Report

“…Not all patients can receive chemotherapy because of comorbidity and impaired renal function after radical surgery. Chemotherapy-related toxicity, particularly nephrotoxicity from platinum derivatives, may significantly reduce survival in patients with postoperative renal dysfunction [23,24]. In our case we have bad prognosis.…”

Oncologic outcomes and prognostic impact of urothelial recurrences in patients undergoing segmental and total ureterectomy for upper tract urothelial carcinoma

“…According to several reports, an estimated 88% to 93% of patients in the post-NU setting have an eGFR <60 and would be ineligible to receive cisplatinbased therapy. 5,11 Although increasing utilization of neoadjuvant chemotherapy for upper tract urothelial carcinoma may partially obviate the importance of ureteral resection in this disease population, these findings retain oncologic importance for several reasons: (1) eligibility for clinical trials; (2) risk for the development of muscle-invasive bladder cancer where chemotherapy is well-established; and (3) lower efficacy of non-cisplatin based palliative chemotherapy. [12][13][14] Segmental resections for upper tract urothelial carcinoma have traditionally been associated with high recurrence rates.…”

“…Potential benefits of ureteral resection for the upper tract urothelial carcinoma population may be even more critical due to the inherent incidence of chronic kidney disease following surgery and the potential need for postoperative chemotherapy. 5 Alternatives to NU include endoscopic tumour resections/ablations, segmental ureterectomy (SU), or total ureterectomy (TU) with urinary tract reconstruction. The potential benefits of renal preservation must be weighed against the potential impact of localized urothelial recurrences, which may or may not affect the overall course of the disease.…”