Prognostic indicators for upper tract urothelial carcinoma after radical nephroureterectomy: the impact of lymphovascular invasion

Abstract

Study Type – Prognosis (case series) Level of Evidence 4 What's known on the subject? and What does the study add? In an array of urological and non‐urological malignancies, lymphovascular invasion (LVI) is a pathological feature known to be associated with adverse outcomes for recurrence and survival. For some cancers, LVI has therefore been incorporated into American Joint Committee on Cancer TNM staging algorithms. This study presents an analysis of the impact of LVI in upper urinary tract urothelial carcinoma (UTUC) treated at our institution over a 20‐year period. In addition to known associations with features of aggressive disease and overall survival, we were able to show that LVI‐positive status upsets the TNM staging for UTUC. Namely, patients with superficial stage and LVI‐positive disease have overall survival outcomes similar to those of patients with muscle‐invasive LVI‐negative carcinoma. Such evidence may support the addition of LVI to future TNM staging algorithms for UTUC. OBJECTIVE To assess the impact of lymphovascular invasion (LVI) on the prognosis of patients with upper urinary tract urothelial cell carcinoma (UTUC) treated with radical nephroureterectomy (RNU). PATIENTS AND METHODS The Columbia University Medical Center Urologic Oncology database was queried and 211 patients undergoing RNU for UTUC between 1990 and 2010 were identified. These cases were retrospectively reviewed, and the prognostic significance of relevant clinical and pathological variables was analysed using log‐rank tests and Cox proportional hazards regression models. Actuarial survival curves were calculated using the Kaplan–Meier method. RESULTS LVI was observed in 68 patients (32.2%). The proportion of LVI increased with advancing stage, high grade, positive margin status, concomitant carcinoma in situ, and lymph node metastases. The 5‐ and 10‐year overall survival rates were 74.7% and 53.1% in the absence of LVI, and 35.7% and 28.6% in the presence of LVI, respectively. In multivariate analysis, age, race and LVI were independent predictors of overall survival. CONCLUSIONS The presence of LVI on pathological review of RNU specimens was associated with worse overall survival in patients with UTUC. LVI status should be included in the pathological report for RNU specimens to help guide postoperative therapeutic options. With confirmation from large international studies, inclusion of LVI in the tumour‐node‐metastasis staging system for UTUC should be considered.

Preoperative sarcopenia status is associated with lymphovascular invasion in upper tract urothelial carcinoma patients treated with radical nephroureterectomy

“…In the present study, the CSS rate was higher than in other studies; the 5-year CSS rate of patients with sarcopenia was 77.9% in our study, 57.1% in that by Ishihara et al, and 69% in that by Fukushima et al. Another reason was that the strong prognostic indicator of LVI [13][14][15] was not evaluated by Ishihara et al. In our study, LVI was the only independent predictor for cancer-specific death and sarcopenia independently predicted…”

Effect of concomitant variant histology on the prognosis of patients with upper urinary tract urothelial carcinoma after radical nephroureterectomy

“…Similarly, in another study conducted by Sakano et al [8] involving 502 patients, patients with advanced pT stage accounted for 42% (38% of patients with pure UTUC and 73% of patients with UTUC with CVH). The proportions of advanced pT stage of other multi-institutional studies also ranged from 30.6% to approximately 35% [13,[22][23][24]. Furthermore, patients with UTUC with CVH were at a significantly higher risk of cancer-specific mortality, disease recurrence, and overall death compared with patients who had pure UTUC, as demonstrated by Kaplan-Meier survival curves.…”

Association between demographic factors and prognosis in urothelial carcinoma of the upper urinary tract: a systematic review and meta-analysis

“…Furthermore, we could not perform meta-analysis for PFS and OS because only 1 study was eligible for PFS [11] and OS [12], respectively. Only 2 studies were evaluated for the impact of race on CSS.…”

“…A total of 1,037 articles were excluded upon examination of the titles and abstracts, while the full text of 315 articles was evaluated. In accordance with all previously mentioned inclusion criteria, a final selection of 79 articles was made [9–12, 18–92]; any discrepancies between the two evaluations were resolved. The PRISMA flow chart depicting the process for the systematic literature search and selection of the studies is shown in Figure 5.…”