Jay D Raman1, Yu-Kuan Lin2, Matthew Kaag2, Timothy Atkinson3, Paul Crispen3, Mark Wille4, Norm Smith5, Mark Hockenberry6, Thomas Guzzo6, Benoit Peyronnet7, Karim Bensalah7, Jay Simhan8, Alexander Kutikov8, Eugene Cha9, Michael Herman9, Douglas Scherr9, Shahrokh F Shariat10, Stephen A Boorjian11. 1. Division of Urology, Penn State Milton S. Hershey Medical Center, Hershey, PA. Electronic address: jraman@hmc.psu.edu. 2. Division of Urology, Penn State Milton S. Hershey Medical Center, Hershey, PA. 3. Division of Urology, University of Kentucky Medical Center, Lexington, KY. 4. Division of Urology, Stroger Cook County Hospitals, Chicago, IL. 5. Section of Urology, University of Chicago Medical Center, Chicago, IL. 6. Department of Urology, University of Pennsylvania, Philadelphia, PA. 7. Department of Urology, University of Rennes, Rennes, France. 8. Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA. 9. Department of Urology, New York-Presbyterian Hospital-Weill Cornell Medical Center, New York, NY. 10. Department of Urology, New York-Presbyterian Hospital-Weill Cornell Medical Center, New York, NY; Division of Medical Oncology, New York-Presbyterian Hospital-Weill Cornell Medical Center, New York, NY. 11. Department of Urology, Mayo Clinic, Rochester, MN.
Abstract
OBJECTIVES: Recurrences remain common following radical nephroureterectomy (RNU) for locally advanced upper-tract urothelial carcinoma (UTUC). We review a cohort of RNU patients to identify the incidence of locally advanced disease, decline in renal function, complications, and utilization of adjuvant chemotherapy (AC). METHODS: Institutional databases from 7 academic medical centers identified 414 RNU patients treated between 2003 and 2012 who had not received neoadjuvant chemotherapy. Glomerular filtration rate was estimated using the Modification of Diet in Renal Disease equation. Complications were classified according to the modified Clavien system. Cox proportional hazard modeling and Kaplan-Meier analysis determined factors associated with cancer-specific survival. RESULTS: Of 414 patients, 177 (43%) had locally advanced disease, including 118 pT3N0/Nx, 13 pT4N0/Nx, and 46 pTanyN+. Estimated 3- and 5-year cancer-specific survival was 47% and 34%, respectively. Only 31% of patients with locally advanced UTUC received AC. Mean estimated glomerular filtration rate declined from 59 to 51 ml/min/1.73 m(2) following RNU, including a new-onset decline below 60 and 45 ml/min/1.73 m(2) in 25% and 15% of patients, respectively (P<0.001 for both). Complications occurred in 46 of 177 (26%) patients, of which one-quarter were grade III or IV. Increasing age (Hazard Ratio (HR) 1.4, P = 0.03), positive surgical margins (HR 2.1, P = 0.01), and positive lymph nodes (HR 4.3, P<0.001) were associated with an increased risk of death from UTUC, whereas receipt of AC (HR 0.85, P = 0.05) was associated with a decrease in UTUC mortality. CONCLUSIONS: Under one-third of RNU patients with locally advanced UTUC cancers received AC. Perioperative complications and decline in renal function may have contributed to this low rate. Such data further underscore the need for continued discussion regarding the use of chemotherapy in a neoadjuvant setting for appropriately selected patients with UTUC.
OBJECTIVES: Recurrences remain common following radical nephroureterectomy (RNU) for locally advanced upper-tract urothelial carcinoma (UTUC). We review a cohort of RNU patients to identify the incidence of locally advanced disease, decline in renal function, complications, and utilization of adjuvant chemotherapy (AC). METHODS: Institutional databases from 7 academic medical centers identified 414 RNU patients treated between 2003 and 2012 who had not received neoadjuvant chemotherapy. Glomerular filtration rate was estimated using the Modification of Diet in Renal Disease equation. Complications were classified according to the modified Clavien system. Cox proportional hazard modeling and Kaplan-Meier analysis determined factors associated with cancer-specific survival. RESULTS: Of 414 patients, 177 (43%) had locally advanced disease, including 118 pT3N0/Nx, 13 pT4N0/Nx, and 46 pTanyN+. Estimated 3- and 5-year cancer-specific survival was 47% and 34%, respectively. Only 31% of patients with locally advanced UTUC received AC. Mean estimated glomerular filtration rate declined from 59 to 51 ml/min/1.73 m(2) following RNU, including a new-onset decline below 60 and 45 ml/min/1.73 m(2) in 25% and 15% of patients, respectively (P<0.001 for both). Complications occurred in 46 of 177 (26%) patients, of which one-quarter were grade III or IV. Increasing age (Hazard Ratio (HR) 1.4, P = 0.03), positive surgical margins (HR 2.1, P = 0.01), and positive lymph nodes (HR 4.3, P<0.001) were associated with an increased risk of death from UTUC, whereas receipt of AC (HR 0.85, P = 0.05) was associated with a decrease in UTUC mortality. CONCLUSIONS: Under one-third of RNU patients with locally advanced UTUC cancers received AC. Perioperative complications and decline in renal function may have contributed to this low rate. Such data further underscore the need for continued discussion regarding the use of chemotherapy in a neoadjuvant setting for appropriately selected patients with UTUC.
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