Current EAU guidelines risk stratification upper tract urothelial carcinoma (UTUC) patients into two risk categories:
But some of the above high-risk patients may be eligible for kidney sparing procedures.
In this study, the authors performed a retrospective analysis of 1,214 patients from 21 centers who underwent ureterorenoscopy (URS) with biopsy followed by radical nephroureterectomy (RNU) for non-metastatic UTUC between 2000 and 2017. A multivariate logistic regression analysis identified predictors of muscle invasion (≥pT2) at RNU, the Youden Index identified cut-offs. This was then utilized to generate a new risk categorization.
Of the 1214 patients, 811 patients (67%) were male, median age was 71 (IQR; 63-77).
When looking at predictors of invasive UTUC (≥pT2) at the time of RNU, the presence of non-organ confined disease on preoperative imaging (p<.0001), sessile tumor (p<.0001), the presence of hydronephrosis (p=0.0003), high-grade cytology (p=0.0043) or biopsy (p=0.0174) and higher age at diagnosis (p=0.029) were independently associated with the primary outcome.
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Tumor size was significantly associated with ≥pT2 disease only in univariate analysis with a cutoff of 2cm
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Tumor size and all other significant categorical variables defined the high-risk (HR) category
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Tumor multifocality and a history of radical cystectomy help to dichotomize between low (LR) and intermediate-risk (IR) categories
When utilizing the risk categories, the OR for muscle invasion were for IR (vs LR) 5.5 (CI95% 1.3;24.0, p= 0.023), and for HR (vs LR) 12.7 (CI95% 3.0; 54.5, p=0.0006).
In this study, they conclude that their low-risk patients and some intermediate-risk patients would be the best candidates for kidney sparing procedures.
Limitations include retrospective design and selection bias (all patients underwent RNU). Ultimately, since they aim to identify patients for kidney sparing procedures, this selection bias may have precluded patients who were eligible for and underwent kidney sparing operations – thereby favoring a more aggressive disease cohort in this analysis.
Presented By: Gautier Marcq, MD MSc, Marcq-en-Baroeul, France
Written By: Thenappan (Thenu) Chandrasekar, MD – Urologic Oncologist, Assistant Professor of Urology, Sidney Kimmel Cancer Center, Thomas Jefferson University, @tchandra_uromd on Twitter during the 2021 European Association of Urology, EAU 2021- Virtual Meeting, July 8-12, 2021.