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EAU Annual Congress 2022

EAU 2022: Clinical Significance of Tumor Location for Ureteroscopic Tumor Grading in Upper Tract Urothelial Carcinoma

(UroToday.com) The 37th Annual European Association of Urology Congress held in Amsterdam, the Netherlands between July 1st, and 4th 2022 was host to an abstract session regarding new insights into the management of upper tract urothelial cancer (UTUC). Dr. Katayama and colleagues evaluated the clinical significance of tumor location with regards to disease upgrading/downgrading at time of radical nephroureterectomy (RNU) in UTUC.

Dr. Katayama began by highlighting the limitations of accurate tumor grading/staging with current ureteroscopic techniques with upgrading rates of 33-51% at time of surgical extirpation.1 It has been demonstrated that UTUC tumor location is associated with survival outcomes, with ureteral tumors having worse prognosis compared to pelvic tumors2 and increased risk of intravesical recurrence.3 However, the effects of tumor location on grade concordance between ureteroscopic biopsy and final surgical pathology have not yet been fully investigated. The objective of this study was thus to evaluate the associations between tumor location and grade concordance.

The authors conducted a multi-institutional, retrospective analysis of UTUC patients who underwent a diagnostic ureteroscopy with biopsy followed by an RNU at 29 centers between 2005 and 2020. The tumor location was divided into four sections: (i) calyceal-pelvis, (ii) proximal ureter, (iii) middle ureter, (iv) distal ureter. The four groups were compared using multiple comparison tests and logistic regression analyses. The study cohort included 1,254 patients, with 58% of tumors in the calyceal-pelvic region, and 16%, 12%, and 14% in the proximal, middle, and distal ureters, respectively.

The alluvial diagram below demonstrates that the rates of upgrading were significantly higher than those for downgrading (54.9% versus 6.8%) with the rates of upgrading visually much higher in patients with middle ureteral disease.

radical nephroureterectomy -1.jpg

The table below demonstrates the rates of upgrading, downgrading, and ungrading by UTUC location. Notably, patients with mid ureteral disease had significantly higher rates of upgrading (73.7%) compared to patient with pelvicalyceal disease (49.6%, p=0.01).

radical nephroureterectomy -2.jpg

Multivariable analysis similarly demonstrated that patients with middle ureteral disease had significantly increased odds of upgrading at time of RNU (OR: 1.81, p=0.008).

radical nephroureterectomy -3.jpg

Dr. Katayama next hypothesized that a middle ureteral location was likely an independent predictor of disease upgrading due to the sharp angulation present at this ureteral segment as it crosses over the common iliac vessels leading to technical difficulty with appropriate disease sampling.

radical nephroureterectomy -4.jpg

Furthermore, ureteral tumors, as compared to pyelocaliceal tumors, are less likely to have advanced staged tumors but have discordantly worse prognoses. This is likely due to: (i) anatomical reasons, whereby the ureter has a thinner layer of adventitia and (ii) pre-operative disease “underestimation” leading to patients with ureteral tumors being less likely to undergo RNUs.4

Dr. Katayama concluded with the following take home messages:

  1. Low-grade UTUC with middle ureteral locations are at high risk of harboring high-grade disease
  2. Understanding the limitations of pre-operative ureteroscopy pathways based on each tumor location may help refine treatment strategies for UTUC

Presented by: Satoshi Katayama, MD, Assistant Professor, Department of Urology, Okayama University, Okayama, Japan

Written by: Rashid Sayyid, MD, MSc – Society of Urologic Oncology (SUO) Clinical Fellow at The University of Toronto, @rksayyid on Twitter during the 2022 European Association of Urology (EAU) Annual Hybrid Meeting, Amsterdam, NL, Fri, July 1 – Mon, July 4, 2022. 

References:

  1. Freund JE, et al. The Diagnostic Yield and Concordance of Ureterorenoscopic Biopsies for Grading of Upper Tract Urothelial Carcinoma: A Dutch Nationwide Analysis. J Endourol. 2020;34(9):907-13.
  2. Kaczmarek K et al. Survival differences of patients with ureteral versus pelvicalyceal tumours: a systematic review and meta-analysis. Arch Med Sci. 2019;17(3):603-12.
  3. Zang X, et al. Development and Validation of a Model for Predicting Intravesical Recurrence in Organ-confined Upper Urinary Tract Urothelial Carcinoma Patients after Radical Nephroureterectomy: a Retrospective Study in One Center with Long-term Follow-up. Pathol Oncol Res. 2020;26(3):1741-8.
  4. Lwin AA, et al. Urothelial Carcinoma of the Renal Pelvis and Ureter: Does Location Make a Difference? Clin Genitourin Cancer. 2020;18(1):45-9.e1.