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MP2-12 PROGNOSTIC IMPACT OF TUMOR STAGE ON POSITIVE LYMPH NODE STATUS IN UPPER TRACT UROTHELIAL CARCINOMA FOLLOWING RADICAL NEPHROURETERECTOMY
THE JOURNAL OF UROLOGYâ
Vol. 193, No. 4S, Supplement, Friday, May 15, 2015
survival (CSS) and overall survivals (OS) by using Cox-proportional hazard mode. RESULTS: A total of 280 patients had renal pelvic tumors (55.7%), 184 had ureteral tumors (28.8%) and remaining 39 patients have multifocal tumors at both renal pelvis and ureter (7.7%). During the median follow-up duration of 52 months, the disease recurrence; the 5years RFS and CSS probabilities were 92%, 79%, 65% and 71% as well as 94%, 84%, 75% and 58% in superficial, T2, pT3 and T4 disease, respectively (p< 0.001 and p< 0.001, respectively). The multivariate analysis concluded advanced tumor stage (reference: Ta/T1/Tis tumor) 70 year-old were independent risk factors predicting RFS, and age¡U CSS and OS after RNU (all p<0.001). In the subgroup analyses stratified by tumor stage and location, only pT3 ureteral tumors a shorter duration of RFS than did renal pelvic tumors (log rank test, p ¼ 0.047). The 5¡Vyear disease RFS rates were 50% and 71% in pT3 ureteral and renal pelvic patients, respectively. But in multivariate analysis, the ureteral tumor was not associated poor prognosis than renal pelvic tumor in pT3 disease. There was no prognostic relevance of tumor location in pTa/Tis/T1, pT2 and pT4 diseases. CONCLUSIONS: The UTUC patients with pT3 ureteral tumors had more frequent disease recurrence and a shorter duration of RFS than did those with pT3 renal pelvic diseases. The advanced tumor 70 year-old were indestage (reference: Ta/T1/Tis tumor) and age¡U pendent risk factors predicting RFS, CSS and OS after RNU (all p<0.001). These results underscore the need for close follow-up and the consideration of adjuvant chemotherapy after RNU for patients with stage pT3 ureteral cancer. Source of Funding: none
MP2-12 PROGNOSTIC IMPACT OF TUMOR STAGE ON POSITIVE LYMPH NODE STATUS IN UPPER TRACT UROTHELIAL CARCINOMA FOLLOWING RADICAL NEPHROURETERECTOMY Atiqullah Aziz*, Hamburg, Germany; Shahrokh F. Shariat, Vienna, Austria; Luis Alex Kluth, Hamburg, Germany; Georgios Gakis, €bingen, Germany; Hans-Martin Fritsche, Regensburg, Germany; Tu Morgan Roupret, Paris, France; Harun Fajkovic, Vienna, Austria; Armin Soave, Hamburg, Germany; Giacomo Novara, Padua, Italy; Armin Pycha, Bolzano, Italy; Mesut Remzi, Korneuburg, Austria; Richard Zigeuner, Graz, Austria; Jay D. Raman, Hershey, PA; Alberto Briganti, Milan, Italy; Karim Bensalah, Rennes, France; Vitaly Margulis, Dallas, TX; Evanguelos Xylinas, Paris, France; Margit Fisch, Michael Rink, Hamburg, Germany INTRODUCTION AND OBJECTIVES: Despite its pivotal role at radical cystectomy for urothelial carcinoma of the bladder (UCB), lymph node (LN) dissection (LND) at radical nephroureterectomy (RNU) for treatment of upper tract urothelial carcinoma (UTUC) is still not routinely performed. The aim of the present study was to analyze the stage-specific impact of LN status on survival outcomes after RNU. METHODS: We collected data of 1112 UTUC patients treated with RNU and LND at 23 centers from 1994 to 2012. A comparative analysis of LN status with pathologic tumor stage and established clinicopathologic parameters was performed. In addition, we controlled for the stage-specific impact of LN status on recurrence-free (RFS), cancer-specific (CSS) and overall survival (OS), respectively. RESULTS: In total, 284 patients (25.5%) had presence of LN metastasis. The distribution of a positive LN status in pT0-Ta-Tis-T1, pT2 and pT3/T4 was 7.7%, 11.6% and 80.6%, respectively (p<0.001). In addition, a pelvicaliceal tumor location, open RNU, high-grade tumors, sessile tumor architecture, tumor necrosis, lymphovascular invasion and administration of adjuvant chemotherapy were significantly associated with presence of LN metastasis (p0.038). In general, patients with LN metastasis had significantly worse outcomes compared to pN0 patients at a median follow-up of 31 months. However, there were significant differences in stage-specific outcome analyses. Interestingly,
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there was no difference in RFS between patients with pT0-Ta-Tis-T1 (74% vs. 83%; p¼0.338) and in OS between patients with pT0-Ta-TisT1 (63% vs. 74%; p¼0.749) and pT2 (53% vs. 56%; p¼0.394), respectively. In contrast, the stage-specific 5-year survival rates were significantly poorer in nodal positive patients with pT0-Ta-Tis-T1 (CSS: 74% vs. 91%; p¼0.023), pT2 (RFS: 48% vs. 62%; CSS: 53% vs. 68%; p0.023 for all) and pT3/4 (RFS: 8% vs. 39%; CSS: 14% vs. 50%; OS: 11% vs. 31%; all p<0.001), respectively, compared to their LN negative counterparts. CONCLUSIONS: A non-negligible number of patients with early disease stages harbor LN metastasis at time of RNU, and thus LND should be recommended in any patient treated with RNU. Similar to UCB, higher stage of disease matters in UTUC due to its significant impact on higher risk for positive LN status, thus resulting to an adverse survival outcome. Source of Funding: none
MP2-13 RADIOGRAPHIC FINDINGS ON CT SCAN ASSOCIATED WITH LYMPH NODE METASTASES IN UPPER TRACT UROTHELIAL CARCINOMA Eugene Cha*, Alyssa Yee, Melissa Assel, Maura Micco, John Sfakianos, Philip Kim, Fara Friedman, Itay Sternberg, Daniel Sjoberg, H. Alberto Vargas, Jonathan Coleman, New York, NY INTRODUCTION AND OBJECTIVES: There is no consensus regarding the indications for lymph node dissection (LND) for upper tract urothelial carcinoma (UTUC) or the extent of LND necessary for adequate staging. We sought to evaluate the performance of various radiographic parameters on CT scan in identifying positive LNs in UTUC patients undergoing radical nephroureterectomy (RNU). METHODS: We analyzed chemotherapy-naïve patients treated at our institution from 1997 to January 2013 with RNU and regional LND for UTUC who had pre-operative CT scans within 90 days of surgery available for review. CT scans were evaluated by a radiologist blinded to pathology results. Radiographic characteristics examined included short axis LN diameter, round vs. oval shape, irregular margins, absence of a fatty hilum, marked enhancement, central necrosis, and total number of LNs visualized. Logistic regression and Fisher’s exact test were used to assess the agreement between radiographic characteristics and positive LNs on pathology. RESULTS: Of 158 patients treated with RNU and LND, 37 (23%) had positive LNs on pathology. The median number LNs identified at time of LND was 8 (IQR 4e15). The sites most often involved with positive LNs were the para-caval and para-aortic regions (13 and 15 patients, respectively). Each of the radiographic characteristics except for the total number of LNs visualized (LN short-axis diameter 1.0 cm, LN short-axis diameter 0.8 cm plus round shape of LN, round shape of LN, absence of fatty hilum of LN, marked enhancement of LN, central necrosis of LN, irregular margins of LN, and short axis diameter of the largest LN as a continuous variable) was statistically associated with LN pathology when evaluated over all LN regions, but none of the definitions provided strong predictive value. Across the significant radiographic characteristics all positive predictive values were 69% or less and the proportion of false negatives among those with a negative test was at least 12%. CONCLUSIONS: We identified radiographic characteristics on CT that are associated with positive pathology at LND during RNU. However, radiographic characteristics could not adequately exclude LN positivity and hence negative imaging does not obviate the need for LND. Prospective studies are needed to assess the distribution of positive LNs in patients with UTUC, stratified by laterality and tumor location, so that LND templates can be standardized. Source of Funding: none
Vol. 193, No. 4S, Supplement, Friday, May 15, 2015
survival (CSS) and overall survivals (OS) by using Cox-proportional hazard mode. RESULTS: A total of 280 patients had renal pelvic tumors (55.7%), 184 had ureteral tumors (28.8%) and remaining 39 patients have multifocal tumors at both renal pelvis and ureter (7.7%). During the median follow-up duration of 52 months, the disease recurrence; the 5years RFS and CSS probabilities were 92%, 79%, 65% and 71% as well as 94%, 84%, 75% and 58% in superficial, T2, pT3 and T4 disease, respectively (p< 0.001 and p< 0.001, respectively). The multivariate analysis concluded advanced tumor stage (reference: Ta/T1/Tis tumor) 70 year-old were independent risk factors predicting RFS, and age¡U CSS and OS after RNU (all p<0.001). In the subgroup analyses stratified by tumor stage and location, only pT3 ureteral tumors a shorter duration of RFS than did renal pelvic tumors (log rank test, p ¼ 0.047). The 5¡Vyear disease RFS rates were 50% and 71% in pT3 ureteral and renal pelvic patients, respectively. But in multivariate analysis, the ureteral tumor was not associated poor prognosis than renal pelvic tumor in pT3 disease. There was no prognostic relevance of tumor location in pTa/Tis/T1, pT2 and pT4 diseases. CONCLUSIONS: The UTUC patients with pT3 ureteral tumors had more frequent disease recurrence and a shorter duration of RFS than did those with pT3 renal pelvic diseases. The advanced tumor 70 year-old were indestage (reference: Ta/T1/Tis tumor) and age¡U pendent risk factors predicting RFS, CSS and OS after RNU (all p<0.001). These results underscore the need for close follow-up and the consideration of adjuvant chemotherapy after RNU for patients with stage pT3 ureteral cancer. Source of Funding: none
MP2-12 PROGNOSTIC IMPACT OF TUMOR STAGE ON POSITIVE LYMPH NODE STATUS IN UPPER TRACT UROTHELIAL CARCINOMA FOLLOWING RADICAL NEPHROURETERECTOMY Atiqullah Aziz*, Hamburg, Germany; Shahrokh F. Shariat, Vienna, Austria; Luis Alex Kluth, Hamburg, Germany; Georgios Gakis, €bingen, Germany; Hans-Martin Fritsche, Regensburg, Germany; Tu Morgan Roupret, Paris, France; Harun Fajkovic, Vienna, Austria; Armin Soave, Hamburg, Germany; Giacomo Novara, Padua, Italy; Armin Pycha, Bolzano, Italy; Mesut Remzi, Korneuburg, Austria; Richard Zigeuner, Graz, Austria; Jay D. Raman, Hershey, PA; Alberto Briganti, Milan, Italy; Karim Bensalah, Rennes, France; Vitaly Margulis, Dallas, TX; Evanguelos Xylinas, Paris, France; Margit Fisch, Michael Rink, Hamburg, Germany INTRODUCTION AND OBJECTIVES: Despite its pivotal role at radical cystectomy for urothelial carcinoma of the bladder (UCB), lymph node (LN) dissection (LND) at radical nephroureterectomy (RNU) for treatment of upper tract urothelial carcinoma (UTUC) is still not routinely performed. The aim of the present study was to analyze the stage-specific impact of LN status on survival outcomes after RNU. METHODS: We collected data of 1112 UTUC patients treated with RNU and LND at 23 centers from 1994 to 2012. A comparative analysis of LN status with pathologic tumor stage and established clinicopathologic parameters was performed. In addition, we controlled for the stage-specific impact of LN status on recurrence-free (RFS), cancer-specific (CSS) and overall survival (OS), respectively. RESULTS: In total, 284 patients (25.5%) had presence of LN metastasis. The distribution of a positive LN status in pT0-Ta-Tis-T1, pT2 and pT3/T4 was 7.7%, 11.6% and 80.6%, respectively (p<0.001). In addition, a pelvicaliceal tumor location, open RNU, high-grade tumors, sessile tumor architecture, tumor necrosis, lymphovascular invasion and administration of adjuvant chemotherapy were significantly associated with presence of LN metastasis (p0.038). In general, patients with LN metastasis had significantly worse outcomes compared to pN0 patients at a median follow-up of 31 months. However, there were significant differences in stage-specific outcome analyses. Interestingly,
e15
there was no difference in RFS between patients with pT0-Ta-Tis-T1 (74% vs. 83%; p¼0.338) and in OS between patients with pT0-Ta-TisT1 (63% vs. 74%; p¼0.749) and pT2 (53% vs. 56%; p¼0.394), respectively. In contrast, the stage-specific 5-year survival rates were significantly poorer in nodal positive patients with pT0-Ta-Tis-T1 (CSS: 74% vs. 91%; p¼0.023), pT2 (RFS: 48% vs. 62%; CSS: 53% vs. 68%; p0.023 for all) and pT3/4 (RFS: 8% vs. 39%; CSS: 14% vs. 50%; OS: 11% vs. 31%; all p<0.001), respectively, compared to their LN negative counterparts. CONCLUSIONS: A non-negligible number of patients with early disease stages harbor LN metastasis at time of RNU, and thus LND should be recommended in any patient treated with RNU. Similar to UCB, higher stage of disease matters in UTUC due to its significant impact on higher risk for positive LN status, thus resulting to an adverse survival outcome. Source of Funding: none
MP2-13 RADIOGRAPHIC FINDINGS ON CT SCAN ASSOCIATED WITH LYMPH NODE METASTASES IN UPPER TRACT UROTHELIAL CARCINOMA Eugene Cha*, Alyssa Yee, Melissa Assel, Maura Micco, John Sfakianos, Philip Kim, Fara Friedman, Itay Sternberg, Daniel Sjoberg, H. Alberto Vargas, Jonathan Coleman, New York, NY INTRODUCTION AND OBJECTIVES: There is no consensus regarding the indications for lymph node dissection (LND) for upper tract urothelial carcinoma (UTUC) or the extent of LND necessary for adequate staging. We sought to evaluate the performance of various radiographic parameters on CT scan in identifying positive LNs in UTUC patients undergoing radical nephroureterectomy (RNU). METHODS: We analyzed chemotherapy-naïve patients treated at our institution from 1997 to January 2013 with RNU and regional LND for UTUC who had pre-operative CT scans within 90 days of surgery available for review. CT scans were evaluated by a radiologist blinded to pathology results. Radiographic characteristics examined included short axis LN diameter, round vs. oval shape, irregular margins, absence of a fatty hilum, marked enhancement, central necrosis, and total number of LNs visualized. Logistic regression and Fisher’s exact test were used to assess the agreement between radiographic characteristics and positive LNs on pathology. RESULTS: Of 158 patients treated with RNU and LND, 37 (23%) had positive LNs on pathology. The median number LNs identified at time of LND was 8 (IQR 4e15). The sites most often involved with positive LNs were the para-caval and para-aortic regions (13 and 15 patients, respectively). Each of the radiographic characteristics except for the total number of LNs visualized (LN short-axis diameter 1.0 cm, LN short-axis diameter 0.8 cm plus round shape of LN, round shape of LN, absence of fatty hilum of LN, marked enhancement of LN, central necrosis of LN, irregular margins of LN, and short axis diameter of the largest LN as a continuous variable) was statistically associated with LN pathology when evaluated over all LN regions, but none of the definitions provided strong predictive value. Across the significant radiographic characteristics all positive predictive values were 69% or less and the proportion of false negatives among those with a negative test was at least 12%. CONCLUSIONS: We identified radiographic characteristics on CT that are associated with positive pathology at LND during RNU. However, radiographic characteristics could not adequately exclude LN positivity and hence negative imaging does not obviate the need for LND. Prospective studies are needed to assess the distribution of positive LNs in patients with UTUC, stratified by laterality and tumor location, so that LND templates can be standardized. Source of Funding: none