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MP78-12 PREOPERATIVE CONTROLLING NUTRITIONAL STATUS (CONUT) SCORE AS A NOVEL PREDICTIVE BIOMARKER OF SURVIVAL IN PATIENTS WITH LOCALIZED UROTHELIAL CARCINOMA OF THE UPPER URINARY TRACT TREATED WITH RADICAL NEPHROURETERECTOMY
THE JOURNAL OF UROLOGYâ
Vol. 197, No. 4S, Supplement, Monday, May 15, 2017
INTRODUCTION AND OBJECTIVES: We reported the lack of therapeutic effect of lymphadenectomy on lower ureteral cancer (LUC). We further examined this mechanism by analyzing the recurrence pattern and factors influencing the outcome of LUC. METHODS: From January 1988 to September 2016, we performed radical nephroureterectomy for 83 patients with non-metastatic (clinically N0 M0) LUC at two Japanese institutes. The lower ureter was designated as located below the crossing of the common iliac artery. Metastatic sites were identified with radiological imaging studies or resected specimens. Regional nodes of LUC were identified as ipsilateral pelvic nodes below the aortic bifurcation, according to the description in our previous study. RESULTS: The mean age of the 83 patients was 71.2 years (range: 38e90 years), and the mean follow-up period was 48 months (range: 2e225 months). Radical nephroureterectomy was performed for 41 patients with right LUC and for 42 patients with left LUC. No significant difference was found in the patients who underwent templatebased lymphadenectomy (34% in the right and 36% in the left LUC, p¼0.88). The 5-year recurrence-free and cancer-specific survival rates were respectively 71.9% and 80.1% in the right LUC, and 50.6% and 62.7% in the left LUC. The difference was statistically significant (p¼0.02 and 0.03, respectively; Figure 1). The incidence of lymph node recurrence was even higher in the patients with left LUC (24%) than in those with right LUC (2%), and 60% of the lymph node recurrences occurred at the extraregional nodes in the left LUC. The multivariate analysis revealed that the factors that influenced cancer-specific survival were left ureteral tumors (hazard ratio [HR], 3.38; p¼0.02) and pathological stage T3 or higher (HR, 28.9; p¼0.002). Template-based lymphadenectomy or adjuvant chemotherapy was not a significant factor. CONCLUSIONS: This multi-institutional study shows a higher risk of extraregional nodes recurrence after nephroureterectomy in patients with left LUC, which is likely to be associated with worse oncological outcome of left LUC than right LUC. Template-based lymphadenectomy alone appears inadequate to improve patient survival in left LUC.
e1035
diagnostic ureteroscopy (DURS) is frequently negative. We aim to assess the positive predictive value (PPV) of CTU for UTUC using DURS as the reference standard. METHODS: The study group comprised 79 consecutive patients from 2 academic institutions. They had CTU findings of upper tract wall thickening, hydronephrosis, a filling defect and/or contrast enhancement diagnosed in consensus by 2 radiologists as suspicious for UTUC. DURS, with either wash cytology when endoscopically negative or biopsies when endoscopically positive, was used as the reference standard. The results of DURS were classified as UTUC, benign lesions (BL) and no pathological findings (NPF). Statistical analysis was conducted. RESULTS: Solitary CTU suspected findings were reported in 45 (57%) patients, including thickness in 8 (10%), hydronephrosis in 5 (6%), filling defect in 30 (38%) and enhancement in 2 (3%). Combinations of suspected findings were reported in 34 (43%) patients. DURS revealed 41 (52%) UTUC, 14 (18%) BL and 24 (30%) NPF. Table shows the calculated PPV. The combination of CTU findings had higher PPV in comparison to solitary findings for detection of UTUC (65% vs 42%, respectively; p<0.05, OR 2.5, 95% CI 1.0076.28) as well as for overall endoscopic pathological findings (82% vs 60%, respectively; p<0.05, OR 3.1, 95% CI 1.07-9.02). Arbitrary stratification of solitary CTU findings as minor UTUC predictors (PPV<50%: thickening, hydronephrosis and enhancement) and major UTUC predictors (PPV50%: filling defect) resulted in a statistically significant better prediction for the major group (p<0.05; OR 7.2, 95% CI 1.39-38.15). CONCLUSIONS: The best PPV of CTU diagnosis of UTUC is achieved based on a combination of findings, with filling defect appearing to be the most significant among them. In the absence of filling defect, other CTU findings, such as thickening, hydronephrosis and enhancement, are not predictive for UTUC. We suggest that the need for DURS in these cases should be re-considered in correlation with other data (e.g., cytology, biomarkers, history of heavy smoking, recurrent hematuria, etc.). DURS remains the diagnostic standard for deciding whether or not to proceed to nephroureterectomy.
Source of Funding: None Source of Funding: None
MP78-11 POSITIVE PREDICTIVE VALUE OF CT UROGRAPHY FOR UPPER TRACT UROTHELIAL CARCINOMA DIAGNOSIS USING DIAGNOSTIC URETEROSCOPY AS THE REFERENCE STANDARD Timothy Chan Chang*, Stanford, CA; Ishay Mintz, Yuval Bar-Yosef, Tel Aviv, Israel; Simon Conti, Stanford, CA; Sophie Barnes, Diego Mercer, Nicola Mabjeesh, Tel Aviv, Israel; Joseph Liao, Stanford, CA; Mario Sofer, Tel Aviv, Israel INTRODUCTION AND OBJECTIVES: CT Urography (CTU) is the initial imaging modality of choice for assessing upper urinary tract pathology, including upper tract urothelial carcinoma (UTUC). However, despite abnormal findings on CTU suggestive of UTUC, follow-up
MP78-12 PREOPERATIVE CONTROLLING NUTRITIONAL STATUS (CONUT) SCORE AS A NOVEL PREDICTIVE BIOMARKER OF SURVIVAL IN PATIENTS WITH LOCALIZED UROTHELIAL CARCINOMA OF THE UPPER URINARY TRACT TREATED WITH RADICAL NEPHROURETERECTOMY Hiroki Ishihara*, Tsunenori Kondo, Kazuhiko Yoshida, Kenji Omae, Toshio Takagi, Junpei Iizuka, Kazunari Tanabe, Tokyo, Japan INTRODUCTION AND OBJECTIVES: The purpose of this study was to investigate the correlation between Controlling Nutritional Status (CONUT) score and survival of patients with localized urothelial carcinoma of the upper urinary tract (UCUT) treated with radical nephroureterectomy (RNU).
THE JOURNAL OF UROLOGYâ
e1036
METHODS: We retrospectively enrolled 109 patients. The CONUT score was based on serum albumin level, lymphocyte count, and total cholesterol level. Receiver-operating characteristic curve analysis for relapse-free survival (RFS) was performed, and the maximum Youden index was used to set the cutoff value of CONUT score. According to this cutoff, patients were classified into two groups (i.e., high and low CONUT score). RFS, cancer-specific survival (CSS), and overall survival (OS) after RNU were compared, and predictors of survival were analyzed. RESULTS: For CONUT score, the area under the curve was 0.588 and the optimal cutoff value was 3. Twenty-five patients (22.9%) had high CONUT score. The CONUT score was not associated with the clinicopathological parameters. The patients with high CONUT score had significantly lower 5-year RFS, CSS, and OS than those with low CONUT scores (RFS: 46.7% vs. 66.0%; CSS: 25.7% vs. 71.7%; OS: 24.2% vs. 66.8%, all p < 0.05). Multivariate analyses, after adjustment for factors, including pT stage, pN stage and tumor grade, revealed that CONUT score was an independent predictor of CSS (hazard ratio [HR], 5.03; p ¼ 0.0006) and OS (HR, 3.01; p ¼ 0.0080), and a statistically marginal difference in RFS (HR, 2.15; p ¼ 0.0513). CONCLUSIONS: Preoperative CONUT score is a novel predictive biomarker in patients with localized UCUT treated with RNU.
Vol. 197, No. 4S, Supplement, Monday, May 15, 2017
RESULTS: A total of 707 men and 559 women with a median age of 70 years and body mass index of 27 kg/m2 were included. Almost 80% of the cohort was white, 17% had an Eastern Cooperative Oncology Group (ECOG) performance status 2, 22% had a Charlson comorbidity index (CCI) score > 5 and 50% had baseline chronic disease (CKD) stage III. Overall, 413 (33%) experienced a complication including 103 (8.1%) with a Clavien grade III. Specific distribution of major complications included 49 Clavien III, 44 Clavien IV, and 10 Clavien V. On univariate analysis, patient age (p¼0.006), ASA score (p¼0.02), ECOG (p<0.0001), CCI (p<0.0001), HTN (p¼0.002), DM (p¼0.02), and CKD stage (p<0.001) all were associated with major complications. A multivariate linear regression model highlighted that ECOG 2 (OR 2.38, p¼0.001), CCI > 5 (OR 3.44, p¼0.007), and CKD stage 3 (OR 3.64, p¼0.008) were independently associated with major complications. (Table) CONCLUSIONS: Major complications occur in 8% of patients undergoing RNU. Impaired preoperative performance status (as determined by ECOG or Charlson comorbidity index) and baseline CKD are associated with a major post-surgical adverse event. These easily measurable indices warrant consideration prior to proceeding with RNU.
Source of Funding: None.
MP78-13 IMPAIRED BASELINE PERFORMANCE STATUS AND CHRONIC KIDNEY DISEASE ARE SIGNIFICANTLY ASSOCIATED WITH MAJOR COMPLICATIONS FOLLOWING RADICAL NEPHROURETERECTOMY Neil Kocher*, Jay Raman, Hershey, PA; David Canes, Burlington, MA; Karim Bensalah, Rennes, France; Morgan Roupret, Paris, France; Costas Lallas, Philadelphia, PA; Vitaly Margulis, Dallas, TX; Shahrokh Shariat, Vienna, Austria; Pierre Colin, Lille, France; Surena Matin, Houston, TX; Chad Tracy, Iowa City, IA; Evanguelos Xylinas, Paris, France; Andrew Wagner, Boston, MA; Mathieu Roumiguie, Toulouse, France; Wassim Kassouf, Montreal, Canada; Tobias Klatte, Vienna, Austria INTRODUCTION AND OBJECTIVES: Radical nephroureterectomy (RNU) is the gold standard for management of bulky, invasive, or high grade upper-tract urothelial carcinoma (UTUC). Patients undergoing RNU are elderly and comorbid therefore placing them at risk for complications following surgery. We review an international multicenter cohort of RNU patients to identify the incidence of major complications and risk factors for their occurrence. METHODS: The charts of 1266 patients undergoing RNU at 14 international academic medical centers between 2002 and 2015 were reviewed. Preoperative clinical, demographic, and comorbidity indices were collected. Complications occurring within 30 days of surgery were graded using the modified Clavien-Dindo scale. Multivariate logistic regression determined the association between preoperative variables and Clavien III or greater post-RNU complications.
Source of Funding: None
MP78-14 IMPORTANCE OF TUMOR SIZE AS RISK STRATIFICATION PARAMETER IN UPPER TRACT UROTHELIAL CARCINOMA (UTUC) Beat Foerster*, Vienna, Austria; Thomas Seisen, Paris, France; Marco Bandini, Milan, Italy; Kees Hendricksen, Amsterdam, Netherlands; Anna K. Czech, Krakow, Poland; Marco Moschini, Mohammad Abufaraj, Vienna, Austria; Marco Bianchi, Milan, Italy; Donald Schweitzer, Amsterdam, Netherlands; Kilian M. Gust, Vienna, Austria; Morgan Roupret, Paris, France; Alberto Briganti, Milan, Italy; Bas G. van Rhijn, Amsterdam, Netherlands; Piotr Chlosta, Krakow, Poland; Pierre Colin, Lille, France; Hubert John, Winterthur, Switzerland; Shahrokh F. Shariat, Vienna, Austria INTRODUCTION AND OBJECTIVES: One of the major challenges regarding upper tract urothelial carcinoma (UTUC) is to identify patients who can safely be managed by kidney-sparing surgery (KSS). European Association of Urology (EAU) Guidelines proposed criteria for pre-treatment risk stratification includes a tumor diameter >1cm as exclusion criteria for KSS. Our aim was to evaluate the performance of different tumor diameters for identifying advanced pathologic stage after RNU and to assess its prognostic value on survival.
Vol. 197, No. 4S, Supplement, Monday, May 15, 2017
INTRODUCTION AND OBJECTIVES: We reported the lack of therapeutic effect of lymphadenectomy on lower ureteral cancer (LUC). We further examined this mechanism by analyzing the recurrence pattern and factors influencing the outcome of LUC. METHODS: From January 1988 to September 2016, we performed radical nephroureterectomy for 83 patients with non-metastatic (clinically N0 M0) LUC at two Japanese institutes. The lower ureter was designated as located below the crossing of the common iliac artery. Metastatic sites were identified with radiological imaging studies or resected specimens. Regional nodes of LUC were identified as ipsilateral pelvic nodes below the aortic bifurcation, according to the description in our previous study. RESULTS: The mean age of the 83 patients was 71.2 years (range: 38e90 years), and the mean follow-up period was 48 months (range: 2e225 months). Radical nephroureterectomy was performed for 41 patients with right LUC and for 42 patients with left LUC. No significant difference was found in the patients who underwent templatebased lymphadenectomy (34% in the right and 36% in the left LUC, p¼0.88). The 5-year recurrence-free and cancer-specific survival rates were respectively 71.9% and 80.1% in the right LUC, and 50.6% and 62.7% in the left LUC. The difference was statistically significant (p¼0.02 and 0.03, respectively; Figure 1). The incidence of lymph node recurrence was even higher in the patients with left LUC (24%) than in those with right LUC (2%), and 60% of the lymph node recurrences occurred at the extraregional nodes in the left LUC. The multivariate analysis revealed that the factors that influenced cancer-specific survival were left ureteral tumors (hazard ratio [HR], 3.38; p¼0.02) and pathological stage T3 or higher (HR, 28.9; p¼0.002). Template-based lymphadenectomy or adjuvant chemotherapy was not a significant factor. CONCLUSIONS: This multi-institutional study shows a higher risk of extraregional nodes recurrence after nephroureterectomy in patients with left LUC, which is likely to be associated with worse oncological outcome of left LUC than right LUC. Template-based lymphadenectomy alone appears inadequate to improve patient survival in left LUC.
e1035
diagnostic ureteroscopy (DURS) is frequently negative. We aim to assess the positive predictive value (PPV) of CTU for UTUC using DURS as the reference standard. METHODS: The study group comprised 79 consecutive patients from 2 academic institutions. They had CTU findings of upper tract wall thickening, hydronephrosis, a filling defect and/or contrast enhancement diagnosed in consensus by 2 radiologists as suspicious for UTUC. DURS, with either wash cytology when endoscopically negative or biopsies when endoscopically positive, was used as the reference standard. The results of DURS were classified as UTUC, benign lesions (BL) and no pathological findings (NPF). Statistical analysis was conducted. RESULTS: Solitary CTU suspected findings were reported in 45 (57%) patients, including thickness in 8 (10%), hydronephrosis in 5 (6%), filling defect in 30 (38%) and enhancement in 2 (3%). Combinations of suspected findings were reported in 34 (43%) patients. DURS revealed 41 (52%) UTUC, 14 (18%) BL and 24 (30%) NPF. Table shows the calculated PPV. The combination of CTU findings had higher PPV in comparison to solitary findings for detection of UTUC (65% vs 42%, respectively; p<0.05, OR 2.5, 95% CI 1.0076.28) as well as for overall endoscopic pathological findings (82% vs 60%, respectively; p<0.05, OR 3.1, 95% CI 1.07-9.02). Arbitrary stratification of solitary CTU findings as minor UTUC predictors (PPV<50%: thickening, hydronephrosis and enhancement) and major UTUC predictors (PPV50%: filling defect) resulted in a statistically significant better prediction for the major group (p<0.05; OR 7.2, 95% CI 1.39-38.15). CONCLUSIONS: The best PPV of CTU diagnosis of UTUC is achieved based on a combination of findings, with filling defect appearing to be the most significant among them. In the absence of filling defect, other CTU findings, such as thickening, hydronephrosis and enhancement, are not predictive for UTUC. We suggest that the need for DURS in these cases should be re-considered in correlation with other data (e.g., cytology, biomarkers, history of heavy smoking, recurrent hematuria, etc.). DURS remains the diagnostic standard for deciding whether or not to proceed to nephroureterectomy.
Source of Funding: None Source of Funding: None
MP78-11 POSITIVE PREDICTIVE VALUE OF CT UROGRAPHY FOR UPPER TRACT UROTHELIAL CARCINOMA DIAGNOSIS USING DIAGNOSTIC URETEROSCOPY AS THE REFERENCE STANDARD Timothy Chan Chang*, Stanford, CA; Ishay Mintz, Yuval Bar-Yosef, Tel Aviv, Israel; Simon Conti, Stanford, CA; Sophie Barnes, Diego Mercer, Nicola Mabjeesh, Tel Aviv, Israel; Joseph Liao, Stanford, CA; Mario Sofer, Tel Aviv, Israel INTRODUCTION AND OBJECTIVES: CT Urography (CTU) is the initial imaging modality of choice for assessing upper urinary tract pathology, including upper tract urothelial carcinoma (UTUC). However, despite abnormal findings on CTU suggestive of UTUC, follow-up
MP78-12 PREOPERATIVE CONTROLLING NUTRITIONAL STATUS (CONUT) SCORE AS A NOVEL PREDICTIVE BIOMARKER OF SURVIVAL IN PATIENTS WITH LOCALIZED UROTHELIAL CARCINOMA OF THE UPPER URINARY TRACT TREATED WITH RADICAL NEPHROURETERECTOMY Hiroki Ishihara*, Tsunenori Kondo, Kazuhiko Yoshida, Kenji Omae, Toshio Takagi, Junpei Iizuka, Kazunari Tanabe, Tokyo, Japan INTRODUCTION AND OBJECTIVES: The purpose of this study was to investigate the correlation between Controlling Nutritional Status (CONUT) score and survival of patients with localized urothelial carcinoma of the upper urinary tract (UCUT) treated with radical nephroureterectomy (RNU).
THE JOURNAL OF UROLOGYâ
e1036
METHODS: We retrospectively enrolled 109 patients. The CONUT score was based on serum albumin level, lymphocyte count, and total cholesterol level. Receiver-operating characteristic curve analysis for relapse-free survival (RFS) was performed, and the maximum Youden index was used to set the cutoff value of CONUT score. According to this cutoff, patients were classified into two groups (i.e., high and low CONUT score). RFS, cancer-specific survival (CSS), and overall survival (OS) after RNU were compared, and predictors of survival were analyzed. RESULTS: For CONUT score, the area under the curve was 0.588 and the optimal cutoff value was 3. Twenty-five patients (22.9%) had high CONUT score. The CONUT score was not associated with the clinicopathological parameters. The patients with high CONUT score had significantly lower 5-year RFS, CSS, and OS than those with low CONUT scores (RFS: 46.7% vs. 66.0%; CSS: 25.7% vs. 71.7%; OS: 24.2% vs. 66.8%, all p < 0.05). Multivariate analyses, after adjustment for factors, including pT stage, pN stage and tumor grade, revealed that CONUT score was an independent predictor of CSS (hazard ratio [HR], 5.03; p ¼ 0.0006) and OS (HR, 3.01; p ¼ 0.0080), and a statistically marginal difference in RFS (HR, 2.15; p ¼ 0.0513). CONCLUSIONS: Preoperative CONUT score is a novel predictive biomarker in patients with localized UCUT treated with RNU.
Vol. 197, No. 4S, Supplement, Monday, May 15, 2017
RESULTS: A total of 707 men and 559 women with a median age of 70 years and body mass index of 27 kg/m2 were included. Almost 80% of the cohort was white, 17% had an Eastern Cooperative Oncology Group (ECOG) performance status 2, 22% had a Charlson comorbidity index (CCI) score > 5 and 50% had baseline chronic disease (CKD) stage III. Overall, 413 (33%) experienced a complication including 103 (8.1%) with a Clavien grade III. Specific distribution of major complications included 49 Clavien III, 44 Clavien IV, and 10 Clavien V. On univariate analysis, patient age (p¼0.006), ASA score (p¼0.02), ECOG (p<0.0001), CCI (p<0.0001), HTN (p¼0.002), DM (p¼0.02), and CKD stage (p<0.001) all were associated with major complications. A multivariate linear regression model highlighted that ECOG 2 (OR 2.38, p¼0.001), CCI > 5 (OR 3.44, p¼0.007), and CKD stage 3 (OR 3.64, p¼0.008) were independently associated with major complications. (Table) CONCLUSIONS: Major complications occur in 8% of patients undergoing RNU. Impaired preoperative performance status (as determined by ECOG or Charlson comorbidity index) and baseline CKD are associated with a major post-surgical adverse event. These easily measurable indices warrant consideration prior to proceeding with RNU.
Source of Funding: None.
MP78-13 IMPAIRED BASELINE PERFORMANCE STATUS AND CHRONIC KIDNEY DISEASE ARE SIGNIFICANTLY ASSOCIATED WITH MAJOR COMPLICATIONS FOLLOWING RADICAL NEPHROURETERECTOMY Neil Kocher*, Jay Raman, Hershey, PA; David Canes, Burlington, MA; Karim Bensalah, Rennes, France; Morgan Roupret, Paris, France; Costas Lallas, Philadelphia, PA; Vitaly Margulis, Dallas, TX; Shahrokh Shariat, Vienna, Austria; Pierre Colin, Lille, France; Surena Matin, Houston, TX; Chad Tracy, Iowa City, IA; Evanguelos Xylinas, Paris, France; Andrew Wagner, Boston, MA; Mathieu Roumiguie, Toulouse, France; Wassim Kassouf, Montreal, Canada; Tobias Klatte, Vienna, Austria INTRODUCTION AND OBJECTIVES: Radical nephroureterectomy (RNU) is the gold standard for management of bulky, invasive, or high grade upper-tract urothelial carcinoma (UTUC). Patients undergoing RNU are elderly and comorbid therefore placing them at risk for complications following surgery. We review an international multicenter cohort of RNU patients to identify the incidence of major complications and risk factors for their occurrence. METHODS: The charts of 1266 patients undergoing RNU at 14 international academic medical centers between 2002 and 2015 were reviewed. Preoperative clinical, demographic, and comorbidity indices were collected. Complications occurring within 30 days of surgery were graded using the modified Clavien-Dindo scale. Multivariate logistic regression determined the association between preoperative variables and Clavien III or greater post-RNU complications.
Source of Funding: None
MP78-14 IMPORTANCE OF TUMOR SIZE AS RISK STRATIFICATION PARAMETER IN UPPER TRACT UROTHELIAL CARCINOMA (UTUC) Beat Foerster*, Vienna, Austria; Thomas Seisen, Paris, France; Marco Bandini, Milan, Italy; Kees Hendricksen, Amsterdam, Netherlands; Anna K. Czech, Krakow, Poland; Marco Moschini, Mohammad Abufaraj, Vienna, Austria; Marco Bianchi, Milan, Italy; Donald Schweitzer, Amsterdam, Netherlands; Kilian M. Gust, Vienna, Austria; Morgan Roupret, Paris, France; Alberto Briganti, Milan, Italy; Bas G. van Rhijn, Amsterdam, Netherlands; Piotr Chlosta, Krakow, Poland; Pierre Colin, Lille, France; Hubert John, Winterthur, Switzerland; Shahrokh F. Shariat, Vienna, Austria INTRODUCTION AND OBJECTIVES: One of the major challenges regarding upper tract urothelial carcinoma (UTUC) is to identify patients who can safely be managed by kidney-sparing surgery (KSS). European Association of Urology (EAU) Guidelines proposed criteria for pre-treatment risk stratification includes a tumor diameter >1cm as exclusion criteria for KSS. Our aim was to evaluate the performance of different tumor diameters for identifying advanced pathologic stage after RNU and to assess its prognostic value on survival.