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ORGAN-SPARING TREATMENT OF NON MUSCLE-INVASIVE UPPER URINARY TRACT TRANSITIONAL CELL CARCINOMA: A MULTI-INSTITUTIONAL EXPERIENCE
THE JOURNAL OF UROLOGY®
Vol. 181, No. 4, Supplement, Sunday, April 26, 2009
374 EXPERIENCE WITH COMPLEX PERCUTANEOUS RESECTIONS FOR UPPER TRACT UROTHELIAL CARCINOMA Brian H Irwin*, Andre Berger, Ricardo Brandina, Cleveland, OH; David Canes, Burlington, MA; Armine K Smith, Sebastien Crouzet, Georges-Pascal Haber, Kazumi Kamoi, Robert J Stein, Mihir M Desai, Cleveland, OH INTRODUCTION AND OBJECTIVE: Percutaneous endoscopic resection is a viable treatment option for upper tract urothelial carcinomas (UC) in carefully selected patients. We present our experience with patients who have undergone percutaneous endoscopic therapy for complex tumors. METHODS: Patients undergoing endoscopic treatment for UC were identified within a prospectively maintained patient database at a single institution. Charts were reviewed to identify complex patients who met at least one of the following criteria: (a) tumor size >2.5cm, (b) preoperative creatinine level >3.0, or (c) anatomical variant such as autotransplanted kidneys, prior partial nephrectomy of effected kidney or prior cystectomy/urinary diversion. Demographic, operative, and oncologic data were captured. Recurrence free, disease specific and overall survivals were calculated for both the complex and the non-complex cases. RESULTS: A total of 48 patients were identified who underwent endoscopic treatment for upper tract UC since 1985. Of these, 17 patients met the criteria for complex resections (tumors >2.5cm (N=9), pre-op creatinine>3.0 (N=3), prior partial nephrectomy (N=2), prior cystectomy (N=2), prior distal ureterectomy (N=1), auto-transplanted kidney (N=1)) with a median follow-up of 22 months. No difference was found between the two groups with regard to mean age (70.3±10.3 years in noncomplex cases versus 69.5±10.9 years in complex cases), complication rate (4% versus 6%) or change in creatinine (1.30 to 1.25 versus 1.40 to 1.38). The incidences of high grade tumors (40% in non-complex cases versus 60% in complex cases), invasive tumors (18% versus 18%), prior contralateral nephroureterectomy (46% versus 56%) and history of prior bladder cancers (52% versus 42%) were similar between the two groups. Patients in the non-complex group were less likely to have solitary kidneys (32% versus 92%) and larger tumors (1.48 ± 0.65cm versus 3.13 ± 0.79cm). No difference was seen cancer specific survival (P=0.97). Improved trends in overall survival (P=0.14) and recurrence free survival (P=0.08) were seen in the non-complex groups when compared to the complex group. CONCLUSIONS: These findings suggest that patients with large tumors, poor renal function and significant anatomical variations may be well served by endoscopic treatment for upper tract UC. These resections may be both safe and feasible even in patients who might be thought to be at high risk for technical and physiologic complications. Source of Funding: None
375 LONG TERM ONCOLOGICAL OUTCOMES FOR UPPER TRACT UROTHELIAL CARCINOMA: ENDOSCOPIC TREATMENT VERSUS NEPHROURETERECTOMY Andre Berger*, Ricardo Brandina, Brian H Irwin, Kazumi Kamoi, Sebastien Crouzet, Georges-Pascal Haber, David Canes, Robert J Stein, Monish Aron, Inderbir S Gill, Mihir M Desai, Cleveland, OH INTRODUCTION AND OBJECTIVE: To compare longterm oncological outcomes following endoscopic treatment and nephroureterectomy (NU) either open or laparoscopic for upper tract transitional cell carcinoma (TCC). METHODS: Between April 1992 and January 2008, 45 patients (76% with solitary kidneys) underwent endoscopic treatment (percutaneous or ureteroscopic) with curative intent and 402 underwent NU (216 laparoscopic and 186 open) for upper tract TCC at our institution. Data were obtained from a prospectively maintained database, patient charts, telephone follow-up and a review of the Social Security Death Index. RESULTS: There were no significant differences between the endoscopic and NU groups as regards mean patient age (70vs. 70 yrs),
135
ASA class and comorbidities. Mean follow-up was 44 and 43 months, respectively. Most patients presented with high grade disease (56% vs. 74% p= 0.01). Five-year overall, cancer-specific survival and recurrencefree survival in the endoscopic group and NU group were, respectively, 56%, 78% and 55% vs. 56%, 78% and 59% (p > 0.05 for all). Tumor grade was the only independent prognostic factor for both cancer-specific (p= 0.02) and recurrence-free survival on a multivariate analysis (p = 0.03). Even after analyzing survival by grade, no statically significant difference was found between the groups. CONCLUSIONS: Long-term oncological outcomes after endoscopic treatment for upper tract TCC comparable to extirpative procedure either in low grade or high grade disease. It can be recommended as an alternative to nephroureterectomy in selected patients. Source of Funding: None
376 ORGAN-SPARING TREATMENT OF NON MUSCLE-INVASIVE UPPER URINARY TRACT TRANSITIONAL CELL CARCINOMA: A MULTI-INSTITUTIONAL EXPERIENCE Ardeshir R Rastinehad*, Long Island, NY; Gianluca Giannarini, George N Thalmann, Urs E Studer, Bern, Switzerland; Arthur D Smith, Long Island, NY INTRODUCTION AND OBJECTIVE: To determine whether the use of Bacillus Calmette-Guèrin (BCG) in the organ-sparing treatment of non muscle-invasive (NMI) upper urinary tract (UUT) transitional cell carcinoma (TCC) has an oncological benefit. METHODS: We retrospectively analyzed the combined series of 118 renal units (RU) in 111 patients (mean age 69.7±11.5 years) treated for NMI UUT TCC. Three approaches were utilized: primary BCG perfusion for RU with carcinoma in situ (CIS) (n=31), and percutaneous resection with (n=54) or without (n=33) adjuvant BCG perfusion for RU with papillary NMI tumors. Recurrence was defined as positive selective UUT cytology after obtaining negative cytology for RU with CIS, and positive biopsy after the 3-month nephroscopy for RU undergoing resection. Progression was defined as an increase in grade or stage of primary tumor at time of recurrence. For the purpose of analysis, RU were stratified by initial treatment modality, primary BCG perfusion versus percutaneous resection. RU undergoing percutaneous resection were stratified by adjuvant BCG therapy. Outcome measures were recurrence, progression, and renal preservation rate, time to recurrence and overall survival. Chi-square and independent t tests were used for comparison of all outcome measures between these strata. RESULTS: Mean and median follow up was 61.8±55.8 and 42 months, respectively. There was no statistical difference in tumor grade or stage between BCG-treated and non-treated RU (p>.05). Overall progression rate was 19.9%, diminishing to 6.5% for RU with CIS. Overall renal preservation rate was 84.7%, reaching 93.5% for RU with CIS. No statistically significant difference between the above mentioned strata was found in the outcome measures (p>.05). All results are detailed in the table. CONCLUSIONS: Our data suggests that organ-sparing treatment of NMI UUT TCC yields a relatively high (>75%) renal preservation rate. The use of adjuvant BCG therapy after resection appeared not to have an impact on recurrence, progression, renal preservation rate, time to recurrence, and overall survival. BCG perfusion seems to give the best results in patients with UUT CIS. Source of Funding: None
377 ENDOSCOPIC MANAGEMENT OF UPPER TRACT UROTHELIAL CARCINOMA IN PATIENTS WITH HEREDITARY NONPOLYPOSIS COLORECTAL CANCER (LYNCH SYNDROME) Scott G Hubosky*, Sarah Charles, Bruce Bowman, Demetrius H Bagley, Philadelphia, PA INTRODUCTION AND OBJECTIVE: Hereditary nonpolyposis colorectal cancer is a genetic disorder associated with extracolonic
Vol. 181, No. 4, Supplement, Sunday, April 26, 2009
374 EXPERIENCE WITH COMPLEX PERCUTANEOUS RESECTIONS FOR UPPER TRACT UROTHELIAL CARCINOMA Brian H Irwin*, Andre Berger, Ricardo Brandina, Cleveland, OH; David Canes, Burlington, MA; Armine K Smith, Sebastien Crouzet, Georges-Pascal Haber, Kazumi Kamoi, Robert J Stein, Mihir M Desai, Cleveland, OH INTRODUCTION AND OBJECTIVE: Percutaneous endoscopic resection is a viable treatment option for upper tract urothelial carcinomas (UC) in carefully selected patients. We present our experience with patients who have undergone percutaneous endoscopic therapy for complex tumors. METHODS: Patients undergoing endoscopic treatment for UC were identified within a prospectively maintained patient database at a single institution. Charts were reviewed to identify complex patients who met at least one of the following criteria: (a) tumor size >2.5cm, (b) preoperative creatinine level >3.0, or (c) anatomical variant such as autotransplanted kidneys, prior partial nephrectomy of effected kidney or prior cystectomy/urinary diversion. Demographic, operative, and oncologic data were captured. Recurrence free, disease specific and overall survivals were calculated for both the complex and the non-complex cases. RESULTS: A total of 48 patients were identified who underwent endoscopic treatment for upper tract UC since 1985. Of these, 17 patients met the criteria for complex resections (tumors >2.5cm (N=9), pre-op creatinine>3.0 (N=3), prior partial nephrectomy (N=2), prior cystectomy (N=2), prior distal ureterectomy (N=1), auto-transplanted kidney (N=1)) with a median follow-up of 22 months. No difference was found between the two groups with regard to mean age (70.3±10.3 years in noncomplex cases versus 69.5±10.9 years in complex cases), complication rate (4% versus 6%) or change in creatinine (1.30 to 1.25 versus 1.40 to 1.38). The incidences of high grade tumors (40% in non-complex cases versus 60% in complex cases), invasive tumors (18% versus 18%), prior contralateral nephroureterectomy (46% versus 56%) and history of prior bladder cancers (52% versus 42%) were similar between the two groups. Patients in the non-complex group were less likely to have solitary kidneys (32% versus 92%) and larger tumors (1.48 ± 0.65cm versus 3.13 ± 0.79cm). No difference was seen cancer specific survival (P=0.97). Improved trends in overall survival (P=0.14) and recurrence free survival (P=0.08) were seen in the non-complex groups when compared to the complex group. CONCLUSIONS: These findings suggest that patients with large tumors, poor renal function and significant anatomical variations may be well served by endoscopic treatment for upper tract UC. These resections may be both safe and feasible even in patients who might be thought to be at high risk for technical and physiologic complications. Source of Funding: None
375 LONG TERM ONCOLOGICAL OUTCOMES FOR UPPER TRACT UROTHELIAL CARCINOMA: ENDOSCOPIC TREATMENT VERSUS NEPHROURETERECTOMY Andre Berger*, Ricardo Brandina, Brian H Irwin, Kazumi Kamoi, Sebastien Crouzet, Georges-Pascal Haber, David Canes, Robert J Stein, Monish Aron, Inderbir S Gill, Mihir M Desai, Cleveland, OH INTRODUCTION AND OBJECTIVE: To compare longterm oncological outcomes following endoscopic treatment and nephroureterectomy (NU) either open or laparoscopic for upper tract transitional cell carcinoma (TCC). METHODS: Between April 1992 and January 2008, 45 patients (76% with solitary kidneys) underwent endoscopic treatment (percutaneous or ureteroscopic) with curative intent and 402 underwent NU (216 laparoscopic and 186 open) for upper tract TCC at our institution. Data were obtained from a prospectively maintained database, patient charts, telephone follow-up and a review of the Social Security Death Index. RESULTS: There were no significant differences between the endoscopic and NU groups as regards mean patient age (70vs. 70 yrs),
135
ASA class and comorbidities. Mean follow-up was 44 and 43 months, respectively. Most patients presented with high grade disease (56% vs. 74% p= 0.01). Five-year overall, cancer-specific survival and recurrencefree survival in the endoscopic group and NU group were, respectively, 56%, 78% and 55% vs. 56%, 78% and 59% (p > 0.05 for all). Tumor grade was the only independent prognostic factor for both cancer-specific (p= 0.02) and recurrence-free survival on a multivariate analysis (p = 0.03). Even after analyzing survival by grade, no statically significant difference was found between the groups. CONCLUSIONS: Long-term oncological outcomes after endoscopic treatment for upper tract TCC comparable to extirpative procedure either in low grade or high grade disease. It can be recommended as an alternative to nephroureterectomy in selected patients. Source of Funding: None
376 ORGAN-SPARING TREATMENT OF NON MUSCLE-INVASIVE UPPER URINARY TRACT TRANSITIONAL CELL CARCINOMA: A MULTI-INSTITUTIONAL EXPERIENCE Ardeshir R Rastinehad*, Long Island, NY; Gianluca Giannarini, George N Thalmann, Urs E Studer, Bern, Switzerland; Arthur D Smith, Long Island, NY INTRODUCTION AND OBJECTIVE: To determine whether the use of Bacillus Calmette-Guèrin (BCG) in the organ-sparing treatment of non muscle-invasive (NMI) upper urinary tract (UUT) transitional cell carcinoma (TCC) has an oncological benefit. METHODS: We retrospectively analyzed the combined series of 118 renal units (RU) in 111 patients (mean age 69.7±11.5 years) treated for NMI UUT TCC. Three approaches were utilized: primary BCG perfusion for RU with carcinoma in situ (CIS) (n=31), and percutaneous resection with (n=54) or without (n=33) adjuvant BCG perfusion for RU with papillary NMI tumors. Recurrence was defined as positive selective UUT cytology after obtaining negative cytology for RU with CIS, and positive biopsy after the 3-month nephroscopy for RU undergoing resection. Progression was defined as an increase in grade or stage of primary tumor at time of recurrence. For the purpose of analysis, RU were stratified by initial treatment modality, primary BCG perfusion versus percutaneous resection. RU undergoing percutaneous resection were stratified by adjuvant BCG therapy. Outcome measures were recurrence, progression, and renal preservation rate, time to recurrence and overall survival. Chi-square and independent t tests were used for comparison of all outcome measures between these strata. RESULTS: Mean and median follow up was 61.8±55.8 and 42 months, respectively. There was no statistical difference in tumor grade or stage between BCG-treated and non-treated RU (p>.05). Overall progression rate was 19.9%, diminishing to 6.5% for RU with CIS. Overall renal preservation rate was 84.7%, reaching 93.5% for RU with CIS. No statistically significant difference between the above mentioned strata was found in the outcome measures (p>.05). All results are detailed in the table. CONCLUSIONS: Our data suggests that organ-sparing treatment of NMI UUT TCC yields a relatively high (>75%) renal preservation rate. The use of adjuvant BCG therapy after resection appeared not to have an impact on recurrence, progression, renal preservation rate, time to recurrence, and overall survival. BCG perfusion seems to give the best results in patients with UUT CIS. Source of Funding: None
377 ENDOSCOPIC MANAGEMENT OF UPPER TRACT UROTHELIAL CARCINOMA IN PATIENTS WITH HEREDITARY NONPOLYPOSIS COLORECTAL CANCER (LYNCH SYNDROME) Scott G Hubosky*, Sarah Charles, Bruce Bowman, Demetrius H Bagley, Philadelphia, PA INTRODUCTION AND OBJECTIVE: Hereditary nonpolyposis colorectal cancer is a genetic disorder associated with extracolonic