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Re: The Effect of Tumor Location on Prognosis in Patients Treated With Radical Nephroureterectomy at Memorial Sloan-Kettering Cancer Center
RENAL, URETERAL AND RETROPERITONEAL TUMORS
463
Re: The Effect of Tumor Location on Prognosis in Patients Treated With Radical Nephroureterectomy at Memorial Sloan-Kettering Cancer Center R. L. Favaretto, S. F. Shariat, D. C. Chade, G. Godoy, A. Adamy, M. Kaag, B. H. Bochner, J. Coleman and G. Dalbagni Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York Eur Urol 2010; 58: 574 –580.
Background: The prognostic impact of primary tumor location on outcomes for patients with uppertract urothelial carcinoma (UTUC) is still contentious. Objective: To test the association between tumor location and disease recurrence and cancer-specific survival (CSS) in patients treated with radical nephroureterectomy (RNU) for UTUC. Design, Setting, and Participants: Prospectively collected data were retrospectively reviewed from 324 consecutive patients treated with RNU between 1995 and 2008 at a single tertiary referral center. Patients who had previous radical cystectomy, preoperative chemotherapy, previous contralateral UTUC, or metastatic disease at presentation were excluded. This left 253 patients for analysis. Tumor location was categorized as renal pelvis or ureter based on the location of the dominant tumor. Recurrences in the bladder only, in nonbladder sites, and in any site were analyzed. Intervention: All patients were treated with RNU. Measurements: Recurrence-free survival and CSS probabilities were estimated using Kaplan-Meier and Cox regression analyses. Results and Limitations: Median follow-up for survivors was 48 mo. The 5-yr recurrencefree probability (including bladder recurrence) and CSS estimates were 32% and 78%, respectively. On multivariable analysis, pathologic stage was the only predictor for disease recurrence (p⫽0.01). Tumor location was not an independent predictor for recurrence (hazard ratio: 1.19; p⫽0.3), and there was no difference in the probability of disease recurrence between ureteral and renal pelvic tumors (p⫽0.18). On survival analysis, we also found no differences between ureteral and renal pelvic tumors on probability of CSS (p⫽0.2). On multivariate analysis, pathologic stage (p⬍0.0001) and nodal status (p⫽0.01) were associated with worse CSS. This study is limited by its retrospective nature. Conclusions: Our study did not show any differences in recurrence and CSS rates between patients with ureteral and renal pelvic tumors treated with RNU. Editorial Comment: The authors evaluate a retrospective, single institution data set of patients undergoing nephroureterectomy for upper tract urothelial cancers to determine if site of disease affects oncologic outcome or survival. They show no difference in outcome between tumors of the renal pelvis and ureter. Distal ureteral tumors are not distinguished from proximal, and while cohorts seem matched, patients undergoing segmental ureterectomy are apparently excluded. As such, unless all patients in the reported period were treated with nephroureterectomy, one could only conclude that ureteral tumors selected for nephroureterectomy have outcomes comparable to renal pelvic tumors. It remains unclear whether the entire denominator of patients with ureteral disease might fare better as a whole. The authors did not address the issue of whether segmental ureterectomy is appropriate for a subset of those with strictly ureteral disease. Samir S. Taneja, M.D.
Changes in Renal Function Following Nephroureterectomy may Affect the Use of Perioperative Chemotherapy M. G. Kaag, R. L. O’Malley, P. O’Malley, G. Godoy, M. Chen, M. C. Smaldone, R. L. Hrebinko, J. D. Raman, B. Bochner, G. Dalbagni, M. D. Stifelman, S. S. Taneja and W. C. Huang Memorial Sloan-Kettering Cancer Center, New York, New York Eur Urol 2010; 58: 581–587.
Background: Nephroureterectomy alone fails to adequately treat many patients with advanced upper tract urothelial carcinoma (UTUC). Perioperative platinum-based chemotherapy has been proposed
463
Re: The Effect of Tumor Location on Prognosis in Patients Treated With Radical Nephroureterectomy at Memorial Sloan-Kettering Cancer Center R. L. Favaretto, S. F. Shariat, D. C. Chade, G. Godoy, A. Adamy, M. Kaag, B. H. Bochner, J. Coleman and G. Dalbagni Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York Eur Urol 2010; 58: 574 –580.
Background: The prognostic impact of primary tumor location on outcomes for patients with uppertract urothelial carcinoma (UTUC) is still contentious. Objective: To test the association between tumor location and disease recurrence and cancer-specific survival (CSS) in patients treated with radical nephroureterectomy (RNU) for UTUC. Design, Setting, and Participants: Prospectively collected data were retrospectively reviewed from 324 consecutive patients treated with RNU between 1995 and 2008 at a single tertiary referral center. Patients who had previous radical cystectomy, preoperative chemotherapy, previous contralateral UTUC, or metastatic disease at presentation were excluded. This left 253 patients for analysis. Tumor location was categorized as renal pelvis or ureter based on the location of the dominant tumor. Recurrences in the bladder only, in nonbladder sites, and in any site were analyzed. Intervention: All patients were treated with RNU. Measurements: Recurrence-free survival and CSS probabilities were estimated using Kaplan-Meier and Cox regression analyses. Results and Limitations: Median follow-up for survivors was 48 mo. The 5-yr recurrencefree probability (including bladder recurrence) and CSS estimates were 32% and 78%, respectively. On multivariable analysis, pathologic stage was the only predictor for disease recurrence (p⫽0.01). Tumor location was not an independent predictor for recurrence (hazard ratio: 1.19; p⫽0.3), and there was no difference in the probability of disease recurrence between ureteral and renal pelvic tumors (p⫽0.18). On survival analysis, we also found no differences between ureteral and renal pelvic tumors on probability of CSS (p⫽0.2). On multivariate analysis, pathologic stage (p⬍0.0001) and nodal status (p⫽0.01) were associated with worse CSS. This study is limited by its retrospective nature. Conclusions: Our study did not show any differences in recurrence and CSS rates between patients with ureteral and renal pelvic tumors treated with RNU. Editorial Comment: The authors evaluate a retrospective, single institution data set of patients undergoing nephroureterectomy for upper tract urothelial cancers to determine if site of disease affects oncologic outcome or survival. They show no difference in outcome between tumors of the renal pelvis and ureter. Distal ureteral tumors are not distinguished from proximal, and while cohorts seem matched, patients undergoing segmental ureterectomy are apparently excluded. As such, unless all patients in the reported period were treated with nephroureterectomy, one could only conclude that ureteral tumors selected for nephroureterectomy have outcomes comparable to renal pelvic tumors. It remains unclear whether the entire denominator of patients with ureteral disease might fare better as a whole. The authors did not address the issue of whether segmental ureterectomy is appropriate for a subset of those with strictly ureteral disease. Samir S. Taneja, M.D.
Changes in Renal Function Following Nephroureterectomy may Affect the Use of Perioperative Chemotherapy M. G. Kaag, R. L. O’Malley, P. O’Malley, G. Godoy, M. Chen, M. C. Smaldone, R. L. Hrebinko, J. D. Raman, B. Bochner, G. Dalbagni, M. D. Stifelman, S. S. Taneja and W. C. Huang Memorial Sloan-Kettering Cancer Center, New York, New York Eur Urol 2010; 58: 581–587.
Background: Nephroureterectomy alone fails to adequately treat many patients with advanced upper tract urothelial carcinoma (UTUC). Perioperative platinum-based chemotherapy has been proposed