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Re: The Impact of Previous Ureteroscopic Tumor Ablation on Oncologic Outcomes After Radical Nephrouretectomy for Upper Urinary Tract Urothelial Carcinoma
Urological Survey
Urological Oncology: Renal, Ureteral and Retroperitoneal Tumors Re: The Impact of Previous Ureteroscopic Tumor Ablation on Oncologic Outcomes After Radical Nephrouretectomy for Upper Urinary Tract Urothelial Carcinoma C. Gurbuz, R. F. Youssef, S. F. Shariat, Y. Lotan, C. G. Wood, A. I. Sagalowsky, R. Zigeuner, E. Kikuchi, A. Weizer, J. D. Raman, M. Remzi, M. Roscigno, F. Montorsi, C. Bolenz, W. Kassouf and V. Margulis University of Texas Southwestern Medical Center, Dallas, Texas J Endourol 2011; Epub ahead of print.
We investigated whether a history of endoscopic tumor ablation impacts oncologic outcomes after radical nephroureterectomy (RNU) for upper urinary tract urothelial carcinoma (UTUC). Using a multi-institutional database that contained patients who were treated with RNU, oncologic outcomes were assessed according to history of ureteroscopic tumor ablation. Disease-free survival (DFS) and cancer-specific survival (CSS) were estimated using the Kaplan-Meier survival analysis. Multivariate Cox regression analyses were performed to determine independent predictors of disease recurrence and cancer-specific mortality after RNU. The study included 1268 patients, 853 men and 415 women, with a mean age of 67.5 years (range 32-94 y) and 52.8 months median follow-up after RNU. A total of 175 (13%) patients underwent RNU after endoscopic tumor ablation and 1093 (87%) patients underwent RNU without a history of endoscopic ablation. The 5-year DFS and CSS rates were 72% and 77% in those with a history of tumor ablation vs 69% and 73% in those without a history of ablation (P ⫽ 0.171 and P ⫽ 0.365, respectively). In multivariate Cox regression analysis, history of ablation therapy was not associated with disease recurrence or cancer-specific mortality (hazard ratio [HR]: 0.79, P ⫽ 0.185 and HR: 0.7, P ⫽ 0.078, respectively). Our collaborative international efforts suggest that in selected patients, endoscopic tumor ablation does not adversely affect the recurrence and survival after subsequent RNU for UTUC. Our data support the continued role of ureteroscopic ablation of UTUC in appropriately selected patients. Editorial Comment: The impact of endoscopic management of upper tract urothelial cancer on the natural history and long-term disease control is relatively unknown. In this series the authors combine data from several institutions to determine the impact of endoscopic ablation on the likelihood of cure following subsequent nephroureterectomy, and they conclude that patients fare no worse than those undergoing immediate nephroureterectomy. It is difficult to interpret the validity of this data set since little information is provided regarding reasons for conversion from endoscopic treatment to nephroureterectomy in this select group—we do not know the interval to nephroureterectomy (delay) in the endoscopic group, patients are not matched for grade at time of diagnosis and the nature of recurrences is not well defined. The majority of patients undergoing endoscopic treatment of upper tract tumors have low grade, low volume disease. Most often these patients suffer local upper tract or bladder recurrences and are at a low risk for metastatic progression. In this cohort patients undergoing delayed nephroureterectomy had similar rates of high grade disease to those undergoing immediate nephroureterectomy, similar recurrence rates and similar cancer specific survival. Since bladder recurrences were excluded, I suspect endoscopic treatment failed at an early interval in these patients due to grade progression or rapid 0022-5347/11/1862-0452/0 THE JOURNAL OF UROLOGY® © 2011 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
452
www.jurology.com
AND
RESEARCH, INC.
Vol. 186, 452-457, August 2011 Printed in U.S.A. DOI:10.1016/j.juro.2011.04.052
RENAL, URETERAL AND RETROPERITONEAL TUMORS
453
recurrence, and as such the interval to nephroureterectomy may have been quite short. In this case the conclusions of the authors may be too strong, given the paucity of presented data. Samir S. Taneja, M.D.
Perioperative Outcomes of Laparoscopic Radical Nephroureterectomy and Regional Lymphadenectomy in Patients With Upper Urinary Tract Urothelial Carcinoma After Neoadjuvant Chemotherapy M. Z. Rajput, A. M. Kamat, J. Clavell-Hernandez, A. O. Siefker-Radtke, H. B. Grossman, C. P. Dinney and S. F. Matin Department of Urology, University of Texas M. D. Anderson Cancer Center, Houston, Texas Urology 2011; Epub ahead of print.
Objectives: To determine the effect of neoadjuvant chemotherapy on the surgical outcomes in patients undergoing laparoscopic radical nephroureterectomy (LNUX) for upper urinary tract urothelial carcinoma (UTUC). Methods: We performed a retrospective review of all patients with UTUC who had undergone LNUX at our institution from January 2003 to June 2010. We compared the differences in demographic, clinicopathologic, and operative parameters, including the estimated blood loss, duration of surgery, length of postoperative hospitalization, and number of complications, between the patients who had undergone LNUX after neoadjuvant chemotherapy and those who had undergone LNUX without neoadjuvant chemotherapy. Logistic regression analysis was performed to identify the predictors of complications. Results: We identified 82 patients with UTUC who had undergone LNUX. Of these patients, 26 had received neoadjuvant chemotherapy. The patients who had undergone LNUX after neoadjuvant chemotherapy had a greater body mass index, greater biopsy tumor grade, and longer operative time than those who had undergone LNUX without neoadjuvant chemotherapy. The patients who received neoadjuvant chemotherapy had undergone regional lymphadenectomy more often, with more lymph nodes and lymphoadipose tissue removed, than those who had not received neoadjuvant chemotherapy. Neoadjuvant chemotherapy resulted in a 15% complete remission rate. No differences in the median estimated blood loss, intraoperative transfusion rate, or length of hospitalization between the 2 groups were found. The perioperative complication rates were similar in both groups. Conclusions: We found no differences in the surgical outcomes between those patients who had undergone LNUX after neoadjuvant chemotherapy and those who had undergone LNUX without neoadjuvant chemotherapy. Our findings support the use of LNUX for selected patients undergoing neoadjuvant chemotherapy for UTUC. Editorial Comment: Use of neoadjuvant chemotherapy before nephroureterectomy for upper tract urothelial carcinoma has been advocated as a means of improving oncologic outcomes. While there are few supportive data, the experience with lower tract urothelial cancers supports the concept, and the nephrotoxic nature of platinum based chemotherapy warrants treatment while glomerular filtration rate is maximized. Given the increasing popularity of the approach, this article importantly demonstrates that operative complications do not appear to be increased in patients receiving neoadjuvant chemotherapy, despite more aggressive surgery. The cohort is small, and further application is warranted for validation. Samir S. Taneja, M.D.
Urological Oncology: Renal, Ureteral and Retroperitoneal Tumors Re: The Impact of Previous Ureteroscopic Tumor Ablation on Oncologic Outcomes After Radical Nephrouretectomy for Upper Urinary Tract Urothelial Carcinoma C. Gurbuz, R. F. Youssef, S. F. Shariat, Y. Lotan, C. G. Wood, A. I. Sagalowsky, R. Zigeuner, E. Kikuchi, A. Weizer, J. D. Raman, M. Remzi, M. Roscigno, F. Montorsi, C. Bolenz, W. Kassouf and V. Margulis University of Texas Southwestern Medical Center, Dallas, Texas J Endourol 2011; Epub ahead of print.
We investigated whether a history of endoscopic tumor ablation impacts oncologic outcomes after radical nephroureterectomy (RNU) for upper urinary tract urothelial carcinoma (UTUC). Using a multi-institutional database that contained patients who were treated with RNU, oncologic outcomes were assessed according to history of ureteroscopic tumor ablation. Disease-free survival (DFS) and cancer-specific survival (CSS) were estimated using the Kaplan-Meier survival analysis. Multivariate Cox regression analyses were performed to determine independent predictors of disease recurrence and cancer-specific mortality after RNU. The study included 1268 patients, 853 men and 415 women, with a mean age of 67.5 years (range 32-94 y) and 52.8 months median follow-up after RNU. A total of 175 (13%) patients underwent RNU after endoscopic tumor ablation and 1093 (87%) patients underwent RNU without a history of endoscopic ablation. The 5-year DFS and CSS rates were 72% and 77% in those with a history of tumor ablation vs 69% and 73% in those without a history of ablation (P ⫽ 0.171 and P ⫽ 0.365, respectively). In multivariate Cox regression analysis, history of ablation therapy was not associated with disease recurrence or cancer-specific mortality (hazard ratio [HR]: 0.79, P ⫽ 0.185 and HR: 0.7, P ⫽ 0.078, respectively). Our collaborative international efforts suggest that in selected patients, endoscopic tumor ablation does not adversely affect the recurrence and survival after subsequent RNU for UTUC. Our data support the continued role of ureteroscopic ablation of UTUC in appropriately selected patients. Editorial Comment: The impact of endoscopic management of upper tract urothelial cancer on the natural history and long-term disease control is relatively unknown. In this series the authors combine data from several institutions to determine the impact of endoscopic ablation on the likelihood of cure following subsequent nephroureterectomy, and they conclude that patients fare no worse than those undergoing immediate nephroureterectomy. It is difficult to interpret the validity of this data set since little information is provided regarding reasons for conversion from endoscopic treatment to nephroureterectomy in this select group—we do not know the interval to nephroureterectomy (delay) in the endoscopic group, patients are not matched for grade at time of diagnosis and the nature of recurrences is not well defined. The majority of patients undergoing endoscopic treatment of upper tract tumors have low grade, low volume disease. Most often these patients suffer local upper tract or bladder recurrences and are at a low risk for metastatic progression. In this cohort patients undergoing delayed nephroureterectomy had similar rates of high grade disease to those undergoing immediate nephroureterectomy, similar recurrence rates and similar cancer specific survival. Since bladder recurrences were excluded, I suspect endoscopic treatment failed at an early interval in these patients due to grade progression or rapid 0022-5347/11/1862-0452/0 THE JOURNAL OF UROLOGY® © 2011 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
452
www.jurology.com
AND
RESEARCH, INC.
Vol. 186, 452-457, August 2011 Printed in U.S.A. DOI:10.1016/j.juro.2011.04.052
RENAL, URETERAL AND RETROPERITONEAL TUMORS
453
recurrence, and as such the interval to nephroureterectomy may have been quite short. In this case the conclusions of the authors may be too strong, given the paucity of presented data. Samir S. Taneja, M.D.
Perioperative Outcomes of Laparoscopic Radical Nephroureterectomy and Regional Lymphadenectomy in Patients With Upper Urinary Tract Urothelial Carcinoma After Neoadjuvant Chemotherapy M. Z. Rajput, A. M. Kamat, J. Clavell-Hernandez, A. O. Siefker-Radtke, H. B. Grossman, C. P. Dinney and S. F. Matin Department of Urology, University of Texas M. D. Anderson Cancer Center, Houston, Texas Urology 2011; Epub ahead of print.
Objectives: To determine the effect of neoadjuvant chemotherapy on the surgical outcomes in patients undergoing laparoscopic radical nephroureterectomy (LNUX) for upper urinary tract urothelial carcinoma (UTUC). Methods: We performed a retrospective review of all patients with UTUC who had undergone LNUX at our institution from January 2003 to June 2010. We compared the differences in demographic, clinicopathologic, and operative parameters, including the estimated blood loss, duration of surgery, length of postoperative hospitalization, and number of complications, between the patients who had undergone LNUX after neoadjuvant chemotherapy and those who had undergone LNUX without neoadjuvant chemotherapy. Logistic regression analysis was performed to identify the predictors of complications. Results: We identified 82 patients with UTUC who had undergone LNUX. Of these patients, 26 had received neoadjuvant chemotherapy. The patients who had undergone LNUX after neoadjuvant chemotherapy had a greater body mass index, greater biopsy tumor grade, and longer operative time than those who had undergone LNUX without neoadjuvant chemotherapy. The patients who received neoadjuvant chemotherapy had undergone regional lymphadenectomy more often, with more lymph nodes and lymphoadipose tissue removed, than those who had not received neoadjuvant chemotherapy. Neoadjuvant chemotherapy resulted in a 15% complete remission rate. No differences in the median estimated blood loss, intraoperative transfusion rate, or length of hospitalization between the 2 groups were found. The perioperative complication rates were similar in both groups. Conclusions: We found no differences in the surgical outcomes between those patients who had undergone LNUX after neoadjuvant chemotherapy and those who had undergone LNUX without neoadjuvant chemotherapy. Our findings support the use of LNUX for selected patients undergoing neoadjuvant chemotherapy for UTUC. Editorial Comment: Use of neoadjuvant chemotherapy before nephroureterectomy for upper tract urothelial carcinoma has been advocated as a means of improving oncologic outcomes. While there are few supportive data, the experience with lower tract urothelial cancers supports the concept, and the nephrotoxic nature of platinum based chemotherapy warrants treatment while glomerular filtration rate is maximized. Given the increasing popularity of the approach, this article importantly demonstrates that operative complications do not appear to be increased in patients receiving neoadjuvant chemotherapy, despite more aggressive surgery. The cohort is small, and further application is warranted for validation. Samir S. Taneja, M.D.