Elsevier

Surgical Oncology

Volume 26, Issue 3, September 2017, Pages 252-256
Surgical Oncology

Endoscopic management of upper tract urothelial carcinoma: Improved prediction of invasive cancer using a ureteroscopic scoring model

https://doi.org/10.1016/j.suronc.2017.04.003Get rights and content

Highlights

  • Lamina propria invasion and presence of a high-grade tumor incorporated in a ureteropic biopsy, was highly predictive of invasive upper tract urothelial carcinoma (UTUC).

  • Risk of invasive UTUC was 83.7% when a ureteroscopic biopsy shows high grade disease with lamina propria invasion exists.

  • Use of this model could improve selection of UTUC patients for neoadjuvant chemotherapy and nephron sparing-surgery.

Abstract

Background

The aim of this study was to investigate clinical and ureteroscopic factors considered as important for the prediction of invasive upper tract urothelial carcinoma (UTUC) and establish a model using a new ureteroscopic scoring.

Methods

We analyzed tumor depth and grade from ureteroscopic biopsies in 172 patients who underwent imaging studies, urine cytology, and radical nephroureterectomy. Invasive UTUC was defined as muscle-invasive or non-organ confined tumors. Ureteroscopic scoring was defined as sum of the risk factors, lamina propria invasion, or presence of a high-grade tumor.

Results

In the multivariate analysis, lamina propria invasion was a significant factor associated with an increased risk of invasive UTUC. Positive urine cytology, hydronephrosis, and local invasion on imaging were also significant. Presence of a high-grade tumor was not significant due to interaction with lamina propria invasion (P < 0.001). In the ureteroscopic scoring model, the odds ratio of invasive UTUC was significantly related to the ureteroscopic scoring number (30.9% (56/81), 66.7% (14/42), and 83.7% (41/49) according to the sum of risk factors 0 to 2, respectively, (P < 0.001). Positive predictive value (PPV) for invasive UTUC was increased in relation to the number of risk factors including urine cytology, hydronephrosis, local invasion on imaging, and any abnormal ureteroscopic finding (lamina propria invasion or presence of high-grade tumors). The PPV gradually increased as follows: 6.3%, 33.3%, 52.1%, 81.6%, to 92.9% for 0 to 4 positive risk factors, respectively (P < 0.001).

Conclusions

When lamina propria invasion and presence of a high-grade tumor were incorporated, our novel ureteroscopic scoring model was highly predictive of invasive UTUC.

Introduction

Although it is a rare genitourinary malignancy, accounting for only 5–10% of urothelial tumors, the incidence of upper tract urothelial carcinoma (UTUC) in the United States has slowly increased over the past 30 years [1], [2]. The current gold standard treatment of UTUC is radical nephroureterectomy (RNU) with bladder cuff excision [3]. Conservative management treatments can be considered in elective cases (normal contralateral kidney), as well as imperative cases of low-risk UTUC (e.g., renal insufficiency, bilateral disease, or solitary functional kidney) [3]. Studies show that these approaches can achieve acceptable oncologic outcomes along with preservation of renal function [4], [5], [6], [7], [8].

The substantial negative impact of chronic kidney disease on cardiovascular events and overall mortality has led to the use of nephron-sparing surgeries for the treatment of small renal cell carcinoma [9], [10], and partial nephrectomy has become a preferred option when technically feasible [11]. By extrapolation of the results in patients with renal cell carcinoma, conservative nephron-sparing management could be further indicated for many UTUC patients [12].

Although there is a growing interest in the conservative management of UTUC, it remains essential to select the appropriate patients for these approaches. However, the clinical staging of UTUC might not be as precise as the staging of renal cell carcinoma and despite advancements in imaging, the accurate T-staging of UTUC remains challenging. Recent recommendations suggest the following selection criteria for the conservative management of UTUC: low grade, unifocal tumor <1 cm, no evidence of infiltrative lesion on imaging, and no hydronephrosis [3], [13], [14], [15]. Ureteroscopic biopsies are necessary for accurate staging in order to determine if conservative management is appropriate. The presence of a high-grade tumor, as determined by biopsy, has been considered an important predictor of UTUC. However, there is a lack of evidence for the role of tumor depth in predicting UTUC, which is likely due to the difficulty in obtaining representative lamina muscularis tissue [16]. We assumed that invasive UTUC should be excluded from conservative management. The current study aimed to investigate the clinical and ureteroscopic factors associated with UTUC, and to establish a model for the improved prediction of invasive UTUC using a newly proposed ureteroscopic scoring system.

Section snippets

Materials and methods

This study was performed with the approval of the Internal Review Board of Samsung Medical Center, Sungkyunkwan University School of Medicine (IRB No. 2015-06-202). Patient records/information was anonymized and de-identified prior to analysis.

Results

Median age at RNU was 66 (57–74) years, and 78.5% of the patients were male. A history of prior or concurrent bladder tumors was present in 26.2% of patients. Tumors were distributed in the renal pelvis (40.7%), ureter (51.2%), and both (8.1%). Hydronephrosis and local invasion were found on imaging in 58.7% and 31.4% of patients, respectively. Overall, 57% of patients had positive urine cytology. A high-grade tumor, CIS, or stromal invasion was found in 32.6%, 10.5%, and 48.8%, respectively,

Discussion

The present study demonstrates that the tumor depth (stromal invasion) as determined by ureteroscopic examination is a more important factor in predicting invasive UTUC than the presence of a high-grade tumor. Interestingly, high-grade tumor presence remained statistically insignificant on multivariate analysis. This may be due to an interaction with tumor depth suggesting that, if the stromal invasion is excluded, high-grade tumor presence could be a significant predictor along with the other

Conflict of interest

None.

Acknowledgements

Statistical analyses were performed by aid of Sin-Ho Jung, Ph.D., and Sun-Kyu Choi, M.S., Biostatistics and Clinical Epidemiology Center, Samsung Medical Center.

References (32)

Cited by (7)

  • Novel Classification for Upper Tract Urothelial Carcinoma to Better Risk-stratify Patients Eligible for Kidney-sparing Strategies: An International Collaborative Study

    2022, European Urology Focus
    Citation Excerpt :

    Chen et al reported that tumors without multifocality (hazard ratio 1.639; p = 0.028) were a predictive factor for muscle-invasive UTUC, which was not found in our cohort. However, several studies have reported that tumor multifocality is not predictive of muscle-invasive disease [11,13–16]. Tumor size was not an independent predictive factor for muscle invasion at RNU in our multivariate analysis.

  • Phase II multi-center trial of optical coherence tomography as an adjunct to white light cystoscopy for intravesical real time imaging and staging of bladder cancer

    2021, Urologic Oncology: Seminars and Original Investigations
    Citation Excerpt :

    In UTUC, risk stratification is a critical determinant of neoadjuvant chemotherapy, regional lymph node dissection during nephroureterectomy, and nephron-sparing surgery [19,20]. However, the clinical staging of UTUC is limited by the poor accuracy of ureteroscopy and inconclusive histopathology although various attempts have been made [21,22]. The use of OCT together with ureteroscopy for detecting UTUC was previously evaluated.

  • Ex-vivo Imaging of Upper Tract Urothelial Carcinoma Using Novel pH Low Insertion Peptide (Variant 3), a Molecular Imaging Probe

    2020, Urology
    Citation Excerpt :

    Normal mucosa was not stained by ICG-Var3 pHLIP, nor were nonmalignant lesions such as ureteritis cystica. Cross-sectional imaging and traditional white-light endoscopic visual have historically demonstrated poor performance for the diagnosis and staging of UTUC.22-24 Recognizing the need for better and more accurate diagnostic methods, new technologies have been proposed.

  • Cryobiopsy in the Upper Urinary Tract: Preclinical Evaluation of a Novel Device

    2019, Urology
    Citation Excerpt :

    Obtaining representative tissue samples from the UUT by URS biopsy represents a major challenge. Biopsy samples are often insufficient in size and tissue quality, precluding valid pathologic evaluation and limiting diagnostic accuracy with regard to stage and grade.1,4-6,8,17-19 In a series of patients who underwent RNU, pathologic upstaging occurred in up to 45% of tumors preoperatively classified as stage pTa.20

  • Multi-institutional Evaluation of Upper Urinary Tract Biopsy Using Backloaded Cup Biopsy Forceps, a Nitinol Basket, and Standard Cup Biopsy Forceps

    2018, Urology
    Citation Excerpt :

    Given our findings, optimal urothelial biopsy is likely achieved on a case-by-case basis, noting the location, morphology, and size of the biopsy to be obtained. Jeon et al30 found that invasion of the lamina propria was present in 84% of patients with >pT2 stage UTUC, albeit with the standard cup forceps obtaining lamina propria in half of its specimens, which is similar to our findings (Table 1). Thus, the presence of lamina propria cannot be understated and reinforces routine ureteroscopic evaluation for UTUC and may improve the selection of patients for neoadjuvant chemotherapy if pursuing NU.

View all citing articles on Scopus
View full text