BERKELEY, CA (UroToday.com) - The presence of lymphovascular invasion (LVI) has been correlated with an increased incidence of lymph node metastasis and decreased survival in patients with transitional cell carcinoma of the bladder. In the December issue of the Journal of Urology, Kikuchi and colleagues from Keio University School of Medicine in Tokyo evaluated the prognostic significance of LVI in 173 consecutive patients with upper tract transitional cell carcinoma treated with surgery.

Thirty percent of patients (52/173) had evidence of LVI on final pathology, which directly correlated with tumor grade and stage. Furthermore, LVI was a strongly associated with the presence of lymph node metastasis (40/40) and only seen in 9% of patients without lymph node involvement (12/133).

The presence of LVI was an independent predictor of decreased survival in multivariate analysis with a 5-year disease specific survival of 85% in the absence of LVI and 40% in the presence of LVI. A model for risk stratification was developed using the 3 independent predictors of survival from the multivariate model: tumor grade, pathologic stage, and LVI.

The authors should be congratulated for developing a model of risk stratification and patient selection for adjuvant chemotherapy after surgical management of upper tract TCC. Locally advanced and regionally metastatic transitional cell carcinoma of the upper tract is notoriously difficult to control. While adjuvant cisplatin-based chemotherapy has been shown to be effective in transitional cell carcinoma, however, its potential nephrotoxicity often limits its comprehensive use in patients with moderate renal insufficiency after nephroureterectomy.

Ideally, our goal should be to develop criteria to identify these patients before surgery in order to administer adequate chemotherapy before their kidney and ureter are removed. Unfortunately, if diagnosing LVI in transurethral bladder cancer specimens may be inconsistent, making the diagnosis in small ureteroscopic biopsies of upper tract lesions is even more difficult for the pathologist.

It would be valuable to ascertain which preoperative variables correlated with the presence of LVI on final pathology: local symptoms? Tumor size on imaging? Tumor grade on ureteroscopic biopsy? Perhaps using these criteria to select patients preoperatively the neoadjuvant chemotherapy paradigm utilized in invasive bladder cancer could be applied to the upper urinary tract.

J Urol. 2005 Dec; 174(6):2120-3