CUA 2017: Outcomes of Urothelial Bladder Cancer Patients who had Previous Upper Tract Urothelial Disease

Toronto, Ontario ( Urothelial carcinoma (UC) is often treated as one entity. However, more and more evidence is demonstrating that upper tract urothelial carcinoma (UTUC) and bladder urothelial carcinoma (BCa) may be two distinct entities. As such, primary BCa and secondary BCa (following UTUC) may behave differently from one another. Studies show that secondary BCa or urothelial bladder carcinoma recurrence (UBCR) occurs in 22–47% of de novo UTUC (dNUTUC) patients.

In this study, the authors evaluated the presentation and predictors of UBCR in patients with dnUTUC. They utilized the SEER database from 1988-2013, encompassing a 25-year time period. Due to the rarity of the condition, this allowed for a much larger cohort than could be expected in a single-institution series. Specifically, they compared incidence, predictors and survival based on the location of the dnUTUC: renal pelvis (RENPEL) or ureter (UL). 

The final cohort included 15,298 patients with dNUTUC, of which 7179 (46.9%) had a UBCR. Of these, 4780 (666%) had a RENPEL tumor and 2399 (33%) had a UL tumor. Key demographics included the following: primarily Caucasian (90-91%) and male (75%), approximately a fifth of these UBCRs are muscle-invasive at diagnosis, and 3% were metastatic at diagnosis. 

Predictors of developing UBCR included RENPEL tumors (odds ratio [OR] 1.318; p=0.03), less advanced disease (OR 0.587; p=0.001), and dNUTUC surgical treatment (OR 5.78; p=0.003). Interestingly, 50% and 75% of the dNUTUC patients are diagnosed with UBCR within 67 and 133 months, respectively, with higher grade UBCRs being diagnosed earlier. 

Survival data showed that age, black race, and more advanced disease were the strongest predictors of disease specific mortality from bladder cancer.

The authors’ take-home points for this abstract are as follows:
1. RENPEL dNUTUC tumours carry a higher risk for developing UBCR, especially when less advanced and treated surgically

2. Postoperative followup of dNUTUC patients should include routine cystoscopies for at least 11 years to diagnose 75% of UBCR

3. Worse BC DSM is associated with black race and older patients with more advanced disease.

Limitations / Discussion Points:
1. As this is a retrospective SEER database, it has inherent limitations. Certain variable capture is not as robust.

2. Black race is a very small proportion of patients, making this likely to contribute to statistical significance. Larger datasets of Black patients needed for further analysis.

3. UTUC staging can be notoriously difficult to accurately capture. Intuitively though, higher stage disease likely has such a poor prognosis, that they do not survive to develop UBCR. Competing risks outweigh risk of downstream recurrence.  

Presented By: Hanan Goldberg, MD, Princess Margaret Hospital, University Health Network, Toronto, ON, Canada

Co-Authors: Thenappan Chandrasekar, Zachary Klaassen, Robert J. Hamilton, Girish S. Kulkarni, Neil E. Fleshner
Insitution: University of Toronto

Written By: Thenappan Chandrasekar, MD (Clinical Fellow, University of Toronto,  Twitter: @tchandra_uromd at the  72nd Canadian Urological Association Annual Meeting - June 24 - 27, 2017 - Toronto, Ontario, Canada

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