We sought to evaluate the discordance between ureteroscopic biopsy and surgical pathology for grading and staging of upper tract urothelial carcinoma (UTUC) and to establish preoperative predictors of aggressive tumors.
We performed a retrospective review of 314 patients who underwent ureteroscopic biopsy followed by surgical management for UTUC from 2000-2016 at three institutions. Our primary outcomes were muscle-invasive (≥pT2) disease at surgical pathology and upgrading of clinical low-grade (cLG) tumors to pathologic high-grade (pHG).
At biopsy, 61% of patients had high-grade (cHG) tumors, and 21% had subepithelial connective tissue invasion (cT1+). On final pathology, 79% had pHG tumors, and 45% had stage ≥pT2. On multivariate analysis, advanced age, cHG, and cT1+ were independently associated with ≥pT2. The combined presence of cHG and cT1+ had a PPV of 86% for muscle invasion, and the combined absence of cHG and cT1+ had a NPV of 80%. The likelihood of missing invasion on biopsy in patients with muscle-invasive disease was increased when biopsy fragments were limited to ≤1mm. Among patients with cLG disease on biopsy, 51% were upgraded at surgery. The presence of positive urine cytology was associated with an increased risk of upgrading; however, this was not statistically significant.
cHG, cT1+ on biopsy, and advanced patient age are independent risk factors for muscle-invasive UTUC. There is a significant risk of upgrading among patients with cLG tumors on biopsy, especially when urine cytology is positive. The predictive value of biopsy can likely be improved by more extensive ureteroscopic sampling.
The Journal of urology. 2018 Feb 07 [Epub ahead of print]
Ezra J Margolin, Justin T Matulay, Gen Li, Xiaosong Meng, Brian Chao, Varun Vijay, Hayley Silver, Timothy N Clinton, Laura-Maria Krabbe, Solomon L Woldu, Nirmish Singla, Aditya Bagrodia, Vitaly Margulis, William C Huang, Marc A Bjurlin, Ojas Shah, Christopher B Anderson
Department of Urology, Columbia University Medical Center, New York, NY., Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY., Department of Urology, New York University Langone Medical Center, New York, NY., Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX., Department of Urology, Columbia University Medical Center, New York, NY. Electronic address: .