With growing support of perioperative chemotherapy for upper tract urothelial carcinoma (UTUC), current biopsy methods are challenging, and little is known as to the degree to which patients would appropriately receive neoadjuvant chemotherapy (NAC) from biopsy alone. Herein, we sought to assess the rates of appropriate clinical use of NAC and identify clinicopathologic factors associated with aggressive UTUC amongst patients undergoing radical nephroureterectomy (RNU) for clinically localized disease.
From 2004 to 2013, we identified all treatment naïve patients diagnosed with clinically localized, high grade UTUC (cTa-4Nx) who underwent RNU from the National Cancer Database (NCDB). Pathologic criteria for NAC (pT2-4N0,x; pTanyN1) from RNU represented the primary outcome. Bivariate and multivariable analyses were utilized to identify covariates associated with primary outcome to determine appropriate use of NAC.
During the study interval, 5,362 patients were diagnosed with clinically localized UTUC and underwent RNU. Overall, 49.1% of patients presented with an unknown primary tumor stage (Tx) and 24.5% had invasive UTUC from biopsy. On multivariable analysis, upper tract tumor size was associated with invasive UTUC eligible for NAC (all P < 0.05). Amongst patients with cTx UTUC from biopsy, half of patients had pathologic noninvasive UTUC (pTa,is,1) from RNU and would be overtreated with NAC.
Significant uncertainty persists in assigning primary upper tract tumor depth and represents a key barrier to widespread implementation of NAC for patients with high grade UTUC. Further research is needed to more accurately determine clinical criteria to identify patients for NAC.
Urologic oncology. 2021 Apr 02 [Epub ahead of print]
Rodrigo Rodrigues Pessoa, Jeffrey C Morrison, Badrinath Konety, Boris Gershman, Paul Maroni, Janet B Kukreja, Nicholas Cost, Thomas Flaig, Elizabeth Kessler, Pranav Sharma, Simon P Kim
University of Colorado Anschutz Medical Center, Division of Urology, Aurora, CO., Rush University Medical Center, Division of Urology, Chicago, IL., Beth Israel Deaconess Medical Center, Division of Urologic Surgery, Boston, MA., University of Colorado Anschutz Medical Center, Division of Urology, Aurora, CO; Children's Hospital of Colorado, Aurora, CO., University of Colorado Anschutz Medical Center, Department of Medical Oncology, Aurora, CO., Texas Tech University Health Sciences Center, Department of Urology, Lubbock, TX., University of Colorado Anschutz Medical Center, Division of Urology, Aurora, CO; Yale University, Cancer Outcomes Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT. Electronic address: .