Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
Cancer. 2010 Jun 15;116(12):2967-73. doi: 10.1002/cncr.25043.
The prevalence of chronic kidney disease (CKD) in patients with upper tract urothelial carcinoma (UTUC) is poorly defined, both before and after nephrouretectomy. Although multimodal treatment paradigms for UTUC are under-developed, this has important implications on patients' ability to receive cisplatin-based combination chemotherapy (CBCC).
Estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease formula in 336 patients with UTUC, who were treated at the Cleveland Clinic by nephroureterectomy since 1992. An eGFR cutoff of 60 mL/min/1.73 m(2) was used to determine the presence of CKD and eligibility for CBCC.
Median age was 72 years and median preoperative eGFR was 59 mL/min/1.73m(2). Before nephroureterectomy, only 48% of patients were eligible to receive CBCC and this decreased to 22% postoperatively (P < .001). In the 144 patients with pT2-pT4 and/or pN1-pN3 disease who are suitable to receive CBCC, these proportions were 40% and 24%, respectively (P = .009). Although 50 patients overall received some form of perioperative chemotherapy, only 3 and 11 patients received neoadjuvant and adjuvant CBCC, respectively.
CKD is prevalent in the UTUC population and a minority of patients has an optimal eGFR to receive neoadjuvant CBCC. Nephrouretectomy may eliminate CBCC as a therapeutic option in 49% of high-risk patients if it is deferred to the adjuvant setting. Multimodal treatment strategies for UTUC should focus on neoadjuvant chemotherapy, as few patients are eligible for adjuvant CBCC because of the substantial decline in eGFR caused by nephroureterectomy.
在上尿路尿路上皮癌（UTUC）患者中，慢性肾脏病（CKD）的患病率在肾输尿管切除术之前和之后都没有得到很好的定义。尽管 UTUC 的多模式治疗方案尚未得到充分发展，但这对患者接受顺铂为基础的联合化疗（CBCC）的能力有重要影响。
336 例在克利夫兰诊所接受肾输尿管切除术治疗的 UTUC 患者，使用改良肾脏病饮食公式（Modification of Diet in Renal Disease formula）计算估计肾小球滤过率（eGFR）。以 60 mL/min/1.73 m² 为 eGFR 截断值，确定 CKD 的存在和 CBCC 的适应证。
中位年龄为 72 岁，术前中位 eGFR 为 59 mL/min/1.73m²。肾输尿管切除术前，只有 48%的患者有资格接受 CBCC，术后这一比例降至 22%（P <.001）。在 144 例适合接受 CBCC 的 pT2-pT4 和/或 pN1-pN3 疾病患者中，这一比例分别为 40%和 24%（P =.009）。尽管 50 例患者总体上接受了某种形式的围手术期化疗，但只有 3 例和 11 例患者分别接受了新辅助和辅助 CBCC。
CKD 在 UTUC 人群中较为常见，只有少数患者具有接受新辅助 CBCC 的最佳 eGFR。如果将肾输尿管切除术推迟到辅助治疗，它可能会使 49%的高危患者失去 CBCC 这一治疗选择。UTUC 的多模式治疗策略应侧重于新辅助化疗，因为由于肾输尿管切除术导致 eGFR 显著下降，只有少数患者有资格接受辅助 CBCC。
