Institute of Urologic Oncology (IUO), Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, CA.
Institute of Urologic Oncology (IUO), Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, CA.
Urol Oncol. 2021 Mar;39(3):194.e17-194.e24. doi: 10.1016/j.urolonc.2020.08.033. Epub 2020 Oct 2.
High-risk ureteral tumors represent an understudied subset of upper tract urothelial carcinoma, whose surgical management can range from a radical nephroureterectomy (NU) to segmental ureterectomy (SU).
To evaluate contemporary trends in the management of high-risk ureteral tumors, the utilization of lymphadenectomy and peri-operative chemotherapy, and their impact on overall survival (OS).
DESIGN, SETTING, AND PARTICIPANTS: We performed a retrospective cohort study of patients in the National Cancer Database from years 2006 to 2013 with clinically localized high-risk ureteral tumors treated with NU or SU.
Chi-squared tests were utilized to assess differences in clinicodemographic features and peri-operative treatment delivery between SU and NU cohorts. Cochran-Armitage tests and linear regressions were performed to evaluate temporal trends in treatment utilization. Multivariable logistic regression models were employed to assess predictors of treatment delivery. Multivariable Cox proportional hazards models evaluated associations with OS.
Of the 1,962 patients included, NU was more commonly performed than SU (72.4%, 1,421/1,962 vs. 27.6%, 541/1,962). Only 22.7% (446/1,962) of the population underwent lymphadenectomy, and 24.8% (271/1,092) of those with advanced pathology (≥pT2 or pN+) received adjuvant chemotherapy. Lymphadenectomy was associated with improved OS in NU patients when more than 3 nodes were removed (hazard ratio [HR] 0.58, 95% confidence interval [CI] 0.39-0.89). Receipt of adjuvant chemotherapy for advanced pathology had no impact OS in both the NU (HR 1.10, 95% CI 0.84-1.44) and SU (HR 0.94, 95% CI 0.61-1.46) cohorts. Performance of SU was not associated with poorer OS on multivariable analysis (HR 1.02, 95% CI 0.89-1.21, P = 0.83).
Our study suggests that SU may be an appropriate alternative to NU for the management of high-risk ureteral tumors. Further, lymphadenectomy may play an important role at the time of NU, and adjuvant chemotherapy is infrequently utilized in patients with advanced pathology.
高危输尿管肿瘤是上尿路上皮癌研究较少的一个亚组，其手术治疗范围可从根治性肾输尿管切除术（NU）到节段性输尿管切除术（SU）。
评估高危输尿管肿瘤的治疗管理的当代趋势，评估淋巴结清扫术和围手术期化疗的应用，以及它们对总生存（OS）的影响。
设计、地点和参与者：我们对 2006 年至 2013 年间国家癌症数据库中接受 NU 或 SU 治疗的局部高危输尿管肿瘤的临床患者进行了回顾性队列研究。
采用卡方检验评估 SU 和 NU 队列之间的临床病理特征和围手术期治疗差异。采用 Cochran-Armitage 检验和线性回归评估治疗方法的时间趋势。采用多变量逻辑回归模型评估治疗方法的预测因素。采用多变量 Cox 比例风险模型评估与 OS 的相关性。
在纳入的 1962 例患者中，NU 的应用较 SU 更为常见（72.4%，1421/1962 比 27.6%，541/1962）。只有 22.7%（446/1962）的人群接受了淋巴结清扫术，24.8%（271/1092）的高级病理（≥pT2 或 pN+）患者接受了辅助化疗。当清扫超过 3 个淋巴结时，NU 患者的淋巴结清扫术与 OS 改善相关（风险比[HR]0.58，95%置信区间[CI]0.39-0.89）。对于高级病理患者，接受辅助化疗对 OS 无影响，无论是在 NU（HR 1.10，95%CI 0.84-1.44）还是 SU（HR 0.94，95%CI 0.61-1.46）队列中。多变量分析显示，SU 的应用与较差的 OS 无关（HR 1.02，95%CI 0.89-1.21，P=0.83）。
本研究表明，SU 可能是高危输尿管肿瘤治疗的 NU 的一种合适替代方法。此外，淋巴结清扫术在 NU 时可能发挥重要作用，而高级病理患者很少应用辅助化疗。
