Inamoto Teruo, Matsuyama Hideyasu, Komura Kazumasa, Ibuki Naokazu, Fujimoto Kiyohide, Shiina Hiroaki, Sakano Shigeru, Nagao Kazuhiro, Mastumoto Hiroaki, Miyake Makito, Tatsumi Yoshihiro, Yasumoto Hiroaki, Azuma Haruhito
Department of Urology, Osaka Medical College, Takatsuki, Osaka.
Department of Urology, Graduate School of Medicine, Yamaguchi University, Ube, Yamaguchi.
Curr Urol. 2020 Dec;14(4):183-190. doi: 10.1159/000499240. Epub 2020 Dec 18.
The predictive impact of primary tumor location for patients with upper-tract urothelial carcinoma (UTUC) in the presence of concomitant urothelial bladder cancer, along with urothelial recurrence after the curative treatment is still contentious. We evaluated the association between precise tumor location and concomitant presence of urothelial bladder cancer and urothelial recurrence-free survival in patients with UTUC treated by radical nephroureterectomy with a bladder cuff.
A total of 1,349 patients with localized UTUC (Ta-4N0M0) from a retrospective multi-institutional cohort were studied. We queried four UTUC databases. This retrospective clinical series was of patients with localized UTUC managed by nephroureter-ectomy with a bladder cuff, for whom data were from the Nishinihon Uro-Oncology Collaborative Group registries. Patients with a history of chemotherapy or radiotherapy were excluded from the study. Associations between the location of the tumor and subsequent outcome following nephroureterectomy were assessed using COX multivariate analysis. The location of the tumor was verified by pathological samples. Urothelial recurrence was defined as tumor relapse in any local urothelium, and coded apart from distant metastasis. The median follow-up was 34 months.
A total of 887 patients had an evaluation of the tumor location in which 475 patients had pelvic tumors (53.6%), 96 had ureteral tumors in the U1 segment (10.8%), 87 in the U2 segment (9.8%), and 176 in the U3 segment (19.8%). There were 52 patients who had multifocal tumors (5.9%) as follows: 8 (0.9%) in the pelvis and ureter, 11 (1.2%) in U1 + U2, 1 (0.1%) in U1 + U3, 27 (3.0 %) in U2 + U3, and 6 (0.7%) in U1 + U2 + U3. In all, 145 (16.3%) had concomitant bladder tumors. Logistic regression analysis of gender, age, hydronephrosis, cytology, performance status, grade, lymphovascular invasion, pT, pN, and tumor focality showed that tumor location was associated with the presence of concomitant bladder cancer (p = 0.004, HR = 1.265). When the tumor location was stratified into 8 segments, including multifocal tumors, only the U3 segment remained as a predictor for the presence of concomitant bladder cancer (p = 0.002, HR = 2.872). Kaplan-Meier analysis for unifocal disease showed that lower ureter tumors (a combination of U2 and U3) had a worse prognosis for urothelial recurrence than pelvic tumors or upper ureteral tumors (U1) (p < 0.001 for lower ureteral tumors versus pelvic tumors, p = 0.322 for upper ureteral tumor versus pelvic tumor by log rank). Multivariate analysis showed that lower ureter remained as a prognostic factor for urothelial recurrence after adjusting for gender, age, hydronephrosis, urine cytology, lymphovascular invasion, pT, and pN (p < 0.001, HR = 1.469), and a similar tendency was found when the analysis was run for patients without concomitant bladder tumors (p = 0.003, HR = 1.446). Patients with lower ureteral tumors had a higher prevalence of deaths (HR = 2.227) compared to patients with upper ureter tumors.
This multi-institutional study showed that the primary tumor locations were independently associated with the presence of concomitant bladder tumors and subsequent urothelial recurrence.
对于上尿路尿路上皮癌（UTUC）患者，在合并膀胱尿路上皮癌的情况下，原发肿瘤位置的预测影响以及根治性治疗后的尿路上皮复发情况仍存在争议。我们评估了接受根治性肾输尿管切除术并保留膀胱袖口的UTUC患者中，精确的肿瘤位置与膀胱尿路上皮癌的合并存在以及无尿路上皮复发生存期之间的关联。
对来自回顾性多机构队列的1349例局限性UTUC（Ta-4N0M0）患者进行了研究。我们查询了四个UTUC数据库。这个回顾性临床系列研究的对象是接受肾输尿管切除术并保留膀胱袖口的局限性UTUC患者，其数据来自日本西部泌尿肿瘤协作组登记处。有化疗或放疗史的患者被排除在研究之外。使用COX多变量分析评估肿瘤位置与肾输尿管切除术后后续结果之间的关联。肿瘤位置通过病理样本进行验证。尿路上皮复发定义为任何局部尿路上皮的肿瘤复发，与远处转移分开编码。中位随访时间为34个月。
共有887例患者对肿瘤位置进行了评估，其中475例患者有盆腔肿瘤（53.6%），96例患者有U1段输尿管肿瘤（10.8%），87例患者有U2段输尿管肿瘤（9.8%），176例患者有U3段输尿管肿瘤（19.8%）。有52例患者有多灶性肿瘤（5.9%），具体如下：盆腔和输尿管8例（0.9%），U1 + U2 11例（1.2%），U1 + U3 1例（0.1%），U2 + U3 27例（3.0%），U1 + U2 + U3 6例（0.7%）。共有145例（16.3%）患者合并膀胱肿瘤。对性别、年龄、肾积水、细胞学、体能状态、分级、淋巴管侵犯、pT、pN和肿瘤灶性进行逻辑回归分析，结果显示肿瘤位置与合并膀胱肿瘤的存在相关（p = 0.004，HR = 1.265）。当将肿瘤位置分为8个节段，包括多灶性肿瘤时，只有U3节段仍然是合并膀胱肿瘤存在的预测因素（p = 0.002，HR = 2.872）。对单灶性疾病进行Kaplan-Meier分析表明，下段输尿管肿瘤（U2和U3的组合）在上尿路复发方面的预后比盆腔肿瘤或上段输尿管肿瘤（U1）更差（下段输尿管肿瘤与盆腔肿瘤相比，p < 0.001；上段输尿管肿瘤与盆腔肿瘤相比，log rank检验p = 0.322）。多变量分析表明，在调整性别、年龄、肾积水、尿液细胞学、淋巴管侵犯、pT和pN后，下段输尿管仍然是上尿路复发的一个预后因素（p < 0.001，HR = 1.469），在对无合并膀胱肿瘤的患者进行分析时也发现了类似的趋势（p = 0.003，HR = 1.446）。与上段输尿管肿瘤患者相比，下段输尿管肿瘤患者的死亡患病率更高（HR = 2.227）。
这项多机构研究表明，原发肿瘤位置与合并膀胱肿瘤的存在以及随后的上尿路复发独立相关。
