Saint Louis University School of Medicine, St. Louis, MO.
Division of Urology, Department of Surgery, Saint Louis University School of Medicine, St. Louis, MO.
Urol Oncol. 2023 Apr;41(4):206.e1-206.e9. doi: 10.1016/j.urolonc.2023.01.017. Epub 2023 Feb 22.
Upper urinary tract malignancies are relatively uncommon, with the majority representing urothelial carcinoma (UC). Variant histology (VH) is rare but has been increasingly shown to confer worse prognoses, and standardized approaches to treatment for upper tract cancers with VH have not been established. Our study aimed to analyze outcomes amongst various treatment modalities for upper tract malignancies based on VH subtype. Additionally, we stratified mortality outcomes associated with the upper tract tumors based on their primary location in the renal pelvis (RP) versus ureter.
The National Cancer Database was queried for patients who were diagnosed with upper tract malignancy of the RP or ureter from 2005 to 2016. Populations were grouped based on tumor location (RP vs. ureter) and substratified based on tumor histology (UC vs. VH). Cox regression (CR) was used for multivariable survival analysis.
A total of 63,826 patients with upper tract malignancies met inclusion criteria: 36,692 (57.5%) cases involving the RP and 27,134 (42.5%) cases involving the ureter. VH was noted in 2.5% of all tumors with the squamous cell variant being the most common subtype (62.5%). VH presented with higher stage, increased mortality, and higher proportion of metastatic disease relative to UC. Patients with VH were less likely to undergo surgical intervention and more likely to receive radiation or adjuvant chemotherapy. Neoadjuvant chemotherapy was not associated with tumor downstaging for VH. On multivariable CR, receiving definitive surgical excision improved survival for patients with any VH, and chemotherapy improved survival for patients with renal VH. On subanalysis of CR by VH subtype, survival benefits for surgery were significant for adenocarcinoma, neuroendocrine, and squamous in a renal location and adenocarcinoma, neuroendocrine, sarcoma, and squamous in a ureteral location. Additionally, benefits of chemotherapy were significant for adenocarcinoma in a renal location and neuroendocrine in a ureteral location.
Patients with upper tract VH are more likely to present at advanced stages and experience higher mortality rates when compared to pure UC. Generally, survival benefits are seen with either surgical excision or chemotherapy for renal VH and with surgical excision for ureteral VH, but mortality rates for these treatment modalities differ amongst specific subtypes.
上尿路恶性肿瘤相对少见，其中大多数为尿路上皮癌（UC）。变体组织学（VH）很少见，但已被证明预后更差，并且尚未建立针对 VH 上尿路癌症的标准化治疗方法。我们的研究旨在根据 VH 亚型分析各种上尿路恶性肿瘤治疗方式的结果。此外，我们根据肿瘤的主要位置（肾盂[RP]与输尿管）对上尿路肿瘤的死亡结局进行分层。
从 2005 年至 2016 年，国家癌症数据库中检索诊断为 RP 或输尿管上尿路恶性肿瘤的患者。根据肿瘤位置（RP 与输尿管）对人群进行分组，并根据肿瘤组织学（UC 与 VH）进行分层。Cox 回归（CR）用于多变量生存分析。
共有 63826 例上尿路恶性肿瘤符合纳入标准：36692 例（57.5%）涉及 RP，27134 例（42.5%）涉及输尿管。所有肿瘤中有 2.5%为 VH，其中鳞状细胞变体最为常见（62.5%）。与 UC 相比，VH 表现出更高的分期、更高的死亡率和更高比例的转移性疾病。VH 患者接受手术干预的可能性较低，接受放疗或辅助化疗的可能性较高。新辅助化疗与 VH 肿瘤降期无关。多变量 CR 显示，任何 VH 患者接受确定性手术切除均可改善生存，化疗可改善肾 VH 患者的生存。根据 VH 亚型的 CR 亚分析，在肾部位，腺癌、神经内分泌癌和鳞状细胞癌，以及在输尿管部位的腺癌、神经内分泌癌、肉瘤和鳞状细胞癌，手术治疗的生存获益具有显著意义。此外，肾部位的腺癌和输尿管部位的神经内分泌癌接受化疗的获益显著。
与纯 UC 相比，上尿路 VH 患者更有可能处于晚期，死亡率更高。一般来说，肾 VH 患者行手术切除或化疗，输尿管 VH 患者行手术切除均可获益，但这些治疗方式的死亡率在不同亚型之间存在差异。
