Carver College of Medicine, University of Iowa, Iowa City, IA.
Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA.
Urol Oncol. 2024 Jul;42(7):221.e9-221.e16. doi: 10.1016/j.urolonc.2024.03.012. Epub 2024 Apr 11.
Nephroureterectomy is commonly performed for high-grade (HG) upper tract (UT) urothelial carcinoma (UC). However, some patients may benefit from a de-escalation of surgical management, particularly for noninvasive disease and carcinoma in situ (CIS). Bacillus Calmette-Guerin (BCG) is currently the only guideline-recommended endoluminal treatment option. Gemcitabine/Docetaxel (Gem/Doce) has shown promising efficacy as a treatment for noninvasive HG UTUC, though a comparison to BCG is lacking. We report the outcomes of patients treated with endoluminal Gem/Doce vs. BCG for UT-CIS.
A single-institutional retrospective review of patients treated with Gem/Doce vs. BCG for UT-CIS was performed. Treatment was instilled via nephrostomy or retrograde ureteral catheter. In both treatment groups, induction consisted of 6 weekly instillations. Maintenance was initiated if disease-free and consisted of 6 monthly instillations in the Gem/Doce group and a reduced dose (one-tenth) 3-week course at 3 months in the BCG group. Recurrence was defined as biopsy-proven disease or HG cytology.
The final cohort included 53 patients with 65 upper tract units; 31 received BCG and 34 received Gem/Doce. Median follow-up was 88 and 29 months in the BCG and Gem/Doce groups, respectively. Presenting pathology included biopsy-proven CIS and HG cytology in 9.7% and 90% of the BCG group, and 8.8% and 91% of the Gem/Doce group, respectively. The 2-year estimates for recurrence-free and nephroureterectomy-free survival were 61% and 89% for the BCG group and 54% and 100% for the Gem/Doce group, respectively. Upon multivariable analysis, instillation via percutaneous nephrostomy tube was associated with an increased risk of recurrence (HR 3.89, 95% CI 1.59-9.53). The development of any symptom was not statistically different between treatment groups (P = 0.12). There were 2 treatment-related deaths that occurred, 1 within each treatment group.
Endoluminal Gem/Doce and BCG have similar oncological outcomes and major adverse event rates in the treatment of UT-CIS. Further prospective evaluation is warranted.
肾输尿管切除术通常用于治疗高级别（HG）上尿路（UT）尿路上皮癌（UC）。然而，对于某些非浸润性疾病和原位癌（CIS）患者，可能需要降低手术管理级别，特别是对于非浸润性疾病和 CIS 患者。卡介苗（BCG）目前是唯一被指南推荐的腔内治疗选择。吉西他滨/多西他赛（Gem/Doce）已显示出作为非浸润性 HG UTUC 治疗方法的良好疗效，尽管缺乏与 BCG 的比较。我们报告了用腔内 Gem/Doce 与 BCG 治疗 UT-CIS 的患者的结局。
对接受 Gem/Doce 与 BCG 治疗 UT-CIS 的患者进行了单机构回顾性研究。通过经皮肾造瘘管或逆行输尿管导管进行治疗。在两组治疗中，诱导治疗均为每周 6 次灌注。如果无疾病，则开始维持治疗，吉西他滨/多西他赛组为 6 个月每月一次，BCG 组为 3 个月时剂量减少（十分之一）的 3 周疗程。复发定义为活检证实的疾病或 HG 细胞学检查阳性。
最终队列包括 53 例患者，共 65 个上尿路单位；31 例接受 BCG 治疗，34 例接受 Gem/Doce 治疗。BCG 组和 Gem/Doce 组的中位随访时间分别为 88 个月和 29 个月。BCG 组和 Gem/Doce 组的首发病理分别为活检证实的 CIS 和 HG 细胞学阳性占 9.7%和 90%，8.8%和 91%。BCG 组的 2 年无复发生存率和无肾输尿管切除术生存估计分别为 61%和 89%，Gem/Doce 组分别为 54%和 100%。多变量分析显示，经皮肾造瘘管灌注与复发风险增加相关（HR 3.89，95%CI 1.59-9.53）。两组之间治疗相关症状的发生没有统计学差异（P=0.12）。两组各有 1 例与治疗相关的死亡。
腔内 Gem/Doce 和 BCG 在治疗 UT-CIS 中的肿瘤学结果和主要不良事件发生率相似。需要进一步进行前瞻性评估。
