Wang Shu, Phelan Michael, Siddiqui Mohummad Minhaj
Division of Urology, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA.
Veterans Affairs Maryland Healthcare System, Baltimore, MD, USA.
Curr Urol. 2024 Sep;18(3):225-231. doi: 10.1097/CU9.0000000000000164. Epub 2024 Sep 20.
Upper tract urothelial carcinoma (UTUC) is an aggressive disease with a high progression rate. The standardmanagement for this disease is nephroureterectomy. Nephron sparing nonradical surgery is an alternative therapeutic approach. In men with limited life expectancy, the potential harm of UTUC progression must be weighed against surgical morbidity and mortality, and thus, more conservative approaches may be selected. This study aims to investigate the comparative benefits of radical and conservative surgical management in patients older than 80 years with localized UTUC.
A search was conducted in the Surveillance, Epidemiology, and End Results database for patients older than 80 years who were diagnosed with localized (T1-2N0M0) cancer in the renal pelvis or ureter as the only malignancy from 2004 to 2015. Patients were divided into 3 therapeutic groups: no surgery, local intervention (ie, local tumor excision or segmented ureterectomy), and radical surgery (nephroureterectomy). Demographic and cancer-related parameter data were collected. Logistic regression analysis was conducted to investigate predictors for surgical treatment. Kaplan-Meier curves and Cox regression were used to analyze survival outcomes.
Data from 774 patients were analyzed, including 205 in the no-surgery group, 181 in the local intervention group, and 388 in the radical surgery group. Older, African American patients with T1 stage disease were less likely to receive surgical treatment. Among surgically treated patients, renal pelvic tumors, and high-grade and T2 stage disease were associated with radical resection. Surgically treated patients had a longer median overall survival (OS) than in those treated nonsurgically (13, 35, and 47 months in no-surgery, local intervention, and radical surgery groups, respectively; < 0.001). Although surgically treated patients demonstrated higher 5-year OS (8.8% [no surgery], 23.2% [local intervention], and 23.5% [radical surgery], < 0.001) and 5-year disease-specific survival (DSS) (41.0%[no surgery], 69.1%[local intervention], and 72.9%[radical surgery]; < 0.001) than in those treated nonsurgically, no significant differences were found between the local intervention and radical surgery groups ( > 0.05). Based on multivariate Cox regression analysis, surgical treatments, including both nonradical and radical resection, were independently associated with improved OS and DSS after controlling for age, marital status, tumor grade, and radiation status.
Patients older than 80 years with localized UTUC who undergo surgery demonstrate longer survival. Radical and nonradical resections seemto have similar OS and DSS outcomes. Thus, when clinically indicated in this population, a more conservative surgical approach may be reasonable.
上尿路尿路上皮癌（UTUC）是一种侵袭性疾病，进展率高。该疾病的标准治疗方法是肾输尿管切除术。保留肾单位的非根治性手术是一种替代治疗方法。对于预期寿命有限的男性，必须权衡UTUC进展的潜在危害与手术的发病率和死亡率，因此可能会选择更保守的方法。本研究旨在调查80岁以上局限性UTUC患者行根治性和保守性手术治疗的相对益处。
在监测、流行病学和最终结果数据库中进行检索，以查找2004年至2015年期间被诊断为局限性（T1-2N0M0）肾盂或输尿管癌且为唯一恶性肿瘤的80岁以上患者。患者分为3个治疗组：未手术、局部干预（即局部肿瘤切除或节段性输尿管切除术）和根治性手术（肾输尿管切除术）。收集人口统计学和癌症相关参数数据。进行逻辑回归分析以调查手术治疗的预测因素。采用Kaplan-Meier曲线和Cox回归分析生存结果。
分析了774例患者的数据，包括未手术组205例、局部干预组181例和根治性手术组388例。年龄较大的非裔美国T1期疾病患者接受手术治疗的可能性较小。在接受手术治疗的患者中，肾盂肿瘤、高级别和T2期疾病与根治性切除相关。接受手术治疗的患者的中位总生存期（OS）比未接受手术治疗的患者更长（未手术组、局部干预组和根治性手术组分别为13个月、35个月和47个月；P<0.001）。虽然接受手术治疗的患者的5年OS（未手术组为8.8%，局部干预组为23.2%，根治性手术组为23.5%，P<0.001）和5年疾病特异性生存期（DSS）（未手术组为41.0%，局部干预组为69.1%，根治性手术组为72.9%；P<0.001）高于未接受手术治疗的患者，但局部干预组和根治性手术组之间未发现显著差异（P>0.05）。基于多变量Cox回归分析，在控制年龄、婚姻状况、肿瘤分级和放疗状态后，包括非根治性和根治性切除在内的手术治疗与改善的OS和DSS独立相关。
80岁以上局限性UTUC患者接受手术治疗后生存期更长。根治性和非根治性切除似乎具有相似的OS和DSS结果。因此，在该人群中临床指征明确时，采用更保守的手术方法可能是合理的。
