Does Hydronephrosis On Preoperative Axial Imaging Predict Worse Outcome For Those Undergoing Nephroureterectomy For Upper-Tract Urothelial Carcinoma?

Main Category: Urology / Nephrology
Also Included In: Cancer / Oncology
Article Date: 23 Feb 2009 - 1:00 PDT

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UroToday.com - One of the major difficulties in the management of upper tract urothelial carcinoma (UTUC) is our inability to predict pathologic stage accurately. Ureteroscopic biopsy samples provide inadequate information on final pathologic staging. In a study by Guarnizo, 45% of tumors were upstaged to pT1+ on final pathologic specimen.ⁱ Many urologists have turned to use ureteroscopic biopsy grade as a surrogate for final pathologic stage. Keely noted that 87% of low to moderate grade ureteroscopic biopsies were low stage (Ta or T1) tumors on final pathology, while 67% of high grade ureteroscopic specimens had muscle invasive tumors. ⁱⁱ

Imaging techniques have also failed to improve our ability to accurately predict pathologic stage preoperative. CT scans have not been able to differentiate between non muscle-invasive tumors (Ta or T1) and muscle-invasive tumors (T2). ⁱⁱⁱ

Previous studies have shown that the presence of hydronephrosis in patients with bladder cancer is associated with advanced disease and is a predictor of poorer outcomes. We sought to evaluate if the presence of hydronephrosis in patients with UTUC is also associated with advanced disease and poorer outcomes. Records from 106 patients who had nephroureterectomies for UTUC from Cornell and UTSW were retrospectively reviewed. We determined that presence of hydronephrosis was a significant predictor of non-organ confined disease on final pathology (hazard ration [HR] 3.7, p=0.01). Furthermore, we found that hydronephrosis was a significant risk factor for metastasis and death due to urothelial disease.

The primary limitation in this study is related to any retrospective data collection, including sample size and follow up duration. Another limitation is that patients were treated by various physicians and specimens were evaluated by various pathologists over a period of time.

As in the case of muscle invasive bladder cancer, there is increasing evidence that extended lymphadenectomy and neoadjuvant chemotherapy may have therapeutic value in the management of UTUC. From a clinical standpoint, the presence of hydronephrosis serves as a marker for advanced stage disease. Suspicion of advanced stage disease will allow physicians to better individually tailor treatments in patients with UTUC. The presence of hydronephrosis implies worse local disease burden, suggesting that endoscopic ablation may be inadequate as a monotheraputic option. Furthermore, the presence of hydronephrosis may encourage more aggressive surgical therapy, such as extended lymphadenectomy or the use of multimodal therapy, such as neoadjuvant or adjuvant chemotherapy.

Since the completion of this study, we have continued to evaluate other preoperative factors that may predict final pathologic stage. We are in the process of evaluating if the combination of hydronephrosis, biopsy grade and urinary cytology can combine to predict pathologic stage more accurately. We believe that such refinement will allow urologists to offer enhanced patient counseling and to improve preoperative surgical planning.

ⁱ Guarnizo, E., Pavlovich, C. P., Seiba, M., Carlson, D. L., Vaughan, E. D., Jr., Sosa, R. E.: Ureteroscopic biopsy of upper tract urothelial carcinoma: improved diagnostic accuracy and histopathological considerations using a multi-biopsy approach. J Urol, 163: 52, 2000
ⁱⁱ Keeley, F. X., Kulp, D. A., Bibbo, M., McCue, P. A., Bagley, D. H.: Diagnostic accuracy of ureteroscopic biopsy in upper tract transitional cell carcinoma. J Urol, 157: 33, 1997
ⁱⁱⁱ Fritz, G. A., Schoellnast, H., Deutschmann, H. A., Quehenberger, F., Tillich, M.: Multiphasic multidetector-row CT (MDCT) in detection and staging of transitional cell carcinomas of the upper urinary tract. Eur Radiol, 16: 1244, 2006

Written by Casey K. Ng, MD, et al. as part of Beyond the Absrtract on UroToday.com

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