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INTRODUCTION: Upper tract urothelial carcinoma (UTUC) accounts for 5% of all urothelial tumours. Due to its rarity, evidence regarding postoperative surveillance is lacking. The objective of this study was to develop a post-radical nephroureterectomy (RNU) surveillance protocol based on recurrence patterns in a large, multi-institutional cohort of patients. METHODS: Retrospective clinical and pathological data were collected from 1029 patients undergoing RNU over a 15-year period (1994-2009) at 10 Canadian academic institutions. A multivariable model was used to identify prognostic clinicopathological factors, which were then used to define risk categories. Risk-based surveillance guidelines were proposed based on actual recurrence patterns. RESULTS: Overall, 555 (49.9%) patients developed recurrence, including 289 (25.9%) in the urothelium and 266 (23.9%) with loco-regional and distant recurrences. Based on multivariable analysis, three risk groups were identified: 1) low-risk patients with pTa-T1, pN0 disease, and no adverse histological features (high tumour grade, lymphovascular invasion [LVI], tumour multifocality); 2) intermediate-risk patients with pTa-T1, pN0 disease with one or more of the adverse histological features; and 3) high-risk patients with a ≥pT2 tumour and/or nodal involvement. Low-, intermediate-, and high-risk patients were free of urothelial recurrence at three years in 72%, 66%, and 63%, respectively, and free of regional/distant recurrence in 93%, 87%, and 62%, respectively. The risks of loco-regional and distant recurrences (p<0.0001) and time to death (p<0.0001) were significantly different between the low-, intermediate-, and high-risk patients. CONCLUSIONS: Based on recurrence patterns in a large, multicentre patient cohort, we have proposed an evidence-based, risk-adapted post-RNU surveillance protocol.
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INTRODUCTION: : We delineated Canadian regional differences in practice patterns in the management of upper tract urothelial carcinoma (UTUC) after nephroureterectomy and relate these to patient outcomes. METHODS: : A database was created with 1029 patients undergoing radical nephroureterectomy for UTUC between 1994 and 2009 at 10 Canadian centres. Demographic, clinical and pathological variables were collected from chart review. Practice pattern variables were defined as: open versus laparoscopic nephroureterectomy, management strategy for the distal ureter, performance of lymphadenectomy and administration of chemotherapy and/or radiation therapy. The outcome measures were overall (OS), disease-specific (DSS) and recurrence-free survival (RFS). The centres were divided into three regions (West, Central, East). Cox proportional multivariable linear regression analysis was used to determine the association between regional differences in practice patterns and clinical outcomes. RESULTS: : There was a significant difference in practice patterns between regions within Canada for: time from diagnosis to surgery (p = 0.001), type of surgery (open vs. laparoscopic, p < 0.01) and method of management of the distal ureter (p = 0.001). As well, there were significant differences in survival between regions across Canada: 5-year OS (West 70%, Central 81% and East 62%, p < 0.0001) and DSS (West=79%, Central=85%, East=75%, p = 0.007) were significantly different, but there was no difference in RFS (West 47%, Central 48%, East 46%, p = 0.88). Multivariable linear regression analysis demonstrated that the differences in survival were independent of region OS (p = 0.78), DSS (p = 0.30) or RFS (p = 0.43). CONCLUSION: : There is significant disparity in practice patterns between regions within Canada, but these do not appear to have an effect on survival. We believe that the variability in practice is a reflection of the lack of standardized treatments for UTUC and underlines the need for multi-institutional studies in this disease.
