Novel Classification for Upper Tract Urothelial Carcinoma to Better Risk-stratify Patients Eligible for Kidney-sparing Strategies: An International Collaborative Study

• Published in: European urology focus 2022-03, Vol.8 (2), p.491-497
• Main Authors: Marcq, Gautier, Foerster, Beat, Abufaraj, Mohammad, Matin, Surena F., Azizi, Mounsif, Gupta, Mohit, Li, Wei-Ming, Seisen, Thomas, Clinton, Timothy, Xylinas, Evanguelos, Mir, M. Carmen, Schweitzer, Donald, Mari, Andrea, Kimura, Shoji, Bandini, Marco, Mathieu, Romain, Ku, Ja H., Guruli, Georgi, Grabbert, Markus, Czech, Anna K., Muilwijk, Tim, Pycha, Armin, D’Andrea, David, Petros, Firas G., Spiess, Philippe E., Bivalacqua, Trinity, Wu, Wen-Jeng, Rouprêt, Morgan, Krabbe, Laura-Maria, Hendricksen, Kees, Egawa, Shin, Briganti, Alberto, Moschini, Marco, Graffeille, Vivien, Autorino, Riccardo, John, Patricia, Heidenreich, Axel, Chlosta, Piotr, Joniau, Steven, Soria, Francesco, Pierorazio, Phillip M., Shariat, Shahrokh F., Kassouf, Wassim
• Format: Article
• Language: English
• Subjects: Aged; Carcinoma, Transitional Cell - pathology; Female; Humans; Kidney - pathology; Kidney - surgery; Male; Retrospective Studies; Risk assessment; Transitional cell carcinoma; Ureteral Neoplasms - pathology; Ureteral Neoplasms - surgery; Ureteroscopy; Urinary Bladder Neoplasms - pathology; Urologic neoplasms; Urologic surgical procedures; Urological diagnostic techniques
• ISSN: 2405-4569; 2405-4569
• DOI: 10.1016/j.euf.2021.03.018

The European Association of Urology risk stratification dichotomizes patients with upper tract urothelial carcinoma (UTUC) into two risk categories. To evaluate the predictive value of a new classification to better risk stratify patients eligible for kidney-sparing surgery (KSS). This was a retrospective study including 1214 patients from 21 centers who underwent ureterorenoscopy (URS) with biopsy followed by radical nephroureterectomy (RNU) for nonmetastatic UTUC between 2000 and 2017. A multivariate logistic regression analysis identified predictors of muscle invasion (≥pT2) at RNU. The Youden index was used to identify cutoff points. A total of 811 patients (67%) were male and the median age was 71 yr (interquartile range 63–77). The presence of non–organ-confined disease on preoperative imaging (p < 0.0001), sessile tumor (p < 0.0001), hydronephrosis (p = 0.0003), high-grade cytology (p = 0.0043), or biopsy (p = 0.0174) and higher age at diagnosis (p = 0.029) were independently associated with ≥pT2 at RNU. Tumor size was significantly associated with ≥pT2 disease only in univariate analysis with a cutoff of 2 cm. Tumor size and all significant categorical variables defined the high-risk category. Tumor multifocality and a history of radical cystectomy help to dichotomize between low-risk and intermediate-risk categories. The odds ratio for muscle invasion were 5.5 (95% confidence interval [CI] 1.3–24.0; p = 0.023) for intermediate risk versus low risk, and 12.7 (95% CI 3.0–54.5; p = 0.0006) for high risk versus low risk. Limitations include the retrospective design and selection bias (all patients underwent RNU). Patients with low-risk UTUC represent ideal candidates for KSS, while some patients with intermediate-risk UTUC may also be considered. This classification needs further prospective validation and may help stratification in clinical trial design. We investigated factors predicting stage 2 or greater cancer of the upper urinary tract at the time of surgery for ureter and kidney removal and designed a new risk stratification. Patients with low or intermediate risk may be eligible for kidney-sparing surgery with close follow-up. Our classification scheme needs further validation based on cancer outcomes. Non–organ-confined disease on imaging, a sessile tumor, hydronephrosis, high-grade cytology or biopsy, and older age are independent factors for ≥pT2 upper tract urothelial carcinoma at the time of radical nephroureterectomy. Our three-level ris