Oncology - Bladder, Renal, Test
Mid-Atlantic Section 76th Annual Meeting
Introduction & Objective :
Nephroureterectomy (NU) is the gold standard for upper-tract urothelial carcinoma (UTUC) of the ureter, but segmental ureterectomy (SU) and endoscopic management (EM) are attractive nephron-sparing approaches in appropriate patients. We sought to determine treatment patterns and outcomes associated with these modalities for ureteral tumors alone.
The National Cancer Database (NCDB) was queried for patients with clinically localized ureteral UTUC (<cT2N0M0) undergoing either NU, SU, or EM from 2004-2015. Patients were excluded with previous cancer diagnoses, non-urothelial histology or incomplete data. Treatment trends and survival outcomes were assessed for the cohorts utilizing multivariable logistic regression and Cox Proportional Hazards Regression.
7121 patients were included in the analysis (NU: n=4121; SU: n=1658; EM: n=1342).
On multivariable logistic regression with respect to EM, increasing tumor size (OR 1.04, CI 1.03-1.05) and high grade histology (OR 4.23, CI 3.20-5.58) were associated with increased likelihood of NU. No specific trend was noted with age, sex, race, payer status, CDCC score, facility designation, or increasing facility volume and treatment with EM or NU (all p>0.05).
With respect to SU, increasing tumor size (OR 1.01, CI 1.01-1.02) and female gender (OR 1.27, CI 1.04-1.54) were associated with increased likelihood of NU. Facility volume in the 1st (OR 1.32, CI -0.95-1.84), 2nd (OR 1.63, CI 1.16-2.28), 3rd (OR 2.24, CI 1.63-3.07) and 4th (1.93, CI 1.44-2.60) quintiles were associated with increased likelihood of NU compared to facilities in the top 5th quintile of treatment volume. No specific trend was noted with age, race, payer status, CDCC score, histology, or facility designation and treatment with SU or NU (all p>0.05).
On Cox Regression when accounting for age and comorbidities, there was no difference in OS between NU and SU (p=0.281) or EM (p=0.605). Facility volume in the 1st (HR 1.39, CI 1.08-1.79), 2nd (HR 1.39, CI 1.06-1.81) and 3rd (HR 1.30, CI 1.01-1.67) quintiles was associated with increased mortality compared to those in the 4th and 5th. Positive margins increased the risk of mortality by 78.7% (HR 1.79, CI 1.46-2.20).
Conclusions : Increasing tumor size, high grade histology and lower volume centers were associated with increased likelihood of NU compared to nephron-sparing management. When accounting for competing risks, no differences in OS were seen between treatment modalities, but lower volume centers may have worse outcomes. Prospective studies that validate the efficacy of nephron sparing management in appropriately selected patients can encourage adoption of these practices.