Location
Suwanee, GA
Start Date
11-5-2023 1:00 PM
End Date
16-5-2023 4:00 PM
Description
Background: Upper urinary tract transitional cell carcinomas (UUT-TCC) comprise any malignancy arising from the renal pelvis to distal ureter. These cancers account for approximately 5-10% of all urothelial tumors. Two-thirds of cases are invasive with an estimated 5-year survival rate less than 50%. Pathologic staging, invasion into local structures, and lymph node involvement influence the overall survival rate. Lymph node dissection (LND) is associated with higher overall survival rates in UUT-TCC patients, likely by decreasing regional lymph node metastasis. Current literature suggests that removing eight to ten regional lymph nodes may improve survival. The outcomes of upper urinary tract malignancies (UTM) have significantly improved, however, no standard guidelines exist regarding the role of LND in UUT-TCC. This analysis aims to investigate the impact of LND on outcomes in patients diagnosed with UUT-TCC.
Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) is a Health Insurance Portability and Accountability Act (HIPAA) compliant data file containing patient cases from 706 participating hospital institutions. A total of 14,186 patients who underwent nephrectomy and nephroureterectomy were initially evaluated. Inclusion criteria included a postoperative diagnosis of UTM (n=923). The cohort was subgrouped to patients with LND. The groups were defined for patients with lymph node positive (LNP) (n=48) and lymph node negative (LNN) (n=255) on pathological staging. Patients without lymph nodes evaluated or unknown status were excluded. The two groups were then compared. Pearson’s Chi-square test was performed for categorical variables, and t-test analysis for continuous variables. A univariate and multivariate analysis was performed with significant variables from the basic statistical analysis to predict independent factors. A Random forest model was also used. Statistical analysis was accepted at p<0.05.
Results: The overall rate of lymph node involvement was 5.2% for 923 patients that underwent nephroureterectomy for UTM. Among 303 patients with at least one lymph node evaluated, 48 (15.8%) were LNP. On Chi-square and t-test analysis, the LNN group had higher pT1 staging and planned laparoscopy. The LNP group had higher pT3, pT4, and pM1 staging, and had more planned open procedures compared to the LNN group. Postoperatively, there were no differences between the two groups including rate of lymphoceles or length of hospital stay (Table 1). On multivariate analysis, pT3 (p=0.001) and pT4 (p<0.001) were associated with lymph node involvement. Additionally, the LNP group was less likely to be planned laparoscopic/robotic compared to the LNN group (p=0.03). The previously statistically significant difference in weight, pT1 staging, and pM1 staging were statistically insignificant on multivariable regression analysis.
Conclusion: UUT-TCC with lymph node involvement is sparsely discussed in literature. Although rare, upper tract malignancy can present a challenge, partially due to the paucity of treatment guidelines. Our study shows that pT3 and pT4 are independently associated with lymph node involvement. No differences in postoperative outcomes were seen on multivariable analysis including number of nodes evaluated, lymphocele occurrences, or length of hospital stay. Our data suggests that for patients with suspected pT3 or pT4 UUT-TCC, nephroureterectomy should be performed in conjunction with LND.
Embargo Period
6-22-2023
Included in
Upper Urinary Tract Transitional Cell Carcinoma and Lymph Node Involvement: Pre and Post Operative Outcomes
Suwanee, GA
Background: Upper urinary tract transitional cell carcinomas (UUT-TCC) comprise any malignancy arising from the renal pelvis to distal ureter. These cancers account for approximately 5-10% of all urothelial tumors. Two-thirds of cases are invasive with an estimated 5-year survival rate less than 50%. Pathologic staging, invasion into local structures, and lymph node involvement influence the overall survival rate. Lymph node dissection (LND) is associated with higher overall survival rates in UUT-TCC patients, likely by decreasing regional lymph node metastasis. Current literature suggests that removing eight to ten regional lymph nodes may improve survival. The outcomes of upper urinary tract malignancies (UTM) have significantly improved, however, no standard guidelines exist regarding the role of LND in UUT-TCC. This analysis aims to investigate the impact of LND on outcomes in patients diagnosed with UUT-TCC.
Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) is a Health Insurance Portability and Accountability Act (HIPAA) compliant data file containing patient cases from 706 participating hospital institutions. A total of 14,186 patients who underwent nephrectomy and nephroureterectomy were initially evaluated. Inclusion criteria included a postoperative diagnosis of UTM (n=923). The cohort was subgrouped to patients with LND. The groups were defined for patients with lymph node positive (LNP) (n=48) and lymph node negative (LNN) (n=255) on pathological staging. Patients without lymph nodes evaluated or unknown status were excluded. The two groups were then compared. Pearson’s Chi-square test was performed for categorical variables, and t-test analysis for continuous variables. A univariate and multivariate analysis was performed with significant variables from the basic statistical analysis to predict independent factors. A Random forest model was also used. Statistical analysis was accepted at p<0.05.
Results: The overall rate of lymph node involvement was 5.2% for 923 patients that underwent nephroureterectomy for UTM. Among 303 patients with at least one lymph node evaluated, 48 (15.8%) were LNP. On Chi-square and t-test analysis, the LNN group had higher pT1 staging and planned laparoscopy. The LNP group had higher pT3, pT4, and pM1 staging, and had more planned open procedures compared to the LNN group. Postoperatively, there were no differences between the two groups including rate of lymphoceles or length of hospital stay (Table 1). On multivariate analysis, pT3 (p=0.001) and pT4 (p<0.001) were associated with lymph node involvement. Additionally, the LNP group was less likely to be planned laparoscopic/robotic compared to the LNN group (p=0.03). The previously statistically significant difference in weight, pT1 staging, and pM1 staging were statistically insignificant on multivariable regression analysis.
Conclusion: UUT-TCC with lymph node involvement is sparsely discussed in literature. Although rare, upper tract malignancy can present a challenge, partially due to the paucity of treatment guidelines. Our study shows that pT3 and pT4 are independently associated with lymph node involvement. No differences in postoperative outcomes were seen on multivariable analysis including number of nodes evaluated, lymphocele occurrences, or length of hospital stay. Our data suggests that for patients with suspected pT3 or pT4 UUT-TCC, nephroureterectomy should be performed in conjunction with LND.