Study Suggests Panurothelial Carcinoma Warrants More Aggressive Surgical Treatment

¹published inScientific Reportsby researchers from China indicates panurothelial carcinoma (panUCC) has a high risk of recurring, progressing, and disseminating after conservative surgery, leading to poor outcomes. Therefore, the study’s authors recommend standardizing more aggressive surgical treatment for these patients, and they advocate complete urinary tract exenteration (CUTE) in carefully selected patients with panUCC, but especially in those with end-stage renal disease.

“The elevated risk of recurrence, progression, and tumor dissemination following conservative surgery reflect potential disadvantages of organ-conserving strategies,” the study authors wrote.

PanUCC, which includes the presence of bilateral upper tract urothelial carcinoma (UTUC) and a concomitant bladder tumor (BT), is a rare disease entity. To better understand the clinicopathologic characteristics and treatment outcomes of panUCC in the Asian population, the authors reviewed the medical records of patients treated for UTUC or BT at Peking University First Hospital, Beijing, China, between 1999 and 2012.

“Considering the heterogeneity and differences in incidence of urothelial carcinoma between Asian and Western patients, profiling the disease in an Asian cohort may facilitate management and elucidation of the underlying mechanisms,” the study authors wrote. “Elucidating the features of this uncommon disease entity, our data may contribute to optimal and personalized risk-based therapy while supporting future investigations into the biological mechanisms underlying multiple urothelial tumors,” they noted.

Overall, 45 patients (mean age, 64.5 years; 15 men and 30 women) met the authors’ study criteria (ie, diagnosis of urothelial carcinoma in the bilateral upper tracts and in the bladder either synchronously or metachronously) and were included in the study. Of these patients, 14 initially presented with unilateral UTUC and 11 with BT. The remainder had multiple tumors, including 10 with bilateral UTUC, 6 with unilateral UTUC and concomitant BT, and 4 with synchronous panUCC.

“In panUCC, regardless of synchronous or metachronous involvement, tumors in different locations still manifest the biological characteristics of primary UTUC and primary BT. In our cohort, BT demonstrated higher rates of multiple foci, while upper tract tumors were frequently muscle-invasive and larger,” the authors wrote.

The median time from patients’ initial presentation to their tumor disseminating to second and third sites was 8 months (range, 0-84 months) and 21 months (range, 0-141 months), respectively. Tumor dissemination took a little longer in those with tumors initially restricted to one site, with a median time of 24 months for tumor dissemination to second and third sites (range, 3-84 months and 3-141 months, respectively). Location of the initial tumor did not affect the time to development of metachronous disease or affect final tumor stage or grade. In addition, no differences in tumor stage or grade were observed between tumors at the first and third tumor sites; however, tumors at the third site were more likely to have sessile architecture and multiple foci.

Most of the study patients (73.3%) received combined management with conservative and radical surgery. Only 5 patients were treated with CUTE. After a median follow-up of 77 months (range, 16-156 months), 18 patients (40%) died, with 15 deaths (33.3%) directly related to urothelial cancer. The 2- and 5-year cancer-specific survival (CSS) rates were 95.6% and 81.2%, respectively. Univariate analysis found only higher tumor stage to be predictive of worse CSS. No patient demographics or tumor characteristics were found to have an impact on overall survival.

Approximately 60% of patients with UTUC received radical surgery initially or after a recurrence, while fewer than 25% of those with BT received radical surgery for either indication. Of those receiving conservative surgery, 19 experienced local recurrences. After undergoing surgical treatment for recurrence, 10 proceeded to receive CUTE.

Postoperatively, a total of 19 patients required permanent dialysis. None of these patients were renal transplant recipients and 6 had at least one kidney.

The authors reported several limitations with their study, including its retrospective design, which they note “precluded evaluation of potentially useful variables such as cytology and lymph node status in all patients.”

They also reported potential recall bias, lack of complete pathological results for some patients, and lack of standardization of the surgical approaches used and of the indications for a second surgery, both of which were based on the clinical judgment of the treating physician and on patients’ preferences and expectations. Furthermore, although not noted by the authors, the small study population and heterogeneity of urothelial carcinoma in different populations might limit the applicability of the findings to other populations, including Western populations and other Asian populations.

References

1. Fang D, Liu P, Li X, et al. Characteristics and treatment outcomes of pan-urothelial cell carcinoma: a descriptive analysis of 45 patients. Sci Rep. 2015;5:18014. doi:10.1038/srep18014.