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Nephrectomy may not be essential for all urinary tract cancers

NEW YORK (Reuters Health) – Patients with low grade upper urinary tract urothelial carcinoma don’t survive any longer with radical resection than they do with nephron-sparing surgery, a new cases series suggests.

The series was a large one: 160 patients treated over a 15-year period by a single tertiary referral surgeon who used the same surgical techniques and treatment algorithms over the entire study period.

“The consecutively accrued nature and size of the study groups, uniformity in treatments, statistical review, and long-term follow-up provide baseline oncological data that help frame future study,” the editors of BJU International wrote in a commentary online March 28.

In their report, Dr Michael Grasso and colleagues at the New York Medical College and Westchester Medical Center in Valhalla, New York, stratified patients according to whether they had ureteroscopy (for low grade lesions), palliation (for high grade lesions), or nephroureterectomy.

The median age at presentation as 73 years, and the average follow-up was for 38.2 months.

About 56% of patients had low-grade disease, and these “were offered ureteroscopic (endoscopic) resection sparing their kidney,” Dr. Grasso told Reuters Health by email. “When compared to those who underwent nephrectomy with low grade disease, survival was identical and thus removing a kidney in this setting can be overtreatment — kidneys can be spared.”

He draws this conclusion from 66 such patients who underwent ureteroscopy and a further 23 who had nephroureterectomy.

Corresponding cancer specific survival rates with uteroscopy and extirpative surgery, respectively, were 98% and 97% at two years and 81% and 78% at 10 years.

For patients with high grade disease treated with nephroureterectomy, two- and 10-year survival rates were 70% and 38%. Two- and 10-year metastasis-free survival rates were 55% and 35%.

For high grade patients treated palliatively, the median survival was 29.2 months and two-year overall survival was 54%.

Tumor grade was the most significant predictor of survival, regardless of treatment method. A high grade lesion on initial presentation carried a hazard ratio of 7.21.

As Dr. Grasso pointed out, “For those with high grade disease treated with nephrectomy the 5 year survival was poor — approximately 50% — and thus in this high risk group surgery alone is often not curative. It is in this group that adjuvant chemotherapy should be employed to improve survival.”

SOURCE: http://bit.ly/JnJCNH

BJU Int 2012.