Current smoking, large tumor size may predict early recurrence after radical nephroureterectomy in patients with low-grade UTUC

While low-grade upper tract urothelial carcinoma (LG-UTUC)—generally considered low-risk—is commonly associated with recurrence in the bladder, development of metastatic disease and cancer-related mortality are both rare after a patient’s disease is managed with radical nephroureterectomy (RNU). Smoking and large tumor size are independently associated with early recurrence within 6 months of RNU.1

The study, which was presented at the Society of Urologic Oncology 22nd Annual Meeting, aimed to describe recurrence patterns and identify predictive risk factors for recurrence after RNU to inform better surveillance strategies for clinicians after their patients receive RNU for LG-UTUC.

“Risk factors for timing and patterns of bladder and contralateral upper tract recurrence as well as development of metastatic disease after definitive management remain poorly described due to the overall low prevalence of the disease,” said Heather L. Huelster, MD, a 4th-year resident at Vanderbilt University Medical Center, during a presentation of the data.

To achieve their findings, investigators performed a retrospective electronic medical record review of 214 RNUs between February 2010 and April 2017. They identified 37 patients with LG-UTUC and excluded those with high-grade UTUC, evidence of nodal or distant metastatic disease, and pre-treatment with systemic therapy. Risk factors for early recurrence of urothelial malignancy (defined as recurrence within 6 months of RNU) were examined, and researchers obtained clinical, pathologic, recurrence, and survival data.

The mean age at surgery was 71.9 years. Most patients were male (74.8%), White (89.2%), and current or former smokers (83.8%), while less than half (40.5%) had history of urothelial carcinoma of the bladder. The median overall survival was 91.3 months, and 54.1% of patients had experienced recurrence over the course of 43.5 months.

Tumor size and multifocality were both associated with early recurrence, while analysis of demographics, surgical factors, and tumor characteristics showed that current smoking (OR, 10.6; P = .03) and increasing tumor size (OR, 1.9; P = .03) were independently associated with early recurrence.

“Current national and international guidelines vary with regard to use of risk stratification and their recommendation of timing of bladder surveillance after nephroureterectomy, citing low level evidence or weak categorization,” Huelster said.

She added that the data supports that large multi-focal tumors or low-grade tumors resected in patients who are current smokers bring a higher risk of early bladder recurrence. This may warrant more frequent cystoscopy at 3 to 6 months post-RNU, while patients without these risk factors may undergo annual cystoscopies.

“Additionally, initial urothelial recurrences are extremely rare more than 2 years after nephroureterectomy, so it may be reasonable to reduce the duration of cystoscopic surveillance, presenting an opportunity to reduce costs and patient burden associated with this,” Huelster said.

Reference

1. Huelster, H; Bilotta, A; Russo, N; et al. Predictive Risk Factors for Early Recurrence After Radical Nephroureterectomy for Low-Grade Upper Tract Urothelial Carcinoma. Presented at Society of Urologic Oncology 22nd Annual Meeting; Virtual. November 30-December 3, 2021. Abstract 117.