Introduction:
Locoregional nodal involvement predicts poor outcomes in patients with upper tract urothelial carcinoma (UTUC). The utilization of neoadjuvant chemotherapy (NAC) for UTUC has been steadily increasing pertinent to the potential of improving survival for high risk patients, including those with concerns for node-positive disease. This study objective is to determine the clinical utility of neoadjuvant chemotherapy in patients with concerns for clinical nodal involvement (cN+) who subsequently underwent radical nephroureterectomy (RNU) in a large population registry.
Methods:
Utilizing the National Cancer Data Base (NCDB), we assessed patients with high grade UTUC who underwent radical nephroureterectomy with or without neoadjuvant chemotherapy between 2006 and 2014. The effect of NAC on patients with concerns for clinical nodal involvement (cN+) was investigated using Kaplan-Meier survival curves, Log-rank test, and Cox proportional hazard regression models.
Results:
A total of 18,133 patients were identified. 739 (4.1%) patients had cN+ status, of which 94 (12.7%) received NAC then RNU and 645 (87.9%) underwent upfront RNU.
A total of 567 (87.91%) patients in the RNU group had pathologic nodal involvement (pN+), and 45 patients (65.22%) in the NAC group were pN+ (p=0.0001). The relative risk of nodal involvement in the absence of NAC was 1.35 higher. NAC was associated with 22.69% of absolute risk reduction in node positivity, and improved median OS compared to RNU alone (24.73 vs 10.22 months, p=0.0009, Figure 1A).
Within the NAC group, patients had better median OS if they had complete nodal response compared to patients who remained node positive (36.1 vs 20.16 months, P=0.002, Figure 1B). In multivariate analysis, NAC patients had improved survival compared to upfront RNU (HR=0.65, P=0.01).
Conclusion:
In this large cohort study of high-grade UTUC patients, concerns of clinical nodes involvement without preoperative chemotherapy correlated with substantially low overall survival. NAC in cN+ patients leads to an absolute decrease in the rate pN+ at RNU over upfront surgery, and translates clinically into survival benefit. Lack of nodal status response to NAC is a poor prognostic sign, which might necessitate further treatment in this group of patients.
Funding: NA
Image(s) (click to enlarge):
THE UTILITY OF NEOADJUVANT CHEMOTHERAPY IN PATIENTS WITH CLINICAL NODE POSITIVE UPPER TRACT UROTHELIAL CARCINOMA IN A LARGE NATIONAL DATA REGISTRY
Category
Kidney Cancer > Advanced
Description
Poster #81
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Presented By: Mohammad Mahmoud
Authors:
Mohammad Mahmoud
Sean Q Kern, MD
Isamu Tachibana, MD
Liang Cheng, MD
Nabil Adra, MD
Hristos Kaimakliotis, MD