Segmental ureterectomy (SU) may be an appropriate alternative to radical nephroureterectomy (NU) for the treatment of high-risk ureteral tumors, according to a recent study.

A retrospective analysis using data from 2006 to 2013 from the National Cancer Database (NCDB) revealed no significant difference in overall survival (OS) between patients treated with SU or NU after adjusting for multiple variables, Patrick M. Lec, MD, of the David Geffen School of Medicine at the University of California, Los Angeles, and colleagues reported in Urologic Oncology.

The study included 1962 patients with clinically localized high-risk ureteral tumors. Patients needed to have at least 1 of the following high-risk features: tumor size larger than 2 cm, variant histology, grade 3 or 4 disease, or clinical stage T2 disease or higher. The selection criteria aimed to approximate the European Association of Urology (EAU) definition of high-risk upper tract urothelial carcinoma (UTUC) within the limits of the NCDB, the investigators explained.

Of the 1962 patients included, 1421 (72.4%) underwent radical NU and 541 (27.6%) underwent SU. Lymphadenectomy was performed in only 446 patients (22.7%). Among the 1092 patients with advanced pathology, 271 (24.8%) received adjuvant chemotherapy. The median follow-up time was 33.2 months for the radical NU group and 31.6 months for the SU group.


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In the NU group, lymphadenectomy was associated with a 42% decreased risk of death when more than 3 nodes were removed (95% CI, 0.39-0.89), the authors reported. Receipt of adjuvant chemotherapy for advanced pathology had no effect on OS in either treatment group.

“This retrospective cohort study supports the performance of lymphadenectomy and SU in patients with high-risk ureteral tumors,” the authors concluded. “It also reflects historically low rates of perioperative systemic therapy in this cohort of patients.”

Dr Lec and colleagues stated that their study had limitations that derive from shortcomings of data extraction methods in the NCDB. Although they were able to restrict their analysis to ureteral tumors, they were not able to discriminate between tumor locations along the ureter or other factors such as multifocality and hydronephrosis “that fall within the EAU definition of high-risk UTUC,” the investigators wrote. “This invites some degree of selection bias, as some of these features technically dictate NU (i.e., proximal location) and others reflect more aggressive disease biology that favor performance of radical extirpative surgery.”

Reference

Lec PM, Venkataramana A, Lenis AT, et al. Trends in management of ureteral urothelial carcinoma and effects on survival: a hospital-based registry study. Published online October 1, 2020. Urol Oncol. doi:10.1016/j.urolonc.2020.08.033