Original Paper Curr Urol 2012;6:156–159 DOI: 10.1159/000343531

Received: March 18, 2012 Accepted: June 29, 2012 Published online: December 21, 2012

Significance of Ureteroscopic Biopsy Grade in Patients with Upper Tract Urothelial Carcinoma Junya Furukawa

Hideaki Miyake

Iori Sakai

Masato Fujisawa

Division of Urology, Kobe University Graduate School of Medicine, Kobe, Japan

Abstract Background: The objective of this study was to assess the significance of the ureteroscopic biopsy grade for patients with upper tract urothelial carcinoma (UTUC). Patients and Methods: This study included 40 patients who were diagnosed with a single focus of UTUC by ureteroscopic biopsy and subsequently underwent nephroureterectomy. The significance of the biopsy grade as a predictive factor for pathological outcomes of nephroureterectomy was retrospectively analyzed. Results: Of these 40 patients, 19 (47.5%) and 21 (52.5%) were diagnosed with low and high grade UTUC, respectively. The ureteroscopic biopsy grade matched the pathological grade of surgically resected specimens in 35 of the 40 cases (87.5%), and there was a significant correlation between the biopsy and pathological grades (p < 0.001). Furthermore, the biopsy grade was also shown to be closely associated with the pathological stage (p < 0.001); that is, only 1 of the 19 patients (5.3%) with biopsy low grade UTUC were pathologically diagnosed as having muscle invasive disease, while 17 of the 21 patients (81.0%) with biopsy high grade UTUC appeared to show tumor invasion into muscle or deeper. Conclusions: The grade of UTUC on ureteroscopic biopsy could provide accurate diagnostic information on the final pathology of nephroureterectomy specimens. Copyright © 2012 S. Karger AG, Basel

© 2012 S. Karger AG, Basel 1015–9770/12/0063–0156$26.00/0 Fax +41 61 306 12 34 E-Mail [email protected] www.karger.com

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Introduction

Upper tract urothelial carcinoma (UTUC) is a relatively rare disease accounting for approximately 5% of malignant urothelial tumors [1]. Although nephroureterectomy with excision of a cuff of the bladder mucosa is currently regarded as the standard for the management of nonmetastatic UTUCs, prognostic outcomes following nephroureterectomy have been shown to vary depending on major pathological factors, particularly the tumor grade and pathological stage [2–5]. For example, Hall et al. [2] reported that when evaluated according to the pathological stage, 5-year survival rates in patients with UTUC undergoing nephroureterectomy ranged from 100% for pTa disease to 41% for pT3 disease, while our previous study demonstrated a significant difference in postoperative cancer-specific survival between patients with low grade UTUC and those with G3 UTUC [3]. However, during the last two decades, more conservative approaches to the treatment of UTUC, such as segmental ureteral resection and transureteral endoscopic management, have gained acceptance for patients requiring a nephron-sparing approach, including those with a solitary kidney, bilateral UTUC, renal impairment or significant comorbidities [6, 7]. Furthermore, some recent studies recommended such conservative managements for selected patients with small, low grade UTUC and a normal contralateral kidney [8, 9]. Considering the wide variety of surgical approaches for UTUC and their complicated indications, it is crucial Hideaki Miyake, MD Division of Urology Kobe University Graduate School of Medicine 7-5-1 Kusunoki-cho, Chuo-ku JP–6500017 Kobe (Japan) Tel. +81 78 382 6155, Fax +81 78 382 6169, E-Mail [email protected]

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Key Words Upper tract urothelial carcinoma • Ureteroscopic biopsy • Urinary cytology

Patients and Methods This study included a total of 40 consecutive patients who were diagnosed with a single focus of UTUC based on the findings on diagnostic ureteroscopy and biopsy, and were subsequently treated with nephroureterectomy at our institution between 2001 and 2009. During this interval, there were additional 87 patients with a single focus of UTUC who underwent nephroureterectomy without an examination by diagnostic ureteroscopy. In this study, patients with multiple tumor foci in the urinary tract were excluded for performing a rigid comparison of primary tumor characteristics between biopsy and surgically resected specimens. The upper urinary tract was examined using rigid 11.5 Fr and/ or flexible 9 Fr ureteroscopes, and biopsies of suspicious lesions were performed with 3 Fr cold cup forceps. All patients underwent nephroureterectomy within 3 months of ureteroscopic biopsy using either a standard open or laparoscopic approach, including the removal of the kidney, entire length of the ureter and adjacent segment of the bladder cuff, as previously described [3]. In this series, it was determined by preoperative clinical status whether regional lymphadenectomy was performed; however, the range of dissection was not uniformly determined. All specimens obtained from biopsy and nephroureterectomy were graded based on the 2004 World Health Organization classification and staged according to the 2002 TNM classification system by a pathologist. Statistical analyses by Pearson’s correlation coefficient for comparing pathological findings between biopsy and surgically resected specimens were carried out using Statview 5.0 software (Abacus Concepts, Inc., Berkeley, CA, USA). Probability (p) values less than 0.05 were considered significant.

Results

Clinicopathological characteristics of the 40 patients included in this study are summarized in table 1. All 40 patients were examined by upper tract urinary cytology, and positive findings were obtained in 15 (37.5%). This outcome was significantly associated with the ureteroscopic biopsy grade (p = 0.041); that is, a positive upper tract cytology was demonstrated in 4 of 19 patients with biopsy low grade disease (21.1%) and 11 of 21 with biopsy high grade disease (52.4%). As shown in table 2, there was a significant association between the tumor grade of ureteroscopic biopsy and that Ureteroscopic Biopsy for Upper Tract Urothelial Carcinoma

Table 1. Patient characteristics

Item

Value

Median age (range), years Gender, % Male Female Tumor location, % Renal pelvis Ureter Tumor site, % Right Left Urinary cytology, % Negative Positive Ureteroscopic biopsy grade, % Low High Pathological grade, % Low High Pathological stage, % pTa pT1 pT2 pT3

70.0 (52–89) 35 (87.5) 5 (12.5) 19 (47.5) 21 (52.5) 11 (27.5) 29 (72.5) 15 (37.5) 25 (62.5) 19 (47.5) 21 (52.5) 14 (35.0) 26 (65.0) 13 (32.5) 9 (22.5) 6 (15.0) 12 (30.0)

Table 2. Association between biopsy and pathological grade and

stage

Biopsy grade Low Pathological grade, % Low High Pathological stage, % pTa pT1 pT2 pT3

p High

14 (100) 5 (19.2)

0 (0) 21 (80.8)

13 (100) 5 (55.6) 1 (16.7) 0 (0)

0 (0) 4 (44.4) 5 (83.3) 12 (100)

Significance of ureteroscopic biopsy grade in patients with upper tract urothelial carcinoma.

The objective of this study was to assess the significance of the ureteroscopic biopsy grade for patients with upper tract urothelial carcinoma (UTUC)...
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