Presentation Authors: Joseph Cheaib, Ross Liao*, Mohit Gupta, Max Kates, Michael Johnson, Noah Hahn, Jean Hoffman-Censits, Trinity Bivalacqua, Phillip Pierorazio, Baltimore, MD
Introduction: Accurate diagnostics to guide management are a technical challenge for many patients with upper tract urothelial carcinoma (UTUC). Some patients who undergo radical nephroureterectomy (RNU) and ultimately have high-grade (HG) UTUC can have non-diagnostic or low-grade (LG) UTUC (discordant pathology) at initial endoscopic evaluation. Stage distribution and survival of HG UTUC patients with discordant pathology may have important implications in the management of HG UTUC.
Methods: We retrospectively analysed 191 UTUC patients with HG disease on surgical pathology who underwent endoscopic diagnostic biopsies prior to RNU from 2003 to 2018. The proportion of patients with muscle-invasive (â‰¥pT2) disease on final pathology was compared in those with concordant versus discordant ureteroscopic pathology using Pearson's chi-squared test. Overall survival estimates for the two groups were obtained using the Kaplan-Meier method and compared using the log-rank test.
Results: There were 58 patients (30.1%) with discordant pathology and 133 patients with concordant pathology between ureteroscopy and RNU. No significant difference in overall survival was found between the two groups (p=0.9). Mean time from ureteroscopic biopsy to RNU was longer by 6 days for patients with discordant pathology (p=0.8). The proportion of â‰¥pT2 disease was not significantly different between patients with concordant and discordant pathologies (55.6% and 48.3% respectively, p=0.3). This was also seen after controlling for neoadjuvant chemotherapy use. A sensitivity analysis using preoperative urine cytology grade instead of biopsy grade did not show any significant difference in survival or proportion of â‰¥pT2 disease between patients with concordant (HG urine cytology) and discordant (LG/atypical/non-diagnostic urine cytology) pathology. A three-group sensitivity analysis combining biopsy and urine cytology grades (both HG vs both LG/atypical/non-diagnostic vs one HG and one LG/atypical/non-diagnostic) also showed no significant differences.
Conclusions: Technical limitations in endoscopy can yield substantial rates of discordance between ureteroscopic and RNU pathology. HG UTUC patients with concordant compared to discordant pathology, however, have no significant differences in overall survival and â‰¥pT2 disease prevalence. These results suggest the importance of prompt evaluation and consideration for RNU in patients for whom there is a high clinical suspicion of HG disease, despite low-grade or non-diagnostic biopsy or urine cytology results.