Presentation Authors: Joseph Cheaib*, Ross Liao, Mohit Gupta, Max Kates, Michael Johnson, Noah Hahn, Jean Hoffman-Censits, Trinity Bivalacqua, Phillip Pierorazio, Baltimore, MD
Introduction: Patients with upper tract urothelial carcinoma (UTUC) treated with radical nephroureterectomy (RNU) are at risk of disease recurrence in the bladder. The use of neoadjuvant chemotherapy (NAC) in conjunction with RNU has recently been advocated to treat high-grade (HG) UTUC. The effects of disease grade and NAC utilization on rates of bladder recurrence in UTUC have not been widely studied.
Methods: We performed a retrospective analysis of 202 UTUC patients who underwent RNU at our institution from 2003 to 2018, received no adjuvant intravesical treatment following RNU, and had documented bladder follow-up. Recurrence rates and bladder recurrence-free survival (BRFS) estimates were obtained with the Kaplan-Meier method and compared using log-rank test. Univariable and multivariable Cox regression analyses were performed to the predict risk of bladder recurrence in HG patients by NAC utilization.
Results: Overall, there were 89 patients (44%) with urothelial disease recurrence in the bladder over a median follow-up of 12 months (interquartile range, 6-30 months). There was no significant difference in BRFS between HG and low-grade (LG) UTUC patients (p=0.5). HG patients had more muscle-invasive bladder recurrences than LG patients (39% vs 0%, p=0.001). Recurrence rates at 1 year and 5 years post-RNU were, respectively, 32% and 52% for LG patients and 37% and 59% for HG patients. Among patients with HG disease (N=155), 69 (45%) developed bladder recurrence. NAC was associated with a significantly longer BRFS in these patients; median BRFS was 23 months in the RNU only cohort (N=129) but was not reached yet at 39 months in the NAC cohort (N=26) (p=0.02). At 1 year post-RNU, the rates of bladder recurrence were 21% and 40% in HG patients treated with and without NAC, respectively. Patients who received NAC were significantly less likely to develop bladder recurrence compared to those who only underwent RNU (HR=0.33, 95% CI: 0.1-0.8, p=0.03). Significance persisted after adjusting for stage, lymphovascular invasion, and adjuvant chemotherapy (HR=0.32, 95% CI: 0.1-0.8, p=0.029).
Conclusions: A significant proportion of patients with UTUC will recur in the bladder. Recurrence rates are independent of grade. Patients receiving NAC may have lower rates of bladder recurrence than those without perioperative chemotherapy.