Pre-Nephroureterectomy Diagnosis of Low-Grade Urothelial Carcinoma Does Not Predict Low Grade Disease On Final Pathology
MOHAMMAD H. HOUT, MD., BORIVOJ GOLIJANIN, BS, CHRIS TUCCI, MS., RN., FRANCES KAZAL, BS, TIMOTHY K. O'ROURKE, Jr., MD., DAVID SOBEL, MD., GYAN PAREEK, MD., DRAGAN GOLIJANIN, MD..
BROWN UNIVERSITY, PROVIDENCE, RI, USA.
BACKGROUND: Upper tract urothelial carcinoma (UTUC) treatment depends on stage and grade of the disease. The gold standard of treatment is radical nephroureterectomy. In recent years UTUC treatment trends for low grade (LG) disease have shifted more towards minimally invasive and endoscopic approaches. Due to the potentially aggressive nature of UTUC, there is a risk of undertreatment especially if high grade (HG) disease is not confirmed on endoscopic biopsies. We sought to explore the risk of upgrading of UTUC, pathological, and long-term outcomes.
METHODS: A retrospective analysis of nephroureterectomy for UTUC cases performed at our hospital system from 1/1/2006 - 12/31/2020 was completed. Clinicopathologic features of patients were collected. Pre-operative pathology and diagnostic methods were analyzed, and descriptive statistics were summarized. Paired, nominal data of pre-operative and post-operative grading were compared using McNemar’s test. All analyses were completed using SPSS Version 26 (IBM Corp, Armonk NY).
RESULTS: 97 patients were included. 68/97 (70%) of patients were diagnosed with UTUC pre-operatively via endoscopic biopsy. 11 (11%) were diagnosed visually by endoscopy and 14 (14%) were diagnosed by cross sectional imaging. Of the 68 patients with biopsies, 37 (54%) were LG and 31 (46%) were HG. Of all patients with preop LG UTUC 25/37 (68%) were upgraded to HG UTUC (p<.0001) on final pathology. A total of 56/68 (84%) patients had HG UTUC on final pathology. Of patients with upgraded final pathology (n=25), 16 (64%) were cT1, 8 (32%) cT2, and 1 (4%) was cT3 and were changed to 10 (40%) pTa, 7 (28%) pT1, 2 (8%) pT2, 5 (20%) pT3, and 1 (4%) pT4. Of upgraded patients with LG and HG on final pathology 2 (16%) and 11 (44%) ultimately passed away, respectively. Type of endoscopic biopsy device was not associated with a difference in LG biopsy upgrading.
CONCLUSIONS: Management of LG UTUC on endoscopic biopsies carries significant risk due to potential of undergrading. Caution is highly advised when selecting patients for minimally invasive or endoscopic management even if adequate pathology specimen has been harvested and results in LG disease. A pre-nephroureterectomy diagnosis of LG UTUC is a poor predictor of final pathology.
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