Chemotherapy: Open Access
Open Access

Abstract

Risk Stratification Model to Predict High-Risk Patients for Adjuvant Chemotherapy in Upper Urinary Tract Urothelial Cancer

Kazuhiro Nagao, Hideyasu Matsuyama, Kiyohide Fujimoto, Haruhito Azuma, Hiroaki Shiina, Shigeru Sakano, Yoshihiro Tatsumi, Teruo Inamoto and Hiroaki Yasumoto

Objective: Optimal patient selection for adjuvant chemotherapy has not been clarified in upper urinary tract urothelial cancer (UTUC). We aimed to develop a risk model to select candidates for adjuvant chemotherapy after radical nephroureterectomy (RNU).

Methods: A retrospective review of 936 patients with UTUC between 1995 and 2015 who received ≥ 2 cycles of platinum-based adjuvant chemotherapy after RNU (n=213) or surgery alone (n=723) was conducted in collaborative institutions. Risk factors for cancer-specific mortality were extracted using the proportional hazard model. The survival benefit in high-risk patients was compared between the groups.

Results: At a median follow-up of 1006 days (34 months), disease recurrence, cancer-specific mortality, and allcause mortality were noted in 253 (27.5%), 206 (22.0%), and 285 (30.4%) patients, respectively. On multivariate analysis, baseline serum C-reactive protein (CRP) ≥ 0.32 mg/dL (HR: 1.74, 95% CI: 1.09–2.75, p=0.0201), pathologic T stage ≥ 3 (pT>3) (HR: 2.17, 95% CI: 1.28–3.76, (p=0.0033), cN+ (HR: 2.84, 95% CI: 1.50–5.01, p=0.0021), and lymphovascular invasion (LVI) (HR: 3.94, 95% CI: 2.23–7.17, p<0.0001) were independent predictors of cancer-specific mortality (CSM) in the training set. When they were used to categorize patients into low (0-1 factor) and high-risk groups (2-4 factors), high-risk patients had significantly worse CSM than those with low-risk. In the high-risk patients, 42.3% who received adjuvant chemotherapy had significantly better CSM and all-cause mortality than those who underwent surgery alone. In high-risk patients, multivariate analysis showed adjuvant chemotherapy as an independent prognostic factor for CSM (HR: 0.52) and all-cause mortality (HR: 0.57).

Conclusion: CRP, pT>3, cN+, and LVI was useful for identifying high-risk patients.