title: Nephroureterectomy for treating upper urinary tract transitional cell carcinoma: Time to change the treatment paradigm?
abstract: OBJECTIVE
  To evaluate factors associated with disease recurrence and survival in patients undergoing nephroureterectomy for upper urinary tract transitional cell carcinoma (UUT-TCC) in one centre over an 18-year period.
  
  
  METHODS
  The records of patients who had a nephroureterectomy for UUT-TCC at our institution from 1986 to 2004 were reviewed for clinical, pathological and treatment period data. Cox's proportional hazards regression model was used to test the statistical significance of several potential prognostic factors for recurrence and survival. RESULTS The median overall duration of follow-up was 2.5 years for 184 patients. Significant prognosticators for disease-specific survival (DSS) by univariate analysis were tumour stage (P < 0.01), tumour grade (P < 0.01), node-positive disease (P < 0.01), multifocality (P = 0.03), previous cystectomy (P < 0.01) and synchronous bilateral UUT-TCC (P = 0.02). On multivariate analysis, only tumour stage (P = 0.03) and grade (P = 0.01) correlated with DSS. The median recurrence-free survival duration was 2.4 years. In 44 patients, the disease recurred outside the bladder; 15 (8.2%) had local recurrence, 20 (10.9%) distant metastasis, and nine (4.9%) both local and distant recurrence. Bladder tumours occurred in 40 (26.1%) patients with no previous cystectomy. The evaluation of treatment outcome during three periods of the study showed no significant effect on DSS.
  
  
  CONCLUSIONS
  Tumour stage and grade correlated with DSS in this cohort, with no improvement in outcome over the 18-year period assessed. Patients with high-stage and high-grade disease continue to fare poorly, suggesting a need for changing the treatment protocol. Judiciously applying a multimodal approach to the management of high-risk patients by incorporating neoadjuvant chemotherapy and surgical resection might provide, for the first time, the opportunity to improve patient outcome.
authors.affiliation: Department of Urology, The University of Texas MD Anderson Cancer Center Houston, TX 77030, USA.
authors.forename: Gordon A
authors.initials: GA
authors.lastname: Brown
authors.forename: J Erik
authors.initials: JE
authors.lastname: Busby
authors.forename: Christopher G
authors.initials: CG
authors.lastname: Wood
authors.forename: Louis L
authors.initials: LL
authors.lastname: Pisters
authors.forename: Colin P N
authors.initials: CP
authors.lastname: Dinney
authors.forename: David A
authors.initials: DA
authors.lastname: Swanson
authors.forename: H Barton
authors.initials: HB
authors.lastname: Grossman
authors.forename: Curtis A
authors.initials: CA
authors.lastname: Pettaway
authors.forename: Mark F
authors.initials: MF
authors.lastname: Munsell
authors.forename: Ashish M
authors.initials: AM
authors.lastname: Kamat
authors.forename: Surena F
authors.initials: SF
authors.lastname: Matin
mesh_terms: D000368:Aged; D002295:Carcinoma, Transitional Cell / Q000401:mortality / Q000601:surgery*; D015331:Cohort Studies; D018572:Disease-Free Survival; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007680:Kidney Neoplasms / Q000401:mortality / Q000601:surgery*; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy / Q000379:methods; D009364:Neoplasm Recurrence, Local / Q000601:surgery; D009367:Neoplasm Staging / Q000379:methods; D009392:Nephrectomy / Q000379:methods*; D011379:Prognosis; D016896:Treatment Outcome; D014513:Ureter / Q000601:surgery; D014516:Ureteral Neoplasms / Q000401:mortality / Q000601:surgery*