title: Preoperative hydronephrosis, ureteroscopic biopsy grade and urinary cytology can improve prediction of advanced upper tract urothelial carcinoma.
abstract: OBJECTIVE
  We evaluated the value of hydronephrosis, ureteroscopic biopsy grade and urinary cytology to predict advanced upper tract urothelial carcinoma.
  
  
  METHODS
  We reviewed the charts of 469 patients with upper tract urothelial carcinoma treated with radical nephroureterectomy or distal ureterectomy. Complete data on hydronephrosis (present vs absent), ureteroscopic grade (high vs low) and urinary cytology (positive vs negative) were available in 172 patients. The outcome was muscle invasive (pT2-pT4) or nonorgan confined (pT3 or greater, or lymph node metastasis) upper tract urothelial carcinoma.
  
  
  RESULTS
  Of the patients 92 (54%) had hydronephrosis, 74 (43%) had high grade disease on ureteroscopic biopsy and 137 (80%) had positive cytology. On univariate analysis hydronephrosis (p <0.001), high ureteroscopic grade (p <0.001) and positive cytology (p = 0.03) were associated with muscle invasive and nonorgan confined disease. On multivariate analysis adjusting for tumor site, gender and age hydronephrosis and high ureteroscopic grade were associated with muscle invasive carcinoma (HR 12.0 and 4.5, respectively, each p <0.001) but cytology was not (HR 2.3, p = 0.17). However, all 3 variables were independently associated with nonorgan confined disease (HR 5.1, p <0.001; HR 3.9, p <0.001; and HR 3.1, p = 0.035, respectively). Combining these 3 tests incrementally improved the prediction of upper tract urothelial carcinoma stage. Abnormality of all 3 tests had 89% and 73% positive predictive value for muscle invasive and nonorgan confined upper tract urothelial carcinoma, respectively, but when all tests were normal, the negative predictive value was 100%.
  
  
  CONCLUSIONS
  Preoperative evaluation for hydronephrosis, ureteroscopic grade and cytology can identify patients at risk for advanced upper tract urothelial carcinoma. Such knowledge may impact surgery choice and extent as well as the need for perioperative chemotherapy regimens.
authors.affiliation: Division of Urology, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA.
authors.forename: James C
authors.initials: JC
authors.lastname: Brien
authors.forename: Shahrokh F
authors.initials: SF
authors.lastname: Shariat
authors.forename: Michael P
authors.initials: MP
authors.lastname: Herman
authors.forename: Casey K
authors.initials: CK
authors.lastname: Ng
authors.forename: Douglas S
authors.initials: DS
authors.lastname: Scherr
authors.forename: Benjamin
authors.initials: B
authors.lastname: Scoll
authors.forename: Robert G
authors.initials: RG
authors.lastname: Uzzo
authors.forename: Mark
authors.initials: M
authors.lastname: Wille
authors.forename: Scott E
authors.initials: SE
authors.lastname: Eggener
authors.forename: John D
authors.initials: JD
authors.lastname: Terrell
authors.forename: Steven M
authors.initials: SM
authors.lastname: Lucas
authors.forename: Yair
authors.initials: Y
authors.lastname: Lotan
authors.forename: Stephen A
authors.initials: SA
authors.lastname: Boorjian
authors.forename: Jay D
authors.initials: JD
authors.lastname: Raman
mesh_terms: D000368:Aged; D001706:Biopsy; D002295:Carcinoma, Transitional Cell / Q000473:pathology* / Q000601:surgery; D016009:Chi-Square Distribution; D005260:Female; D006801:Humans; D006869:Hydronephrosis / Q000473:pathology*; D016015:Logistic Models; D008207:Lymphatic Metastasis; D008297:Male; D009361:Neoplasm Invasiveness; D009367:Neoplasm Staging; D009392:Nephrectomy / Q000379:methods; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D014516:Ureteral Neoplasms / Q000473:pathology* / Q000601:surgery; D018666:Ureteroscopy; D001749:Urinary Bladder Neoplasms / Q000473:pathology* / Q000601:surgery; D014556:Urine / Q000166:cytology*