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Survival outcomes in patients undergoing neoadjuvant chemotherapy for upper tract urothelial cell carcinoma.

311 Background: High-grade upper tract urothelial carcinoma (UTUC) is frequently upstaged at surgery and has uniformly poor survival rates. Neoadjuvant chemotherapy (NAC) may provide an avenue to improve clinical outcomes in these patients prior to loss of renal function after nephroureterectomy.


METHODS
We performed a retrospective review of patients with high risk UTUC who received NAC followed by surgical extirpation from 2004 to 2008, a time period during which NAC was uniformly offered to patients. The study group was then compared to a historical cohort of similar risk patients who underwent initial surgical treatment from 1993-2004.


RESULTS
Of the 120 patients, 31 patients with high-risk cN0 disease received NAC, 76 had initial surgery, and 13 had surgical consolidation of clinically involved lymph nodes after chemotherapy. Those receiving NAC had an improved OS and DSS (p=0.018 and p=0.0005, respectively). The 3 and 5 year DSS for cN0 patients receiving NAC was 90% and 90% (OS 87% and 80% respectively) with median follow up of 64 months. The 3 and 5 year DSS and OS for the historical group was 70% and 62%, with median follow up of 87 months. The two groups had similar demographics and clinical features, except for a higher proportion of sessile tumor architecture in the NAC group (p=0.021). Full dose cisplatin or high dose ifosfamide based chemotherapy was given to 22 (71%) patients, while 4 (13%) received a modified dose of cisplatin, and 5 (16%) received a nephron sparing combination. Pathologic downstaging to <=pT1N0 was significantly associated with NAC (65% vs 26% initial, p=0.004). The 13 patients with node positive disease at presentation received NAC followed by surgical consolidation with median OS 78 months. The 3 and 5 year DSS was 77% and 67% (OS 69% and 60% respectively).


CONCLUSIONS
Neoadjuvant chemotherapy improves survival in patients with UTUC compared with historical expectations. Patients with high-risk UTUC should be considered for neoadjuvant chemotherapy especially considering the limitations of administering curative cisplatin-based chemotherapy after nephrectomy.