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JU INSIGHT Survival Impact of Variant Histology Diagnosis in Upper Tract Urothelial Carcinoma

By: Lucas M. Nogueira, MD; Wesley Yip, MD; Melissa J. Assel, MS; Andrew T. Tracey, MD; Nathan C. Wong, MD; Ricardo G. Alvim, MD; Hikmat Al-Ahmadie, MD; Dean F. Bajorin, MD; Jonathan A. Coleman, MD | Posted on: 01 Oct 2022

Nogueira LM, Yip W, Assel MJ, et al. Survival impact of variant histology diagnosis in upper tract urothelial carcinoma. J Urol. 2022;208(4)813-820.

Study Need and Importance

Variant histology is present in up to a third of bladder cancer cases, which is associated with adverse pathological features and worse oncologic outcomes. The impact of variant histology in upper tract urothelial carcinoma (UTUC) is still not well defined, and most disease management is extrapolated from the bladder cancer data. As diagnosis of variant histology is increasing in UTUC, it is important to define its impact on patient outcomes to help tailor disease management, adjuvant therapy, and followup strategy. In this study, we sought to evaluate the impact of variant histology pathological diagnosis on survival outcomes at our institution.

What We Found

We included 705 unique radical nephroureterectomy patients in our analysis, of whom 47 patients (6.7%) had variant histology in their specimens. A higher proportion of cases was diagnosed after the departmental subspecialization of genitourinary pathologists. The presence of variant histology was associated with an increased risk for the outcome of both cancer-specific and overall survival. However, after adjusting for pathological T stage, variant histology was not significantly associated with survival outcomes (see Figure).

Limitations

Our study is limited by the ­homogeneity of data afforded by a single-institution study, and ­patients selected for radical nephroureterectomy usually present with more advanced and aggressive disease. We relied on pathological findings at the time of initial surgery and re-review was not performed, which might impact the observed prevalence of histological subtypes.

Figure. Kaplan-Meier plot for overall survival after nephroureterectomy, separately for patients with no variant histology (gray line) and those with any variant histology on pathology (black line).

Interpretation for Patient Care

Data from this series suggest that variant histology in UTUC is a useful biomarker associated with higher stage and poor oncologic outcomes when pathological stage is unknown, such as in the pretreatment biopsy setting. However, finding variant histology on surgical pathology does not provide additional prognostic information beyond TNM staging risk after nephroureterectomy.

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