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JU INSIGHT: Diagnostic Accuracy of Clinical Lymph Node Staging for Upper Tract Urothelial Cancer Patients

By: Maximilian Pallauf, MD, Comprehensive Cancer Center, Medical University of Vienna, Austria, Paracelsus Medical University Salzburg, University Hospital Salzburg, Austria; David D’Andrea, MD, PhD, Comprehensive Cancer Center, Medical University of Vienna, Austria; Frederik König, MD, Comprehensive Cancer Center, Medical University of Vienna, Austria, University Medical Center Hamburg-Eppendorf, Germany; Ekaterina Laukhtina, MD, Comprehensive Cancer Center, Medical University of Vienna, Austria; Takafumi Yanagisawa, MD, Comprehensive Cancer Center, Medical University of Vienna, Austria, The Jikei University School of Medicine, Tokyo, Japan; Morgan Rouprêt, MD, PhD, AP-HP, Pitié-Salpêtriére Hospital, Sorbonne University, Paris, France; Siamak Daneshmand, MD, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles; Hooman Djaladat, MD, MS, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles; Alireza Ghoreifi, MD, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles; Francesco Soria, MD, San Giovanni Battista Hospital, University of Studies of Torino, Italy; Kazutoshi Fujita, MD, PhD, Kindai University Faculty of Medicine, Osaka, Japan; Stephen A. Boorjian, MD, Mayo Clinic, Rochester, Minnesota; Aaron M. Potretzke, MD, PhD, Mayo Clinic, Rochester, Minnesota; Andrea Mari, MD, University of Florence, Careggi Hospital, Italy; Mathieu Roumiguié, MD, CHU Institut Universitaire du Cancer de Toulouse, France; Alessandro Antonelli, MD, PhD, University of Verona, Azienda Ospedaliera Universitaria Integrata di Verona, Italy; Alberto Bianchi, MD, Comprehensive Cancer Center, Medical University of Vienna, Austria, University of Verona, Azienda Ospedaliera Universitaria Integrata di Verona, Italy; Zine-Eddine Khene, MD, University of Rennes, France; John P. Sfakianos, MD, PhD, Icahn School of Medicine at Mount Sinai, New York, New York; Marcus Jamil, MD, Vattikuti Urology Institute, Henry Ford Health System, Detroit, Michigan; Joost L. Boormans, MD, PhD, Erasmus MC Cancer Institute, University Medical Center Rotterdam, The Netherlands; Jay D. Raman, MD, Penn State Health, Hershey, Pennsylvania; Nico C. Grossmann, MD, Comprehensive Cancer Center, Medical University of Vienna, Austria, University Hospital Zurich, Switzerland, Luzerner Kantonsspital, Lucerne, Switzerland; Alberto Breda, MD, PhD, Fundació Puigvert, Autonomous University of Barcelona, Spain; Axel Heidenreich, MD, PhD, Comprehensive Cancer Center, Medical University of Vienna, Austria, University Hospital Cologne, Germany; Francesco Del Giudice, MD, “Sapienza” University of Rome, Policlinico Umberto I Hospital, Italy; Nirmish Singla, MD, The James Buchanan Brady Urological Institute, The Johns Hopkins, University School of Medicine, Baltimore, Maryland; Shahrokh F. Shariat, MD, Comprehensive Cancer Center, Medical University of Vienna, Austria, Hourani Center for Applied Scientific Research, Al-Ahliyya Amman University, Jordan, Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria, Weill Cornell Medical College, New York, New York, University of Texas Southwestern, Dallas, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Benjamin Pradere, MD, MSc, Comprehensive Cancer Center, Medical University of Vienna, Austria, La Croix du Sud Hospital, Quint-Fonsegrives, France | Posted on: 17 Mar 2023

Pallauf M, D’Andrea D, König F, et al. Diagnostic accuracy of clinical lymph node staging for upper tract urothelial cancer patients: a multicenter, retrospective, observational study. J Urol. 2023;209(3):515-524.

Study Need and Importance

Upper tract urothelial cancer (UTUC) is a rare but aggressive urological malignancy. Treatment options for management are based on accurate staging. However, the performance of conventional cross-sectional imaging (CCI) for clinical lymph node staging (N-staging) remained poorly investigated. In this study, we present robust data on the performance of CCI for UTUC N-staging, which will aid physicians in treatment planning and patient counseling.

What We Found

In a multicenter, retrospective, observational study, we assessed 865 UTUC patients who received preoperative CCI before curative intended radical surgery and lymph node dissection. Comparing clinical and pathological N-staging results, we detected low sensitivity but high specificity of CCI. Of 224 patients with pathologically confirmed node-positive disease, CCI missed 168 (75%). On the other hand, of 115 patients with lymph nodes classified as suspicious of tumor invasion on CCI, pathological examination confirmed 56 (49%). Clinically node-positive disease increased the likelihood of reaching pathological confirmation approximately 3 times. We further stratified patients based on the lymph node size, tumor location, and the year of diagnosis. Although we detected statistically significant differences in comparing clinical and pathological N-staging results within the subgroups, these trends did not reach statistical significance for diagnostic accuracy.

Limitations

The study is limited by the retrospective design and missing central radiological and pathological review. However, the study design permitted including a large patient cohort, promoting the applicability of our findings to routine clinical practice. Further, we conducted sensitivity analyses to account for these limitations, showing comparable results.

Interpretation for Patient Care

In summary, our study reveals that CCI works most effectively as a rule-in but not a rule-out test. Therefore, lymph node dissection should remain the standard during radical surgery to obtain accurate N-staging in high-risk UTUC patients. However, lymph nodes suspicious of tumor invasion on CCI could be a strong argument for early systemic treatment (see Figure).

Figure. Illustration of change between the clinical and the pathological N-stage for all patients.

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