Independent prognostic value of tumour diameter and tumour necrosis in upper urinary tract urothelial carcinoma

To identify significant prognostic indicators of upper urinary tract (UUT) urothelial carcinoma (UC) and to assess a risk stratification of patients. We retrospectively analysed data from 162 patients with non-metastatic UC primarily occurring in UUT treated with open nephroureterectomy. Variables assessed included age, gender, pT, tumour grade, tumour necrosis extension, pN, tumour location, multifocal location, tumour diameter, and subsequent development of a bladder tumour. Tumour necrosis was measured using commercial software (Eureka interface system, version 4.0.22, HESP technology, Menarini Diagnostics, Italy) and was classified as none, focal (< 10% of tumour area) or extensive, >= 10% of tumour area). The prognostic significance of each variable on metastasis-free survival (MFS) and disease-free survival (DFS) was tested in univariable analysis with the log-rank test. Variables with significance levels of P < 0.05 according to the univariable analyses were entered into a multivariable forward-stepwise Cox regression model. At a mean follow-up of 66 months, 20 cancer-related deaths (12.3%) were censored. In multivariable analysis, tumour diameter, pT stage and tumour necrosis were independent predictors of MFS and DFS. All events occurred in patients with extensive tumour necrosis and a tumour diameter of >= 3 cm. The median survival of patients with advanced-stage tumours, extensive necrosis and a tumour diameter of >= 3 cm were significantly impaired by increasing pT stage(P < 0.001). Tumour necrosis and tumour diameter are compelling prognostic factors that deserve further study in a prospective setting to determine if their use in combination with more traditional variables, such as pT stage, might better determine prognosis and guide the follow-up and treatment of patients.