Highlights
- •Fit elderly patients with high-risk UTUC may benefit equally from NAC and RNU as their younger counterparts
- •Cisplatin-based chemotherapy results in the highest pathologic response rates across both age groups
- •Elderly, cisplatin-ineligible patients, experienced the worst response rates after non-cisplantin-based NAC and might therefore benefit rather from immediate RNU
Abstract
Introduction
Although upper tract urothelial carcinoma (UTUC) is more common in the elderly, outcomes
of neoadjuvant chemotherapy (NAC) in this population have never been explored. The
objective of the study was to assess the impact of NAC on pathologic response and
oncological outcomes stratified by age.
Patients and Methods
This multicenter study included 164 patients treated with NAC and radical nephroureterectomy
(RNU) for clinically non-metastatic, high-risk UTUC. The cohort was stratified into
two groups according to median age. Patients received either cisplatin-based or non-cisplatin-based
chemotherapies. Pathologic responses were defined as pathologic objective response
(pOR; ≤ ypT1N0) and pathologic complete response (pCR; ypT0N0). Univariable and multivariable
logistic and Cox regression analyses were performed to identify predictors for pathologic
response and survival outcomes.
Results
The cohorts’ median age was 68 years with the elderly group (> 68 years) comprising
74 patients. Neoadjuvant chemotherapy included methotrexate-vinblastine-doxorubicin-cisplatin
(MVAC) in 66 (40%), gemcitabine cisplatin (GC) in 66 (40%) and non-cisplatin chemotherapy
in 32 patients (20%). Younger patients received more often MVAC (50% vs. 28%) while
elderly received more GC (34% vs. 47%) or non-cisplatin chemotherapy (16% vs. 24%)
(P = .02). Overall, pOR and pCR were similar across age groups (52% vs. 47%; P = .5 and 10% vs. 8%; P = .7). While GC and non-cisplatin chemotherapy showed a lower pCR of 5% and 3%, respectively,
MVAC revealed a pCR of 17% (P = .03) and was independently associated with a higher pCR (OR 4.31; P = .03). Kaplan-Meier analysis showed no difference in recurrence-free and cancer-specific
survival, whereas a lower rate was seen in overall survival for the elderly.
Conclusion
Elderly patients with high-risk UTUC eligible for cisplatin-based NAC prior to RNU
may benefit from this multimodal therapy equally as their younger counterparts. Cisplatin-ineligible
patients undergoing non-cisplatin-based NAC appeared to have lower response rates
and should be considered for immediate RNU.
Keywords
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Article info
Publication history
Published online: January 11, 2022
Accepted:
January 4,
2022
Received in revised form:
December 11,
2021
Received:
May 12,
2021
Identification
Copyright
© 2022 Elsevier Inc. All rights reserved.
