1. Adjuvant Radiotherapy for Locally Advanced Urothelial Carcinoma of the Upper Urinary Tract
Yung-Jen Cheng M.D.
國立成功大學附設醫院 放射腫瘤科
Department of Radiation Oncology
National Cheng Kung University Hospital, Tainan, Taiwan

2. Background Urothelial carcinoma of the upper urinary tract (UTUC)
Transitional cell carcinoma (TCC) of the renal pelvis or ureter
A rare entity of malignancy
The role of adjuvant therapy after curative surgery to advanced stage UTUC?

3. Epidemiology in Taiwan (2013)
Ref:
衛生福利部國民健康署 (2017, Jan 10)
102年癌症登記年報

4. Epidemiology in Europe report
The European Association of Urology (EAU) Guideline Group
Urothelial Carcinoma (TCC):
Bladder tumors: 90-95%
Upper urinary tract: 5-10%
In Taiwan: 40.9% (UTUC)
Phenacetin 
1950 年代末期，北門、布袋、學甲和義竹等地區，

5. Prognosis outcome & Pattern of failure

6. 12 centers, 1363 patients, 1992-2006, retrospective
Prognostic variables:
Tumor grade
T stage
LN status
LVI
Neoadjuvant and/or adjuvant C/T was administered to 3% and 13%
Postoperative R/T was administered to 2%
Results

7. Pattern of failure
30-year experience in 252 patients. Hall MC, Urology. 1998
LR: 9%
new invasive urothelial tumors: 69%
DM: 22%
30% with stage III and 52% with stage IV received post-OP R/T [Median dose: 39.8 Gy. (range 10 to 60)]
65 patients with locally advanced disease (T3-4N0 or N+). Catton CN, Urol Oncol. 1996
DM: 53%, and LRF: 35%
If N+, DM: 77%; LRF: 95%
85% received post-OP R/T (35Gy/ 20fx)

8. Role of adjuvant C/T in locally advanced UTUC
No randomized trials…
Most extensive observational data from NCDB
3253 patients, , retrospective
AC or observation after RNU
Renal function is a big question!

9. Aim of our study
Define the benefit of adjuvant R/T following curative surgery of locally advanced UTUC by determining the clinical outcomes in our institution

10. Methods Exclusion 2006-2015 Pathological T3/4 and/or N+ UTUC
The administration of adjuvant R/T or chemotherapy (C/T) was at physician’s discretion
All patient data, including staging information, treatment and outcome variables, were collected retrospectively by chart review
Distant metastasis
Synchronous bladder cancer
History of previous R/T
History of any malignancy (unless free of cancer for at least 10 years)
Exclusion

11. Statistical Analysis
Kaplan-Meier method & log-rank tests were used to estimate:
Cancer-specific survival (CSS)
Loco-regional recurrence-free survival (LRFS)
Bladder recurrence-free survival (BRFS)
Distant metastasis-free survival (DMFS)
Differences in risk-adjusted outcomes between RT and non-RT groups were assessed using a multivariate Cox proportional hazards model

12. End points Loco-regional failure Distant metastasis Bladder recurrence
Any recurrence in the tumor bed, regional nodes, or in the ureteral stump
Distant metastasis
Any relapse outside the aforementioned regions excluding the bladder
Bladder recurrence
Pathologically confirmed recurrence within the bladder (not included in the R/T field)
All events were timed from the beginning of initial radical surgery

13. Results

14. Results A total of 106 patients had pT3-4 and/or N+ UTUC
Post-OP R/T was administered in 20 (18.9%) of patients
Post-OP C/T was administered in 46 (43.4%) of patients (most GC)
Median dose of RT was 50.4 Gy (range, 45.0 to 64.8 Gy), all IMRT
Median follow-up time: 29.3 months

15. Patient Demographics and Clinical Characteristics

16. Patient Demographics and Clinical Characteristics

17. Survival analysis 84.4% vs. 73.1% 81.5% vs. 60.9% 92.3% vs. 77.4%
p=0.38
84.4% vs. 73.1%
81.5% vs. 60.9%
92.3% vs. 77.4%
73.1% vs. 59.1%

18. Multivariate analysis with Cox hazards regression

19. Conclusions
In patients with locally advanced stage UTUC who had received curative surgery, the following adjuvant R/T may improve loco-regional control
Adjuvant R/T may be another considerable treatment modality, especially as an alternative treatment for patient who is not suitable to receive adjuvant C/T
More qualified patients recruitment and longer follow-up time are necessary for further persuasive results

20. Acknowledgements Presenter Supervisor Department of Radiation Oncology
鄭詠仁 醫師
Yung-Jen Cheng
Presenter
薛尉廷 醫師
Wei-Ting Hsueh
Supervisor
國立成功大學附設醫院 放射腫瘤科
Department of Radiation Oncology
National Cheng Kung University Hospital, Tainan, Taiwan

21. Thank you for your listening