Abstract

Purpose: Upper tract urothelial carcinoma (UTUC) is an uncommon neoplasm, comprising 5% of all urothelial malignancies. The incidence of UTUC has increased over the past 30 years, with 40% of patients presenting with regional or distant disease. Studies have suggested that patients with Upper Tract Transitional Cell Carcinoma who undergo lymph node dissection (LND) during surgery have improved survival. We investigated the incidence and trends of lymphadenectomy in conjunction with surgery for UTUC between 1998 and 2008.   Methods: In a retrospective review of the Surveillance, Epidemiology and End Results (SEER) registry between 1988 and 2008, we identified eligible patients with UTUC who underwent nephroureterectomy with or without LND. Patients with histology codes for transitional cell carcinoma were included. Patients were included in the analysis when the number of nodes examined and the number of pathologically positive nodes were documented. Patients with unknown tumor grade and stage or metastatic disease at diagnosis were excluded from our cohort. Patients were segregated on the presence of LND, and grouped according to 1-2 and 3 or more nodes examined. The primary outcome measures were the incidence of LND and the mean number of lymph nodes examined per year of diagnosis. We used logistic regression analysis to investigate the relationship between year of diagnosis and undergoing lymphadenectomy.   Results: Between January 1988 and December 2008, we identified 10,213 patients with transitional cell carcinoma of the renal pelvis who underwent radical nephrectomy or nephroureterectomy. In our final cohort, 1,861 (18%) underwent LND at the time of surgery. The proportion of patients undergoing any lymph node dissection (1-2 or 3 or more) increased by an average of 4% from 1988 to 2008 (p < 0.001). Patients with advanced disease (i.e. T2N0M0 or higher) or with high-grade disease (2+ or higher) were more likely to undergo LND at the time of surgery (p < 0.02). Additionally, patients in the South and Midwest were less likely to undergo LND compared to patients in the Northeast (OR: 0.74; 95%CI: 0.60-0.90 and 0.79; 95% CI: 0.67-0.95, respectively). Though not statistically significant, year of diagnosis showed an increasing predictive role for the likelihood of undergoing lymph node dissection.   Conclusions: Between 1988 and 2008, there has been little change in the performance of LND and node counts among patients with UTUC. Furthermore, our findings indicate, that in the United States, it appears there are geographical variations among surgeons regarding the use of LND in patients with UTUC. Despite increased interest in the effects of LND during surgery for other GU cancers, the discussion for the performance of LND at the time of surgery has largely sidestepped UTUC.