上尿路尿路上皮癌伴其他组织学类型的临床病理特征和预后分析

Clinical and pathological characteristics and prognostic analysis of upper tract urothelial carcinoma with concurrent histological variants

目的探讨上尿路尿路上皮癌(UTUC)伴其他组织学类型的临床病理特征及其对预后的影响。方法回顾性分析2007年1月至2021年4月北京大学人民医院收治的566例UTUC患者的临床资料。男289例,女277例;年龄(67.3±10.0)岁。其中97例有吸烟史,29例有肾移植手术史,120例有糖尿病史,76例有冠心病史,146例有高脂血症史,271例有高血压病史,50例有慢性肾病史。43例既往有膀胱癌病史;确诊UTUC时366例合并肾积水,55例合并膀胱癌。566例中,肾盂癌210例,肾盂输尿管连接部肿瘤5例,输尿管癌226例,多灶肿瘤125例。根据术后病理结果将患者分为单纯UTUC组和UTUC伴其他组织学类型组,比较两组的临床及病理特征。采用logistic回归分析UTUC出现其他组织学类型的危险因素。采用log-rank检验比较两组的总生存率和肿瘤特异性生存率,采用Cox回归分析影响UTUC预后的危险因素。结果566例中,511例为单纯UTUC;55例伴其他组织学类型,其中伴鳞状分化30例,腺样分化6例,黏液变性5例,肉瘤样癌5例,微乳头状癌2例,神经内分泌癌2例,巨细胞癌1例,其他混合性组织学类型4例。UTUC伴其他组织学类型组中既往有肾移植手术史患者占比大于单纯UTUC组[14.5%(8/55)与4.1%(21/511)],差异有统计学意义(P=0.003)。UTUC伴其他组织学类型组较单纯UTUC组的术后高级别肿瘤[98.2%(54/55)与80.2%(410/511)]、肌层浸润性肿瘤[89.1%(49/55)与68.1%(348/511)]、淋巴结转移比例[10.9%(6/55)与2.3%(12/511)]和肿瘤最大径[(3.60±2.64)cm与(2.96±1.98)cm]均明显升高(P<0.05)。多因素logistic回归分析结果显示,肾移植手术史(OR=4.991,95%CI 1.749~13.615,P=0.002)是发生其他组织学类型的独立预测因素。随访1~174个月,中位随访时间32.8(13.0,59.5)个月,UTUC伴其他组织学类型组较单纯UTUC组的5年总生存率(35.2%与69.3%)和5年肿瘤特异性生存率(49.9%与77.1%)更低(均P<0.05)。多因素Cox回归分析结果示,UTUC伴其他组织学类型是影响总生存(HR=1.860,95%CI1.228~2.816,P=0.003)和肿瘤特异性生存(HR=2.146,95%CI 1.349~3.412,P=0.001)的独立危险因素。结论UTUC伴其他组织学类型的术后肿瘤分级和肿瘤分期均高于单纯UTUC,且伴其他组织学类型是UTUC患者不良总生存和肿瘤特异性生存的独立危险因素。

Objective To investigate the clinical and pathological characteristics and prognosis of upper tract urothelial carcinoma(UTUC)with concurrent other histological variants.Methods The clinical data of 566 UTUC patients admitted to Peking University People's Hospital from January 2007 to April 2021 were retrospectively analyzed.Among them,289 were males and 277 were females,with an average age of(67.3±10.0)years old.Among the patients,97 had a history of smoking,29 had undergone kidney transplantation,120 had diabetes,76 had coronary heart disease,146 had hyperlipidemia,271 had hypertension,and 50 had a history of chronic kidney disease.Among the UTUC cases,366 had concurrent hydronephrosis,55 had concurrent bladder cancer,and 43 had a history of previous bladder cancer.The distribution included 210 cases of renal pelvis carcinoma,5 cases of carcinoma at the renal pelvis-ureter junction,226 cases of ureteral carcinoma,and 125 cases of multifocal tumors.Patients were classified into the pure UTUC group and the UTUC with concurrent other histological variants group based on postoperative pathology,and their clinical and pathological features were compared.Logistic regression analysis was used to explore risk factors for the occurrence of histological variations in UTUC.The log-rank test was employed to compare the overall survival(OS)and cancer-specific survival(CSS)between the two groups,while Cox regression analysis was performed to investigate prognostic factors.Results Among the 566 cases,511 were pure UTUC and 55 were UTUC with concurrent other histological variants.Among the latter,30 cases had squamous differentiation,6 had glandular differentiation,5 had mucinous differentiation,5 had sarcomatoid carcinoma,2 had micropapillary carcinoma,2 had neuroendocrine carcinoma,1 had giant cell carcinoma,and 4 had other mixed histological variations.The proportion of patients with a history of kidney transplantation was higher in the UTUC with concurrent histological variants group than that in the pure UTUC group[14.5%(8/55)vs.4.1%(21/511)],with statistically significant difference(P=0.003).In the UTUC with concurrent histological variants group,the proportion of postoperative high-grade tumors[98.2%(54/55)vs.80.2%(410/511)],muscle-invasive tumors[89.1%(49/55)vs.68.1%(348/511)],lymph node metastasis tumors[10.9%(6/55)vs.2.3%(12/511)],and maximum tumor diameter[(3.60±2.64)cm vs.(2.96±1.98)cm]were higher than those in the pure UTUC group(P<0.05).Multivariate logistic regression analysis showed that a history of kidney transplantation(OR=4.991,95%CI 1.749-13.615,P=0.002)was an independent predictive factor for the occurrence of histological variants.Follow-up was conducted for 1 to 174 months,with a median follow-up time of 32.8 months.UTUC with concurrent histological variants was significantly associated with worse OS and CSS(P<0.05).Multivariate Cox regression analysis indicated that histological variants were an independent risk factor for OS(HR=1.860,95%CI 1.228-2.816,P=0.003)and CSS(HR=2.146,95%CI 1.349-3.412,P=0.001).Conclusions UTUC with concurrent other histological variants exhibited higher postoperative tumor grade and stage compared to pure UTUC,and UTUC with concurrent other histological variants was an independent risk factor for worse prognosis.