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Journal of Peking University(Health Sciences) ›› 2019, Vol. 51 ›› Issue (6): 1056-1061. doi: 10.19723/j.issn.1671-167X.2019.06.014

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Evaluating the impact of preoperative anemia on the prognosis of upper tract urothelial carcinoma following radical nephroureterectomy: A single-center retrospective study of 686 patients

Bao GUAN1,Mai WENG2,Hang FAN2,Ding PENG1,Dong FANG1,Geng-yan XIONG1,Xue-song LI1,△(),Li-qun ZHOU1   

  1. 1. Department of Urology, Peking University First Hospital, Beijing 100034, China
    2. Department of Urology, Beijing Armed Police Corps Hospital, Beijing 100039, China
  • Received:2017-10-12 Online:2019-12-18 Published:2019-12-19
  • Contact: Xue-song LI E-mail:pineneedle@sina.com
  • Supported by:
    Supported by the Natural Science Foundation of Beijing(7152146);the Clinical Features Research of Capital(151100004015173)

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Abstract:

Objective: To identify the effect of preoperative anemia on the prognosis of patients with upper tract urothelial carcinoma (UTUC) following radical nephroureterectomy. Methods: Clinicopathological and prognosis data on 686 patients with UTUC who underwent RNU at Peking University First Hospital between January 2000 and December 2013 were retrospectively analyzed. Preoperative anemia was defined as hemoglobin ＜130 g/L in men and ＜120 g/L in women based on the World Health Organization classification. The Kaplan-Meier method with log-rank test was applied to estimate the effect of anemia on survival. The associations of clinicopathologic features with overall survival and cancer-specific survival were evaluated using univariate and multivariate Cox regression models. Results: There were 303(44.2%, 303/686) male and 383(55.8%, 383/686) female patients, and the median age was 68 years (interquartile range: 60-74 years). In all, 320(46.6%, 320/686)patients were anemic before surgery. The median follow-up duration was 47 months. In all, 160 (23.3%) patients died, 141 (20.6%) died of cancer and 19 (2.7%) died of other disease or accidents. Preoperative anemia was associated with gender (P=0.002), age (P＜0.001), lymph node positive (P=0.026), increased tumor grade (P=0.018), concomitant carcinoma in situ (P=0.038), tumor necrosis (P=0.007) and poor renal function (P＜0.001). In univariate analysis, overall mortality was correlated with pre-operative anemia (P＜0.001), gender (P=0.009), hydronephrosis (P=0.024), tumor stage (P＜0.001), lymph node positive (P＜0.001), tumor grade (P＜0.001), tumor architecture(P＜0.001), sarcomatoid differentiation (P=0.013), history of ureteroscope (P=0.033) and tumor hemorrhage (P＜0.001); cancer-specific mortality was correlated with preoperative anemia (P=0.001), gender (P=0.001), hydronephrosis (P=0.043), tumor stage (P＜0.001), lymph node positive (P＜0.001), tumor grade (P＜0.001), tumor architecture (P＜0.001), sarcomatoid differentiation (P=0.016), history of ureteroscope (P=0.028) and tumor hemorrhage (P=0.003). A multivariate Cox proportional hazards model indicated that preoperative anemia was an independent prognositic predictor for overall mortality (P＜0.001, HR=1.861) and cancer-specific mortality (P=0.003, HR=1.688). Conclusion: The preoperative anemia is an independent risk factor for cancer-specific survival and overall survival. Hemoglobin levels should be considered during patient counseling and in decision-making for further therapy.

Key words: Upper tract urothelial carcinoma, Radical nephroureterectomy, Hemoglobin, Anemia

CLC Number: 

  • R730.261

Table 1

Associations of preoperative hemoglobin and clinicopathological characteristics"

Items Overall, n Normal hemoglobin, n Anemia, n P value
Total 686 366 320
Gender 0.002*
Male 303 182 121
Female 383 184 199
Age group/years old ＜0.001*
＜50 48 35 13
50 - 115 76 39
60 - 217 119 98
70 - 248 115 133
>80 58 21 37
Hydronephrosis 0.868
Absent 296 159 137
Present 390 207 183
Pathological stage 0.586
Ta, Tis, T1 245 134 111
T2 238 124 114
T3 183 102 81
T4 20 6 14
Lymph node status 0.026*
Negative 632 345 287
Positive 54 21 33
Tumor grade status 0.018*
G1 20 16 4
G2 366 203 163
G3 300 147 153
Concomitant CIS 0.038*
Absent 664 359 305
Present 22 7 15
Tumor architecture 0.086
Papillary 518 286 232
Sessile 168 80 88
Items Overall, n Normal hemoglobin, n Anemia, n P value
Tumor necrosis 0.007*
Absent 609 336 273
Present 77 30 47
Tumor multifocality 0.519
Absent 487 256 231
Present 199 110 89
Tumor differentiation 0.025*
Urothelium 573 317 256
Squamous 60 25 35
Sarcomatoid 28 10 18
Adenoid 25 14 11
eGFR/(mL/min) ＜0.001*
>90 58 44 14
60- 250 172 78
30- 290 143 147
15- 34 4 30
≤15 54 3 51
History of ureteroscope 0.655
Present 88 45 43
Absent 598 321 277
Tumor hemorrhage 0.347
Present 29 13 16
Absent 657 353 304

Figure 1

Kaplan-Meier estimated cancer-specific survival curves stratified by preoperative hemoglobin"

Figure 2

Kaplan-Meier estimated overall survival curves stratified by preoperative hemoglobin"

Table 2

Univariable and multivariable Cox regression analyses predicting overall survival and cancer-specific survival for UTUC patients"

Parameters Overall survival Cancer-specific survival
Univariate analysis Multivariate analysis Univariate analysis Multivariate analysis
HR 95%CI P HR 95%CI P HR 95%CI P HR 95%CI P
Anemia (yes vs. no) 1.915 1.390-2.638 ＜0.001* 1.861 1.337-2.590 ＜0.001* 1.733 1.236-2.428 0.001* 1.688 0.191-2.391 0.003*
Gender (male vs. female) 1.508 1.106-2.056 0.009* 1.498 1.086-2.065 0.014* 1.776 1.273-2.477 0.001* 1.702 1.207-2.401 0.002*
Age (continuous) 1.002 0.988-1.017 0.773 1.012 0.998-1.026 0.091
Hydronephrosis (yes vs. no) 1.451 1.051-2.002 0.024* 1.747 1.256-2.429 0.001* 1.424 1.011-2.007 0.043* 1.744 1.228-2.477 0.002*
Tumor stage (≤T2 vs. T3&T4) 1.830 1.524-2.196 ＜0.001* 1.706 1.399-2.079 ＜0.001* 1.921 1.582-2.33 ＜0.001* 1.745 1.413-2.154 ＜0.001*
Lymph node status (positive vs. negative) 2.871 1.841-4.476 ＜0.001* 1.696 1.047-2.747 0.032* 3.210 2.049-5.029 ＜0.001* 1.830 1.121-2.988 0.016*
Tumor grade (G3 vs.G1&G2) 1.735 1.298-2.318 ＜0.001* 1.764 1.293-2.408 ＜0.001*
Concomitant CIS (yes vs. no) 1.014 0.448-2.294 0.973 0.970 0.397-2.369 0.947
Tumor architecture (papillary vs. sessile) 1.872 1.343-2.610 ＜0.001* 1.955 1.378-2.773 ＜0.001*
Tumor multifocality (yes vs. no) 0.903 0.643-1.266 0.553 0.845 0.586-1.219 0.367
Sarcomatoid differentiation (yes vs. no) 2.166 1.173-4.000 0.013* 2.209 1.161-4.204 0.016*
Renal function (CKD vs. normal) 1.103 0.949-1.280 0.201 1.034 0.879-1.216 0.688
Treated with ureteroscope (yes vs. no) 0.561 0.33-0.955 0.033* 0.516 0.285-0.933 0.028*
Tumor hemorrhage (yes vs. no) 2.451 1.481-4.056 ＜0.001* 2.204 1.317-3.687 0.003* 2.294 1.320-3.987 0.003* 2.125 1.210-3.732 0.009*
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