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Sir,

There is increasing evidence that lymphovascular invasion (LVI) is one of important prognostic indicators in upper urinary tract urothelial carcinoma (UUT-UC) [1]. A recent report from Akao et al.[2] in the BJU Int suggested LVI status might be a better predictive marker for cancer-specific survival in patients UUT-UC and treated by radical surgery. They also reported that patients with pT3N0M0 disease without LVI had a significantly better prognosis than those who were pT3N0M0 with LVI. The presence of LVI represents a higher probability of metastasis, so many investigators who respectively evaluated the role of retroperitoneal lymph node dissection in UUT-UC concluded that lymphadenectomy has a therapeutic effect, especially for patients with advanced UUT-UC [3–5]. We totally agree with the conclusion of the authors, as LVI is a good prognostic factor for predicting the outcome of pT3 disease, especially for patients who have a primary tumour in the renal pelvis. Traditionally, the prognosis of UUT-UC is strongly correlated with pathological stage, especially with invasion of the muscularis. The muscular layer of the ureter is much thinner than in the renal pelvis. Ureteric UC is associated with a greater local or distant failure rate than renal pelvic UC [6]. However, the TNM staging system combines renal pelvic and ureteric carcinomas, despite their different anatomy. However, different from the ureter and the urinary bladder, lamina propria is lacking beneath the urothelial lining, and the renal papillae in the renal pelvis, and is quite thin along the minor calyces. Moreover, within the renal sinus, the muscularis propria might be very thin or imperceptible near the calyces, and is surrounded by sinus fat. Renal sinus fat invasion is not addressed in the TNM staging system. Guinan et al.[7] suggested a modification of the TNM staging system, separating renal pelvic and ureteric tumours, and reported a significant survival difference between stage T3 and stage T4N+M+ in renal pelvic tumours. They concluded that renal parenchyma is a relative anatomical barrier to the spread of renal pelvic tumours, and that stage T3 renal pelvic tumours invading the renal parenchyma are not comparable with stage T3 ureteric tumours invading peri-ureteric tissues. Wu et al.[8] evaluated 72 patients with pT3 UUT-UC and concluded that superficial renal parenchymal invasion should be considered as a lower-stage disease. They also indicated that vascular involvement is the only independent prognostic factor for pT3 disease. The concept could be supported by the findings of Akao et al., who indicated that LVI status is the most useful independent factor for predicting cancer-specific survival by multivariate analysis using Cox proportional hazard model. We could consider LVI status for risk stratification of patients with pT3 UUT-UC, to decide whether adjuvant chemotherapy will be added [9].

  • 1
    Saito K, Kawakami S, Fujii Y, Sakura M, Masuda H, Kihara K. Lymphovascular invasion is independently associated with poor prognosis in patients with localized upper urinary tract urothelial carcinoma treated surgically. J Urol 2007;178: 22916
  • 2
    Akao J, Matsuyama H, Yamamoto Y et al. Clinical significance of lymphovascular invasion in upper urinary tract urothelial cancer. BJU Int 2008 May 15
  • 3
    Brausi MA, Gavioli M, De Luca G et al. Retroperitoneal lymph node dissection (RPLD) in conjunction with nephroureterectomy in the treatment of infiltrative transitional cell carcinoma (TCC) of the upper urinary tract: impact on survival. Eur Urol 2007; 52: 14148
  • 4
    Kondo T, Nakazawa H, Ito F, Hashimoto Y, Toma H, Tanabe K. Impact of the extent of regional lymphadenectomy on the survival of patients with urothelial carcinoma of the upper urinary tract. J Urol 2007; 178: 12127
  • 5
    Roscigno M, Cozzarini C, Bertini R et al. Prognostic value of lymph node dissection in patients with muscle-invasive transitional cell carcinoma of the upper urinary tract. Eur Urol 2008; 53: 794802
  • 6
    Lehmann J, Suttmann H, Kovac I et al. Transitional cell carcinoma of the ureter: prognostic factors influencing progression and survival. Eur Urol 2007; 51: 12818
  • 7
    Guinan P, Volgelzang NJ, Randazzo R et al. Renal pelvic transitional cell carcinoma: the role of the kidney in tumor-node-metastasis staging. Cancer 1992; 69: 17735
  • 8
    Wu CF, Pang ST, Chen CS, Chuang CK, Chen Y, Lin PY. The impact factors on prognosis of patients with pT3 upper urinary tract transitional cell carcinoma. J Urol 2007; 178: 44650
  • 9
    Kwak C, Lee SE, Jeong IG, Ku JH. Adjuvant systemic chemotherapy in the treatment of patients with invasive transitional cell carcinoma of the upper urinary tract. Urology 2006; 68: 537