Trends in the utilization of imaging for upper tract urothelial carcinoma

Abstract

Objectives To evaluate the changes in use of the different imaging modalities for diagnosing upper tract urothelial carcinoma (UTUC) and assess how these changes have affected tumor stage at the time of surgery. Materials and methods We assessed the Surveillance, Epidemiology, and End Results (SEER) cancer registry and linked Medicare claims data (1992–2009) for 5377 patients who underwent surgery for UTUC. We utilized International Classification of Disease—Oncology 3 codes to identify UTUC. International Classification of Disease, ninth Revision, Clinical Modification and Current Procedure Terminology codes identified surgical treatment and imaging modalities. We assessed for use of intravenous pyelography, retrograde pyelography (RGP), computed tomography urography (CTU), magnetic resonance urography (MRU), and endoscopy. For each modality, patients were categorized as having received the modality at least once or not at all. Patient characteristics were compared using chi-squared tests. Usage of imaging modalities and tumor stage was trended using Cochran-Armitage tests. We stratified our data into 2 multivariate logistic regression models to determine the effect of imaging modalities on tumor stage: 1992 to 1999 with all modalities except MRU, and 2000 to 2009 with all modalities. Results Our patient population was predominantly White males of more than 70 years old. Intravenous pyelography and RGP declined in use (62% and 72% in 1992 vs. 6% and 58% in 2009, respectively) while computed tomography urography, MRU, and endoscopy increased in use (2%, 0%, and 37% in 1992 vs. 44%, 6%, and 66% in 2009, respectively). In both regression analyses, endoscopy was associated with lower-stage tumors. In the 2000 to 2009 model, RGP was associated with lower-stage tumors, and MRU was associated with higher-stage tumors. Finally, our data showed an increasing number of modalities utilized for each patient (1% receiving 4 modalities in 1992 vs. 20% in 2009). Conclusions We found trends toward the utilization of newer imaging modalities to diagnose UTUC and more modalities per patient. Endoscopy and RGP were associated with smaller tumors, whereas MRU was associated with larger tumors. Further studies are needed to evaluate the utility of the different modalities in diagnosing UTUC.

Imaging Tips and Tricks in Management of Renal and Urothelial Malignancies

“…Some studies have also documented the role of T1 fat-suppressed post-gadolinium images in differentiating T3 and higher stage ureteric tumors (irregular or disruptive enhancing rim) from T2 or lower stage tumors (smooth rim enhancement). 21 25 …”

“…9 ); however, differentiating atypical presentations of such benign entities from malignant strictures can be challenging at times and correlation with urinary cytology, ureteroscopic, or laparoscopic biopsy and follow-up imaging should be sought for in doubtful cases. 21 25 …”

“…Some studies have also documented the role of T1 fat-suppressed post-gadolinium images in differentiating T3 and higher stage ureteric tumors (irregular or disruptive enhancing rim) from T2 or lower stage tumors (smooth rim enhancement). 21,25 Majority of high-risk UTUCs are treated with RNU with bladder cuff excision as the standard treatment. Bladder cuff and distal ureteric excision alongside nephrectomy is regularly considered beneficial because of high incidence of recurrence in the distal ureter.…”

Retrograde Pyelography in the Presence of Urothelial Bladder Cancer Does Not Affect the Risk of Upper Tract Urothelial Cancer: A Retrospective Analysis of a Single-Centre Cohort

“…When imaging is performed, CT urography (CTU) should be the preferred imaging procedure [7, 8], whereas intravenous urography should only be performed if CTU is not available or in case of contraindications [9]. Another alternative to CTU is MR urography [10]. Even though not recommended in actual guidelines anymore, retrograde pyelography (RPG) has been a standard imaging procedure for the upper urinary tract.…”

“…Even though not recommended in actual guidelines anymore, retrograde pyelography (RPG) has been a standard imaging procedure for the upper urinary tract. Although its utilization decreased in the last 3 decades, RPG was still used in 58% of UTUC cases in 2009 [10].…”