Prognostic value of plasma fibrinogen levels in patients with localized upper tract urothelial carcinoma

What's known on the subject? and What does the study add? • Upper tract urothelial carcinoma (UTUC) is relatively uncommon, accounting for only ∼5% of urothelial malignancies and 10% of all renal tumours. Radical nephroureterectomy (RNU) with bladder cuff excision is the surgical standard of care for treating localized UTUC, but the prognosis for patients who undergo RNU remains poor. Evidence suggests that an interactive relationship exists between haemostatic factors and tumour biology. A number of procoagulant and fibrinolytic factors have been found to be overexpressed in tumours. One of these factors is plasma fibrinogen. Recent studies have shown that elevated pre-therapeutic plasma fibrinogen levels are associated with worse outcome in various malignancies; however, the prognostic value of plasma fibrinogen levels for UTUC has not yet been reported. • To the best of our knowledge, this is the first paper to evaluate the prognostic impact of preoperative plasma fibrinogen levels in patients with localized UTUC treated surgically. We believe that the present results may assist in decision-making with respect to the need for lymph node dissection and neoadjuvant chemotherapy. Objective: • To investigate the prognostic value of plasma fibrinogen levels as a predictor of patient outcome in upper tract urothelial carcinoma (UTUC). Patients and Methods: • A total of 218 patients who underwent radical nephroureterectomy (RNU) for localized UTUC (pTa-4N0M0) were identified between 1995 and 2009. • The association between preoperative plasma fibrinogen levels and clinicopathological variables was analysed. Results: • Forty-five patients experienced tumour recurrence, and 36 died from disease during the mean follow-up of 51 months. The mean (sd) preoperative plasma fibrinogen level was 362 (103) mg/dL. • Kaplan-Meier curves showed that subsequent tumour recurrence was strongly predicted in patients with preoperative plasma fibrinogen levels ≥450 mg/dL, and similar results were observed for cancer-specific survival. • On multivariate analysis we found that a preoperative plasma fibrinogen level of ≥450 mg/dL was an independent risk factor for subsequent tumour recurrence and cancer-specific survival. • The 5-year recurrence-free survival rate was 56.9% in patients with plasma fibrinogen levels ≥450 mg/dL and 81.5% in patients with plasma fibrinogen levels <450 mg/dL (P < 0.001). The 5-year cancer-specific survival rate was 59.5% in patients with plasma fibrinogen levels of ≥450 mg/dL and 84.8% in patients with plasma fibrinogen levels <450 mg/dL (P < 0.001). • On multivariate analysis, controlling for preoperative indicators, a preoperative plasma fibrinogen level of ≥450 mg/dL predicted worse pathological features, such as ≥pT3 disease and positive lymphovascular invasion, in surgical specimens. Conclusions: • Preoperative elevated plasma fibrinogen level was an independent predictor for poor survival after RNU and for worse pathological features. • Plasma fibrinogen levels may become a useful biomarker, particularly because of its low associated cost and easy accessibility.