Risk stratification using Bmi-1 and Snail expression is a useful prognostic tool for patients with upper tract urothelial carcinoma.

OBJECTIVES: To investigate the expression levels of E-cadherin, Snail, Twist and Bmi-1 in the human upper tract urothelial carcinoma, and to assess whether these factors could be prognostic markers.

METHODS: Immunohistochemistry was carried out to determine the expression of E-cadherin, Snail, Twist and Bmi-1 in upper tract urothelial carcinoma samples from 144 patients that underwent total nephroureterectomy between January 1995 and December 2010. The patient population had a median age of 71 years, and comprised 104 men and 40 women, with a median follow-up period of 40 months. The prognostic value of these markers was assessed by univariate and multivariate analysis. A risk stratification analysis was carried out.

RESULTS: Snail and Bmi-1 expression predicted worse overall survival (P = 0.0075 and 0.0035), cancer-specific survival (P = 0.0919 and 0.0085) and recurrence-free survival (P = 0.0360 and 0.0817, respectively) compared with tumors that lacked Snail and Bmi-1 expression. Additionally, clinical parameters, grade, stage and lymphovascular invasion correlated with overall survival, cancer-specific survival and recurrence-free survival. Multivariate analysis showed that Bmi-1 expression was among the most significant factors in predicting cancer-specific survival (P = 0.0333). The combination of Snail, Bmi-1 and pathological stage was the most useful prognostic biomarker for upper tract urothelial carcinoma.

CONCLUSION: Risk stratification by epithelial-mesenchymal transition and cancer stem cell-regulated genes, such as Snail and Bmi-1, might be useful prognostic markers for upper tract urothelial carcinoma.