Clinical-Bladder cancer Prognostic role of preoperative De Ritis ratio in upper tract urothelial carcinoma treated with nephroureterectomy Keiichiro Mori, M.D. a,b , Florian Janisch, M.D. a,c , Hadi Mostafaei, M.D. a,d , Shoji Kimura, M.D. a,b , Ivan Lysenko, M.D. a , Pierre I. Karakiewicz, M.D. e , Alberto Briganti, M.D. f , Dmitry V. Enikeev, M.D. g , Morgan Roupr ^ et, M.D. h , Vitaly Margulis, M.D. i , Piotr Chlosta, M.D. j , Peter Nyirady, M.D. k , Marek Babjuk, M.D. l , Shin Egawa, M.D. b , Shahrokh F. Shariat, M.D. a,g,i,l,m,n, * a Department of Urology, Medical University of Vienna, Vienna, Austria b Department of Urology, The Jikei University School of Medicine, Tokyo, Japan c Department of Urology, Medical University of Hamburg, Hamburg, Germany d Research Center for Evidence Based Medicine, Tabriz University of Medical Sciences, Tabriz, Iran e Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Centre, Montreal, Canada f Department of Urology, Vita Salute San Raffaele University, Milan, Italy g Institute for Urology and Reproductive Health, I.M. Sechenov First Moscow State Medical University, Moscow, Russia h Sorbonne Universit  e, GRC n°5, ONCOTYPE-URO, AP-HP, H^ opital Piti  e-Salp^ etri  ere, Urology Department, PARIS, France i Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX j Department of Urology, Jagiellonian University, Krakow, Poland k Department of Urology, Semmelweis University, Budapest, Hungary l Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic m Department of Urology, Weill Cornell Medical College, New York, NY n Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria Received 14 October 2019; received in revised form 25 December 2019; accepted 5 February 2020 Abstract Purpose: To validate the predictive and prognostic role of the De Ritis ratio in patients with upper tract urothelial carcinoma (UTUC) treated with radical nephroureterectomy in a large multi-institutional cohort. Materials and methods: The preoperative De Ritis ratio was assessed in a multi-institutional cohort of 2,492 patients. An altered De Ritis ratio was defined as a ratio >1.35. Logistic regression analyses were performed to assess the association of the De Ritis ratio with advanced dis- ease. The association of the De Ritis ratio with survival outcomes was evaluated using Cox proportional hazards regression models. Results: An altered De Ritis ratio was observed in 985 (41.5%) patients; it was associated with a more advanced pathological features. In a preoperative model, the De Ritis ratio was an independent predictive factor for the presence of lymph node metastasis and muscle-invasive and nonorgan-confined disease (P < 0.05). Compared to patients with a normal De Ritis ratio, those with an altered De Ritis ratio had worse recur- rence free (P <0.0001), cancer specific (P = 0.0003), and overall survival (P = 0.0014) in the Kaplan-Meier analyses. In the multivariable analy- ses that was adjusted for the effects of standard clinicopathologic features, the De Ritis ratio did not retain its independent prognostic value. Conclusions: In UTUC, the preoperative De Ritis ratio is associated with adverse clinicopathologic features and independently predicts features of biologically and clinically aggressive UTUC. Therefore, it might be useful to incorporate the De Ritis ratio into prognostic tools in selecting appropriate treatment strategies. Ó 2020 Elsevier Inc. All rights reserved. Keywords: De Ritis ratio; Lymph node metastasis; Nephroureterectomy; Nonorgan-confined disease; Upper tract urothelial carcinoma Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. *Corresponding author. Tel.: +4314040026150; fax: +4314040023320. E-mail address: shahrokh.shariat@meduriwien.ac.at (S.F. Shariat). https://doi.org/10.1016/j.urolonc.2020.02.008 1078-1439/Ó 2020 Elsevier Inc. All rights reserved. ARTICLE IN PRESS Urologic Oncology: Seminars and Original Investigations 000 (2020) 1-8