(UroToday.com) The 2023 American Urological Association (AUA) Meeting included a Friday afternoon plenary session featuring a panel discussion on the management of upper tract urothelial carcinoma. This discussion was moderated by Dr. Surena Matin and included a distinguished panel consisting of Dr. Jay Raman, Dr. Tomonori Habuchi, and Dr. Sima Porten. Dr. Matin opened up the session with an online poll session during which audience members joined in order to participate and answer questions throughout the discussion.
The first case presented was of an 85 year old female with painless gross hematuria for 6 months. Dr. Matin showed a CT scan from the patient and described how a 3cm right distal ureteral tumor was found. A poll that was directed to the panel with the question “Which laser do you use for endoscopic management of upper tract urothelial carcinoma” was displayed and it was found that all 4/4 of the physicians of the panel attested to using the holmium/YAG laser, whereas none of the panel members attested to using the thulium laser. Dr. Matin then went onto highlight the unique differences between the holmium and thulium lasers. Going back to the case at hand, Dr. Matin posed a question for the audience in regards to how they would proceed with treating a recurrence of the cancer for the patient. He also posed a polling question for the audience: “Do you give intravesical chemo after ureteroscopy for upper tract urothelial carcinoma?”, to which 62% of the audience responded NO and 38% responded YES. Following the poll, Dr. Porten chimed in and responded that she does give intravesical chemotherapy following this scenario. The panel went into an interesting discussion regarding what the proper route of treatment would be, and Dr. Habuchi noted that this is a quite difficult and nuanced scenario in regards to a recurrent case of upper tract cancer.
Dr. Matin noted that there is emerging data the more a urologist manipulates an upper tract tumor ureteroscopically, this is associated with bladder recurrence of the tumor. Dr. Raman from the panel responded by saying that this does not mean ureteroscopy with biopsy should not be done, but that the procedure should be done cautiously and while bearing in mind that there is a risk.
The next question posed to the audience was “Do you use mitomycin hydrogel?”, to which 68% of the audience responded NO and 32% responded YES. Barriers to the use of this treatment were discussed, and Dr. Porten described her personal practice and noted that she would not use it because intravesical chemotherapies are given in the infusion center at her institution and this makes use of mitomycin difficult.
Dr. Matin noted that there are novel ways to administer mitomycin including anterograde administration through a nephrostomy tube. He referenced some recent studies on the topic and how the original use of the medication was for adjuvant chemotherapy. Dr. Matin also noted that in his current practice, he performs maximal mechanical laser ablation with ureteroscopy prior to delivering UGN-101 through a nephrostomy tube. In going back to the patient case, it was discussed that the patient had a negative ureteroscopy 8 weeks after induction of the mitomycin gel.
Another case was presented about a 71 year old female with a 2cm left upper pole tumor that was found incidentally, and the CT scan of the tumor was displayed.
When asked what treatment would be offered to this patient, 37% of the audience responded with neoadjuvant chemotherapy following by nephroureterecomy whereas 59% responded they would perform nephroureterecomy first. Dr. Habuchi joined the discussion noting that he would personally perform neoadjuvant chemotherapy first. The panel of physicians said that both answers are fair, but that pursuing endoscopic management would be a wrong approach.
To conclude the session, Dr. Matin included some key take home points in his presentation:
- Mitomycin hydrogel should be considered for recurrent low-grade disease
- Intravesicular chemotherapy with nephroureterectomy is supported by strong, level 1 data
- Intravesicular chemotherapy after ureterescopy with biopsy is supposed by a multitude of cicrumstanstial data
- Lymphadnectomy for high risk cases should be considered.
Moderated by: Surena Matin, MD, MD Anderson Cancer Center, Houston, TX
Panel: Jay Raman, MD- Penn State Health; Tomonori Habuchi, MD - Akita University; Sima Porten, MD - UCSF
Written by: Allen Rojhani, BS; MD Candidate at the Drexel University College of Medicine and 2022-2023 LIFT Research Fellow at the University of California, Irvine Department of Urology during the 2023 American Urological Association (AUA) Annual Meeting, Chicago, IL, April 27 – May 1, 2023