(UroToday.com) At the 2023 AUA Annual Meeting, Dr. Coleman took the stage to present the updated guidelines for the rare disease of upper tract urothelial carcinoma (UTUC).
Diagnosis: For diagnosis, all patients require the following: cystoscopy, cross-sectional imaging, a gentle diagnostic ureteroscopy utilizing a pre-stenting for difficult access to the tumor, selective cytology, and biopsy, which can be done percutaneously for frail patients. UTUC is the 3rd most common cancer associated with Lynch syndrome; therefore, all patients diagnosed with UTUC with a high probability of Lynch syndrome by history should undergo definitive testing with subsequent genetic counseling if a positive result returns.
Dr. Coleman stressed that a standardized diagnostic report is recommended that contains information such as sites of involvement, number of tumors, tumor appearance, and size of largest tumor referenced by comparison to endoscopic equipment such as the brush as well as description of imaging via retrograde pyelogram and cross-sectional imaging.
Risk stratification ablative treatment, and systemic therapy eligibility: After diagnosis and stratification, a full discussion of potential treatments and their risk should by conducted with the patient for shared decision making. Dr. Coleman made a point to highlight that, if lower tract disease is observed, it should be managed in the same setting at the upper tract disease.
Risk stratification as well as ablation eligibility and systemic therapy treatment should be made based on the following table weighted mostly by grade and cytology:
Intravesical therapy: Intravesical therapy can be offered following the ablation procedure if there was no perforation. BCG can also be given for patients with high risk (HR) favorable UTUC after complete ablation or patients with upper tract CIS.
Non-ablative surgical treatment: If ablation is not feasible based on the risk assessment above (i.e. all patients with HR UTUC), radical nephroureterectomy (RNU) or segmental resection of ureter (SU) should be offered based on the location of the tumor and functionality of the kidney. Lymph node dissection (LND) low risk (LR) UTUC is optional, but all HR UTUC should have LND at time of RNU or SU.
Systemic therapy: For systemic therapy, patients with the appropriate renal function should be offered platinum based neoadjuvant chemotherapy (NAC), especially patients with CKD. Patients with advanced UTUC who did not previously receive NAC should get platinum-based adjuvant chemotherapy.
Adjuvant nivolumab is available for patients in certain situations. Patients with positive lymph nodes are eligible for consolidation RNU or ureterectomy with partial or complete response to NAC. Unresectable UTUC should be offered clinical trial
Monitoring: Treatment specific follow up regimens are available in the following chart:
Survivorship: Dr. Coleman closed the discussion by mentioning survivorship. Those patients with declining renal function should be followed by a nephrologist and all patients should be encouraged to adopt healthy lifestyles.
Presented by: Jonathan Coleman, MD, Memorial Sloan Kettering Cancer Center
Written by: Zachary E. Tano, MD, Endourology Fellow, Department of Urology, University of California Irvine, during the 2023 American Urological Association (AUA) Annual Meeting, Chicago, IL, April 27 – May 1, 2023
Related Content:
Insights into the AUA Guidelines for Upper Tract Urothelial Carcinoma: Standardizing Diagnosis and Treatment for Better Patient Outcomes - Jonathan A. Coleman