(UroToday.com) The 2021 American Urological Association (AUA) Summer School session on Upper Tract Urothelial Carcinoma included a case-based discussion led by moderator Dr. Surena Matin who was joined by panelists Dr. Sima Porten and Dr. Vitaly Margulis. This case highlighted high-risk upper tract urothelial carcinoma in a solitary kidney with synchronous bladder urothelial carcinoma. The patient was a 58-year-old female with Lynch Syndrome and a surgical history consistent with a hysterectomy 10 years ago for endometrial cancer. Additionally, she had a right nephroureterectomy in 2005 (unknown stage and grade of tumor), with new recurrence bladder CIS after BCG induction (no maintenance given), with a new left high-grade upper tract urothelial carcinoma at the ureteropelvic junction (cTx-1), as well as mid and distal ureteral tumors:
For this patient with a solitary kidney with a left ureteral cT1 (suspected lamina propria invasion) with recurrent CIS (with a history of Lynch syndrome), Dr. Matin posed several treatment options to the panel for discussion:
- Neoadjuvant chemotherapy?
- Cystectomy plus ureterectomy with an ileal ureter?
- Cystectomy plus nephroureterectomy with dialysis?
- Hold off on radical cystectomy and re-treat with BCG?
Dr. Porten states that it is important in this situation to have a conversation with the patient as to what their goals for treatment are and what they are willing to go through/sacrifice. From an oncological perspective, removing the remaining urothelium with subsequent dialysis is the optimal treatment, but the conversation with the patient is key. Dr. Margulis notes that in the appropriately motivated patient, a dialysis is a reasonable option, particularly given the option of home/peritoneal dialysis.
This patient state that she was tired of multiple interventions and wanted the single most effective oncologic treatment, accepting dialysis and not desiring a kidney transplant. Thus, she underwent neoadjuvant gemcitabine plus taxol plus adriamycin, followed by dose-dense MVAC, followed by a robotic nephroureterectomy plus retroperitoneal lymphadenectomy plus cystectomy plus bilateral pelvic lymphadenectomy. The final pathology demonstrated ypT3 (ureter) + extensive CIS (bladder) ypN0/66R0. At 5 years of follow-up, she has had no recurrence but was still not interested in a renal transplant, which she would have been eligible for, given her time without evidence of disease.
Moderator: Surena F. Matin, MD, MD Anderson Cancer Center, Houston, TX
Panelists: Sima Porten, MD, MPH, University of California – San Francisco, San Francisco, CA & Vitaly Margulis, MD, UT Southwestern, Dallas, TX
Written by: Zachary Klaassen, MD, MSc – Urologic Oncologist, Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, @zklaassen_md on Twitter during the AUA2021 May Kick-off Weekend May 21-23.