Kidney-Sparing Approaches, Current Treatment Pathways for Low-Grade UTUC

A roundtable discussion, moderated by Katie S. Murray, DO, MS, discussed the risk stratification and treatment options for low-grade upper tract urothelial carcinoma (UTUC), as well as recent trial data from the 2024 American Urological Association (AUA) Annual Meeting. Dr. Murray was joined by Scot Niglio, MD; Alice Yu, MD; Hong Truong, MD, MS; and Adam Feldman, MD, MPH.

In the third segment of the roundtable series, the panel highlights nephron-sparing approaches as well as current treatment pathways for low-grade UTUC.

Watch the next segment in this series.

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Dr. Murray: Several people have already mentioned kidney-sparing approaches, and I would like to delve into the current treatment and what lies ahead. Endoscopic ablations have been a topic of discussion. The concept of sparing organs is not new; we have applied it in various diseases within urology and GU, including the upper tract. However, with advancing technologies, we are refining our approaches. So, when we talk about kidney sparing in UTUC, what does that mean to you?

Dr. Yu: To me, it means opting for endoscopic management, aiming to avoid nephroureterectomy whenever possible.

Dr. Truong: Patients amenable to kidney sparing span the spectrum of UTUC. Although we consider risk stratification categories, we should not overlook patient factors. Favorable low-risk patients are ideal candidates for kidney sparing through complete laser ablation. For those who may not tolerate chemotherapy or surgery well, due to competing risk factors, a kidney-sparing approach might be appropriate, even deviating from guidelines.

Dr. Feldman: Organ sparing and preservation are crucial aspects of our treatment options. Yet, we need to consider the impact of repetitive procedures, especially in the elderly, on cognitive function. For instance, I had a patient in her late 80s with high volume low-grade disease on 1 kidney. Despite options for repetitive ablations, we opted for nephroureterectomy due to its 1-time nature, avoiding multiple anesthesia episodes.

Dr. Murray: Right, it is crucial to explain to patients the diligence required for repetitive ablations, whether mechanical or chemotherapy ablations. Patients need to understand the commitment involved. When imperative indications arise, such as having only 1 kidney or poor kidney function, the decision may be easier. However, when it is not imperative, it is essential to weigh the options carefully.

Now, moving on to an interesting point: we have urologists and a medical oncologist here. Our oncologist has been involved in treating patients with low-grade upper tract disease and administering UGN-101 therapy. Any insights now that you are involved in this aspect of patient care, Dr. Niglio?

Dr. Niglio: It has been an exciting learning experience. Organ sparing is paramount, especially in low-grade cases where UGN-101 is a valuable option. While I will touch on a niche area, a small percentage of cases may be MSI-high or microsatellite stable. Though not standard practice, there is potential for immune checkpoint blockade like PD-1 or PD-L1 inhibitors to spare organs, as seen in rectal cancer cases with remarkable responses.

Dr. Feldman: Indeed, pembrolizumab is FDA-approved for MSI-high cases. And there is promising data from MD Anderson showcasing impressive cases.

Dr. Niglio: Absolutely. Ongoing clinical trials are exploring this avenue further for upper tract cancers with MSI-high or DDR deficiencies.

Dr. Feldman: As my medical oncology colleague says, this disease does not always play by the rules. I had a patient with bilateral low-grade disease, seemingly perfect for organ-sparing treatment. UGN-101 showed great response, and she remained disease-free. But 18 months later, a lung nodule appeared, revealing metastatic urothelial cancer. It is a reminder to remain vigilant.