Lymph Node Selection, Adjuvant Considerations for Low-Grade UTUC

*Dr. Scot Niglio would like to clarify: With the POUT data, in certain situations, chemotherapy for T2 UTUC is a reasonable choice.

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 final segment of the roundtable series, the panel offers concluding thoughts on selection criteria for lymph node dissection in patients with low-grade UTUC, advice for community physicians considering adopting UGN-101 in their practice, and other relevant adjuvant therapy considerations in this patient population.

Watch previous segments in this series.

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Dr. Murray: Any questions from our panel or anything else we have not covered that might interest everyone?

Dr. Yu: I have a question. Regarding lymph node dissection, you mentioned a case of low-grade earlier. You did a nephroureterectomy. What are your criteria for lymph node dissection? Is it for certain high-grade or higher risk patients only?

Dr. Murray: According to the guidelines, which I just reviewed, it is quite specific. For a patient undergoing nephroureterectomy for low-grade, it says a physician or clinician may perform a lymph node dissection. For high-grade, it is recommended that a clinician should perform a lymph node dissection. So the guidelines allow for discretion. Personally, if I am doing a nephroureterectomy for bulky low-grade disease due to the risk of upgrading and upstaging, I opt for a regional lymphadenectomy.

Dr. Feldman: I completely agree. We also need to consider atherosclerosis in the aorta and vessels. But yes, for high-grade or bulky low-grade, especially those at higher risk for upgrading, size is a significant factor.

Dr. Truong: It is important to follow the template as well, right?

Dr. Murray: Absolutely.

Dr. Truong: Depending on the tumor location, ensure the appropriate template for lymph node dissection. It is okay not to do it, but if you do, do it right.

Dr. Murray: Exactly.

Dr. Feldman: Right. For renal pelvis and proximal ureter, it is paracaval on the right and para-aortic on the left.

Dr. Murray: One last question before we finish. Dr. Feldman, you integrated UGN-101 into your practice from the beginning. Many struggle with integrating new practices. Any advice for those wanting to adopt new procedures?

Dr. Feldman: It was indeed challenging, but 1 patient pushed me to do it as it was the only option. Convincing the pharmacy, organizing staff, and resources was tough. But once you establish the process for change, it becomes easier. Engage as many people in your department or division to push it forward. It is a lot of work, but worth it.

Dr. Murray: Does anyone else have advice for adopting new practices?

Dr. Niglio: Neoadjuvant therapy, though less supported, is important to discuss. Patients not receiving it should discuss with a medical oncologist for adjuvant therapy based on tumor size and node positivity, such as platinum-based chemotherapy or adjuvant checkpoint with nivolumab, as per CheckMate 274.

Dr. Feldman: Yes, especially for high-grade disease or if there is adenopathy, systemic therapy before surgery is crucial.

Dr. Niglio: Definitely. And for patients ineligible for cisplatin post-nephroureterectomy, there is a choice between gem/carbo and nivolumab, each with its considerations.

Dr. Feldman: Our medical oncologists would likely agree. It is not an easy decision.

Dr. Yu: Regarding neoadjuvant chemotherapy, staging is a challenge, especially with traditional imaging. Not everyone responds to it either, as shown in a study where only 25% had a response.

Dr. Feldman: True. But it is important to consider who progressed through neoadjuvant chemotherapy, as there is a percentage that does not respond to adjuvant either.

Dr. Murray: True. When it is straightforward, it is easy. But for cases where staging is uncertain, it is more complicated, especially if their GFR post-op is a concern.

Dr. Feldman: Right. In patients with adequate GFR after surgery, proceeding with surgery is reasonable. Dr. Niglio, for a patient with T2N0, would you offer adjuvant if they are cisplatin eligible?

Dr. Niglio: And they received no neoadjuvant therapy? No, not for T2 disease.

Dr. Feldman: For T2N0?

Dr. Niglio: I would not do that. I have been in those situations before where it was actually a whopping tumor and I say, “I would recommend neoadjuvant chemotherapy.” They say no, and then it comes out, and it is T1 and I was flabbergasted. I think those cases are out there and at some point, it is going to be a combination of imaging, who knows, AI computers trying to figure it, urine-based biomarkers or cell-free DNA.

And I think at some point, we will get in upper tract some BI-RADS or VI-RADS.

Dr. Feldman: But I think that speaks to why, in somebody who is going to have an adequate GFR after surgery, then it is very reasonable to just go forward with surgery.

Dr. Murray: Thank you all for this insightful discussion on UTUC. This concludes today’s session for GU Oncology Now at AUA 2024.