Risk Stratification in UTUC: Guidelines and Management Strategies

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 first segment of the roundtable series, the panel engages in a brief discussion related to risk stratification in UTUC, including current approaches to stratification, factors influencing stratification, and identification of high-risk patients.

Watch the next segment in this series.

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Dr. Murray: In 2023, the AUA and SUO released the first guidelines for UTUC, allowing us to stratify patients by risk. Anyone want to discuss this risk stratification between low and high risk?

Dr. Feldman: I’ll start. The guidelines help us categorize patients, making it easier to guide treatment decisions. We have options like endoscopic management, nephroureterectomy, and intracavitary therapy. This is especially helpful for community urologists who may not deal with upper tract cancers daily.

Dr. Yu: Exactly. These risk categories provide structure, aiding in education and decision-making. Without them, creating guidelines would be challenging.

Dr. Murray: It is interesting for patients too. Knowing their risk level helps them understand their treatment options better. Do you agree, Dr. Truong?

Dr. Truong: Absolutely. It helps patients understand why certain diagnostic procedures are necessary and guides their management decisions and surveillance.

Dr. Feldman: Additionally, having specific guidelines for UTUC raises awareness and promotes research in this less common type of urothelial cancer.

Dr. Murray: As a medical oncologist, I find it important to collaborate with urologists based on these guidelines. When do you consider sending patients for neoadjuvant or adjuvant therapy?

Dr. Niglio: The AUA guidelines are extremely helpful, even for medical oncologists. The NCCN guidelines are less defined. For me, high-risk, high-grade patients always prompt a discussion about neoadjuvant chemotherapy, especially if they are cisplatin-eligible.

Dr. Murray: The guidelines also emphasize the need for universal tumor testing for hereditary diseases like Lynch syndrome. What is your approach to this, Dr. Truong?

Dr. Truong: At Penn State, we have worked with pathologists to ensure universal tumor testing for upper tract cancer. We use immunohistochemical staining for mismatch repair deficiency proteins or next-generation sequencing for microsatellite instability (MSI). If positive, patients are referred for confirmatory germline testing.

Dr. Feldman: Is the MSI testing reflexive in addition to IHC?

Dr. Truong: If IHC staining is not possible, we can send for other tumor profiling tests like FoundationOne, which provide microsatellite status and tumor mutation burden.