UTUC Guidelines Offer Treatment Suggestions for Kidney Sparing, Lymph Node Dissection, and More

During an afternoon plenary session, Jonathan Coleman, MD, Memorial Sloan Kettering Cancer Center, presented the updates to the American Urological Association guideline for upper tract urothelial carcinoma (UTUC).

Beginning with standardized evaluation, Dr. Coleman noted cystoscopy and cross-sectional imaging of the upper tract for patients with suspected UTUC. Clinicians should evaluate patients with suspected UTUC with diagnostic ureteroscopy and biopsy. In patients who have concomitant lower tract tumors discovered at the time of ureteroscopy, the lower tract tumors should be managed in the same setting as ureteroscopy. However, in cases where ureteroscopy cannot be safely performed, an attempt at selective upper tract washing or barbotage for cytology may be made. Additionally, patients with suspected or diagnosed UTUC should have a discussion with their clinicians on known hereditary risk factors for familial diseases associated with Lynch Syndrome.

As for risk stratification based on standardized evaluation, the guideline states that at the time of identified UTUC, clinicians should perform a standardized assessment documenting clinically meaningful endoscopic and radiographic features to facilitate clinical staging and risk assessment. After that, clinicians should risk-stratify patients as “low-“ or “high-“ risk for invasive disease (pT2 or greater).

Tumor ablation should be the initial management option for patients with low-risk favorable UTUC, Dr. Coleman continued. Tumor ablation may be the initial management option offered to patients with low-risk unfavorable UTUC and select patients with high-risk favorable disease who have low-volume tumors.

Once ablation is complete and there is no perforation of the bladder or upper tract, clinicians may instill adjuvant pelvicalyceal chemotherapy or intravesical chemotherapy. Pelvicalyceal therapy with BCG may be offered to patients with high-risk favorable UTUC after complete tumor ablation or patients with upper tract carcinoma in situ.

The guideline also offered updates to surgical management of UTUC. Dr. Coleman shared that clinicians should recommend radical nephroureterectomy (RNU) or segmental ureterectomy (SU) for surgically eligible patients with high-risk UTUC. When performing NU or distal ureterectomy, the entire distal ureter—including the intramural ureteral tunnel and ureteral orifice—should be excised, and the urinary tract should be closed in a watertight fashion. Patients undergoing RNU or SU should receive a single dose of perioperative intravesical chemotherapy to reduce the risk of bladder recurrence.

Continuing to lymph node dissection, Dr. Coleman said that patients with low-risk disease may have their lymph nodes resected at the time of nephroureterectomy or ureterectomy. For patients with high-risk UTUC, the guideline strongly recommends that clinicians should perform lymph node dissection at the time of nephroureterectomy or ureterectomy.

Clinicians should offer cisplatin-based neoadjuvant chemotherapy to patients with high-risk UTUC undergoing RNU or ureterectomy. Platinum-based adjuvant chemotherapy should be offered to patients with advanced pathological stage UTUC after RNU or ureterectomy. Adjuvant nivolumab may be offered to patients who received neoadjuvant platinum-based chemotherapy or who are ineligible for perioperative cisplatin.

Lastly, Dr. Coleman mentioned that patients with reduced or deteriorating renal function following nephroureterectomy or other intervention should be referred to nephrology. Clinicians should discuss disease-related stresses and risk factors and they should encourage patients with urothelial cancer to adopt healthy lifestyle habits, including smoking cessation.

In his concluding remarks, Dr. Coleman mentioned a few trials that will likely contribute to the future direction of UTUC care, including the ENLIGHTED study for instrumentation and ablative treatments and the ECOG-ACRIN study for multidisciplinary care.