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Zhao J, Shen Y, Guo M, Matin SF, Hansel DE, Guo CC. Diagnostic accuracy of upper tract urothelial carcinoma using biopsy, urinary cytology, and nephroureterectomy specimens: A tertiary cancer center experience. Am J Clin Pathol 2024:aqae065. [PMID: 38860463 DOI: 10.1093/ajcp/aqae065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 05/06/2024] [Indexed: 06/12/2024] Open
Abstract
OBJECTIVES We studied the diagnostic accuracy and discordance of upper tract urothelial carcinoma (UTUC) by comparing biopsy and urinary cytology with matched nephroureterectomy specimens. METHODS Sixty-nine patients with UTUC without neoadjuvant treatment were retrospectively identified who had matched biopsy and nephroureterectomy specimens. Twenty patients had concurrent upper tract cytology. H&E and cytology slides were re-reviewed. Statistical analysis was performed. RESULTS Patients included 48 men and 21 women with a mean age of 69 years. A concordant grade between biopsy and surgical specimen was present in 49 (71%) patients. The mean size of biopsy specimens in the discordant group was significantly smaller than that in the concordant group. Invasion was evaluated in 48 biopsy cases that had adequate subepithelial tissue, and 33 of them were diagnosed with concordant invasion status. Mean tumor size in both tumor grade and invasion discordant groups was significantly larger than that in the concordant group. High-grade urothelial carcinoma was detected in 84% of cases using urinary cytology. CONCLUSIONS Our study demonstrates the diagnostic challenges of UTUC on small biopsy specimens. Biopsy specimen size and tumor size are significantly associated with the diagnostic discordance. Upper tract cytology showed high diagnostic accuracy and should be complementary to the biopsy.
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Affiliation(s)
- Jianping Zhao
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, TX, US
| | - Yuan Shen
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, TX, US
| | - Ming Guo
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, TX, US
| | - Surena F Matin
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, US
| | - Donna E Hansel
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, TX, US
| | - Charles C Guo
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, TX, US
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2
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Gravestock P, Cullum D, Somani B, Veeratterapillay R. Diagnosing upper tract urothelial carcinoma: A review of the role of diagnostic ureteroscopy and novel developments over last two decades. Asian J Urol 2024; 11:242-252. [PMID: 38680592 PMCID: PMC11053284 DOI: 10.1016/j.ajur.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 08/13/2022] [Indexed: 11/29/2022] Open
Abstract
Objective The role of ureteroscopy in the diagnosis of upper tract urothelial carcinoma is yet to be fully determined. We aimed to provide an up to date evaluation of its role and the emerging technologies in the field. Methods A literature search of the last two decades (from 24th May, 2001 to 24th May, 2021) was carried out identifying 147 papers for potential inclusion within this narrative review. Results Diagnostic ureteroscopy is undeniably useful in its ability to visualise and biopsy indeterminate lesions, and to risk stratify malignant lesions that may be suitable for kidney sparing surgery. However, an increased risk of intravesical recurrence following nephroureterectomy when a prior diagnostic ureteroscopy has been performed, inadequate sampling at biopsy, complications from the procedure, and difficult ureteric access are all potential drawbacks. Furthermore, whilst generally an accurate diagnostic procedure, it risks missing carcinoma in-situ lesions. Despite this, evidence shows that routine use of ureteroscopy changes the management of patients in a large proportion of cases, preventing unnecessary surgery or facilitating kidney sparing surgery. The overall rate of complications is low, and improved biopsy techniques and the use of tissue biomarkers for improved staging and grading are encouraging. The risks of delays to definitive management and post-ureteroscopy intravesical recurrence do not seem to affect survival, and trials are in progress to determine whether intravesical therapy can mitigate the latter. Further promising techniques are being investigated to improve shortcomings, particularly in relation to improved diagnosis of carcinoma in situ and preoperative staging. Conclusion Ureteroscopy has a role in the diagnosis of upper tract malignancy, though whether it should be used routinely is yet to be determined.
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Affiliation(s)
- Paul Gravestock
- Urology Department, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Daniel Cullum
- Urology Department, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Bhaskar Somani
- Department of Urology, University Hospital Southampton, Southampton, UK
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3
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Baard J, Cormio L, Dasgupta R, Maruzzi D, Rais-Bahrami S, Serrano A, Geavlete B, Giannakopoulos S, de la Rosette J, Laguna P. Unveiling the challenges of UTUC biopsies and cytology: insights from a global real-world practice study. World J Urol 2024; 42:177. [PMID: 38507109 PMCID: PMC10954852 DOI: 10.1007/s00345-024-04866-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 02/08/2024] [Indexed: 03/22/2024] Open
Abstract
PURPOSE Diagnostic ureteroscopy (dURS) is optional in the assessment of patients with upper tract urothelial carcinoma (UTUC) and provides the possibility of obtaining histology. METHODS To evaluate endoscopic biopsy techniques and outcomes, we assessed data from patients from the CROES-UTUC registry. The registry includes multicenter prospective collected data on diagnosis and management of patients suspected having UTUC. RESULTS We assessed 2380 patients from 101 centers. dURS with biopsy was performed in 31.6% of patients. The quality of samples was sufficient for diagnosis in 83.5% of cases. There was no significant association between biopsy techniques and quality (p = 0.458). High-grade biopsy accurately predicted high-grade disease in 95.7% and high-risk stage disease in 86%. In ureteroscopic low-grade tumours, the prediction of subsequent low-grade disease was 66.9% and low-risk stage Ta-disease 35.8%. Ureteroscopic staging correctly predicted non-invasive Ta-disease and ≥ T1 disease in 48.9% and 47.9% of patients, respectively. Cytology outcomes did not provide additional value in predicting tumour grade. CONCLUSION Biopsy results adequately predict high-grade and high-risk disease, but approximately one-third of patients are under-staged. Two-thirds of patients with low-grade URS-biopsy have high-risk stage disease, highlighting the need for improved diagnostics to better assess patient risk and guide treatment decisions. CLINICAL TRIAL REGISTRATION The study was registered at ClinicalTrials.gov (ClinicalTrials.gov NCT02281188; https://clinicaltrials.gov/ct2/show/NCT02281188 ).
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Affiliation(s)
- Joyce Baard
- Department of Urology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands.
| | - Luigi Cormio
- Department of Urology, University of Foggia, Foggia, Italy
| | - Ranan Dasgupta
- Department of Urology, Imperial College Healthcare NHS Trust, London, UK
| | - Daniele Maruzzi
- Department of Urology, S. Maria Degli Angeli Hospital, Pordenone, Italy
| | - Soroush Rais-Bahrami
- Departments of Urology and Radiology, O'Neal Comprehensive Cancer Center at UAB, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Alvaro Serrano
- Department of Urology, Hospital Clínico San Carlos, Madrid, Spain
| | | | - Stilianos Giannakopoulos
- Department of Urology, School of Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Jean de la Rosette
- Department of Urology, Istanbul Medipol Mega University Hospital, Istanbul Medipol University, Istanbul, Turkey
| | - Pilar Laguna
- Department of Urology, Istanbul Medipol Mega University Hospital, Istanbul Medipol University, Istanbul, Turkey
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Jia L, Rood T, Kirkpatrick J, Sarode V. Utility of The Paris System (TPS) for upper urinary tract cytopathology: correlation with histology follow-up and UroVysion fluorescence in situ hybridization (FISH) analysis. J Am Soc Cytopathol 2024; 13:149-155. [PMID: 38341300 DOI: 10.1016/j.jasc.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 12/24/2023] [Accepted: 12/28/2023] [Indexed: 02/12/2024]
Abstract
INTRODUCTION The Paris System (TPS) provides a uniform reporting system of urine cytology based on well-defined cytologic criteria. Due to their rarity, there are limited data on the utility of TPS in upper urinary tract (UUT) lesions and follow-up histology of cases with abnormal cytology. We aimed to evaluate the utility of TPS for UUT lesions by correlating the cytologic diagnoses using TPS criteria with subsequent histology. Additionally, the diagnostic utility of UroVysion (Abbott) fluorescence in situ hybridization (FISH) was assessed. MATERIALS AND METHODS A total of 148 UUT cytology specimens were retrospectively identified (2018-2022). Cytologic interpretation was performed using TPS, and then correlated with the findings of concurrent or subsequent histologic specimens. The performance of UroVysion FISH was analyzed. Sensitivity and specificity, positive predictive value (PPV) and negative predictive value (NPV) for detecting high-grade urothelial carcinoma (HGUC) were determined. RESULTS Among 83 patients who had concurrent or subsequent histologic specimens, cyto-histologic discrepancy was seen in 7 cases (8.4%). The sensitivity, specificity, PPV, and NPV using TPS criteria for detecting HGUC were 87%, and 92%, 96.4%, and 73%, respectively. UroVysion FISH was performed in 21 patients with atypical cytologic findings. The sensitivity and specificity of UroVysion for detecting HGUC was 75% and 86%, respectively, while PPV and NPV were 86% and 75%, respectively. CONCLUSIONS In our experience, the application of TPS criteria for reporting upper urinary cytology was reliable at detecting UUT lesions, especially HGUC. UroVysion FISH was a valuable ancillary test for detecting HGUC of UUT.
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Affiliation(s)
- Liwei Jia
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Tricia Rood
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - James Kirkpatrick
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Venetia Sarode
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas
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Abstract
Upper urinary tract urothelial carcinoma (UTUC) is an uncommon malignancy involving the renal pelvis and ureter. Careful pathologic analysis plays a critical role in the diagnosis and clinical management of UTUC. In combination with clinical and radiologic evaluation, pathologic features can be used to stratify patients into low-risk and high-risk groups. This risk stratification can help clinicians select the optimal treatment for patients with UTUC, such as kidney-sparing (conservative) treatment, radical nephroureterectomy or ureterectomy, and perioperative systemic therapy. However, due to the technical difficulty of obtaining sufficient tissue from the upper urinary tract, it is often challenging for pathologists to accurately grade the tumor and assess tumor invasion in small biopsy specimens. Although the majority of UTUCs are pure urothelial carcinoma, a considerable subset of UTUCs show histologic subtypes or divergent differentiation. Recent studies have identified genetically distinct molecular subtypes of UTUC by examining DNA, RNA, and protein expression profiles. The prognosis of pT3 UTUC, particularly renal pelvic UC, remains controversial, and several studies have proposed subclassification of pT3 UTUC. Lynch syndrome is a significant risk factor for UTUC, and screening tests may be considered in young patients and those with familial histories of the disease. Despite significant progress in recent years, several issues remain to be addressed in the pathologic diagnosis, molecular classification, and treatment of UTUC.
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Affiliation(s)
- Jianping Zhao
- Department of Anatomical Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Charles C. Guo
- Department of Anatomical Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Priya Rao
- Department of Anatomical Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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High Pretreatment Serum PD-L1 Levels Are Associated with Muscle Invasion and Shorter Survival in Upper Tract Urothelial Carcinoma. Biomedicines 2022; 10:biomedicines10102560. [PMID: 36289821 PMCID: PMC9599956 DOI: 10.3390/biomedicines10102560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 09/30/2022] [Accepted: 10/06/2022] [Indexed: 11/17/2022] Open
Abstract
Programmed death ligand-1 (PD-L1) is an immune checkpoint molecule and a widely used therapeutic target in urothelial cancer. Its circulating, soluble levels (sPD-L1) were recently suggested to be associated with the presence and prognosis of various malignancies but have not yet been investigated in upper tract urothelial carcinoma (UTUC). In this study, we assessed sPD-L1 levels in 97 prospectively collected serum samples from 61 UTUC patients who underwent radical nephroureterectomy (RNU), chemotherapy (CTX), or immune checkpoint inhibitor (ICI) therapy. In addition to pretreatment samples, postoperative and on-treatment sPD-L1 levels were determined in some patients by using ELISA. In the RNU group, elevated preoperative sPD-L1 was associated with a higher tumor grade (p = 0.019), stage (p < 0.001) and the presence of metastasis (p = 0.002). High sPD-L1 levels were significantly associated with worse survival in both the RNU and CTX cohorts. sPD-L1 levels were significantly elevated in postoperative samples (p = 0.011), while they remained unchanged during CTX. Interestingly, ICI treatment caused a strong, 25-fold increase in sPD-L1 (p < 0.001). Our results suggest that elevated preoperative sPD-L1 level is a predictor of higher pathological tumor stage and worse survival in UTUC, which therefore may help to optimize therapeutic decision-making. The observed characteristic sPD-L1 flare during immune checkpoint inhibitor therapy may have clinical significance.
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Zhang ML, Miki Y, Hang JF, Vohra M, Peyton S, McIntire PJ, VandenBussche CJ, Vohra P. A review of upper urinary tract cytology performance before and after the implementation of The Paris System. Cancer Cytopathol 2020; 129:264-274. [PMID: 32897658 DOI: 10.1002/cncy.22343] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 07/27/2020] [Accepted: 07/29/2020] [Indexed: 12/22/2022]
Abstract
Urinary cytology (UC) is one of the primary diagnostic modalities used for the screening and surveillance of urothelial carcinoma. Despite its widespread use, UC has suffered from a lack of standardized or reproducible criteria and wide interobserver variability, particularly of the designation of atypical urothelial cells. The Paris System for Reporting Urinary Cytology (TPS), published in 2016, aimed to provide a standardized approach for evaluating UC by creating diagnostic categories with specific cytomorphologic criteria. Recent studies have primarily investigated the application of TPS on lower urinary tract specimens and have mostly shown that TPS implementation has improved the performance of UC specimens. Only a few studies have reported the impact of TPS on upper urinary tract (UUT) cytology. Additionally, there is uncertainty as to which cytological features are most predictive of high-grade urothelial carcinoma (HGUC) in the UUT. This review summarizes the literature regarding the utility and performance of UUT cytology and highlights findings before and after the implementation of TPS.
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Affiliation(s)
- M Lisa Zhang
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Yurina Miki
- Department of Cellular Pathology, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Jen-Fan Hang
- Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Manjiv Vohra
- Environmental Chemical Corp, Burlingame, California
| | - Stephen Peyton
- QML Pathology, Anatomical Pathology, Brisbane, Queensland, Australia
| | - Patrick J McIntire
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York
| | | | - Poonam Vohra
- Department of Anatomic Pathology, University of California, San Francisco, California
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8
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Zhang ML, VandenBussche CJ, Hang JF, Miki Y, McIntire PJ, Peyton S, Vohra P. A review of urinary cytology in the setting of upper tract urothelial carcinoma. J Am Soc Cytopathol 2020; 10:29-35. [PMID: 32792229 DOI: 10.1016/j.jasc.2020.06.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 06/18/2020] [Indexed: 12/27/2022]
Abstract
Urothelial carcinomas of the upper urinary tract (UUT) are uncommon. Cytological examination of voided urine or washings from the UUT has been part of the standard workup for upper tract urothelial carcinoma (UTUC); however, its value remains controversial. The lack of uniform terminology and specific diagnostic criteria could also have contributed to the inferior performance of urinary cytology for detecting UTUC. The Paris System for Reporting Urinary Cytology (TPS) has provided a standardized reporting system for urinary cytology specimens with clearly defined cytomorphologic diagnostic criteria and found acceptance on an international level after its implementation in 2016. Recent studies have shown that TPS has led to improved diagnostic performance of urinary cytology; however, most of these studies had focused on the evaluation of lower urinary tract cytology specimens. Only a limited number of new research studies have analyzed the effect of TPS when applied to UUT cytology specimens. In the present report, we have summarized the current understanding and utility of UTUC, including its molecular biology, and reviewed the current literature.
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Affiliation(s)
- M Lisa Zhang
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Jen-Fan Hang
- Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yurina Miki
- Department of Cellular Pathology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Patrick J McIntire
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York
| | - Stephen Peyton
- Department of Anatomical Pathology, QML Pathology, Brisbane, Queensland, Australia
| | - Poonam Vohra
- Department of Anatomic Pathology, University of California, San Francisco, San Francisco, California.
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9
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Subiela JD, Territo A, Mercadé A, Balañà J, Aumatell J, Calderon J, Gallioli A, González-Padilla DA, Gaya JM, Palou J, Breda A. Diagnostic accuracy of ureteroscopic biopsy in predicting stage and grade at final pathology in upper tract urothelial carcinoma: Systematic review and meta-analysis. Eur J Surg Oncol 2020; 46:1989-1997. [PMID: 32674841 DOI: 10.1016/j.ejso.2020.06.024] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/21/2020] [Accepted: 06/14/2020] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE To assess the accuracy of ureteroscopic (URS) biopsies in predicting stage and grade at final pathology in upper tract urothelial carcinoma (UTUC). MATERIALS AND METHODS The meta-analysis was performed in accordance with the PRISMA statement. Studies providing data on tumor stage and grade at URS biopsy and surgical specimens were included. The negative predictive value (NPV) implies concordance between the absence of subepithelial connective tissue invasion or the presence of low-grade tumors at URS biopsy and the absence of a muscle-invasive disease in the final pathology. RESULTS A total of 23 studies were included (3547 patients). The stage-to-stage match between URS biopsy/final pathology showed a positive predictive value (PPV) for cT1+/muscle-invasive disease of 94% (95% CI: 84%-100%) and a NPV for cTa-Tis/non-muscle-invasive disease of 60% (95% CI: 52%-68%). The grade-to-grade match between URS biopsy/final pathology was 66% (95% CI: 55%-77%) for low-grade (cLG/pLG) tumors and 97% (95% CI: 94%-98%) for high-grade (cHG/pHG) tumors. The PPV for cHG/muscle-invasive disease was 60% (95% CI: 54%-66%) and the NPV for cLG/non-muscle-invasive disease was 77% (95% CI: 73%-82%). The undergrading and understaging rates were 32% (95%CI: 25%-38%) and 46% (95% CI: 38%-54%), respectively. CONCLUSIONS There is a substantial correlation between tumor grade at URS biopsy and the final pathology. The identification of cHG tumors and subepithelial connective tissue invasion (cT1+) in URS biopsy showed a moderate and a strong correlation with invasive UTUC, respectively. Nevertheless, a certain risk of undergrading and understaging should be assumed.
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Affiliation(s)
- José Daniel Subiela
- Oncology Urology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Carrer de Cartagena 340-350, 08025, Barcelona, Spain.
| | - Angelo Territo
- Oncology Urology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Carrer de Cartagena 340-350, 08025, Barcelona, Spain.
| | - Asier Mercadé
- Oncology Urology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Carrer de Cartagena 340-350, 08025, Barcelona, Spain.
| | - Josep Balañà
- Oncology Urology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Carrer de Cartagena 340-350, 08025, Barcelona, Spain.
| | - Julia Aumatell
- Oncology Urology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Carrer de Cartagena 340-350, 08025, Barcelona, Spain.
| | - Julio Calderon
- Oncology Urology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Carrer de Cartagena 340-350, 08025, Barcelona, Spain.
| | - Andrea Gallioli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Urology, Department of Clinical Sciences and Community Health, University of Milan, Via della Commenda, 10, 20122, Milan, Italy.
| | | | - Josep Maria Gaya
- Oncology Urology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Carrer de Cartagena 340-350, 08025, Barcelona, Spain.
| | - Joan Palou
- Oncology Urology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Carrer de Cartagena 340-350, 08025, Barcelona, Spain.
| | - Alberto Breda
- Oncology Urology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Carrer de Cartagena 340-350, 08025, Barcelona, Spain.
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10
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Kleinmann N, Matin SF, Pierorazio PM, Gore JL, Shabsigh A, Hu B, Chamie K, Godoy G, Hubosky S, Rivera M, O'Donnell M, Quek M, Raman JD, Knoedler JJ, Scherr D, Stern J, Weight C, Weizer A, Woods M, Kaimakliotis H, Smith AB, Linehan J, Coleman J, Humphreys MR, Pak R, Lifshitz D, Verni M, Adibi M, Amin MB, Seltzer E, Klein I, Konorty M, Strauss-Ayali D, Hakim G, Schoenberg M, Lerner SP. Primary chemoablation of low-grade upper tract urothelial carcinoma using UGN-101, a mitomycin-containing reverse thermal gel (OLYMPUS): an open-label, single-arm, phase 3 trial. Lancet Oncol 2020; 21:776-785. [PMID: 32631491 DOI: 10.1016/s1470-2045(20)30147-9] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 02/20/2020] [Accepted: 02/21/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Most patients with low-grade upper tract urothelial cancer are treated by radical nephroureterectomy. We aimed to assess the safety and activity of a non-surgical treatment using instillation of UGN-101, a mitomycin-containing reverse thermal gel. METHODS In this open-label, single-arm, phase 3 trial, participants were recruited from 24 academic sites in the USA and Israel. Patients (aged ≥18 years) with primary or recurrent biopsy-proven, low-grade upper tract urothelial cancer (measuring 5-15 mm in maximum diameter) and an Eastern Cooperative Oncology Group performance status score of less than 3 (Karnofsky Performance Status score >40) were registered to receive six instillations of once-weekly UGN-101 (mitomycin 4 mg per mL; dosed according to volume of patient's renal pelvis and calyces, maximum 60 mg per instillation) via retrograde catheter to the renal pelvis and calyces. All patients had a planned primary disease evaluation 4-6 weeks after the completion of initial therapy, in which the primary outcome of complete response was assessed, defined as negative 3-month ureteroscopic evaluation, negative cytology, and negative for-cause biopsy. Activity (complete response, expected to occur in >15% of patients) and safety were assessed by the investigator in all patients who received at least one dose of UGN-101. Data presented are from the data cutoff on May 22, 2019. This study is registered with ClinicalTrials.gov, NCT02793128. FINDINGS Between April 6, 2017, and Nov 26, 2018, 71 (96%) of 74 enrolled patients received at least one dose of UGN-101. 42 (59%, 95% CI 47-71; p<0·0001) patients had a complete response at the primary disease evaluation visit. The median follow-up for patients with a complete response was 11·0 months (IQR 5·1-12·4). The most frequently reported all-cause adverse events were ureteric stenosis in 31 (44%) of 71 patients, urinary tract infection in 23 (32%), haematuria in 22 (31%), flank pain in 21 (30%), and nausea in 17 (24%). 19 (27%) of 71 patients had study drug-related or procedure-related serious adverse events. No deaths were regarded as related to treatment. INTERPRETATION Primary chemoablation of low-grade upper tract urothelial cancer with intracavitary UGN-101 results in clinically significant disease eradication and might offer a kidney-sparing treatment alternative for these patients. FUNDING UroGen Pharma.
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Affiliation(s)
- Nir Kleinmann
- Department of Urology, Sheba Medical Center, Ramat Gan, Israel
| | - Surena F Matin
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - John L Gore
- Department of Urology, University of Washington Medical Center, Seattle, WA, USA
| | - Ahmad Shabsigh
- Department of Urology, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Brian Hu
- Department of Urology, Loma Linda University, Loma Linda, CA, USA
| | - Karim Chamie
- Department of Urology, University of California Los Angeles, Los Angeles, CA, USA
| | - Guilherme Godoy
- Department of Urology, Baylor College of Medicine, Houston, TX, USA
| | - Scott Hubosky
- Department of Urology, Sidney Kimmel Medical College at Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Marcelino Rivera
- Department of Urology, Mayo Clinic Health System, Rochester, MN, USA
| | | | - Marcus Quek
- Department of Urology, Loyola University Medical Center, Maywood, IL, USA
| | - Jay D Raman
- Division of Urology, Penn State Health Milton S Hershey Medical Center, Hershey, PA, USA
| | - John J Knoedler
- Division of Urology, Penn State Health Milton S Hershey Medical Center, Hershey, PA, USA
| | - Douglas Scherr
- Department of Urology, Weill Medical College of Cornell University, New York, NY, USA
| | - Joshua Stern
- Department of Urology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Christopher Weight
- Department of Urology, University of Minnesota Health, Minneapolis, MN, USA
| | - Alon Weizer
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Michael Woods
- Department of Urology, Loyola University Medical Center, Maywood, IL, USA
| | - Hristos Kaimakliotis
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Angela B Smith
- Department of Urology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Jennifer Linehan
- Department of Urology, John Wayne Cancer Institute, Santa Monica, CA, USA
| | - Jonathan Coleman
- Department of Urology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Raymond Pak
- Department of Urology, Mayo Clinic Jacksonville, Jacksonville, FL, USA
| | - David Lifshitz
- Department of Urology, Rabin Medical Center, Tel Aviv, Israel
| | | | - Mehrad Adibi
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mahul B Amin
- Department of Pathology, University of Tennessee Health Science Center, Memphis, TN, USA
| | | | | | | | | | | | - Mark Schoenberg
- Department of Urology, Albert Einstein College of Medicine, Bronx, NY, USA; UroGen Pharma, New York, NY, USA
| | - Seth P Lerner
- Department of Urology, Baylor College of Medicine, Houston, TX, USA.
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