1
|
McElree IM, Mott SL, Hougen HY, Packiam VT, O'Donnell MA, Steinberg RL. Sequential endoluminal gemcitabine and docetaxel vs. Bacillus Calmette-Guérin for the treatment of upper tract carcinoma in situ. Urol Oncol 2024; 42:221.e9-221.e16. [PMID: 38609747 DOI: 10.1016/j.urolonc.2024.03.012] [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: 01/24/2024] [Revised: 02/27/2024] [Accepted: 03/18/2024] [Indexed: 04/14/2024]
Abstract
INTRODUCTION Nephroureterectomy is commonly performed for high-grade (HG) upper tract (UT) urothelial carcinoma (UC). However, some patients may benefit from a de-escalation of surgical management, particularly for noninvasive disease and carcinoma in situ (CIS). Bacillus Calmette-Guerin (BCG) is currently the only guideline-recommended endoluminal treatment option. Gemcitabine/Docetaxel (Gem/Doce) has shown promising efficacy as a treatment for noninvasive HG UTUC, though a comparison to BCG is lacking. We report the outcomes of patients treated with endoluminal Gem/Doce vs. BCG for UT-CIS. METHODS A single-institutional retrospective review of patients treated with Gem/Doce vs. BCG for UT-CIS was performed. Treatment was instilled via nephrostomy or retrograde ureteral catheter. In both treatment groups, induction consisted of 6 weekly instillations. Maintenance was initiated if disease-free and consisted of 6 monthly instillations in the Gem/Doce group and a reduced dose (one-tenth) 3-week course at 3 months in the BCG group. Recurrence was defined as biopsy-proven disease or HG cytology. RESULTS The final cohort included 53 patients with 65 upper tract units; 31 received BCG and 34 received Gem/Doce. Median follow-up was 88 and 29 months in the BCG and Gem/Doce groups, respectively. Presenting pathology included biopsy-proven CIS and HG cytology in 9.7% and 90% of the BCG group, and 8.8% and 91% of the Gem/Doce group, respectively. The 2-year estimates for recurrence-free and nephroureterectomy-free survival were 61% and 89% for the BCG group and 54% and 100% for the Gem/Doce group, respectively. Upon multivariable analysis, instillation via percutaneous nephrostomy tube was associated with an increased risk of recurrence (HR 3.89, 95% CI 1.59-9.53). The development of any symptom was not statistically different between treatment groups (P = 0.12). There were 2 treatment-related deaths that occurred, 1 within each treatment group. CONCLUSION Endoluminal Gem/Doce and BCG have similar oncological outcomes and major adverse event rates in the treatment of UT-CIS. Further prospective evaluation is warranted.
Collapse
Affiliation(s)
- Ian M McElree
- Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Sarah L Mott
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA
| | - Helen Y Hougen
- Department of Urology, University of Iowa, Iowa City, IA
| | | | - Michael A O'Donnell
- Department of Urology, University of Iowa, Iowa City, IA; Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA
| | | |
Collapse
|
2
|
McElree IM, Belzer A, Mott SL, Packiam VT, O'Donnell MA, Steinberg RL. Sequential endoluminal gemcitabine and docetaxel for the treatment of clinically non-invasive high-grade upper tract urothelial carcinoma. Urol Oncol 2024; 42:20.e9-20.e15. [PMID: 37805338 PMCID: PMC10841482 DOI: 10.1016/j.urolonc.2023.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 07/30/2023] [Accepted: 08/19/2023] [Indexed: 10/09/2023]
Abstract
PURPOSE There is an unmet need for effective renal sparing treatments for upper tract urothelial carcinoma (UTUC). Gemcitabine/Docetaxel (Gem/Doce) has shown favorable efficacy in nonmuscle invasive bladder cancer. We report the outcomes of patients treated with endoluminal Gem/Doce for noninvasive high-grade UTUC. METHODS A retrospective review of patients treated with Gem/Doce for clinically noninvasive high-grade UTUC with no radiographic or endoscopically visible disease, either at diagnosis or following ablation, was performed. Treatment was instilled via nephrostomy or retrograde ureteral catheter. Induction instillations were performed weekly for 6 weeks, followed by 6 monthly instillations if disease-free. Recurrence was defined as biopsy-proven disease or high-grade (HG) cytology. Progression was defined by development of muscle invasion, metastases, or death due to cancer. Survival was assessed with the Kaplan-Meier method. RESULTS The final cohort included 31 patients with 41 upper tract units, 51% of which would have been dialysis dependent with nephroureterectomy. Median (IQR) age was 74 years (68-81). Median follow-up was 29 months (IQR 20-58). Prior to treatment, 37 (90%) units presented with a localizing HG cytology (presumed occult CIS), and 4 (9.8%) with HG biopsy-proven disease. Sixteen (52%) patients reported any side effects; 5 were Grade 3 and 1 was Grade 5. Recurrence-free survival was 76%, 54%, and 40% at 1, 2, and 3 years, respectively. Five patients died from urothelial carcinoma. The 3-year progression-free and overall survival were 75% and 75%, respectively. CONCLUSIONS Gem/Doce demonstrates promising safety and efficacy as a renal-sparing treatment option for high-grade UTUC in appropriately selected patients.
Collapse
Affiliation(s)
- Ian M McElree
- Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Alex Belzer
- Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Sarah L Mott
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA
| | | | - Michael A O'Donnell
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA; Department of Urology, University of Iowa, Iowa City, IA
| | | |
Collapse
|
3
|
Evmorfopoulos K, Mitrakas L, Karathanasis A, Zachos I, Tzortzis V, Vlachostergios PJ. Upper Tract Urothelial Carcinoma: A Rare Malignancy with Distinct Immuno-Genomic Features in the Era of Precision-Based Therapies. Biomedicines 2023; 11:1775. [PMID: 37509415 PMCID: PMC10376290 DOI: 10.3390/biomedicines11071775] [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: 04/19/2023] [Revised: 06/11/2023] [Accepted: 06/19/2023] [Indexed: 07/30/2023] Open
Abstract
Upper tract urothelial carcinoma (UTUC) is a rare malignancy, occurring in 5-10% of patients diagnosed with UC, and involves the renal pelvis, calyces, or ureters. UTUC can be sporadic or hereditary as a clinical manifestation of Lynch syndrome. Therapeutic management of these patients is challenging. Following risk stratification of localized disease, patients with low-grade UTUC may undergo kidney-sparing surgery or radical nephroureterectomy (RNU) and/or chemoablation with mitomycin-c instillation to reduce recurrence. In high-grade disease, RNU followed by adjuvant chemotherapy remains the standard of care. For decades, platinum-based chemotherapy has been the cornerstone of treatment for locally advanced and metastatic disease. The aim of the present review is to summarize recent advances in UTUC's therapeutic management through the lens of its genomic and immune landscape. Accumulating knowledge on the genetic and immune aspects of UTUC tumors has increased our understanding of their underlying biology, supporting a luminal papillary, T-cell depleted contexture and enrichment in fibroblast growth factor receptor (FGFR) expression. These advances have fueled successful clinical testing of several precision-based therapeutic approaches, including immune checkpoint inhibitors (ICIs), the antibody-drug conjugates (ADCs) enfortumab vedotin and sacituzumab govitecan, and agents targeting the FGFR axis such as erdafitinib and other kinase inhibitors, allowing their entry into the therapeutic armamentarium and improving the prognosis of these patients. Not all patients respond to these precision-based targeted therapies; thus, validating and expanding the toolkit of potential biomarkers of response or resistance, including molecular subtypes, FGFR pathway gene alterations, DNA repair gene defects, tumor mutational burden (TMB), circulating tumor DNA (ctDNA), nectin-4, TROP2, and programmed death ligand-1 (PD-L1), are key to maximizing the benefit to these particular subgroups of patients.
Collapse
Affiliation(s)
- Konstantinos Evmorfopoulos
- Department of Urology, School of Health Sciences, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece
| | - Lampros Mitrakas
- Department of Urology, School of Health Sciences, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece
| | - Athanasios Karathanasis
- Department of Urology, School of Health Sciences, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece
| | - Ioannis Zachos
- Department of Urology, School of Health Sciences, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece
| | - Vassilios Tzortzis
- Department of Urology, School of Health Sciences, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece
| | - Panagiotis J. Vlachostergios
- Department of Urology, School of Health Sciences, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece
- Department of Medical Oncology, IASO Thessalias Hospital, 41500 Larissa, Greece
- Division of Hematology and Medical Oncology, Department of Medicine, Weill Cornell Medicine, New York, NY 10065, USA
| |
Collapse
|
4
|
Territo A, Fontanet S, Meneghetti I, Gallioli A, Sanguedolce F, Rodriguez-Faba Ó, Gaya J, Palou J, Huguet J, Breda A. Manejo del carcinoma in situ de tramo urinario superior diagnosticado por biopsia ureteroscópica: ¿es el bacilo de Calmette-Guérin una alternativa a la nefroureterectomía? Actas Urol Esp 2023. [DOI: 10.1016/j.acuro.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
|
5
|
Clinical Characteristics and Current Status of Treatment for Recurrent Bladder Cancer after Surgeries on Upper Tract Urothelial Carcinoma. Diagnostics (Basel) 2023; 13:diagnostics13051004. [PMID: 36900148 PMCID: PMC10000489 DOI: 10.3390/diagnostics13051004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 02/08/2023] [Accepted: 03/02/2023] [Indexed: 03/09/2023] Open
Abstract
Upper tract urothelial carcinoma (UTUC) is a relatively rare, but highly malignant, disease with an estimated annual incidence of 2 cases per 100,000 people. The main surgical treatment modalities for UTUC are radical nephroureterectomy (RNU) with bladder cuff resection. After surgery, intravesical recurrence (IVR) can occur in up to 47% of patients, and 75% of them present with non-muscle invasive bladder cancer (NMIBC). However, there are few studies focused on the diagnosis and treatment of postoperatively recurrent bladder cancer for patients with previous UTUC history (UTUC-BC), and many of the influencing factors are still controversial. In this article, we performed a narrative review of the recent literature, mainly summarizing the factors influencing postoperative IVR in patients with UTUC and discussing the subsequent prevention, monitoring, and treatment tools for it.
Collapse
|
6
|
Asimakopoulos AD, Kochergin M, Klöcker C, Gakis G. The Role of Local Agents for the Treatment of Localized Upper Tract Urothelial Carcinoma: A Review of the Current Evidence. Bladder Cancer 2023. [DOI: 10.3233/blc-220093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Kidney-sparing surgery (KSS) for upper urinary tract urothelial carcinoma (UTUC) is a promising alternative to radical nephroureterectomy, especially for low-risk cases. However, due to the established risk of ipsilateral UTUC recurrence caused by the implantation of floating neoplastic cells after endoscopic resection, adjuvant endocavitary (endoureteral) instillations have been proposed. Instillation therapy may be also used as primary treatment for UTUC. The two most studied drugs that have been evaluated in both the adjuvant and primary setting of endocavitary instillation are mitomycin C and Bacillus Calmette-Guerin. The current paper provides an overview of the endocavitary treatments for UTUC, focusing on methods of administration, novel formulations, oncologic outcomes (in terms of endocavitary recurrence and progression), as well as on complications. In particular, the role of UGN-101 as a primary chemoablative treatment of primary noninvasive, endoscopically unresectable, low-grade, UTUC has been analysed. The drug achieved a complete response rate of 58% after the induction cycle, with a durable response independently of the maintenance cycle. The cumulative experience on the role of UUT instillation therapy appears encouraging; however, no definitive conclusions can be drawn about its therapeutic benefit. Given the current state of the art, any decision to administer adjuvant endoureteral therapy for UTUC should be carefully weighed against the potential adverse events. Nevertheless, newer investigations that improve visualization during ureteroscopy, genomic characterization, novel drugs and innovative strategies of improved drug delivery are under evaluation. The landscape of KSS for the treatment of the UTUC is evolving and seems promising.
Collapse
Affiliation(s)
| | - Maxim Kochergin
- Department of Urology and Neurourology, BG Unfallkrankenhaus Berlin, Berlin, Germany
| | - Christian Klöcker
- Department of Urology and Pediatric Urology, University Hospital of Würzburg, Würzburg, Germany
| | - Georgios Gakis
- Department of Urology and Pediatric Urology, University Hospital of Würzburg, Würzburg, Germany
| |
Collapse
|
7
|
Territo A, Fontanet S, Meneghetti I, Gallioli A, Sanguedolce F, Rodriguez-Faba Ó, Gaya JM, Palou J, Huguet J, Breda A. Management of primary upper urinary tract carcinoma in situ diagnosed by ureteroscopic biopsy: Is bacillus Calmette-Guerin an alternative to nephroureterectomy? Actas Urol Esp 2022; 47:221-228. [PMID: 36379260 DOI: 10.1016/j.acuroe.2022.11.002] [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: 08/23/2022] [Revised: 10/19/2022] [Accepted: 10/20/2022] [Indexed: 11/14/2022]
Abstract
BACKGROUND Radical nephroureterectomy (RNU) represents the gold standard treatment for upper tract urothelial carcinoma (UTUC); however, attempts have been made to treat upper urinary tract CIS (UT-CIS) conservatively. The aim of this study was to compare the outcome of patients with primary UT-CIS treated in our center by means of RNU vs. bacillus Calmette-Guérin (BCG) instillations. METHODS This retrospective study included patients with diagnosis of primary UT-CIS between 1990 and 2018. All patients had histological confirmation of UT-CIS in the absence of other concomitant UTUC. Histological confirmation was obtained by ureteroscopy with multiple biopsies. Patients were treated with BCG instillations, RNU or distal ureterectomy. Clinicopathological features and outcomes were compared between RNU and BCG groups. RESULTS A total of 28 patients and 29 renal units (RUs) were included. Sixteen (57.1%) patients (17 RUs) received BCG. BCG was administered via nephrostomy tube in 4 patients, with a single-J ureteral stent in 5, and using a Double-J stent in 7. Complete response and persistence or recurrence were detected in ten (58.8%) and seven (41.2%) RUs treated with BCG, respectively. Eight (27.6%) RUs underwent RNU, and 4 (13.8%) Rus distal ureterectomy. No differences were found in recurrence-free survival (p=0.841) and cancer-specific survival (p=0.77) between the RNU and BCG groups. CONCLUSIONS Although RNU remains the gold standard treatment for UT-CIS, our results confirm that BCG instillations are also effective. Histological confirmation of UT-CIS is mandatory before any treatment.
Collapse
Affiliation(s)
- A Territo
- Departamento de Urología, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - S Fontanet
- Departamento de Urología, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, Spain.
| | - I Meneghetti
- Departamento de Urología, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - A Gallioli
- Departamento de Urología, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - F Sanguedolce
- Departamento de Urología, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Ó Rodriguez-Faba
- Departamento de Urología, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - J M Gaya
- Departamento de Urología, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - J Palou
- Departamento de Urología, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - J Huguet
- Departamento de Urología, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - A Breda
- Departamento de Urología, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, Spain
| |
Collapse
|
8
|
Ham WS, Park JS, Jang WS, Kim J. Nephron-Sparing Approaches in Upper Tract Urothelial Carcinoma: Current and Future Strategies. Biomedicines 2022; 10:biomedicines10092223. [PMID: 36140325 PMCID: PMC9496458 DOI: 10.3390/biomedicines10092223] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/01/2022] [Accepted: 09/04/2022] [Indexed: 11/23/2022] Open
Abstract
Upper tract urothelial carcinoma (UTUC) is a relatively rare cancer, and much of the approach to treatment has been derived from strategies employed in treating bladder cancer. Radical nephroureterectomy (RNU) is regarded as the gold standard treatment for UTUC. However, due to potential complications, such as renal function impairment, that can affect oncologic outcomes, the demand for nephron-sparing treatment to effectively treat cancer while preserving renal function has increased. As a result, various treatment methods for low-grade, low-volume UTUC, such as segmental ureterectomy, endoscopic resection, and intraluminal therapy, have been attempted and reported. Although these treatment modalities have exhibited acceptable oncological results, further studies are required. In the future, the introduction of new technologies, such as improved diagnostic and surgical equipment, and new drug delivery systems, could enhance the effectiveness of nephron-sparing strategies in the treatment of UTUC. Additionally, understanding the biological and genetic characteristics of UTUC that distinguish it from those of bladder cancer will also aid in establishing strategies for nephron-sparing.
Collapse
Affiliation(s)
- Won Sik Ham
- Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Jee Soo Park
- Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul 03722, Korea
- Department of Urology, Sorokdo National Hospital, Goheung 59562, Korea
| | - Won Sik Jang
- Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Jongchan Kim
- Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul 03722, Korea
- Department of Urology, Yongin Severance Hospital, Yonsei University Health System, Yongin 16995, Korea
- Correspondence: ; Tel.: +82-31-5189-8479; Fax: +82-31-5189-8568
| |
Collapse
|
9
|
Ng Chieng Hin J, Hettiarachchilage D, Gravestock P, Rai B, Somani BK, Veeratterapillay R. Role of Ureteroscopy in Treatment of Upper Tract Urothelial Carcinoma. Curr Urol Rep 2021; 22:49. [PMID: 34622345 PMCID: PMC8497313 DOI: 10.1007/s11934-021-01065-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2021] [Indexed: 12/25/2022]
Abstract
Purpose of Review Upper tract urothelial carcinoma (UTUC) is uncommon accounting for less than 10% of all urothelial tumours. Ureteroscopic management (URS) is the first line treatment for low-risk disease and has been increasingly utilised due to technological advances and increasing surgical experience. This review looks at patient outcomes relating to URS, emerging technologies and the role of adjuvant intracavitary therapy in the management of UTUC. Recent Findings URS has firmly established itself in the management algorithm for UTUC, and a good body of evidence supports its use for low-risk disease, wherein oncological outcomes are comparable to traditional nephroureterectomy (RNU). Larger tumours can now be managed using URS with a lower morbidity than radical surgery, though with higher associated local recurrence rate and risk of progression to RNU, and as a result, patient selection and close surveillance remains key. There is limited evidence for adjuvant intracavitary therapy (Mitomycin C or BCG) in UTUC although the development of novel polymers and biodegradable stents may improve drug delivery to the upper urinary tract. Summary URS has a clearly defined role in low-risk UTUC, and its use in larger tumours appears to be appropriate in a selected cohort of patients. The efficacy of adjuvant intracavitary therapy is as of yet undetermined, though developments in delivery techniques are promising. Likewise further developments of laser technology are anticipated to further expand the role of URS. Supplementary Information The online version contains supplementary material available at 10.1007/s11934-021-01065-7.
Collapse
Affiliation(s)
| | | | | | - Bhavan Rai
- Department of Urology, Freeman Hospital, Newcastle, UK
| | - Bhaskar K Somani
- Department of Urology, University Hospital Southamptom, Southamptom, UK.
| | | |
Collapse
|
10
|
Aronowitz J, Ding L, Yates J, Zong Y, Zheng L, Jiang Z, Yancey J, Mittal K, Fitzgerald TJ. Stereotactic Body Radiotherapy for Palliation of Hematuria Arising From Urothelial Carcinoma of the Kidney in Unfavorable Surgical Candidates. Am J Clin Oncol 2021; 44:175-180. [PMID: 33710134 DOI: 10.1097/coc.0000000000000801] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Hematuria can be a distressing and debilitating complication of urothelial carcinoma (UC) of the kidney for patients who are not candidates for surgery or ureteroscopic ablation. We retrospectively assessed the efficacy, tolerability, and safety of stereotactic body radiotherapy (SBRT) for controlling gross hematuria in this patient population. MATERIALS AND METHODS Institutional Review Board (IRB)-approved review of the records, laboratory values, pathology, and imaging of 8 consecutive patients treated with SBRT over a 5-year period for uncontrolled gross hematuria caused by UC of the renal pelvis or calyces. RESULTS Therapy was delivered in 3 to 5 treatments over 1 to weeks. Individual treatments lasted an average of 17.2 minutes. No patient experienced treatment-related pain, vomiting, or diarrhea. All enjoyed cessation of bleeding within a week of completing therapy. Hematuria recurred in 2 patients in 4 and 22 months. Of the patients who have not re-bled, 3 expired of metastatic disease or co-morbidities, and 3 remain alive up to 6 years posttreatment. Of patients who have survived longer than a year, creatinine has changed by -0.05 to +0.35, and estimated glomerular filtration rate has fallen by an average of 22%. No patient has required dialysis. CONCLUSIONS SBRT appears to be an effective and well-tolerated means of palliating gross hematuria secondary to UC of the renal pelvis or calyces in patients who are unfavorable candidates for nephrectomy or ureteroscopic ablation. Treatment was associated with a moderate decline in renal function.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Jessica Yancey
- Department of Radiation Oncology, Tufts University Medical School, Boston, MA
| | - Kriti Mittal
- Medicine, Division of Medical Oncology, University of Massachusetts Medical School, Worcester
| | | |
Collapse
|
11
|
Marcq G, Foerster B, Abufaraj M, Matin SF, Azizi M, Gupta M, Li WM, Seisen T, Clinton T, Xylinas E, Mir MC, Schweitzer D, Mari A, Kimura S, Bandini M, Mathieu R, Ku JH, Guruli G, Grabbert M, Czech AK, Muilwijk T, Pycha A, D'Andrea D, Petros FG, Spiess PE, Bivalacqua T, Wu WJ, Rouprêt M, Krabbe LM, Hendricksen K, Egawa S, Briganti A, Moschini M, Graffeille V, Autorino R, John P, Heidenreich A, Chlosta P, Joniau S, Soria F, Pierorazio PM, Shariat SF, Kassouf W. Novel Classification for Upper Tract Urothelial Carcinoma to Better Risk-stratify Patients Eligible for Kidney-sparing Strategies: An International Collaborative Study. Eur Urol Focus 2021; 8:491-497. [PMID: 33773965 DOI: 10.1016/j.euf.2021.03.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/23/2021] [Accepted: 03/14/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND The European Association of Urology risk stratification dichotomizes patients with upper tract urothelial carcinoma (UTUC) into two risk categories. OBJECTIVE To evaluate the predictive value of a new classification to better risk stratify patients eligible for kidney-sparing surgery (KSS). DESIGN, SETTING, AND PARTICIPANTS This was a retrospective study including 1214 patients from 21 centers who underwent ureterorenoscopy (URS) with biopsy followed by radical nephroureterectomy (RNU) for nonmetastatic UTUC between 2000 and 2017. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS A multivariate logistic regression analysis identified predictors of muscle invasion (≥pT2) at RNU. The Youden index was used to identify cutoff points. RESULTS AND LIMITATIONS A total of 811 patients (67%) were male and the median age was 71 yr (interquartile range 63-77). The presence of non-organ-confined disease on preoperative imaging (p < 0.0001), sessile tumor (p < 0.0001), hydronephrosis (p = 0.0003), high-grade cytology (p = 0.0043), or biopsy (p = 0.0174) and higher age at diagnosis (p = 0.029) were independently associated with ≥pT2 at RNU. Tumor size was significantly associated with ≥pT2 disease only in univariate analysis with a cutoff of 2 cm. Tumor size and all significant categorical variables defined the high-risk category. Tumor multifocality and a history of radical cystectomy help to dichotomize between low-risk and intermediate-risk categories. The odds ratio for muscle invasion were 5.5 (95% confidence interval [CI] 1.3-24.0; p = 0.023) for intermediate risk versus low risk, and 12.7 (95% CI 3.0-54.5; p = 0.0006) for high risk versus low risk. Limitations include the retrospective design and selection bias (all patients underwent RNU). CONCLUSIONS Patients with low-risk UTUC represent ideal candidates for KSS, while some patients with intermediate-risk UTUC may also be considered. This classification needs further prospective validation and may help stratification in clinical trial design. PATIENT SUMMARY We investigated factors predicting stage 2 or greater cancer of the upper urinary tract at the time of surgery for ureter and kidney removal and designed a new risk stratification. Patients with low or intermediate risk may be eligible for kidney-sparing surgery with close follow-up. Our classification scheme needs further validation based on cancer outcomes.
Collapse
Affiliation(s)
- Gautier Marcq
- Department of Surgery, Division of Urology, McGill University Health Center, Montreal, Canada; Urology Department, Claude Huriez Hospital, CHU Lille, Lille, France
| | - Beat Foerster
- Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Mohammad Abufaraj
- Department of Urology, Medical University of Vienna, Vienna, Austria; Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan
| | - Surena F Matin
- Department of Urology, MD Anderson Cancer Center, Houston, TX, USA
| | - Mounsif Azizi
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL, USA; Department of Surgery, Division of Urology, Hôpital du Sacré-Coeur de Montréal, University of Montreal, Montreal, Canada
| | - Mohit Gupta
- Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Wei-Ming Li
- Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Urology, School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Thomas Seisen
- Urology, GRC 5, Predictive ONCO-URO, Pitié-Salpêtrière Hospital, AP-HP, Sorbonne University, Paris, France
| | - Timothy Clinton
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Evanguelos Xylinas
- Department of Urology, Bichat-Claude Bernard Hospital, AP-HP, Paris Descartes University, Paris, France
| | - M Carmen Mir
- Instituto Valenciano de Oncologia Foundation, Valencia, Spain
| | - Donald Schweitzer
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Andrea Mari
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy
| | - Shoji Kimura
- Department of Urology, Jikei University School of Medicine, Tokyo, Japan
| | - Marco Bandini
- Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | - Romain Mathieu
- Department of Urology, University of Rennes, Rennes, France
| | - Ja H Ku
- Department of Urology, Seoul National University Hospital, Seoul, Korea
| | - Georgi Guruli
- Division of Urology, Virginia Commonwealth University, Richmond, VA, USA
| | - Markus Grabbert
- Department of Urology, Uro-Oncology, University Hospital Cologne, Cologne, Germany
| | - Anna K Czech
- Department of Urology, Jagiellonian University Medical College, Krakow, Poland
| | - Tim Muilwijk
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Armin Pycha
- Department of Urology, Provincial Hospital of Bozen, Bozen, Italy; Medical School, Sigmund Freud University, Vienna, Austria
| | - David D'Andrea
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Firas G Petros
- Department of Urology, MD Anderson Cancer Center, Houston, TX, USA; Department of Urology and Kidney Transplant, The University of Toledo Medical Center and Eleanor N. Dana Cancer Center, Toledo, OH, USA
| | - Philippe E Spiess
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Trinity Bivalacqua
- Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Wen-Jeng Wu
- Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Urology, School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Morgan Rouprêt
- Urology, GRC 5, Predictive ONCO-URO, Pitié-Salpêtrière Hospital, AP-HP, Sorbonne University, Paris, France
| | - Laura-Maria Krabbe
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Urology, University Hospital Muenster, Muenster, Germany
| | - Kees Hendricksen
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Shin Egawa
- Department of Urology, Jikei University School of Medicine, Tokyo, Japan
| | - Alberto Briganti
- Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | - Marco Moschini
- Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy; Department of Urology, Luzerner Kantonsspital, Lucerne, Switzerland
| | | | - Riccardo Autorino
- Division of Urology, Virginia Commonwealth University, Richmond, VA, USA
| | - Patricia John
- Department of Urology, Uro-Oncology, University Hospital Cologne, Cologne, Germany
| | - Axel Heidenreich
- Department of Urology, Uro-Oncology, University Hospital Cologne, Cologne, Germany
| | - Piotr Chlosta
- Department of Urology, Jagiellonian University Medical College, Krakow, Poland
| | - Steven Joniau
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Francesco Soria
- Department of Urology, Medical University of Vienna, Vienna, Austria; Division of Urology, Department of Surgical Sciences, University of Torino School of Medicine, Turin, Italy
| | - Phillip M Pierorazio
- Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shahrokh F Shariat
- Department of Urology, Medical University of Vienna, Vienna, Austria; Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan; Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Urology, Weill Cornell Medical College, New York, NY, USA; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria; Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Institute for Urology and Reproductive Health, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Wassim Kassouf
- Department of Surgery, Division of Urology, McGill University Health Center, Montreal, Canada.
| |
Collapse
|
12
|
Wang YL, Zhang HL, Du H, Wang W, Gao HF, Yu GH, Ren Y. Retroperitoneal laparoscopic partial resection of the renal pelvis for urothelial carcinoma: A case report. World J Clin Cases 2021; 9:1916-1922. [PMID: 33748242 PMCID: PMC7953403 DOI: 10.12998/wjcc.v9.i8.1916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 12/26/2020] [Accepted: 01/06/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The standard treatment of transitional cell carcinoma of the upper urinary tract consists of radical nephroureterectomy with bladder cuff removal, which can be performed either in open or laparoscopy or robot-assisted laparoscopy. Treatment of chronic renal insufficiency patients with upper urothelial tumor is in a dilemma. Urologists weigh and consider the balance between tumor control and effective renal function preservation. European Association of Urology guidelines recommend that select patients may benefit from endoscopic treatment, but laparoscopic treatment is rarely reported.
CASE SUMMARY In this case report, we describe a case of 79-year-old female diagnosed with urothelial carcinoma of the renal pelvis and adrenal adenoma with chronic renal insufficiency. The patient was treated with retroperitoneal laparoscopic partial resection of the renal pelvis and adrenal adenoma resection simultaneously.
CONCLUSION Retroperitoneal laparoscopic partial resection of the renal pelvis is an effective surgical procedure for the treatment of urothelial carcinoma of the renal pelvis.
Collapse
Affiliation(s)
- Yan-Long Wang
- Department of Urology, Dalian Municipal Central Hospital Affiliated of Dalian Medical University, Dalian 116033, Liaoning Province, China
| | - Hong-Lin Zhang
- Center for Reproductive Health, Dalian Maternity Hospital Affiliated of Dalian Medical University, Dalian 116033, Liaoning Province, China
| | - Hao Du
- Department of Urology, Dalian Municipal Central Hospital Affiliated of Dalian Medical University, Dalian 116033, Liaoning Province, China
| | - Wei Wang
- Department of Urology, Dalian Municipal Central Hospital Affiliated of Dalian Medical University, Dalian 116033, Liaoning Province, China
| | - Hai-Feng Gao
- Department of Urology, Dalian Municipal Central Hospital Affiliated of Dalian Medical University, Dalian 116033, Liaoning Province, China
| | - Guang-Hai Yu
- Department of Urology, Dalian Municipal Central Hospital Affiliated of Dalian Medical University, Dalian 116033, Liaoning Province, China
| | - Yu Ren
- Department of Urology, Dalian Municipal Central Hospital Affiliated of Dalian Medical University, Dalian 116033, Liaoning Province, China
| |
Collapse
|
13
|
Maruyama Y, Araki M, Wada K, Yoshinaga K, Mitsui Y, Sadahira T, Nishimura S, Edamura K, Kobayashi Y, Watanabe M, Watanabe T, Monga M, Nasu Y, Kumon H. Long-term ureteroscopic management of upper tract urothelial carcinoma: 28-year single-centre experience. Jpn J Clin Oncol 2021; 51:130-137. [PMID: 32715306 DOI: 10.1093/jjco/hyaa132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 07/06/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Long-term survival outcomes of patients who undergo endoscopic management of non-invasive upper tract urothelial carcinoma remain uncertain. The longest mean follow-up period in previous studies was 6.1 years. This study reports the long-term outcomes of patients with upper tract urothelial carcinoma who underwent ureteroscopic ablation at a single institution over a 28-year period. METHODS We identified all patients who underwent ureteroscopic management of upper tract urothelial carcinoma as their primary treatment at our institution between January 1991 and April 2011. Survival outcomes, including overall survival, cancer-specific survival, upper-tract recurrence-free survival and renal unit survival, were estimated using Kaplan-Meier methodology. RESULTS A total of 15 patients underwent endoscopic management, with a mean age at diagnosis of 66 years. All patients underwent ureteroscopy, and biopsy-confirmed pathology was obtained. Median (range; mean) follow-up was 11.7 (2.3-20.9, 11.9) years. Upper tract recurrence occurred in 87% (n = 13) of patients. Twenty percent (n = 3) of patients proceeded to nephroureterectomy. The estimated cancer-specific survival rate was 93% at 5, 10, 15 and 20 years. Estimated overall survival rates were 86, 80, 54 and 20% at 5, 10, 15 and 20 years. Only one patient experienced cancer-specific mortality. The estimated mean and median overall survival times were 14.5 and 16.6 years, respectively. The estimated mean cancer-specific survival time was not reached. CONCLUSIONS Although upper tract recurrence is common, endoscopic management of non-invasive upper tract urothelial carcinoma provides a 90% cancer-specific survival rate at 20 years in selected patients.
Collapse
Affiliation(s)
- Yuki Maruyama
- Department of Urology, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Motoo Araki
- Department of Urology, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Koichiro Wada
- Department of Urology, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Kasumi Yoshinaga
- Department of Urology, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Yosuke Mitsui
- Department of Urology, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Takuya Sadahira
- Department of Urology, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Shingo Nishimura
- Department of Urology, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Kohei Edamura
- Department of Urology, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Yasuyuki Kobayashi
- Department of Urology, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Masami Watanabe
- Department of Urology, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Toyohiko Watanabe
- Department of Urology, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Manoj Monga
- Department of Urology, The Cleveland Clinic, Cleveland, OH, USA
| | - Yasutomo Nasu
- Department of Urology, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Hiromi Kumon
- Innovation Center Okayama for Nanobio-Targeted Therapy, Okayama University, 2-5-1, Shikata-cho, Kita-ku, Okayama, 700-8558, Japan.,Niimi University, 1263-2, Niimi, Okayama, 718-8585, Japan
| |
Collapse
|
14
|
Farrow JM, Kern SQ, Gryzinski GM, Sundaram CP. Nephron-sparing management of upper tract urothelial carcinoma. Investig Clin Urol 2021; 62:389-398. [PMID: 34190434 PMCID: PMC8246013 DOI: 10.4111/icu.20210113] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/12/2021] [Accepted: 06/07/2021] [Indexed: 11/18/2022] Open
Abstract
Urothelial carcinoma of the upper urinary tract is uncommon and presents unique challenges for diagnosis and management. Nephroureterectomy has been the preferred management option, but it is associated with significant morbidity. Nephron-sparing treatments are a valuable alternative and provide similar efficacy in select cases. A PubMed literature review was performed in English language publications using the following search terms: urothelial carcinoma, upper tract, nephron-sparing, intraluminal and systemic therapy. Contemporary papers published within the last 10 years were primarily included. Where encountered, systematic reviews and meta-analyses were given priority, as were randomized controlled trials for newer treatments. Core guidelines were referenced and citations reviewed for inclusion. A summary of epidemiological data, clinical diagnosis, staging, and treatments focusing on nephron-sparing approaches to upper tract urothelial carcinoma (UTUC) are outlined. Nephron-sparing management strategies are viable options to consider in patients with favorable features of UTUC. Adjunctive therapies are being investigated but the data remains mixed. Protocol variability and dosage differences limit statistical interpretation. New mechanisms to improve treatment dwell times in the upper tracts are being designed with promising preliminary results. Studies investigating systemic therapies are ongoing but implications for nephron-sparing management are uncertain. Nephron-sparing management is an acceptable treatment modality best suited for favorable disease. More work is needed to determine if intraluminal and/or systemic therapies can further optimize treatment outcomes beyond resection alone.
Collapse
Affiliation(s)
- Jason M Farrow
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Sean Q Kern
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Gustavo M Gryzinski
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Chandru P Sundaram
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN, USA
| |
Collapse
|
15
|
Roupret M, Seisen T, Grande P. Adjuvant Therapy for Upper Tract Urothelial Carcinoma after Endoscopic Management. Bladder Cancer 2021. [DOI: 10.1007/978-3-030-70646-3_36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
16
|
Sarmah PB, Ehsanullah SA, Sarmah BD. Long-term follow-up and outcomes of percutaneous nephron-sparing surgery for upper tract urothelial carcinoma. Indian J Urol 2020; 36:276-281. [PMID: 33376263 PMCID: PMC7759167 DOI: 10.4103/iju.iju_93_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 06/18/2020] [Accepted: 07/16/2020] [Indexed: 11/04/2022] Open
Abstract
Introduction Upper tract urothelial carcinoma (UTUC) is uncommon, accounting for 5%-10% of all urothelial carcinomas. Current standard of care for localized disease consists of radical nephroureterectomy (RNU) which leads to loss of half the patient's functioning nephrons. Percutaneous nephron-sparing surgery (PCNSS) is an alternative minimally-invasive approach in selected cases where nephron preservation is desired. The long-term outcomes of this procedure at a single center are described. Methods All patients undergoing PCNSS, with the operation carried out by a single surgeon, were included. Equipment used was a standard 26Ch resectoscope through a 30Ch Amplatz sheath, with all patients receiving postoperative intrapelvic Mitomycin. Data for each patient were collected on patient age; tumor size at diagnosis; grade; stage; oncological recurrence; requirement for subsequent RNU; and overall survival. Primary outcomes were disease recurrence and overall mortality, and secondary outcome was rate of subsequent RNU. Results Fifteen patients in total underwent PCNSS, 14 were diagnosed with UTUC; benign leiomyoma was proven in one patient and excluded from final analysis. Overall survival at 5 and 10 years was 92.9% and 78.6%, respectively, with disease-specific mortality at 10 years of 7.1% (one patient who developed metastatic carcinoma); 21.4% of patients had recurrent ipsilateral UTUC and all required subsequent RNU for this indication. No patients had seeding of the percutaneous tract. Conclusion PCNSS for UTUC is a feasible approach to consider in carefully selected patients who agree to intensive follow-up, even for higher grade tumors. Where recurrent UTUC occurs, further management options still exist for disease treatment.
Collapse
Affiliation(s)
- Piyush Bhargav Sarmah
- Department of Urology, Birmingham Heartlands Hospital, University Hospitals of Birmingham, Birmingham, UK
| | - Syed Ali Ehsanullah
- Department of Urology, Birmingham Heartlands Hospital, University Hospitals of Birmingham, Birmingham, UK
| | - Bhupendra Dev Sarmah
- Department of Urology, Birmingham Heartlands Hospital, University Hospitals of Birmingham, Birmingham, UK
| |
Collapse
|
17
|
Katims AB, Tam AW, Rosen DC, Zampini AM, Atallah W, Mehrazin R, Gupta M. Novel treatment of upper tract urothelial carcinoma in situ with docetaxel in BCG refractory patients. Urol Oncol 2020; 39:234.e9-234.e13. [PMID: 32958446 DOI: 10.1016/j.urolonc.2020.08.002] [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: 06/14/2020] [Revised: 07/15/2020] [Accepted: 08/02/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Patients with upper-tract carcinoma in situ (UT-CIS) that have failed treatment with BCG are recommended for radical nephroureterectomy (RNU). We describe a cohort of patients with BCG-refractory UT-CIS that were treated with docetaxel, a novel agent in the approach to topical therapy. METHODS Patients with pathologically proven UT-CIS from 2012 to 2020 with an imperative indication for organ preservation and history of BCG-refractory disease were included. Each patient underwent ureteroscopy with biopsy and selective cytology pre- and postinduction, and after each maintenance course. Complete response (CR) was defined as the absence of visualized lesions on ureteroscopy, negative selective cytology, and absence of clinical progression. No response (NR) was defined as persistence of lesions after induction or absence of visualized lesions with persistently positive cytology. RESULTS Seven patients and 10 renal units were treated. Six of the 10 renal units had initial CR (60%). Three patients with NR went on to have RNU, one of which subsequently died due to cancer-specific mortality. One patient with bilateral disease had NR in 10 renal unit and cure in the other. This patient subsequently developed recurrence in his remaining renal unit. A second patient had CR in both kidneys for 6 years, but 1 year after finishing maintenance regimen developed HG disease in 1 ureter. Average follow-up was 33 months. CONCLUSION This study demonstrates efficacy of docetaxel as a treatment option for patients with UT-CIS with a contraindication to RNU after failing BCG. Response rates of 60% appear to be similar to those of BCG-refractory bladder CIS.
Collapse
Affiliation(s)
- Andrew B Katims
- Icahn School of Medicine at Mount Sinai, Department of Urology, New York, NY.
| | - Andrew W Tam
- Icahn School of Medicine at Mount Sinai, Department of Urology, New York, NY
| | - Daniel C Rosen
- Icahn School of Medicine at Mount Sinai, Department of Urology, New York, NY
| | - Anna M Zampini
- Icahn School of Medicine at Mount Sinai, Department of Urology, New York, NY
| | - William Atallah
- Icahn School of Medicine at Mount Sinai, Department of Urology, New York, NY
| | - Reza Mehrazin
- Icahn School of Medicine at Mount Sinai, Department of Urology, New York, NY
| | - Mantu Gupta
- Icahn School of Medicine at Mount Sinai, Department of Urology, New York, NY
| |
Collapse
|
18
|
Abstract
While radical nephroureterectomy (RNU) remains the gold-standard treatment for upper tract urothelial carcinoma (UTUC), a growing volume of literature surrounding endoscopic, organ-sparing procedures has developed over the past few decades. Based on this, endoscopic management of UTUC has gained acceptance as a standard of care approach, particularly among those with low-risk disease or with imperative indications for organ preservation. As a rare disease, however, data is mostly restricted to retrospective single institution series with relatively small numbers. Therefore, comparative outcomes of endoscopic management to RNU remain incompletely defined. Furthermore, the comparative utility of endoscopic approaches (ureteroscopy versus percutaneous resection) and topical therapy following resection lacks prospective analysis. In this article we review the available literature on endoscopic management of UTUC.
Collapse
Affiliation(s)
- John J Knoedler
- Division of Urology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| |
Collapse
|
19
|
Metcalf M, Pierorazio PM. Future strategies to enhance kidney preservation in upper urinary tract urothelial carcinoma. Transl Androl Urol 2020; 9:1831-1840. [PMID: 32944547 PMCID: PMC7475682 DOI: 10.21037/tau.2019.11.09] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Though radical nephroureterectomy remains the gold standard treatment for high grade or invasive disease in upper tract urothelial cancer (UTUC), kidney-sparing surgery has become preferred for low risk disease, in order to minimize morbidity and preserve renal function. Many methods exist for endoscopic management, whether via an antegrade percutaneous or retrograde ureteroscopic approach, including electroresection, laser ablation, and fulguration. There has been an increase in use of adjuvant intracavitary therapy, predominantly using mitomycin and bacillus Calmette-Guerin (BCG), to reduce recurrence after primary endoscopic management for noninvasive tumors, although efficacy remains questionable. Intraluminal BCG has additionally been used for primary treatment of CIS in the upper tract, with around 50% success. Newer investigations include use of narrow band imaging or photodynamic diagnosis with ureteroscopy to improve visualization during diagnosis and treatment. Genomic characterization may improve selection for kidney-sparing surgery as well as identify actionable mutations for systemic therapy. The evolution in adjuvant management has seen strategies to increase the dwell time and the urothelial contact of intraluminal agents. Lastly, chemoablation using a hydrogel for sustained effect of mitomycin is under investigation with promising early results. Continued expansion of the armamentarium available and better identification and characterization of tumors ideal for organ-sparing treatment will further improve kidney preservation in UTUC.
Collapse
Affiliation(s)
- Meredith Metcalf
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Phillip M Pierorazio
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
20
|
Okeke Z, Rai A. Editorial Comment on: "Adjuvant Single-Dose Upper Urinary Tract Instillation of Mitomycin C After Therapeutic Ureteroscopy for Upper Tract Urothelial Carcinoma: A Single-Centre Prospective Non-Randomized Trial" by Gallioli et al. J Endourol 2020; 34:791-793. [PMID: 32292039 DOI: 10.1089/end.2020.0293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Zeph Okeke
- Smith Institute for Urology, Zucker School of Medicine at Hofstra/Northwell, Lake Success, New York, USA
| | - Arun Rai
- Smith Institute for Urology, Zucker School of Medicine at Hofstra/Northwell, Lake Success, New York, USA
| |
Collapse
|
21
|
Joseph JP, Potretzke TA, Packiam V, Sharma V, Toussi A, Miest TS, Juvet T, Boorjian SA, Thompson RH, Welle CL, Atwell TD, Leibovich BC, Tollefson MK, Potretzke AM. Percutaneous Image-guided Core Needle Biopsy for Upper Tract Urothelial Carcinoma. Urology 2019; 135:95-100. [PMID: 31655078 DOI: 10.1016/j.urology.2019.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 10/06/2019] [Accepted: 10/09/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To better understand the safety and diagnostic yield of percutaneous core-needle biopsy (PCNB) for upper tract urothelial carcinoma (UTUC). METHODS Of 444 patients undergoing radical nephroureterectomy (RNU) for UTUC between 2009 and 2017 at our institution, 42 who had PCNB prior to RNU were identified for analysis. Endpoints included safety, diagnostic yield, and concordance with RNU pathology. PCNB specimens were deemed histologically concordant with RNU specimens for cases when cytologic evaluation of biopsy specimen and corresponding pathologic evaluation of RNU specimen both made a histologic diagnosis of urothelial carcinoma. RESULTS Median tumor size was 3.8 cm (1.2-10.2 cm). All lesions arose from the pelvicalyceal system. CT-guidance was utilized in 52% (n = 22), and ultrasound-guidance in 48% (n = 20). Relative to RNU pathology, 95% of PCNBs demonstrated histologic concordance. Histologic grade was provided in 69% (n = 29) of PCNBs, with a 90% (n = 26) concordance with surgical pathology. Grades 1-2 and 3 complications occurred in 14.3% (n = 6) and 2.4% (n = 1), respectively. At a median follow-up of 28.2 months (range, 1.2-97.1 months) after biopsy, no cases of radiographic tract seeding were identified. CONCLUSION In our cohort of 42 patients undergoing RNU for UTUC, PCNB appeared a safe diagnostic tool with high histologic yield and grade concordance. With greater than 2 years of follow-up, no cases of tract seeding were identified.
Collapse
Affiliation(s)
| | | | | | - Vidit Sharma
- Department of Urology, Mayo Clinic, Rochester, MN
| | - Amir Toussi
- Department of Urology, Mayo Clinic, Rochester, MN
| | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Organ-sparing procedures in GU cancer: part 3-organ-sparing procedures in urothelial cancer of upper tract, bladder and urethra. Int Urol Nephrol 2019; 51:1903-1911. [PMID: 31352580 DOI: 10.1007/s11255-019-02232-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 07/10/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE The impact of radical surgery for urothelial carcinoma is significant on patient's quality of life. Organ-sparing surgery (OSS) can provide comparable oncological outcomes and with improved quality of life. In this review, we summarize the indications, techniques and outcomes of OSS for these tumors. METHODS PubMed® was searched for relevant articles. Keywords used were: for upper tract urothelial carcinoma (UTUC): endoscopic, ureteroscopic/percutaneous management, laser ablation; for urothelial bladder cancer: bladder preservation, trimodal therapy, muscle invasive bladder cancer (MIBC); for urethral cancer: urethra/penile-sparing, urethral carcinoma. RESULTS Kidney-sparing surgery is an option in patients with low-risk UTUC with better renal function preservation and comparable oncological control to radical nephroureterectomy. In select patients with MIBC, trimodal therapy has better quality of life and comparable oncological control to radical cystectomy. In distal male urethral cancer, penile conserving surgery is feasible and offers acceptable survival outcomes. In female urethral cancer, organ preservation can be achieved, in addition to OSS, through radiation. CONCLUSIONS In the appropriately selected patient, OSS in upper tract, bladder and urethral carcinoma has comparable oncological outcomes to radical surgery and with the additional benefit of improved quality of life.
Collapse
|
23
|
Endocavitary treatment for upper tract urothelial carcinoma: A meta-analysis of the current literature. Urol Oncol 2019; 37:430-436. [DOI: 10.1016/j.urolonc.2019.02.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 01/28/2019] [Accepted: 02/10/2019] [Indexed: 12/12/2022]
|
24
|
Aragon-Ching JB, Choudhury A, Margulis V, Yu EY. Formidable Scenarios in Urothelial and Variant Cancers of the Urinary Tract. Am Soc Clin Oncol Educ Book 2019; 39:262-275. [PMID: 31099661 DOI: 10.1200/edbk_237451] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Diagnostic and therapeutic challenges in the field of bladder and upper tract cancers provide opportunities for multidisciplinary care. Urothelial cancers make up the majority of the histologic subtype of bladder and upper tract cancers. Although the existence of variant histology, nonurothelial cancers, and urethral cancers is rare, these cancers pose a challenging clinical dilemma given the lack of well-defined consensus treatment guidelines. This review focuses on key issues of treatment: cisplatin ineligibility with emphasis on the definition, nuances of chemotherapy and frontline immune checkpoint inhibitor therapy, use of radiation in bladder-preservation strategies, upper tract urothelial cancer management, and highlights of urothelial variants and nonurothelial tumors and management.
Collapse
Affiliation(s)
| | - Ananya Choudhury
- 2 The Christie National Health Service Foundation Trust, Manchester, United Kingdom
| | - Vitaly Margulis
- 3 The Univeristy of Texas Southwestern Medical Center, Dallas, TX
| | - Evan Y Yu
- 4 University of Washington, Seattle, WA
| |
Collapse
|
25
|
Squamous Cell Carcinoma in a Calyceal Diverticulum Detected by Percutaneous Nephroscopic Biopsy. Case Rep Oncol Med 2018; 2018:3508537. [PMID: 30140478 PMCID: PMC6081520 DOI: 10.1155/2018/3508537] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 07/10/2018] [Indexed: 11/27/2022] Open
Abstract
A 73-year-old woman was referred to our department with a complaint of asymptomatic gross hematuria. Dynamic computed tomography revealed a complicated (Bosniak type IIF) cyst in the upper pole of her right kidney, which was diagnosed as a calyceal diverticulum. The diagnosis was confirmed by ureteroscopy. The diverticulum was filled with a soft protein matrix that was difficult to completely remove from the inner surface of the calyceal diverticulum. Endoscopy combined with intrarenal surgery (ECIRS) was performed to completely remove the matrix. Percutaneous nephroscopy further revealed papillary lesions on the surface of the diverticulum, confirmed as squamous cell carcinoma on pathological assessment. A laparoscopic right radical nephroureterectomy was performed, with curative intent. Pathological assessment confirmed a high-grade squamous cell carcinoma with renal parenchymal invasion (pT3). Although carcinomas in a calyceal diverticulum are highly uncommon, when present, these tend to be high-grade neoplasms that deeply invade the parenchymal wall. As the effective management of these lesions is difficult, early-stage diagnosis is required for curative treatment. We report the case of squamous cell carcinoma in a calyceal diverticulum that was difficult to diagnose on preoperative computed tomography, urinal cytology examination, and ureteroscopy but was found during ECIRS.
Collapse
|
26
|
An Analysis of Staging and Treatment Trends for Upper Tract Urothelial Carcinoma in the National Cancer Database. Clin Genitourin Cancer 2018; 16:e743-e750. [DOI: 10.1016/j.clgc.2018.01.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 01/20/2018] [Accepted: 01/27/2018] [Indexed: 11/19/2022]
|
27
|
Freifeld Y, Krabbe LM, Clinton TN, Woldu SL, Margulis V. Therapeutic strategies for upper tract urothelial carcinoma. Expert Rev Anticancer Ther 2018; 18:765-774. [PMID: 29848133 DOI: 10.1080/14737140.2018.1481395] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Many controversies exist regarding the appropriate management of patients with upper tract urothelial carcinoma (UTUC), including staging, surgical management, use of systemic therapy, and prevention of bladder recurrence. Due to the rarity of this condition, high-level evidence is often lacking and in many cases guidelines are extrapolated from existing evidence on urothelial bladder cancer. Areas covered: This review paper summarizes the evidence on proper diagnosis and staging, surgical techniques, prevention of bladder recurrences, the use of local or systemic treatments in both neoadjuvant and adjuvant settings as well as special consideration for hereditary UTUC. Expert commentary: UTUC is a rare malignancy and slow progress is being made in the acquisition of high-quality evidence in this field. Treatments that facilitate preservation of the kidney are being explored such as advanced endoscopic techniques or partial resection of ureteral disease with seemingly acceptable oncological results. Further prospective evidence is needed.
Collapse
Affiliation(s)
- Yuval Freifeld
- a Department of Urology , University of Texas Southwestern Medical Center , Dallas , TX , USA
| | - Laura-Maria Krabbe
- a Department of Urology , University of Texas Southwestern Medical Center , Dallas , TX , USA.,b Department of Urology , University of Muenster Medical Center , Muenster , Germany
| | - Timothy N Clinton
- a Department of Urology , University of Texas Southwestern Medical Center , Dallas , TX , USA
| | - Solomon L Woldu
- a Department of Urology , University of Texas Southwestern Medical Center , Dallas , TX , USA
| | - Vitaly Margulis
- a Department of Urology , University of Texas Southwestern Medical Center , Dallas , TX , USA
| |
Collapse
|
28
|
Samson P, Smith AD, Hoenig D, Okeke Z. Endoscopic Management of Upper Urinary Tract Urothelial Carcinoma. J Endourol 2018; 32:S10-S16. [PMID: 29774823 DOI: 10.1089/end.2018.0036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Endoscopic management of upper tract urothelial carcinoma has become more popular over the last few decades as there has been an impetus for renal preservation in these patients. While radical nephroureterectomy has been the gold standard in treatment of this disease, ureteroscopic and percutaneous management has become a viable option for select patients. METHODS AND MATERIALS The literature on endoscopic management of upper urinary tract tumors was explored. Different management methods are discussed, both from published literature and experience of the authors of this chapter. RESULTS We review the indications, details of the procedure, and troubleshooting methods in the endoscopic management of upper tract urothelial carcinoma. Imperative indications as well as controversial indications are discussed. The role and efficacy of adjuvant intrarenal topical agents are examined as well as the protocol for administering these agents. Follow-up protocols are also reviewed. DISCUSSION In select patients, endoscopic management with ureteroscopy and/or percutaneous resection of upper tract urothelial tumors is appropriate and can preserve renal function while obtaining comparable oncologic control compared with radical surgery.
Collapse
Affiliation(s)
- Patrick Samson
- The Smith Institute for Urology, Department of Urology, Zucker School of Medicine at Hofstra/Northwell , New Hyde Park, New York
| | - Arthur D Smith
- The Smith Institute for Urology, Department of Urology, Zucker School of Medicine at Hofstra/Northwell , New Hyde Park, New York
| | - David Hoenig
- The Smith Institute for Urology, Department of Urology, Zucker School of Medicine at Hofstra/Northwell , New Hyde Park, New York
| | - Zeph Okeke
- The Smith Institute for Urology, Department of Urology, Zucker School of Medicine at Hofstra/Northwell , New Hyde Park, New York
| |
Collapse
|
29
|
Knoedler JJ, Raman JD. Intracavitary therapies for upper tract urothelial carcinoma. Expert Rev Clin Pharmacol 2018; 11:487-493. [PMID: 29634361 DOI: 10.1080/17512433.2018.1461560] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
INTRODUCTION While radical nephroureterectomy remains the gold-standard for upper tract urothelial carcinoma (UTUC), there is a growing push for organ-sparing therapy in low-risk disease. Herein we review the use of intracavitary topical therapy for treatment of UTUC. Areas covered: A PubMed search was performed for studies pertaining to upper tract urothelial carcinoma, with 236 articles reviewed, and distilled for content pertinent to intracavitary therapy for UTUC. Topics discussed include agents used for management of UTUC, most commonly BCG, as well as techniques for administration. Additionally, we review the evidence for curative treatment for Cis versus adjuvant therapy for Ta/T1 disease. Finally, we discuss emerging technologies to improve agent delivery and efficacy in the upper tract. Expert commentary: No significant advances have occurred in topical management of UTUC in the past 2 decades. However, advances in diagnostic techniques such as modern ureteroscopes, and improved diagnostic imaging at the time of ureteroscopy may help improve our patient selection. Additional advances in topical therapy focused on increasing the duration of contact between agent delivered and the upper tract urothelium offer hope that a new leap forward in topical therapy is on the horizon.
Collapse
Affiliation(s)
- John J Knoedler
- a Department of Surgery, Division of Urology , Penn State Hershey Surgical Specialties , Hershey , PA , USA
| | - Jay D Raman
- a Department of Surgery, Division of Urology , Penn State Hershey Surgical Specialties , Hershey , PA , USA
| |
Collapse
|
30
|
Abstract
A select group of patients with upper tract urothelial carcinoma (UTUC) may meet indications for endoscopic management. Strategies for disease management are provided, based on a comprehensive review of the data using PubMed and Medline databases and marrying this with our experience with endoscopic management of UTUC. Endoscopic management of UTUC via retrograde or antegrade approaches is a viable treatment option for appropriately selected patients with low-risk UTUC, including those with low-grade, low-volume, and solitary tumors. However, recurrence risk limits these procedures to compliant patients under a vigilant surveillance program. Efficacious adjuvant therapies are needed to reduce local recurrences.
Collapse
Affiliation(s)
- Firas G Petros
- Department of Urology, UT MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Roger Li
- Department of Urology, UT MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Surena F Matin
- Department of Urology, UT MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
| |
Collapse
|
31
|
Reekhaye A, Sriprasad S, Madaan S. A review of the contemporary management of upper urinary tract urothelial carcinoma. JOURNAL OF CLINICAL UROLOGY 2018. [DOI: 10.1177/2051415817717906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Upper tract urothelial carcinoma (UTUC) is relatively rare and accounts for approximately 5% of all urothelial carcinomas. The estimated annual incidence of UTUC in Western countries is about two new cases per 100,000 inhabitants. The management of patients with upper tract urothelial carcinomas has changed significantly over the last decade with improved diagnostic techniques and treatment options. The gold-standard treatment used to be open radical nephroureterectomy with removal of the ipsilateral bladder cuff. The use of minimally invasive techniques for the diagnosis and management of upper urinary tract urothelial carcinoma is however expanding and has led to a paradigm shift in treatment strategies of upper tract urothelial carcinomas. In this article, we review the current diagnostic modalities and various endoscopic techniques being currently used in the management of this relatively rare tumour.
Collapse
Affiliation(s)
| | | | - Sanjeev Madaan
- Department of Urology and Nephrology, Darent Valley Hospital, UK
| |
Collapse
|
32
|
Andrada AO, García IL, Fúnez FA, Canet FD, Ruiz GD, Dos Santos VG, Revilla FJB. Conservative treatment of upper urinary tract carcinoma: Long-term results. Can Urol Assoc J 2017; 11:E291-E296. [PMID: 28761590 DOI: 10.5489/cuaj.4173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION We sought to assess the long-term results of conservative treatment for upper urinary tract carcinoma (UUTC) with regard to tumour recurrence and preservation of renal unit. METHODS From October 1987 to January 2014, 65 patients (median age 68 years) were diagnosed with UUTC and underwent endoscopic and open surgical techniques. Thirteen patients had bilateral disease and one had a single kidney. The primary approach was endoscopic in 37 reno-ureteral units (20 percutaneous resections, 17 ureteroscopies ). Open surgery was performed in 19 cases. A total of 20 patients received mitomycin C. RESULTS Superficial stage pTa or T1 was noted in 37 patients, infiltrating stage pT2 and pT3 in seven and inverted papilloma in one. The stage of the tumour was impossible to classify in 20. With a median followup of 75.12 months (interquartile range [IQR] 144.71-17.41), the kidney preservation, recurrence, specific survival, and global survival rates were 78.5% (51/65), 40.0% (26/65), 92.3% (60/65), and 69.2% (45/65), respectively. From the patients who had recurrence, 15 were salvaged with radical nephroureterectomy (RNU). The bladder tumour recurrence rate after the surgery was 30.76% (20/65). At the end of the followup, five patients had died of UUTC progression and 16 from other causes. Postoperative complications included one case of fistula, one case of stricture, and one case of nephrectomy due to bleeding. CONCLUSIONS In selected cases, conservative management is a safe and feasible alternative to RNU, with the advantage of renal unit preservation.
Collapse
Affiliation(s)
| | - Inés Laso García
- Department of Urology, Ramón y Cajal University Hospital, Madrid, Spain
| | | | | | - Gemma Duque Ruiz
- Department of Urology, Ramón y Cajal University Hospital, Madrid, Spain
| | | | | |
Collapse
|
33
|
Metcalfe M, Wagenheim G, Xiao L, Papadopoulos J, Navai N, Davis JW, Karam JA, Kamat AM, Wood CG, Dinney CP, Matin SF. Induction and Maintenance Adjuvant Mitomycin C Topical Therapy for Upper Tract Urothelial Carcinoma: Tolerability and Intermediate Term Outcomes. J Endourol 2017; 31:946-953. [PMID: 28731777 DOI: 10.1089/end.2016.0871] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Endoscopic management of upper tract urothelial carcinoma (UTUC) is associated with higher recurrences, which could be reduced by application of topical therapy. Adjuvant induction Bacillus Calmette-Guerin has shown inferior outcomes for UTUC compared to bladder cancer, and maintenance regimens for UTUC are unexplored. We report on the efficacy, safety, and tolerability of Mitomycin C (MMC) induction and maintenance adjuvant topical therapy for UTUC. MATERIALS AND METHODS Patients with UTUC who received adjuvant topical therapy after complete endoscopic control of Ta/T1 tumors were retrospectively reviewed. Patients were treated using percutaneous nephrostomy tube (NT) or cystoscopically placed weekly ureteral catheters, per patient preference, and all patients were offered induction and maintenance. Standardized follow-up of every 3 months in the first year, then at a minimum every 6 months, with ureteroscopy and at least annual CT, was performed. Primary outcomes were recurrence-free, progression-free, nephroureterectomy-free rate and cancer-specific and overall survival. Secondary outcomes were safety and treatment tolerability. RESULTS Twenty-seven patients with 28 renal units received adjuvant topical therapy from January 2008 to March 2015. Median follow-up was 19 months (range 7-92). Three year recurrence-free, progression-free, and nephroureterectomy-free survival rates were 60% [confidence interval (95% CI): 42, 86%], 80% [95% CI: 64, 100%], and 76% [95% CI: 60, 97%]. Cancer-specific mortality rate was 0%, and 3-year overall survival was 92.9%. Nine patients experienced adverse outcomes, all related to interventions and none related to systemic toxicity. CONCLUSIONS Induction and maintenance adjuvant topical MMC for endoscopically resected UTUC is feasible, well tolerated and shows promising intermediate term data on recurrence, progression, and nephroureterectomy-free survival.
Collapse
Affiliation(s)
- Michael Metcalfe
- 1 Department of Urology, MD Anderson Cancer Center, The University of Texas , Houston, Texas
| | - Gavin Wagenheim
- 1 Department of Urology, MD Anderson Cancer Center, The University of Texas , Houston, Texas.,2 Department of Urology, The University of Texas Health Science Center at Houston , Houston, Texas
| | - Lianchun Xiao
- 3 Department of Biostatistics, MD Anderson Cancer Center, The University of Texas , Houston, Texas
| | - John Papadopoulos
- 1 Department of Urology, MD Anderson Cancer Center, The University of Texas , Houston, Texas
| | - Neema Navai
- 1 Department of Urology, MD Anderson Cancer Center, The University of Texas , Houston, Texas
| | - John W Davis
- 1 Department of Urology, MD Anderson Cancer Center, The University of Texas , Houston, Texas
| | - Jose A Karam
- 1 Department of Urology, MD Anderson Cancer Center, The University of Texas , Houston, Texas
| | - Ashish M Kamat
- 1 Department of Urology, MD Anderson Cancer Center, The University of Texas , Houston, Texas
| | - Christopher G Wood
- 1 Department of Urology, MD Anderson Cancer Center, The University of Texas , Houston, Texas
| | - Colin P Dinney
- 1 Department of Urology, MD Anderson Cancer Center, The University of Texas , Houston, Texas
| | - Surena F Matin
- 1 Department of Urology, MD Anderson Cancer Center, The University of Texas , Houston, Texas
| |
Collapse
|
34
|
Raman JD, Park R. Endoscopic management of upper-tract urothelial carcinoma. Expert Rev Anticancer Ther 2017; 17:545-554. [DOI: 10.1080/14737140.2017.1326823] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
35
|
Mandalapu RS, Remzi M, de Reijke TM, Margulis V, Palou J, Kapoor A, Yossepowitch O, Coleman J, Traxer O, Anderson JK, Catto J, de la Rosette J, O'Brien T, Zlotta A, Matin SF. Update of the ICUD-SIU consultation on upper tract urothelial carcinoma 2016: treatment of low-risk upper tract urothelial carcinoma. World J Urol 2017; 35:355-365. [PMID: 27233780 PMCID: PMC5554604 DOI: 10.1007/s00345-016-1859-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 05/17/2016] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION The conservative management of upper tract urothelial carcinoma (UTUC) has historically been offered to patients with imperative indications. The recent International Consultation on Urologic Diseases (ICUD) publication on UTUC stratified treatment allocations based on high- and low-risk groups. This report updates the conservative management of the low-risk group. METHODS The ICUD for low-risk UTUC working group performed a thorough review of the literature with an assessment of the level of evidence and grade of recommendation for a variety of published studies in this disease space. We update these publications and provide a summary of that original report. RESULTS There are no prospective randomized controlled studies to support surgical management guidelines. A risk-stratified approach based on clinical, endoscopic, and biopsy assessment allows selection of patients who could benefit from kidney-preserving procedures with oncological outcomes potentially similar to radical nephroureterectomy with bladder cuff excision, with the added benefit of renal function preservation. These treatments are aided by the development of high-definition flexible digital URS, multi-biopsies with the aid of access sheaths and other tools, and promising developments in the use of adjuvant topical therapy. CONCLUSIONS Recent developments in imaging, minimally invasive techniques, multimodality approaches, and adjuvant topical regimens and bladder cancer prevention raise the hope for improved risk stratification and may greatly improve the endoscopic treatment for low-risk UTUC.
Collapse
Affiliation(s)
| | | | | | - Vitaly Margulis
- Department of Urology, University of Texas Southwestern, Dallas, TX, USA
| | - J Palou
- Fundacio Puigvert, Barcelona, Spain
| | - A Kapoor
- McMaster University, Hamilton, ON, Canada
| | | | - Jonathan Coleman
- Department of Urology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Olivier Traxer
- Hôpital Tenon, Université Pierre et Marie Curie Paris 6, Paris, France
| | - J Kyle Anderson
- University of Minnesota Medical Center, Minneapolis, MN, USA
| | - James Catto
- Academic Urology Unit, University of Sheffield, Sheffield, UK
| | | | | | | | - Surena F Matin
- Department of Urology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1373, Houston, TX, 77030, USA.
| |
Collapse
|
36
|
Pan S, Smith AD, Motamedinia P. Minimally Invasive Therapy for Upper Tract Urothelial Cell Cancer. J Endourol 2017; 31:238-245. [PMID: 28117602 DOI: 10.1089/end.2016.0475] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Minimally invasive therapy for upper tract urothelial cell cancer has assumed an important role in the management of this relatively uncommon genitourinary malignancy. In this review, current standards for patient selection, surgical approach, as well as overall outcomes will be discussed. Moreover, the use of intraluminal agents in upper tract disease is examined along with its efficacy and associated complications.
Collapse
Affiliation(s)
- Shu Pan
- 1 Yale University School of Medicine , New Haven, Connecticut
| | - Arthur D Smith
- 2 Smith Institute for Urology, Northwell-Hofstra University , New Hyde Park, New York
| | | |
Collapse
|
37
|
Abstract
A 58-year-old female presented with renal colic and was found to have renal transitional cell carcinoma at the time of percutaneous surgery. She developed percutaneous tract seeding that clinically presented as subcutaneous skin nodules. After local treatment with surgical excision and radiation treatment, the patient developed retroperitoneal recurrence 5 years later. Percutaneous tract seeding is rare. There is no general consensus on prevention of tract seeding during percutaneous resection of renal urothelial tumors. Various recommendations from the literature are discussed.
Collapse
|
38
|
Szarvas T, Módos O, Horváth A, Nyirády P. Why are upper tract urothelial carcinoma two different diseases? Transl Androl Urol 2016; 5:636-647. [PMID: 27785420 PMCID: PMC5071198 DOI: 10.21037/tau.2016.03.23] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
In the last few years growing evidence highlighted the differences between upper tract urothelial carcinoma (UTUC) and urothelial bladder carcinoma (UBC) which cannot be explained solely by their different anatomical location. The aim of this review was to summarize current progress in UTUC research and to underline the differences and similarities between UTUC and UBC by focusing on epidemiology, etiology, staging and risk factors as well as on surgical and medical management. UBC and UTUC sharing common risk factors such as smoking and aromatic amines, while aristolochic acid exposure or familiar Lynch syndrome are rather specific for UTUC. The grading of UBC and UTUC are identical, but inherent from their different anatomical locations, there are some differences between their stage classifications. As an example, in contrast to UBC where a clear recommendation for pT3 subclassification exists, in UTUC current research aims to define an adequate subclassification for pelvic pT3 cases aiming to provide a better risk stratification. The primary treatment for both UBC and UTUC is surgery. Similarly to UBC, UTUC patients at high risk of disease progression are treated by radical surgery. However, because of the inaccurate preoperative or transurethral staging of UTUC, many radical nephroureterectomies are performed unnecessarily. Preoperative prediction of pathological stage or patients' prognosis may reduce this overtreatment by selecting patients for nephron-sparing surgery. To this end, predictive models combining histological and molecular features together with imaging data may be used. The antegrade or retrograde instillation of BCG or mitomycin C, as topical agents is feasible after conservative treatment of UTUC or for the treatment of CIS. However, the prognostic significance of lymph node positivity in UTUC seems to be similar to that of UBC, the therapeutic benefit of lymph node dissection (LND) in UTUC has not been firmly established yet. In addition, the number of lymph nodes to be removed and the sequence of lymphadenectomy also remain to be defined. Systemic neoadjuvant and adjuvant chemotherapies appear to have beneficial effect on UTUC survival, however, this has to be confirmed by large prospective studies. Due to the intensive research of the last few years, our knowledge on UTUC has been largely improved, but many questions remained to be answered. Further research on the molecular background of UTUC holds the potential to identify prognostic or predictive markers which, together with imaging and histologic data, may help to overcome the inaccuracy of ureteroscopic endoscopy and may therefore help to improve therapeutic decision-making. Further, prospective studies should confirm the benefit of LND and adjuvant chemotherapy. Considering the low incidence of UTUC, conduction of such studies is difficult and may only be performed in a multicenter setting.
Collapse
Affiliation(s)
- Tibor Szarvas
- Department of Urology, Semmelweis University, Budapest, Hungary; ; Department of Urology, University Hospital of Essen, University of Duisburg-Essen, Essen, Germany
| | - Orsolya Módos
- Department of Urology, Semmelweis University, Budapest, Hungary
| | - András Horváth
- Department of Urology, Semmelweis University, Budapest, Hungary
| | - Péter Nyirády
- Department of Urology, Semmelweis University, Budapest, Hungary
| |
Collapse
|
39
|
Seisen T, Peyronnet B, Dominguez-Escrig JL, Bruins HM, Yuan CY, Babjuk M, Böhle A, Burger M, Compérat EM, Cowan NC, Kaasinen E, Palou J, van Rhijn BWG, Sylvester RJ, Zigeuner R, Shariat SF, Rouprêt M. Oncologic Outcomes of Kidney-sparing Surgery Versus Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma: A Systematic Review by the EAU Non-muscle Invasive Bladder Cancer Guidelines Panel. Eur Urol 2016; 70:1052-1068. [PMID: 27477528 DOI: 10.1016/j.eururo.2016.07.014] [Citation(s) in RCA: 184] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Accepted: 07/11/2016] [Indexed: 12/21/2022]
Abstract
CONTEXT There is uncertainty regarding the oncologic effectiveness of kidney-sparing surgery (KSS) compared with radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). OBJECTIVE To systematically review the current literature comparing oncologic outcomes of KSS versus RNU for UTUC. EVIDENCE ACQUISITION A computerised bibliographic search of the Medline, Embase, and Cochrane databases was performed for all studies reporting comparative oncologic outcomes of KSS versus RNU. Approaches considered for KSS were segmental ureterectomy (SU) and ureteroscopic (URS) or percutaneous (PC) management. Using the methodology recommended by the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines, we identified 22 nonrandomised comparative retrospective studies published between 1999 and 2015 that were eligible for inclusion in this systematic review. A narrative review and risk-of-bias (RoB) assessment were performed using cancer-specific survival (CSS) as the primary end point. EVIDENCE SYNTHESIS Seven studies compared KSS overall (n=547) versus RNU (n=1376). Information on the comparison of SU (n=586) versus RNU (n=3692), URS (n=162) versus RNU (n=367), and PC (n=66) versus RNU (n=114) was available in 10, 5, and 2 studies, respectively. No significant difference was found between SU and RNU in terms of CSS or any other oncologic outcomes. Only patients with low-grade and noninvasive tumours experienced similar CSS after URS or PC when compared with RNU, despite an increased risk of local recurrence following endoscopic management of UTUC. The RoB assessment revealed, however, that the analyses were subject to a selection bias favouring KSS. CONCLUSIONS Our systematic review suggests similar survival after KSS versus RNU only for low-grade and noninvasive UTUC when using URS or PC. However, selected patients with high-grade and invasive UTUC could safely benefit from SU when feasible. These results should be interpreted with caution due to the risk of selection bias. PATIENT SUMMARY We reviewed the studies that compared kidney-sparing surgery versus radical nephroureterectomy for upper tract urothelial carcinoma. We found similar oncologic outcomes for favourable tumours when using ureteroscopic or percutaneous management, whereas indications for segmental ureterectomy could be extended to selected cases of aggressive tumours.
Collapse
Affiliation(s)
- Thomas Seisen
- Academic Department of Urology, Pitié-Salpétrière Hospital, Assistance-Publique Hôpitaux de Paris; Pierre et Marie Curie Medical School, University Paris 6, Paris, France.
| | | | | | - Harman M Bruins
- Department of Urology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Cathy Yuhong Yuan
- Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton, ON, Canada
| | - Marko Babjuk
- Department of Urology, Hospital Motol, Second Faculty of Medicine, Charles University, Praha, Czech Republic
| | - Andreas Böhle
- Department of Urology, HELIOS Agnes-Karll-Krankenhaus, Bad Schwartau, Germany
| | - Maximilian Burger
- Department of Urology, Caritas St. Josef Medical Centre, University of Regensburg, Regensburg, Germany
| | - Eva M Compérat
- Department of Pathology, Hôpital La Pitié-Salpétrière, UPMC, Paris, France
| | - Nigel C Cowan
- Radiology Department, Queen Alexandra Hospital, Portsmouth, UK
| | - Eero Kaasinen
- Department of Urology, Hyvinkää Hospital, Hyvinkää, Finland
| | - Joan Palou
- Department of Urology, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Bas W G van Rhijn
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | | | - Richard Zigeuner
- Department of Urology, Medical University of Graz, Graz, Austria
| | - Shahrokh F Shariat
- Department of Urology, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Morgan Rouprêt
- Academic Department of Urology, Pitié-Salpétrière Hospital, Assistance-Publique Hôpitaux de Paris; Pierre et Marie Curie Medical School, University Paris 6, Paris, France
| |
Collapse
|
40
|
Strijbos WE, van der Heij B. Percutaneous resection of upper tract urothelial cell carcinoma: When, how, and is it safe? Asian J Urol 2016; 3:134-141. [PMID: 29264181 PMCID: PMC5730826 DOI: 10.1016/j.ajur.2016.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 04/27/2016] [Accepted: 04/28/2016] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION In the management of upper tract urothelial cell carcinoma (UTUC) endoscopic, nephron sparing procedures like ureterorenoscopy (URS) or percutaneous tumour resection (PCTR) still play a very limited role. This could lead to possible unnecessary radical nephroureterectomies (RNU), still being the gold standard treatment. The risk of chronic kidney disease (CKD) later in life is important. In this study we present the results of 24-year experience with PCTR in a single institution. METHODS We identified 44 patients who underwent PCTR between 1992 and 2015. Radical resection was achieved in 40 patients who were included in this study. Demographic and clinical data, including tumour recurrence, progression to RNU, tumour grade and overall survival (OS) were retrospectively acquired. An outcome analysis was conducted. RESULTS Median age at diagnosis was 68 years (range 42-94 years). Low grade tumours were found in 37 patients (92.5%) and high grade tumours in three patients (7.5%). Median follow-up was 53 months during which 20 patients developed upper tract recurrences (50.0%). The longest time to recurrence was 97 months. At follow-up 11 patients (27.5%) underwent an RNU and two patients died from UTUC. RNU could be avoided in 29 patients (72.5%). In this study we found that multifocality is a significant risk factor for recurrence, but not for stage progression to RNU. CONCLUSION PCTR is a surgically and oncologically safe procedure. Renal preservation in patients with UTUC who are eligible for percutaneous resection can be achieved in the majority of patients. Selection criteria for PCTR should be further refined, leading to a wider application of PCTR in the future. Follow-up needs invasive procedures and should be long term.
Collapse
Affiliation(s)
- Willem E. Strijbos
- Department of Urology, Zuyderland Medical Centre, Heerlen, The Netherlands
| | | |
Collapse
|
41
|
Gakis G, Schubert T, Alemozaffar M, Bellmunt J, Bochner BH, Boorjian SA, Daneshmand S, Huang WC, Kondo T, Konety BR, Laguna MP, Matin SF, Siefker-Radtke AO, Shariat SF, Stenzl A. Update of the ICUD-SIU consultation on upper tract urothelial carcinoma 2016: treatment of localized high-risk disease. World J Urol 2016; 35:327-335. [DOI: 10.1007/s00345-016-1819-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 03/23/2016] [Indexed: 12/11/2022] Open
|
42
|
Fiuk JV, Schwartz BF. Upper tract urothelial carcinoma: Paradigm shift towards nephron sparing management. World J Nephrol 2016; 5:158-165. [PMID: 26981440 PMCID: PMC4777787 DOI: 10.5527/wjn.v5.i2.158] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 09/10/2015] [Accepted: 01/29/2016] [Indexed: 02/06/2023] Open
Abstract
Upper tract urothelial carcinoma (UTUC) is relatively rare compared to urothelial carcinoma of the lower tract, comprising only 5%-10% of all urothelial cancers. Although both entities share histologic properties, UTUC tends to be more invasive at diagnosis and portend a worse prognosis, with a 5 year overall mortality of 23%. To date, the gold standard management of UTUC has been radical nephroureterectomy (RNU), with nephron sparing techniques reserved for solitary kidneys or cases where the patient could not tolerate radical surgery. Limited data from these series, as well as select series where nephron-sparing endoscopic management has been offered to a broader patient base, suggest that minimally invasive, nephron sparing techniques can offer comparable oncologic and survival outcomes to RNU in appropriately selected patients. We review the current literature on the topic and discuss long term outcomes and sequelae of the gold standard treatment, RNU. We also discuss the oncologic outcomes of minimally invasive, endoscopic management of UTUC. Our goal is to provide the reader a comprehensive overview of the current state of the field in order to inform and guide their treatment decisions.
Collapse
|
43
|
Mathieu R, Bensalah K, Lucca I, Mbeutcha A, Rouprêt M, Shariat SF. Upper urinary tract disease: what we know today and unmet needs. Transl Androl Urol 2016; 4:261-72. [PMID: 26816829 PMCID: PMC4708228 DOI: 10.3978/j.issn.2223-4683.2015.05.01] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Purpose Upper tract urothelial carcinoma (UTUC) is a rare and poorly investigated disease. Intense collaborative efforts have increased our knowledge and improved the management of the disease. The objective of this review was to discuss recent advances and unmet needs in UTUC. Methods A non-systematic Medline/PubMed literature search was performed on UTUC using the terms “upper tract urothelial carcinoma” with different combinations of keywords. Original articles, reviews and editorials in English language were selected based on their clinical relevance. Results UTUC is a disease with specific epidemiologic and risk factors different to urothelial carcinoma of the bladder (UCB). Similarly to UCB, smoking increases the risk of UTUC and worsens its prognosis, whereas aristolochic acid (AA) exposure and mismatch repair genes abnormality are UTUC specific risk factors. A growing understanding of biological pathways involved in the tumorigenesis of UTUC has led to the identification of promising prognostic/predictive biomarkers. Risk stratification of UTUC is difficult due to limitations in staging and grading. Modern imaging and endoscopy have improved clinical decision-making, and allowed kidney-sparing management and surveillance in favorable-risk tumors. In high-risk tumors, radical nephroureterectomy (RNU) remains the standard. Complete removal of the intramural ureter is necessary with inferiority of endoscopic management. Post-RNU intravesical instillation has been shown to decrease bladder cancer recurrence rates. While the role of neoadjuvant cisplatin based combination chemotherapy and lymphadenectomy are not clearly established, the body of evidence suggests a survival benefit to these. There is currently no evidence for adjuvant chemotherapy (AC) in UTUC. Conclusions Despite growing interest and understanding of UTUC, its management remains challenging, requiring further high quality multicenter collaborations. Accurate risk estimation is necessary to avoid unnecessary RNUs while advances in technology are still required for optimal kidney-sparing approaches.
Collapse
Affiliation(s)
- Romain Mathieu
- 1 Department of Urology, Rennes University Hospital, Rennes, France ; 2 Department of Urology, General Hospital, Medical University Vienna, Vienna, Austria ; 3 Department of Urology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland ; 4 Academic Department of Urology, La Pitié-Salpetrière Hospital, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Pierre et Marie Curie, University Paris 6, Paris, France ; 5 Department of Urology, University of Texas Southwestern Medical Center, Dallas, USA ; 6 Department of Urology, Weill Cornell Medical College, New York, USA
| | - Karim Bensalah
- 1 Department of Urology, Rennes University Hospital, Rennes, France ; 2 Department of Urology, General Hospital, Medical University Vienna, Vienna, Austria ; 3 Department of Urology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland ; 4 Academic Department of Urology, La Pitié-Salpetrière Hospital, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Pierre et Marie Curie, University Paris 6, Paris, France ; 5 Department of Urology, University of Texas Southwestern Medical Center, Dallas, USA ; 6 Department of Urology, Weill Cornell Medical College, New York, USA
| | - Ilaria Lucca
- 1 Department of Urology, Rennes University Hospital, Rennes, France ; 2 Department of Urology, General Hospital, Medical University Vienna, Vienna, Austria ; 3 Department of Urology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland ; 4 Academic Department of Urology, La Pitié-Salpetrière Hospital, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Pierre et Marie Curie, University Paris 6, Paris, France ; 5 Department of Urology, University of Texas Southwestern Medical Center, Dallas, USA ; 6 Department of Urology, Weill Cornell Medical College, New York, USA
| | - Aurélie Mbeutcha
- 1 Department of Urology, Rennes University Hospital, Rennes, France ; 2 Department of Urology, General Hospital, Medical University Vienna, Vienna, Austria ; 3 Department of Urology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland ; 4 Academic Department of Urology, La Pitié-Salpetrière Hospital, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Pierre et Marie Curie, University Paris 6, Paris, France ; 5 Department of Urology, University of Texas Southwestern Medical Center, Dallas, USA ; 6 Department of Urology, Weill Cornell Medical College, New York, USA
| | - Morgan Rouprêt
- 1 Department of Urology, Rennes University Hospital, Rennes, France ; 2 Department of Urology, General Hospital, Medical University Vienna, Vienna, Austria ; 3 Department of Urology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland ; 4 Academic Department of Urology, La Pitié-Salpetrière Hospital, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Pierre et Marie Curie, University Paris 6, Paris, France ; 5 Department of Urology, University of Texas Southwestern Medical Center, Dallas, USA ; 6 Department of Urology, Weill Cornell Medical College, New York, USA
| | - Shahrokh F Shariat
- 1 Department of Urology, Rennes University Hospital, Rennes, France ; 2 Department of Urology, General Hospital, Medical University Vienna, Vienna, Austria ; 3 Department of Urology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland ; 4 Academic Department of Urology, La Pitié-Salpetrière Hospital, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Pierre et Marie Curie, University Paris 6, Paris, France ; 5 Department of Urology, University of Texas Southwestern Medical Center, Dallas, USA ; 6 Department of Urology, Weill Cornell Medical College, New York, USA
| |
Collapse
|
44
|
Motamedinia P, Keheila M, Leavitt DA, Rastinehad AR, Okeke Z, Smith AD. The Expanded Use of Percutaneous Resection for Upper Tract Urothelial Carcinoma: A 30-Year Comprehensive Experience. J Endourol 2015; 30:262-7. [PMID: 26630130 DOI: 10.1089/end.2015.0248] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
INTRODUCTION The gold standard treatment for upper tract urothelial carcinoma (UTUC) is radical nephroureterectomy (RNU). The role of endoscopic resection is limited to low-risk patients. In this study, we present our 30-year experience in the endoscopic management of UTUC. METHODS In this retrospective study, we identified 141 patients who underwent percutaneous UTUC resection. Demographic and clinical data were collected, including tumor characteristics, bacillus Calmette-Guérin (BCG) and mitomycin use, tumor recurrence, progression to RNU, and overall survival (OS), and compared in univariate and multivariate analyses. RESULTS Median follow-up was 66 months. Recurrence occurred in 37% of low-grade patients and 63% of high-grade (HG) patients, with a median time to recurrence of 71.4 vs 36.4 months, respectively. Grade was the only predictor of recurrence (HR 2.12, p = 0.018). The latest time to recurrence occurred after 116 months of surveillance. RNU was avoided by 87% of patients. Age, imperative indications for endoscopy, a history of bladder cancer, and tumor stage and grade were predictors of OS; however, in multivariate analysis, grade and stage lost significance. BCG and mitomycin did not protect against recurrence, progression to RNU, or death over resection alone. CONCLUSION Percutaneous management of UTUC allows for renal preservation in the majority of patients with resectable disease. Patients with HG tumors are more likely to experience recurrence, but are not at an increased risk of death. Intraluminal BCG and mitomycin continue to have a limited adjuvant role to resection. Recurrence may occur many years following initial resection and therefore prolonged surveillance is advised.
Collapse
Affiliation(s)
- Piruz Motamedinia
- 1 Arthur Smith Institute for Urology, North Shore-Long Island Jewish Medical Center, New Hyde Park, New York.,2 Department of Urology, Yale University, New Haven, Connecticut
| | - Mohamed Keheila
- 1 Arthur Smith Institute for Urology, North Shore-Long Island Jewish Medical Center, New Hyde Park, New York
| | - David A Leavitt
- 1 Arthur Smith Institute for Urology, North Shore-Long Island Jewish Medical Center, New Hyde Park, New York.,3 Vattikuti Urology Institute, Henry Ford Health System, Detroit, Michigan
| | | | - Zeph Okeke
- 1 Arthur Smith Institute for Urology, North Shore-Long Island Jewish Medical Center, New Hyde Park, New York
| | - Arthur D Smith
- 1 Arthur Smith Institute for Urology, North Shore-Long Island Jewish Medical Center, New Hyde Park, New York
| |
Collapse
|
45
|
Sharma P, Zargar-Shoshtari K, Sexton WJ. Valrubicin in refractory non-muscle invasive bladder cancer. Expert Rev Anticancer Ther 2015; 15:1379-87. [DOI: 10.1586/14737140.2015.1115350] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
46
|
Risk-adapted strategy for the kidney-sparing management of upper tract tumours. Nat Rev Urol 2015; 12:155-66. [DOI: 10.1038/nrurol.2015.24] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|
47
|
Audenet F, Rouprêt M, Houédé N, Colin P. Traitements non chirurgicaux des tumeurs de la voie excrétrice supérieure : état-de-l’art pour le rapport annuel de l’Association française d’urologie. Prog Urol 2014; 24:1030-40. [DOI: 10.1016/j.purol.2014.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 06/27/2014] [Accepted: 07/06/2014] [Indexed: 11/26/2022]
|
48
|
Pignot G, Colin P, Rouprêt M, Traxer O. Traitement conservateur des tumeurs de la voie excrétrices supérieure : revue de littérature systématique pour le rapport scientifique annuel de l’Association française d’urologie. Prog Urol 2014; 24:1011-20. [DOI: 10.1016/j.purol.2014.07.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Accepted: 07/17/2014] [Indexed: 01/11/2023]
|
49
|
Huang SY, Ahrar K, Gupta S, Wallace MJ, Ensor JE, Krishnamurthy S, Matin SF. Safety and diagnostic accuracy of percutaneous biopsy in upper tract urothelial carcinoma. BJU Int 2014; 115:625-32. [DOI: 10.1111/bju.12824] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Steven Y. Huang
- Department of Interventional Radiology; The University of Texas MD Anderson Cancer Center; Houston TX USA
| | - Kamran Ahrar
- Department of Interventional Radiology; The University of Texas MD Anderson Cancer Center; Houston TX USA
| | - Sanjay Gupta
- Department of Interventional Radiology; The University of Texas MD Anderson Cancer Center; Houston TX USA
| | - Michael J. Wallace
- Department of Interventional Radiology; The University of Texas MD Anderson Cancer Center; Houston TX USA
| | - Joe E. Ensor
- Department of Biostatistics; The University of Texas MD Anderson Cancer Center; Houston TX USA
| | - Savitri Krishnamurthy
- Department of Pathology; The University of Texas MD Anderson Cancer Center; Houston TX USA
| | - Surena F. Matin
- Department of Urology; The University of Texas MD Anderson Cancer Center; Houston TX USA
| |
Collapse
|
50
|
Oya M, Kikuchi E. Evidenced-based clinical practice guideline for upper tract urothelial carcinoma (summary--Japanese Urological Association, 2014 edition). Int J Urol 2014; 22:3-13. [PMID: 25243652 DOI: 10.1111/iju.12630] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 08/28/2014] [Indexed: 01/24/2023]
Abstract
Upper tract urothelial carcinoma is more rare than bladder cancer, although they are both categorized as urothelial carcinoma. Because of the low incidence, little clinical evidence is available regarding the treatment of the former. However, recently such evidence has slowly begun to accumulate. The guideline presented herein was compiled for the purpose of ensuring proper diagnosis and treatment by physicians involved in the treatment of upper tract urothelial carcinoma. We carefully selected 16 clinical questions essential for daily clinical practice and grouped them into four major categories: epidemiology, diagnosis, surgery and systemic chemotherapy/other matters. Related literature was searched using PubMed and Japan Medical Abstracts Society databases for articles published between 1987 and 2013. If the judgment was made on the basis of insufficient or inadequate evidence, the grade of recommendation was determined on the basis of committee discussions and resultant consensus statements. Here, we present a short English version of the original guideline, and overview its key clinical issues.
Collapse
Affiliation(s)
- Mototsugu Oya
- Department of Urology, Keio University School of Medicine, Tokyo, Japan
| | | | | | | |
Collapse
|