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Mahlow J, Gupta S. Pathology focused review of morphologic subtypes and molecular variants of urothelial carcinoma with an emphasis on clinical/treatment relevance. Urol Oncol 2024; 42:193-202. [PMID: 38341364 DOI: 10.1016/j.urolonc.2024.01.016] [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: 09/07/2023] [Revised: 12/07/2023] [Accepted: 01/12/2024] [Indexed: 02/12/2024]
Abstract
Urothelial carcinoma (UC) has significant morbidity, mortality, and remains the most financially costly carcinoma to manage and treat. This review will cover special morphologic features of UC that may be noted by the pathologist and any subsequent significance in terms of clinical management or treatment considerations as mentioned or recommended in the latest WHO 2022 classification of GU tumors. Many important potentially therapy altering morphologic findings can be consistently identified and reported on routine microscopic examination of hematoxylin and eosin (H&E) stained slides. Furthermore, there has been a rapid advancement of molecular diagnostics and tailored therapies throughout oncology, and we will briefly highlight some of these as they relate to the management of UC. We will actively attempt to limit the discussion of histologic descriptions or pathologic diagnostic criteria of these entities and focus rather on the recognition of their importance/implication for clinicians who must make clinical management decisions based upon these findings. Finally, the importance of open lines of communication with the pathologists who review clinical specimens as well as their practice and reporting methods cannot be overstated.
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Affiliation(s)
- Jonathon Mahlow
- Department of Pathology, University of Utah, Salt Lake City, UT.
| | - Sumati Gupta
- Huntsman Cancer Institute, Division of Medical Oncology, University of Utah, Salt Lake City, UT; George E. Whalen Department of Veterans Affairs Medical Center, Salt Lake City UT
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2
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Gabriel PE, Cancel-Tassin G, Audenet F, Masson-Lecomte A, Allory Y, Roumiguié M, Pradère B, Loriot Y, Léon P, Traxer O, Xylinas E, Rouprêt M, Neuzillet Y, Seisen T. A collaborative review of the microsatellite instability/deficient mismatch repair phenotype in patients with upper tract urothelial carcinoma. BJU Int 2024. [PMID: 38813615 DOI: 10.1111/bju.16405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
OBJECTIVE To perform a collaborative review of the literature exploring the microsatellite instability/deficient mismatch repair (MSI/dMMR) phenotype in patients with upper tract urothelial carcinoma (UTUC). METHOD A collaborative review of the literature available on Medline was conducted by the Cancer Committee of the French Association of Urology to report studies describing the genetic mechanisms, investigation, prevalence and impact of the MSI/dMMR phenotype in UTUC patients. RESULTS The predominant genetic mechanism leading to the MSI/dMMR phenotype in UTUC patients is related to the constitutional mutation of one allele of the MMR genes MLH1, MSH2, MSH6 and PMS2 within Lynch syndrome. Indications for its investigation currently remain limited to patients with a clinical suspicion for sporadic UTUC to refer only those with a positive testing for germline DNA sequencing to screen for this syndrome. With regard to technical aspects, despite the interest of MSIsensor, only PCR and immunohistochemistry are routinely used to somatically investigate the MSI and dMMR phenotypes, respectively. The prevalence of the MSI/dMMR phenotype in UTUC patients ranges from 1.7% to 57%, depending on the study population, investigation method and definition of a positive test. Younger age and a more balanced male to female ratio at initial diagnosis are the main specific clinical characteristics of UTUC patients with an MSI/dMMR phenotype. Despite the conflicting results available in the literature, these patients may have a better prognosis, potentially related to more favourable pathological features. Finally, they may also have lower sensitivity to chemotherapy but greater sensitivity to immunotherapy. CONCLUSION Our collaborative review summarises the available data from published studies exploring the MSI/dMMR phenotype in UTUC patients, the majority of which are limited by a low level of evidence.
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Affiliation(s)
- Pierre-Etienne Gabriel
- GRC 5 Predictive Onco-Uro, Sorbonne University, AP-HP, Urology, Pitie-Salpetriere Hospital, Paris, France
| | | | - François Audenet
- Department of urology, Georges Pompidou European Hospital, APHP, Centre, Université Paris Cité, Paris, France
| | | | - Yves Allory
- Department of Pathology, Institut Curie, Saint-Cloud, Paris, France
| | | | - Benjamin Pradère
- Department of Urology, La Croix Du Sud Hospital, Quint Fonsegrives, France
| | - Yohann Loriot
- Department of Oncology, Gustave Roussy, Villejuif, France
| | | | - Olivier Traxer
- Department of Urology, Tenon Hospital, AP-HP, Paris, France
| | - Evanguelos Xylinas
- Department of Urology, Bichat-Claude Bernard Hospital, AP-HP, Université de Paris, Paris, France
| | - Morgan Rouprêt
- GRC 5 Predictive Onco-Uro, Sorbonne University, AP-HP, Urology, Pitie-Salpetriere Hospital, Paris, France
| | - Yann Neuzillet
- Department of Urology, Foch Hospital, University of Versailles-Saint-Quentin-en-Yvelines, Université Paris-Saclay, Suresnes, France
| | - Thomas Seisen
- GRC 5 Predictive Onco-Uro, Sorbonne University, AP-HP, Urology, Pitie-Salpetriere Hospital, Paris, France
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3
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Abstract
Upper urinary tract urothelial carcinoma (UTUC) is an uncommon malignancy involving the renal pelvis and ureter. Careful pathologic analysis plays a critical role in the diagnosis and clinical management of UTUC. In combination with clinical and radiologic evaluation, pathologic features can be used to stratify patients into low-risk and high-risk groups. This risk stratification can help clinicians select the optimal treatment for patients with UTUC, such as kidney-sparing (conservative) treatment, radical nephroureterectomy or ureterectomy, and perioperative systemic therapy. However, due to the technical difficulty of obtaining sufficient tissue from the upper urinary tract, it is often challenging for pathologists to accurately grade the tumor and assess tumor invasion in small biopsy specimens. Although the majority of UTUCs are pure urothelial carcinoma, a considerable subset of UTUCs show histologic subtypes or divergent differentiation. Recent studies have identified genetically distinct molecular subtypes of UTUC by examining DNA, RNA, and protein expression profiles. The prognosis of pT3 UTUC, particularly renal pelvic UC, remains controversial, and several studies have proposed subclassification of pT3 UTUC. Lynch syndrome is a significant risk factor for UTUC, and screening tests may be considered in young patients and those with familial histories of the disease. Despite significant progress in recent years, several issues remain to be addressed in the pathologic diagnosis, molecular classification, and treatment of UTUC.
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Affiliation(s)
- Jianping Zhao
- Department of Anatomical Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Charles C. Guo
- Department of Anatomical Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Priya Rao
- Department of Anatomical Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Chandran EBA, Iannantuono GM, Atiq SO, Akbulut D, Sinaii N, Simon NI, Banday AR, Boudjadi S, Gurram S, Nassar AH, Rosenberg JE, Butera G, Teo MY, Sonpavde G, Coleman JA, Apolo AB. Mismatch repair deficiency and microsatellite instability in urothelial carcinoma: a systematic review and meta-analysis. BMJ ONCOLOGY 2024; 3:e000335. [PMID: 39086924 PMCID: PMC11203074 DOI: 10.1136/bmjonc-2024-000335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
Background Mismatch repair deficiency (dMMR) and microsatellite instability-high (MSI-H) occur in a subset of cancers and have been shown to confer sensitivity to immune checkpoint inhibition (ICI); however, there is a lack of prospective data in urothelial carcinoma (UC). Methods and analysis We performed a systematic review to estimate the prevalence of dMMR and MSI-H in UC, including survival and clinical outcomes. We searched for studies published up to 26 October 2022 in major scientific databases. We screened 1745 studies and included 110. Meta-analyses were performed if the extracted data were suitable. Results The pooled weighted prevalences of dMMR in bladder cancer (BC) and upper tract UC (UTUC) were 2.30% (95% CI 1.12% to 4.65%) and 8.95% (95% CI 6.81% to 11.67%), respectively. The pooled weighted prevalences of MSI-H in BC and UTUC were 2.11% (95% CI 0.82% to 5.31%) and 8.36% (95% CI 5.50% to 12.53%), respectively. Comparing localised versus metastatic disease, the pooled weighted prevalences for MSI-H in BC were 5.26% (95% CI 0.86% to 26.12%) and 0.86% (95% CI 0.59% to 1.25%), respectively; and in UTUC, they were 18.04% (95% CI 13.36% to 23.91%) and 4.96% (95% CI 2.72% to 8.86%), respectively. Cumulatively, the response rate in dMMR/MSI-H metastatic UC treated with an ICI was 22/34 (64.7%) compared with 1/9 (11.1%) with chemotherapy. Conclusion Both dMMR and MSI-H occur more frequently in UTUC than in BC. In UC, MSI-H occurs more frequently in localised disease than in metastatic disease. These biomarkers may predict sensitivity to ICI in metastatic UC and resistance to cisplatin-based chemotherapy.
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Affiliation(s)
- Elias B A Chandran
- Genitourinary Malignancies Branch, National Institutes of Health, Bethesda, Maryland, USA
| | | | - Saad O Atiq
- Genitourinary Malignancies Branch, National Institutes of Health, Bethesda, Maryland, USA
| | - Dilara Akbulut
- Laboratory of Pathology, National Institutes of Health, Bethesda, Maryland, USA
| | - Ninet Sinaii
- Biostatistics and Clinical Epidemiology Service, National Institutes of Health, Bethesda, Maryland, USA
| | - Nicholas I Simon
- Genitourinary Malignancies Branch, National Institutes of Health, Bethesda, Maryland, USA
| | - Abdul Rouf Banday
- Genitourinary Malignancies Branch, National Institutes of Health, Bethesda, Maryland, USA
| | - Salah Boudjadi
- Genitourinary Malignancies Branch, National Institutes of Health, Bethesda, Maryland, USA
| | - Sandeep Gurram
- Urologic Oncology Branch, National Institutes of Health, Bethesda, Maryland, USA
| | - Amin H Nassar
- Department of Hematology/Oncology, Yale New Haven Hospital, New Haven, Connecticut, USA
| | | | - Gisela Butera
- Division of Library Services, National Institutes of Health, Bethesda, Maryland, USA
| | - Min Yuen Teo
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Guru Sonpavde
- Medical Oncology, AdventHealth Central Florida, Orlando, Florida, USA
| | | | - Andrea B Apolo
- Genitourinary Malignancies Branch, National Institutes of Health, Bethesda, Maryland, USA
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Pivovarcikova K, Pitra T, Alaghehbandan R, Buchova K, Steiner P, Hajkova V, Ptakova N, Subrt I, Skopal J, Svajdler P, Farcas M, Slisarenko M, Michalova K, Strakova Peterikova A, Hora M, Michal M, Daum O, Svajdler M, Hes O. Lynch syndrome-associated upper tract urothelial carcinoma frequently occurs in patients older than 60 years: an opportunity to revisit urology clinical guidelines. Virchows Arch 2023; 483:517-526. [PMID: 37612527 DOI: 10.1007/s00428-023-03626-2] [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: 07/17/2023] [Revised: 08/09/2023] [Accepted: 08/10/2023] [Indexed: 08/25/2023]
Abstract
Upper tract urothelial carcinoma (UTUC) is the third most common malignancy associated with Lynch syndrome (LS). The current European urology guidelines recommend screening for LS in patients with UTUC up to the age of 60 years. In this study, we examined a cohort of patients with UTUC for potential association with LS in order to establish the sensitivity of current guidelines in detecting LS. A total of 180 patients with confirmed diagnosis of UTUC were enrolled in the study during a 12-year period (2010-2022). Loss of DNA-mismatch repair proteins (MMRp) expression was identified in 15/180 patients (8.3%). Germline analysis was eventually performed in 8 patients confirming LS in 5 patients (2.8%), including 4 germline mutations in MSH6 and 1 germline mutation in MSH2. LS-related UTUC included 3 females and 2 males, with a mean age of 66.2 years (median 71 years, range 46-75 years). Four of five LS patients (all with MSH6 mutation) were older than 65 years (mean age 71.3, median 72 years). Our findings indicate that LS-associated UTUCs can occur in patients with LS older than 60 years. In contrast to previous studies which used mainly highly pre-selected populations with already diagnosed LS, the most frequent mutation in our cohort involved MSH6 gene. All MSH6 mutation carriers were > 65 years, and UTUC was the first LS manifestation in 2/4 patients. Using current screening guidelines, a significant proportion of patients with LS-associated UTUC may be missed. We suggest universal immunohistochemical MMRp screening for all UTUCs, regardless of age and clinical history.
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Affiliation(s)
- Kristyna Pivovarcikova
- Šikl's Department of Pathology, The Faculty of Medicine and Faculty Hospital in Pilsen, Charles University, Alej Svobody 80, 304 60, Pilsen, Czech Republic.
- Biopticka Laborator S.R.O., Pilsen, Czech Republic.
| | - Tomas Pitra
- Department of Urology, Faculty of Medicine in Plzeň, Charles University in Prague, Pilsen, Czech Republic
| | - Reza Alaghehbandan
- Cleveland Clinic, Department of Anatomic Pathology, Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland, OH, USA
| | - Karolina Buchova
- Šikl's Department of Pathology, The Faculty of Medicine and Faculty Hospital in Pilsen, Charles University, Alej Svobody 80, 304 60, Pilsen, Czech Republic
| | - Petr Steiner
- Šikl's Department of Pathology, The Faculty of Medicine and Faculty Hospital in Pilsen, Charles University, Alej Svobody 80, 304 60, Pilsen, Czech Republic
- Biopticka Laborator S.R.O., Pilsen, Czech Republic
| | - Veronika Hajkova
- Šikl's Department of Pathology, The Faculty of Medicine and Faculty Hospital in Pilsen, Charles University, Alej Svobody 80, 304 60, Pilsen, Czech Republic
- Biopticka Laborator S.R.O., Pilsen, Czech Republic
| | - Nikola Ptakova
- Šikl's Department of Pathology, The Faculty of Medicine and Faculty Hospital in Pilsen, Charles University, Alej Svobody 80, 304 60, Pilsen, Czech Republic
- Biopticka Laborator S.R.O., Pilsen, Czech Republic
| | - Ivan Subrt
- Department of Medical Genetics, Faculty of Medicine in Plzeň, Charles University in Prague, Pilsen, Czech Republic
| | - Josef Skopal
- Šikl's Department of Pathology, The Faculty of Medicine and Faculty Hospital in Pilsen, Charles University, Alej Svobody 80, 304 60, Pilsen, Czech Republic
| | - Peter Svajdler
- Šikl's Department of Pathology, The Faculty of Medicine and Faculty Hospital in Pilsen, Charles University, Alej Svobody 80, 304 60, Pilsen, Czech Republic
- Cytopathos S. R. O., Bratislava, Slovakia
| | - Mihaela Farcas
- Šikl's Department of Pathology, The Faculty of Medicine and Faculty Hospital in Pilsen, Charles University, Alej Svobody 80, 304 60, Pilsen, Czech Republic
- Onco Team Diagnostic, Bucharest, Romania
| | - Maryna Slisarenko
- Šikl's Department of Pathology, The Faculty of Medicine and Faculty Hospital in Pilsen, Charles University, Alej Svobody 80, 304 60, Pilsen, Czech Republic
| | - Kvetoslava Michalova
- Šikl's Department of Pathology, The Faculty of Medicine and Faculty Hospital in Pilsen, Charles University, Alej Svobody 80, 304 60, Pilsen, Czech Republic
- Biopticka Laborator S.R.O., Pilsen, Czech Republic
| | - Andrea Strakova Peterikova
- Šikl's Department of Pathology, The Faculty of Medicine and Faculty Hospital in Pilsen, Charles University, Alej Svobody 80, 304 60, Pilsen, Czech Republic
- Biopticka Laborator S.R.O., Pilsen, Czech Republic
| | - Milan Hora
- Department of Urology, Faculty of Medicine in Plzeň, Charles University in Prague, Pilsen, Czech Republic
| | - Michal Michal
- Šikl's Department of Pathology, The Faculty of Medicine and Faculty Hospital in Pilsen, Charles University, Alej Svobody 80, 304 60, Pilsen, Czech Republic
- Biopticka Laborator S.R.O., Pilsen, Czech Republic
| | - Ondrej Daum
- Šikl's Department of Pathology, The Faculty of Medicine and Faculty Hospital in Pilsen, Charles University, Alej Svobody 80, 304 60, Pilsen, Czech Republic
- Biopticka Laborator S.R.O., Pilsen, Czech Republic
| | - Marian Svajdler
- Šikl's Department of Pathology, The Faculty of Medicine and Faculty Hospital in Pilsen, Charles University, Alej Svobody 80, 304 60, Pilsen, Czech Republic
- Biopticka Laborator S.R.O., Pilsen, Czech Republic
- Cytopathos S. R. O., Bratislava, Slovakia
| | - Ondrej Hes
- Šikl's Department of Pathology, The Faculty of Medicine and Faculty Hospital in Pilsen, Charles University, Alej Svobody 80, 304 60, Pilsen, Czech Republic
- Biopticka Laborator S.R.O., Pilsen, Czech Republic
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Rasmussen M, Sowter P, Gallon R, Durhuus JA, Hayes C, Andersen O, Nilbert M, Schejbel L, Høgdall E, Santibanez-Koref M, Jackson MS, Burn J, Therkildsen C. Mismatch repair deficiency testing in Lynch syndrome-associated urothelial tumors. Front Oncol 2023; 13:1147591. [PMID: 37143941 PMCID: PMC10151563 DOI: 10.3389/fonc.2023.1147591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 03/23/2023] [Indexed: 05/06/2023] Open
Abstract
Introduction Lynch syndrome-associated cancer develops due to germline pathogenic variants in one of the mismatch repair (MMR) genes, MLH1, MSH2, MSH6 or PMS2. Somatic second hits in tumors cause MMR deficiency, testing for which is used to screen for Lynch syndrome in colorectal cancer and to guide selection for immunotherapy. Both MMR protein immunohistochemistry and microsatellite instability (MSI) analysis can be used. However, concordance between methods can vary for different tumor types. Therefore, we aimed to compare methods of MMR deficiency testing in Lynch syndrome-associated urothelial cancers. Methods Ninety-seven urothelial (61 upper tract and 28 bladder) tumors diagnosed from 1980 to 2017 in carriers of Lynch syndrome-associated pathogenic MMR variants and their first-degree relatives (FDR) were analyzed by MMR protein immunohistochemistry, the MSI Analysis System v1.2 (Promega), and an amplicon sequencing-based MSI assay. Two sets of MSI markers were used in sequencing-based MSI analysis: a panel of 24 and 54 markers developed for colorectal cancer and blood MSI analysis, respectively. Results Among the 97 urothelial tumors, 86 (88.7%) showed immunohistochemical MMR loss and 68 were successfully analyzed by the Promega MSI assay, of which 48 (70.6%) were MSI-high and 20 (29.4%) were MSI-low/microsatellite stable. Seventy-two samples had sufficient DNA for the sequencing-based MSI assay, of which 55 (76.4%) and 61 (84.7%) scored as MSI-high using the 24-marker and 54-marker panels, respectively. The concordance between the MSI assays and immunohistochemistry was 70.6% (p = 0.003), 87.5% (p = 0.039), and 90.3% (p = 1.00) for the Promega assay, the 24-marker assay, and the 54-marker assay, respectively. Of the 11 tumors with retained MMR protein expression, four were MSI-low/MSI-high or MSI-high by the Promega assay or one of the sequencing-based assays. Conclusion Our results show that Lynch syndrome-associated urothelial cancers frequently had loss of MMR protein expression. The Promega MSI assay was significantly less sensitive, but the 54-marker sequencing-based MSI analysis showed no significant difference compared to immunohistochemistry. Data from this study alongside previous studies, suggest that universal MMR deficiency testing of newly diagnosed urothelial cancers, using immunohistochemistry and/or sequencing-based MSI analysis of sensitive markers, offer a potentially useful approach to identification of Lynch syndrome cases.
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Affiliation(s)
- Maria Rasmussen
- Department of Clinical Research, Copenhagen University Hospital - Amager and Hvidovre, Copenhagen, Denmark
| | - Peter Sowter
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Richard Gallon
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Jon Ambæk Durhuus
- Department of Clinical Research, Copenhagen University Hospital - Amager and Hvidovre, Copenhagen, Denmark
- Center for Healthy Aging, Department of Cellular and Molecular Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christine Hayes
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Ove Andersen
- Department of Clinical Research, Copenhagen University Hospital - Amager and Hvidovre, Copenhagen, Denmark
| | - Mef Nilbert
- Institute of Clinical Sciences, Division of Oncology and Pathology, Lund University, Lund, Sweden
| | - Lone Schejbel
- Molecular Unit, Department of Pathology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Estrid Høgdall
- Molecular Unit, Department of Pathology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Mauro Santibanez-Koref
- Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Michael S Jackson
- Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - John Burn
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Christina Therkildsen
- The Danish HNPCC Register, Gastro Unit, Copenhagen University Hospital - Amager and Hvidovre, Copenhagen, Denmark
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7
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Rouprêt M, Seisen T, Birtle AJ, Capoun O, Compérat EM, Dominguez-Escrig JL, Gürses Andersson I, Liedberg F, Mariappan P, Hugh Mostafid A, Pradere B, van Rhijn BWG, Shariat SF, Rai BP, Soria F, Soukup V, Wood RG, Xylinas EN, Masson-Lecomte A, Gontero P. European Association of Urology Guidelines on Upper Urinary Tract Urothelial Carcinoma: 2023 Update. Eur Urol 2023; 84:S0302-2838(23)02652-0. [PMID: 36967359 DOI: 10.1016/j.eururo.2023.03.013] [Citation(s) in RCA: 130] [Impact Index Per Article: 130.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 03/06/2023] [Indexed: 06/18/2023]
Abstract
CONTEXT The European Association of Urology (EAU) guidelines panel on upper urinary tract urothelial carcinoma (UTUC) has updated the guidelines to aid clinicians in evidence-based management of UTUC. OBJECTIVE To provide an overview of the EAU guidelines on UTUC as an aid to clinicians. EVIDENCE ACQUISITION The recommendations provided in these guidelines are based on a review of the literature via a systematic search of the PubMed, Ovid, EMBASE, and Cochrane databases. Data were searched using the following keywords: urinary tract cancer, urothelial carcinomas, renal pelvis, ureter, bladder cancer, chemotherapy, ureteroscopy, nephroureterectomy, neoplasm, (neo)adjuvant treatment, instillation, recurrence, risk factors, metastatic, immunotherapy, and survival. The results were assessed by a panel of experts. EVIDENCE SYNTHESIS Even though data are accruing, for many areas there is still insufficient high-level evidence to provide strong recommendations. Patient stratification on the basis of histology and clinical examination (including imaging) and assessment of patients at risk of Lynch syndrome will aid management. Kidney-sparing management should be offered as a primary treatment option to patients with low-risk UTUC and two functional kidneys. In particular, for patients with high-risk or metastatic UTUC, new treatment options have become available. In high-risk UTUC, platinum-based chemotherapy after radical nephroureterectomy, and adjuvant nivolumab for unfit or patients who decline chemotherapy, are options. For metastatic disease, gemcitabine/carboplatin chemotherapy is recommended as first-line treatment for cisplatin-ineligible patients. Patients with PD-1/PD-L1-positive tumours should be offered a checkpoint inhibitor (pembrolizumab or atezolizumab). CONCLUSIONS These guidelines contain information on the management of individual patients according to the current best evidence. Urologists should take into account the specific clinical characteristics of each patient when determining the optimal treatment regimen according to the risk stratification of these tumours. PATIENT SUMMARY Cancer of the upper urinary tract is rare, but because 60% of these tumours are invasive at diagnosis, timely and appropriate diagnosis is most important. A number of known risk factors exist.
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Affiliation(s)
- Morgan Rouprêt
- GRC 5 Predictive Onco-Uro, Sorbonne University, AP-HP, Urology, Pitie-Salpetriere Hospital, Paris, France.
| | - Thomas Seisen
- GRC 5 Predictive Onco-Uro, Sorbonne University, AP-HP, Urology, Pitie-Salpetriere Hospital, Paris, France
| | - Alison J Birtle
- Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK; University of Manchester, Manchester, UK
| | - Otakar Capoun
- Department of Urology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czechia; Department of Pathology, General Hospital of Vienna, Medical University of Vienna, Vienna, Austria
| | - Eva M Compérat
- Department of Urology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czechia; Department of Pathology, General Hospital of Vienna, Medical University of Vienna, Vienna, Austria; Department of Pathology, Sorbonne University, AP-HP, Hôpital Tenon, Paris
| | | | | | - Fredrik Liedberg
- Department of Translational Medicine, Lund University, Malmö, Sweden; Department of Urology, Skåne University Hospital, Malmö, Sweden
| | - Paramananthan Mariappan
- Department of Urology, Edinburgh Bladder Cancer Surgery, Western General Hospital, Edinburgh, UK
| | - A Hugh Mostafid
- Department of Urology, The Stokes Centre for Urology, Royal Surrey Hospital, Guildford, UK
| | - Benjamin Pradere
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, La Croix Du Sud Hospital, Quint Fonsegrives, France
| | - Bas W G van Rhijn
- Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany; Department of Surgical Oncology (Urology), Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Shahrokh F Shariat
- Department of Urology, Teaching Hospital Motol and 2nd Faculty of Medicine, Charles University Praha, Prague, Czechia; Department of Urology, Comprehensive Cancer Center, Medical University Vienna, Vienna General Hospital, Vienna, Austria
| | - Bhavan P Rai
- Department of Urology, Freeman Hospital, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Francesco Soria
- Department of Urology, Città della Salute e della Scienza, University of Torino School of Medicine, Torino, Italy
| | - Viktor Soukup
- Department of Urology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czechia; Department of Pathology, General Hospital of Vienna, Medical University of Vienna, Vienna, Austria
| | | | - Evanguelos N Xylinas
- Department of Urology, Bichat-Claude Bernard Hospital, AP-HP, Université de Paris, Paris, France
| | | | - Paolo Gontero
- Department of Urology, Città della Salute e della Scienza, University of Torino School of Medicine, Torino, Italy
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8
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Nassour AJ, Jain A, Hui N, Siopis G, Symons J, Woo H. Relative Risk of Bladder and Kidney Cancer in Lynch Syndrome: Systematic Review and Meta-Analysis. Cancers (Basel) 2023; 15:506. [PMID: 36672455 PMCID: PMC9856836 DOI: 10.3390/cancers15020506] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/07/2023] [Accepted: 01/08/2023] [Indexed: 01/17/2023] Open
Abstract
Background: The association between Lynch syndrome (LS) and a higher risk of upper tract urothelial carcinoma is well established, but its effect on the risk of bladder and kidney cancers remains controversial. This review aimed to compare the relative risk (RR) of bladder and kidney cancer in confirmed LS germline mutation carriers compared to the general population. Methods: Medline, Embase, Cochrane Central, and Google Scholar were searched on 14 July 2022 for studies published in English that reported on the rates of urological cancer in adults with confirmed LS germline mutation. The quality of included studies was assessed using Cochrane’s tool to evaluate risk of bias in cohort studies. Random effects meta-analysis estimated the pooled relative risk of bladder and kidney cancer in LS carriers compared to the general population. The quality of the overall evidence was evaluated using GRADE. Results: Of the 1839 records identified, 5 studies involving 7120 participants from 3 continents were included. Overall, LS carriers had a statistically significantly higher RR of developing bladder cancer (RR: 7.48, 95% CI: 3.70, 15.13) and kidney cancer (RR: 3.97, 95% CI: 1.23, 12.81) compared to unaffected participants (p < 0.01). The quality of the evidence was assessed as “low” due to the inclusion of cohort studies, the substantial heterogeneity, and moderate-to-high risk of bias. Conclusion: Lynch syndrome is associated with a significant increase in the relative risk of kidney and bladder cancer. Clinicians should adopt a lower threshold for germline mutation genetic testing in individuals who present with bladder cancer. Further studies evaluating the role and cost-effectiveness of novel urine-based laboratory tests are needed. High-quality studies in histologically proven renal cell carcinoma and their underlying germline mutations are necessary to strengthen the association with LS.
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Affiliation(s)
- Anthony-Joe Nassour
- SAN Prostate Centre of Excellence, Sydney Adventist Hospital, Wahroonga, NSW 2076, Australia
- Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW 2006, Australia
| | - Anika Jain
- SAN Prostate Centre of Excellence, Sydney Adventist Hospital, Wahroonga, NSW 2076, Australia
| | - Nicholas Hui
- SAN Prostate Centre of Excellence, Sydney Adventist Hospital, Wahroonga, NSW 2076, Australia
- Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW 2006, Australia
| | - George Siopis
- Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW 2006, Australia
- Institute for Physical Activity and Nutrition, Deakin University, Geelong, VIC 3125, Australia
| | - James Symons
- SAN Prostate Centre of Excellence, Sydney Adventist Hospital, Wahroonga, NSW 2076, Australia
- Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW 2006, Australia
- College of Health and Medicine, The Australian National University, Canberra, ACT 2601, Australia
| | - Henry Woo
- SAN Prostate Centre of Excellence, Sydney Adventist Hospital, Wahroonga, NSW 2076, Australia
- College of Health and Medicine, The Australian National University, Canberra, ACT 2601, Australia
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Oki R, Urasaki T, Ueki A, Inamura K, Komai Y, Takahashi S, Yonese J, Yuasa T. A radiological complete response to pembrolizumab in a patient with metastatic upper urinary tract urothelial cancer and Lynch syndrome. IJU Case Rep 2022; 6:33-36. [PMID: 36605683 PMCID: PMC9807341 DOI: 10.1002/iju5.12542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 09/26/2022] [Indexed: 01/04/2023] Open
Abstract
Introduction In Lynch syndrome, urothelial cancer is the third most common cancer, following colorectal and endometrial cancers. Little is known, however, about the efficacy of immune checkpoint inhibitors in the treatment of metastatic urothelial cancer in Lynch syndrome. Case presentation A 49-year-old patient with metastatic urothelial cancer underwent pembrolizumab therapy after platinum-containing chemotherapy. The efficacy of the pembrolizumab therapy was good. Her lung and bone metastatic lesions disappeared in imaging studies and her back pain decreased dramatically. Pathogenic mutations of MSH2 and BRCA2 were found in the DNA extracted from her tumor, and subsequent genetic analysis confirmed the germline pathogenic variant of MSH2. As such, this case was genetically diagnosed as Lynch syndrome. Conclusion We report metastatic urothelial cancer in a patient with Lynch syndrome who demonstrated a radiological complete response to pembrolizumab therapy. Accurate genetic diagnosis can provide useful information to both the patient and their relatives.
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Affiliation(s)
- Ryosuke Oki
- Department of Medical Oncology, Cancer Institute HospitalJapanese Foundation for Cancer ResearchTokyoJapan
| | - Tetsuya Urasaki
- Department of Medical Oncology, Cancer Institute HospitalJapanese Foundation for Cancer ResearchTokyoJapan
| | - Arisa Ueki
- Department of Clinical Genetic Oncology, Cancer Institute HospitalJapanese Foundation for Cancer ResearchTokyoJapan
| | - Kentaro Inamura
- Department of Pathology, Cancer Institute HospitalJapanese Foundation for Cancer ResearchTokyoJapan
| | - Yoshinobu Komai
- Department of Urology, Cancer Institute HospitalJapanese Foundation for Cancer ResearchTokyoJapan
| | - Shunji Takahashi
- Department of Medical Oncology, Cancer Institute HospitalJapanese Foundation for Cancer ResearchTokyoJapan
| | - Junji Yonese
- Department of Urology, Cancer Institute HospitalJapanese Foundation for Cancer ResearchTokyoJapan
| | - Takeshi Yuasa
- Department of Urology, Cancer Institute HospitalJapanese Foundation for Cancer ResearchTokyoJapan
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10
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Persistent asymptomatic isolated microscopic hematuria in adolescents is not associated with an increased risk for early onset urinary tract cancer. Urology 2022; 169:29-34. [PMID: 35985524 DOI: 10.1016/j.urology.2022.06.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 06/22/2022] [Accepted: 06/26/2022] [Indexed: 10/15/2022]
Abstract
OBJECTIVE To elucidate the association between adolescent microscopic hematuria and early onset urothelial carcinoma and renal cell carcinoma. METHODS Nationwide, population-based, retrospective cohort study using medical data of 970,366 adolescents aged 16 through 19 years (58.6% male) examined for fitness for military service between 1980 and 1997. Diagnoses of persistent isolated microscopic hematuria were given after thorough work up process excluding any other renal abnormalities. Incident cases of urothelial carcinoma and renal cell carcinoma diagnosed during the years of 1982 to 2012 were retrieved from the Israeli National Cancer Registry. Cox proportional hazards models were used to estimate the hazard ratio (HR) separately for urothelial carcinoma and renal cell carcinoma. RESULTS During a cumulative follow-up of 22,115,629 person-years (median follow-up, 22.8), persistent isolated microscopic hematuria was diagnosed among 5509 (0.6%) adolescents. Urothelial carcinoma and renal cell carcinoma developed in 332 (3 among those with persistent isolated microscopic hematuria) and 292 (2) individuals, respectively. The adjusted HR for incident urothelial carcinoma among adolescents with isolated microscopic hematuria was 1.17 (95% CI, 0.38-3.66) and the adjusted HR for renal cell carcinoma was 1.02 (95% CI, 0.25-4.12). CONCLUSIONS Persistent asymptomatic isolated microscopic hematuria at adolescence was not associated with increased risk for urothelial carcinoma nor renal cell carcinoma.
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