Photodynamic Diagnosis with Oral 5-Aminolevulinic Acid for Upper Urinary Tract Carcinoma: A Prospective Clinical Trial

Diagnosing upper tract urothelial carcinoma: A review of the role of diagnostic ureteroscopy and novel developments over last two decades

Objective

The role of ureteroscopy in the diagnosis of upper tract urothelial carcinoma is yet to be fully determined. We aimed to provide an up to date evaluation of its role and the emerging technologies in the field.

Methods

A literature search of the last two decades (from 24th May, 2001 to 24th May, 2021) was carried out identifying 147 papers for potential inclusion within this narrative review.

Results

Diagnostic ureteroscopy is undeniably useful in its ability to visualise and biopsy indeterminate lesions, and to risk stratify malignant lesions that may be suitable for kidney sparing surgery. However, an increased risk of intravesical recurrence following nephroureterectomy when a prior diagnostic ureteroscopy has been performed, inadequate sampling at biopsy, complications from the procedure, and difficult ureteric access are all potential drawbacks. Furthermore, whilst generally an accurate diagnostic procedure, it risks missing carcinoma in-situ lesions. Despite this, evidence shows that routine use of ureteroscopy changes the management of patients in a large proportion of cases, preventing unnecessary surgery or facilitating kidney sparing surgery. The overall rate of complications is low, and improved biopsy techniques and the use of tissue biomarkers for improved staging and grading are encouraging. The risks of delays to definitive management and post-ureteroscopy intravesical recurrence do not seem to affect survival, and trials are in progress to determine whether intravesical therapy can mitigate the latter. Further promising techniques are being investigated to improve shortcomings, particularly in relation to improved diagnosis of carcinoma in situ and preoperative staging.

Conclusion

Ureteroscopy has a role in the diagnosis of upper tract malignancy, though whether it should be used routinely is yet to be determined.

Development and Validation of a Preoperative Nomogram for Endoscopic Management Decision Making in Upper Urinary Tract Urothelial Carcinoma

OBJECTIVE

We aimed to develop and validate a preoperative nomogram that predicts low-grade, non-muscle invasive upper urinary tract urothelial carcinoma (LG-NMI UTUC), thereby aiding in the accurate selection of endoscopic management (EM) candidates.

METHODS

This was a retrospective study that included 454 patients who underwent radical surgery (Cohort 1 and Cohort 2), and 26 patients who received EM (Cohort 3). Utilizing a multivariate logistic regression model, a nomogram predicting LG-NMI UTUC was developed based on data from Cohort 1. The nomogram's accuracy was compared with conventional European Association of Urology (EAU) and National Comprehensive Cancer Network (NCCN) models. External validation was performed using Cohort 2 data, and the nomogram's prognostic value was evaluated via disease progression metrics in Cohort 3.

RESULTS

In Cohort 1, multivariate analyses highlighted the absence of invasive disease on imaging (odds ratio [OR] 7.04; p = 0.011), absence of hydronephrosis (OR 2.06; p = 0.027), papillary architecture (OR 24.9; p < 0.001), and lack of high-grade urine cytology (OR 0.22; p < 0.001) as independent predictive factors for LG-NMI disease. The nomogram outperformed the two conventional models in predictive accuracy (0.869 vs. 0.759-0.821) and exhibited a higher net benefit in decision curve analysis. The model's clinical efficacy was corroborated in Cohort 2. Moreover, the nomogram stratified disease progression-free survival rates in Cohort 3.

CONCLUSION

Our nomogram ( https://kmur.shinyapps.io/UTUC_URS/ ) accurately predicts LG-NMI UTUC, thereby identifying suitable candidates for EM. Additionally, the model serves as a useful tool for prognostic stratification in patients undergoing EM.

Primary Carcinoma In Situ of the Ureter Without Concurrent Renal Pelvis or Bladder Carcinoma: A Case Report and Literature Review

Primary carcinoma in situ (CIS) solely affecting the ureter without concurrent involvement of the kidney or bladder is an exceptionally rare condition. This case report presents the clinical management of a 67-year-old male patient with primary ureteral CIS, highlighting the diagnostic workup, surgical approach, and postoperative outcomes. The diagnosis was established through the use of CT and ureteroscopy, leading to the decision for radical laparoscopic nephroureterectomy. Additionally, a comprehensive literature review was conducted to discuss the diagnostic challenges and management options for primary ureteral CIS.

Learning from the past and present to change the future: Endoscopic management of upper urinary tract urothelial carcinoma

Current guidelines recommend endoscopic management (EM) for patients with low-risk upper urinary tract urothelial carcinoma, as well as those with an imperative indication. However, regardless of the tumor risk, radical nephroureterectomy is still mainly performed worldwide despite the benefits of EM, such as renal function maintenance, no hemodialysis requirement, and treatment cost reduction. This might be explained by the association of EM with a high risk of local recurrence and progression. Furthermore, the need for rigorous patient selection and close surveillance following EM may be relevant. Nevertheless, recent developments in diagnostic modalities, pathological evaluation, surgical devices and techniques, and intracavitary regimens have been reported, which may contribute to improved risk stratification and treatments with superior oncological outcomes. In this review, considering recent advances in endourology and oncology, we propose novel treatment strategies for optimal EM.

Current methods facilitating diagnosis of upper tract urothelial carcinoma: a comprehensive literature review

PURPOSE OF REVIEW

Currently, kidney-sparing surgeries are considered the preferred approach in low-risk tumours and in selected high-risk patients. Therefore, accurate diagnosis of UTUC is crucial for further management. The purpose of this review is to summarize available methods facilitating the diagnosis of upper tract urothelial carcinoma (UTUC).

RECENT FINDINGS

Recent articles propose numerous techniques of UTUC diagnosis. In this review, imaging, as well as, urine-based and endoscopic methods have been described and assessed.

SUMMARY

Regarding imaging, computed tomography urography remains a gold standard, while PET is superior in search for small lesions and nodal metastases. However, contrast-enhanced ultrasonography also shows promise. On the contrary, available urine tests, such as urinary cytology, fluorescent in-situ hybridization, Xpert, DNA methylation analysis, urine-based liquid biopsy, p16/Ki-67 dual immunolabelling, ImmunoCyt and NMP22 are either poorly researched, or not accurate enough to use solely. Finally, during ureterorenoscopy, photodynamic diagnosis and narrow-band imaging can facilitate proper visualization of the tumor. Endoluminal ultrasonography and confocal laser endomicroscopy can potentially improve staging and grading of UTUC. Also, the 'form tackle' biopsy should be performed using a basket in papillary lesions and cold-cup biopsy of flat or sessile lesions. Even though cryobiopsy shows promise in UTUC diagnosis, in-vivo studies are necessary before it is introduced into clinical practice.

The role of endoscopic management and adjuvant topical therapy for upper tract urothelial cancer

Upper tract urothelial carcinoma (UTUC) has traditionally been managed with radical nephroureterectomy, and while this approach remains the gold standard for high-risk disease, endoscopic, kidney-sparing management has increasingly been adopted for low-risk disease as it preserves kidney function without compromising oncologic outcomes. Ureteroscopy and percutaneous renal access not only provide diagnoses by tumor visualization and biopsy, but also enable treatment with electrocautery or laser ablation. Several modalities exist for laser ablative treatments including thulium:YAG, neodymium:YAG, holmium:YAG, and combinations of the preceding. Furthermore, due to high recurrence rates after endoscopic management, adjuvant intracavitary instillation of various agents such as mitomycin C and bacillus Calmette-Guerin have been used given benefits seen in non-muscle invasive urothelial bladder cancer. Other formulations also being studied include gemcitabine, anthracyclines, and immunotherapies. More recently, Jelmyto, a mitomycin reverse thermal gel, has been developed to allow for adequate drug delivery time and potency since urine flow could otherwise dilute and washout topical therapy. In this article, the authors review techniques, indications, best practices, and areas of current investigation in endoscopic management and adjuvant topical therapy for UTUC.

A prospective, single-arm trial of fluorescent ureteroscopy-assisted thulium-holmium:YAG dual laser ablation for upper urinary tract cancer: Study protocol of the FLUAM trial

Background

Latest guidelines recommend kidney-sparing management as the primary treatment option for selected patients with upper urinary tract urothelial carcinoma (UTUC). One of the biggest issues of ureteroscopic laser ablation (ULA) is a high rate of surgical site recurrence, which is largely attributed to residual lesions at the initial ULA. Another clinical issue is a significant lack of non-invasive reliable detection tools of urinary recurrent tumors in this treatment setting.

Methods

The FLUAM trial is a prospective, single-center, single-arm pilot trial to investigate the efficacy of 5-aminolevulinic acid-mediated photodynamic diagnosis (ALA-PDD)-assisted ULA for localized UTUC and the usefulness of the UroVysion® assay (multiprobe fluorescence in situ hybridization) as a monitoring test after the kidney-sparing treatment. After the screening and registration, a total of 20 patients with localized UTUC will undergo the initial ALA-PDD-assisted ULA followed by the second look ALA-PDD-assisted ureteroscopic examination. The primary endpoint is progression-free survival. Secondary endpoints include patient reported outcomes, diagnostic accuracy of UroVysion assay to detect tumor recurrence, adverse events, and safety of the intervention.

Conclusion

The goal of this trial is to determine the potential benefit of ALA-PDD assistance in patients who undergo the ULA. The evidence of this novel technique is still limited. The results are expected to change the standard of care and lead to better management of localized UTUC.

Trial registration

This clinical trial was prospectively registered with the Japan Registry of Clinical Trials on 23 June 2021. The reference number is jRCTs051210042, nara0023 (Certified Review Board of Nara Medical University).

Photodynamic Diagnosis-guided Dual Laser Ablation for Upper Urinary Tract Carcinoma: Preoperative Preparation, Surgical Technique, and Clinical Outcomes

Background

Although ureteroscopic surgery (URS) is beneficial for low-risk upper urinary tract carcinoma (UTUC), there is no standardized URS technique or navigation system for challenging cases.

Objective

To present a URS technique for UTUC using thulium (Tm):YAG and holmium (Ho):YAG lasers under photodynamic diagnosis (PDD) guidance, named PDD-guided dual laser ablation (PDD-DLA) and compare its efficacy with that of conventional Ho:YAG laser ablation (HLA; historical control).

Design, setting, and participants

The study included ten consecutive UTUC patients who underwent PDD-DLA between 2017 and 2019. The control group comprised 16 consecutive patients who underwent HLA between 2006 and 2016.

Surgical procedure

After oral administration of 5-aminolevulinic acid (20 mg/kg), UTUC tumors were endoscopically resected via PDD-DLA.

Measurements

Clinical data were prospectively collected for our institutional UTUC data set. Disease progression, UTUC recurrence, and clinical outcomes were assessed.

Results and limitations

PDD-DLA was successfully performed in all patients. The median tumor size was 23.5 mm (interquartile range [IQR] 12.8–30.0) and there were four cases (40.0%) of high-grade tumor. The median operative time was 120 min (IQR 98.5–142.5). No Clavien-Dindo grade ≥3 complications were observed. There were no differences in most clinical characteristics between the PDD-DLA and HLA groups. The 2-yr progression-free survival rate was 100% in the PDD-DLA group and 58.7% in the HLA group (p = 0.0197), and the 2-yr recurrence-free survival rate was 57.1% and 41.3%, respectively (p = 0.072). The PDD-DLA group had a lower incidence rate of salvage RNU compared with the HLA group (0.0% vs 50%; p = 0.009). The small sample size might affect the reproducibility of these results.

Conclusions

PDD-DLA seems to be an effective and feasible endoscopic technique for UTUC treatment with favorable oncological outcomes.

Patient summary

We investigated a new laser technique for treating cancer of the upper urinary tract called photodynamic diagnosis–guided dual laser ablation. Our strategy was effective in removing tumors and stopping bleeding. Further studies in larger groups of patients are needed to confirm whether this technique improves cancer outcomes.

Diagnostic accuracy of photodynamic diagnosis for upper urinary tract urothelial carcinoma: A systematic review and meta-analysis

BACKGROUND

This study aimed to evaluate the effectiveness of photodynamic diagnosis (PDD) for upper urinary tract urothelial carcinoma (UTUC) by performing a meta-analysis.

METHOD

Relevant articles were retrieved from the Cochrane Library, PubMed, and Embase databases. Studies evaluating the accuracy of PDD for the diagnosis of upper UTUC were included. The pooled sensitivity, specificity, and area under the curve (AUC) were calculated by STATA 16.0 at the per-lesion level.

RESULTS

Six studies with 289 lesions were included in this systematic review and meta-analysis. The pooled results showed that PDD can differentiate upper UTUC from benign lesions with a sensitivity of 0.96 (95 % confidence interval: 0.85-0.99) and a specificity of 0.86 (95 % confidence interval: [0.64-0.95]; AUC, 0.97). Compared with white-light ureterorenoscopy, PDD can significantly improve the additional detection rate of UTUC (RR 0.16, 95 % CI 0.07-0.34 P = 0.000).

CONCLUSIONS

PDD is a valid technique that improves the diagnostic accuracy of UTUC compared with standard white-light ureterorenoscopy at the per-lesion level. PDD is a promising endoscopic technique for upper UTUC.

[Upper urinary tract urothelial cell carcinoma]

Upper urinary tract urothelial cell carcinoma (UTUC) is a rare entity. The incidence in Germany is approximately 2/100,000 with a ratio between women and men of 1:2.5. Most clinical signs are nonspecific, which is why early diagnosis is rarely successful. Computed tomography urography in combination with diagnostic ureterorenoscopy is currently the gold standard in the diagnostics of UTUC. Regarding surgical treatment, radical nephroureterectomy (RNU) with resection of a bladder cuff remains the method of choice, although the radical approach is developing towards laparoscopic/robotic or endourological procedures with preservation of kidney tissue. Due to the high recurrence rate (22-47%) of urothelial carcinoma inside the bladder, close follow-up after RNU is mandatory.