ANAHEIM, CA (UroToday.com) - Dr. Jerome Richie presented a State-of-the-Art Lecture “What is New in the Management of Upper Tract Transitional Cell Carcinoma” at the Wednesday Plenary Session of the AUA in Anaheim, May 23, 2007.

CT scanning is the mainstay of upper tract imaging, Dr. Richie started. Intravenous pyelograms are rarely available anymore, and CT is validated as having high sensitivity. Cytology remains important, as does getting a biopsy, although the latter is often hampered by the small amount of tissue obtained. Positive cytologies should be followed closely and monitored to document a tumor, but one should not act on treating a positive marker test alone.

Conservative management by cytology, biopsy and ablation using a laser can then be followed by intracavitary chemotherapy or immunotherapy. However, a study by Johnson (BJU, 2005) demonstrated a 68% recurrence rate with this protocol. It should be considered for low grade tumors only. He then showed numerous small series with recurrence rates of 12-85%, and a combined mean of 36%.

Progression however remained the bigger concern. Tumor stage, grade and lymph node involvement are most critical to predict survival in the MD Anderson series (Brown, BJU, 2006). Lower stage and grade tumors had reasonable 5 year survival but higher grade and stage fared worse. Positive LN have a <40% 5 year survival. While stage T2 upper tract TCC has an 80% 5 year survival, it decreases to 30% with T4 disease.

Laparoscopic nephroureterectomy (NU) is an excellent option for surgical management. Oncologic outcomes are equivalent to open surgery. There are numerous ways to remove the distal ureter, but he felt an open incision to do this part of the operation was best.

Gemcitabine with cisplatin is less toxic with a similar response rate to MVAC. Paclitaxel with carboplatin for regionally advanced disease showed 5 year survival of 40%, and holds promise.

Molecular markers are numerous, and CD24 and COX-2 expression were presented at this AUA, but were not significantly better than standard markers. C-reactive protein is another marker under development.

He concluded that better imaging and diagnostic techniques along with conservative therapy for selected patients are changing the field. Minimally invasive surgery is a welcome advancement, but there are needs for improved early detection, predictors of aggressive behavior and better multimodal therapy.

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Written by Christopher P. Evans, MD, a Contributing Editor with UroToday.

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