AUA 2019: Topical Treatment for High-Grade Upper Tract Cytology with Negative Imaging

Chicago, IL ( One common frustration for urologists is confirming a diagnosis of upper tract urothelial carcinoma in patients who have positive high-grade cytology but no visible lesions on imaging. While the standard of care for high-grade upper tract urothelial carcinoma is a radical nephroureterectomy with bladder cuff, there are no specific guidelines for the management of high-grade upper tract cytology without a visible lesion.

Dr. Andrew Vitale from the University of Iowa Hospitals and Clinics presented his group’s work that aims to try and help shed light on this difficult clinical scenario. They retrospectively collected data on 66 patients who underwent some type of upper tract therapy (UTT) for high-grade upper tract cytology with negative imaging. UTT regimens included weekly BCG+Interferon for 6 weeks, BCG+Interferon+IL2+GMCSF for 6 weeks, gemcitabine/docetaxel for 6 weeks, or adramycin and gemcitabine alternating weekly with sequential mitomycin and docetaxel for 6 weeks. After induction, patients were restaged with cystoscopy and upper tract cytologies, imaging and ureteroscopy. They then calculated recurrence-free survival from the time of treatment.

Of the 66 enrolled patients, 43 (65%) of patients had coexistent bladder cancer recurrences, while 38 (57%) of patients had upper tract recurrence. Of the patients who had upper tract recurrence 20% underwent nephroureterectomy, 14% refused treatment or were not appropriate surgical candidates, and 12% developed metastatic disease. At 44-month follow-up, 14 (21%) of patients had died due to urothelial carcinoma. They then created Kaplan-Meier curves to evaluate recurrence-free survival based on the type of UTT regimen the patient received. (Figure 1)

Figure 1.
AUA 2019 upper tract recurrence free survival

Vitale concluded that topical treatments for upper tract urothelial carcinoma may provide a durable recurrence-free survival in patients with positive high-grade upper tract cytology and negative imaging, however, close follow-up is necessary, because many patients do eventually recur, progress, or develop metastatic disease.

Presented by: Andrew Vitale, MD, University of Iowa Hospitals and Clinic, Iowa City, Iowa

Written By: Brian Kadow, MD. Society of Urologic Oncology Fellow, Fox Chase Cancer Center, Philadelphia, PA. @btkmduro at American Urological Association's 2019 Annual Meeting (AUA 2019), May 3 – 6, 2019 in Chicago, Illinois