AUA 2019: Confederacion Americana De Urologia: Upper Tract Transitional Cell Cancer: 2020

Chicago, IL USA (UroToday.com) The grading and staging of upper tract urothelial carcinoma (UTUC) remain unreliable and problematic. Treatment guidelines for UTUC continue to evolve as more data is available for outcomes of minimally invasive management. In 2015, the European Association of Urology (EAU) guidelines recommended endoscopic management for unifocal disease, tumors <2 cm, low grade cytology, and no findings indicative of invasion on CT urography. A study by Roupret et al published in European Urology 2017 demonstrated 5-year recurrence-free survival (RFS) up to 75% and progression-free survival (PFS) of 95% for patients managed endoscopically.

Contemporary studies have shown that CT imaging findings do not correlate with ureteroscopy findings. If a nephroureterectomy is performed based on CT findings alone, 30% of the time the pathology is discordant at the time of surgery. At present, ureteroscopy prior to radical surgery is strongly recommended.

Unfortunately, ureteroscopy has its own diagnostic and therapeutic challenges and limitations. Biopsy reliability is variable, and there is a relatively high rate of non-diagnostic biopsy readings. For example, a 3 Fr focep (2x2mm) is inconclusive 68% of the time. Nitinol baskets are usually diagnostic when a specimen is obtained, but 20% of the time they cannot be used based on tumor location, size, or composition. A 6 Fr forcep (BIGopsy®) (33x33mm) is inconclusive 15% of the time and in the majority of cases requires continuous flow.

New technologies are under development that may help in the grading and staging of UTUC.

Confocal laser endomicroscopy (CLE) was developed several years ago, and recent pilot studies by Dr. Liao et al at Stanford have shown that there is potential for distinguishing low from high grade urothelial carcinoma intraoperatively. Low grade UTUC is characterized by uniform cellular aggregates around fibrovascular stalks, and relatively small cells surrounding fibrotic cores. High grade UTUC is characterized by dysmorphic cellular aggregates with distorted microarchitecture and indistinct cell borders; tortuous vessels can also be seen. Dr. Breda showed a technique of obtaining a biopsy, then performing CLE on the back table using a larger French probe for improved visualization. Studies have shown that there is 100% and 83% concordance between CLE and final histopathology in low, and high-risk UTUC, respectively. There is substantial interobserver agreement (Cohen’s k=0.64).

Optical coherence tomography (OCT) is another new technology that functions like an intraoperative CT scan. Real-time images of urothelial tumors are obtained, and the depth of invasion can be measured. With advancements in this technology, staging of UTUC may become significantly more reliable which may lead to significant paradigm shifts in the management and treatment of this disease.

He discusses his preference for laser and concludes that a combination of Thulium and Holmium are superior to either laser alone.

Dr. Breda concludes that management of tumors < 2 cm should be performed endoscopically, that diagnostic ureteroscopy is mandatory before radical surgery and that it may be enhanced by technologies in the future such as CLE and OCT, that treatment of UTUC should be done with combination laser technology, and that our field continues to strive toward excellence and improvement in diagnosis and treatment of UTUC.

Presented by: Alberto Breda, MD, Fundació Puigvert, Department of Urology

Written by: Selma Masic, MD, Urologic Oncology Fellow (SUO), Fox Chase Cancer Center, @selmasic at the American Urological Association's 2019 Annual Meeting (AUA 2019), May 3 – 6, 2019 in Chicago, Illinois