Washington, DC USA (UroToday.com) In today’s general session at the 2015 Society of Urologic Oncology, Dr Siefker-Radtke Arlene from MD Anderson Cancer center discussed the issue of administering neo-adjuvant chemotherapy (NAC) in upper tract urothelial carcinoma (UTUC). Clinically, the goal of any NAC regimen is to maximize efficacy of the treatment while reducing toxicity.
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The rates of pathological T0 at nephroureterctomy are 39% for patients who received NAC, similar to bladder cancer cases. On contrary, the rates of pT0 for patients who did not receive NAC are in the single digit range. So, there is no doubt on the efficacy of NAC in UTUC.The main issue is the nephrons. Before NAC administration, kidney function should always be optimized. However, the definition of normal kidney function differs between studies and clinicians. Creatinine clearance (CrCl) <60 cc/min is the classical definition and community standard. However, this definition may be to stringent and by using it many patients may lose the benefits of NAC. Dr Siefker-Radtke uses CrCl <50 cc/min same as was done in several clinical trials and is the MD Anderson Cancer Center standard. Next, Dr Siefker-Radtke described the different methods to achieve optimized renal function. First, avoidance of nephrotoxic drugs such as ACE inhibitors. Aminoglycoside should be avoided at any cost even in patients who might potentially receive cisplatinum in the future. Drugs that might transitionally impair CrCl (e.g. Cipro, Bactrim) should be stopped and renal function should be allowed to recover. Second, a split dose of cisplatinum may be used in patients with borderline renal function (CrCl 40-50).
In these patients hydration is critical. “I would start the treatment by giving 1 liter of fluids and finish with additional 3 liters. If the patients are fluid overloaded than I would add a diuretic but would not reduce the amount of fluids given” says Dr Siefker-Radtke. Finally, some patients are truly Cis –ineligible (CrCL<40 cc/min). These patients would receive nephron sparing regimens such as Gemcitabine, paclitaxel and doxorubicin. If renal function improves than cisplatinum can be incorporated in the future.
Dr Siefker-Radtke finalizes her talk with a quick review on different subtypes of UTUC. “Urothelial cancer is no longer 1 disease with basal and luminal subtyped by their genome. Different subtypes have different responses to NAC and the future will enable us to predict this response”.
MD Anderson Cancer Center
Dr. Miki Haifler from the 2015 Winter Meeting of the Society of Urologic Oncology (SUO) "Defining Excellence in Urologic Oncology" - December 2 - 4 - Washington, DC USA
*Fox Chase Cancer Center, Philadelphia, PA USA