SUO 2017: Chemotherapy Prior to Radical Nephroureterectomy in Patients with Advanced Upper Tract Urothelial Carcinoma

Washington, DC ( Dr. Miest and colleagues presented their institutional experience of chemotherapy prior to radical nephroureterectomy for patients with advanced upper tract urothelial carcinoma (UTUC). Although chemotherapy improves survival in muscle-invasive urothelial carcinoma of the bladder, its use in the management of UTUC either before or after radical nephroureterectomy remains unclear. The objective of this study was to determine the outcomes of neoadjuvant chemotherapy in patients with UTUC. 

The authors identified 676 patients who underwent radical nephroureterectomy for UTUC from 1995-2011 at the Mayo Clinic. Patients were categorized by radiographic and pathologic response to neoadjuvant chemotherapy. Postoperative cancer-specific survival was estimated using the Kaplan-Meier method and compared using the log rank test. Among these patients, there were 42 (6.2%) that underwent chemotherapy prior to nephroureterectomy. The majority of these patients had clinical lymphadenopathy (n=25, 59.5%) or limited metastatic disease (n=8, 19%) prior to chemotherapy. Nearly all patients (n=40, 95%) received a cisplatin-based chemotherapy regimen and patients received a median of 4 cycles of chemotherapy prior to surgery. The median reduction in radiographic tumor size was 36%. A total of 13 patients (31%) were down-staged to non-invasive, node negative disease at surgery. Cancer-specific survival was significantly associated with complete radiographic response (p=0.04) and pathologic down-staging to non-invasive, node negative urothelial carcinoma (p=0.018). Not surprisingly, the majority of patients that harbored residual invasive or nodal disease died of UTUC. 

In summary, neoadjuvant cisplatin-based chemotherapy demonstrated similar efficacy in down-staging UTUC as bladder urothelial carcinoma. Furthermore, patients that experience complete radiographic response and/or pathologic downstaging have durable long-term survival. Due to the high mortality of advanced UTUC, increased utilization of neoadjuvant chemotherapy for appropriate patients should be encouraged, as well as further studies assessing the timing, method and type of chemotherapy/immunotherapy.

Presented by: Tanner Miest, MD, PhD

Co-Authors: Amir Toussi MD, Stephen Boorjian MD, Houston Thompson MD, Brian Costello MD, Bradley Leibovich MD and Matthew Tollefson MD
Affiliation: Department of Urology, Mayo Clinic, Rochester, MN

Written by: Zachary Klaassen, MD, Society of Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre @zklaassen_md at the 18th Annual Meeting of the Society of Urologic Oncology, November 20-December 1, 2017 – Washington, DC

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