WCE 2017: Current Role of Chemotherapy and Lymphadenectomy for Upper Tract Urothelial Carcinoma

Vancouver, Canada (UroToday.com) There are two key limitations of imaging and endoscopy for staging and risk stratification of upper urinary tract urothelial carcinoma (UTUC). First, ureteroscopy/ureteroscopic (URS) is unable to obtain deep tissue with muscle in a safe and reliable fashion, thereby limiting the applicability of URS biopsy to staging only clinical Tx, Ta, Tis, and T1. Second, imaging is a poor prognosticator as it is unable to confidently rule out invasion except in late-stage disease, i.e., cT3+.

Matin’s group recently developed a multiplex nomogram for non-organ confined disease (i.e., pT3-4, N+) with variables for biopsy grade, eGFR, architecture (i.e., papillary vs. sessile), and hemoglobin. It was validated using a sample size of 652 patients and was found to have an accuracy of 78%.

After radical nephroureterectomy (RNU), renal function is known to significantly deteriorate to the extent that most patients are precluded from receiving effective adjuvant chemotherapy. In 2004, MD Anderson began to routinely offer neoadjuvant chemotherapy (NAC) to all patients with high-risk UTUC, as defined by the presence of large, sessile, high-grade lesions. In a subsequent retrospective, risk-matched study, NAC was found to significantly improve disease-specific survival (DSS) (HR 0.19, p = 0.0015): see Porten & Matin (2014).

EORTC-ACRIN 8141 is a currently ongoing, open-label, nonrandomized, two-arm trial of NAC with an accrual goal of 60 patients. Arm A has completed accrual, while arm B (gemcitabine + carboplatin, x4 cycles) has accrued 14 out of a goal of 30 patients.

Templates for lymphadenectomy (LND) have been well described by Matin’s group: see Matin et al. (2015). LND reduces the local recurrence rate from 11-18% to less than 3%. In addition, caution should be taken in the use of CT imaging to evaluate lymph nodes, as approximately 50% of pN+ disease have normal imaging: see MP77-14 (AUA 2014).

Presenter: Surena F. Matin, MD

Affiliation: Anderson Cancer Center, Houston, TX, USA

Written by: Michael Owyong (@ohyoungmike), LIFT Fellow, Department of Urology, UC Irvine Medical Center, Orange, CA, USA at 35th World Congress of Endourology– September 12-16, 2017, Vancouver, Canada.

Login