Risk-Adapted Oncologic Surveillance Post-Radical Nephroureterectomy for High-Risk Upper-Tract Urothelial Carcinoma - Expert Commentary

Patients with upper tract urothelial carcinoma (UTUC) can be divided into low-risk or high-risk groups. Surveillance recommendations for patients with high-risk UTUC are extrapolated from those used in bladder cancer. Martini et al. aimed to refine surveillance recommendations specific to UTUC. The investigators used a dataset of 1,378 high-risk UTUC patients treated with radical nephroureterectomy at eight participating European academic centers between 1992 and 2016. The current European Association of Urology (EAU) guidelines stipulate that imaging should be de-intensified at two years and performed semiannually. At this point, the investigators found that the risk of non-bladder recurrence was 42% in patients without a history of bladder cancer and 47% in patients with prior bladder cancer.


According to the guidelines, cystoscopies can be de-intensified after 5 years to be performed annually. However, at 4 years, the risk of bladder recurrence was 13% and other-site recurrence was 23%, while the risk of bladder recurrence dropped to 10% at five years and continued to decrease over time. Martini et al., therefore, suggest that intensifying the frequency of imaging to semiannual till the 4th year after radical nephroureterectomy, the time point after which the risk of recurrence was almost halved.

With respect to the duration of surveillance, the authors suggest that among patients without a prior bladder cancer diagnosis, patients younger than 70 years old should be monitored with cystoscopies and cross-sectional imaging for more than 10 years after RNU due to the risk of recurrence. They suggest that cystoscopies can be discontinued among patients between the ages of 70 and 79, while cross-sectional imaging should be continued for more than 10 years after RNU. Patients older than 80 can discontinue all surveillance as the risk of other-cause mortality exceeds the risk of recurrence. For patients with a history of bladder cancer, the authors recommend that both cystoscopies and cross-sectional imaging should be continued for more than 10 years.

Previous studies had evaluated surveillance measures after RNU but did not provide assessments stratified by risk of recurrence. The current study provides a risk-adapted personalized surveillance strategy, and subsequent recommendations would prevent patients from being needlessly subjected to a battery of tests while ensuring that patients at higher risk of recurrence will be well-monitored and well-managed. However, due to the retrospective nature of the data, some variation in patient follow-up and management can be expected. Accordingly, further validation will be required.

Written by: Bishoy M. Faltas, MD, Director of Bladder Cancer Research, Englander Institute for Precision Medicine, Weill Cornell Medicine, New York City, New York

References:

  1. Martini, A., Lonati, C., Nocera, L., Fallara, G., Raggi, D., Herout, R., Zamboni, S., Ploussard, G., Predere, B., Mattei, A., Simeone, C., Krajewski, W., Simone, G., Soria, F., Gontero, P., Roupret, M., Montorsi, F., Briganti, A., Shariat, S. F., Necchi, A., … Moschini, M. (2022). Oncologic Surveillance After Radical Nephroureterectomy for High-risk Upper Tract Urothelial Carcinoma. European urology oncology, S2588-9311(22)00061-X. Advance online publication. https://doi.org/10.1016/j.euo.2022.04.003.

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