Expert roundtables focus on upper tract urothelial carcinoma

Katie S. Murray, DO

Urology Times® recently hosted 2 case-based roundtable discussions on advancing care for patients with low-grade upper tract urothelial carcinoma (UTUC). Moderated by Katie S. Murray, DO, professor of urology at New York University Grossman School of Medicine chief of the Urology Service at Bellevue Hospital Center, New York, New York, each discussion aimed to share insights and experiences to improve patient outcomes. The rarity and complexity of this cancer type, making up about 6% of all urothelial cancers, were underscored, highlighting the challenges in accurate diagnosis and the limitations of current biopsy techniques. Multiple treatment options were discussed, along with patient case studies. What follows is a summary of both discussions.

This summary was AI generated and edited by human editors for clarity and length.

Roundtable 1

The panelists discussed several key aspects of UTUC management, including diagnosis and staging. They emphasized the importance of a thorough work-up, including urine cytology, CT urography, and ureteroscopy with biopsy. It was noted that accurate staging is crucial for determining the optimal treatment approach.

In terms of treatment options, the group acknowledged that active surveillance is a viable option for patients with low-grade, low-risk UTUC. However, they also discussed the importance of close monitoring and the potential need for intervention if the tumor progresses.

The panelists also discussed the advantages and limitations of endoscopic resection, including the risk of recurrence and the possibility of incomplete resection. Regarding radical nephroureterectomy, although typically reserved for high-grade UTUC or tumors that are not amenable to endoscopic resection, some participants expressed a willingness to consider radical nephroureterectomy for low-grade UTUC in certain patients, such as those with a history of bladder cancer or other risk factors.

Mitomycin reverse thermal hydrogel (Jelmyto) was also discussed. The panelists highlighted the efficacy of mitomycin gel in achieving local tumor control and preventing recurrence.

The panelists identified several risk factors for UTUC recurrence, including smoking history, prior bladder cancer, and the presence of multiple tumors. According to the group, patients with these risk factors may require more intensive surveillance.

The panelists emphasized the importance of shared decision-making with patients. This includes a discussion of the risks and benefits of different treatment options, as well as the potential for recurrence and progression. In addition, patients often have concerns about the impact of UTUC on their quality of life, including the risk of kidney dysfunction and the need for long-term surveillance. The panelists said it is important to address these concerns and provide reassurance.

The discussion also included case studies. For one of these, a 75-year-old male patient presented with painless hematuria and was found to have a low-grade tumor in the upper urinary tract. The patient had significant comorbidities, including hypertension and diabetes. The discussion focused on the pros and cons of endoscopic resection vs radical nephrectomy. The consensus was that endoscopic resection with adjuvant mitomycin C gel was a reasonable treatment option for this patient due to his age, comorbidities, and the low-grade nature of the tumor.

Another patient, a 60-year-old female, presented with a history of multiple endoscopic resections for low-grade UTUC. Despite repeated treatments, the patient continued to experience recurrent disease. The discussion explored the potential use of mitomycin C gel as a long-term maintenance therapy to prevent further recurrences. The experts agreed that mitomycin C gel could be a valuable option for patients with recurrent low-grade UTUC who are not candidates for radical nephrectomy.

Roundtable 2

In this discussion, the panelists highlighted the challenges of staging and grading, particularly the risk of underestimating the severity of the disease. Specifically, panelists expressed concerns about the limitations of current diagnostic tools, such as biopsy techniques, and the potential for missing high-grade disease.

As in the first roundtable, the panel explored various treatment options for low-grade UTUC, including radical nephroureterectomy and kidney-sparing techniques like endoscopic ablations .and segmental ureterectomy. Some panelists advocated for more conservative approaches, emphasizing the benefits of preserving kidney function. They discussed the role of intraluminal therapies, such as chemotherapy or BCG therapy, as adjuvant treatments. The panelists also considered the implications of the National Comprehensive Cancer Network guidelines, which recommend endoscopic resection with post-surgical intrapelvic chemotherapy as a primary treatment for low-grade disease.

As the panel discussed, endoscopic surgery is often the preferred method for managing low-grade tumors due to its minimally invasive nature. However, several challenges can complicate this approach. High tumor volume, social factors, and difficult tumor locations can make endoscopic surgery less feasible. In such cases, nephroureterectomy may be considered. Several panelists agreed that endoscopic management is generally suitable for low-grade tumors, focusing on recurrence rather than metastasis. The decision between nephroureterectomy and endoscopic ablation involves considering the patient's age, frailty, and the need for multiple procedures over time. Murray emphasized setting clear expectations for follow-up, which might include regular ureteroscopies or CT urography, depending on the patient's initial diagnosis and overall health status.

The introduction of chemoablation and chemotherapy, such as mitomycin reverse thermal hydrogel, has significantly affected the management of low-grade upper tract tumors. Panelists expressed optimism about these therapies, which can complement endoscopic ablation by targeting residual tumor cells. This approach is particularly beneficial for tumors that are difficult to access or completely remove endoscopically. The use of percutaneous administration of mitomycin reverse thermal hydrogel is preferred for logistical reasons, according to the panel.

The panel also discussed a case study of a 71-year-old male with recurrent non–muscle-invasive bladder cancer. The patient, with a history of smoking and diabetes, presents with low-grade papillary tumors in the ureter and renal pelvis. The panel discussed various treatment options, including surveillance, chemo ablation, and nephroureterectomy. One panelist advocated for surveillance after complete ablation, whereas another expressed concerns about ureteral strictures from ablative therapies. The case study highlighted the nuanced decision-making process in managing bladder cancer, balancing treatment efficacy with potential complications.