UTUC roundtable discussions highlight guidelines, patient cases

Katie S. Murray, DO, MS

In 2 recent expert roundtable discussions, urologists convened to discuss the management of patients with low-grade upper tract urothelial carcinoma (UTUC). The gatherings focused on the challenges and evolving treatment strategies in this disease. The discussions were moderated by Katie S. Murray, DO, MS, professor of urology at New York University Grossman School of Medicine chief of the Urology Service at Bellevue Hospital Center, New York, New York. What follows is a summary of these discussions.

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

Roundtable 1

Utilization of American Urological Association (AUA) guidelines. The discussion began with a focus on AUA guidelines for UTUC. Participants expressed varying degrees of adherence to the guidelines, particularly regarding risk stratification for low-risk and high-risk disease. One participant noted the importance of identifying patients who may benefit from topical treatments for low-grade tumors, whereas another emphasized differentiating patients based on their disease's aggressiveness.

One participant said that patient context, including kidney function and overall health, plays a crucial role in decision-making. The consensus was that although guidelines are valuable, clinical judgment remains vital in managing patients with upper tract disease.

Challenges in diagnosis and treatment. The group addressed the inherent challenges in diagnosing and treating upper tract tumors. With a low incidence of these tumors, urologists often face difficulties in obtaining adequate biopsies. One participant highlighted the importance of ensuring that kidneys are functioning well before deciding on aggressive treatment options.

A significant concern raised was the potential for upgrading low-grade tumors during treatment, prompting the group to advocate for thorough sampling and consideration of alternative diagnostic approaches, including percutaneous biopsies.

Adjuvant therapies and new treatment options. As the discussion progressed, the panel explored adjuvant therapies, particularly the use of intracavitary treatments like mitomycin reverse thermal hydrogel (Jelmyto). Participants shared their experiences with the drug, noting its potential benefits in preserving kidney function while managing low-grade tumors. One participant emphasized the importance of treatment adherence and patient education regarding the risks of disease progression.

The panel also acknowledged the challenges associated with traditional chemotherapeutics like BCG and mitomycin C. One participant pointed out that although BCG has been used in upper tract management, data supporting its efficacy remain limited.

Case discussions. As part of the roundtable, the panel discussed 2 patient cases. The first involved a 61-year-old woman who presented with intermittent painless gross hematuria. A CT scan revealed a 1.5-cm filling defect in the lower pole of the left kidney, which was confirmed to be low-grade upon biopsy. The cystoscopy was negative, and the urine cytology was also negative. The panelists discussed treatment options, with some suggesting endoscopic resection followed by intracavitary chemotherapy like mitomycin reverse thermal hydrogel, whereas others felt that endoscopic resection alone was sufficient due to the solitary tumor and low-risk category. The general consensus leaned toward endoscopic treatment first, with the possibility of adjuvant therapy if recurrence occurred, particularly due to the potential for multifocality in low-grade tumors.

The second case revolved around a 71-year-old man with a history of low-grade non-muscle invasive bladder cancer who presented with hematuria and was found to have multiple small papillary tumors in the ureter and renal pelvis. A diagnostic ureteroscopy confirmed these tumors as low-grade. The panel debated whether to proceed with adjuvant chemotherapy given the multifocal nature of the disease and the patient's renal function (GFR of 52). Although some advocated for a nephroureterectomy due to the multifocality and risk of recurrence, others argued for surveillance after ablation, emphasizing the patient’s history and renal preservation

The roundtable underscored the complexities of managing low-grade UTUC, highlighting the need for individualized treatment plans that consider patient history, tumor characteristics, and functional kidney status. As the field continues to evolve, ongoing collaboration and sharing of insights among experts will be essential in improving patient outcomes.

Roundtable 2

This roundtable began by highlighting that although UTUC constitutes only about 6% of all urothelial cancers, it presents unique challenges in diagnosis and treatment. Participants noted that only 25% to 30% of patients present with low-grade disease, making it imperative for clinicians to accurately identify these cases. Risk stratification plays a critical role in managing UTUC, with Murray emphasizing the importance of thorough patient evaluations, including urine cytology and imaging studies.

Treatment strategies. Several treatment options were explored during the roundtable. One participant discussed the benefits of nephron-sparing techniques, including endoscopic approaches and laser ablation, particularly in patients with smaller tumors. The consensus among the group was that endoscopic resection should be considered for low-grade tumors, with many opting to combine this with adjuvant therapies such as mitomycin gel, particularly following ablation.

One discussant raised an important point regarding the challenges of managing multifocal tumors and the potential for under-staging. He noted that although low-grade tumors can be managed conservatively, the risk of high-grade disease necessitates careful monitoring and sometimes aggressive treatment, particularly in younger patients or those with significant comorbidities.

Emerging therapies. The roundtable also highlighted recent advancements in the field, particularly the introduction of like mitomycin reverse thermal hydrogel. This formulation has shown promise in providing a minimally invasive option for patients with low-grade UTUC. Murray emphasized the importance of knowing the renal pelvis volume to ensure effective administration of the treatment, as dosage is contingent on this measurement.

Case discussions. As in the previous roundtable, the panel discussed patient cases, which were the same profiles as in the first roundtable. In the first case, the participants discussed whether to perform endoscopic resection and if they would do the ablation at the same time as the biopsy. Most agreed that they would perform both procedures concurrently, but there was a divergence regarding the administration of mitomycin reverse thermal hydrogel at the same time as the biopsy, with some expressing uncertainty about that approach.

For the second case, the discussion revolved around treatment options for this patient. Some participants suggested that the presence of multiple tumors in 2 separate locations would lead them to recommend nephroureterectomy due to concerns about complete tumor removal. Others expressed that with experience using mitomycin reverse thermal hydrogel, they might consider it a reasonable option for treatment, highlighting the importance of the patient's compliance and overall health status in their decision-making.

As the discussion concluded, the group recognized the importance of collaborative efforts to enhance treatment protocols for low-grade UTUC. The exchange of ideas underscored the need for ongoing education, research, and adaptation of practices based on emerging evidence. Murray expressed gratitude for the insights shared during the roundtable and encouraged participants to remain engaged in the evolving landscape of urologic oncology.

The expert roundtable provided a platform for urologists to share their experiences and perspectives on managing low-grade UTUC, reflecting a commitment to improving patient outcomes through collaborative learning and innovation.