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BackTable / Urology / Article
Evaluating Upper Tract Urothelial Carcinoma (UTUC)
Ishaan Sangwan • Apr 25, 2023 • 49 hits
Upper tract urothelial carcinoma (UTUC) is an uncommon cancer, and the American Urological Association does not currently risk-stratify the disease. However, it is important to risk stratify in practice, as it can help determine the optimal treatment options available to patients.
Dr. Silva and Dr. Murray discuss how they approach this entity, and the options they offer their patients based on staging. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable Urology Brief
• Patients with upper tract disease usually present with hematuria, and initial workup includes CT urogram and enhanced cystoscopy.
• Low grade disease with negative cytology and smaller tumor size can be treated with ablation therapies.
• JELMYTO is an intracavitary chemotherapy treatment which has been shown to lower recurrence rates in low grade disease.
• Ureterectomy and nephroureterectomy is typically preferred over ablation in high grade disease.
Table of Contents
(1) Initial Workup for Upper Tract Urothelial Carcinoma
(2) Treating Low Grade Upper Tract Urothelial Carcinoma
(3) Treating High Grade Upper Tract Urothelial Carcinoma
Initial Workup for Upper Tract Urothelial Carcinoma
Patients eventually diagnosed with upper tract disease often present to the Urology office for follow-up of gross or microscopic hematuria. All patients with gross hematuria receive a routine cystoscopy, with the option of an enhanced cystoscopy along with a CT urogram. Patients with microscopic hematuria often receive the same workup, especially if they have risk factors including advanced age, smoking history, or family history of the disease. For patients who have filling defects or masses on CT urogram, biopsies are obtained to further evaluate the disease.
[Dr. Jose Silva]
Those patients, when you're doing microscopic workup or hematuria workup, you're doing the CT urogram, cystoscopy, are you doing cystoscopy in these patients in the office with blue light, or what are you doing just regular cystoscopies?
[Dr. Katie Murray]
I do a regular cystoscopy. At our institution, we have Olympus Towers, Olympus Scopes. I use routine cystoscopy with the option of narrow-band imaging or NBI technology as an enhanced cystoscopy. Part of that, I think, is important for whatever technology you have for enhanced cystoscopy is to use it on as many patients as you can just to get that experience. NBI does have the capability of being able to flip the switch and not do that preoperative preparation with a catheter in the Cysview.
You can flip over to NBI and take a quick glance at patients' bladders with that. I will do that on a majority of cystos that I do. Part of it's for my own experience. Of course, I'm at a training institution as well, so to see that with that enhanced cystoscopy. Definitely CT urogram, cystoscopy for those patients with gross hematuria. Then a majority of patients, especially if they have any sort of risk factors, older age, previous history of smoking, any family history, we're talking about doing that for microscopic hematuria as well.
[...]
[Dr. Jose Silva]
Let's go ahead and talk about a patient that you already know has something there, did the CT urogram, came back with some sort of filling defect. Most likely, there is a mass let's say that is not infiltrating into the parenchyma, a filling defect in the renal pelvis. What do you tell the patient? What are you going to do? What's the planning for that patient?
[Dr. Katie Murray] That's the patients that I'm sitting at clinic. I have the CT urogram in front of me. I show them the pictures. There's clearly something blocking the drainage. It's not filling up right here, so I'm going to take you to the operating room. We get multiple things with one operation. I get to look inside your bladder at the time. I evaluate that. If there's anything inside your bladder, I'll take care of that. At the same time, I'm going to throw the ureteroscope or run the scope all the way up your ureter, so I can insert and see that entire tube and then up in your kidney. First things first, I'm going to take a biopsy of that. Those are hard biopsies for us to get.
I explain that to the patient, off the get-go, that we may have complications in getting that tissue and what kind of scope we're working through, and what we're dealing with. We'll talk about that, but attempt to do a biopsy. If it looks to be something that I can easily endoscopically ablate, I'll tell the patient, "If it's something I can take care of, I'll try to take care of it right then and there, on the spot, so you get it all for one."
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Treating Low Grade Upper Tract Urothelial Carcinoma
The AUA, unlike the European guidelines, does not risk stratify upper tract disease. However, this distinction is significant, and should guide surgical and medical management. Low grade disease has negative cytology and smaller tumor sizes, and can be amenable to nephron sparing ablation treatments. Additionally, JELMYTO, an intracavitary chemotherapy treatment, can be administered over a six week induction period to further lower recurrence rates. Dr. Murray recommends using a nephrostomy tube to deliver JELMYTO, although it can be administered retrograde during a cystoscopy as well.
[Dr. Katie Murray]
I think low grade is, you've mentioned multiple times about guidelines. One thing that the Europeans have is they have some risk stratification for upper tract disease that we don't have in our AUA Guidelines. We have it in bladder cancer, we talk about low risk, intermediate risk, high risk, but we don't have that in upper tract disease and the European Guidelines do. They talk about low-risk patients, which are low-grade patients with negative cytology, with smaller tumor sizes in the collecting system that are also a good indication for nephron sparing, i.e. ablations or whether that be an endoscopic ablation, chemo ablation.
Somebody's low grade, while I've ablated into completion, I'm going to talk to them about the ongoing concern for recurrence. Recurrence rates are high with endoscopic ablations pushing over 50% and pushing 70% nearly, for those ablations but is there something else out there? I will talk to him about intracavitary chemotherapeutic. In today's world since 2020, that's JELMYTO and what that looks like for that patient population.
We're looking at a six-week induction course of JELMYTO with or without maintenance therapy of that ongoing for this low-risk or low-grade patients versus ongoing endoscopic ablations because that recurrence is going to happen. It's pushing like I said, 70% in large studies of patients with low-grade disease.
[Dr. Jose Silva]
What are you doing for the patients on JELMYTO? I think you can do it like nephrostomy and inject it weekly or also take the patient to the OR and just do a retrograde. What's your practice?
[Dr. Katie Murray]
It's a cool new thing that chemo ablator that gives us options for our patients. I've done a mixed bag. I've injected both ways, but 80% of the patients I've treated, I've treated with a nephrostomy tube.
I've done it through the nephrostomy tube for a majority of my patients that I've treated, a little bit for convenience, a little bit because the patients don't want to have cysto every week for six weeks, a little bit because I don't have fluoroscopy available right in there in my clinic. If I knew I have a nephrostomy tube in place, and I know that it drains urine, it's in the correct location, I can safely instill my chemotherapy.
Treating High Grade Upper Tract Urothelial Carcinoma
For high grade disease, ablation may still be an option, but it should be carefully considered as it is usually not curative, and can lead to complications. Unlike the bladder, the ureter lacks muscle for additional integrity, and can be damaged during ablation. Careful staging, including pelvic node biopsy and a CT scan of the chest, abdomen, and pelvis, can help determine if ablation should be considered. Patients with absolute contraindications to ureterectomy or nephroureterectomy, including solitary or horseshoe kidney and bilateral disease, are the best candidates for ablation.
[Dr. Katie Murray]
I would caution people to jump again and doing just ablations on patients who can have other things for high-grade disease. A couple of things that always come to mind that I really think about is we can't forget that high-grade disease, especially in the ureter, it doesn't have that backing that we have in the bladder. It doesn't have muscle around it. It's in the ureter or it's out of the ureter. One thing that I always remind is don't forget to do your staging. Don't forget to check your pelvic nodes. Don't forget to look at your chest. I prefer to do a CT chest in all of the rest, abdomen, pelvis on any patient with high-grade disease, no matter where it's at.
I will do ablations on people with high-grade disease, but those are the people with absolute contraindications to having something else. Our solitary kidneys and bilateral disease. Our patients who you do a nephroureterectomy or even you do a distal ureterectomy you're worried about putting the patient on dialysis, something like that. Absolute discussion that the standard of care is taking it out to completion. Is that a nephroureterectomy on distal tumors? It's probably a distal ureterectomy with a lymph node dissection in a ureteral reimplant.
Podcast Contributors
Dr. Katie Murray
Dr. Katie Murray is a urologic oncologist with the University of Missouri.
Dr. Jose Silva
Dr. Jose Silva is a board certified urologist practicing in Central Florida.
Cite This Podcast
BackTable, LLC (Producer). (2022, August 17). Ep. 50 – Breaking Down Upper Tract Malignancy [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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