EAU 2020 Upper Tract Urothelial Cancer GL

Question 1

what is the incidence of UTUC in western countries?

Answer 1

2/100,000

Question 2

What percentage of UTUC are invasive at diangosis?

Answer 2

2/3 vs 15-25% of bladder UC

Question 3

after RC what percentage of patients will develop UTUC?

Answer 3

3-5%

Question 4

what mutation is associated with Lynch syndrome?

Answer 4

MSH2, mismatch repair genes smaller percentage also have microsatellite instability

Question 5

what are risk factors for UTUC?

Answer 5

smoking, aristocholic acid(cause p53 mutations), exposure to aromatic amines( benzidine, beta-naphthalene), arsenic, ( others are listed in campbell’s too)

Question 6

Who should have referral and testing done for lynch syndrome?

Answer 6

• Age<65 with UTUC - personal history of lynch spectrum disorder(CRC, endometrial, ovarian, skin) - first degree relative < 50 with lynch spectrum cancer - two first degree relatives with lynch spectrum cancers

Question 7

what kind of diagnostic and work up imaging should one do?

Answer 7

CTU, CH chest abdo pelvis for staging, MRU if needed

Question 8

What are the two best diagnostic tests for UTUC?

Answer 8

CT Urogram and Ureterorensocopy

Question 9

what is 5 year survival for pt4 tumors?

Answer 9

<10%

Question 10

what is 5 year survival for pT2/pT3 tumors

Answer 10

<50%

Question 11

What are preoperative prognostic factors for UTUC?

Answer 11

Tumor focality, location, presence of hydronephrosis, presence of systemic symptoms, age, race, ECOG, ASA score, BMI>30, neutrophil: lymphocyte ratio, surgery delay >3 months, grade(biopsy), tobacco consumption

Question 12

what are intra and post-operative prognostic factors?

Answer 12

tumor stage, grade, necrosis, LN involvement, LVI, CIS, tumor architecture( sessile vs papillary), positive margins, distal ureter management, variant histology

Question 13

what are risk factors for bladder recurrence after RNU?

Answer 13

Patient: male gender, previous bladder cancer, smoking, preoperative CKD Disease : positive preop urine cytology, ureteral location, multifocality, invasive pT stage, necrosis Treatment specific: lap approach, extravesical bladder cuff removal, positive margins, use of diagnostic URS

Question 14

What criteria need to be met for low risk UTUC?

Answer 14

unifocal, <2cm, low grade on biopsy, low grade cytology, non-invasive on CTU

Question 15

if any of these is present patient has high risk UTUC. what are they?

Answer 15

hydro nephrosis, tumor >2cm, high grade cytology, high grade biopsy, multifocal, variant histology, previous RC for high grade bladder Ca.

Question 16

is there a risk of tumor seeding with perc access for management of low risk UTUC?

Answer 16

Yes

Question 17

Offer kidney-sparing management as primary treatment option to patients with …… tumours.

Answer 17

low risk

Question 18

Offer kidney-sparing management to patients with high-risk tumors limited to …..

Answer 18

the distal ureter. an option but best is still nephroU

Question 19

if someone undergoes ureteral resection Can a LN be performed too

Answer 19

yes, do it at the same time

Question 20

Following local therapy for low risk UTUC, how do you give adjuvant therapy

Answer 20

anterograde with NT or retrograde with single J open ended, some have suggested using a double J but this likely does not reach the pelvis. ( all approaches are equal)

Question 21

what is the management of high risk UTUC?

Answer 21

radical nephroU+ excision of bladder cuff(open is standard) take precautions if doing lap

Question 22

what considerations need to be taken when performing MIS NephroU

Answer 22

1- avoid entering the urinary tract 2- avoid direct contact bw instruments and the tumor 3- dont morcelate, do it in a closed system and use endobag 4- kidney and ureter should be removed en bloc with the bladder cuff 5- T3,T4 N+ or M+ are contraindications to MIS. do it open

Question 23

How should bladder cuff be managed?

Answer 23

complete bladder cuff excision. none of this fancy shit with striping and pluck. just open it up and cut it out

Question 24

Does LND improve survival?

Answer 24

yes, if performed according to template even in node negative patients.

Question 25

what are the templates for renal pelvis and proximal ureteric UTUC LND?

Answer 25

Right: hilar, paracaval, retrocaval +/- interaortocaval Left: hilar, paraortic+/- interaortocaval

Question 26

what should be template for patients with UTUC mid ureter right and left?

Answer 26

Right: interaortocaval +/-paracaval +/- common iliac left: paraortic+/-common iliac+/- internal iliac

Question 27

what is the LND template for distal ureter UTUC right and left?

Answer 27

right: Common iliac +pelvic nodes+/- paracaval
left: common iliac + pelvic nodes +/- paraortic

Question 28

Is there any evidence for neoadjuvant chemo for UTUC?

Answer 28

yes, improves Complete response, DFS but no RCTs

Question 29

Is there any benefit for adjuvant chemo in UTUC?

Answer 29

yes, based on RCT(pout)

gem-cis chemo within 90 days of RNU assoicated with improved DFS in patients with locally advanced disease UTUC

Question 30

is there a role for adjuvan RT?

Answer 30

Nope

no sufficient evidence

Question 31

Is there a role for intravesical chemo preoperatively?

Answer 31

yes with RNU or nephron sparing approach

within 2-10 days give a single dose of intravesical mitomycin/pirarubicin

Question 32

Is there a role for RNU in patients with metastatic disease

Answer 32

For palliation

or in patients with minimal mets with complete response with chemo can be discussed

Question 33

Is there a role for metastetectomy for UTUC?

Answer 33

individual patient

shared decision making

Question 34

what is first line chemo for metastatic UTUC?

Answer 34

Cisplatin based chemo (GC, MVAC), give with G-CSF or PCG

if ineligible then pembro is approved too(only for PD-L1) positive patients so is atezolizumab( PD-L1 should be positive)

see the pic

Question 35

what is second line chemo for metastatic UTUC?

Answer 35

Pembrolizumab(50% reduction in risk of death)-

Vinflunine

Question 36

does carboplatin based chemo works as well as cusplatin based chemo?

Answer 36

No, worse OS

Question 37

What FU should be done after RNU if it is a low risk UTUC? hwat about high risk

Answer 37

LR: cystoscopy at 3,9 and yearly for 5 years

HR: Q 3 months for 2 years, then q6 until 5. then yearly

CT uro and chest q6 months x 2 years then yearly

Question 38

what FU should be done after kidney sparing surgery for low risk UTUC and high risk UTUC?

Answer 38

low risk: Cysto and CTU at 3,6 months then yearls, URS at 3 months at then some more

high risk: cysto, urine cytology, CTU and CT chest at 3 and 6 months then yearly

URS and urinary cytology in situ at 3 and 6 months.