EAU 2020 Upper Tract Urothelial Cancer GL Flashcards
what is the incidence of UTUC in western countries?
2/100,000
What percentage of UTUC are invasive at diangosis?
2/3 vs 15-25% of bladder UC
after RC what percentage of patients will develop UTUC?
3-5%
what mutation is associated with Lynch syndrome?
MSH2, mismatch repair genes smaller percentage also have microsatellite instability
what are risk factors for UTUC?
smoking, aristocholic acid(cause p53 mutations), exposure to aromatic amines( benzidine, beta-naphthalene), arsenic, ( others are listed in campbell’s too)
Who should have referral and testing done for lynch syndrome?
- 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
what kind of diagnostic and work up imaging should one do?
CTU, CH chest abdo pelvis for staging, MRU if needed
What are the two best diagnostic tests for UTUC?
CT Urogram and Ureterorensocopy
what is 5 year survival for pt4 tumors?
<10%
what is 5 year survival for pT2/pT3 tumors
<50%
What are preoperative prognostic factors for UTUC?
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
what are intra and post-operative prognostic factors?
tumor stage, grade, necrosis, LN involvement, LVI, CIS, tumor architecture( sessile vs papillary), positive margins, distal ureter management, variant histology
what are risk factors for bladder recurrence after RNU?
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
What criteria need to be met for low risk UTUC?
unifocal, <2cm, low grade on biopsy, low grade cytology, non-invasive on CTU
if any of these is present patient has high risk UTUC. what are they?
hydro nephrosis, tumor >2cm, high grade cytology, high grade biopsy, multifocal, variant histology, previous RC for high grade bladder Ca.
is there a risk of tumor seeding with perc access for management of low risk UTUC?
Yes
Offer kidney-sparing management as primary treatment option to patients with …… tumours.
low risk
Offer kidney-sparing management to patients with high-risk tumors limited to …..
the distal ureter. an option but best is still nephroU
if someone undergoes ureteral resection Can a LN be performed too
yes, do it at the same time
Following local therapy for low risk UTUC, how do you give adjuvant therapy
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)
what is the management of high risk UTUC?
radical nephroU+ excision of bladder cuff(open is standard) take precautions if doing lap
what considerations need to be taken when performing MIS NephroU
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
How should bladder cuff be managed?
complete bladder cuff excision. none of this fancy shit with striping and pluck. just open it up and cut it out
Does LND improve survival?
yes, if performed according to template even in node negative patients.
what are the templates for renal pelvis and proximal ureteric UTUC LND?
Right: hilar, paracaval, retrocaval +/- interaortocaval Left: hilar, paraortic+/- interaortocaval
what should be template for patients with UTUC mid ureter right and left?
Right: interaortocaval +/-paracaval +/- common iliac left: paraortic+/-common iliac+/- internal iliac
what is the LND template for distal ureter UTUC right and left?
right: Common iliac +pelvic nodes+/- paracaval
left: common iliac + pelvic nodes +/- paraortic
Is there any evidence for neoadjuvant chemo for UTUC?
yes, improves Complete response, DFS but no RCTs
Is there any benefit for adjuvant chemo in UTUC?
yes, based on RCT(pout)
gem-cis chemo within 90 days of RNU assoicated with improved DFS in patients with locally advanced disease UTUC
is there a role for adjuvan RT?
Nope
no sufficient evidence
Is there a role for intravesical chemo preoperatively?
yes with RNU or nephron sparing approach
within 2-10 days give a single dose of intravesical mitomycin/pirarubicin
Is there a role for RNU in patients with metastatic disease
For palliation
or in patients with minimal mets with complete response with chemo can be discussed
Is there a role for metastetectomy for UTUC?
individual patient
shared decision making
what is first line chemo for metastatic UTUC?
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
what is second line chemo for metastatic UTUC?
Pembrolizumab(50% reduction in risk of death)-
Vinflunine
does carboplatin based chemo works as well as cusplatin based chemo?
No, worse OS
What FU should be done after RNU if it is a low risk UTUC? hwat about high risk
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
what FU should be done after kidney sparing surgery for low risk UTUC and high risk UTUC?
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.
