Upper Tract Uothelial Carcinoma (UTUC) Flashcards
1
Q
Risk factors for UTUCs:
A
Smoking
Aromatic amines
Phenacetin
Balkan endemic nephropaty
Endemic in sothwest Taiwan: aristolochoic acid
Polymorphisms: SULT1A1 reduction of sulfotransferase activity
Hereditary linked to HNPCC (lynch syndrome)
2
Q
What types of cancers can individuals with HNPCC (lynch syndrome) get?
A
Endometrial Stomach UTUCs Biliary ducts Ovarian Small intestines Skin Brain
3
Q
When should Lynch syndrome be suspected?
A
UTUC in patient <60 years and
personal history of HNPCC-type cancer
or
First degree relalitve <50 years old with HNPCC-type cancer
or
Two first degree relatives with HNPCC-type cancer
4
Q
What is the recommended investigation for suspected UTUC?
A
Urinary cytology
Cystoskopy to rule out concomittant bladder tumour
CT urography
5
Q
The sensivity for cytology in UTUCs is less or greater than bladder cancer?
A
less sensitive
6
Q
With how much does NBI (narrow band imaging) increase detection rate of UTUCs?
A
23%
7
Q
What can you use Optical Coherence Tomography for?
A
Staging of UTUCs
8
Q
What share of biopsies from the urether are non diagnostic for UTUC?
A
20%
9
Q
Pre-operative prognostic factors for UTUCs (12):
A
Tumour focality Tumour location Grade (biopsy, cytology) Age BMI Tobacco comsumption ECOG ASA score systemic symptoms hydronephrosis Delayed surgery >3 months Neutrophil-to-lymphocyte ratio
10
Q
Intra- and post-operative prognostic factors for UTUCs (10):
A
Stage Grade CIS Lymphovascular invasion Lympnode involvement Tumour architecture Positive surgical margins Tumour necrosis Variant histology Distal urether management
11
Q
What share of patients with a diagnos of a G1 tumour from URS biopsies where upgraded?
A
96%
12
Q
What are the criterias for Low-risk UTUCs?
A
Unifocal disease Tumour size < 2cm Low-grade cytology Low-grade URS biopsy Non invasive on CT-urography
OBS all criteria must be present
13
Q
What are the criterias for High-risk UTUCs?
A
Multifocal disease Tumour size > 2cm High-grade cytology High-grade URS biopsy Hydronephrosis Previous radical cystectomy for bladder cancer
14
Q
Which are the factors that are best in predicting ≥ pT2 disease in UTUCs?
A
High grade cytology or biopsy
Tumour size > 2 cm
15
Q
After endoscopic treatment of a UTUC, when should you perform a second look?
A
within 2 months
16
Q
When using laser vaporisation of a UTUC, what is the correct surgical technique?
A
Laser settings: 10Hz/1J
Don’t touch the tumour
Apnoe
17
Q
What are the criterias for Segmental Distal Ureterectomy?
A
Solitary tumour
Lower 1/3 of the ureter
Stage ≤ p T2
18
Q
Is there a difference between renal pelvis & ureteral tumours with regards to bladder recurrence, overall recurrence, cancer-specific or overall survival?
A
No
19
Q
Which is the superior technique for radical nefroureterectomy, open or laprascopic?
A
They are comparable when it comes to recurrence and disease-specific survival
20
Q
What technique is not recommended for the management of the bladder cuff in a radical nephroureterectomy?
A
Extravesical approach
Intravesical approach
(or a combination of extravescal and intravesical)
Endoscopic approach
21
Q
What technique is recommended for the management of the bladder cuff in a radical nephroureterectomy?
A
Transvesical approach
22
Q
What are the benefits of performing a Lymph node dissection at the time of a radical nephroureterectomy?
A
Staging
Therapeutic benefit
23
Q
When is Lymph node disseiction recommended in UTUCs?
A
Muscle-invasive UTUCs
24
Q
In patients with high-risk upper tract urothelial carcinoma which of the following statements is true?
- Adjuvant chemotherapy after radical nephroureterectomy iproves progression-free survival
- Singe dose intravesical chemotherapy after radical nephroureterectomy lower intravesical recurrence rate
- The open approach is preferred to the laparascopic in clinicallay non organ confined disease
- Lymphadenectomy should be performed in all invasive cases
- All of the above
A
- All of the above
25
What is the ddx of a ureteral mass?
tumor (enhancement with contrast, concern for UC)
fungus ball
blood clot
obstructing papillae
radiolucent stone
26
What is standard workup of upper tract UC?
1. CT A/P (Urogram)→assess filling defects and RP adenopathy
2. Cysto → initial screen for hematuria
3. RGP → confirm filling defects in pelvis or ureter, can send aspirate or barbotage for cytology
4. URS → direct vision and bx or brushing
5. Antegrade pyelography → if retrograde fails
6. Nephroscopy → endoscopic eval and mgmt. of selected low-grade tumors by fulguration and/or resection
27
Treatment options for ureteral tumor?
1. Nephroureterectomy with cuff of bladder
Indications: normal contralateral kidney and high -grade tumor or uncontrollable local recurrences
\*High grade ureteral and pelvic tumors unsuitable for local resection should undergo radical surgical extirpation +/- NAC or adjuvant chemo
\*If bilateral or solitary kidney, may be necessary for renal txp (wait 2 years)
2. Segmental resection
Indications: conservative measure (e.g. segmental resection or endoscopic treatment) are indicated when preservation of renal function is mandatory (e.g. low-stage b/l dz, azotemia, solitary kidney) or low grade lesions
\*Distal ureteral excision with removal of bladder cuff and reimplant is best option
\*Proximal excision and anastomosis not ideal for very distal, reserved for mid to proximal ureteral tumors
3. Ureteroscopy and resection or fulguration
Indications: distal ureter or not candidates for major surgery due to comorbidities, risk of ureteral stricture, perforation, and high rates of recurrence
28
What is the utilization of Mitomycin C in upper tract UC?
Can be given intravesically after nephroureterectomy
29
Describe epidemology of upper tract UC:
comprises 5-10 % of all UC
majority present at higher stage compared to bladder
average age at dx slightly older
Gender disparity less compared to bladder, M:F → 2:1
30
Risk factor for UC of upper tract?
Same as bladder (tobacco, chemical carcinogens, analgesics, chronic inflammation/infection)
1. Balkan Nephropathy: interstitial nephritis causing renal insufficiency, possible consumption of contaminated wheat (aristolochia), 100-200 x higher risk, also in herbal remedies
2. Lynch syndrome: AD DNA mismatch repair increasing risk of colorectal and endometrial; lifetime risk 10-15%
3. Arsenic
4. History of bladder UC
31
Relationship between upper tract and bladder UC?
1. Chance of UTUC after bladder UC ~5%, but 15-20% of pts with UTUC have hx of bladder ca
2. highest for patient with CIS or HG
3. hx of UC at trigone or bladder neck
4. hx of multifocal bladder ca
5. VUR
6. UC at ureteral margin or distal ureters during cystectomy
7. after UTUC probability of bladder ca 50-70%
8. probability of UC in contralateral side 2-5%
32
What is ddx of calyceal or pelvic collecting system mass?
radiolucent stone
blood clot
fungus ball
papillary necrosis
tumor
complex/peripelvic cyst
33
Treatment option for renal/pelvic UC?
1. Nephroureterectomy with bladder cuff
2. Segmental resection or local excision
1. Open pyelotomy with tumor excision/fulguration
2. appropriate for select low grade, low stage tumors in both kidney or solitary kidney with poor GFR (not best option)
3. Partial nephrectomy: where renal failure must be avoided (not best option)
4. Ureteroscopic resection and/or fulguration
1. Vigilant follow up and repeat URS
2. Good for small, noninvasive Ta, or poor functional status
5. Percutaneous treatment
1. Advantage is facilitating tumor removal and instillation of anti-tumor meds via PCN
2. Risks: bleeding, tumor spillage, tumor implantation
3. Small, solitary tumors not accessible by URS, can consider laser
6. Instillation therapy
1. Multiple superficial tumors or CIS with b/l or CKD
34
What is surveillance after URS resection/fulguration?
Cysto and ipsilateral (tumor side) URS q 6 mo for 3 years then annually
35
Name a diabetic medicine that can increase risk of UC?
Pioglitozone
36
Any medications that can interfere with treatment efficacy of high grade protocols for all UC?
Warfarin can decrease efficacy of BCG (but studies equivocal, rarely stopped)
37
What are some additional treatment options for high grade/invasive UTUC?
1. Radiation therapy: best used for local control and adjuvant or palliative therapy
2. Angioinfarction: symptomatic patients with incurable distant mets or not candidate for Nx
38
Describe follow up after nephroureterectomy for UTUC for a HG invasive lesion?
cysto: q 3 mo x 2 years, q 6 mo x 2 years, then q year
cytology: q3 mo x 2 years, q 6 mo x 2 years, the q year
CTU: q 3-6 mo x 2 years, then discretion
CXR: q6 mo x 2 years, then discretion
39
Staging of UTUC:
40
Proposed risk classification from EAU for UTUC:
41
UTUCs
| TX
Primary tumour can not be assessed
42
UTUCs
| T0
No evidence of primary tumour
43
UTUCs
| Ta
Non-invasive papillary carcinoma
44
UTUCs
| Tis
Carcinoma in situ
45
UTUCs
| T1
Tumour invades subepithelial connective tissue
46
UTUCs
| T2
Tumour invades muscularis
47
UTUCs
| T3
(renal pelvis) Tumour invades beyond musscularis into peripelvic fat o renal parnchyma
(ureter) Tumour invades beyond muscularis into periureteric fat
48
UTUCs
| T4
Tumour invades adjacent organs or through the kidney into perinephric fat
49
UTUCs
| NX
Regional lymph nodes can not be assessed
50
UTUCs
| N0
No regional lymph node metastasis
51
UTUCs
| N1
Metastasis in a single lymph node 2 cm or less in greatest dimension
52
UTUCs
| N2
Metastasis in a single lymph node more than 2 cm, or multiple lymph nodes
53
UTUCs
| M0
No distant metastasis
54
UTUCs
| M1
Distant metastasis
55
Question 1: Diagnosis and Evaluation
Topic: UTUC Diagnosis - Initial Steps
Vignette: A 45-year-old man presents with hematuria and is suspected of having upper tract urothelial carcinoma (UTUC). Which of the following is the most appropriate initial diagnostic step according to guidelines?
Options:
A) Cystoscopy alone
B) MRI of the abdomen and pelvis
C) Cystoscopy and cross-sectional imaging with contrast
D) Urine cytology
Correct Answer: C
Explanation: The guideline strongly recommends performing a cystoscopy and cross-sectional imaging with contrast for patients with suspected UTUC.
Memory Tool: "C for Comprehensive" - Cystoscopy and Cross-sectional imaging with Contrast.
Reference Citation: Paragraph 1, Diagnosis and Evaluation
Rationale for Information: Understanding the initial diagnostic steps for UTUC is crucial for timely and accurate management. The question tests your understanding of these critical first steps.
56
Question 2: Diagnosis and Evaluation
Topic: UTUC Diagnosis - Role of Ureteroscopy
Vignette: In a patient with suspected UTUC, what should be performed alongside diagnostic ureteroscopy?
Options:
A) Biopsy of any lesion and cytologic washing
B) Immediate surgical intervention
C) MRI of the pelvis
D) Abdominal X-ray
Correct Answer: A
Explanation: Alongside diagnostic ureteroscopy, clinicians should perform a biopsy of any identified lesion and cytologic washing from the upper tract system being inspected.
Memory Tool: "A for Additional" - Additional steps like biopsy and cytologic washing should be done Alongside ureteroscopy.
Reference Citation: Paragraph 2, Diagnosis and Evaluation
Rationale for Information: The question emphasizes the importance of comprehensive evaluation using biopsy and cytologic washing in conjunction with ureteroscopy for suspected UTUC.
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Question 3: Risk Stratification
Topic: Risk Stratification of UTUC
Vignette: In a patient diagnosed with UTUC, what should be documented to facilitate clinical staging and risk assessment?
Options:
A) Family medical history
B) Clinically meaningful endoscopic and radiographic features
C) Previous surgical interventions
D) Lifestyle factors like smoking and diet
Correct Answer: B
Explanation: The guideline strongly recommends that clinicians perform a standardized assessment documenting clinically meaningful endoscopic and radiographic features.
Memory Tool: "B for Big Picture" - Both endoscopic and radiographic features need to be looked at for a Big picture.
Reference Citation: Paragraph 9, Risk Stratification
Rationale for Information: Comprehensive assessment of risk factors is crucial for appropriate treatment planning in UTUC, which this question aims to evaluate.
58
Question 4: Treatment
Topic: Kidney Sparing Management
Vignette: A patient with low-risk (LR) favorable UTUC is being considered for treatment. What is the initial management option according to guidelines?
Options:
A) Radical nephroureterectomy (RNU)
B) Tumor ablation
C) Active surveillance
D) Chemotherapy
Correct Answer: B
Explanation: For patients with LR favorable UTUC, the guideline strongly recommends tumor ablation as the initial management option.
Memory Tool: "B for Better Option" - Better spare the kidney with tumor aBlation for LR favorable UTUC.
Reference Citation: Paragraph 13, Kidney Sparing Management
Rationale for Information: Understanding the initial management options based on risk stratification is essential for patient-centered care, which this question tests.
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Question 5: Diagnosis and Evaluation
Topic: Managing Lower Tract Tumors
Vignette: A patient undergoing ureteroscopy for suspected UTUC is found to have a concomitant lower tract tumor. What is the best management strategy for the lower tract tumor?
Options:
A) Address it in a separate surgical setting
B) Manage it in the same setting as ureteroscopy
C) Initiate chemotherapy immediately
D) Refer the patient to a medical oncologist
Correct Answer: B
Explanation: If lower tract tumors are discovered at the time of ureteroscopy, they should be managed in the same setting as per expert opinion.
Memory Tool: "B for Both" - Both upper and lower tract issues should be managed in the same setting.
Reference Citation: Paragraph 3, Diagnosis and Evaluation
Rationale for Information: Managing lower tract tumors in the same setting as ureteroscopy can be crucial for optimal patient care, and this question tests your understanding of that.
60
Question 6: Risk Stratification
Topic: Risk Factors for Post-Surgical Kidney Issues
Vignette: What should be assessed in patients with UTUC prior to undergoing surgery?
Options:
A) Emotional wellbeing
B) Risk of post-NU CKD or dialysis
C) Family history of UTUC
D) Financial status
Correct Answer: B
Explanation: According to expert opinion, patients with UTUC should be assessed for the risk of post-nephroureterectomy chronic kidney disease (CKD) or dialysis before undergoing surgery.
Memory Tool: "B for Before" - Before surgery, Better check for CKD or dialysis risk.
Reference Citation: Paragraph 11, Risk Stratification
Rationale for Information: Assessing renal function and risks prior to surgery is vital for patient safety and long-term outcomes, making this an important concept to grasp.
61
Question 7: Treatment
Topic: Kidney Sparing Management - High Risk
Vignette: For a patient with high-risk unfavorable UTUC and low-volume tumors, what may be the initial management option?
Options:
A) Radical nephroureterectomy (RNU)
B) Tumor ablation
C) Active surveillance
D) Immediate chemotherapy
Correct Answer: B
Explanation: For patients with high-risk unfavorable UTUC and low-volume tumors, tumor ablation may be the initial management option as per a conditional recommendation.
Memory Tool: "B for Balancing Act" - Balancing high risk with low-volume tumors may lead to aBlation.
Reference Citation: Paragraph 14, Kidney Sparing Management
Rationale for Information: Differentiating between initial management options based on risk and tumor volume can guide appropriate treatment, making this an essential concept.
62
Question 8: Treatment
Topic: Surveillance After Kidney Sparing for Low-Risk Patients
Vignette: A patient with low-risk UTUC has successfully undergone kidney-sparing treatment. What is the frequency of recommended cystoscopic surveillance of the bladder for the first two years?
Options:
A) Every 1 to 3 months
B) Every 3 to 6 months
C) Every 6 to 9 months
D) Annually
Correct Answer: C
Explanation: For low-risk patients managed with kidney-sparing treatment, cystoscopic surveillance of the bladder should be done at least every 6 to 9 months for the first two years, according to expert opinion.
Memory Tool: "C for Calm and Consistent" - Calm because it's low-risk, Consistent checks every 6 to 9 months.
Reference Citation: Paragraph 32, Surveillance After Kidney Sparing
Rationale for Information: Knowing the frequency of follow-up for different risk categories is vital for long-term management and patient care.
63
Question 9: Treatment
Topic: Surgical Management Options for High-Risk UTUC
Vignette: For surgically eligible patients with high-risk UTUC, what is the recommended surgical treatment?
Options:
A) Tumor ablation
B) Radical nephroureterectomy (RNU) or Segmental Ureterectomy (SU)
C) Kidney transplantation
D) Laparoscopic surgery
Correct Answer: B
Explanation: According to a strong recommendation, clinicians should recommend RNU or SU for surgically eligible patients with high-risk UTUC.
Memory Tool: "B for Big Risks, Big Steps" - Big risks like high-risk UTUC require Big steps like RNU or SU.
Reference Citation: Paragraph 20, Surgical Management
Rationale for Information: The question tests your knowledge on the appropriate surgical interventions based on risk stratification, which is crucial for treatment planning.
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Question 10: Treatment
Topic: Perioperative Intravesical Chemotherapy
Vignette: In a patient undergoing RNU or SU for UTUC, what should be administered perioperatively to reduce the risk of bladder recurrence?
Options:
A) Oral antibiotics
B) Intravenous fluids
C) Intravesical chemotherapy
D) Anti-inflammatory medication
Correct Answer: C
Explanation: The guideline strongly recommends administering a single dose of perioperative intravesical chemotherapy to reduce the risk of bladder recurrence.
Memory Tool: "C for Chemo Cuts Chances" - Chemo can Cut the Chances of bladder recurrence.
Reference Citation: Paragraph 23, Surgical Management
Rationale for Information: This question emphasizes the importance of perioperative management in reducing the risk of bladder recurrence, which is essential for long-term patient outcomes.
65
Question 11: Surveillance and Survivorship
Topic: Surveillance After Radical Nephroureterectomy for High-Stage Disease
Vignette: A patient has undergone radical nephroureterectomy for >pT2 Nx/0 UTUC. What is the frequency of recommended cross-sectional imaging of the abdomen and pelvis for the first two years?
Options:
A) Every 3 to 6 months
B) Every 6 to 9 months
C) Every 6 to 12 months
D) Annually
Correct Answer: A
Explanation: For patients who have undergone nephroureterectomy for >pT2 Nx/0 disease, cross-sectional imaging of the abdomen and pelvis should be performed every 3 to 6 months for the first two years according to expert opinion.
Memory Tool: "A for Aggressive Monitoring" - Aggressive disease (>pT2) requires Aggressive Monitoring every 3 to 6 months.
Reference Citation: Paragraph 36, T2+ Managed with NU
Rationale for Information: Understanding the frequency of surveillance for high-stage disease is vital for monitoring and early detection of recurrence or progression.
66
Question 12: Survivorship
Topic: Lifestyle Habits Post-Treatment
Vignette: What should clinicians discuss with patients who have been treated for urothelial cancer to promote long-term health benefits and quality of life?
Options:
A) Only medication management
B) Only surgical options for any future recurrence
C) Healthy lifestyle habits like smoking cessation, exercise, and diet
D) New experimental treatments
Correct Answer: C
Explanation: According to expert opinion, clinicians should discuss disease-related stresses and encourage patients to adopt healthy lifestyle habits for long-term health benefits and quality of life.
Memory Tool: "C for Comprehensive Care" - Comprehensive Care includes not just treatment but also lifestyle changes.
Reference Citation: Paragraph 38, Survivorship
Rationale for Information: Addressing lifestyle habits is an often-overlooked but crucial aspect of long-term survivorship and quality of life, making this an essential concept.
67
Question 13: Diagnosis and Evaluation
Topic: Ureteral Strictures and Upper Tract Access
Vignette: In patients with existing ureteral strictures, what should clinicians focus on to minimize the risk of ureteral injury during diagnostic evaluation?
Options:
A) Using aggressive dilation techniques
B) Using gentle dilation techniques like pre-stenting
C) Immediate surgical intervention
D) Avoiding any form of dilation
Correct Answer: B
Explanation: According to expert opinion, clinicians should minimize the risk of ureteral injury by using gentle dilation techniques such as temporary stenting (pre-stenting).
Memory Tool: "B for Be Gentle" - Be Gentle with those ureters by pre-stenting.
Reference Citation: Paragraph 4, Diagnosis and Evaluation
Rationale for Information: Minimizing ureteral injury is crucial for patient safety, especially in challenging anatomical situations like ureteral strictures.
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Question 14: Treatment
Topic: Watchful Waiting and Surveillance
Vignette: In which patients with UTUC is watchful waiting or surveillance alone most appropriate?
Options:
A) Patients with high surgical risks and significant comorbidities
B) Young patients with no prior medical history
C) Patients with low-risk UTUC
D) Patients who request immediate surgical intervention
Correct Answer: A
Explanation: According to expert opinion, watchful waiting or surveillance alone may be offered to patients with significant comorbidities, competing risks of mortality, or at significant risk of End-Stage Renal Disease (ESRD) with any intervention.
Memory Tool: "A for Assess Carefully" - Assess risks and comorbidities carefully before choosing Active surveillance.
Reference Citation: Paragraph 19, Treatment
Rationale for Information: Knowing when to opt for conservative management like watchful waiting is vital for personalized patient care, particularly for those with high surgical risks.
69
Question 15: Surveillance and Survivorship
Topic: Surveillance After Kidney Sparing for High-Risk Patients
Vignette: After kidney-sparing treatment for high-risk UTUC, what is the recommended frequency for upper tract imaging for the first three years?
Options:
A) Every 3 to 6 months
B) Every 6 to 9 months
C) Annually
D) Every 1 to 2 years
Correct Answer: A
Explanation: According to expert opinion, upper tract imaging should be performed every 3 to 6 months for the first three years for high-risk patients managed with kidney-sparing treatment.
Memory Tool: "A for Always Alert" - Always be Alert with high-risk patients; check every 3 to 6 months.
Reference Citation: Paragraph 33, Surveillance and Survivorship
Rationale for Information: Frequent imaging surveillance is critical for high-risk patients to detect any recurrence or new lesions early.
70
Question 16: Neoadjuvant/Adjuvant Chemotherapy and Immunotherapy
Topic: Cisplatin-based Neoadjuvant Chemotherapy
Vignette: In which patients with UTUC should cisplatin-based neoadjuvant chemotherapy be offered?
Options:
A) All patients irrespective of disease stage
B) Those undergoing RNU or ureterectomy with high-risk UTUC
C) Those with low-risk UTUC
D) Elderly patients only
Correct Answer: B
Explanation: According to a strong recommendation, cisplatin-based neoadjuvant chemotherapy should be offered to patients undergoing RNU or ureterectomy with high-risk UTUC.
Memory Tool: "B for Before Big Surgery" - Before Big surgeries like RNU in high-risk UTUC, go for cisplatin-Based chemotherapy.
Reference Citation: Paragraph 26, Neoadjuvant/Adjuvant Chemotherapy and Immunotherapy
Rationale for Information: The use of neoadjuvant chemotherapy in specific high-risk UTUC cases can significantly affect treatment outcomes, making this a key concept to understand.
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Question 17: Diagnosis and Evaluation
Topic: Genetic Counseling for UTUC
Vignette: What should be obtained in patients with suspected or diagnosed UTUC to evaluate the need for genetic counseling?
Options:
A) Blood glucose levels
B) Personal and family history for hereditary risk factors
C) Serum creatinine levels
D) Patient's educational background
Correct Answer: B
Explanation: According to expert opinion, clinicians should obtain a personal and family history to identify known hereditary risk factors for familial diseases associated with Lynch Syndrome for which referral for genetic counseling should be offered.
Memory Tool: "B for Background Check" - Better do a Background Check on personal and family history for genetic counseling.
Reference Citation: Paragraph 7, Diagnosis and Evaluation
Rationale for Information: Genetic counseling can be an important aspect of management for UTUC, especially in the context of hereditary syndromes like Lynch Syndrome.
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Question 18: Risk Stratification
Topic: UTUC Risk Stratification
Vignette: How should clinicians stratify the risk of patients with identified UTUC based on obtained findings?
Options:
A) Low-risk or high-risk for invasive disease
B) Based on age and gender
C) Low-risk, medium-risk, or high-risk for all types of urological cancers
D) Solely based on radiographic findings
Correct Answer: A
Explanation: According to a strong recommendation, clinicians should risk-stratify patients as “low-” or “high-” risk for invasive disease based on obtained endoscopic, cytologic, pathologic, and radiographic findings.
Memory Tool: "A for Accurate Stratification" - Accurately stratify into low- or high-risk categories based on multiple findings.
Reference Citation: Paragraph 10, Risk Stratification
Rationale for Information: Proper risk stratification is crucial for determining the appropriate course of treatment for UTUC.
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Question 19: Treatment
Topic: Adjuvant Therapy
Vignette: Which adjuvant therapy may be offered to patients who received neoadjuvant platinum-based chemotherapy for UTUC?
Options:
A) Adjuvant nivolumab therapy
B) High-dose vitamin C
C) Continued platinum-based chemotherapy
D) Immunotherapy with a different agent
Correct Answer: A
Explanation: According to a conditional recommendation, adjuvant nivolumab therapy may be offered to patients who received neoadjuvant platinum-based chemotherapy.
Memory Tool: "A for After Platinum" - After Platinum-based chemo, consider Adding nivolumab.
Reference Citation: Paragraph 28, Neoadjuvant/Adjuvant Chemotherapy and Immunotherapy
Rationale for Information: Understanding the available adjuvant therapies based on prior treatments is essential for comprehensive patient care.
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Question 20: Surveillance and Survivorship
Topic: Referral to Nephrology
Vignette: When should clinicians consider referral to nephrology in patients treated for UTUC?
Options:
A) In all patients post-treatment
B) In patients with reduced or deteriorating renal function
C) Only in elderly patients
D) In patients who request a referral
Correct Answer: B
Explanation: According to expert opinion, clinicians should consider referral to nephrology for patients with reduced or deteriorating renal function following treatment for UTUC.
Memory Tool: "B for Better Renal Care" - Bad renal function after treatment? Better head to nephrology.
Reference Citation: Paragraph 37, Survivorship
Rationale for Information: Monitoring and managing renal function post-treatment is crucial, and knowing when to refer to a specialist can significantly impact patient outcomes.
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Question 21: Diagnosis and Evaluation
Topic: Imaging for Suspected UTUC
Vignette: What type of imaging is recommended for patients with suspected UTUC?
Options:
A) MRI without contrast
B) CT with contrast including delayed images
C) Ultrasound
D) X-ray of the abdomen
Correct Answer: B
Explanation: For patients with suspected UTUC, cross-sectional imaging of the upper tract with contrast including delayed images is strongly recommended.
Memory Tool: "B for Better Imaging" - Better get all the details with CT and contrast.
Reference Citation: Paragraph 1, Diagnosis and Evaluation
Rationale for Information: Imaging is the cornerstone for diagnosing UTUC, and the choice of imaging modality can greatly influence diagnostic accuracy.
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Question 22: Treatment
Topic: Pelvicalyceal Therapy Options
Vignette: Which therapeutic option may be offered to patients with high-risk favorable UTUC after complete tumor ablation?
Options:
A) Pelvicalyceal therapy with BCG
B) Intravesical chemotherapy only
C) No further treatment
D) High-dose oral steroids
Correct Answer: A
Explanation: According to expert opinion, pelvicalyceal therapy with Bacillus Calmette–Guérin (BCG) may be offered to patients with high-risk favorable UTUC after complete tumor ablation.
Memory Tool: "A for Additional Armor" - After ablation, Add BCG as an armor against recurrence.
Reference Citation: Paragraph 17, Kidney Sparing Management
Rationale for Information: Post-ablation therapy options are important to prevent recurrence, and knowing which to use in specific risk categories is vital.
77
Question 23: Risk Stratification
Topic: Pre-Surgical Assessment for Post-NU CKD or Dialysis
Vignette: What should be assessed in patients with UTUC prior to surgery?
Options:
A) Risk of post-NU CKD or dialysis
B) Patient's willingness for surgery
C) Blood type for transfusion
D) Vitamin D levels
Correct Answer: A
Explanation: According to expert opinion, patients with UTUC should be assessed prior to surgery for the risk of post-NU CKD (chronic kidney disease) or dialysis.
Memory Tool: "A for Assess Ahead" - Always Assess the risk of CKD Ahead of surgery.
Reference Citation: Paragraph 11, Risk Stratification
Rationale for Information: Pre-surgical assessment for the risk of post-surgical CKD or dialysis is essential for proper patient management and informed consent.
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Question 24: Surveillance and Survivorship
Topic: Surveillance After Kidney Sparing for Low-Risk Patients
Vignette: After kidney-sparing treatment for low-risk UTUC, when should the first upper tract endoscopy be performed?
Options:
A) Within 1 to 3 months
B) At 6 months
C) At 1 year
D) Every 2 years
Correct Answer: A
Explanation: According to expert opinion, low-risk patients managed with kidney sparing treatment should undergo a follow-up cystoscopy and upper tract endoscopy within one to three months to confirm successful treatment.
Memory Tool: "A for Act Quickly" - Act Quickly to confirm success in low-risk patients with a 1-3 month endoscopy.
Reference Citation: Paragraph 32, Surveillance After Kidney Sparing
Rationale for Information: Timely surveillance after kidney-sparing treatment is crucial for confirming the success of the treatment and planning future care.
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Question 25: Treatment
Topic: Treatment for Patients with Metastatic UTUC
Vignette: What should not be offered as initial therapy in patients with metastatic (M+) UTUC?
Options:
A) Radical nephroureterectomy or ureterectomy
B) Systemic therapy
C) Best supportive care
D) Palliative radiation
Correct Answer: A
Explanation: According to expert opinion, radical nephroureterectomy or ureterectomy should not be offered as initial therapy in patients with metastatic (M+) UTUC.
Memory Tool: "A for Avoid Surgery" - Avoid surgery as the initial step in metastatic UTUC.
Reference Citation: Paragraph 29, Treatment
Rationale for Information: Knowing what not to do is as important as knowing what to do, especially in the context of metastatic disease where the treatment approach varies significantly.
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Question 1: Epidemiology of UTUC
Clinical Vignette: A 45-year-old male patient presents with recurrent UTIs. On further investigation, you suspect Upper Urinary Tract Carcinomas (UTUCs). What is the least likely presenting pattern for UTUCs in this patient?
Options:
A) Bilateral disease
B) Involvement of the pelvicalyceal system
C) Invasive tumors
D) Concurrent bladder cancer
Correct Answer: A) Bilateral disease
Explanation:
The majority of UTUCs are presented in a single renal unit, and only up to 5% of patients have bilateral disease. Therefore, bilateral disease is the least likely pattern.
Memory Tool:
Think "Uni-UTUC" to remember that most UTUCs are unilateral.
Reference Citation:
Paragraph 2, Epidemiology section
Rationale:
This question is designed to test your understanding of the epidemiology of UTUC, specifically the rarity of bilateral disease, which is a key aspect when considering diagnosis and treatment.
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Question 2: Risk Factors of UTUC
Clinical Vignette: A 60-year-old male smoker presents with hematuria. On evaluation, you suspect UTUC. Which risk factor is most strongly associated with UTUC?
Options:
A) Familial predisposition
B) Tobacco use
C) Male gender
D) Black non-Hispanic race
Correct Answer: B) Tobacco use
Explanation:
The routine use of tobacco increases the relative risk for UTUC from 2.5 to 7 times, making it the most significant risk factor in this scenario.
Memory Tool:
Think "Up in Smoke" to remember that tobacco use significantly ups the risk for UTUC.
Reference Citation:
Paragraph 12, Risk Factors section
Rationale:
This question targets your knowledge of risk factors for UTUC, emphasizing the role of tobacco, which is crucial for patient counseling and preventive strategies.
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Question 3: Diagnosis of UTUC
Clinical Vignette: A 50-year-old woman complains of flank pain and weight loss. You suspect advanced UTUC. Which diagnostic tool has the highest diagnostic accuracy for UTUC?
Options:
A) Cystoscopy
B) Flexible ureteroscopy with biopsy
C) Computed tomography urography
D) Urine cytology
Correct Answer: C) Computed tomography urography
Explanation:
Computed tomography urography has the highest diagnostic accuracy for UTUC.
Memory Tool:
Think "CT is the Key" to remember that CT urography is the most accurate for diagnosing UTUC.
Reference Citation:
Paragraph 25, Diagnosis section
Rationale:
This question aims to assess your understanding of the diagnostic tools for UTUC, particularly the importance of CT urography for accurate diagnosis.
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Question 5: Prognosis of UTUC
Clinical Vignette: A 55-year-old female is diagnosed with UTUC that invades the muscle wall. What is the 5-year specific survival for pT2/pT3 stage UTUC?
Options:
A) Less than 10%
B) Less than 50%
C) 60-90%
D) 40-87%
Correct Answer: B) Less than 50%
Explanation:
The 5-year specific survival for pT2/pT3 stage UTUC that invades the muscle wall is less than 50%.
Memory Tool:
Think "Muscle Invasion = Diminished Survival" to remember the poor prognosis of muscle-invading UTUC.
Reference Citation:
Paragraph 40, Prognosis section
Rationale:
This question aims to assess your knowledge on the prognosis of UTUC based on tumor stage, which is essential for patient counseling and treatment planning.
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Question 6: Surgical Management of UTUC
Clinical Vignette: A 67-year-old male is diagnosed with a high-grade tumor in the renal pelvis. What is the gold standard treatment for this condition?
Options:
A) Lymphadenectomy
B) Radical nephroureterectomy
C) Endourologic management
D) Flexible ureteroscopy with biopsy
Correct Answer: B) Radical nephroureterectomy
Explanation:
Radical nephroureterectomy with excision of a bladder cuff is the gold standard for large, high-grade, suspected invasive tumors of the renal pelvis and proximal ureter.
Memory Tool:
Think "Radical Problem, Radical Solution" to remember that radical nephroureterectomy is the gold standard.
Reference Citation:
Paragraph 48, Surgical Management section
Rationale:
This question focuses on the recommended surgical treatments for high-grade UTUC, essential for making informed clinical decisions.
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Question 7: Histopathology of UTUC
Clinical Vignette: A 50-year-old woman undergoes a biopsy for a suspected UTUC. The pathology report describes hyperplasia to dysplasia and carcinoma in situ (CIS). What is the likelihood that this case will progress to muscle invasion or beyond?
Options:
A) Very likely
B) Likely
C) Unlikely
D) Very Unlikely
Correct Answer: A) Very likely
Explanation:
UTUC develops through a gradual progression of hyperplasia to dysplasia and eventually carcinoma in situ (CIS) in a significant proportion of cases. Muscle invasion is more likely to take place in the upper tract.
Memory Tool:
Think "Hyper-Dys-CIS: High Danger" to remember the progression likelihood.
Reference Citation:
Paragraph 16, Histopathology section
Rationale:
This question assesses your understanding of the histopathological progression of UTUC, which is critical for prognosis and treatment planning.
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Question 9: Endourologic Management
Clinical Vignette: A 35-year-old woman has a small tumor in the lower pole calyx of the kidney. Which approach is preferred for this location?
Options:
A) Retrograde ureteroscopic approach
B) Antegrade percutaneous approach
C) Radical nephroureterectomy
D) Lymphadenectomy
Correct Answer: B) Antegrade percutaneous approach
Explanation:
An antegrade percutaneous approach is preferred for larger tumors of the upper ureter or kidney and for those that cannot be adequately manipulated in a retrograde approach due to location, such as the lower pole calyx.
Memory Tool:
Think "Antegrade for Awkward Angles" to remember the preferred approach for tricky locations like the lower pole calyx.
Reference Citation:
Paragraph 62, Endourologic Management section
Rationale:
This question focuses on the surgical approaches for treating UTUCs in different locations, important for surgical planning.
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Question 10: Mortality Rate of UTUC
Clinical Vignette: A 70-year-old male patient is diagnosed with UTUC. What factor is NOT associated with increased mortality in UTUC?
Options:
A) Increasing age
B) Male gender
C) Hispanic race
D) Advanced tumor stage
Correct Answer: C) Hispanic race
Explanation:
Disease mortality has been related to increasing age, male gender, black non-Hispanic race, and advanced tumor stage. Hispanic race is not mentioned as a factor affecting mortality.
Memory Tool:
Think "ABD but not C" to remember that Age, Black non-Hispanic race, and advanced Disease stage are factors, but not Hispanic race.
Reference Citation:
Paragraph 11, Epidemiology section
Rationale:
This question assesses your understanding of the factors affecting mortality rates in UTUC, which is crucial for prognosis and patient counseling.
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Question 11: Genetic Predisposition in UTUC
Clinical Vignette: A 55-year-old woman with a family history of colon cancer is diagnosed with UTUC. What syndrome should you consider?
Options:
A) Hereditary Breast and Ovarian Cancer (HBOC) syndrome
B) Familial Adenomatous Polyposis (FAP)
C) Hereditary Nonpolyposis Colorectal Carcinoma (HNPCC) or Lynch syndrome
D) Multiple Endocrine Neoplasia (MEN)
Correct Answer: C) Hereditary Nonpolyposis Colorectal Carcinoma (HNPCC) or Lynch syndrome
Explanation:
Familial or hereditary UTUCs are linked to Hereditary Nonpolyposis Colorectal Carcinoma (HNPCC) syndrome (or Lynch syndrome).
Memory Tool:
Think "UTUC-Lynch Link" to remember the association between UTUC and Lynch syndrome.
Reference Citation:
Paragraph 13, Risk Factors section
Rationale:
This question aims to test your knowledge on the genetic predispositions that are associated with UTUC, which is essential for guiding further genetic testing and family counseling.
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Question 12: Disease Recurrence After Treatment
Clinical Vignette: A 60-year-old man undergoes treatment for UTUC. What is the most common site for disease recurrence?
Options:
A) Bladder
B) Contralateral upper tract
C) Lymph nodes
D) Bones
Correct Answer: A) Bladder
Explanation:
Disease recurrence after treatment involves the bladder in 22%–47% of cases, making it the most common site for recurrence.
Memory Tool:
Think "Back to Bladder" to remember that recurrence often involves the bladder.
Reference Citation:
Paragraph 7, Epidemiology section
Rationale:
This question evaluates your understanding of the patterns of disease recurrence after UTUC treatment, which is crucial for follow-up care.
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