Can pedunculated high-grade Upper Tract Urothelial Carcinoma (UTUC) in the renal calyx be treated endoscopically with laser, topical chemotherapy, or both?

From the Guidelines

Pedunculated high-grade Upper Tract Urothelial Carcinoma (UTUC) in the renal calyx should not be treated endoscopically with laser, topical chemotherapy, or both as the primary treatment option, due to the high-risk nature of the tumor and the poor prognosis associated with muscle-invasive UTUCs. According to the ESMO clinical practice guideline for diagnosis, treatment, and follow-up of bladder cancer, which includes recommendations for UTUC, high-risk UTUC patients should undergo open or laparoscopic radical nephroureterectomy with bladder cuff excision regardless of tumor location 1.

Key Considerations

• High-risk UTUCs, such as pedunculated high-grade tumors, have a poor prognosis with a 5-year cancer-specific survival of <50% for patients with pT2-pT3 tumors and <10% for those with pT4 tumors 1.
• The guideline recommends kidney-sparing management, such as endoscopic laser ablation, only for patients with low-risk UTUC, which includes unifocal tumors of <1 cm, low-grade disease at cytology/biopsy, and no invasive features on CT urography 1.
• For high-risk UTUC patients, radical nephroureterectomy remains the gold standard treatment, and adjuvant cisplatin-based chemotherapy should be considered based on the POUT trial data and the OS meta-analysis for cisplatin-based treatment of urothelial bladder cancer 1.

Treatment Approach

• Radical nephroureterectomy with bladder cuff excision is the recommended treatment for high-risk UTUC patients, including those with pedunculated high-grade tumors in the renal calyx.
• Adjuvant cisplatin-based chemotherapy should be considered for patients with locally advanced or metastatic disease, based on the available evidence from the POUT trial and the bladder cancer literature 1.

Monitoring and Follow-up

• Patients with high-grade UTUC should be monitored closely with regular ureteroscopic surveillance, as the recurrence risk is significant.
• However, the primary treatment approach for pedunculated high-grade UTUC in the renal calyx should prioritize radical surgery over endoscopic management, due to the high-risk nature of the tumor and the associated poor prognosis.

From the Research

Treatment Options for Pedunculated High-Grade Upper Tract Urothelial Carcinoma (UTUC)

• Endoscopic management of UTUC using laser ablation, percutaneous resection, or topical chemotherapy is a viable treatment option for selected patients with solitary kidneys or those who want to preserve renal function 2, 3, 4, 5.
• The use of laser ablation, specifically thulium laser, has been shown to be effective in treating UTUC, with a high success rate and minimal complications 5.
• Topical chemotherapy, such as mitomycin C, can be used as an adjuvant therapy to reduce the risk of recurrence after endoscopic resection 3, 4.
• Percutaneous resection is another option for treating UTUC, especially for larger tumors or those that are not accessible by ureteroscopy 4.

Efficacy and Safety of Endoscopic Management

• The efficacy of endoscopic management of UTUC varies depending on the tumor grade and stage, with higher-grade tumors having a higher risk of recurrence and progression 6, 4.
• The safety of endoscopic management is generally good, with minimal complications and a low risk of systemic toxicity 3, 5.
• However, the risk of ureteral stricture and tumor recurrence is higher with endoscopic management compared to radical nephroureterectomy (RNU) 5.

Patient Selection and Follow-up

• Patient selection is crucial for endoscopic management of UTUC, with factors such as tumor grade, stage, and location, as well as patient comorbidities and overall health, being taken into consideration 2, 6, 4.
• Close follow-up is essential for patients undergoing endoscopic management of UTUC, with regular ureteroscopy and imaging studies to monitor for recurrence and progression 3, 4, 5.