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 recommended treatment for high-risk UTUC is open or laparoscopic radical nephroureterectomy with bladder cuff excision [II, B] 1.
Patient Selection and Treatment Approach
The treatment approach for UTUC depends on the risk category of the tumor, with low-risk tumors being eligible for kidney-sparing management such as endoscopic laser ablation, and high-risk tumors requiring more aggressive treatment 1. High-grade UTUCs are considered high-risk and 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.
Endoscopic Management
While endoscopic management may be considered for carefully selected patients with low-risk UTUC, it is not recommended for high-grade tumors due to the high risk of recurrence and progression 1. The use of laser ablation and adjuvant topical chemotherapy may be considered for low-risk tumors, but the evidence for this approach in high-grade UTUC is limited 1.
Surveillance and Follow-up
Close surveillance with ureteroscopy and cytology is essential for patients with UTUC, particularly those with high-grade tumors, to monitor for recurrence and progression 1. However, this does not change the fact that radical nephroureterectomy remains the gold standard for high-grade UTUC, and endoscopic management represents a kidney-sparing alternative with higher recurrence risk.
Key Considerations
- High-grade UTUC carries a significant risk of recurrence and progression 1
- Radical nephroureterectomy is the recommended treatment for high-risk UTUC [II, B] 1
- Endoscopic management may be considered for low-risk UTUC, but is not recommended for high-grade tumors 1
- Close surveillance with ureteroscopy and cytology is essential for patients with UTUC, particularly those with high-grade tumors 1
From the Research
Treatment Options for Pedunculated High-Grade Upper Tract Urothelial Carcinoma (UTUC)
- Endoscopic management of UTUC is a viable option for selected patients, particularly those with low-grade tumors or those who are not candidates for radical nephroureterectomy (RNU) 2, 3.
- The use of laser ablation, such as thulium laser, in combination with ureteroscopy, has shown promising results in treating UTUC, with a lower risk of renal function loss and shorter hospitalization times 4.
- Topical chemotherapy, including mitomycin C, has been used as an adjuvant therapy to reduce recurrence rates in patients with UTUC, with some studies showing promising intermediate-term outcomes 5, 6.
- However, the effectiveness of endoscopic treatment for high-grade UTUC is limited, and RNU remains the gold standard treatment for these patients 2, 3.
Considerations for Endoscopic Treatment
- Patient selection is crucial, with factors such as tumor grade, size, and location, as well as patient comorbidities and overall health, influencing the decision to pursue endoscopic treatment 2, 3.
- The risk of recurrence and progression is higher in patients with high-grade UTUC, and lifetime intensive surveillance is necessary to monitor for these complications 4.
- The use of adjuvant therapies, such as topical chemotherapy, may help reduce recurrence rates, but more research is needed to determine their effectiveness in combination with endoscopic treatment 5, 6.
Outcomes and Survival Rates
- Studies have reported varying outcomes and survival rates for patients with UTUC treated with endoscopic management, with overall survival rates ranging from 23% to 94% depending on tumor grade and patient selection 2, 3, 4.
- Disease-specific survival rates have also been reported, with rates ranging from 39% to 96% depending on tumor grade and treatment approach 2, 3, 4.