What are the treatment options for low-grade Upper Tract Urothelial Carcinoma (UTUC)?

From the Guidelines

Kidney-sparing management, such as endoscopic laser ablation, should be offered as the primary treatment option to patients with low-risk UTUC. This approach is based on the most recent evidence from the 2022 ESMO clinical practice guideline for diagnosis, treatment, and follow-up of bladder cancer, which includes recommendations for UTUC 1. The guideline stratifies UTUCs into two risk categories, low- and high-risk tumours, and recommends kidney-sparing management for low-risk tumours, which include unifocal tumours of <1 cm, low-grade (LG) disease at cytology/biopsy, and no invasive features on CT urography.

Some key points to consider when treating low-grade UTUC include:

• The presence of concomitant CIS of the upper tract, which is between 11% and 36% of cases 1
• The most common symptom is haematuria (70%-80%) or flank pain (10%-20%) 1
• The key investigations for UTUC are CT urography and diagnostic ureteroscopy, with an in situ cytology sample of the upper tract collected during ureteroscopy 1
• UTUCs invading the muscle wall usually have a poor prognosis, with a 5-year cancer-specific survival of <50% for patients with pT2-pT3 tumours and <10% for those with pT4 1

The treatment options for low-grade UTUC may also include:

• Endoscopic laser ablation or resection of the tumor
• Regular surveillance with ureteroscopy and imaging every 3-6 months to monitor for recurrence
• Adjuvant therapy with intracavitary chemotherapy, such as mitomycin C or BCG (Bacillus Calmette-Guérin), to reduce recurrence risk
• Radical nephroureterectomy (surgical removal of the kidney, ureter, and a cuff of bladder) for patients with multifocal disease, high recurrence rates, or when endoscopic management is not feasible 1

From the Research

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

• Endoscopic laser ablation is a recommended treatment for low-grade and non-invasive UTUC 2
• Endoscopic management, including retrograde ureteroscopic and antegrade percutaneous approaches, is a reasonable alternative for patients with renal insufficiency, a solitary functional kidney, bilateral disease, or significant comorbidity that precludes radical surgery 3
• Select patients with a functional contralateral kidney who have low-grade, low-stage tumors may also be candidates for endoscopic management 3
• Adjuvant topical therapy with Bacillus Calmette-Guerin or mitomycin C can be used after endoscopic management of UTUC to reduce recurrence 3, 4
• Percutaneous resection is another endoscopic approach that allows for renal preservation in the majority of patients with resectable disease 4

Key Considerations

• The risk of recurrence is high after endoscopic treatment, but it is associated with a low risk of progression and high overall survival and disease-specific survival 2
• Careful selection of patients is crucial for successful endoscopic management, and patients must be compliant and motivated for lifelong surveillance 3
• Tumor grade is an important predictor of recurrence, with high-grade tumors being more likely to experience recurrence 4
• Prolonged surveillance is advised, as recurrence may occur many years after initial resection 4

Emerging Trends

• Endoscopic treatment with laser ablation has an evolving role in treating low-grade UTUC, including select large and multifocal tumors 5
• Advances in immunologic therapy have shown promise in treating metastatic UTUC, and immunologic-based therapies have been incorporated into treatment regimens 5