Editing Upper Urinary Tract Urothelial Cancer (section)

====Special scenarios====

===== CIS of the Upper Urinary Tracts =====
* '''In most cases, the diagnosis is one of exclusion wherein there is a persistent positive selective cytology in the absence of any ureteroscopic or radiographic findings.'''
** The diagnosis of CIS of the upper urinary tracts difficult because of the inability to evaluate the urothelium of the upper tracts with adequate tissue samples
* '''Management'''
** '''Not well established'''
** '''<span style="color:#ff0000">Current approaches for presumed upper tract CIS include topical immunotherapy or chemotherapy'''
*** '''Most experience is from use of BCG via a nephrostomy tube for primary treatment of CIS.'''
**** '''<span style="color:#ff00ff">Systematic review and meta-analysis evaluating intraluminal therapy for UTUC (2019)</span>'''
***** Inclusion criteria: studies evaluating patients with upper tract urothelial carcinoma receiving instillation treatment as adjuvant/curative therapy for pTa/pT1 and CIS, respectively.
***** Studies with ≥10 participants included in quantitative analyses
***** Results
****** Included 226 patients from 15 studies of patients that underwent BCG instillation for CIS
****** Recurrence-free survival: 84%
****** Cancer-specific survival: 34%
****** Overall survival: 16%
****** No difference in survival based on approach (antegrade, retrograde, or combined) or drug (MMC vs. BCG)
***** Foerster, Beat, et al. "Endocavitary treatment for upper tract urothelial carcinoma: a meta-analysis of the current literature." ''Urologic Oncology: Seminars and Original Investigations''. Vol. 37. No. 7. Elsevier, 2019.
*** Historically, '''<span style="color:#ff0000">radical nephroureterectomy</span>''' was performed for a unilateral cytologic abnormality of the upper tract to eliminate presumed CIS. This practice '''<span style="color:#ff0000">is not recommended</span>''' in the absence of any histologic, radiographic, or endoscopic finding '''owing to the limitations of cytology alone with false-positive results and the high risk for bilateral disease in the future'''
*** '''Observation is also not appropriate without further evaluation given the repeated abnormal cytologies.'''
* Management of CIS of ureteral margins during radical cystectomy is controversial

===== CIS limited to the region within the ureteral orifice =====
*Topical therapies such as BCG along with refluxing ureteral stenting that has been used for in cases of CIS near the ureterovesical junction or transurethral resection of the transmural portion of the ureter for very distal tumors, as an extension of bladder resection procedures, when tumor is limited to the region inside the ureteral orifice and not beyond the bladder wall, thus anatomically managed as bladder cancer

===== Watchful waiting or surveillance =====
*May be offered to select patients with UTUC with
**Significant comorbidities/competing risks of mortality
** Significant risk of End-Stage Renal Disease (ESRD) with any intervention resulting in dialysis.
*Discussion of treatment related risks including perioperative mortality may lead to a shared decision to proceed with active surveillance (whereby periodic assessments such as imaging or limited endoscopic assessment are performed) or watchful waiting/expectant management, where interventions are limited to palliation or awaiting symptomatic progression – especially in those with very limited life expectancy.
**In such cases, patients and family should be counseled and prepared for disease-related events such as bleeding, obstruction, infection, and pain with options for palliation that may be limited.