Editing Upper Urinary Tract Urothelial Cancer (section)

===== 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