Editing Upper Urinary Tract Urothelial Cancer (section)

=== Advanced disease ===
==== Clinical, regional node-positive (N+)====
* '''Should initially be treated with systemic therapy.'''
*'''Consolidative RNU or ureterectomy with lymph-node dissection may be performed in those with a partial or complete response.'''
**Pooled data from comparative outcomes utilizing NAC in patients with clinically node positive (cN+) disease supports this approach.
====Distant metastatic disease (M+)====
* '''Systemic therapy and alternative approaches (i.e., radiotherapy with or without chemotherapy in selected cases) should be favored for inoperable or symptomatic patients with M+ UTUC'''
**RNU or ureterectomy should not be offered as initial therapy
***Oncologic outcomes in the metastatic setting are strongly determined by response to systemic therapy, and surgical treatment has no demonstrable therapeutic efficacy for cytoreduction or as a single modality in this setting.
**Limited data on the efficacy of chemotherapy in metastatic UTUC
*** Prospective randomized trials comparing chemotherapeutic regimens for UTUC are not feasible owing to the rarity of these patients.
** '''Regimen: MVAC (methotrexate, vinblastine, doxorubicin (Adriamycin), and cisplatin)'''
*** '''Continues to have the highest response rate'''
*** '''Carboplatin is frequently substituted instead of cisplatin because of either limitations of renal function or concerns over nephrotoxicity associated with cisplatin. Results with carboplatin are inferior than cisplatin.'''
* Complete responses are rare in the metastatic setting, and the duration of response is limited, with overall survival of 12-24 months
====Unresectable UTUC====
*Localized disease may be deemed unresectable or ineligible for extirpative surgical management due to significant medical comorbidities or other factors including refusal to accept surgical treatment (e.g., solitary kidney).
*Should be offered a clinical trial or best supportive care including palliative management (radiation, systemic approach, endoscopic, or ablative) for refractory symptoms such as hematuria.
**Formulating alternative care options should be approached with multi-disciplinary input with a focus on realistic goals of care such as providing means of local control for functional preservation (e.g., renal function) and palliation (e.g., bleeding, infection)
**Multi-modal approaches include combination of endoscopic management to maintain upper and lower tract function (e.g., stents, nephrostomies, ablation for bleeding and local control) in addition to systemic treatment options if available. Rarely, radiation, angioembolization, or percutaneous ablation for palliation of bleeding can be offered