Editing Upper Urinary Tract Urothelial Cancer (section)

====== Neoadjuvant ======
* '''No randomized trials evaluating benefit of neoadjuvant therapy for UTUC.'''
* '''Chemotherapy'''
** The use of agents for UTUC has been extrapolated from chemotherapy regimens used in bladder urothelial cancer
** '''<span style="color:#ff0000">Cisplatin-based neoadjuvant chemotherapy should be offered to patients undergoing RNU or ureterectomy with HR UTUC, particularly in those patients whose post-operative eGFR is expected to be <60 mL/min/1.73m2 or those with other medical comorbidities that would preclude platinum-based chemotherapy in the post-operative setting.[https://pubmed.ncbi.nlm.nih.gov/37096584/]</span>'''
***The strongly positive data from phase II trials, the established high-level evidence seen in bladder cancer trials, the consistent findings from pooled meta-analytic data, and the compelling clinical challenges imposed by post-RNU renal function on cis-platinum eligibility '''support the standard use of NAC regimens for HR UTUC.'''
***Phase II trial of 30 patients with high-grade UTUC found that 4 cycles of neoadjuvant methotrexate, vinblastine, doxorubicin and cisplatin was associated with a 14% pathological complete response rate.[https://pubmed.ncbi.nlm.nih.gov/31702432/]
*** 2020 meta-analysis of 14 studies for NAC in UTUC found that the pooled pathologic complete response rate (≤ypT0N0M0) was 11% and pathologic partial response rate (≤ypT1N0M0) was 43%.[https://pubmed.ncbi.nlm.nih.gov/32798146/]
**'''In the neoadjuvant setting, dosing regimens may be better tolerated, allowing more courses to be completed, and permitting patients to proceed to appropriate surgical intervention.'''
*** A disadvantage of adjuvant chemotherapy is that many patients have baseline chronic kidney disease, which worsens after nephroureterectomy, rendering them ineligible to receive the full-dose cisplatin-based chemotherapy
**'''Alternatives to cisplatin-based chemotherapy''' (i.e., immune checkpoint inhibitors, carboplatin, antibody drug conjugates, targeted FGFR therapies) '''are not recommended in the neoadjuvant setting''' (prior RNU or ureterectomy) outside of clinical trials