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AUA: Upper Tract Urothelial Carcinoma (2023): Difference between revisions

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* Literature search up to January 2023
* Literature search up to January 2023
'''*****All of the information below is contained in the more comprehensive [[Upper Urinary Tract Urothelial Cancer|Upper Urinary Tract Urothelial Cancer Chapter Notes]]*****'''


== Background ==
== Background ==
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== Surveillance and Survivorship ==
== Surveillance and Survivorship ==


=== Post-Treatment Surveillance ===
=== Oncologic Surveillance ===


* '''See [https://www.auanet.org/images/Guidelines/Guideline%20Images/UTUC%202023/Table%206%20UTUC%20Word%20Version.jpg Table] from Original Guidelines'''
* '''See [https://www.auanet.org/images/Guidelines/Guideline%20Images/UTUC%202023/Table%206%20UTUC%20Word%20Version.jpg Table] from Original Guidelines'''
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* '''Low-risk patients managed with kidney sparing treatment'''  
* '''Low-risk patients managed with kidney sparing treatment'''  
** '''Cystoscopy and upper tract endoscopy within 1-3 months of treatment to confirm successful treatment.'''
** Cystoscopy and upper tract endoscopy within 1-3 months of treatment to confirm successful treatment.
**'''If successful treatment confirmed (no evidence of disease), perform'''
**If successful treatment confirmed (no evidence of disease), perform
***'''Cystoscopy of the bladder once again within the first year after treatment, then at least every 6-9 months for the first 2 years and then at least annually thereafter.'''
***Cystoscopy of the bladder once again within the first year after treatment, then at least every 6-9 months for the first 2 years and then at least annually thereafter.
***'''Upper tract endoscopy at 6 months and 1 year [after treatment].'''
***Upper tract endoscopy at 6 months and 1 year [after treatment].  
****Can be subsequently performed for any symptoms or significant findings on upper tract imaging.
****Can be subsequently performed for any symptoms or significant findings on upper tract imaging.
***'''Upper tract imaging should be performed at least every 6-9 months for first 2 years, then annually up to 5 years.'''
***Upper tract imaging should be performed at least every 6-9 months for first 2 years, then annually up to 5 years.
***'''Surveillance after 5 years in the absence of recurrence should be based on shared decision-making.'''
***Surveillance after 5 years in the absence of recurrence should be based on shared decision-making.
**Risk of distant metastasis with low-risk disease is low
**No distant metastatic evaluation since risk is low with low-risk disease
* '''High-risk patients managed with kidney sparing treatment'''  
* '''High-risk patients managed with kidney sparing treatment'''  
** '''Cystoscopy, upper tract endoscopy, and upper tract urine cytology within 1-3 months of treatment to confirm successful treatment.'''
** Cystoscopy, upper tract endoscopy, and upper tract urine cytology within 1-3 months of treatment to confirm successful treatment.
**'''If successful treatment confirmed (no evidence of disease), perform'''
**If successful treatment confirmed (no evidence of disease), perform
***'''Cystoscopy of the bladder and cytology at least every 3-6 months for the first 3 years and then every 6-12 months up to 5 years.'''
***Cystoscopy of the bladder and cytology at least every 3-6 months for the first 3 years and then every 6-12 months up to 5 years.
***'''Upper tract endoscopy should be performed at least at 6 months and 1 year [after treatment]'''
***Upper tract endoscopy should be performed at least at 6 months and 1 year [after treatment]
***'''Upper tract imaging and BMP should be performed every 3-6 months for 3 years, then every 6-12 months for 2 years, and then annually thereafter.'''
***Upper tract imaging and BMP should be performed every 3-6 months for 3 years, then every 6-12 months for 2 years, and then annually thereafter.
***'''Distant metastatic evaluation: Chest imaging (chest X-ray or CT) is recommended every 6-12 months to evaluate for intrathoracic metastasis up to 5 years following last diagnosis/treatment'''
***Distant metastatic evaluation: Chest imaging (chest X-ray or CT) is recommended every 6-12 months to evaluate for intrathoracic metastasis up to 5 years following last diagnosis/treatment
***'''Surveillance after 5 years in the absence of recurrence should be based on shared decision-making.'''
***Surveillance after 5 years in the absence of recurrence should be based on shared decision-making.
* '''If patient develops urothelial recurrence in the bladder or urethra or positive cytology following kidney sparing treatment for UTUC, evaluate for possible ipsilateral recurrence or development of new contralateral upper tract disease.'''
* '''If patient develops urothelial recurrence in the bladder or urethra or positive cytology following kidney sparing treatment for UTUC, evaluate for possible ipsilateral recurrence or development of new contralateral upper tract disease.'''


==== Surveillance after radical NU ====
==== Surveillance after radical nephroureterectomy ====


* Follow up after NU for patients with non-muscle invasive, node-negative UTUC should be largely focused on the risk of intravesical recurrence
* Intravesical recurrence
** Rates of intravesical recurrence after NU: ≈29%; median time to recurrence 6-22 months
**Rates of intravesical recurrence after nephroureterectomy: ≈29%
** Most recurrences occur within the first 2 years
*** Most recurrences occur within the first 2 years
*** Unclear how long bladder surveillance should continue for after 2 years
**** Unclear how long bladder surveillance should continue for after 2 years
**Risk factors for intravesical recurrence:
**Risk factors for intravesical recurrence:
***Male sex
**#Male sex
***Previous bladder cancer
**#Previous bladder cancer
***Preoperative CKD
**#Preoperative CKD
***Positive preoperative urinary cytology
**#Positive preoperative urinary cytology
***Ureteral tumor size
**#Ureteral tumor size
***Multifocality
**#Multifocality
***Invasive pathologic T-stage
**#Invasive pathologic T-stage
***Presence of necrosis
**#Presence of necrosis
***Laparoscopic approach
**#Laparoscopic approach
***Extravesical bladder cuff removal
**#Extravesical bladder cuff removal
***Positive surgical margins
**#Positive surgical margins
***Prior ureteroscopic biopsy
**#Prior ureteroscopic biopsy
**Given the substantial risk of local (bladder) recurrences within the first years following NU, risk adapted surveillance with cystoscopy and urine cytology at routine intervals is indicated to facilitate prompt detection of bladder recurrences.
**Given the substantial risk of local (bladder) recurrences within the first years following nephroureterectomy, risk adapted surveillance with cystoscopy and urine cytology at routine intervals is indicated to facilitate prompt detection of bladder recurrences.
* Risk of recurrence to the contralateral upper: ≈2%
* Contralateral recurrence
** Upper tract imaging should be performed with CT urogram, if possible.
**Risk of recurrence to the contralateral upper tract: ≈2%
*Locoregional, retroperitoneal, and distant metastases
*Locoregional, retroperitoneal, and distant metastases
**Risk factors for recurrence
**Risk factors
***Multifocality
***Multifocality
***Stage T3-4
***Stage T3-4
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***Brain
***Brain
****Rare following nephroureterectomy
****Rare following nephroureterectomy
****Patients undergoing follow-up for HR UTUC following NU with acute neurological signs or symptoms should undergo prompt neurologic evaluation with cross-sectional imaging of the brain and/or spine by CT or MRI
****Patients undergoing follow-up for HR UTUC following nephroureterectomy with acute neurological signs or symptoms should undergo prompt neurologic evaluation with cross-sectional imaging of the brain and/or spine by CT or MRI


* '''<pT2 N0/M0 managed with NU'''
* '''<pT2 N0/M0 managed with NU'''
** Cystoscopy and urine cytology within 3 months after surgery, then repeated based on pathologic grade.  
** Cystoscopy and urine cytology within 3 months after surgery, then repeated based on pathologic grade.  
***For LG this should repeated at least every six to nine months for the first two years and then at least annually thereafter.  
***For LG this should repeated at least every 5-9 months for the first 2 years and then at least annually thereafter.
***For HG, this should be repeated at least every three to six months for the first three years and then at least annually thereafter.  
***For HG, this should be repeated at least every 3-6 months for the first 3 years and then at least annually thereafter.
**Cross-sectional imaging of the abdomen and pelvis should be done within 6 months after surgery and then at least annually for a minimum of 5 years
**Cross-sectional imaging of the abdomen and pelvis should be done within 6 months after surgery and then at least annually for a minimum of 5 years
***Due to the metastasis risk and estimated 5% probability for contralateral disease
***Due to the metastasis risk and estimated 5% probability for contralateral disease
***Follow up after nephroureterectomy for patients with non-muscle invasive, node-negative UTUC should be largely focused on the risk of intravesical recurrence
**Surveillance after five years in the absence of recurrence should be encouraged and based on shared decision-making between the patient and clinician
**Surveillance after five years in the absence of recurrence should be encouraged and based on shared decision-making between the patient and clinician
* '''T2+ managed with NU'''
* '''T2+ managed with NU'''
** Cystoscopy with cytology at three months after surgery, then every three to six months for 3 years, and then annually thereafter.  
** Cystoscopy with cytology at 3 months after surgery, then every 3-6 months for 3 years, and then annually thereafter.
**Cross-sectional imaging of the abdomen and pelvis with multiphasic contrast-enhanced CT urography should be performed every three to six months for years one and two, every six months at year three, and annually thereafter to year five.  
**Cross-sectional imaging of the abdomen and pelvis with multiphasic contrast-enhanced CT urography should be performed every 3-6 months for years 1 and 2, every 6 months at year 3, and annually thereafter to year 5.
**Chest imaging, preferably with chest CT, every 6-12 months for the first 5 years.  
**Chest imaging, preferably with chest CT, every 6-12 months for the first 5 years.  
**Beyond five years after surgery in patients without recurrence, ongoing surveillance with cystoscopy and upper tract imaging may be continued on an annual basis according to principles of shared/informed decision-making
**Beyond five years after surgery in patients without recurrence, ongoing surveillance with cystoscopy and upper tract imaging may be continued on an annual basis according to principles of shared/informed decision-making
*'''Sequelae of NU'''
*'''Sequelae of nephroureterectomy'''
**'''Periodic laboratory assessment including serum creatinine level, eGFR, and urinalysis.'''  
**'''Repeat assessment of blood pressure, eGFR, and proteinuria should be performed soon after nephroureterectomy then again in 3-6 months to assess for development or progression of CKD.'''  
***With significant nephron mass loss, hyperfiltration can occur resulting in glomerular damage, exacerbation of proteinuria and progressive sclerosis with further decline in GFR.
***The long-term impact of renal dysfunction increases risks of osteoporosis, anemia, metabolic and cardiovascular disease, hospitalization and death.
***Effective treatment strategies are available to slow the progression of CKD and reduce cardiovascular risks, and therefore timely identification of progressive renal dysfunction and/or proteinuria can provide opportunity for medical intervention when indicated.
****Careful management of DM and HTN and avoidance of substantial weight gain may slow or prevent CKD progression and should be prioritized on a long-term basis
****Identifying modifiable risk factors including diabetes mellitus (DM), hypertension (HTN) and smoking is essential. Optimizing glycemic and blood pressure control, smoking cessation and minimizing risk of acute kidney injury (with avoidance of hypotension and nephrotoxic agents such as intravenous contrast or non-steroidal anti-inflammatory drugs) should reduce the degree of renal dysfunction in the perioperative period.
***'''In patients who develop progressive renal insufficiency or proteinuria should be referred to nephrology.'''
***'''In patients who develop progressive renal insufficiency or proteinuria should be referred to nephrology.'''
**Other laboratory evaluations (e.g., CBC, LDH, liver function tests, and alkaline phosphatase) may be obtained at the discretion of the clinician or if advanced disease is suspected.  
**Other laboratory evaluations (e.g., CBC, LDH, liver function tests, and alkaline phosphatase) may be obtained at the discretion of the clinician or if advanced disease is suspected.  
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=== Survivorship ===
=== Survivorship ===


* '''Repeat assessment of blood pressure, eGFR, and proteinuria should be performed soon after nephrectomy then again in 3-6 months to assess for development or progression of CKD.'''
**With significant nephron mass loss, hyperfiltration can occur resulting in glomerular damage, exacerbation of proteinuria and progressive sclerosis with further decline in GFR.
**The long-term impact of renal dysfunction increases risks of osteoporosis, anemia, metabolic and cardiovascular disease, hospitalization and death.
**Effective treatment strategies are available to slow the progression of CKD and reduce cardiovascular risks, and therefore timely identification of progressive renal dysfunction and/or proteinuria can provide opportunity for medical intervention when indicated.
***Careful management of DM and HTN and avoidance of substantial weight gain may slow or prevent CKD progression and should be prioritized on a long-term basis
***Identifying modifiable risk factors including diabetes mellitus (DM), hypertension (HTN) and smoking is essential. Optimizing glycemic and blood pressure control, smoking cessation and minimizing risk of acute kidney injury (with avoidance of hypotension and nephrotoxic agents such as intravenous contrast or non-steroidal anti-inflammatory drugs) should reduce the degree of renal dysfunction in the perioperative period.
* Discuss disease-related stresses and risk factors and encourage patients with urothelial cancer to adopt healthy lifestyle habits, including smoking cessation, exercise, and a healthy diet, to promote long-term health benefits and quality of life.
* Discuss disease-related stresses and risk factors and encourage patients with urothelial cancer to adopt healthy lifestyle habits, including smoking cessation, exercise, and a healthy diet, to promote long-term health benefits and quality of life.
**UTUC is associated with metabolic syndrome and obesity, with obesity adversely impacting disease-specific outcomes among patients undergoing RNU.
**UTUC is associated with metabolic syndrome and obesity, with obesity adversely impacting disease-specific outcomes among patients undergoing RNU.
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