Presentation Authors: Andrew Vitale*, Jeremy West, Brenton Sherwood, Kenneth Nepple, Sarah Mott, Michael O'Donnell, Iowa city, IA
Introduction: The standard of care for high-grade Upper Tract Urothelial Carcinoma has been nephroureterectomy (NU) with excision of a bladder cuff. However, no specific guidelines exist for the management of localizing high grade cytology for which no visible lesions are apparent. Topical therapy may be appropriate in such patients.
Methods: Data was collected retrospectively on patients with HGUTCNI receiving upper tract treatments (UTT). Induction treatment regimens included weekly BCG + interferon (IFN) X 6, BCG + IFN + IL2 + GMCSF (quad immunotherapy) X 6, sequential gemcitabine/docetaxel (gem/doce) X 6, and a 4-drug regimen of sequential adriamycin and gemcitabine alternating weekly with sequential mitomycin and docetaxel (quad chemo) X 8. Responders underwent one 3 week maintenance cycle for BCG regimens and 6 once monthly maintenance treatments for chemo regimens. Patients were preferentially treated with a BCG regimen unless previously BCG unresponsive whereupon gem/doce followed by quad chemo were used. After induction, patients were restaged with cystoscopy and cytology from the bladder and upper tracts, upper tract imaging and ureteroscopy. Recurrence-free survival was calculated from time of treatment to recurrence based on Kaplan-Meier plots.
Results: Sixty-six patients received UTT for HGUTCNI; 43 of these had coexistant bladder cancer recurrences (65%). 38 patients (57%) had upper tract recurrence of which 13 underwent NU (20%), 9 were not surgical candidates or refused NU (14%), and 8 developed metastatic disease (12%). At median follow-up of 44 months, 22 patients (34%) died with 14 (21%) attributable to urothelial carcinoma. Overall UT recurrence free survival (RFS) at 1 year was 64%. Patients receiving BCG, Quad BCG, Gem/Doce, or Quad Chemo had 1-year RFS rates of 67%, 67%, 91% and 33%, respectively (see Figure). At 24 months, RFS for patients receiving any BCG was 61% and the median time to recurrence was >57 months.
Conclusions: Topical treatment may provide durable RFS in patients with HGUTCNI, however, close follow up is necessary as progression and even metastasis is possible from both coexistant bladder cancer and UT disease.