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Perioperative chemotherapy for upper tract urothelial cancer

Nature Reviews Urology volume 9, pages 266–273 (2012)Cite this article

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Abstract

Upper tract urothelial cancer (UTUC) is an aggressive disease associated with significant morbidity and mortality. Radical nephroureterectomy (RNU) with bladder cuff removal is considered the standard of care for most invasive UTUCs but distant relapses after surgery for locally advanced, high-grade disease are common. Although multimodality treatment with perioperative chemotherapy has been investigated thoroughly in recent years, adjuvant chemotherapy has primarily been analyzed in small retrospective uncontrolled studies and a clear benefit for this treatment modality is yet to be established. It is likely that the high incidence of renal insufficiency after surgery substantially limits the applicability of adjuvant chemotherapy with cisplatin-based regimens. Neoadjuvant cisplatin-based chemotherapy has several practical advantages over adjuvant therapy, including better patient tolerance in the preoperative setting when a patient has two kidneys rather than one and the obtainment of prognostic information from pathological downstaging. Although, some academic centers have adopted neoadjuvant chemotherapy as a de facto treatment standard for patients with high-grade locally advanced UTUC, this treatment approach has not been prospectively validated or adopted in general urologic practice. A multicenter trial of neoadjuvant chemotherapy for locally advanced high-grade UTUC could further define the role of neoadjuvant chemotherapy in treating UTUC.

Key Points

  • Outcomes after surgery for patients with high-risk upper tract urothelial carcinoma (UTUC) are suboptimal

  • Chemotherapy has a role in the management of patients with advanced UTUC, including in the perioperative context

  • Decline in renal function after nephroureterectomy is common and restricts the use of cisplatin-based adjuvant chemotherapy regimens

  • Neoadjuvant chemotherapy has shown promising efficacy and excellent tolerability in preliminary datasets

  • Larger prospective trials are needed to further examine the utility of neoadjuvant chemotherapy treatment for UTUC

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Figure 1: Recurrence-free survival after surgery for patients with upper tract urothelial cancer (UTUC).

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Authors and Affiliations

  1. Department of Hematology and Oncology, Division of Internal Medicine, University of Michigan, C351 Med Inn, SPC 5848, 1500 E. Medical Center Drive, Ann Arbor, 48109, MI, USA

    Ajjai S. Alva

  2. Department of Urology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1373, Houston, 77030, TX, USA

    Surena F. Matin & Arlene O. Siefker-Radtke

  3. Baylor College of Medicine, 6620 Main Street, Ste 1325, Houston, 77030-2726, TX, USA

    Seth P. Lerner

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A. Alva and A. O. Siefker-Radtke researched data and wrote the article. S. Matin and S. Lerner provided substantial contributions to discussions of content. All authors reviewed the manuscript prior to submission.

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Alva, A., Matin, S., Lerner, S. et al. Perioperative chemotherapy for upper tract urothelial cancer. Nat Rev Urol 9, 266–273 (2012). https://doi.org/10.1038/nrurol.2012.57

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