Upper Tract Urothelial Carcinoma Survivorship

153 Upper Tract Urothelial Carcinoma Survivorship

Spencer Craven and Jennifer Marie Taylor

SURVIVAL

While urothelial carcinoma (UC) is the fourth most common cancer, upper tract urothelial carcinomas (UTUCs) account for only 5% to 10% of UC tumors (1). Compared to bladder tumors, UTUC tends to present at a more advanced stage, with almost 60% already invasive at diagnosis (2). UTUC also has a tendency for multifocality, local recurrence, and metastasis. Recurrence of disease in the bladder, which is not considered metastasis, occurs in 22% to 47% of UTUC patients, while recurrence in the contralateral upper tract occurs in 2% to 6% of patients (3). Prognosis for UTUC depends heavily on stage and grade as well as nodal involvement, lymphovascular invasion, and tumor multifocality. Stage Ta and Tis tumors have 5-year survival rates approaching 100%, while 5-year survival rate for stage T3 tumors does not exceed 50% (4).

FOLLOW-UP

Given the poor prognosis for many patients as well as the high rates of recurrence, continued counseling and follow-up after initial diagnosis and treatment are key. All patients should be counseled to quit smoking, as this is a risk factor for all UCs. Patients who have undergone radical nephroureterectomy (RNU) must be counseled on the risks of having only a single functioning renal unit. Studies have shown an association between chronic kidney disease and cardiovascular morbidity and mortality after nephrectomy for renal tumors, which can 154be extrapolated to RNU patients. The estimated glomerular filtration rate (eGFR) has also been shown to be significantly diminished after RNU, particularly in the elderly (5).

Regular surveillance is necessary in all UTUC patients in order to detect local recurrence, metachronous bladder tumors, and distant metastases. The follow-up for these patients is frequent, expensive, and invasive, adding considerable morbidity to the disease. Both the National Comprehensive Cancer Network (NCCN) and the European Association of Urology (EAU) provide guidelines for surveillance of UTUC. The NCCN recommends uniform follow-up for all stages and treatment modalities including cystoscopy every 3 months for 1 year and then at increasing intervals after that. Imaging of the upper tracts is also recommended at 3 to 12 month intervals (6). The EAU breaks their recommendations down based on treatment modality and tumor characteristics. Following RNU, patients with noninvasive tumors should have cystoscopy and urine cytology at 3 months and then yearly thereafter. Patients with invasive tumors should have an additional CT urogram (CTU) every 6 months over 2 years and then yearly. Patients managed conservatively should receive cytology and CTU at 3 and 6 months followed by yearly exams. Cystoscopy, ureteroscopy, and cytology are recommended at 3 and 6 months, then every 6 months over 2 years, and then yearly thereafter. All conservatively managed patients should be followed for at least 5 years (2). The frequency of surveillance visits speaks to the need for continued comanagement between Urology and Medical Oncology in most cases.

Probabilities of recurrence, metastasis, and death evolve over time and decrease with increased survivorship. This is known as conditional survival (7). For all UTUC patients, 5-year survival increased from 62.6% at the time of treatment to 71.6% after 5 years. This effect is even more pronounced in patients with adverse pathologic features. Patents with pT3-4 disease increased from 39% at the time of treatment to 65% after 5 years. These estimates provide a dynamic view of cancer survivorship for both patients and physicians that can aid in patient counseling and surveillance planning.

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