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A 70-year-old man with stage 3 chronic kidney disease (glomerular filtration rate of 40 mL/min/1.73 m2) presents with gross hematuria. A magnetic resonance imaging scan reveals a large volume of tumor in the left kidney and the left ureter. There is no evidence of metastases or associated lymphadenopathy. Chest imaging is unremarkable. A MAG-3 renal scan shows the left kidney to be non-functional. Cystoscopy, left ureteroscopy, and right retrograde pyelogram demonstrate normal lower and right upper tract. Left upper tract ureteroscopic biopsies confirm low grade urothelial disease. The man undergoes an uneventful laparoscopic nephroureterectomy with a formal bladder cuff resection. Final pathology demonstrates high volume Ta low grade urothelial carcinoma with foci of high grade T1 disease.
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Answer: D
Level 1 evidence for management of upper tract urothelial disease has been largely non-existent. Nevertheless, in the summer of 2011, investigators in the United Kingdom published findings of a prospective, randomized multiinstitutional trial of 284 patients undergoing nephroureterectomy who had no previous history of lower urinary tract disease.1
Of these patients, 144 received a dose of mitomycin C upon catheter removal (once a negative cystogram was documented), whereas 140 received standard of care and were followed with surveillance cystoscopy. A remarkable 40% relative risk reduction in development of subsequent urothelial disease in the bladder was observed during the first year of follow up.
As such, on modified intention-to-treat analysis, 17% of patients demonstrated bladder recurrence in the mitomycin C arm, whereas 27% of patients in the standard treatment cohort developed urothelial disease in the bladder, a significant difference between treatment arms. No significant ill-effect of mitomycin C treatment were documented in this trial.1
The case was prepared by Alexander Kutikov, MD, of Fox Chase Cancer Center in Philadelphia.
- O’Brien T, Ray E, Singh R, et al. Prevention of bladder tumours after nephroureterectomy for primary upper urinary tract urothelial carcinoma: a prospective, multicentre, randomised clinical trial of a single postoperative intravesical dose of mitomycin C (the ODMIT-C Trial). Eur Urol. 2011;60:703-710.
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