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Figure 1
CT Urogram demonstrating a left upper tract filling defect and a left 1.5 x 1.2cm left para-aortic lymph node
The patient is a 64-year-old Caucasian man with a history of stage I, pT1N0Mx, high grade urothelial carcinoma (nested variant) treated with a radical cystoprostatectomy and creation of an orthotopic, continent, neobladder which was performed in January of 2017. His past medical history is otherwise unremarkable.
Surveillance imaging revealed no evidence of disease recurrence until August 2018, when a computed tomography (CT) urogram revealed a left upper tract filling defect and a 1.5 x 1.2 cm para-aortic lymph node. His urinary cytology was positive for high-grade urothelial carcinoma (UC) suggestive of an upper tract recurrence. Fine needle aspiration of the para aortic lymph node confirmed regionally metastatic upper tract UC. A CT of his chest was negative for distant metastatic disease.
Submit your diagnosis to see full explanation.
This clinical quiz was prepared by Marc C. Smaldone, MD, MSHP, FACS, of Fox Chase Cancer Center, Philadelphia.
References
1. Gakis G, Black PC, Bochner BH, et al. Systematic review on the fate of the remnant urothelium after radical cystectomy. Eur Urol. 2017;71:545-557. doi: 10.1016/j.eururo.2016.09.035.
2. Simhan J, Smaldone MC, Egleston BL, et al. Nephron-sparing management vs radical nephroureterectomy for low- or moderate-grade, low-stage upper tract urothelial carcinoma. BJU Int. 2014;114:216-220. doi: 10.1111/bju.12341.
3. Kaag MG, O’Malley RL, O’Malley P, et al. Changes in renal function following nephroureterectomy may affect the use of perioperative chemotherapy. Eur Urol. 2010;58:581-587. doi: 10.1016/j.eururo.2010.06.029.
4. Grossman HB, Natale RB, Tangen CM, et al. Neoadjuvant chemotherapy plus cystectomy compared with cystectomy alone for locally advanced bladder cancer. N Engl J Med. 2003;349:859-866. Erratum in: N Engl J Med. 2003;349:1880.
5. Birtle AJ, Chester JD, Jones R, et al. Results of POUT: A phase III randomized trial of prospective chemotherapy versus surveillance in upper tract urothelial cancer. Presented at the 2018 Genitourinary Cancers Symposium in San Francisco. Abstract 407. https://meetinglibrary.asco.org/record/157669/abstract
Answer: E
Explanation
After extensive counseling, as the patient was cisplatin naïve, the patient was treated with 3 cycles of dose dense MVAC neoadjuvant chemotherapy. Restaging cross sectional imaging demonstrated resolution of the para-aortic lymph node and no evidence of metastatic disease. He then underwent robotic left nephroureterectomy with retroperitoneal lymph node dissection, which revealed ypT2N0Mx high grade upper tract urothelial carcinoma (0/28 lymph nodes positive).
Rigorous surveillance of the upper tract is mandatory following local therapy for both non-muscle-invasive and muscle-invasive high-grade UC of the bladder. Lifelong risks of upper tract recurrence range from 4%-10% following cystectomy and are higher when there is a concomitant diagnosis of carcinoma in situ or distal ureteral disease.1 Conservative measures such as endoscopic ablation are potential management options for patients with low volume, low grade disease, while endoscopic ablation, percutaneous resection, and segmental resection have been applied to high grade disease in elderly co-morbid patients, those with bilateral disease or a solitary renal unit, and patients with chronic renal insufficiency at risk for requiring dialysis.2 While the gold standard for surgical resection of upper tract UC remains radical nephroureterectomy, there is increased consensus among experts that neoadjuvant cisplatin-based chemotherapy be employed prior to consolidative surgical resection.
In the absence of level I evidence, these recommendations are largely influenced by the impact on cisplatin eligibility due to decreased estimated glomerular filtration rate following nephrectomy,3 extrapolation of the survival benefit demonstrated in the muscle invasive bladder cancer population,4 and recently published data demonstrating a survival benefit in the adjuvant setting (POUT study).5
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