Risk assessment and evaluation of disease extent remain crucial elements in the optimal treatment and management of upper tract urothelial carcinoma, according to experts who emphasise the need for doctors to conduct a better assessment of disease characteristics.
“Treatment outcomes strongly depend on several pre-treatment factors at presentation as well on the choice of the right treatment for the right patient,” said Dr. Sara M Falzarano, Genitourinary Pathology Fellow at the Robert J. Tomsich Pathology & Laboratory Medicine Institute at the Cleveland Clinic (USA)*.
“In upper tract urothelial carcinoma (UTUC), risk assessment is extremely important and includes evaluation of risk factors,” said Falzarano, one of the discussants and resource speakers at the 9th European Multidisciplinary congress on Urological Cancers (EMUC17) to be held in Barcelona from November 16 to 19.
A multidisciplinary congress, EMUC provides a platform for onco-urological experts and is now on its ninth edition of gathering leading opinion leaders, researchers and cancer specialists to critically examine treatment strategies for urological malignancies. The event is annually organised by three of Europe’s leading and specialised medical associations- the European Society for Medical Oncology (ESMO), the European SocieTy for Radiotherapy & Oncology (ESTRO) and the European Association of Urology (EAU).
Upper urinary tract (ureter and renal pelvis) disease represents about 5% of urothelial carcinoma at initial diagnosis, the remaining predominantly occurring in the lower urinary tract (bladder and urethra).
“Compared with bladder urothelial carcinoma, patients with UTUC generally are reported to harbour higher grade and stage disease at presentation, with a worse overall prognosis. Since many patients are asymptomatic, early diagnosis can be challenging. Delays from presentation to treatment may represent a concrete issue,” explained Falzarano.
A combination of imaging modalities and pathologic confirmation is required to diagnose UTUC, and the data obtained are essential for risk assessment to identify the best treatment option. The current gold standard surgical management of invasive high-grade UTUC is radical nephroureterectomy (RNU), although kidney-sparing approaches might be indicated in non-invasive low-risk disease, distal ureteric tumours amenable for segmental ureteric resection, and other special circumstances such as solitary (anatomically or functionally) upper urinary tract (due to prior nephrectomy for contralateral urothelial carcinoma, or other reasons).
Challenges in diagnostic staging
Regarding disease progression and survival, the strongest prognostic indicator in UTUC is the level of tumour spread at presentation. “However, accurate pre-operative pathologic staging of UTUC is challenging due to limitations of the biopsy specimen and the fact that it often does not allow for accurate assessment of the depth of invasion of the tumour into the upper urinary tract wall,” noted Falzarano.
After risk assessment, Falzarano pointed out that a consequent choice of the most appropriate therapeutic modality (open/laparoscopic surgery, radical/segmental resection, endoscopic management, neoadjuvant and adjuvant chemotherapy, etc.) has an essential role in achieving optimal treatment outcomes.
These challenges in the diagnosis and management of UTUC cases, she said, underscore the importance of an efficient multidisciplinary team (MDT) approach.
“The communication between members of the team is essential in achieving the best outcome. Discussion and presentation of the different aspects (clinical evaluation, imaging, pathology, etc.) of cases at multidisciplinary tumour boards with integration of professional expertise is a great example of an increasingly implemented strategy to improve multidisciplinary approach,” said Falzarano. She added that appropriate use of electronic medical records and granting the availability of essential patient information in a timely manner to all professionals involved in patient management is another crucial aspect for MDTs.
The EMUC, as an annual international platform for knowledge exchange and discussion of best practices fulfils a meaningful role among urological cancer experts, according to Falzarano.
“Consultative meetings create the invaluable educational opportunity by bringing together the expertise of professionals from different countries and practices to achieve a better picture of the state-of-the-art in the different management areas of a certain disease,” she said. A wider exchange of novel and potential breakthroughs and discoveries in the field can help foster in-depth knowledge, helping doctors provide high-quality care, she added.
The EMUC’s main Scientific Programme will be preceded on 16 November with the EMUC Symposium on Genitourinary Pathology and Molecular Diagnostics (ESUP), the 6th Meeting of the EAU Section of Urological Imaging (ESUI17) and European School of Urology (ESU) Courses. Besides the ESU course and Hands-on Training sessions, ESTRO is organising a delineation contouring workshop with the topic “Target volume contouring in bladder cancer.” A Uropathology Training Workshop will also be held for participants to gain practical insights on uropathology procedures.
*Falzarano will take on the role of Assistant Professor of Pathology at the University of Florida in October this year.