The Role of Systemic Chemotherapy in Management of Upper Tract Urothelial Cancer
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UROTHELIAL CANCER (A SAGALOWSKY, SECTION EDITOR)
The Role of Systemic Chemotherapy in Management of Upper Tract Urothelial Cancer Bishoy A. Gayed & Gregory R. Thoreson & Vitaly Margulis
Published online: 24 January 2013 # Springer Science+Business Media New York 2013
Abstract Upper tract urothelial cancer (UTUC) accounts for roughly 5 % of all urothelial cancers. At presentation, 30 % of patients demonstrate invasive and/or locally advanced disease, 30–40 % have regional lymph node involvement, and 20 % harbor metastatic disease. Systemic recurrence and progression rates after surgery for patients with advanced disease range between 45–60 %. Five-year cancer specific survival rates for pT2 and pT3 tumors are 73 % and 40 %, respectively. Median survival for patients with pT4 disease is approximately 6 months. Nonetheless, there is a lack of improvement in the rates of systemic recurrence and progression in patients with advanced UTUC. Extrapolating evidence obtained from experience with multi-modal therapy of patients with urothelial bladder cancer, additional improvements in oncological outcomes for patients with UTUC can be achieved through integration of effective systemic chemotherapy with local tumor control. We provide an overview of the rationale and utilization strategies of peri-operative systemic chemotherapy in patients with UTUC. Keywords Upper urinary tract urothelial cancer . Neoadjuvant chemotherapy . Adjuvant chemotherapy . Nephro-ureterectomy . Risk stratification . Oncologic outcomes
Introduction UTUC is a rare malignancy with the current incidence rate of 2.06 cases per 100000 person-years [1]. On average, 45– 60 % of patients with locally advanced disease will relapse B. A. Gayed : G. R. Thoreson : V. Margulis (*) University of Texas Southwestern Medical Center, Dallas, TX, USA e-mail: [email protected]
after extirpative surgery alone [2]. Margulis et al., reported 5-year survival rates for pT2, pT3, N+ and pT4 to be 74.7 %, 54 %, 35.3 %, and 12.2 %, respectively, in a large multicenter collaborative study of 1363 patients treated with radical nephroureterectomy (RNU) [3••]. There is a paucity of clinical trials comparing different treatment strategies and chemotherapeutic regimens of patients with UTUC, likely due to the rarity of the disease [4••]. Thus, most of the evidence for the treatment of patients with UTUC may be extrapolated from experience with bladder cancer. Historically, patients with metastatic bladder cancer have been effectively treated with methotrexate, vinblastine, adriamycin, and cisplatin (MVAC) or gemcitabine/cisplatin (GC) regimens that have shown similar efficacy in this setting [5]. The Southwest Oncology group’s Phase 3 trial comparing the effects of MVAC+ cystectomy versus cystectomy alone in 307 patients with ≥ T2 bladder cancer revealed an improvement in survival from 77 months in the MVAC+ surgery group vs 46 months in the surgery alone group (p=0.06). Additionally, the use of neoadjuvant MVAC was significantly associated with the absence of res
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