Zusammenfassung
Hintergrund
Das Therapiespektrum des Urothelkarzinoms des oberen Harntraktes ist breit und hängt maßgeblich von der individuellen Risikokonstellation ab. Eine möglichst exakte Diagnosestellung und Ausbreitungsdiagnostik sind unabdingbar für die Einordnung in die Niedrig- bzw. Hochrisikogruppe (low-risk bzw. high-risk).
Ziel
Darstellung der weiterentwickelten Diagnostik- und Therapiemöglichkeiten sowie der differenzierten Behandlungsstrategien des lokal begrenzten Urothelkarzinoms des oberen Harntrakts.
Material und Methoden
Selektive Literaturrecherche in der Datenbank PubMed zu den Themen Urothelkarzinom des oberen Harntrakts, Diagnostik, organerhaltende Therapie, radikale Nephroureterektomie sowie multimodale Therapiekonzepte.
Ergebnisse
Die Fortschritte bei der Bildgebung und den endoskopischen Techniken haben die diagnostische Sicherheit für das Urothelkarzinom des oberen Harntraktes erhöht und das Understaging reduziert. Die möglichst akkurate Einordnung in die Hoch- oder Niedrigrisikogruppe vereinfacht eine Therapieentscheidung. Nierenerhaltende Verfahren, z. B. eine endoskopische lasergestützte Tumorablation oder eine Uretersegmentresektion, können in bestimmten Konstellationen eingesetzt werden. Die radikale Nephroureterektomie ist der Goldstandard bei high-risk Karzinomen aufgrund des hohen Risikos für eine Progression und Metastasierung. Bei einem klinischen Tumorstadium ≥cT3 wird ein offener Zugang gegenüber einer laparoskopischen Vorgehensweise favorisiert. Eine adjuvante platinhaltige Chemotherapie soll nach der radikalen Nephroureterektomie bei einem pathologischen Tumorstadium ≥pT2 und/oder pN+ durchgeführt werden.
Diskussion
Mittlerweile bieten neue Algorithmen die Möglichkeit, therapieinduzierte Morbidität zu reduzieren und das onkologische Outcome zu verbessern, v. a. durch effektivere Multimodalkonzepte.
Abstract
Background
The treatment spectrum of urothelial carcinoma of the upper urinary tract is broad and depends largely on the individual risk constellation. The diagnosis and diagnostics of spreading need to be as accurate as possible for the classification into the low-risk or high-risk group.
Objective
Presentation of new achievements in diagnostics and treatment options as well as the differentiated treatment strategies for localized urothelial carcinoma of the upper urinary tract.
Material and methods
A selective literature search was carried out in PubMed on the topic of urothelial carcinoma of the upper urinary tract, diagnostics, organ-preserving strategies, radical nephroureterectomy and multimodal treatment concepts.
Results
Advances in imaging and endoscopic techniques, in particular, have increased the diagnostic certainty and reduced understaging. An accurate stratification as possible into the low-risk or high-risk group simplifies clinical decision making. Kidney-preserving procedures, such as endoscopic laser-guided tumor ablation or ureteral segmental resection, can be used in certain constellations. Radical nephroureterectomy remains the gold standard for high-risk urothelial carcinoma of the upper urinary tract due to the high risk of progression and metastases. For clinical stage ≥cT3 tumors an open approach is favored over a laparoscopic approach. Adjuvant platinum-based chemotherapy should be performed in a pathological tumor stage ≥pT2 and/or pN+ following radical nephroureterectomy.
Discussion
New algorithms meanwhile provide the possibility to reduce treatment-induced morbidity and to improve the oncological outcome, particularly through more effective multimodal concepts.
Literatur
Siegel RL et al (2021) Cancer Statistics, 2021. CA Cancer J Clin 71(1):7–33
Rouprêt M et al (2021) European association of urology guidelines on upper urinary tract urothelial carcinoma: 2020 update. Eur Urol 79(1):62–79
System, E.-E.C.I (2022) Incidence and mortality statistics, by registry and cancer site
Robert-Koch-Institut, Z.f.K.i. (2021) Datenbankabfrage mit Schätzung der Inzidenz, Prävalenz und des Überlebens von Krebs in Deutschland auf Basis der epidemiologischen Landeskrebsregisterdaten
Fernández MI et al (2020) Arsenic exposure is associated with significant upper tract urothelial carcinoma health care needs and elevated mortality rates. Urol Oncol 38(7):638.e7–638.e13. https://doi.org/10.1016/j.urolonc.2020.01.014
Huang D et al (2018) Systematic review: an update on the spectrum of urological malignancies in lynch syndrome. Bladder Cancer 4(3):261–268
Green DA et al (2013) Urothelial carcinoma of the bladder and the upper tract: disparate twins. J Urol 189(4):1214–1221
Margulis V et al (2009) Outcomes of radical nephroureterectomy: a series from the upper tract urothelial carcinoma collaboration. Cancer 115(6):1224–1233
Brown GA et al (2006) Nephroureterectomy for treating upper urinary tract transitional cell carcinoma: time to change the treatment paradigm? BJU Int 98(6):1176–1180
Birtle A et al (2020) Adjuvant chemotherapy in upper tract urothelial carcinoma (the POUT trial): a phase 3, open-label, randomised controlled trial. Lancet 395(10232):1268–1277
Lughezzani G et al (2012) Prognostic factors in upper urinary tract urothelial carcinomas: a comprehensive review of the current literature. Eur Urol 62(1):100–114
Matsumoto K et al (2011) Racial differences in the outcome of patients with urothelial carcinoma of the upper urinary tract: an international study. BJU Int 108(8 Pt 2):E304–E309
Rink M et al (2013) Impact of smoking on oncologic outcomes of upper tract urothelial carcinoma after radical nephroureterectomy. Eur Urol 63(6):1082–1090
Simsir A et al (2011) Prognostic factors for upper urinary tract urothelial carcinomas: stage, grade, and smoking status. Int Urol Nephrol 43(4):1039–1045
Carrion A et al (2016) Intraoperative prognostic factors and atypical patterns of recurrence in patients with upper urinary tract urothelial carcinoma treated with laparoscopic radical nephroureterectomy. Scand J Urol 50(4):305–312
Ehdaie B et al (2011) Obesity adversely impacts disease specific outcomes in patients with upper tract urothelial carcinoma. J Urol 186(1):66–72
Rouprêt M et al (2012) Genetic variability in 8q24 confers susceptibility to urothelial carcinoma of the upper urinary tract and is linked with patterns of disease aggressiveness at diagnosis. J Urol 187(2):424–428
Xia L et al (2018) Impact of surgical waiting time on survival in patients with upper tract urothelial carcinoma: a national cancer database study. Urol Oncol 36(1):10.e15–10.e22
Nishiyama N et al (2018) Upper tract urothelial carcinoma following intravesical bacillus Calmette-Guérin therapy for nonmuscle-invasive bladder cancer: Results from a multi-institutional retrospective study. Urol Oncol 36(6):306.e9–306.e15
Messer JC et al (2013) Multi-institutional validation of the ability of preoperative hydronephrosis to predict advanced pathologic tumor stage in upper-tract urothelial carcinoma. Urol Oncol 31(6):904–908
Janisch F et al (2020) Diagnostic performance of multidetector computed tomographic (MDCTU) in upper tract urothelial carcinoma (UTUC): a systematic review and meta-analysis. World J Urol 38(5):1165–1175
Takahashi N et al (2010) Gadolinium enhanced magnetic resonance urography for upper urinary tract malignancy. J Urol 183(4):1330–1365
Malm C et al (2017) Diagnostic accuracy of upper tract urothelial carcinoma: how samples are collected matters. Scand J Urol 51(2):137–145
Koll FJ et al (2021) Evaluation of pre-operative biopsy, surgical procedures and oncologic outcomes in upper tract urothelial carcinoma (UTUC). Front Surg 8:790738
Ritter M et al (2013) Standardized ex vivo comparison of different upper urinary tract biopsy devices: impact on ureterorenoscopes and tissue quality. World J Urol 31(4):907–912
Foerster B et al (2019) Biopsy techniques in the upper urinary tract for the diagnosis of urothelial carcinoma: systematic review. Urologe A 58(1):14–21
Klein JT et al (2019) Cryobiopsy in the upper urinary tract: preclinical evaluation of a novel device. Urology 123:273–279
Kriegmair MC et al (2021) Enhanced imaging in urological endoscopy. Urologe A 60(1):8–18
Bus MT et al (2016) Optical coherence tomography as a tool for in vivo staging and grading of upper urinary tract urothelial carcinoma: a study of diagnostic accuracy. J Urol 196(6):1749–1755
Sonn GA et al (2009) Optical biopsy of human bladder neoplasia with in vivo confocal laser endomicroscopy. J Urol 182(4):1299–1305
Territo A et al (2021) Diagnostic ureteroscopy for upper tract urothelial carcinoma: friend or foe? Arab J Urol 19(1):46–58
Seisen T, Colin P, Rouprêt M (2015) Risk-adapted strategy for the kidney-sparing management of upper tract tumours. Nat Rev Urol 12(3):155–166
Rouprêt M, Colin P, Yates DR (2014) A new proposal to risk stratify urothelial carcinomas of the upper urinary tract (UTUCs) in a predefinitive treatment setting: low-risk versus high-risk UTUCs. Eur Urol 66(2):181–183
Margulis V et al (2010) Preoperative multivariable prognostic model for prediction of nonorgan confined urothelial carcinoma of the upper urinary tract. J Urol 184(2):453–458
Seisen T et al (2016) Oncologic outcomes of kidney-sparing surgery versus radical nephroureterectomy for upper tract urothelial carcinoma: a systematic review by the EAU non-muscle invasive bladder cancer guidelines panel. Eur Urol 70(6):1052–1068
Shoen E et al (2021) Use of the T‑1470 litetouch™ laser in the en bloc resection of an upper tract urothelial cancer. Case Rep Urol. https://doi.org/10.1155/2021/6623326
Grasso M et al (2012) Ureteroscopic and extirpative treatment of upper urinary tract urothelial carcinoma: a 15-year comprehensive review of 160 consecutive patients. BJU Int 110(11):1618–1626
Vemana G et al (2016) Survival comparison between endoscopic and surgical management for patients with upper tract urothelial cancer: a matched propensity score analysis using surveillance, epidemiology and end results-medicare data. Urology 95:115–120
Fang D et al (2016) A systematic review and meta-analysis of oncological and renal function outcomes obtained after segmental ureterectomy versus radical nephroureterectomy for upper tract urothelial carcinoma. Eur J Surg Oncol 42(11):1625–1635
Azizi M et al (2019) Optimal management of upper tract urothelial carcinoma: an unmet need. Curr Treat Options Oncol 20(5):40
Piraino JA et al (2020) Nephroureterectomy vs. segmental ureterectomy of clinically localized, high-grade, urothelial carcinoma of the ureter: practice patterns and outcomes. Urol Oncol 38(11):851.e1–851.e10
Bagrodia A et al (2013) Comparative analysis of oncologic outcomes of partial ureterectomy vs radical nephroureterectomy in upper tract urothelial carcinoma. Urology 81(5):972–977
Colin P et al (2012) Comparison of oncological outcomes after segmental ureterectomy or radical nephroureterectomy in urothelial carcinomas of the upper urinary tract: results from a large French multicentre study. BJU Int 110(8):1134–1141
Foerster B et al (2019) Endocavitary treatment for upper tract urothelial carcinoma: a meta-analysis of the current literature. Urol Oncol 37(7):430–436
Giannarini G et al (2011) Antegrade perfusion with bacillus Calmette-Guérin in patients with non-muscle-invasive urothelial carcinoma of the upper urinary tract: who may benefit? Eur Urol 60(5):955–960
Kleinmann N et al (2020) Primary chemoablation of low-grade upper tract urothelial carcinoma using UGN-101, a mitomycin-containing reverse thermal gel (OLYMPUS): an open-label, single-arm, phase 3 trial. Lancet Oncol 21(6):776–785
Matin SF et al (2021) Durability of response to primary chemoablation of low-grade upper tract urothelial carcinoma using UGN-101, a mitomycin-containing reverse thermal gel: OLYMPUS trial final report. J Urol. https://doi.org/10.1097/ju.0000000000002350
Peyronnet B et al (2019) Oncological outcomes of laparoscopic nephroureterectomy versus open radical nephroureterectomy for upper tract urothelial carcinoma: an European Association of Urology guidelines systematic review. Eur Urol Focus 5(2):205–223
Matin SF et al (2015) Patterns of lymphatic metastases in upper tract urothelial carcinoma and proposed dissection templates. J Urol 194(6):1567–1574
Kondo T et al (2010) Template-based lymphadenectomy in urothelial carcinoma of the upper urinary tract: impact on patient survival. Int J Urol 17(10):848–854
Dominguez-Escrig JL et al (2019) Potential benefit of lymph node dissection during radical nephroureterectomy for upper tract urothelial carcinoma: a systematic review by the European Association of Urology guidelines panel on non-muscle-invasive bladder cancer. Eur Urol Focus 5(2):224–241
Hwang EC et al (2019) Single-dose intravesical chemotherapy after nephroureterectomy for upper tract urothelial carcinoma. Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.CD013160.pub2
Li WM et al (2010) Oncologic outcomes following three different approaches to the distal ureter and bladder cuff in nephroureterectomy for primary upper urinary tract urothelial carcinoma. Eur Urol 57(6):963–969
O’Brien T et al (2011) 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 60(4):703–710
Hosogoe S et al (2018) Platinum-based neoadjuvant chemotherapy improves oncological outcomes in patients with locally advanced upper tract urothelial carcinoma. Eur Urol Focus 4(6):946–953
Kubota Y et al (2017) Oncological outcomes of neoadjuvant chemotherapy in patients with locally advanced upper tract urothelial carcinoma: a multicenter study. Oncotarget 8(60):101500–101508
Zennami K et al (2021) Two cycles of neoadjuvant chemotherapy improves survival in patients with high-risk upper tract urothelial carcinoma. BJU Int 127(3):332–339
D’Andrea D et al (2021) Comparative effectiveness of neoadjuvant chemotherapy in bladder and upper urinary tract urothelial carcinoma. BJU Int 127(5):528–537
Yip W et al (2022) Final results of a multicenter prospective phase II clinical trial of gemcitabine and cisplatin as neoadjuvant chemotherapy in patients with high-grade upper tract urothelial carcinoma. J Clin Oncol 40(6_suppl):440–440
Kaag MG et al (2010) Changes in renal function following nephroureterectomy may affect the use of perioperative chemotherapy. Eur Urol 58(4):581–587
Leow JJ et al (2021) Neoadjuvant and adjuvant chemotherapy for upper tract urothelial carcinoma: a 2020 systematic review and meta-analysis, and future perspectives on systemic therapy. Eur Urol 79(5):635–654
Hird AE et al (2021) Neoadjuvant versus adjuvant chemotherapy for upper tract urothelial carcinoma: a microsimulation model. Clin Genitourin Cancer 19(2):e135–e147
Bajorin DF et al (2021) Adjuvant nivolumab versus placebo in muscle-invasive urothelial carcinoma. N Engl J Med 384(22):2102–2114
Bellmunt J et al (2021) Adjuvant atezolizumab versus observation in muscle-invasive urothelial carcinoma (IMvigor010): a multicentre, open-label, randomised, phase 3 trial. Lancet Oncol 22(4):525–537
Iwata T et al (2019) The role of adjuvant radiotherapy after surgery for upper and lower urinary tract urothelial carcinoma: a systematic review. Urol Oncol 37(10):659–671
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Interessenkonflikt
M. Marx, L.-M. Krabbe, F. Wezel, J.-T. Klein, F. Zengerling und C. Bolenz geben an, dass kein Interessenkonflikt besteht.
Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.
Additional information
QR-Code scannen & Beitrag online lesen
Rights and permissions
About this article
Cite this article
Marx, M., Krabbe, LM., Wezel, F. et al. Urothelkarzinom des oberen Harntraktes: aktuelle Behandlungsstrategien. Onkologie 28, 753–763 (2022). https://doi.org/10.1007/s00761-022-01220-w
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00761-022-01220-w
Schlüsselwörter
- Nephroureterektomie
- Übergangszellkarzinom
- Multimodale Therapie
- Klinische Entscheidungsfindung
- Algorithmen