Diagnostic dilemmas in patients with upper tract urothelial carcinoma

Abstract

Upper tract urothelial carcinoma (UTUC) is a rare condition and recommendations based on a high level of evidence for diagnosis, treatment and follow-up monitoring are lacking. Current decision-making is often based on evidence from trials investigating urothelial carcinoma of the lower tract. Radical nephroureterectomy has been the standard of care for UTUC but kidney-sparing treatment using endoscopic approaches has been established for a select patient group with low-grade and low-stage disease. Optimal treatment choice requires correct tumour characterization. According to available recommendations, diagnostic work-up of UTUC includes evaluation by CT urography or MRI urography, cystoscopy and urine cytology. Ureterorenoscopy and lesion biopsy are grade C recommendations in patients with suspected UTUC. When kidney-sparing treatment is planned, ureterorenoscopy and biopsy should be considered and are the procedures of choice in most cases. These diagnostics have limitations and their accuracy varies in defining tumour characteristics and predicting grade and stage. Urinary tests have higher sensitivity than cytology for detection of lower tract urothelial carcinoma but evidence of their benefit in UTUCs is lacking. New optical and image enhancement techniques are being developed to facilitate real-time diagnostics with increased accuracy. A new diagnostic algorithm for patients with suspected UTUC that integrates the diagnosis, treatment and clinical risk stratification is required.

Optical Coherence Tomography in Urologic Oncology: a Comprehensive Review

“…Together with interpretation problems due to the limited biopsy volume, fragmentation and inter-observer variability, up to 20% of upper urinary tract biopsies are inconclusive. This results in limited reliability of UTUC grading and staging by ureteroscopic biopsies [31,32].…”

Prediction of high-grade ureteral urothelial carcinoma on CT urography

“…Furthermore, the accuracy of ureteroscopic biopsy in predicting tumour stage and grade is limited, and the limitations of endoscopic biopsy must be balanced against the possible advantage of avoiding radical surgery. 8 Thus, accurate preoperative prediction of tumour grade could be helpful in selecting more appropriate therapeutic options.…”

Delayed post-diuretic 18F-FDG PET/CT for preoperative evaluation of renal pelvic cancer

“…Although most of renal pelvic space-occupying lesions are renal pelvic cancer, it should also be distinguished from other renal pelvic spaceoccupying benign lesions [17]. Early differentiation between renal pelvic cancer and benign polyp is crucial for executing an effective treatment plan and predicting prognosis.…”