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Apr 30, 2021
1-yes & nephrectomy is effective on overall survival
2_ciplatin base if GFR is more than 60
3_l don't know
May 16, 2021
A large papillary urothelial carcinoma (low grade disease is unlikely to be locally advanced and metastatic and I would get pathology second opinion) of the upper tract with primarily squamous differentiation and likely metastatic disease (adrenal) qualifies for surgery if possible, but systemic chemotherapy with neoadjuvant intent is reasonable in this case if complete excision looks difficult currently. The adrenal lesion is likely to be a metastasis but would get a biopsy to clarify- obviously, if this is a metastasis, therapy would involve systemic chemotherapy in the neoadjuvant or adjuvant setting. The caveat is that the efficacy of systemic therapy in predominant squamous cell carcinoma appears suboptimal and current therapy in the real world extrapolates data from urothelial/predominant urothelial carcinoma enrolled in most trials (i.e cisplatin-gemcitabine [GC] or dose dense MVAC). Off-trial and in settings where a better response rate may improve the probability of complete excision, I have considered paclitaxel added to GC or dose dense MVAC rather than standard GC in the neoadjuvant intent setting (since firstline metastatic disease trials in urothelial carcinoma suggest better response rates for these strategies [albeit without definitively improved long-term outcomes -although dose-dense MVAC did improve survival in one underpowered randomized trial compared to standard MVAC]). There are no biomarkers to guide firstline therapy, but genomic profiling for FGFR3/2 is important especially since upper tract carcinoma is more likely to harbor them (erdafitinib is approved for post-platinum therapy at progression). If complete surgical resection before or after chemotherapy is not possible, I would offer switch maintenance avelumab if stable or responding to chemotherapy. Further future options include enfortumab vedotin, erdafitinib (if FGFR2/3 mutations/fusions), sacitizumab govitecan and trials.
Aug 13, 2022
Pending Moderator approval.
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