Therapie des high-risk Urothelkarzinoms des oberen Harntraktes

Zusammenfassung

Das Urothelkarzinom des oberen Harntrakts („upper tract urothelial carcinoma“, UTUC) stellt eine seltene Tumorerkrankung dar, die häufig erst in fortgeschrittenen Stadien diagnostiziert wird. Die Diagnostik basiert auf einer CT-Urografie, Spülzytologie aus dem oberen Harntrakt und einer Ureterorenoskopie (URS). Die Risikostratifizierung in eine Low- und High-Risk-UTUC dient als Grundlage für die Therapieentscheidung. Beim High-Risk-UTUC stellt die radikale Nephroureterektomie (RNU) mit Blasenmanschettenresektion den operativen Standard dar, wobei in selektionierten Fällen auch nierenerhaltene Verfahren erwogen werden können. Da die RNU einen signifikanten Rückgang der Nierenfunktion mit sich bringt und erste prospektive Daten eine gute radiologische und pathologische Remissionsrate zeigen, wird die neoadjuvante Chemotherapie beim UTUC zunehmend diskutiert. Der Behandlungsstandard hingegen für Tumoren im pT2–pT4-Stadium oder bei einem positiven Lymphknotenstatus (pN+) ist die adjuvante platinbasierte Kombinationschemotherapie, sofern diese nicht bereits als neoadjuvante Therapie erfolgt ist. Die adjuvante Immuntherapie mit Nivolumab zeigte in der UTUC-Kohorte im Vergleich zum Harnblasenkarzinom keinen signifikanten Therapievorteil und sollte nur Patienten im Tumorstadium ≥pT3 und/oder pN+ (oder ≥ypT2 und/oder ypN+ nach neoadjuvanter Chemotherapie) angeboten werden, die für eine platinbasierte Kombinationschemotherapie ungeeignet sind oder diese ablehnen.

Abstract

Upper tract urothelial carcinoma (UTUC) is a rare malignancy that is frequently diagnosed at an advanced stage. The diagnostic methods include CT urography, cytology of the upper urinary tract, and ureterorenoscopy (URS). Treatment decisions are guided by risk stratification into low- and high-risk UTUC. In cases of high-risk UTUC, radical nephroureterectomy with bladder cuff excision is considered the surgical gold standard. However, organ-sparing procedures may also be considered in selected cases. Due to the significant reduction in kidney function following RNU and recent prospective data showing favourable radiological and pathological remission rates, the importance of neoadjuvant chemotherapy is being increasingly discussed. For tumours classified as pT2 to pT4 or those with positive lymph node involvement (pN+), adjuvant platinum-based combination chemotherapy is recommended, provided that neoadjuvant chemotherapy has not already been administered. Adjuvant immunotherapy with nivolumab demonstrated no significant therapeutic benefit in the UTUC cohort compared with its use for the treatment of bladder cancer. It should only be considered for patients with tumours ≥pT3 and/or pN+ (or≥ypT2 and/or ypN+ after neoadjuvant chemotherapy) who are either ineligible for or decline platinum-based combination chemotherapy.

Schlüsselwörter

Urothelkarzinom des oberen Harntrakts - high-risk UTUC - Nephroureterektomie - perioperative Systemtherapie

Keywords

Upper tract urothelial carcinoma - high-risk UTUC - nephroureterectomy - perioperative systemic therapy

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