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I have a 76 year old ECOG 1 patient with multiple cardiac comorbidities with a high grade papillary urothelial carcinoma of the renal pelvis. It measured 7x11 mm on CT imaging as a filling defect. She had a R ureteroscopy which again characterized high grade non-invasive urothelial carcinoma without muscularis propria visible. She is queued up for a nephro-ureterectomy with the question for role of neoadjuvant chemo. Questions: 1. Do you typically aim for a neoadjuvant approach if patients are functional? My read of that data is that it's more indeterminate than bladder but often recommended, so I would appreciate your thoughts. 2. If chemo, have you used the split dosing of cisplatin 35 mg/m2 on D1 and D8 with gemcitabine every 21 days? I might be wrong but I'm not sure she has the fitness for cisplatin 70 mg/m2 and would appreciate your thoughts on the most tolerable neoadjuvant approach in your borderline patients. 3. Silly question perhaps, but does the lack of muscularis propria on her biopsy specimen carry the same importance in renal pelvis malignancies as it does in bladder?
I do for larger and locally advanced tumors. Best data for chemo is adjuvant POUT trial - with carbo or cisplatin - https://ascopubs.org/doi/10.1200/JCO.23.01659. I follow exactly same regimen you are referring to (same as paper). Often upper tract UC will not have muscle so usually don't make decisions based on presence of muscle in these situations for that reason. For this relatively small tumor, it's fine to surgery and then consider adjuvant chemo OR maybe adjuvant nivolumab if not chemo candidate (comorbidities etc). I tend to also do ctDNA post surgery in theses cases.
