Oligometastic UTUC: Systemic vs Local Therapy

Guru Sonpavde

Nov 17, 2020

In summary, this 70 year old patient had a pT3N0 upper tract urothelial carcinoma and underwent nephroureterectomy--> has metastatic recurrence 2 years later with a biopsy proven 1.6x1.8 cm retroperitoneal left periaortic node metastasis- and has a 2.6x1.4cm right inguinal lymph node (not biopsy proven). Overall, management would be guided by the patient's preferences given the absence of a single proven optimal approach. I would consider a 1) PET scan to assess for other sites of disease and 2) biopsy the inguinal node if this is suspicious for malignancy. 
Assuming only 2-3 sites of nodal disease are seen after PET scan and given the long interval from initial diagnosis to metastasis: If the patient prefers an aggressive approach, my preference is initial cisplatin-based chemo for 4-6 cycles followed by SBRT - then followed by switch maintenance avelumab per JAVELIN Bladder-100 trial data (Powles T et al, NEJM 2020). I would consider an SBRT alone approach to target the nodes without systemic chemo if the patient is motivated to avoid systemic chemo. If there are other >3 sites of metastatic disease or a visceral organ involved, I would initiate cisplatin-based chemotherapy x 4-6 cycles followed by switch maintenance avelumab in accordance with JAVELIN-Bladder-100 data (although surveillance following cisplatin-based chemo may be reasonable if she attains a CR, since a proportion of patients with nodal disease only and CR is cured by cisplatin). Please see the following papers regarding metastasis directed therapy:
1. Sweeney P, et al. Is there a therapeutic role for post-chemotherapy retroperitoneal lymph node dissection in metastatic transitional cell carcinoma of the bladder? Urol 2003 Jun;169(6):2113-7.
2. Ogihara K, et al. Can urologists introduce the concept of "oligometastasis" for metastatic bladder cancer after total cystectomy? Oncotarget 2017 Dec 4;8(67):111819-111835. 
3. Patel V, et al. Survival after Metastasectomy for Metastatic Urothelial Carcinoma: A Systematic Review and Meta-Analysis. Bladder Cancer 2017 Apr 27;3(2):121-132.
4. Faltas, B, et al. Metastasectomy in older adults with urothelial carcinoma: Population-based analysis of use and outcomes. Urol Oncol. 2018 Jan;36(1): 9.e11-9.e17.
5. Augugliaro M, et al. Recurrent oligometastatic transitional cell bladder carcinoma: is there room for radiotherapy? Neoplasma. 2019 Jan 15;66(1):160-165.