- UTUC is rare, accounting for only 5% of all urothelial cancers. 
- UTUC are more difficult to visualize and treat endoscopically.
- UTUC are morphologically similar to bladder cancers but have different embryologic origins and genetic characteristics.
- Like urothelial cancer of the bladder, stage (i.e. depth of invasion) is the most important predictor of prognosis. However, unlike the bladder, grade is highly correlated to stage:
- 91% of high-grade tumors in the renal pelvis are invasive
- 64% of high-grade tumors in the ureter are invasive 
- Prognosis is different for UTUC compared to urothelial cancer of the bladder.
- Upwards of 19% of patients with UTUC present with metastases.
- However, in matched cohorts with less aggressive disease, progression and death occurred with equal frequency among patients with UTUC and bladder cancers.
- The role of neoadjuvant and adjuvant chemotherapy is not well-established in UTUC (see below).
Similarly, neoadjuvant chemotherapy (NAC or chemotherapy before surgery) has a growing role in the treatment of muscle-invasive urothelial cancer of the bladder (please see prior blog entry Neoadjuvant Chemotherapy for Bladder Cancer: What Does It All Mean?).
Adjuvant Chemotherapy (AC) Following Nephroureterectomy (NU)
Neoadjuvant Chemotherapy (NAC) Prior to Nephroureterectomy (NU)
- NAC works for the bladder.
- Survival is improved 5-10% with chemotherapy before surgical removal of the bladder.
- UTUC is biologically similar to urothelial cancer of the bladder.
- NAC effectively down-stages urothelial cancer (discussed below)
- Many patients who undergo NU are not eligible for chemotherapy after surgery because they are older and/or have baseline chronic kidney disease.
- The best chemotherapies for urothelial cancer are filtered by the kidneys.
- Reduced filtering ability of the kidneys can cause:
- decreased efficacy of chemotherapy
- increased toxicities including worsening renal function
- adequate renal function
- high-risk pathological features (pT3 or pT4, N1 or positive surgical margins)
- invasive high-grade UTUC
- high-volume, high-grade UTUC with clinical suspicion of invasive disease
- baseline renal dysfunction that may preclude chemotherapy following surgery