Considerations for lymph node dissection in high-risk UTUC

In this video, Suzanne Lange, MD, and Surena F. Matin, MD, discuss the implications of their European Urology Focus study, “Optimizing Lymph Node Dissection at the Time of Nephroureterectomy for High-risk Upper Tract Urothelial Carcinoma.” Lange is a urologic oncology fellow at the University of Texas MD Anderson Cancer Center in Houston and Matin is a professor of urology at the University of Texas MD Anderson Cancer Center.

Transcript:

Based on these findings, are you likely to alter anything about your clinical practice?

Lange: Dr. Matin and I had a discussion about this the other day. For me, this highlighted that it is an important practice and that we should be considering incorporating this more into our guidelines. There are a very limited amount of guidelines for upper tract urothelial carcinoma in the first place, and they are beginning to comment that we should consider lymph node dissection in high-risk disease. That can be very vague [in terms of] how you define it. And then on top of that, like Dr. Matin was talking about, the templates are not very well defined. And so I think it's really important that over time, we work to further incorporate that into the guidelines to ensure that people utilize it more in practice.

Matin: I think for me, it helped highlight some of the practice that we were already performing. On the other hand, we do have to keep an open mind and recognize that we may be overemphasizing some of the benefits as well in some cases, I think that the most difficult part for most practitioners is twofold. Number 1 is correctly identifying which patients you are going to do a lymph node dissection on, and as Dr. Lange said, how you classify high risk is its own debate. Number 2 is the comfort level that a urologist may have in performing lymph node dissection, whether they're doing it open, or increasingly, folks are doing it robotically. And then there's a practical issue; it takes a bit more time. And then there are concerns about potential complications of it as well. So there are several barriers to its incorporation, and we hope that with time, we can address each of those.

Lange: And it was a pretty brief review, but we did discuss some of those barriers in our paper and how we [might] overcome those. The data do not really show a significantly increased risk for complications. The big concern is always for chylous ascites, and so you have to be meticulous with sealing those vessels, either with suture or with vessel sealers or clips. We also touched on [the fact] that there are better methods for controlling things like that. IR embolization could be an option. It's very dependent on where you are, but it has been demonstrated to be helpful with that. We also talked about staging because preoperative staging in these patients really is notoriously poor, because it's difficult to get biopsies and imaging lacks granularity. And so, what we discussed in the paper is there are a couple of nomograms that are good for predicting either T2 or higher disease at time of surgery, so on final pathology, or T3 or higher. And so those are good options for people to have in their toolkit when making these decisions.

Matin: Yes, and we use those routinely to help guide patient care. We don't rely on them on an absolute fashion, but they do provide helpful guidance.

This transcript was edited for clarity.