Case Presentation

How to cite: Gupta S. Case Presentation. December 2025. Accessed Oct 2026. https://grandroundsinurology.com/case-presentation/

Summary

Shilpa Gupta, MD, Director, Genitourinary Medical Oncology and Co-Leader, Genitourinary Oncology Program, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio, presents a case exploring the management of clinically invasive upper tract urothelial carcinoma in a patient with borderline renal function, focusing on the sequencing of neoadjuvant therapy, surgical decision-making, and the role of adjuvant immunotherapy.

A 67-year-old woman with controlled hypertension and a baseline estimated glomerular filtration rate of 50 mL per minute presented with microscopic hematuria. Imaging demonstrated an enhancing mass in the right renal pelvis with hydronephrosis suspicious for at least T2 disease. Ureteroscopic biopsy revealed high-grade urothelial carcinoma with lamina propria invasion, and cytology confirmed high-grade disease. Clinical staging was cT2–T3 N0 M0.

The panel debated whether to administer neoadjuvant gemcitabine and cisplatin or proceed directly to nephroureterectomy. Renal function decline after nephroureterectomy often limits eligibility for cisplatin in the adjuvant setting, and experience from the POUT trial highlights the difficulty of completing adjuvant cisplatin-based therapy. For this reason, neoadjuvant chemotherapy was favored when feasible.

Discussion then focused on whether organ preservation of the affected upper tract could be justified after systemic therapy, particularly in a patient with a normal contralateral kidney. Most panelists expressed discomfort with retaining the kidney due to high recurrence risk, challenges in surveillance, and limitations of circulating tumor DNA detection for localized mucosal or submucosal disease. Detection rates for purely muscle-invasive localized tumors were described as uncertain and potentially low.

The group emphasized that upper tract disease behaves aggressively and that opportunities for cure should not be deferred. While selective kidney preservation may be considered in patients with Lynch syndrome or patients at risk of dialysis , consensus favored definitive surgical removal in patients with adequate contralateral renal function. The role of adjuvant immunotherapy remains unclear, particularly in upper tract subsets from larger trials.