In This Article
- Treatment options for urothelial cancer have historically been at two ends of a spectrum: laser or cautery for a small, low-grade tumor or radical nephroureterectomy
- Those options may not be ideal for a subset of patients with compromised renal function and low-grade, upper-tract urothelial cancer
- Massachusetts General Hospital is one of few centers in the nation to offer this novel, minimally invasive therapy
Massachusetts General Hospital is one of only a few places in the nation offering a novel nonsurgical treatment to a subset of adult patients with low-grade, upper-tract urothelial cancer (LG-UTUC). Mitomycin treatment with a mitomycin gel is a chemoablative method that treats cancer and can prevent the need for radical nephroureterectomy.
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"This is a new option for patients who have biopsy-demonstrated LG-UTUC and enough tumor volume that we can't treat it with a laser or cautery. That group of patients didn't previously have an option other than nephroureterectomy, but we now have another choice for them," says Adam S. Feldman, MD, MPH, urologic oncologist in the Department of Urology at Massachusetts General Hospital and the Mass General Cancer Center, co-director of the Combined Harvard Urologic Oncology Fellowship, and director of Urologic Research. "It can hopefully avoid removal of their kidney and ureter, therefore improving future health and decreasing risk of non-cancer mortality. It's especially important for patients who have underlying chronic kidney disease and patients who have only one kidney to help them avoid dialysis."
Selecting Appropriate Cases of Urothelial Cancer
Brian Eisner, MD, medical director of the Mass General Department of Urology and chief of the Urology Service at Newton-Wellesley Hospital, emphasizes the importance of patient selection for mitomycin gel.
"The ideal candidate for this treatment is someone with low-volume, low-grade, non-invasive UTUC," says Dr. Eisner. "It may also play a role for patients with high-volume, low-grade UTUC who have poor renal function, or in compassionate or palliative treatment of patients with high-grade UTUC who also have a solitary kidney. But low-grade, low-volume UTUC is the strongest indication for this treatment."
Mitomycin gel is effective for chemoablation and decreased the risk of recurrence for patients with low grade UTUC, as demonstrated by the OLYMPUS trial. (The study was published in Lancet Oncology.)
Patients should be carefully evaluated by a multidisciplinary team from oncology and urology using biopsy and imaging such as a CT scan or MRI.
"We take everything into account: the patient's age, overall health, risk of suffering if we offer the standard kidney removal and what we think would be the prognosis if we offer them this less invasive treatment where they keep their kidneys," Dr. Eisner says. "The onus is on the surgeons to say, 'You're a great candidate for this,' or 'you're not.'"
Delivering Mitomycin Endoscopically
Mitomycin gel, commercially known as Jelmyto, is delivered in six induction doses plus 11 maintenance doses via an endoscopic outpatient procedure.
"First, we perform a cystoscopy to look into the bladder, then we pass a catheter up to the kidney and instill the mitomycin. The mitomycin comes in a gel that slowly dissolves over four to six hours and travels down the renal pelvis. It migrates down the ureter into the bladder and then voids out," Dr. Feldman says. "It's really topical chemotherapy, so there aren't the same side effects of systemic therapy, such as hair loss."
According to the OLYMPUS trial, common side effects include ureteric stenosis (44%), urinary tract infection (32%), hematuria (31%), flank pain (30%) and nausea (24%).
Applying Vast Experience to New Approaches
Mass General is well positioned to become one of the few hospitals to offer mitomycin gel, given the institutional expertise in similar disease states.
"Our urologists have significant experience in treating UTUC and a long history of excellence in treating bladder cancer," Dr. Feldman says. "We also have a very long history with minimally invasive endoscopic treatment of kidney stones, and this uses the same tool set."
The urologists are now working to introduce mitomycin gel to patients with LG-UTUC, and perhaps eventually include other patient populations.
"As we get more experience and more post-approval data of how well Jelmyto performs, we may expand the indications of the future," Dr. Eisner says. "We're very interested in building one of the most robust programs of this in the Northeast."
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