For a patient who is cisplatin-eligible with localized, high-grade upper tract urothelial carcinoma, but no muscularis propria seen on biopsy, what is your approach?

The risk of clinical under-staging is notorious in UTUC; therefore, we aim to maximize control of disease and address the meaningful risk of micro-metastasis. In that context and outside clinical trial option, we favor the use of neoadjuvant cisplatin-based chemotherapy using either dose dense MVAC (with G-CSF on a 2-week cycle) or gemcitabine/cisplatin (3-week cycle) in cases with clinical suspicion of >T1 stage, based on CT images, endoscopic assessment, tumor size & appearance, high grade on path, etc. There are data from the EA-8141 phase II trial (Dr. Margulis et al.) with neoadjuvant dose dense MVAC (pCR rate 14%), while Dr. Almassi et al. showed compelling retrospective data (PMID 30217764), while a large phase 3 co-operative group t...