No data to define any benefit to ‘cytoreductive’ nephroureterectomy in patients with metastatic disease.
Can be offered if symptomatic/bleeding/obstructed.
Observational data suggests potential benefit if low volume mets, and fit enough for chemo, but likely highly selected patients.
No prospective evidence to support metastasectomy.
First line therapy
Standard of care for metastatic UTUC is cisplatin based chemotherapy (gem-cis or MVAC)
Carboplatin / gemcitabine alternative if can’t use cisplatin.
Checkpoint inhibitors may be used if unfit for cisplatin.
Maintenance avelumab has been shown to have OS benefit after initial first-line chemo in patients who don’t progress on cisplatin/carboplatin, vs best supportive care.
Approved and now PBS funded in Aust.
Second line therapy
Offer checkpoint inhibitors (pembro, nivo, atezolimumab) to patients who progress during or after platinum chemo
Pembro PBS authority funded in Aust as second line after platinum chemo
Fibroblast growth factor (FGFR) inhibitors
Erdafitinib is a TKI associated with response in patients who progress on chemo and who have FGFR DNA genomic alterations