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Background Upper urinary tract urothelial carcinoma (UUTUC) is rare, accounting for less than 5% of urothelial malignancies. Standard treatment is radical nephroureterectomy (RNU) with systematic excision of bladder cuff. While commonly used for bladder urothelial carcinoma, the role of primary or adjuvant radiotherapy for UUTUC is unclear. Furthermore, there are no guidelines for management of inoperable patients, whether due to extensive disease burden, solitary kidney, poor performance status, or patient refusal. Stereotactic body radiation therapy (SBRT) may be a treatment option for this unique patient population. Case presentation A 93-year old male presented with a one year of intermittent gross hematuria. CT imaging showed a 4.5 cm soft tissue mass in the upper left intra-renal collecting system without evidence for regional lymphadenopathy or distant metastatic disease. Urine cytology confirmed urothelial carcinoma. He was staged clinical T2, N0, M0. Following urology and cardiology evaluation, the patient was deemed medically-inoperable for RNU due to cardiac comorbidities. He was not a candidate for percutaneous ablation due to tumor location in renal pelvis and anesthesia risk. He was treated using SBRT with 50 Gy in 4 fractions over 4 consecutive days. His hematuria resolved approximately 10 days after completion of SBRT. The patient showed no clinical signs of acute or late adverse events. He underwent routine evaluation and at his most recent 31-month post-SBRT evaluation, imaging showed a complete response (RECIST criteria v1.1) without evidence of locoregional recurrence or distant metastasis. He expired 33 months after SBRT due to decompensated systolic heart failure. Conclusion The role for radiotherapy in the management of UUTUC is unclear. Utilizing conventionally fractionated radiotherapy, the outcomes of all retrospective data are marginal with weak grade recommendations. SBRT is a promising technique for medically-inoperable UUTUC. Limited reported outcomes are favorable and warrant further investigation of the role of SBRT in the treatment of UUTUC.

Stereotactic body radiation therapy for medically inoperable, clinically localized, urothelial carcinoma of the renal pelvis: A case report