Upper tract urothelial carcinoma (UTUC) is a rare but aggressive malignancy, often diagnosed at an advanced stage, particularly among Asian populations. The standard treatment remains radical nephroureterectomy with bladder cuff excision. Neoadjuvant chemotherapy (NAC) has emerged as a promising strategy to improve oncologic outcomes, especially in patients with high-risk disease. However, pathologic complete response (pCR) following NAC remains uncommon, occurring in approximately 10% of UTUC cases in Taiwan. We present a case of UTUC with complete pathologic remission after NAC, highlighting the potential for kidney-preserving approaches and the need for further investigation in select patients.

A 65-year-old woman with a history of liver cirrhosis, splenomegaly, and chronic hepatitis B presented with intermittent gross hematuria and left flank pain. KUB radiography revealed no evidence of ureteral stones. Renal ultrasound showed left-sided hydronephrosis; no gross bladder lesions were identified. Abdominal CT demonstrated right hydronephrosis and a suspected mass in the right renal pelvis (Figure 1A-B). Urine cytology was suspicious for malignancy. Left ureteroscopic biopsy confirmed high-grade infiltrating urothelial carcinoma. Laboratory evaluation revealed a hemoglobin level of 11.3 g/dL, white blood cell count of 6.77 × 10³/μL, and serum creatinine level of 1.42 mg/dL. Left renal pelvic cancer was impressed with cT3N0M0 (stage III) disease. The patient received neoadjuvant chemotherapy with gemcitabine and cisplatin for four cycles. Post-treatment CT revealed marked tumor shrinkage and resolution of hydronephrosis (Figure 2A-B). Subsequently, the patient underwent an uneventful laparoscopic nephroureterectomy with bladder cuff excision. Final pathology showed no residual tumor (ypT0) at the renal pelvis, ureter, bladder cuff, indicating a complete pathologic response to chemotherapy.

At one-year follow-up, the patient remained disease-free, with preserved renal function (serum creatinine 1.31 mg/dL) and no evidence of recurrence on surveillance cystoscopy.