B/3. Tumors of the pyelon and ureter

Question 1

tumors of pyelon and ureter are =

Answer 1

upper tract urothelial cancer (UTUC)

Question 2

Transitional cell tumors (urothelial carcinoma) include

Answer 2

• bladder cancer (90%)
• renal pelvis tumor (8%)
• ureter or urethra tumor (2%).

Question 3

UTUCs (upper tract urothelial cancer) share most features with
what are the exceptions

Answer 3

urothelial carcinoma of the bladder
* exceptions and specific points regarding UTUC’s
*Urothelial tumors can spread to urothelial structures that are either distal or proximal to the primary tumor (so called ‘drop metastases’).
*Upper urinary tract tumors frequently are multiple or occur synchronously with
bladder tumors (in up to 17% of cases)
*neoplastic cells can flow down from the renal pelvis
or reflux from the bladder to the ureter, forming an invasive implant

Question 4

what is ‘drop metastases

Answer 4

• Urothelial tumors can spread to urothelial structures that are either distal or proximal to the primary tumor (so called drop metastases)

Question 5

Tumors of the pyelon and ureter age and gender

Answer 5

mean age of diagnosis 73 years,
male to female ratio 2:1

Question 6

etiology of Tumors of the pyelon and ureter

Answer 6

Lynch syndrome/Hereditary nonpolyposis colorectal cancer (DNA mismatch repair) is associated with 10% increased risk of renal pelvis and ureter cancers, but not with bladder cancer.

Question 7

Lynch syndrome

Answer 7

• (DNA mismatch repair)
• is associated with increased risk of renal pelvis and ureter cancers,
• but not with bladder cancer.

Question 8

clinical findings of Tumors of the pyelon and ureter

Answer 8

• Painless gross hematuria 70-80% of cases)
• flank pain (30-40% of cases)
• less commonly palpable mass

Question 9

diagnostics of Tumors of the pyelon and ureter

Answer 9

• CT urography or MRI urography
• further imaging modalities include
  *retrograde pyelography (demonstrates filling defect)
  *and flexible ureteropyeloscopy.
• Urine cytology is usually positive only in advanced disease

Question 10

when is urin cytology positive in pyelon and ureter tumors

Answer 10

Urine cytology is usually positive only in advanced disease.

Question 11

Treatment of pyelon and ureter tumors depends on

Answer 11

depends on staging at the time of diagnosis

Question 12

Localized pyelon and ureter tumor surgical approach treatments

Answer 12

• Depending on tumor characteristics (location, size, stage) and patient risk group
• surgical approach:
  *Endoscopic laser ablation
  *Percutaneous nephroscopy resection
  *Segmental ureterectomy + ureter neo-implantation (if tumor is localized to the distal part of the ureter)
  
  • Psoas-hitch technique (ureter neo-implantation)
  • Boari bladder flap (ureter neo-implantation)
• Radical nephron-ureterectomy
• Adjuvant chemotherapy: BCG, Mitomycin C, MVAC, GC

Question 13

Segmental ureterectomy + ureter neo-implantation when is it done?

Answer 13

• (if tumor is localized to the distal part of the ureter)
  
  • Psoas-hitch technique (ureter neo-implantation)
  • Boari bladder flap (ureter neo-implantation)

Question 14

when is LN resection considered in pyelon and ureter tumors

which LN?

Answer 14

• considered based on imaging or intraoperative findings (involved
  node : kidney hilum nodes, para-aortic nodes, pelvic nodes

Systemic chemotherapy (GC or MVAC protocols) is considered in case of positive surgical margins and/or LN involvement

Question 15

Adjuvant chemotherapy in localized pyelon, ureter tumors

Answer 15

• Consider Mitomycin-C instillation post-operatively
• BCG instillation should be considered for selected cases of CIS
• Systemic chemotherapy (GC or MVAC protocols) is considered in case of positive surgical margins and/or LN involvement

Question 16

Advanced or
metastatic pyelon, ureter tumors
treatment

Answer 16

• Chemotherapy (GC or MVAC protocols)
• Immumotherapy (Nivolumab, Pembrolizumab = Anti-PD1 )