Upper Tract Carcinoma Flashcards
What is the ddx of a ureteral mass?
tumor (enhancement with contrast, concern for UC)
fungus ball
blood clot
obstructing papillae
radiolucent stone
What is standard workup of upper tract UC?
- CT A/P (Urogram)→assess filling defects and RP adenopathy
- Cysto → initial screen for hematuria
- RGP → confirm filling defects in pelvis or ureter, can send aspirate or barbotage for cytology
- URS → direct vision and bx or brushing
- Antegrade pyelography → if retrograde fails
- Nephroscopy → endoscopic eval and mgmt. of selected low-grade tumors by fulguration and/or resection
Treatment options for ureteral tumor?
- Nephroureterectomy with cuff of bladder
Indications: normal contralateral kidney and high -grade tumor or uncontrollable local recurrences
*High grade ureteral and pelvic tumors unsuitable for local resection should undergo radical surgical extirpation +/- NAC or adjuvant chemo
*If bilateral or solitary kidney, may be necessary for renal txp (wait 2 years)
- Segmental resection
Indications: conservative measure (e.g. segmental resection or endoscopic treatment) are indicated when preservation of renal function is mandatory (e.g. low-stage b/l dz, azotemia, solitary kidney) or low grade lesions
*Distal ureteral excision with removal of bladder cuff and reimplant is best option
*Proximal excision and anastomosis not ideal for very distal, reserved for mid to proximal ureteral tumors
- Ureteroscopy and resection or fulguration
Indications: distal ureter or not candidates for major surgery due to comorbidities, risk of ureteral stricture, perforation, and high rates of recurrence
What is the utilization of Mitomycin C in upper tract UC?
Can be given intravesically after nephroureterectomy
Describe epidemology of upper tract UC:
comprises 5-10 % of all UC
majority present at higher stage compared to bladder
average age at dx slightly older
Gender disparity less compared to bladder, M:F → 2:1
Risk factor for UC of upper tract?
Same as bladder (tobacco, chemical carcinogens, analgesics, chronic inflammation/infection)
- Balkan Nephropathy: interstitial nephritis causing renal insufficiency, possible consumption of contaminated wheat (aristolochia), 100-200 x higher risk, also in herbal remedies
- Lynch syndrome: AD DNA mismatch repair increasing risk of colorectal and endometrial; lifetime risk 10-15%
- Arsenic
- History of bladder UC
Relationship between upper tract and bladder UC?
- Chance of UTUC after bladder UC ~5%, but 15-20% of pts with UTUC have hx of bladder ca
- highest for patient with CIS or HG
- hx of UC at trigone or bladder neck
- hx of multifocal bladder ca
- VUR
- UC at ureteral margin or distal ureters during cystectomy
- after UTUC probability of bladder ca 50-70%
- probability of UC in contralateral side 2-5%
What is ddx of calyceal or pelvic collecting system mass?
radiolucent stone
blood clot
fungus ball
papillary necrosis
tumor
complex/peripelvic cyst
Treatment option for renal/pelvic UC?
- Nephroureterectomy with bladder cuff
- Segmental resection or local excision
- Open pyelotomy with tumor excision/fulguration
- appropriate for select low grade, low stage tumors in both kidney or solitary kidney with poor GFR (not best option)
- Partial nephrectomy: where renal failure must be avoided (not best option)
- Ureteroscopic resection and/or fulguration
- Vigilant follow up and repeat URS
- Good for small, noninvasive Ta, or poor functional status
- Percutaneous treatment
- Advantage is facilitating tumor removal and instillation of anti-tumor meds via PCN
- Risks: bleeding, tumor spillage, tumor implantation
- Small, solitary tumors not accessible by URS, can consider laser
- Instillation therapy
- Multiple superficial tumors or CIS with b/l or CKD
What is surveillance after URS resection/fulguration?
Cysto and ipsilateral (tumor side) URS q 6 mo for 3 years then annually
Name a diabetic medicine that can increase risk of UC?
Pioglitozone
Any medications that can interfere with treatment efficacy of high grade protocols for all UC?
Warfarin can decrease efficacy of BCG (but studies equivocal, rarely stopped)
What are some additional treatment options for high grade/invasive UTUC?
- Radiation therapy: best used for local control and adjuvant or palliative therapy
- Angioinfarction: symptomatic patients with incurable distant mets or not candidate for Nx
Describe follow up after nephroureterectomy for UTUC for a HG invasive lesion?
cysto: q 3 mo x 2 years, q 6 mo x 2 years, then q year
cytology: q3 mo x 2 years, q 6 mo x 2 years, the q year
CTU: q 3-6 mo x 2 years, then discretion
CXR: q6 mo x 2 years, then discretion
Staging of UTUC:
Proposed risk classification from EAU for UTUC:
