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|Transitional Cell Carcinoma of the Renal Pelvis and Ureter - Upper Tract TCC|
The renal pelvis is an area in the center of the kidney where urine drains into the ureter, the tube which directs urine flow to the bladder. Primary upper tract urothelial tumors of the renal pelvis and ureters are relatively rare. Tumors of the renal pelvis account for approximately 10% of all renal tumors and approximately 5% of all urothelial tumors. Ureteral tumors are even more uncommon, occurring with one quarter the incidence of renal pelvis tumors.
For those with TCC of the bladder, the risk of upper tract recurrence may be as high as 25%.
TCC is on the inner lining of the kidney; RCC-renal cell carcinoma- is cancer of the kidney itself. Upper tract TCC is treated much like TCC of the bladder. Fortunately, TCC is also much more treatable than RCC, which is very resistant to most forms of chemotherapy and radiation.
Staging is much the same as with bladder cancer, based on the depth of tumor invasion and classified using the tumor, node, metastases (TNM) system.
Tis - Carcinoma in situ
1. Surgery to remove the kidney, ureter, and the top part of the bladder
Medical treatment of upper tract urothelial tumors involves the instillation of chemotherapeutic agents mitomycin C, thiotepa, or the immunotherapy bacille Calmette-Guérin (BCG). These agents can be administered either percutaneously, through a ureteral catheter, or intravesically in patients with vesicoureteral reflux. This approach is most appropriate for patients with multiple superficial disease or carcinoma in situ who also have bilateral disease and/or limited renal function. This appears to be safe as adjuvant therapy, but its efficacy is not firmly established. Thus, it should be considered second-line therapy.
The potential benefits of systemic chemotherapy for localized diseases have not been established at the current time.
Nephroureterectomy with excision of the bladder cuff is considered standard treatment. This procedure is indicated in patients with renal pelvis TCC, regionally extensive disease, and high-grade or high-stage lesions. Typically, the operation is performed through one abdominal incision or a flank incision combined with a lower abdominal incision. An ipsilateral pelvic lymphadenectomy can be performed for staging purposes and may have therapeutic benefit.
Laparoscopic nephroureterectomy: Operative time is approximately
doubled when compared to the standard open procedure. Benefits associated
with this minimally invasive operation include decreased patient analgesic
requirements, shorter hospitalization, and patients usually are able to
resume normal activity more quickly. Currently, it is being used in a
more widespread fashion and appears equivalent to the open procedure with
regard to cancer cure.
Laparoscopic Nephroureterectomy for Upper Urinary Tract Transitional Cell Carcinoma: Is it Better than Open Surgery? Jens J. Rassweilera, , , Michael Schulzea, Reinaldo Marreroa, Thomas Fredea, Juan Palou Redortab and Pierfrancesco Bassic aDepartment of Urology, SLK Kliniken Heilbronn, Am Gesundbrunnen 20, D-74078 Heilbronn, Germany; bDepartment of Urology, Fundacion Puigvert, Barcelona, Spain; cInstituto di Urologia, Università di Padova, Padova, Italy
Conclusions:Open radical nephroureterectomy still represents
the golden standard for the management of upper tract transitional cell
carcinoma, however, laparoscopic radical nephroureterectomy offers the
advantages of minimally invasive surgery without deteriorating the oncological
outcome. In case of advanced tumors (pT3,N+) open surgery is still recommended.
European Urology Volume 46, Issue 6 , December 2004, Pages 690-697
Conclusions: Both techniques proved technically and
oncologically safe. Bladder tumor recurrence rate was in the range reported
for classic nephroureterectomy. No extravesical tumor recurrence in the
former ureteral bed or on the scar of the resected ureteral orifice occurred.
Segmental ureterectomy coupled with ureteral reimplantation is a procedure indicated for patients with ureteral tumors located in the (far end near the bladder) distal ureter. Unfortunately, due to the multifocal nature of TCC, the ipsilateral (same side) recurrence rate is 25% after segmental ureterectomy.
Renal-sparing surgery, including segmental ureterectomy and endoscopic therapy, maintains a vital role in the urologic management of upper tract urothelial tumors. Typically, patients with small, lower-grade superficial lesions are best approached in this manner. Some investigators use this approach more frequently in patients with one kidney, bilateral disease, compromised renal function, or greater operative risk.
In the case of regional (pelvic) spread, distant metastases or recurrent disease, systemic chemotherapy and/or radiation may be used in attempt to control symptoms, though cure is unlikely.
Information made available in March, 2007 states that systemic adjuvant or neoadjuvant chemotherapy with Cisplatin does provide significantly better long term survival. Radiation therapy did not contribute to longer survival. 1
Stage Tis, Ta, T1 - 91%
Management of Upper Tract Transitional Cell Carcinoma
Urothelial Tumors of the Renal Pelvis and Ureters Excellent
article from emedicine.com, a professional resource
For some first hand experiences see; Tale From the Trenches -TCC of the renal pelvis/ureter, here on WebCafe
1. European Urology Supplements Volume 6, Issue 8 , March 2007, Pages 549-554 Trends in Modern Management of Uro-oncological Diseases, doi:10.1016/j.eursup.2007.01.009 European Association of Urology Ne Neo/Adjuvant Therapy in Upper Tract Urothelial Carcinoma Levent N. Türkeri, a, aDepartment of Urology, Marmara University School of Medicine, Tophanelioglu cad No. 13–15, Altunizade, 34662, Istanbul, Turkey