TCC of the Upper Urinary Tracts

CHAPTER 40 TCC of the Upper Urinary Tracts

Thomas W. Jarrett, MD

What is the mean age of occurrence of transitional cell cancer of the upper urinary tracts?

65 years.

What is Balkan nephropathy?

A degenerative interstitial nephropathy common to certain rural Balkan areas. Affected individuals are 100 to 200 times more susceptible to upper tract transitional cell carcinoma (TCC). Tumors tend to be low grade, multiple, and bilateral.

What is the most common presenting sign of upper tract urothelial tumors?

Hematuria is seen in 75% of cases followed by flank pain in 30% of cases. Rarely do upper tract tumors remain asymptomatic.

What percentage of urothelial tumors are located in the upper urinary tract?

Approximately 5% to 8% of all urothelial tumors are located in the ureter and/or renal collecting system.

What percentage of primary renal tumors will be of urothelial origin?

Five percent of primary renal tumors will be of urothelial origin.

What histology is most commonly found with urothelial tumors of the upper urinary tract?

TCC accounts for more than 90% of upper tract urothelial tumors. Squamous cell and adenocarcinoma make up the majority of the remaining tumors.

What are some of the tumor markers reported for upper tract tumors?

These include cyclooxygenase 2, EP4 receptors, oncoprotein p53, proliferation marker Ki67, and tissue inhibitor of metalloproteinase I. p53 over expression tends to correlate with tumor progression.

What are acceptable ways of making the diagnosis of upper urinary tract TCC?

Diagnosis was traditionally made by the characteristic radiolucent filling defect of the upper urinary tract as well as cytologic evaluation of the urine. In some cases, sonography or cross-sectional imaging may be necessary to rule out a radiolucent stone as the cause of a filling defect. With improvements in upper urinary tract endoscopy, ureteroscopy with biopsy should be strongly considered in all patients to confirm the diagnosis.

Are there any limitations of ureteroscopic biopsy?

Ureteroscopic biopsy has a high correlation with final tumor grade but does not accurately diagnose tumor stage.

What other histologic patterns are found with upper tract tumors?

Squamous cell carcinoma and adenocarcinoma are less commonly seen and are usually associated with chronic inflammation from kidney stones, obstruction, and/or infection.

What is the most common risk factor contributing to the development of upper urinary tract TCC?

Cigarette smoking is the risk factor most strongly associated with transitional cell carcinoma of the bladder and upper urinary tracts. The risk increases 3-fold in a patient with a history of significant tobacco abuse when compared to the general population.

What are some other risk factors for upper tract TCC?

Exposure to cyclophosphamide, phenacetin, arsenic, and various aromatic amines and amides.

What is acrolein?

A metabolic breakdown product of cyclophosphamide. It is thought to be the causative agent in the development of TCC.

True/False: Tumors linked to chemotherapy use tend to be high grade.

True.

What is Lynch syndrome II?

An autosomal dominant hereditary syndrome involving upper urinary tract tumors and early colon tumors.

What is the incidence of a bilateral upper tract involvement (either synchronous or metachronous)?

Approximately 2% to 5% of patients with upper tract TCC will have involvement of the contralateral system at some point in their lives. The percentage may be higher in patients with associated carcinoma in situ (CIS).

How is bilateral disease treated?

Renal-sparing surgeries are recommended when possible. These techniques include ureteroscopic, percutaneous, and segmental resections. Rarely, autotransplantation and pyleoneocystostomy may be necessary.

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