Transitional cell carcinoma of the renal pelvis: radical or conservative surgical treatment?

The management of transitional cell carcinoma in solitary renal units

Ten patients with urothelial malignancies involving a solitary functioning renal unit were treated at our center for an average of 24 months or until death. These patients were all managed by parenchyma-sparing methods, including percutaneous as well as ureteroscopic tumor resection. Of our patients 9 have received adjunctive chemotherapy in the form of bacillus Calmette-Guerin instillations. At the time of this report 5 of our patients were alive without evidence of disease, 4 were alive with evidence of either residual or recurrent neoplasia and 1 was dead of disease 5 years after original presentation. Patients with higher grade tumors or carcinoma in situ did less well than patients with low grade disease. We present an analysis of our experience with this complex patient population and discuss the implications of these data within the context of a growing literature on the topic of upper tract urothelial malignancy.

Carcinoma of the renal pelvis and ureter following bladder carcinoma: frequency, risk factors and clinicopathological findings

We followed 657 primary bladder carcinoma patients for at least 10 years or until death. Subsequent carcinomas of the renal pelvis or ureter were found in 11 patients (1.7 per cent) 10 months to 13 years after the primary bladder tumor. In 3 patients the tumors were diagnosed or suspected by excretory urography, while in 5 the tumors were not found until autopsy. Four patients had undergone cystectomy and 9 had multiple bladder tumors at the initial assessment or during followup. The initial or recurrent bladder tumor involved the ipsilateral ureteral orifice in 6 patients. We conclude that in bladder cancer patients routine excretory urography is not indicated in the absence of upper urinary tract symptoms but it should be performed in selected patients, that is those with multiple and recurrent bladder tumors or tumors involving the ureteral orifices, or those with a previous cystectomy.

Squamous cell carcinoma of renal pelvis

Squamous carcinoma of the renal pelvis was diagnosed in only 11 of 2,166 renal tumors (0.5%) seen over a twenty-seven-year period. The combination of an insidious onset and a prolonged duration of symptoms (median: 5 months) resulted in all patients having invasive disease at diagnosis. Ten patients died two to twenty-eight months after diagnosis (median survival: 5 months), and only 1 patient is currently alive at nine months. We conclude that the treatment of choice is radical nephrectomy followed by adjuvant chemotherapy.

Chemotherapy of carcinoma of renal pelvis: preliminary report

Seven patients with metastatic and/or recurrent transitional cell carcinoma of the renal pelvis treated with systemic chemotherapy are evaluated. The median age of the patients was fifty-five; 6 were men, 6 of the tumors were histologic grade III and Stage C at the time of nephroureterectomy. Most of the patients presented with a large recurrent mass at the original site of surgery in addition to bone and/or pulmonary metastases. Four patients were treated with CISCA combination chemotherapy (cis-platinum, cyclophosphamide, and doxorubicin), and responded with 1 partial remission, 1 less than partial remission, and 2 symptomatic improvement. Two patients were treated with FAM combination chemotherapy (5-fluorouracil, doxorubicin, and mitomycin C) and demonstrated an objective response. One patient had a less than partial remission (30 per cent) and the second patient a partial remission. The seventh patient was treated with alternating courses of CISCA and FAM and thus far has received 8 courses and is in complete remission. The median survival time of the 7 patients is seven months (range four to fourteen months). Transitional cell carcinoma of the renal pelvis is responsive to chemotherapy; therefore, trials are indicated.

Management of high grade transitional cell cancer of the upper urinary tract

A total of 175 patients was operated on for grade 2, 3 or 4 transitional cell epithelioma of the upper urinary tract. Followup was between 5 and 26 years. The operations involved total nephroureterectomy, simple nephrectomy and local resection. Patient survival correlated well with tumor stage and, particularly, with tumor grade, and, consistently, was inferior to that of an age and sex-matched control group. The correlation of survival and ipsilateral tumor recurrence with the type of operation suggests that patients with grade 2 tumors may benefit from total nephroureterectomy. The incidence of ipsilateral tumor recurrence (28 per cent) was high in this group. The radical procedure seems to be of no benefit to patients with grade 3 or 4 tumors. The incidence of subsequent bladder tumor was 30 per cent in patients with grades 2 and 3 tumors. The latent period ranged from 2 months to 10 years (average 23 months); 82 per cent of the tumors occurred within 3 years of treatment of the upper tract tumor.

Primary grade 1 transitional cell carcinoma of the renal pelvis and ureter

During a 22-year period 224 patients were seen for treatment of transitional cell carcinoma of the renal pelvis or ureter. Of these patients 49 (22 per cent) had grade 1 lesions. Followup ranged from 5 to 25 years. The most common symptom was hematuria. In only 54 per cent of the 49 patients was a filling defect noted on excretory urography. Forty-seven patients (96 per cent) had stage I disease. Treatment included total nephroureterectomy, nephrectomy or segmental resection. In 11 patients (23 per cent) evidence of bladder tumor developed 8 months to 12 years (average 4 years) after the diagnosis of tumor of the upper urinary tract and 73 per cent of these recurrences were noted within the first 3 years. In 1 patient a tumor developed in the opposite upper urinary tract. In only 1 of 15 patients who had had partial ureterectomy or local excision tumor developed in the ipsilateral ureter. Patient survival time was identical to that in an age-matched control group. We conclude that the most significant findings are the subsequent high incidence (23 per cent) of bladder tumor and the comparable survival in these pateints and in an age-matched control group. Furthermore, these results suggest that operations preserving the renal parenchyma, that is segmental resection, should be used more frequently.

Transvesical intussusception (Lich) ureterectomy

Intussusception ureterectomy has been used to excise prophylactically the distal ureter in 10 patients with carcinoma of the renal pelvis. The procedure has proved safe and expeditious, as well as permitting more precise excision of the surrounding vesical mucosa.

Tumours of the renal pelvis and ureter. Symptomatology, diagnosis, treatment and prognosis

Forty-two cases of tumour of the renal pelvis and/or ureter are presented. The primary tumour was in the renal pelvis in 25 cases and in the ureter in nine. A co-existent tumour elsewhere in the uroepithelium was found in 16 of these 34 patients. In the remaining eight patients, tumour of the urinary bladder was the initial diagnosis, but tumours of the upper urinary tract subsequently appeared. The principal symptom (38 of 42 cases) was haematuria, but flank pain and a mass in the kidney region also occurred. In most cases the diagnosis was indicated by the urograms and was confirmed by retrograde pyelography. Nephro-ureterectomy was done in most of the patients. The possibility that local tumour resection may be sufficient is briefly discussed. The tumours were classified as papillary in 24 patients and as solid in nine. There was no histologic classification in nine cases. The mean observation time was 29 months. Since new growths tend to arise at other sites in the uro-epithelium, follow-up examination should always include cystoscopy and urography. The prognosis was particularly poor in solid tumours: two-thirds of these patients died in the first postoperative year. Survival was clearly dependent on the tumour differentiation. High-grade tumours carried a poor prognosis.