Transitional cell carcinomas of the renal pelvis and the ureter: comparative demographic characteristics, pathological grade and stage and 5-year survival in a Taiwanese population

Three cancers in the renal pelvis, bladder, and colon: A case report

BACKGROUND

Multiple primary cancers are rare occurrences that can involve either metachronous or synchronous development. It is particularly rare for an individual to have more than two primary cancers. In this report, we present a case study of an elderly man who was diagnosed with three heterochronous cancers in the renal pelvis, bladder, and colon.

CASE SUMMARY

On December 30, 2014, a 51-year-old Chinese man was admitted to our hospital with complaints of intermittent painless gross hematuria for the preceding week. A computed tomography (CT) scan revealed wall thickening in the left ureter's upper segment, while a CT urography revealed a left renal pelvis tumor. A successful laparoscopic radical resection of the left renal pelvis tumor was subsequently performed at Shanghai Zhongshan Hospital in January 2015. The pathological findings after the surgery revealed a low-grade papillary urothelial carcinoma of the renal pelvis. The final pathological tumor stage was pT1N0M0. After surgery, this patient received 6 cycles of intravenous chemotherapy with gemcitabine and carboplatin, as well as bladder infusion therapy with gemcitabine. On December 18, 2017, the patient was admitted once again to our hospital with a one-day history of painless gross hematuria. A CT scan showed the presence of a space-occupying lesion on the posterior wall of bladder. Cystoscopic examination revealed multiple tumors in the bladder and right cutaneous ureterostomy was performed under general anesthesia on December 29, 2017. The postoperative pathological findings disclosed multifocal papillary urothelial carcinoma of the bladder (maximum size 3.7 cm × 2.6 cm). The bladder cancer was considered a metastasis of the renal pelvis cancer after surgery. The pathological tumor stage was pT1N0M1. The patient refused chemotherapy after surgery. After another six years, the patient returned on February 28, 2023, complaining of periumbilical pain that had lasted six days. This time, a CT scan of the abdomen showed a tumor in the ascending colon, but a subsequent colonoscopy examination indicated a tumor in the descending colon. On March 12, 2023, a subtotal colectomy and an ileosigmoidal anastomosis were carried out under general anesthesia. Postoperative pathological findings revealed that all three tumors were adenocarcinomas. The final pathological tumor stage was pT3N0M0. The patient had an uneventful postoperative recovery and was discharged without complications.

CONCLUSION

The case of this elderly man presents a rare occurrence of metachronous primary cancers in the renal pelvis and colon. Bladder cancer is considered a metastasis of renal pelvis cancer after surgery. Optimal treatment can be implemented by evaluating the patient's histological features, clinical history, and tumor distribution correctly.

Is Robotic Superior to Laparoscopic Approach for Radical Nephroureterectomy with Bladder Cuff Excision in Treating Upper Urinary Tract Urothelial Carcinoma?

Background: Laparoscopic nephroureterectomy (LNU) has become popular in treating upper urinary tract urothelial carcinoma (UTUC) and an emerging trend was observed in robotic approaches. Therefore, we compared robot-assisted radical nephroureterectomy (RANU) and LNU for the treatment of UTUC. Materials and Methods: This observational and retrospective case-series study included UTUC patients who underwent LNU or RANU. A pure laparoscopic approach was adopted in the LNU treatment group, and bladder cuff excision (BCE) was performed mostly with the open approach. Either the da Vinci Si or Xi surgical system was used for RANU. Extravesical BCE was performed, and bladder defects were closed intracorporeally. Perioperative and oncologic outcomes were compared between the LNU and RANU groups. Results: A total of 231 patients who underwent RANU (n = 87) or LNU (n = 144) were included. No significant differences were noted between the groups in terms of demographics, tumor characteristics, operative time, catheter time, or complications. Compared with LNU, RANU had a lower intraoperative blood loss (30 vs. 150 mL, p < 0.001) and shorter postoperative hospital stay (8 vs. 9 days, p = 0.009). The 5-year overall survival, cancer-specific survival, and bladder recurrence-free survival were comparable between the groups. Conclusion: Compared with LNU, RANU had similar perioperative and oncologic outcomes but was superior in terms of intraoperative blood loss and postoperative length of hospital stay. However, considering the potential biases owing to the heterogeneity of our cases, the interpretation of the results must be very cautious.

Development and Validation of a Predictive Model to Evaluate the Risk of Bone Metastasis in Kidney Cancer

Background

Bone is a common target of metastasis in kidney cancer, and accurately predicting the risk of bone metastases (BMs) facilitates risk stratification and precision medicine in kidney cancer.

Methods

Patients diagnosed with kidney cancer were extracted from the Surveillance, Epidemiology, and End Results (SEER) database to comprise the training group from 2010 to 2017, and the validation group was drawn from our academic medical center. Univariate and multivariate logistic regression analyses explored the statistical relationships between the included variables and BM. Statistically significant risk factors were applied to develop a nomogram. Calibration plots, receiver operating characteristic (ROC) curves, probability density functions (PDF), and clinical utility curves (CUC) were used to verify the predictive performance. Kaplan-Meier (KM) curves demonstrated survival differences between two subgroups of kidney cancer with and without BMs. A convenient web calculator was provided for users via “shiny” package.

Results

A total of 43,503 patients were recruited in this study, of which 42,650 were training group cases and 853 validation group cases. The variables included in the nomogram were sex, pathological grade, T-stage, N-stage, sequence number, brain metastases, liver metastasis, pulmonary metastasis, histological type, primary site, and laterality. The calibration plots confirmed good agreement between the prediction model and the actual results. The area under the curve (AUC) values in the training and validation groups were 0.952 (95% CI, 0.950–0.954) and 0.836 (95% CI, 0.809–0.860), respectively. Based on CUC, we recommend a threshold probability of 5% to guide the diagnosis of BMs.

Conclusions

The comprehensive predictive tool consisting of nomogram and web calculator contributes to risk stratification which helped clinicians identify high-risk cases and provide personalized treatment options.

Predictors of Locoregional Recurrence and Delineation of Adjuvant Radiation Therapy Fields for Patients With Upper Tract Urothelial Carcinoma Receiving Nephroureterectomy

PURPOSE

To identify factors predictive of locoregional recurrence (LRR) in upper tract urothelial carcinoma (UTUC) treated with nephroureterectomy and to propose adjuvant radiation therapy (ART) fields.

METHODS AND MATERIALS

Clinical and pathologic variables for patients receiving nephroureterectomy for UTUC between 1995 and 2009 were analyzed for associations with outcomes. Sites of LRR from all patients with available imaging (39) were contoured on computed tomography image sets of patients with representative anatomy, and ART fields were proposed based on these distributions.

RESULTS

A total of 279 patients with a median follow-up of 13.0 years were analyzed. The 5-year cumulative incidence of LRR was 16.7% (95% CI, 12.2-21). Pathologic risk factors (PRFs) associated with increased risk of LRR included tumor in both the renal pelvis and ureter, T stage ≥2, lymph node involvement, grade 3 histology, and positive surgical margins (P < .05). Patients with an increased number of PRFs had a significantly greater risk of LRR. The 5-year cumulative incidence estimates of LRR were 5.3% (95% CI, 1.8%-16.0%), 15.6% (95% CI, 9.5%-25.7%), and 43.9% (95% CI, 31.1%-62.1%) for those with 1, 2, and ≥3 PRFs, respectively. ART fields covering the renal fossa and retroperitoneal lymph nodes from the superior border of L1 through the aortic bifurcation would encompass all sites of LRR for 33 of 46 patients (72%). Non-LRR bladder and distant failure occurred in 101 (36.2%) and 73 (26.2%) of the patients, respectively. The 5-year cumulative incidence estimate of distant failure was 22.5% (95% CI, 17.4%-27.3%).

CONCLUSIONS

In patients receiving nephroureterectomy for UTUC, LRR is significantly increased in patients with 2 or more PRFs. These data provide clinically valuable insight into the selection of candidates for ART and the design of ART fields.

Urothelial Carcinoma of the Renal Pelvis and Ureter: Does Location Make a Difference?

BACKGROUND

There is a paucity of data on outcomes of upper tract urothelial carcinoma (UTUC) arising from the renal pelvis (RPUC) versus UTUC arising from the ureter (UUC). The published literature is conflicting, and there is no consensus on patient prognosis based on disease location. The aim of this study is to compare clinical and survival outcomes based on location of primary tumor using a large national registry.

MATERIALS AND METHODS

The National Cancer Database was queried from 2010 to 2016 for patients with localized (cN0M0) UTUC. Patients were stratified based on location of tumor. Survival analysis was performed using Cox proportional hazard regression and inverse probability of treatment weighting (IPTW)-adjusted Kaplan-Meier curves. We also performed exploratory analyses based on tumor stage.

RESULTS

We identified 11,922 patients who underwent surgical treatment. The median follow-up was 32.1 months. Patients with RPUC presented with higher tumor stage and grade. Patients with UUC were treated with less radical nephroureterectomy (56.4% vs. 84.3%; P < .01). IPTW-adjusted Kaplan-Meier curves demonstrated higher median overall survival for RPUC versus UUC (71.1 vs. 66.8 months, respectively; P = .01). This benefit was consistent across tumor stage subgroups, reaching statistical significance in patients with T1 disease. On multivariable analysis, ureteral location of tumor was a predictor of worse survival.

CONCLUSION

Patients with UUC were found to be treated with less radical surgery and to have worse survival than those with RPUC. These patients may suffer from poor initial staging and suboptimal treatments. Further studies are needed to evaluate potential biological differences of UTUC based on tumor location.

c-Myc Acts as a Competing Endogenous RNA to Sponge miR-34a, in the Upregulation of CD44, in Urothelial Carcinoma

MicroRNAs (miRNAs) have been shown to play a crucial role in the progression of human cancers, including urothelial carcinoma (UC), the sixth-most common cancer in the world. Among them, miR-34a has been implicated in the regulation of cancer stem cells (CSCs); however, its role in UC has yet to be fully elucidated. In this study, bioinformatics and experimental analysis confirmed that miR-34a targets CD44 (a CSC surface marker) and c-Myc (a well-known cell cycle regulator) in UC. We found that, surprisingly, most UC cell lines and patient samples did express miR-34a, although epigenetic silencing by promoter hypermethylation of miR-34a expression was observed only in UMUC3 cells, and a subset of patient samples. Importantly, overexpression of c-Myc, a frequently amplified oncogene in UC, was shown to upregulate CD44 expression through a competing endogenous RNA (ceRNA) mechanism, such that overexpression of the c-Myc 3'UTR upregulated CD44, and vice versa. Importantly, we observed a positive correlation between the expression of c-Myc and CD44 in clinical samples obtained from UC patients. Moreover, overexpression of a dominant-negative p53 mutant downregulated miR-34a, but upregulated c-Myc and CD44, in UC cell lines. Functionally, the ectopic expression of miR-34a was shown to significantly suppress CD44 expression, and subsequently, suppression of cell growth and invasion capability, while also reducing chemoresistance. In conclusion, it appears that aberrant promoter methylation, and c-Myc-mediated ceRNA mechanisms, may attenuate the function of miR-34a, in UC. The tumor suppressive role of miR-34a in controlling CSC phenotypes in UC deserves further investigation.

Invasion of Adjacent Lumbar Vertebral Body from Renal Pelvis Carcinoma: Associated With Bone Metastasis But Easily Overlooked on Initial CT Scan

BACKGROUND/AIM

We hypothesized that regional tumor growth into L1 and L2 vertebral bodies from renal pelvis carcinoma was linked to the development of bone metastases.

MATERIALS AND METHODS

Criteria for the study were: (i) Metastatic renal pelvis carcinoma confirmed via pathology and computed tomographic (CT) scan, (ii) L1 and L2 invasion confirmed from retrospective CT scan review, and (iii) detection of bone metastases using radionuclide images/CT scans.

RESULTS

A total of 71 cases were enrolled in the study. Initial L1 and L2 vertebral body invasion. were detected in 45 (63%) patients. As well as L1 and L2 invasion, 32 (71%) had development of bone metastases. All bone lesions were osteolytic. Initial L1 and L2 invasion (p<0.00001) was associated with the development of bone metastasis.

CONCLUSION

CT scan can help to detect L1 and L2 vertebral body invasion in patients with renal pelvis carcinoma. Early identification and optimal management of such patients is necessary.

Comparison of oncological and perioperative outcomes of open, laparoscopic, and robotic nephroureterectomy approaches in patients with non-metastatic upper-tract urothelial carcinoma

BACKGROUND

To compare the oncological and perioperative outcomes of different nephroureterectomy approaches in patients with non-metastatic upper tract urothelial carcinoma (UTUC).

METHODS

We retrospectively analyzed the data of 422 patients who underwent open, laparoscopic, or robotic nephroureterectomy for non-metastatic UTUC. Perioperative and postoperative survival outcomes were compared using Kaplan-Meier analyses and Cox-proportional hazard models.

RESULTS

Of the patients, 161, 137, and 124 were treated with an open, laparoscopic, and robotic approach, respectively. Laparoscopic and robotic approaches involved significantly less blood loss (p = 0.001), shorter hospital stay (p < 0.001), and longer operation time (p < 0.001) compared with the open approach. There were no significant differences in intraoperative complications (open, 8.1%; laparoscopic, 5.1%; robotic, 7.3%; p = 0.363) or early postoperative complications (open, 14.9%; laparoscopic, 14.6%; robotic, 13.7%; p = 0.880). The laparoscopic and robotic groups showed significantly less postoperative analgesic use (p = 0.015). The robotic group showed significantly longer progression-free, cancer-specific, and overall survivals than the open approach group on univariate Kaplan-Meier analysis, but surgery type was not significantly associated with survival outcomes per multivariate Cox proportional tests (all p-values > 0.05).

CONCLUSION

The laparoscopic and robotic approaches yielded better perioperative outcomes, such as less intraoperative bleeding, shorter hospital stays, less analgesic usage, and non-inferior oncological outcomes, compared with the open approach. Further prospective studies are needed to compare these surgical techniques.

Pre-therapy CT scan showing peritoneal thickening from metastatic renal pelvis carcinoma patients

We investigated clinical significance of peritoneal thickening from metastatic renal pelvis based on pretherapy computed tomography (CT) scan findings. The criteria for inclusion were as follows: (1) pathology and CT scan confirmed metastatic renal pelvis carcinoma and (2) peritoneal thickening based on pre-therapy CT scan findings. We investigated the route of spread, gastrointestinal (GI) complications, and response to chemotherapy. A total of 68 cases were enrolled in this study, including seven patients with liver metastases and three with abdominal wall invasion. GI complications included obstruction in ten patients and bleeding in three. Response to chemotherapy demonstrated by reduced peritoneal thickening was noted in 24 patients. In conclusion. peritoneal thickening with clinical suspicion of peritoneal involvement can get indirect evidence from route of spread (liver or abdominal wall), GI complications (obstruction or bleeding) or response to chemotherapy (obvious decrease peritoneal thickening) from metastatic renal pelvis carcinoma patients. Pretherapy CT scan with peritoneal thickening should be alert that tumor has spread to the peritoneum.

Risk Stratification of Upper Urinary Tract Urothelial Carcinoma Patients for Survival Prediction: A Simple Summation Scoring Method

Purpose: To stratify upper urinary tract urothelial carcinoma (UTUC) patients into risk groups in terms of 5-year survival.

Methods and materials: All potential UTUC patients recorded in our cancer registry database from 1997 to 2011 were evaluated for authentic presence of UTUC. Age at diagnosis, sex, organ involvement, dialysis, renal transplantation status, clinical stage, survival to the last follow-up, and the cause of death of each patient were recorded. All patients were randomized into a developmental set or a validation set at a 1:1 ratio. Survival prediction models and scores were developed using the developmental set and validated in terms of discrimination and calibration using the validation set. Patients were stratified into risk groups using the summed risk scores and their survival compared by the log rank test.

Results: We enrolled 1,120 authentic UTUC patients. In the developmental set, older age, male sex, and higher clinical staging were significant predictors of 5-year death after controlling for other variables. Based on these three clinical variables, patients were stratified into low-, intermediate-, high-, and very high-risk groups using the summed risk scores. The 5-year all-cause and cancer-specific survivals of UTUC patients in the low-, intermediate-, high-, and very high-risk groups were 83.0% and 85.0%, 57.7% and 70.9%, 16.8% and 26.3%, and 2.2% and 7.5%, respectively (p < 0.001). Both discrimination and calibration were good for the validation set (overall concordance index = 0.762).

Conclusions: Stratification of UTUC patients using summed risk scores was a simple and useful way to estimate survivals and to select appropriate treatments.

Methylomics analysis identifies ZNF671 as an epigenetically repressed novel tumor suppressor and a potential non-invasive biomarker for the detection of urothelial carcinoma

The molecular mechanism underlying the lethal phenomenon of urothelial carcinoma (UC) tumor recurrence remains unresolved. Here, by methylation microarray, we identified promoter methylation of the zinc-finger protein gene, ZNF671 in bladder UC tumor tissue samples, a finding that was independently validated by bisulphite pyrosequencing in cell lines and tissue samples. Subsequent assays including treatment with epigenetic depressive agents and in vitro methylation showed ZNF671 methylation to result in its transcriptional repression. ZNF671 re-expression in UC cell lines, via ectopic expression, inhibited tumor growth and invasion, in possible conjunction with downregulation of cancer stem cell markers (c-KIT, NANOG, OCT4). Clinically, high ZNF671 methylation in UC tumor tissues (n=96; 63 bladder, 33 upper urinary tract) associated with tumor grade and poor locoregional disease-free survival. Quantitative MSP analysis in a training (n=97) and test (n=61) sets of voided urine samples from bladder UC patients revealed a sensitivity and specificity of 42%-48% and 89%-92.8%, respectively, for UC cancer detection. Moreover, combining DNA methylation of ZNF671 and 2 other genes (IRF8 and sFRP1) further increased the sensitivity to 96.2%, suggesting a possible three-gene UC biomarker. In summary, ZNF671, an epigenetically silenced novel tumor suppressor, represents a potential predictor for UC relapse and non-invasive biomarker that could assist in UC clinical decision-making.

[Carcinogenic pathways and natural history of upper tract urothelial carcinomas: state-of-the-art review for the yearly scientific report of the French National Association of Urology]

OBJECTIVE

To describe natural history and carcinogenesis of upper tract urothelial carcinoma (UTUC).

METHODS

A systematic review of the scientific literature was performed in the Medline database (Pubmed) using different associations of the following keywords: upper tract urothelial carcinoma; clonality; carcinogenesis; mutation; chromosomal instability; Lynch syndrome; genetic polymorphism.

RESULTS

Local development of UTUC is characterized by a highly prevalent multifocality that might be explained by the overlap of "field change" and "intraluminal seeding and implantation" theories. UTUC and bladder tumors share common carcinogenesis mechanisms such as mutations of FGFR3 and TP53 defining two distinct pathways of pathogenesis. Epigenetic alterations corresponding to the hypermethylation of different promoters regulating genes expression and chromosomal instability such as chromosome 9 deletions are also involved in UTUC carcinogenesis. Furthermore, specific genetic risk factors fro UTUC including Lynch syndrome and different polymorphisms might explain an individual susceptibility for developing these tumors.

CONCLUSIONS

Significant advances have been done in the field of basic research in UTUCs in recent years and have been of particular interest to provide better descriptions of their natural history. Despite these important findings however, some carcinogenic mechanisms remains not elucidated and unknown in the field of UTUC so far.

Comparing the joint effect of arsenic exposure, cigarette smoking and risk genotypes of vascular endothelial growth factor on upper urinary tract urothelial carcinoma and bladder cancer

Arsenic exposure and cigarette smoking are environmental risk factors for urothelial carcinoma (UC). Vascular endothelial growth factor (VEGF) is the key regulator of angiogenesis in various malignancies. This study investigates the joint effect of arsenic exposure, cigarette smoking, and VEGF polymorphisms on UC risk. This was a hospital-based case-control study consisting of 730 histopathologically confirmed UC cases, including 470 bladder cancers, 260 upper urinary tract UCs (UUTUCs), and 850 age-matched controls, recruited from September 1998 to December 2009. UC risk was estimated by odds ratios and 95% confidence intervals using unconditional logistic regression. Ever smokers with high arsenic exposure had significantly increased risks of 5.7 and 6.4 for bladder cancer and UUTUC, respectively. Moreover, ever smokers with high arsenic exposure carrying 1 or 2 risk genotypes of the VEGF gene had a significantly increased risk of 6.6 for bladder cancer and a strikingly higher risk of 9.9 for UUTUC. Additionally, UUTUC cases with high arsenic exposure carrying 1 or 2 risk genotypes of the VEGF gene had a non-significant increased risk of advanced tumor stage. Our findings suggest that arsenic exposure, cigarette smoking, and risk genotypes of VEGF contribute to a higher risk of UUTUC than of bladder cancer.

Upper urinary tract urothelial carcinoma: what have we learned in the last 4 years?

In the last 4 years many studies have been published on the topic of upper urinary tract urothelial carcinoma (UTUC). This is a recent review of the available literature of the last 3 years. A systematic Medline/PubMed search on UTUC including limits for clinical trials and randomized, controlled trials was performed for English-language articles using the keywords 'upper urinary tract carcinoma', 'nephroureterectomy', 'laparoscopic', 'ureteroscopy', 'percutaneous', 'renal pelvis', 'ureter' and their combinations from January 2008 to December 2010. Additional selected reports from 2007 were included. Case reports and non-English literature were excluded. Publications were mostly retrospective, including some large, multicentre studies from the Upper Tract Urothelial Carcinoma Collaboration (UTUCC). The authors of this article are members of the UTUCC. Altogether, 92 original articles dealing with UTUC were identified and summarized. The vast majority of the available literature has a low level of evidence (level IV), although many multicentre studies tried to overcome the problem of low numbers by pooling data. It was concluded that in the last 3 years our knowledge regarding UTUC has increased dramatically, although new study concepts allowing us to increase the level of evidence are needed.

Radiotherapy may improve overall survival of patients with T3/T4 transitional cell carcinoma of the renal pelvis or ureter and delay bladder tumour relapse

BACKGROUND

Since transitional cell carcinoma (TCC) of the upper urinary tract is a relatively uncommon malignancy, the role of adjuvant radiotherapy is unknown.

METHODS

We treated 133 patients with TCC of the renal pelvis or ureter at our institution between 1998 and 2008. The 67 patients who received external beam radiotherapy (EBRT) following surgery were assigned to the radiation group (RT). The clinical target volume included the renal fossa, the course of the ureter to the entire bladder, and the paracaval and para-aortic lymph nodes, which were at risk of harbouring metastatic disease in 53 patients. The tumour bed or residual tumour was targeted in 14 patients. The median radiation dose administered was 50 Gy. The 66 patients who received intravesical chemotherapy were assigned to the non-radiation group (non-RT).

RESULTS

The overall survival rates for the RT and non-RT groups were not significantly different (p = 0.198). However, there was a significant difference between the survival rates for these groups based on patients with T3/T4 stage cancer. A significant difference was observed in the bladder tumour relapse rate between the irradiated and non-irradiated bladder groups (p = 0.004). Multivariate analysis indicated that improved overall survival was associated with age < 60 years, T1 or T2 stage, absence of synchronous LN metastases, and EBRT. Acute gastrointestinal and bladder reactions were the most common symptoms, but mild non-severe (> grade 3) hematologic symptoms also occurred.

CONCLUSION

EBRT may improve overall survival for patients with T3/T4 cancer of the renal pelvis or ureter and delay bladder tumour recurrence in all patients.