8-armed octopus: Evaluation of clinicopathologic prognostic factors of urothelial carcinoma of the upper urinary system

Background/aim

This study was designed to determine the characteristic features of upper urinary system urothelial carcinomas (UUSUCs) and to evaluate the clinicopathological parameters associated with prognosis.

Materials and methods

A total of 74 cases of UUSUC were included, from three different centers. Demographic data and histopathological features such as tumor localization, concomitant tumor in the urinary system, distant metastasis with overall survival and disease-free survival obtained from the hospital records were evaluated retrospectively. Histopathologic prognostic features such as grade, perineural invasion, lymphovascular invasion, tumor necrosis, and surgical margin status were also evaluated.

Results

Seventy cases (94.6%) underwent open nephroureterectomy whereas 4 cases (5.4%) had laparoscopic nefroureterectomy. Thirty-eight (51.4%) cases were located in the pelvis, 7 (9.5%) in the ureter, 29 (39.2%) both in the pelvis and ureter. Fifty-six (75.7%) cases were alive; however, 18 (24.3%) patients were found to be dead. pTa, pT1, pT2, pT3, and pT4 tumors were reported in 16 (21.6%), 13 (17.6%), 4 (5.4%), 28 (37.8%), and 13 (17.6%) patients, respectively. Histopathologically, 17 cases (23%) were low-grade, 57 cases (77%) were high-grade. Statistically significant correlation was observed between overall survival and lymph node metastasis, distant metastasis, tumor necrosis, and differentiation by univariate analysis. Only distant metastasis was statistically associated with overall survival by multivariate analysis. We found no significant relationship between disease-free survival and all parameters.Conclusions: Differentiation and necrosis of tumor, lymph node involvement, and presence of distant metastasis is associated with the overall survival of urothelial carcinoma of the upper urinary system.

Preoperative hydronephrosis is associated with less decline in renal function after radical nephroureterectomy for upper tract urothelial carcinoma

INTRODUCTION

To compare renal function changes after radical nephroureterectomy (RNU) in patients with upper tract urothelial carcinoma (UTUC) based on the presence of preoperative hydronephrosis.

MATERIALS AND METHODS

Clinicopathologic data of 208 patients with UTUC treated surgically from 1998 to 2013 were compiled. Patients with bilateral disease, less than 1 month follow up, missing hydronephrosis data, or who underwent nephron-sparing approaches were excluded. Estimated glomerular filtration rate (eGFR) was calculated preoperatively, at first follow up (within 3 months) and at last follow up using the Modification of Diet in Renal Disease equation. Events were defined as new-onset stage III chronic kidney disease (CKD) or worsening of CKD stage in preexisting CKD. Kaplan-Meier event-free survival was assessed. Cox regression was performed to identify predictors of events.

RESULTS

A total of 132 patients were analyzed, including 62 (47.0%) with hydronephrosis. Median follow up was 28.6 months. Patients with hydronephrosis had larger tumors (p = 0.045) and higher pathologic stage (p = 0.010) than those without hydronephrosis. Baseline eGFR was comparable between groups (p = 0.088). Patients without hydronephrosis experienced greater declines in eGFR following surgery (p < 0.001) and higher event rates at first (42.8% versus 24.2%, p = 0.028) and last (54.2% versus 30.6%, p = 0.008) follow up. On Cox regression, hydronephrosis predicted lower event likelihood in the long term (univariate HR 0.54, p = 0.033), while ureteral tumor location predicted lower event likelihood in the short term (HR 0.52, p = 0.030).

CONCLUSIONS

Patients with hydronephrosis undergoing RNU for UTUC experience less decline in renal function than those without hydronephrosis. Given the prevalence of renal dysfunction in patients with UTUC, our results may help inform preoperative counseling.

Urothelial neoplasms of the kidney and ureter. An epidemiologic, pathologic, and clinical review

Urothelial neoplasms occur with varying frequency at different sites along the urothelial tract. Approximately 5% of urothelial neoplasms occur in the kidneys and ureters, while the majority of these tumors occur in the urinary bladder. Consequently, urothelial disease of the bladder has been evaluated to a greater extent than urothelial tumors elsewhere, and many of the features of bladder urothelial neoplasms have been applied to these tumors at other sites. While the classification of urothelial neoplasms is the same for tumors in the bladder, kidney, and ureter, there are some features of urothelial neoplasms of the kidney and ureter that are unique to these sites. An epidemiologic, pathologic, and clinical review of urothelial neoplasms of the kidney and ureter is presented.

Is renal function at the tumor side a prognostic factor in ureteral transitional cell carcinoma?

OBJECTIVES

To evaluate whether the ipsilateral renal function on the tumor side is a prognostic factor in transitional cell carcinoma (TCC) of the ureter.

PATIENTS AND METHODS

We retrospectively reviewed 129 consecutive patients with ureteral TCC between September 1973 and July 1993 at our hospital. There were 98 males and 31 females aged from 31 to 84 years (mean 64.9). Of them, 126 patients who received intravenous pyelography (IVP) were divided into 3 groups according to their radiological findings (group 1: nonvisualization of kidney at tumor side; group 2: hydronephrosis or hydroureter; group 3: no obstruction). Eighty patients receiving radionuclide (131I-hippuran) renal function test (RRFT) with available effective renal plasma flow (ERPF) were divided into 2 groups using ipsilateral ERPF 50 ml/min as a cutoff value (group 1: < 50 ml/min; group 2: > or = 50 ml/min). The mean survival of each group was estimated by the Kaplan-Meier method.

RESULTS

For patients receiving IVP, the mean survivals were 61.7, 99.7 and 83.8 months for groups 1, 2, and 3, respectively, and the differences between each 2 of the 3 groups were statistically significant (p < 0.05). For patients having RRFT, the mean survivals were 65.8 months for group 1 and 89.2 months for group 2 patients, and the difference between them was statistically significant (p < 0.05). When renal function, tumor number, grade, stage and type of treatment were analyzed using a multivariate method, only tumor stage was statistically significant as a prognostic factor.

CONCLUSION

Ipsilateral renal function at the tumor side is not a good prognostic factor for patients with ureteral TCC. However, when the stage of tumor is not available, renal function at the tumor side may provide an implication of the patient's prognosis.

[Squamous cell carcinoma of ureter in a patient with functional solitary kidney treated by partial ureterectomy: a case report]

We report a case of squamous cell carcinoma of ureter. A 60-year-old female was referred to our hospital for the right hydronephrosis and the left atrophic kidney. She had been suffering from severe renal dysfunction and had hemodialysis a month earlier. Retrograde and antegrade right pyelography revealed complete obstruction of the right lower ureter about 2 cm in length. Transcutaneous retrograde left pyelography revealed vesicoureteral junction stenosis. After improvement of the renal function by transcutaneous right nephrostomy, the patient underwent right partial ureterectomy. Pathological examination revealed squamous cell carcinoma, grade 2, pT3 in the right ureter. Neither local recurrence nor distant metastasis has occurred for 19 months and the patient retains moderate renal function. We reviewed sixty-four cases of ureteral squamous cell carcinoma in the Japanese literature and discussed the renal parenchymal sparing surgery for the disease.

Loss of human E-cadherin (ECD) correlated with invasiveness of transitional cell cancer in the renal pelvis, ureter and urinary bladder

Loss or decreased expression of E-cadherin (ECD), which forms an epithelial junction complex that includes several other proteins and triggers signal transduction, may contribute to tumor progression. In the present study, we examined 90 transitional cell cancers (TCCs), 47 urinary bladder cancers and 43 ureteral or renal pelvic cancers, as well as TCC and papilloma cell lines to determine whether they express ECD. We classified ECD expression into normo-expression (like normal epithelial), decreased and loss of ECD staining on TCCs (urinary bladder, renal pelvic or ureteral). We found that low-stage TCCs expressed normal ECD in 68%, decreased of ECD in 20% and loss of ECD in 12%, whereas high-stage TCCs expressed 29%, 41% and 30% of ECD staining, respectively (P < 0.01). Furthermore, grade 1 TCCs were all estimated to show normo-expression, grade 2 TCCS expressed normal ECD in 49%, decreased of ECD in 41% and loss of ECD in 10% grade 3 TCCs classified as 20%, 30% and 50%, respectively (P < 0.01). Staining for cultured cell lines showed positive membranous staining for ECD in a benign papilloma cell line, RT4 and a TCC cell line, HT1376, but not in a TCC cell line, T24. Reverse-transcription polymerase chain reaction showed the presence of ECD and alpha-catenin mRNA in RT4 and HT1376, and only alpha-catenin in T24. Thus, it is more likely that decrease or loss of ECD might contribute to the malignant character of tumor cells and result in tumor progression.

Organ-sparing treatment for ureteral carcinoma?

OBJECTIVE

Nephroureterectomy (NUE) with a bladder cuff is the standard therapy for ureteral cancer. Based on an analysis of the literature and a retrospective study, this concept is questioned.

METHODS

Between 1980 and 1991, 40 patients with ureteral tumors underwent surgery at the Krankenhaus der Barmherzigen Brüder in Munich. Tumoral stages were pTa and pTl in 62% of the patients; 37% showed an invasive carcinoma. Radical surgery (NUE with bladder cuff) was performed in 22 patients and conservative treatment (ureterocystoneostomy or end-to-end-anastomosis) in 13 patients.

RESULTS

The median follow-up was 42 months in the conservative group and 59 months in the radical surgery group. A recurrence in the conservatively operated patients was observed only in primary invasive tumors (4/13), whereas none of the remaining patients had a recurrent tumor. In terms of time to progression and tumor-specific survival, there was a good correlation of the ureteral carcinoma according to grading and staging. In terms of survival, patients with superficial tumors run a similar course whether treated by conservative or radical surgery.

CONCLUSION

The conservative treatment of patients presenting with superficial ureteral lesions seems to be a good alternative to radical surgery.

Transitional cell carcinoma of the renal pelvis and ureter in Taiwan. DNA analysis by flow cytometry

BACKGROUND

The incidence of upper urinary tract tumors is relatively high in southern Taiwan. DNA analysis by means of flow cytometry is not well investigated with regard to tumors of the upper urinary tract and the differences in DNA ploidy between transitional cell carcinomas in endemic and nonendemic areas.

METHODS

A retrospective nuclear DNA ploidy analysis by flow cytometry comprised 41 formaldehyde solution-fixed, paraffin-embedded tissue specimens of transitional cell carcinoma of the renal pelvis and ureter. The preparation of nuclear suspensions from paraffin-embedded tissue blocks and staining were modified by means of the techniques of Hedley and Vindeløv.

RESULTS

There was no statistical correlation between DNA ploidy, histologic grade, and pathologic stage, however, 82% of the DNA nondiploid tumors showed tumor progression. In contrast, only 46% of the DNA diploid tumors revealed tumor progression. Among Grade 2 tumors, 85% of the DNA nondiploid tumors showed postoperative tumor progression, whereas only 31% of the DNA diploid tumors showed tumor progression. Seventy-nine percent of the nondiploid patterns were present in patients native to the Pa Chang Valley, where the so-called "blackfoot disease" and urothelium tumor are endemic, whereas only 22% appeared in patients living in other areas.

CONCLUSIONS

DNA flow cytometry can identify a group of patients with poor outcome unpredictable by pathologic examination, and is an important tool in research into the pathogenesis of cancer.