Percutaneous Treatment of Transitional Cell Carcinoma of the Upper Urinary Tract

Background We evaluated the long-term effect of percutaneous resection in 2 Japanese patients with transitional cell carcinoma of the renal pelvis, and reviewed the medical literature on similar patients, to determine the appropriate indications for percutaneous treatment of transitional cell carcinoma in the upper urinary tract.
Results Indications for endoscopic resection in the 2 patients were renal insufficiency and unsuitability for major open surgery. The patients had no recurrence during follow-up. Seven previous reports described percutaneous resection of upper urinary tract transitional cell carcinoma in 82 patients. Although 72.6% of the patients were successfully treated by percutaneous resection, half of the patients with grade 3 carcinoma developed recurrence.
Conclusion These results, together with those of the 7 published reports, suggest that percutaneous resection should be limited to selected patients with low-grade transitional cell carcinoma.     

Laser Therapy for Upper Urinary Tract Transitional Cell Carcinoma: Indications and Management

Context

Ureteroscopically guided laser techniques are commonly used in the treatment of upper urinary tract transitional cell carcinoma (UUTT); however, there is an ongoing debate with regard to indication and management.

Objective

To review the indication, feasibility, and treatment outcome of laser application for definitive endoscopic treatment of UUTT, focusing on technical aspects of different laser devices and their impact on tissue.

Evidence acquisition

PubMed and Medline were searched for reports on laser therapy in UUTT from 1980 to 2008, with particular focus on the technical background of various laser systems.

Evidence synthesis

For decades, nephroureterectomy has been considered the gold standard for treating UUTT. With the intent to preserve functioning renal parenchyma, minimally invasive approaches, initially advocated for patients requiring a nephron-sparing approach (ie, single functioning kidney, renal insufficiency or significant comorbidities), have gained widespread acceptance due to advances in ureteroscopy, percutaneous renal surgery, and laparoscopy. Ureteroscopically guided laser ablation has been used successfully, resulting in recurrence rates ranging from 31% to 65% and disease-free rates of 35% to 86%, depending on stage and grade at diagnosis.

Conclusions

To obtain the highest treatment success, the initial staging and grading of the tumour is crucial. Because low-grade tumours rarely if ever progress in stage or grade, the success rate of ureteroscopic therapy parallels that of endoscopic resection of identical bladder tumours. In the treatment of higher grade, advanced tumours, ureteroscopic therapy is less likely to be curative, and thus, endoscopic manoeuvres can only be palliative. Due to the relatively low prevalence of this tumour and the lack of comparable randomised, multicentre trials, the indications for an endoscopic laser treatment option has to be defined based on the patient's individual situation.     

上尿路移行细胞癌患者预后因素的Cox模型分析

目的：通过Cox比例风险模型。分析上尿路移行细胞癌患者的预后因素。指导临床治疗。方法：45例肾盂、输尿管移行细胞癌患者接受分析。年龄、性别、就诊时问、术前血色素、术中输血量、手术方式、病理分级、临床分期、肿瘤数目、肿瘤大小、术后有无复发、PCNA指数等12个变量进入Cox模型。结果：临床分期、PCNA指数、肿瘤数目、就诊时问四项参数与预后有关,其中临床分期、PCNA指数关系非常密切。病理分级、手术方式两项参数也有一定关系。根据临床分期和PCNA指数将患者分为A、B、C三组,术后5年生存率分别为92．65、38．4％与3％。差异非常显著。结论：Cox模型表明临床分期、PCNA指数与预后关系最密切。肿瘤数目、病理分级、就诊时问、手术方式对预后也有重要影响。根据临床分期和PCNA指数将患者分为不同的组,对判断预后。指导临床治疗有一定意义。     

Ureteroscopic Management of Patients with Upper Tract Transitional Cell Carcinoma

ObjectivesThis paper reviews the indications, technique, and treatment outcomes for the ureteroscopic management of upper tract transitional cell carcinomas (UTTCCs).MethodsThe author reports on his experience and reviews of the most recent data published in the literature.ResultsThe expanding experience with minimally invasive techniques to treat UTTCCs has demonstrated its safety and efficacy in selected patients. Diagnostic accuracy can be enhanced and pathologic confirmation of tumour grade and stage can be regularly obtained. In selected patients with unique, small tumours with low grade and low stage, the results of endoscopic management are encouraging. Patients with a functional solitary kidney, bilateral disease, or renal insufficiency can also be considered for conservative treatment. The patient must be willing to and capable of undergoing vigilant and frequent endoscopies during the follow-up. However, conservative management remains controversial in a patient with low-grade/low-stage disease and a normal contralateral kidney.ConclusionsUreteroscopic management of UTTCC is feasible and safe using, preferably, laser fulguration.     

腹腔镜治疗上尿路移行细胞癌的手术路径选择

目的 探讨腹腔镜治疗上尿路移行细胞癌不同的手术路径选择.方法 将116例上尿路移行细胞癌患者分为A、B两组,A组为肾孟及输尿管上段肿瘤组,采用后腹腔镜联合经尿道电切的方法;B组为输尿管下段肿瘤组,6例输尿管局部浸润的患者列入本组,采用70°斜侧卧位经腹腔途径肾、输尿管切除并膀胱袖状切除.结果 116例手术均获成功,无术中并发症.A组手术时间平均125.5 min,术中出血平均60 ml,术后24～48 h胃肠功能恢复;术后住院时间平均7 d;B组手术时间平均140.6 min,术中出血平均96 ml,术后24～72 h胃肠功能恢复;术后住院时间平均7.5 d.有90例患者获得随访,平均随访时间27个月,未发现切口及穿刺孔种植转移,但有10例行膀胱镜检查发现膀胱肿瘤.结论 腹腔镜肾、输尿管全切和膀胱袖状切除治疗上尿路移行细胞癌符合肿瘤治疗原则,安全可行.应根据肿瘤的位置来决定手术方式的采用.     

Diagnostic Accuracy of Ureteroscopic Biopsy in Upper Tract Transitional Cell Carcinoma

Purpose

Our aim was to determine the accuracy of ureteroscopic biopsies and cytological techniques compared to open surgical specimens of upper tract transitional cell carcinoma.

Materials and Methods

From 1985 to 1995, 51 cases of upper tract transitional cell carcinoma were diagnosed ureteroscopically and distal ureterectomy or nephroureterectomy was performed. Each patient underwent direct ureteroscopic inspection and biopsy. Fresh samples were delivered to the cytopathology laboratory, where they were examined using cytospin and smear. A cell block was prepared when visible tissue was present. Grades of ureteroscopic biopsies were compared to grades and stages of surgical specimens in 42 cases.

Results

Cytological evaluation was positive for malignancy in 48 of the 51 cases (94.1%). Grading of ureteroscopic specimens was possible in 42 cases (82.4%). Transitional cell carcinoma grade on ureteroscopy accurately predicted tumor grade and stage in the surgical specimens. Of 30 low or moderate grade ureteroscopic specimens 27 (90%) proved to be low or moderate grade transitional cell carcinoma in the surgical specimens, while 11 of the 12 high grade ureteroscopic specimens (91.6%) proved to be high grade transitional cell carcinoma (p <0.0001). Of 30 low or moderate grade ureteroscopic specimens 26 (86.6%) had a low stage (Ta or T1) tumor. In contrast, 8 of 12 high grade ureteroscopic specimens (66.7%) had invasive tumor (stage T2 or T3) in the surgical specimen (p = 0.0006).

Conclusions

Ureteroscopic inspection and biopsy combined with cytological techniques provide accurate information regarding grade and stage of upper tract transitional cell carcinoma.     

Urinary Nuclear Matrix Protein as a Marker for Transitional Cell Carcinoma of the Urinary Tract

Purpose

The purpose of this trial was to evaluate an immunoassay for urinary nuclear matrix protein, NMP22,^* as an indicator for transitional cell carcinoma of the urinary tract.

Materials and Methods

Three groups of subjects participated in this trial of NMP22: 1--175 with transitional cell carcinoma, 2--117 with benign urinary tract conditions and 3--375 healthy volunteers. Each subject provided a single (3 voids) urine sample for analysis at the time of study entry. Each sample was assayed for the level of NMP22.

Results

In normal healthy volunteers and in subjects with benign conditions median NMP22 levels were 2.9 and 3.3 units per ml., respectively. Median urinary NMP22 levels in patients with transitional cell carcinoma were significantly greater than in comparison subjects. Patients with active transitional cell carcinoma had significantly greater median urinary NMP22 levels than those with no evidence of disease (6.04 versus 4.11 units per ml., p = 0.027, 1-tailed Mann-Whitney U test). We noted no effect of tumor grade, extent of disease or exposure to intravesical therapy on urinary NMP22 levels.

Conclusions

NMP22 is a promising urinary tumor marker for monitoring transitional cell carcinoma. Nuclear matrix proteins are a new class of tumor markers that represent the basis for the development of assays with increased efficacy for the detection and treatment of cancer.     

Factors Affecting the Survival of Patients Treated by Standard Nephroureterectomy for Transitional Cell Carcinoma of the Upper Urinary Tract

Purpose:In this study we tried to evaluate the predictive factors for survival in patients with upper urinary tract tumors. Materials and methods: From 1993 to 2003, 46 patients were treated by standard nephroureterectomy for upper urinary tract tumor, but only 24 patients (52%) who had regular follow-up were included in the study. Age, sex, presenting symptoms of the patients, tumor localization, tumor stage and grade were analyzed with respect to survival. Univariate and multivariate analyses were done using Kaplan–Meier method with log-rank test and Cox proportional hazards regression model, respectively. Results: The median of patient age was 61 years (34–74). Of the 24 patients, 9 (37.5%) were disease-free and alive at a mean time of 54 (26–97) months, 8 (33.3%) died of disease at a mean period of 23.4 months (2 because of bladder tumor, 2 had liver metastases, 1 had lung metastasis and 3 had lung and liver metastases) and 7 (29.2%) died disease-free at a mean period of 30.3 months. Metastases were detected in a mean period of 11.8 (6–24) months. Survival according to tumor stage Ta, T1-2, and invasive tumors were 87.5, 43.9, 15.7 months (p = 0.0001), respectively. Survival of the patients with low-grade tumors was significantly longer than those with high-grade tumors (77.3 and 31.4 months, respectively, p = 0.01). Patients with pelvis tumors when compared to ureter tumors (28.5 and 61.6 months, respectively, p = 0.038) and those presenting with flank pain when compared to those presenting with macroscopic hematuria and bladder cancer (17.7, 45.7, and 57.9 months, respectively, p = 0.046) had shorter survival rates. When multivariate analyses were done using Cox regression test, the only factor that affected survival was the stage of the tumor. Age and gender had no impact on survival. Conclusions: In univariate analysis, the stage, grade, localization of the tumor and presenting symptoms were found important predictors that affect the prognosis of the transitional carcinoma of the upper tract. However, tumor stage was the only independent predictor of survival in multivariate analysis. For high grade and high stage tumors, really effective adjuvant treatments along with aggressive surgery may be considered.     

Fever Following Intracavitary Bacillus Calmette-Guerin Therapy for Upper Tract Transitional Cell Carcinoma

Purpose

We attempted to identify the source of fever during intracavitary upper tract instillation of bacillus Calmette-Guerin (BCG).

Materials and Methods

Of 34 patients who had previously undergone percutaneous resection of upper tract transitional cell carcinoma 18 received weekly intracavitary BCG through the nephrostomy tubes for 6 consecutive weeks. After treatment 6 all patients underwent nephroscopy and biopsy, and all cases were retrospectively reviewed. Parameters analyzed were BCG related symptoms, maximum temperature during treatment, maximum renal pelvic pressure during treatment, culture results, chest x-ray findings, pretreatment serum creatinine concentration, serum liver enzyme values, untoward events and treatments performed for BCG related complications.

Results

No obvious pattern in appearance of fever occurred. During 88 treatment episodes evaluated there were 14 temperature elevations to more than 100F in 7 patients (39 percent). Positive urine cultures were associated with fever in only 4 cases and none was positive for Mycobacterium. There was no correlation between greater renal pelvic pressures and fever. All chest radiographs and serum creatinine levels were unchanged, and liver enzymes were normal in all but 1 patient. Two patients had prolonged fever with elevations to greater than 104F following treatment: 1 died in a motor vehicle accident and 1 died after the third BCG infusion led to overwhelming sepsis. No source of fever was identified in either patient.

Conclusions

Patients with low grade fever coincident with upper tract BCG may be treated conservatively simply by withholding the infusion. Fever greater than 103F should be considered an emergency condition with high potential for mortality. Immediate and aggressive attempts at identifying a source along with institution of antituberculous therapy are priorities.     

双侧同时性上尿路移行细胞癌诊治研究

目的：提高双侧上尿路移行细胞癌的诊断率并探讨双侧上尿路同时发生移行细胞癌患者的治疗策略。方法：报告5例双侧上尿路同时发生移行细胞癌患者的临床资料,均有无痛性全程肉眼血尿,有2例肾功不全,4例术前行B超、IVP、CTU及逆行造影检查,2例术前获得诊断,2例一侧仅表现异常,术中获得确诊。4例均行保肾手术。1例在外院仅诊断一侧肿瘤,并行根治性切除术,20天后又在我院确诊对侧也存在肿瘤并行保肾手术。结果：随访14～40个月,平均26个月。随访期间1例死亡,2例术后发生膀胱肿瘤。2例未见肿瘤复发。结论：双侧上尿路同时发生移行细胞癌易漏诊一侧,保肾手术是治疗的最优选择。     

Contralateral Nephroureterectomy for Renal Transplant Recipients With Unilateral Upper Urinary Tract Transitional Cell Carcinoma: A Report of 12 Cases

Background

We sought to analyze the feasibility of prophylactic contralateral nephroureterectomy for renal transplant recipients with urothelial carcinomas.

Methods

We analyzed the medical records of 12 renal transplant patients who underwent unilateral laparoscopic nephroureterectomy (first operation). Postoperative pathologic examinations confirmed that they all had urinary tract transitional cell carcinomas. At 1–3 months after the first operation, all patients underwent prophylactic contralateral nephroureterectomy (second operation).

Results

Before the second operation, 2 patients were found to have hydronephrosis on computed tomography (CT), and postoperative pathologic examinations confirmed the lesions to be urothelial carcinomas. The other 10 patients had no detectable signs of urothelial tumors before the second operation, but postoperative pathologic examinations indicated that 3 had transitional cell carcinomas. All patients were followed for 4–70 months. Eleven patients survived; 1 died of heart attack unrelated to the procedures.

Conclusions

The incidence of contralateral upper urinary tract urothelial carcinoma is high in renal transplant recipients with posttransplantation urinary tract malignancies. If there are no other health risks, prophylactic contralateral nephroureterectomy should be considered.