Upper tract urothelial cancer (sometimes called transitional cell carcinoma) is a cancer that occurs in either the inner lining of the tube that connects the kidney to the bladder (the ureter) or within the inner lining of the kidney.
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UPPER TRACT UC PRESENTATION.pptx
1. Urology & Nephrology Center
Mansoura University
Urology and Nephrology Center
Mansoura, Egypt
UNC THURSDAY MEETING
THE 8TH FEB, 2024
2. Urology & Nephrology Center
Mansoura University
Upper tract urothelial
carcinoma
ABDINUR JAMA
Urology resident
Urology and Nephrology Center
Mansoura, Egypt
3. Urology & Nephrology Center
Mansoura University
Introduction
• UTUC
– Refers to urothelial tumors that
originate from the inner lining of
the ureter, calyces, or renal
pelvis.
4. Urology & Nephrology Center
Mansoura University
EPIDEMIOLOGY
Upper urinary tract carcinomas make up only 5%
of the urothelial cancers.
The highest incidence is observed in individuals age
70 to 90 years in the Balkan countries, where UTUC
represents the 40% of all renal neoplasms.
Multifocal presence of UTUC is diagnosed in 10% to
20% of cases.
Concurrent bladder cancer is diagnosed in 17% of
cases.
UTUCs are twice as frequent in men than in women.
5. Urology & Nephrology Center
Mansoura University
Risk factors
1. Genetic predisposition
2. Environmental factors
tobacco exposure
occupation
analgesics
chronic inflammation and infection
arsenic
6. Urology & Nephrology Center
Mansoura University
HISTOPATHOLOGY
• Urothelial carcinomas represent more than
90% of the upper urinary tract tumors.
• Pure non-urothelial upper urinary tract
cancers are rare conditions.
• Variants of urothelial cancer are
encountered in approximately 25% of
UTUCs.
• Papillomas, inverted papillomas, and von
Brunn nests are usually benign lesions.
7. Urology & Nephrology Center
Mansoura University
• UTUC develops through a gradual progression
of hyperplasia to dysplasia and eventually
carcinoma in situ (CIS) in a significant
proportion of UTUC cases.
• CIS is difficult to diagnose with significant
morphologic variations.
• The muscle invasion or invasion to the renal
parenchyma or the surrounding adventitia is
more likely to take place on the upper tract.
8. Urology & Nephrology Center
Mansoura University
Clinical features
• Upper urinary tract tumors are associated
with several symptoms and signs.
• The common symptoms include:
– Hematuria:(56-98%), dysuria, flank pain,
which are usually related to localized disease.
– Advanced disease is characterized by flank or
abdominal mass, weight loss, anorexia, and
bone pain.
9. Urology & Nephrology Center
Mansoura University
Diagnosis
• UTUCs are diagnosed using imaging,
cystoscopy, urinary cytology and diagnostic
ureteroscopy.
• Computed tomography urography has the
highest diagnostic accuracy of the available
imaging techniques.
11. Urology & Nephrology Center
Mansoura University
Staging and grading systems
• The UICC 2017 TNM (Tumour, Node,
Metastasis Classification) for the renal
pelvis and ureter is used for staging (Table
1).
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Mansoura University
Table 1: TNM Classification 2017
13. Urology & Nephrology Center
Mansoura University
N - Regional lymph nodes
M - Distant metastasis
14. Urology & Nephrology Center
Mansoura University
Table.2 :AJCC Staging System in Conjunction
With the TNM System
15. Urology & Nephrology Center
Mansoura University
Prognosis
• Invasive UTUCs usually have a very
poor prognosis.
• The main factors to consider for risk
stratification are listed in Figure 1.
16. Urology & Nephrology Center
Mansoura University
Figure 1: Risk stratification of non-metastatic
UTUC
17. Urology & Nephrology Center
Mansoura University
Risk Stratification
• Tumor stage is difficult to assert based on
the clinical criteria.
• The UTUC cases could be stratified between
low- and high-risk tumors to distinguish the
cases that are more appropriate for kidney-
sparing treatment rather than radical
surgery
18. Urology & Nephrology Center
Mansoura University
• Overall Survival of Patients With Upper Tract Urothelial Tumors
(Renal Pelvis or Ureter) by Stage and Grade ( Campbell Walsh 12th
edition)
19. Urology & Nephrology Center
Mansoura University
Disease management
1. Localised disease
Kidney-sparing surgery
• Kidney-sparing surgery for low-risk UTUC
consists of surgery preserving the upper
urinary renal unit and should be discussed
in all low-risk tumours, irrespective of the
status of the contralateral kidney.
20. Urology & Nephrology Center
Mansoura University
• Kidney-sparing surgery potentially allows
avoiding the morbidity associated with open
radical surgery without compromising
oncological outcomes and kidney function.
21. Urology & Nephrology Center
Mansoura University
• Kidney-sparing surgery can also be
considered in select patients with serious
renal insufficiency or solitary kidney (i.e.,
imperative indications).
22. Urology & Nephrology Center
Mansoura University
High-risk non-metastatic disease
Radical nephroureterectomy
• Open nephroureterectomy (RNU) with
bladder cuff excision is the standard
treatment for high-risk UTUC, regardless of
tumour location.
• Minimally-invasive approaches (i.e., pure
laparoscopic and/or robot-assisted RNU)
have shown oncologic equivalence in
experienced hands.
23. Urology & Nephrology Center
Mansoura University
• Neoadjuvant chemotherapy has been
associated with significant downstaging at
surgery and ultimately survival benefit as
compared to RNU alone.
24. Urology & Nephrology Center
Mansoura University
• Adjuvant chemotherapy was only associated
with an overall survival benefit in patients
with pure UC and the main limitation of
using adjuvant chemotherapy for advanced
UTUC remains the limited ability to deliver
full dose cisplatin-based regimen after RNU,
given that this surgical procedure is likely to
impact renal function.
25. Urology & Nephrology Center
Mansoura University
• In patients with regional lymph node
invasion who are cisplatin-unfit after RNU,
induction chemotherapy with radiological
evaluation and consolidating surgery is a
treatment option.
26. Urology & Nephrology Center
Mansoura University
• A single post-operative dose of intravesical
chemotherapy (mitomycin C, pirarubicin)
2–10 days after surgery reduces the risk of
bladder tumour recurrence within the first
years post-RNU.
30. Urology & Nephrology Center
Mansoura University
Figure 2: Proposed flowchart for the
management of UTUC
31. Urology & Nephrology Center
Mansoura University
Figure 3: Surgical treatment according to location and
risk status
32. Urology & Nephrology Center
Mansoura University
2.Metastatic disease
• Radical nephroureterectomy has no benefit
in metastatic (M+) disease but may be used
in palliative care.
• As UTUCs are urothelial tumours,
platinum-based chemotherapy should
provide similar results to those in bladder
cancer.
37. Urology & Nephrology Center
Mansoura University
Follow-up after initial treatment
• In all cases, there should be strict follow-up
after radical management to detect
metachronous bladder tumours, as well as
invasive tumours, local recurrence and
distant metastases.
38. Urology & Nephrology Center
Mansoura University
• When kidney-sparing surgery is performed,
the ipsilateral upper urinary tract requires
careful follow-up due to the high risk of
recurrence.
Balkan countries e.g Bosnia, Albania, Serbia, Kosovo, Hungry, Turkey etc.
Analgesic causes declined due to replacement of phenacetin with paracetamol.
UICC: Union for International Cancer Control
AJCC, American Joint Committee on Cancer; TNM, tumor node metastasis.
CT = computed tomography; URS = ureteroscopy;
UTUC = upper urinary tract urothelial carcinoma.
*All these factors need to be present.
**Any of these factors need to be present.
Y: stage assessed after chemotherapy and/or radiation therapy.
* In patients with a solitary kidney, consider a more
conservative approach.
* In patients with solitary kidney, consider a more conservative
approach.
