Carcinoma of renal parenchyma, renal pelvis and ureter—radiological diagnosis and treatment planning

Abstract

VI. Summary Tumors of the renal parenchyma, the renal pelvis and the ureter are regarded as only poorly sensitive to radiation and chemotherapy. Therefore operative removal of the tumor remains the primary treatment. Postoperative radiation, commonly applied to other tumors, is of questionable value in renal cell carcinomas (Table 10). Non-operative techniques should be applied to palliate metastases and recurrences. Their effectiveness alone or in combination remains to a great extent unproven, since even patients with advanced primary tumors may survive several years. However, the basis of the present review was the fact that recent advances in diagnosis allow better evaluation of non-surgical treatment results some of which indeed appear promising. Of particular value in the diagnostic work-up of the postoperative patient are CT and ultrasound, two non-invasive techniques which allow repeated assessment of the effects of radiation therapy, chemotherapy, immunotherapy and also embolization therapy. Based on the TNM-classification system (UICC, 1978) an attempt was made to establish the usefulness of the newer diagnostic and therapeutic modalities for which the following considerations are pertinent: (a) CT and Ultrasound provide considerable improvement in pre-operative evaluation of the suspected renal cell carcinoma and allow exact pre-operative staging. The postoperative follow-up has been improved. CT especially allows control of effectiveness of non-operative procedures. (b) Surgery is still the treatment of choice for renal cell carcinomas, carcinomas of the renal pelvis and the ureter. Nephrectomy in the presence of metastases, however, is only indicated if hematuria, local pain, tumor debulking or treatment of paraneoplastic symptoms is necessary. The possibility of spontaneous remission of metastases does not in itself justify an aggressive surgical regimen. (c) Pre-operative embolization is primarily designed to facilitate surgical removal, however, palliative turnor embolization appears to be a worthwhile method particularly for massive or recurrent hematuria. (d) For metastatic tumors endocrine therapy, chemotherapy and immunotherapy are available. Endocrine therapy may become more important with the availability of antiestrogenes. The effectiveness of chemotherapy may be increased by drug combinations and also by combination of chemotherapy and immunotherapy. (e) Carcinomas of the renal pelvis and ureter are rare entities. Surgery, either radical or segmental is still the treatment of choice. The infrequency of these tumors, does not allow sufficient experience with non-operative treatment for a pertinent recommendation at this time. Extrapolation of results with transitional cell carcinoma of the bladder appears justifiable, especially regarding grading.