Tract Transitional Cell Carcinoma Research Articles

The Patterns and Risk Factors for Subsequent Bladder Recurrence in Patients with Transitional Cell Carcinoma of the Upper Urinary Tract: A Long-Term Follow-Up Study

Purpose: We wanted to evaluate the patterns and risk factors for subsequent bladder recurrence after surgical management for upper urinary tract transitional cell carcinoma (TCC). Materials and Methods: Between 1986 and 2004, the medical records of the patients who were diagnosed and surgically treated for upper urinary tract TCC were retrospectively analyzed. A total of 215 patients were enrolled in this study, and the median follow-up duration was 53 months (range: 12-240). The bladder recurrence-free survival curve was generated by the Kaplan-Meier method. To investigate the risk factors for subsequent bladder recurrence among the various clinicopathological features, the log rank test and Cox's proportional hazard model were used. Results: Recurrence developed in 81 patients (37.7%). Of them, 70 patients (86.4%) had recurred within 24 months, and 76 patients (93.8%) had superficial bladder cancer. Muscle-invasive bladder cancer developed in only 8 patients (9.9%) during follow-up. On univariate analysis, the T stage, age and urine cytology had an influence on bladder recurrence with statistical (borderline) significance. Multivariate analysis revealed that urine cytology was the only independent risk factor for bladder recurrence (p=0.020). Conclusions: Subsequent bladder recurrence after treatment for upper urinary tract transitional cell cancer usually occurred within two years after surgery, and positive urine cytology is an independent prognostic factor for subsequent bladder recurrence. (Korean J Urol 2008;49:294-299) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

Upper Urinary Tract Transitional Cell Carcinoma. A 10-year Experience

To present our 10-year experience with patients surgically treated for upper urinary tract transitional cell carcinoma. We reviewed the medical records of 264 patients (218 males and 46 females), aged 37-93 years (mean, 69.5), treated surgically for upper tract transitional cell carcinoma during the period January 1996 to December 2005. During the mean follow-up of 58 months (range, 12-120), local relapse was diagnosed in 14% of the patients. The mean time to recurrence was 13 months (range, 1-102). The overall mortality was 14%, and the mean survival was 109 months. Survival was significantly influenced by the following parameters: male gender (P = 0.0151), age over 80 years (P = 0.0012), location in both the pelviocaliceal system and the ureter (P = 0.051), a two incision operation (P = 0.0075), grade III (P = 0.0314), stage T3 and T4 (P < 0.0001). Tumor stage was identified as the most important determinant in predicting recurrence and survival. Other predictors of survival included male gender, age over 80 years, location in the pelviocaliceal system and the ureter, a two incision operation, and high grade.

Conservative management of upper tract transitional cell carcinoma

Our aim was to review the current literature describing the endoscopic management of upper tract transitional cell carcinoma (TCC). Review of published, peer-reviewed articles relating the primary ureteroscopic or percutaneous management of upper tract TCC was performed using the MEDLINE database. Historically, the gold-standard management for upper tract TCC consists of nephroureterectomy with excision of a bladder cuff. The employment of endoscopic management with these neoplasms was initially instituted in individuals with imperative indications, including bilateral disease, solitary kidney, and/or renal insufficiency. For individuals treated with ureteroscopy, recurrence rates range from 30 to 71% and cancer-specific survival rates from 50 to 93%. Results are dependent primarily on tumor grade and stage. In individuals with low-stage, low-grade tumors treated percutaneously, recurrence rates, and cancer-specific survival rates are 18-33% and 94-100%, respectively. Adjuvant therapy has been employed with thiotepa, mitomycin, and BCG, but none have been able to demonstrate a statistically significant difference in recurrence or cancer-specific survival rates. Endoscopic management is a safe and effective treatment alternative to nephroureterectomy in the management of upper tract TCC. Survival outcomes are comparable, but renal preservation therapy offers the advantage of reduced morbidity, complications, and the potential for better quality of life. Recurrence and disease progression are not uncommon and underscore the need for strict tumor surveillance.

Prognostic Factors for Upper Tract Transitional Cell Carcinoma: A Retrospective Review of 66 Patients

We assessed the prognostic factors on recurrence and disease-specific survival of patients treated for upper tract transitional cell carcinoma (TCC). Data on 66 patients who were treated for upper tract TCC in a single centre over a 13-year period were analysed. Mean follow-up time was 49.2 months. Fifty-five out of 66 (83.3%) underwent nephroureterectomy with excision of a bladder cuff. Four (6.1%) patients had nephrectomy alone while three (4.5%) had renal-sparing surgery. Four patients did not receive surgery due to advanced age and other comorbidities. Age, sex, tumour location, stage and grade were analysed as prognostic factors for disease recurrence and disease-specific survival using log rank univariate analysis. Disease recurrence occurred in 45 (68.2%) patients at a median time of 11.0 months. Recurrences were found in the bladder in 27.3%, the contralateral renal pelvis in 4.5%, local retroperitoneum in 19.7%, distant sites in 13.6%, with simultaneous local and distant metastases occurring in 3.0%. Tumour stage was the only significant prognostic factor for recurrence. Presence of extraurothelial recurrence, stage and grade were significant prognostic factors for disease-specific survival. Tumour stage was the most consistent predictor of both disease recurrence and survival. These findings would guide the need for any adjuvant chemoradiotherapy.

Ureteroscopic management of upper tract transitional cell carcinoma and ureteropelvic obstruction

Introduction:Technological advances have increased the application of the endoscopic management of upper tract transitional cell carcinoma (TCC) and ureteropelvic junction obstruction (UPJO).Materials and Methods:Published, peer-reviewed articles on endoscopic treatment of upper tract TCC and UPJO were identified using the MEDLINE database.Results:Although nephroureterectomy remains the gold standard for upper tract TCC treatment, low-grade, low-stage and small tumors, especially in patients with solitary kidneys or poor renal function can be managed with encouraging success rates, despite the considerable recurrence rate. Endoscopic alternatives to pyeloplasty for UPJO can be used especially in cases with absence of crossing vessels, stricture length less than 1.5 cm, severe hydronephrosis and renal function less than 30%.Conclusion:Proper patient selection is critical for the successful endoscopic management of treatment of upper tract TCC and UPJO.

70 degrees recumbent position transperitoneal laparoscopy for treatment of upper urinary tract transitional cell carcinoma

To study the effect of 70 degrees recumbent position transperitoneal laparoscopy for treatment of upper urinary tract transitional cell carcinoma (TCC). From May 2004 to January 2007, 70 degrees recumbent position transperitoneal laparoscopy combined with urethral resectoscope was used to treat 31 cases of upper urinary tract transitional cell carcinoma. At the same time titanium clip to occlude the two extremities of ureter tumor was used, extracting specimen by oblique incision of lower quadrant. All operations were finished successfully, no one was turned to open surgery; mean operation time was 140 min, mean blood loss 80 ml, mean hospital stay time 8 d, without complications of urine leakage and intestinal fistula and so on. 70 degrees recumbent position transperitoneal laparoscopy for resection of whole kidney and ureter is worth of general clinical application because it could provide large space for operation, simplify the treatment of renal pedicle vessels, decrease operation risk, reduce operation trauma and offer early recovery. But its effect on tumor spread and recurrence will still need long term follow-up.

Endoscopic Management of Upper Tract Transitional Cell Carcinoma in Patients with Normal Contralateral Kidneys

Endoscopic Management of Upper Tract Transitional Cell Carcinoma in Patients with Normal Contralateral Kidneys

Pathologic Features of Recurrent Bladder Tumors after Upper Urinary Tract Transitional Cell Carcinoma

Purpose: Recurrence of upper urinary tract transitional cell carcinoma is common, and especially for bladder cancer. We evaluated the pathologic features, grade and recurrence rate of bladder tumors for patients who suffered with upper urinary tract transitional cell carcinoma and who were surgically treated at our hospital. Materials and Methods: Between 2001 and 2006, a total of 68 patients without a history of bladder cancer underwent nephroureterectomy for upper urinary tract transitional cell carcinoma. We reviewed the pathologic features, the stage and the grade of the recurrent bladder cancer at a median follow up of 17.1 months. Results: A total of 22 of 68 patients experienced recurred bladder tumors after nephroureterectomy for upper urinary tract transitional cell carcinoma at a mean interval of 17.1 months. Of the 22 patients with recurred bladder tumors, 21 of the patients (95%) had superficial tumor (Stage Ta, Tis, T1), 4 (19%) of the patients had superficial tumors of a low grade (grades 1 and 2) and 17 patients (81%) had high grade tumor (grade 3). One patient had muscle invasive bladder tumor, so this was treated with radical cystectomy during the follow-up period. Regardless of the grade of the upper urinary tract transitional cell carcinoma, the pathologic grade of the bladder tumor was mostly high grade (82%). Regardless of the stage of upper urinary tract transitional cell carcinoma, the stage of the recurrent bladder tumors was almost superficial (95%). Conclusions: Bladder tumors recurred in 33% (22/68) of the patients after surgery for upper urinary tract transitional cell carcinoma. Of these bladder tumors, 95% were superficial and 81% were high grade. Therefore, conducting follow-up studies for bladder cancer is important after nephroureterectomy for upper urinary tract transitional cell carcinoma. (Korean J Urol 2008;49:502-505) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

Risk Factors for Intravesical Recurrence After Surgical Management of Transitional Cell Carcinoma of the Upper Urinary Tract

To identify risk factors for developing subsequent bladder cancer in patients undergoing surgical management of transitional cell carcinoma (TCC) of the upper urinary tract. This study included 177 patients who were diagnosed as having clinically localized upper urinary tract TCC and thereafter underwent nephroureterectomy after exclusion of those with a previous and/or concurrent history of bladder cancer. Univariate and multivariate analyses using both the logistic regression model and the Cox proportional hazards model were carried out in these 177 patients to determine the risk factors for intravesical recurrence after nephroureterectomy. Of the 177 patients, 63 (35.6%) developed recurrent bladder cancer after a median interval of 7.5 months. Intravesical recurrence-free survival rates for these 177 patients at 1, 3, and 5 years were 75.7%, 63.7%, and 54.1%, respectively. Univariate analyses showed that patients with low-stage tumors and those with multifocal tumors were likely to undergo subsequent intravesical recurrence; however, there was no significant impact of other factors on subsequent intravesical recurrence, including age, tumor side, tumor location, surgical modality, operation time, management of the distal ureter, tumor grade, lymph node metastasis, microvascular invasion, lymphatic invasion, and margin status. Furthermore, pathologic stage and tumor multifocality were identified as independent predictors for the development of recurrent bladder cancer by multivariate analyses. The incidence of intravesical recurrence after nephroureterectomy for upper urinary tract TCC is comparatively high. It could be important to perform careful follow-up targeting intravesical recurrence for such patients after nephroureterectomy, particularly those with low-stage tumors and/or multifocal tumors.

Grade Concordance between Transitional Cell Carcinoma of the Bladder and the Upper Urinary Tract

Purpose: Transitional cell carcinoma (TCC) is thought to involve the entire urothelium as a multifocal field change. The tumor grade is a major prognostic factor in TCC and predicting the grade of TCC may be of clinical significance. The objective of this study is to clarify the grade concordance between upper tract TCC and bladder TCC. Materials and Methods: From 1994 to 2006, a total of 241 patients underwent nephroureterectomy for upper tract TCC. Seventy-four of the 241 patients who had a history of previous bladder cancer and/or synchronous or metachronous bladder TCC were included in this study. The grade was recorded for each tumor. Fisher's exact test of concordance was used for statistical analysis. Results: For the 74 patients who were analyzed, 42 patients (56.8%) developed bladder TCC during their follow up after nephroureterectomy, 14 patients (18.9%) had a history of bladder TCC prior to nephroureterectomy and 18 patients (24.3%) had a synchronous bladder tumor. In the case of developing bladder TCC during their follow up after nephroureterectomy, the grade concordance is highest between upper tract TCC and bladder TCC in 81.0% of the cases (p=0.005). Overall, the concordance rate between the upper tract TCC grade and the bladder TCC grade was 77.0% (p<0.001). Conclusions: Concordance of the TCC in the upper urinary tract and bladder was present in 77.0% of the cases. The patients who developed bladder tumor during their follow up after nephroureterectomy had the highest grade concordance between upper tract TCC and bladder TCC in 81.0% of the cases. This knowledge can have a significant impact on the therapeutic and follow up plans for transitional cell carcinoma. (Korean J Urol 2008;49:7-11) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

Incidence of Local Recurrence and Port Site Metastasis After Laparoscopic Radical Nephroureterectomy

To address the incidence of local recurrence and port site metastasis in patients who underwent laparoscopic radical nephroureterectomy (RNU) for upper tract transitional cell carcinoma (TCC). Between August 1993 and February 2006 116 laparoscopic RNU were performed in 115 patients at our institution. A traditional open excision, a laparoscopic stapler resection or a different approach was used for the management of the distal ureter in 76, 27, and 11 cases, respectively. Clinical follow-up as well as perioperative and pathologic data were retrospectively collected. Perioperative and pathologic data were available in all 116 cases. Clinical outcomes were available in 107 patients with a mean follow-up of 30.5 months (range 1 to 148). Six patients (5.6%) had a local recurrence develop, including 1 patient with port site metastasis (0.9%) at an average of 5.7 months. In 2 of these patients, violation of the ipsilateral urinary tract was noted perioperatively. We report, in this large single-center series of laparoscopic RNU, a low incidence of local recurrence. Our results confirm that a laparoscopic approach to upper tract TCC does not result in a clinically significant increased risk of tumor spillage provided that principles of oncologic surgery are followed.

Upper tract transitional cell carcinoma: Finding a way forward

The author discusses an article in this issue of Cancer by Novara and colleagues, who presented the results from a multicenter, international, retrospective study that adds to the body of literature divining predictors of disease‐specific survival for patients with transitional cell carcinoma of the upper urinary tract who undergo radical prostatectomy.

MP-16.17: A study of microsatellite instability of upper urinary tract transitional cell carcinoma

Purpose: The objective of this study was to evaluate the role of microsatellite instability (MSI) in upper tract transitional cell carcinomas (TCC). Materials and Methods: A total of 48 surgically treated renal pelvis and ureteral TCC patients were included in this study. MSI was determined by polymerase chain reaction (PCR) for amplification of the microsatellite sequences at mononucleotides BAT25 and BAT26, and dinucleotides D17S250, D2S123 and D5S346 in DNA and hMLH1 protein, p53 and Ki-67 expressions were determined by immunohistochemistry on retrieved tumor tissue. Results: Twenty seven (56.2%) and 21 (43.8%) of the 48 patients had renal pelvis and ureteral TCC, respectively. Eighteen (37.5%) and 30 (62.5%) patients had superficial and invasive TCC, according to the pathological stage, while 24 each (50%) had low and high grade TCC, respectively. MSI was observed in 20.8% of tumors at mono-MSI and 22.9% at di-MSI. MSI-high and -low (instability >2 and <2 loci, respectively) were observed in 12.5 and 22.9%, respectively. From a univariate analysis, age, stage, tumor grade, tumor recurrence and the expressions of hMLH1 and Ki-67 were not related to MSI. However, in recurred cases, infiltrative tumors had 100% MSI compared to superficial tumors, and the expressions of p53 and Ki-67 were related to the stage and tumor grade, respectively (p<0.05). Conclusions: These results suggest that MSI may occur in upper tract TCC, as observed in other tumors. MSI was more frequently expressed in ureteral than renal pelvis tumors. However, MSI was not correlated with stage or grade, but was significantly correlated with the stage in recurred cases; and the expressions of p53 and Ki-67 were related to the stage and tumor grade. (Korean J Urol 2006;47:1269-1277)

MP-14.16: Upper urinary tract transitional cell carcinoma: recurrence rate after percutaneous endoscopic resection

MP-14.16: Upper urinary tract transitional cell carcinoma: recurrence rate after percutaneous endoscopic resection

POD-03.02: Minimally invasive management of upper tract transitional cell carcinoma at a tertiary care center

POD-03.02: Minimally invasive management of upper tract transitional cell carcinoma at a tertiary care center

Management of patients with upper urinary tract transitional cell carcinoma

Multiple therapeutic options are available for the management of patients with upper urinary tract transitional cell carcinoma (TCC). Radical nephroureterectomy with an ipsilateral bladder cuff is the gold-standard therapy for upper-tract cancers. However, less invasive alternatives have a role in the treatment of this disease. Endoscopic management of upper-tract TCC is a reasonable strategy for patients with anatomic or functional solitary kidneys, bilateral upper-tract TCC, baseline renal insufficiency, and significant comorbid diseases. Select patients with a normal contralateral kidney who have small, low-grade lesions might also be candidates for endoscopic ablation. Distal ureterectomy is an option for patients with high-grade, invasive, or bulky tumors of the distal ureter not amenable to endoscopic management. In appropriately selected patients, outcomes following distal ureterectomy are similar to that of radical nephroureterectomy. Bladder cancer is a common occurrence following the management of upper-tract TCC. Currently, there are no variables that consistently predict which patients will develop intravesical recurrences. As such, surveillance with cystoscopy and cytology following surgical management of upper-tract TCC is essential. Extrapolating from data on bladder TCC, both regional lymphadenectomy and neoadjuvant chemotherapy regimens are likely to be beneficial for patients with upper-tract TCC, particularly in the setting of bulky disease.

Ability of Clinical Grade to Predict Final Pathologic Stage in Upper Urinary Tract Transitional Cell Carcinoma: Implications for Therapy

To evaluate whether the clinical grade predicts the final pathologic stage in upper urinary tract transitional cell carcinoma. We retrospectively reviewed the records of 184 consecutive patients undergoing nephroureterectomy for upper urinary tract transitional cell carcinoma at our institution from 1986 to 2004. Their clinical, surgical, and pathologic data were reviewed to determine the positive and negative predictive values of the clinical biopsy grade with respect to the final pathologic disease stage. Of the 184 patients, 119 (64.7%) had information available regarding the clinical grade of disease from the preoperative endoscopic biopsy. The distribution was grade 1 in 2 (1.6%), grade 2 in 46 (38.7%), and grade 3 in 71 (59.7%) patients. Of the 71 patients with grade 3 disease, 47 had Stage pT2 disease or higher (66% positive predictive value). Of the 48 patients with less than grade 3 disease, 35 had less than pT2 disease (72% negative predictive value). Of the 71 patients with grade 3 disease, 30 had pT3 disease or greater (42% positive predictive value), and of the 48 patients with less than grade 3 disease, 44 had less than pT3 disease (92% negative predictive value). The histologic grade obtained from the diagnostic biopsy for upper urinary tract transitional cell carcinoma can be used to predict the pathologic disease stage. This information can be used to counsel patients before surgery and to identify patients for whom neoadjuvant chemotherapy would be most beneficial.

Office-Based Surveillance Ureteroscopy After Endoscopic Treatment of Transitional Cell Carcinoma: Technique and Clinical Outcome

The reference standard treatment for transitional cell carcinoma (TCC) of the upper tract remains nephroureterectomy. However, with improvements in endoscopic technology and techniques, endoscopic ablation of upper tract TCC has become a reality for highly selected patients. We report our present technique and 16-year experience of office-based ureteroscopy for surveillance of TCC after initial endoscopic ablation. The office and hospital records of all patients undergoing office-based anesthesia-free ureteroscopy were retrospectively reviewed. The patient characteristics, tumor characteristics, ureteroscopic technique and findings, and complications were documented. Ten patients with a mean age of 68.8 years were treated with endoscopic ablation of upper tract TCC. A total of 67 (range 1 to 19 per patient) surveillance ureteroscopies in the office setting were performed. Office ureteroscopy revealed seven upper tract TCC recurrences in 5 patients. A thorough ureteroscopic examination in the operating room of these patients revealed that only 1 patient had more extensive disease than was recognized during the office-based ureteroscopy. All patients tolerated office-based ureteroscopy well, and each procedure was successfully completed with minimal patient discomfort. No acute complications were noted. One patient who experienced multiple recurrences and underwent ablation of extensive ureteral TCC developed a benign ureteral stricture. The results of our study have shown that for the rare patient undergoing endoscopic management of upper tract TCC, office-based anesthesia-free ureteroscopic surveillance is a reasonable management strategy. The technique has been free of complications and appears to be as accurate as surveillance ureteroscopy performed in the operating room.

Imperative Indications for Conservative Management of Upper Tract Transitional Cell Carcinoma

We report our experience with patients with imperative indications for endoscopic treatment for upper tract transitional cell carcinoma. Between 1983 and 2004 we identified 37 patients with a solitary kidney, bilateral disease or preoperative creatinine greater than 2.0 mg/dl who underwent endoscopic treatment for localized upper tract transitional cell carcinoma. A retrospective chart review was performed. Of the 37 patients 32 had a solitary kidney, 3 had bilateral disease and 2 had preoperative creatinine greater than 2.0 mg/dl. Median age at diagnosis was 75 years (range 56 to 88). Bladder cytology was positive or atypical in 15 of 31 patients (48%). Tumors were grade 1 to 3 in 2, 13 and 7 patients, respectively, and diagnosed visually in 15. At a median followup of 2.7 years for survivors 23 patients (62%) had a total of 56 upper tract transitional cell carcinoma recurrences. Grade and stage progression occurred in 3 and 3 patients, respectively. Ten of the 23 patients who experienced upper tract recurrence died of transitional cell carcinoma. Overall kidney preservation was achieved in 24 of the 32 patients (75%) with a solitary kidney. At last followup 24 patients had died, including 11 (29.7%) of transitional cell carcinoma, at a median of 2.9 years. Cancer specific survival at 5 years for this cohort was 49.3%. Our results indicate that upper tract tumor recurrence occurs in a majority of patients with imperative indications for endoscopic treatment, underscoring the need for frequent surveillance. While most kidneys can be preserved, cancer specific death is common.

Upper genitourinary tract transitional cell carcinoma (TCC): Long-term outcome data from a large single institutional series

15582 Background: TCC of the upper urinary tract (renal pelvis and ureters) is a relatively rare entity and carries a poor prognosis. Literature regarding long term outcomes are lacking. We embarked on a review of pt records to evaluate patterns of practice: ie adjuvant therapies and survival outcomes of pts treated at our tertiary care institution. Methods: IRB approval was obtained for this retrospective analysis. Tumor registry data were analysed for all adult pts with TCC of the renal pelvis and ureter diagnosed from 1995 to 2005. Only patients with locoregionally confined disease were included in this study. Pt characteristics recorded: age, sex, site of disease, stage, grade, treatment modalities and survival outcome. Results: 175 patients were identified. Med. age: 75 yrs (range 40–90). Gender: M:F:107:68; Sites: Renal Pelvis: n=128; Ureters: n=47; Stages: Stg 0: n=46 (26.28%), Stg I: n=68 (38.85%), Stg II: n=19 (10.85%), Stg III: n=29 (16.57%), Stg IV (excl. M1):n=13 (7.4%). Gr 1: n=13 (7%), Gr 2: n=49 (28%), Gr 3: n=78 (45%), Gr 4: n=20 (11%); Unknown n=14 (8%). Gr 3/4 distribution for Stages 0, I, II, III, and IV were 17 (37%), 32 (47%), 15 (72%), 23 (79%) and 11 (84%) respectively. Treatment Modalities: All pts were treated with surgical resection; adjuvant chemotherapy was utilized in Stg I: 5/68; Stg II: 3/19; Stg III: 5/29; Stg IV: 1/13 pts. Adjuvant RT was administered in Stg III: 1/29; Stg IV: 3/13 pts. Med. survival and OS at 1, 2, 5 and 10 yrs are shown in Table 1 for all pts treated with surgical resection alone as standard therapy. Med. Survival of all patients who received any adjuvant therapy was 24 mos. Conclusions: Increasing frequency of higher grade disease was present in higher stage patients. Long term survival of early stage disease despite surgical resection is poor with 5 year OS of 45–62% in Stages 0-II and worse with higher stages III and IV with 5 yr OS of 17- 21%. Clearly, better adjuvant or neo-adjuvant strategies are needed to improve this dismal prognosis. [Table: see text] No significant financial relationships to disclose.