Tumors Of Upper Urinary Tract Research Articles

Clinical review of 100 consecutive surgically treated patients with upper urinary tract transitional tumours.

To determine the outcome of conservative or radical treatment in a retrospective study of 100 consecutive patients with upper urinary tract tumours. From 1965 to 1995, 100 patients (78 men and 22 women, mean age 65 years, range 27-82) with upper urinary tract tumours were treated surgically, using nephroureterectomy with excision of a cuff of bladder in 53 and organ-sparing treatment in 47. The outcome was assessed as survival and recurrence during a follow-up of up to 15 years. After radical and organ-sparing treatment, the 15-year cancer-specific survival was 69% and 25%, respectively; metastases developed in 17% and 19% and global recurrence in 40% and 70%, respectively. While locoregional and bladder recurrences were similar in the two groups (9% vs 8% and 30% vs 38%, respectively), ureteric-stump recurrence in the conservative group was 23%. There were no significant differences in survival rates between patients with single or multiple presentation, or for localization, while the grading of the lesions proved to be an accurate prognostic indicator. This experience of urothelial neoplasia of the upper tract highlights the difficulty in diagnosing this pathology and in entrusting screening to a non-invasive technique such as urinary cytology. The percentage recurrence observed after organ-sparing therapy indicates that this treatment should be used cautiously.

ASSOCIATION OF IN VITRO GROWTH POTENTIAL OF URINARY EXFOLIATED CELLS WITH TUMOR LOCALIZATION AND INTRALUMINAL RECURRENCE RATES OF UROTHELIAL CANCERS

Purpose One problem in the treatment of urothelial cancers, in particular of upper urinary tract cancers, is multifocal synchronous and/or metachronous tumor development in the heterotopic urothelium. We investigated the abilities of exfoliated cells in the urine of patients with urothelial cancers to colonize and proliferate in vitro. Materials and Methods Short-term cultures of 129 urine samples obtained from patients with urothelial cancers and 53 samples from healthy volunteers were compared as to the growth potential of urinary-exfoliated cells and clinico-pathological features, in particular tumor localization and evidence of intraluminal tumor recurrence. Results Primary cell outgrowth occurred in 112 (86.8%) of the 129 cell cultures from the patients and in 29 (54.7%) of the 53 from the healthy volunteers (p <0.0001). “Sufficient cell growth” (more than 10 5 cells per flask) was obtained for 77 (59.7%) of the 129 cultures from patients and 7 (13.2%) of the 53 from the healthy volunteers (p <0.0001). In terms of tumor localization, the rate of sufficient cell growth was significantly higher for patients with upper urinary tract tumor (21/25, 84.0%) than for those with bladder tumor (56/104, 53.8%) (p = 0.0062). Proportional hazard regression analysis showed that only the growth potential of the urinary-exfoliated cells was significantly predictive of intravesical tumor recurrence in patients with superficial bladder tumors (p = 0.011). Conclusions The potentials for the colonization and proliferation of urinary-exfoliated cells are associated with intraluminal multifocal tumor recurrence of urothelial cancers.

Frequent loss of heterozygosity on chromosome 10q in muscle-invasive transitional cell carcinomas of the bladder.

Loss of heterozygosity (LOH) on chromosome 10 has been observed in several human cancers including glioblastomas, meningiomas, melanomas and endometrial and prostate carcinomas. We have investigated the incidence of LOH on chromosome 10 in 36 human transitional cell carcinomas (TCCs) of the bladder, three upper urinary tract TCCs and one lymph node metastasis, using a panel of 27 highly polymorphic markers spanning 10p (short arm) and 10q (long arm). Fourteen bladder tumours (39%), the three upper urinary tract tumours and the lymph node metastasis showed LOH for at least one locus on chromosome 10. Remarkably, LOH on chromosome 10 was observed mainly in muscle-invasive (P = 0.01) and high grade tumours (P = 0.03). For five tumours and the lymph node metastasis, LOH was found at all informative loci, indicating monosomy or isodisomy of chromosome 10. The deletion mapping of the tumours with partial loss delineated two minimal regions of loss on chromosome 10q. One region, the most telomeric, was bounded by markers D10S214 and D10S169 and the other, the most proximal, was bounded by markers D10S222 and D10S531. Our results demonstrate that chromosome 10q LOH is common in muscle-invasive bladder cancers and that two potential tumour suppressor loci, at 10q24.1-q24.3 and 10q26.1-q26.2, may contribute to the malignant progression of these tumours. Localization of the smallest common regions of loss in bladder tumours provides a starting point for the identification of the genes involved.

Upper urinary tract tumours: Latest diagnostic methods

— The diagnostic and therapeutic approach to upper urinary tract tumours has been a problem for a long time. The recent introduction of endourological instruments (ureterorenoscopy), the possibility of well-aimed cellular analysis (selective urinary cytology, brush biopsy) as well as the development of imaging methods, have all improved the accuracy of diagnosis and staging with the consequent rationalisation of treatment. Using ureterorenoscopy in addition to the main diagnostic examinations for this pathology i.e. urinary cytology and urography, diagnostic accuracy has increased from 58 to over 85%. This allows identification of early, single and low grade forms, which are susceptible to conservative, possibly endoscopic, treatment.

Nd:YAG laser application in the treatment of upper urinary tract tumours

— 29 patients were referred to our Department for upper urinary tract tumours and underwent ureteropyeloscopy with laser irradiation of the neoplasm. All the patients had been selected for this treatment previously because of solitary kidney, bilateral tumours, poor renal function, refusal of nephroureterectomy. The tumours were treated with Nd:YAG laser irradiation at 25–30 Watts/3 sec. Before the procedure, the ureter and pelvis were accessed by a 0.035 inch guide wire or 4 French ureteral catheter. No important side effects were noted after the procedure in 27 of the 29 patients. Two patients developed ureteral stenosis; the first after several treatments, the other after the first treatment. Follow-up consists of endoscopic surveillance every three months in the first year then every 6 months in the absence of recurrences. At present 10 patients are tumour-free, 3 patients underwent nephroureterectomy for massive recurrences and the other patients underwent new laser irradiation.

Transitional cell carcinoma of the distal portion of ureter protruding into the sigmoid conduit six years after cystoprostatectomy

Bladder tumors develop after the diagnosis of upper urinary tract carcinoma in approximately 20% of cases, whereas the incidence of upper urinary tract tumor after the diagnosis of bladder cancer is low, approximately 2%. In a 64-year-old man who had undergone cystoprostatectomy treatment of bladder carcinoma 6 years previously, with the sigmoid conduit used for supravesicle diversion, a transitional cell carcinoma that developed in the conduit was not revealed with intravenous pyelography at regular follow-up intervals. The patient had only hematuria. After an obstructed left kidney, left ureteral stricture, and a filling defect in the conduit were observed radiologically and biopsy revealed a transitional cell carcinoma at the ureterosigmoid junction, the patient underwent left nephroureterectomy, partial resection of a third of the sigmoid conduit, and right ureteral reimplantation. The occurrence of upper urinary tract carcinoma after treatment of bladder cancer should be considered even in light of intravenous pyelography that shows no abnormality; and when such carcinomas occur in this situation, disease involving the conduit should be ruled out.

Expression of Multidrug Resistance Gene Product (P-Glycoprotein) in Transitional Cell Carcinomas of the Upper Urinary Tract

We assessed the expression of P-glycoprotein, the product of the multidrug resistance gene, in 107 specimens from patients with transitional cell carcinoma of the upper urinary tract, using an immunohistochemical method with a polyclonal antibody. P-glycoprotein was expressed in 28 of 107 (26%) specimens. While P-glycoprotein expression was not related to the grade or stage of these tumors, the incidence of P-glycoprotein in specimens with tumors which coexisted in renal pelvic and ureter is significantly higher than those with either renal pelvic or ureter tumor alone. In the patients with advanced upper urinary tract tumor who had adjuvant chemotherapy including at least one P-glycoprotein-transported drug (mdr regimen), overall survival of patients with P-glycoprotein-positive tumor was significantly shorter than that of patients with negative tumor. This pilot study demonstrates that P-glycoprotein can be expressed in one fourth of transitional cell carcinomas of the upper urinary tract and that P-glycoprotein expression serves as a prognostic indicator in patients with these tumors who are treated with mdr regimens.

A clinical study on renal pelvic and ureteral tumor associated with bladder tumor

Of 65 cases of renal pelvic and/or ureteral tumor treated at Department of Urology, The University of Tokyo, during the period from January 1975 through December 1991, 26 had bladder tumors as well. These cases were divided into three groups; 1) bladder tumor preceding upper urinary tract tumor, 2) bladder tumor found simultaneously with upper urinary tract tumor, and 3) bladder tumor following upper urinary tract tumor. In group 1 (nine cases), the last bladder tumor preceded renal pelvic and/or ureteral tumors by 3 to 42 months (mean 14.6 months), and in seven cases, bladder tumor recurred 3 to 29 months (mean 9.0 months) after nephroureterectomy. The interval between the diagnosis of preceding bladder tumor and upper urinary tract tumor was highly correlated with the latent period of postoperative recurrence of bladder tumor (r = 0.948). Highly malignant pathological grade of bladder tumor featured seven cases of group 2, with the survival rate being significantly (p < 0.01) lower than that of other groups. In the group 3 consisting of ten cases, bladder tumors subsequently developed 6 to 37 months (mean 15.0 months). The latent period of bladder tumor was significantly (p < 0.01) longer than that in group 1. These results indicated that the bladder tumors associated with renal pelvic and/or ureteral tumors have distinct characteristics depending on the sequence of association.

Endourologic Treatment of Transitional Cell Carcinoma of the Upper Urinary Tract

Endourologic treatment was used for transitional cell carcinoma of the upper urinary tract in 16 patients. The presenting symptom was hematuria in 13 patients and flank pain in 1; in 2 cases, the diagnosis was made by chance at intravenous urography (IVU). Ureterorenoscopy (URS) was attempted in 11 cases, with removal of superficial transitional tumors of the ureter in 6 cases. In five cases, URS was diagnostic only. The remaining 10 patients were treated percutaneously. Pathological examination revealed 11 Ta Grade 1-2 papillary tumors, 4 T1 Grade 1-2 lesions, and 1 inverted papilloma. A single-J ureteral catheter was left in place after the procedure in 10 cases for 48 to 72 hours. In six cases, a nephrostomy tube was left in place in order to perform BCG immunotherapy (five cases) or mitomycin C chemotherapy (one case). Cytologic, radiographic, and endoscopic studies were negative after a median follow-up of 17 months in 10 patients. Four patients underwent nephroureterectomy for recurrence of tumor at 3 (two cases), 30 (1 case), and 36 (one case) months. One patient died of myocardial infarction, and one refused follow-up examinations. We believe that URS is the first-choice modality in the diagnosis and treatment of superficial transitional cell tumors of upper urinary tract. A percutaneous approach is a feasible option in selected cases, particularly those with a high surgical risk.

Upper tract urothelial tumor after transurethral resection for bladder tumor.

We present a retrospective review of 30 patients who developed upper urinary tract tumors (UUTT) after having been diagnosed and treated for a bladder neoplasm. The mean patient age was 63 years (range 54-72). An average of 4.8 (range 1-10) transurethral resections (TUR) had been performed for bladder cancer prior to the appearance of UUTT. The length of time elapsed between the initial bladder TUR and the subsequent diagnosis of UUTT was variable, with increased incidence in the first 24-72 months (63.3% of the cases). In 21 cases (70%) the bladder tumor was multiple and in 28 (93.3%) the tumor was recurrent. In those patients with unilateral vesicoureteral reflux, an increased incidence of UUTT was found in the refluxing renal unit. In patients with poorly differentiated (grade 3 and grade 2-3) bladder tumors, UUTT was of the similar grade of anaplasia in 75% of cases. These observations, together with those previously published in the literature, allow us to recommend the use of excretory urography (IVP) every 2 years during the first 6 years of follow-up in patients treated for recurrent and/or multiple bladder tumor. Thereafter, follow-up would depend upon the individual clinical situation.

Recurrence of Bladder Tumors following Surgery for Transitional Cell Carcinoma of the Upper Urinary Tract

A retrospective analysis of 53 patients with an upper urinary tract (UUT) transitional cell carcinoma, which was treated surgically, was performed in relation to the development of a subsequent bladder tumor. In 19 of the 53 patients (35.8%) bladder tumors developed following surgery of a UUT tumor. The simultaneous occurrence of a bladder tumor and more than two tumors in the UUT had a significant influence on the rate of bladder tumor recurrence. On the other hand, location, mode of growth, grade, stage and vascular invasion of the UUT tumor, and history of bladder tumors did not seem to be related to the frequency of subsequent bladder tumors. These findings suggest that the diversity of UUT tumors at the time of diagnosis is an important factor in bladder tumor recurrence. Therefore, clinical and pathological examinations should be carefully performed in patients with UUT tumors.

職業性尿路腫瘍の臨床的研究

We experienced 32 cases of occupational uroepithelial cancer at Jichi Medical School Hospital from 1974 to 1990. All of them were dyestuff workers who had been engaged in production or handling of benzidine, beta-naphthylamine or alpha-naphthylamine. In these 32 cases, upper urinary tract tumors were found in 7 cases, one of these having bilateral lesions. The mean age when the tumor of the urinary tract was first disclosed was 48 years old, with a range of 36 to 66 years old. The mean age of this occupational group was about 16 years younger than that of the spontaneous urinary tract tumor group in our hospital. We divided our cases into two groups according to duration of carcinogen exposure; less than 5 years and 5 years or more. However we did not obtain significant difference in the grade of tumors or prognosis between the two groups. But when we divided them into two groups according to the type of work; production group and handling group, 18 of 21 production workers had high grade tumors. On the other hand, only 3 of 11 handling workers had high grade tumors, which was a significant difference. Besides, 10 of 21 production workers or only one of 11 handling workers were fatal. The difference was also significant. There was no significant correlation among the type of work, the duration of exposure and the age of onset. In our study, we showed that the type of work was quite important to predict the grade of tumors and the prognosis in occupational uroepithelial cancer patients.(ABSTRACT TRUNCATED AT 250 WORDS)

軟性腎盂尿管鏡を使用した経尿道的アプローチによる腎尿管結石破砕の経験

Disintegration of urinary stones by electrohydraulic lithotripsy (EHL) under transurethral flexible nephro-ureteroscopy was performed for 39 renal and ureteral stones in 38 patients. The use of a ureteral guide tube facilitated the endoscopic manipulation and allowed the endoscope to access the stones in all cases except for two with a severe ureteral stricture. Thirty-seven of the 39 stones (94.9%) were successfully disintegrated and 35 stones (89.7%) were distracted. And 33 stones were completely excreted within 6 months (average, 27.9 days). Complications including ureteral perforation in 3 cases, one of whom required open ureterolithotomy, urinary extravasation in one, failure of removing the ureteral stent in one and perirenal abscess in one who underwent surgical incision. The transurethral flexible endoscope provides a clear vision in the whole urinary tract up to the renal calyx with a minimal complication. This technique could be used as a non-invasive treatment of urolithiasis adjunct to extracorporeal shock wave lithotripsy (ESWL), and also it could be an effective measure for other urological diseases such as the upper urinary tract tumors.

Relationship Between Blood Groups and Tumors of the Upper Urinary Tract

Comparing the relationship between upper urinary tract tumors and blood group ABO and the rhesus system showed that patients with blood group A and blood type rhesus positive had more invasive tumors with a higher grade of dysplasia than patients with blood group O and blood type rhesus negative.

Primary carcinoma of the upper urinary tract.

Thirty-seven patients with upper urinary tract tumours were evaluated for grade, stage, histological type, location, presence or absence of vascular invasion, abnormalities in the urothelium adjacent to the tumours, tumour multiplicity and patient survival. A good correlation between tumour grade and stage was found in the transitional cell tumours. Squamous cell carcinomas and adenocarcinomas were high-stage tumours. Vascular invasion was present in most high-grade tumours, squamous cell carcinoma and adenocarcinomas. Four patients had multifocal tumours of both pelvis and ureter. Three developed ureteric stump carcinomas and 13 had further development of bladder carcinomas. The cumulative 5 and 10 year survival rates were 43 and 23% respectively.

Consideration for Treatment of Upper Urinary Tract Tumors With Topical Therapy

The use of topical chemotherapy for the treatment of upper urinary tract urothelial tumors and the selection of patients to receive this treatment remain problematic because of the relatively infrequent occurrence of these tumors compared with similar tumors within the bladder. The lack of clinicopathologic information on upper urinary tract urothelial tumors makes pretherapy diagnosis and clinical staging difficult. In addition, there are problems associated with delivery of the agent, and there is not as yet an effective method of surveillance after treatment. Only continued investigation with endoscopic diagnosis and treatment, as well as longitudinal follow-up, will determine methods of patients selection and the optimal use of topical chemotherapy.

Immunohistological detection of T antigen and ABH blood group antigens in upper urinary tract tumours.

The status of T antigen was assessed by means of peanut agglutinin (PNA) used in an immunoperoxidase technique, and the status of ABH blood group antigens was determined by the specific red cell adherence (SRCA) test. Thirty-eight patients with upper urinary tract tumours were examined. Our data indicated that T antigen status did not correlate with conventional prognostic indicators such as grade and stage of tumour and survival of patients, while the expression or deletion of ABH blood group antigens did correlate well. It was concluded that ABH blood group antigen determination might provide a useful prognostic probe in upper urinary tract tumours should it find clinical application.

Scanning electron microscopy of upper urinary tract tumors.

Scanning electron microscopy (SEM) was performed on specimens from 16 patients with low-grade tumors, and 4 patients with benign lesions of the upper urinary tract. Pleomorphic microvilli could be seen at a low frequency on the majority of the tumor specimens as well as on surface cells of specimens from patients with inverted papilloma, fibroepithelial polyp, and hydronephrosis. The SEM appearance of the lining cells was similar whether the specimen was obtained from a patient with a tumor, or an inflammatory or proliferative lesion. Furthermore, pleomorphic microvilli were observed in five histologically normal bladders in which the covering cells had been rubbed off with a cold loop of a resectoscope. Pleomorphic microvilli are thus not morphologic markers of preneoplastic hyperplasia or tumor. It is likely that their presence merely reflects an increased rate of detachment of superficial epithelial cells which are replaced by cells from the deeper part of the epithelium. The demonstration of pleomorphic microvilli is therefore of questionable value in the preoperative diagnosis of tumors of the upper urinary tract and, consequently, their significance must be re-evaluated.

Value of exfoliative urinary cytology for differentiation between uric acid stone and tumor of upper urinary tract

The differentiation between uric acid stone and epithelial tumor in the upper urinary tract by exfoliative urinary cytology is recommended in the literature. To demonstrate the value of cytologic examination a comparative study was performed in unselected urologic outpatients, patients with stones, and patients with epithelial tumors in the renal pelvis or ureter. The over-all accuracy rate of the cytologic diagnosis was 70 per cent, but the reliability was decreased by about 10 per cent of falsely positive results in patients with stones.

Improved technique for retrograde brushing in diagnosis of urothelial tumors of upper urinary tract

Our experience with retrograde brushing of radiolucent filling defects in the upper urinary tract in 4 patients is presented. The Meditech steerable catheter represents a significant improvement in technique. Brush cytology adds considerably to preoperative diagnosis and is indicated to provide the information necessary to decide between conservative and radical surgery.