Management of Patients With Upper Urinary Tract Transitional Cell Carcinoma

Bladder Cancer Following Upper-tract TCC

Transitional epithelial cells line the whole urinary tract; consequently, it has been suggested that in cases of TCC the entire urothelium is at risk of developing subsequent tumors. Bladder tumors reportedly occur in 15–50% of patients following upper-tract TCC ( Table 2 ).^{[89,90,91,92,93]} Several studies have attempted to identify potential risk factors for the development of subsequent bladder tumors; unfortunately, the collective data show marked heterogeneity in identifiable risk factors, which include pathologic stage, multifocality of the upper-tract lesion, female gender, incomplete distal ureterectomy, and a prior history of bladder tumors.^{[89,90,91,92,93,94]} The lack of consensus presumably reflects different surgical techniques, management strategies, and surveillance regimens used in the management of this disease.

Raman and colleagues reported that, following definitive surgical resection of upper-tract TCC (nephroureterectomy or segmental ureterectomy), bladder tumors developed in 44% of patients at a mean follow-up duration of 13.9 months;^[95] 60% of these bladder tumors were superficial low-grade lesions. While the bladder lesions presented at a lower pathologic stage than the primary upper-tract tumors, patients with high-grade upper urinary tract tumors had a significantly increased risk of developing high-grade bladder recurrences. Collectively, these data underscore that intravesical recurrences occur quite frequently after the management of upper-tract TCC. This finding remains true even when the ipsilateral proximal urothelium is definitively resected. To date, there are no available variables to reliably predict which patients will develop bladder recurrences. As such, close surveillance with cystoscopy and cytology following surgical management of upper-tract TCC is essential.

A related issue revolves around the incidence of metachronous upper-tract TCC and upper-tract TCC following bladder cancer. Kang and colleagues reported on a large series of almost 200 patients with upper-tract TCC and noted that metachronous disease occurred in 5.8% of patients.^[93] Renal insufficiency, uremia, and concurrent bladder tumors significantly predisposed patients to develop contralateral upper-tract tumors after primary upper-tract TCC. Upper-tract TCC has also been noted to occur in 2–4% of patients with bladder cancer, with a mean interval to recurrence of 17–70 months.^{[25,96,97,98]} Risk factors that have been suggested to predict upper-tract disease following bladder cancer include stage, grade, multifocality of bladder lesions, carcinoma in situ, and tumors at the ureteral orifice.^{[99,100,101,102]} Longer-term series further indicate that the incidence of metachronous disease might be much higher than 5% and can be directly related to the grade of the bladder lesion.^[97,100]

Nat Clin Pract Urol. 2007;4(8):432-443. © 2007 Nature Publishing Group

The authors declared no competing interests.