Renal Transitional Cell Carcinoma
- Author: Bagi RP Jana, MD; Chief Editor: Jules E Harris, MD more...
Background
Renal urothelial carcinoma (transitional cell carcinoma [TCC]) is a malignant tumor arising from the transitional (urothelial) epithelial cells lining the urinary tract from the renal calyces to the ureteral orifice. Urothelial carcinoma (UC) is the most common tumor of the renal pelvis. Over 70,000 cases of bladder cancer are diagnosed annually in the United States. Upper urinary tract TCC is estimated to occur in 5% of all urothelial cancers and in less than 10% of renal tumors. Evidence indicates that the frequency of upper urinary tract malignancies is increasing.[1]
Images of urothelial carcinoma are shown below:
CT scan with contrast, vascular phase. Mass can be seen in the left renal pelvis (black arrows). Patient underwent nephroureterectomy. Tumor was high-grade urothelial carcinoma invading subepithelial tissue (stage T1) and measuring 7.5 X 3.2 X 3 cm.
Retrograde pyelography. Filling defect can be seen in the left renal pelvis and lower calix (black arrows). Patient underwent left nephroureterectomy. Tumor was low-grade urothelial carcinoma measuring 2.5 X 2 X 1 cm. Pathophysiology
Transitional cell carcinoma accounts for more than 90% of renal pelvic tumors. Other cancer types seen include squamous cell carcinoma (SCC) and adenocarcinoma. The predominant histologic pattern of UC is a papillary tumor with stratified, nonkeratinizing epithelium supported on a thin fibrovascular core. TCC of the upper urinary tract is histologically identical to urinary bladder cancer. These 2 malignancies share the same risk factors and can occur as a part of "field cancerization," which results from exposure of urothelium to carcinogens excreted by or activated in the urine. Hence, upper-urinary-tract urothelial tumors may be multifocal, and in 2-10% of cases, they are bilateral as well.
Patients with upper-tract urothelial tumors are at risk of developing bladder tumors, with an estimated occurrence of 20-48%. Bladder cancer usually appears within 5 years. Patients with primary bladder cancer develop upper-tract UC in 2-4% of cases. The frequency of upper-tract UC may reach 21% in patients with bladder carcinoma in situ (CIS) and in those with certain occupational exposures (see Causes).
Epidemiology
Frequency
United States
According to American Cancer Society, an estimated 70,980 bladder cancers and 57,760 kidney cancers will be diagnosed in the United States in 2009. Primary renal pelvis and ureteric malignancies, on the other hand, are much less common; it is estimated that 2,270 renal pelvic and ureteric cancers will be diagnosed and 790 patients will die of this disease in 2009.[2] Deaths from urothelial malignancies have been decreasing since 1995.
International
Worldwide statistics vary and are inaccurate, since renal pelvis tumors are not reported separately. The highest incidence is found in Balkan countries (eg, Bosnia, Bulgaria, Croatia, Romania, Serbia), where UCs account for 40% of all renal cancers and are bilateral in 10% of cases.
Mortality/Morbidity
Renal urothelial carcinoma is uniformly fatal unless it is treated. In a multicenter study of 1363 patients with upper-tract urothelial carcinoma who were treated with radical nephroureterectomy, the 5-year cancer-specific survival probability was approximately 73%.[3]
Race
The incidence is slightly higher in African Americans than in other races; reported rates are similar among white Americans, Hispanics, and Native Americans. Renal pelvic tumors are less in common in Asian Americans.
Sex
Men are affected approximately 2 times as frequently as women.
Age
Renal pelvis tumors rarely occur before the age of 40 years. The peak incidence is in the 60- to 70-year age group.
Jemal A, Siegel R, Ward E, Hao Y, Xu J, Thun MJ. Cancer statistics, 2009. CA Cancer J Clin. Jul-Aug 2009;59(4):225-49. [Medline]. [Full Text].
American Cancer Society. Cancer Facts & Figures 2009. Available at http://www.cancer.org/downloads/STT/500809web.pdf. Accessed December 12, 2009.
Margulis V, Shariat SF, Matin SF, Kamat AM, Zigeuner R, Kikuchi E, et al. Outcomes of radical nephroureterectomy: a series from the Upper Tract Urothelial Carcinoma Collaboration. Cancer. Mar 15 2009;115(6):1224-33. [Medline].
Grollman AP, Shibutani S, Moriya M, Miller F, Wu L, Moll U, et al. Aristolochic acid and the etiology of endemic (Balkan) nephropathy. Proc Natl Acad Sci U S A. Jul 17 2007;104(29):12129-34. [Medline].
Colin P, Koenig P, Ouzzane A, Berthon N, Villers A, Biserte J, et al. Environmental factors involved in carcinogenesis of urothelial cell carcinomas of the upper urinary tract. BJU Int. Nov 2009;104(10):1436-40. [Medline].
Vikram R, Sandler CM, Ng CS. Imaging and staging of transitional cell carcinoma: part 2, upper urinary tract. AJR Am J Roentgenol. Jun 2009;192(6):1488-93. [Medline].
Jeong YB, Kim HJ. Is It Transitional Cell Carcinoma or Renal Cell Carcinoma on Computed Tomography Image?. Urology. Dec 21 2011;[Medline].
Rastinehad AR, Ost MC, Vanderbrink BA, Greenberg KL, El-Hakim A, Marcovich R, et al. A 20-year experience with percutaneous resection of upper tract transitional carcinoma: is there an oncologic benefit with adjuvant bacillus Calmette Guérin therapy?. Urology. Jan 2009;73(1):27-31. [Medline].
Demery ME, Thézenas S, Pouessel D, Culine S. Systemic chemotherapy in patients with advanced transitional cell carcinoma of the urothelium and impaired renal function. Anticancer Drugs. Feb 2012;23(2):143-8. [Medline].
Pak RW, Moskowitz EJ, Bagley DH. What is the cost of maintaining a kidney in upper-tract transitional-cell carcinoma? An objective analysis of cost and survival. J Endourol. Mar 2009;23(3):341-6. [Medline].
Hsueh TY, Huang YH, Chiu AW, et al. A comparison of the clinical outcome between open and hand-assisted laparoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma. BJU Int. Oct 2004;94(6):798-801.
Kawauchi A, Fujito A, Ukimura O, et al. Hand assisted retroperitoneoscopic nephroureterectomy: comparison with the open procedure. J Urol. Mar 2003;169(3):890-4; discussion 894. [Medline].
Ong AM, Bhayani SB, Pavlovich CP. Trocar site recurrence after laparoscopic nephroureterectomy. J Urol. Oct 2003;170(4 Pt 1):1301. [Medline].
Park J, Ha SH, Min GE, Song C, Hong B, Hong JH, et al. The protective role of renal parenchyma as a barrier to local tumor spread of upper tract transitional cell carcinoma and its impact on patient survival. J Urol. Sep 2009;182(3):894-9. [Medline].
Novara G, De Marco V, Dalpiaz O, Galfano A, Bouygues V, Gardiman M, et al. Independent predictors of contralateral metachronous upper urinary tract transitional cell carcinoma after nephroureterectomy: multi-institutional dataset from three European centers. Int J Urol. Feb 2009;16(2):187-91. [Medline].
Boorjian S, Ng C, Munver R, et al. Impact of delay to nephroureterectomy for patients undergoing ureteroscopic biopsy and laser tumor ablation of upper tract transitional cell carcinoma. Urology. Aug 2005;66(2):283-7.
Chen GL, Bagley DH. Ureteroscopic surgery for upper tract transitional-cell carcinoma: complications and management. J Endourol. May 2001;15(4):399-404; discussion 409. [Medline].
Chew BH, Pautler SE, Denstedt JD. Percutaneous management of upper-tract transitional cell carcinoma. J Endourol. Jul-Aug 2005;19(6):658-63.
Clark PE, Streem SB. Endourologic management of upper tract transitional cell carcinoma. ScientificWorldJournal. Jun 7 2004;4 Suppl 1:62-75.
Daneshmand S, Quek ML, Huffman JL. Endoscopic management of upper urinary tract transitional cell carcinoma: long-term experience. Cancer. Jul 1 2003;98(1):55-60. [Medline].
Deligne E, Colombel M, Badet L, et al. Conservative management of upper urinary tract tumors. Eur Urol. Jul 2002;42(1):43-8. [Medline].
Gettman MT, Segura JW. Endourological management of upper tract transitional cell carcinoma. BJU Int. Dec 2003;92(9):881-5. [Medline].
Goh M, Montie JE, Wolf SJ, Jr. Urothelial carcinoma of the upper urinary tract. In: Gillenwather JY, Grayhack JT, Howards Ss, Mitchell ME, eds. Adult and Pediatric Urology. Philadelphia: Lippincott Williams & Wilkins. 2002;Vol. 1, 4th ed:Chapter 17.
Ho KL, Chow GK. Ureteroscopic resection of upper-tract transitional-cell carcinoma. J Endourol. Sep 2005;19(7):841-8.
Holmang S, Johansson SL. Urothelial carcinoma of the upper urinary tract: comparison between the WHO/ISUP 1998 consensus classification and WHO 1999 classification system. Urology. Aug 2005;66(2):274-8.
Ignjatovic I, Dinic L, Prjiv B, Stojkovic I. CT staging of the upper urinary tract urothelial tumors. Medicine and Biology. 2003;10:135-8.
Johnson GB, Grasso M. Ureteroscopic management of upper urinary tract transitional cell carcinoma. Curr Opin Urol. Mar 2005;15(2):89-93.
Kirkali Z, Tuzel E. Transitional cell carcinoma of the ureter and renal pelvis. Crit Rev Oncol Hematol. Aug 2003;47(2):155-69. [Medline].
Matin SF. Radical laparoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma: current status. BJU Int. Mar 2005;95 Suppl 2:68-74.
McCaffrey JA, Herr HW. Adjuvant and neoadjuvant chemotherapy for urothelial carcinoma. Surg Oncol Clin N Am. Oct 1997;6(4):667-81. [Medline].
Melamed MR, Reuter VE. Pathology and staging of urothelial tumors of the kidney and ureter. Urol Clin North Am. May 1993;20(2):333-47. [Medline].
Messing EM. Urothelial tumors of the renal pelvis and ureter. In: Walsh PC, Retik AB, Vaughan ED, Wein AG, eds. Campbell's Urology. Philadelphia: Saunders. 2002;Vol 4:2765-84.
Michaelson MD, Kaufman DS, Oh WK. Transitional cell carcinoma of the upper uroepithelial tract. Clin Adv Hematol Oncol. Feb 2003;1(2):102-4; discussion 105.
Pohar KS, Sheinfeld J. When is partial ureterectomy acceptable for transitional-cell carcinoma of the ureter?. J Endourol. May 2001;15(4):405-8; discussion 409. [Medline].
Sagalowsky AI, Jarrett TW. Management of urothelial tumors of the renal pelvis and ureter. In: Walsh PC, Retik AB, Vaughan ED, Wein AG, eds. Campbell's Urology. Philadelphia: Saunders. 2002;Vol 4:2845-75.
Scher HI, Yagoda A, Herr HW, et al. Neoadjuvant M-VAC (methotrexate, vinblastine, doxorubicin and cisplatin) for extravesical urinary tract tumors. J Urol. Mar 1988;139(3):475-7. [Medline].
Srinivas S, Guardino AE. A nonplatinum combination in metastatic transitional cell carcinoma. Am J Clin Oncol. Apr 2005;28(2):114-8. [Medline].
Stewart GD, Bariol SV, Grigor KM, et al. A comparison of the pathology of transitional cell carcinoma of the bladder and upper urinary tract. BJU Int. Apr 2005;95(6):791-3.
Wang SS, Ho HC, Su CK, et al. Seeding of malignant renal tumor through a nephrostomy tract. J Chin Med Assoc. Jun 2004;67(6):308-10. [Medline].

