eMedicine Specialties > Oncology > Carcinomas of the Genitourinary Tract

Transitional Cell Carcinoma, Renal: Treatment & Medication

Author: Georgi Guruli, MD, PhD, Consulting Staff, Department of Surgery, Division of Urology, University Hospital; Assistant Professor, Department of Surgery, Division of Urology, UMDNJ - New Jersey Medical School
Coauthor(s): Badrinath R Konety, MD, Associate Professor, Department of Urology, University of California at San Francisco
Contributor Information and Disclosures

Updated: Jul 27, 2006

Treatment

Medical Care

Medical therapy usually is administered as an adjuvant to surgical therapy or in patients in whom surgical treatment is contraindicated (eg, poor general condition, advanced disease). Local immunotherapy or chemotherapy can be attempted as an independent treatment method in cases of CIS or to reduce the recurrence rate after endoscopic management of the upper-tract UC.

• Topical immunotherapy or chemotherapy
  • Local treatment in general is administered as adjuvant, after endoscopic treatment of the urothelial carcinoma (UC), to decrease the recurrence rate.
  • Methods of delivery vary (eg, irrigation through ureteroscopic catheter, intravesical instillation after ensuring vesicoureteral reflux); however, irrigation through percutaneous nephrostomy catheter is the most reliable method.
  • BCG instillation through a percutaneous catheter resulted in conversion of urine cytology from positive to negative in 7 of 10 patients with upper-tract CIS. BCG sepsis was observed in 1 patient and was treated successfully.
  • Administration of BCG as a prophylactic agent after endoscopic treatment of superficial urothelial tumors resulted in a recurrence rate of 12.5% in one study. However, some studies stated a recurrence rate of up to 50%.
  • Mitomycin-C irrigation reduced the recurrence rate to 14.2%.
  • Unlike bladder cancer, the ability of BCG to treat high-grade UC of the upper tract or reduce the progression rate is not determined. Therefore, high-grade upper-tract UC requires radical surgical intervention.
  • BCG does not have an advantage of reducing the progression rate in upper-tract UC in comparison with mitomycin-C, and the recurrence rate after the use of either of these agents is comparable. However, the possibility of complications is much less with mitomycin-C, making it more attractive as a first-line agent in the prophylaxis of upper-tract UC.
• Systemic chemotherapy
  • The combination of methotrexate, vinblastine, doxorubicin (Adriamycin), and cisplatin (MVAC) is the best-studied chemotherapy regimen for upper-tract TCC. Durable, complete responses were obtained in only 5-10% of patients. Serious complications were encountered in 41% of patients; treatment-related mortality rate was 2-4%. Gemcitabine-based combinations (gemcitabine + cisplatin or carboplatin) have activity similar to MVAC in bladder cancer with less toxicity.
  • Some studies claimed comparable effectiveness of the gemcitabine + paclitaxel combination as well, with less nephrotoxicity in comparison with cisplatin-based therapies.
• Radiation therapy
  • The role of radiation therapy in the management of upper-tract TCC is not well defined.
  • Some studies suggest that radiation therapy may have some effect as adjuvant therapy to improve local control after radical surgical treatment for high-grade disease.

Surgical Care

Treatment is mandatory for upper-tract TCC after making the diagnosis. Surgical intervention is the main form of radical treatment for localized disease.

• In choosing a treatment, the following should be considerations:
  • Patients with low-stage, low-grade tumors respond well to either radical or conservative treatment.
  • Patients with high-stage, high-grade tumors respond poorly to either radical surgery or conservative surgery.
  • Patients with positive cytologic findings but normal radiographic and endoscopic examinations are not treated, but are monitored closely by periodic IVU or RPG.
• Radical nephroureterectomy
  • Traditional radical surgery for renal UC consists of total nephroureterectomy with excision of a bladder cuff around the ureteral orifice. Otherwise, 30-75% of patients develop tumor recurrence in the ureteral stump or around the ipsilateral ureteral orifice.
  • Avoid transection of the ureter, because of the high risk of tumor spillage in the retroperitoneum.
  • Laparoscopic or hand-assisted laparoscopic nephroureterectomy is as effective oncologically as an open technique for localized disease. In general, the laparoscopic approach is accompanied by less blood loss, less pain and discomfort, faster recovery, and shorter hospital stay. Trocar site recurrence is very rare (3 cases have been reported so far).
  • Patients with poorly differentiated tumors or high-stage disease (especially those with microscopic lymph node involvement) may benefit from extensive retroperitoneal lymphadenectomy. The benefit, however, is marginal, and appropriate candidates must be chosen carefully.
• Conservative open surgical treatment
  • Conservative excision for upper-tract urothelial tumors includes segmental ureteral resection with reanastomosis or ureteroneocystostomy and partial nephrectomy.
  • Conservative management is especially appropriate for solitary or functionally dominant kidneys, bilateral tumors, or small, low-grade ureteral tumors.
  • Upper ureteral and midureteral tumors may be treated with segmental resections if they are low-grade, solitary lesions.
  • Manage distal ureteral tumors with distal ureterectomy and ureteral reimplantation if no evidence of multifocality is noted. In these cases, distal ureterectomy may be as successful as total nephroureterectomy, since proximal spread of UC after resection is rare.
  • Partial nephrectomy may be performed in patients with localized renal pelvic tumors; however, employ this approach only in situations requiring avoidance of renal failure.
• Endoscopic treatment
  • Urothelial tumors of the upper urinary tract can be excised using an endoscope, similar to superficial bladder tumors.
  • Indications for endoscopic management are the same as for conservative resection and include low-grade tumors, bilateral involvement, and compromised renal function that necessitates a nephron-sparing approach.
  • Electrocautery and fulguration are used most commonly in the endoscopic setting. Currently, lasers (Ho:YAG and Nd:YAG) are being used for management of upper-tract low-grade urothelial tumors. In cases of larger low-grade tumors with low metastatic potential, which cannot be eliminated during one session, ureteroscopic management can be performed several times.
  • Tumor size (>1.5 cm), multifocal disease, and high-grade tumors are the main risk factors for recurrence after ureteroscopic management of upper-tract UC.
  • The presence of high-grade or invasive tumors, which cannot be eradicated endoscopically, necessitates radical surgical intervention (open or laparoscopic nephroureterectomy in most cases).

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