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Transitional Cell Cancer of the Renal Pelvis and Ureter Treatment (PDQ®)

Stage Information for Transitional Cell Cancer of the Renal Pelvis and Ureter

Though comparable in many respects to staging systems described for bladder cancer, unique structural aspects of the renal pelvis and ureter have led to several differences in the classification schema of tumors that involve the upper tracts. Clinical staging is based on a combination of radiographic procedures (e.g., intravenous pyelogram and computed tomographic scans) and, more recently, ureteroscopy and biopsy.

The advent of rigid and flexible ureteroscopic techniques has permitted endoscopic access to the ureter and renal pelvis. This may permit greater accuracy in preoperative definition of the stage and grade of an upper tract neoplasm. In addition, fulguration and endourological access permit resection or laser coagulation of highly selected low-stage, low-grade lesions of the ureters.[1] However, this approach is still under clinical evaluation since there is the possibility of inaccurate assessment of the stage and extent of disease, and the adequacy and risks of such treatment have not yet been defined.[2-5]

Because of the inaccessibility of ureteral and pelvic anatomy, accurate staging requires pathologic analysis of the surgically excised specimen.

Definitions of TNM

The American Joint Committee on Cancer (AJCC) has designated staging by TNM classification to define carcinoma of the renal pelvis and ureter.[6]

Table 1. Primary Tumor (T)a
aReprinted with permission from AJCC: Renal pelvis and ureter. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 491-6.
TXPrimary tumor cannot be assessed.
T0No evidence of primary tumor.
TaPapillary noninvasive carcinoma.
TisCarcinoma in situ.
T1Tumor invades subepithelial connective tissue.
T2Tumor invades the muscularis.
T3(For renal pelvis only) Tumor invades beyond muscularis into peripelvic fat or the renal parenchyma T3. (For ureter only) Tumor invades beyond muscularis into periureteric fat.
T4Tumor invades adjacent organs, or through the kidney into the perinephric fat.
Table 2. Regional Lymph Nodes (N)a,b
aReprinted with permission from AJCC: Renal pelvis and ureter. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 491-6.
bLaterality does not affect the N classification.
NXRegional lymph nodes cannot be assessed.
N0No regional lymph node metastasis.
N1Metastasis in a single lymph node, ≤2 cm in greatest dimension.
N2Metastasis in a single lymph node, >2 cm but not >5 cm in greatest dimension; or multiple lymph nodes, none >5 cm in greatest dimension.
N3Metastasis in a lymph node, >5 cm in greatest dimension.
Table 3. Distant Metastasis (M)a
aReprinted with permission from AJCC: Renal pelvis and ureter. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 491-6.
M0No distant metastasis.
M1Distant metastasis.
Table 4. Anatomic Stage/ Prognostic Groupsa
StageTNM
aReprinted with permission from AJCC: Renal pelvis and ureter. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 491-6.
0aTaN0M0
0isTisN0M0
IT1N0M0
IIT2N0M0
IIIT3N0M0
IVT4N0M0
Any TN1M0
Any TN2M0
Any TN3M0
Any TAny NM1

Patients may also be designated as having localized, regional, or metastatic disease, as follows:

Localized

Patients with localized disease may be classified into three groups:

  • Group 1: Low-grade tumor confined to the urothelium without lamina propria invasion (“Papilloma” Grade I transitional cell cancer).
  • Group 2: Grade I–III carcinomas without demonstrable subepithelial invasion or focal microscopic invasion or papillary carcinomas with carcinoma in situ and/or carcinoma in situ elsewhere in the urothelium.
  • Group 3: High-grade tumors that have infiltrated the renal pelvic wall or renal parenchyma or both but are still confined to the kidney. Infiltration of muscle in the upper tract may not be associated with as much potential for distant dissemination as appears to be the case for bladder cancer.

Regional

  • Group 4: Extension of tumors beyond the renal pelvis or parenchyma and invasion of peripelvic and perirenal fat, lymph nodes, hilar vessels, and adjacent tissues.

Metastatic

  • Spread of the tumor to distant tissues.

Each of these classifications has been subclassified into categories of unicentricity or multicentricity. The latter category indicates a more pervasive tumor diathesis and generally a less favorable prognosis.

Although the classifications listed above have prognostic significance, they can only be determined at the time of nephroureterectomy, which is the treatment of choice for patients with this disease. Because of the high incidence of tumor recurrence within the intramural ureter among patients who have had incomplete excision of this area, nephroureterectomy should include the entire ureter and a margin of periureteral orifice mucosa (i.e., bladder cuff).

A TNM system for staging has been established and has demonstrated accurate predictions of survival. The TNM staging system may be a better predictor of prognosis than tumor grade, though both are strongly predictive of survival. Median survival for patients with tumors confined to the subepithelial connective tissue was 91.1 months compared to 12.9 months for patients with tumors invading the muscularis and beyond in one report. Flow cytometry analysis identifies low-stage, low-grade tumors at high risk of recurrence by virtue of their aneuploid histograms.[7,8]

References

  1. Grossman HB, Schwartz SL, Konnak JW: Ureteroscopic treatment of urothelial carcinoma of the ureter and renal pelvis. J Urol 148 (2 Pt 1): 275-7, 1992. [PUBMED Abstract]
  2. Batata M, Grabstald H: Upper urinary tract urothelial tumors. Urol Clin North Am 3 (1): 79-86, 1976. [PUBMED Abstract]
  3. Cummings KB, Correa RJ Jr, Gibbons RP, et al.: Renal pelvic tumors. J Urol 113 (2): 158-62, 1975. [PUBMED Abstract]
  4. Nocks BN, Heney NM, Daly JJ, et al.: Transitional cell carcinoma of renal pelvis. Urology 19 (5): 472-7, 1982. [PUBMED Abstract]
  5. Heney NM, Nocks BN, Daly JJ, et al.: Prognostic factors in carcinoma of the ureter. J Urol 125 (5): 632-6, 1981. [PUBMED Abstract]
  6. Renal pelvis and ureter. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, p 493.
  7. Huben RP, Mounzer AM, Murphy GP: Tumor grade and stage as prognostic variables in upper tract urothelial tumors. Cancer 62 (9): 2016-20, 1988. [PUBMED Abstract]
  8. Blute ML, Tsushima K, Farrow GM, et al.: Transitional cell carcinoma of the renal pelvis: nuclear deoxyribonucleic acid ploidy studied by flow cytometry. J Urol 140 (5): 944-9, 1988. [PUBMED Abstract]
  • Updated: March 12, 2014