Upper tract urothelial carcinoma is a cancer that can occur any way from the inner linings of the kidney, down the ureter, in the bladder and down the urethra.

Typically 92% of all urothelial carcinomas occur in the bladder, but about 7-8% of urothelial carcinomas can occur in the upper lining of the kidney, which we call the calyx and renal pelvis. It could also occur in the ureter, or in the urethra. The upper tract urothelial carcinoma cancer (UTUC) in the renal pelvis or in the ureter, can develop cancer in the bladder over time.

Descending tumors are tumors that occur in the renal pelvis, or in the calyx, or in the ureters, and it actually feeds down into the bladder. And for those patients we find that 22-47% of those patients will develop bladder cancer some time down in the future.

Causes:

  • Smoking
  • Analane dyes
  • Radiation
  • Genetics

Patients with a syndrome called Lynch Syndrome have an increased chance of developing upper tract urothelial carcinoma. Lynch Syndrome is an inherited cancer syndromes. UTUC is the third most common type of cancer of that syndrome, the most common being colon cancer. We estimate that 21% of patients with upper tract urothelial carcinoma have a variant of Lynch Syndrome.

Signs and Symptoms

Symptoms of UTUC

  • Blood in the urine, which may be microscopic on a urine test
  • Urinary tract infections
  • Flank pain, side and back pain or kidney pain
Risk Factors

Risk Factors

It is well known that tobacco increases risk for all types or urothelial carcinoma. Patients are two to three times at increased risk of developing urothelial carcinoma if they have exposure to analane dyes. Balkan endemic nephropathy, these are patients that are born or grew up in the Balkans, so Croatia, Bosnia Herzegovina, Romania, that have been exposed to a certain type of plant which is often used with wheat to make bread, but it’s European Birthwort, and increases their chance of not only renal failure, but increases their chance of actually getting upper tract urothelial carcinoma. Some actually use that same herb to make some of these Chinese herbs in Chinese medicines.

The following careers are at a higher risk of chemical exposure:

  • Dry Cleaners
  • Painters
  • Autoworkers
  • Truck drivers
  • Paper manufactures
  • Metal workers
  • Plumbers
  • Hairdressers
  • Tire and rubber workers
  • Chemical workers
  • Petroleum workers
Diagnosis

Diagnosis of Upper tract Urothelial Carcinoma

Often times a CT scan, usually a CT urogram is done. Somtimes depending on the kidney function, a MR urogram, which is MRI test, can be used instead. Somtimes the urologist has to diagnose UTUC by looking into the ureter and kidney. Retrograde pyelogram is where a urologist takes the patient to the operating roomand uses a tiny camera passed up the urethra into the bladder and up into the ureter. Then some contrast dye is injected into the ureter, which then fills up the collecting system and can demonstrate a tumor.

A simple urine sample called a urine cytology is often helpful. The pathologist looks under the microscope and tells us that these are cancerous cells that are coming from the urinary system. It’s not a very sensitive test but it is a specific test. So see if a tumor is there then we have to use a camera and a very small scope to go and look at the ureter and the renal pelvis and try to get a biopsy

Staging

Staging

  • Stage 0, or stage TA or TIS, is a tumor that is just involving the mucosa, the lining on the top. This occurs in 31% of patients with upper tract urothelial carcinoma.
  • Stage 1 occurs in 25% of patients, and that is when the tumor not only invades the mucosa, but the lamina propria. The lamina propria is a basement membrane, and there are some lymphatics and blood supply there where the tumor, if it sits there long enough, or if it’s aggressive, may actually spread.
  • Stage 2 muscle-invasive upper tract urothelial carcinoma, tumors not only invade the mucosa, not only invade the lamina propria, but they also invade the muscle lining of the ureter or the renal pelvis. This occurs in 14% of patients.
  • Stage 3 cancers this occurs in 24% of patients. It involves the mucosa, the lamina propria, the muscle. In the kidney, it can actually grow from the renal pelvis into the kidney or the fat around the renal pelvis or ureter.
  • Stage 4 upper tract urothelial carcinoma can involve surrounding organs or, if it spreads to lymph nodes in the lung or in the retroperitoneum, it would also be considered locally advanced or stage 4 upper tract urothelial carcinoma. This occurs in about 6% of patients.

Grading:

  • 35% are low grade or non-aggressive tumors
  • 65% of the times are high grade or  aggressive