Manual for Staging of Cancer; Fifth Edition; Edited by Irvin D. Fleming, M.D., Jay S. Cooper, M.D., Donald Earl Henson, M.D., Robert V.P. Hutter, M.D., B.J. Kennedy, M.D., Gerald Murphy, M.D., D.S.c., Brian O'Sullivan, M.B., F.R.C.P.C., F.R.C.P.I., Leslie H. Sobin, M.D., John W. Yarbro, M.D., Ph.D.; Copyright 1997, the American Joint Committee on Cancer. Published by Lippincott-Raven Publishers. Chapter 37, pp. 235 - 240.

Transitional cell carcinoma may occur at any site within the upper urinary collecting system from the renal calyx to the ureterovesical junction. The tumors occur most commonly in adults and are rare before 40 years of age. There is a two- to three-fold increase in incidence in men compared with women. The lesions are often multiple and are more common in patients with a history of transitional cell carcinoma of the bladder. Local staging depends upon the depth of invasion. A common staging system is used regardless of tumor location within the upper urinary collecting system except for category T3, which differs between the pelvis or calyceal system and the ureter.

ANATOMY

Primary Site. The renal pelvis and ureter form a single unit that cephalad is continuous with the collecting ducts of the renal pyramides and comprises the minor and major calyces, which are continuous with the renal pelvis. The ureteropelvic junction is variable in position and location, but serves as a "landmark" that separates the renal pelvis and the ureter, which continues caudad and traverses the wall of the urinary bladder as the intramural ureter opening in the trigone of the bladder at the ureteral orifice. The renal pelvis and ureter are composed of the following layers: epithelium, subepithelial connective tissue, and muscularis, which is continuous with a connective tissue adventitial layer. It is in this outer layer that the major blood supply and lymphatics are found.

The intrarenal portion of the renal pelvis is surrounded by renal parenchyma; the extra renal pelvis, by perihilar fat. The ureter courses through the retroperitoneum adjacent to the parietal peritoneum and rests on the retroperitoneal musculature above the pelvic vessels. As it crosses the vessels and enters the deep pelvis, the ureter is surrounded by pelvic fat until it traverses the bladder wall.

Regional Lymph Nodes. The regional lymph nodes are:

For Renal Pelvis:
     Renal hilar
     Paracaval
     Aortic
     Retroperitoneal, NOS

For Ureter:
     Renal hilar
     Iliac (common, internal [hypogastric], external)
     Paracaval
     Peri-ureteral
     Pelvic, NOS

Any amount of regional lymph node metastasis is a poor prognostic finding and outcome is minimally influenced by the number, size, or location of the regional nodes which are involved.

Metastatic Sites. Distant spread to lung, bone, or liver is most common.

RULES FOR CLASSIFICATION

Clinical Staging. Primary tumor assessment includes radiographic imaging, usually by intravenous and/or retrograde pyelography. Computerized tomography scanning can be used to assess regional nodes. Ureteroscopic visualization of the tumor is desirable and tissue biopsy through the ureteroscope may be performed if feasible. Urine cytology may help determine tumor grade if tissue is not available. Staging of tumors of the renal pelvis and ureter is not influenced by the presence of any concomitant bladder tumors which may be identified.

Pathologic Staging. Pathologic staging depends upon histologic determination of the extent of invasion by the primary tumor. Treatment frequently requires resection of the entire kidney, ureter, and a cuff of bladder surrounding the ureteral orifice. Appropriate regional nodes may be sampled. A more conservative surgical resection may be performed, especially with distal ureteral tumors or in the presence of compromised renal function.

Endoscopic resection through a ureteroscope or a percutaneous approach may be used in some circumstances. Submitted tissue may be insufficient for accurate histologic examination and pathologic staging. Laser or electrocautery coagulation or vaporization of the tumor may be performed, especially if the visible appearance is consistent with a low grade and low stage tumor. Under these circumstances, there may be no material available for histologic review.

DEFINITION OF TNM

Primary Tumor (T)

*Note: Laterality does not affect the N classification.

STAGE GROUPING

HISTOPATHOLOGIC TYPE

Transitional cell carcinoma
Squamous cell carcinoma
Epidermoid carcinoma
Adenocarcinoma
Urothelial carcinoma

HISTOPATHOLOGIC GRADE

BIBLIOGRAPHY

Anderstrom C, Johansson SL, Pettersson S, et al: Carcinoma of the ureter: a clinicopathologic study of 49 cases. J Urol 142(2 Pt 1):280-283, 1989

Borgmann V, al-Abadi H, Nagel R: Prognostic relevance of DNA ploidy and proliferative activity in urothelial carcinoma of the renal pelvis and ureter. A study on a follow-up period of 6 years. Urol Int 47(1):7-11, 1991

Corrado F, Ferri C, Mannini D, et al: Transitional cell carcinoma of the upper urinary tract: evaluation of prognostic factors by histopathology and flow cytometric analysis. J Urol 145(6):1159-1163, 1991

Huben RP, Mounzer AM, Murphy GP: Tumor grade and stage as prognostic variables in upper urothelial tumors. Cancer 62(9):2016-2020, 1988

Jinza S, Iki M, Noguchi S, et al: Nucleolar organizer regions: a new prognostic factor for upper tract urothelial cancer. J Urol 154(5):1688-1692, 1995

Williams RD: Tumors of the kidney, ureter, and bladder. West J Med 156(5):523-534, 1992

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