EDITORIAL COMMENT
2
PERCUTANEOUS MANAGEMENT OF UPPER TRACT TRANSITIONAL CELL CARCINOMA 775 rences and extend the time to recurrence. While the value of that protocol is perhaps an area of controversy in regard to bladder recurrences, in this setting of mostly geriatric pa- tients with solitary kidneys extending the time to an upper tract recurrence can have a significant, positive impact on the quality of life. As such, lacking any data proving other- wise, we continue to use this agent prophylactically. Although percutaneous management of upper tract trans- itional cell carcinoma is being performed with increasing frequency its long-term effect on renal function remains un- known. Jarrett et a1 reported 2 cases of chronic renal insuf- ficiency at the outset of therapy in which end stage renal disease developed within 16 months.6 We believe that our results add significantly to the understanding of the effect of percutaneous management in this setting. Of our patients 12 had tumor in a solitary kidney and 1 had bilateral tumors. With a mean followup approaching 2 years regarding renal function, serum creatinine in these patients as a group has been unchanged. Furthermore, only 1 of these 13 patients required dialysis, which followed curative salvage nephroureterectomy for an ipsilateral recurrence. As such, this extended followup in this large number of patients treated percutaneously for upper tract transitional cell car- cinoma in solitary kidneys clearly proves the efficacy of this approach for preservation of renal function, which is again a primary consideration for these patients. CONCLUSIONS Percutaneous management of upper tract transitional cell carcinoma is technically feasible and applicable to a signifi- cant number of patients in whom nephron sparing treatment is warranted. Although cancer-free survival is not equivalent to standard management, that is nephroureterectomy, re- sults are at least comparable to other forms of conservative treatment in properly selected patients. With contemporary diagnostic techniques, patients with relatively low grade, low stage tumors can be appropriately selected for while those with higher grade and stage tumors can be excluded from this therapy. While intracavitary BCG can be given safely in the setting of upper tract transitional cell carcinoma follow- ing percutaneous tumor resection, its efficacy awaits prospec- tive randomized trials. Finally, percutaneous management of upper tract transitional cell carcinoma in patients with soli- tary kidneys is clearly associated with preservation of renal function. REFERENCES 1. Charbit, L., Gendreau, M. C., Mee, S. and Cuher, J.: Tumors of the upper urinary tract: 10 years experience. J. Urol., 146: 1243, 1991. 2. Shinka, T., Uekado, Y., Aoshi, H., Hirano, A. and Ohkawa. T.: Occurrence of uroepithelial tumors of the upper urinary tract after the initial diagnosis of bladder cancer. J. Urol., 140 745, 1988. 3. Catalona, W. J.: Urothelial tumors of the urinary tract. In: Campbell’s Urology, 6th ed. Edited by P. C. Walsh, A. B. Retik, T. A. Stamey and E. D. Vaughan, Jr.: Philadelphia: W. B. Saunders Co., chapt. 28, p. 1094, 1992. 4. Wallace, D. M. A,, Wallace, P, M., Whitfield. H. N., Hendry, W. F. and Wickham, J. E.: The late results of conservative surgery for upper tract urothelial carcinomas. Brit. J. Urol., 53 537, 1981. 5. Ziegelbaum, M., Novick, A. C., Streem, S. B., Montie, J. E.. Pontes, J. E. and Straffon, R. A.: Conservative surgery for transitional cell carcinoma of the renal pelvis. J. Urol., 138 1146, 1987. 6. Jarrett, T. W., Sweetser, P. M., Weiss, G. H. and Smith, A. D.: Percutaneous management of transitional cell carcinoma of the renal collecting system: 9-year experience. J. Urol., 154: 1629, 1995. 7. Streem, S. B.: Percutaneous management of upper-tract transi- tional cell carcinoma. Urol. Clin. N. Amer., 22 221, 1995. 8. Huffman, J. L., Bagley. D. H., Lyon, E. S., Morse, M. J., Herr, H. W. and Whitmore, W. F.: Endoscopic diagnosis and treat- ment of upper-tract urothelial tumors. A preliminary report. Cancer, 55 1422, 1985. 9. Streem, S. B. and Pontes, E. J.: Percutaneous management of upper tract transitional cell carcinoma. J. Urol., 135: 773, 1986. 10. Woodhouse, C. R. J., Kellett, M. J. and Bloom, H. J.: Percutane- ous renal surgery and local radiotherapy in the management of renal pelvic transitional cell carcinoma. Brit. J. Urol., 69: 245, 1986. 11. Orihuela, E. and Smith, A. D.: Percutaneous treatment of trans- itional cell carcinoma of the upper urinary tract. Urol. Clin. N. Amer., 15 425, 1988. 12. Nolan, R. L., Nickel, J. C. and Froud, P. J.: Percutaneous en- dourologic approach for transitional cell carcinoma of the renal pelvis. Urol. Rad., 9 217, 1988. 13. Blute, M. L., Segura, J. W., Patterson, D. E., Benson, R. C., Jr. and Zincke, H.: Impact of endourology on diagnosis and man- agement of upper urinary tract urothelial cancer. J. Urol., 141: 1298, 1989. 14. Tasca, A. and Zattoni, F.: The case for a percutaneous approach to transitional cell carcinoma of the renal pelvis. J. Urol., 143: 902, 1990. 15. Martinez-Pineiro, J. A., Matres, M. J. G. and Martinez-Pineiro, L.: Endourological treatment of upper tract urothelial carcino- mas: analysis of a series of 59 tumors. J. Urol., 166: 377, 1996. 16. Keeley, F. X., Jr., Bibbo, M. and Bagley, D. H.: Ureteroscopic treatment and surveillance of upper urinary transitional cell carcinoma. J. Urol., 157: 1560, 1997. 17. Vasavada. S. P., Streem, S. B. and Novick, A. C.: Definitive tumor resection and percutaneous bacillus calmette-guerin for management of renal pelvic transitional cell carcinoma in solitary kidneys. Urology, 45 381, 1995. 18. McCoy, J. G., Honda, H., Reznicek, M. and Williams, R. D.: Computerized tomography for detection and staging of local- ized and pathologically defined upper tract urothelial tumors. J. Urol., 146 1500, 1991. 19. Planz, B., George, R., Adam, G., Jakse, G. and Planz, K.: Com- puted tomography for detection and staging of transitional cell carcinoma of the upper urinary tract. Eur. Urol., 27: 146,1995. 20. Keeley, F. X.. Kulp, D. A., Bibbo, M., McCue, P. A. and Bagley, D. H.: Diagnostic accuracy of ureteroscopic biopsy in upper tract transitional cell carcinoma. J. Urol., 157: 33, 1997. 21. Gerber, G. S. and Lyon, E. S.: Endourological management of upper tract urothelial tumors. J . Urol., 150 2, 1993. 22. Patel, A., Soonawalla, P., Shepherd, S. F., Dearnaley, D. P., Kellett, M. J. and Woodhouse, C. R. J.: Long-term outcome aRer percutaneous treatment of transitional cell carcinoma of the renal pelvis. J. Urol., 155 868, 1996. EDITORIAL COMMENT In this retrospective study the authors present a short-term fol- lowup (mean 23.6 months) of 17 patients with pyelocaliceal transi- tional cell cancer treated with percutaneous resection or electroco- agulation since 1985. The indication for this approach was mandatory in 14 patients and relative in 3. Most of the tumors were of low gradelstage. The outcome did not differ substantially from that of other series reported previously. Collected results of 167 patients with upper tract transitional cell cancer treated endoscopicaIly, in- cluding the present series, show a 23.3% (39 cases) rate of ipsilateral local recurrence and a cancer specific death rate of 11.2% (references 6, 15 and 21 in article). Many of the recurrences were treated with repeat endourological procedures and all deaths occurred in patients with grade 3, T2-3 tumors in whom the conservative approach was mandatory and/or contraindications existed for nephroureterectomy due to co-morbidity. These data are similar to those reported in Europe with open renal sparing surgery (reference 4 in article).’,’ Of 97 cases treated with local excision of the renal pelvis, partial ne- phrectomy or partial ureterectomy disease recurred in 23 (23.78) and the cause specific 5-year sunrival rate was 73.7% (70 of 95). Also the results from worldwide series of267 patients collected by Wallace et a1 are consistent with these figures. The ipdateral recurrence rate was 29% (60 of 208 cases), cancer death rate 14.56 and the overall %year survival rate 68%. These data are in disagreement with the statement of the authors
Transcript of EDITORIAL COMMENT
PERCUTANEOUS MANAGEMENT OF UPPER TRACT TRANSITIONAL CELL CARCINOMA 775 rences and extend the time to recurrence. While the value of that protocol is perhaps an area of controversy in regard to bladder recurrences, in this setting of mostly geriatric pa- tients with solitary kidneys extending the time to an upper tract recurrence can have a significant, positive impact on the quality of life. As such, lacking any data proving other- wise, we continue to use this agent prophylactically.
Although percutaneous management of upper tract trans- itional cell carcinoma is being performed with increasing frequency its long-term effect on renal function remains un- known. Jarrett et a1 reported 2 cases of chronic renal insuf- ficiency at the outset of therapy in which end stage renal disease developed within 16 months.6 We believe that our results add significantly to the understanding of the effect of percutaneous management in this setting. Of our patients 12 had tumor in a solitary kidney and 1 had bilateral tumors. With a mean followup approaching 2 years regarding renal function, serum creatinine in these patients as a group has been unchanged. Furthermore, only 1 of these 13 patients required dialysis, which followed curative salvage nephroureterectomy for an ipsilateral recurrence. As such, this extended followup in this large number of patients treated percutaneously for upper tract transitional cell car- cinoma in solitary kidneys clearly proves the efficacy of this approach for preservation of renal function, which is again a primary consideration for these patients.
CONCLUSIONS
Percutaneous management of upper tract transitional cell carcinoma is technically feasible and applicable to a signifi- cant number of patients in whom nephron sparing treatment is warranted. Although cancer-free survival is not equivalent to standard management, that is nephroureterectomy, re- sults are at least comparable to other forms of conservative treatment in properly selected patients. With contemporary diagnostic techniques, patients with relatively low grade, low stage tumors can be appropriately selected for while those with higher grade and stage tumors can be excluded from this therapy. While intracavitary BCG can be given safely in the setting of upper tract transitional cell carcinoma follow- ing percutaneous tumor resection, its efficacy awaits prospec- tive randomized trials. Finally, percutaneous management of upper tract transitional cell carcinoma in patients with soli- tary kidneys is clearly associated with preservation of renal function.
REFERENCES
1. Charbit, L., Gendreau, M. C., Mee, S . and Cuher, J.: Tumors of the upper urinary tract: 10 years experience. J . Urol., 146: 1243, 1991.
2. Shinka, T., Uekado, Y., Aoshi, H., Hirano, A. and Ohkawa. T.: Occurrence of uroepithelial tumors of the upper urinary tract after the initial diagnosis of bladder cancer. J. Urol., 140 745, 1988.
3. Catalona, W. J.: Urothelial tumors of the urinary tract. In: Campbell’s Urology, 6th ed. Edited by P. C. Walsh, A. B. Retik, T. A. Stamey and E. D. Vaughan, Jr.: Philadelphia: W. B. Saunders Co., chapt. 28, p. 1094, 1992.
4. Wallace, D. M. A,, Wallace, P, M., Whitfield. H. N., Hendry, W. F. and Wickham, J. E.: The late results of conservative surgery for upper tract urothelial carcinomas. Brit. J. Urol., 5 3 537, 1981.
5. Ziegelbaum, M., Novick, A. C., Streem, S. B., Montie, J. E.. Pontes, J. E. and Straffon, R. A.: Conservative surgery for transitional cell carcinoma of the renal pelvis. J. Urol., 138 1146, 1987.
6. Jarrett , T. W., Sweetser, P. M., Weiss, G. H. and Smith, A. D.: Percutaneous management of transitional cell carcinoma of the renal collecting system: 9-year experience. J. Urol., 154: 1629, 1995.
7. Streem, S. B.: Percutaneous management of upper-tract transi- tional cell carcinoma. Urol. Clin. N. Amer., 2 2 221, 1995.
8. Huffman, J . L., Bagley. D. H., Lyon, E. S., Morse, M. J., Herr, H. W. and Whitmore, W. F.: Endoscopic diagnosis and treat- ment of upper-tract urothelial tumors. A preliminary report. Cancer, 5 5 1422, 1985.
9. Streem, S. B. and Pontes, E. J.: Percutaneous management of upper tract transitional cell carcinoma. J. Urol., 135: 773, 1986.
10. Woodhouse, C. R. J., Kellett, M. J . and Bloom, H. J.: Percutane- ous renal surgery and local radiotherapy in the management of renal pelvic transitional cell carcinoma. Brit. J. Urol., 69: 245, 1986.
11. Orihuela, E. and Smith, A. D.: Percutaneous treatment of trans- itional cell carcinoma of the upper urinary tract. Urol. Clin. N. Amer., 1 5 425, 1988.
12. Nolan, R. L., Nickel, J. C. and Froud, P. J.: Percutaneous en- dourologic approach for transitional cell carcinoma of the renal pelvis. Urol. Rad., 9 217, 1988.
13. Blute, M. L., Segura, J . W., Patterson, D. E., Benson, R. C., Jr. and Zincke, H.: Impact of endourology on diagnosis and man- agement of upper urinary tract urothelial cancer. J . Urol., 141: 1298, 1989.
14. Tasca, A. and Zattoni, F.: The case for a percutaneous approach to transitional cell carcinoma of the renal pelvis. J . Urol., 143: 902, 1990.
15. Martinez-Pineiro, J. A., Matres, M. J. G. and Martinez-Pineiro, L.: Endourological treatment of upper tract urothelial carcino- mas: analysis of a series of 59 tumors. J. Urol., 166: 377, 1996.
16. Keeley, F. X., Jr., Bibbo, M. and Bagley, D. H.: Ureteroscopic treatment and surveillance of upper urinary transitional cell carcinoma. J. Urol., 157: 1560, 1997.
17. Vasavada. S. P., Streem, S . B. and Novick, A. C.: Definitive tumor resection and percutaneous bacillus calmette-guerin for management of renal pelvic transitional cell carcinoma in solitary kidneys. Urology, 4 5 381, 1995.
18. McCoy, J. G., Honda, H., Reznicek, M. and Williams, R. D.: Computerized tomography for detection and staging of local- ized and pathologically defined upper tract urothelial tumors. J. Urol., 146 1500, 1991.
19. Planz, B., George, R., Adam, G., Jakse, G . and Planz, K.: Com- puted tomography for detection and staging of transitional cell carcinoma of the upper urinary tract. Eur. Urol., 27: 146,1995.
20. Keeley, F. X.. Kulp, D. A., Bibbo, M., McCue, P . A. and Bagley, D. H.: Diagnostic accuracy of ureteroscopic biopsy in upper tract transitional cell carcinoma. J . Urol., 157: 33, 1997.
21. Gerber, G. S. and Lyon, E. S.: Endourological management of upper tract urothelial tumors. J . Urol., 150 2, 1993.
22. Patel, A., Soonawalla, P., Shepherd, S. F., Dearnaley, D. P., Kellett, M. J. and Woodhouse, C. R. J.: Long-term outcome aRer percutaneous treatment of transitional cell carcinoma of the renal pelvis. J. Urol., 155 868, 1996.
EDITORIAL COMMENT
In this retrospective study the authors present a short-term fol- lowup (mean 23.6 months) of 17 patients with pyelocaliceal transi- tional cell cancer treated with percutaneous resection or electroco- agulation since 1985. The indication for this approach was mandatory in 14 patients and relative in 3. Most of the tumors were of low gradelstage. The outcome did not differ substantially from that of other series reported previously. Collected results of 167 patients with upper tract transitional cell cancer treated endoscopicaIly, in- cluding the present series, show a 23.3% (39 cases) rate of ipsilateral local recurrence and a cancer specific death rate of 11.2% (references 6, 15 and 21 in article). Many of the recurrences were treated with repeat endourological procedures and all deaths occurred in patients with grade 3, T2-3 tumors in whom the conservative approach was mandatory and/or contraindications existed for nephroureterectomy due to co-morbidity. These data are similar to those reported in Europe with open renal sparing surgery (reference 4 in article).’,’ Of 97 cases treated with local excision of the renal pelvis, partial ne- phrectomy or partial ureterectomy disease recurred in 23 (23.78) and the cause specific 5-year sunrival rate was 73.7% (70 of 95). Also the results from worldwide series of267 patients collected by Wallace et a1 are consistent with these figures. The ipdateral recurrence rate was 29% (60 of 208 cases), cancer death rate 14.56 and the overall %year survival rate 68%.
These data are in disagreement with the statement of the authors
776 PERCUTANEOUS MANAGEMENT OF UPPER TRACT TRANSITIONAL CELL CARCINOMA
contending that results with open conservative procedures have been disappointing in regard to definitive cancer control. Survival does not depend on the type of surgery but on the grade and stage of the tumor.' In the series by Sole Balcolls and Zungri of 26 patients with pT1, grade l/2 tumors treated conservatively only 3 died of progres- sion (11.5%), while of 68 with pT1, grade l/2 tumors treated with radical surgery 19 died (27.9% 1 either postoperatively or with me- tastases. Thus. the problem lies in the gradelstage of the tumor. While grade Y2, Ta tumors are curable with conservative means, grade 3, T any stage cannot be controlled with less than radical surgery.
Consequently, the problem is the accurate prediction of s tag4 grade, which was rarely possible before the advent of ureteroscopy and percutaneous nephroscopy in 1980. Presently, 18 years later there is little doubt about the feasibility and benefits of the endo- scopic approach in appropriate cases. Low gradelstage, small (2 to 3 cm. or less), exophytic, accessible, transitional cell cancer growths of the upper tract can be controlled by resection, fulguration or laser photocoagulation with the same efficacy as in the bladder, with the added bonus of renal parenchyma preservation. In this field, as in
others of urology, treatment should be tailored to the characteristics of the patient and the tumor. The existing data from patients fol- lowed for more than 10 years in some series proved that in select cases (grade U2, Ta T1) long-term cancer-free survival is possible with conservative surgery and that the elective indication is a valid alternative. In grade 3, pT1 transitional cell cancers these proce- dures may serve as an alternative for local control when mandatory but then the results are poor and perhaps nephroureterectomy with dialysis is the better option.
Jose A. Martinez-Pirieiro Urological Service University Hospital La Pat Madrid, Spain
1. Petkovic, S. D.: L'epidemiologie, le pathologie et le traitement des tumeurs du bassinet et de l'uretere. In Tumeurs de la vole Excretice Haute. J. d'Urol., pp. 10-21, 1981.
2. Sole Balcolls, F. and Zungri, E.: Les tumeurs de la voie excretice haute. J. dUrol., pp. 93-105, 1981.
