British Journalof Urology (1991), 67, 32-36 01991British Journal of Urology
Transitional Cell Carcinoma of the Upper Urinary Tract: Prognostic Variables and Post-operative Recurrences J. KROGH.
E. KVIST and B. RYE
Department of Urology 0, Bispebjerg Hospital, Copenhagen
Summary-In a retrospective study of 198 patients with transitional cell carcinoma of the upper urinary tract, post-operative recurrences developed as contralateral tumours in 2.5%, in the ureteric stump after conservative resection in 19%and in the bladder in 36.4%.Upper tract recurrences resembled the primary tumours in terms of grade and stage; of the bladder tumours, 89%were similar in grade and 72% similar in stage to the primary tumours. Age, sex, grade and stage had no effect on the number of bladder recurrences, but ureteric tumours had significantly more recurrences than renal pelvicaliceal tumours. Sex, bladder recurrences and site of primary tumours did not influence survival. Thus grade and stage of the primary tumour were the only predictive variables of the final outcome.
Transitional cell carcinoma (TCC) of the upper urinary tract is an uncommon disease that accounts for approximately 6 to 8% of all upper tract and urothelial tumours (McCarron et al., 1983; Huben et al., 1988). The various parts of the urinary tract form a coherent whole and due to the fact that coexistence of widespread dysplasia has been demonstrated (Auld et al., 1984; Kakizoe et al., 1980) and that bladder tumours in many respects behave like tumours of the upper urinary tract (Kvist et al., 1988), follow-up is needed to detect further tumour development in the remaining urothelium. Earlier studies have shown subsequent contralateral tumours in up to 9% of patients (Hatch et al., 1988; Kirkali et al., 1989), ipsilateral tumours in about 22% after local resection (Mufti et al., 1989), ureteric stump recurrences in 15 to 64% of nephrectomy and partial nephro-ureterectomy (Kakizoe et al., 1980; Kirkali et al., 1989) and bladder tumours in 18 to 48% (Kakizoe et al., 1980; Mufti et al., 1989). Although follow-up may include cytology of the urine and ultrasound examination of the bladder, cystoscopy remains the conventional means of detecting bladder tumours, with intra-
venous urography and pyelography used in the case of pelvicaliceal and ureteric tumours. Endoscopic monitoring is time-consuming, expensive and inconvenient for patients, but necessary as long as no effective adjuvant radiotherapy or chemotherapy can be offered (Huben et al., 1988; Mufti et al., 1989). The intervals between post-operative endoscopic checks must be based upon data showing the likelihood of consistency between grades of dysplasia and invasive potential among primary and secondary tumours ; estimates of time-related risks for the latter are mandatory. We have examined our records over the last 22 years in order to define prognostic factors that could affect the number of recurrences or survival following TCC of the upper urinary tract. Patients and Methods A total of 280 patients were treated for TCC of the upper urinary tract between 1965 and 1987. For a variety of reasons (age, physical debility, advanced disease, removal to other areas, other concurrent neoplasm or death), no follow-up was done in 82 cases. This left 198 patients (median age 68 years, range 42-88) for evaluation. Surgical procedures
Accepted for publication 15 February 1990
32
TRANSITIONAL CELL CARCINOMA OF THE UPPER URINARY TRACT
included 9 nephrectomies, 28 partial nephroureterectomies and 129nephro-ureterectomies with excision of cuff of bladder. Local resections were performed in 32 patients as the only procedure and in 2 cases due to bilateral involvement. In the observation period 3 patients underwent radical cystectomy. Follow-up (mean 46 months, rang,e 3-240) include cystoscopy every 3 months regardless of stage and grade, although the intervals were gradually increased until no recurrence had been demonstrated over the course of 5 years. If ureteric or pelvicaliceal tumours were suspected, cytology of the urine, intravenous urography and retrograde pyelography were done. Data concerning the status of the patients were provided by the National Register; 124 patients died during the ,studyperiod. Dysplasia (grades 0-IV) was classified according to Bergkvist et al. (1965). Grades I and I1 represented low grade tumours and grades 111 and IV represented high grade tumours. Grade I corresponds to Grade I (WHO), Grade I1 to Grade I1 (WHO) and Grades I11 and IV lo Grade IJI (WHO) in the 1973 WHO classification (de Voogt et al., 1979). Staging was done according to the TNM classification (UICC, 1978). Tumours inffiltrating the subepithelial connective tissue were considered invasive. Statistical methods Tumour recurrence rates according to age, sex, grade or dysplasia, stage and location were analysed using Fisher's exact test (1 d.f.). Survival and description of the first post-operative bladder tumour were calculated using Kaplan and Meier's life-table method. Comparison of survival rates was based on the log-rank test (d.f. =no. of groups - 1). Unless otherwise indicated, intervals (percentages) in brackets represent the 957; confidence limits (binomial). A 5% level of probability (P
Transitional Cell Carcinoma of the Upper Urinary Tract: Prognostic Variables and Post-operative Recurrences J. KROGH.
E. KVIST and B. RYE
Department of Urology 0, Bispebjerg Hospital, Copenhagen
Summary-In a retrospective study of 198 patients with transitional cell carcinoma of the upper urinary tract, post-operative recurrences developed as contralateral tumours in 2.5%, in the ureteric stump after conservative resection in 19%and in the bladder in 36.4%.Upper tract recurrences resembled the primary tumours in terms of grade and stage; of the bladder tumours, 89%were similar in grade and 72% similar in stage to the primary tumours. Age, sex, grade and stage had no effect on the number of bladder recurrences, but ureteric tumours had significantly more recurrences than renal pelvicaliceal tumours. Sex, bladder recurrences and site of primary tumours did not influence survival. Thus grade and stage of the primary tumour were the only predictive variables of the final outcome.
Transitional cell carcinoma (TCC) of the upper urinary tract is an uncommon disease that accounts for approximately 6 to 8% of all upper tract and urothelial tumours (McCarron et al., 1983; Huben et al., 1988). The various parts of the urinary tract form a coherent whole and due to the fact that coexistence of widespread dysplasia has been demonstrated (Auld et al., 1984; Kakizoe et al., 1980) and that bladder tumours in many respects behave like tumours of the upper urinary tract (Kvist et al., 1988), follow-up is needed to detect further tumour development in the remaining urothelium. Earlier studies have shown subsequent contralateral tumours in up to 9% of patients (Hatch et al., 1988; Kirkali et al., 1989), ipsilateral tumours in about 22% after local resection (Mufti et al., 1989), ureteric stump recurrences in 15 to 64% of nephrectomy and partial nephro-ureterectomy (Kakizoe et al., 1980; Kirkali et al., 1989) and bladder tumours in 18 to 48% (Kakizoe et al., 1980; Mufti et al., 1989). Although follow-up may include cytology of the urine and ultrasound examination of the bladder, cystoscopy remains the conventional means of detecting bladder tumours, with intra-
venous urography and pyelography used in the case of pelvicaliceal and ureteric tumours. Endoscopic monitoring is time-consuming, expensive and inconvenient for patients, but necessary as long as no effective adjuvant radiotherapy or chemotherapy can be offered (Huben et al., 1988; Mufti et al., 1989). The intervals between post-operative endoscopic checks must be based upon data showing the likelihood of consistency between grades of dysplasia and invasive potential among primary and secondary tumours ; estimates of time-related risks for the latter are mandatory. We have examined our records over the last 22 years in order to define prognostic factors that could affect the number of recurrences or survival following TCC of the upper urinary tract. Patients and Methods A total of 280 patients were treated for TCC of the upper urinary tract between 1965 and 1987. For a variety of reasons (age, physical debility, advanced disease, removal to other areas, other concurrent neoplasm or death), no follow-up was done in 82 cases. This left 198 patients (median age 68 years, range 42-88) for evaluation. Surgical procedures
Accepted for publication 15 February 1990
32
TRANSITIONAL CELL CARCINOMA OF THE UPPER URINARY TRACT
included 9 nephrectomies, 28 partial nephroureterectomies and 129nephro-ureterectomies with excision of cuff of bladder. Local resections were performed in 32 patients as the only procedure and in 2 cases due to bilateral involvement. In the observation period 3 patients underwent radical cystectomy. Follow-up (mean 46 months, rang,e 3-240) include cystoscopy every 3 months regardless of stage and grade, although the intervals were gradually increased until no recurrence had been demonstrated over the course of 5 years. If ureteric or pelvicaliceal tumours were suspected, cytology of the urine, intravenous urography and retrograde pyelography were done. Data concerning the status of the patients were provided by the National Register; 124 patients died during the ,studyperiod. Dysplasia (grades 0-IV) was classified according to Bergkvist et al. (1965). Grades I and I1 represented low grade tumours and grades 111 and IV represented high grade tumours. Grade I corresponds to Grade I (WHO), Grade I1 to Grade I1 (WHO) and Grades I11 and IV lo Grade IJI (WHO) in the 1973 WHO classification (de Voogt et al., 1979). Staging was done according to the TNM classification (UICC, 1978). Tumours inffiltrating the subepithelial connective tissue were considered invasive. Statistical methods Tumour recurrence rates according to age, sex, grade or dysplasia, stage and location were analysed using Fisher's exact test (1 d.f.). Survival and description of the first post-operative bladder tumour were calculated using Kaplan and Meier's life-table method. Comparison of survival rates was based on the log-rank test (d.f. =no. of groups - 1). Unless otherwise indicated, intervals (percentages) in brackets represent the 957; confidence limits (binomial). A 5% level of probability (P
