Epidemiology
- About 5 – 10 % of urothelial cancers
- Rare – 2 / 100 000 – but more common in Balkan countries
- More common in men, and 70 – 80s
- 2:1 pelvicalyceal to ureter
- Ureteric disease – distal > mid > prox
- Usually single unit, but 5 % bilateral disease
- Mutifocal in 10 – 20 %, concurrent CIS in 10 – 30 %
- Approx 60 % invasive at diagnosis
- Approx 7 % metastasised at diagnosis
- Concurrent bladder cancer in 20 % of patients with upper tract cancer (as opposed to 2 – 5 % chance of upper tract cancer if bladder cancer)
- 20 – 50 % chance of recurrence in bladder after treatment
Risk factors
- Smoking
- Male > female 3:1
- Aristolochic acid, a toxin produced by the aristolochia plant
- Medicinal chinese herb
- Wheat in the Balkan countries is contaminated by aristolochia -> Balkan nephropathy/interstitial nephritis and 100 x risk of UTUC
- Phenacetin (Bex) – chemical structure similar to aniline dyes
- Occupation exposures similar to TCC
- Cyclophosphamide
- Arsenic
- Lynch syndrome (HNPCC)
- Chronic inflammation ?SCC
- Bladder cancer
- CIS, trigonal/UO disease, stent at time of TURBT, reflux
- Positive ureteric margin at cystectomy – 2-6 % develop UTUC
Pathology
- Almost all are pure urothelial carcinomas – SCC/adenocarcinoma etc are very rare
- Biopsies are usually very small specimens are stage is difficult to analyse
- Grade (high vs low grade) used as surrogate for stage
- Ureteric tumours more likely to be higher stage than pelvicalyceal
Metastatic disease
- Lungs, liver, bones and regional lymph nodes are common sites
- Renal pelvis/upper ureter tends to go to retroperitoneal nodes, while distal ureteric tends to go to pelvic nodes
| Upper tract lesions – differential | |
| Benign | Malignant |
| Blood clot
Fungal ball Sloughed papillae Stones Fibroepithelial polyp Inverted papilloma Malakoplakia |
Urothelial cancer
SCC Adenocarcinoma
|