ENDOUROLOGY & LAPAROSCOPY

Imperative Indications for Conservative Management of Upper Tract Transitional Cell Carcinoma
Krambeck AE, Thompson RH, Lohse CM, Patterson DE, Elliott DS, Blute ML
Departments of Urology and Health Sciences Research, Mayo Medical School and Mayo Clinic, Rochester, Minnesota
J Urol. 2007; 178:792-7

• Purpose: We report our experience with patients with imperative indications for endoscopic treatment for upper tract transitional cell carcinoma.
• Materials and Methods: Between 1983 and 2004 we identified 37 patients with a solitary kidney, bilateral disease or preoperative creatinine greater than 2.0 mg/dL who underwent endoscopic treatment for localized upper tract transitional cell carcinoma. A retrospective chart review was performed.
• Results: Of the 37 patients 32 had a solitary kidney, 3 had bilateral disease and 2 had preoperative creatinine greater than 2.0 mg/dL. Median age at diagnosis was 75 years (range 56 to 88). Bladder cytology was positive or atypical in 15 of 31 patients (48%). Tumors were grade 1 to 3 in 2, 13 and 7 patients, respectively, and diagnosed visually in 15. At a median followup of 2.7 years for survivors 23 patients (62%) had a total of 56 upper tract transitional cell carcinoma recurrences. Grade and stage progression occurred in 3 and 3 patients, respectively. Ten of the 23 patients who experienced upper tract recurrence died of transitional cell carcinoma. Overall kidney preservation was achieved in 24 of the 32 patients (75%) with a solitary kidney. At last followup 24 patients had died, including 11 (29.7%) of transitional cell carcinoma, at a median of 2.9 years. Cancer specific survival at 5 years for this cohort was 49.3%.
• Conclusions: Our results indicate that upper tract tumor recurrence occurs in a majority of patients with imperative indications for endoscopic treatment, underscoring the need for frequent surveillance. While most kidneys can be preserved, cancer specific death is common.
  
  
• Editorial Comment
  Transitional Cell Carcinoma (TCC) of the Upper Tract is one of the most challenges diseases, especially when involves solitary kidneys. The development of digital imaging may have improved the diagnosis of the TCC in the upper tract, as well as, the treatment of small burden disease with laser technology. The treatment of adjuvant intra-collecting system therapy with BCG or other agents was not expanded in this article due to the small number of patients. It will be helpful to establish a multi-center trial to define the role of conservative endoscopic therapy with adjuvant intra-collecting system chemotherapy agents for upper tract TCC.

Dr. Fernando J. Kim
Chief of Urology, Denver Health Med Ctr
Assistant Professor, Univ Colorado Health Sci Ctr
Denver, Colorado, USA
E-mail: fernando.kim@uchsc.edu