Ureter


 * **Epidemiolgy:** || ** Cancer of the Ureter1 **
 * Transitional cell carcinoma of the upper urinary tract accounts for 7% of all renal neoplasms and 5% of all urothelial malignancies
 * The estimated number of deaths each year is 12,890 for both sexes
 * Two to three times more common in men than women
 * Peak incidence is among ages 50-70
 * Patients with cancer at one site in the upper urinary tract are at greater risk of developing transitional tumors elsewhere
 * 1/3 of patients with upper urinary tract tumors develop bladder cancer ||
 * **Etiology:** || Because the mucosal surfaces of the renal pelvis, ureter, and bladder have the same embryologic origin, many of the etiologic factors factors in renal pelvis and ureter tumors also apply to tumors of the urinary bladder. 2

https://uwlmedicaldosimetry2012.wikispaces.com/Bladder

GX Grade cannot be assessed G1 -Well differentiated G2 -Moderately differentiated or undifferentiated G3-4 ---Poorly differentiated or undifferentiated ||
 * Causes of Ureter Cancer ** 2
 * Urban residency
 * Tobacco use
 * Aminophenol exposure
 * Renal stones
 * Phenacetin abuse ||
 * **Signs & Symptoms:** || ** Signs and Symptoms of Ureter Cancer ** 2
 * Gross or microscopic hematuria occurs in 70% to 90% of patients
 * Pain (8% to 40%)
 * Bladder irritation (5% to 10%)
 * 10% to 20% of patients may present with a flank mass secondary to the tumor or hydronephrosis ||
 * **Diagnostic Procedures:** || DIAGNOSTIC PROCEDURES FOR URETER CARCINOMA3
 * Intravenous urography is frequently used to evaluated patients with renal pelvis carcinoma; a filling defect in the renal pelvis or collecting system is common.
 * Retrograde pyelography can be used to define the lower margin of a ureteral lesion, especially if there is significant proximal obstruction to flow of contrast from the renal pelvis.
 * CT or MRI of the abdomen and pelvis before and after contrast administration gives useful information about possible extension of tumor outside the collecting system.
 * An accurate cytologic diagnosis can be made in more than 80% of cases. ||
 * **Histology:** || In the ureter over 90% of tumors are transitional cell carcinomas. 7-8% are squamous cell carcinomas.3 ||
 * **Lymph node drainage:** || Drainage of the ureter is segmented and diffuse and may involve any of the renal hilar, abdominal para-aortic, paracaval, common iliac, internal iliac or external iliac lymph nodes.3 ||
 * **Metastatic spread:** || Transitional cell carcinoma of the upper urothelial tract may spread by both direct extension and blood-borne and lymphatic metastases 3 The most common sites for distant metastases are the lungs, liver, bladder and peritoneal cavity. 4 ||
 * **Grading:** || Histopathologic grade 3
 * **Staging:** || AJCC Staging System 3

Primary tumor (T) TX: Primary tumor cannot be assessed T0: No evidence of primary tumor Ta: Papillary noninvasive carcinoma Tis: Carcinoma in situ T1: Tumor inades subepithelial connective tissue T2: Tumor invades muscularis T3: Tumor invades beyond muscularis into periureteric fat T4: Tumor invades adjacent organs or through the kidney into perinephric fat

Regional lymph nodes (N)a NX: Regional lymph nodes cannot be assessed N0: No regional lymph node metastasis N1: Metastasis in a single lymph node, less than or equal to 2 cm in greatest dimension N2: Metastasis in a single lymph node, greater than 2 cm but less than 5 cm in greatest dimension N3: Metastasis in a lymph node greater than 5 cm in greatest dimension

Distant metastasis MX: Distant metastasis cannot be assessed M0: No distant metastasis M1: Distant metastasis || Radiation Therapy > || Kidney: (1/3)5000 cGy, (2/3)3000 cGy, (3/3)2300 cGy Spinal Cord: (1/3) 5cm-5000 cGy, (2/3) 10cm- 5000 cGy, (3/3) 20cm- 4700 cGy Bladder: (1/3)N/A, (2/3)8000 cGy, (3/3)6500 cGy Liver: (1/3)5000 cGy, (2/3)3500 cGy, (3/3)3000 cGy Cauda Equina: (1/3)N/A, (2/3)N/A, (3/3)6000 cGy ||
 * **Radiation side effects:** || Radiation side effects are similar to those from irradiation of upper abdomen and may include: nausea, vomiting, diarrhea, and abdominal cramping. When patients are treated for right-sided lesions, radiation-induced damage to the liver is possible.4 ||
 * **Prognosis:** || Staging and grading are the two major prognostic factors. Lower survival is associated with distant metastasis. In addition to these factors, DNA patterns (diploid vs. nondiploid) and number of lesions also play a role in survival. Patients with diploid tumors had a 79% survival rate, compared with only 46% in those with nondiploid tumors. Most transitional cell cancer of the renal pelvis and ureter can be cured if found early.4 ||
 * **Treatments:** || Surgery
 * Radical nephroureterectomy (including the removal of the contents of Gerota's fascia and the ipslateral ureter with a cuff of bladder at its distal end) is an appropriate initial therapy for patients with transitional cell carcinoma of the renal pelvis or ureter.
 * Conservative Surgery should only be used for low grade, low stage and solitary tumors with poor kidney function or only one kidney. If this is used, post-operative radiation therapy should be considered.
 * Postoperative radiation therapy is used in the management of ureter cancer; retrospective data suggests a decreased local recurrence with this regimen.
 * The clinical target volume for upper ureter lesions should include the renal fossa, the entire ureter down to the bladder wall at the ipslateral trigone. This field can be modified to include the paracaval and paraaortic lymph nodes at risk.The renal hilar nodes are also included.
 * Doses of 45-50 Gy (1.8 to 2.0) are used to treat subclinical and microscopic disease.
 * Higher doses are considered for more extensive disease (multiple positive lymph nodes or positive surgical margins) by boosting the area with an additional 5 to 10 Gy.
 * The dose to the contralateral kidney should not exceed 18 Gy.
 * The volume of liver and stomach may be reduced with AP/PA fields.
 * Lateral fields are used to keep the spinal cord dose within tolerance (45 Gy).
 * Lower ureteral lesions, the pelvic lymph nodes should be included in the fields. A three (PA and lateral fields) or four field technique is used based on the posterior location of the ureter with the patient lying prone (minimized small bowel dose). 5
 * Unresectable or bulky disease is treated with higher doses. This treatment may include oblique and lateral fields. Toxicity is a challenge with the multiple field arrangements. Chemotherapy
 * Palliative chemotherapy is considered for metastatic disease.
 * Regimens of Methotrexate, Vinblastine, Doxorubicin and cisplatin have shown objective response rates in about 70% of patients with metastatic transitional cell carcinoma of the ureter. 5
 * [[image:renal pelvis.jpg]]
 * Figure 1: Postoperative Radiation Portal for Renal Pelvis and Ureter. 5
 * Chemotherapy
 * Palliative chemotherapy is considered for metastatic disease.
 * Regimens of Methotrexate, Vinblastine, Doxorubicin and cisplatin have shown objective response rates in about 70% of patients with metastatic transitional cell carcinoma of the ureter. 5
 * **TD 5/5:** || TD 5/5 is a statistical guideline to consider which states that there has been a five percent probability of complication in five years. These values are based on a 200cGy 5 fraction a week treatment schedule.6
 * **References:** || # Hoppe RT, Phillips TL, Mack III M. Leibel and Phillips Textbook of Radiation Oncology. 3rd ed. Philadelphia Pa: Elsevier Saunders; 2010.
 * 1) Perez CA, Brady LA, Halpern EC, Schmidt-Ullrich RK. Principles and Practice of Radiation Oncology. 4th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2004.
 * 2) Chao KC, Perez CA, Brady LW. Radiation Oncology Management Decisions. 3rd ed. Philadelphia, PA; Lippincott Williams & Wilkins. 2011: 469-479.
 * 3) Washington CM, Leaver D. Principles and Practice of Radiation Therapy. 3th ed. St. Louis, MI: Mosby. 2004: 845-860.
 * 4) Chao KS, Perez CA, Brady LW. Radiation Oncology Management Decisions. 2nd edition. Philadelphia, PA: Lippincott Williams & Wilkins. 2002; 422-428.
 * 5) Radiation Oncology/Toxicity/Emami. Wikibooks. Available at: [] . Accessed: June 12, 2012. ||

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