Issues in Assessing for Recurrence
- The propensity of upper tract tumors for multifocal recurrence and metastatic spread with more dysplastic lesions makes follow-up complicated.
- Postoperative evaluation must routinely include evaluation of the bladder, the ipsilateral (if organ-sparing therapy was chosen) and contralateral urinary tracts, and the extraurinary sites for local and metastatic spread.
- A follow-up regimen is thus dependent on the time from surgery, the approach chosen (organ sparing vs. radical), and the potential for metastatic spread.
Physical Examination, urine cytology (for high grade lesions) and cystoscopy:
- Every three months for the first year
- Every six months for years two and three
- Annually for years four and beyond.
Contralateral imaging - annually
Ipsilateral endoscopy (for patients of organ-saparing therapy)
- Every six months for the first several years
- Annually thereafter
Metastatic evaluation is necessary in all patients with significant risk of disease progression (high grade or invasive disease).
- Phyical examination, chest xray, comprehensive metabolic panel with liver enzymes:
- Every three months for the first year
- Every six months for years two and three
- Annually for years four and five
- After year five: evaluation of urothelium only
- Computed tomography (CT) or MRI pelvis and abdomen
- Every six months years one and two
- Annualy years three through five.
- Bone scan only for elevated alkaline phosphatase level symptoms of bone pain.
This schedule is largely based on work with bladder TCC that shows that most tumor recurrences after bladder resection develop in the first year.
One marker that may be preferentially more involved in upper tract TCC than in bladder TCC is the DNA mismatch repair gene MSH2.
Metastatic Restaging
- Metastatic restaging is required in all patients at significant risk for disease progression to local or distant sites.
- This group includes those with high-grade or high-stage disease.
- Metastatic restaging is generally not necessary for low-grade disease when the risks of invasive and subsequent metastatic disease are negligible.
- Included in metastatic restaging is imaging of the ipsilateral renal bed for recurrence with cross-sectional imaging.
- Follow-up restaging includes chest radiograph, liver function tests, cross-sectional body imaging, and selective use of bone scintigraphy based on an understanding of natural disease history and metastatic pathways.
Treatment of Metastatic Disease
- Outcomes are poor in patients with metastatic urothelial tumors of the upper urinary tract.
- The systemic chemotherapy regimens offered for treatment are the same as those used for TCC of the bladder.
- The MVAC (methotrexate/vinblastine/doxorubicin [Adriamycin]/cisplatin) regimen continues to have the highest response rate.
- Complete responses are rare, and the duration of response is limited, with overall survival of 12 to 24 months. Toxicity is high and dose limited in some patients.
- Controlled trials limited to upper tract tumors are not practical because of the low prevalence of disease.
References:
- Babaian RJ, Johnson DE, Llamas L, et al: Metastases from transitional cell carcinoma of the urinary bladder. Urology 1980; 16:142.
- Keeley FX, Bibbo M, Bagley DM: Ureteroscopic treatment and evaluation of the upper tract TCC. J Urol 1997; 157:1560.
- Kerbl K, Clayman RV: Incision of the ureterovesical junction for endoscopic surveillance of transitional cell cancer of the upper urinary tract. J Urol 1993; 150:1440-1443.
- Murphy DM, Zincke H, Furlow WL: Management of high grade transitional cell cancer of the upper urinary tract. J Urol 1981; 125:25-29.
- Petkovic SD: Epidemiology and treatment of renal pelvic and ureteral tumors. J Urol 1975; 114:858-865.
- Sternberg DW, Yagoda A, Scher HI, et al: Methotrexate, vinblastine, doxorubicin, and cisplatin for advanced transitional cell carcinoma of the urothelium: efficacy and patterns of response and relapse. Cancer 1989; 64:2448-2458.