Upper Tract Urothelial Tumors

Front 1

Age range for UTUC?
Who's more likely affected, men or women?
whites or blacks?

Back 1

50-79yo
men
whites

Front 2

most important modifiable risk factor a/w UTUC?

Back 2

smoking

Front 3

risk factors for UTUC?

Back 3

smoking
analgesic abuse (phenacetin)
chemicals, coal, asphalt,benzidine, aniline dyes
chronic bacterial infection a/w stones/obstruction
cyclophosphamide
Lynch syndrome II (colonic tumors, extracolonic CA
female

Front 4

risk factor a/w squamous cell CA?

Back 4

chronic bacterial infection a/w urinary stones/obstruction

Front 5

where do ureteral tumors appear more frequently?

Back 5

lower >> upper tract

Front 6

delayed recurrence is most common in the renal pelvis or ureter?

Back 6

ureter

Front 7

are upper tract urothelial cancers a/w good or poor prognosis?

Back 7

poor

Front 8

how do UTUC spread?
3 ways

Back 8

1) direct invasion into the renal parenchyma or surrounding structures
2) lymph or vasc invasion
3) epithelial spread by seeding or direct extension

Front 9

where is the lymphatic spread of UTUC?

Back 9

para-aortic > paracaval > I/L common iliac PLN

Front 10

most common sites of hematongenous mets are?

Back 10

liver, lung, bone

Front 11

the majority of upper tract urothelial cancers are?

Back 11

transitional cell

Front 12

what are the layers of the renal pelvis and calyces?

Back 12

fibrous connective tissue and two layers smooth muscle

Front 13

what are the layers of the proximal and mid ureter?

Back 13

two continuous thin muscle layers

Front 14

what are the layers of the distal (1/3) ureter?

Back 14

3 continuous thin muscle layers

Front 15

upper tract non-transitional cell CA are?

Back 15

squamous cell > adenoCA > micropapillary

Front 16

what is the most important predictor of survival?

Back 16

stage

Front 17

tumor suppressor genes a/w UTUC?

Back 17

TP53
retinoblastoma (RB on 13q
chromosome 9

Front 18

most common location of UTUC?

Back 18

renal pelvis
distal ureter (if in ureter)

Front 19

T1 UTUC

Back 19

invades subepithelial connective tissue

Front 20

T2 UTUC

Back 20

invades muscularis

Front 21

T3

Back 21

renal pelvis- invades into peripelvic fat/renal parenchyma

ureter- invades into periureteral fat

Front 22

T4

Back 22

invades adjacent organs or through kidney into perinephric fat

Front 23

N1

Back 23

single LN 2cm or less

Front 24

N2

Back 24

single LN > 2 cm,but not more than 5

OR
multiple LN none > 5 cm

Front 25

N3

Back 25

LN > 5cm

Front 26

standard treatment of UTUC?

Back 26

nephU- including entire ureter with bladder cuff

Front 27

Which factor is the major determinant of the type of tx for UTUC?

Back 27

stage and grade

Front 28

What are the most common symptoms of localized upper tract tumors?

Back 28

dysuria and hematuria

Front 29

What are the most common symptoms of advanced upper tract tumors?

Back 29

weight loss, fatigue, anemia, bone pain

Front 30

What is the most common finding in imaging studies?

Back 30

filling defect

Front 31

The majority of renal pelvis tumors are...
papillary or sessile?
invasive or noninvasive?

Back 31

papillary
invasive

Front 32

the majority of ureteral tumors are...
low grade or high grade?
invasive or noninvasive?

Back 32

low grade
noninvasive

Front 33

where do most ureteral tumors occur?
distal, mid, or proximal ureter?

Back 33

distal > middle > proximal

Front 34

what type of recurrence is most common after conservative treatment of UTUC?

what % of cases?

Back 34

ipsilateral in a proximal to distal direction

33-55%

Front 35

the high rate of ipsilateral recurrence is due to?

Back 35

multifocal field change

Front 36

what is the best predictor of outcome in patients with multifocal upper tract tumors?

Back 36

stage

Front 37

what is the single most important determinant of outcome in the treatment of upper tract tumors?

Back 37

stage

Front 38

what is the earliest site of spread of proximal ureteral tumors?

Back 38

para-aortic nodes > paracaval nodes

Front 39

3 reasons to consider nephron-sparing surgery for patients with upper tract tumors include?

Back 39

1) tumor in solitary kidney
2) synchronous B/L tumors
3) predisposition to form multiple recurrences- ie Balkan nephropathy, diabetic nephropathy

Front 40

what is the earliest site of spread of distal ureteral tumors?

Back 40

pelvic nodes

Front 41

a 60yo diabetic man is dx with 4cm, grade 2-3/3 TCC of renal pelvis. Cr 2.2. Best treatment option is?

a. ureteroscopic ablation
b. antegrade percutaneous resection
c. pyelotomy and tumor excision
d. radical nephU
e. ileal ureteral substitution

Back 41

d. radical nephU

Front 42

when is a radical nephU the recommended treatment?

Back 42

large, high-grade, invasive tumors of the renal pelvis/proximal ureter

Front 43

A 57yo main with a grade 3, stage T2 tumor of proximal ureter is undergoing radical nephU. Correct management of the ureter requires what?

Back 43

complete distal ureterectomy with a bladder cuff

Front 44

regional lymphadenectomy is or is not helpful for determining prognosis?q

Back 44

is

Front 45

when are segmental ureterectomy and ureteroureterectomy indicated?

Back 45

noninvasive grade 1 and 2 tumors of the proximal and mid ureter that are too large for complete endoscopic ablation

grade 3 or invasive tumors when nephron sparing for preservation of renal function is a factor

Front 46

indications for ureteropyeloscopy?

Back 46

isolated, positive cytologic result from upper tract with normal RPG, bladder washings, cysto, bx because you need direct visualization of small lesions

Front 47

does adjuvant radiation after radical nephU for high-stage disease decrease local relapse or protect against high rate of distant failure, or improve survival?

Back 47

no

Front 48

doe metastatic TCC of the upper tract respond to the same chemo as that used for bladder cancer?

Back 48

yes

Front 49

after a proper laparoscopic nephU, surveillance is best accomplished by?

Back 49

cystoscopy and cytology

Front 50

when is a retrograde ureteroscopic approach used?

Back 50

low-volume ureteral and renal tumors

Front 51

when is an antegrade percutaneous approach preferred?

Back 51

larger tumors of the upper ureter or kidney

OR

those that cannot be adequately manipulated in a retrograde approach because of location (lower calyx) or previous urinary diversion

Front 52

what are 4 advantages of the ureteroscopic approach?

Back 52

1) decreased morbidity when compared with percutaneous renal surgery

2) maintenance of a closed system without exposure of nonurothelial surfaces to tumor cells

3) ease of access to the entire urinary tract without extensive dilitation of the ureteral orifice

4) can usually be done as OP

Front 53

has there been demonstrated improvement in survival or recurrence rate with adjuvant instillation therapies, mitomycin or BCG, for upper tract TCC?

Back 53

no

Front 54

what is the treatment when a tumor protrudes from the UO?

Back 54

complete ureteroscopic ablation of the tumor

OR

aggressive transurethral resection of the entire most distal ureter

Front 55

which of the following is NOT true regarding f/u after treatment of UTUC?

a. patients unergoing conservative tx need interval endoscopy of I/L urinary tract for tumor recurrence
b. f/u should be identical for all patients regardless of tumor stage or grade
c. cross-sectional imaging with CT of MRI is necessary with high-grade and high-stage tumors to assess for local recurrence and metastatic spread
d. efficient and cost-effective f/u should be based on tumor grade and stage
e. all patients ned interval eval of the C/L urinary tract to assess for B/L disease

Back 55

b. f/u whould be identical for all patients regardless of tumor stage/grade

Front 56

all of the following statements regarding percutaneous approach to UTUC are true except?

a. nephrostomy should be maintained for postop surveillance nephroscopy of the tract for tumor implantation
b. tumor seeding of the nephrostomy tract is a common complication
c. adjuvant therapy with BCG can be given through the established nephrostomy
d. the larger endoscopes used for percutaneous removal of TCC allow for tumor staging as well as grading
e. percutaneous tumor resection has a higher morbidity rate when compared with ureteroscopic approach

Back 56

b. tumor seeing of the nephrostomy tract may occur, but is NOT common

Front 57

what does low-grade, noninvasive TCC look like?

Back 57

papillary architecture
orderly nature of cells
low mitotic numbers
no ureteral wall invasion

Front 58

UTUC develop in what % of patients with bladder CA?

Back 58

2-4%

Front 59

what % of patient with UTUC develop bladder CA?

Back 59

30%

Front 60

what is the most significant predictor of metastases in renal pelvic tumors?

Back 60

parenchymal invasion

Front 61

long term obstruction, inflammation, and occasionally calculi are a/w which type of CA?

Back 61

squamous cell & adenoCA

Front 62

is it likely that cancers will arise from inverted papilloma?

Back 62

no

Front 63

is lymphovascular invasion a predictor of a good or poor prognosis?

Back 63

poor

Front 64

what is the % recurrence rate in ureteral tissue left distal to an invasive ureteral CA?

Back 64

30-50%

Front 65

Who has a better survival rate?
Patient with a T3 tumor in the renal pelvis or on with a T3 tumor in the ureter?

Back 65

renal pelvis

Front 66

Is an adrenalectomy indicated for patients undergoing a nephU for UTUC?

Back 66

no

Front 67

Why is a perc neph tube left in place for several weeks after resection?

Back 67

for revisualization to be certain that all tumors have been removed

Front 68

What is Balkan nephropathy?

Back 68

interstitial nephritis that causes renal insufficiency in people endemic to SE Europe- Croatia, Bosnia, Serbia, Romania, Bulgaria.

Greater risk of UTUC

Front 69

What is Lynch Syndrome II?

Back 69

autosomal dominant hereditary syndrome involving early colon tumors and UTUC

Front 70

most UTUC are
low or high grade?
low or high stage?
papillary or sessile?

Back 70

low grade
low stage
papillary

Front 71

what is the most common symptom a/w UTUC?

Back 71

hematuria- micro or gross

Front 72

when do you preform nephron sparing surgery?

Back 72

low grade, low stage lesions

Front 73

when is endoscopic/ureteroscopic surgery best?

Back 73

low grade, unifocal lesions of ureter, pelvis, upper pole calyx

Front 74

DDx of upper tract filling defect

Back 74

1 radiolucent stone
2 blood clot
3 renal papillae
4 fungus ball
5 extrinsic vascular compression
6 renal parenchymal tumor
7 urothelial cancer
8 ureteritis/pyelitis cystica
9 TB
10 stricture
11 endometriosis

Front 75

best treatment for low-grade distal ureteral tumors?

Back 75

distal ureteral excision and reimplantation

Front 76

best treatment option for low grade mid to proximal ureteral tumors?

Back 76

primary excision and anastamosis

Front 77

when do you perform segmental resection or local excision?

Back 77

low grade, low stage tumors in both kidneys or solitary kidney with poor renal function

Front 78

when do you perform instillation therapy?

Back 78

multiple superficial tumors or CIS with comporomised renal function or B/L disease

Front 79

when is radiation therapy indicated?

Back 79

local control of tumor and as adjuvant therapy for high-grade or invasive lesions

Front 80

why do you have to put in a stent before chemo if a patient has hydro?

Back 80

cisplatin is nephrotoxic and you want to preserve as much renal function as possible

Front 81

Balkan nephropathy is a/w what type of tumors?

Back 81

low grade
B/L
multiple

Front 82

two most common presenting signs of UTUC?

Back 82

hematuria
flank pain

Front 83

what % of urothelial tumors are located in the upper tract?

Back 83

5-8%

Front 84

what % of primary renal tumors are of urothelial origin?

Back 84

5%

Front 85

tumor marker a/w tumor progression most often?

Back 85

p53

Front 86

Ureteroscopic biopsy is accurate for final tumor stage, grade, neither, or both?

Back 86

grade, but not stage because can't get good enough bite.. sample is usually too small

Front 87

what is acrolein?

Back 87

metabolic breakdown product of cyclophosphamide

Front 88

Are tumors a/w chemo high or low grade?

Back 88

high

Front 89

% incidence of B/L UTUC either synchronous or metachronous?

Back 89

2-5%

Front 90

what % of UTUC present with mets?

Back 90

19%

Front 91

what is the pattern of spread for UTUC?

Back 91

direct extension
lymphatic invasion
vascular invasion

Front 92

how often will TCC of the upper tracts develop in patients with CIS of the bladder?

Back 92

25%

Front 93

What is ARISTOLOCHIA FANCHI? why is it important urologically?

Back 93

chinese herb used for weight loss a/w UTUC

Front 94

what is the MOA of cisplatin?

Back 94

inhibit DNA covalent bond and cross linking