© 1991 S. Karger AG, Basel 0302-2838/91/0191-0019$2.75/0
Eur Urol 1991;19:19-23
Clinicopathological Study of Upper Urinary Tract Tumors Associated with Bladder Tumors
1603436
H. Sekine, I. Fukui, T. Yamada, K. Kihara, K. Ishizaka, H. Ohshima Department of Urology, Tokyo Medical and Dental University School of Medicine, Tokyo, Japan
Key Words. Upper urinary tract tumor • Bladder tumor • Implantation • Multicentricity Abstract. Among 535 cases of urothelial tumors (upper urinary tract and bladder tumors) from 1970 to 1988, 40 had upper urinary tract tumor associated with bladder tumor. Of 40 cases, 18 (45%) were synchronous, 17 (43%) were metachronous with primary upper urinary tract tumor followed by subsequent bladder tumor 18.5 ± 14.1 (x ± SD) months later and 5 (12%) were metachronous with primary bladder tumor followed by subsequent upper urinary tract tumor 40.2 ± 13.6 months later. The incidence (17/52 = 0.32) of bladder tumor occurrence subsequent to primary upper urinary tract tumor was much higher than that (5/465 = 0.01) of upper urinary tract tumor subsequent to primary bladder tumor. The histologic grades of upper urinary tract tumor and associated bladder tumor were consistent in 73%. Except in 1 case, multiple occurrence of upper urinary tract tumor was always observed unilaterally on the side involved. The current results not only support the theory of multicentricity but raise the possibility that tumor cell implantation may play some role at least in the development of bladder tumor subsequent to upper urinary tract tumor.
In the clinical management of urothelial tumors, the high incidence of tumor recurrence and the occurrence of multiple tumors at multiple sites of the urinary tract are most important problems. In upper urinary tract tumors (renal pelvis and ureter), concurrent or subse quent occurrence of bladder tumors has been known to be rather frequent, with an incidence of 30-50% [1-3]. On the other hand, occurrence in the upper urinary tract subsequent to the treatment of primary bladder tumor is not so common [4, 5], eventhough the incidence of blad der tumors in general is several times higher than that of upper urinary tract tumors [6]. The current study was performed to investigate the clinicopathological charac teristics of multiple tumor development in both upper urinary tract and bladder, and to shed some light on the mechanism of multiple occurrence and recurrence of urothelial tumors.
Materials and Methods Since recurrence of urothelial tumors may take place shortly or long after the treatment of initial tumors, patients selected for the current study were 535 cases who had been initially treated for uro thelial tumors at our institute from 1970 to 1988. The patients were followed up by cystoscopy and urinary cytology every 3 months, and by intravenous pyelography every 6 months. Retrograde pyelogra phy and washing cytology of the upper urinary tract were indicated whenever upper urinary tract tumor was suspected. The follow-up was completed in December 1989. Of these 535 patients, 75 had urothelial tumor in the upper urinary tract; 40 were associated with metachronous or synchronous bladder tumors and 35 with upper urinary tract tumors only (table 1). There were no cases in which subsequent tumor recurrence in other sites of the urinary tract was diagnosed at autopsy. Histopathological slides of 32 cases among 40 with upper uri nary tract tumor associated with bladder tumor were available with diagnosis of transitional cell carcinoma. Grading and staging of bladder tumor were done according to a guideline defined by the Japanese Urological Association [7]. As for upper urinary tract tumor, grading followed the above guideline and staging followed Downloaded by: University of Exeter 144.173.6.94 - 5/7/2020 2:51:29 AM
Introduction
Table 1. Patients followed for primary urothelial tumors and subsequent tumor recurrence in other urinary tract Number of cases
Primary tumor
Number of cases
Subsequent tumors BT(-)
UUTT
52
UUTT+BT
18
BT(+)
17
Tumor type
Median age years
Male:Female
35
UUTT only
26:9
65
40
UUTT+BT
30:10
63
350:110
64
406:129
64
'
f UUTT(+) 5 465
BT
460
UUTT(-)
BT only
535
Total
BT = Bladder tumor; UUTT = upper urinary tract tumor.
Table 2. Incidence and time interval of metachronous occurrence of subsequent bladder tumors and upper urinary tract tumors Site of UUTT renal pelvis Metachronous UUTT -> BT BT -> UUTT Synchronous Total
ureter
Total cases
Incidence
Interval, months (mean ± SD)
17/52 = 0.32 5/465 = 0.01
18.5± 14.1* 40.2 ±13.6*
renal pelvis and ureter
9 3 4
6
2
2
0
10
4
17 5 18
16
18
6
40
* p < 0.02. See footnote of table 1 for abbreviations.
Table 3. Time interval (years) between the manifestation of initial and subsequent tumors according to the grade of upper urinary tract tumor Grade
Total
UUTT -> BT interval 3
4
5
0
1
0
0
1
3 2
0
0
2
1
0
0
8 8
5
2
0
2
17
1
2
G, g2 G3
0 3 5
Total
8
BT —> UUTT interval
Total
1
2
3
4
5
0 0
0
1 0 0
0
0
2
0
0
2 3
0
0
0
0
1
2
0
1
5
0
0
1 0
1
6
See footnote of table 1 for abbreviations.
Results Among 40 patients with upper urinary tract tumor and bladder tumor, 18 had both synchronously, 17 had primary upper urinary tract tumors and 5 had primary bladder tumors (table 1). Multiple occurrence of upper urinary tract tumor was observed in 16 of 40 cases, and was always unilateral except in 1 case. Downloaded by: University of Exeter 144.173.6.94 - 5/7/2020 2:51:29 AM
the TNM system [8]. Treatment of upper urinary tract tumors con sisted of total nephroureterectomy in 32 cases, simple nephrectomy in 5, partial resection of the lower portion of the ureter with ureteroneocystostomy in 2 and no surgery in 1. The remaining contra lateral kidney was removed in 1 patient who had metachronous bilateral upper urinary tract tumors. Survival rates were analyzed by actuarial calculation with the Kaplan-Meier method. The Cox-Mantel test was used to compare survival curves.
Upper Urinary Tract Tumor Associated with Bladder Tumor
21
100%
Eur Urol 1991;19:19-23
Clinicopathological Study of Upper Urinary Tract Tumors Associated with Bladder Tumors
1603436
H. Sekine, I. Fukui, T. Yamada, K. Kihara, K. Ishizaka, H. Ohshima Department of Urology, Tokyo Medical and Dental University School of Medicine, Tokyo, Japan
Key Words. Upper urinary tract tumor • Bladder tumor • Implantation • Multicentricity Abstract. Among 535 cases of urothelial tumors (upper urinary tract and bladder tumors) from 1970 to 1988, 40 had upper urinary tract tumor associated with bladder tumor. Of 40 cases, 18 (45%) were synchronous, 17 (43%) were metachronous with primary upper urinary tract tumor followed by subsequent bladder tumor 18.5 ± 14.1 (x ± SD) months later and 5 (12%) were metachronous with primary bladder tumor followed by subsequent upper urinary tract tumor 40.2 ± 13.6 months later. The incidence (17/52 = 0.32) of bladder tumor occurrence subsequent to primary upper urinary tract tumor was much higher than that (5/465 = 0.01) of upper urinary tract tumor subsequent to primary bladder tumor. The histologic grades of upper urinary tract tumor and associated bladder tumor were consistent in 73%. Except in 1 case, multiple occurrence of upper urinary tract tumor was always observed unilaterally on the side involved. The current results not only support the theory of multicentricity but raise the possibility that tumor cell implantation may play some role at least in the development of bladder tumor subsequent to upper urinary tract tumor.
In the clinical management of urothelial tumors, the high incidence of tumor recurrence and the occurrence of multiple tumors at multiple sites of the urinary tract are most important problems. In upper urinary tract tumors (renal pelvis and ureter), concurrent or subse quent occurrence of bladder tumors has been known to be rather frequent, with an incidence of 30-50% [1-3]. On the other hand, occurrence in the upper urinary tract subsequent to the treatment of primary bladder tumor is not so common [4, 5], eventhough the incidence of blad der tumors in general is several times higher than that of upper urinary tract tumors [6]. The current study was performed to investigate the clinicopathological charac teristics of multiple tumor development in both upper urinary tract and bladder, and to shed some light on the mechanism of multiple occurrence and recurrence of urothelial tumors.
Materials and Methods Since recurrence of urothelial tumors may take place shortly or long after the treatment of initial tumors, patients selected for the current study were 535 cases who had been initially treated for uro thelial tumors at our institute from 1970 to 1988. The patients were followed up by cystoscopy and urinary cytology every 3 months, and by intravenous pyelography every 6 months. Retrograde pyelogra phy and washing cytology of the upper urinary tract were indicated whenever upper urinary tract tumor was suspected. The follow-up was completed in December 1989. Of these 535 patients, 75 had urothelial tumor in the upper urinary tract; 40 were associated with metachronous or synchronous bladder tumors and 35 with upper urinary tract tumors only (table 1). There were no cases in which subsequent tumor recurrence in other sites of the urinary tract was diagnosed at autopsy. Histopathological slides of 32 cases among 40 with upper uri nary tract tumor associated with bladder tumor were available with diagnosis of transitional cell carcinoma. Grading and staging of bladder tumor were done according to a guideline defined by the Japanese Urological Association [7]. As for upper urinary tract tumor, grading followed the above guideline and staging followed Downloaded by: University of Exeter 144.173.6.94 - 5/7/2020 2:51:29 AM
Introduction
Table 1. Patients followed for primary urothelial tumors and subsequent tumor recurrence in other urinary tract Number of cases
Primary tumor
Number of cases
Subsequent tumors BT(-)
UUTT
52
UUTT+BT
18
BT(+)
17
Tumor type
Median age years
Male:Female
35
UUTT only
26:9
65
40
UUTT+BT
30:10
63
350:110
64
406:129
64
'
f UUTT(+) 5 465
BT
460
UUTT(-)
BT only
535
Total
BT = Bladder tumor; UUTT = upper urinary tract tumor.
Table 2. Incidence and time interval of metachronous occurrence of subsequent bladder tumors and upper urinary tract tumors Site of UUTT renal pelvis Metachronous UUTT -> BT BT -> UUTT Synchronous Total
ureter
Total cases
Incidence
Interval, months (mean ± SD)
17/52 = 0.32 5/465 = 0.01
18.5± 14.1* 40.2 ±13.6*
renal pelvis and ureter
9 3 4
6
2
2
0
10
4
17 5 18
16
18
6
40
* p < 0.02. See footnote of table 1 for abbreviations.
Table 3. Time interval (years) between the manifestation of initial and subsequent tumors according to the grade of upper urinary tract tumor Grade
Total
UUTT -> BT interval 3
4
5
0
1
0
0
1
3 2
0
0
2
1
0
0
8 8
5
2
0
2
17
1
2
G, g2 G3
0 3 5
Total
8
BT —> UUTT interval
Total
1
2
3
4
5
0 0
0
1 0 0
0
0
2
0
0
2 3
0
0
0
0
1
2
0
1
5
0
0
1 0
1
6
See footnote of table 1 for abbreviations.
Results Among 40 patients with upper urinary tract tumor and bladder tumor, 18 had both synchronously, 17 had primary upper urinary tract tumors and 5 had primary bladder tumors (table 1). Multiple occurrence of upper urinary tract tumor was observed in 16 of 40 cases, and was always unilateral except in 1 case. Downloaded by: University of Exeter 144.173.6.94 - 5/7/2020 2:51:29 AM
the TNM system [8]. Treatment of upper urinary tract tumors con sisted of total nephroureterectomy in 32 cases, simple nephrectomy in 5, partial resection of the lower portion of the ureter with ureteroneocystostomy in 2 and no surgery in 1. The remaining contra lateral kidney was removed in 1 patient who had metachronous bilateral upper urinary tract tumors. Survival rates were analyzed by actuarial calculation with the Kaplan-Meier method. The Cox-Mantel test was used to compare survival curves.
Upper Urinary Tract Tumor Associated with Bladder Tumor
21
100%
