THE JOURNAL OF UROLOGY
Vol. 113, February
Copyright© 1975 by The Williams & Wilkins Co.
Printed in U.S.A.
RENAL PELVIC TUMORS KENNETH B. CUMMINGS, ROY J. CORREA, JR., ROBERT P. GIBBONS, HOWARD M. STOLL, ROGER F. WHEELIS AND J. TATE MASON From the Departments of Urology and Pathology, Virginia Mason Medical Center, Seattle, Washington
The observed direct relationship between grade and stage of bladder tumors with prognosis prompted an attempt at a meaningful classification of transitional cell tumors of the renal pelvis. The anatomic structure of the kidney in which renal pelvic tumors extend, in contrast to the bladder, requires certain modifications of Jewett's classification for staging to permit correlation with prognosis. MATERIAL
From 1951 to 1973, 35 patients with tumors of the renal pelvis whose diagnosis was confirmed surgically were treated at our center. Patients ranged in age from 29 to 83 years old, with the highest incidence during the sixth and seventh decades. The series included 24 men and 11 women. Of the 35 patients 18 had additional urothelial tumors (table 1). All pathologic material was reviewed by one of the authors (R. F. W.). CLASSIFICATION OF RENAL PELVIC TUMORS
Tumors were classified separately by histologic grade and staged by a modification of Jewett's staging of bladder tumors. 1 Grade. Tumors were graded histologically from I to IV: grade I-papillary with normal mucosa (thickness and morphology); grade II-papillary with minimal pleomorphism, mitosis, giant cells and invasion; grade III-flat, transitional cells (plant life) to epidermoid (keratin forming) with significant pleomorphism, mitosis, giant cells and invasion, and grade IV-extreme pleomorphism or marked undifferentiation (fig. 1). Stage. Data regarding the gross extent of tumors were taken from the pathologic examination of submitted surgical specimens and the operative report. The conventional classification of Jewett for transitional cell tumors of the bladder does not lend itself to staging tumors of this cell type when they involve the renal pelvis. The thin musculature of the pelvis, proximity of the urothelium to the collecting ducts of the renal pyramid and potential for extension through renal substance required the following modifications: stage I-non-invasive tumors, stage II-tumors with superficial invasion, Accepted for publication May 31, 1974. Read at annual meeting of Western Section, American Urological Association, San Francisco, California, March 31-April 5, 1974. 1 Jewett, H. J. and Strong, G. H.: Infiltrating carcinoma of the bladder: relation of depth of penetration of the bladder wall to incidence of local extension and metastases. J. Urol., 55: 366, 1946.
stage III-invasion of pelvic musculature or renal substance and stage IV-extension through the adventitia of the pelvis or kidney capsule with or without contiguous organ or lymph node involvement (fig. 2). With these criteria there is a direct correlation between grade and stage of tumor. CLINICAL PRESENTATION
The predominant symptom was gross hematuria. However, in 6 patients persistent microscopic hematuria was the only finding (table 2). The interval between symptoms and diagnosis is shown in table 3. There was no statistically significant difference in the interval between presentation of symptoms and diagnosis as determined by stage. CLINICAL EVALUATION
Excretory urography (IVP) was done in all patients (table 4). The predominant finding was a filling defect in the renal pelvis. TABLE
1. Presence of additional urothelial tumors (}8
of 35 cases) No. Cases Ureter Bladder Both
6
Synchronous Asynchronous
9 9
Prior Subsequent
6
8 4
3
Retrograde pyelography was done in 30 patients. In 29 cases this study contributed to the clarification of the pelvic lesion and in 6 cases it demonstrated a ureteral tumor not evident on the IVP. Selective cytology was used in 9 patients. In 2 patients it was diagnostic and in the remaining 7 it was suggestive. Renal arteriography was done in 6 patients. In 5 patients it was of value in establishing the diagnosis or clarifying the extent of the disease. The findings included: 1) encasement of the intrarenal arteries, 2) hypertrophy of renal pelvic artery and 3) tumor blush for tumors larger than 3 cm. in diameter (fig. 3). TREATMENT
The diagnosis of renal pelvic tumor had been confirmed surgically in all cases. Fifteen patients underwent radical nephroureterectomy, including a 158
RENAL PELVIC TUMORS
Fm. 1. A, histologic grade I. B, histologic grade III
and UfetefeCtOmy upon before 1960. Of the 3 patients were who were considered as had a diagnostic 2 were determined to be inoperable and, because of the risk of an the remaining had a needle to establish the diagnosis of a mass lesion of the h
ro>('j
Orn V
SURVIVAL
With use of the criteria of tumor and the method of there was a direct reof sur-
rnl'rm,,wc,n
process of varying
by grade and stage is difficult. Enumeration of survival for each patient in the series, cause of is and possesses in establishing conclusions. 10-year survivals for this type of tun10r foils to indicate that lethal of the high stage tumor or the relative properly managed low low stage tumor. Survival curves of the Berkson and actuarial type are effective for larger than study permits. 2 As an alternative survival was established independently for of tumor and mor state. It is as months survived fm 'Berkson, J. and Gage, R. P.: Calculation of survival rates for cancer. Proc. Mayo C!in., 25: 270, 1950.
160
CUMMINGS AND ASSOCIATES
taging of Tumors I 0
FIG. 2. Proposed staging of transitional cell tumors of renal pelvis as modified from Jewett's staging of bladder tumors. TABLE
2. Clinical presentation (35 cases) No. Cases
Hematuria: Microscopic Gross Pain: With gross hematuria Without gross hematuria Weight loss Incidental pyelographic observation
TABLE
6 28 5 7
2 2
3. Interval from symptoms to diagnosis
Grade
No.Pts.
I II III IV
4 12 10
9
Mos. ± S.E.M. * 11.2 6.0 6.7 8.5
± 16.6 ± 6.3 ± 4.9 ± 7.6
* Mean interval-months plus or minus standard error of mean. TABLE
4. Observations on IVP No.Pts.
Filling defect lnfundibular obstruction Mass Hydronephrosis Non-visualization Total
15 3 4 5 8
FIG. 3. Patient with transitional cell tumor presenting as mass lesion of left kidney. Abnormal left kidney exhibits encasement of intrarenal arteries and hypertrophy at renal pelvic artery.
35
those who died of tumor and as months of risk for those who died free of tumor or are alive. Survival by stage. Table 5 illustrates the mean survival for those who died of tumor and mean period at risk for those who died free of tumor or who are alive. All 9 patients with stage IV disease were dead, with a mean survival of 11.6 months (range of 2 to 30 months). Seven of 10 patients with stage III disease had a mean survival of 10.2
months (range of 3 to 24 months). One patient died free of tumor and had been at risk for 49 months. Two patients were alive free of tumor and at risk for 14 and 34 months, respectively. Six of 12 patients with stage II disease were alive free of tumor, with a mean period at risk of 64.3 months (range of 6 to 147 months). Three patients were dead but free of tumor and had been at risk for a mean of 73.3 months (range of 21 to 120 months), and 3 were dead of tumor in the unresected terminal ureter with a mean survival of 48.3
RENAL PELVIC TUMORS TABLE
5. Survival by stage Dead Free of Tumor
Dead With Tumor Stage
Alive Free of Tumor
No. Pts. (mos. ± S.E.M. *)
No
No.
(mos.± S.E.M.+)
No.
1 3
73 73 ± 49.7 49
3
4
II III
12 10
IV
9
3 7 9
48.3 ± 8.5 10.2 ± 7.0 11.6 .± 10.2
(mos. ±
126.3 ± 64.3 + fiO.iJ
6 2
24
* Mean survival-months plus or minus standard error of mean. period at risk-months plus or minus standard error of mean.
t IV1ean
TABLE
6. Suruiual by grade Dead Free of Tumor
Dead With Tumor Grade
Alive Free of Tun1or
No. Pts. No.
(mos.± S.E.M.*)
No.
(mos.± S.E.M.t)
4
73.2 ± 40.6 49
2 8
2 II III IV
15 10 8
3 8 8
48.3 ± 8.fi 13.2 ± 6.4
No.
(mos. ce S.E.IW. lll 69.6
d-
50.9
r
31
9.1 ± 9.2
·~ l\/Jean survival-months plus or minus standard error of mean. period at risk-months plus or minus standard error of mean.
t Mean
months of 40 to 57 months). Three of 4 patients stage I disease were alive free of tumor with a mean at risk of 126.3 months of 75 to 157 months), One patient died free of tumor and had been at risk for 73 months. Survival Table 6 illustrates survival as determined tumor All 8 patients with IV disease died of tumor, with a mean survival of 9.1 months of 2 to 30 months). of 10 patients with III disease died of tumor, with a mean survival of 13,2 months (range of 3 to 24 111c'l1cwo1 One died free of tumor, been at risk for 49 and the remainmg was alive free of tumor, having been at risk for 31 months, of 15 with grade H disease were alive and free of tumor, having been at risk for a mean of 69.6 months (range of 6 to 157 months), Four we~e dead but free of tumor, with a mean at risk of 73.2 months of 21 to 86 and 3 were dead of tumor in the unresected distal ureter, with a mean survival of 48,3 months of 40 to 57 months), The 2 with I disease survived free of tumor and were at risk for 75 and 147 months, D!SCUSSJON
This series was of sufficient breadth to establish certain conclusions, Carcinoma of the renal pelvis in in their is witnessed most sixth and seventh decades. The additional obseris in general vation of a 2 to 1 male agreement with other series, 3 The observed increased incidence of additional urothelial tumors in more than 50 per cent of in this series has been witnessed in other 3 Williams, C. B. and MitcheII, J. P,: Carcinoma of the renal pelvis: a review of 43 cases. BriL J. Urol., 45: 370, 1973.
large series. and associates observed incidence of 58,5 per cent of additional. urotheLa 1 tumors in 53 cases of transitional. cell tumors of renal pelvis. 4 Hematuria, as noted in other reviews, wac; tlv.:: predominant symptom and occurred in 90 of our patients. 5 In 6 the microscopic hematuria. The value of sis is apparent and can be selective urinary grade neoplasms in the absence of inflam mation can readily be the gist from barbotaged from the pelvis. Clumps of ,,--v·-u value in establishing tumors of lower grade. method of retrograde brushing as described Gill and associates being used in our center and is of value achieving the aforementioned end. 6 The method of staging renal advanced in this series correlated well with grading of transitional cell tumors and bore u direct correlation with The presence additional urothelial tumors did not affect prognosis and these tumors, therefore, not included in the method of classification in trast to the ~w,,rn, classification of GrabstaJ.d and associates, 7 grade (III tc High stage (III to IV) and 00
'Kaplan, J. H., McDonald, J. R. and Thompson, G. J.: Multicentric origin of papillary tumors of the tract. J. UroL, 66: 792, 1951. 'Taylor, W. N.: Tumors of the kidney pelvis. J. lJroL, 82: 452, 1959. 6 Gill, W. B., Lu, C, T. and Thomsen, S.: Retrogra,ie brushing: a new technique for obtaining w.c,w,-b,~ cyto!ogic material from ureteral, renal pelvic caliceal lesions. J. HI!!: 573, 1973. 7 Grabstald, W. F. and Melamed. R.: Renal pelvic 281: 845, 197L
162
CUMMINGS AND ASSOCIATES
carried a uniformly poor prognosis independent of the surgical procedure applied. Low grade (I to II) and low stage (I to II) carried a uniformly good prognosis provided adequate surgery and followup were permitted. The 3 patients in the latter category who died of transitional cell tumors are noteworthy. These patients had, by current standards, inadequate surgery (nephrectomy and partial ureterectomy) and died not from the original pelvic tumor but from tumor in the distal unresected ureteral remnant. In all instances the tumor in the distal ureter was of a higher grade than the original pelvic tumor and in 2 cases it was of a higher stage. Surgical management directed at cure should include radical nephroureterectomy, including a cuff of bladder. It is our persuasion that regional lymph nodes should routinely be included with the possible exception of the higher surgical risk pa-
tient when examination of the operative specimen clearly reveals a low grade, low stage tumor. Routine endoscopic and pyelographic followup is essential because of the 50 per cent incidence of additional urothelial tumors observed in this series. SUMMARY
A study was made of 35 patients with tumors of the renal pelvis. Tumors were independently graded and staged by a newly proposed method. The method of staging correlated well with grading of renal pelvic tumors and bore a direct relationship with prognosis. The high incidence of associated urothelial tumors, especially on the involved side, mandated radical nephroureterectomy including a bladder cuff as the treatment of choice.
Vol. 113, February
Copyright© 1975 by The Williams & Wilkins Co.
Printed in U.S.A.
RENAL PELVIC TUMORS KENNETH B. CUMMINGS, ROY J. CORREA, JR., ROBERT P. GIBBONS, HOWARD M. STOLL, ROGER F. WHEELIS AND J. TATE MASON From the Departments of Urology and Pathology, Virginia Mason Medical Center, Seattle, Washington
The observed direct relationship between grade and stage of bladder tumors with prognosis prompted an attempt at a meaningful classification of transitional cell tumors of the renal pelvis. The anatomic structure of the kidney in which renal pelvic tumors extend, in contrast to the bladder, requires certain modifications of Jewett's classification for staging to permit correlation with prognosis. MATERIAL
From 1951 to 1973, 35 patients with tumors of the renal pelvis whose diagnosis was confirmed surgically were treated at our center. Patients ranged in age from 29 to 83 years old, with the highest incidence during the sixth and seventh decades. The series included 24 men and 11 women. Of the 35 patients 18 had additional urothelial tumors (table 1). All pathologic material was reviewed by one of the authors (R. F. W.). CLASSIFICATION OF RENAL PELVIC TUMORS
Tumors were classified separately by histologic grade and staged by a modification of Jewett's staging of bladder tumors. 1 Grade. Tumors were graded histologically from I to IV: grade I-papillary with normal mucosa (thickness and morphology); grade II-papillary with minimal pleomorphism, mitosis, giant cells and invasion; grade III-flat, transitional cells (plant life) to epidermoid (keratin forming) with significant pleomorphism, mitosis, giant cells and invasion, and grade IV-extreme pleomorphism or marked undifferentiation (fig. 1). Stage. Data regarding the gross extent of tumors were taken from the pathologic examination of submitted surgical specimens and the operative report. The conventional classification of Jewett for transitional cell tumors of the bladder does not lend itself to staging tumors of this cell type when they involve the renal pelvis. The thin musculature of the pelvis, proximity of the urothelium to the collecting ducts of the renal pyramid and potential for extension through renal substance required the following modifications: stage I-non-invasive tumors, stage II-tumors with superficial invasion, Accepted for publication May 31, 1974. Read at annual meeting of Western Section, American Urological Association, San Francisco, California, March 31-April 5, 1974. 1 Jewett, H. J. and Strong, G. H.: Infiltrating carcinoma of the bladder: relation of depth of penetration of the bladder wall to incidence of local extension and metastases. J. Urol., 55: 366, 1946.
stage III-invasion of pelvic musculature or renal substance and stage IV-extension through the adventitia of the pelvis or kidney capsule with or without contiguous organ or lymph node involvement (fig. 2). With these criteria there is a direct correlation between grade and stage of tumor. CLINICAL PRESENTATION
The predominant symptom was gross hematuria. However, in 6 patients persistent microscopic hematuria was the only finding (table 2). The interval between symptoms and diagnosis is shown in table 3. There was no statistically significant difference in the interval between presentation of symptoms and diagnosis as determined by stage. CLINICAL EVALUATION
Excretory urography (IVP) was done in all patients (table 4). The predominant finding was a filling defect in the renal pelvis. TABLE
1. Presence of additional urothelial tumors (}8
of 35 cases) No. Cases Ureter Bladder Both
6
Synchronous Asynchronous
9 9
Prior Subsequent
6
8 4
3
Retrograde pyelography was done in 30 patients. In 29 cases this study contributed to the clarification of the pelvic lesion and in 6 cases it demonstrated a ureteral tumor not evident on the IVP. Selective cytology was used in 9 patients. In 2 patients it was diagnostic and in the remaining 7 it was suggestive. Renal arteriography was done in 6 patients. In 5 patients it was of value in establishing the diagnosis or clarifying the extent of the disease. The findings included: 1) encasement of the intrarenal arteries, 2) hypertrophy of renal pelvic artery and 3) tumor blush for tumors larger than 3 cm. in diameter (fig. 3). TREATMENT
The diagnosis of renal pelvic tumor had been confirmed surgically in all cases. Fifteen patients underwent radical nephroureterectomy, including a 158
RENAL PELVIC TUMORS
Fm. 1. A, histologic grade I. B, histologic grade III
and UfetefeCtOmy upon before 1960. Of the 3 patients were who were considered as had a diagnostic 2 were determined to be inoperable and, because of the risk of an the remaining had a needle to establish the diagnosis of a mass lesion of the h
ro>('j
Orn V
SURVIVAL
With use of the criteria of tumor and the method of there was a direct reof sur-
rnl'rm,,wc,n
process of varying
by grade and stage is difficult. Enumeration of survival for each patient in the series, cause of is and possesses in establishing conclusions. 10-year survivals for this type of tun10r foils to indicate that lethal of the high stage tumor or the relative properly managed low low stage tumor. Survival curves of the Berkson and actuarial type are effective for larger than study permits. 2 As an alternative survival was established independently for of tumor and mor state. It is as months survived fm 'Berkson, J. and Gage, R. P.: Calculation of survival rates for cancer. Proc. Mayo C!in., 25: 270, 1950.
160
CUMMINGS AND ASSOCIATES
taging of Tumors I 0
FIG. 2. Proposed staging of transitional cell tumors of renal pelvis as modified from Jewett's staging of bladder tumors. TABLE
2. Clinical presentation (35 cases) No. Cases
Hematuria: Microscopic Gross Pain: With gross hematuria Without gross hematuria Weight loss Incidental pyelographic observation
TABLE
6 28 5 7
2 2
3. Interval from symptoms to diagnosis
Grade
No.Pts.
I II III IV
4 12 10
9
Mos. ± S.E.M. * 11.2 6.0 6.7 8.5
± 16.6 ± 6.3 ± 4.9 ± 7.6
* Mean interval-months plus or minus standard error of mean. TABLE
4. Observations on IVP No.Pts.
Filling defect lnfundibular obstruction Mass Hydronephrosis Non-visualization Total
15 3 4 5 8
FIG. 3. Patient with transitional cell tumor presenting as mass lesion of left kidney. Abnormal left kidney exhibits encasement of intrarenal arteries and hypertrophy at renal pelvic artery.
35
those who died of tumor and as months of risk for those who died free of tumor or are alive. Survival by stage. Table 5 illustrates the mean survival for those who died of tumor and mean period at risk for those who died free of tumor or who are alive. All 9 patients with stage IV disease were dead, with a mean survival of 11.6 months (range of 2 to 30 months). Seven of 10 patients with stage III disease had a mean survival of 10.2
months (range of 3 to 24 months). One patient died free of tumor and had been at risk for 49 months. Two patients were alive free of tumor and at risk for 14 and 34 months, respectively. Six of 12 patients with stage II disease were alive free of tumor, with a mean period at risk of 64.3 months (range of 6 to 147 months). Three patients were dead but free of tumor and had been at risk for a mean of 73.3 months (range of 21 to 120 months), and 3 were dead of tumor in the unresected terminal ureter with a mean survival of 48.3
RENAL PELVIC TUMORS TABLE
5. Survival by stage Dead Free of Tumor
Dead With Tumor Stage
Alive Free of Tumor
No. Pts. (mos. ± S.E.M. *)
No
No.
(mos.± S.E.M.+)
No.
1 3
73 73 ± 49.7 49
3
4
II III
12 10
IV
9
3 7 9
48.3 ± 8.5 10.2 ± 7.0 11.6 .± 10.2
(mos. ±
126.3 ± 64.3 + fiO.iJ
6 2
24
* Mean survival-months plus or minus standard error of mean. period at risk-months plus or minus standard error of mean.
t IV1ean
TABLE
6. Suruiual by grade Dead Free of Tumor
Dead With Tumor Grade
Alive Free of Tun1or
No. Pts. No.
(mos.± S.E.M.*)
No.
(mos.± S.E.M.t)
4
73.2 ± 40.6 49
2 8
2 II III IV
15 10 8
3 8 8
48.3 ± 8.fi 13.2 ± 6.4
No.
(mos. ce S.E.IW. lll 69.6
d-
50.9
r
31
9.1 ± 9.2
·~ l\/Jean survival-months plus or minus standard error of mean. period at risk-months plus or minus standard error of mean.
t Mean
months of 40 to 57 months). Three of 4 patients stage I disease were alive free of tumor with a mean at risk of 126.3 months of 75 to 157 months), One patient died free of tumor and had been at risk for 73 months. Survival Table 6 illustrates survival as determined tumor All 8 patients with IV disease died of tumor, with a mean survival of 9.1 months of 2 to 30 months). of 10 patients with III disease died of tumor, with a mean survival of 13,2 months (range of 3 to 24 111c'l1cwo1 One died free of tumor, been at risk for 49 and the remainmg was alive free of tumor, having been at risk for 31 months, of 15 with grade H disease were alive and free of tumor, having been at risk for a mean of 69.6 months (range of 6 to 157 months), Four we~e dead but free of tumor, with a mean at risk of 73.2 months of 21 to 86 and 3 were dead of tumor in the unresected distal ureter, with a mean survival of 48,3 months of 40 to 57 months), The 2 with I disease survived free of tumor and were at risk for 75 and 147 months, D!SCUSSJON
This series was of sufficient breadth to establish certain conclusions, Carcinoma of the renal pelvis in in their is witnessed most sixth and seventh decades. The additional obseris in general vation of a 2 to 1 male agreement with other series, 3 The observed increased incidence of additional urothelial tumors in more than 50 per cent of in this series has been witnessed in other 3 Williams, C. B. and MitcheII, J. P,: Carcinoma of the renal pelvis: a review of 43 cases. BriL J. Urol., 45: 370, 1973.
large series. and associates observed incidence of 58,5 per cent of additional. urotheLa 1 tumors in 53 cases of transitional. cell tumors of renal pelvis. 4 Hematuria, as noted in other reviews, wac; tlv.:: predominant symptom and occurred in 90 of our patients. 5 In 6 the microscopic hematuria. The value of sis is apparent and can be selective urinary grade neoplasms in the absence of inflam mation can readily be the gist from barbotaged from the pelvis. Clumps of ,,--v·-u value in establishing tumors of lower grade. method of retrograde brushing as described Gill and associates being used in our center and is of value achieving the aforementioned end. 6 The method of staging renal advanced in this series correlated well with grading of transitional cell tumors and bore u direct correlation with The presence additional urothelial tumors did not affect prognosis and these tumors, therefore, not included in the method of classification in trast to the ~w,,rn, classification of GrabstaJ.d and associates, 7 grade (III tc High stage (III to IV) and 00
'Kaplan, J. H., McDonald, J. R. and Thompson, G. J.: Multicentric origin of papillary tumors of the tract. J. UroL, 66: 792, 1951. 'Taylor, W. N.: Tumors of the kidney pelvis. J. lJroL, 82: 452, 1959. 6 Gill, W. B., Lu, C, T. and Thomsen, S.: Retrogra,ie brushing: a new technique for obtaining w.c,w,-b,~ cyto!ogic material from ureteral, renal pelvic caliceal lesions. J. HI!!: 573, 1973. 7 Grabstald, W. F. and Melamed. R.: Renal pelvic 281: 845, 197L
162
CUMMINGS AND ASSOCIATES
carried a uniformly poor prognosis independent of the surgical procedure applied. Low grade (I to II) and low stage (I to II) carried a uniformly good prognosis provided adequate surgery and followup were permitted. The 3 patients in the latter category who died of transitional cell tumors are noteworthy. These patients had, by current standards, inadequate surgery (nephrectomy and partial ureterectomy) and died not from the original pelvic tumor but from tumor in the distal unresected ureteral remnant. In all instances the tumor in the distal ureter was of a higher grade than the original pelvic tumor and in 2 cases it was of a higher stage. Surgical management directed at cure should include radical nephroureterectomy, including a cuff of bladder. It is our persuasion that regional lymph nodes should routinely be included with the possible exception of the higher surgical risk pa-
tient when examination of the operative specimen clearly reveals a low grade, low stage tumor. Routine endoscopic and pyelographic followup is essential because of the 50 per cent incidence of additional urothelial tumors observed in this series. SUMMARY
A study was made of 35 patients with tumors of the renal pelvis. Tumors were independently graded and staged by a newly proposed method. The method of staging correlated well with grading of renal pelvic tumors and bore a direct relationship with prognosis. The high incidence of associated urothelial tumors, especially on the involved side, mandated radical nephroureterectomy including a bladder cuff as the treatment of choice.
