Upper Urinary Tract Cancer

Healthy kidneys work like clockwork to clean the blood. These 2 bean-shaped organs are found near the middle of the back below the rib cage. They filter about 200 quarts of blood daily. Every day, the kidneys remove about 2 quarts of water and waste products in the form of urine. The urine then moves into the kidney's collecting system, the renal pelvis. It then flows through the ureters to the bladder, where it is stored until it is pushed out of the urethra.

Diagram of the How the Kidneys Work

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Since the exact cause of this cancer is not known, it is difficult to prevent. Still, there are certain  risk factors that are known to affect cancer development.

Hematuria (blood in the urine)

Blood in the urine is the most common sign of upper urinary tract cancer. As a rule it is painless. But since it can happen with a variety of urinary tract problems, your health care team should check for all likely sources of any blood found in your urine.

Pain

You may have no symptoms if the tumor is growing slowly. An X-ray or ultrasound may be the only way to see whether a slow-growing tumor is present. If the tumor is fast-growing, it could cause pain by blocking the kidney's collecting system. This could cause nausea and sharp pain in your lower back, side or stomach. Since these are also signs of kidney stones, you should see a urologist right away.

Less Common Complaints

Weight loss, anorexia, and bone pain may be signs of advanced disease. A mass in your side or abdomen can also be signs of advanced disease.

Medical History and Physical Exam

If your primary care doctor feels that you should see an expert, you will be referred to a urologist. The urologist will ask a variety of questions about your health history and will check your body with a variety of tests. He or she will feel your belly, sides and back for lumps, and will order blood tests.

A microscopic exam of cells in the urine (cytology) can help find an upper urinary tract cancer. Sometimes normal urine from the other kidney can water down a sample, making cancerous cells hard to find. If your doctor suspects cancer or cannot find the source of blood in the urine, he or she may order imaging tests.

Imaging

Ultrasound and CT (computerized tomography) scans are painless, nonsurgical ways to check the urinary tract. But while CT scans can show stones in the kidney and ureter, they are less useful in showing tumors. To see tumors more clearly, the doctor may use a contrast dye with the CT scan. To check whether the cancer has spread to other organs, MRI (magnetic resonance imaging) may also be helpful. Adding a retrograde X-ray (X-ray using a special dye) may be needed if you have poor kidney function.

Illustration of Cystoscopy

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Cystoscopy

If the source of bleeding is still in doubt, your doctor may order cystoscopy. A cystoscope uses a special fiber optic tool (like a camera lens) to look through the urethra into the bladder and urinary tract.

Illustration of Ureteroscopy

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Endoscopy/Ureteroscopy

If the urologist needs more information, he or she may do a direct visual inspection of your upper urinary tract. This is usually done while you are under anesthesia. An endoscope (a scope with a light attached) is inserted through the urethra into the bladder. It is then moved up to see inside the ureter and renal pelvis. If needed, the doctor will remove a sample of tissue to help in the diagnosis (a biopsy).

Imaging for Metastases

If the urologist has a confirmed cancer diagnosis, he or she will check to see if it has spread. If urinary tract cancer cells are found in other sites, it is called metastatic cancer.

Tests to see if the cancer has spread to common sites include:

• CT scan (of the abdomen, pelvis, and nearby lymph nodes and organs) 
• MRI
• chest X-ray (to look at the lungs)
• bone scan (to look at the skeleton)

If cancer cells are found, your doctor will need to know the tumor grade and stage. Understanding these will help your health care team develop your treatment plan.

Grading

The grade tells how fast the tumor is likely to grow. The most widely used grading systems group tumors into 2 main grades: low and high.

• Low-grade tumors grow more slowly. They often come back after treatment, but rarely get into the upper urinary tract wall. They also don't tend to spread to other parts of the body.
• High-grade tumors grow more quickly. They often come back after treatment and are more likely to spread to other parts of the body.

Staging

Your doctor must also learn how deeply the tumor has gone into the collecting system wall. This is called "staging." Your doctor also wants to find out if the tumor has spread to other parts of the body (metastasis). In general, the higher the stage number, the more serious the cancer. Often the stage is not clearly defined until the tumor is removed and studied by a pathologist (an expert who looks for cancer cells in tissue samples).

Staging of Upper Urinary Tract Cancer

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What you and your doctor choose depends on many issues, such as:

• tumor grade (how aggressive the tumor is)
• tumor size, location and extent
• your age
• medical history
• overall health
• kidney collecting system anatomy

Options include:

• surgery
• chemotherapy
• radiation

Surgery

Removal of Kidney and Ureter

The majority of upper urinary tract cancers are treated with nephroureterectomy (surgery to remove the kidney and an entire ureter). The "radical" form involves removing nearby lymph nodes and tissue as well. Since you will only have 1 kidney, your doctor will closely watch your overall kidney function. You would not need dialysis unless you already have serious kidney problems.

The type of surgery you are offered will depend on surgeon preference, tumor size, tumor location and tumor aggressivenes. Options include:

• traditional: a 10-inch cut into the abdomen is made to remove the tumor(s)
• laparoscopy: tube-like instruments are inserted into the abdomen through small "key-hole" cuts.

Kidney Sparing Surgery

In kidney sparing surgery your doctor will try to keep the remaining kidney and ureter on the side with the tumor. This is an option if you already:

• lost a kidney to cancer
• lost a kidney because of stones, infection or trauma
• have kidney problems because of diabetes, high blood pressure or glomerulonephritis

If your doctor decides to spare the kidney, the tumor can be managed with segmental resection or endoscopic removal.

Segmental resection: removing the cancerous part of the urinary tract and then reattaching it so the kidney is still joined to the bladder. This is done if the cancer hasn't spread past the surface.

Endoscopic removal: removing the tumor through a small scope called a ureteroscope. The ureteroscope is inserted through the bladder into the upper urinary tract. Then the tumor can be destroyed with a laser. This is done if the growth is small and low-grade.

Percutaneous tumor removal: a scope is placed directly into the kidney's collecting system through a small puncture in the back.

Chemotherapy

Topical chemotherapy and immunotherapy 
In bladder cancer, drugs can be inserted in the bladder to prevent cancer from coming back. But they are not often used for renal pelvis or ureteral cancer. The bladder holds fluid for hours, so the tissue has plenty of exposure to the drugs. But the upper urinary tract doesn't hold as much fluid as the bladder or for as long. Still, your doctor may use drugs in addition to surgery.

Systemic chemotherapy
Chemotherapy uses drugs to kill cancer cells. It may be used to treat upper urinary tract cancer before or after the kidney and ureter are removed.

You may receive chemotherapy in different ways: 

• By mouth: Some drugs are pills that you can swallow. They may be given before or after surgery.
• Into a vein (intravenous): The drugs enter the bloodstream and travel throughout your body. Chemotherapy may be given before or after surgery.

You may have your treatment in an outpatient part of the hospital, at the doctor's office, or at home. Rarely, you may need to stay in the hospital.

Chemotherapy is usually given in cycles. Each cycle has a treatment period followed by a rest period.

If the drugs are given by vein or taken by mouth, the side effects depend mainly on which drugs are given and how much. Chemotherapy kills fast-growing cancer cells, but the drugs can also harm normal cells that divide rapidly: 

• Blood cells: When drugs lower the levels of healthy blood cells, you're more likely to get infections, bruise or bleed easily, and feel very weak and tired. Your health care team will check for low levels of blood cells. If your levels are low, your health care team may stop the chemotherapy for a while or reduce the dose of the drug. There are also medicines that can help your body make new blood cells.
• Cells in hair roots: Chemotherapy may cause hair loss. If you lose your hair, it will grow back after treatment, but the color and texture may be changed.
• Cells that line the digestive system: Chemotherapy can cause a poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores. Your health care provider can give you medicines and suggest other ways to help with these problems. They usually go away when treatment ends.

Some drugs used for upper urinary tract cancer may also cause tingling or numbness in your hands and feet. Your health care team can suggest ways to control many of these side effects.

Radiation

High-energy radiation is used to destroy cancer cells with minimal damage to nearby organs. Radiation is rarely used for urothelial tumors since the area to be treated is so small and hard to target. Your doctor will only use radiation if he or she can avoid damaging nearby tissue.

Are you interested in participating in a clinical trial to treat upper urinary tract cancer? Clinical trials are research studies to test if a new treatment or procedure is safe and effective. These studies also aim to find which medical approaches work best for certain illnesses or groups of people.

Clinical trials follow strict scientific standards. These standards protect patients and help produce reliable study results.

Talk with your doctor about whether you can qualify for a clinical trial. Learn about the risks and benefits of the treatment being studied.
To search for information on current or recent clinical trials for the treatment of upper urinary tract cancer, visit the UrologyHealth.org Clinical Trials Resource Center.

When an upper urinary tract cancer is caught early, the chances of surgical cure are good. Overall the outlook depends on 2 factors:

1. How aggressive the cancer cells are. Low-grade disease is less aggressive and has a lower chance of spreading to other organs. High-grade disease is more aggressive with a higher chance of spreading.
2. How far the tumor has spread. If the tumor does not involve nearby lymph nodes or other tissue, there is a high likelihood of cure. Additional treatments would not be needed. But if the cancer has spread to nearby lymph nodes, your doctor will probably recommend additional systemic chemotherapy.

Recovery and Followup

Your recovery depends on your treatment. A minimally invasive approach will lead to a quicker recovery than traditional open surgery. The best treatment option is often the one that offers the best long-term outcome. If your surgeon has removed 1 kidney and the remaining kidney works well, your quality of life and future health should not be seriously affected. One good kidney can usually do the work of 2.

After treatment you will need continued check-ups to watch for regrowth of cancer. Upper urinary tract cancer is more likely to occur in multiple places than other cancers. For the first few years after treatment, your doctor will perform cystoscopy and other exams. These visits should continue at least yearly throughout your life.

Questions to Ask Your Health Care Provider

• Do I have urinary tract cancer or something else?
• What is the stage and grade of my cancer, and what does that mean?
• Has it spread anywhere else?
• Do I need other tests before we can decide on treatment?
• What are my treatment options and which do you recommend? Why?
• What are the chances my cancer can be cured? 
• What are the chances that my cancer will return after treatment?
• What risks or side effects should I expect from treatment? For how long?
• What should I do to prepare for treatment? What will it be like? 
• What will we do if the treatment doesn't work or if the cancer comes back?
• Can you recommend another urologist for a second opinion?
• Is there anything I can do to protect my health, or prevent the cancer from coming back?
• How often will I need to have check-ups after treatment?