Role of partial nephrectomy in the treatment of upper tract transitional cell carcinoma

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May 22 2006

Traditionally, upper tract transitional cell carcinoma (TCC) is managed with nephroureterectomy with excision of a bladder cuff.

In cases of locally advanced or regionally advanced disease, neoadjuvant systemic chemotherapy may be offered prior to surgery. There exists a subset of patients that are not optimal candidates for nephroureterectomy, particularly those with solitary kidneys, those with baseline insufficiency, and those with bilateral synchronous tumors. For these patients, novel, creative approaches are required to establish cancer control while attempting to maintain enough functioning renal mass to avoid renal replacement therapy. While many cases can be managed with endoscopic tumor resection/ablation, some patients are not candidates for or refuse these minimally invasive therapies. In this study, Goel and colleagues, out of the Cleveland Clinic, examine their experience with partial nephrectomy as a surgical therapy for upper tract TCC.

Twelve patients over a period of 11 years were treated with partial nephrectomy for upper tract TCC. Indications for this approach included patients with a solitary kidney (10), chronic renal insufficiency, and bilateral synchronous tumors. Mean patient age was 68.5 years and the mean follow-up was 40.8 months. Six patients were found to have T3 disease, 2 with T2, 3 with T1, and 1 with Tis. In 6 patients, negative margins were obtained at the time of surgery and 4 of 12 remain tumor free with a median follow-up of 57.7 months. In the patients with positive surgical margins, 1 developed a local recurrence, 3 demonstrated metastatic progression, and 4 patients were dead with a median follow-up of 31.3 months. Overall, 42% of patients demonstrated evidence of recurrence and 50% demonstrated evidence of metastatic progression. In this very select group, stage, grade, and margin status appeared to be the most important predictor of outcome. The authors suggest that patients considered for this procedure should have tumors confined to one renal pole, in the absence of carcinoma-in-situ, and that neoadjuvant chemotherapy should be considered prior to surgery in patients with locally advanced (T3) disease. Notably, only two patients in this series required dialysis.

While the ideal therapy for patients with upper tract TCC remains nephroureterectomy with bladder cuff excision, partial nephrectomy can be a viable alternative in highly selected mandatory cases, so as to avoid the need for renal replacement therapy. It should be considered in polar tumors where endoscopic management would be considered suboptimal.

By Christopher G. Wood, MD

Reference:

Urology 67(3): 490-495, 2006