Ureter

The incidence of renal pelvic tumors is 3:1 in men versus women. Approximately 7% of all renal neoplasms and less than 1% of all genitourinary tumors are transitional cell carcinoma. Also, about one third of patients with an upper urinary tract carcinoma develop bladder carcinoma. 1 || While the cause of ureteral cancer is unknown, there are a few factors believed to increase someone's risk: 1
 * **Epidemiolgy:** || Becky
 * **Etiology:** || Adam
 * Smoking
 * Exposure to certain chemicals used in dye factories and other industrial settings
 * Extended use of painkillers resulting in kidney damage (painkillers containing phenacetin in particular) ||
 * **Signs & Symptoms:** || Megan

With ureteral cancer, there are oftentimes no warnings signs. On the other hand, the symptoms that do exist for this cancer, can be closely linked to many conditions, so careful diagnosis is mandatory. Blood in the urine, or hematuria, is often a sign. Other symptoms can include flank pain or pain within the space between the ribs, extreme tiredness, unreasonable weight loss, or painful and frequent urination. 1 ||
 * **Diagnostic Procedures:** || Kevin T

1 ||
 * **Histology:** || Erin

Transitional cell and squamous cell carcinomas make up the histology of ureter tumors. The majority (>90%) are transitional cell, while only 7-8% are squamous cell carcinomas.1 || The lymphatic drainage of the ureter can involve the following lymph nodes:1 There are three ways that cancer of the ureter can spread to other tissue and organs in the body. The tumor can spread directly through tissue, by the lymphatic system and using the circulatory system through the blood. Cancer of the ureter can invade the layer of tissue surrounding the lining of the ureter, and the muscle around the ureter. If left untreated and or diagnosis is delayed, the lymph nodes in the lower abdomen and pelvic region will also be at risk. In certain cases, the disease will metastasize to distant lymph nodes and organs such as the liver, lung and bone.¹ || GX: Grade cannot be accessed G1: Well differentiated G2: Moderately well differentiated G3-4: Poorly differentiated or undifferentiated ||
 * **Lymph node drainage:** || Spencer
 * Common Iliac
 * Internal Iliac
 * External Iliac
 * Paracaval
 * Para-Aortic
 * Abdominal
 * Renal Hilar ||
 * **Metastatic spread:** || Pablo
 * **Grading:** || Becky
 * Histopathologic Grade**:
 * **Staging:** || Adam

American Joint Committee on Cancer Staging Classification for Ureter Tumors: 2 Primary Tumor (T) TX - Primary tumor cannot be assessed T0 - No evidence of primary tumor Ta - Papillary noninvasive tumor Tis - Carcinoma in situ T1 - Tumor invades subepithelial tissue T2 - Tumor invades the muscularis T3 - Tumor invades beyond muscularis into periureteric fat T4 - Tumor invades adjacent organs

Regional Lymph Nodes (N) NX - Regional LNs cannot be assessed N0 - No regional LN metastasis N1 - Metastasis in a single LN, 2 cm or less in greatest dimension N2 - Metastasis in a single LN, more than 2 cm but not more than 5 cm in greatest dimension; or multiple LNs, none more than 5 cm in greatest dimension N3 - Metastasis in a LN, more than 5 cm in greatest dimension.

Distant Metastasis (M) M0 - No distant metastasis (no pathologic M0; use clinical M to complete stage group) M1 - Distant metastasis ||
 * **Radiation side effects:** || Megan

Although radiation is used in combination with surgery in male patients, radiation alone can be used to treat early stage disease in women. Side effects of the radiation are nausea, diarrhea, skin irritation leading to redness and soreness, burning during urination, and fatigue. Usually these side effects go away after treatment, and many can be managed with certain drugs. Some side effects may be long-lasting, such as urethral or vaginal strictures (narrowing because of scar tissue). There are treatment options for these strictures such as vaginal dilators and intercourse. Stretching of the treated area should be done a minimum of 3 times per week. 2 ||
 * **Prognosis:** || Kevin T

For many patients, especially those with high-stage and high-grade tumors with local extension, or those who have regional lymph node mets, a combination of radiation and chemotherapy is the best treatment option.2 For patients with metastatic transitional cell carcinoma of the ureter, combination chemotherapy consisting of methotrexate, vinblastine, adriamycin, and cisplatin (MVAC) offers more than 70% response. If surgery is done, radiation can be given post operatively.2 These fields would include the entire renal fossa, urethral bed, and ipsilateral bladder trigone, although this is dictated based on the clinical findings during surgery. Often times, the paraaortic and paracaval lymph nodes are involved, so these may need to be included in the treatment fields. The dose typically given is 5040cGy (180cGy/fraction) with a boost of 540cGy to a reduced volume, for a total dose of 5400cGy. This dose is usually limited by surrounding normal tissue and organ tolerances. AP/PA fields are common for the large fields, and if possible for the boost. Otherwise slight obliques may be necessary for the boost fields. || Tissue dose associated with 5% injury rate within 5 years.2 Bladder – 6500cGy – Contracture Kidney Spinal Cord – 4500cGy – Infarction/Necrosis Liver – 2500cGy – Acute and Chronic Hepatitis || 1. Chao, K, Perez, C, Brady, L. Radiation Oncology Management Decisions. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2002. 2. Hand C, Kim S, Waldow S. Overview of Radiobiology. In: Washington C, Leaver D, eds. Principles and Practice of Radiation Therapy. 2nd ed. St Louis, MO: Mosby-Elsevier; 2004:55-84. 1. Fletcher Allen Health Care. Website []. Accessed Jun 18, 2013. 1. Cancer of the ureter and renal pelvis. Macmillian Cancer Center Web Site. http://www.macmillan.org.uk/Cancerinformation/Cancertypes/Kidney/Aboutkidneycancer/Ureterrenalpelvis.aspx#DynamicJumpMenuManager_6_Anchor_3. Accessed June 21, 2013. 2. Chao KS, Perez CA, Brady LW. Radiation Oncology Management Decisions. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011. 1. Kuban DA, Trad ML. Male reproductive and genitourinary tumors. In: Washington CM, Leaver D, eds. //Principles and Practice of Radiation Therapy.// 3rd ed. St. Louis, MO: Mosby-Elsevier; 2010: 823-863. 1. Mayo Clinic. Cancer of the Ureter. []. 2013. Accessed June 19, 2013. 2. University of Rochester Medical Center. Urethral Cancer Radiation Therapy. Modified June 19, 2013. []. Accessed June 19, 2013. 1. Chao KS, Perez CA, Brady LW. Radiation Oncology Management Decisions. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2002:421. 2. Washington CM, Leaver D. Principles and Practice of Radiation Therapy. 3rd ed. St. Louis, MO: Mosby Inc; 2010:857-859. 1. Chao C, Perez C, Brady L. Radiation Oncology Management Decisions. 3rd ed. PA: Lippincott Williams and Wilkins; 2011:469-479. || Back to Week 4
 * Initial stage and grade of the tumor are the major prognostic factors1
 * LN metastases are associated with distant dissemination and lower survival ||
 * **Treatments:** || Erin
 * **TD 5/5:** || <span style="color: #ff0000; font-family: Arial,Helvetica,sans-serif;">Spencer
 * <span style="color: #ff0000; font-family: Arial,Helvetica,sans-serif;">Whole – 1500cGy – Acute and Chronic Nephrosclerosis
 * <span style="color: #ff0000; font-family: Arial,Helvetica,sans-serif;">Partial – 2000cGy - Acute and Chronic Nephrosclerosis
 * **References:** || <span style="color: #0055ff; font-family: Arial,Helvetica,sans-serif;">Pablo