Endoscopic diagnosis of upper-tract TCC – Correlating indications, investigations and histology
Finch W, Shah N, Wiseman OAddenbrooke’s Hospital
Cambridge
Endoscopic diagnosis of Upper-tract TCC Confirm Diagnosis prior to Nephroureterectomy
10.2% - Benign disease
Increasing pressure for nephron sparing endoscopic approaches Solitary kidney, bilateral tumours, renal impairment High surgical risk patient Low grade low stage tumours
Traditionally difficult to assess upper tract stage with imaging
Ureteroscopic biopsies – accurate? 75% accurate in predicting upper-tract TCC grade Biopsy grade can predict pathological stage
Chitale et al. Ann R Coll Surg Engl 2008;90:45-50Williams et al. J Endourol 2008;22:71-75
Keeley et al. J Urol 1997;157:1560-56
Study Aims
Evaluate
Indications for referral
Accuracy of ureteroscopy in staging upper-tract TCCUreteroscopic findingsUpper-tract urine cytologyUreteroscopic biopsy
Correlate with Final surgical histology
Study Cohort 85 patients
55M : 30F Average age 68 yrs (range 28-98) 75 Routine diagnostic 10 Complex diagnostic
conduit / distal ureterectomy / horseshoe kidney
2004 2005 2006 2007 2008 2009 2010
0
5
10
15
20
25
Referral pattern 2004 - 2010
Ca
ses
pe
r ye
ar
Tumour seen at U
O
Ongoing Haematuria ?cause
Atypical Voided Urin
e Cytology
Filling Defect o
n Imaging
Positive Voided Urin
e Cytology
Atypical voided Urin
e Cytology and filling defect
Positive voided Urin
e Cytology and filling defect
OVERALL0%
10%20%30%40%50%60%70%80%90%
100%
TCC No TCC
Indications for referral and diagnosis
Cohort Outcome
85 patients referred for endoscopic
diagnosis of upper-tract TCC
45 patientsNo evidence of upper-tract
TCC
40 patientsUpper-tract TCC
18 patientsNephroureterectomy
3 patientsAwaiting
Nephroureterectomy
15 patientsEndoscopic
Management
4 patientsDeclined treatment
Palliative Care
45 patientsDischarged
Back to referring clinician
Ureteroscopic findings and final histology
Uretero-ileal anastamosis – 4%TCC not visualised – 5%
• Stricture• Tortuous upper ureter
Renal Upper pole – 10%Renal Interpolar – 4%Renal Lower pole – 8%Renal Pelvis – 22%Renal Extensive – 8%
Ureter Upper 1/3 – 0%Ureter Middle 1/3 – 8%Ureter Lower 1/3 – 26%Ureter Extensive – 5%
When TCC seen endoscopically
ALL final histology confirmed TCC
Negative Atypical Positive0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Grade IIIGrade IIGrade I
Upper-tract urine cytology
Ca
ses
Pathological grade
Upper-tract cytology and Pathological grade
BenignGrade I
Grade II
Grade III
TCC ungraded
not interpretable
Small Cell C
a0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Small Cell CaGrade IIIGrade IIGrade IBenign
Ureteroscopic biopsy
Ureteroscopic biopsy grade and Pathological grade
Pathological grade
Benign
Grade I
Grade II
Grade III
TCC ungraded
not interpretable
Small Cell C
a0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Small Cell CaMuscle Invasive TCCSuperficial TCC
Ureteroscopic biopsy
Ureteroscopic biopsy grade and Pathological stage
Pathological stage
Pathological stage
Biopsy
Cytology
Cytology and biopsy
Ureteroscopy
Ureteroscopy and biopsy
Ureteroscopy and cytology
Ureteroscopy and cytology and biopsy0
0.5
1
1.5
2
2.5
3
3.5
4
Superficial TCCMuscle Invasive TCCSmall Cell Ca
Endoscopic Investigations
Positive endoscopic investigations and Surgical grade
Conclusions
Failure to investigate endoscopically may result in unnecessary procedures for benign disease
Filling defects on prior imaging - No TCC demonstrated in 66% cases
Ureteroscopically - if it looks like TCC – it usually is
Upper-tract urine cytology helps identify high grade disease
Ureteroscopic biopsy is not always accurate - but can predict high grade disease
The combination of ureteroscopic appearance, cytology and biopsy
1. will diagnose upper-tract TCC
2. may help identify patients not suitable for conservative therapy