Elliot K. Fishman M.D.
Johns Hopkins Hospital

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Transitional cell carcinoma of the renal pelvis, accounting for only 7% of all kidney tumors, and transitional cell cancer of the ureter, accounting for only 1 of every 25 upper urinary tract tumors, are curable in more than 90% of patients if they are superficial and confined to the renal pelvis or ureter.”

Localized

• Patients with localized disease may be classified into three groups:
• Group 1: Low-grade tumor confined to the urothelium without lamina propria invasion (papilloma grade I transitional cell cancer).
• Group 2: Grade I–III carcinomas without demonstrable subepithelial invasion or focal microscopic invasion or papillary carcinomas with carcinoma in situ and/or carcinoma in situ elsewhere in the urothelium.
• Group 3: High-grade tumors that have infiltrated the renal pelvic wall or renal parenchyma or both but remain confined to the kidney. Infiltration of muscle in the upper tract may not be associated with as much potential for distant dissemination as appears to be the case for bladder cancer.

Regional

• Group 4: Extension of tumors beyond the renal pelvis or parenchyma and invasion of peripelvic and perirenal fat, lymph nodes, hilar vessels, and adjacent tissues.

Metastatic

• Spread of the tumor to distant tissues.

Purpose of review
 To assess patterns of presentation, diagnostics and treatment in patients with upper tract urothelial carcinoma (UTUC), a multicentre registry was launched. Clinical data of UTUC patients were prospectively collected over a 5-year period.
Recent findings 
Data from 2380 patients were included from 2014 to 2019 (101 centres in 29 countries). Patients were predominantly male (70.5%) and 53.3% were past or present smokers. The majority of patients (58.1%) were evaluated because of symptoms, mainly macroscopic hematuria. Computed tomography (CT) was the most common performed imaging modality (90.5%). 
Contemporary patterns of presentation, diagnostics and management of upper tract urothelial cancer in 101 centres: the Clinical Research Office of the Endourological Society Global upper tract urothelial carcinoma registry, 
Baard, Joyce et al.
Current Opinion in Urology: July 2021 - Volume 31 - Issue 4 - p 354-362

“Our data is in line with the known epidemiologic characteristics of UTUC. CT imaging is the preferred imaging modality as also recommended by guidelines. Diagnostic URS (ureteroscopy) gained a stronger position, however, in almost half of patients a definitive treatment decision was made without complete endoscopic information. Only one-third of patients with UTUC are currently treated with kidney sparing surgery.”
Contemporary patterns of presentation, diagnostics and management of upper tract urothelial cancer in 101 centres: the Clinical Research Office of the Endourological Society Global upper tract urothelial carcinoma registry,
Baard, Joyce et al.
Current Opinion in Urology: July 2021 - Volume 31 - Issue 4 - p 354-362

“The major risk factors for urothelial carcinoma of the upper urinary tract include male gender, increasing age, cigarette smoking and tobacco use, phenacetin abuse, exposure to certain chemicals and drugs (such as cyclophosphamide), chronic hydronephrosis, and a history of prior recurrent or severe urinary tract infections..”
Upper and Lower Tract Urothelial Imaging Using Computed Tomography Urography 
Siva P. Raman, MD*, Elliot K. Fishman
Urol Clin N Am 45 (2018) 389–405

“Urothelial cancer (UC) constitute up to 10% of neoplasms of the upper urinary tract. UC occurs most frequently in the extrarenal part of the renal pelvis, followed by the infundibulocaliceal region. When manifesting as an infiltrative pattern, UC expands out of the renal pelvis into the parenchyma with distortion of the normal renal corticomedullary architecture with preservation of the reniform shape, which is not typically the case in RCC.”
CT imaging spectrum of infiltrative renal diseases
David H. Ballard et al.
Abdom Radiol (2017) 42:2700–2709

Hydrate the patient extensively prior to study

• 1000 cc of water 20 minutes prior to the study
• Reduces the incidence of contrast-induced nephropathy (CIN)
• Improves urinary tract distension
• Improves bladder distension

“However, the utility of CT urography, whether in the upper or lower urinary tract, is heavily contingent on the use of optimized CT protocols and proper image acquisition techniques, because poor technique can create significant barriers to making a correct radiologic interpretation, particularly given that identification of subtle tumors can be nearly impossible in the absence of good collecting system distension and opacification. Moreover, although standard axial image review may be sufficient in most other parts of the abdomen and pelvis, evaluation of the collecting systems and ureters presents a prime example of an application for which standard axial images may not be sufficient to identify many subtle urothelial tumors, and for which the use of multiplanar reformations and three-dimensional (3D) imaging techniques may be helpful (or even necessary) for the identification of small or difficult-to-see lesions.”
Upper and Lower Tract Urothelial Imaging Using Computed Tomography Urography 
Siva P. Raman, MD*, Elliot K. Fishman
Urol Clin N Am 45 (2018) 389–405

“In particular, our own experience has suggested that these reconstructions are particularly helpful in evaluating the ureters, where subtle urothelial thickening or even ureteral strictures are easy to overlook on the source axial images (and are commonly missed), whereas these abnormalities tend to be more conspicuous using a coronal MIP reconstruction. In particular, MIP images allow the entirety of the collecting systems and ureters to be viewed at a single glance (providing a global overview of the collecting systems), which is a great advantage compared with standard axial image review, in which the intrarenal collecting systems and ureters are constantly moving in and out of plane, making careful evaluation difficult.”
Upper and Lower Tract Urothelial Imaging Using Computed Tomography Urography 
Siva P. Raman, MD*, Elliot K. Fishman
Urol Clin N Am 45 (2018) 389–405

“The identification of transitional cell carcinomas throughout the upper and lower urinary tract (including the intrarenal collecting systems, ureters, and bladder) can be very difficult, and relies on several subtle imaging features. However, it is important to be cognizant that the identification of these imaging features is heavily contingent on proper imaging technique and protocol design. Failure to acquire the correct contrast enhancement phases, or, alternatively, failure to adequately distend the collecting system, can make identification of even large tumors difficult.”
Upper and Lower Tract Urothelial Imaging Using Computed Tomography Urography 
Siva P. Raman, MD*, Elliot K. Fishman
Urol Clin N Am 45 (2018) 389–405

Most upper tract TCCs are small, superficial, and frond-like with good prognosis

• Small minority are infiltrative and multifocal
• Most common location is the renal pelvis due to large area of urothelium
• Strong tendency for bilaterality and multifocality