Ureter

- Misusing certain pain medications, including over-the-counter pain medicines, for a long period of time. - Being exposed to certain dyes and chemicals used in making leather goods, textiles, plastics, and rubber. - Smoking cigarettes 6 || Table 1. Diagnostic workup renal pelvis and ureter carcinoma. 1 || Transitional cell carcinomas account for more than 90% of malignant tumors of the renal pelvis and ureter. Squamous cell carcinomas comprise only 7% to 8%. "Squamous cancers of the renal pelvis and ureter are often locally advanced and associated with a high local recurrence rate." 2 || Figure 1.1 Anatomy of the abdominal cavity  3 || GX Grade cannot be assessed G1 -Well differentiated G2 -Moderately differentiated or undifferentiated G3-4 ---Poorly differentiated or undifferentiated 1 ||
 * ​ Epidemiology: || Cancer can grow in the urine collecting system, but is uncommon. As a group, renal pelvis and ureter cancers account for no more than 5% of all cancers of the kidney and upper urinary tract. They affect men more often than women and are more common in people older than 65. 7 ||
 * Etiology: || Risk factors include...
 * Signs & Symptoms: || Hematuria (gross or microscopic) presents in 70% to 95% of patients. Less common symptoms include pain in approximately 8% to 40% of patients and bladder irritation in approximately 5% to 10% of patients. A flank mass from the tumor or hydronephrosis is seen in approximately 10% to 20% of patients. 1 ||
 * Diagnostic Procedures: || "Retrograde pyelography can be used to define the lower margin of a ureteral lesion, especially if there is significant proximal obstruction to flow of contrast from the renal pelvis." A CT or MRI with images before and after contrast can help determine possible tumor extension outside of the collection system. Urine cytology should be obtained endoscopically and an accurate cytologic diagnosis can be made from it in 80% of cases. 1
 * Histology: || * Transitional Cell
 * Squamous Cell
 * Lymph Node Drainage: || The kidneys, ureters, and there vascular supply, and lymphatics are located within the retroperitoneal space of the abdominal cavity. The anatomy can be seen in figure 1.1 below .3 According to Washington and Leaver, " The lymphatic drainage of the ureter is segmented and diffuse, involving any of the following : renal hilar, abdominal periaortic, paracaval, common iliac, internal iliac, or external iliac nodes." 3 
 * Metastatic Spread: || <span style="color: #0000ff; font-family: 'Times New Roman',Times,serif;">In ureteral carcinoma it is common for the regional lymph nodes to be involved before other sites of metastasis. The most common sites for distant metastases are the lungs, liver, bladder and peritoneal cavity. 3 A higher incidence of metastasis is associated with high grade tumors. 1 ||
 * Grading: || <span style="color: #0000ff; font-family: Georgia,serif;">__Histopathologic grade__
 * Staging: || <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 110%;">AJCC Staging System

__Primary tumor (T)__ TX: Primary tumor cannot be assessed T0: No evidence of primary tumor Ta: Papillary noninvasive carcinoma Tis: Carcinoma //in situ// T1: Tumor inades subepithelial connective tissue T2: Tumor invades muscularis T3: Tumor invades beyond muscularis into periureteric fat T4: Tumor invades adjacent organs or through the kidney into perinephric fat

__Regional lymph nodes (N) a __ NX: Regional lymph nodes cannot be assessed N0: No regional lymph node metastasis N1: Metastasis in a single lymph node, less than or equal to 2 cm in greatest dimension N2: Metastasis in a single lymph node, greater than 2 cm but less than 5 cm in greatest dimension N3: Metastasis in a lymph node greater than 5 cm in greatest dimension

__Distant metastasis__ MX: Distant metastasis cannot be assessed M0: No distant metastasis M1: Distant metastasis 1

|| The treatment options depend on the following: -The stage and grade of the tumor -Where the tumor is -Whether the patient's other kidney is healthy -Whether the cancer has recurred
 * Radiation Side Effects: || <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 110%;">Radiation side effects may include: nausea, vomitting, diarrhea, and abdominal cramping. When patients are treated for right-sided lesions, radiation-induced damage to the liver is possible. 1 ||
 * Prognosis: || The prognosis (chance of recovery) depends on the stage and grade of the tumor.

Most transitional cell cancer of the renal pelvis and ureter can be cured if found early. 6 ||
 * Treatments: || <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif;">" The performance status and medical comorbidity of the patient are major considerations in deciding the aggressiveness of treatment ." <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; vertical-align: super;">4 <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif;">

- Mainstay of treatment for renal pelvis and ureter cancers. <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; vertical-align: super;">4 <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif;"> -Radical nephroureterectomy (including the removal of the contents of Gerota's fascia and the ipslateral ureter with a cuff of bladder at its distal end) is an appropriate intial therapy for patients with transitional cell carcinoma of the renal pelvis or ureter. <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; vertical-align: super;">1 <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif;"> -Conservative Surgery should only be used for low grade, low stage and solitary tumors with poor kidney function or only one kidney. If this is used, post operative radiation therapy should be considered. <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; vertical-align: super;">1 <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif;"> -"The role of lymph node disection is unclear ." <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; vertical-align: super;">1 <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif;">
 * __Surgery__**

-Postoperative radiation therapy is used in the management of ureter cancer, retrospective data suggests a decreased local recurance with this regimen. <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; vertical-align: super;">1 <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif;"> -The clinical target volume for upper ureter lesions should include the renal fossa, the entire ureter down to the bladder wall at the ipslateral trigone. This field can be modified to include the paracaval and paraaortic lymph nodes at risk. <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; vertical-align: super;"> 1 <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif;"> The renal hilar nodes are also included. <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; vertical-align: super;">4 <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif;"> Figure 1: Postoperative Radiation Portal for Renal Pelvis and Ureter. <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; vertical-align: super;">1 <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif;">- Doses of 45-50 Gy (1.8 to 2.0) are used to treat subclinical and microscopic disease. - Higher doses are considered for more extensive disease ( multiple positive lymph nodes or positive surgical margins) by boosting the area with an additional 5 to 10 Gy. -The dose to the contralateral kidney should not exceed 18 Gy. - The volume of liver and Stomach may be reduced with AP/PA fields. - Lateral fields are used to keep the spinal cord dose within tolerance (45 Gy). -Lower ureteral lesions, the pelvic lymph nodes should be included in the fields. A three (PA and lateral fields)or four field technique is used based on the posterior location of the ureter with the patient lying prone ( minimized small bowel dose). <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; vertical-align: super;">4 <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif;"> - Unresectable or bulky disease is treated with higher doses. This treatment may include oblique and lateral fields. Toxicity is a challenge with the mulitple field arrangements. Figure 2: Portal image for a unresetable renal transitional cell carcinoma of the renal pelvis and ureter. <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; vertical-align: super;">1 <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif;">- Painful metastates respond to 20 to 40 Gy using 2 to 4 Gy daily. <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; vertical-align: super;">4 <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif;"> -A single treatment of 8 Gy may provideshort term palliation for patients with poor performance status and/or a short life expectancy. <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; vertical-align: super;">4 <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif;"> -Adjuvant chemotherapy has no defined role in ureter cancer. -Palliative chemotherapy is considered for metastatic disease. -Regimens of Methotrexate, Vinblastine, Doxorubicin and cisplatin have shown objective response rates in about 70% of patients with metastatic transitional cell carcinoma of the ureter. <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; vertical-align: super;">1 <span style="color: #0000ff; font-family: 'Times New Roman',Times,serif;">Figure 3 : Isodose distribution of an Ap/Pa and oblique field with wedges.3 || <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif;">Table provided by Wikibooks. <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; vertical-align: super;">5 || <span style="color: #000000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">References: <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 110%;"> 1. Chao KS, Perez CA, Brady LW. Radiation Oncology Management Decisions. 2nd ed. Philadelphia, PA: Lippincott, Williams, and Wilkins. 2002. Pg. 423, 428. 420-421.<span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 110%;"> <span style="color: #0000ff; font-family: Georgia,serif;">423, <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif;">427-429. <span style="color: #228000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">2. Perez CA, Brady LW, Halperin EC, Scmidt-Ullrich RK. //Principles and Practice of Radiation Oncology.// 4th editiion. Philadelphia, PA: Lippincott, Williams, & Wilkins. 2004: 1651-1653. <span style="color: #0000ff; font-family: 'Times New Roman',Times,serif;">3. Washington CM, Leaver DT. //Principles and Practice of Radiation Therapy Practical Applications.// St. Louis, Missouri : Mosby, Inc. 1997; 276-278.282. <span style="color: fuchsia; font-family: 'Times New Roman',Times,serif; font-size: 12pt;">4.Gunderson, LL & Tepper, JE. (Eds.) //<span style="font-family: 'Calibri','sans-serif';">Clinical Radiation Oncology //. 2nd edition. Philadelphia, PA: Elsevier, Churchill & Livingstone. 2007: 1294-1300. <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; font-size: 121%;">5. Radiation Oncology/Toxicity/Emami. Wikibooks. Available at: <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; font-size: 110%;">[]. <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; font-size: 121%;">Accessed: January 27, 2010. <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 121%;"> 6. National Cancer Institute. Transitional Cell Cancer of the Renal Pelvis and Ureter Treatment (PDQ). Available at: []. Accessed: January 31, 2010. 7. Medicine Plus. Cancer - renal pelvis or ureter. Available at: []. Accessed: January 31, 2010.
 * __Radiation Therapy__**
 * __Chemotherapy__**
 * TD5/5: || [[image:td55ureternew.jpg width="334" height="310"]]