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