Source: Cancer Resource Room

What is Renal Pelvis and Ureter Cancer?
Renal pelvis cancers are cancers that start in the middle of a kidney, where urine collects before going to the bladder. Ureter cancers start in one of the tubes that connect the kidney to the bladder. Cancer is a disease caused by a group of abnormal cells that grow and multiply without stopping. As these cells grow and multiply, they form a tumor or lump. The tumor cells replace the normal cells of the organ. Tumor cells crowd out the normal cells. This leaves fewer healthy cells to do the job of that organ. The tumor can also block passages that help the organ work. Tumor cells can grow from one organ into nearby tissues and other organs. They can also travel through the blood and lymph to other parts of the body and form more tumors. These tumors are called metastases.

Renal pelvis and ureter cancers start in the cells that line the inside of these structures. The lining tissue is made up of two types of cells, transitional cells and squamous cells. Most renal pelvis and ureter cancers start from transitional cells. Cancers that start from this type of cell are called, “transitional cell” cancers. Another name for renal pelvis and ureter cancer is urothelial cancer. Tumor cells grow in the lining tissue, and can invade through the layers of the renal pelvis or ureter, and spread to lymph nodes and other tissues nearby.

Renal pelvis and ureter cancers are not common cancers. When someone has one of these cancers, the person is also examined for tumors in the bladder. 30% to 50% of patients with cancer of the renal pelvis or ureter have or will have bladder cancer at some time.

What are the renal pelvis and ureter? What do the renal pelvis and ureter do?
The renal pelvis is in the center of each kidney. It is where urine collects before it goes to the bladder. The ureters are tubes of tissue that connect the renal pelvis to the bladder.

Both are made up of three main layers of tissue:

1. The inside or lining layer is called the mucosa. It is mostly made up of transitional cells. Under the lining are thin layers of cells that support the mucosa. These are the submucosa and the lamina propria.
2. The next major layer is the muscle layer. The muscles contract and squeeze out the urine when the renal pelvis gets full. The urine goes from the renal pelvis to the ureter and then to the bladder.
3. The outer layer is called the serosa. It covers the muscle layer and separates the renal pelvis and ureter from nearby organs.

The renal pelvis is a temporary storage part of the kidney. The kidneys make urine all the time. The urine collects in the renal pelvis. Urine flows from the renal pelvis to the bladder through a long tube called the ureter. Each kidney has its own ureter. The two ureters attach to the back of the bladder.

Are all renal pelvis and ureter cancers the same?
There are only about 2000 new cases of renal pelvis and ureter cancer diagnosed in the United States each year. About 90 percent of these cancers are transitional cell cancers. The other types are called squamous cell cancer and adenocarcinoma. The name of the cancer describes the type of cells that started the disease.

How are renal pelvis and ureter cancers diagnosed?
Diseases are diagnosed by putting together several bits of information. Some information comes from the patient, like symptoms, or how the patient feels. Other information comes from the patient’s medical history, or what medical problems the person has had in the past. Information also comes from the doctor’s examination of the patient. Technical information comes from blood tests and xrays or other imaging studies. When all the pieces of information are collected, a likely diagnosis can be made.

Renal pelvis and ureter cancers are diagnosed by the patient’s symptoms, medical history, physical exam, blood tests, xrays, and special tests of the urinary organs. Sometimes these cancers are discovered from a urine test done as part of a medical check-up. A urine test that shows microscopic amounts of blood in the urine can be a sign of cancer in the urinary system.

Sometimes the diagnosis needs to be proved by doing a biopsy. In a biopsy, the doctor takes a small sample of tissue or cells. Another doctor, called a pathologist, looks at these samples under a microscope. This is the only way to know the exact diagnosis of a disease.

Symptoms of renal pelvis and ureter cancer—What does the patient feel or notice?
Renal pelvis and ureter cancers start in the lining layer of these structures. The renal pelvis and ureter can keep working normally, even though a cancer has started in part of it. Symptoms caused by these cancers are often from the tumor tissue bleeding. The bleeding can be seen in the toilet when the person urinates (pees). Other symptoms can come from the tumor growing large enough to block the flow of urine from the kidney to the bladder. This can cause pain called flank pain. Some symptoms are also caused by cancer cells growing into other tissues or putting pressure on nerves.

When symptoms occur they include:

• Blood in the urine
• Pain in the side or back
• Lump or fullness in the side or back

These symptoms can happen with common illnesses, like kidney stones or infections. They should be checked by a doctor.

Patient’s history—What should the doctor know?
A patient’s medical history and physical exam are the first steps in making a diagnosis of any disease. In the case of renal pelvis and ureter cancers, the patient’s history may include information about:

• Tobacco use or exposure to second-hand smoke
• Work in the rubber, chemical, or leather industries
• Work as a printer, painter, machinist, hairdresser, or trucker
• Infection with a parasite (in tropical climates)
• Treatment for other illnesses with cyclophosphamide or arsenic
• Radiation treatment in the pelvis or abdomen
• Other family members with urinary system cancer
• Previous bladder or other urinary system cancer

Physical exam—What will the doctor look for?
The physical exam has two purposes. One is for the doctor to examine the patient for any lumps (masses) in the abdomen or pelvis that may be caused by a cancer. The examination should include a rectal exam, and for women, a vaginal exam. The other purpose of the physical exam is to learn about the patient’s overall health. The doctor will listen to the person’s heart and lungs, feel the abdomen for tender places, any lumps, or for an enlarged liver, and check for bone pain in the spine, arms and legs.

Blood tests:
There are no blood tests just for renal pelvis and ureter cancer. But some blood tests give useful information about the general health of the patient. These can alert the doctor to a problem. Some common blood tests are:

• CBC—blood count to check for anemia (low red blood cell count)
• LFT’s—liver tests that can be abnormal if cancer spreads to the liver
• Alk Phos—alkaline phosphatase is a bone enzyme that can be abnormal if cancer spreads to the bones
• BUN/Creatinine—check for normal kidney function

Urine tests:

• Urine specimen—tested for small amounts of red blood cells, bacteria, white blood cells, sugar, proteins and crystals
• Urine cytology—tests for abnormal cells in the urine from a cancer

Xrays and other imaging tests:

• Chest xray—This may show cancer spread to the lungs.
• IVP(IntraVenous Pyelogram)—An IVP uses dye to outline the inside of the kidneys, ureters, and part of the bladder. A special dye, called contrast, is put into the blood through an arm vein. This special dye can be seen on xrays. A series of xrays are taken as the dye flows in the urine through the kidneys, renal pelvis, ureter and bladder. The xrays show how the dye outlines the inside of the urinary organs. Any change in the smooth shape or size of the kidneys, ureters, or bladder will show on the xrays. An IVP is done in the radiology department. It requires an IV in the hand or arm for the contrast dye and fluid. The patient needs to lie on an xray table for twenty to sixty minutes. Some people are allergic to the dye used in this test. Tell the radiology staff if you have any allergies, especially an allergy to shellfish.
• CT scan—A CT scan is a series of xrays showing cross-sections of a body region. An abdominal CT scan shows both kidneys in cross-section pictures from top to bottom. If contrast dye is given to the patient through an IV, the images will show the inside of the kidneys, the ureters, and the bladder. A CT scan is a good way to find a tumor, to see what size it is, and to see whether or not it has spread to nearby lymph nodes or other tissues. CT scans are not painful, but do require lying on a table for about 30 minutes. If contrast dye is used, it is given through an IV. The dye can make a person feel very warm for a short time, and it causes the sensation of needing to pee urgently. Both feelings pass quickly.
• MRI—This test is like a CT scan, except it uses magnets instead of xrays to make the cross-section pictures of the body. MRI may be used in bladder and other urinary system cancers to check for spread of the disease into the nearby tissues, organs, or lymph nodes. Contrast dye is given through an IV, just as it is for a CT scan.
• Bone scan—A bone scan makes pictures of the entire skeleton. A small amount of fluid with a radioactive substance is injected into a patient’s arm vein. The fluid has to travel in the blood for about two hours before the scan can be done. The scan is painless, and requires the patient to lie on a radiology table for about twenty minutes. The scanner moves slowly over the patient’s body, from head to foot, recording a picture of the skeleton. Anything that changes normal bone tissue (arthritis, infection, injury, cancer) shows up as a dark spot on the scan. If a spot is seen on a bone scan, regular xrays and a CT or MRI scan can be done of that bone to show what caused the changes. A bone scan is done to look for any possible spread of cancer to the bones.

Special tests:

• Cystoscopy—Cystoscopy is an important test for finding urinary cancers. A cystoscope is a tool for looking inside the bladder and ureters. The cystoscope is a narrow tube, about the size of a pencil. It has a tiny camera in the end that sends pictures to a TV for the doctor to look at. The cystoscope is passed through the urethra, starting where urine comes out, and into the lower part of the bladder. This is not usually painful, but a numbing gel can be used if needed. The doctor can look at the lining of the bladder and up into the ureters for any signs of tumors. If any abnormal tissue is seen, samples can be taken out through the cystoscope. Urine is also collected to look for cancer cells. Small pieces of tissue are taken from normal-looking areas inside the bladder and ureters. These are looked at for possible early or precancerous changes in the cells. If many tissue samples (biopsies) are going to be taken, or if tumors are found that need to be removed, then this procedure will be done under general anesthesia in an operating room.
• Retrograde pyelography—This test is done during cystoscopy. The cystoscope is used to find the openings of the ureters into the bladder. A tube is placed into the ureter through that opening, and contrast dye is injected up into the ureter. Xrays are taken that show the inside shapes of the ureters and kidneys. These pictures are clearer than those from an IVP, but require cystoscopy.
• Antegrade pyelography—This is another test that uses dye to show the inside of the kidneys, renal pelvis and ureters. The kidney is located using ultrasound or a CT scan, and dye is injected into the kidney through a needle. Local anesthetic (like Novocain) is used to numb the skin where the needle is put in. Like the retrograde pyelogram, the xrays are clearer than in an IVP, but this test does not require cystoscopy.

Biopsy—What it is and what it means to the patient
A biopsy means taking a small sample of cells or tissue to look at under a microscope. This is the only way to know for sure if a patient has cancer. For renal pelvis and ureter cancer, the biopsies are done during a cystoscopy (see description above in the “Special tests” section). Small pieces of tissue are taken from the lining of the bladder, ureter, or renal pelvis. The samples of tissue are looked at by a pathologist who can tell whether or not the tissue is normal. Several biopsies can be done during one cystoscopy.

If a small tumor is seen in the lining of the bladder, ureter, or renal pelvis during cystoscopy, the doctor can remove the whole thing. When the biopsy removes the whole tumor, it is called an excisional biopsy. All the tissue is looked at by a pathologist, who can make a diagnosis and tell how far into the bladder lining the tumor has grown.

If the biopsy shows cancer, the patient can have tests to tell how much cancer there is and whether or not it has spread beyond the lining tissue.

Stage and Grade in renal pelvis and ureter cancer

What is the “grade” of a cancer?
The grade of a cancer describes how abnormal the cancer cells look compared to normal cells. When a pathologist looks at the biopsy tissue with a microscope, he/she is comparing that tissue to normal. The more abnormal the cells are in size, shape, and arrangement, the higher the grade of the cancer. Higher-grade cancers are often more aggressive and spread beyond the renal pelvis or ureter. Low-grade cancers are called Grade 1. High-grade cancers are either Grade 2 or Grade 3. The grade of a cancer is important in deciding how to treat a person’s disease.

What is the “stage” of renal pelvis and ureter cancer?

Stage describes:

• How large the tumor is
• Whether or not the tumor cells have grown through the lining tissue of the renal pelvis or ureter
• Whether it has spread to tissues, blood vessels, and/or lymph nodes around the area of the renal pelvis or ureter
• Whether it has spread to lymph nodes and to other parts of the body, such as the lungs, bones, or brain.

In general, the stages are:

• Stage 1—Cancer cells have formed a small lump on the surface of the lining of the renal pelvis or ureter (papillary carcinoma) without growing any deeper. Or, cancer cells are growing on the surface of the lining without making a bump (carcinoma in situ), and without growing any deeper.
• Stage 2—Early cancer in the lining of the renal pelvis or ureter. Tumor cells may go through the lining layer, but do not go into the muscle layer.
• Stage 3—Cancer cells have grown through the lining and into the muscle layer.
• Stage 4—The cancer has spread to nearby tissues. Or, cancer has spread to far away lymph nodes, bones, brain, lungs, or other organs.

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