Ureteral cancer is a malignant neoplasm originating from the mucous membrane of the ureter or resulting from the spread of cancer cells from another organ (usually from the renal pelvis). It is manifested by hematuria, pain in the lumbar region and a sharp increase in body temperature in the evening. Subsequently, anemia develops, urination disorders are possible. When the ureteral lumen is obstructed, hydronephrosis occurs. The diagnosis of “ureteral cancer” is made taking into account the clinical picture, ultrasound, CT, nephroscopy, cystoscopy, tumor biopsy and other studies. The treatment is operative in combination with chemotherapy and radiotherapy.
Meaning
Ureteral cancer is a rare malignant tumor that affects one or both ureters. It can be primary or secondary. In 68% of cases it is localized in the lower parts, in 20% it affects the middle third of the organ, in 9% it is located in the upper parts, in 2% it spreads to the entire ureter. It is diagnosed with the same frequency on the right and on the left, in 2-4% of cases it is found in both ureters. Mostly men suffer. In 80% of cases, ureteral cancer is detected at the age of 40-70 years.
Primary malignant neoplasms of the ureter make up from 1 to 4% of the total number of oncological lesions of the upper urinary tract. Secondary ureteral cancer usually occurs as a result of implantation metastasis of renal pelvis cancer. The presence of a proximally located tumor of the urinary tract dramatically increases the likelihood of a malignant process in the lower parts of the urinary system. Almost half of patients with ureteral cancer subsequently develop bladder cancer. With multifocal lesions, the risk of malignant neoplasm of the bladder increases to 70%. The treatment is carried out by specialists in the field of oncology and urology.
Causes
The epithelium of the urinary tract is very sensitive to a variety of harmful effects: chemical, mechanical, stagnant, inflammatory, etc. Among the negative chemical factors that increase the risk of developing ureteral cancer are smoking (which causes the formation of tryptophan products with carcinogenic activity), constant contact with nitrobiphenyl, aminobiphenyl, diaminodiphenyl, naphthylamine, benzidine, arsenic and some other substances.
The probability of ureteral cancer in smokers directly correlates with the experience of the smoker and the number of cigarettes smoked daily. Constant contact with arsenic and other compounds usually belongs to the category of occupational hazards, although exceptions are possible. In particular, arsenic can be contained in water, some other substances – in the atmosphere of ecologically unfavorable areas. Experts believe that the high level of environmental pollution explains the higher incidence of ureteral cancer in urban residents compared to rural residents.
Other factors that provoke the development of ureteral cancer include urolithiasis and inflammatory diseases of the urinary tract. Moving along the urinary tract, concretions cause constant irritation of the mucous membrane, which eventually leads to its hyperplasia. Inflamed or hyperplastic mucosa becomes more vulnerable to the action of carcinogens. An additional negative role is played by stagnation of urine, which increases the time of contact of the mucosa with harmful chemical compounds.
In addition, among the risk factors for developing ureteral cancer, oncologists indicate arterial hypertension (both primary and caused by other diseases) and long-term use of diuretics. It was found that in patients with close relatives with ureteral cancer and tumors of the renal pelvis, this pathology develops more often than the average in the population, but the probability of the disease in such cases increases slightly.
Classification
The tumor of the ureter can be primary or secondary. The primary neoplasm develops directly from the epithelium of the organ, the secondary one occurs as a result of implantation of malignant cells migrating with the urine flow from the renal pelvis. Secondary ureteral cancer, developed as a result of distant metastasis of tumors of other localizations, is rarely diagnosed. Ureteral cancer is often multifocal (with simultaneous or almost simultaneous appearance of several foci of malignancy). If there is one focus, the neoplasm is considered a single one, if several– then multiple.
Taking into account the features of the histological structure, three types of ureteral cancer are distinguished: squamous, transitional cell and adenocarcinoma. In the vast majority of cases (92-99%), specialists diagnose transitional cell carcinoma. Squamous cell tumors are detected in 1-8% of patients. Adenocarcinomas are extremely rare. In addition, ureteral cancer differs in the degree of differentiation of cells. There are four groups: highly differentiated, moderately differentiated, low-differentiated and undifferentiated neoplasms.
Another indicator that determines the therapeutic tactics and prognosis for malignant lesions of the ureter is the prevalence of the oncological process. Ureteral cancer can be local, regional or with metastases. Local neoplasm does not go beyond the ureter, regional ureteral cancer sprouts nearby organs, periurethral, perirenal or perihelvical tissue, affects lymphatic vessels and regional lymph nodes. In cancer with metastases, secondary tumors in other organs are detected.
Symptoms and diagnosis
The reason for the first visit to the doctor is usually hematuria. Blood in the urine and pain in the lumbar region on the side of the lesion in the early stages are observed in about half of patients with ureteral cancer. Subsequently, hematuria becomes more pronounced, repeated blood loss leads to anemia. Obstruction of the ureteral lumen by a growing tumor provokes hydronephrosis and renal colic. In some patients, urinary disorders are detected.
Another characteristic symptom of ureteral cancer is an increase in temperature to febrile numbers in the evening. Otherwise, the manifestations of the disease are similar to other oncological lesions. Patients with ureteral cancer lose their appetite, suffer from weakness and fatigue. In advanced cases, cachexia, pronounced anemia and symptoms of damage to various organs due to hematogenous metastasis are added.
Ureteral cancer is diagnosed on the basis of clinical symptoms and additional examination data. The examination program includes kidney CT, kidney ultrasound, renal angiography, detailed and cytological analysis of urine and other studies. The most informative diagnostic methods for ureteral cancer are excretory urography and retrograde ureteropyelography (if there are contraindications, antegrade pyelography is prescribed) and cystoscopy.
During cystoscopy, a tumor-like formation protruding from the mouth of the ureter is detected. In some cases, blood discharge is visible. X-ray studies with contrast make it possible to determine the localization of ureteral cancer, to see the expansion of the pelvis and the upper parts of the ureter, as well as to recognize hydroureteronephrosis (if present). Retrograde urography show a characteristic picture of the “snake’s tongue” caused by the leakage of contrast medium on both sides of the tumor. The final diagnosis is made taking into account the data of the histological examination of the material.
Treatment and prognosis
The treatment is operative. With a small, low-lying tumor, the ureter is removed along with part of the bladder, ureterocystoanastomosis is formed. With advanced ureteral cancer, nephroureterectomy is performed in combination with removal of the bladder. In some cases (with severe combined pathology, bilateral lesion of a single kidney and chronic renal failure), less radical endoscopic techniques are used. In the postoperative period, patients with ureteral cancer are prescribed radiotherapy, chemotherapy or intra-ureteral immunochemotherapy. In case of inoperable neoplasms, conservative palliative therapy is carried out.
The prognosis for ureteral cancer is determined by the stage of the tumor, the level of cell differentiation, the condition of the second kidney, the age of the patient, concomitant somatic diseases and other factors. With non-invasive transitional cell carcinoma of the ureter, recovery can be achieved in 80% of patients, with invasive – in only 15%. Chemotherapy does not completely eliminate the cancer process, but in about 40% of cases it provides long-term stabilization of the disease, however, the prognosis for metastatic tumors and recurrent ureteral cancer remains unfavorable.
