Renal pelvis tumors

Definition

Renal pelvis tumors are rare kidney cancers appearing in a specific part of the kidney known as the pelvis of the kidney.

Description

The word renal means having to do with the kidneys. A part of each kidney in the human body is called the renal pelvis. The renal pelvis in each kidney is the portion of the collecting system of the kidney that empties into the ureters (tubes that carry urine from the kidneys to the bladder). Tumors of the renal pelvis are rare.

Renal pelvis tumors usually appear after an earlier condition, called renal papillary necrosis, has already developed. The tumors can be composed of any one of several different types of cells. Most commonly, these tumors are of a type of cell known as a transitional cell carcinoma.

A transitional cell is intermediate between the flat squamous cell and the tall columnar cell. It is restricted to the epithelium (cellular lining) of the urinary bladder, ureters, and the renal pelvis. Transitional cell carcinomas have a wide range in their gross appearance depending on their locations. Some of these carcinomas are flat in appearance, some are papillary (small elevation), and others are in the shape of a node. Under the microscope, however, most of these carcinomas have a papillary-like look. There are three generally recognized grades of transitional cell carcinoma. The grade of the carcinoma is determined by particular characteristics found in the cells of the tumor. Transitional cell carcinoma typically affects the mucosa (the moist tissue layer that lines hollow organs or the cavity of the body) in the areas where it originates— in this case, the kidney.

Demographics

Because statistics on these tumors are gathered with statistics on other kidney tumors, little information specific to tumors of the pelvic area of the kidney, as opposed to other areas of the kidney, is available. It seems probable, however, that these tumors appear most commonly in persons between the ages of 50 and 70.

Causes and symptoms

The appearance of renal pelvis tumors is associated with a history of cigarette smoking and the overuse of certain pain medicines, as well as with a history of either urinary tract inflammation kidney stones, or bladder cancer . People who have worked in the rubber, paint, dye, printing, textile, and plastic industries and been exposed to certain chemicals are also at increased risk for this type of cancer. The risk is elevated, as well, for people with a rare kidney condition called Balkan nephropathy. This condition is more likely to affect people from Romania, Greece, Bulgaria, Serbia, Croatia, Bosnia-Herzegovina, and other countries that formerly comprised Yugoslavia.

Approximately four out of five patients have symptoms of blood in the urine at the time of diagnosis. Approximately one out of three patients experiences pain in the side. Other patients may have no symptoms, while others may feel generally ill, visit the doctor for this general complaint, and have the cancer diagnosed at that time.

Diagnosis

Either urography or pyelography may be used to diagnose renal pelvis tumors. Both urography and pyelography are types of x-ray procedures that may be used to visualize portions of the urinary tract. The kidneys are part of the urinary tract. If urography is used, it is usually followed by cystoscopy . Cystoscopy involves the use of a medical instrument that permits the physician to look directly at portions of the urinary tract.

A newer technique is called ureteroscopy. Performing ureteroscopy increases the diagnostic accuracy doctors are able to attain. However, there is a risk that ureteroscopy may cause damage to some portion of the urinary tract. Therefore, ureteroscopy is usually reserved for those patients for whom unanswered questions remain after conventional diagnostic approaches have been completed.

The doctor may also order an x ray of the chest, a bone scan, and liver function tests to see whether the cancer has spread.

Clinical staging, treatments, and prognosis

Clinical staging

Tumor stage and grade provide important information on how an individual patient's renal pelvis tumor (s) will be treated and on the patient's prognosis. The primary tumor is staged on the basis of whether it remains superficial or has settled into the kidney. Patients with more superficial tumors have the best prognosis. However, even these patients may develop new tumors later.

Another factor important in determining treatment and prognosis is to determine the type and character of the individual cells that make up the tumor. Cells with a well-differentiated structure are associated with longer patient survival than cells with poorly differentiated structure.

Treatments

Surgery constitutes standard treatment for renal pelvis tumors. The surgical procedure may involve removal of a portion of the bladder, as well.

Some patients should not receive surgical treatment for this cancer. Other patients should undergo a relatively more limited surgical procedure than the standard procedure—one in which less of the kidney is removed. Those who should be approached in the more limited way may include patients with only one single kidney, patients with cancer of both kidneys, and patients with Balkan nephropathy. In addition, patients who are in generally poor health may not be good candidates for surgery or may receive a limited surgical procedure.

Of course, patients with a single tumor comprised of well-differentiated cells are likely to have a better long-term outcome following a limited surgical procedure than are patients with several tumors comprised of poorly differentiated cells. It should be understood, however, that more limited procedures may involve a greater likelihood that the cancer will return.

Patients with Balkan nephropathy usually benefit from receiving the more limited procedure. These patients are at pre-existing risk of kidney failure because of the Balkan nephropathy; thus, the more of their kidneys preserved, the better for their future overall medical outcomes.

Some surgical procedures used for renal pelvis tumors are performed using a medical device that moves along the body channels used by urine. The use of this device in the treatment of renal pelvis tumors is, however, limited to extremely small tumors.

X-ray therapy may be used following a surgical pro cedure for renal pelvis tumors. In particular, it may be used if there is any evidence that tumor cells have affected any of the surrounding organs or if they are appearing in the lymph nodes. In addition, x-ray therapy may be recommended for patients who are at a higher-than-average risk for reappearance of cancer, for example, patients who are heavy smokers. Some authorities believe that additional studies are needed to clarify the effects of xray therapy for these patients.

Patients who experience pain related to renal pelvis tumors may receive x-ray treatment to control pain. Such treatment may be very effective. Patients with such pain may also benefit from chemotherapy .

The patient with advanced renal pelvis cancer does not receive treatment that attempts to cure the disease. Rather, the treatment is palliative—it is used in an attempt to make the patient feel better and to improve the patient's quality of life. Cisplatin used alone has been shown to be an effective chemotherapy medicine in this situation.

It may, however, be preferable to use combination chemotherapy rather than cisplatin alone for patients with advanced disease, as a recent study demonstrated. The combination chemotherapy used in this study is the so-called M-VAC regimen, which consists of methotrexate , vinblastine , Adriamycin (doxorubicin ), and cisplatin. This combination of medicines permitted patients both to live for a longer time without return of cancer and to live for a longer time overall.

Another combination of chemotherapy medicines studied for patients with advanced disease is the so-called CMV, which consists of cisplatin, methotrexate, and vinblastine.

It is important to examine the side effects that may accompany chemotherapy in these patients. Some of these side effects are severe, and a small percentage of patients treated using this modality die. Both the M-VAC and the CMV regimens help approximately half of patients and give some patients additional months of life.

Other, newer medicines that have been tried as chemotherapy for patients with renal pelvis tumors and advanced disease are paclitaxel (Taxol) and gemcitabine (Gemzar). In 2001, it was questionable whether the use of either one of these medicines as single-drug chemotherapy produces superior results to the M-VAC or CMV regimens.

Prognosis

In terms of patient survival, almost all patients with superficial tumors composed of relatively well-differentiated cells live more than five years. In contrast, patients with poorly differentiated (abnormal in maturity and function) tumors that have invaded deep into the kidney and transplanted cells to other parts of the body may live only one year or less.

Approximately two out of five patients given limited surgical treatment for renal pelvis tumors will have new tumors develop. Therefore, it is important that these patients receive careful and regular follow-up. Some authorities recommend examinations for new tumors of and near the renal pelvis at three-, six-, nine-, twelve-, eighteen, and twenty-four months following surgery, and annually afterwards.

Coping with cancer treatment

Cancer patients need supportive care to help them come through the treatment period with physical and emotional strength in tact. Many patients experience feelings of depression , anxiety, and fatigue , and many experience nausea, vomiting, and other side effects during treatment. Studies have shown that these can be managed effectively if the patient discusses these issues with the treating physician.

Prevention

Smoking cessation is the most important step. In addition, persons working in the rubber, paint, dye, printing, textile, and plastic industries might speak with their doctor about whether they are at elevated risk of developing this cancer.

Resources

BOOKS

Braunwald, Eugene, et al. Harrison's Principles of Internal Medicine. 15th ed. New York: McGraw-Hill, 2001.

Haskell, Charles M. Cancer Treatment, 5th ed. Philadelphia: W. B. Saunders, 2001.

Pazdur, Richard, et al. Cancer Management: A Multidiscipli-nary Approach: Medical, Surgical, & Radiation Oncology 4th ed. Melville, NY: PRR, 2000.

Bob Kirsch

KEY TERMS

Balkan nephropathy

—A rare, inherited kidney disorder that is associated with increased risk of developing renal pelvis tumors.

Cystoscopy

— A medical procedure involving the use of a medical instrument that permits the physician to look directly at portions of the urinary tract.

Pyelography

— A type of x-ray procedure applied to a portion of the urinary tract, of which the kidneys form part.

Renal

— Having to do with the kidneys.

Renal pelvis

—That portion of the collecting system of the kidney that empties into the ureter.

Renal papillary necrosis

— A medical condition affecting the kidney and that increases a person's risk of developing a tumor of the renal pelvis.

Urography

—A type of x-ray procedure applied to a portion of the urinary tract, of which the kidneys form part.

Ureteroscopy

— A diagnostic procedure that increases the diagnostic accuracy of the examination of possible renal pelvis tumors. Ureteroscopy may cause damage to some portion of the urinary tract. Therefore, ureteroscopy is usually reserved for those patients for whom unanswered questions remain after conventional diagnostic approaches have been completed.

QUESTIONS TO ASK THE DOCTOR

• How can I obtain supportive care so I come through this not only alive but with my family and emotional life intact?
• What sort of benefit and what sort of side effects might each of the available treatment options bring?
• Would you please inform me about treatment options and let me tell you about the priorities in my life so I can participate in forming a treatment plan?
• What is my prognosis?
• What are the chances, after I have completed treatment, that cancer may return? How frequently should I be checked so we can defeat any cancer that appears in the future?