58

Urothelial Tumors of the Upper

Urinary Tract and Ureter

Thomas W. Jarrett; Armine K. Smith; Surena F. Matin

Questions

1.Which of the following factors would raise the possibility of hereditary upper tract urothelial cancer and prompt microsatellite instability evaluation or genetic testing?

a.Young age

b.Personal history of colon cancer

c.Two first-degree relatives with endometrial cancer

d.All of the above

e.None of the above

2.Which environmental factor has NOT been shown to be associated with development of upper tract urothelial carcinoma?

a.Long-term use of phenacetin

b.Smoking

c.Obesity

d.Aristolochic acid ingestion

e.Exposure to aromatic amines

3.The majority of ureteral tumors occur in the:

a.proximal ureter.

b.midureter.

c.distal ureter.

d.proximal and midureter.

e.distal and mid ureter.

4.The most important determinant of oncologic outcome in upper tract urothelial carcinoma is:

a.stage and grade.

b.number of tumors.

c.location.

d.tumor size.

e.tumor architecture.

5.The most frequent presenting symptom of upper tract urothelial carcinoma is:

a.dysuria.

b.flank pain.

c.weight loss.

d.hematuria.

e.abdominal mass.

6.Computed tomography (CT) urography outperforms intravenous pyelography in detection of upper tract tumors.

a.True

b.False

7.At the time of nephroureterectomy, the ureteral stump can be safely left in place for patients with urothelial tumors of the renal pelvis.

a.True

b.False

8.Initial evaluation of positive cytology should include which of the following?

a.Cystoscopy

b.Ureteroscopy

c.CT urography

d.a, b, and c

e.a and b

f.a and c

9.All of the following agents have been used in instillation therapy EXCEPT:

a.bacille Calmette-Guérin (BCG).

b.cisplatin.

c.mitomycin C (MMC).

d.thiotepa.

e.gemcitabine.

.Neoadjuvant chemotherapy is the standard of care in patients with locally advanced upper tract urothelial carcinoma.

a.True

b.False

Pathology

1.A 38-year-old woman has right flank pain and microscopic hematuria. Cytology is atypical. CT scan shows a mass in the distal right ureter with hydronephrosis. Cystoscopy is negative, and attempted ureteroscopy is unsuccessful. The distal ureter is excised, and the pathology is depicted in Figure 58-1 and is reported as endometriosis. The patient should be advised to:

FIGURE 58-1 (From Bostwick DG, Cheng L. Urologic surgical pathology. 2nd ed.

Edinburgh: Mosby; 2008.)

a.have a diagnostic laparoscopy.

b.receive ablative hormonal therapy.

c.have periodic upper tract imaging.

d.have cystoscopy and cytology twice yearly for the next 2 years.

e.have a hysterectomy and bilateral salpingo-oophorectomy.

2.A 60-year-old man has a right ureteral mass excised. The pathology is lowgrade noninvasive transitional cell carcinoma (TCC) (Figure 58-2). He has no prior history of upper tract disease or bladder cancer. Management should consist of:

FIGURE 58-2 (From Bostwick DG, Cheng L. Urologic surgical pathology. 2nd ed. Edinburgh: Mosby; 2008.)

a.interval cystoscopies and cytology.

b.instillation of BCG into the right upper tract.

c.systemic platinum chemotherapy.

d.periodic ureteroscopies of the left system.

e.no further follow-up.

Imaging

1. See Figure 58-3. A CT scan of a 62-year-old man with hematuria is shown.