Upper urinary tract urothelial carcinoma and how it leads to other conditions

Upper urinary tract urothelial carcinoma and how it leads to other conditions? The urinary system can be divided into sections- the upper and the lower urinary systems. The upper urinary tract comprises the kidneys and the ureters. The ureter is a tube-like structure that transports the urine from the kidneys to the urinary bladder. The human body has two kidneys, and each has its own ureter to transport urine to the bladder. The lower urinary system is comprised of another tube called the urethra and the urinary bladder. The urethra transports urine out of the body from the urinary bladder. These two sections perform the function of waste removal from the body and regulate the body’s water and salt balance.

The upper urinary system

Kidneys: These bean-shaped organs are located near one’s back just below the rib-cage. The position of the liver causes the right kidney to sit a little higher than the left kidney. In a normal adult free from medical complications, the kidney is around 10 cm long, 3 cm thick, and 6 cm long. It alone weighs around 150 gm.

The kidney is actually shaped like a kidney-bean. It has a concave and convex structure on the inner and outsides, respectively. The kidney acts as an entrance and an exit for many, including the ureter, the blood vessels, lymphatic vessels, and nerves. The kidney is covered by three protective layers. The tough outer layer, the middle fatty layer, and the inner layer are the three layers of the kidney. The outermost layer of the kidney is the strongest layer, and it protects the kidney from trauma. The inner layers are the ones that make the urine. The nephrons are the tiny little units that filter out the blood that flows into the kidney to produce urine. This is then sent to the ureter. The kidney mainly creates a balance between salt and water, filters blood to produce urine, and also produces hormones.

Ureter: These tubes which connect the kidney and urinary bladder are approximately 30 cm long and 6 mm wide. These enter the bladder at an angle from the back, creating a valve that stops the backflow of the urine back into the kidney. The ureter wall is made up of three layers. It consists of a muscle layer which to contract and propel the urine from the kidney into the bladder.

Types of bladder cancer

Different cells that are present in the body can cause different types of cancer. The type of bladder cell that becomes cancerous in the body determines the type of bladder cancer. The most common type of bladder cancer is urothelial carcinoma. The others occur much rarely. These cancers include:

• Squamous Cell Carcinoma: This type of bladder cancer is generally associated with chronic irritation of the bladder. It can either be due to the use of a urinary catheter or a long-term infection. This form of cancer is mostly found in people who live in places where the parasitic infection is a very common cause of bladder infection. This is known as schistosomiasis.

• Adenocarcinoma: The cells of the mucus-secreting glands of the bladder generally are the root cause of this type of cancer. This is the rarest form of bladder cancer. These cells are present in many parts of the body. The most common types of cancer are generally breast, lungs, pancreatic, prostate, etc. It rarely occurs in the urinary system.

• Urothelial Carcinoma: Urothelial carcinoma is a type of bladder cancer. It is also known as transitional cell carcinoma (TCC). This is the most common type of bladder cancer. This generally begins in the urothelial cells, which line the inner part of the bladder. These cells also line other parts of the urinary system, like kidneys, renal pelvis, urethra, and ureter. This form of cancer is generally accompanied by tumors. Thus, it is important to look for tumors to rule out all possibilities of urothelial cancer. Most times, this type of cancer can be diagnosed at an early stage and be treated. The only drawback of this type of cancer is that it can come back in due time.

In the upper urinary tract, the urothelial cells present in the renal pelvis, renal calyces, and the ureters can be abnormal. These form tumors or masses. These cells are cancerous and can grow in the body without any control. As the accurate causes of these cancerous cell formation are unknown, it is hard to avoid these cancers. However, risk factors are known, and these can affect cancer development.

Cause of Upper Urinary Tract Urothelial Carcinoma

Bladder cancer is caused due to the mutations of the urothelial cells of the urinary system. The mutations cause changes in the DNA of these cells. The DNA contains the functions of the cell. It informs the cells about what to do. When the cells mutate, the DNA composition varies, causing them to mutate rapidly and continuously while the healthy cells die. These unhealthy or abnormal cells form a mass or tumor. These masses and tumors invade healthy tissues and destroy them. Over a period of time, these abnormal or unhealthy cells spread all over the body. This is how cancerous cells cause cancer.

Symptoms of Upper Urinary Tract Urothelial Carcinoma

There are not that many symptoms that point to upper urinary tract carcinoma. However, there are a few symptoms to look out for. These include:

• Hematuria (Blood in the urine): This is the most common symptom of upper urinary tract urothelial carcinoma. However, this could also occur for several other reasons. Hence, it is necessary to ensure that all the other causes are ruled-out before making a diagnosis. The blood makes the urine look red or cola-like in color. There are also times when the blood is not visible but is found in the labs.

• Pain: If the tumor is growing slowly, pain may be the only symptom. An ultrasound or an X-ray shall determine the size and form of the tumor is present. If the tumor is growing rapidly, it can cause severe pain due to the blockage of the kidney’s collecting system. Pain on the sides, stomach, and back along with nausea, can also be a symptom. These are symptoms similar to those of kidney stones; hence it should be ruled out.

• Uncommon Symptoms: Weight loss or anorexia accompanied by bone pain can be a symptom of advanced upper urinary tract carcinoma. A mass on the external or internal side of the body can also be a symptom of advanced cancer.

• Frequent urination and painful urination: Increased frequency of urination and pain during urination are also symptoms of cancer. This can also occur for simple bladder infections and kidney stones. Thus, it is necessary to rule out all possible diseases before diagnosing cancer.

Risk factors of Upper Urinary Tract Urothelial Carcinoma

There are several factors that influence the chances of acquiring upper urinary tract urothelial carcinoma. These risk factors include:

• Increasing age: Age is a key factor that plays a role in urothelial carcinoma. This can occur at any age. However, it is seen that most people diagnosed with this type of cancer are generally above the age of 55.

• Prior cancer treatments: The risk of bladder cancer increases with the treatment of the anti-cancer drug cyclophosphamide. Radiation treatment focused on the pelvic area increases the risk of this type of cancer.

• Chronic bladder inflammation: Repeated urinary inflammations or infections can happen with long-term use of catheters. This increases the risk of bladder cancer.

• Heredity: This can be embedded in one’s genes also. If the family has a past of such cancer diseases, one may be more susceptible to it. If one has already suffered from cancer, that person is more likely at risk of getting bladder cancer as well.

• Smoking: Smoking pipes, cigarettes, cigars, etc., can also increase the risk of this type of cancer. It causes various chemicals to accumulate in your urinary tract, thus making cancer more likely. These chemicals can also damage the lining of the urinary bladder increases the risk of cancer.

• Exposure to harmful chemicals: Kidneys are the organs that filter out the chemicals present in the blood. Thus, exposure to certain chemicals can increase the risk of cancer. Chemicals like arsenic chemicals used in dyes, rubber, leather, textile, and paint products can affect the urinary system.

• Gender: Men are more likely to be affected by this type of cancer compared to women.

Diagnosis of Upper Urinary Tract Urothelial Carcinoma

This type of cancer can be hard to identify and diagnose. This is because it does not have definite symptoms. A complete physical exam also sometimes may not be sufficient to diagnose this disease. A urinalysis is generally done in order to check for the levels of blood, bacteria, and protein. Based on the results of these tests, a professional shall suggest additional tests to confirm the diagnosis. These additional tests will be done to study the renal pelvis, bladder, and ureter. The additional tests may include:

• Ureteroscopy: This is done to check the condition and presence of abnormalities in both the ureters and renal pelvis.

• Intravenous Pyelogram (IVP): The IVP is done to study the fluid flow rate from kidney to bladder. This uses an X-ray dye to show the kidneys and the urinary tract.

• CT scan: It uses computers and rotations X-rays to get a detailed view to study the kidneys and ureter.

• Biopsy: The cells from the renal pelvis or the ureter are sampled to check for any kind of abnormalities and cancer.

• MRI: This is a non-invasive test that uses radio waves and magnets to get a detailed image of the urinary system. It helps in making an accurate diagnosis.

• Abdominal ultrasound: These use high-frequency sound waves to capture images or videos of the abdomen to study it and make the correct diagnosis.

• Grading: This tells one the rate at which the tumor is growing. The tumors can either be low-grade tumors that grow very slowly or high-grade tumors that grow rapidly.

• Staging: This is done in order to how deep the tumor has gone into the collecting region. This also tells us if cancer has spread to other parts of the body.

Treatment for Upper Urinary Tract Urothelial Carcinoma

The treatment depends on various key factors like the tumor grade, age, medical history, tumor size, location of the tumor, the extent of the tumor, kidney collecting anatomy, overall health, etc. Based on these factors, three courses of action can be chosen to treat upper urinary tract urothelial carcinoma:

• Surgery

• Radiation

• Chemotherapy

Surgery:

• Removal of the kidneys and ureters: The upper urinary tract urothelial carcinoma is treated with nephroureterectomy. This surgery involves the complete removal of the ureter and parts of the kidney. Even parts of the nearby lymph nodes can be taken out. The body shall function on only one kidney, making it necessary to regularly check the overall kidney function. Dialysis is needed if there are serious complications in the kidney. The surgery is dependent on the tumor size, nature of the tumor, and its location.

• Kidney Sparing Surgery: This surgery involves removing the remaining kidney and ureter on the tumor side. This is generally considered when the patient has already lost one kidney to cancer, kidney stones, infections, or diabetes. If this process is chosen, the tumor shall be managed with segmental resection or endoscopic removal.

1. Segmental resection: Removing the diseased part of the kidney or the urinary tract. This is done only if cancer has not spread.

2. Endoscopic removal: Removal of the tumor through a small tube called a ureteroscope. The tumor is destroyed with the help of a laser. This method is used if the tumor is small or low-grade.

3. Percutaneous tumor removal: A small scope is placed into the collecting part of the kidney through a small puncture in the back. This is also done for low-grade tumors.

Chemotherapy:

• Topical chemotherapy and immunotherapy: In this form of treatment, powerful drugs are injected into the urinary system to stop the rapid growth of the cancerous cells. However, this is not often used in the renal pelvis and the ureter. As the bladder holds the fluids for long durations, there is sufficient exposure to the drugs. However, in the upper tract, there is not much fluid retention. So, additional drugs may be used.

• Systemic Chemotherapy: In chemotherapy, drugs are used to kill cancerous cells. This method can be used to treat upper urinary tract urothelial cancer before and after removal of the ureter and kidneys. Chemotherapy can be intravenous or orally. If it is received orally, they are given pills to swallow. This can be done before or after surgery. If it is intravenous, the drugs are injected into the bloodstream. This may be done before or after the surgery. Chemotherapy is generally given in regular intervals of time. Each course has a treatment period and a resting period.

The side effects of the treatment depend on the dose of drugs and the type of drugs. Chemotherapy can even harm the normally dividing cells.

1. Blood Cells: the feeling of weakness, tiredness, bruises, etc., is seen when the number of blood cells in the body is lowered due to the high-powered drugs. If this is persistent, chemotherapy is stopped for a while, or the dosage is reduced. The medication for the development of new blood cells is used.

2. Digestive system lining cells: Chemotherapy can cause a number of issues like nausea, poor appetite, vomiting, lip sores, etc. These are not permanent, but they do go away when the treatment has been stopped.

3. Hair follicles: Chemotherapy affects hair growth. There may be a large amount of hair loss, but it grows back after the treatment. However, the texture and color of the hair may change.

Radiation:

High energy radiation is a minimally damaging process used to destroy cancer cells. This method is not generally used for upper urinary tract urothelial carcinoma as the area is very small, and focusing the waves is tedious. Radiation shall be used only to treat in such a way that the professional avoids tissue damage.

Post Treatment for Upper Urinary Tract Urothelial Carcinoma:

If this form of cancer is caught in the early stages, the surgical options provide a good cure. The outlook mainly depends on:

• The aggressiveness of the cancer cells: Low-grade diseases have a low chance of spreading and a higher chance of being cured. On the other hand, high-grade diseases have a higher chance of spreading and a lower chance of curing.

• The extent of the tumor: If the tumor has not invaded nearby tissues and lymph nodes, the chances of cure are extremely great. There will not be a need for additional treatments. Chemotherapy is needed if cancer has spread to the other cells.

Recovery and follow-up:

The recovery depends on the type of treatment. Minimally invasive treatments require a shorter recovery period and provide a better and safer solution. After treatment, regular follow-up scans and check-ups are necessary. This form of cancer is likely to occur in multiple places than other forms of cancer. These visits should never be missed in order to keep an eye on the cancerous cells.

An outlook of Upper Urinary Tract Urothelial Carcinoma

The recovery after treatment for upper urinary tract urothelial carcinoma depends on these factors:

1. Stage of Cancer: The survival rate depends on the stage of cancer. The higher the stage and advancement of cancer, the lower is the rate of survival. This includes the treatment effect, as well.

2. The overall health of the urinary system: The urinary system should not have any form of underlying treatment. If the patient possesses these problems, the chances of survival are lower despite the treatments.

3. Cancer recurrence: The recurrence of cancer is generally a bad sign. These are stronger and require a higher form of treatment. Cancer recurrence is a sign of lower survival.

4. Tumor location: The location of the tumor also plays a vital role in the recovery and chances of survival. In case the tumor is located beyond the renal pelvis, and it may quickly spread to the other regions of the body, reducing the survival rate significantly. The treatments may also no make much of a difference.

5. Metastasis: The spreading of cancer cells to different parts of the body reduces the survival rates and the effect of treatments significantly.

Prevention of Upper Urinary Tract Urothelial Carcinoma

The causes of cancer are still unknown to man. Therefore, it is not easy to avoid any form of cancer. Despite there not being a guaranteed method or procedure to prevent bladder cancer, a few tips help in reducing the risk of being affected by upper urinary tract urothelial carcinoma. The following may help in minimizing the risk of bladder cancer:

1. Avoid Smoking: Avoid smoking as the chemicals present in the inhaled smoke can affect your urinary system. Quitting may not be easy but can be practiced with the help of support groups and the right medical guidance and treatment.

2. Care around Chemicals: Follow all forms of safety procedures if you are working with chemicals and hazardous things. Ensure that you do not expose yourself to them for long durations of time, as they can affect one’s body very rapidly, leading to a large number of complications.

3. Incorporate a large variety of fruits and vegetables into your diet: A rich and healthy diet shall take one a long way. The antioxidants present in fruits and vegetables help in minimizing the risk of cancer. These keep the body healthy and also help in flushing out the toxins. A healthy diet can also reduce the risk of other diseases.

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