Renal pelvis cancer

　　Aromatic amines such as β-naphthylamine, diphenylamine, etc., in industrial raw materials such as dyes, leather, rubber, paint, etc., are carcinogens for renal pelvis cancer. Disordered tryptophan metabolism, smoking, and long-term use of nonsteroidal anti-inflammatory drugs significantly increase the incidence of renal pelvis cancer. Infection or long-term stone stimulation can cause squamous cell carcinoma or adenocarcinoma. Cystic pyelonephritis and glandular pyelonephritis can develop into renal pelvis cancer.

　　About 30-50% of patients with renal pelvis transitional cell carcinoma may have concurrent bladder transitional cell carcinoma, the main symptom is hematuria. Almost all patients have hematuria, among which about 85% is the first symptom, most of which are gross hematuria, but microscopic hematuria often occurs before gross hematuria, in the early stage of the lesion. The characteristics of gross hematuria are painless, mostly gross hematuria throughout, but can also be manifested as initial or terminal hematuria during urination, presenting intermittent occurrence, but can also persist, the interval time varies from a few days to several months, generally the early interval time is longer, and gradually increases with the development of the disease.

　　Shorten the interval period. If there is a tumor in both the renal pelvis and the ureter, the possibility of bladder cancer increases to 75%. Late patients may have anemia and cachexia.

　　About 70-90% of renal pelvis cancer patients have the most important early clinical symptom of painless gross hematuria, a few patients may experience lumbar discomfort, hidden pain, and distension due to tumor obstruction at the renal pelvis-ureteral junction, occasionally due to blood clots or tumor shed, renal colic due to tumor growth or obstruction, it is rare to have lumbar mass due to hydronephrosis, and there are also a small number of patients with urinary tract irritation symptoms, late patients may appear anemia and cachexia.

　　1. Renal pelvis cancer is clinically divided into 5 stages:

　　Stage O: Tumor confined to the mucosal stage;

　　Stage A: Tumor invasion of the basement membrane;

　　Stage B: Tumor invasion of the muscular layer;

　　Stage C: Tumor extension to perinephric fat or renal parenchyma;

　　Stage D: Regional lymph node involvement or metastasis to other sites.

　　2. Hematuria:The incidence is about 90%,表现为 intermittent, painless, visible, gross hematuria throughout, and can excrete thread-like blood clots.

　　3. Pain: Blood clots during hematuria can cause ureteral obstruction, leading to renal colic, and the tumor causing hydronephrosis can result in discomfort and pain in the lumbar area.

　　4. Mass: Located mostly in the lumbar or upper abdominal area, the appearance of a mass indicates that the tumor has blocked the ureter, leading to hydronephrosis or that the condition is near the late stage.

　　5. General symptoms: General malaise, decreased appetite, weight loss are common systemic symptoms in tumor patients, and some patients may also have varying degrees of fever, anemia, or hypertension.

　　6. Metastasis manifestations: Renal pelvis tumors often have early metastasis, and sometimes enlarged lymph nodes can be palpated above the clavicle.

　　Patients with the above clinical manifestations and signs should consider the possibility of renal pelvis tumor. Combined with laboratory examination, cytological examination, and imaging, a diagnosis can usually be made.

　　There are no special effective preventive measures for renal pelvis cancer, but some adjustments can be made in diet:

　　1. Maintain an ideal weight.

　　2. Consume a variety of foods.

　　3. Include a variety of vegetables and fruits in daily diet.

　　4. Consume more high-fiber foods (such as whole grain oatmeal, beans, vegetables, fruits).

　　5. Reduce the total intake of fat.

　　6. Limit the intake of alcoholic beverages.

　　7. Limit the intake of preserved, smoked, and nitrite-containing foods.

　　The current clinical examination of renal pelvis cancer is divided into two aspects: laboratory examination and imaging examination.

　　First, Laboratory examination

　　1. Urinalysis can often detect red blood cells.

　　2. Urine cytology examination requires multiple checks, with a positive rate of 35% to 55%. Acridine orange staining fluorescence microscopy can achieve a positive rate of up to 80%.

　　Second, Imaging examination

　　1. Renal pelvis angiography: IVU combined with retrograde renal pelvis angiography is the basic method for locating and diagnosing renal pelvis tumors, and for estimating the gross morphology and tumor staging of the tumor. The positive rate of IVU is 58% to 80.8%, and retrograde renal pelvis angiography can detect tumors in 86% of cases. Using double the dose of contrast agent or performing retrograde renal pelvis angiography on kidneys that do not show up can help clarify the diagnosis.

　　Renal parenchymal tumors and renal pelvis tumors are sometimes difficult to distinguish due to similar changes in kidney shape and renal calyx X-ray signs. Generally, there is no change in kidney shape, while a larger filling defect in the renal pelvis suggests a higher possibility of renal pelvis tumor. When the tumor is small, it often requires repeated renal pelvis angiography to make a clear diagnosis. It is advisable to use a dilute contrast agent during retrograde renal pelvis angiography, and taking photos from different angles can help in discovery.

　　2. Ultrasound examination: The diagnostic rate of ultrasound examination for early renal pelvis tumor is not high, but it can make a correct diagnosis for renal pelvis tumors that have developed to a certain degree. The filling defect shown by renal pelvis angiography is often difficult to distinguish from translucent stones and blood clots, while ultrasound can qualitatively differentiate renal pelvis tumors from negative stones and blood clots. The ultrasound image of renal pelvis tumor shows separated renal sinus echo, with a hypoechoic area inside, and can clearly display the surface morphology of the tumor. When the corresponding renal cortex and medullary structure are disordered, it indicates that the tumor has invaded the renal parenchyma; if there is irregular deformation of the renal contour on this basis, it suggests that the tumor has invaded the deep renal parenchyma or the infiltration has exceeded the renal capsule. If hydronephrosis is caused by the tumor, ultrasound images of hydronephrosis may also be present.

　　2. CT scan: CT scan has high resolution. After plain scan and contrast-enhanced scan, it can clearly show the density of the lesion, the extent of infiltration, and the relationship with surrounding organs. The accuracy of diagnosis for renal pelvis tumors can reach more than 90%, and it is of great value in clinical staging of tumors and formulating surgical plans. The CT signs of renal pelvis tumors are related to the extent of tumor infiltration, and CT scan can also detect perinephric infiltration and regional lymph node metastasis.

　　3. Renal arteriography: It is generally not used for the diagnosis of renal pelvis tumors. Renal arteriography is difficult to distinguish due to its confusion with inflammatory diseases of the kidney, with a false-positive rate of up to 40%. Selective renal arteriography may show the following signs in renal pelvis tumors: missing artery branches; small tumor vessels; when the renal parenchyma is invaded, the renal parenchyma phase shows irregularly reduced density areas; renal arteriography has certain value in distinguishing renal pelvis tumors from other causes such as renal aneurysms, and renal pelvis atrophy caused by vascular compression.

　　Patients with renal pelvis cancer should consume a variety of foods, including a variety of vegetables and fruits in their daily diet; consume more high-fiber foods (such as whole grain oatmeal, beans, vegetables, fruits); reduce the total intake of fat; limit the intake of alcoholic beverages; limit the intake of preserved, smoked, and nitrite-containing foods.

　　In principle, radical resection should be performed for renal pelvis tumors, but for solitary, low-grade and stage tumors, organ-preserving surgery can also be adopted. The treatment of renal pelvis cancer still relies mainly on surgery, including the removal of the diseased kidney and the entire ureter, including the part of the bladder adjacent to the ureteral orifice, to prevent the recurrence of tumors in the residual ureter. Due to the large differences in the differentiation and infiltration degree of cancer cells, the prognosis is also very different. For renal pelvis tumors with good differentiation and no infiltration, the 5-year survival rate after surgery is more than 60%, but the survival rate after surgery for renal pelvis cancer is generally lower than that for renal cancer. It has been reported that the addition of radiotherapy after surgery can have a certain effect on improving survival rates.

　　1. Radical surgery

　　Surgical resection is the main treatment method for renal pelvis tumors. The standard surgical procedure is: for patients without distant metastasis, radical surgery should be performed routinely, including the removal of the kidney, renal fat capsule, ipsilateral adrenal gland, entire ureter, and sleeve-like resection of the bladder. Generally, two incisions are used to perform the surgery, and it is advisable to perform the operation under direct vision when dealing with the interstitial segment of the bladder wall, which will be beneficial for preventing postoperative bladder implantation. As for whether to perform regional lymph node dissection, there is still controversy at present.

　　2. Organ-preserving surgery

　　1. Ureterorenoscopy or percutaneous nephrosopy electrocoagulation or resection: Ureteroscopy for renal pelvis tumors is suitable for tumors with low stage and grade, solitary superficial tumors, with advantages such as small surgical trauma and rapid patient recovery, but with a high recurrence rate that requires long-term follow-up, with a recurrence rate of 13.4% to 50%, and the recurrent tumors are mostly low-grade papillary tumors. Reports show that the failure rate of ureteroscopy for renal pelvis tumor surgery is as high as 25%, and the incidence rate of major complications is 7%.

　　Percutaneous nephrolithotomy has a large endoscopic operation space, and if a percutaneous nephrostomy tube is left in place, chemotherapy drugs can be infused for treatment, which is suitable for solitary small low-grade superficial renal pelvis tumors, although percutaneous nephrolithotomy has risks of bleeding, tumor extrusion, and implantation. Some scholars have reported that the recurrence rate of percutaneous nephrolithotomy for renal pelvis tumors is 45.4%, and it is recommended that if a nephrostomy tube is left in place, a repeat renaloscopy should be performed to ensure complete tumor resection, and the suspicious area should be ablated with neodymium-doped yttrium aluminum garnet laser (Nd:YAG laser).

　　2. Open tumor resection: Open surgery with organ preservation has achieved good results in the treatment of unilateral or bilateral renal pelvis tumors with low-grade, low-grade, and superficial local growth, such as local simple tumor resection, renal pelvis incision electrocoagulation resection, or YAG laser resection; if the tumor has not involved the renal parenchyma, partial nephrectomy can be performed, but close follow-up after surgery is necessary to be vigilant for tumor recurrence.

　　3. Palliative Surgery If there is distant metastasis, and symptoms such as obstruction, infection, or severe hematuria, consider simple nephrectomy or renal artery embolization to relieve symptoms. For treatment of metastases to the liver, bones, lungs, and other sites, systemic chemotherapy can be tried after surgery, which may be helpful, but radiotherapy is ineffective.

　　4. Radiotherapy and Chemotherapy Radiotherapy as adjuvant treatment is often used after surgery for renal pelvis tumors, but the effectiveness is not clear. It is generally believed that radiotherapy has certain therapeutic effects on high-grade tumors. Systemic chemotherapy has little value in the treatment of renal pelvis tumors.