The gold standard management for ureter transitional cell carcinoma (UTCC) is radical nephroureterectomy with excision of the bladder cuff. However, some patients cannot undergo this procedure for several reasons. In the case reports described herein, we performed stereotactic body radiotherapy (SBRT) on three patients with inoperable or surgery-rejected localized UTCC. Two out of the three patients did not develop local recurrence or distant metastasis during the observation period. However, recurrence was detected in the bladder of one patient 22 months after the treatment. No acute or late adverse events occurred in any of the three patients. SBRT may become one of the treatment options for inoperable or surgery-rejected UTCC patients.
Ureter transitional cell carcinoma (UTCC) is rare, accounting for only 1–3% of urinary transitional cell carcinoma cases [
An 87-year-old woman with rheumatism presented with gross hematuria and dysuria. A cystoscopic examination showed a papillary tumor at the left ureteral orifice protuberating into the bladder. A histological examination confirmed transitional cell carcinoma grade 2. A CT scan revealed the mass at the distal ends of the left ureter with no lymphatic or distant metastasis. Therefore, this patient was diagnosed with ureter cancer T2N0M0. Radical nephroureterectomy was considered to be nonadaptive because of comorbidities of chronic kidney disease (CKD) and rheumatism; therefore, she was referred to our department. SBRT was performed by coplanar dynamic conformal radiotherapy with a linear accelerator (LINAC) (EXL-15DP, Mitsubishi Electric, Tokyo, Japan). A total dose of 60 Gy was delivered in 10 fractions at the center of planning target volume (PTV) using 10 MV photons (Figure
SBRT plan isodose line of case 1.
An 87-year-old man presented with occult hematuria. A cystoscopic examination showed no abnormal findings. The result of urine cytology was class V, transitional cell carcinoma. A CT scan showed a small tumor at the distal one-third of the left ureter with dilation of the upper ureter and ipsilateral renal pelvis. There was no evidence of lymphatic or distant metastasis. Therefore, the patient was diagnosed with ureter cancer T2N0M0. The patient refused surgery and was referred to our department. SBRT was performed by noncoplanar dynamic arch radiotherapy with a LINAC. A total dose of 50 Gy was delivered in 10 fractions at the center of PTV using 10 MV photons (Figure
SBRT plan isodose line of case 2.
An 85-year-old woman presented with gross hematuria. A cystoscopic examination revealed a tumor in the left ureter. A histological examination confirmed transitional cell carcinoma grade 3. A CT scan showed the tumor at the distal ends of the left ureter with no lymphatic or distant metastasis (Figure
Contrast-enhanced CT scan of the patient. (a) A CT scan showed the tumor as enhanced thickness of the wall at the distal ends of the left ureter before the treatment (see arrow). (b) The enhanced thickness of the ureteral wall improved 3 months after SBRT.
The standard treatment of UTCC is surgical resection. In the present study, summarized in Table
Summary of case presentations.
Case 1 | Case 2 | Case 3 | |
---|---|---|---|
Age | 87 | 87 | 85 |
Sex | F | M | F |
Tumor location in ureter | Orifice | Distal one-third | Distal end |
TNM staging | T2N0M0 | T2N0M0 | T2N0M0 |
Cause for avoidance of surgery | CKD |
Patient refusal | Patient refusal |
Dose/fractionations | 60 Gy/10 fr | 50 Gy/10 fr | 60 Gy/10 fr |
Tumor size in 3 months | Decreased | Decreased | Decreased |
Acute adverse events | None | None | None |
LPFS (month) | 12 | 12 | 24 |
Recurrence of disease | None | None | Bladder |
OS (month) | 33 | 13 | 38 |
Cause of death | Rheumatism | Bacterial pneumonia | Cancer |
Abbreviations: CKD, Chronic kidney disease; LPFS, Local progression-free survival; OS, Overall survival.
In the present study, the prescribed doses differed between cases. In cases 1 and 3, the tumor was localized at the distal end or orifice of the ureter, and 60 Gy was delivered in 10 fractions, which was equal to 96 Gy on a biological effective dose of 10 (BED10). In contrast, in case 2, the tumor was localized at the distal one-third of the ureter, and the small intestine was in close proximity to the tumor. Therefore, the tumor was treated with 50 Gy in 10 fractions, equal to 75 Gy on BED10, in order to suppress the exposure dose to the small intestine. However, there were no decisive differences of local control in all three cases.
There are various techniques of SBRT in sight of irradiation and image guidance. The most commonly used one is a linear accelerator (LINAC), and we performed SBRT with a CT-LINAC system in all three cases. Incidentally, SBRT with dedicated machines, including cyberknife, is also often performed especially for localized prostate cancer in genitourinary organs [
The sizes of the tumors in all three cases had decreased within 3 months of the treatment. Furthermore, there was no evidence of recurrence in the observation period spanning between 13 and 24 months. Therefore, SBRT was considered sufficiently effective for local control. Cases 1 and 2 showed no evidence of local recurrence, lymph node relapse, or distant metastasis in the observation period (12 and 13 months, resp.). However, bladder relapse was detected in case 3 22 months after the treatment. Hall et al. examined 252 patients treated surgically for upper urinary tract TCC and reported 12 months as the median time of disease relapse in 67 patients (27%) [
No acute or late adverse events were observed in any of the three cases presented herein. However, a longer observation period may be needed to more accurately estimate late adverse events.
In conclusion, SBRT may become one of the treatment choices for inoperable localized UTCC. Further studies including a larger number of cases and longer observation periods are needed.
The authors declare that there is no conflict of interests regarding the publication of this paper.