From the Guidelines
When a CT urogram reveals a lesion in the renal pelvis in a patient with hematuria, the appropriate workup to diagnose upper tract urothelial carcinoma (UTUC) should include ureteroscopy with direct visualization of the lesion and biopsy, as it is the gold standard for diagnosis and allows for direct tissue sampling 1.
Diagnostic Approach
The diagnostic approach for UTUC involves several key steps, including:
- Ureteroscopy with direct visualization of the lesion and biopsy, which should be performed by a urologist experienced in endoscopic procedures
- Selective urine cytology from the affected renal unit to look for malignant cells
- Complementary imaging studies like retrograde pyelography to better delineate the collecting system anatomy
Importance of Accurate Diagnosis
Accurate diagnosis of UTUC is critical because it can be aggressive, and diagnosis guides appropriate treatment selection while helping to preserve renal function when possible 1.
Staging and Treatment
Following diagnosis, staging should include chest imaging (typically CT) to evaluate for metastatic disease 1. The next steps after diagnosis depend on tumor characteristics, but typically involve either radical nephroureterectomy with bladder cuff excision for high-grade or invasive tumors, or kidney-sparing approaches (endoscopic ablation or resection) for small, low-grade, or solitary lesions in patients with compromised renal function.
Key Considerations
It is essential to note that UTUC can present as high-grade invasive disease at the time of diagnosis, and multifocal disease has been reported in approximately 25% to 30% of UTUC 1. Therefore, a thorough diagnostic workup is crucial to ensure accurate diagnosis and appropriate treatment.
From the Research
Diagnostic Approach for Upper Tract Urothelial Carcinoma (UTUC)
When a patient presents with hematuria and a Computed Tomography (CT) urogram reveals a lesion in the renal pelvis, the following steps can be considered in the diagnostic workup for Upper Tract Urothelial Carcinoma (UTUC):
- CT urography is recommended as the initial imaging test for hematuria in patients at high-risk for UTUC, due to its high diagnostic accuracy for urothelial cell carcinoma (UCC) 2.
- The CT urography should be performed with at least one series of images acquired during the excretory phase after intravenous contrast administration to evaluate the kidneys, ureters, and bladder.
- If the CT urogram reveals a filling defect in the renal pelvis, it is essential to consider differential diagnoses, including benign conditions such as subepithelial hematoma (Antopol-Goldman lesion) 3, 4.
- In patients with hematuria and a suspicious lesion on CT urography, repeat CT urography within 3 years is unlikely to show a urinary tract malignancy, unless there are new or changing symptoms 5.
- The severity of hematuria (microscopic or gross) may be associated with the tumor stage, with microscopic hematuria predicting lower stage UTUC 6.
Considerations for Differential Diagnoses
- Subepithelial hematoma (Antopol-Goldman lesion) should be considered in the differential diagnosis of upper urinary tract lesions, especially in patients with hematuria and filling defects in the urinary tract 3, 4.
- The presence of amyloidosis may increase the likelihood of an Antopol-Goldman lesion, and Congo-Red staining can be used to verify the presence of amyloid 4.