Editing Upper Urinary Tract Urothelial Cancer (section)

=== Imaging ===

==== Primary ====

===== <span style="color:#ff0000">Options[https://pubmed.ncbi.nlm.nih.gov/37096584/ §]</span> =====
*'''<span style="color:#ff0000">Cross-sectional imaging of the upper tract with contrast including delayed images</span>'''
**'''<span style="color:#ff0000">Preferred modality: multiphase computed tomography (CT) scan with excretory phase imaging of the urothelium</span>'''
***'''<span style="color:#ff0000">Pooled sensitivity of 92%</span>'''
***'''<span style="color:#ff0000">Pooled specificity of 95%</span>'''
**'''<span style="color:#ff0000">If contraindications to contrast-enhanced CT such as chronic kidney disease (CKD) (e.g. eGFR <30[https://medicine.yale.edu/diagnosticradiology/patientcare/policies/nephropathy/]) or untreatable allergy to iodinated contrast medium, use magnetic resonance (MR) urography</span>'''
***'''<span style="color:#ff0000">MRI is less sensitive than CT, similar specificity</span>'''
**'''<span style="color:#ff0000">If contraindications to multiphasic CT and MR urography, use retrograde pyelography in conjunction with non-contrast axial imaging (renal ultrasound) to assess the upper urinary tracts.</span>'''

====== <span style="color:#ff0000">CT urography</span> ======
* High sensitivity (100%) and moderate specificity (60%) for upper tract malignant disease
*'''Typical findings suggestive of an upper urinary tract tumor (3):'''
*# '''Radiolucent filling defects'''
*# '''Non-visualization of the collecting system'''
*# '''Obstruction'''
* '''<span style="color:#ff0000">Differential diagnosis of filling defect includes (11): [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7766367/]</span>'''
*# '''<span style="color:#ff0000">Tumour (UTUC, renal cell carcinoma, renal lymphoma, fibroepithelial polyp)</span>'''
*# '''<span style="color:#ff0000">Blood clot</span>'''
*# '''<span style="color:#ff0000">Suburothelial hemorrhage</span>'''
*#'''<span style="color:#ff0000">Stones</span>'''; higher HFU than urothelial carcinoma
*# '''<span style="color:#ff0000">Renal papillary necrosos/sloughed papilla</span>'''
*# '''<span style="color:#ff0000">Hypertrophied papilla</span>'''
*#'''<span style="color:#ff0000">Inflammation</span>'''
*#'''<span style="color:#ff0000">Fungus ball</span>'''
*# '''<span style="color:#ff0000">Tuberculosis</span>'''
*#'''<span style="color:#ff0000">Polyureteritis cystics</span>'''
*#'''<span style="color:#ff0000">Retroperitoneal fibrosis</span>'''
* '''Urothelial cancers are enhancing on arterial/early nephrographic phase, dark/filling defect in urographic phase.''' 
*'''Urothelial cancers have more infiltrative features compared to RCC'''
*'''Radiolucent, noncalcified lesions may require additional evaluation by retrograde urography or ureteroscopy, with or without biopsy and cytology'''
* '''<span style="color:#ff0000">Important to evaluate contralateral kidney to assess (2):'''
**'''<span style="color:#ff0000">Possible bilateral disease''' 
**'''<span style="color:#ff0000">Functionality of the contralateral kidney''' 
[[File:Renal parenchymal phase CT of transitional cell carcinoma.jpg|CT urogram demonstrating filling defect in left renal pelvis. [[commons:File:Renal_parenchymal_phase_CT_of_transitional_cell_carcinoma.jpg|Source]]|center|frame]]

===== <span style="color:#ff0000">Metastasis</span> =====
* '''<span style="color:#ff0000">Chest X-Ray</span>'''
* '''Bone scan,''' consider in the presence of bone pain, elevated calcium or elevated alkaline phosphatase
*PET scans[https://pubmed.ncbi.nlm.nih.gov/37096584/]
**Should not be obtained routinely
**May be selectively considered for patients who are at risk for metastatic recurrence and are not able to have contrast enhanced CT and MRI
*Patients with findings suggestive of metastatic UTUC should be evaluated to define the extent of disease and referred to medical oncology for further management[https://pubmed.ncbi.nlm.nih.gov/37096584/]