Transitional cell cancers (TCC), also known as urothelial cancers, are rare carcinomas (cancers arising from tissues that line organs) that develop in either the ureter (the long tubes connecting the kidneys to the bladder) or the renal pelvis (the upper end of the ureter that connects to the kidney). More specifically, they develop in the transitional cells of these structures, which are cells that can change shape and stretch to allow for expansion without breaking apart.
The kidneys are a pair of bean-shaped organs that sit in the middle of your back on each side of your spine. It is responsible for filtering excess water and waste products from the blood, and converting them into urine to be removed from the body. The kidneys also produce and secrete certain hormones that regulate blood pressure and initiate the production of red blood cells.
TCCs are more common in men, and are generally diagnosed after 70 years of age. However, this disease can develop in anyone.
If TCC is detected, it will be staged and graded based on size, metastasis (whether the cancer has spread to other parts of the body) and how the cancer cells look under the microscope. Staging and grading helps your doctors determine the best treatment for you.
Cancers can be staged using the TNM staging system:
- T (tumour) indicates the size and depth of the tumour.
- N (nodes) indicates whether the cancer has spread to nearby lymph nodes.
- M (metastasis) indicates whether the cancer has spread to other parts of the body.
This system can also be used in combination with a numerical value, from stage 0-IV:
- Stage 0: this stage describes cancer cells in the place of origin (or ‘in situ’) that have not spread to nearby tissue.
- Stage I: cancer cells have begun to spread to nearby tissue. It is not deeply embedded into nearby tissue and had not spread to lymph nodes. This stage is also known as early-stage cancer.
- Stage II: cancer cells have grown deeper into nearby tissue. Lymph nodes may or may not be affected. This is also known as localised cancer.
- Stage III: the cancer has become larger and has grown deeper into nearby tissue. Lymph nodes are generally affected at this stage. This is also known as localised cancer.
- Stage IV: the cancer has spread to other tissues and organs in the body. This is also known as advanced or metastatic cancer.
Cancers can also be graded based on the rate of growth and how likely they are to spread:
- Grade I: cancer cells present as slightly abnormal and are usually slow growing. This is also known as a low-grade tumour.
- Grade II: cancer cells present as abnormal and grow faster than grade-I tumours. This is also known as an intermediate-grade tumour.
- Grade III: cancer cells present as very abnormal and grow quickly. This is also known as a high-grade tumour.
Once your tumour has been staged and graded, your doctor may recommend genetic testing, which analyses your tumour DNA and can help determine which treatment has the greatest chance of success. They will then discuss the most appropriate treatment option for you.
Treatment is dependent on several factors, including location, stage of disease and overall health.
Treatment options for TCCs may include:
- Surgery, potentially including:
- Nephroureterectomy (removal of entire kidney and ureter).
- Distal resection of ureter (removal of the bottom portion of the ureter).
- Ureteroscopy surgery (a thin tube with a light and camera attached (ureteroscope) is passed through urethra, bladder and ureter to reach the renal pelvis. Cancer is removed using laser and/or heat – early-stage and low-grade cancers only).
- Percutaneous renoscopy surgery (a thin tube with a light and camera attached (endoscope) is passed through a small incision in the mid-back. Cancer removed via tools passed through endoscope - early-stage and low-grade cancers only).
- Radiation therapy.
- Clinical trials.
- Complementary therapies.
- Palliative care.
For more information on the treatment options, please refer to the Rare Cancers Australia treatment options page.
While the cause of TCC remains unknown, the following factors may increase the risk of developing the disease:
- A history of smoking.
- A history of ureter and/or kidney inflammation.
- Exposure to certain chemicals and/or arsenic.
- Prior treatment with chemotherapy and/or radiation therapy.
- Long-term use of large quantities of painkiller medication.
- Having a personal or family history of bladder or kidney cancer.
- Having certain conditions, such as:
- Lynch syndrome.
- Balkan nephropathy.
Not everyone with these risk factors will develop the disease, and some people who have the disease may have none of these risk factors. See your general practitioner (GP) if you are concerned.
Symptoms of TCC may include:
- Haematuria (blood in the urine).
- Back pain that doesn’t go away.
- Unexplained weight loss.
- Frequent urinary tract infections (UTIs).
- Painful urination.
- Polyuria (frequent urination).
Not everyone with the symptoms above will have cancer, but see your GP if you are concerned.
If your doctor suspects you have TCC, they will order a range of diagnostic tests to confirm the diagnosis, and refer you to a specialist for treatment.
Your doctor will collect your overall medical history, as well as your current symptoms. Following this, they may examine your body to check for any abnormalities.
The doctor will take images of your body using magnetic resonance imaging (MRI), a computed tomography scan (CT scan), x-ray, and/or positron emission tomography (PET scan), depending on where it is suspected the cancer is. The doctor may also look at other parts of the body and looks for signs of metastasis.
Urine & blood tests
Urine and blood tests are used to assess overall health and detect any abnormalities. Some of these tests may include:
- General blood test to assess overall health.
- Full blood count, which measure the levels of red blood cells, white blood cells and platelets.
- Blood chemistry and/or blood hormone studies, which analyse the levels of certain hormones and other substances in the blood.
- Urinalysis, which analyses the colour of your urine and its contents (e.g., sugar, protein, red and/or white blood cells etc.).
Exploratory procedures & biopsy
You may require an exploratory procedure if you have blood in your urine, or if the imaging scans were inconclusive. Some of these procedures include a cystoscopy (an examination of the bladder), ureteroscopy (examination of the ureters) and ureterorenoscopy (examination of the kidneys). In all procedures, thin tube with a light and a camera is inserted through the genital tract to examine these areas and detect any abnormalities.
Once the location(s) of the cancer has been identified, the doctor will perform a biopsy to remove a section of tissue using a needle. The tissue sample will then be analysed for cancer cells. This can be done by a fine needle aspiration (FNA) or a core needle biopsy (CNB).
Prognosis (Certain factors affect the prognosis and treatment options)
While it is not possible to predict the exact course of the disease, your doctor may be able to give you a general idea based on the rate and depth of tumour growth, susceptibility to treatment, age, overall fitness, and medical history. Generally, early-stage TCCs have a better prognosis and survival rates. However, if the cancer is advanced and has spread, the prognosis may not be as good and there may be a higher risk of cancer recurrence. It is very important to discuss your individual circumstances with your doctor to better understand your prognosis.
Some references are to overseas websites. There may be references to drugs and clinical trials that are not available here in Australia.