2: Kidney & Bladder Cancer Flashcards

1
Q

where does renal cell carcinoma present

A

in the parenchyma of the kidney
- affects tissue made from metanephric blastema
- renal cortex, mainly from PCTs and often appearing in the upper pole of the kidney

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2
Q

where does transitional cell carcinoma (TCC) present

A

from calyx to the bladder
- affects tissue from ureteric blood

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3
Q

how is RCC staged

A
  • 1 : < 7cm
  • 2: > 7cm
  • 3 : Gerota’s fascia
  • 4 : lymph nodes
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4
Q

describe the epidemiology of RCC

A
  • ~90% of renal malignant rumours in adults are RCCs
  • arise from tubular epithelium
  • rare in children
  • peak incidence in 60-70
  • male:female is 3:1
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5
Q

describe the prognosis of RCC

A

prognosis is poor
- 30% of patients have metastatic disease at diagnosis
- 5 year survival is estimated at 12%

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6
Q

what are risk factors of RCC

A
  • SMOKING
  • industrial exposure e.g. cadmium lead
  • dialysis
  • HTN
  • obesity
  • anatomical abnormalities e.g. PKD and horshoe kidney
  • genetic disorders e.g. von Hippel-Lindau, BAP, Birt-Hogg-Dube
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7
Q

how does RCC present

A
  • 90% with haematuria or incidental finding
  • non specific: fatigue, weight loss and fever
  • may present with mass in the loin
  • RCCs often metastaise before local symptoms develop
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8
Q

how might advanced RCC present

A
  • small number can secrete hormone like substances e.g. PTH-rP so the pt presents w hypercalcaemia
  • large varicocele
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9
Q

why might varicocele be present in RCC

A

tumour grows along renal vein and compresses gonadal vein so it cant drain and fluid collects in the scrotum (only on left as right drains into IVC)

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10
Q

what investigations are carried out in RCC (3)

A
  • radiology: US or ⭐️ CT abdo pelvis pre and post IV contrast
  • endoscopy: flexible cystoscopy
  • urine: cytology
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11
Q

how is localised RCC treated

A
  • surveillance
  • increasingly small tumours are removed with partial nephrectomy to preserve some renal function
  • large tumours w no distant metastases: radical nephrectomy with removal of the associated adrenal gland, perinephric fat, upper ureter and para-aortic lymph nodes
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12
Q

what treatment is available for metastatic RCC

A
  • little effective treatment for metastatic disease as it is chemo and radiotherapy resistant
  • palliative treatment: target angiogenesis
  • biological agents e.g. Sunitinib and Pazopanib (tyrosine kinase inhibitors)
  • metastectomy where disease is resectable and patient is otherwise well
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13
Q

how does urothelial cell carcinoma present

A
  • painless haematuria
  • incidental finding on imaging (US or CT)
  • weight loss, loss of appetite
  • signs/symptoms of obstruction
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14
Q

what is bladder cancer caused by

A
  • analgesic misuse
  • exposure to aniline dyes used in the industrial manufacturing of dyes, rubber and plastics
  • smoking
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15
Q

how is bladder cancer diagnosed (3)

A
  • CT or MRI
  • CXR
  • cystoscopy or ureteroscopy
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16
Q

are most cancers of the bladder superficial or muscle invasive

A

75% superficial
5% carcinoma in situ
20% muscle invasive

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17
Q

how is bladder cancer investigated

A

cytoscopy and biopsy which allows histological examination and staging

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18
Q

how is TCC diagnosed

A

based on cytological examination of the urine to check for the presence of malignant cells and cystoscopy of the LUT

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19
Q

how is low risk non-muscle invasive TCC treated

A

TURBT +/- intraveseical (directly inside the bladder) chemotherapy

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20
Q

how is high risk non-muscle invasive TCC treated

A

TURBT +/- intravesical chemo, intravesical BCG, cystectomy

21
Q

how is muscle invasive bladder cancer treated

A

radical cystectomy (removal of bladder) + radiotherapy or paliative care
- also considered for neoadjuvant chemo + cisplatin combination
- following this, patients will require urinary diversion:
- ileal conduit formation: urine drains via urostomy
- bladder reconstruction or neobladder: segment of small bowel and urine drains urethrally or via catheter (routine bloods, B12 and folate levels)
- continent cutaneous diversion aka indiana pouch: fashioned from right hemicolon and catheterisable stoma

22
Q

what is a cystectomy

A

removal of the bladder
create stoma that comes out the body and add stoma bag to collect urine

23
Q

what investigations should you request if bladder cancer is suspected

A
  • urine dipstick - exclude UTI
  • urine cytology - good for seeing differentiated tumour or in situ
  • FBC
  • U&Es - assess renal function
  • biochemical profile - evidence of bone or liver metastases
  • USS - renal cancers, hydronephrosis
  • flexible cystoscopy
24
Q

how is TCC of the upper urinary tract treated

A

nephro-ureterectomy (kidney, fat, ureter, cuff or bladder)

25
Q

how does a TCC of the upper urinary tract present

A

haematuria
obstruction
- occurs early as renal pelvis projects directly into pelvicalycael cavity

26
Q

why is the risk of develpping bladder cancer high from an upper urinary tract TCC

A

get seeding
cells move further down system and develop tumours elsewhere

27
Q

how can RCCs spread

A
  • direct invasion: into perinephric tissues, adrenal gland, renal vein, IVC
  • lymphatics: pre-aortic and hilar lymph nodes
  • haematogenous: bones, liver, brain, lung
28
Q

what is tumour thrombosis

A

distinct feature of RCCs by which they invade through the renal vein wall and into the lumen

29
Q

define a paraneoplastic syndrome

A

a group of clinical disorders that are associated with malignant diseases and not directly related to the physical effects of primary/metastatic tumours

30
Q

what paraneoplastic syndromes are associated with RCC

A
  • polycythaemia due to EPO
  • hypercalcaemia due to PTH
  • HTN due to renin
  • Stauffer’s syndrome
31
Q

what are the 4 layers of the bladder wall

A
  1. urothelium (inner)
  2. lamina propria
  3. muscularis propria
  4. fatty connective tissue (outer)
32
Q

how is metastatic disease associated with RCC treated

A
  • neph and resection of metastases if possible
  • tyrosine kinase inhibitors +/- cytoreductive neph e.g. sunitiib, pazopanib
  • intergere w VEGF pathways and inhibits angiogenesis
33
Q

what is TURBT

A

Transurethral Resection of Bladder Tumour - involves resection of bladder tissue by diathermy during rigid cystoscopy
- performed under general or regional anaesthesia
- biopsy samples can help assess stage: non-muscle invasive (Ta/T1) and muscle invasive (T2+)

34
Q

what is the prognostic importance of patients with bladder cancer

A

at higher risk of developing urinary tract tumours and urethral tumours
- superficial disease have a 5 year survival 80-90%
- muscle invasive and met have 30-60% and 10-15%
- superficial bladders tumours have high rate of recurrence and these are more likely to be invasive so need regular cytology and cystoscopy follow up

35
Q

what does a CT urogram entail

A

CT scan + contrast medium usually iodine
- highlights kidneys, ureters and bladder

36
Q

what is the commonest type of RCC and what is it associated with

A

clear cell RCC
- Von Hippel-Lindau syndrome

37
Q

how are renal cysts classified

A

Bosniak classification
I - benign, simple
II - mildly complex, benign
IIF - very likely benign but need follow-up
III - 60% chance of cancer
IV - definite RCC

38
Q

how does staging of RCC decide further treatment

A

T1a <4cm
- surveillance (older, co-morbid patients)
- ablation
- lap radical nephrectomy
- partial neph

T1b 4-7cm
- partial neph
- lap radical neph

T2a and above
- lap or open radical neph +/- lymph node dissection

39
Q

how does staging of bladder cancer decide further treatment (4)

A
  • superficial Ta1/T1 = single dose intravesical mitomycin
  • low risk (G1/2, Ta, solitary): cytoscopic surveillance only
  • intermediate risk (G1/2, Ta, multiple or large): 6x weekly mitomycin instillations then surveillance
  • high risk (G3, T1, CIS): BCG regimen or cystectomy upfront
40
Q

what is BCG regime

A

bacillus calmette guerin
- live attenuated mycobacterium bovis
- used for TB inoculation
- stimulates type IV hypersensitivity reaction that activates immune cells to tumour antigens
- reduces progression whereas mitomycin reduces recurrence

41
Q

what are the side effects of BCG

A
  • dysuria, frequency, urgency
  • UTI
  • haematuria
42
Q

what is a radical cystectomy in females

A

anterior exenteration
- removal of bladder, uterus, tubes, ovaries and anterior vaginal wall
- + pelvic lymph node dissection

43
Q

when is urinary diversion contraindicated after cystectomy

A
  • renal/hepatic impairment
  • inadequate small bowel e.g. Crohn’s
  • unable to catheterise
  • neobladder contraindicated if tumour extends to prostatic urethra
44
Q

what are issues with continent diversions

A
  • hyperchloraemic metabolic acidosis
  • incontinence
  • stones
  • mucus
  • perforation
  • every 3 hours at night to empty at start
45
Q

what are indications for a PSA test

A
  • asymptomatic pt under 70 but no mortality benefit over 70
  • pt w LUTS unless life expectancy <10 years and benign DRE
  • avoid in retention/haematuria unless DRE is malignant
46
Q

what is the most common presentation of upper tract TCC

A

visible haematuria

47
Q

what are the investigations of upper tract TCC

A

CT urogram
- ureteroscopy +/- biopsy may be needed to confirm diagnosis

48
Q

how is upper tract TCC treated

A
  • small, low grade tumours treated w laser ablation
  • majority of non-met cases treated w lap nephro-ureterctomy