2: Kidney & Bladder Cancer Flashcards
where does renal cell carcinoma present
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
where does transitional cell carcinoma (TCC) present
from calyx to the bladder
- affects tissue from ureteric blood
how is RCC staged
- 1 : < 7cm
- 2: > 7cm
- 3 : Gerota’s fascia
- 4 : lymph nodes
describe the epidemiology of RCC
- ~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
describe the prognosis of RCC
prognosis is poor
- 30% of patients have metastatic disease at diagnosis
- 5 year survival is estimated at 12%
what are risk factors of RCC
- 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
how does RCC present
- 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
how might advanced RCC present
- small number can secrete hormone like substances e.g. PTH-rP so the pt presents w hypercalcaemia
- large varicocele
why might varicocele be present in RCC
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)
what investigations are carried out in RCC (3)
- radiology: US or ⭐️ CT abdo pelvis pre and post IV contrast
- endoscopy: flexible cystoscopy
- urine: cytology
how is localised RCC treated
- 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
what treatment is available for metastatic RCC
- 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
how does urothelial cell carcinoma present
- painless haematuria
- incidental finding on imaging (US or CT)
- weight loss, loss of appetite
- signs/symptoms of obstruction
what is bladder cancer caused by
- analgesic misuse
- exposure to aniline dyes used in the industrial manufacturing of dyes, rubber and plastics
- smoking
how is bladder cancer diagnosed (3)
- CT or MRI
- CXR
- cystoscopy or ureteroscopy
are most cancers of the bladder superficial or muscle invasive
75% superficial
5% carcinoma in situ
20% muscle invasive
how is bladder cancer investigated
cytoscopy and biopsy which allows histological examination and staging
how is TCC diagnosed (2)
based on cytological examination of the urine to check for the presence of malignant cells and cystoscopy of the LUT
how is low risk non-muscle invasive TCC treated
TURBT +/- intraveseical (directly inside the bladder) chemotherapy
how is high risk non-muscle invasive TCC treated
TURBT +/- intravesical chemo, intravesical BCG, cystectomy
how is muscle invasive bladder cancer treated
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
what is a cystectomy
removal of the bladder
create stoma that comes out the body and add stoma bag to collect urine
what investigations should you request if bladder cancer is suspected
- 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
how is TCC of the upper urinary tract treated
nephro-ureterectomy (kidney, fat, ureter, cuff or bladder)
how does a TCC of the upper urinary tract present
haematuria
obstruction
- occurs early as renal pelvis projects directly into pelvicalycael cavity
why is the risk of develpping bladder cancer high from an upper urinary tract TCC
get seeding
cells move further down system and develop tumours elsewhere
how can RCCs spread
- direct invasion: into perinephric tissues, adrenal gland, renal vein, IVC
- lymphatics: pre-aortic and hilar lymph nodes
- haematogenous: bones, liver, brain, lung
what is tumour thrombosis
distinct feature of RCCs by which they invade through the renal vein wall and into the lumen
define a paraneoplastic syndrome
a group of clinical disorders that are associated with malignant diseases and not directly related to the physical effects of primary/metastatic tumours
what paraneoplastic syndromes are associated with RCC
- polycythaemia due to EPO
- hypercalcaemia due to PTH
- HTN due to renin
- Stauffer’s syndrome
what are the 4 layers of the bladder wall
- urothelium (inner)
- lamina propria
- muscularis propria
- fatty connective tissue (outer)
how is metastatic disease associated with RCC treated
- neph and resection of metastases if possible
- tyrosine kinase inhibitors +/- cytoreductive neph e.g. sunitiib, pazopanib
- intergere w VEGF pathways and inhibits angiogenesis
what is TURBT
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+)
what is the prognostic importance of patients with bladder cancer
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
what does a CT urogram entail
CT scan + contrast medium usually iodine
- highlights kidneys, ureters and bladder
what is the commonest type of RCC and what is it associated with
clear cell RCC
- Von Hippel-Lindau syndrome
how are renal cysts classified
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
how does staging of RCC decide further treatment
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
how does staging of bladder cancer decide further treatment (4)
- 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
what is BCG regime
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
what are the side effects of BCG
- dysuria, frequency, urgency
- UTI
- haematuria
what is a radical cystectomy in females
anterior exenteration
- removal of bladder, uterus, tubes, ovaries and anterior vaginal wall
- + pelvic lymph node dissection
when is urinary diversion contraindicated after cystectomy
- renal/hepatic impairment
- inadequate small bowel e.g. Crohn’s
- unable to catheterise
- neobladder contraindicated if tumour extends to prostatic urethra
what are issues with continent diversions
- hyperchloraemic metabolic acidosis
- incontinence
- stones
- mucus
- perforation
- every 3 hours at night to empty at start
what are indications for a PSA test
- 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
what is the most common presentation of upper tract TCC
visible haematuria
what are the investigations of upper tract TCC
CT urogram
- ureteroscopy +/- biopsy may be needed to confirm diagnosis
how is upper tract TCC treated
- small, low grade tumours treated w laser ablation
- majority of non-met cases treated w lap nephro-ureterctomy
