2. Tumours of the urinary system - urothelial and renal cancer Flashcards
what areas are affected by urothelial cancers
bladder upper tract (ie ureter, renal pelvis, collecting system)
define what urothelial tumours are
malignant tumours of the lining transitional cell epithelium (urothelium)
can occur at any point from renal calyces to tip of the urethra
what is the most common site of urothelial cancers
bladder - make up 90% cases
what are the different types of bladder cancer
transitional cell carcinoma (TCC) - most common
squamous cell carcinoma
what are three risk factors for TC
smoking (accounts for 40% of cases)
aromatic amines
non-hereditary genetic abnormalities (e.g. TSG incl. p53 and Rb)
what are five risk factors for squamous cell carcinoma
Schistosomiasis (S. haematobium only)
chronic cystitis (e.g. recurrent UTI, long term catheter, bladder stone)
cyclophosphamide therapy
pelvic radiotherapy
Adenocarcinoma
-Urachal
what are the most common presenting features of bladder cancer
**painless visible haematuria
(BUT haematuria can be frank or microscopic )
others
- recurrent UTI
- storage bladder symptoms (dysuria, frequency, nocturia, urgency +/- urge)
- pain
what investigations should be done to investigate the haematuria
urine culture
- majority of painful haematuria = UTI
cystourethoscopy
- commonest neoplastic cause is TCC bladder
Upper tract imagine
- CT urogram (IVU)
- US scan
urine cytology
- limited use in dipstick haematuria
BP
U&E’s
what is the risk of malignancy in >50yrs with FRANK haematuria
25-35%
what investigations should be done if there is FRANK haematuria
Flexible cystourethroscopy within 2 weeks
Ct urogram & USS
Urine Cytology may also be useful (but not very sensitive nor specific)
what is the risk of malignancy in >50yrs with DIPSTIX or MICROSCOPIC haematuria
5-10%
what investigations should be done if there is DIPSTIX or MICROSCOPIC haematuria
Flexible cystourethroscopy within 4-6 weeks
IVU & USS
why are IVU and USS used together
IVU alone will miss a proportion of renal cell tumours (especially if <3cm)
USS alone will miss a proportion of urothelial tumours of the upper tracts
How are bladder cancers diagnosed
cystoscopy and endoscopic resection (TURBT)
EUA to assess bladder mass/thickening before and after TURBT
TURBT = transurethral resection of bladder cancer
what investigations can help stage bladder cancer
cross sectional imagine (CT, MRI)
bone scan if symptomatic
CTU for upper tract TCC
how are bladder tumours classified
grade of tumour
stage of tumour
combined to describe TCC eg G1pTa
what are the grades (G) of TCC
G1 = Well diff. - commonly non-invasive
G2 = Mod. diff. - often non-invasive
G3 = Poorly diff. - often invasive
Carcinoma in situ (CIS) – non-muscle invasive but VERY aggressive (hence treated differently)
what are the stagings of TCC
TNM classification
T-stage
- non-muscle invasive (or ‘superficial’)
- muscle invasive
from Tis, Ta, T1, T2a, T2b, T3a, T3b, T4a, T4b - getting more invasive as number and letter go up
what determines treatment of bladder cancer
site
clinical stage
histological grade of tumour
patient age and co-morbidities
how would you treat low grade non-muscle invasive tumours (i.e. Ta or T1)
endoscopic resection followed by single intravesical chemo (mitomycin) within 24hrs
prolonged endoscopic follow up
prolonged course of intravesical chemo for repeated recurrences
how would you treat a high grade non-muscle invasive or CIS tumour
very aggressively
endoscopic resection alone not sufficient
intravesical BCG therapy - maintenance course weekly for 3 weeks repeated 6 monthly over 3 years
patients refractory to BCG - need radical surgery
how would you treat muscle invasive bladder tumours (i.e. T2-T3)
neoadjuvant chemo fr local and systemic control followed by either:
- radical radiotherapy
- radical surgery
what determines prognosis form bladder cancer
stage grade size multifocality presence of concurrent CIS recurrence at 3 months
what is the % 5 year survival for non-invasive, low grade bladder tumour
90%
what is the % 5 year survival for invasive, high grade bladder tumour
50%
what are the main symptoms for Upper tract urothelial cancer (UTUC)
Frank haematuria
Unilateral ureteric obstruction
Flank or loin pain
Symptoms of nodal or metastatic disease
- Bone pain
- Hypercalcaemia
- Lung
- Brain
what diagnostic investigations are used to diagnose UTUC
CT- IVU or IVU - shows filling defects in renal pelvis
urine cytology
ureteroscopy and biopsy
where is the most common site of UTUC
renal pelvis or collecting system
what is the most common treatment for UTUC
nephro-ureterectomy
due to high risk of recurrence if treated endoscopically or my segmental resection
what treatment would be used if a patient could not undergo nephron-ureterectomy
nephron-sparring endoscopica treatements - ureteroscopic laser ablation
also need regular surveillance
why is surveillance cystoscopy needed in UTUC
in all cases there is a high risk of synchronous and metachronous bladder TCC (40% over 10 years)
what are the benign renal tumours called
oncocytoma
angiomyolipoma
what are the malignant renal tumours called
renal adenocarcinoma
hypernephroma
grawits tumour
where do most malignant renal tumours arise
from the proximal tubule
what are the 4 histological subtypes of malignant renal tumours
clear cell (85%)
papillary (10%)
chromophobe (4%)
Bellini type ductal carcinoma (1%)
what are risk factors for renal adenocarcinoma
Family history (autosomal dominant e.g. vHL, familial clear cell RCC, hereditary papillary RCC; can be bilateral and/or multifocal)
Smoking
Anti-hypertensive
medication
Obesity
End-stage renal failure
Acquired renal cystic disease
how does adenocarcinoma present
asymptotically - 50%
classic triad - 10%
- flank pain, mass, haematuria
paraneoplastic syndrome - 30%
- anorexia, cachexia and pyrexia
- hypertension, hypercalcaemia and abnormal LFTs
- anaemia, polycythaemia and raised ESR
metastatic disease - 30%
- bone, brain, lungs, liver
what are the stages of renal cancer
T1 - tumour <7cm confined within renal capsule
T2 - tumour >7cm confined within capsule
T3 - Local extension outside capsule
- T3a - Into adrenal or peri-renal fat
- T3b - Into renal vein or IVC below diaphragm
- T3c - Tumour thrombus in IVC extends above diaphragm
T4 - Tumour invades beyond Gerota’s fascia
how does renal adenocarcinoma spread
- direct spread (invasion) through renal capsule
- venous invasion to renal vein and vena cava
- haematogenous spread to lungs and bone/lymphatic spread to paracaval nodes
what are mandatory investigations for renal adenocarcinoma
CT scan of abdomen and chest
- provides radiological diagnosis and complete TNM staging
- assesses contralateral kidney
Bloods
- U&Es, FBC
what are optional investigations for renal adenocarcinoma
IVU shows calyceal distortion and soft tissue mass
Ultrasound differentiates tumour from cyst
DMSA or MAG-3 renogram to assess split renal function if doubts about contralateral kidney
what is the treatment for adenocarcinoma
surgical i.e. radical nephrectomy
standard for T1 tumours = laparoscopic radical nephrectomy
(curative if
how can patients with metastatic disease who have symptoms from primary tumour be treated
palliative cytoreductive nephrectomy still beneficial
can prolong median survival by 6 months
how are adenocarcinoma metastases treated
- multitargeted receptro tyrosine kinase inhibitors
- sunitinib, sorafenib, panzopanib,temsirolimus - immunotherapy
- Interferon alpha
- Interleukin-2
response rate with either 20% at most
what are the prognosis’ for different stage adenocarcinoma
T1 – 95% 5-year survival
T2 – 90% 5-year survival
T3 – 60% 5-year survival
T4 – 20% 5-year survival
N1 or N2 – 20% 5-year survival
M1 – Median survival 12-18 months
