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URINARY > 2. Tumours of the urinary system - urothelial and renal cancer > Flashcards

2. Tumours of the urinary system - urothelial and renal cancer Flashcards

1
Q

what areas are affected by urothelial cancers

A 
bladder
upper tract (ie ureter, renal pelvis, collecting system)
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2
Q

define what urothelial tumours are

A

malignant tumours of the lining transitional cell epithelium (urothelium)

can occur at any point from renal calyces to tip of the urethra

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3
Q

what is the most common site of urothelial cancers

A

bladder - make up 90% cases

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4
Q

what are the different types of bladder cancer

A

transitional cell carcinoma (TCC) - most common

squamous cell carcinoma

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5
Q

what are three risk factors for TC

A

smoking (accounts for 40% of cases)

aromatic amines

non-hereditary genetic abnormalities (e.g. TSG incl. p53 and Rb)

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6
Q

what are five risk factors for squamous cell carcinoma

A

Schistosomiasis (S. haematobium only)

chronic cystitis (e.g. recurrent UTI, long term catheter, bladder stone)

cyclophosphamide therapy

pelvic radiotherapy

Adenocarcinoma
-Urachal

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7
Q

what are the most common presenting features of bladder cancer

A

**painless visible haematuria
(BUT haematuria can be frank or microscopic )

others

  • recurrent UTI
  • storage bladder symptoms (dysuria, frequency, nocturia, urgency +/- urge)
  • pain
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8
Q

what investigations should be done to investigate the haematuria

A

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

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9
Q

what is the risk of malignancy in >50yrs with FRANK haematuria

A

25-35%

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10
Q

what investigations should be done if there is FRANK haematuria

A

Flexible cystourethroscopy within 2 weeks

Ct urogram & USS

Urine Cytology may also be useful (but not very sensitive nor specific)

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11
Q

what is the risk of malignancy in >50yrs with DIPSTIX or MICROSCOPIC haematuria

A

5-10%

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12
Q

what investigations should be done if there is DIPSTIX or MICROSCOPIC haematuria

A

Flexible cystourethroscopy within 4-6 weeks

IVU & USS

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13
Q

why are IVU and USS used together

A

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

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14
Q

How are bladder cancers diagnosed

A

cystoscopy and endoscopic resection (TURBT)

EUA to assess bladder mass/thickening before and after TURBT

TURBT = transurethral resection of bladder cancer

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15
Q

what investigations can help stage bladder cancer

A

cross sectional imagine (CT, MRI)

bone scan if symptomatic

CTU for upper tract TCC

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16
Q

how are bladder tumours classified

A

grade of tumour
stage of tumour

combined to describe TCC eg G1pTa

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17
Q

what are the grades (G) of TCC

A

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)

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18
Q

what are the stagings of TCC

A

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

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19
Q

what determines treatment of bladder cancer

A

site
clinical stage
histological grade of tumour
patient age and co-morbidities

20
Q

how would you treat low grade non-muscle invasive tumours (i.e. Ta or T1)

A

endoscopic resection followed by single intravesical chemo (mitomycin) within 24hrs

prolonged endoscopic follow up

prolonged course of intravesical chemo for repeated recurrences

21
Q

how would you treat a high grade non-muscle invasive or CIS tumour

A

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

22
Q

how would you treat muscle invasive bladder tumours (i.e. T2-T3)

A

neoadjuvant chemo fr local and systemic control followed by either:

  • radical radiotherapy
  • radical surgery
23
Q

what determines prognosis form bladder cancer

A 
stage
grade
size
multifocality
presence of concurrent CIS
recurrence at 3 months
24
Q

what is the % 5 year survival for non-invasive, low grade bladder tumour

A

90%

25
Q

what is the % 5 year survival for invasive, high grade bladder tumour

A

50%

26
Q

what are the main symptoms for Upper tract urothelial cancer (UTUC)

A

Frank haematuria

Unilateral ureteric obstruction

Flank or loin pain

Symptoms of nodal or metastatic disease

  • Bone pain
  • Hypercalcaemia
  • Lung
  • Brain
27
Q

what diagnostic investigations are used to diagnose UTUC

A

CT- IVU or IVU - shows filling defects in renal pelvis

urine cytology

ureteroscopy and biopsy

28
Q

where is the most common site of UTUC

A

renal pelvis or collecting system

29
Q

what is the most common treatment for UTUC

A

nephro-ureterectomy

due to high risk of recurrence if treated endoscopically or my segmental resection

30
Q

what treatment would be used if a patient could not undergo nephron-ureterectomy

A

nephron-sparring endoscopica treatements - ureteroscopic laser ablation

also need regular surveillance

31
Q

why is surveillance cystoscopy needed in UTUC

A

in all cases there is a high risk of synchronous and metachronous bladder TCC (40% over 10 years)

32
Q

what are the benign renal tumours called

A

oncocytoma

angiomyolipoma

33
Q

what are the malignant renal tumours called

A

renal adenocarcinoma
hypernephroma
grawits tumour

34
Q

where do most malignant renal tumours arise

A

from the proximal tubule

35
Q

what are the 4 histological subtypes of malignant renal tumours

A

clear cell (85%)

papillary (10%)

chromophobe (4%)

Bellini type ductal carcinoma (1%)

36
Q

what are risk factors for renal adenocarcinoma

A

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

37
Q

how does adenocarcinoma present

A

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

38
Q

what are the stages of renal cancer

A

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

39
Q

how does renal adenocarcinoma spread

A
  • 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
40
Q

what are mandatory investigations for renal adenocarcinoma

A

CT scan of abdomen and chest

  • provides radiological diagnosis and complete TNM staging
  • assesses contralateral kidney

Bloods
- U&Es, FBC

41
Q

what are optional investigations for renal adenocarcinoma

A

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

42
Q

what is the treatment for adenocarcinoma

A

surgical i.e. radical nephrectomy

standard for T1 tumours = laparoscopic radical nephrectomy

(curative if

43
Q

how can patients with metastatic disease who have symptoms from primary tumour be treated

A

palliative cytoreductive nephrectomy still beneficial

can prolong median survival by 6 months

44
Q

how are adenocarcinoma metastases treated

A
  1. multitargeted receptro tyrosine kinase inhibitors
    - sunitinib, sorafenib, panzopanib,temsirolimus
  2. immunotherapy
    - Interferon alpha
    - Interleukin-2

response rate with either 20% at most

45
Q

what are the prognosis’ for different stage adenocarcinoma

A

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

URINARY (27 decks)

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