235. Urothelial Cancer

Question 1

UCa

• epidemiology: location, race, sex, age
• types of tumor presentation
• epi: prevalence
• etiology (5)

Answer 1

location: Bladder&raquo_space; ureter > pelvis
Race: Whites > AA > Hispanics > Asians
Sex: M > F 3:1
Age > 65yo (elderly)

CP: 75% NMIBC (non muscle invasive), 20% MIBC (muscle invasive), 5% metastatic

4th most common ca, 8th most deadly in M

E: SMOKING, Chronic Cystitis (infections, stones, foreign body), Schistosoma, Enviro exposure to aryl amines, drugs (phenacetin, cyclophosphamide, ifosfomide)

Question 2

Bladder Cancer

• mLc Pathology
• Genetics (general, low grade, high grade)
• Sx/CP
• Dx (3)
• Most common pathology

Answer 2

mLc: risk influenced by differences in detoxification pathways (higher risk for slow acetylators)
Genetics: higher risk if +FamHx, higher susceptibility if SNPs in detoxification mechanisms; Low grade (proliferative, loss of 9q); High Grade (invasion, mutations in p53, Rb)

Sx: Hematuria, irritative voiding, flank pain, palpable mass

Dx: 1. Cytoscopy

2. TURBT (complete removal of lesions if possible)
3. Upper urinary tract imaging (prior to TURBT)

Most common path: Transitional Cell Carcinoma

Question 3

Bladder Cancer

• recurrence risk
• mgmt of superficial bladder cancer
• natural hx of T1 tumor (NMI)
• natural hx of T2+ tumor (MI)

Answer 3

Recurrence: very common (more with higher stage)
Superficial: TURBT, Surveillance, Intravesicular BCG, Chemoprevention (less smoking, more water, high dose vitamins), Intravesicular Chemotx

T1 Tumor: 25-30% progress to MI, frequently require 2nd LOOK TURBT

T2+ Tumor: NOT amenable to BCG

• GOLD STD TX: RADICAL CYSTECTOMY (with neoadjuvant chemo)
• Pelvic LND: minimum: bilateral ext iliac, hypogastric, obturator
• urine diversion: STOMA

Question 4

Ureter (upper Tract) UCa

• recurrence risk for upper tract vs bladder UCa
• Syndrome assoc with upper tract Uca
• tx
• Dx
• common met sites
• tx of mets

Answer 4

50% Upper Tract UCas develop Bladder Uca (5% bladder go upstream to upper tract uca)

Lynch II Syndrome: AD mutation in DNA MMR genes (MLH1/2) - higher risk of upper tract UCa, cancer in ovary, pancreas, bile duct, uterus

Tx:
GOLD STD - radical nephroureterectomy
- segmental ureteral resection, distal ureterectomy/reimplantation

Dx: GOBLET SIGN (tumor compresses ureter flow - can be stone clot fungus tumor Uca)

Met sites: 90% LNs (liver > lung > bone)

Met Tx: Chemo (MVAC or GC regimen), PD1/PDL1 inhibition (block T cells)

Question 5

Urethra UCa

• Epi, M vs W
• Dx
• Histo
• Ant Urethra vs Post Urethra (LNs drainage, tx, prognosis)

Answer 5

RARE, only GU cancer W > M
Dx: Retrograde Urethrogram (RUG), Cystourethroscopy-biopsy, CT/MRI abd/pelvis (check LNs)
Histo: Squamous Ca most common (metastatic change of distal epithelium)

Ant Urethra

• drains inguinal LNs
• only dissect LNs if groin mass present
• tx: distal urethrectomy
• dx earlier, lower stage, less radical resection, better prognosis

Post Urethra

• drains to pelvic LNs
• tx: radical cystectomy, prostatectomy, urethrectomy, penectomy
• Prophylactic pelvic LN dissection
• worse prognosis, more radical resection