Bladder + renal cancer Flashcards
Urothelial carcinoma aka
+ affects what organ the most
transitional cell carcinoma (TCC)
affects BLADDER (90%) but technically speaking can affect anywhere from renal calyces to tip of urethra as transitional epithelium is all along the tract
2 types of bladder cancer + which more common
Transitional cell carcinoma - 90%
Squamous cell carcinoma
Squamous cell carcinoma of the the bladder is less common and is mostly caused by
Schistosomiasis infection by S. haematobium
Risk factors of TCC of the bladder (3)
Smoking - MAIN
Occupational exposure to chemical carcinogens - aromatic amines
Age >55, male
Risk factors of SCC of the bladder (3)
Schistosomiasis infection
Chronic cystitis (from recurrent UTIs, stones)
Systemic chemotherapy - e/g/ cyclophosphamide
Main symptom of bladder cancer +
symptoms/signs of bladder carcinoma in situ (superficial but aggressive high grade form)
Painless frank haematuria
If carcinoma in situ (aggressive)
- dysuria
- frequency
- urgency
- bladder pain
Investigations of bladder cancer
- biochem (2)
- imaging (2)
- definitive diagnosis
Urinalysis - microscopy etc
Urine cytology
Imaging
- CT urogram
- renal and bladder USS
CYSTOSCOPY + BIOPSY
-cystoscopy itself good for low grade cancers but high grade less visible as their cells are flatter
Painless frank haematuria itself suggests what diagnosis whereas painful haematuria suggests what
Painless - bladder cancer
Painful - UTI
IV urogram is not used as much anymore to investigate TCCs - why?
Small bladder tumours are often not visible, good for upper urinary tract but still can miss out tumours
Definitive diagnostic investigation of TCCs of the bladder
Cystoscopy guided biopsy
Staging investigations of TCCs of the bladder
CT
MRI
Bone scan - to see bone metastases
Treatment of bladder TCC
- if low grade superficial (2)
- if high grade superficial/CIS (3)
- if muscle invasive (T2 onwards) (2)
If non-muscle invasive (superficial)
-transurethral resection of a bladder tumour (TURBT) via cystoscopy
AND
-immediate post op intravesical chemotherapy
If high grade superficial/CIS
-above
AND
-2 weeks post op intravesical BCG vaccine
If muscle invasive
- radical cystectomy + pelvic lymph node dissection
- neoadjuvant chemo +/- adjuvant
Grading of tumours is different to staging, describe the 3 grades of bladder tumours
G1 = Well diff. - commonly non-invasive
G2 = Mod. diff. - often non-invasive
G3 = Poorly diff. - often invasive + metastatic
Carcinoma in situ (CIS) - non muscle invasive (so still superficial) but very AGGRESSIVE
What are the different stages of bladder cancer (NOT GRADE) (4)
Carcinoma in situ (CIS) - non muscle invasive but very AGGRESSIVE
Ta - superficial
T1 - superficial
T2 onwards - muscle invasive
Although carcinoma in situ is superficial, what grade is it
high grade because very aggressive
Non-invasive low-grade (TaG1) bladder tumours have a low risk of stage progression but recurrence…
is still high post resection so need follow up cystoscopy 3 months later
TCCs of the upper urinary tract mostly affect
renal pelvis or calyces; not so much the ureter
Symptoms (1) /signs (2) of upper urinary tract TCC (i.e. affecting renal pelvis/calyces/ureter)
Flank/loin pain
Frank haematuria
Unilateral obstruction –> unilateral hydronephrosis
Investigations of an upper urinary tract TCC (affecting renal pelvis/calyces/ureter)
- urine (2)
- imaging (2)
Urinalysis - microscopy
Urine cytology
CT urogram - tumour shows as filling defect
Ureteroscopy + biopsy
Treatment of upper urinary tract TCCs (affecting renal pelvis/calyces/ureter)
Nephro-ureterectomy
If unfit for this or disease is only low grade
-endoscopic ablation
Benign tumours of the kidney (2)
Oncocytoma
Angiomyolipoma
Malignant tumours of the kidney (2)
Renal cell adenocarcinoma aka renal cell carcinoma (NOT THE SAME AS CLEAR CELL CARCINOMA; clear cell is a subtype of renal cell carcinoma)
TCC of kidney
Histological subtypes of renal adenocarcinoma/ renal cell carcinoma (4)
Clear cell - MOST COMMON
Papillary
Chromophobe
Bellini type ductal carcinoma
Renal cell carcinoma (RCC) is renal malignancy arising from the renal parenchyma/cortex, and accounts for about 85% of renal cancers, much more common than what cancer of the kidney
TCC of the kidney
Commonest renal cell carcinoma
Clear cell renal cell carcinoma
Risk factors of renal cell carcinoma (aka renal cell adenocarcinoma) (6)
Smoking Male Age >55 Obesity Hypertension Family history of RCC Polycystic kidneys
Symptoms/signs of renal cell carcinoma
- 50% cases people are
- single presentation
- classic triad in <10% (suggests local advanced)
50% actually asymptomatic and only found INCIDENTALLY on imaging of something else
Haematuria alone
Classic triad
- flank pain
- palpable mass
- haematuria
Some renal cell carcinomas present as paraneoplastic syndromes
What are some of the symptoms/signs presented here
Systemic symptoms
-fever, weight loss, night sweats, cachexia (weakness + wasting)
Ectopic secretions
- erythropoetin –> polycythemia (high RBCs)
- renin –> hypertension
- PTH –> hypercalcaemia
- ACTH –> Cushing’s syndrome
Renal cell carcinoma metastases to what places (4)
Bone
Brain
Lungs
Liver
What stage of renal cell carcinoma indicates it has extended outwith the fibrous capsule of the kidney
T3 and onwards
T1 and T2 - still confined in capsule
Routes renal cell carcinoma can spread (3)
Direct spread (local invasion through fibrous capsule) -e.g. into renal vein/IVC
Via blood
Via lymph
-to paracaval lymph nodes
Investigations of renal cell carcinoma (6)
-imaging (2)
FBC - may show anaemia or polycythaemia (from EPO secreting paraneoplastic syndrome)
U+Es - may be high creatinine if low GFR
LFTs - abnormal enzymes may indicate liver metastases
Urinalysis - microscopy (for haematuria)
CT abdo/pelvis - DEFINITIVE DIAGNOSIS
CT chest - to look for metastases
Treatment of renal cell carcinoma
- if localised mass (stage 1/2)
- if spread outwith capsule (stage 3) (1)
- if stage 4 (metastatic) (2)
Chemotherapy/radiotherapy RESISTANT
Surgery
- tumour resection/local ablation if just stage 1/2 (localised)
- radical nephrectomy if stage 3
Metastastic
- targeted molecular therapy (TYROSINE KINASE RECEPTOR INHIBITORS)
- immunotherapy
Renal cell carcinoma is resistant to what treatment
Chemotherapy/radiotherapy
