Cancer of the Urinary System Flashcards by Hannah Thomas

What is the difference between the stage and grade of a cancer?

Staging assesses how far the cancer has spread and uses the TNM system.
Grading assesses the aggressiveness of the tumour, usually uses histology to determine whether the cancer cells are well-differentiated (better prognosis) or poorly-differentiated (worse prognosis).

How well did you know this?

Not at all

Perfectly

What are the two histological types of bladder cancer?

Transitional cell carcinoma

Squamous cell carcinoma

How well did you know this?

Not at all

Perfectly

What is the most common symptom of bladder cancer?

Painless visible haematuria

How well did you know this?

Not at all

Perfectly

Give three risk factors for transitional cell carcinoma

Smoking
Aromatic amines (excreted in urine)
Non-hereditary genetic abnormalities

How well did you know this?

Not at all

Perfectly

Which infectious disease is a risk factor for squamous cell carcinoma of the bladder?

Schistosomiasis

S. haematobium

How well did you know this?

Not at all

Perfectly

Give eight investigations that should be done in a patient presenting with haematuria

Urinalysis (including urine culture and microscopy)
FBC
U&amp;Es
Urine cytology
Cystourethrocopy
IVU
USS
Blood pressure

How well did you know this?

Not at all

Perfectly

What is the most important step in investigating patients over 50 presenting with frank haematuria?

Flexible cystourethroscopy should be conducted within two weeks

How well did you know this?

Not at all

Perfectly

What is the risk of malignancy in a patient with frank haematuria who is over 50 years of age?

25 - 35%

How well did you know this?

Not at all

Perfectly

If muscle-invasive bladder cancer is suspected, should imagining (CT/MRI) be conducted before or after TURBT?

Before

How well did you know this?

Not at all

Perfectly

What is TURBT?

Transurethral resection of bladder tumour

How well did you know this?

Not at all

Perfectly

What is EUA and why is it used?

Examination Under Anaesthetic

Used to assess bladder mass/thickening before and after TURBT

How well did you know this?

Not at all

Perfectly

Describe the investigations involved in TNM staging of bladder cancer

Cross-sectional imaging (contrast CT, MRI) - determine T-stage
Bone scan if symptomatic
IVU (intravenous urogram)
CT scanning of chest, abdomen and pelvis to look for metastases (only done if cancer is muscle-invasive)

How well did you know this?

Not at all

Perfectly

Which lymph nodes might bladder cancer first invade?

Hypogastric
Obturator
External iliac
Presacral

How well did you know this?

Not at all

Perfectly

If there are any lymph node or distant metastases, what stage is the cancer?

Stage 4

How well did you know this?

Not at all

Perfectly

Describe the management of low grade non-muscle invasive bladder cancer

complete transurethral resection (TUR), including part of underlying muscle, followed by single dose of mitomycin C within 24 hours

How well did you know this?

Not at all

Perfectly

What is mitomycin C?

an intravesical chemotherapy used to treat low grade TCC

How well did you know this?

Not at all

Perfectly

Describe the treatment for carcinoma in situ (bladder TCC)

Intravesical BCG immunotherapy

- weekly for 3 weeks repeated 6 monthly over 3 years

How well did you know this?

Not at all

Perfectly

Describe the management of muscle invasive bladder TCC

Neoadjuvant chemo (cisplatin combination regimen)

2. radical radiotherapy and/or radical cystectomy

Give three types of urinary diversion procedures

Incontinent urinary diversion (i.e. ileal conduit)
Continent diversion (e.g. bowel pouch with catheterisable stoma)
Orthotopic bladder substitution.

What is the prognosis for non-invasive, low grade bladder TCC?

90% 5-year survival

What is the prognosis for invasive, high grade bladder TCC?

50% 5-year survival

Describe the complications associated with bladder TCC

UTI.
Urinary retention.
Hydronephrosis.
Recurrence of tumour.
Increased risk of urethral transitional cell carcinoma.
Complications of surgery e.g. bowel obstruction, obstruction of the ureter, pyelonephritis and infection of the wound.
Radical cystectomy damages the S2,3,4 outlet and causes complete erectile dysfunction
Orthotopic bladders have a risk of urinary incontinence.

What is the most common type of upper tract urothelial carcinoma?

Transitional cell carcinoma (TCC)

Where are the most common sites for upper tract urothelial carcinoma to occur?

Renal pelvis

Collecting system

Describe the presentation of UTUC

``` Frank haematuria Unilateral ureteric obstruction Flank or loin pain Symptoms of nodal or metastatic disease - Bone mets - bone pain, hypercalcaemia - Lung - Brain ```

Describe the standard investigation process for haematuria

Urine cytology Upper tract imaging (CT-IVU) Cystoscopy

What is the first-line treatment for UTUC? Why?

Nephro-ureterectomy | High risk of local recurrence ad difficulty of follow up if endoscopic/segmental resection is used

What is ureteroscopic laser ablation? When is it indicated in the treatment of UTUC?

A nephron-sparing endoscopic treatment If a patient is unfit for nephro-ureterectomy If a patient has bilateral disease

Describe how UTUC patients are followed up after treatment?

Regular surveillance cystoscopy

Give two types of benign renal tumours

oncocytoma | angiomyolipoma

What is the commonest type of renal malignancy?

Renal adenocarcinoma

From which tissue do most renal adenocarcinomas originate from?

Proximal renal tubular epithelium

Give four histological subtypes of renal adenocarcinoma

Clear cell Papillary Chromophobe Bellini type ductal carcinoma

List some risk factors for renal cell carcinoma

``` Family history Smoking Obesity Anti-hypertensive medication End-stage renal failure Acquired renal cystic disease ```

What percentage of renal cell carcinomas are asymptomatic? (i.e. are found incidentally on imaging)

50%

What is the "classic triad" of symptoms of renal cell adenocarcinoma? In practice, how often does this triad present?

Flank pain Mass Haematuria Only seen in 10% of patients

What are the four most likely sites for renal cancer to metastasise to?

Bone Brain Lung Liver

Describe and explain the paraneoplastic syndrome that may present in patients with renal cancer

– anorexia, cachexia (weakness/wasting of the body) and pyrexia. – hypertension, hypercalcaemia (due to production of a PTH-like hormone by tumour) and abnormal LFTs. – anaemia, polycythaemia (too many RBCs) and raised ESR – due to production of erythropoietin by the tumour.

Give four routes of spread of renal cell carcinoma

- Direct through the renal capsule - Venous to renal vein and vena cava - Lymphatic to nodes - Haematogenous to bone and lungs.

Why is ultrasound useful in the diagnosis of renal cell carcinoma?

Good for differentiating between a tumour and a cyst

What would be seen on an IVU in a patient with renal cancer?

calyceal distortion | soft tissue mass

What is the treatment for renal cell adenocarcinoma? How successful is this treatment?

``` Radical nephrectomy (laparoscopic) Curative in patients with TNM stage ≤T2. In patients with more advance cancer, palliative cytoreductive nephrectomy can prolong survival by 6 months ```

Why are RCC metastases difficult to treat?

RCC is radioresistant and chemoresistant

What are the treatment options for metastatic RCC?

``` Immunotherapy - interferon alpha - interleukin-2 Multitargeted recepto tyrosine kinase inhibitors - sunitinib - sorafenib - temsirolimus ```