Cancers - RCC And TCC

Question 1

What types of tumours are commonly present in the urinary system?

Answer 1

RCC - renal cell carcinoma that appears in the kidney.

TCC - transition cell carcinoma that appears in the kidney, urethra and bladder.

Question 2

How does RCC present?

Answer 2

Early:
Haematuria
Incidental finding on imaging
Rarely - palpable mass

Late:
Large varicocele 
Pulmonary / tumour embolus
Loss of weight / appetite / symptoms of metastasis 
Hypercalcaemia

Question 3

How does TCC present?

Answer 3

Localised or advanced:
Haematuria
Indicendal finding on imaging

Advanced:
Loss of weight / appetite / symptom of metastasis
DVT
Lymphoedema

Question 4

How do you classify haematuria?

Answer 4

Visible

Non visible - symptomatic or asymptomatic

Question 5

How is hamaturia important?

Answer 5

20% of those presenting with visible haematuria have urological cancer.

Question 6

What are some common causes of haematuria?

Answer 6

Cancer:
RCC
Bladder cancer
Upper urinary tract TCC
Advanced prostate cancer

Other:
Stones
Infection
Inflammation
Large BPH

Question 7

When is it more likely be a Nephrological cause?

Answer 7

Nephrology:
High BP
Protein urea 
Under 40 
Not visible haematuria

Question 8

What things do you look for in history for haematuria?

Answer 8

Smoking 
Occupation 
Pain? - if pain-stone?
Other LUTS (lower urinary tract symptoms)
Family history

Question 9

What things do you look for upon examination of haematuria?

Answer 9

BP
Abdominal mass 
Varicocele
Leg swelling
Assess prostate by DRE -size, texture

Question 10

What othe things do you check when come for haematuria?

Answer 10

Radiology -USS of urinary tract (stones, - hydronephrosis, tumour in kidney), CT if abnormal USS

Endoscopy -flexible cystoscopy (see smaller tumours)

Urine - cytology to look for abnormal cells or culture and sensitivity

Bloods (done in primary care) -FBC and U&E

Question 11

Describe the epidemiology of RCC

Answer 11

7th most common cancer in UK

95% of all upper urinary tract tumour.

Incidence and mortality are rising

Mortality is projected to fall in the next decade

M:F 3:2

30% have metastases on presentation

Aetiology:
Smoking
Obeisity
Dialysis

Question 12

How does RCC spread?

Answer 12

IVC spread to right atrium

Perinephric spread

Lymph node metastasis

Question 13

How do you treat RCC?

Answer 13

Surveillance

Excision

• Radical nephrectomy (open or laparoscopic)
• Partial nephroectomy (Open or robotic)

Ablation

• Cryoblation
• Radiofrequency ablation

Question 14

How do you treat metastatic RCC?

Answer 14

Palliative

Biological therapies
-Targeted therapies = Those targeting angiogenesis (tyrosine kinase inhibitors) are now 1st choice. -Sunitinib

Question 15

Describe the epidemiology of bladder cancer

Answer 15

8th most common in men, 14th in women

Incidence is decreasing

Presentation is more advanced in women

Mortality is decreasing (less in women)

M:F 3:1

White> non-white

Question 16

What are the risk factors for bladder TCC?

Answer 16

Smoking (4x. Risk)

Occupation exposure:
-Rubber or plastics manufacture
-Handling of carbon, crude oil, combustion, smelting
Painters, mechanics, printers, hairdressers

Question 17

How do you treat bladder cancer initially?

Answer 17

Transurethral removal of bladder tumour.

Question 18

How else do you treat badder TCC?

Answer 18

Low risk non-muscle invasive:
-Check cystoscopy
+/- intravesical chemotherapy

High risk non muscle-invasive:
-Check cytoscopies
Intravesical immunotherapy

Muscle-invasive (most serious):
Neoadjuvant chemotherapy
Radical cystectomy or radiotherapy
BUT, sometimes palliative chemo or radio.

Question 19

Describe the epidemiology of upper urinary tract TCC

Answer 19

Only 5% of all malignancies of upper urinary tract

Aetiology:
Smoking
Phenacetin (similar to paracetamol by carcinogenic - banned) abuse
Balkan’s nephropathy

Question 20

Where to upper urinary tract TCC typically spread to?

Answer 20

40% spread to the bladder

Question 21

What are the initial investigations if you suspect an upper urinary tract TCC

Answer 21

USS - hydronephrosis

CT Urogram - filling defect, ureteric stricture

Retrograde pyelogram

Ureteroscopy - biopsy, washings for cytology

Question 22

What is the standard treatment of upper urinary tract TCC?

Answer 22

Nephro-ureterectomy (kidney, fat, ureter, cuff of bladder)

Question 23

What is the treatment of metastatic TCC?

Answer 23

Systemic chemotherapy - Cis-platin based

Biological therapies - immunothrapies