Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Repro Week 2 > ICL 5.5: Malignancies of the Ureter and Bladder > Flashcards

ICL 5.5: Malignancies of the Ureter and Bladder Flashcards

1
Q

what are the types of congenital anomalies of the bladder?

A
  1. vesicoureteral reflux

2. extropy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

what is extrophy?

A

aka congenital vedic-cutaneous fistula

there’s an incomplete closure the anterior abdominal wall and the anterior bladder wall

this leads to exposure of the bladder mucosa which leads to irritation, infection etc.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

what causes extrophy?

A

overgrowth of cloacal membrane

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

what are the complications of extrophy?

A
  1. acute and chronic infections
  2. metaplastic changes (due to chronic infections and irritation) (adenomatous or squamous changes)
  3. risk of neoplastic transformation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

what metaplastic changes can happen in the bladder due to chronic infection/irritation?

A
  1. swuamout metaplasia schistosomiasis

2. adenomatous metaplasia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

what are the inflammatory diseases of the bladder?

A
  1. chronic interstitial cystitis (Hunner’s ulcer)

2. malakoplakia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

45 year old women present with urge to empty her bladder every 30-40 minutes. this is sometimes associated with suprapubic pain.

UA: negative, no cells, no blood

esterase negative

nitrites: negative

cystoscopy reveals edematous mucosa with
focal ulcerations

diagnosis?

A

Hunner’s ulcer

if it was cystitis, there would’ve been WBCs and RBCs

esterase and nitrites are negative which also doesn’t indicate UTI

so it looks like acute infectious cystitis but it’s definitely not….there’s edema and ulcerations of mucosa

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

what is Hunner’s ulcer?

A
  1. middle age women
  2. suprapubic pain
  3. frequency
  4. urgency
  5. edema, ulcerations and granulation tissue

pathologenesis thought to be autoimmune

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

what are the components of granulation tissue?

A
  1. fibroblasts/collagen
  2. lymphocytes/macrophages
  3. new blood vessels
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

A 35 year old, 9 years post renal transplant patient, presents with what appears to be recurrent urinary tract infections for the last 3 years. He had multiple negative cultures as well as empirical antibiotic therapy with no improvement.

Cystoscopy reveals multiple calcified mucosal plaques.

A

post-renal transplant = immunosuppressants

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

what is malakoplakia?

A

usually seen in immunosuppressed patients

raised mucosal plaques made of:

  1. large foamy macrophages PAS positive
  2. occasional giant cells
  3. ymphocytes

intracellular concretions “Michaelis-Gutman bodies”

they are laminated concretions resulting from deposition of calcium in enlarged lysosomes**

pathogenesis chronic infections

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

what is cystitis glandularis and cystitis cystica?

A

downward growth of transitional epithelium “Brun nests” into lamina propria with metaplastic changes –> if it is just down growth, it’s cystitis cystica but if there metaplasia with gland formation it’s cystitis cystica

most commonly glandular

occasionally seen in normal bladder but usually in chronically irritated bladder

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

what are the complications associated with cystitis glandularis?

A

adenocarcinoma with the cystitis glandularis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

what is the blood supply of the bladder?

A

superior and inferior vesical arteries which are branches of the anterior division of the internal iliac artery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

what is the venous drainage of the bladder?

A

inferior and superior vesical veins, which in turn drain into the internal iliac vein

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

what is the lymphatic drainage of the bladder?

A

level I nodes(internal iliac, obturator,andexternal iliac which drain into..

level II nodes: common iliac, presacral) which drain into..

level III nodes: paracaval, para-aortic,andinteraortocaval

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

what is the urothelium?

A

the epithelium that lines the urinary tract and extends from the tip of the renal papillae to the urethra

typically has3-6 layers of cellsthat are comprised of (from basement membrane to lumen)basal cells, intermediate cells, and umbrella cells

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

what layer of the urothelium is bladder cancer though to arise from?

A
  1. basal cells
    ex. CIS, muscle-invasive urothelial carcinoma, and squamous cell carcinoma
  2. intermediate cells in some cases
    ex. non-invasive urothelial carcinoma
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

65 year old smoker presents with painless hematuria.

UA: many RBC’s

Metabolic Panel: within normal limits

Cystoscopy: one ulcerated lesion at the dome

Biopsy: urothelial carcinoma of bladder

A

(:

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

how common is bladder cancer?

A

bladder cancer is the fourth most common cancer in men and the fifth most common malignancy overall

in the United States in2019,80,470new cases of bladder urothelial carcinoma

male to female ratio is 4:1, with an age standardized incidence rate of 10/100,000 for males and 2.5/100,000 for females.

1 in 26 malesand1 in 87 femaleswill develop bladder cancer over the course of their lifeand17,670deaths from bladder cancerare expected to

caucasians are more likely to develop bladder cancer than other ethnic groups

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

how does age effect bladder cancer?

A

increase in incidence with age such thatmen over 70 have a 3.7% probability of developing bladder cancer compared with 0.92% of men 60 to 69 and 0.38% for men 40 to 59

22
Q

what are the risk factors for developing cancer?

A
  1. current smoker
  2. former smoker
  3. aromatic hydrocarbons (metal processing, truck drives, oil and coal production)
  4. aromatic amines (textiles, painters, hairdressers, chemical plant)
  5. n-nitrosamines
  6. blackfoot disease (arsenic exposure in Taiwan)
  7. formaldehyde
  8. Lynch syndrome
  9. U-Fraumeni syndrome
  10. chronic cystitis (recurrent UTIs, indwelling foley, schistosome, bladder stones can cause SCC)
  11. radiation
  12. cyclophosphamide
  13. pioglitazone
23
Q

which genes are associated with bladder cancer?

A
  1. NAT1
  2. NAT2
  3. GST gene
24
Q

what is the non-invasive pathway in development of bladder cancer?

A

characterized by mutations in oncogenes FGFR3 and PIK3CA as well as loss of heterozygosity on chromosome 9q

can develop non-muscular invasive cancer

25
Q

what is the invasive pathway in development of bladder cancer?

A

characterized by mutations in the TP53 and RB1tumor suppressor genes

can develop muscle invasive bladder cancer

26
Q

what are the most common histologies associated with bladder cancer?

A
  1. urohtelial carcinoma of the bladder – MOST common
  2. squamous cell carcinoma (3-7%, bladder stones,diverticuli,chronic infections,or bilharziasis)
  3. adenocarcinoma at dome
  4. non-urothelial bladder tumors: small cell, carcinosarcoma
  5. non-epithelial bladder tumors: neurofibroma, pheochromocytoma, lymphoma, sarcomas
27
Q

what are the signs and symptoms of bladder cancer?

A
  1. hematuria (most common presenting symptom)

2. irritative voiding symptoms

28
Q

what type of bladder cancer is associated with irritative voiding symptoms?

A

carcinoma in situ

primary symptoms, such as urgency, dysuria, frequency and nocturia, or be mis-diagnosed as recurrent bacterial cystitis

29
Q

what are the 2 types of hematuria and how are they defined?

A
  1. microscopic hematuria

dipstick isn’t sufficient, 3+RBCs per high power field is microscopic hematuria

  1. gross hematuria
30
Q

what are the diagnostic tests for hematuria?

A
  1. cystoscopy
  2. urine cytology (not super sensitive for low grade cancers but it’s good for high risk cancers
  3. CT urography)
  4. retrograde pyelography
  5. ureterscopy
31
Q

what is CT urography?

A

single best imaging modality for evaluation of urinary stones, renal and peri-renal infection, renal cell carcinoma, urothelial carcinoma of pelvicaliceal system or ureter

32
Q

what is a retrograde pyelography?

A

done at cystoscopy or transurethral resection of bladder tumor (TURBT)

it is another acceptable method of screening the upper urinary tracts for urothelial cancer

33
Q

what is a ureterscopy?

A

if there are suspicious filling defects seen on the retrograde pyelograms then subsequent ureteroscopy (+/- biopsy) should be
performed

it’s a camera in the ureter to look at it and if you need you can take biopsy too

34
Q

is invasive or noninvasive bladder cancer more common?

A

75% of bladder cancers are non-invasive on diagnosis

25% are invasive on diagnosis

treatment is based on grade and stage

35
Q

what are the stages of bladder cancer?

A

stage 0: if it is carcinoma in situ, papillary tumor just in the mucosa

stage 1: tumor has growth into the lamina propria

stage 2: if the tumor has grown into the muscle; higher rates of metastasis

stage 3: if the tumor is in the fat outside the bladder

stage 4: mets

36
Q

a 60 year old has a muscle invasive urothelial carcinoma on TURBT. The preoperative CT scan shows loss of fat plane on right side of the bladder. Patient has a clinical stage:

A- T2
B- T1
C- T3a
D- T4
E- T3b
A

T3b

it’s macroscopic loss of fat, not microscopic

37
Q

what doe the course of bladder cancer treatment depend on?

A

depends on grade and stage!!

presence of blood group antigen is associated with good prognosis

presence of chromosome abnormalities and gene mutation is associated with poor prognosis

38
Q

what are low grade bladder tumors?

A

usually papillary

DNA is usually diploid

no or limited chromosome or gene abnormalities

retains blood group antigen

39
Q

what are high grade bladder tumors?

A

papillary or nodular

DNA is usually aneuploidy

marked anaplasia

high frequency chromosomes and gene abnormalities

lack blood group antigens

40
Q

what is TURBT?

A

Transurethral Resection of bladder Tumor = diagnostic AND therapeutic! because you remove and biopsy the tumor

small tumorscan be removed withcold cup biopsy forcepsand the biopsy crater and surrounding urothelium (important due tofield effect) can be fulgurated

larger tumorsrequire the use of anendoscopic resectoscope.

41
Q

what are the indications for a second TURBT?

A

a second-look (repeat) TURBT is sometimes done within 2-6 weeks of the first TURBT

the indications for this include:
1. incomplete first TURBT

  1. large (> 3 cm) or highly multifocal tumor
  2. high grade Ta tumor and T1 tumor

when a second TURBT is done Ta 50% had residual disease and 15% were upstaged and with T1 tumors, 48% had persistent NMIBC and 30% were upstaged to muscle invasion –> this is why it’s so important to do the second TURBT!

the AUA guidelines recommend that in a patient with high-risk, high-grade Ta/T1 tumors, a clinician should consider performing repeat transurethral resection of the primary tumor site within six weeks of the initial TURBT

42
Q

how do you treat noninvasive bladder cancer?

A

based on stage and invasion!

  1. surveillance with repeat resections as needed
  2. intravesical therapy

mitomycin-C or Gemcitabine or epirubicin within 24 hours of TURBT

or six week course of induction intravesical chemotherapy or immunotherapy (BCG) with maintenance therapy

43
Q

how do you treat muscle invasive bladder cancer?

A

neoadjuvant chemotherapy followed by radical cystectomy with urinary diversion

radiation with chemotherapy

44
Q

what are the general pearls for treatment of bladder cancer?

A

the standard induction course is the same for immunotherapies and chemotherapies, andis given weekly for a total of 6 doses and then cystoscopy is done 6 weekslater to assess for response

patients must retain the drug for two hours for peak efficacy

patients should not drink for 4-6 hours prior to treatment

clinical trials have demonstrated benefit for maintenance therapy for both mitomycin C and BCG

the most common maintenance schedule for BCG is theLamm/SWOG regimen (triplets of BCG given at 3, 6, 12, 18, 24, 30 and 36 months)

the most common maintenance schedule for chemotherapy is once monthly for 1-3 years

45
Q

what are the risk factors for upper urinary tract neoplasms?

A
  1. smoking
  2. bladder cancer
  3. Lynch
  4. Balkan nephropathy, Chinese and Taiwanese herbal nephropathy
  5. arsenic
  6. analgesics
  7. occupational exposure
  8. chronic inflammation and infection
  9. cyclophosphamide
46
Q

what are the clinical signs and symptoms of upper urinary tract urothelial carcinoma?

A
  1. hematuria
  2. flank pain
  3. dysuria
  4. symptoms of advanced disease
  5. common mets to the liver, lungs, bones, regional lymph nodes
47
Q

what are the risk factors for advanced upper tract urothelial carcinoma?

A
  1. tumor grade
  2. positive cystology
  3. sessile tumor architecture
  4. multifoacility
  5. hydronephrosis
  6. tumor size 3+ cm
48
Q

what is the nonsurgical treatment of upper tract urothelial carcinoma?

A
  1. intracavitary therapy: bacillus, calmette, guerin (BCG), mitomycin C
  2. neoadjuvant chemo
  3. surgical management: partial ureterectomy or radical nephroureterectomy
49
Q 
65 year old male with a solitary 3.0 cm low-grade appearing papillary tumor endoscopically resected. Next step?
1- Intravenous chemotherapy 
2- Intravesical chemotherapy 
3- Intramuscular chemotherapy 
4- Oral chemotherapy
A

2- Intravesical chemotherapy

solitary, first time presenting with polyp, so just 1 dose of chemo via catheter

50
Q

35 year old Egyptian farmer presents with hematuria and suprapubic pain. Past medical history: treated for schistosomiasis when he was 28 years.
UA: RBC’s and epithelial squames
Cystoscopy: fungating mass
Biopsy: Histology type?

A

squamous cell carcinoma

51
Q

A 75 year old male presents with 6 months of painless hematuria. He has a past medical history of prostate cancer treated with radiation 7 years ago.
UA: negative
Urine Culture: negative

DD:
Pathogenesis:

A

prostate cancer with radiation treatment in the past so he maybe got bladder cancer from the radiation but do cystoscopy and upper tract imaging to check – UTI should also be on the differential

but ultimatelyl he probably has radiation cystitis where blood vessels rupture because they became brittle and rupture

Repro Week 2 (21 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions