Lecture 20 Tumours of the Urinary System 2 (Bladder and Renal Cancer) Flashcards
What cells are involved in urothelial cancers
Transitional cell epithelium
Where can Uroethelial cancers occur
• Can occur at point from the renal calyces to the tip of the urethra
Where Schistosomiasis is endemic what type of bladder cancer
Squamous cell carcinoma
Risk factors doe TCC
Smoking
Aromatic amines
Non-hereditary genetic abnormalities (e.g. TSG incl. p53 and Rb)
Risk factors for SCC
– Schistosomiasis (S. haematobium only)
– chronic cystitis (e.g. recurrent UTI, long term catheter, bladder stone)
– cyclophosphamide therapy
– pelvic radiotherapy
What are the presenting features
Painless visible Haematuria Recurrent UTI Storage bladder symptoms : – dysuria, frequency, nocturia, urgency +/- urge incontinence – bladder pain
Investigations of Haematuria
Urine culture Cystourethroscopy • CT Urogram (IVU) • ultrasound scan • Urine Cytology – Limited use in Dipstick haematuria • BP and U&E’s
What action should be taken if an individual has frank haematuria and >50 years
Flexible cystourethroscopy within 2 weeks
CT urogram & USS
Urine Cytology may also be useful
Risk of malignancy- 25-35%
What action should be taken if an individual has dipstick or microscopic haematuria and >50 years
- Flexible cystourethroscopy within 4-6 weeks
* USS
How is a diagnosis made for uroethelilal cancers
- Cystoscopy and endoscopic resection (TURBT)
* EUA to assess bladder mass/thickening before and after TURBT
How are endothelial cancers treated
Endoscopic or Radical Cystectomy
Grade of tumour G1
Well differentiated
Commonly non-invasive
Grade of tumour G2
Moderately differentiated
Often non-invase
Grade of tumour G3
Poorly differentiated
Often invasive
Grade of Carcinoma in situ
Not invasive but very aggressive
Stage Ta/T1
Non muscle invasive
Stage T2/T2b
Muscle invasive
Stage T3a/3b
Muscle invaisve
Stage T4a
Prostate invasive
Treatment of low grade non-muscle invasive bladder cancer
– endoscopic resection followed by single instillation of intravesical chemotherapy (mitomycin C) within 24 hours
– prolonged endoscopic follow up for moderate grade tumours
– consider prolonged
Treatment for high grade non muscle invasive or CIS
– CIS consider intravesical BCG therapy (maintenance course, weekly for 3 weeks repeated 6 monthly over 3 years)
– Patients refractory to BCG – need radical surgery
Treatment for muscle invasive bladder (T2-T3)
Neoadjuvat therapy
Radical therapy
radical cystoprostatectomy
anterior pelvic exenteration with urethrectomy
– radical surgery combined with incontinent urinary diversion
What does the prognosis of bladder cancer depend on
- stage
- grade
- size
- multifocality
- presence of concurrent CIS
- recurrence at 3 months
What are the main symptoms of upper tract urothelial cancer
Frank haematuria Unilateral ureteric obstruction Flank or loin pain Metastatses or nodal: Bone pain Hypercalcaemia Lung Brain
Diagnostic Investigations of upper tract urothelial cancer
- CT-IVU or IVU- Urogram
- Urine cytology
- Ureteroscopy and biopsy
Upper tract TCC are most commonly seen in the __
renal pelvis or collecting system
What grade are upper tract TCC most commonly
High grade
Multifocal
What is the treatment of UT TCC
nephro-ureterectomy
if unfit or has bilateral disease ureteroscopic laser ablation
Name benign renal conditons
Oncocytoma
Angiomyolipoma
Name malignant renal conditions
Renal adenocarcinoma
Where does renal adenocarcinoma most commonly arise
Proximal tubules
What are the histological types of renal adenocarcinoma
Clear cell
Papilloma
Chromophobe
Bellini type ductal carcinoma
Name risk factors of renal adenocarcinoma
Family history Smoking Anti-hypertensice medication Obesity ESRF Acquired renal cystic disease
What is the clinical presentation of renal adenocarcinoma
• Asymptomatic
• Flank pain, mass and haematuria
• Paraneoplastic syndrome
Metastatic- bone, brain, liver and lungs
What is T1 staging of renal cancer
<7cm confined within renal capsule
What is T2 staging of renal cancer
> 7cm confined within Rena capsule
What is T3 staging for renal cancer
Local extension outside the capsule
What is T3a staging for renal cancer
- Into adrenal or peri-renal fat
What is T3b staging for renal cancer
- Into renal vein or IVC below diaphragm
What is T3c staging for renal cancer
Tumour thrombus in IVC extends above diaphragm
What is T4 staging for renal cancer
Tumour invades beyond Gerota’s fascia
What investigations are carried out for a renal cancer
CT- abdomen and chest
Bloods- U&Es, FBC
US
– DMSA or MAG-3 renogram to assess split renal function
How is renal cancer metastasis treated
RCC is radioresistant and – multitargeted receptor tyrosine kinase inhibitors • relatively new – immunotherapy • Interferon alpha • Interleukin-1
