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Renal/Urology > Lecture 21 - Tumours of the Urinary System > Flashcards

Lecture 21 - Tumours of the Urinary System Flashcards

1
Q

What are urothelial tumours?

A

Malignant tumours of the lining transitional epithelium (urothelium) occurring at any point from the renal calyces to the tip of the urethra

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2
Q

What site is most commonly affected by urothelial tumours?

A

Bladder (90%)

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3
Q

What is the most common type of bladder cancer?

A

Transitional cell carcinoma (90%)

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4
Q

Where what is endemic SCC of the bladder is the most common tumour type?

A

Schistosomiasis (parasite causes chronic bladder inflammation)

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5
Q

What are risk factors for TCC of the bladder?

A

Smoking
Aromatic amines (e.g. in dyes)
Non-hereditary genetic abnormalities (e.g. TSG incl. p53+ Rb)

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6
Q

What are risk factors for SCC of the bladder?

A 
Schistosomiasis (S. haematobium only)
Chronic cystitis (e.g. recurrent UTI, long term catheter, bladder stone)
Cyclophosphamide therapy
Pelvic radiotherapy
Adenocarcinoma
Urachal
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7
Q

What is the most frequent presenting symptom of bladder cancer?

A

Painless visible haematuria

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8
Q

What are other less common presenting features of bladder cancer?

A

Symptoms of invasive/metastatic disease (rare)
Recurrent UTIs
Storage bladder symptoms (e.g. dysuria, frequency, nocturia, urgency +/- urge incontinence)
Bladder pain

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9
Q

If bladder is pain is present what should you suspect?

A

CIS (carcinoma in situ)

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10
Q

How should you investigate haematuria?

A 
Urine culture (most common cause painful haematuria = UTI)
Cystourethroscopy 
Upper tract imaging (CT urogram, USS)
Urine cytology 
BP, UE
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11
Q

Why should you do a cystourethroscopy in haematuria investigations?

A

Commonest cause of neoplastic haematuria is TCC bladder which can be visualised with cystourethroscopy

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12
Q

What is the risk of malignancy in a >50 year old presenting with frank haematuria?

A

25-35%

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13
Q

How should a >50 year old presenting with frank haematuria be investigated?

A

Flexible cystourethroscopy within 2 weeks
CT urogram and USS thereafter
Urine cytology may be useful

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14
Q

What is the risk of malignancy in an >50 year old presenting with microscopic haematuria?

A

5-10%

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15
Q

How should a >50 year old presenting with microscopic haematuria be investigated?

A

Flexible cystourethroscopy within 4-6 weeks

USS

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16
Q

How do you diagnose bladder cancer and obtain the T stage?

A

Cystoscopy + endoscopic resection (TURBT)

EUA to assess bladder mass/thickening before + after TURBT

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17
Q

What imaging techniques should be used to stage for bladder cancer?

A

Cross sectional imaging, e.g. CT/MRI
Bone scan if symptomatic
CTU for upper tract TCC

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18
Q

How is bladder cancer treated?

A

Endoscopic or radically

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19
Q

What staging system is used to stage bladder cancer?

A

TNM

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20
Q

What is the T stage of TNM staging for bladder cancer based on?

A

Non-muscle invasive (superficial) OR muscle invasive

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21
Q

How are bladder cancers staged?

A

G1 -= well differentiated (commonly non-invasive)

G2 = moderately differentiated (often non-invasive)

G3 = poorly differentiated (often invasive)

CIS - non-muscle invasive but VERY aggressive

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22
Q

When talking about muscle invasive in bladder cancer what muscle is being referred to?

A

Detrusor

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23
Q

What are the layers of the bladder wall?

A

Mucosa
Lamina propria
Superficial muscle
Deep muscle

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24
Q

What does the treatment of bladder cancer depend on? (4)

A

Site
Clinical stage
Histological grade of tumour
Patient age and comorbs

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25
What is the treatment of low grade non-invasive bladder cancer (i.e. Ta/T1)?
Endoscopic resection followed by single dose intravesical chemo (mitomycin C) within 24h Prolonged endoscopic follow up for moderate grade tumours Consider prolonged intravesicular chemo (6w-m) for repeated recurrences
26
How is high grade non-muscle invasive/CIS treated?
THIS IS V AGGRESSIVE Risk of progression to muscle invasive, so endoscopic resection alone is not sufficient CIS consider intravesicular BCG therapy (maintenance course, weekly for 3 weeks, repeated 6mthly for 3y) Refractory to BCG --> req. radical surgery
27
How is invasive bladder cancer treated? (T2-3)
Neoadjuvant chemo followed by either: Radical radio +/or Radical cystoprostatectomy (men) or anterior pelvic exenteration with urethrectomy (women) with extended lymphadenectomy
28
What is radical surgery for bladder cancer combined with?
Incontinence urinary diversion (i.e. ileal conduit), continent diversion (w.g. bowel pouch with catheterisable stoma) or orthotopic bladder substitution
29
What is the prognosis of bladder cancer dependent on?
``` Stage Grade Size Multifocality Presence of concurrent CIS Recurrece at 3 months ```
30
What is the 5YS of a non-invasive low grade bladder cancer?
90%
31
What is the 5YS of an invasive high grade bladder cancer?
50%
32
Who does bladder cancer most commonly affect?
Males between age of 50-80 | Smokers
33
Give two e.g.s of benign bladder tumours
Inverted urothelial papilloma Nephrogenic adenoma (these are uncommon)
34
What are the three bladder malignancies?
Transitional cell carcinoma SCC Adenocarcinoma
35
How do transitional cell carcinomas tend to appear?
Solitary lesions or may be multifocal due to field change effect within urothelium Usually superficial in location and thus have a better prognosis
36
What is the appearance of SCC/adenocarcinomas of the bladder?
Either mixed papillary and solid growth or pure solid growth
37
Bladder cancer: | T0
No evidence of tumour
38
Bladder cancer: | Ta
Non-invasive papillary carcinoma
39
Bladder cancer: | T1
Tumour invades subepithelial connective tissue
40
Bladder cancer: | T2a
Tumour invades superficial muscularis propria (inner half)
41
Bladder cancer: | T2b
Tumour invades deep muscularis propria (outer half)
42
Bladder cancer: | T3
Tumour extends to perivesical fat
43
Bladder cancer: | T4
Tumour invades any of: prostatic stroma, seminal vesicles, uterus, vagina
44
Bladder cancer: | T4a
Invasion of uterus, prostate or bowel
45
Bladder cancer: | T4b
Invasion of pelvic sidewall/abdominal wall
46
Bladder cancer: | N0
No nodal disease
47
Bladder cancer: | N1
Single regional lymph node metastasis in the true pelvis (hypogastric, obturator, external iliac, or presacral lymph node)
48
Bladder cancer: | N2
Multiple regional lymph node metastasis in the true pelvis (hypogastric, obturator, external iliac, or presacral lymph node metastasis)
49
Bladder cancer: | N3
Lymph node metastasis to the common iliac lymph nodes
50
Bladder cancer: | M0
No distant mets
51
Bladder cancer: | M1
Distant mets
52
How is locoregional spread best determined in bladder cancer?
Pelvic MRI
53
How is distant disease best staged in bladder cancer?
CT scanning
54
How do upper TCCs tend to present?
Frank haematuria Unilateral ureteric obstruction Flank/lion pain Symptoms of nodal/met disease (e.g. bone pain, hypercalcaemia, lung/brain symptoms)
55
How should you diagnose upper TTC?
CT-IVU or IVU Urine cytology Ureteroscopy and biopsy
56
What can CT-IVU/IVU demonstrate?
Filling defect in the renal pelvis
57
What does TURBT stand for?
Transurethral resection of bladder tumour
58
Where are the most common places to get a upper tract TCC?
Renal pelvis/collecting system
59
How are most upper tract TCCs treated?
Nephro-ureterectomy If unfit or bilateral disease - indication for nephron-sparing treatment e.g. ureteroscopic laser ablation If unifocal + low grade disease - relative indication for endoscopic treatment
60
If someone has a upper tract TCC what are they at higher risk for?
Bladder TCC - req. surveillance cystoscopy
61
Give examples of benign renal tumours
Oncocytoma | Angiomyolipoma
62
What is the most common malignant renal tumour?
Renal adenocarcinoma
63
What are other names for a renal adenocarcinoma?
Hypernephroma | Grawitz tumour
64
Where do most renal adenocarcinomas arise from?
Proximal tubules
65
What are the histological subtypes of renal adenocarcinomas?
Clear cell Papillary Chromophobe Bellini type ductal carcinoma
66
What are RFs for renal adenocarcinoma?
``` FH (AD, e.g. vHL, familial clear cell RCC, hereditary papillary RCC) Smoking Anti-hypertensive meds Obesity End stage renal failure Acquired renal cystic disease ```
67
How do 50% of renal adenocarcinomas present?
Asymptomatically as an incidental finding
68
10% of renal adenocarcinomas present as a the classic triad of what?
Flank pain Mass Haematuria
69
How do 60% of renal adenocarcinomas present?
Paraneoplastic syndrome - 30% (anorexia, cachexia, pyrexia, HTN, hyperCa, abnormal LFTs, anaemia, polycythaemia, raised ESR) Mets - 30% Bone, brain, lungs, liver
70
How is renal cancer staged?
TNM
71
What are the T stages for renal cancer?
T1 - Tumour < 7cm confined within renal capsule T2 - Tumour >7cm & confined within capsule T3 - Local extension outside capsule T3a - Into adrenal or peri-renal fat T3b - Into renal vein or IVC below diaphragm T3c - Tumour thrombus in IVC extends above diaphragm T4 - Tumour invades beyond Gerota’s fascia
72
What are the 4 ways renal cancer can spread?
Direct spread (invasion) through renal capsule Venous invasion to renal vein + vena cava Haematogenous spread to lungs + bone Lymphatic spread to paracaval nodes
73
How is renal adenocarcinoma investigated?
CT scan abdo + chest to complete staging and assess other kidney UE, FBC Optional tests - IVU shows calyceal distortion + soft tissue mass, USS differentiates tumour from cyst, DSMA/MAG-3 renogram to assess split renal function if doubts about other kidney
74
How is renal adenocarcinoma treated?
Surgically
75
What is the standard treatment of choice for T1 tumours?
Laparoscopic radical nephrectomy
76
What T stage can surgery be curative for?
T2 or less
77
Should you still operate on those who have metastatic disease and symptoms from the primary tumour?
Yes | Palliative cytoreductive nephrectomy is beneficial (prolongs survival by 6m)
78
What is important to remember in the treatment of RCC?
RCC is radioresistant and chemoresistant
79
What therapies are available for metastatic RCC?
Multitargeted receptor tyrosine kinase inhibitors, e.g. sunitinib Immunotherapy, IFa, IL2
80
Where does renal cell cancer arise from?
Proximal tubule
81
What is the most common histological subtype of renal cancer?
Clear cell

Renal/Urology (29 decks)

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