Lecture 21 - Tumours of the Urinary System Flashcards
What are urothelial tumours?
Malignant tumours of the lining transitional epithelium (urothelium) occurring at any point from the renal calyces to the tip of the urethra
What site is most commonly affected by urothelial tumours?
Bladder (90%)
What is the most common type of bladder cancer?
Transitional cell carcinoma (90%)
Where what is endemic SCC of the bladder is the most common tumour type?
Schistosomiasis (parasite causes chronic bladder inflammation)
What are risk factors for TCC of the bladder?
Smoking
Aromatic amines (e.g. in dyes)
Non-hereditary genetic abnormalities (e.g. TSG incl. p53+ Rb)
What are risk factors for SCC of the bladder?
Schistosomiasis (S. haematobium only) Chronic cystitis (e.g. recurrent UTI, long term catheter, bladder stone) Cyclophosphamide therapy Pelvic radiotherapy Adenocarcinoma Urachal
What is the most frequent presenting symptom of bladder cancer?
Painless visible haematuria
What are other less common presenting features of bladder cancer?
Symptoms of invasive/metastatic disease (rare)
Recurrent UTIs
Storage bladder symptoms (e.g. dysuria, frequency, nocturia, urgency +/- urge incontinence)
Bladder pain
If bladder is pain is present what should you suspect?
CIS (carcinoma in situ)
How should you investigate haematuria?
Urine culture (most common cause painful haematuria = UTI) Cystourethroscopy Upper tract imaging (CT urogram, USS) Urine cytology BP, UE
Why should you do a cystourethroscopy in haematuria investigations?
Commonest cause of neoplastic haematuria is TCC bladder which can be visualised with cystourethroscopy
What is the risk of malignancy in a >50 year old presenting with frank haematuria?
25-35%
How should a >50 year old presenting with frank haematuria be investigated?
Flexible cystourethroscopy within 2 weeks
CT urogram and USS thereafter
Urine cytology may be useful
What is the risk of malignancy in an >50 year old presenting with microscopic haematuria?
5-10%
How should a >50 year old presenting with microscopic haematuria be investigated?
Flexible cystourethroscopy within 4-6 weeks
USS
How do you diagnose bladder cancer and obtain the T stage?
Cystoscopy + endoscopic resection (TURBT)
EUA to assess bladder mass/thickening before + after TURBT
What imaging techniques should be used to stage for bladder cancer?
Cross sectional imaging, e.g. CT/MRI
Bone scan if symptomatic
CTU for upper tract TCC
How is bladder cancer treated?
Endoscopic or radically
What staging system is used to stage bladder cancer?
TNM
What is the T stage of TNM staging for bladder cancer based on?
Non-muscle invasive (superficial) OR muscle invasive
How are bladder cancers staged?
G1 -= well differentiated (commonly non-invasive)
G2 = moderately differentiated (often non-invasive)
G3 = poorly differentiated (often invasive)
CIS - non-muscle invasive but VERY aggressive
When talking about muscle invasive in bladder cancer what muscle is being referred to?
Detrusor
What are the layers of the bladder wall?
Mucosa
Lamina propria
Superficial muscle
Deep muscle
What does the treatment of bladder cancer depend on? (4)
Site
Clinical stage
Histological grade of tumour
Patient age and comorbs
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
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
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
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
What is the prognosis of bladder cancer dependent on?
Stage Grade Size Multifocality Presence of concurrent CIS Recurrece at 3 months
What is the 5YS of a non-invasive low grade bladder cancer?
90%
What is the 5YS of an invasive high grade bladder cancer?
50%
Who does bladder cancer most commonly affect?
Males between age of 50-80
Smokers
Give two e.g.s of benign bladder tumours
Inverted urothelial papilloma
Nephrogenic adenoma
(these are uncommon)
What are the three bladder malignancies?
Transitional cell carcinoma
SCC
Adenocarcinoma
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
What is the appearance of SCC/adenocarcinomas of the bladder?
Either mixed papillary and solid growth or pure solid growth
Bladder cancer:
T0
No evidence of tumour
Bladder cancer:
Ta
Non-invasive papillary carcinoma
Bladder cancer:
T1
Tumour invades subepithelial connective tissue
Bladder cancer:
T2a
Tumour invades superficial muscularis propria (inner half)
Bladder cancer:
T2b
Tumour invades deep muscularis propria (outer half)
Bladder cancer:
T3
Tumour extends to perivesical fat
Bladder cancer:
T4
Tumour invades any of: prostatic stroma, seminal vesicles, uterus, vagina
Bladder cancer:
T4a
Invasion of uterus, prostate or bowel
Bladder cancer:
T4b
Invasion of pelvic sidewall/abdominal wall
Bladder cancer:
N0
No nodal disease
Bladder cancer:
N1
Single regional lymph node metastasis in the true pelvis (hypogastric, obturator, external iliac, or presacral lymph node)
Bladder cancer:
N2
Multiple regional lymph node metastasis in the true pelvis (hypogastric, obturator, external iliac, or presacral lymph node metastasis)
Bladder cancer:
N3
Lymph node metastasis to the common iliac lymph nodes
Bladder cancer:
M0
No distant mets
Bladder cancer:
M1
Distant mets
How is locoregional spread best determined in bladder cancer?
Pelvic MRI
How is distant disease best staged in bladder cancer?
CT scanning
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)
How should you diagnose upper TTC?
CT-IVU or IVU
Urine cytology
Ureteroscopy and biopsy
What can CT-IVU/IVU demonstrate?
Filling defect in the renal pelvis
What does TURBT stand for?
Transurethral resection of bladder tumour
Where are the most common places to get a upper tract TCC?
Renal pelvis/collecting system
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
If someone has a upper tract TCC what are they at higher risk for?
Bladder TCC - req. surveillance cystoscopy
Give examples of benign renal tumours
Oncocytoma
Angiomyolipoma
What is the most common malignant renal tumour?
Renal adenocarcinoma
What are other names for a renal adenocarcinoma?
Hypernephroma
Grawitz tumour
Where do most renal adenocarcinomas arise from?
Proximal tubules
What are the histological subtypes of renal adenocarcinomas?
Clear cell
Papillary
Chromophobe
Bellini type ductal carcinoma
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
How do 50% of renal adenocarcinomas present?
Asymptomatically as an incidental finding
10% of renal adenocarcinomas present as a the classic triad of what?
Flank pain
Mass
Haematuria
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
How is renal cancer staged?
TNM
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
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
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
How is renal adenocarcinoma treated?
Surgically
What is the standard treatment of choice for T1 tumours?
Laparoscopic radical nephrectomy
What T stage can surgery be curative for?
T2 or less
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)
What is important to remember in the treatment of RCC?
RCC is radioresistant and chemoresistant
What therapies are available for metastatic RCC?
Multitargeted receptor tyrosine kinase inhibitors, e.g. sunitinib
Immunotherapy, IFa, IL2
Where does renal cell cancer arise from?
Proximal tubule
What is the most common histological subtype of renal cancer?
Clear cell
