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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
Q

What is the treatment of low grade non-invasive bladder cancer (i.e. Ta/T1)?

A

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

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26
Q

How is high grade non-muscle invasive/CIS treated?

A

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

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27
Q

How is invasive bladder cancer treated? (T2-3)

A

Neoadjuvant chemo followed by either:
Radical radio +/or
Radical cystoprostatectomy (men) or anterior pelvic exenteration with urethrectomy (women) with extended lymphadenectomy

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28
Q

What is radical surgery for bladder cancer combined with?

A

Incontinence urinary diversion (i.e. ileal conduit), continent diversion (w.g. bowel pouch with catheterisable stoma) or orthotopic bladder substitution

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29
Q

What is the prognosis of bladder cancer dependent on?

A 
Stage
Grade
Size
Multifocality
Presence of concurrent CIS
Recurrece at 3 months
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30
Q

What is the 5YS of a non-invasive low grade bladder cancer?

A

90%

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31
Q

What is the 5YS of an invasive high grade bladder cancer?

A

50%

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32
Q

Who does bladder cancer most commonly affect?

A

Males between age of 50-80

Smokers

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33
Q

Give two e.g.s of benign bladder tumours

A

Inverted urothelial papilloma
Nephrogenic adenoma

(these are uncommon)

34
Q

What are the three bladder malignancies?

A

Transitional cell carcinoma
SCC
Adenocarcinoma

35
Q

How do transitional cell carcinomas tend to appear?

A

Solitary lesions or may be multifocal due to field change effect within urothelium
Usually superficial in location and thus have a better prognosis

36
Q

What is the appearance of SCC/adenocarcinomas of the bladder?

A

Either mixed papillary and solid growth or pure solid growth

37
Q

Bladder cancer:

T0

A

No evidence of tumour

38
Q

Bladder cancer:

Ta

A

Non-invasive papillary carcinoma

39
Q

Bladder cancer:

T1

A

Tumour invades subepithelial connective tissue

40
Q

Bladder cancer:

T2a

A

Tumour invades superficial muscularis propria (inner half)

41
Q

Bladder cancer:

T2b

A

Tumour invades deep muscularis propria (outer half)

42
Q

Bladder cancer:

T3

A

Tumour extends to perivesical fat

43
Q

Bladder cancer:

T4

A

Tumour invades any of: prostatic stroma, seminal vesicles, uterus, vagina

44
Q

Bladder cancer:

T4a

A

Invasion of uterus, prostate or bowel

45
Q

Bladder cancer:

T4b

A

Invasion of pelvic sidewall/abdominal wall

46
Q

Bladder cancer:

N0

A

No nodal disease

47
Q

Bladder cancer:

N1

A

Single regional lymph node metastasis in the true pelvis (hypogastric, obturator, external iliac, or presacral lymph node)

48
Q

Bladder cancer:

N2

A

Multiple regional lymph node metastasis in the true pelvis (hypogastric, obturator, external iliac, or presacral lymph node metastasis)

49
Q

Bladder cancer:

N3

A

Lymph node metastasis to the common iliac lymph nodes

50
Q

Bladder cancer:

M0

A

No distant mets

51
Q

Bladder cancer:

M1

A

Distant mets

52
Q

How is locoregional spread best determined in bladder cancer?

A

Pelvic MRI

53
Q

How is distant disease best staged in bladder cancer?

A

CT scanning

54
Q

How do upper TCCs tend to present?

A

Frank haematuria
Unilateral ureteric obstruction
Flank/lion pain
Symptoms of nodal/met disease (e.g. bone pain, hypercalcaemia, lung/brain symptoms)

55
Q

How should you diagnose upper TTC?

A

CT-IVU or IVU
Urine cytology
Ureteroscopy and biopsy

56
Q

What can CT-IVU/IVU demonstrate?

A

Filling defect in the renal pelvis

57
Q

What does TURBT stand for?

A

Transurethral resection of bladder tumour

58
Q

Where are the most common places to get a upper tract TCC?

A

Renal pelvis/collecting system

59
Q

How are most upper tract TCCs treated?

A

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
Q

If someone has a upper tract TCC what are they at higher risk for?

A

Bladder TCC - req. surveillance cystoscopy

61
Q

Give examples of benign renal tumours

A

Oncocytoma

Angiomyolipoma

62
Q

What is the most common malignant renal tumour?

A

Renal adenocarcinoma

63
Q

What are other names for a renal adenocarcinoma?

A

Hypernephroma

Grawitz tumour

64
Q

Where do most renal adenocarcinomas arise from?

A

Proximal tubules

65
Q

What are the histological subtypes of renal adenocarcinomas?

A

Clear cell
Papillary
Chromophobe
Bellini type ductal carcinoma

66
Q

What are RFs for renal adenocarcinoma?

A 
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
Q

How do 50% of renal adenocarcinomas present?

A

Asymptomatically as an incidental finding

68
Q

10% of renal adenocarcinomas present as a the classic triad of what?

A

Flank pain
Mass
Haematuria

69
Q

How do 60% of renal adenocarcinomas present?

A

Paraneoplastic syndrome - 30% (anorexia, cachexia, pyrexia, HTN, hyperCa, abnormal LFTs, anaemia, polycythaemia, raised ESR)

Mets - 30%
Bone, brain, lungs, liver

70
Q

How is renal cancer staged?

A

TNM

71
Q

What are the T stages for renal cancer?

A

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
Q

What are the 4 ways renal cancer can spread?

A

Direct spread (invasion) through renal capsule

Venous invasion to renal vein + vena cava

Haematogenous spread to lungs + bone

Lymphatic spread to paracaval nodes

73
Q

How is renal adenocarcinoma investigated?

A

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
Q

How is renal adenocarcinoma treated?

A

Surgically

75
Q

What is the standard treatment of choice for T1 tumours?

A

Laparoscopic radical nephrectomy

76
Q

What T stage can surgery be curative for?

A

T2 or less

77
Q

Should you still operate on those who have metastatic disease and symptoms from the primary tumour?

A

Yes

Palliative cytoreductive nephrectomy is beneficial (prolongs survival by 6m)

78
Q

What is important to remember in the treatment of RCC?

A

RCC is radioresistant and chemoresistant

79
Q

What therapies are available for metastatic RCC?

A

Multitargeted receptor tyrosine kinase inhibitors, e.g. sunitinib
Immunotherapy, IFa, IL2

80
Q

Where does renal cell cancer arise from?

A

Proximal tubule

81
Q

What is the most common histological subtype of renal cancer?

A

Clear cell

Renal/Urology (29 decks)

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