Malignant tumours of the urinary tract

Question 1

Which age group are most commonly affected by kidney cancer?

Answer 1

people aged 50-70

affects twice as many men

Question 2

What are the risk factors for kidney cancer?

Answer 2

smoking - double the incidence 
obesity, hypertension, unopposed oestrogen therapy 
chemical exposure - asbestos 
chronic renal failure 
genetics - familial cancers
- von hippel lindau, hereditary clear cell carcinoma, hereditary papillary carcinoma 
- tuberous sclerosis 
-? other

Question 3

What are the symptoms of kidney cancer?

Answer 3

haematuria
low back pain, not associated with injury
mass or lump in the abdomen
fatigue
weight loss
chronic fever
paraneoplastic syndrome - (polycythenia, hypercalcaemia, hypertension)

Question 4

What imaging techniques are used to diagnose kidney cancer?

Answer 4

US
CT
MRI
CXR and bone scans

Question 5

How are kidney cancers treated?

Answer 5

surgery
radiation therapy
chemotherapy
biologic therapy - interferon or immunotherapy

Question 6

What surgeries are available for kidney cancer?

Answer 6

radical nephrectomy

• most pts undergo this
• remove the kidney, adrenal gland, surrounding tissue and nearby lymph node

Partial nephrectomy

• remove the cancer and some tissue around it
• prevent loss of kidney function
• may only have a single functioning kidney

Question 7

What are the classifications of renal epithelial tumours in adults?

Answer 7

clear cell carcinoma (75%)
papillary carcinoma (type I and II)
-type I = less aggressive
- type II = aggressive LN metastasis 
chromophobe cell carcinoma 
collecting duct carcinoma - rare but highly aggressive - arise from principal cells 
Unclassified 
Oncocytoma

Question 8

What does a clear cell carcinoma look like?

Answer 8

large yellowish, haemorrhagic renal tumour
cystic changes
branching like appearance

Question 9

What is the prognosis of clear cell carcinoma?

Answer 9

Grading = fuhmann- reflects biological behaviour -better prognosis the lower the grade
by grade 4 there are multi-nucleated cells - most aggressive
staging

Question 10

What is the staging of renal cancer?

Answer 10

T1 = 7cm or less
T2 = more than 7cm
T3 = extends into major veins or invades adrenal gland but not beyond gerota’s fascia
T4 = invades beyond gerota’s fascia
N1 - single regional lymph node
N2 = metastasis in more than one regional lymph node

Question 11

What are the other types of renal cancer?

Answer 11

angiomyolipoma (benign)
lymphoma 
sarcoma 
metastasis 
inflammatory pseudo-tumour

Question 12

What is an angiomyolipoma made up of?

Answer 12

mix of 3 components:
- blood vessels 
- smooth muscle 
- fat 
=> can cause haemorrhaging - need to be surgically removed

Question 13

What is Wilm’s tumour?

Answer 13

renal cancer in children 
nephroblastoma 
- 6% of childhood cancers
- most common type of kidney cancer in children 
- higher incidence in F younger than 5

Question 14

What is the most common cancer of the urinary tract?

Answer 14

80-90% urothelial/transitional cell carcinoma

bladder cancer 2-3 times more common in men

Question 15

What are the risk factors for urinary tract cancer?

Answer 15

smoking
repeated exposure to chemicals such as aromatic amines used in petroleum and other industries; dyes, leather, rubber, paint, organic chemicals
chronic bladder inflammation
diet high in sat fat
family history of bladder cancer
infection with schistosoma haematobium
treatment with certain drugs = cyclophosphamide, analgesic abuse

Question 16

What are the symptoms of urinary tract cancer?

Answer 16

same as an infection of UT
- Haematuria, frequency, urgency, dysuria, pain

size and site of the tumour influences symptoms

Question 17

How is cancer of the urinary tract diagnosed?

Answer 17

cytoscopy with biopsy or transurethral resection
- diagnosis, treatment
urine cytology - diagnosis and follow up

Question 18

For advanced tumours what diagnostic techniques are used?

Answer 18

intravenous pyelogram (IVP), CT scan of the abdomen and pelvis 
US

Question 19

How are urinary tract tumours classification ?

Answer 19

WHO 2004 
non-invasive 
- benign papilloma 
- papillary urothelial neoplasm of low grade malignant potential 
- papillary TCC low grade 
- paillary TCC high grade 

TCC used to be classified as invasive

Question 20

What is the natural history of bladder cancer?

Answer 20

low grade cancer - papillary, multiple recurrences, 2-10% develop high grade

high grade cancer - papillary, invasive or both, develop metastase. high risk of progression (some are de novo but most develop from low grade) - genetically unstable (overexpression of oncogenes)

invasive cancer - high grade, 60% progression rate, 35% 10 year survival

carcinoma in situ - flat abnormality with malignant cells in surface urothelium

Question 21

What are most bladder tumours?

Answer 21

most are papillary lesions

Question 22

What is a grade 1 papillary TCC like?

Answer 22

central fibrovascular core lined by urothelium (thicker than normal)
grading is based on loss of polarity

Question 23

What is the TNM staging of urothelial cancer?

Answer 23

T1= invades supepithelial connective tissue 
T2= invades muscle 
T3= invades perivesical/peripelvic/periuteric tissues
T4= invades adjacent organs/perinephric fat 

N1 = single lymph node <2cm 
N2= single node >2cm or multiple nodes<5cm 
N3= metastasis in LN >5cm

Question 24

How is urothelial cancer treated?

Answer 24

conservative treatment for carcinoma in situ

• transurethral resection
• BCG therapy - or immunotherpay => for high grade superficial tumours

surgery

• transurethral resection
• partial or radical cystectomy, urethrectomy, nephrectomy

chemotherapy
radiation therapy

Question 25

What are the 2 main lesions of the prostate?

Answer 25

benign prostatic hypertrophy (transitional zone of prostate = adenoma)- increase in number of glands and also stroma
adenocarcinoma (peripheral zone mainly)

Question 26

What are the symptoms and diagnosis of benign prostatic hyperplasia?

Answer 26

UTIs, urinary retention, leads to decrease in renal function and hydronephrosis

rectal exam and US

Question 27

What are the treatments for BPH?

Answer 27

alpha blockers or/and transurethral resection of prostate

Question 28

What is the incidence of prostate cancer?

Answer 28

6th most common cancer
- <1% below 50 increasing to 70% >70
black men at highest risk and men from far east lowest
high fat diet, androgen hormone and genetic RF

Question 29

What are the symptoms of prostate cancer?

Answer 29

usually none

Question 30

How can prostate cancer be diagnosed early?

Answer 30

PSA blood test - not totally specific to cancer (BPH, ptostatitis)

digital rectal exam - may be able to palpate nodules

Question 31

How is prostate cancer formally diagnosed?

Answer 31

transrectal needle core biopsy on USS guidance - nowadays MRI targeted biopsies carried out

Question 32

How is prostate cancer graded?

Answer 32

gleason grading

- 5 grade (1 = low and 5 = high) - now dont have grades 1 and 2 so 3 is the lowest

Question 33

What does a gleason grade 3 pattern look like?

Answer 33

cells with large round nuclei and prominent nucleoli, loss of basal cell layer

Question 34

What does a gleason grade 4/5 pattern look like?

Answer 34

loss of basal cell layer i tumour cells

immunohistochemistry with specific antibody for baseal

Question 35

How is prostate cancer treated?

Answer 35

surgery

• radical prostectomy (remove prostate, seminal vesicles, nearby lymph nodes)
• survival at 10 yrs is 80%
• SE: urinary incontinence, sterility, erectile dysfunction

Hormone therapy

• reduces size of tumour in 80% but doesnt kill cancaer cells
• based on reducing the level of testosterone

Radiotherapy
- alternative to radical prostectomy

Question 36

How is prostate cancer staged?

Answer 36

T1 = clinically inapparent tumour diagnosed on histology 
T2 = tumour within prostate
T3 = tumour extends through capsule 
T4 = tumour invades adjacent structures 
N1 =metastasis in regional LN