Neoplasia of Urinary Tract Flashcards
What are the 3 (well there’s four according to mark) golden rules of a cancer case?
- Establish the diagnosis (type and grade of tumour)
- Establish the extent/stage of the disease
- Investigate any complications
- ASK THE OWNER WHAT THEY WOULD DO!!! Can just be academic
How likely is the kidnye to be a site of metastasis?
Relatively common site
How likely are primary renal tumurs?
Uncommon
What is the appearance of primary renal tumours?
Solitary and unilateral
What is the appearance of renal metastatic tumours?
Multiple and bizarre
What are the 5 primary renal tumours?
- Adenoma
- Fibroma
- Haemangioma
- Interstitial cell tumour
- Leiomyoma
What are the 6 malignant renal tumours?
- Adenocarcinoma/carcinoma
- Lymphoma
- Fibrosarcoma
- Haemangiosarcoma
- Leiomyosarcoma
- TCC
Which renal malignant tumour affects the GSD?
•(CYSTOADENCARNIMOA and nodular dermatofibrosis)
What renal tumour do dogs most commonly get?
Adenocarcinoma - unilateral
What is the typical dog which gets a renal tumour?
More commonly seen in middle-aged and older dogs
Males>females
What is the most frequent renal tumour in cats?
Lymphoma
What is the typical cat which gets a renal tumour?
ØMost frequently seen in cats 6-7 years of age
ØFeLV is a risk factor
Other than lymphoma, what other renal tumours do cats get commonly?
Renal adenocarcinoma
What is a nephroblastoma?
Who is commonly affected?
Where is it commonly present?
What is seen histologically?
•Is an embryoma (embryonal tumour)
–Almost like a teratoma as they can have bits in them
- Occurs most frequently in young dogs often <1 year
- May be present in only one pole of an affected kidney
- Histological is many demonstrate primitive epithelial and mesenchymal tissue such as muscle, cartilage and bone and various stages of differentiation
What are the vague clinical signs of a renal tumour? (5)
–Anorexia
–Depression
–Weight loss
–Lethargy
–(just generally “not very well” )
What are the more specific clinical signs of a renal tumour? (4)
–Palpable abdominal mass/masses
–Haematuria throughout urination
–Abdominal pain or distension
–Development of pelvic limb oedema if lymphatic drainage is compromised
What can we see diagnostically for renal tumours? (4)
- Bloods often unremarkable
- May show a regenerative anaemia if significant haematuria is present
- If there is severe bilateral involvement may see azotaemia
- Hypercalcaemia can occasionally be seen as a paraneoplastic syndrome
What can happen on rare occassions what can happen to renal tumours?
•Rare cases are polycythaemic, can have bone metastases or hypertrophic osteopathy
What can be seen diagnositcally on urinalysis for a renal tumour?
- Proteinuria is a common finding
- +- haematuria (may see protein or blood)
- Neoplastic cells very uncommon
–Exfoliate cells may not be common due to the route of he urine
What can be seen with imaging of renal tumors?
•Renal tumours that demonstrate renomegaly may be apparent on plain survey radiographs
–But often not obvious
- Renal ultrasonography usually superior
- Could consider advanced imaging such as CT or MRI
What do you need to find out if there is a mass in the region of a kidney?
1.Is it a renal mass? Adrenal? Other?
●
- Is it neoplastic? Cystic? Granuloma? cPSS (congenital porto systemic shunt), pyelonephritis, acute kidney injury, amyloidosis?
- If neoplastic, is it benign or malignant?
–Tissue sample (see later)
–Finding this out is important!!!
- If malignant, metastasis check
–Palpation (bones, lymph nodes) and imaging (thorax)
How do we decide between a sample by aspirate, tru cut or surgical?
–Is it something you can do yourself?
–How much does it cost?
–What are the risks?
–What is the likely diagnostic yield?
–Is it going to change what the owner will do?
How do we treat renal tumour?
•Unless it’s lymphoma, remove the whole affected kidney = nephrectomy +/- adjunctive chemotherapy
What is the prognosis of a carcinoma and sarcoma if the kidney is removed?
–Carcinoma: median survival time 8 months (but some long survivors)
–Sarcomas: median survival time 5 months
How do you cure a nephroblastoma?
Surgery
What is the presentation of a cat with renal lymphoma?
–Median age 7.5 years, may be FeLV +ve
–33-50% association with CNS lymphoma, including nasal lymphoma – SYSTEMIC disease
–Present with bilateral renomegally and azotemia +/- renal pain
What is the presentation of a dog with renal lymphoma?
–Much less common, may be uni or bilateral
–Often no associated clinical signs
What is this?
Feline renal lymphoma
LHS kidney – huge
Often the kidneys will stick out from their flanks
How do we treat renal lymphoma?
•Chemotherapy (systemic disease)
–COP/CHOP fine, or others possible combinations
•Cannot remove the kidneys……
–Remember renal drug excretion – dose reduction?
•Take care if the animal is azotemic.
What are the negative prognostic indicators for renal lymphoma? (3)
–FeLV
–CNS involvement – don’t do so well with brain involvement
–Severity of renal failure
What is the survival time of a renal lymphoma?
5-13 months
When do budgies get renal tumours…. what are the signs?
5 yo
Clinical signs:
- Unilateral or bilateral hind limb lameness or even paralysis without history of trauma
- Reduced sensation below stifle joint
- Abdominal enlargement
- General unwell and weight loss
How can you diagnose budge renal tumour?
Imaging
Abdominal mass
How do you treat budgie renal tumours?
NOT surgery. Steroids? Very difficult as hard to treat
How common are ureteral tumours?
Rare as hens teeth
What is the benign ureteral tumour?
Leiomyoma
What are the malignant ureterl tumours? (2)
- Leiomyosarcoma
- TCC
Can pass up the ureter to the urethra! Rare.
What is the most common cancer of the urinary tract of the dog?
Bladder cancer
How common is a bladdder tumour in a cat?
2 most common urinary tract tumour
what are most of the bladdertumours?
Vast majority malignant and epithelial (TCC)
– Benign tumours (polyps) rare and related to chronic urinary tract disease and calculi
Where do most bladder tumours arise?
Trigone
What is the spread of bladder tumours?
Locally and distant
- TCC usually locally invasive and may extend beyond the bladder wall into adjacent organs such as vagina, uterus, prostate
- Distant metastasis to local LN, liver, lung, spleen are present in up to 50% of cases. Local peritoneum around it
What bladder tumours are there in horses?
–Uncommon, Squamous CC>> Transitional CC
What is an option for treating horse bladder tumours?
Laser therapy
What is the prevalence of bladder tumours in sheep and goats?
- Cattle>>sheep
- Prevalence of bovine bladder neoplasia is as high as 90% in cattle that graze infested pastures long-term
- Intoxication is cumulative. Ptaquiloside. With bracken.
- Bovine papillomaviruses (BPV-2 and BPV-4) have been associated with the development of neoplasia in cattle exposed to bracken fern
- Mix of the bracken increased exposure and viral exposure…
What is the pathophysiology of bracken and tumours?
Who is at risk of bladder tumours in small animals?
- Female, neutered, older dogs (mean age 10 years)
- Scotties, Beagle, JRT, collies, WHWTs, staffies, boxers
- Some have history of UTI
–Clinical signs of a TCC can be exacerbated by the UTI
–If a case of TCC suddenly gets worse – check for a UTI
•Exposure to flea powders, dips, collars, herbicides, insecticides increase risk 3-4x
–Possible this is from old data and use of OP
•Cat, no breed predispositions. Mean age 10 years
What are the easy (3) and harder (4) clinical signs to spot of urethral bladder?
•Easy ones:
–Stranguria
–Haematuria
–Pollakiuria
•Harder ones to spot:
–Bone metastasis causing lameness
–Hypertrophic osteopathy
–Cough/ dyspnoea from thoracic metastasis
–Dysuria with no clear urinary abnormalities
What is this?
Hypertrophic osteopathy
What are the next steps if you suspect a urethral/bladdder mass?
- Is it a urethral/bladder mass?
- Is it benign or malignant?
- If looks malignant (on sample!!!), STAGE
What can be seen on urinalysis with a bladder tumour? (3)
+- Proteinuria
+- haematuria
•Sometimes see neoplastic cells-see
What imaging can we do for bladder tumours?
•Contrast radiography
–If you can do it
•*Ultrasonography*
–Most commonly used
•Cystoscopy
What is seen on U/s bladder neoplasia?
- kened, irregular, bladder wall
- Do not mis interpret an empty bladder for a diffuse tumour!!!!
- Usually in trigone
Desribe appearnace here
Transmural thickening
Irregular surface
Classic at the trigone
What are the possible ways of sampling for a bladder tumour? (3)
- Look for tumour cells in urine?
–<30% of tumours exfoliate into urine
–BUT dysplastic vs neoplastic hard to tell…..
- Look for tumour antigen in urine?
–Dipstick is available for detection of bladder tumour antigen test; care when interpreting as false positives common
–Commonly used in people – unreliable in animals
–True negative is fine, but false positives is riskayy
- Get a piece of the tumour
–How?
- FNA
- Biopsy
–Encscope
–Catheter suction biopsy
»Side ports are U/S onto mass and aspirated back and sucked out
Why do we need to take such care when sampling bladder tumours?
•Tumour cells can seed along the needle tract (same with any carcinoma)
Do we need a definitive diagnosis?
- In the ideal world, yes
- BUT realistically only if it will change what you do:
–There are few other things which look/behave like this
–Limited Tx options
–ALWAYS give clients the options with pros and cons to help them inform their choice
–NB DO NOT give chemo drugs without being certain that you have a malignancy (do not speculate – not ethical)
How can we stage bladder and urethral tumours?
•Check local LNs
–Most of them start here for spread.
- Thoracic radiographs or thoracic CT
- Abdominal ultrasonography
- FNAs/biopsy
–Regional LN
How do you treat bladder tumours? (5)
- Surgery– partial cystectomy
–Usually in the trigone so Sx difficult (cannot be curative at the trigone)
–Can be really widespread so very hard
- Radiotherapy
–Poor candidate, intra-operative only – no!
–Most people do not do this due to the challenge
- Laser ablation
–Debrides
- Palliative urinary diversion
–Via cystostomy tube – can work well short term
- Stent placement
–Referral procedure
–Palliative and you will not fix it
–Can give them incontinence! And risk of ascending UTI
*All are palliative, cure very unlikely*
What can help the prognosis of stenting?
•Better prognosis if pre-treated with NSAIDs and after with chemo drugs
How can we medically manage a bladder/urethral tumour? (3)
•NSAIDs
–Original papers about unlicenced non-COX selective Piroxicam
–COX-2 inhibitors – meloxicam/piroxicam/firocoxib now thought to be as effective?
–Typically see about 15-20% partial remission, most stable disease
- If these dogs can go from dysuric to non = you have improved this dog! Made them stable. O happy with this
- Adjunctive chemotherapy
–Carboplatin (££ less side effects though), doxorubicin, mitoxantrone can be added to NSAIDs.
–Result in improved remission rates and times in a subset of dogs
•Metronomic chemotherapy
–Chlorambucil daily may help where others fail?
–70% dogs had stable disease. Median survival time of 221 days (range, 7 to 747 days)http://www.ncbi.nlm.nih.gov/pubmed/23683018
–Lower dose continued chemo – antigenic property. Whether it works? Unknown!
How long will a dog with a bladder TCC live?
Inclde those with:
Srugery?
NSAids?
combined modalities?
Survival depends on site and TNM grade
- Prognosis generally POOR:
- Generally tell the owner 6-9months. If they are asymptomatic; do better!
- Surgery – median survival time 3 months
- NSAIDs (most work done with piroxicam) –Median survival time about 6 months, HUGE range
- Combined modalities
–Doxorubicin + piroxicam, MST about 6 months
–Metronomic chemotherapy using chlorambucil. MST of 221 days (range, 7 to 747 days)
