RCC and TCC

Question 1

Risk factors for RCC

Answer 1

• Obesity
• Smoking x 2
• HTN
• Dialysis
• VHL syndrome - Von Hippel Lindau
• Industrial exposure to carcinogens - lead or aromatic hydrocarbons
• PCKD

Question 2

Pathology of RCC

Answer 2

Adenocarcinoma from proximal renal tubular epithelium

Question 3

Presentation of RCC

Answer 3

• Triad

• Haematuria
• loin pain
• loin mass
• Systemic: anorexia, malaise, wt. loss, PUO
• Clot retention
• Invasion of L renal vein → varicocele
• Cannonball mets → SOB

Question 4

Paraneoplastic Features of RCC

Answer 4

• EPO → polycythaemia
• PTHrP → ↑ Ca
• Renin → HTN
• ACTH → Cushing’s syn.
• Amyloidosis

Question 5

Ix of RCC

Answer 5

Blood: polycythaemia, ESR, U+E, ALP, Ca

• Urine: dip, cytology
• Imaging
• first line USS: mass
• CXR: cannonball mets
• IVU (intravenous urography): filling defect
• CT KUB IV contrast - gold standard
• biopsy

Question 6

Mx of RCC

Answer 6

• Medical

• pts. with poor prognosis
• Temsirolimus

• Surgical + immunotherapy:

• Radical nephrectomy
• Consider partial if small tumour or 1 kidney

Chemotherapy - ineffective

Question 7

Transitional Cell Carcinoma Risk factors

Answer 7

• Smoking
• Amine exposure (rubber industry)
• Cyclophosphamide

Question 8

Transitional Cell Carcinoma Pathology

Answer 8

• Highly malignant
• Locations
- Bladder: 50%
- Ureter
- Renal pelvis

Question 9

Presentation of TCC

Answer 9

• Painless haematuria
• Frequency, urgency, dysuria
• Urinary tract obstruction
• UTI

Question 10

Mx of TCC

Answer 10

• Nephro-uretectomy

* Regular f/up: 50% develop bladder tumours

Question 11

Wilm’s Tumour

Answer 11

• Nephroblastoma
• Childhood tumour of primitive renal tubules and
mesenchymal cells

Presentation:
• 2-5yrs
• 5-10% bilateral
• Abdo mass 
• Haematuria
• Abdo pain
• HTN

Question 12

SCC

Answer 12

Associated with chronic infected staghorn calculi

Associated with schistosomiasis - bladder

Question 13

Mx of bladder Ca

Answer 13

T1 (non muscular invasive) - Transurethral resection of bladder tumour (TURBT)

Invasive:

• Radical cystectomy with ileal conduit (urostomy)
• Radiotherapy
• Neoadjuvant chemo - cisplatin
• Regular follow-up with CT imaging

T4:

• Palliative chemo/radiotherapy
• Long term catheter

Question 14

RCC spread

Answer 14

Direct invasion - adrenal gland, renal vein or the inferior vena cava. R

Lymphatic system - pre-aortic and hilar nodes

Haematogenous spread - bones, liver, brain and lung

Question 15

Radical nephrectomy

Answer 15

Remove the kidney, perinephric fat and local lymph nodes en bloc

Question 16

Not fit for renal surgery

Answer 16

Percutaneous radiofrequency ablation

or

laparoscopic/percutaneous cryotherapy

Renal artery embolisation - required for haemorrhaging disease prior to any radiofrequency ablation

Question 17

At what vertebral level do the renal hilum typically lie

Answer 17

L1

Question 18

Classifications of bladder cancer

Answer 18

• Non-muscle-invasive bladder cancer – does not penetrate into the deeper bladder wall (80% cases)
• Muscle-invasive bladder cancer – penetrates the bladder wall
• Locally advanced or metastatic bladder cancer – spreading beyond the bladder and distally

Question 19

Investigations of bladder cancer

Answer 19

• Urine cytology
• CT staging
• IVU: pelviceal filling defect
• urgent flexible bladder cystoscopy
• If lesion identified - rigid cystoscopy with bladder biopsy

Question 20

For a patient presenting with new visible haematuria, what is the recommended first-line investigations (after routine bloods and urine dipstick testing)?

Answer 20

CT scan KUB + flexible cystoscopy

Question 21

New pigmented lesion on trunk after renal transplantation

Answer 21

Squamous cell carcinoma