Renal cancer

Question 1

Bladder cancer risk factors

Answer 1

• Age – rare
• Race- more common in caucasians
• Environmental Carcinogens
• Chronic inflammation- stones, infection (schistosamiasis), long term catheters
• Drugs- phenacitin, cyclophosphamide
• Pelvic radiotherapy
• Occupation
• smokers - 30-50% of all bladder cancer
• Due to dyes- aromatic hydrocarbons

Question 2

Bladder cancer epidemiology

Answer 2

• Male:female 2.5:1
• More common in the elderly

Question 3

Presentation of bladder cancer

Answer 3

• Painless haematuria - 25% serious cause for this in over 65s
• Even microscopic haematuria - (5% serious causes)
• All haematuria needs to be investigated with cystoscopy
• UTIs
• pneumaturia
• metastic syndromes

Question 4

Pathology of renal cancer

Answer 4

• Transitional cell carcinoma 90%, ¾ is superficial and ¼ invasive
• Squamous-> 5% - radiation or chronic inflammation
• Adenocarcinoma –>2% -appears at the dome of the bladder
• Secondaries

Question 5

Grading of bladder cancer

Answer 5

• Cellular system
• Grade1: Well differentiated – good prognosis
• Grade 2: Moderately differentiated
• Grade 3: Poorly differentiatedàleast likely and more likely to progress to invasive disease
• Carcinoma in situ-actually a poor prognostic sign as it is likely to advance

Question 6

Staging of bladder cancer

Answer 6

TMN classification used

• Tis-in situ
• Ta- not beyond the lamina propria.
• T1-invaded into lamina propria but not muscularis propria
• T2-into the muscle
• T3a-into the fat/serosal
• T3b-beyond and into adventitia connective tissue
• T4a-prostate/vagina/uterus
• T4b-bony pelvis
• Also N & M

Question 8

Treatment of bladder cancer

Answer 8

• Diagnosed in one stop haematuria clinic
• Receive flexible cystoscopy
• Referred for urgent Trans-urethral resection of bladder tumour
• CT IVU- imaging of upper tract as it is very common for there to be transitional cancer affecting the upper urinary tract - (5% chance upper tract involvement)

Question 9

Superficiial TCC

Answer 9

• Good prognosis and low risk of progression
• H/E flexible check cystoscopy is required at 3 months as there is a 50% chance of recurrence
• Given 6 weeks mitomycin-C (catheterised Chemotherapy) for persistent Ta tumours

Question 10

T1 cis

Answer 10

• 50% chance of progression to muscle invasive disease and commonly the cancers reoccur
• Do early cystoscopy and re-biopsy
• Treat with Intravesical BCG immunotherapy -6 week’s course and then 2 year maintenance – this is effective in 50%. Then further cystoscopy and re-biopsy
• Cystectomy if it fails

Question 11

Invasive TCC (T2-4)

Answer 11

• Require radical cystectomy or radiotherapy (poor if multifocal disease or widespread CIS)àif unfit radiotherapy is better
• No evidence for one over the other
• Radiotherapy poor if multifocal disease or widespread CIS
• Adjuvant chemotherapy

Question 12

Radical cystectomy

Answer 12

• Bladder and prostate/uterus removed
• Urine diverted into an ileal conduit/urostomy. Or an orthothopic neobladder(rare)
• Complex surgery, mortality 2%
• Sometimes required after failed radiotherapyàsalvage cystectomy

Question 13

Metastatic disease

Answer 13

• Uncommon, most commonly site lymph nodes, chest, liver, bones – always need CXR
• Chemotherapy
  
  • M-VAV- methotrexate, vinblastine, doxorubicin, cisplatin
  • Highly toxic