Renal/Urinary Cancers Flashcards
What are the different types of cancer that may affect the renal/urinary tract?
Transitional cell (urothelium) carcinoma - can occur at any point from renal calyces to urethral tip
Squamous cell carcinoma
Can also get adenocarcinoma from urachus remnant
Renal
- benign - oncocytoma, angiomyolipoma
- malignant - adenocarcinoma (most commonly clear cell)
What is the most common type of urinary tract cancer?
90% in bladder and mostly TCC
SCC where schistosomiasis is endemic
What are the risk factors for each type of urinary tract cancer?
TCC
- smoking (accounts for 40% of cases)
- aromatic amines
- non-hereditary genetic abnormalities (e.g. TSG inc p53 and Rb)
SCC
- schistosomiasis (s. haematobium only)
- chronic cystitis (e.g. recurrent UTI, long-term catheter, bladder stone)
- cyclophosphamide therapy
- pelvic radiotherapy
How does bladder cancer present?
Most frequent presenting symptom is painless visible haematuria
Occasionally symptoms due to invasive or metastatic disease
Haematuria may be frank or microscopic
Other features
- recurrent UTI
- storage bladder symptoms:
- dysuria, frequency, nocturia, urgency +/- urge incontinence, bladder pain, if present - suspect carcinoma in situ
What investigations should be performed in suspected urinary tract cancer? What investigations are done to stage and confirm diagnosis?
Urine culture (exclude UTI - most common cause of painful haematuria)
Cystourethroscopy - bladder cancer most common
Upper tract imaging - CT urogram (frank)/IV urogram (microscopic) - can show filling defects suggesting pelvis cancer, USS
Urine cytology, BP, U&Es
Ureteroscopy if suspected upper tract
If frank haematuria - flexible cystourethroscopy within 2 weeks, otherwise within 4-6 weeks
Grading and T-staging
- cytoscopy and endoscopic resection (TURBT)
- EUA to assess bladder mass/thickening before and after TURBT
- CT/MRI
- bone scan if suspected disease
What are the different grades of bladder tumour?
G1 - well differentiated - commonly non-invasive
G2 - moderately differentiated - often non-invasive
G3 - poorly differentiated - often invasive
CIS - non muscle invasive but aggressive, treated differently
How is bladder cancer treated?
Endoscopically
Radically
Endoscopic resection followed by chemotherapy
- can do prolonged followup for moderate grade
- continual BCG therapy for aggressive but non muscle-invasive
Neoadjuvant chemo followed by radiotherapy, surgery for muscle invasive (cystoprostatectomy, urethrecromy, lymphadenectomy)
Where is the most common site of upper urinary tract cancer?
Renal pelvis/collecting system
Ureter less common
How is upper urinary tract cancer treated?
Nephro-ureterectomy
If unfit for nephro-ureterectomy or bilateral, absolute indication for nephron-sparing endoscopic treatment i.e. ureteroscopic laser ablation, needs regular surveillance ureteroscopy
If unifocal and low-grade disease - relative indication for endoscopic treatment
What are the histological subtypes of renal cancer?
Most arise from proximal tubules histological subtypes: - clear cell (85%) - papillary (10%) - chromophobe (4%) - bellini type ductal carcinoma (1%)
What are the risk factors for renal cancer?
Family history Smoking Anti-hypertensive medication Obesity - biggest risk factor? End-stage renal failure Acquired renal cystic disease
Family history
- autosomal dominant e.g. vHL, familial clear cell RCC, hereditary papillary RCC - can be bilateral and/or multifocal
How does renal cancer present?
Presentation
- asymptomatic - 50%
- classic triad - flank pain, mass, haematuria - 10%
- paraneoplastic syndrome - 30%
- metastatic disease - 30% (bone, brain, lungs, liver)
Paraneoplastic syndrome
- anorexia, cachexia, pyrexia
- hypertension, hypercalcaemia, abnormal LFTs
- anaemia, polycythaemia and raised ESR
What investigations should be done in suspected renal cancer?
CT scan (triple phase) of abdomen and chest is mandatory
Bloods - U&Es, FBC
Other optional tests
CT scan
- provides radiological diagnosis and complete TNM staging
- assesses contralateral kidney
Optional tests
- IVU shows calyceal distortion and soft tissue mass
- USS differentiates tumour from cyst
- DMSA or MAG-3 renogram to assess split renal function if doubts about contralateral kidney
How is renal cancer staged?
T1 - <7cm confined within renal capsule
T2 - >7cm confined
T3 - local extension outside capsule
T4 - invades beyond Gerota’s fascia
T3a - into adrenal or peri-renal fat
T3b - into renal vein or IVC below diaphragm
T3c - tumour thrombus in IVC extends above diaphragm
How is renal cancer treated?
Surgical i.e. radical nephrectomy
Even in patients with metastatic disease who have symptoms from primary tumour, palliative cytoreductive nephrectomy is beneficial
Laparoscopic radical nephrectomy is standard of care for T1 tumours (T2 in laparoscopic centres)
- worthwhile even with major venous invasion (>T3b)
- curative if T2 or less
Metastases
- RTKis - sunitinib, sorafenib, panzopanib, temsirolimus
- immunotherapy - interferon alpha, IL-2
- generally not very effective
