S11: carcinomas & cysts

Question 1

Describe the difference in location of a renal cell carcinoma vs transitional cell carcinoma

Answer 1

Renal cell carcinoma – presents in the parenchyma of the kidney
Transitional cell carcinoma – from calyx to the bladder

Question 2

Describe the epidemiology of RCC

Answer 2

Arise from tubular epithelium
Rare in children, peak incidence in 60–70-year-olds, more common in males
Risk factors: dialysis, smoking & obesity

Question 3

Describe the presentation of RCC

Answer 3

Hematuria or incidental finding
Nonspecific symptoms – fatigue, weight loss & fever
Often metastasise before local symptoms develop
If advanced:
1) Small number can secrete PTH-rP (present with hypercalcaemia)
2) Large varicocele may be present

Question 4

List investigations for RCC

Answer 4

Radiology – ultrasound/CT scan
Endoscopy – flexible cystoscopy
Urine – cystology (looks for cancerous cells in urine, not common to do for RCC)

Question 5

Describe the treatment for localised RCC

Answer 5

Surveillance
Increasingly small tumours removed with partial nephrectomy to preserve some renal function
Large tumours: radical nephrectomy with removal of adrenal gland, perinephric, upper ureter & para-aortic lymph nodes

Question 6

Describe the treatment for metastatic RCC

Answer 6

Little effective treatment for metastatic disease

Palliative treatment – target angiogenesis (limit blood supply to growing tumour)

Question 7

Describe the presentation of TCC

Answer 7

Hematuria
Incidental finding on imaging (USS or CT)
Weight loss, loss of appetite
Signs/symptoms of obstruction

Question 8

Describe the causes, diagnosis & treatment of bladder TCC

Answer 8

Causes: analgesic misuse, exposure to aniline dyes (used in industrial manufacture) & smoking
More common in males
Can be diagnosed & treated by transurethral resection of bladder tumour (TURBT)

Question 9

Describe diagnosis of bladder TCC

Answer 9

Investigation via cystoscopy and biopsy allows histological examination & staging
Diagnosis based on cytological examination of urine to check for the presence of malignant cells & cystoscopy of lower urinary tract

Question 10

What are the differential diagnoses for TCC?

Answer 10

Bleeding from the prostate 
RCC
UTI
Nephritic conditions 
Polycystic kidney disease

Question 11

Describe the treatment of bladder TCC

Answer 11

Low risk non-muscle invasive: treated with TURBT +/- intravesical chemotherapy to bladder
High risk non-muscle invasive: TURBT + intravesical chemotherapy, intravesical BCG treatment, cystectomy
Muscle invasive cancer – cystectomy + radiotherapy/palliative care

Question 12

What is a cystectomy?

Answer 12

Complete removal of the bladder
Small part of the ileum (conduit) is used to act as an exit for the urine
Urine goes into stoma bag

Question 13

Describe the presentation and treatment of TCC of upper urinary tract

Answer 13

Presentation: haematuria, obstruction occurs early because renal pelvis projects directly into the pelvicalyceal cavity
Treatment: nephron-ureterectomy (kidney, fat, ureter, cuff of bladder)

Question 14

Describe carcinoma of the prostate

Answer 14

Risk factors: increased age, family history, ethnicity (black>white>Asian)
Lesions are most commonly found in the periphery compared with the more central location of BPH
Presentation: symptoms of UTI, prostatism or metastatic disease in the bone causing bone pain
In asymptomatic men, elevated PSA can be found which indicates carcinoma of prostate

Question 15

What is prostate specific antigen?

Answer 15

Causes of a raised PSA – prostate cancer, infection, inflammation, large prostate & urinary retention
Having normal PSA does not mean you do not have prostate cancer and vice versa (normal PSA, but abnormal feeling prostate on DRE)

Question 16

Describe the presentation of prostatic carcinoma

Answer 16

Urinary symptoms 
Bone pain 
Raised PSA, biopsy 
Opportunistic finding from DRE
Incidental finding at transurethral resection of prostate

Question 17

What staging and grading is used for prostatic carcinoma?

Answer 17

Grade – Gleason classification
-grade 1: well differentiated tumour composed of uniform tumour cells
-grade 5: anaplastic diffuse tumour with cells showing great variation in their structure & high mitotic rate
Stage – TNM system

Question 18

Describe the diagnosis of prostatic carcinoma

Answer 18

Digital rectal examination: hard & irregular prostate
Ultrasound: prostatic mass
Increased PSA level in blood (not definite)
Biopsy of prostate
Radiographs & bone scans – used to stage the tumour

Question 19

What can develop in advanced prostate cancer?

Answer 19

Can develop sclerotic bone regions

‘Hot spots’ on bone scan

Question 20

Describe the treatment for localised prostate cancer

Answer 20

Surgery, hormone therapy & radiotherapy
Treatment depends on the stage of the tumour
-T1/T2: radical surgical resection of prostate may be curative
Local radiotherapy can be used if patient unfit for surgery
Surveillance

Question 21

Describe the treatment for advanced prostate cancer

Answer 21

Hormonal manipulation is beneficial since testosterone promotes tumour growth
Surgical castration
Medical castration – LHRH agonists, GnRH agonists
Side effects of castration: hot flashes, impotence, increase in breast size, weight gain & mood changes
Palliative care

Question 22

What are differential diagnoses for prostate cancer?

Answer 22

BPH
Prostatitis 
Urethral stricture 
Multiple myeloma 
Any neurological condition

Question 23

Describe polycystic kidney disease

Answer 23

Autosomal dominant
Presentation: 30-40 (passed onto kids before they knew it) years of age with complications of hypertension, acute loin pain and/or haematuria or bilateral palpable kidneys
Cysts can develop anywhere in the kidney – compress the surrounding parenchyma & impair renal function

Question 24

Why is genetic screening not used for polycystic kidney disease?

Answer 24

Not a useful tool unless many family members with the disease are available for linkage
Young children – screen on annual basis for elevated BP/urine dipstick abnormalities
Late teens – ultrasound can be performed (absence of cysts at this stage would make the disease unlikely)
Repeated when they are > 30 years – no cysts this time then, APKD is virtually excluded

Question 25

Describe the macroscopic and microscopic appearance of the cysts

Answer 25

Macroscopically – kidneys are large with yellow fluid-filled cysts replacing the parenchyma
Haemorrhage into the cysts can occur
Microscopically – cysts are lined by cuboidal epithelium
USS/CT scan shows bilateral enlarged kidneys with multiple cysts

Question 26

Describe the complications & treatment of polycystic kidney disease

Answer 26

Morbidity & mortality are often the result of hypertension, eg. MI & cerebrovascular disease (Berry aneurysm in brain)
Condition also leads to progressive CKD
Treatment: control BP & dialysis and renal transplant needed if end-stage renal failure develops