S11: carcinomas & cysts Flashcards
Describe the difference in location of a renal cell carcinoma vs transitional cell carcinoma
Renal cell carcinoma – presents in the parenchyma of the kidney
Transitional cell carcinoma – from calyx to the bladder
Describe the epidemiology of RCC
Arise from tubular epithelium
Rare in children, peak incidence in 60–70-year-olds, more common in males
Risk factors: dialysis, smoking & obesity
Describe the presentation of RCC
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
List investigations for RCC
Radiology – ultrasound/CT scan
Endoscopy – flexible cystoscopy
Urine – cystology (looks for cancerous cells in urine, not common to do for RCC)
Describe the treatment for localised RCC
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
Describe the treatment for metastatic RCC
Little effective treatment for metastatic disease
Palliative treatment – target angiogenesis (limit blood supply to growing tumour)
Describe the presentation of TCC
Hematuria
Incidental finding on imaging (USS or CT)
Weight loss, loss of appetite
Signs/symptoms of obstruction
Describe the causes, diagnosis & treatment of bladder TCC
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)
Describe diagnosis of bladder TCC
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
What are the differential diagnoses for TCC?
Bleeding from the prostate RCC UTI Nephritic conditions Polycystic kidney disease
Describe the treatment of bladder TCC
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
What is a cystectomy?
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
Describe the presentation and treatment of TCC of upper urinary tract
Presentation: haematuria, obstruction occurs early because renal pelvis projects directly into the pelvicalyceal cavity
Treatment: nephron-ureterectomy (kidney, fat, ureter, cuff of bladder)
Describe carcinoma of the prostate
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
What is prostate specific antigen?
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)
Describe the presentation of prostatic carcinoma
Urinary symptoms Bone pain Raised PSA, biopsy Opportunistic finding from DRE Incidental finding at transurethral resection of prostate
What staging and grading is used for prostatic carcinoma?
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
Describe the diagnosis of prostatic carcinoma
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
What can develop in advanced prostate cancer?
Can develop sclerotic bone regions
‘Hot spots’ on bone scan
Describe the treatment for localised prostate cancer
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
Describe the treatment for advanced prostate cancer
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
What are differential diagnoses for prostate cancer?
BPH Prostatitis Urethral stricture Multiple myeloma Any neurological condition
Describe polycystic kidney disease
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
Why is genetic screening not used for polycystic kidney disease?
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
Describe the macroscopic and microscopic appearance of the cysts
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
Describe the complications & treatment of polycystic kidney disease
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
