Tumours of the renal system: bladder and renal cancer Flashcards
Describe briefly sites of urothelial tumours
Malignant tumours of the lining transitional cell epithelium (urothelium) can occur at any point
– From renal calyces
– To the tip of the urethra.
Most common site - bladder - 90%
– “Bladder Cancer”
Where is the most common site of urothelial tumours?
Bladder (90%)
What is the most common tumour type in bladder cancer?
transitional cell carcinoma
What is the most common tumour type of bladder cancer in areas endemic to Schistosomiasis?
Squamous cell carcinoma
What are some risk factors for transitional cell carcinoma (TCC) of the bladder?
– Smoking (accounts for 40% of cases)
– Aromatic amines
– Non-hereditary genetic abnormalities (e.g. TSG incl. p53 and Rb)
Also if had previous UTUC
What are some risk factors for squamous cell carcinoma of the bladder?
– Schistosomiasis (S. haematobium only)
– Chronic cystitis (e.g. recurrent UTI, long term catheter, bladder stone)
– Cyclophosphamide therapy
– Pelvic radiotherapy
How do bladder cancers often present?
Most often = Painless visible haematuria
Occasionally symptoms due to invasive or metastatic disease
Other features: – Recurrent UTI • Storage bladder symptoms • Dysuria, frequency, nocturia, urgency +/- urge incontinence • Bladder pain
What should be suspected if someone presents with bladder pain?
Carcinoma in situ
What investigations should be carried out if someone presents with haematuria?
Urine culture
o Majority of painful haematuria = UTI
Cystourethroscopy
o Commonest neoplastic cause is TCC bladder
Upper tract imaging
o CT Urogram (IVU)
o Ultrasound scan
Urine Cytology
o Limited use in Dipstick haematuria
BP and U&E’s
What is the risk of malignancy if a patient >50 presents with frank haematuria?
25-35%
What is the risk of malignancy if a patient >50 presents with DIPSTIX or microscopic haematuria?
5-10%
How should DIPSTIX or microscopic haematuria be investigated?
o Flexible cystourethroscopy within 2 weeks
o CT Urogram & USS
o Urine Cytology may also be useful (but not very sensitive nor specific)
How should frank haematuria be investigated?
o Flexible cystourethroscopy within 4-6 weeks
o IVU & USS
Describe the grades of TCC according to WHO 1973
– G1 = Well diff. - commonly non-invasive
– G2 = Mod. diff. - often non-invasive
– G3 = Poorly diff. - often invasive
– Carcinoma in situ (CIS) – non-muscle invasive but VERY aggressive (hence treated differently)
Describe the treatment of low grade non-muscle invasive (i.e. Ta or T1) bladder cancer
- Endoscopic resection followed by single instillation of intravesical chemotherapy (mitomycin C) within 24 hours
- Prolonged endoscopic follow up for moderate grade tumours
- Consider prolonged course of intravesical chemotherapy (6 weeks months) for repeated recurrences
Describe the treatment of high grade non-muscle invasive or CIS bladder cancer
- Very aggressive – 50-80% risk of progression to muscle invasive stage
- Endoscopic resection alone not sufficient
- CIS consider intravesical Bacillus Calmette-Guerin (BCG) therapy (maintenance course, weekly for 3 weeks repeated 6 monthly over 3 years)
- Patients refractory to BCG – need radical surgery
Describe the treatment of muscle invasive bladder (T2 - T3) cancer
- Neoadjuvant chemotherapy for local (i.e. downstaging) and systemic control; followed by either:
- Radical radiotherapy and/or;
- Radical cystoprostatectomy (men) or anterior pelvic exenteration with urethrectomy (women); with extended lymphadenectomy
- Radical surgery combined with incontinent urinary diversion (i.e. ileal conduit), continent diversion (e.g. bowel pouch with catheterisable stoma) or orthotopic bladder substitution
Describe the 5 year survival of those with non-invasive low grade bladder TCC
90% 5 year survival
Describe the 5 year survival of those with invasive high grade bladder TCC
50% 5 year survival
How does upper tract urothelial cancer (UTUC) present?
Frank haematuria
Unilateral ureteric obstruction
Flank or loin pain
Symptoms of nodal or metastatic disease • Bone pain • Hypercalcaemia • Lung • Brain
What diagnostic investigations are used for upper tract urothelial cancers?
- CT-IVU or IVU – will show filling defect in renal pelvis due to tumour etc
- Urine cytology
- Ureteroscopy and biopsy
Where can upper tract urothelial tumours be found?
– Renal pelvis or collecting system commonest
– Ureter less commonly
Where is the most common site of UTUCs?
Renal pelvis/collecting system
How are most UTUCs treated?
Nephro-ureterectomy due to high reoccurrence rate following being treated endoscopically or by segmental resection
How is UTUC treated if unfit for nephro-ureterectomy or have bilateral disease?
If unfit for nephro-ureterectomy or has bilateral disease - absolute indication for nephron-sparing endoscopic treatment (i.e. ureteroscopic laser ablation); needs regular surveillance ureteroscopy
How high is the risk of TCC of the bladder following UTUC?
40% after 10 years
Name 2 benign renal carcinomas
oncocytoma
angiomyolipoma
Name a malignant renal carcinoma
Adenocarcinoma
What is the most common adult renal malignancy?
Renal adenocarcinoma
What are some synonyms of renal adenocarcinoma?
Synonyms: hypernephroma or Grawitz tumour
From which part of the kidneys do most renal adenocarcinoma?
Most arise from proximal tubules
What histological subtype do most renal adenocarcinomas belong to?
- Clear cell (85%)
- Papillary (10%)
- Chromophobe (4%)
- Bellini type ductal carcinoma (1%)
List some risk factors for renal adenocarcinoma
- Family history (autosomal dominant e.g. vHL, familial clear cell RCC, hereditary papillary RCC; can be bilateral and/or multifocal)
- Smoking
- Anti-hypertensive medication
- Obesity
- End-stage renal failure
- Acquired renal cystic disease
Describe the proportion of presentation of those with renal adenocarcinoma
50% - asymptomatic/incidental findings
30% - metastatic disease to liver, lungs, bone or brain
30% - paraneoplastic syndrome
10% - ‘Classic triad’ of flank pain, mass and haematuria
Describe the TNM staging of renal adenocarcinoma
T1 - Tumour < 7cm confined within renal capsule
T2 - Tumour >7cm & confined within capsule
T3 - Local extension outside capsule
– T3a - Into adrenal or peri-renal fat
– T3b - Into renal vein or IVC below diaphragm
– T3c - Tumour thrombus in IVC extends above diaphragm
T4 - Tumour invades beyond Gerota’s fascia
Describe the spread of renal adenocarcinoma through direct spread, venous, haematogenous and lymphatic spread
- Direct spread (invasion) through the renal capsule
- Venous invasion through renal veins and vena cava
- Haematogenous spread to lungs and bone
- Lymphatic spread to paracaval nodes
Which lymph nodes are often first invaded by
metastasising renal adenocarcinoma?
Paracaval LNs
How is renal adenocarcinoma investigated?
CT scan (triple phase) of abdomen and chest is mandatory
– Provides radiological diagnosis and complete TNM staging
– Assesses contralateral kidney
Bloods: U&E, FBC
Optional tests:
– IVU shows calyceal distortion and soft tissue mass
– Ultrasound differentiates tumour from cyst
– DMSA or MAG-3 renogram to assess split renal function if doubts about contralateral kidney
How is renal adenocarcinoma treated?
radical nephrectomy
How are metastases of renal adenocarcinoma treated?
Metastases - little effective treatment since RCC is radioresistant and chemoresistant
Multitargeted receptor tyrosine kinase inhibitors
• Relatively new
• Sunitinib, sorafenib, panzopanib,temsirolimus
• Superior response rates to immunotherapy
• Trials ongoing
Immunotherapy
• Interferon alpha
• Interleukin-2
• Response rate with either 20% at most
What is the 5 year survival rate of T1 renal adenocarcinoma?
95% 5 year survival
What is the 5 year survival rate of T2 renal adenocarcinoma?
90% 5 year survival
What is the 5 year survival rate of T3 renal adenocarcinoma?
60% 5 year survival
What is the 5 year survival rate of T4 renal adenocarcinoma?
20% 5 year survival
What is the 5 year survival rate of N1/N2 renal adenocarcinoma?
20% 5 year survival
What is the mean survival of those with M1 renal adenocarcinoma?
Median survival 12-18 months
