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Urinary system > Tumours of the renal system: bladder and renal cancer > Flashcards

Tumours of the renal system: bladder and renal cancer Flashcards

1
Q

Describe briefly sites of urothelial tumours

A

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”

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2
Q

Where is the most common site of urothelial tumours?

A

Bladder (90%)

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3
Q

What is the most common tumour type in bladder cancer?

A

transitional cell carcinoma

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4
Q

What is the most common tumour type of bladder cancer in areas endemic to Schistosomiasis?

A

Squamous cell carcinoma

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5
Q

What are some risk factors for transitional cell carcinoma (TCC) of the bladder?

A

– Smoking (accounts for 40% of cases)
– Aromatic amines
– Non-hereditary genetic abnormalities (e.g. TSG incl. p53 and Rb)

Also if had previous UTUC

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6
Q

What are some risk factors for squamous cell carcinoma of the bladder?

A

– Schistosomiasis (S. haematobium only)
– Chronic cystitis (e.g. recurrent UTI, long term catheter, bladder stone)
– Cyclophosphamide therapy
– Pelvic radiotherapy

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7
Q

How do bladder cancers often present?

A

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
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8
Q

What should be suspected if someone presents with bladder pain?

A

Carcinoma in situ

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9
Q

What investigations should be carried out if someone presents with haematuria?

A

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

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10
Q

What is the risk of malignancy if a patient >50 presents with frank haematuria?

A

25-35%

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11
Q

What is the risk of malignancy if a patient >50 presents with DIPSTIX or microscopic haematuria?

A

5-10%

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12
Q

How should DIPSTIX or microscopic haematuria be investigated?

A

o Flexible cystourethroscopy within 2 weeks
o CT Urogram & USS
o Urine Cytology may also be useful (but not very sensitive nor specific)

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13
Q

How should frank haematuria be investigated?

A

o Flexible cystourethroscopy within 4-6 weeks

o IVU & USS

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14
Q

Describe the grades of TCC according to WHO 1973

A

– 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)

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15
Q

Describe the treatment of low grade non-muscle invasive (i.e. Ta or T1) bladder cancer

A
  • 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
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16
Q

Describe the treatment of high grade non-muscle invasive or CIS bladder cancer

A
  • 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
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17
Q

Describe the treatment of muscle invasive bladder (T2 - T3) cancer

A
  • 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
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18
Q

Describe the 5 year survival of those with non-invasive low grade bladder TCC

A

90% 5 year survival

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19
Q

Describe the 5 year survival of those with invasive high grade bladder TCC

A

50% 5 year survival

20
Q

How does upper tract urothelial cancer (UTUC) present?

A

Frank haematuria
Unilateral ureteric obstruction
Flank or loin pain

 Symptoms of nodal or metastatic disease 
•	Bone pain
•	Hypercalcaemia
•	Lung
•	Brain
21
Q

What diagnostic investigations are used for upper tract urothelial cancers?

A
  • CT-IVU or IVU – will show filling defect in renal pelvis due to tumour etc
  • Urine cytology
  • Ureteroscopy and biopsy
22
Q

Where can upper tract urothelial tumours be found?

A

– Renal pelvis or collecting system commonest

– Ureter less commonly

23
Q

Where is the most common site of UTUCs?

A

Renal pelvis/collecting system

24
Q

How are most UTUCs treated?

A

Nephro-ureterectomy due to high reoccurrence rate following being treated endoscopically or by segmental resection

25
Q

How is UTUC treated if unfit for nephro-ureterectomy or have bilateral disease?

A

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

26
Q

How high is the risk of TCC of the bladder following UTUC?

A

40% after 10 years

27
Q

Name 2 benign renal carcinomas

A

oncocytoma

angiomyolipoma

28
Q

Name a malignant renal carcinoma

A

Adenocarcinoma

29
Q

What is the most common adult renal malignancy?

A

Renal adenocarcinoma

30
Q

What are some synonyms of renal adenocarcinoma?

A

Synonyms: hypernephroma or Grawitz tumour

31
Q

From which part of the kidneys do most renal adenocarcinoma?

A

Most arise from proximal tubules

32
Q

What histological subtype do most renal adenocarcinomas belong to?

A
  • Clear cell (85%)
  • Papillary (10%)
  • Chromophobe (4%)
  • Bellini type ductal carcinoma (1%)
33
Q

List some risk factors for renal adenocarcinoma

A
  • 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
34
Q

Describe the proportion of presentation of those with renal adenocarcinoma

A

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

35
Q

Describe the TNM staging of renal adenocarcinoma

A

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

36
Q

Describe the spread of renal adenocarcinoma through direct spread, venous, haematogenous and lymphatic spread

A
  • 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
37
Q

Which lymph nodes are often first invaded by

metastasising renal adenocarcinoma?

A

Paracaval LNs

38
Q

How is renal adenocarcinoma investigated?

A

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

39
Q

How is renal adenocarcinoma treated?

A

radical nephrectomy

40
Q

How are metastases of renal adenocarcinoma treated?

A

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

41
Q

What is the 5 year survival rate of T1 renal adenocarcinoma?

A

95% 5 year survival

42
Q

What is the 5 year survival rate of T2 renal adenocarcinoma?

A

90% 5 year survival

43
Q

What is the 5 year survival rate of T3 renal adenocarcinoma?

A

60% 5 year survival

44
Q

What is the 5 year survival rate of T4 renal adenocarcinoma?

A

20% 5 year survival

45
Q

What is the 5 year survival rate of N1/N2 renal adenocarcinoma?

A

20% 5 year survival

46
Q

What is the mean survival of those with M1 renal adenocarcinoma?

A

Median survival 12-18 months

Urinary system (22 decks)

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