Tumours of the Urinary System 2 Flashcards
Where can urothelial tumours arise?
Malignant tumours of the lining transitional cell epithelium (urothelium) can occur at any point:
- From renal calyces
- To the tip of the urethra
What is the most common urothelial tumour site?
Bladder (90%)
-“Bladder cancer”
What are the two types of bladder cancer?
What causes them?
Most often transitional cell carcinoma (i.e. 90% in UK)
Where Schistosomiasis is endemic, squamous cell carcinoma of the bladder is the common tumour type
What are the risk factors for transitional cell carcinoma?
Smoking (accounts for 40% of cases)
Aromatic amines
Non-hereditary genetic abnormalities (e.g. TSG incl. p53 and Rb)
What are the risk factors for Squamous cell carcinoma?
Schistosomiasis (S. Haematobium only)
Chronic cystitis (e.g. recurrent UTI, long term catheter, bladder stone)
Cyclophasphamide therapy
Pelvic radiotherapy
What is the commonest symptom of bladder cancer?
What other presenting symptoms may it have?
Painless visible or frank haematuria
Occasionally symptoms due to invasive or metastatic disease
Other features:
- recurrent UTI
- storage bladder symptoms
- –Dysuria, frequency, nocturia, urgency +/- urge incontinence
- –Bladder pain
- –If present, suspect CIS
How do you investigate painful haematuria?
Urine culture
-Majority of painful haematuria is UTI
How do you investigate frank haematuria?
> 50 yrs risk of malignancy - 25-35%
Flexible cystourethroscopy within 2 weeks
-Only way to rule out cancer
IVU and USS (or CT-IVU)
-Upper tract
Urine Cytology may also be useful
(but not very sensitive or specific)
How do you investigate DIPSTIX or microscopic haematuria?
> 50 years Risk of malignancy - 5-10%
Flexible cystourethroscopy within 4-6 weeks
IVU and USS
What is the haematuria equation in terms of investigations for frank haematuria?
Cystoscopy and CT-IVU
how do you diagnose bladder tumour?
Cystoscopy and endoscopic resection (TURBT)
Examination under anaesthesia to assess bladder mass/ thickening before and after TURBT
How do you stage bladder cancer? (T,N and M stage)
Scross-sectional imaging (CT, MRI)
Bone scan if symptomatic
IVU for upper tract TCC (2-7% risk over 10 years; higher risk if high grade, stage or multifocal bladder tumours)
What is the treatment of bladder tumours?
Endoscopic or radical
How do you clssify bladder tumours?
Grade of tumour
Stage of tumour
- TNM classification
- T stage
- –Non-Muscle invasive (or superficial)
- –Muscle invasive
Combines to describe TCC
-e.g. G1pTa
What does the grading of a tumour mean?
Assessment of its aggressiveness
Describe the correlation between grade and stage
Close correlation
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)
What is the risk of bladder cancer in a patient who presents with unexplained frank haematuria
20-25%
What does the appropriate treatment depend on?
Site
Clinical stage
Histological grade of tumour
Patient age and co-morbidities
What is 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
Prolongued endoscopic follow up for moderate grade tumours
Consider prolongued course of intravesical chemotherapy (6 weeks to 6 months) for repeated recurrences
What is the treatment for high grade non-muscle invasive or CIS?
Endoscopic resection alone not sufficent
Need intravesical BCG therapy (maintanence course, weekly for 3 weeks repeated 6 monthly over 3 years)
Patients refractory to BCG need radical surgery
How does intravesical BCG treatment work?
BCG works by inducing immunomodulatory tumour cell killing (mediated by NK cells and cytokines)
1% risk of systemic BCG (similar to TB, treated with anti-tuberculous drugs)
How do you treat muscle invasive (T2-T3) bladder 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
What does the prognosis in bladder cancer depend on?
Stage Grade Size Multifocality Presence of concurrent CIS Recurrence at 3 months
What is the prognosis of non-invasive, low grade bladder TCC compared with invasive high grade bladder TCC?
90% 5-year survival
50% 5-year survival
