Tumours of the Urinary system 2 Flashcards
What is urothelial cancer?
Tumour of the lining transitional cell epithelium
Commonly known as Bladder cancer
Where could you find a urothelium
Can occur at any point
from renal calyces
to the tip of the urethra.
Most common site = bladder = 90%
What is the most common tumour type in bladder cancer in the UK?
Transitional cell carcinoma
In places where Schistosomiasis is endemic what is the most common bladder cancer tumour type?
Squamous cell carcinoma
Risk factors for transitional cell carcinoma of the bladder (3)
Smoking (accounts for 40% of cases)
Aromatic amines - found in things like tobacco smoke, commercial hair dyes, and diesel exhaust.
Non-hereditary genetic abnormalities (e.g. TSG incl. p53 and Rb)
Risk factors for Squamous cell carcinoma of the bladder?
Schistosomiasis
Chronic cystitis
Cyclophosphamide therapy
Pelvic radiotherapy
Adenocarcinoma
Most frequent presenting symptom in bladder cancer?
Painless visible haematuria
May be frank - reported by patient or microscopic - detected by doctor
Other presenting features of bladder cancer?
Recurrent UTI
Storage bladder symptoms - dysuria, frequency, nocturia, urgency, incontinence.
Bladder pain
How might you investigate haematuria?
Urine culture - majority of painful haematuria = UTI
Cystourethroscopy - commonest neoplastic cause is TCC bladder
Urine cytology
Upper tract imaging - CT urogram (IVU), USS
BP and U+Es
Frank haematuria (macroscopic) - incidence, investigations and imaging
> 50 yrs - Risk of malignancy - 25-35%
Flexible cystourethroscopy within 2 weeks
CT urogram (IVU) & USS
How is bladder cancer diagnosed?
Grade and TNM for staging
Cystoscopy and endoscopic resection (TURBT)
Examination under anaesthetic to assess bladder mass/thickening before and after TURBT
Which investigations are used to stage bladder cancer?
CT
MRI
Bone scan if symptomatic
CT urogram for upper tract TCC
What does classification of bladder tumours depend on?
Grade of tumour
Stage of tumour
- TNM classification
- T-stage : non-muscle invasive (or ‘superficial’) vs muscle invasive
Grades of TCC
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)
Treatment of low grade non-muscle invasive tumour in the bladder? (Tis, Ta or T1 - site within bladder)
Diathermy via Endoscopic resection of the bladder tumour.
Then a single instillation of intravesical BCG (inserted into the bladder). Works to fight the tumour (chemo)
Follow up cystoscopy after 9 months or so
Treatment of high grade non-muscle invasive tumour in the bladder?
Radical cystectomy = the gold standard + radiotherapy
Post-op chemo
Treatment of muscle invasive tumour in the bladder? (T2-T3)
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 is the prognosis of low grade bladder TCC
90% 5 year survival
What is the prognosis of invasive high grade bladder TCC
50% 5 year survival
Presenting features of Upper tract TCC or upper tract urothelial cancer – UTUC
Frank haematuria - patient notices
Unilateral ureteric obstruction
Flank or loin pain
Symptoms of nodal or metastatic disease: Bone pain Hypercalcaemia Lung Brain
Diagnostic investigations for Upper Urinary Tract Cancer (UUTC)
CT-IVU or IVU
Urine cytology
Ureteroscopy and biopsy
What does CT-IVU or IVU show in UTUC?
Filling defect in renal pelvis
Upper tract TCC most commonly affects which part of the urinary system
Renal pelvis or collecting system
If a patient is unfit for nephron-ureterectomy or has bilateral disease what treatment should they get?
nephron-sparing endoscopic treatment - ureteroscopic laser ablation
Look
UTUC tumours are often high-grade and multifocal on one side
High risk of local recurrence if treated endoscopically or by segmental resection
Low risk of having contralateral disease
difficult to follow up if treated endoscopically
How are most most upper tract TCCs treated?
nephro-ureterectomy - removes a patient’s renal pelvis, kidney, ureter, and bladder cuff.
Benign renal cancers (2)
Oncocytoma
Angiomyolipoma
Malignant renal cancer
Renal adenocarcinoma
Histological subtypes of renal adenocarcinoma
clear cell (85%)
papillary (10%)
chromophobe (4%)
Bellini type ductal carcinoma (1%)
Risk factors of 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
Presentation of renal adenocarcinoma
Asymptomatic (i.e. incidentally noted on imaging for unrelated symptoms) : 50%
‘Classic triad’ of flank pain, mass and haematuria : 10%
Paraneoplastic syndrome : 30%
anorexia, cachexia and pyrexia
hypertension, hypercalcaemia and abnormal LFTs
anaemia, polycythaemia and raised ESR
Metastatic disease : 30%
bone, brain, lungs, liver
TNM staging of Renal cancer
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
Direct spread of renal cancer is directly through what?
The renal capsule
Renal cancer: Venous invasion to which veins?
Renal vein and vena cava
Where does renal cancer spread to through the blood?
The lungs and bone
Where does renal cancer spread to through the lymph?
The paracaval nodes
Investigations done for renal adenocarcinoma?
CT abdomen and chest is mandatory - to provide radiological diagnosis and complete TNM staging
Bloods - U+E’s, FBC
Optional: USS - differentiates tumour from cyst or DMSA or MAG-3 renogram to assess split renal function if doubts about contralateral kidney
Treatment of renal adenocarcinoma
Surgery - radical nephrectomy (removal of the whole kidney, the fatty tissues surrounding the kidney and part of the ureter)
Even in patients with metastatic disease who have symptoms from primary tumour, palliative cytoreductive nephrectomy is beneficial (prolongs median survival by 6 months)
What is the standard surgical procedure for T1 renal tumours?
laparoscopic radical nephrectomy - curative if T2 or less
Treatment in renal adenocarcinoma metastases
little effective treatment since it is radioresistant and chemoresistant
Multi-targeted receptor tyrosine kinase inhibitors
e.g suntinib - trials ongoing
Immunotherapy - Interferon alpha, interleukin-1
Renal adenocarcinoma prognosis
T1 – 95% 5-year survival
T2 – 90% 5-year survival
T3 – 60% 5-year survival
T4 – 20% 5-year survival
N1 or N2 – 20% 5-year survival
M1 – Median survival 12-18 months
