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
