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year 2 renal > Tumours of the Urinary System 2 (Bladder and Renal Cancer) > Flashcards

Tumours of the Urinary System 2 (Bladder and Renal Cancer) Flashcards

1
Q

Urothelial cancers

A
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2
Q

what are the 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

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3
Q

what is the most common sites for urothelial tumours?

A

Most common site - bladder - 90%

“Bladder Cancer”

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4
Q

Bladder cancer

A
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5
Q

what is the most common tumour type of a bladder cancer?

A

The tumour type is most often transitional cell carcinoma (i.e. 90% in UK)

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6
Q

Where Schistosomiasis is endemic, what is the common type of bladder tumour?

A

squamous cell carcinoma of the bladder is the common tumour type

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7
Q

what are the risk factors for TCC bladder cancer?

A

smoking (accounts for 40% of cases)

aromatic amines

non-hereditary genetic abnormalities (e.g. TSG incl. p53 and Rb)

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8
Q

what are the risk factors for squamous cell carcinoma bladder cancer?

A

Schistosomiasis (S. haematobium only)

chronic cystitis (e.g. recurrent UTI, long term catheter, bladder stone)

cyclophosphamide therapy

pelvic radiotherapy

Adenocarcinoma - Urachal (a fibrous remnant of the allantois, a canal that drains the urinary bladder of the fetus that joins and runs within the umbilical cord)

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9
Q

what are the presenting features of bladder cancer?

A

Most frequent presenting symptom = painless visible haematuria

Occasionally - symptoms due to invasive or metastatic disease

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10
Q

Haematuria may be what types?

A

Frank - reported by patient

Microscopic - detected by doctor

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11
Q

what are some other features that may present with bladder cancer?

A

Other features :

  • recurrent UTI
  • storage bladder symptoms:
  • dysuria, frequency, nocturia, urgency +/- urge incontinence
  • bladder pain
  • if present, suspect CIS
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12
Q

what are some investigaitons for haematuria?

A

urine culture - majority of painful haematuria = UTI

Cystourethroscopy (test to check the health of your urethra and bladder) - commonest neoplastic cause is TCC bladder

Upper tract imaging - CT Urogram (IVU), ultrasound scan

Urine Cytology - Limited use in Dipstick haematuria

BP and U&E’s

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13
Q

what is the management of frank haematuria?

A

>50 yrs - Risk of malignancy - 25-35%

Flexible cystourethroscopy within 2 weeks

IVU & USS

CT urogram (an imaging exam used to evaluate your urinary tract, including your kidneys, your bladder and the tubes (ureters))

Urine Cytology may also be useful (but not very sensitive nor specific) - test to look for abnormal cells in your urine

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14
Q

how do you manage DIPSTIX or microscopic haematuria?

A

>50 yrs - Risk of malignancy - 5-10%

Flexible cystourethroscopy within 4-6 weeks

USS

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15
Q

Will IVU and USS miss tumours?

A

IVU alone will miss a proportion of renal cell tumours (especially if <3cm)

USS alone will miss a proportion of urothelial tumours of the upper tracts

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16
Q

how do you diagnose urothelial tumours?

A

cystoscopy and endoscopic resection (TURBT)

EUA to assess bladder mass/thickening before and after TURBT

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17
Q

How is staging (T, N and M-stage) of urothelial tumours (bladder) done?

A

cross-sectional imaging (CT, MRI)

Bone scan if symptomatic

CTU for upper tract TCC (2-7% risk over 10 years; higher risk if high grade, stage or multifocal bladder tumours)

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18
Q

what is the treatment of urothelial tumours (bladder)?

A

endoscopic or radical

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19
Q

Endoscopic view of TCC

A
20
Q

TURBT

A

Fluorescent Cystoscopy & CIS

21
Q

what is the classification of a bladder tumour?

A
  • Grade of tumour
  • Stage of tumour
  • TNM classification
  • T-stage: on-muscle invasive (or ‘superficial’), muscle invasive

• Combined to describe TCC e.g. G1pTa

22
Q

How is grading and staging of a tumour done?

A
  • Close correlation between grade and stage
  • Grades of TCC (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)

(picture shwoing T stage of bladder TCC)

23
Q

Appropriate treatment of bladder cancer depends on what?

A

Site

Clinical stage

Histological grade of tumour

Patient age and co-morbidities

24
Q

what is the bladder cancer treatment that is low grade non-muscle invasive (i.e. Ta or T1)

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
25
Q

what si the treatment of bladder cancer that is High grade non-muscle invasive or CIS?

A
  • very aggressive – 50-80% risk of progression to muscle invasive stage
  • endoscopic resection alone not sufficient
  • CIS consider intravesical BCG therapy (maintenance course, weekly for 3 weeks repeated 6 monthly over 3 years)
  • patients refractory to BCG – need radical surgery
26
Q

what is the treatment of bladder cancer that is muscle invasive bladder (T2 - T3)?

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
27
Q

what does the prognosis of bladder cancer depend on?

A
  • stage
  • grade
  • size
  • multifocality
  • presence of concurrent CIS
  • recurrence at 3 months
  • Non-invasive, low grade bladder TCC: 90% 5-year survival
  • Invasive, high grade bladder TCC: 50% 5-year survival
28
Q

Upper tract TCC (or upper tract urothelial cancer – UTUC)

A
29
Q

What are the main symptoms of UTUC?

A

Frank haematuria

Unilateral ureteric obstruction

Flank or loin pain

Symptoms of nodal or metastatic disease:

  • Bone pain
  • Hypercalcaemia
  • Lung
  • Brain
30
Q

what are diagnostic investigations for UTUC?

A
  • CT-IVU or IVU
  • Urine cytology
  • Ureteroscopy and biopsy
31
Q

UTUC - diagnosis

What does IVU/CT-IVU show?

A

shows filling defect in renal pelvis

32
Q

what are the features of an upper tract TCC UTUC?

A

renal pelvis or collecting system commonest

ureter less commonly

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

hence, most upper tract TCCs are treated by nephro-ureterectomy

33
Q

What is the management of Upper tract TCC UTUC?

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
  • If unifocal and low-grade disease - relative indication for endoscopic treatment
  • In ALL cases, high risk of synchronous and metachronous bladder TCC (40% over 10 years); hence need surveillance cystoscopy
34
Q

renal cancer

A
35
Q

what is this picture showing?

A

Renal Cell Carcinoma

36
Q

what are types of benign renal tumours?

A

oncocytoma, angiomyolipoma

37
Q

whata re types of maligant renal tumours?

A

• renal adenocarcinoma - commonest adult renal malignancy

synonyms : hypernephroma or Grawitz tumour

most arise from proximal tubules

histological subtypes :

  • clear cell (85%)
  • papillary (10%)
  • chromophobe (4%)
  • Bellini type ductal carcinoma (1%)
38
Q

what are the risk factors for a 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
39
Q

what is the presentation of adenocarcinoma?

A
  • 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
40
Q

What is the TNM staging of renal cancer?

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

41
Q

Renal Adenocarcinoma - spread

What is shown here?

A

Direct spread (invasion) through the renal capsule

42
Q

Renal Adenocarcinoma - spread

What is shown here?

A

Venous invasion to renal vein and vena cava

43
Q

Renal Adenocarcinoma - spread

What is shown here?

A

Haematogenous spread to lungs and bone

Lymphatic spread to paracaval nodes

44
Q

what investigationa can be done for renal adenocarcinomas?

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 :
  • Ultrasound differentiates tumour from cyst
  • DMSA or MAG-3 renogram to assess split renal function if doubts about contralateral kidney
45
Q

what is the treatment of renal adenocarcinomas?

A

• Treatment is surgical – i.e. radical nephrectomy

  • laparoscopic radical nephrectomy is standard of care for T1 tumours (T2 tumours in laparoscopic centres)
  • worthwhile even with major venous invasion (≥T3b)
  • curative if ≤T2

• Even in patients with metastatic disease who have symptoms from primary tumour, palliative cytoreductive nephrectomy is beneficial (prolongs median survival by 6 months)

46
Q

what is the treatment of rena adenocarcinomas if there is metastases?

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-1
47
Q

what is the prognosis of renal adenocarcinomas?

A

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

year 2 renal (26 decks)

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