Tumours of the Urinary System 2 (Bladder and Renal Cancer) Flashcards
Urothelial cancers
what are the sites of Urothelial tumours?
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 sites for urothelial tumours?
Most common site - bladder - 90%
“Bladder Cancer”
Bladder cancer
what is the most common tumour type of a bladder cancer?
The tumour type is most often transitional cell carcinoma (i.e. 90% in UK)
Where Schistosomiasis is endemic, what is the common type of bladder tumour?
squamous cell carcinoma of the bladder is the common tumour type
what are the risk factors for TCC bladder cancer?
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 bladder cancer?
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)
what are the presenting features of bladder cancer?
Most frequent presenting symptom = painless visible haematuria
Occasionally - symptoms due to invasive or metastatic disease
Haematuria may be what types?
Frank - reported by patient
Microscopic - detected by doctor
what are some other features that may present with bladder cancer?
Other features :
- recurrent UTI
- storage bladder symptoms:
- dysuria, frequency, nocturia, urgency +/- urge incontinence
- bladder pain
- if present, suspect CIS
what are some investigaitons for haematuria?
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
what is the management of frank haematuria?
>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
how do you manage DIPSTIX or microscopic haematuria?
>50 yrs - Risk of malignancy - 5-10%
Flexible cystourethroscopy within 4-6 weeks
USS
Will IVU and USS miss tumours?
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
how do you diagnose urothelial tumours?
cystoscopy and endoscopic resection (TURBT)
EUA to assess bladder mass/thickening before and after TURBT
How is staging (T, N and M-stage) of urothelial tumours (bladder) done?
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)
what is the treatment of urothelial tumours (bladder)?
endoscopic or radical
Endoscopic view of TCC
TURBT
Fluorescent Cystoscopy & CIS
what is the classification of a bladder tumour?
- Grade of tumour
- Stage of tumour
- TNM classification
- T-stage: on-muscle invasive (or ‘superficial’), muscle invasive
• Combined to describe TCC e.g. G1pTa
How is grading and staging of a tumour done?
- 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)
Appropriate treatment of bladder cancer depends on what?
Site
Clinical stage
Histological grade of tumour
Patient age and co-morbidities
what is the bladder cancer treatment that is low grade non-muscle invasive (i.e. Ta or T1)
- 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
what si the treatment of bladder cancer that is High grade non-muscle invasive or CIS?
- 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
what is the treatment of bladder cancer that is muscle invasive 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 does the prognosis of bladder cancer depend on?
- 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
Upper tract TCC (or upper tract urothelial cancer – UTUC)
What are the main symptoms of UTUC?
Frank haematuria
Unilateral ureteric obstruction
Flank or loin pain
Symptoms of nodal or metastatic disease:
- Bone pain
- Hypercalcaemia
- Lung
- Brain
what are diagnostic investigations for UTUC?
- CT-IVU or IVU
- Urine cytology
- Ureteroscopy and biopsy
UTUC - diagnosis
What does IVU/CT-IVU show?
shows filling defect in renal pelvis
what are the features of an upper tract TCC UTUC?
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
What is the management of Upper tract TCC UTUC?
- 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
renal cancer
what is this picture showing?
Renal Cell Carcinoma
what are types of benign renal tumours?
oncocytoma, angiomyolipoma
whata re types of maligant renal tumours?
• 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%)
what are the risk factors for a 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
what is the presentation of 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
What is the 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
Renal Adenocarcinoma - spread
What is shown here?
Direct spread (invasion) through the renal capsule
Renal Adenocarcinoma - spread
What is shown here?
Venous invasion to renal vein and vena cava
Renal Adenocarcinoma - spread
What is shown here?
Haematogenous spread to lungs and bone
Lymphatic spread to paracaval nodes
what investigationa can be done for renal adenocarcinomas?
• 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
what is the treatment of renal adenocarcinomas?
• 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)
what is the treatment of rena adenocarcinomas if there is metastases?
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
what is the prognosis of renal adenocarcinomas?
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
