Tumours of the Urinary System 2: Urothelial and Renal Cancers Flashcards
what are 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.
Most common site - bladder - 90%
“Bladder Cancer”
what is the most common tumour type for bladder cancer?
transitional cell carcinoma (i.e. 90% in UK)
what are the risk factors for bladder cancer?
smoking (accounts for 40% of cases)
aromatic amines
non-hereditary genetic abnormalities (e.g. TSG incl. p53 and Rb)
what are 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
what is the most frequent presenting symptom of bladder cancer?
painless visible haematuria
what are occasional symptoms of bladder cancer?
Occasionally
symptoms due to invasive or metastatic disease
recurrent UTI
storage bladder symptoms
dysuria, frequency, nocturia, urgency +/- urge incontinence
bladder pain
if present, suspect CIS
how may haematuria present?
Frank - reported by patient
Microscopic - detected by doctor
what should be done urgently in investigation of haematuria?
Upper tract imaging
CT Urogram (IVU)
ultrasound scan
Urine Cytology
Limited use in Dipstick haematuria
BP and U&E’s
what should be done in investigation of haematuria?
Urine culture
majority of painful haematuria = UTI
Cystourethroscopy
commonest neoplastic cause is TCC bladder
what investigations should be done for frank haematuria?
> 50 yrs - Risk of malignancy - 25-35%
Flexible cystourethroscopy within 2 weeks
IVU & USS
CT Urogram & USS
Urine Cytology may also be useful (but not very sensitive nor specific)
what investigation should be done for microscopic haematuria?
> 50 yrs - Risk of malignancy - 5-10%
Flexible cystourethroscopy within 4-6 weeks
USS
how are urothelial tumours diagnosed?
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
cystoscopy and endoscopic resection (TURBT)
EUA to assess bladder mass/thickening before and after TURBT
how are urothelial tumours in the bladder staged?
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 treatment available for urothellial tumours of the bladder?
endoscopic or radical
how are bladder tumours classified?
Grade of tumour
Stage of tumour
- TNM classification
- T-stage :
- non-muscle invasive (or ‘superficial’)
- muscle invasive
Combined to describe TCC e.g. G1pTa
what does appropriate treatment of bladder cancer depend?
Site
Clinical stage
Histological grade of tumour
Patient age and co-morbidities
what is treatment for 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 is treatment for 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 treatment for 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 is prognosis of bladder cancer dependent on?
stage
grade
size
multifocality
presence of concurrent CIS
recurrence at 3 months
what is the five year survival of non-invasive, low grade bladder TCC?
90% 5-year survival
what is the five year survival of invasive, high grade bladder TCC?
50%
Upper tract TCC (or upper tract urothelial cancer – UTUC) main symptoms?
Frank haematuria
Unilateral ureteric obstruction
Flank or loin pain
Symptoms of nodal or metastatic disease
Bone pain
Hypercalcaemia
Lung
Brain
what diagnostic investigations are done for UTUC?
CT-IVU or IVU
Urine cytology
Ureteroscopy and biopsy
what will IVU/CT-IVU show in UTUC?
shows
filling defect
in renal pelvis
upper tract TCC?
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
indications for treatment in 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
what are examples of benign renal tumours?
oncocytoma, angiomyolipoma
what are examples of malignant 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 risk factors for 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 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
how is renal cancer staged?
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
what are the different mechanisms of spread for renal adenocarcinoma?
Direct spread
(invasion) through
the renal capsule
Venous invasion
to renal vein
and vena cava
Haematogenous
spread to lungs
and bone
Lymphatic spread
to paracaval nodes
what investigations are done for renal adenocarcinoma?
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 for renal adenocarcinoma?
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)
how are metastases of renal adenocarcinoma treated?
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 for different stages of renal carcinoma?
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
