Tumours of the urinary system 2 - urothelial and renal Flashcards
What are urothelial cancers?
Malignant tumours of the lining transitional cell epithelium (uroepithelium) which occurs at any point of the urinary tract
Where is the most common site of urothelial cancers?
bladder - 90%
Most common bladder cancer cell type
TCC
When is TCC not the most common type of bladder cancer?
where schistosomiasis is endemic - squamous cell carcinoma
TCC risk factors (most common?)
SMOKING
aromatic amines
non-hereditary genetic abnormalities
SCC risk factors
schistosomiasis!
chronic cystitis
pelvic radiotherapy
cyclophosphamide therapy
Most common presenting symptom of bladder cancer
frank haematuria
Other ways bladder cancer can present
occasionally due to invasive/mets
others eg recurrent UTI, storage LUTS
What are the storage bladder symptoms?
dysuria, frequency, nocturia, ugency +/- urge incontinence
If LUTS are the presenting symptom of bladder cancer what should you expect?
carcinoma in situ
5 investigations of haematuria
urine culture - majority of painful haematuria due to UTI cystoscopy urine cytology CTU or USS Blood pressure and U+E's
What is the % risk of malignancy with frank haematuria?
25-35%
Risk of malignancy with dipstick/microscopic haematuria?
5-10%
What are the drawbacks with IVU and USS alone?
IVU miss renal cell tumours <3cm
USS miss some urothelial tumours of upper tract
How is bladder cancer diagnosed? What information does this give?
cystoscopy and TURBT - endoscopic resection
grade and T stage
How is TNM staging of bladder cancer done?
CT, MRI
bone scan if symptomatic
CTU for upper tract TCC
What does T stage of bladder cancer tell us?
superficial or muscle invasive
Grades of bladder cancer
G1 - well diff
G2 - mid diff
G3 - poorly diff
CIS - very aggressive and non muscle invasive
4 things treatment of bladder cancer depends on
site
stage
histological grade
age and co morbidities of patient
Treatment of low grade non muscle invasive bladder cancer
endoscopic resection and intravesical chemotherapy which can both be prolonged and endoscopic follow up
Treatment of high grade non muscle invasive or CIS bladder cancer
endoscopic resection alone insufficient
BCG therapy if CIS
if BCG not working - radical surgery
Muscle invasive bladder cancer treatment
neoadjuvant chemotherapy
radical radiotherapy and/or radical cystoprostatectomy
urinary diversion and lymphadenectomy
6 factors prognosis of bladder cancer is dependent on
size stage grade multifocality recurrence in 3 months presence of concurrent CIS
Main symptoms of upper tract urothelial cancer
frank haematuria
loin/flank pain
ureteric obstruction
symptoms of nodal or mets eg bone pain
Diagnosis of upper tract urothelial cancer
CT IVU or IVU
urine cytology
ureteroscopy and biopsy
Where is TCC of upper tract usually found and describe it briefly
very aggressive - high grade and multifocal
renal pelvis or collecting system
high risk of local recurrence
high risk of bladder TCC
How is TCC of upper tract treated? exceptions.
nephro-ureterectomy
unfit or bilateral disease requires endoscopic treatment
2 benign renal tumours
oncocytoma
angiomyolipoma
Malignant renal tumour main type
renal adenocarcinoma
What part of the kidney do most renal adenocarcinomas arise?
proximal tubules
4 subtypes of renal adenocarcinoma and the main one
CLEAR CELL
papillary
chromophobe
bellini type ductal carcinoma
Risk factors of renal adenocarcinoma
FH smoking obesity anti-hypertensive medications ESRD acquired renal cystic disease
How do most renal tumours present?
asymptomatic
Other ways in which renal tumours present
mets symptoms
TRIAD = loin pain, haematuria, mass
paraneoplatic syndrome
What T stage of renal disease is the first which goes beyond the capsule?
3
How can renal adenocarcinoma spread?
direct spread - through renal capsule
venous invasion - renal vein and IVC
haematogenous spread to lungs and bones
lymphatic spread to paracaval nodes
Investigations of renal adenocarcinoma
CT scan abdomen and chest
bloods - U+Es and FBC
optional eg IVU, uss, dmsa, mag-3
Treatment of renal adenocarcinoma
surgical - laprascopic radical nephrectomy
Why is metastases treatment of renal adenocarcinoma so difficult?
RCC is chemo and radio RESISTANT
Other treatments for renal adenocarcinoma
targeted receptor tyrosine kinase inhibitors
immunotherapy
