Tumours of the Urinary System Flashcards
What can urothelial / transition cell cancer affect
Bladder (90%)
Ureter
Renal pelvic
Collecting system
ALL TCC
What is the most common bladder cancer
Transitional cell carcinoma
What is associated with TCC
Age Smoking Aromatic amines - hair dye / industrial paint - ask occupational hx Cyclophosphamide Genetics - p53 + Rb Chron's Renal transplant Obesity
What other cancers can affect the bladder
SCC
Adeno <1%
What is associated with SCC
Schistosomiasis Staghorn calculi Smoking Chronic cystitis from UTI / stone / catheter Pelvic RT
A person with vasculitis + haematuria
Investigate for bladder TCC as likely treat with cyclophosphamide
What is the grade of bladder cancer
Grade 1 = well differentiated, non-invasive
Grade 2 = moderate, non invasive
Grade 3 = poorly differentiated, invasive
What is CIS
Non invasive
Aggressive so high risk
What is Tis, T1
Non-invasive
What is T2 and >
Invades detrusor muscle
What are the symptoms of bladder TCC
Painless visible haematuria = most common Weight loss Recurrent UTI Bladder pain Voiding irritability Storage Sx if tumour big enough - Dysuria - Frequency - Nocturia Urge incontinence May present as obstruction in acute urinary retention
Where does bladder cancer spread too
Local to pelvic
Para aortic and iliac nodes
Blood to liver and lungs
Bone = pain and hypercalcaemia
What can a bladder mass do
Obstruct ureter
Hydronephrosis
Nephrotic syndrome / renal failure
What do you do for unexplained non visible haematuria + no other sx
Refer <2 weeks for rigid cystourethroscopy + biopsy if frank and 4 weeks if microscopic
If
>50
RF
FH
Can do urine cytology as non-invasive test and will show malignant cells = 1st line
What other investigations for haematuria
Dipstick + MSSU to exclude infection
Bloods incl U+E
Urine cytology
Renal USS
How do you Dx and grade bladder cancer
TURBT - cystoscopy and resect including detrusor
EUA - biopsy
Flurosecent cystoscopy
Urine cytology can be useful in high grade as non-invasive and shows malignant cells
How do you stage
CTU to stage
MRI - pelvic node
Bone scan
How do you treat low grade non invasive
TURBT
Intravesicle chemo into bladder
Regular BCG vaccine into bladder
Most are this as people present with haematuria
How do you follow up
High risk of recurrence
Regular cystoscopy every 3 months for 2 years
Intense follow up
How do you treat high grade non invasive
50-80% will become invasive
Immunotherapy
Radical surgery - cystectomy with ideal conduit
Neoadjuvant chemo
How can high grade present
May appear like infection with no mass
How do you treat muscle invasive
Radical cystectomy = gold standard Chemotherapy - Neo and adjuvant Radical RT Cystoprostatectomy in men Anterior pelvic exenteration + urethrectomy in women
How do you treat T4
Palliative chemo / RT
Long term catheter
What are complications of cystectomy
Sexual and urinary malfunction
Bladder haemorrhage - disease or surgery
Increased risk of adenocarcinoma due to bowel being used in reconstruction
What can you do for advanced disease with intractable haematuria
Alum solution bladder irrigation
If no renal failure
But intractable haematuria
Where else can TCC affect
Renal pelvis = common
Ureter
How does Upper tract TCC present
Frank haematuria
Unilateral ureteric obstruction
Flank or loin pain
Met symptoms
What are symptoms of mets
Bone pain
Hypercalcaemia
Lung
Brain
How do you investigate upper tract TCC
Haematruia investigation CTU Urine cytology Ureteroscopy + biopsy = diagnostic CT / MRI to stage
How do you treat
NEPHROURETERECTOMY
What do you do if unfitt for surgery
Ureterscopic laser ablation
Surveillance
Endoscopic if univocal and low grad
What is the risk of upper tract TCC
High risk of bladder TCC
40% over 10 years
What type of cancer is renal cell carcinoma
Adenocarcinoma
15% TCC
Wilms in children
What are benign cancer
Oncocytoma
Angiomyolipoma - associated TS
What are adenocarcinoma
Clear cell = 85% Papillary Hydronephroma Grawitz Wilm's in children
What is the classic triad of renal cell carcinoma
Flank pain
Abdo mass
Haematuria
What are parneoplastic symptoms
PUO Anorexia Malaise Weight loss Hypertension Hypercalcaemia Polycythaemia L varicocele Hepatic dysfunction - LFT / cholestasis Renal vein thrombosis
What causes hypertension
Renin secretion
What causes hypercalcaemia
PTH secretion
What causes polycythaemia
Erythropoeitin secretion
What causes L varicocele
Renal vein compressing testicular
Testicular drains into renal so if renal blocks then varicocele forms
Do renal USS if patient presents
Metastatic spread of renal cell carcinoma (25% at presentation)
Direct into posts / bowel / renal vein / adrenal Haematogenous Lymphatic - para-caval Lungs - cannon ball met = haemoptysis Bone Brain Liver
What are investigations for RCC
Haematuria Bloods- FBC, U+E, ALP Bone profile for mets Urine cytology Renal tract USS CXR for lung
What is diagnostic
CT scan CAP and KUB
Look for vascular invasion
When would you do bone scan
If symptoms
When would you do biopsy
If ablation planned
Why ALP
Bone mets
What are other options
USS
CTU
DMSA / MAG-3 for function
What should you always do
Assess contralateral kidney and testis
How do you treat
Radical nephrectomy
Curative if
+- RT / chemo
What do you do if unfit
Cyrotherapy
Radiofrequency ablation
Watch and wait
What predicts survival
Mayo Prognostic Risk Score
How do you treat mets / advanced disease
Immunotherapy as chemo and RT resistant - interleukin / interferon Tyrosine kinase inhibtor Targeted therapy against VEGF Surgery = not an option Palliative = only option
How does renal vein thrombosis present
Haematuria
Loin pain
High creatinine and Hb
What is T1
<7cm and confined
What is T2
> 7cm and confined
What is T3
Local extension outside capsule - invades renal vein / IVC / LN
What is T4
Invades beyond Great fascia
What is common renal malignancy in children
Nephroblastoma
How does it present
Mass
Haematuria
Early lung mets
What are RF for Renal cell cancer
Age Male FH Smoking DM Obesity Hypertension ESRF / dialysis Polycystic kidney Tuberous sclerosis VHL
What suggests poor prognosis in renal cancer
Poor performance status
Hb 1.5x
Calcium high
Presence of liver / lung / retroperitoneal LN
Anatomy kidney
Retroperitoneal T12-L3 L higher than R Renal artery of AA - L1/2 Renal vein to IVC Para-aortic node
Why do hydroceles occur on the L
L renal vein has to stretch over as IVC on the R side
Anatomy of ureter
Comes out renal pelvic ( Travels on anterior surface of psoas Transitional epithelium Crosses pelvic brim at sacroiliac joint to enter pelvic (PUJ) Enters blader at VUJ
What is water under bridge
Ureter (water) i posterior to uterine artery (bridge) in F and vas deferens in M
IMPORTANT FOR SURGERY
Don’t want to clip
Anatomy of bladder
Continuaion of TCC
vHL
AD
RCC
Phaeochromocytoma
Haemangioblastoma
