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Renal Pathology > Tumours of the Urinary System > Flashcards

Tumours of the Urinary System Flashcards

1
Q

Where do you get urothelial cancer?

A

Bladder
Upper tract (i.e. ureter, renal pelvis and collecting system) - UTUC
FROM THE RENAL CALYCES TO THE TIP OF THE URETHRA

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2
Q

What are urothelial tumours?

A

Malignant tumours of the lining transitional cell epithelium (urothelium)

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3
Q

What is the commonest site for urothelial tumours? What % occurs here?

A

Bladder

90%

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4
Q

Types of bladder cancer

A

Transitional cell carcinoma
Squamous cell carcinoma
Adenocarcinoma

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5
Q

What is the commonest type of bladder cancer in the UK?

A

Transitional cell carcinoma

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6
Q

Where is squamous cell carcinoma of the bladder common?

A

In areas where schistosomiasis is endemic

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7
Q

Risk factors for TCC of bladder

A

Smoking (40% of cases)
Aromatic amines
Non hereditary genetic abnormalities (e.g. TSG including p53 and Rb)

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8
Q

Risk factors for SCC of the bladder

A

Schistosomiasis (H. haematobium only)
Chronic cystitis (e.g. recurrent UTI, long term catheter, bladder stone)
Cyclophosphamide therapy
Pelvic radiotherapy

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9
Q

Risk factors for adenocarcinoma of the bladder

A

Urachal

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10
Q

Presentation of bladder cancer

A

Painless visible haematuria
Symptoms due to invasive or metastatic disease (occasionally)
Recurrent UTI
Storage bladder symptoms
- dysuria, frequency, nocturia, urgency +/- urge incontinence
- bladder pain

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11
Q

Types of haematuria

A

Frank

Microscopic

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12
Q

Investigations of bladder cancer

A

Cystoscopy and endoscopic resection (TURBT)
EUA
- to assess bladder mass/thickening before and after TURBT

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13
Q

Staging of bladder cancer

A

Cross sectional imaging (CT, MRI)
Bone scan if symptomatic
CTU for upper tract TCC

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14
Q

Grades of TCC

A

G1 = Well differentiated - commonly non invasive
G2 = moderately differentiated - often non invasive
G3 = Poorly differentiated - often invasive
Carcinoma in situ (CIS) - non muscle invasive but VERY aggressive

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15
Q

Treatment of bladder cancer

A

Endoscopic or radical
TA OR T1 - IN THE BLADDER, LOW GRADE NON MUSCLE INVASIVE
- endoscopic resection followed by single instillation of intravesical chemotherapy within 24 hours
- prolonged endoscopic follow up for moderate grade tumours
- consider prolonged course of intravesical chemotherapy (6 weeks) for repeated recurrences
HIGH GRADE NON MUSCLE INVASIVE OR CIS
- endoscopic resection (alone not sufficient)
- CIS consider intravesical BCG therapy (weekly for 3 weeks then repeated 6 monthly over 3 years)
- patients refractory to BCG - need radical surgery
MUSCLE INVASIVE BLADDER CANCER
- neoadjuvant chemotherapy
- followed by radial 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 catherterisable stoma) or orthotopic bladder substitution

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16
Q

What % risk do patients with high grade non muscle invasive or CIS bladder cancer have of progression to the muscle invasive stage?

A

50-80%

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17
Q

What does the prognosis of bladder cancer depend on?

A 
Stage
Grade
Size 
Multifocality 
Presence of concurrent CIS
Recurrence at 3 months
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18
Q

What is the 5 year survival of non invasive, low grade bladder TCC?

A

90%

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19
Q

What is the 5 year survival of invasive, high grade bladder TCC?

A

50%

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20
Q

Presentation of upper tract TCC

A

Frank haematuria
Unilateral ureteric obstruction
Flank or loin pain
Symptoms of nodal of metastatic disease

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21
Q

What are some symptoms of nodal or metastatic disease from an upper tract TCC?

A

Bone pain
Hypercalcaemia
Lung
Brain

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22
Q

Investigations for upper tract TCC

A

CT-IVU or IVU
Urine cytology
Ureteroscopy and biopsy

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23
Q

What does CT-IVUs show?

A

Filling defects in the renal pelvis

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24
Q

What part of the upper tract is most common for getting TCC?

A

Renal pelvis

Collecting system

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25
Q

Treatment of upper tract TCC

A

Nephro-uretectomy
If unfit / bilateral disease
- nephron sparing endoscopic treatment (i.e. ureteroscopic laser ablation) = needs regular surveillance ureteroscopy

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26
Q

What is an indication in upper tract TCC for just endoscopic treatment?

A

Unifocal

Low grade disease

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27
Q

In all cases of upper tract TCC, what needs to be done and why?

A

Surveillance cystoscopy

High risk of synchronous and metachronous bladder TCC (40% over 10 years)

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28
Q

What is the cause of the majority of cases of painful haematuria?

A

UTI

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29
Q

What is the commonest neoplastic cause of haematuria?

A

TCC bladder

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30
Q

Investigations of haematuria

A 
Urine culture
Cystourethroscopy 
CT urogram (IVU)
USS
BP
U and Es
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31
Q

If a patient is > 50 y/o and has frank haematuria, what is the risk of malignancy?

A

25-35%

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32
Q

Investigations of a > 50 y/o patient presenting with frank haematuria

A

Flexible cystourethroscopy (within 2 weeks)
IVU and USS
CT urogram and USS
Urine cytology

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33
Q

If a patient is > 50 y/o with microscopic haematuria, what is the risk of malignancy?

A

5 - 10%

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34
Q

Investigations of a >50 y/o patient with microscopic haematuria

A

Flexible cystourethroscopy within 4- 6 weeks

IVU and USS

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35
Q

What are the benign renal tumours?

A

Oncocytoma

Angiomyolipoma

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36
Q

What are the malignant renal tumours?

A

Renal adenocarcinoma

37
Q

What is the commonest adult renal malignancy?

A

Renal adenocarcinoma

38
Q

Other names for renal adenocarcinoma

A

Hypernephroma

Grawitz tumour

39
Q

Histological subtypes of renal adenocarcinoma

A

Clear cell (85%)
Papillary (10%)
Chromophobe (4%)
Bellini type ductal carcinoma (1%)

40
Q

Risk factors for renal adenocarcinoma

A 
FH 
Smoking
Anti-hypertensive medication 
Obesity
ESRF
Acquired renal cystic disease
41
Q

What autosomal dominant conditions of the kidneys can put you at risk of renal adenocarcinoma?

A

vHL
Familial clear cell RCC
Hereditary papillary RCC

42
Q

Presentation of renal adenocarcinoma

A 
Asymptomatic 50%
Flank pain 10%
Mass 10%
Haematuria 10%
Paraneoplastic syndrome 30%
Metastatic disease 30%
43
Q

What is the classic triad of symptoms of renal adenocarcinoma?

A

Flank pain
Mass
Haematuria

44
Q

What % of renal adenocarincomas have the classic triad?

A

10%

45
Q

What are the features of paraneoplastic syndrome?

A 
Anorexia
Cachexia
Pyrexia
HTN
Hypercalcaemia
Abnormal LFTs
Anaemia
Polycythaemia
Raised ESR
46
Q

Where does renal adenocarcinoma metastasise to?

A

Bone
Brain
Lungs
Liver

47
Q

Investigations of renal adenocarcinoma

A

CT scan of abdomen and chest
Bloods
U and Es
Optional
- IVU ; calyceal distortion and soft tissue mass
- USS ; differentiates tumour from a cyst
- DMSA or MAG-3 renogram to assess split renal function if doubts about contralateral kidney

48
Q

Treatment of renal adenocarcinoma

A

Radical nephrectomy

49
Q

Treatment of metastatic renal adenocarcinoma

A

TKIs e.g. sunitinib
Immunotherapy
- interferon alpha
- interleukin 2

50
Q

Palliative treatment of renal adenocarcinoma - how long does this prolong the survival for?

A

Cytoreductive nephrectomy

6 months

51
Q

5 year survival prognosis of T1 renal adenocarcinoma

A

95%

52
Q

5 year survival prognosis of T2 renal adenocarcinoma

A

90%

53
Q

5 year survival prognosis of T3 renal adenocarcinoma

A

60%

54
Q

5 year survival of T4 renal adenocarcinoma

A

20%

55
Q

5 year survival of N1 or N2 renal adenocarcinoma

A

20%

56
Q

Prognosis of metastasised renal adenocarcinoma

A

12 - 18 months

57
Q

How does renal adenocarcinoma metastasise?

A

Direct spread/invasion through the renal capsule
Venous invasion to renal vein and vena cava
Haematogenous spread to lungs and bones
Lymphatic spread to paracaval nodes

58
Q

What is the TNM staging of renal cancer?

A

T1 = tumour < 7cm confined within the renal capsule
T2 = tumour > 7cm and confined within the capsule
T3 = local extension outside capsule
a - intro adrenal and peri renal fat
b - into renal vein or IVC below diaphragm
c - tumour thrombus in IVC extends above diaphragm
T4 - tumour invades beyond Gerotas fascia

59
Q

What is the commonest cancer diagnosed in men?

A

Prostate cancer

60
Q

75% of prostate cancers are diagnosed in what age of men?

A

> 65 y/o

61
Q

Risk factors for prostate cancer

A 
Increasing age
African or afro-carribean men living in western countries
Geography 
FH 
- First degree relative 2x risk
62
Q

What genes are implicated in familial prostate cancer?

A

HPC1
BRCA 1
BRCA 2

63
Q

What are McNeals prostatic zones?

A

Transition zone
Central zone
Peripheral zone

64
Q

What % newly diagnosed prostate cancers are localised?

A

80%

65
Q

Diagnosis of prostate cancer

A

PSA
DRE
TRUS-guided prostate biopsies

66
Q

What does PSA stand for?

A

Prostate specific antigen

67
Q

What does DRE stand for?

A

Digital rectal exam

68
Q

What is PSA specific to?

A

Prostate

69
Q

Presentation of local prostate cancer

A 
Weak stream 
Hesitancy 
Sensation of incomplete emptying 
Frequency 
Urgency 
Urge incontinence
UTI
70
Q

Presentation of locally invasive prostate cancer

A 
Haematuria
Perineal and suprapubic pain
Impotence 
Incontinence 
Loin pain or anuria resulting from obstruction of ureters
Symptoms of renal failure 
Haemospermia
Rectal symptoms including tenesmus
71
Q

Presentation of metastatic prostate cancer

A

Distant
- bone pain or sciatica
- paraplegia secondary to spinal cord compression
- lymph node enlargement
- lymphoedema, particularly in the lower limbs
- loin pain or anuria due to obstruction of the ureters by lymph nodes
Widespread
- lethargy
- weight loss and cachexia

72
Q

What does PSA do?

A

Liquifies semen

73
Q

What is PSA produced by?

A

Glands of the prostate

74
Q

Normal serum range of PSA

A

0-4.0

75
Q

What does the upper normal limit of PSA increase with?

A

Age

76
Q

Causes of elevations of PSA

A 
UTI
Chronic prostatitis 
Instrumentation (e.g. catheterisation)
Physiological (e.g. ejaculation) 
Recent urological procedure 
BPH 
Prostate cancer
77
Q

What is the half life of PSA?

A

2.2 days

78
Q

If a repeat PSA is needed, when should It be rechecked?

A

In 3 weeks

79
Q

If PSA = 0-1.0, what is the cancer probability?

A

5%

80
Q

If PSA = 1.0-2.5, what is the cancer probability?

A

15%

81
Q

If PSA = 2.5-4.0, what is the cancer probability?

A

25%

82
Q

If PSA = 4.0-10.0, what is the cancer probability?

A

40%

83
Q

If PSA = > 10, what is the cancer probability?

A

70%

84
Q

What is the prostate cancer grading system?

A

Gleason

85
Q

How many grades does the Gleason grading system have?

A

5

86
Q

What is the most common Gleason score?

A

3

87
Q

What are the stages of prostate cancer?

A
  1. Localised stage
  2. Locally advanced stage
  3. Metastatic stage
  4. Hormone refractory stage
88
Q

Staging investigations for prostate cancer

A 
DRE (local staging)
PSA
Transrectal US guided biopsies
CT (regional and distant staging)
MRI (local staging)

Renal Pathology (13 decks)

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