Tumours of urinary system and imaging Flashcards
Where do malignant tumours of the lining transitional cell epithelium occur?
At any point from renal calyces to the tip of the urethra. Most common site - bladder - 90%
Bladder cancer - most common type of tumour is?
Transitional cell carcinoma (90% in UK)
Schistosomiasis (flatworm) is endemic, squamous cell carcinoma of bladder is the common tumour type.
Risk factors for Bladder cancer?
TCC:
- smoking (40% cases)
- aromatic amines
- non-hereditary genetic abnormalities (TSG)
Squamous cell carcinoma:
- Schistosomiasis
- Chronic cystitis (long term catheter, bladder stone, recurrent UTI)
- Cyclophosphamide therapy
- pelvic radiotherapy
Adenocarcinoma
- Urachal
Presenting features of bladder cancer
Most frequent presenting symptom: - Painless visible haematuria Haematuria may be - Frank - Microscopic Occasionally: Symptoms due to invasive or metastatic disease.
Recurrent UTI Storage bladder symptoms: - dysuria, frequency,nocturne,urgency +/- urge incontinence. - bladder pain - if present, suspect CIS
Investigations of Haematuria
Urine culture:
- majority of painful haematuria = UTI
Upper tract imaging:
CT urogram (IVU)
US scan
Cystourethroscopy:
- commonest neoplastic cause is TCC bladder
Urine cytology
- limited use in dipstick haematuria
BP and U&E’s.
What is the risk of malignancy and what investigations are carried out for FRANK haematuria?
> 50 yrs - risk of malignancy -25-35%
- Flexible cystourethroscopy within 2 weeks
- CT urogram & USS
- Urine cytology may also be useful (not very sensitive nor specific)
Risk of malignancy for Dipstick or microscopic haematuria and investigations carried out?
> 50 yrs - risk of malignancy = 5-10%
- Flexible cystourethroscopy within 4-6 weeks
- USS
How do you diagnose bladder cancer?
Cystoscopy and endoscopic resection. (TURBT)
EUA to assess bladder mass/thickening before and after TURBT
How do you investigate the staging?
Cross-sectional imaging (CT, MRI)
Bone scan if symptomatic
CTU for upper tract TCC
Treatment for bladder cancer
Endoscopic or radical
How do you classify bladder tumours?
Grade Stage of tumour - TNM classification - T stage: - non-muscle invasive - muscle invasive
- Combined to describe TCC.
What are the grades of TCC?
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)
T stage of Bladder TCC
Tis Ta T1 T2a T2b T3a T3b T4a - prostate T4b
What does appropriate treatment depend on?
- Site
- Clinical stage
- Histological grade of tumour
- Patient age and co-morbidities
- What is survival for non- invasive low grade bladder TCC?
- Invasive, high grade bladder TCC?
- 90% 5 - year survival
2. 50% 5 - year survival
Treatment for Low grade non-muscle invasive bladder cancer
Ta or T1
- endoscopic resection followed by single instillation of intravesical chemotherapy within 24hr.
- consider prolonged course of chemo for repeated recurrences.
Treatment for high grade non-muscle invasive or CIS
Very aggressive - 50-80% risk of progression to muscle invasive stage.
Intravesical BCG therapy.
Treatment for muscle invasive bladder cancer?
T2-T3 - neoadjuvant chemo for local and systemic control; followed by: Radical radiotherapy or radical cystoprostatectomy.. Radical surgery.
Upper Tract urothellia cancer presenting features
Main symptoms:
- Frank haematuria
- Unilateral ureteric obstruction
- Flank or loin pain
- Symptoms of nodal or metastatic disease:
- bone pain, hypercalcaemia, lung, brain.
Diagnostic investigations for UTUC
CT-IVU (shows filling defect)
Urine cytology
Ureteroscopy and biopsy
Upper tract TCC where is it common and what is the treatment?
Renal pelvis or collecting system commonest.
Tumours often high-grade and multifocal on one side.
Treatment = endoscopically or segmental resection.
most treated by - Nephron-ureterectomy.
What are the types of Renal tumours?
Benign: oncocytoma, angiomyolipoma
Malignant: renal adenocarcinoma - commonest adult renal malignancy - most arise from proximal tubules Histology subtypes: - clear cell (85% - Papillary (10%) - Chromophobe (4%) - Bellini type ductal carcinoma (1%)
Risk factors of Renal adenocarcinoma
Family history (autosomal dominant) Smoking Anti-hypertensive medication Obesity End - stage renal failure Acquired renal cystic disease
Renal adenocarcinoma presentation
Asymptomatic - 50%
Classic “triad” of flank pain, mass and haematuria - 10%
Paraneoplastic syndrome: 30%
- anorexia, pyrexia, hypertension, hypercalaemia, anemia.
Metastatic disease - 30%
- bone, brain, lung, liver
TNM staging of renal cancer
T1 - tumour <7cm confined within renal capsule
T2 - tumour > 7cm and 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
Investigations for renal adenocarcinoma
CT scan of abdomen and chest- staging and assesses contralateral kidney.
Bloods: U&E, FBC
US - cyst or tumour.
Treatment for renal Adenocarcinoma
Surgical - radical nephrectomy - laparoscopic radical nephrectomy standards for T1.
Prognosis for renal adenocarcinoma in terms of staging for 5 year survival.
T1 - 95% T2 - 90% T3 - 60% T4 - 20% N1 or N2 - 20%
M1 - median survival 12-18 months.
When would we want to use renal imaging?
- Renal colic and renal stone disease for diagnosis and follow up.
- haematuria
- suspected renal mass
- UTIs
- hypertension
What are the different imaging techniques?
- Plain film
- Contrast studies - IVU, cystography.
- Ultrasound +/- contrast
- CT and CTU
- MR and MRU
- Isotope scans
- PET-CT
Advantages and Disadvantages of Plain films
+ cheap, readily available, functional and anatomical information (IVU)
- Low sensitivity and specificity for urological diseases
- radiation
Advantages and disadvantages of US
+ cheap, readily available, no radiation, contrast not nephrotoxic, real time imaging
- limited by body habits and gas, poor visualisation of ureters, operator dependent, no functional information.
Advantages and disadvantages of CT
+ Imaging modality of choice for detection of renal stones, staging renal tumours, investigation of heamaturia.
- Radiation dose
- Cost
- Contrast resolution less than MR
- Contrast reaction and nephrotoxicity
Advantages and disadvantages of MR
+ multiplayer imaging, excellent contrast resolution, imaging of urothelium without contrast injection
- poor spatial resolution, poor detection of calcification and stones, Cost, contraindications and contrast reaction.
- What is a MAG3 used for?
2. What is DMSA?
- Renal function and drainage.
2. Look for renal scarring
