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*Urinary System > Tumours of Urinary System (Bladder + Renal Cancer) > Flashcards

Tumours of Urinary System (Bladder + Renal Cancer) Flashcards

1
Q

Where is urothelial cancer found?

A

Bladder

Upper tract (i.e. ureter, renal pelvis, collecting system)

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2
Q

What cancer is found in the kidney?

A

Renal cell carcinoma

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3
Q

Malignant tumours of the lining transitional cell epithelium (urothelium) can occur at any point from where to where?

A

Renal calyces to the tip of the urethra

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4
Q

Where is the most common site of urothelial tumour?

A

Bladder (90%)

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5
Q

What is the most common tumour type in bladder cancer?

A

Transitional cell carcinoma (90% in UK)

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6
Q

Where Schistomiasis is endemic, what is the most common tumour type in bladder cancer?

A

Squamous cell carcinoma

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7
Q

Give 3 risk factors for TCC bladder cancer

A

Smoking (40% of cases)

Aromatic amines

Non-hereditary genetic abnormalities (e.g. TSG inc p53 and Rb)

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8
Q

GIve 4 risk factors for squamous cell carcinoma bladder cancer

A
  • Schistomiasis
  • Chronic cystitis (e.g. recurrent UTI, long term catheter, bladder stone)
  • Cyclophosphamide therapy
  • Pelvic radiotherapy
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9
Q

What type of bladder cancer is adenocarcinoma?

A

Urachal (rare form of bladder cancer that arises from the urachus, a vestigial musculofibrous band that extends from the dome of the bladder to the umbilicus - usually presents at advanced stage)

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10
Q

Give the most frequent presenting symptoms for bladder cancer

A

PAINLESS VISIBLE HAEMATURIA !

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11
Q

Haematuria can be 2 types:

A

FRANK - reported by patient

MICROSCOPIC - detected by doc

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12
Q

3 other symptoms of bladder cancer? (if present - suspect CIS)

A
  • Recurrent UTI
  • Storage bladder symptoms: dysuria, frequency, nocturia, urgency +/- urge incontinence
  • Bladder pain
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13
Q

What are the methods of investigation for haematuria? (5)

A
  • Urine culture - majority of painful haematuria = UTI
  • Cystourethroscopy - commonest neoplastic cause is TCC bladder
  • Upper tract imaging - CT urogram; USS
  • Urine cytology - limited use in dipstick haematuria
  • BP and U+Es
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14
Q

In someone over 50yrs old with frank haematuria, what is the risk of malignant cause? So what should be done within 2 weeks? And what other tests are useful?

A

25-35%

  • Flexible cystourethroscopy* in 2 wks
  • CT urogram, USS, IVU (IV urogram), urine cytology* (although it isnt sensitive or specific)
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15
Q

Why should IVU not be done alone? Why should USS not be done alone?

A

IVU alone will miss a proportion of renal cell tumours (esp if <3cm)

USS alone will miss a proportion of urothelial tumours of the upper tracts

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16
Q

Pic of urothelial tumour of bladder

A
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17
Q

How is bladder cancer graded and T-staged?

A
  • Cytoscopy and endoscopic resection (TURBT)
  • EUA to assess bladder mass/thickening before and after TURBT
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18
Q

How is bladder cancer T, N and M-staged?

A
  • Cross-sectional imaging (CT, MRI)
  • Bone scan if symptomatic
  • CTU for upper tract TCC (2-7% risk over 10 yrs; higher risk if high grade, stage or multifactorial bladder tumours)
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19
Q

What are the 2 methods for treatment for bladder cancer?

A

Endoscopic

Radical

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20
Q

Endoscopic view of TCC

A
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21
Q

What are the T-stages of bladder cancer TCC?

A
  • Non-muscle invasive (or ‘superficial’)
  • Muscle invasive

(combined with G to describe TCC e.g. G1pTa)

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22
Q

What are the grades of TCC?

A

G1 = well diff. (commonly non-invasive)

G2 = moderately diff. (often non-invasive)

G3 = poorly diff. (often invasive)

CIS (Carcinoma in Situ) - non-muscle invasive but VERY aggressive (hence treated differently)

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23
Q

What 4 factors does appropriate treatment for bladder cancer depend on?

A
  • Site
  • Clinical stage
  • Histological grade of tumour
  • Patient age and co-morbidities
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24
Q

Give the treatment plan for LOW GRADE NON-MUSCLE INVASIVE bladder cancer (i.e. Ta or T1)

A
  • Endoscopic resection followed by single instillation of intravesical chemo (mitomycin C) within 24 hrs
  • Prolonged endoscopic follow up for moderate grade tumours
  • Consider prolonged course of intravesical chemo (6 wks - months) for repeated recurrences
25
Q

Give the treatment plan for HIGH GRADE NON-MUSCLE INVASIVE or CIS bladder cancer

(v aggressive - 50-80% risk of progression to muscle invasive; endoscopic resection alone is not sufficient)

A
  • CIS consider intravesical BCG therapy (maintenance course, weekly for 3 wks repeated 6 monthly over 3 yrs)
  • Patients refractory to BCG - need radical surgery
26
Q

Give the treatment plan for MUSCLE INVASIVE bladder cancer (T2/T3)

A
  • Neoadjuvant chemo for local (i.e. downstaging) and staging control; followed by either:
  • Radical chemo and/or;
  • Radical cystoprostatectomy (men) or anterior pelvic exenteration with urethrectomy (women); with extended lymphadenectomy
  • Radical surgery combined with incontinent urinrary diversion (i.e. ileal conduit), continent diversion (e.g. bowel pouch with catheterisable stoma) or orthotopic bladder substitution
27
Q

What is the prognosis of non-invasive, low grade bladder TCC?

A

90% survival at 5 yrs

28
Q

What is the prognosis of invasive, high grade bladder TCC?

A

50% survival at 5yrs

29
Q

GIve the 4 presenting features of UTUC (upper tract urothelial cancer)

A
  • Frank haematuria
    • Unilateral ureteric obstruction*
    • Flank or loin pain*
    • Symptoms of nodal/metastatic disease*: bone pain, hypercalcaemia, lung, brain
30
Q

3 diagnostic investigations for UTUC?

A

- CT-IVU or IVU

- Urine cytology

- Ureteroscopy and biopsy

31
Q

What does this drawing of a IVU/CT-IVU of UTUC show?

A

Filling defect in renal pelvis

32
Q

Where does UTUC most commonly and least commonly occur?

A

Most commonly renal pelvis or collecting system

Less commonly ureter

33
Q

What is the nature of majority of UTUC tumours?

A

Often high-grade and multifocal on one side

34
Q

If UTUC treated endoscopically or by segmental resection, what is there a high risk of?

A

Local recurrence

(also difficult to follow up)

(low risk of having contralateral disease)

35
Q

So how are most upper tract UCCs treated? (due to high risk of local recurrence and difficulty of follow up w endoscopic treatment)

A

Nephro-ureterectomy

36
Q

What is an absolute indication for nephron-sparing endoscopic treatment (i.e. ureteroscopic laser ablation) in UTUC bladder cancer?

A

If unfit for nephro-ureterectomy or has bilateral disease

(needs regular surveillance ureteroscopy)

37
Q

What is a relative indication for endoscopic treatment of UTUC?

A

If unifocal and low-grade disease

38
Q

In ALL cases, high risk of synchronous and metachronous bladder TCC (40% over 10 yrs), so what is needed?

A

Surveillance cytoscopy

39
Q

Renal cell carcinoma

40
Q

Give the 2 benign renal tumours

A

Oncocytoma

Angiomyolipoma

41
Q

What is the commonest adult renal malignancy?

A

Renal adenocarcinoma

(aka hypernephroma or Grawitz tumour)

42
Q

Where in the nephron do most renal adenocarcinomas arise?

A

Proximal tubules

43
Q

What is the histological subtype of 85% of renal adenocarcinomas? Name the other 3 types

A

Clear cell

Papillary (10%)

Chromophobe (4%)

Bellini type ductal carcinoma (1%)

44
Q

GIve 6 risk factors for renal adenocarcinoma

A
  • Family history
  • Smoking
  • Anti-hypertensive meds
  • Obesity
  • End-stage renal failure
  • Acquired renal cystic disease
45
Q

What is the presentation of renal adenocarcinoma 50% of the time?

A

ASYMPTOMATIC (i.e incidentally noted on imaging for unrelated symptoms)

46
Q

What is the ‘classic triad’ for renal adenocarcinoma? (10% of presentations)

A

Flank pain

Mass

Haematuria

47
Q

What percentage of renal adenocarcinoma patients present with paraneoplastic syndrome? What are the symptoms of it?

A

30%

  • Anorexia, cachexia, pyrexia
  • Hypertension, hypercalcaemia, abnormal LFTs
  • Anaemia, polycythaemia, raised ESR
48
Q

What percentage of renal adenocarcinoma patients present with metastatic disease? Give 4 metastatic sites

A

30%

Bone, brain, lungs, liver

49
Q

Describe T1 stage of renal cancer

A

Tumour <7cm confined within renal capsule

50
Q

Describe T2 stage of renal cancer

A

Tumour >7cm and confined within capsule

51
Q

Describe T3 stage of renal cancer

A

Local extension outside capsule

  • T3a = into adrenal/peri-renal fat
  • T3b = into renal vein or IVC below diaphragm
  • T3c = tumour thrombus in IVC extends above diaphragm
52
Q

Describe T4 stage of renal cancer

A

Tumour invades beyond Gerota’s fascia (fascia encapsulating kidneys and adrenal glands)

53
Q

GIve 4 methods of adenocarcinoma spread

A

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

54
Q

Investigations for renal adenocarcinoma?

A
  • CT scan (triple phase) abdo and chest = mandatory (radiological diagnosis + complete TNM staging; assesses contralateral kidney)
  • Bloods: U+E, FBC
  • Optional tests: USS (differentiate tumour from cyst); DMSA or MAG-3 renogram to assess split renal function (if doubts about contralateral kidney)
55
Q

What is the treatment for renal adenocarcinoma?

A

Surgical

Iaparoscopic radical nephrectomy

Curative if ≤T2

Worthwhile even w major venous invasion

56
Q

In patients even with metastatic disease who have symptoms from primary tumour, what surgery is beneficial?

A

Palliative cytoreductive nephrectomy (prolongs median survival by 6 months)

57
Q

Why is there little effective treatment for metastases of renal adenocarcinoma?

A

RCC is radioresistant and chemoresistant

58
Q

What is the current treatment for renal adenocarcinoma metastases?

A

Multitargeted receptor tyrosine kinase inhibitors = sunitinib, sorafenib, panzopanib,temsirolimus (new; superior response rates to immunotherapy; trials ongoing)

Immunotherapy = interferon alpha, interleukin-2 (response rate with either 20% at most)

59
Q

Prognosis for renal adenocarcinoma?

A
  • 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

*Urinary System (26 decks)

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