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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
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)
- **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
Give the treatment plan for MUSCLE INVASIVE bladder cancer **(T2/T3)**
- **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
What is the prognosis of non-invasive, low grade bladder TCC?
90% survival at 5 yrs
28
What is the prognosis of invasive, high grade bladder TCC?
50% survival at 5yrs
29
GIve the 4 presenting features of UTUC (upper tract urothelial cancer)
- *Frank haematuria* * - Unilateral ureteric obstruction* * - Flank or loin pain* * - Symptoms of nodal/metastatic disease*: bone pain, hypercalcaemia, lung, brain
30
3 diagnostic investigations for UTUC?
**- CT-IVU** or **IVU** **-** Urine **cytology** **- Ureteroscopy** and **biopsy**
31
What does this drawing of a IVU/CT-IVU of UTUC show?
Filling defect in renal pelvis
32
Where does UTUC most commonly and least commonly occur?
Most commonly renal pelvis or collecting system Less commonly ureter
33
What is the nature of majority of UTUC tumours?
Often high-grade and multifocal on one side
34
If UTUC treated endoscopically or by segmental resection, what is there a high risk of?
Local recurrence (also difficult to follow up) (low risk of having contralateral disease)
35
So how are most upper tract UCCs treated? (due to high risk of local recurrence and difficulty of follow up w endoscopic treatment)
**Nephro-ureterectomy**
36
What is an *absolute indication* for nephron-sparing endoscopic treatment (i.e. **ureteroscopic laser ablation**) in UTUC bladder cancer?
If unfit for nephro-ureterectomy or has bilateral disease (needs regular surveillance ureteroscopy)
37
What is a relative indication for endoscopic treatment of UTUC?
If unifocal and low-grade disease
38
In ALL cases, *high risk of synchronous and metachronous bladder TCC* (40% over 10 yrs), so what is needed?
**Surveillance cytoscopy**
39
Renal cell carcinoma
40
Give the 2 benign renal tumours
Oncocytoma Angiomyolipoma
41
What is the commonest adult renal malignancy?
Renal adenocarcinoma | (aka hypernephroma or Grawitz tumour)
42
Where in the nephron do most renal adenocarcinomas arise?
Proximal tubules
43
What is the histological subtype of 85% of renal adenocarcinomas? Name the other 3 types
Clear cell Papillary (10%) Chromophobe (4%) Bellini type ductal carcinoma (1%)
44
GIve 6 risk factors for renal adenocarcinoma
- Family history - Smoking - Anti-hypertensive meds - Obesity - End-stage renal failure - Acquired renal cystic disease
45
What is the presentation of renal adenocarcinoma 50% of the time?
ASYMPTOMATIC (i.e incidentally noted on imaging for unrelated symptoms)
46
What is the 'classic triad' for renal adenocarcinoma? (10% of presentations)
**Flank pain** **Mass** **Haematuria**
47
What percentage of renal adenocarcinoma patients present with paraneoplastic syndrome? What are the symptoms of it?
30% - Anorexia, cachexia, pyrexia - Hypertension, hypercalcaemia, abnormal LFTs - Anaemia, polycythaemia, raised ESR
48
What percentage of renal adenocarcinoma patients present with metastatic disease? Give 4 metastatic sites
30% Bone, brain, lungs, liver
49
Describe T1 stage of renal cancer
Tumour \<7cm confined within renal capsule
50
Describe T2 stage of renal cancer
Tumour \>7cm and confined within capsule
51
Describe T3 stage of renal cancer
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
Describe T4 stage of renal cancer
Tumour invades beyond Gerota's fascia (fascia encapsulating kidneys and adrenal glands)
53
GIve 4 methods of adenocarcinoma spread
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
Investigations for renal adenocarcinoma?
- 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
What is the treatment for renal adenocarcinoma?
Surgical Iaparoscopic radical nephrectomy Curative if ≤T2 Worthwhile even w major venous invasion
56
In patients even with metastatic disease who have symptoms from primary tumour, what surgery is beneficial?
Palliative cytoreductive nephrectomy (prolongs median survival by 6 months)
57
Why is there little effective treatment for metastases of renal adenocarcinoma?
RCC is radioresistant and chemoresistant
58
What is the current treatment for renal adenocarcinoma metastases?
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
Prognosis for renal adenocarcinoma?
* 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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