Urological Cancers Flashcards
What types of kidney cancers are there and how common are each in %?
- 85% are renal cell carcinomas (adenocarcinomas)
- 10% are transitional cell carcinomas
- 5% are sarcoma/Wilms tumour/other types
What aetiological factors are there that cause kidney cancers?
- Smoking
- Hypertension
- Renal failure and dialysis
- Genetic predisposition with Von Hippel-Lindau syndrome (50% of individuals will develop RCC) (increases the risk of tumour and cyst production in different parts of organs)
Obesity
As well as age,having hepatitis c,exposure to certain dyes asbestos cadmium herbicides and solvents,birt hogg dube syndrome,tue tuberculosis sclerosis and familial papillary renal cell carcinoma
What clinical features can you find in kidney cancers? (7
You may or may not feel a mass- if there is a mass there’s likely to be systemic symptoms too like weight loss or anaemic or polycythaemic (because of paraneoplastic syndromes), hypercalcaemia (again since tumour might secrete this)
- Loin pain
- Palpable mass
-varicocele as you get compression of renal vein - Metastatic disease symptoms like bone pain, haemoptysis, shortness of breath
- Commonest- painless haematuria (particularly if large tumour like transitional cell carcinoma) or persistent microscopic haematuria- a red flag and can reflect urological malignancies
If you can’t find a mass how then do we often find kidney cancers? And what symptoms do we see in renal cancer
A lot of them are incidentally found on scans
Blood in urine,back pain below the ribs that doesn’t go away,unexplained weight loss or loss of appetite,fatigue,fever,lump in side belly or lower back,anaemia,night sweats,family history of kidney disease,high bp and high calcium in blood
Main types of renal cell carcinoma/cancers
Clear cell most common,appear as bright yellow due to high lipid content and associated with VHL
Papillary has a papillary growth pattern
Chromophobe renal cell cancer Origim from distal tubules and has better prognosis due to low metastasis
What investigations would we do on painless visible haematuria? (4)
Ask a history about smoking, coagulation problems
CT urogram
Flexible cystoscopy
Renal function
CT urogram- what is this used to look at?
- The top end of the urinary system- CT scan of kidneys which could reveal masses
- Can look down ureters too to look for pathology there e.g. ureteric filling defect which could indicate transitional cell carcinomas or stones (which also cause haematuria)
- Get a little idea of the bladder but we don’t look at it directly- if we see a large bladder mass causing haematuria we might see a filling defect or clot in the bladder
Flexible cystoscopy- what is this and what are we looking for? (4)
- Looking at bladder under local anaesthetic- looking for exophytic lesions (looking for tumours) or bleeding from ureteric orifices which could mean bleed is higher (e.g. ureters) and its trickling down into bladder
- Can look at urethra for transitional cell carcinoma
- Can see strictures that cause haematuria or bleeding prostate
- Red patches in bladder could indicate pre-cancer or carcinoma in-situ
What investigations do we do on persistent non visible haematuria? (2)
- Flexible cystoscopy
- US KUB (US of kidneys, ureter and bladder)
What is non-visible haematuria?
When you see RBCs in urine on microscopy or dipstick but not visually
Which out of visible and non-visible haematuria are we more concerned about?
- Visible because 50-60% of these cases have serious underlying pathology
- Often see them in clinic with large bladder and anaemic and have to wash out bladder because of clots
- Non visible has 1-3% chance
- Also have to check for visible haematuria to see if there’s a renal problem, esp if there’s proteinuria
How do we investigate a suspected renal cancer? (3)
- CT renal triple phase
- Staging CT chest
- Bone scan if symptomatic
What staging system would we use for RCC?
TNM staging
- T1?Tumour ≤ 7cm
- T2?Tumour >7cm
- T3?Extends outside kidney but not beyond ipsilateral adrenal or perinephric fascia
- T4?Tumour beyond perinephric fascia into surrounding structures
- N1?Metastasis in single regional LN e.g. paraaortic
- N2?Mets in ≥2 regional LN
- M1?Distant metastasis
What grading system can we use for kidney cancer?
Fuhrman grade
- 1 = well differentiated
- 2 = moderately differentiated
- 3 + 4 = poorly differentiated
4 based in sarcomatoid/rhabdoid differentiation
1x3 on nuclear size
What is management dependent on
Patient specific- depends on:
- ASA status (healthiness of patient)
- Comorbidities
- Classification of lesion
How do we manage kidney cancer in patients with small tumours who are unfit for surgery?
- Cryosurgery- freeze the lesion
- Can follow it up with serial scanning
What is the gold standard for management?
Excision either via:
- Partial nephrectomy- when do we do it? (4)
- single kidney
- bilateral tumour
- multifocal RCC in patients with VHL (multiple small lesions)
- T1 tumours (up to 7cm)
- Radical nephrectomy (full kidney removal)- describe the technique for thiscan remove large tumours through loin or transperitoneal esp if there’s tumour thrombus in IVC to get control of blood vessels
What about metastatic disease? (2)
- Receptor tyrosine kinase inhibitors
- Immunotherapy
What are we trying to avoid with these patients?
Taking out so much kidney that we have to put them on dialysis
What types of bladder cancers are there and how common are each in %?
- > 90% are transitional cell carcinoma- what problem could occur from one of these in the bladder?
- TCC arises from transitional epithelium which also lines ureter and kidney
- If you have a bladder cancer you could get a field change where the cancer travels all the way up from urethra to kidney
- What does this mean bladder cancer patients also have to get done?A CT scan to assess urothelium everywhere else
- 1-7% are squamous cell carcinoma- 75% SCC where schistosomiasis is endemic- what is this?An infection caused by blood flukes (parasites)
- 2% are adenocarcinoma
