Urological Cancers Flashcards
Name three types of renal cancer:
- Renal cell Carcinoma (RCC)
- Transitional CC
- Although rare in renal, pelvis, ureter, it is more common in bladder - Squamous CC
- Metaplasia-dysplasia process
- Associated w/irritation e.g. stones and schiastomosis
Prognosis and sites of metastases in Renal Cell Carcinoma
(1. ) Most common malignant tumour of the kidney in adults. Usually found incidentally
(2. ) Tumour arises from renal tubular cells
(3. ) Metastases
- Lymph, bone, liver, lung
- Invasion of renal vein -> tumour thrombosis can travel to RA
(4. ) Prognosis: 10yr survival
- Score 0-1 =96.5%
- Score >10 = 19.2%
RF of Renal Cell Carcinoma (10).
- Smoking
- obesity
- HTN
- renal failure
- social deprivation
- male
- 55y (mean age)
- haemodialysis
- VHL syndrome (genetic)
- renal transplant
Clinical features of Renal Cell Carcinoma (6.)
(1. ) Asymptomatic
(2. ) Haematuria
(3. ) Loin pain
(4. ) Palpable mass
- –> 10% of pt present with a triad of haematuria, loin pain, palpable mass
(5. ) Systemic Sx: fever, raised ESR, coag disorder, hypercalcaemia, abnormal LFTs, plasma proteins
(6. ) Sx of metastatic disease: fatigue, weight loss, bone pain
Investigations of Renal Cell Carcinoma (4.)
(1. ) U&E, ESR, FBC (polyathaemia), LFTS (ALP, coag issues?), Ca levels.
(2. ) Renal US: Differentiate tumour or cyst
(3. ) CT of abdo & chest, bone scan
- staging, ‘cannonball’ metastases
(4.) Special tests to consider: renal biopsy, genetic tests
Management of Renal Cell Carcinoma (5.)
RCC does NOT respond to radiotherapy
(1. ) Radical or Partial nephrectomy
- Partial is GOLD standard for small tumours <4cm confined to kidney
(2. ) Radiofrequency ablation
- For pt at high operative risk and small tumours
(3. ) Active surveillance w/serial imaging
- In pt w/renal masses <4cm
(4. ) Kinase inhibitors, MTORi, IL-2
- In unresectable or metastatic disease
RF for Transitional Cell carcinoma
- > 50y
- male
- smoking
- chemicals: rubber, dye, diseasal exhausts
- Drugs = pioglitazone, phenacetin, Cyclophosphamide
- Occupation = hairdresser, leather, chemical worker, driver
Presentation of Transitional Cell carcinoma
- Painless haematuria
- frequency
- urgency
- dysuria
- urinary tract obstruction
Ix for Transitional Cell carcinoma
- Urine cytology
- IV urogram
- GOLD: Cystoscopy and biopsy
- CT/MRI
Management of Upper Tract TCC Transitional Cell carcinoma
(1. ) Nephroureterectomy = GOLD standard and curative Tx
(2. ) Ureteroscopy with laser = used for small lesions in local tx of upper tract TCC
What is Wilms Tumour? Presentation? Mx?
- Nephroblastoma
- Childhood tumour of primitive renal tubule and mesenchymal cells
- Present w/abdominal mass and haematuria, can cause HTN
- Mx = refer to paediatric urologist urgently
Threes Types of bladder cancer?
- Transitional Cell Carcinoma TCC (>90%)
- from transitional epithelium - Squamous cell carcinoma (5%)
- 5% in UK
- 75% in Egypt due to schistomasis - Adenocarcinoma (2%)
Pathophysiology of bladder cancer?
- 70-80% of bladder cancers don’t involve bladder muscle wall
- Carcinoma in situ is potentially aggressive and may occur anywhere in the urinary tract
- Malignant changes usually confined to the bladder mucosa
- Tumours of the upper urinary tract often present late
- Low-grade tumours are papillary and easy to visualise, but high-grade tumours are often flat or in situ, and difficult or impossible to visualise
RF for bladder cancer (9)
- Male
- Smoking (biggest RF)
- > 50y
- Pelvic radiology
- Exposure to chemical carcinogens: rubber industry
- Chronic cystitis
- **Schistosomiasis (inc risk of SCC)
- long term catheterisation insertion
- Fx
TNM Stages of bladder cancer
- Tis carcinoma in situ: potentially aggressive and can occur anywhere in the track
- T0 = tumour confined to epithelium
- T1 = tumour in submucosa
- T2 = Invades muscle
- T3 = Extends into peri vesicle fat
- T4 = Invade adjacent organ e.g. prostate, pelvic wall
- N0 = no lymph node involved
- N1-3 = progressive LN involvement (iliac or para-aortic LN)
- M0 = No metastases
- M1 = Distant metastasis - liver, lung, bone, adrenal
Presentation of bladder cancer (4.)
- Painless haematuria (85%) (can be gross or microscopic)
- Dysuria
- Recurrent UTI
- Voiding irritability
- Storage LUTS: Frequency, Urgency, Nocturia
Examination and Investigation of bladder cancer (8).
(1. ) Examine: Lower abdo mass
(2. ) DRE: May be above or infiltrating prostate
(3. ) Urinalysis
(4. ) Cystoscopy w/biopsy (TURBT) Key for diagnosis
(5. ) Urine microscopy/cytology
- presence of pyuria: presence of WBC
(6. ) CT urogram
- CT kidney ureters and bladders with contrast is very effective and imaging bladder cancer
- Diagnostic and provides staging
(7. ) Bimanual EUA
- helps assess spread
(8. ) MRI
- show involved lymph nodes
Treatment and Management of bladder cancer
(1. ) TURBT
- Tis/Ta/T1
- If no muscle involvement
(2. ) Radical or partial cystectomy
- T2-3
(3. ) Neoadjuvant and adjuvant chemotherapy
- Locally advanced
(4. ) Radiotherapy
- If unfit for surgery or palliative
- ***NOTE: TCC is radio insensitive
(5. ) Ileal Conduit
- Diversion and reconstruction
- Ureter directed to ileum
- CONS: big operation, poor QoL
When would you refer suspected bladder cancer?
NICE: 2ww referral if bladder cancer suspected, must meet the following:
- > 45y = Unexplained visible haematuria without UTI
- > 45y = Visible haematuria that persists or recurs after successful treatment of UTI
- > 60y = Unexplained non-visible haematuria + either dysuria or a raised WBC
