Urological Cancers

Question 1

Name three types of renal cancer:

Answer 1

1. Renal cell Carcinoma (RCC)
2. Transitional CC
   - Although rare in renal, pelvis, ureter, it is more common in bladder
3. Squamous CC
   - Metaplasia-dysplasia process
   - Associated w/irritation e.g. stones and schiastomosis

Question 2

Prognosis and sites of metastases in Renal Cell Carcinoma

Answer 2

(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%

Question 3

RF of Renal Cell Carcinoma (10).

Answer 3

1. Smoking
2. obesity
3. HTN
4. renal failure
5. social deprivation
6. male
7. 55y (mean age)
8. haemodialysis
9. VHL syndrome (genetic)
10. renal transplant

Question 4

Clinical features of Renal Cell Carcinoma (6.)

Answer 4

(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

Question 5

Investigations of Renal Cell Carcinoma (4.)

Answer 5

(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

Question 6

Management of Renal Cell Carcinoma (5.)

Answer 6

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

Question 7

RF for Transitional Cell carcinoma

Answer 7

• > 50y
• male
• smoking
• chemicals: rubber, dye, diseasal exhausts
• Drugs = pioglitazone, phenacetin, Cyclophosphamide
• Occupation = hairdresser, leather, chemical worker, driver

Question 8

Presentation of Transitional Cell carcinoma

Answer 8

• Painless haematuria
• frequency
• urgency
• dysuria
• urinary tract obstruction

Question 9

Ix for Transitional Cell carcinoma

Answer 9

• Urine cytology
• IV urogram
• GOLD: Cystoscopy and biopsy
• CT/MRI

Question 10

Management of Upper Tract TCC Transitional Cell carcinoma

Answer 10

(1. ) Nephroureterectomy = GOLD standard and curative Tx

(2. ) Ureteroscopy with laser = used for small lesions in local tx of upper tract TCC

Question 11

What is Wilms Tumour? Presentation? Mx?

Answer 11

• 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

Question 12

Threes Types of bladder cancer?

Answer 12

1. Transitional Cell Carcinoma TCC (>90%)
   - from transitional epithelium
2. Squamous cell carcinoma (5%)
   - 5% in UK
   - 75% in Egypt due to schistomasis
3. Adenocarcinoma (2%)

Question 13

Pathophysiology of bladder cancer?

Answer 13

• 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

Question 14

RF for bladder cancer (9)

Answer 14

• 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

Question 15

TNM Stages of bladder cancer

Answer 15

• 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

Question 16

Presentation of bladder cancer (4.)

Answer 16

• Painless haematuria (85%) (can be gross or microscopic)
• Dysuria
• Recurrent UTI
• Voiding irritability
• Storage LUTS: Frequency, Urgency, Nocturia

Question 17

Examination and Investigation of bladder cancer (8).

Answer 17

(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

Question 18

Treatment and Management of bladder cancer

Answer 18

(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

Question 19

When would you refer suspected bladder cancer?

Answer 19

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