Urothelial and Renal Cancers Flashcards

1
Q

Where can urothelial tumours occur?

A

•Malignant tumours of the lining transitional cell epithelium (urothelium) can occur at any point

–from renal calyces

–to the tip of the urethra.

•Most common site - bladder - 90%

–“Bladder Cancer”

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2
Q

What is the most common cancer type of the bladder?

A
  • The tumour type is most often transitional cell carcinoma (i.e. 90% in UK)
  • Where Schistosomiasis is endemic, squamous cell carcinoma of the bladder is the common tumour type
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3
Q

What are risk factors for TCC?

A

–smoking (accounts for 40% of cases)

–aromatic amines

–non-hereditary genetic abnormalities (e.g. TSG incl. p53 and Rb)

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4
Q

What are the risk factors for squamous cell carcinoma?

A

•Squamous cell carcinoma :

–Schistosomiasis (S. haematobium only)

–chronic cystitis (e.g. recurrent UTI, long term catheter, bladder stone)

–cyclophosphamide therapy

–pelvic radiotherapy

Adenocarcinoma

-Urachal

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5
Q

What is the most frequent presenting symptom for badder cancer?

A

–painless visible haematuria

Occasionally - symptoms due to invasive or metastatic disease

•Haematuria may be

–Frank - reported by patient

–Microscopic - detected by doctor

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6
Q

Besides haematuria, what are the presenting features?

A

–recurrent UTI

–storage bladder symptoms

  • dysuria, frequency, nocturia, urgency +/- urge incontinence
  • bladder pain
  • if present, suspect CIS
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7
Q

What are the investigations for haematuria?

A

Urine culture - majority of painful haematuria = UTI

Cystourethroscopy - commonest neoplastic cause is TCC bladder

Upper tract imaging - CT urogram (IVU), ultrasound scan

Urine Cytology - limited use in dipstick haematuria

BP and U and E’s

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8
Q

What is the investigation for frank haematuria for patients over the age of 50?

A

–>50 yrs - Risk of malignancy - 25-35%

–Flexible cystourethroscopy within 2 weeks

–IVU (CT Urogram) & USS

(IVU alone will miss a proportion of renal cell tumours (especially if less than 3 cm)

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

Urine cytology may also be useful (but not very sensitive or specific)

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9
Q

How do you diagnose bladder cancer?

(grade and T stage)

A

–cystoscopy and endoscopic resection (TURBT) - Transurethral resection of bladder tumour

–EUA to assess bladder mass/thickening before and after TURBT

(examination under anaesthesia)

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10
Q

How do we determine the staging - T,N,M?

A

Cross sectional imaging (CT, MRI)

Bone scan if symptomatic

–CTU for upper tract TCC (2-7% risk over 10 years; higher risk if high grade, stage or multifocal bladder tumours)

Treatment - endoscopic or radical

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11
Q

What determines the treatment of bladder cancer?

A

–Site

–Clinical stage

–Histological grade of tumour

–Patient age and co-morbidities

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12
Q

What is the treatment for low grade non invasive (i.e Ta or T1)

A
  • endoscopic resection followed by single instillation of intravesical chemotherapy (mitomycin C) within 24 hours
  • prolonged endoscopic follow up for moderate grade tumours
  • consider prolonged course of intravesical chemotherapy (6 weeks months) for repeated recurrences
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13
Q

What is the treatment for high grade non-muscle invasive or CIS (carcinoma in situ)

A
  • very aggressive – 50-80% risk of progression to muscle invasive stage
  • endoscopic resection alone not sufficient
  • CIS consider intravesical BCG therapy (maintenance course, weekly for 3 weeks repeated 6 monthly over 3 years)

Bacillus Calmette-Guerin therapy: Bacillus Calmette-Guerin (BCG) is the main intravesical immunotherapy for treating early-stage bladder cancer.

•patients refractory to BCG – need radical surgery

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14
Q

What is the bladder cancer treatment for muscle invasive cancer? (T2-T3)

A
  • neoadjuvant chemotherapy for local (i.e. downstaging) and systemic control; followed by either :
  • radical radiotherapy and/or;
  • radical cystoprostatectomy (men) or anterior pelvic exenteration with urethrectomy (women); with extended lymphadenectomy
  • radical surgery combined with incontinent urinary diversion (i.e. ileal conduit), continent diversion (e.g. bowel pouch with catheterisable stoma) or orthotopic bladder substitution
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15
Q

Define cystoprostatectomy

A

Surgery to remove the bladder (the organ that holds urine) and the prostate. In a radical cystoprostatectomy, the seminal vesicles are also removed

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16
Q

Define pelvic exenteration

A

Pelvic exenteration (or pelvic evisceration) is a radical surgical treatment that removes all organs from a person’spelvic cavity. The urinary bladder, urethra, rectum, and anus are removed. The procedure leaves the person with a permanent colostomy and urinary diversion

17
Q

What is the prognosis for bladder cancer?

A

–stage

–grade

–size

–multifocality

–presence of concurrent CIS

–recurrence at 3 months

  • Non-invasive, low grade bladder TCC: 90% 5-year survival
  • Invasive, high grade bladder TCC: 50% 5-year survival
18
Q

What are the presenting features of upper tract urothelial cancer?

A

–Frank haematuria

–Unilateral ureteric obstruction

– Flank or loin pain

– Symptoms of nodal or metastatic disease

  • Bone pain
  • Hypercalcaemia
  • Lung
  • Brain
19
Q

What are the diagnostic investigations for upper tract urothelial cancer?

A

CT - IVU (CT urogram) or IVU - shows filling defect in the renal pelvis

Urine cytology

Ureteroscopy and biopsy

20
Q

Where is a TCC likely to be in the upper tract?

A

Rnal pelvis or collecting system commonest

Ureter less commonly

21
Q

How are most transitional cell carcinomas in the upper tact treated?

A

Nephro-ureterectomy

22
Q

Why aren’t upper tract cancers treated endoscopically?

A

High risk of local recurrence - risk of recurrence is also present if treated by segmental resection

Difficult to follow up if treted endoscopically

23
Q

Define nephroureterectomy

A

Nephroureterectomy is a minimally invasive surgical procedure to remove a patient’s renal pelvis, kidney, ureter, and bladder cuff.

24
Q

When is ureteroscopic laser ablation indicated?

A

This is a nephron sparing endoscopic treatment

Used in patients unfit for nephro-ureterectomy or patients with bilateral disease

25
Q

When is endoscopic treatment for upper tract cancer indicated?

A

•If unifocal and low-grade disease - relative indication for endoscopic treatment

26
Q

Why is there a need for surveillance cystoscopy after treatment for upper tract bladder cancer removal?

A

•In ALL cases, high risk of synchronous and metachronous bladder TCC (40% over 10 years); hence need surveillance cystoscopy

27
Q

What are the benign renal cancers?

A

Oncocytoma

Angiomyolipoma

28
Q

What is the most common adult renal malignancy?

A

Renal adenocarcinoma

Most arise from proximal tubules

Histological subtypes:

  • clear cell (85%)
  • papillary (10%)
  • chromophobe (4%)
  • Bellini type ductal carcinoma (1%)
29
Q

What are risk factors for renal adenocarcinoma?

A
  • Family history (autosomal dominant e.g. vHL, familial clear cell RCC, hereditary papillary RCC; can be bilateral and/or multifocal)
  • Smoking
  • Anti-hypertensive medication
  • Obesity
  • End-stage renal failure
  • Acquired renal cystic disease
30
Q

What is the presentation of renal adenocarcinoma?

A
  • Asymptomatic (i.e. incidentally noted on imaging for unrelated symptoms) : 50%
  • ‘Classic triad’ of flank pain, mass and haematuria : 10%
  • Paraneoplastic syndrome : 30%

–anorexia, and pyrexia

–hypertension, hypercalcaemia and abnormal LFTs

–anaemia, polycythaemia and raised ESR

•Metastatic disease : 30%

–bone, brain, lungs, liver

31
Q

What are the ways renal cancer spreads?

A

Direct - through renal capsule

Venous invasion - to renal vein and vena cava

Haematogenous spread to lungs and bone

Lymphatic spread to paracaval nodes

32
Q

What are the investigations for renal adenocarcinoma?

A

•CT scan (triple phase) of abdomen and chest is mandatory

–provides radiological diagnosis and complete TNM staging

–assesses contralateral kidney

Bloods: U and E, FBC

This may indicate some of the paraneoplastic syndrome (hypercalcaemia, abnormal LFTs, anaemia, polycthaemia)

Optional tests:

–IVU shows calyceal distortion and soft tissue mass

–Ultrasound differentiates tumour from cyst

–DMSA or MAG-3 renogram to assess split renal function if doubts about contralateral kidney

33
Q

What is the treatment for renal adenocarcinoma?

A

•Treatment is surgical – i.e. radical nephrectomy

–laparoscopic radical nephrectomy is standard of care for T1 tumours (T2 tumours in laparoscopic centres)

–worthwhile even with major venous invasion (≥T3b)

–curative if ≤T2

•Even in patients with metastatic disease who have symptoms from primary tumour, palliative cytoreductive nephrectomy is beneficial (prolongs median survival by 6 months)

34
Q

What is the treatment for renal adenocarcinoma?

A

•Metastases - little effective treatment since RCC is radioresistant and chemoresistant

–multitargeted receptor tyrosine kinase inhibitors

  • relatively new
  • sunitinib, sorafenib, panzopanib,temsirolimus
  • superior response rates to immunotherapy
  • trials ongoing

immunotherapy

  • Interferon alpha
  • Interleukin-2
  • response rate with either 20% at most
35
Q

Here is some classification of bladder tumours

A

•Stage of tumour

  • TNM classification
  • T-stage :
  • non-muscle invasive (or ‘superficial’)
  • muscle invasive

•Combined to describe TCC e.g. G1pTa