Urothelial and Renal Cancers Flashcards
What are the sites of urothelial tumours?
Malignant tumours of the lining transitional cell epithelium - from renal calyces to tip of the urethra
Most common site is the bladder
What is the pathology of bladder cancer?
Most common - transitional cell carcinoma (TCC)
Schistosomiasis is endemic - squamous cell carcinoma
What are the risk factors for transitional cell carcinoma (TCC)?
Smoking, aromatic amines and non-hereditary genetic abnormalities
What are the risk factors for squamous cell carcinoma?
Schistosomiasis, chronic cystitis, cyclophosphamide therapy and pelvic radiotherapy
What are the presenting features of bladder cancer?
Most frequent symptom - painless visible haematuria
Occasionally symptoms of invasive or metastatic disease
Haematuria - frank or microscopic
Recurrent UTIs and storage bladder symptoms
How is haematuria investigated?
Urine culture
Cystourethroscopy
Upper tract imaging - CT urogram
Urine cytology - dipstick
BP and U+Es
How is frank haematuria investigated?
Flexible cystourethroscopy within 2 weeks
CT urogram and USS
Urine cytology may be useful
What is the risk of malignancy with frank haematuria if over 50yrs?
25-35%
How is dipstick or microscopic haematuria investigated?
Flexible cystourethroscopy within 4-6 weeks
USS
What is the risk of malignancy of microscopic haematuria if over 50yrs?
5-10%
Why is IVU and USS not used alone in diagnosis of urothelial tumours?
IVU can miss proportion of renal cell tumour - esp. if under 3cm
USS can miss a proportion of urothelial tumours in upper tracts
How is grade and T stage diagnosed in urothelial tumours - bladder?
Cystoscopy and endoscopic resection (TURBT)
EUA to assess bladder thickness
How is urothelial tumours staged?
Cross sectional imaging - CT and MRI
Bone scan if symptomatic
CTU for upper tract
How are bladder tumours classified?
Grade of tumour
Stage of tumour - TNM (T is muscle invasion or superficial)
Combined to describe TCC
What are the grades of TCC?
G1 - well differentiated (commonly non-invasive)
G2 - moderately differentiated (often non-invasive)
G3 - poorly differentiated (often invasive)
CIS - carcinoma in situ (very aggressive)
What does above T2b mean in staging and grading?
Detrusor muscle invasion
What does treatment of bladder cancer depend on?
Site, clinical stage, histological grade of tumour and patients age and co-morbidities
What is the treatment for low grade non-muscle invasive bladder cancer?
Endoscopic resection followed by single installation of intravesical chemo within 24hrs
Prolonged endoscopic follow up
Consider prolonged course of chemo for repeated recurrences
What is the treatment for high grade non-muscle invasive or CIS bladder cancer?
Endoscopic resection alone is not sufficient
CIS consider intravesical BCG therapy
If refractory to BCG then need radical surgery
What is the treatment for muscle invasive bladder cancer (T2-3)?
Neoadjuvant chemo for local and systemic control by either - radical RT or radical cystoprostatectomy or anterior pelvic exenteration with urethrectomy with extended lymphadenectomy
Radical surgery with incontinent urinary diversion, continent diversion or orthotopic bladder substitution
Describe the prognosis of bladder cancer
Depends on stage, grade, size, CIS, recurrence at 3 months and multifocality
Non-invasive 5 year survival is 90%
Invasive is 50%
What are the presenting features of upper tract TCC (UTUC)?
Frank haematuria, unilateral ureteric obstruction, flank or loin pain, and symptoms of nodal or metastatic disease - bone pain, hypercalcaemia, lung and brain
What diagnostic investigations are used for UTUC?
CT-IVU or IVU
Urine cytology
Ureteroscopy and biopsy
What does IVU/ CT-IVU show in UTUC?
Filling defect in renal pelvis
How are most upper tract TCCs treated?
Nephroureterectomy
If unfit or has bilateral disease then indication for for nephron sparing endoscopic treatment
What are the sites of upper tract TCC?
Renal pelvis or collecting system commonest
Ureter less common
Often high grade and multifocal on one side
High risk of recurrence if treated endoscopically or segmental resection
What treatment is needed in upper tract TCC which is low grade and unifocal?
Endoscopic treatment
What do all cases of upper urinary TCC need?
Surveillance cystoscopy
As high risk of synchronous and metachronous bladder TCC
What are some benign renal tumours?
Oncocytoma and angiomyolipoma
Describe malignant renal tumour
Renal adenocarcinoma - commonest adult renal malignancy
Most arise from proximal tubules
Subtypes - clear cell, papillary, chromophobe and Bellini type ductal
What are some risk factors for renal adenocarcinoma?
FH (autosomal dominant), smoking, anti-hypertensive medication, obesity, end-stage renal failure and acquired renal cystic disease
What is the presentation of renal adenocarcinoma?
Asymptomatic - 50%
Classic triad - flank pain, mass and haematuria
Paraneoplastic syndrome
Metastatic disease - bone, brain, lungs and liver
What is paraneoplastic syndrome?
Anorexia, cachexia, pyrexia, hypertension, hypercalcaemia, abnormal LFTs, anaemia, raised ESR and polycythaemia
Describe the TNM staging for renal cancer
T1 - <7cm within renal capsule
T2 - >7cm and within capsule
T3 - local extension outside capsule
T4 - tumour invades beyond Gerota’s fascia
What is direct spread of renal adenocarcinoma?
Through renal capsule
What can renal adenocarcinoma spread to - venous invasion?
Renal vein and vena cava
What is the haematogenous and lymphatic spread of renal adenocarcinoma?
Haematogenous - lungs and bone
Lymphatic - paracaval nodes
What investigations are done for renal adenocarcinoma?
CT scan of abdomen and chest
Bloods - U+Es and FBC
Optional - US and DMSA or MAG-3 for renal split function
What is the treatment for renal adenocarcinoma?
Surgical - laparoscopic radical nephrectomy standard for T1
Worthwhile in major venous invasion and curative if less than T2
Even in metastatic disease is beneficial
What is the treatment for metastatic renal adenocarcinoma?
Is radio-resistant and chemo-resistant so little effective treatment
Multitargeted receptor kinase inhibitors and immunotherapy
What is the prognosis of renal adenocarcinoma?
T1 - 95% 5 years survival
T4 - 20% 5 year survival
M1 - median 12-18 months
