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Urinary System > Urothelial and Renal Cancers > Flashcards

Urothelial and Renal Cancers Flashcards

1
Q

What are the sites of urothelial tumours?

A

Malignant tumours of the lining transitional cell epithelium - from renal calyces to tip of the urethra
Most common site is the bladder

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2
Q

What is the pathology of bladder cancer?

A

Most common - transitional cell carcinoma (TCC)
Schistosomiasis is endemic - squamous cell carcinoma

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3
Q

What are the risk factors for transitional cell carcinoma (TCC)?

A

Smoking, aromatic amines and non-hereditary genetic abnormalities

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4
Q

What are the risk factors for squamous cell carcinoma?

A

Schistosomiasis, chronic cystitis, cyclophosphamide therapy and pelvic radiotherapy

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5
Q

What are the presenting features of bladder cancer?

A

Most frequent symptom - painless visible haematuria
Occasionally symptoms of invasive or metastatic disease
Haematuria - frank or microscopic
Recurrent UTIs and storage bladder symptoms

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6
Q

How is haematuria investigated?

A

Urine culture
Cystourethroscopy
Upper tract imaging - CT urogram
Urine cytology - dipstick
BP and U+Es

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7
Q

How is frank haematuria investigated?

A

Flexible cystourethroscopy within 2 weeks
CT urogram and USS
Urine cytology may be useful

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8
Q

What is the risk of malignancy with frank haematuria if over 50yrs?

A

25-35%

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9
Q

How is dipstick or microscopic haematuria investigated?

A

Flexible cystourethroscopy within 4-6 weeks
USS

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10
Q

What is the risk of malignancy of microscopic haematuria if over 50yrs?

A

5-10%

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11
Q

Why is IVU and USS not used alone in diagnosis of urothelial tumours?

A

IVU can miss proportion of renal cell tumour - esp. if under 3cm
USS can miss a proportion of urothelial tumours in upper tracts

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12
Q

How is grade and T stage diagnosed in urothelial tumours - bladder?

A

Cystoscopy and endoscopic resection (TURBT)
EUA to assess bladder thickness

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13
Q

How is urothelial tumours staged?

A

Cross sectional imaging - CT and MRI
Bone scan if symptomatic
CTU for upper tract

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14
Q

How are bladder tumours classified?

A

Grade of tumour
Stage of tumour - TNM (T is muscle invasion or superficial)
Combined to describe TCC

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15
Q

What are the grades of TCC?

A

G1 - well differentiated (commonly non-invasive)
G2 - moderately differentiated (often non-invasive)
G3 - poorly differentiated (often invasive)
CIS - carcinoma in situ (very aggressive)

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16
Q

What does above T2b mean in staging and grading?

A

Detrusor muscle invasion

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17
Q

What does treatment of bladder cancer depend on?

A

Site, clinical stage, histological grade of tumour and patients age and co-morbidities

18
Q

What is the treatment for low grade non-muscle invasive bladder cancer?

A

Endoscopic resection followed by single installation of intravesical chemo within 24hrs
Prolonged endoscopic follow up
Consider prolonged course of chemo for repeated recurrences

19
Q

What is the treatment for high grade non-muscle invasive or CIS bladder cancer?

A

Endoscopic resection alone is not sufficient
CIS consider intravesical BCG therapy
If refractory to BCG then need radical surgery

20
Q

What is the treatment for muscle invasive bladder cancer (T2-3)?

A

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

21
Q

Describe the prognosis of bladder cancer

A

Depends on stage, grade, size, CIS, recurrence at 3 months and multifocality
Non-invasive 5 year survival is 90%
Invasive is 50%

22
Q

What are the presenting features of upper tract TCC (UTUC)?

A

Frank haematuria, unilateral ureteric obstruction, flank or loin pain, and symptoms of nodal or metastatic disease - bone pain, hypercalcaemia, lung and brain

23
Q

What diagnostic investigations are used for UTUC?

A

CT-IVU or IVU
Urine cytology
Ureteroscopy and biopsy

24
Q

What does IVU/ CT-IVU show in UTUC?

A

Filling defect in renal pelvis

25
Q

How are most upper tract TCCs treated?

A

Nephroureterectomy
If unfit or has bilateral disease then indication for for nephron sparing endoscopic treatment

26
Q

What are the sites of upper tract TCC?

A

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

27
Q

What treatment is needed in upper tract TCC which is low grade and unifocal?

A

Endoscopic treatment

28
Q

What do all cases of upper urinary TCC need?

A

Surveillance cystoscopy
As high risk of synchronous and metachronous bladder TCC

29
Q

What are some benign renal tumours?

A

Oncocytoma and angiomyolipoma

30
Q

Describe malignant renal tumour

A

Renal adenocarcinoma - commonest adult renal malignancy
Most arise from proximal tubules
Subtypes - clear cell, papillary, chromophobe and Bellini type ductal

31
Q

What are some risk factors for renal adenocarcinoma?

A

FH (autosomal dominant), smoking, anti-hypertensive medication, obesity, end-stage renal failure and acquired renal cystic disease

32
Q

What is the presentation of renal adenocarcinoma?

A

Asymptomatic - 50%
Classic triad - flank pain, mass and haematuria
Paraneoplastic syndrome
Metastatic disease - bone, brain, lungs and liver

33
Q

What is paraneoplastic syndrome?

A

Anorexia, cachexia, pyrexia, hypertension, hypercalcaemia, abnormal LFTs, anaemia, raised ESR and polycythaemia

34
Q

Describe the TNM staging for renal cancer

A

T1 - <7cm within renal capsule
T2 - >7cm and within capsule
T3 - local extension outside capsule
T4 - tumour invades beyond Gerota’s fascia

35
Q

What is direct spread of renal adenocarcinoma?

A

Through renal capsule

36
Q

What can renal adenocarcinoma spread to - venous invasion?

A

Renal vein and vena cava

37
Q

What is the haematogenous and lymphatic spread of renal adenocarcinoma?

A

Haematogenous - lungs and bone
Lymphatic - paracaval nodes

38
Q

What investigations are done for renal adenocarcinoma?

A

CT scan of abdomen and chest
Bloods - U+Es and FBC
Optional - US and DMSA or MAG-3 for renal split function

39
Q

What is the treatment for renal adenocarcinoma?

A

Surgical - laparoscopic radical nephrectomy standard for T1
Worthwhile in major venous invasion and curative if less than T2
Even in metastatic disease is beneficial

40
Q

What is the treatment for metastatic renal adenocarcinoma?

A

Is radio-resistant and chemo-resistant so little effective treatment
Multitargeted receptor kinase inhibitors and immunotherapy

41
Q

What is the prognosis of renal adenocarcinoma?

A

T1 - 95% 5 years survival
T4 - 20% 5 year survival
M1 - median 12-18 months

Urinary System (26 decks)

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