Urothelial and Renal Cancers Flashcards
Where can urothelial tumours occur?
•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”
What is the most common cancer type of the bladder?
- 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
What are risk factors for TCC?
–smoking (accounts for 40% of cases)
–aromatic amines
–non-hereditary genetic abnormalities (e.g. TSG incl. p53 and Rb)
What are the risk factors for squamous cell carcinoma?
•Squamous cell carcinoma :
–Schistosomiasis (S. haematobium only)
–chronic cystitis (e.g. recurrent UTI, long term catheter, bladder stone)
–cyclophosphamide therapy
–pelvic radiotherapy
Adenocarcinoma
-Urachal
What is the most frequent presenting symptom for badder cancer?
–painless visible haematuria
Occasionally - symptoms due to invasive or metastatic disease
•Haematuria may be
–Frank - reported by patient
–Microscopic - detected by doctor
Besides haematuria, what are the presenting features?
–recurrent UTI
–storage bladder symptoms
- dysuria, frequency, nocturia, urgency +/- urge incontinence
- bladder pain
- if present, suspect CIS
What are the investigations for haematuria?
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
What is the investigation for frank haematuria for patients over the age of 50?
–>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)
How do you diagnose bladder cancer?
(grade and T stage)
–cystoscopy and endoscopic resection (TURBT) - Transurethral resection of bladder tumour
–EUA to assess bladder mass/thickening before and after TURBT
(examination under anaesthesia)
How do we determine the staging - T,N,M?
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
What determines the treatment of bladder cancer?
–Site
–Clinical stage
–Histological grade of tumour
–Patient age and co-morbidities
What is the treatment for low grade non invasive (i.e Ta or T1)
- 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
What is the treatment for high grade non-muscle invasive or CIS (carcinoma in situ)
- 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
What is the bladder cancer treatment for muscle invasive cancer? (T2-T3)
- 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
Define cystoprostatectomy
Surgery to remove the bladder (the organ that holds urine) and the prostate. In a radical cystoprostatectomy, the seminal vesicles are also removed
Define pelvic exenteration
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
What is the prognosis for bladder cancer?
–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
What are the presenting features of upper tract urothelial cancer?
–Frank haematuria
–Unilateral ureteric obstruction
– Flank or loin pain
– Symptoms of nodal or metastatic disease
- Bone pain
- Hypercalcaemia
- Lung
- Brain
What are the diagnostic investigations for upper tract urothelial cancer?
CT - IVU (CT urogram) or IVU - shows filling defect in the renal pelvis
Urine cytology
Ureteroscopy and biopsy
Where is a TCC likely to be in the upper tract?
Rnal pelvis or collecting system commonest
Ureter less commonly
How are most transitional cell carcinomas in the upper tact treated?
Nephro-ureterectomy
Why aren’t upper tract cancers treated endoscopically?
High risk of local recurrence - risk of recurrence is also present if treated by segmental resection
Difficult to follow up if treted endoscopically
Define nephroureterectomy
Nephroureterectomy is a minimally invasive surgical procedure to remove a patient’s renal pelvis, kidney, ureter, and bladder cuff.
When is ureteroscopic laser ablation indicated?
This is a nephron sparing endoscopic treatment
Used in patients unfit for nephro-ureterectomy or patients with bilateral disease
