Urothelial Cancers Flashcards
Where can Urothelial cancers occur
occur at any point from real callouses to the tip of the urethra
What is the most common site for a Urothelial cancer
The bladder (90%)
What is urothelial cancer also known as
Transitional cell carcinoma
What is the 5 year survival rate of a Non-invasive, low grade bladder TTC
90%
What is the 5 year survival rate of a invasive, high grade bladder TTC
50%
What % of bladder cancers are TCC
90%
What is the other cell type found in bladder cancer apart from TCC
Squamous cell carcinoma
Where are Squamous cell carcinomas more common
In places where schistosomiasis is endemic
Whats the risk factor for TCC bladder cancer
Smoking (accounts for 40% of cases)
Aromatic amines
Non-hereditary genetic abnormalities (e.g. TSG incl. p53 and Rb)
What the risk factor for SSC in the bladder
Schistosomiasis (S. haematobium only)
Chronic cystitis (e.g. recurrent UTI, long term catheter, bladder stone)
Cyclophosphamide therapy
Pelvic radiotherapy
Where are adenocarcinomas found (very rare)
The Urachal
What is a urachal
A canal in the foetus that drains urine from bladder to belly button
What the presenting symptoms for bladder cancer
Painless visible haematuria
Recurrent UTI
Storage bladder symptoms dysuria, frequency, nocturia, urgency +/- urge incontinence bladder pain
What should you suspect if the patient presents with storage bladder symptoms
If present, suspect Carcinoma in Situ (CIS)
What is carcinoma in Situ
Carcinoma in situ (CIS) is a group of abnormal cells that are found only in the place where they first formed in the body (see left panel). These abnormal cells may become cancer and spread to nearby normal tissue (see right panel).
What investigations should you carry out for bladder cancer
Urine culture
Cystourethroscopy
Upper tract imaging
Urine Cytology
- Limited use in Dipstick haematuria
BP and U&E’s
What the risk of malignancy if you find Frank haematuria and patient is >50
25-35%
What the risk of malignancy if you find microscopic haematuria and patient is >50
5-10%
What investigations should you do if patient has frank haematuria
Flexible cystourethroscopy within 2 weeks
Ct urogram & USS
Urine Cytology may also be useful (but not very sensitive nor specific)
What investigations should you do if patient has microscopic haematuria
Flexible cystourethroscopy within 4-6 weeks
USS
What procedures can be used to diagnose the bladder cancer
Cystoscopy and endoscopic resection (TURBT)
EUA to assess bladder mass/thickening before and after TURBT
What procedures can be used to stage the bladder cancer
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)
What is treatment for Low grade non-muscle 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 treatment for high grade non-muscle invasive or CIS
-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)
patients refractory to BCG – need radical surgery
What is treatment for Muscle invasive bladder (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
Where is the most common upper tract TCC located
Renal pelvis or collecting symptoms
Where is the most least common upper tract TCC located
Ureter
What is usually common for upper tract TCC
Tumours are often high-grade and multifocal on one side
What are the presenting symptoms of upper tract TCC
Frank haematuria
Unilateral ureteric obstruction
Flank or loin pain
What are symptoms of nodal or metastatic disease
Bone pain
Hypercalcaemia
Lung involvement
Brain involvement
What are Diagnostic investigations for upper tract TCC
CT-IVU or IVU
Urine cytology
Ureteroscopy and biopsy
What is treatment for upper tract TCC
Most upper tract TCCs are treated by nephro-ureterectomy
Why are upper tract TCC not treated endoscopically or by segmental resection
High risk of local recurrence if treated endoscopically or by segmental resection
Difficult to follow up if treated endoscopically
What do you do If unfit for nephro-ureterectomy or has bilateral disease with upper tract TCC
If unfit for nephro-ureterectomy or has bilateral disease - absolute indication for nephron-sparing endoscopic treatment (i.e. ureteroscopic laser ablation); needs regular surveillance ureteroscopy
If uni-focal and low-grade disease
Relative indication for endoscopic treatment
If endoscopic treatment is used for upper TCC then what should be done
In ALL cases, high risk of synchronous and metachronous bladder TCC (40% over 10 years); hence need surveillance cystoscopy
