2. Tumours of the urinary system - urothelial and renal cancer Flashcards
(45 cards)
what areas are affected by urothelial cancers
bladder upper tract (ie ureter, renal pelvis, collecting system)
define what urothelial tumours are
malignant tumours of the lining transitional cell epithelium (urothelium)
can occur at any point from renal calyces to tip of the urethra
what is the most common site of urothelial cancers
bladder - make up 90% cases
what are the different types of bladder cancer
transitional cell carcinoma (TCC) - most common
squamous cell carcinoma
what are three risk factors for TC
smoking (accounts for 40% of cases)
aromatic amines
non-hereditary genetic abnormalities (e.g. TSG incl. p53 and Rb)
what are five risk factors for 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 are the most common presenting features of bladder cancer
**painless visible haematuria
(BUT haematuria can be frank or microscopic )
others
- recurrent UTI
- storage bladder symptoms (dysuria, frequency, nocturia, urgency +/- urge)
- pain
what investigations should be done to investigate the haematuria
urine culture
- majority of painful haematuria = UTI
cystourethoscopy
- commonest neoplastic cause is TCC bladder
Upper tract imagine
- CT urogram (IVU)
- US scan
urine cytology
- limited use in dipstick haematuria
BP
U&E’s
what is the risk of malignancy in >50yrs with FRANK haematuria
25-35%
what investigations should be done if there is FRANK haematuria
Flexible cystourethroscopy within 2 weeks
Ct urogram & USS
Urine Cytology may also be useful (but not very sensitive nor specific)
what is the risk of malignancy in >50yrs with DIPSTIX or MICROSCOPIC haematuria
5-10%
what investigations should be done if there is DIPSTIX or MICROSCOPIC haematuria
Flexible cystourethroscopy within 4-6 weeks
IVU & USS
why are IVU and USS used together
IVU alone will miss a proportion of renal cell tumours (especially if <3cm)
USS alone will miss a proportion of urothelial tumours of the upper tracts
How are bladder cancers diagnosed
cystoscopy and endoscopic resection (TURBT)
EUA to assess bladder mass/thickening before and after TURBT
TURBT = transurethral resection of bladder cancer
what investigations can help stage bladder cancer
cross sectional imagine (CT, MRI)
bone scan if symptomatic
CTU for upper tract TCC
how are bladder tumours classified
grade of tumour
stage of tumour
combined to describe TCC eg G1pTa
what are the grades (G) of TCC
G1 = Well diff. - commonly non-invasive
G2 = Mod. diff. - often non-invasive
G3 = Poorly diff. - often invasive
Carcinoma in situ (CIS) – non-muscle invasive but VERY aggressive (hence treated differently)
what are the stagings of TCC
TNM classification
T-stage
- non-muscle invasive (or ‘superficial’)
- muscle invasive
from Tis, Ta, T1, T2a, T2b, T3a, T3b, T4a, T4b - getting more invasive as number and letter go up
what determines treatment of bladder cancer
site
clinical stage
histological grade of tumour
patient age and co-morbidities
how would you treat low grade non-muscle invasive tumours (i.e. Ta or T1)
endoscopic resection followed by single intravesical chemo (mitomycin) within 24hrs
prolonged endoscopic follow up
prolonged course of intravesical chemo for repeated recurrences
how would you treat a high grade non-muscle invasive or CIS tumour
very aggressively
endoscopic resection alone not sufficient
intravesical BCG therapy - maintenance course weekly for 3 weeks repeated 6 monthly over 3 years
patients refractory to BCG - need radical surgery
how would you treat muscle invasive bladder tumours (i.e. T2-T3)
neoadjuvant chemo fr local and systemic control followed by either:
- radical radiotherapy
- radical surgery
what determines prognosis form bladder cancer
stage grade size multifocality presence of concurrent CIS recurrence at 3 months
what is the % 5 year survival for non-invasive, low grade bladder tumour
90%
