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2ND YEAR SYSTEMS: Urinary > Tumours of the Urinary system 2 > Flashcards

Tumours of the Urinary system 2 Flashcards

1
Q

What is urothelial cancer?

A

Tumour of the lining transitional cell epithelium

Commonly known as Bladder cancer

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2
Q

Where could you find a urothelium

A

Can occur at any point
from renal calyces
to the tip of the urethra.

Most common site = bladder = 90%

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3
Q

What is the most common tumour type in bladder cancer in the UK?

A

Transitional cell carcinoma

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4
Q

In places where Schistosomiasis is endemic what is the most common bladder cancer tumour type?

A

Squamous cell carcinoma

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5
Q

Risk factors for transitional cell carcinoma of the bladder (3)

A

Smoking (accounts for 40% of cases)

Aromatic amines - found in things like tobacco smoke, commercial hair dyes, and diesel exhaust.

Non-hereditary genetic abnormalities (e.g. TSG incl. p53 and Rb)

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6
Q

Risk factors for Squamous cell carcinoma of the bladder?

A

Schistosomiasis

Chronic cystitis

Cyclophosphamide therapy

Pelvic radiotherapy

Adenocarcinoma

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7
Q

Most frequent presenting symptom in bladder cancer?

A

Painless visible haematuria

May be frank - reported by patient or microscopic - detected by doctor

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8
Q

Other presenting features of bladder cancer?

A

Recurrent UTI

Storage bladder symptoms - dysuria, frequency, nocturia, urgency, incontinence.

Bladder pain

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9
Q

How might you investigate haematuria?

A

Urine culture - majority of painful haematuria = UTI

Cystourethroscopy - commonest neoplastic cause is TCC bladder

Urine cytology

Upper tract imaging - CT urogram (IVU), USS

BP and U+Es

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10
Q

Frank haematuria (macroscopic) - incidence, investigations and imaging

A

> 50 yrs - Risk of malignancy - 25-35%

Flexible cystourethroscopy within 2 weeks

CT urogram (IVU) & USS

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11
Q

How is bladder cancer diagnosed?

A

Grade and TNM for staging

Cystoscopy and endoscopic resection (TURBT)

Examination under anaesthetic to assess bladder mass/thickening before and after TURBT

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12
Q

Which investigations are used to stage bladder cancer?

A

CT
MRI
Bone scan if symptomatic
CT urogram for upper tract TCC

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13
Q

What does classification of bladder tumours depend on?

A

Grade of tumour

Stage of tumour

  • TNM classification
  • T-stage : non-muscle invasive (or ‘superficial’) vs muscle invasive
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14
Q

Grades of TCC

A 
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)

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15
Q

Treatment of low grade non-muscle invasive tumour in the bladder? (Tis, Ta or T1 - site within bladder)

A

Diathermy via Endoscopic resection of the bladder tumour.

Then a single instillation of intravesical BCG (inserted into the bladder). Works to fight the tumour (chemo)

Follow up cystoscopy after 9 months or so

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16
Q

Treatment of high grade non-muscle invasive tumour in the bladder?

A

Radical cystectomy = the gold standard + radiotherapy

Post-op chemo

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17
Q

Treatment of muscle invasive tumour in the bladder? (T2-T3)

A

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

18
Q

What is the prognosis of low grade bladder TCC

A

90% 5 year survival

19
Q

What is the prognosis of invasive high grade bladder TCC

A

50% 5 year survival

20
Q

Presenting features of Upper tract TCC or upper tract urothelial cancer – UTUC

A

Frank haematuria - patient notices

Unilateral ureteric obstruction

Flank or loin pain

Symptoms of nodal or metastatic disease:
Bone pain
Hypercalcaemia
Lung
Brain
21
Q

Diagnostic investigations for Upper Urinary Tract Cancer (UUTC)

A

CT-IVU or IVU

Urine cytology

Ureteroscopy and biopsy

22
Q

What does CT-IVU or IVU show in UTUC?

A

Filling defect in renal pelvis

23
Q

Upper tract TCC most commonly affects which part of the urinary system

A

Renal pelvis or collecting system

24
Q

If a patient is unfit for nephron-ureterectomy or has bilateral disease what treatment should they get?

A

nephron-sparing endoscopic treatment - ureteroscopic laser ablation

25
Q

Look

A

UTUC tumours are often high-grade and multifocal on one side

High risk of local recurrence if treated endoscopically or by segmental resection

Low risk of having contralateral disease
difficult to follow up if treated endoscopically

26
Q

How are most most upper tract TCCs treated?

A

nephro-ureterectomy - removes a patient’s renal pelvis, kidney, ureter, and bladder cuff.

27
Q

Benign renal cancers (2)

A

Oncocytoma

Angiomyolipoma

28
Q

Malignant renal cancer

A

Renal adenocarcinoma

29
Q

Histological subtypes of renal adenocarcinoma

A

clear cell (85%)
papillary (10%)
chromophobe (4%)
Bellini type ductal carcinoma (1%)

30
Q

Risk factors of Renal adenocarcinoma

A

Family history (autosomal dominant e.g. vHL, familial clear cell RCC, hereditary papillary RCC; can be bilateral and/or multifocal)

Smoking

Anti-hypertensive medication

Obesity

End-stage renal failure

Acquired renal cystic disease

31
Q

Presentation of renal adenocarcinoma

A

Asymptomatic (i.e. incidentally noted on imaging for unrelated symptoms) : 50%

‘Classic triad’ of flank pain, mass and haematuria : 10%

Paraneoplastic syndrome : 30%
anorexia, cachexia and pyrexia
hypertension, hypercalcaemia and abnormal LFTs
anaemia, polycythaemia and raised ESR

Metastatic disease : 30%
bone, brain, lungs, liver

32
Q

TNM staging of Renal cancer

A

T1 - Tumour < 7cm confined within renal capsule

T2 - Tumour >7cm & confined within capsule

T3 - Local extension outside capsule

  • T3a - Into adrenal or peri-renal fat
  • T3b - Into renal vein or IVC below diaphragm
  • T3c - Tumour thrombus in IVC extends above diaphragm

T4 - Tumour invades beyond Gerota’s fascia

33
Q

Direct spread of renal cancer is directly through what?

A

The renal capsule

34
Q

Renal cancer: Venous invasion to which veins?

A

Renal vein and vena cava

35
Q

Where does renal cancer spread to through the blood?

A

The lungs and bone

36
Q

Where does renal cancer spread to through the lymph?

A

The paracaval nodes

37
Q

Investigations done for renal adenocarcinoma?

A

CT abdomen and chest is mandatory - to provide radiological diagnosis and complete TNM staging

Bloods - U+E’s, FBC

Optional: USS - differentiates tumour from cyst or DMSA or MAG-3 renogram to assess split renal function if doubts about contralateral kidney

38
Q

Treatment of renal adenocarcinoma

A

Surgery - radical nephrectomy (removal of the whole kidney, the fatty tissues surrounding the kidney and part of the ureter)

Even in patients with metastatic disease who have symptoms from primary tumour, palliative cytoreductive nephrectomy is beneficial (prolongs median survival by 6 months)

39
Q

What is the standard surgical procedure for T1 renal tumours?

A

laparoscopic radical nephrectomy - curative if T2 or less

40
Q

Treatment in renal adenocarcinoma metastases

A

little effective treatment since it is radioresistant and chemoresistant

Multi-targeted receptor tyrosine kinase inhibitors
e.g suntinib - trials ongoing

Immunotherapy - Interferon alpha, interleukin-1

41
Q

Renal adenocarcinoma prognosis

A

T1 – 95% 5-year survival
T2 – 90% 5-year survival
T3 – 60% 5-year survival
T4 – 20% 5-year survival

N1 or N2 – 20% 5-year survival

M1 – Median survival 12-18 months

2ND YEAR SYSTEMS: Urinary (25 decks)

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