Bladder + renal cancer

Question 1

Urothelial carcinoma aka

+ affects what organ the most

Answer 1

transitional cell carcinoma (TCC)

affects BLADDER (90%) but technically speaking can affect anywhere from renal calyces to tip of urethra as transitional epithelium is all along the tract

Question 2

2 types of bladder cancer + which more common

Answer 2

Transitional cell carcinoma - 90%

Squamous cell carcinoma

Question 3

Squamous cell carcinoma of the the bladder is less common and is mostly caused by

Answer 3

Schistosomiasis infection by S. haematobium

Question 4

Risk factors of TCC of the bladder (3)

Answer 4

Smoking - MAIN
Occupational exposure to chemical carcinogens - aromatic amines
Age >55, male

Question 5

Risk factors of SCC of the bladder (3)

Answer 5

Schistosomiasis infection
Chronic cystitis (from recurrent UTIs, stones)
Systemic chemotherapy - e/g/ cyclophosphamide

Question 6

Main symptom of bladder cancer +

symptoms/signs of bladder carcinoma in situ (superficial but aggressive high grade form)

Answer 6

Painless frank haematuria

If carcinoma in situ (aggressive)

• dysuria
• frequency
• urgency
• bladder pain

Question 7

Investigations of bladder cancer

• biochem (2)
• imaging (2)
• definitive diagnosis

Answer 7

Urinalysis - microscopy etc
Urine cytology

Imaging

• CT urogram
• renal and bladder USS

CYSTOSCOPY + BIOPSY
-cystoscopy itself good for low grade cancers but high grade less visible as their cells are flatter

Question 8

Painless frank haematuria itself suggests what diagnosis whereas painful haematuria suggests what

Answer 8

Painless - bladder cancer

Painful - UTI

Question 9

IV urogram is not used as much anymore to investigate TCCs - why?

Answer 9

Small bladder tumours are often not visible, good for upper urinary tract but still can miss out tumours

Question 10

Definitive diagnostic investigation of TCCs of the bladder

Answer 10

Cystoscopy guided biopsy

Question 11

Staging investigations of TCCs of the bladder

Answer 11

CT
MRI
Bone scan - to see bone metastases

Question 12

Treatment of bladder TCC

• if low grade superficial (2)
• if high grade superficial/CIS (3)
• if muscle invasive (T2 onwards) (2)

Answer 12

If non-muscle invasive (superficial)
-transurethral resection of a bladder tumour (TURBT) via cystoscopy
AND
-immediate post op intravesical chemotherapy

If high grade superficial/CIS
-above
AND
-2 weeks post op intravesical BCG vaccine

If muscle invasive

• radical cystectomy + pelvic lymph node dissection
• neoadjuvant chemo +/- adjuvant

Question 13

Grading of tumours is different to staging, describe the 3 grades of bladder tumours

Answer 13

G1 = Well diff. - commonly non-invasive

G2 = Mod. diff. - often non-invasive

G3 = Poorly diff. - often invasive + metastatic

Carcinoma in situ (CIS) - non muscle invasive (so still superficial) but very AGGRESSIVE

Question 14

What are the different stages of bladder cancer (NOT GRADE) (4)

Answer 14

Carcinoma in situ (CIS) - non muscle invasive but very AGGRESSIVE

Ta - superficial

T1 - superficial

T2 onwards - muscle invasive

Question 15

Although carcinoma in situ is superficial, what grade is it

Answer 15

high grade because very aggressive

Question 16

Non-invasive low-grade (TaG1) bladder tumours have a low risk of stage progression but recurrence…

Answer 16

is still high post resection so need follow up cystoscopy 3 months later

Question 17

TCCs of the upper urinary tract mostly affect

Answer 17

renal pelvis or calyces; not so much the ureter

Question 18

Symptoms (1) /signs (2) of upper urinary tract TCC (i.e. affecting renal pelvis/calyces/ureter)

Answer 18

Flank/loin pain

Frank haematuria
Unilateral obstruction –> unilateral hydronephrosis

Question 19

Investigations of an upper urinary tract TCC (affecting renal pelvis/calyces/ureter)

• urine (2)
• imaging (2)

Answer 19

Urinalysis - microscopy
Urine cytology

CT urogram - tumour shows as filling defect
Ureteroscopy + biopsy

Question 20

Treatment of upper urinary tract TCCs (affecting renal pelvis/calyces/ureter)

Answer 20

Nephro-ureterectomy

If unfit for this or disease is only low grade
-endoscopic ablation

Question 21

Benign tumours of the kidney (2)

Answer 21

Oncocytoma

Angiomyolipoma

Question 22

Malignant tumours of the kidney (2)

Answer 22

Renal cell adenocarcinoma aka renal cell carcinoma (NOT THE SAME AS CLEAR CELL CARCINOMA; clear cell is a subtype of renal cell carcinoma)

TCC of kidney

Question 23

Histological subtypes of renal adenocarcinoma/ renal cell carcinoma (4)

Answer 23

Clear cell - MOST COMMON
Papillary
Chromophobe
Bellini type ductal carcinoma

Question 24

Renal cell carcinoma (RCC) is renal malignancy arising from the renal parenchyma/cortex, and accounts for about 85% of renal cancers, much more common than what cancer of the kidney

Answer 24

TCC of the kidney

Question 25

Commonest renal cell carcinoma

Answer 25

Clear cell renal cell carcinoma

Question 26

Risk factors of renal cell carcinoma (aka renal cell adenocarcinoma) (6)

Answer 26

``` Smoking Male Age >55 Obesity Hypertension Family history of RCC Polycystic kidneys ```

Question 27

Symptoms/signs of renal cell carcinoma - 50% cases people are - single presentation - classic triad in <10% (suggests local advanced)

Answer 27

50% actually asymptomatic and only found INCIDENTALLY on imaging of something else Haematuria alone Classic triad - flank pain - palpable mass - haematuria

Question 28

Some renal cell carcinomas present as paraneoplastic syndromes What are some of the symptoms/signs presented here

Answer 28

Systemic symptoms -fever, weight loss, night sweats, cachexia (weakness + wasting) Ectopic secretions - erythropoetin --> polycythemia (high RBCs) - renin --> hypertension - PTH --> hypercalcaemia - ACTH --> Cushing's syndrome

Question 29

Renal cell carcinoma metastases to what places (4)

Answer 29

Bone Brain Lungs Liver

Question 30

What stage of renal cell carcinoma indicates it has extended outwith the fibrous capsule of the kidney

Answer 30

T3 and onwards T1 and T2 - still confined in capsule

Question 31

Routes renal cell carcinoma can spread (3)

Answer 31

``` Direct spread (local invasion through fibrous capsule) -e.g. into renal vein/IVC ``` Via blood Via lymph -to paracaval lymph nodes

Question 32

Investigations of renal cell carcinoma (6) | -imaging (2)

Answer 32

FBC - may show anaemia or polycythaemia (from EPO secreting paraneoplastic syndrome) U+Es - may be high creatinine if low GFR LFTs - abnormal enzymes may indicate liver metastases Urinalysis - microscopy (for haematuria) CT abdo/pelvis - DEFINITIVE DIAGNOSIS CT chest - to look for metastases

Question 33

Treatment of renal cell carcinoma - if localised mass (stage 1/2) - if spread outwith capsule (stage 3) (1) - if stage 4 (metastatic) (2)

Answer 33

Chemotherapy/radiotherapy RESISTANT Surgery - tumour resection/local ablation if just stage 1/2 (localised) - radical nephrectomy if stage 3 Metastastic - targeted molecular therapy (TYROSINE KINASE RECEPTOR INHIBITORS) - immunotherapy

Question 34

Renal cell carcinoma is resistant to what treatment

Answer 34

Chemotherapy/radiotherapy