Tumours of the renal system: bladder and renal cancer Flashcards
(46 cards)
Describe briefly sites of urothelial tumours
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”
Where is the most common site of urothelial tumours?
Bladder (90%)
What is the most common tumour type in bladder cancer?
transitional cell carcinoma
What is the most common tumour type of bladder cancer in areas endemic to Schistosomiasis?
Squamous cell carcinoma
What are some risk factors for transitional cell carcinoma (TCC) of the bladder?
– Smoking (accounts for 40% of cases)
– Aromatic amines
– Non-hereditary genetic abnormalities (e.g. TSG incl. p53 and Rb)
Also if had previous UTUC
What are some risk factors for squamous cell carcinoma of the bladder?
– Schistosomiasis (S. haematobium only)
– Chronic cystitis (e.g. recurrent UTI, long term catheter, bladder stone)
– Cyclophosphamide therapy
– Pelvic radiotherapy
How do bladder cancers often present?
Most often = Painless visible haematuria
Occasionally symptoms due to invasive or metastatic disease
Other features: – Recurrent UTI • Storage bladder symptoms • Dysuria, frequency, nocturia, urgency +/- urge incontinence • Bladder pain
What should be suspected if someone presents with bladder pain?
Carcinoma in situ
What investigations should be carried out if someone presents with haematuria?
Urine culture
o Majority of painful haematuria = UTI
Cystourethroscopy
o Commonest neoplastic cause is TCC bladder
Upper tract imaging
o CT Urogram (IVU)
o Ultrasound scan
Urine Cytology
o Limited use in Dipstick haematuria
BP and U&E’s
What is the risk of malignancy if a patient >50 presents with frank haematuria?
25-35%
What is the risk of malignancy if a patient >50 presents with DIPSTIX or microscopic haematuria?
5-10%
How should DIPSTIX or microscopic haematuria be investigated?
o Flexible cystourethroscopy within 2 weeks
o CT Urogram & USS
o Urine Cytology may also be useful (but not very sensitive nor specific)
How should frank haematuria be investigated?
o Flexible cystourethroscopy within 4-6 weeks
o IVU & USS
Describe the grades of TCC according to WHO 1973
– 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)
Describe the treatment of low grade non-muscle invasive (i.e. Ta or T1) bladder cancer
- 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
Describe the treatment of high grade non-muscle invasive or CIS bladder cancer
- Very aggressive – 50-80% risk of progression to muscle invasive stage
- Endoscopic resection alone not sufficient
- CIS consider intravesical Bacillus Calmette-Guerin (BCG) therapy (maintenance course, weekly for 3 weeks repeated 6 monthly over 3 years)
- Patients refractory to BCG – need radical surgery
Describe the treatment of muscle invasive bladder (T2 - T3) cancer
- 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
Describe the 5 year survival of those with non-invasive low grade bladder TCC
90% 5 year survival
Describe the 5 year survival of those with invasive high grade bladder TCC
50% 5 year survival
How does upper tract urothelial cancer (UTUC) present?
Frank haematuria
Unilateral ureteric obstruction
Flank or loin pain
Symptoms of nodal or metastatic disease • Bone pain • Hypercalcaemia • Lung • Brain
What diagnostic investigations are used for upper tract urothelial cancers?
- CT-IVU or IVU – will show filling defect in renal pelvis due to tumour etc
- Urine cytology
- Ureteroscopy and biopsy
Where can upper tract urothelial tumours be found?
– Renal pelvis or collecting system commonest
– Ureter less commonly
Where is the most common site of UTUCs?
Renal pelvis/collecting system
How are most UTUCs treated?
Nephro-ureterectomy due to high reoccurrence rate following being treated endoscopically or by segmental resection
