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12. Year 2: Urinary System COPY > Tumours of the Urinary System 2 > Flashcards

Tumours of the Urinary System 2 Flashcards

1
Q

What are urothelial cancers?

A

These are malignant tumours of the lining transitional cell epithelium (urothelium) and can occur at any point:

  • From renal calyces to tip of uretra
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2
Q

What is the most common site of urothelial cancers?

A

Most common site is the bladder:

  • 90% of cases
  • Known as “bladder cancer”
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3
Q

What tumour type is most often responsible for bladder cancer?

A

Tumour type is most often transitional cell carcinoma (about 90% in UK)

Where schistosomiasis is endemic, squamous cell carcinoma of the bladder is the most common type

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4
Q

What are risk factors for bladder cancer?

A
  • TCC (transitional cell carcinoma)
    • Smoking (accounts for 40% of cases)
    • Aromatic amines
    • Non-hereditary genetic abnormalities
      • Such as TSG including p53 and Rb
  • Squamous cell carcinoma
    • Schistosomiasis (S. Haematobium only)
    • Chronic cystitis (such as recurrent UTI, long term catheter, bladder stone)
    • Cyclophosphamide therapy
    • Pelvic radiotherapy
  • Adenocarcinoma
    • Urachal
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5
Q

What does TCC stand for?

A

Transitional cell carcinoma

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6
Q

What are risk factors for TCC bladder cancer?

A
  • Smoking (accounts for 40% of cases)
  • Aromatic amines
  • Non-hereditary genetic abnormalities
    • Such as TSG including p53 and Rb
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7
Q

What are risk factors for squamous cell carcinoma bladder cancer?

A
  • Schistosomiasis (S. Haematobium only)
  • Chronic cystitis (such as recurrent UTI, long term catheter, bladder stone)
  • Cyclophosphamide therapy
  • Pelvic radiotherapy
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8
Q

What are the presenting features of bladder cancer?

A
  • Painless visible haematuria (most frequent symptoms)
  • Occasionally symptoms due to invasive or metastatic disease
  • Haematuria may be
    • Frank (reported by patient i.e. they can see it - macroscopic)
    • Microscopic (detected by doctor)
  • Recurrent UTI
  • Storage bladder symptoms
    • Dysuria, frequency, nocturia, urgency with or without urge incontinence
    • Bladder pain
    • If present, suspect CIS
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9
Q

What investigations shoud be done for haematuria?

A
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10
Q

Is the risk of malignancy higher with frank haematuria or microscopic haematuria?

A

Frank haematuria

frank - 25-35%

micro - 5-10%

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11
Q

What investigations should be done for frank haematuria?

A
  • Flexible cystourethroscopy within 2 weeks
  • CT urogram and USS
  • Urine cytology may also be useful (but not very sensitive nor specific)
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12
Q

What investigations should be done for microscopic haematuria?

A
  • Flexible cystourethroscopy within 4-6 weeks

USS

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13
Q

What does IVP stand for?

A

Intravenous pyelogram

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14
Q

What is a intravenous pyelogram (IVU)?

A

X-ray exam that uses an injection of contrast material to evaluate your kidneys, ureters and bladder and help diagnose blood in the urine or pain in your side or lower back

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15
Q

Why should IVU and USS be done together and not be done alone?

A

IVU will miss a proportion of renal cell tumours especially if <3cm

USS will miss a proportion of urothelial tumours of the upper tracts

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16
Q

What is diagnosis of bladder cancer done by?

A
  • Cystoscopy and endoscopic resection (TURBT)
  • Examination under anaesthetic (EUA) to assess bladder mass/thickening before and after TURBT
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17
Q

What is TNM staging of bladder cancer done by?

A
  • Cross sectional imaging (CT, MRI)
  • Bone scan if symptomatic
  • CTU for upper tract TCC
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18
Q

What are the broad categories of treatment options for bladder cancer?

A
  • Endoscopic or radical
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19
Q

How are bladder tumours classified?

A
  • Grade of tumour
  • Stage of tumour
    • TNM classification
    • T stage
      • Non-muscle invasive (or superficial)
      • Muscle invasive
  • Combined to describe TCC (such as G1pTa)
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20
Q

What are the different grades of TCC?

A
  • G1
    • Well differentiated
    • Commonly non-invasive
  • G2
    • Moderately differentiated
    • Often non-invasive
  • G3
    • Poorly differentiated
    • Often invasive
  • Carcinoma in situ (CIS)
    • Non-muscle invasive but very aggressive so treated differently
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21
Q

What is G1 grade?

A
  • Well differentiated
  • Commonly non-invasive
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22
Q

What is a G2 grade?

A
  • Moderately differentiated
  • Often non-invasive
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23
Q

What is a G3 grade?

A
  • Poorly differentiated
  • Often invasive
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24
Q

What is a carcinoma in situ (CIS) grade?

A
  • Non-muscle invasive but very aggressive so treated differently
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25
Q

What does CIS stand for?

A

Carinoma in situ

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26
Q

What are the different T stages of bladder cancer?

A
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27
Q

What does treatment of bladder cancer depend on?

A
  • Site
  • Clinical stage
  • Histological grade of tumour
  • Patient age and co-morbidities
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28
Q

what is the treatment of bladder cancer

A

•In the bladder

  • 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
  • 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
  • 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
29
Q

What does the prognosis of bladder cancer depend on?

A
  • Stage
  • Grade
  • Size
  • Multifocality
  • Presence of concurrent CIS
  • Recurrence at 3 months
30
Q

What is the prognosis of low grade bladder TCC?

A
  • 90% 5 year survival
31
Q

What is the prognosis of invasive, high grade bladder TCC?

A
  • 50% 5 year survival
32
Q

What is the treatment for low grade non-muscle invasive (such as T1) bladder cancer?

A
  • 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) for repeated recurrences
33
Q

What is the treatment for high grade non-muscle invasive or CIS bladder cancer?

A
  • Very aggressive, 50-80% change of progression to muscle invasive stage
  • Endoscopic resection alone not sufficient
  • CIS consider intravesical BCG therapy
  • Patients refractory to BCG need radical surgery
34
Q

What is the treatment for muscle invasive bladder cancer (T2-T3)?

A
  • Neoadjuvant chemotherapy for local (ie downstaging) and systemic control, followed by either
    • Radical chemotherapy and/or
    • Radical cystoprostatectomy (men) or anterior pelvic exenteration with urethrectomy (woman) with extended lymphadenectomy
    • Radical surgery combined with incontinent urinary diversion continent diversion (ie bowel pouch with catheterisable stoma) or orthotopic bladder substitution
35
Q

What does UTUC stand for?

A

Upper tract urothelial cancer

36
Q

What is upper tract TCC also known as?

A

Upper tract urothelial cancer

37
Q

What are the presenting features of upper tract TCC?

A
  • Frank haematuria
  • Unilateral ureteric obstruction
  • Flank or loin pain
  • Symptoms of nodule or metastatic disease
    • Bone pain
    • Hypercalcaemia
    • Lung
    • Brain
38
Q

What are diagnostic investigatioons for upper tract TCC?

A
  • CT-IVU or IVU
  • Urine cytology
  • Ureteroscopy and biopsy
39
Q

What does a IVU show?

A

Filling defect in the renal pelvis

40
Q

What does upper tract TCC typically affect?

A
  • Renal pelvis or collecting system commonest
  • Ureter less commonly
41
Q

Are the upper tract TCC tumours normally low grade or high grade and bilateral or unilateral?

A

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
42
Q

How are most upper tract TCCs treated?

A
  • Hence, most upper tract TCCs are treated by nephro-ureterectomy
    • If unfit for nephron-ureterectomy or has bilateral disease is absolute indication for nephron-sparing endoscopic treatment (such as ureteroscopic laser ablation)
      • Needs regular surveillance ureteroscopy)
    • Unifocal and lowgrade disease is relative indication for endoscopic treatment
43
Q

What are absolute indications for nephron-sparing endoscopic treatment for upper tract TCC?

A

Unfit for nephron-ureterectomy or has bilateral disease

44
Q

What are relative indications for endoscopic treatment for upper tract TCC?

A

Unifocal and lowgrade disease

45
Q

Why is there a need for surveillance cytoscopy in all cases of upper tract TCC?

A

High risk of synchronous and metachrondous bladder TCC

46
Q

What are the different kinds of benign renal cancers?

A
  • Oncocytoma, angiomyolipoma
47
Q

What is malignant renal cancer called?

A
  • Renal adenocarcinoma
48
Q

What are synonyms for renal adenocarcinoma?

A
  • Synonyms are hypernephroma or Grawitz tumour
49
Q

Where do most renal adenocarcinomas arise from?

A

Proximal tubules

50
Q

What are the different histological subtypes of renal cancer?

A
  • Clear cell (85%)
  • Papillary (10%)
  • Chromophobe (4%)
  • Bellini type ductal carcinoma (1%)
51
Q

What are risk factors for renal cancer?

A
  • Family history
    • Autosomal dominant such as vHL, familial clear cell RCC, hereditary papillary RCC
  • Smoking
  • Anti-hypertensive medication
  • Obesity
  • End-stage renal failure
  • Acquired renal cystic disease
52
Q

What is the link between family history and renal cancer?

A
  • Family history
    • Autosomal dominant such as vHL, familial clear cell RCC, hereditary papillary RCC
53
Q

What is the clinical presentation of renal cancer?

A
  • Asymptomatic (ie incidental finding 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
54
Q

What is the ‘classic triad’ of symptoms/signs for renal cancer?

A
  • ‘Classic triad’ of flank pain, mass and haematuria 10%
55
Q

Describe the TNM staging for renal cancer?

A
56
Q

For renal cancer, what is T1?

A
57
Q

For renal cancer, what is T2?

A
58
Q

For renal cancer, what is T3?

A
59
Q

For renal cancer, what is T4?

A
60
Q

What are methods of renal cancer spreading?

A
  • Direct spread (invasion) through renal capsule
  • Venous invasion to renal vein and vena cava
  • Haematogenous spread to lungs and bone
  • Lymphatic spread to paracaval nodes
61
Q

What lymph nodes does renal cancer often spread to?

A
  • Lymphatic spread to paracaval nodes
62
Q

What organs does renal cancer often haematogenously spread to?

A

Lungs and bones

63
Q

What investigations are done for renal cancer?

A
  • CT scan (triple phase) of abdomen and chest is mandatory
    • Provides radiological diagnosis and complete TNM staging
    • Assesses contralateral kidney
  • Bloods
    • U&E, FBC
  • Optional tests
    • USS differentiates tumour from cyst
    • DMSA or MAG-3 renogram to assess split renal function if doubts about contralateral kidney
64
Q

What bloods are done for renal cancer?

A
  • U&E, FBC
65
Q

What is the treatment for renal cancer?

A
  • Treatment is surgical (ie radical nephrectomy)
    • Laparoscopic radical nephrectomy is standard of care for T1 tumours (T2 tumours in laparoscopic cenres)
    • Worthwhile even with major venous invasion (>=T3b)
    • Curative if <=T2
    • Palliative cytoreductive nephrectomy is beneficial even in patients with metastatic disease who have symptoms from primary tumour
  • Metastases
    • Little effective treatment since RCC is radioresistant and chemoresistant
    • Multitargeted receptor tyrosine kinase inhibitors
      • Relatively new
      • Sunitinib, sorafenib, panzopanib, temsirolimus
      • Superior response rates to immunotherapy
      • Trials ongoing
    • Immunotherapy
      • Interferon alpha
      • IL-1
66
Q

Why does radiotherapy and chemotherpy have little use in treating metastases of renal cancer?

A

RCC is radioresistant and chemoresistant

67
Q

What immunotherapy can be used as treatment for renal cancer metastases?

A
  • Interferon alpha
  • IL-1
68
Q

What is the prognosis of renal cancer?

A

12. Year 2: Urinary System COPY (30 decks)

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