Tumours of the Urinary System 2 Flashcards Preview

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Flashcards in Tumours of the Urinary System 2 Deck (46):
1

Where can urothelial tumours arise?

Malignant tumours of the lining transitional cell epithelium (urothelium) can occur at any point:
-From renal calyces
-To the tip of the urethra

2

What is the most common urothelial tumour site?

Bladder (90%)
-"Bladder cancer"

3

What are the two types of bladder cancer?

What causes them?

Most often transitional cell carcinoma (i.e. 90% in UK)

Where Schistosomiasis is endemic, squamous cell carcinoma of the bladder is the common tumour type

4

What are the risk factors for transitional cell carcinoma?

Smoking (accounts for 40% of cases)

Aromatic amines

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

5

What are the risk factors for Squamous cell carcinoma?

Schistosomiasis (S. Haematobium only)

Chronic cystitis (e.g. recurrent UTI, long term catheter, bladder stone)

Cyclophasphamide therapy

Pelvic radiotherapy

6

What is the commonest symptom of bladder cancer?

What other presenting symptoms may it have?

Painless visible or frank haematuria

Occasionally symptoms due to invasive or metastatic disease

Other features:
-recurrent UTI
-storage bladder symptoms
---Dysuria, frequency, nocturia, urgency +/- urge incontinence
---Bladder pain
---If present, suspect CIS

7

How do you investigate painful haematuria?

Urine culture
-Majority of painful haematuria is UTI

8

How do you investigate frank haematuria?

> 50 yrs risk of malignancy - 25-35%

Flexible cystourethroscopy within 2 weeks
-Only way to rule out cancer

IVU and USS (or CT-IVU)
-Upper tract

Urine Cytology may also be useful
(but not very sensitive or specific)

9

How do you investigate DIPSTIX or microscopic haematuria?

>50 years Risk of malignancy - 5-10%

Flexible cystourethroscopy within 4-6 weeks

IVU and USS

10

What is the haematuria equation in terms of investigations for frank haematuria?

Cystoscopy and CT-IVU

11

how do you diagnose bladder tumour?

Cystoscopy and endoscopic resection (TURBT)

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

12

How do you stage bladder cancer? (T,N and M stage)

Scross-sectional imaging (CT, MRI)

Bone scan if symptomatic

IVU for upper tract TCC (2-7% risk over 10 years; higher risk if high grade, stage or multifocal bladder tumours)

13

What is the treatment of bladder tumours?

Endoscopic or radical

14

How do you clssify bladder tumours?

Grade of tumour

Stage of tumour
-TNM classification
-T stage
---Non-Muscle invasive (or superficial)
---Muscle invasive

Combines to describe TCC
-e.g. G1pTa

15

What does the grading of a tumour mean?

Assessment of its aggressiveness

16

Describe the correlation between grade and stage

Close correlation

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)

17

What is the risk of bladder cancer in a patient who presents with unexplained frank haematuria

20-25%

18

What does the appropriate treatment depend on?

Site

Clinical stage

Histological grade of tumour

Patient age and co-morbidities

19

What is 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

Prolongued endoscopic follow up for moderate grade tumours

Consider prolongued course of intravesical chemotherapy (6 weeks to 6 months) for repeated recurrences

20

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

Endoscopic resection alone not sufficent

Need intravesical BCG therapy (maintanence course, weekly for 3 weeks repeated 6 monthly over 3 years)

Patients refractory to BCG need radical surgery

21

How does intravesical BCG treatment work?

BCG works by inducing immunomodulatory tumour cell killing (mediated by NK cells and cytokines)

1% risk of systemic BCG (similar to TB, treated with anti-tuberculous drugs)

22

How do you treat muscle invasive (T2-T3) bladder 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

23

What does the prognosis in bladder cancer depend on?

Stage
Grade
Size
Multifocality
Presence of concurrent CIS
Recurrence at 3 months

24

What is the prognosis of non-invasive, low grade bladder TCC compared with invasive high grade bladder TCC?

90% 5-year survival

50% 5-year survival

25

What are the main symptoms of Upper tract urothelial cancer?

Frank haematuria

Unilateral ureteric obstruction

Flank or loin pain

Symptoms of nodal or metastatic disease
-Bone pain
-Hypercalcaemia
-Lung
-Brain

26

What are the diagnostic investigations for upper tract urothelial cancer?

CT-IVU or IVU

Urine cytology

ureteroscopy and biopsy

27

Where is the most common place for Upper Tract TCC?

What is the grade like?

Renal pelvis or collecting system
Ureter less commonly

Often high grade and multifocal on one side

28

What is the risk of treating upper tract urothelial cancer endoscopically or by segmental resection?

High risk of local recurrence

29

How are most upper TCCs treated?

Nephro-ureterectomy

30

If the patient is unfit for nephron-ureterectomy of has bilateral disease how do you treat their upper tract TCC?

Nephron-sparing endoscopic treatment (i.e. ureteroscopic laser ablation); needs regular surveillance ureteroscopy

31

Why do you need to carry out surveillance cystoscopy in upper tract urothelial cancer patients?

High risk of synchronous and metachronous bladder TCC (40% over 10 years); hence need surveillance cystoscopy

32

Recel cancers all arise from where?

Parenchyma

33

What benign renal tumours can you get?

Oncocytoma
Angiomyolipoma

34

Describe renal adenocarcinoma

Commonest adult renal malignancy

AKA
-Hypernephroma
-Grawitz tumour

Most arise from proximal tubules

35

What are the histological subtypes of renal adenocarcinoma?

Clear cell (85%)

Papillary (10%)

Chromophobe (4%)

Bellini type ductal carcinoma (1%)

36

What are the risk factors for renal adenocarcinoma?

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
-ESRF
-Acquired renal cystic disease

37

What is the presentation of renal adenocarcinoma?

Asymptomatic 50%
(incidentally noted on imagine for unrelated symptoms)

Classic triad:
-Flank pain, mass and haematuria (10%)

Paraneoplastic syndrome 30%

Metastatic disease (30%
-Bone, brain, lungs, liver

38

What is included in the renal adenocarcinoma paraneoplastic syndrome?

Anorexia, cachexia and pyrexia

Hypertension, hypercalcaemia and abnormal LFTs

Anaemia, polycythaemia and raised ESR

39

How does renal adenocarcinoma spread?

Direct through the renal capsule

venous to renal vein and vena cava

lymphatic to nodes

Haematogenous to bone and lungs

40

What is the TNM staging of renal cancer?

T1 = Tumour 7cm and confined within capsule

T3 = local extension outside capsule
-T3a = into adrenal or peri-renal fat
-T3b = Into renal vein or IVC below diafragm
-T3c = Tumour thrombus in IVC extends above diaphragm

T4 = Tumour invades beyond Gerota's fascia

41

How do you investigate Renal Adenocarcinoma?

CT scan (triple phase) of abdomen and chest
-provides radiological diagnosis and complete TNM staging
-Assesses contralateral kidney

Bloods: U+E and FBC

42

What optional tests can you do in Renal adenocarcinoma?

IVU
-Shows calyceal distortion and soft tissue mass

Ultrasound
-Differentiates tumour from cyst

DMSA or MAG-3 renogram
-To assess split renal function if doubts about contralateral kidney

43

What is the treatment of renal adenocarcinoma?

Surgical - i.e. redical nephrectomy
-Laparoscopic radical nephrectomy is standard of care for T1 tumours (T2 tumours in laparoscopic centres)
-Worthwhile even with major venous invasion (>/= T3b)
-Curative if = T2

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

44

How do you treat renal adenocarcinoma metastases?

Little effective treatment since RCC is radioresistant and chemoresistant

Rare spontaneous regression of metastases occurs following nephrectomy

Immunotherapy
-Interferon alpha
-IL 2

Multitargeted receptor tyrosine kinase inhibitors
-Relatively new
-3 types on market: sunitinib, sorafenib, temsirolimus

45

How do multitargeted receptor tyrosine kinase inhibitors compare to immunotherapy for renal adenocarcinoma?

Superior response rates to immunotherapy but so far no improvement in survival

Trials ongoing

46

How do you predict risk of metastases after nephrectomy in renal adenocarcinoma?

Mayo scoring system
-Low risk = 0-2
-medium risk = 3-5
High risk = 6 or more