Flashcards in Tumours of the Urinary System 2 Deck (46):
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
What is the most common urothelial tumour site?
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
What are the risk factors for transitional cell carcinoma?
Smoking (accounts for 40% of cases)
Non-hereditary genetic abnormalities (e.g. TSG incl. p53 and Rb)
What are the risk factors for Squamous cell carcinoma?
Schistosomiasis (S. Haematobium only)
Chronic cystitis (e.g. recurrent UTI, long term catheter, bladder stone)
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
-storage bladder symptoms
---Dysuria, frequency, nocturia, urgency +/- urge incontinence
---If present, suspect CIS
How do you investigate painful haematuria?
-Majority of painful haematuria is UTI
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)
Urine Cytology may also be useful
(but not very sensitive or specific)
How do you investigate DIPSTIX or microscopic haematuria?
>50 years Risk of malignancy - 5-10%
Flexible cystourethroscopy within 4-6 weeks
IVU and USS
What is the haematuria equation in terms of investigations for frank haematuria?
Cystoscopy and CT-IVU
how do you diagnose bladder tumour?
Cystoscopy and endoscopic resection (TURBT)
Examination under anaesthesia to assess bladder mass/ thickening before and after TURBT
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)
What is the treatment of bladder tumours?
Endoscopic or radical
How do you clssify bladder tumours?
Grade of tumour
Stage of tumour
---Non-Muscle invasive (or superficial)
Combines to describe TCC
What does the grading of a tumour mean?
Assessment of its aggressiveness
Describe the correlation between grade and stage
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)
What is the risk of bladder cancer in a patient who presents with unexplained frank haematuria
What does the appropriate treatment depend on?
Histological grade of tumour
Patient age and co-morbidities
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
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
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)
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
What does the prognosis in bladder cancer depend on?
Presence of concurrent CIS
Recurrence at 3 months
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
What are the main symptoms of Upper tract urothelial cancer?
Unilateral ureteric obstruction
Flank or loin pain
Symptoms of nodal or metastatic disease
What are the diagnostic investigations for upper tract urothelial cancer?
CT-IVU or IVU
ureteroscopy and biopsy
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
What is the risk of treating upper tract urothelial cancer endoscopically or by segmental resection?
High risk of local recurrence
How are most upper TCCs treated?
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
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
Recel cancers all arise from where?
What benign renal tumours can you get?
Describe renal adenocarcinoma
Commonest adult renal malignancy
Most arise from proximal tubules
What are the histological subtypes of renal adenocarcinoma?
Clear cell (85%)
Bellini type ductal carcinoma (1%)
What are the risk factors for renal adenocarcinoma?
-Autosomal dominant e.g. vHL, familial clear cell RCC, hereditary papillary RCC; can be bilateral and/or multifocal
-Acquired renal cystic disease
What is the presentation of renal adenocarcinoma?
(incidentally noted on imagine for unrelated symptoms)
-Flank pain, mass and haematuria (10%)
Paraneoplastic syndrome 30%
Metastatic disease (30%
-Bone, brain, lungs, liver
What is included in the renal adenocarcinoma paraneoplastic syndrome?
Anorexia, cachexia and pyrexia
Hypertension, hypercalcaemia and abnormal LFTs
Anaemia, polycythaemia and raised ESR
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
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
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
What optional tests can you do in Renal adenocarcinoma?
-Shows calyceal distortion and soft tissue mass
-Differentiates tumour from cyst
DMSA or MAG-3 renogram
-To assess split renal function if doubts about contralateral kidney
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
How do you treat renal adenocarcinoma metastases?
Little effective treatment since RCC is radioresistant and chemoresistant
Rare spontaneous regression of metastases occurs following nephrectomy
Multitargeted receptor tyrosine kinase inhibitors
-3 types on market: sunitinib, sorafenib, temsirolimus
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