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MBChB - Y2 - Systems - Urinary > Tumours of the Urinary System 2 (Bladder and Renal Cancer) > Flashcards

Tumours of the Urinary System 2 (Bladder and Renal Cancer) Flashcards

1
Q

Where are urothelial tumours found?

A

Transitional cell epithelium malignant tumour can occur anywhere from the renal calyces to the tip of the urethra

Most common site is the bladder (90%)

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2
Q

What is the tumour type in bladder cancer?

A

The tumour type is most often transitional cell carcinoma (90% in the UK)

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

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3
Q

What are the risk factors for transitional cell carcinoma?

A

Smoking (accounts for 40% of cases)

Aromatic amines

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

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4
Q

What are the risk factors for squamous cell carcinoma?

A

–Schistosomiasis (S. haematobium only)

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

–cyclophosphamide therapy

–pelvic radiotherapy

Adenocarcinoma

-Urachal

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5
Q

What are the presenting features of bladder cancer?

A

•Most frequent presenting symptom

–painless visible haematuria

•Occasionally

–symptoms due to invasive or metastatic disease

•Haematuria may be

–Frank - reported by patient

–Microscopic - detected by doctor

•Other features :

–recurrent UTI

–storage bladder symptoms

  • dysuria, frequency, nocturia, urgency +/- urge incontinence
  • bladder pain
  • if present, suspect CIS
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6
Q

What are the investigations of haematuria?

A

•Urine culture

–majority of painful haematuria = UTI

•Cystourethroscopy

–commonest neoplastic cause is TCC bladder

•Upper tract imaging:

  • CT Urogram (IVU)
  • ultrasound scan
  • Urine Cytology

–Limited use in Dipstick haematuria

•BP and U&E’s

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7
Q

What are the limitations of IVU and USS (these are used to image the upper urinary tract)

A
  • IVU alone will miss a proportion of renal cell tumours (especially if <3cm)
  • USS alone will miss a proportion of urothelial tumours of the upper tracts
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8
Q

How is diagnosis (grade and T stage) achieved?

A

•Diagnosis (Grade & T-stage)

–cystoscopy and endoscopic resection (TURBT) - transurethral resection of bladder tumour

–EUA to assess bladder mass/thickening before and after TURBT

EUA - examination under anaesthesia

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9
Q

How is staging (T,N and M stage made)?

A

–cross-sectional imaging (CT, MRI)

–Bone scan if symptomatic

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

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10
Q

What is treatment of bladder tumours?

A

Endoscopic or radical

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11
Q

What are the T stages of bladder tumours?

A

T - stage is either non-muscle invasive (‘superficial’)

OR

Muscle invasive

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12
Q

Here’s how the bladder cancer is graded

A

•Grades of TCC (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)

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13
Q

How is low grade non-muscle invasive (Ta or T1) bladder cancer treated?

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 months) for repeated recurrences

Resection, intravesicle chemo and surveillance

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14
Q

How is high grade non-muscle invasive or carcinoma in situ treated?

A
  • 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

Bacillus Calmette-Guerin therapy: Bacillus Calmette-Guerin (BCG) is the main intravesical immunotherapy for treating early-stage bladder cancer

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15
Q

What is the treatment for muscle invasive bladder cancer?

(T2 - T3)

A
  • 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

https://www.youtube.com/watch?v=LaSiV8tRdk8

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16
Q

Prognosis of bladder cancer

A

•Prognosis is dependent on

–stage

–grade

–size

–multifocality

–presence of concurrent CIS

–recurrence at 3 months

  • Non-invasive, low grade bladder TCC: 90% 5-year survival
  • Invasive, high grade bladder TCC: 50% 5-year survival
17
Q

What are the upper tract urinary cancer presenting features?

A

Main symptoms:

–Frank haematuria

–Unilateral ureteric obstruction

– Flank or loin pain

– Symptoms of nodal or metastatic disease

  • Bone pain
  • Hypercalcaemia
  • Lung
  • Brain
18
Q

What are the UTUC diagnostic investigations?

A
  • CT-IVU or IVU
  • Urine cytology
  • Ureteroscopy and biopsy
19
Q

Where does upper tract TCC occur?

A

–renal pelvis or collecting system commonest

–ureter less commonly

20
Q

Describe the grade of UTUC tumours

A

–tumours are often high-grade and multifocal on one side

21
Q

What is the risk of recurrence if treated endoscopically or by segmental resection?

A

High

22
Q

What is the risk of contralateral disease in UTUC?

A

Los risk

23
Q

How are most upper tract TCC’s treated?

A

Nephro-ureterectomy

24
Q

When would nephron sparing endocsopic treatment be used?

Give an example of this type of treatment

A

Ureteroscopic laser ablation - used for patients unfit for nephroureterectomy or has bilateral disease

25
Q

What is the indication for endoscopic treatment?

A

Unifocal and low grade disease

26
Q

Why is there a need for surveillance cystoscopy in UTUC?

A

•In ALL cases, high risk of synchronous and metachronous bladder TCC (40% over 10 years); hence need surveillance cystoscopy

27
Q

What are the benign types of renal tumours?

A

Oncocytoma

Angiomyolipoma

28
Q

What are the malignant forms of renal tumours?

A

•Malignant : renal adenocarcinoma

–commonest adult renal malignancy

–synonyms : hypernephroma or Grawitz tumour

–most arise from proximal tubules

–histological subtypes :

  • clear cell (85%)
  • papillary (10%)
  • chromophobe (4%)
  • Bellini type ductal carcinoma (1%)
29
Q

What are the risk factors for renal adenocarcinoma?

A
  • 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

•End-stage renal failure

•Acquired renal cystic disease

30
Q

What is the presentation of renal adenocarcinoma?

A
  • Asymptomatic (i.e. incidentally noted 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

31
Q

TNM staging of renal cancer

A
  • T1 - Tumour < 7cm confined within renal capsule
  • T2 - Tumour >7cm & confined within capsule
  • T3 - Local extension outside capsule

–T3a - Into adrenal or peri-renal fat

–T3b - Into renal vein or IVC below diaphragm

–T3c - Tumour thrombus in IVC extends above diaphragm

•T4 - Tumour invades beyond Gerota’s fascia

32
Q

What are the mechanisms of spread of renal adenocarcinoma?

A

Direct spread (invasion) through the renal capsule

Venous invasion to renal vein and vena cava

Haematogenous spread to lungs and bone

Lymphatic spread to paracaval nodes

33
Q

What are the investigations for renal adenocarcinoma?

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 :

–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

34
Q

What is the treatment for renal adenocarcinoma?

A

•Treatment is surgical – i.e. radical 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 (prolongs median survival by 6 months)

35
Q

What is the treatment for renal adenocarcinoma that has metastasised?

A

•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
  • Interleukin-2
  • response rate with either 20% at most
36
Q

Prognosis

A
  • T1 – 95% 5-year survival
  • T2 – 90% 5-year survival
  • T3 – 60% 5-year survival
  • T4 – 20% 5-year survival
  • N1 or N2 – 20% 5-year survival
  • M1 – Median survival 12-18 months
37
Q
A

MBChB - Y2 - Systems - Urinary (28 decks)

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