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

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

Flashcards in Tumours of the Urinary System 2 (Bladder and Renal Cancer) Deck (37):
1

Where are urothelial tumours found?

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%)

 

 

2

What is the tumour type in bladder cancer?

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

3

What are the risk factors for transitional cell carcinoma?

Smoking (accounts for 40% of cases)

Aromatic amines

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

4

What are the risk factors for squamous cell carcinoma?

–Schistosomiasis (S. haematobium only)

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

–cyclophosphamide therapy

–pelvic radiotherapy

Adenocarcinoma

-Urachal

5

What are the presenting features of bladder cancer?

•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

6

What are the investigations of haematuria?

•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

7

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

•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

8

How is diagnosis (grade and T stage) achieved?

•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

9

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

–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)

10

What is treatment of bladder tumours?

Endoscopic or radical

11

What are the T stages of bladder tumours?

T - stage is either non-muscle invasive ('superficial')

OR

Muscle invasive

 

 

12

Here's how the bladder cancer is graded

•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)

13

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

•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

14

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

•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

15

What is the treatment for muscle invasive bladder cancer?

(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

 

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

16

Prognosis of bladder cancer

•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

What are the upper tract urinary cancer presenting features?

Main symptoms:

–Frank haematuria

–Unilateral ureteric obstruction

– Flank or loin pain

– Symptoms of nodal or metastatic disease

•Bone pain

•Hypercalcaemia

•Lung

•Brain

18

What are the UTUC diagnostic investigations?

•CT-IVU or IVU

•Urine cytology

•Ureteroscopy and biopsy

19

Where does upper tract TCC occur?

–renal pelvis or collecting system commonest

–ureter less commonly

20

Describe the grade of UTUC tumours

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

21

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

High

22

What is the risk of contralateral disease in UTUC?

Los risk

23

How are most upper tract TCC's treated?

Nephro-ureterectomy

24

When would nephron sparing endocsopic treatment be used?

Give an example of this type of treatment

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

25

What is the indication for endoscopic treatment?

Unifocal and low grade disease

26

Why is there a need for surveillance cystoscopy in UTUC?

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

27

What are the benign types of renal tumours?

Oncocytoma

Angiomyolipoma

28

What are the malignant forms of renal tumours?

•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

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

•End-stage renal failure

•Acquired renal cystic disease

30

What is the presentation of renal adenocarcinoma?

•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

TNM staging of renal cancer

•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

What are the mechanisms of spread of renal adenocarcinoma?

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

What are the investigations for renal adenocarcinoma?

•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

What is the treatment for renal adenocarcinoma?

•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

What is the treatment for renal adenocarcinoma that has metastasised?

•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

Prognosis

•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