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%)
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
What are the risk factors for transitional cell carcinoma?
Smoking (accounts for 40% of cases)
Non - hereditary abnormalities (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 are the presenting features of bladder cancer?
•Most frequent presenting symptom
–painless visible haematuria
–symptoms due to invasive or metastatic disease
•Haematuria may be
–Frank - reported by patient
–Microscopic - detected by doctor
•Other features :
–storage bladder symptoms
•dysuria, frequency, nocturia, urgency +/- urge incontinence
•if present, suspect CIS
What are the investigations of haematuria?
–majority of painful haematuria = UTI
–commonest neoplastic cause is TCC bladder
•Upper tract imaging:
•CT Urogram (IVU)
–Limited use in Dipstick haematuria
•BP and U&E’s
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
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
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)
What is treatment of bladder tumours?
Endoscopic or radical
What are the T stages of bladder tumours?
T - stage is either non-muscle invasive ('superficial')
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)
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
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
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
Prognosis of bladder cancer
•Prognosis is dependent on
–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
What are the upper tract urinary cancer presenting features?
–Unilateral ureteric obstruction
– Flank or loin pain
– Symptoms of nodal or metastatic disease
What are the UTUC diagnostic investigations?
•CT-IVU or IVU
•Ureteroscopy and biopsy
Where does upper tract TCC occur?
–renal pelvis or collecting system commonest
–ureter less commonly
Describe the grade of UTUC tumours
–tumours are often high-grade and multifocal on one side
What is the risk of recurrence if treated endoscopically or by segmental resection?
What is the risk of contralateral disease in UTUC?
How are most upper tract TCC's treated?
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
What is the indication for endoscopic treatment?
Unifocal and low grade disease
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
What are the benign types of renal tumours?
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%)
•Bellini type ductal carcinoma (1%)
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)
•End-stage renal failure
•Acquired renal cystic disease
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
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
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
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
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)
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
• sunitinib, sorafenib, panzopanib,temsirolimus
•superior response rates to immunotherapy
•response rate with either 20% at most
•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