Tumours of the urinary system 2 - urothelial and renal

Question 1

What are urothelial cancers?

Answer 1

Malignant tumours of the lining transitional cell epithelium (uroepithelium) which occurs at any point of the urinary tract

Question 2

Where is the most common site of urothelial cancers?

Answer 2

bladder - 90%

Question 3

Most common bladder cancer cell type

Answer 3

TCC

Question 4

When is TCC not the most common type of bladder cancer?

Answer 4

where schistosomiasis is endemic - squamous cell carcinoma

Question 5

TCC risk factors (most common?)

Answer 5

SMOKING
aromatic amines
non-hereditary genetic abnormalities

Question 6

SCC risk factors

Answer 6

schistosomiasis!
chronic cystitis
pelvic radiotherapy
cyclophosphamide therapy

Question 7

Most common presenting symptom of bladder cancer

Answer 7

frank haematuria

Question 8

Other ways bladder cancer can present

Answer 8

occasionally due to invasive/mets

others eg recurrent UTI, storage LUTS

Question 9

What are the storage bladder symptoms?

Answer 9

dysuria, frequency, nocturia, ugency +/- urge incontinence

Question 10

If LUTS are the presenting symptom of bladder cancer what should you expect?

Answer 10

carcinoma in situ

Question 11

5 investigations of haematuria

Answer 11

urine culture - majority of painful haematuria due to UTI
cystoscopy 
urine cytology 
CTU or USS 
Blood pressure and U+E's

Question 12

What is the % risk of malignancy with frank haematuria?

Answer 12

25-35%

Question 13

Risk of malignancy with dipstick/microscopic haematuria?

Answer 13

5-10%

Question 14

What are the drawbacks with IVU and USS alone?

Answer 14

IVU miss renal cell tumours <3cm

USS miss some urothelial tumours of upper tract

Question 15

How is bladder cancer diagnosed? What information does this give?

Answer 15

cystoscopy and TURBT - endoscopic resection

grade and T stage

Question 16

How is TNM staging of bladder cancer done?

Answer 16

CT, MRI
bone scan if symptomatic
CTU for upper tract TCC

Question 17

What does T stage of bladder cancer tell us?

Answer 17

superficial or muscle invasive

Question 18

Grades of bladder cancer

Answer 18

G1 - well diff
G2 - mid diff
G3 - poorly diff
CIS - very aggressive and non muscle invasive

Question 19

4 things treatment of bladder cancer depends on

Answer 19

site
stage
histological grade
age and co morbidities of patient

Question 20

Treatment of low grade non muscle invasive bladder cancer

Answer 20

endoscopic resection and intravesical chemotherapy which can both be prolonged and endoscopic follow up

Question 21

Treatment of high grade non muscle invasive or CIS bladder cancer

Answer 21

endoscopic resection alone insufficient
BCG therapy if CIS
if BCG not working - radical surgery

Question 22

Muscle invasive bladder cancer treatment

Answer 22

neoadjuvant chemotherapy
radical radiotherapy and/or radical cystoprostatectomy
urinary diversion and lymphadenectomy

Question 23

6 factors prognosis of bladder cancer is dependent on

Answer 23

size 
stage 
grade 
multifocality 
recurrence in 3 months 
presence of concurrent CIS

Question 24

Main symptoms of upper tract urothelial cancer

Answer 24

frank haematuria
loin/flank pain
ureteric obstruction
symptoms of nodal or mets eg bone pain

Question 25

Diagnosis of upper tract urothelial cancer

Answer 25

CT IVU or IVU urine cytology ureteroscopy and biopsy

Question 26

Where is TCC of upper tract usually found and describe it briefly

Answer 26

very aggressive - high grade and multifocal renal pelvis or collecting system high risk of local recurrence high risk of bladder TCC

Question 27

How is TCC of upper tract treated? exceptions.

Answer 27

nephro-ureterectomy | unfit or bilateral disease requires endoscopic treatment

Question 28

2 benign renal tumours

Answer 28

oncocytoma | angiomyolipoma

Question 29

Malignant renal tumour main type

Answer 29

renal adenocarcinoma

Question 30

What part of the kidney do most renal adenocarcinomas arise?

Answer 30

proximal tubules

Question 31

4 subtypes of renal adenocarcinoma and the main one

Answer 31

CLEAR CELL papillary chromophobe bellini type ductal carcinoma

Question 32

Risk factors of renal adenocarcinoma

Answer 32

``` FH smoking obesity anti-hypertensive medications ESRD acquired renal cystic disease ```

Question 33

How do most renal tumours present?

Answer 33

asymptomatic

Question 34

Other ways in which renal tumours present

Answer 34

mets symptoms TRIAD = loin pain, haematuria, mass paraneoplatic syndrome

Question 35

What T stage of renal disease is the first which goes beyond the capsule?

Answer 35

3

Question 36

How can renal adenocarcinoma spread?

Answer 36

direct spread - through renal capsule venous invasion - renal vein and IVC haematogenous spread to lungs and bones lymphatic spread to paracaval nodes

Question 37

Investigations of renal adenocarcinoma

Answer 37

CT scan abdomen and chest bloods - U+Es and FBC optional eg IVU, uss, dmsa, mag-3

Question 38

Treatment of renal adenocarcinoma

Answer 38

surgical - laprascopic radical nephrectomy

Question 39

Why is metastases treatment of renal adenocarcinoma so difficult?

Answer 39

RCC is chemo and radio RESISTANT

Question 40

Other treatments for renal adenocarcinoma

Answer 40

targeted receptor tyrosine kinase inhibitors | immunotherapy