Tumours of the Urinary System Flashcards by Annie Caldwell

Where do you get urothelial cancer?

Bladder
Upper tract (i.e. ureter, renal pelvis and collecting system) - UTUC
FROM THE RENAL CALYCES TO THE TIP OF THE URETHRA

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What are urothelial tumours?

Malignant tumours of the lining transitional cell epithelium (urothelium)

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What is the commonest site for urothelial tumours? What % occurs here?

Bladder

90%

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Types of bladder cancer

Transitional cell carcinoma
Squamous cell carcinoma
Adenocarcinoma

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What is the commonest type of bladder cancer in the UK?

Transitional cell carcinoma

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Where is squamous cell carcinoma of the bladder common?

In areas where schistosomiasis is endemic

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Risk factors for TCC of bladder

Smoking (40% of cases)
Aromatic amines
Non hereditary genetic abnormalities (e.g. TSG including p53 and Rb)

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Risk factors for SCC of the bladder

Schistosomiasis (H. haematobium only)
Chronic cystitis (e.g. recurrent UTI, long term catheter, bladder stone)
Cyclophosphamide therapy
Pelvic radiotherapy

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Risk factors for adenocarcinoma of the bladder

Urachal

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Presentation of bladder cancer

Painless visible haematuria
Symptoms due to invasive or metastatic disease (occasionally)
Recurrent UTI
Storage bladder symptoms
- dysuria, frequency, nocturia, urgency +/- urge incontinence
- bladder pain

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Types of haematuria

Frank

Microscopic

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Investigations of bladder cancer

Cystoscopy and endoscopic resection (TURBT)
EUA
- to assess bladder mass/thickening before and after TURBT

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Staging of bladder cancer

Cross sectional imaging (CT, MRI)
Bone scan if symptomatic
CTU for upper tract TCC

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Grades of TCC

G1 = Well differentiated - commonly non invasive
G2 = moderately differentiated - often non invasive
G3 = Poorly differentiated - often invasive
Carcinoma in situ (CIS) - non muscle invasive but VERY aggressive

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Treatment of bladder cancer

Endoscopic or radical
TA OR T1 - IN THE BLADDER, LOW GRADE NON MUSCLE INVASIVE
- endoscopic resection followed by single instillation of intravesical chemotherapy within 24 hours
- prolonged endoscopic follow up for moderate grade tumours
- consider prolonged course of intravesical chemotherapy (6 weeks) for repeated recurrences
HIGH GRADE NON MUSCLE INVASIVE OR CIS
- endoscopic resection (alone not sufficient)
- CIS consider intravesical BCG therapy (weekly for 3 weeks then repeated 6 monthly over 3 years)
- patients refractory to BCG - need radical surgery
MUSCLE INVASIVE BLADDER CANCER
- neoadjuvant chemotherapy
- followed by radial 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 catherterisable stoma) or orthotopic bladder substitution

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What % risk do patients with high grade non muscle invasive or CIS bladder cancer have of progression to the muscle invasive stage?

50-80%

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What does the prognosis of bladder cancer depend on?

Stage
Grade
Size 
Multifocality 
Presence of concurrent CIS
Recurrence at 3 months

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What is the 5 year survival of non invasive, low grade bladder TCC?

90%

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What is the 5 year survival of invasive, high grade bladder TCC?

50%

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Presentation of upper tract TCC

Frank haematuria
Unilateral ureteric obstruction
Flank or loin pain
Symptoms of nodal of metastatic disease

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What are some symptoms of nodal or metastatic disease from an upper tract TCC?

Bone pain
Hypercalcaemia
Lung
Brain

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Investigations for upper tract TCC

CT-IVU or IVU
Urine cytology
Ureteroscopy and biopsy

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What does CT-IVUs show?

Filling defects in the renal pelvis

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What part of the upper tract is most common for getting TCC?

Renal pelvis

Collecting system

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Treatment of upper tract TCC

Nephro-uretectomy If unfit / bilateral disease - nephron sparing endoscopic treatment (i.e. ureteroscopic laser ablation) = needs regular surveillance ureteroscopy

What is an indication in upper tract TCC for just endoscopic treatment?

Unifocal | Low grade disease

In all cases of upper tract TCC, what needs to be done and why?

Surveillance cystoscopy | High risk of synchronous and metachronous bladder TCC (40% over 10 years)

What is the cause of the majority of cases of painful haematuria?

UTI

What is the commonest neoplastic cause of haematuria?

TCC bladder

Investigations of haematuria

``` Urine culture Cystourethroscopy CT urogram (IVU) USS BP U and Es ```

If a patient is > 50 y/o and has frank haematuria, what is the risk of malignancy?

25-35%

Investigations of a > 50 y/o patient presenting with frank haematuria

Flexible cystourethroscopy (within 2 weeks) IVU and USS CT urogram and USS Urine cytology

If a patient is > 50 y/o with microscopic haematuria, what is the risk of malignancy?

5 - 10%

Investigations of a >50 y/o patient with microscopic haematuria

Flexible cystourethroscopy within 4- 6 weeks | IVU and USS

What are the benign renal tumours?

Oncocytoma | Angiomyolipoma

What are the malignant renal tumours?

Renal adenocarcinoma

What is the commonest adult renal malignancy?

Renal adenocarcinoma

Other names for renal adenocarcinoma

Hypernephroma | Grawitz tumour

Histological subtypes of renal adenocarcinoma

Clear cell (85%) Papillary (10%) Chromophobe (4%) Bellini type ductal carcinoma (1%)

Risk factors for renal adenocarcinoma

``` FH Smoking Anti-hypertensive medication Obesity ESRF Acquired renal cystic disease ```

What autosomal dominant conditions of the kidneys can put you at risk of renal adenocarcinoma?

vHL Familial clear cell RCC Hereditary papillary RCC

Presentation of renal adenocarcinoma

``` Asymptomatic 50% Flank pain 10% Mass 10% Haematuria 10% Paraneoplastic syndrome 30% Metastatic disease 30% ```

What is the classic triad of symptoms of renal adenocarcinoma?

Flank pain Mass Haematuria

What % of renal adenocarincomas have the classic triad?

10%

What are the features of paraneoplastic syndrome?

``` Anorexia Cachexia Pyrexia HTN Hypercalcaemia Abnormal LFTs Anaemia Polycythaemia Raised ESR ```

Where does renal adenocarcinoma metastasise to?

Bone Brain Lungs Liver

Investigations of renal adenocarcinoma

CT scan of abdomen and chest Bloods U and Es Optional - IVU ; calyceal distortion and soft tissue mass - USS ; differentiates tumour from a cyst - DMSA or MAG-3 renogram to assess split renal function if doubts about contralateral kidney

Treatment of renal adenocarcinoma

Radical nephrectomy

Treatment of metastatic renal adenocarcinoma

TKIs e.g. sunitinib Immunotherapy - interferon alpha - interleukin 2

Palliative treatment of renal adenocarcinoma - how long does this prolong the survival for?

Cytoreductive nephrectomy | 6 months

5 year survival prognosis of T1 renal adenocarcinoma

95%

5 year survival prognosis of T2 renal adenocarcinoma

90%

5 year survival prognosis of T3 renal adenocarcinoma

60%

5 year survival of T4 renal adenocarcinoma

20%

5 year survival of N1 or N2 renal adenocarcinoma

20%

Prognosis of metastasised renal adenocarcinoma

12 - 18 months

How does renal adenocarcinoma metastasise?

Direct spread/invasion through the renal capsule Venous invasion to renal vein and vena cava Haematogenous spread to lungs and bones Lymphatic spread to paracaval nodes

What is the TNM staging of renal cancer?

T1 = tumour < 7cm confined within the renal capsule T2 = tumour > 7cm and confined within the capsule T3 = local extension outside capsule a - intro adrenal and peri renal fat b - into renal vein or IVC below diaphragm c - tumour thrombus in IVC extends above diaphragm T4 - tumour invades beyond Gerotas fascia

What is the commonest cancer diagnosed in men?

Prostate cancer

75% of prostate cancers are diagnosed in what age of men?

> 65 y/o

Risk factors for prostate cancer

``` Increasing age African or afro-carribean men living in western countries Geography FH - First degree relative 2x risk ```

What genes are implicated in familial prostate cancer?

HPC1 BRCA 1 BRCA 2

What are McNeals prostatic zones?

Transition zone Central zone Peripheral zone

What % newly diagnosed prostate cancers are localised?

80%

Diagnosis of prostate cancer

PSA DRE TRUS-guided prostate biopsies

What does PSA stand for?

Prostate specific antigen

What does DRE stand for?

Digital rectal exam

What is PSA specific to?

Prostate

Presentation of local prostate cancer

``` Weak stream Hesitancy Sensation of incomplete emptying Frequency Urgency Urge incontinence UTI ```

Presentation of locally invasive prostate cancer

``` Haematuria Perineal and suprapubic pain Impotence Incontinence Loin pain or anuria resulting from obstruction of ureters Symptoms of renal failure Haemospermia Rectal symptoms including tenesmus ```

Presentation of metastatic prostate cancer

Distant - bone pain or sciatica - paraplegia secondary to spinal cord compression - lymph node enlargement - lymphoedema, particularly in the lower limbs - loin pain or anuria due to obstruction of the ureters by lymph nodes Widespread - lethargy - weight loss and cachexia

What does PSA do?

Liquifies semen

What is PSA produced by?

Glands of the prostate

Normal serum range of PSA

0-4.0

What does the upper normal limit of PSA increase with?

Age

Causes of elevations of PSA

``` UTI Chronic prostatitis Instrumentation (e.g. catheterisation) Physiological (e.g. ejaculation) Recent urological procedure BPH Prostate cancer ```

What is the half life of PSA?

2.2 days

If a repeat PSA is needed, when should It be rechecked?

In 3 weeks

If PSA = 0-1.0, what is the cancer probability?

If PSA = 1.0-2.5, what is the cancer probability?

15%

If PSA = 2.5-4.0, what is the cancer probability?

25%

If PSA = 4.0-10.0, what is the cancer probability?

40%

If PSA = > 10, what is the cancer probability?

70%

What is the prostate cancer grading system?

Gleason

How many grades does the Gleason grading system have?

What is the most common Gleason score?

What are the stages of prostate cancer?

1. Localised stage 2. Locally advanced stage 3. Metastatic stage 4. Hormone refractory stage

Staging investigations for prostate cancer

``` DRE (local staging) PSA Transrectal US guided biopsies CT (regional and distant staging) MRI (local staging) ```

Tumours of the Urinary System Flashcards

(88 cards)