Tumours of urinary system and imaging Flashcards
Where do malignant tumours of the lining transitional cell epithelium occur?
At any point from renal calyces to the tip of the urethra. Most common site - bladder - 90%
Bladder cancer - most common type of tumour is?
Transitional cell carcinoma (90% in UK)
Schistosomiasis (flatworm) is endemic, squamous cell carcinoma of bladder is the common tumour type.
Risk factors for Bladder cancer?
TCC:
- smoking (40% cases)
- aromatic amines
- non-hereditary genetic abnormalities (TSG)
Squamous cell carcinoma:
- Schistosomiasis
- Chronic cystitis (long term catheter, bladder stone, recurrent UTI)
- Cyclophosphamide therapy
- pelvic radiotherapy
Adenocarcinoma
- Urachal
Presenting features of bladder cancer
Most frequent presenting symptom: - Painless visible haematuria Haematuria may be - Frank - Microscopic Occasionally: Symptoms due to invasive or metastatic disease.
Recurrent UTI Storage bladder symptoms: - dysuria, frequency,nocturne,urgency +/- urge incontinence. - bladder pain - if present, suspect CIS
Investigations of Haematuria
Urine culture:
- majority of painful haematuria = UTI
Upper tract imaging:
CT urogram (IVU)
US scan
Cystourethroscopy:
- commonest neoplastic cause is TCC bladder
Urine cytology
- limited use in dipstick haematuria
BP and U&E’s.
What is the risk of malignancy and what investigations are carried out for FRANK haematuria?
> 50 yrs - risk of malignancy -25-35%
- Flexible cystourethroscopy within 2 weeks
- CT urogram & USS
- Urine cytology may also be useful (not very sensitive nor specific)
Risk of malignancy for Dipstick or microscopic haematuria and investigations carried out?
> 50 yrs - risk of malignancy = 5-10%
- Flexible cystourethroscopy within 4-6 weeks
- USS
How do you diagnose bladder cancer?
Cystoscopy and endoscopic resection. (TURBT)
EUA to assess bladder mass/thickening before and after TURBT
How do you investigate the staging?
Cross-sectional imaging (CT, MRI)
Bone scan if symptomatic
CTU for upper tract TCC
Treatment for bladder cancer
Endoscopic or radical
How do you classify bladder tumours?
Grade Stage of tumour - TNM classification - T stage: - non-muscle invasive - muscle invasive
- Combined to describe TCC.
What are the grades of TCC?
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)
T stage of Bladder TCC
Tis Ta T1 T2a T2b T3a T3b T4a - prostate T4b
What does appropriate treatment depend on?
- Site
- Clinical stage
- Histological grade of tumour
- Patient age and co-morbidities
- What is survival for non- invasive low grade bladder TCC?
- Invasive, high grade bladder TCC?
- 90% 5 - year survival
2. 50% 5 - year survival
Treatment for Low grade non-muscle invasive bladder cancer
Ta or T1
- endoscopic resection followed by single instillation of intravesical chemotherapy within 24hr.
- consider prolonged course of chemo for repeated recurrences.
Treatment for high grade non-muscle invasive or CIS
Very aggressive - 50-80% risk of progression to muscle invasive stage.
Intravesical BCG therapy.
Treatment for muscle invasive bladder cancer?
T2-T3 - neoadjuvant chemo for local and systemic control; followed by: Radical radiotherapy or radical cystoprostatectomy.. Radical surgery.
Upper Tract urothellia 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.
Diagnostic investigations for UTUC
CT-IVU (shows filling defect)
Urine cytology
Ureteroscopy and biopsy
Upper tract TCC where is it common and what is the treatment?
Renal pelvis or collecting system commonest.
Tumours often high-grade and multifocal on one side.
Treatment = endoscopically or segmental resection.
most treated by - Nephron-ureterectomy.
What are the types of Renal tumours?
Benign: oncocytoma, angiomyolipoma
Malignant: renal adenocarcinoma - commonest adult renal malignancy - most arise from proximal tubules Histology subtypes: - clear cell (85% - Papillary (10%) - Chromophobe (4%) - Bellini type ductal carcinoma (1%)
Risk factors of Renal adenocarcinoma
Family history (autosomal dominant) Smoking Anti-hypertensive medication Obesity End - stage renal failure Acquired renal cystic disease
Renal adenocarcinoma presentation
Asymptomatic - 50%
Classic “triad” of flank pain, mass and haematuria - 10%
Paraneoplastic syndrome: 30%
- anorexia, pyrexia, hypertension, hypercalaemia, anemia.
Metastatic disease - 30%
- bone, brain, lung, liver
