Urothelial and Renal Cancers

Question 1

What are the sites of urothelial tumours?

Answer 1

Malignant tumours of the lining transitional cell epithelium - from renal calyces to tip of the urethra
Most common site is the bladder

Question 2

What is the pathology of bladder cancer?

Answer 2

Most common - transitional cell carcinoma (TCC)
Schistosomiasis is endemic - squamous cell carcinoma

Question 3

What are the risk factors for transitional cell carcinoma (TCC)?

Answer 3

Smoking, aromatic amines and non-hereditary genetic abnormalities

Question 4

What are the risk factors for squamous cell carcinoma?

Answer 4

Schistosomiasis, chronic cystitis, cyclophosphamide therapy and pelvic radiotherapy

Question 5

What are the presenting features of bladder cancer?

Answer 5

Most frequent symptom - painless visible haematuria
Occasionally symptoms of invasive or metastatic disease
Haematuria - frank or microscopic
Recurrent UTIs and storage bladder symptoms

Question 6

How is haematuria investigated?

Answer 6

Urine culture
Cystourethroscopy
Upper tract imaging - CT urogram
Urine cytology - dipstick
BP and U+Es

Question 7

How is frank haematuria investigated?

Answer 7

Flexible cystourethroscopy within 2 weeks
CT urogram and USS
Urine cytology may be useful

Question 8

What is the risk of malignancy with frank haematuria if over 50yrs?

Answer 8

25-35%

Question 9

How is dipstick or microscopic haematuria investigated?

Answer 9

Flexible cystourethroscopy within 4-6 weeks
USS

Question 10

What is the risk of malignancy of microscopic haematuria if over 50yrs?

Answer 10

5-10%

Question 11

Why is IVU and USS not used alone in diagnosis of urothelial tumours?

Answer 11

IVU can miss proportion of renal cell tumour - esp. if under 3cm
USS can miss a proportion of urothelial tumours in upper tracts

Question 12

How is grade and T stage diagnosed in urothelial tumours - bladder?

Answer 12

Cystoscopy and endoscopic resection (TURBT)
EUA to assess bladder thickness

Question 13

How is urothelial tumours staged?

Answer 13

Cross sectional imaging - CT and MRI
Bone scan if symptomatic
CTU for upper tract

Question 14

How are bladder tumours classified?

Answer 14

Grade of tumour
Stage of tumour - TNM (T is muscle invasion or superficial)
Combined to describe TCC

Question 15

What are the grades of TCC?

Answer 15

G1 - well differentiated (commonly non-invasive)
G2 - moderately differentiated (often non-invasive)
G3 - poorly differentiated (often invasive)
CIS - carcinoma in situ (very aggressive)

Question 16

What does above T2b mean in staging and grading?

Answer 16

Detrusor muscle invasion

Question 17

What does treatment of bladder cancer depend on?

Answer 17

Site, clinical stage, histological grade of tumour and patients age and co-morbidities

Question 18

What is the treatment for low grade non-muscle invasive bladder cancer?

Answer 18

Endoscopic resection followed by single installation of intravesical chemo within 24hrs
Prolonged endoscopic follow up
Consider prolonged course of chemo for repeated recurrences

Question 19

What is the treatment for high grade non-muscle invasive or CIS bladder cancer?

Answer 19

Endoscopic resection alone is not sufficient
CIS consider intravesical BCG therapy
If refractory to BCG then need radical surgery

Question 20

What is the treatment for muscle invasive bladder cancer (T2-3)?

Answer 20

Neoadjuvant chemo for local and systemic control by either - radical RT or radical cystoprostatectomy or anterior pelvic exenteration with urethrectomy with extended lymphadenectomy
Radical surgery with incontinent urinary diversion, continent diversion or orthotopic bladder substitution

Question 21

Describe the prognosis of bladder cancer

Answer 21

Depends on stage, grade, size, CIS, recurrence at 3 months and multifocality
Non-invasive 5 year survival is 90%
Invasive is 50%

Question 22

What are the presenting features of upper tract TCC (UTUC)?

Answer 22

Frank haematuria, unilateral ureteric obstruction, flank or loin pain, and symptoms of nodal or metastatic disease - bone pain, hypercalcaemia, lung and brain

Question 23

What diagnostic investigations are used for UTUC?

Answer 23

CT-IVU or IVU
Urine cytology
Ureteroscopy and biopsy

Question 24

What does IVU/ CT-IVU show in UTUC?

Answer 24

Filling defect in renal pelvis

Question 25

How are most upper tract TCCs treated?

Answer 25

Nephroureterectomy If unfit or has bilateral disease then indication for for nephron sparing endoscopic treatment

Question 26

What are the sites of upper tract TCC?

Answer 26

Renal pelvis or collecting system commonest Ureter less common Often high grade and multifocal on one side High risk of recurrence if treated endoscopically or segmental resection

Question 27

What treatment is needed in upper tract TCC which is low grade and unifocal?

Answer 27

Endoscopic treatment

Question 28

What do all cases of upper urinary TCC need?

Answer 28

Surveillance cystoscopy As high risk of synchronous and metachronous bladder TCC

Question 29

What are some benign renal tumours?

Answer 29

Oncocytoma and angiomyolipoma

Question 30

Describe malignant renal tumour

Answer 30

Renal adenocarcinoma - commonest adult renal malignancy Most arise from proximal tubules Subtypes - clear cell, papillary, chromophobe and Bellini type ductal

Question 31

What are some risk factors for renal adenocarcinoma?

Answer 31

FH (autosomal dominant), smoking, anti-hypertensive medication, obesity, end-stage renal failure and acquired renal cystic disease

Question 32

What is the presentation of renal adenocarcinoma?

Answer 32

Asymptomatic - 50% Classic triad - flank pain, mass and haematuria Paraneoplastic syndrome Metastatic disease - bone, brain, lungs and liver

Question 33

What is paraneoplastic syndrome?

Answer 33

Anorexia, cachexia, pyrexia, hypertension, hypercalcaemia, abnormal LFTs, anaemia, raised ESR and polycythaemia

Question 34

Describe the TNM staging for renal cancer

Answer 34

T1 - <7cm within renal capsule T2 - >7cm and within capsule T3 - local extension outside capsule T4 - tumour invades beyond Gerota's fascia

Question 35

What is direct spread of renal adenocarcinoma?

Answer 35

Through renal capsule

Question 36

What can renal adenocarcinoma spread to - venous invasion?

Answer 36

Renal vein and vena cava

Question 37

What is the haematogenous and lymphatic spread of renal adenocarcinoma?

Answer 37

Haematogenous - lungs and bone Lymphatic - paracaval nodes

Question 38

What investigations are done for renal adenocarcinoma?

Answer 38

CT scan of abdomen and chest Bloods - U+Es and FBC Optional - US and DMSA or MAG-3 for renal split function

Question 39

What is the treatment for renal adenocarcinoma?

Answer 39

Surgical - laparoscopic radical nephrectomy standard for T1 Worthwhile in major venous invasion and curative if less than T2 Even in metastatic disease is beneficial

Question 40

What is the treatment for metastatic renal adenocarcinoma?

Answer 40

Is radio-resistant and chemo-resistant so little effective treatment Multitargeted receptor kinase inhibitors and immunotherapy

Question 41

What is the prognosis of renal adenocarcinoma?

Answer 41

T1 - 95% 5 years survival T4 - 20% 5 year survival M1 - median 12-18 months