Urothelial and Renal Cancers Flashcards Preview

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Flashcards in Urothelial and Renal Cancers Deck (35):
1

Where can urothelial tumours occur?

•Malignant tumours of the lining transitional cell epithelium (urothelium) can occur at any point

–from renal calyces

–to the tip of the urethra.

•Most common site - bladder - 90%

–“Bladder Cancer”

2

What is the most common cancer type of the bladder?

•The tumour type is most often transitional cell carcinoma (i.e. 90% in UK)

 

•Where Schistosomiasis is endemic, squamous cell carcinoma of the bladder is the common tumour type

3

What are risk factors for TCC?

–smoking (accounts for 40% of cases)

–aromatic amines

–non-hereditary genetic abnormalities (e.g. TSG incl. p53 and Rb)

4

What are the risk factors for squamous cell carcinoma?

•Squamous cell carcinoma :

–Schistosomiasis (S. haematobium only)

–chronic cystitis (e.g. recurrent UTI, long term catheter, bladder stone)

–cyclophosphamide therapy

–pelvic radiotherapy

Adenocarcinoma

-Urachal

5

What is the most frequent presenting symptom for badder cancer?

–painless visible haematuria

 

Occasionally - symptoms due to invasive or metastatic disease

 

•Haematuria may be

–Frank - reported by patient

–Microscopic - detected by doctor

6

Besides haematuria, what are the presenting features?

–recurrent UTI

–storage bladder symptoms

•dysuria, frequency, nocturia, urgency +/- urge incontinence

•bladder pain

•if present, suspect CIS

7

What are the investigations for haematuria?

Urine culture - majority of painful haematuria = UTI

Cystourethroscopy - commonest neoplastic cause is TCC bladder

Upper tract imaging - CT urogram (IVU), ultrasound scan

Urine Cytology - limited use in dipstick haematuria

BP and U and E's

 

8

What is the investigation for frank haematuria for patients over the age of 50?

–>50 yrs - Risk of malignancy - 25-35%

–Flexible cystourethroscopy within 2 weeks

–IVU (CT Urogram) & USS

(IVU alone will miss a proportion of renal cell tumours (especially if less than 3 cm)

(USS alone will miss a proportion of urothelial tumours of the upper tracts)

Urine cytology may also be useful (but not very sensitive or specific)

9

How do you diagnose bladder cancer?

(grade and T stage)

–cystoscopy and endoscopic resection (TURBT) - Transurethral resection of bladder tumour

–EUA to assess bladder mass/thickening before and after TURBT

(examination under anaesthesia)

10

How do we determine the staging - T,N,M?

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)

 

Treatment - endoscopic or radical

11

What determines the treatment of bladder cancer?

–Site

–Clinical stage

–Histological grade of tumour

–Patient age and co-morbidities

12

What is the treatment for low grade non invasive (i.e Ta or T1)

•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

13

What is the treatment for high grade non-muscle invasive or CIS (carcinoma in situ)

•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)

 

Bacillus Calmette-Guerin therapy: Bacillus Calmette-Guerin (BCG) is the main intravesical immunotherapy for treating early-stage bladder cancer.

•patients refractory to BCG – need radical surgery

14

What is the bladder cancer treatment for muscle invasive 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

15

Define cystoprostatectomy

Surgery to remove the bladder (the organ that holds urine) and the prostate. In a radical cystoprostatectomy, the seminal vesicles are also removed

16

Define pelvic exenteration

Pelvic exenteration (or pelvic evisceration) is a radical surgical treatment that removes all organs from a person'spelvic cavity. The urinary bladder, urethra, rectum, and anus are removed. The procedure leaves the person with a permanent colostomy and urinary diversion

17

What is the prognosis for bladder cancer?

–stage

–grade

–size

–multifocality

–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

18

What are the presenting features of upper tract urothelial cancer?

–Frank haematuria

–Unilateral ureteric obstruction

– Flank or loin pain

– Symptoms of nodal or metastatic disease

•Bone pain

•Hypercalcaemia

•Lung

•Brain

19

What are the diagnostic investigations for upper tract urothelial cancer?

CT - IVU (CT urogram) or IVU - shows filling defect in the renal pelvis

Urine cytology

Ureteroscopy and biopsy

20

Where is a TCC likely to be in the upper tract?

Rnal pelvis or collecting system commonest

Ureter less commonly

21

How are most transitional cell carcinomas in the upper tact treated?

Nephro-ureterectomy

22

Why aren't upper tract cancers treated endoscopically?

High risk of local recurrence  - risk of recurrence is also present if treated by segmental resection

 

Difficult to follow up if treted endoscopically

23

Define nephroureterectomy

Nephroureterectomy is a minimally invasive surgical procedure to remove a patient's renal pelvis, kidney, ureter, and bladder cuff.

24

When is ureteroscopic laser ablation indicated?

This is a nephron sparing endoscopic treatment 

 

Used in patients unfit for nephro-ureterectomy or patients with bilateral disease

25

When is endoscopic treatment for upper tract cancer indicated?

•If unifocal and low-grade disease - relative indication for endoscopic  treatment

26

Why is there a need for surveillance cystoscopy after treatment for upper tract bladder cancer removal?

•In ALL cases, high risk of synchronous and metachronous bladder TCC (40% over 10 years); hence need surveillance cystoscopy

27

What are the benign renal cancers?

Oncocytoma

Angiomyolipoma

28

What is the most common adult renal malignancy?

Renal adenocarcinoma

 

Most arise from proximal tubules

Histological subtypes:

•clear cell (85%)

•papillary (10%)

•chromophobe (4%)

•Bellini type ductal carcinoma (1%)

29

What are 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)

•Smoking

•Anti-hypertensive medication

•Obesity

•End-stage renal failure

•Acquired renal cystic disease

30

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, and pyrexia

–hypertension, hypercalcaemia and abnormal LFTs

–anaemia, polycythaemia and raised ESR

•Metastatic disease : 30%

–bone, brain, lungs, liver

31

What are the ways renal cancer spreads?

Direct - through renal capsule

Venous invasion - to renal vein and vena cava

Haematogenous spread to lungs and bone

Lymphatic spread to paracaval nodes

32

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 and E, FBC 

This may indicate some of the paraneoplastic syndrome (hypercalcaemia, abnormal LFTs, anaemia, polycthaemia)

 

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

33

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) 

34

What is the treatment for renal adenocarcinoma?

 

•Metastases - little effective treatment since RCC is radioresistant and chemoresistant

–multitargeted receptor tyrosine kinase inhibitors

•relatively new

• sunitinib, sorafenib, panzopanib,temsirolimus

•superior response rates to immunotherapy

•trials ongoing 

immunotherapy

•Interferon alpha

•Interleukin-2

•response rate with either 20% at most

35

Here is some classification of bladder tumours

 

 

•Stage of tumour

  -  TNM classification

  -  T-stage :

     -  non-muscle invasive (or ‘superficial’)

     -  muscle invasive

•Combined to describe TCC e.g. G1pTa