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%
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
What are risk factors for TCC?
–smoking (accounts for 40% of cases)
–non-hereditary genetic abnormalities (e.g. TSG incl. p53 and Rb)
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)
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
Besides haematuria, what are the presenting features?
–storage bladder symptoms
•dysuria, frequency, nocturia, urgency +/- urge incontinence
•if present, suspect CIS
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
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)
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)
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
What determines the treatment of bladder cancer?
–Histological grade of tumour
–Patient age and co-morbidities
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
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
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
Surgery to remove the bladder (the organ that holds urine) and the prostate. In a radical cystoprostatectomy, the seminal vesicles are also removed
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
What is the prognosis for bladder cancer?
–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
What are the presenting features of upper tract urothelial cancer?
–Unilateral ureteric obstruction
– Flank or loin pain
– Symptoms of nodal or metastatic disease
What are the diagnostic investigations for upper tract urothelial cancer?
CT - IVU (CT urogram) or IVU - shows filling defect in the renal pelvis
Ureteroscopy and biopsy
Where is a TCC likely to be in the upper tract?
Rnal pelvis or collecting system commonest
Ureter less commonly
How are most transitional cell carcinomas in the upper tact treated?
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
Nephroureterectomy is a minimally invasive surgical procedure to remove a patient's renal pelvis, kidney, ureter, and bladder cuff.
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
When is endoscopic treatment for upper tract cancer indicated?
•If unifocal and low-grade disease - relative indication for endoscopic treatment
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
What are the benign renal cancers?
What is the most common adult renal malignancy?
Most arise from proximal tubules
•clear cell (85%)
•Bellini type ductal carcinoma (1%)
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)
•End-stage renal failure
•Acquired renal cystic disease
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
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
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)
–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
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)
What is the treatment for renal adenocarcinoma?
•Metastases - little effective treatment since RCC is radioresistant and chemoresistant
–multitargeted receptor tyrosine kinase inhibitors
• sunitinib, sorafenib, panzopanib,temsirolimus
•superior response rates to immunotherapy
•response rate with either 20% at most
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