Bladder cancer, renal cancer and upper tract transitional cell carcinoma – Flashcards
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What is a urothelial tumour?
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Malignant tumour of the lining transitional cell epithelium (urothelium) of the urinary tract. AKA transitional cell carcinoma (TCC). Can occur at any point from the renal calyces to the tip of the urethra.
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Most common site of urothelial tumours
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Bladder (90%).
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Types of bladder cancer
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90% TCC. SCC (rare in Western world but more common in developing world like Africa and Eygpt due to schistosomiasis). Adenocarcinoma (rare in Western world).
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Risk factors for only TCC bladder cancer
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Smoking (most important risk factor). Occupational exposure to aromatic amines, aromatic/chlorinated hydrocarbons (found in paint, dye, solvents, tyre, rubber, metal processing plants, combustion plants, petroleum). Cyclophosphamide.
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Risk factors for only SCC bladder cancer
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Chronic inflammation: UTIs, stones, indwelling catheters. Schistosomiasis.
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Risk factors for TCC and SCC bladder cancer
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Pelvic radiotherapy. Older age. Male. White ethnicity.
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Bladder cancer epidemiology
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M:F = 3:1. 4th most common cancer in men, 12th most common cancer in women. 2nd most common urological cancer. Can present from around the age of 20 onwards but peaks in 70s.
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Bladder carcinoma in situ
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Very superficial but highly aggressive tumour cells on the urothelial lining. Not invasive.
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Superficial vs invasive bladder tumours
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Superficial AKA non muscle invasive bladder cancer (NMIBC) - 80% of cases Muscle invasive bladder cancer (MIBC) - 20% of cases
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Bladder cancer grading
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G1 - well differentiated. G2 - moderately differentiated. G3 - poorly differentiated.
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Presentation of bladder cancer
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85% present with visible (frank) painless haematuria. Less commonly present with NVH and/or storage related LUTS, recurrent UTIs, bladder outflow obstruction. May have symptoms/signs of anaemia. Abdo/pelvic examination may reveal a pelvic mass in advanced cases although often entirely normal. NOT often an incidental diagnosis on CT/US.
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What % of bladder tumours present with metastases?
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5%.
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Indications for urgent urological investigation for suspected bladder cancer
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>45yo + unexplained VH without UTI or that persists or recurs after successful treatment of UTI. >=60yo + unexplained NVH + either dysuria or raised WBC count on blood test.
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Indications for NON-urgent urological investigation for suspected bladder cancer
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>=60 yo with recurrent or persistent unexplained UTI.
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Investigations for bladder cancer
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Urine cytology: - may be helpful but negative result does not exclude disease - important in the diagnosis and follow-up of carcinoma in situ Flexible cystoscopy + biopsies.
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Bladder cancer staging
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T-staging before surgery: MRI/CT. Contrast CT chest/abdomen/pelvis + CT urography (for complete examination of upper urinary tracts) if MIBC diagnosed after initial surgery.
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Bladder cancer stages
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Ta = non-invasive papillary carcinoma. Tis = carcinoma in situ "flat tumour". T1 = invades subepithelial connective tissue i.e. lamina propria. T2a = invades superficial muscle. T2b = invades deep muscle. T3 = invades beyond muscle layer. T4 = invades any of the prostate, uterus, vagina, pelvic wall or abdominal wall.
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Treatment of NMIBC i.e. Ta or T1 tumours.
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Trans-urethral resection of bladder tumour (TURBT) + adjuvant single dose intravesical chemotherapy with Mitomycin C (reduces recurrence rate but not likelihood of progression to MIBC). Further TURBT after 6 weeks to ensure adequate resection if high grade disease or no detrusor muscle included in the initial resection. In patients with recurrent/multifocal carcinoma in situ or high grade tumours, intravesical immunotherapy with BCG (evokes inflammatory response) can be used to reduce recurrence and progression risk to MIBC after resection.
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What does TURBT involve?
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Cystoscopy and endoscopic resection. Must sample the detrusor muscle to determine whether the cancer is invasive or not. Both diagnostic and curative for NMIBC but only diagnostic for MIBC.
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Risks of BCG treatment
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Bladder irritation causing urgency, frequency, dysuria etc. Systemic absorption resulting in development of TB.
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Recurrence risk for non-invasive bladder cancers
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High grade tumours have quite a high recurrence rate, hence the need for follow-up TURBT at 6 weeks.
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Treatment of MIBC i.e. T2-T3 tumours.
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If initial TURBT shows the tumour invading into the detrusor muscle, curative treatment is with cisplatin-based neoadjuvant chemo + radical cystectomy and urinary diversion (ileal conduit or neobladder). An alternative to surgery is radical external-beam radiotherapy.
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What does a cystectomy involve?
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Men: cystoprotatectomy (removal of bladder and prostate). Women: excision of bladder, urethra, uterus, fallopian tubes, ovaries and anterior vaginal wall. Includes removal of regional lymph nodes.
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Potential complication of cystectomy
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Erectile dysfunction due to nerve damage.
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Ileal conduit?
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Urinary drainage system creating using section of ileum connected to ureters with opening to stoma on abdominal surface.
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Neobladder?
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A continent urinary reservoir (essentially a replacement bladder) made from a segment of bowel or stomach, with implantation of ureters and urethra.
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Treatment of metastatic/nodal bladder cancer
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Chemotherapy with cisplatin-based agents. Palliative radiotherapy for symptoms.
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Bladder cancer prognosis
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Low grade superficial tumours: >=90% survive 5 yrs. High grade superficial/invasive tumours: 50% survive 5 yrs at best or as low as 10% at worst e.g. for stage 4 tumours.
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Bladder cancer follow-up for all cases
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Regular flexible cystoscopies. Upper urinary tract imaging. GFR monitoring. CT to look for recurrence. Loopogram (imaging of ileal conduit).
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Most kidney tumours benign or malignant?
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Malignant.
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Most common benign kidney tumours
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Oncocytoma. Angiomyolipoma.
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85% of renal cancers are what type?
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Adenocarcinomas.
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Other names for renal adenocarcinoma
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Hypernephroma. Grawitz tumour. Clear cell carcinoma. Renal cell carcinoma.
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Pathology of renal cell carcinoma
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80% originate from proximal convoluted tubule epithelial cells (either clear cell or granular). 10-15% papillary. 5% chromophobe. Rarely: collecting duct (Bellini) or medullary cell.
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Renal cell carcinoma epidemiology
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Cause largely unknown. 8th most common malignancy. Most lethal of all urological cancers. M:F = 3:1. Peak incidence between 50-60yo.
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Risk factors for renal cell carcinoma
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Smoking. Obesity. Hypertension. Tuberous sclerosis. Renal transplant. Long-term renal dialysis. Renal cystic disease. Cadmium exposure. Employment in leather industry. 2-3% cases are hereditary, most commonly seen with von Hippel-Lindau syndrome.
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Renal cell carcinoma presentation
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50% asymptomatic and most commonly diagnosed incidentally with CT/USS. Often no abnormality of examination. 10% present with "too late triad" of locally advanced disease: visible haematuria, flank pain and palpable mass - more common to present with just one of these. Can present with paraneoplastic syndromes. 30% present with metastases and systemic symptoms e.g. bone pain, haemoptysis. Left varicocele due to occlusion of left testicular vein. Pyrexia of unknown origin.
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Possible renal cell carcinoma paraneoplastic syndromes (4 most common first)
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Anaemia. Polycythaemia. Hypercalcaemia. Hypertension. Raised ESR. Peripheral oedema. "Stauffer's syndrome": abnormal LFTs, decreased WBCs, fever, hepatic necrosis.
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What % of cases of Stauffer's syndrome due to renal cell carcinoma are reversible following nephrectomy?
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60%.
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Renal cancer staging
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T1 = 7cm, confined within renal capsule. T3 = local extension - T3a = intro adrenal gland or peri-renal fat - T3b = into renal vein or IVC - T3c = tumour thrombus in IVC extends above diaphragm T4 = invades beyond Gerota's fascia AKA renal fascia.
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How renal cancers spread
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Direct invasion through renal capsule. Venous invasion into renal vein and IVC. Haematogenous spread to other organs. Lymphatic spread to paracaval nodes.
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Most common sites of renal cell carcinoma metastases
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Lung (most commonly) - cannon ball mets. Bone. Brain. Liver.
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Investigations of renal cell carcinoma
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Bloods (FBC, ESR, U&Es, LFTs, coagulation screen, LDH, Ca2+). Renal USS (determines whether solid or cystic lesion). Abdominal, pelvic and chest CT: stage tumour and plan surgery. +/- bone scan if clinical evidence of bone mets. Assess function of contralateral kidney.
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Renal cell carcinoma treatment
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Localised tumours: - laproscopic partial nephrectomy OR radical nephrectomy (removal of the kidney and adrenal with intact renal fascia) if >7cm - if patient also has CKD, do partial to preserve as much kidney as possible - unsuitable for surgery: image-guided percutaneous radio frequency ablation or cryotherapy Metastatic disease: - radical nephrectomy (in rare cases, metastases can even regress after radical nephrectomy) - + interferon-alpha/interleukin-2 if clear cell subtype - + tyrosine kinase inhibitors e.g. sunitinib, pazopanib if unsuitable for immunotherapy - can sometimes perform mestastasectomy Does not respond well the chemo/radiotherapy.
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Renal cell carcinoma 5 year survival rates
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Generally very unpredictable, with occasional long survival with extensive disease.
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Most common renal cancer in children
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Wilm's tumour.
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Risk factors for upper tract transitional cell carcinoma
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Smoking. Older age. Phenacetin ingestion. Balkan nephropathy. Lynch syndrome (HNPCC).
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Epidemiology of upper tract transitional cell carcinoma
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Rare. M:F = 3:1.
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Pathology of upper tract transitional cell carcinoma
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Frequently multifocal and high-grade but more commonly unilateral. 90% are papillary TCCs.
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Presentation of upper tract transitional cell carcinoma
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Majority present with visible haematuria. About a third present with flank pain "clot colic". Minority asymptomatic and detected when investigating synchronous bladder tumour.
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Investigations for upper tract transitional cell carcinoma
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CT urogram OR renal USS + IVU. Cystoscopy +/- retrograde pyelogram. If continued bleeding and negative investigations: urine cytology. Flexible ureterorendoscopy + biopsy. Staging: CT chest/abdomen/pelvis.
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Treatment of upper tract transitional cell carcinoma
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Non-metastatic with normal contralateral kidney: radical nephro-ureterectomy + bladder cuff excision + node sampling. Single functioning kidney/bilateral disease/unilateral low grade tumour <1cm/unfit for surgery: percutaneous, segmental nephron-sparing ureterorendoscopic resection/laser ablation +/- mitomycin C. Metastatic disease: systemic combination platinum-based chemo + palliative surgery/arterial embolisation/radiotherapy for haematuria.
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Upper tract transitional cell carcinoma prognosis
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At follow-up 50% will develop bladder TCC too and minority will develop contralateral upper tract TCC. Very poor prognosis if nodal involvement or mets.
