Bladder and Renal Cancer

 

• Suspected urological cancer referral criteria

  Urgent referral:

  • Age ≥45: unexplained visible haematuria without UTI (or despite treatment of UTI).
  • Age ≥60: unexplained microhaematuria plus (a) dysuria or (b) ↑WBC on blood test.

  Non-urgent referral:

  • Age ≥60: recurrent or persistent unexplained UTI.

• Bladder cancer

  Pathology

  • In the UK, 90% are urothelial carcinomas (aka transitional cell carcinoma).
  • Remainder are squamous or adenocarcinoma.

  Epidemiology

  • 1 in 40 lifetime risk in UK.
  • Commoner worldwide, mostly squamous cell carcinomas linked to schistosomiasis.

  Risk factors

  • Smoking causes 50%.
  • Industrial chemicals: aromatic amines (rubber and dye industry), polycyclic aromatic hydrocarbons (aluminium and coal industry).
  • Pelvic radiation e.g. for prostate.
  • Schistosomiasis (squamous).
  • Long-term catheter (squamous).
  • Family history
  • Age

  Signs and symptoms

  • Macro/microscopic haematuria.
  • Usually painless, but dysuria can occur.

  Investigations

  Initial:

  • Urinalysis: blood and RBC casts.
  • FBC: may show ↓Hb from haematuria.
  • U+E

  Diagnosis:

  • Urine cytology: not completely sensitive, but helps pick up carcinoma in situ (CIS) which may be missed on cystoscopy as they are flat.
  • Cystoscopy is especially good for picking up papillary tumours (low-grade). Suspicious lesions should be biopsied, and random biopsies are taken to look for carcinoma in situ (CIS).
  • Fluorescence-guided biopsy should be used if CIS suspected e.g. +ve cytology.

  Staging:

  • Non-invasive cancer: upper urinary tract imaging, either IV pyelogram, CT urogram, or MR urogram.
  • Detrusor invasion: CT chest-abdo-pelvis including CT urogram.

  Management

  Non-invasive cancer:

  • Transurethral resection of bladder tumour (TURBT) via cystoscopy plus post-op intravesical chemotherapy (e.g. mitomycin).
  • Adjunctive intravesical immunotherapy with BCG for CIS or other high-risk tumours. May continue up to 3 years.
  • Cystectomy if treatment fails.

  Detrusor invasion:

  • Neoadjuvant chemo with cisplatin-based regimen
  • Cystoprostatectomy or cystectomy plus hysterectomy, and pelvic lymphadenectomy.
  • Urostomy then formed via ileal conduit to allow passage of urine i.e. bladder 'replaced' by ureteric diversion to a segment of resected ileum, which is formed into a stoma. A direct ureteric stoma would likely just stenose due to its small diameter. Alternative is a synthetic orthotopic bladder substitute.

  Complications and prognosis

  • Obstructing tumour → retention, hydronephrosis.
  • Surgical complications: bowel obstruction, ureter obstruction, incontinence from orthotopic bladders.
  • Ureteric cancer.
  • High recurrence rate (80%) for non-invasive cancer, especially CIS. Needs regular cystoscopy follow up, the first within 3 months, then every year or two.
  • 5 year survival: 90% if non-invasive, 50% if invasive.

• Renal cell carcinoma

  Pathology and epidemiology

  • RCCs are adenocarcinomas, of which 80% are clear cell carcinomas (usually in the proximal tubule) and most of the rest papillary tumours.
  • Risk factors: smoking (causes 25%), obesity, hypertension, family history, age.
  • 1 in 60 lifetime risk.
  • Non-RCC kidney cancers: transitional cell carcinoma (pelvis or ureters), Wilms' tumour (aka nephroblastoma, presents age 2-3).

  Signs and symptoms

  • Often asymptomatic (50%), most commonly an incidental detection on unrelated abdominal US or CT.
  • Classic triad: macro or microscopic haematuria (commonest symptom), flank pain, abdominal mass. All three only present in 10%.
  • Others: weight loss, oedema, fever, metastatic symptoms (25% at presentation) such as bone pain or SOB.

  Investigations

  Urinalysis:

  • Blood ± protein.
  • Cytology

  Bloods:

  • FBC: ↓Hb of chronic disease or ↑RBC from ↑EPO production.
  • U+E: may show CKD.
  • Prognostic markers: ↑LDH, ↑Ca2+ (↑PTH production).
  • LFTs: mets, Stauffer's syndrome (paraneoplastic cholestasis).

  Imaging:

  • CT urogram – a CT KUB with IV contrast – is the 1st line imaging modality.
  • Kidney US detects most lesions, but is less sensitive than CT. Often where incidental lesions are found.
  • Cannonball mets on CXR. Also seen in other genitourinary cancers, including endometrial, prostate, and testicular cancers. Chest CT may also be done for staging.
  • May also have a cystoscopy as part of urgent urology workup.

  Histopathology:

  • Usually done as part of nephrectomy.
  • Biopsy only in metastatic disease if nephrectomy not initially planned.

  Management

  • Nephrectomy, open or laparoscopic. Partial nephrectomy ('nephron-sparing') for tumours <4 cm, otherwise radical nephrectomy.
  • If not fit for surgery, consider radiofrequency ablation (percutaneous) or cryotherapy (percutaneous or laparoscopic).
  • Metastases: anti-VEGF and PDGF tyrosine kinase inhibitors (sunitinib, pazopanib) are 1st line. Cytokine immunotherapy (IFNα or IL-2) is 2nd line.

  Complications and prognosis

  • 5 year survival: 50% overall. 90% if local, 10% if metastatic.
  • Poor prognostic signs: older, ↑LDH, ↑Ca2+, ↓Hb.
  • Metastases: adrenals, liver, spleen, pancreas, lung, bone, brain.

• Cystoscopy

  Procedure

  • Camera into bladder via urethra.
  • Usually flexible, but rigid cystoscopy needed for some therapeutic procedures.
  • Usually under local anaesthetic – lidocaine 5-10 minutes before – but can be general.

  Diagnostic uses

  • Obtain samples for suspected bladder cancer (and for post-treatment surveillance).
  • Visualise anatomical lesions: tumours, fistulas, stones, anatomical abnormalities.

  Therapeutic uses

  • Remove bladder or ureteric stone.
  • Remove polyps or cancer from bladder.
  • Ureteric stenting.
  • Dye insertion for XR.
  • Prostatectomy

  Side effects

  • Mild burning for 24 hrs.
  • Urgency
  • Pink urine.
  • Worrying signs: severe pain or bleeding, symptoms >2 days, UTI.