Get in Touch
Contact Us
Click here for our Contact Form
Share:
Next Lesson - All done here! Check out our other subjects
Abstract
- Urological malignancies are cancers of the urinary system and are a common cancer in the UK. There are two main urological malignancies, renal cell carcinomas and transitional cell carcinomas.
- Haematuria is the main presenting complaint in patients with urological malignancies.
- Renal cell carcinomas are adenocarcinomas arising in the kidney nephron and are the most common renal cancer. They are mainly found in the upper kidney. Some of the risk factors include smoking, obesity, male gender and hypertension.
- Renal cell carcinomas mainly present with haematuria but other symptoms include flank pain, weight loss, lethargy, abdominal mass and a left-sided varicocele.
- The main investigations for a renal cell carcinoma are urinalysis, ultrasound scan, CT scan and biopsy. Biopsies are usually only undertaken if the tumour is not going to be excised.
- Management of renal cell carcinomas is via surgical excision, ablative therapy and systemic immunotherapy. Surgical excision is by either partial or radical nephrectomy. Ablative therapies aim to destroy the tumour using techniques other than surgical excision and systemic immunotherapy.
- Transitional cell carcinomas are the main cancer affecting the bladder and are classified by how far the cancer invades into the bladder wall. The three classifications are non-muscle invasive, muscle invasive and locally advanced. Some risk factors include smoking, occupational exposure to carcinogens, male and long term catheter use.
- Transitional cell carcinomas present with haematuria, lower urinary tract symptoms, pelvic pain, pelvis mass and weight loss.
- The main investigations for a transitional cell carcinoma are cystoscopy, ultrasound scan and blood tests. Flexible and rigid cystoscopies are used to investigate transitional cell carcinomas.
- Management of transitional cell carcinomas depends on the TNM staging system and on the tumour’s classification but treatment includes transurethral resection of bladder tumour, chemotherapy, cystectomy and palliative treatment.
Core
The term urological cancer is used to describe cancers of the urinary system, for example kidney and bladder cancer. Urological cancers are fairly common in the UK. The main two types of urological cancer are renal cell carcinomas, which are more common in the kidney, and transitional cell carcinomas, which are more common in the bladder.
One of the main presentations of urological malignancy is haematuria, which can be visible or invisible (found on a urinary dipstick). This is important as if a patient presents to the GP with unexplained haematuria, they will need to be referred by two week wait to urology. This article will mainly focus on the treatment and investigations that will be done by urologists but it is important to know when to refer a patient to urology. The UK referral criteria is:
- Aged 45 and over with:
- Unexplained visible haematuria without urinary tract infection, or
- Visible haematuria that persists or recurs after treatment of urinary tract infection.
- Aged 60 and over with:
- Unexplained non-visible haematuria and either dysuria or a raised white cell count, or
- Recurrent or persistent unexplained urinary tract infection.
Renal cell carcinomas (RCCs) are the most common renal cancer in adults. It is most common in those aged above 60 years and is uncommon in those aged under 40 years. It is mostly affects the kidney but can affect other parts of the urinary system, but for this article we will focus on renal cell carcinoma of the kidney. Other types of renal cancers include transitional cell carcinomas, nephroblastomas and squamous cell carcinomas.
Renal cell carcinomas are adenocarcinomas that arise in the lining of the proximal renal epithelium, and they usually appear histologically as clear cell carcinomas, and they are called this because the cells are full of glycogen. Other types of RCCs include papillary, chromophobe and renal medullary carcinoma.
They commonly affect the upper pole of the kidney and then spread by direct invasion into the surrounding tissue first, before then spreading via the lymphatics and the blood.
- Smoking
- Male
- Obesity
- Dialysis
- Hypertension
- Industrial exposure to carcinogens
- Family history – a small number of renal cell carcinomas have a genetic aetiology
- Haematuria – this is one of the main symptoms of renal cell carcinomas. It can either be visible or invisible.
- Flank or loin pain
- Weight loss
- Lethargy
- Fever
- Palpable abdominal mass – if a patient with renal cell carcinoma has a palpable abdominal mass then it typically means the malignancy is quite advanced.
- Paraneoplastic syndromes – these are a group of syndromes that occur as a result of the malignancy and occur in around 20% of patients. In RCCs the main paraneoplastic syndromes are caused by hormone secretion:
- Renin – increased renin secretion causes hypertension.
- Parathyroid hormone – increase parathyroid hormone secretion results in hypercalcaemia.
- Erythropoietin – increased erythropoietin production causes polycythaemia as it increases the production of red blood cells.
- Adrenocorticotropic hormone – results in Cushing’s disease due to a raised cortisol level.
- Left-sided varicocele – if a renal cell carcinoma impinges on the left testicular vein then it can cause a build up of blood within the testicular venous plexus causing a varicocele.
- This will only occur with left sided RCCs as the left gonadal vein drains into the renal vein so can be compressed by a tumour, while the right gonadal vein drains into the inferior vena cava, and so will not be compressed by a renal tumour.
If a patient is suspected to have a renal cell carcinoma then they will be referred to urology for further investigations and management. The first line investigations for renal cell carcinoma are blood tests, urinalysis and urine cytology. Patients will undergo imaging to identify the site and size of the lesion.
- The main blood tests to undertake are a full blood count, urea and electrolytes, calcium and liver function tests.
- Urinalysis will be used to look for haematuria which is a red flag for urological malignancy while the urine cytology will look for malignant cells in the urine.
- Some renal cell carcinomas can be asymptomatic and are picked up as an incidental finding on imaging.
- Ultrasound, CT and MRI scans are used in the imaging in renal cell carcinoma as they can identify the lesion and can help in carrying out a biopsy of the lesion. A CT chest-abdo-pelvis scan may be done to look for metastases that may be present.
- CT and MRI scans are performed with and without contrast to ensure any RCC is not missed.
- Biopsy of the malignancy is usually only performed if the tumour is not going to be excised. A core needle biopsy is performed in these patients which can help with choosing the systemic chemotherapy agent that may be used.
- Those who have surgical excision of the tumour will have it sent to pathology so that the type of renal cell carcinoma can be defined.
The TNM staging system is used to stage renal cell carcinomas as this gives an idea about the prognosis of the malignancy, with a Stage I RCC having a 90% 5 year survival, while a Stage IV RCC only has a 10% 5 year survival.
The management of renal cell carcinoma depends on the size of the cancer and on the presence of metastases. Those with local disease typically undergo surgical excision of the malignancy while those with metastatic disease undergo surgical excision with systemic immunotherapy.
- Surgical excision is the main treatment for local renal cell carcinomas and for those with lymphatic metastases. The two main types of surgical excision are:
- Partial Nephrectomy – this is where only part of the kidney is removed. It is either performed by open, laparoscopic (keyhole) or by robotic surgery. Only small RCCs are removed by partial nephrectomy.
- Radial Nephrectomy – this is where the whole kidney is removed, along with the adrenal gland and the fat surrounding the kidney. This can be either open surgery or laparoscopic and is for RCCs that cannot be excised by partial nephrectomy.
- Ablative therapies can be used to destroy some small tumours, though these tumours must have had a biopsy first to check they are susceptible to ablation. Ablative therapies include cryoablation, radiofrequency ablation and renal artery embolisation.
- Metastatic disease is treated depending on the number of metastases. Those with metastatic disease are categorised as stage IV and so have a very poor prognosis, this means the main aim of treatment is palliative care to slow disease progression and to help the patient remain comfortable.
- If there is only a solitary metastatic lesion then cytoreductive nephrectomy is undertaken, which involves the removal of as much of the renal tumour as possible. This is coupled with systemic immunotherapy with or without metastatectomy (surgical resection of solitary metastasis).
- If there are multiple metastatic lesions then the main treatment is systemic immunotherapy. Cytoreductive nephrectomy may also be performed in those with a more favourable prognosis.
The urinary system is lined by transitional cell epithelium, the urothelium, so it is at risk of developing a transitional cell carcinoma (TCC). The majority of TCCs are found in the bladder but they can also be found in the upper urinary system, i.e. in the kidney and ureter. This article will focus on bladder transitional cell carcinomas.
Bladder Transitional Cell Carcinomas
Bladder transitional cell carcinomas (TCCs) are the most common urological malignancy in the UK and typically affect men aged 50-80 years. Other bladder cancer types include squamous cell carcinomas and adenocarcinomas, though these are less common in the UK.
Bladder cancers are classified by how far the cancer invades into the muscle of the bladder wall. There are three main classifications:
- Non-Muscle Invasive – the bladder cancer does not penetrate into the deeper layers of the bladder wall and remains quite superficial.
- Muscle Invasive – the bladder cancer penetrates into the deeper layers of the bladder wall but not into surrounding structures.
- Locally Advanced – the bladder cancer penetrates through the entire bladder wall and spreads beyond the bladder, into the surrounding structures.
- Smoking – this is the greatest risk factor for transitional cell carcinoma.
- Occupational exposure – some occupations have an increased risk of bladder cancer because of the carcinogens they are exposed to in the work environment, e.g. rubber/plastic manufacturer, crude oil, smelting, painter, mechanic and hairdresser.
- Caucasian
- Male
- Chronic irritation – e.g. infection, schistosomiasis, bladder stone and long term catheter. These typically increase the risk of bladder squamous cell carcinomas and not transitional cell carcinomas.
- Cyclophosphamide
- Haematuria – this may be macroscopic (visible) or microscopic (invisible, picked up on a urinary dipstick). Patients typically present with macroscopic haematuria in bladder cancer.
- Lower urinary tract symptoms – these include nocturia, urgency, frequency, incomplete emptying, terminal dribble, hesitancy, straining and post-micturition dribble.
- Recurrent urinary tract infections
- Pelvic pain – patients may present with pelvic pain if they have locally advanced disease.
- Pelvic mass
- Weight loss
- Loss of appetite
- Urinary retention – patients may present with urinary retention if the tumour obstructs the internal urethral orifice.
- Systemic symptoms of metastases if late stage.
Bladder carcinomas may be an incidental finding on imaging that was done to investigate something else.
Bladder transitional cell carcinomas are investigated by cystoscopy, blood tests, ultrasound scan, MRI and CT scans. Urinalysis is also used to check for blood in the patients urine as haematuria is an indicator of bladder TCCs.
Cystoscopy is the main investigation used for transitional cell carcinomas. A flexible cystoscopy is used to visualise the bladder and assess for any suspicious lesions, and is usually the first investigation performed if bladder malignancy is suspected. If a suspicious lesion if found then a rigid cystoscopy is performed to biopsy the lesion if it is large, or remove the lesion if it is small. A transurethral resection of the bladder tumour may be performed during the rigid cystoscopy if the tumour is small.
An ultrasound scan can be used to look for any lesions prior to cystoscopy, and is also used to check for urinary retention if indicated. A pelvic MRI or CT scan are used to assess the size of the bladder malignancy and see if it has invaded into the muscle wall or surrounding structures. MRI and CT scans can also be used to look for any metastases.
It is also important to check the patient’s renal function and full blood count (for anaemia and infection). Other blood tests to do include liver function and alkaline phosphatase. If alkaline phosphatase is high then a whole-body bone scan is indicated to look for bone metastases.
The treatment of bladder transitional cell carcinoma depends on whether the tumour has invaded into the muscle wall or if it has metastasised. Bladder TCCs use the TNM staging system to stage the severity of the bladder malignancy.
Non-muscle invasive TCCs are treated by transurethral resection of the bladder tumour (TURBT), which involves going in through the urethra and removing the tumour. The tumour can then be sent off to pathology for further analysis.
- Other treatments for non-muscle invasive TCCs include intravesical cytotoxic chemotherapy and intravesical BCG. Cytotoxic chemotherapy involves injecting chemotherapy directly into the tumour area after surgery to reduce the risk of recurrence. Intravesical BCG is an immunotherapy that can be used to decrease the risk of recurrence.
- Superficial bladder tumours have a high rate of recurrence so patients will require regular surveillance with cystoscopy and cytology. Surveillance is normally continued until disease free for 10 years.
Muscle invasive TCCs are treated with either cystectomy or chemoradiation. Cystectomy is the removal of the bladder along with the prostate in men, and the uterus and ovaries in women. Neoadjuvant chemotherapy is often given before the cystectomy as it increases patient survival rate. After cystectomy, patients require regular follow-up with a CT scan.
- After a cystectomy, patients require either an ileal conduit formation or bladder reconstruction. In ileal conduit formation, part of the ileum is used to form a urostomy, where the urine then drains from. Bladder reconstruction involves using part of the small bowel to form a new bladder, with urine then being drained by the urethra or the catheter.
- Chemoradiotherapy is the other treatment for muscle invasive TCCs, where patients are treated with both systemic chemotherapy and targeted radiotherapy.
Metastatic disease is treated with the intention to control symptoms and prolong survival of the patient as metastatic disease is incurable, so is treated palliatively. The management is decided by a multi-disciplinary team and is split into measures for local disease and for systemic disease.
- Local treatment includes radical cystectomy and urinary diversion, both for symptomatic relief. Radiotherapy can also be directed at the tumour site either before or instead of surgery.
- Systemic treatment is with radiotherapy and chemotherapy. Radiotherapy is used for symptomatic metastases and chemotherapy is used to manage metastases.
- Patients will have regular follow ups and reviews for detection and treatment of progressive disease and to treat any new symptoms that may develop.
Edited by: Dr. Maddie Swannack
Reviewed by: Adrian Judge
- 9
