Urinary tract malignancies

Renal cell carcinoma

• Arises from the proximal tubule epithelium
• Accounts for 90% of renal cancers
• 15% of those on haemodialysis will get RCC
• Clinical features;
  • May be an incidental finding
  • Haematuria
  • Lone pain
  • Abdominal mass
  • Anorexia
  • Malaise
  • Weight loss
  • Rarely invasion of the left renal vein compresses the left testicular vein causing a left variocele
• Spread may be direct, via lymph or haematogenous (bone, liver, lung)
• Tests;
  • Bloods – FBC (polycythaemia due to EPO secretion, ESR, U&Es, alk phos (bony mets?)
  • Urine – RBC, cytology
  • Imaging – US, CT/MRi, renal agiography, CXR (cannonball mets)
• Treatment
  • Radical nephrectomy is gold standard
  • Metastatic disease is reason to consider immunotherapy with IFN? and IL2

Transitional cell carcinoma

• May arise from the bladder, ureter or renal pelvis
• Presentation;
  • Painless haematuria, frequency, urgency, dysuria, urinary tract obstruction
• Diagnosis
  • Urine cytology
  • IVU
  • Cytoscopy and biopsy
  • CT/MRI scan

Wilms’ tumour

• Nephroblastoma – childhood tumour of primitive renal tubules and mesenchymal cells
• Presents with abdominal mass and haematuria
• Check for associated syndromes – Beckwith-Wiedemann
• Tests
  • Urine cytology, US, IVU, renal angiography, CT/MRI
  • Avoid biopsy
• Treatment
  • Nephrectomy, radiotherapy and chemotherapy

Prostate cancer

• 2^nd commonest malignancy in men
• Incidence rises with age 80% in men over 80
• Most are adenocarcinomas arising from the peripheral prostate
• Spread may be local (seminal vesicles, bladder, rectum), via nodes or haematological (sclerotic bony mets)
• Symptoms
  • Nocturia, hesitancy, terminal dribbling, urinary obstruction, weight loss plus bone pain suggests mets
• PR may show a hard irregular prostate
• Diagnosis
  • Raised PSA
  • Transrectal ultrasound and biopsy
  • Bone x-rays
  • Bone scan
  • CT/MRI
  • Staging via MRI
• Treatment options;
  • Watchful waiting
  • Radical prostatectomy – associated with erectile dysfunction and incontinence
  • Radiotherapy
  • For metastatic disease hormonal drugs may provide benefit e.g.
    • GnRH analogues
    • Cyproterone acetate
    • Flutamide
    • Diethylstilboestrol
• Symptomatic treatment;
  • Analgesia
  • Treat hypercalcaemia
  • Radiotherapy for bone mets or spinal cord compression
• Screening
  • Rectal exam
  • PSA
  • Transrectal ultrasound
• Prognostic factors
  • Age, pre-treatment PSA, tumour stage and grade e.g. Gleeson score