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Malignant diseases of the urinary tract 

Malignant diseases of the urinary tract

Chapter:
Malignant diseases of the urinary tract
Author(s):

Lih-Ming Wong

and David Neal

DOI:
10.1093/med/9780199204854.003.2118_update_002

February 27, 2014: This chapter has been re-evaluated and remains up-to-date. No changes have been necessary.

Update:

Transitional cell bladder cancer—revised (2009) TNM classification.

Renal cell carcinoma—detailed description of 2009 TNM classification. Discussion of conservative management of small tumours in patients with limited long-term survival.

Prostate cancer—revised (2009) TNM classification

Updated on 31 May 2012. The previous version of this content can be found here.
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date: 29 April 2017

Urological cancers are an important cause of morbidity and mortality. Their treatment frequently involves a combination of surgery, radiotherapy, and chemotherapy, with patients needing both local therapy to treat the primary tumour and systemic therapy to decrease the risk of metastatic relapse.

Bladder cancer

Bladder cancer usually arises from the transitional epithelium and typically presents with haematuria, lower urinary tract symptoms, pelvic pain, or (metastatic disease) systemic symptoms. Most cases are sporadic and related to cigarette smoking. They are graded histologically as: 1 (low risk of future progression), 2, or 3 (high risk of progression/metastases), and staged according to the tumour–nodes–metastases (TNM) classification, with the most important issues being whether the tumour is muscle invasive (T2 or above) or localized to urothelium only (Ta), and whether there is metastatic disease.

Management—(1) Low-risk noninvasive cancers (TaG1 and TaG2) are treated by endoscopic resection. (2) High-risk non-invasive cancers (TaG3, T1G3, carcinoma in situ) are treated by endoscopic resection plus intravesical immunotherapy with BCG (bacille Calmette–Guerin). (3) Muscle-invasive cancers with no evidence of metastatic disease are treated with radical surgery (cystoprostatectomy or cystectomy/hysterectomy/oophorectomy, with both requiring urinary diversion) or radiotherapy. Systemic chemotherapy is an option as either neo-adjuvant or adjuvant treatment for muscle invasive disease.

Kidney cancer

Kidney cancer most commonly (75–85% of cases) arises from the epithelium of the proximal tubule (clear cell renal carcinoma). Most cases are sporadic, but the condition is common in the von Hippel–Lindau syndrome, and almost all sporadic tumours show mutations in the VHL tumour suppressor gene. Histologically they are graded into Fuhrman grades 1 (best prognosis) to 4 (worst), and staged according to the TNM classification. The most common presentation is as an incidental finding on abdominal imaging, but other presentations include haematuria, loin pain or loin mass.

Management—(1) Surgery (laparoscopic or open) is the primary treatment for localized renal cell carcinoma, which is not responsive to conventional chemotherapy and not radiosensitive. (2) Metastatic renal cell carcinoma has a poor outcome (median survival 8 months): treatments include biological response modifiers to stimulate the immune system (e.g. interleukin and interferon) and small molecules targeting pathways involved in tumour-cell proliferation and angiogenesis (e.g. sorafenib), but response is limited. (3) Small asymptomatic renal masses that are detected incidentally in older patients often grow very slowly and may not alter life expectancy.

Prostate cancer

Prostate cancer is the commonest malignancy in men in the United Kingdom and the United States of America. Diagnosis and treatment is not straightforward because some prostate cancers are indolent and very unlikely to progress, whereas others are highly aggressive.

Diagnosis, grading, and staging—early prostate cancer is asymptomatic: diagnosis is made by combining a digital rectal examination (DRE) with serum prostate-specific antigen (PSA) measurement linked to transrectal ultrasound scanning and biopsy. Symptomatic presentation of more advanced disease is typically with lower urinary tract symptoms, or with evidence of metastatic disease. Histologically graded by the Gleason score (well differentiated, 6 or less; moderately differentiated, 7; poorly differentiated, 8–10), and staged according to the TNM classification.

Management—(1) Disease localized to the prostate may be treated with curative intent, either with surgery or radiotherapy, or by ‘active monitoring’ (regular PSA testing and DRE, with treatment if there is evidence of progression). (2) Locally advanced disease can be managed using a combination of radiotherapy and neo-adjuvant hormone therapy. (3) Metastatic prostate cancer is incurable but dramatically responsive to androgen blockade, which is most commonly achieved with luteinizing hormone-releasing hormone (LHRH) agonists, although eventually the cancer develops into a hormone-independent state.

Testicular cancer

Typically presents with a painless testicular swelling that may grow rapidly. Ninety per cent are of germ-cell origin—either seminomatous or nonseminomatous. Staged according to the TNMs classification, where ‘s’ designates the serum tumour marker (α‎-fetoprotein, β‎-human chorionic gonadotropin (β‎-hCG), and lactate dehydrogenase (LDH)) level.

Management—all solid testicular masses are usually treated with radical inguinal orchidectomy, after which treatment depends on histological type: (1) seminomas—Stage 1 may be offered para-aortic radiotherapy, or single-dose chemotherapy, or surveillance with chemotherapy given at the time of clinical relapse; Stage 2 is treated with radiotherapy or chemotherapy; (2) nonseminomatous germ cell cancer—Stage 1 may be offered surveillance with chemotherapy on relapse, prophylactic chemotherapy, or primary retroperitoneal lymph node dissection; metastatic disease is treated with chemotherapy.

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