Cancer of the urinary system

urinary system body diagram

Bladder cancer

Facts and figures

Bladder cancer is the 7th most common cancer in the UK, accounting for 3% of all new cancer cases. Higher incidence in men, male to female ratio is 25:10. Age related, approximately 90% are diagnosed in those over 60 years and an average of 53% is in the 75+ years age group.

Risk factors include smoking, occupational exposure related to the production of dyes, rubber, textiles and pesticides, fossil and carbon containing fuels and arsenic.

Medical conditions such as chronic bladder infection, Crohn’s disease, HPV infection and possibly diabetes and also a first degree relative being diagnosed with bladder cancer. 75% are diagnosed in the early stages and consequently have a good prognosis. Over 90% of these tumours are transitional cell carcinomas.

Symptoms may include:

  • Blood in the urine (haematuria) - occurs in 80% of cases.
  • Urinary frequency.
  • Urinary urgency.
  • Pain on passing urine (dysuria).

Some of these symptoms can be caused by other conditions such as infection or an enlarged prostate.

Diagnosis

Investigation may include:

  • Urine tests (likely to be carried out initially to investigate for possible urinary tract infection).
  • Physical examination.
  • Cystoscopy (may be under a local or general anaesthetic).
  • CT scan –may be a CT urogram (CT scan of the urinary tract).
  • Intravenous urogram (IVU) – x-ray of the urinary system.
  • Ultrasound scan.

Treatment

Depends on several factors:

  • The type of tumour.
  • The grade of the cancer cells.
  • The stage of the cancer.
  • Age and general health.

Surgery

In early stage bladder cancer where the cancer cells are still in the lining of the bladder, the areas affected by the disease can be removed from the bladder lining, which can be done during a cystoscopy.

The tissue that has been removed will be analysed to assess the grade of the tumour cells. This may be adequate treatment but if there is a risk of recurrence, chemotherapy may necessary, which involves putting the chemotherapy drug directly into the bladder or in some cases BCG vaccine.

BCG is a vaccine used to prevent tuberculosis, which has been found to stop or delay the recurrence or spread of high grade early tumours, it is thought to work as a type of immunotherapy.

Radiotherapy

Radiotherapy is used to treat invasive bladder cancer and has the benefit of bladder preservation if it is successful, although the bladder does shrink.

There is also less risk of nerve damage in the genital area and therefore less effect on sexual function compared to surgery. Although in approximately 30% of cases, the disease recurs so removal of the bladder will be necessary.

Radiotherapy may be given in combination with chemotherapy (chemoradiation) which makes the radiotherapy more effective and the recurrence rate for patients receiving chemoradiation is 18-30%.

In cases where the tumour is in the surface layer of the muscle, a transurethral resection of the bladder (TUBRT) is performed followed by chemoradiation.

Radiotherapy may be given in advanced cases to try and control the disease and relieve symptoms such as pain or bleeding.

Chemotherapy

Chemotherapy may be used in early stage bladder and is put directly into the bladder, this is called intravesical therapy, and the chemotherapy drugs frequently used are mitomycin C, epirubicin or doxorubicin.

Chemotherapy may also be used in invasive bladder cancer to shrink the tumour before chemotherapy or radiotherapy (neoadjuvant) or after surgery to reduce the risk of recurrence (adjuvant).

Chemotherapy is also given in combination with radiotherapy (chemoradiation) and this has been shown to reduce the risk of recurrence. Chemotherapy is often a combination of the following drugs gemcitabine, cisplatin, carboplatin, doxorubicin, methotrexate and vinblastine.

Renal cancer (cancer of the kidney)

Facts and figures

Cancer of the kidney 8th most common cancer in the UK, accounting for 3% of all new cases. Male to female ratio of 16:10. Age related, the incidence rises sharply from 45 years of age, 75% diagnosed in those over 60 years of age and 35% in the 75+ years age group.

Risk factors include smoking, being overweight/obese and some medical conditions; chronic kidney disease, hypertension (may be related to the drug treatments), use of diuretics, kidney stones (41% increased risk in men but no increase risk in females), sickle cell disease, high doses of non aspirin non-steroidal anti-inflammatory drugs and paracetamol and having a first degree relative diagnosed with renal cancer.

85% of these tumours are renal cell carcinomas. Symptoms may include:

  • Blood in the urine (haematuria).
  • Unexplained, rapid weight loss.
  • High temperature/night sweats.
  • Chronic fatigue.
  • Leg and ankle swelling (oedema).
  • Hypertension.
  • Pain in the side of lower back.
  • Lump in the area of the kidney/abdomen.

Diagnosis

Investigations may include:

  • Urine tests (likely to be carried out initially to investigate for possible urinary tract infection or blood in the urine if not apparent).
  • Physical examination.
  • CT scan –may be a CT urogram (CT scan of the urinary tract).
  • Intravenous urogram (IVU) –x-ray of the urinary system.
  • Ultrasound scan.

Treatment

Depends on several factors:

  • The type of kidney tumour.
  • The stage of the cancer.
  • General health.

Surgery

Surgery is the main treatment for early stage renal cancer (stage 1 and 2) where the disease is contained in the kidney. This may involve partial or complete removal of the kidney (nephrectomy); the whole kidney is usually removed if the tumour is larger than 7cms.

This is normally a simple nephrectomy which includes the kidney and ureter. This may be adequate treatment for these cases. In later stage tumours that have spread to the lymph nodes or adrenal gland (locally advanced) these can sometimes be cured by radical nephrectomy which involves removing the kidney, adrenal gland, surrounding tissues and lymph nodes.

Radiotherapy

Radiotherapy is not often used for renal cancer as kidney cancer cells are not sensitive to radiation, post-operative radiotherapy is rarely recommended. It may be used palliatively to control symptoms such as pain or bleeding.

Also, renal cancer tends to spread to the brain so patients may receive palliative radiotherapy to the brain.

Chemotherapy

Chemotherapy is not standard treatment for renal cell carcinoma as biological therapies are found to be more effective, but it may be used for transitional cell carcinomas (usually includes mitomycin C and possibly a new drug called vinflunine).

Biological therapy

These are targeted therapies that stop the cancer cells from making new blood vessels and therefore inhibit cell growth. Sunitinibis is often used for patients with stage 3 or 4 renal cancer.

Bevacizumab is a monoclonal antibody that stops the development of blood vessels and is used with interferon to treat advanced renal cancer.

Cryotherapy

Cryotherapy is most likely to be used if the patient is not fit for surgery.

Needles containing liquid nitrogen are passed through the skin near the kidney, CT or ultrasound imaging is then used to move the needles into position. The liquid nitrogen freezes and destroys the cancer cells when they come into contact with it.

Radiofrequency ablation (RFA)

This uses radio waves to heat up the cancer cells until they are destroyed.

Under local or general anaesthetic, a needle is put through the skin (guided by ultrasound or CT scan) and then radio waves are sent down the needle to the tumour site.

Cancer of the ureter

Facts and figures

Cancer of the renal pelvis (small area in the centre of the kidney that the ureter arises from) and ureter are very rare. They are considered bladder cancers rather than kidney cancers. Higher incidence in men than women. The incidence rises from the age of 65 years and is even rarer under this age.

Risk factors are smoking, heavy usage of phenacetin (a pain relieve drug that is now banned) and possibly arsenic in drinking water. Over 90% of the tumours are transitional cell carcinomas.

Symptoms may include:

  • Blood/blood clots in the urine (haematuria).
  • Pain in the side of lower back.
  • Pain or burning sensation on passing urine.
  • Difficulty in passing urine.

Some of these symptoms can be caused by other conditions such as infection.

Diagnosis

Investigation may include:

  • Urine tests (likely to be carried out initially to investigate for possible urinary tract infection or blood in the urine if not apparent).
  • CT scan –may be a CT urogram (CT scan of the urinary tract).
  • Intravenous urogram (IVU) –x-ray of the urinary system.
  • Utereroscopy.

Treatment

Depends on several factors:

  • The type and grade of tumour.
  • The position of the tumour.
  • The stage of the cancer.
  • General health.

Surgery

Surgery is the main treatment and the extent and type of surgery depends on the stage of the disease and the position of the tumour.

In early stage of a tumour in the ureter, it may be possible to removes the part of the ureter affected by the tumour and some of the surrounding healthy tissue and then join the ends of the ureter back together.

If it is an early stage tumour near the bladder it may be possible to perform a ureterneocystomy, where the affected part of the ureter and the bladder cuff are removed and then the remaining ureter is joined to the bladder.

In other cases, it may involve removing the kidney, surrounding fat, ureter and the tissue where the ureter enters the bladder. Also, the adrenal gland and local lymph nodes may be removed.

Radiotherapy

Radiotherapy may be used to treat this condition which will involve treating the tumour and surrounding tissue with the intention of curing the disease or it may be used palliatively to control symptoms in more advanced cases.

Chemotherapy

Chemotherapy may be used if the disease has spread to the lymph nodes or other parts of the body. It may be advised post-surgery (adjuvant) if malignant cells are found in the lymph nodes removed during surgery to reduce the risk of recurrence.

Chemotherapy is often a combination of the following drugs gemcitabine, cisplatin, carboplatin, doxorubicin, methotrexate and vinblastine.

Cancer of the urethra

Facts and figures

Cancer of the urethra is very rare. Higher incidence in women than men. Age related, usually in those over 60 years of age.

Risk factors include previous bladder cancer, history of STDs (sexually transmitted diseases), recurrent urinary tract infections. Most of the tumours are squamous cell carcinomas.

Symptoms may include:

  • Weak or interrupted urinary flow.
  • Blood in the urine (haematuria).
  • Urinary frequency.
  • Lump or thickness in the perineum or penis.
  • Discharge from the urethra.

Diagnosis

Investigations may include:

  • Urine tests (likely to be carried out initially to investigate for possible urinary tract infection or blood in the urine if not apparent).
  • Physical examination (including pelvic and rectal examination).
  • Cystoscopy.
  • Uteroscopy.
  • Chest X-ray.
  • CT scan.
  • MRI scan.

Treatment

Depends on several factors:

  • The size and position of tumour.
  • The stage of the cancer.
  • General health.

Surgery

Surgery is the most common treatment. In very early stage tumours, laser surgery may be an option.

Regular surgery is likely to be removal of the bladder and urethra (cystourethrectomy) or removal of the bladder and prostate (cystoprostatectomy).

More extensive surgery may be required depending on the stage of the disease. If the urethra is removed, a stoma (urostomy) will need to be performed to enable the urine to be collected.

Radiotherapy

Radiotherapy may be given in some case to treat urethral cancer, which has the benefit of avoiding major surgery. It is also given post-operatively (adjuvant) sometimes to reduce the risk of recurrence.

Chemotherapy

Chemotherapy has been used for disease that has spread to other parts of the body or in combination with radiotherapy and/or surgery for locally advanced urethral cancer.

The chemotherapy drugs used may include cisplatin, fluorouracil (5FU), mitomycin C, bleomycin, gemcitabine and irinotecan.

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