Hematuria as a Marker of Occult Urinary Tract Cancer (Lynch Syndrome patients)

Patients referred for AMH have a relatively lower (0.5% to 5.0%) but nontrivial probability of underlying occult cancer (2, 7–15) that is estimated to range from 7% to greater than 20% in higher-risk subgroups in some series (9, 16–18).

 The investigation of hematuria includes radiologic evaluation to identify potential pathology in the upper urinary tract.

upper urinary tract cancer:

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 Hematuria as a Marker of Occult Urinary Tract Cancer: Advice for High-Value Care From the American College of Physicians
 
Background: The presence of blood in the urine, or hematuria, is a common finding in clinical practice and can sometimes be a sign of occult cancer. This article describes the clinical epidemiology of hematuria and the current state of practice and science in this context and provides suggestions for clinicians evaluating patients with hematuria.
 
High-Value Care Advice 1: Clinicians should include gross hematuria in their routine review of systems and specifically ask all patients with microscopic hematuria about any history of gross hematuria.
High-Value Care Advice 2: Clinicians should not use screening urinalysis for cancer detection in asymptomatic adults.
High-Value Care Advice 3: Clinicians should confirm heme-positive results of dipstick testing with microscopic urinalysis that demonstrates 3 or more erythrocytes per high-powered field before initiating further evaluation in all asymptomatic adults.
High-Value Care Advice 4: Clinicians should refer for further urologic evaluation in all adults with gross hematuria, even if self-limited.
High-Value Care Advice 5: Clinicians should consider urology referral for cystoscopy and imaging in adults with microscopically confirmed hematuria in the absence of some demonstrable benign cause.
High-Value Care Advice 6: Clinicians should pursue evaluation of hematuria even if the patient is receiving antiplatelet or anticoagulant therapy.
High-Value Care Advice 7: Clinicians should not obtain urinary cytology or other urine-based molecular markers for bladder cancer detection in the initial evaluation of hematuria.

 Hematuria is frequently encountered among adults in ambulatory care (1, 2). Despite the absence of recommendations for hematuria screening (3, 4), millions of patients have urine dipstick testing and microscopic examinations as part of routine primary care practice (5, 6). The frequency of urinalysis with the primary intent of cancer screening is unknown; however, hematuria may often be an incidental finding on tests pursued for other purposes, given the multiplex nature of dipstick tests. Referral series underscore the potential for a positive test result to be the presenting sign of occult cancer, and existing hematuria guidelines emphasize structured urologic investigation related to this risk with endoscopy of the bladder (cystoscopy), imaging, and potentially other diagnostic tests and procedures. However, the magnitude of the risk for underlying cancer varies greatly (7–9), and the quality of evidence informing practice creates uncertainty......

 Hematuria occasionally has a dramatic presentation as grossly visible blood in the urine. Symptomatic gross hematuria with associated flank pain or renal colic is the classic presentation of urinary stone disease, whereas painless gross hematuria has a stronger association with cancer......