14 - Urological Malignancy Flashcards
How common in renal cancer?
3% of all cancers
3 in 10,000
What are the RF for renal cancer?
Obesity
Smoking
DM
Asbestos / Cadmium / Lead
FHx
Von Hippel-Lindau gene (tumour suppressor gene)
What are the protective factors for renal cancer?
Moderate alcohol
Exercise
Which is the commonest renal cancer?
Clear Cell RCC - 75%
Chromophobe RCC
Type I Papillary
How does renal cancer present?
Mass
Haematuria
Pain
Systemic effects
What paraneoplastic effects can occur from renal cancer?
Malaise
Weight loss
Hypercalcaemia
Polycythaemia
Liver dysfunction
What investigations can you do for renal cancer?
Bloods
USS
CT
MRI
Biopsy
What do kidney cancer bone mets look like? How does this differ to prostate bone mets?
Kidney = Lytic lesions
Prostate = sclerotic lesions
Kidney mets - dont show up well on a bone scan
Prostate mets - show up well on a bone scan
At what stage kidney cancer is the tumour no longer limited to the kidney?
Stage III
What is the difference between active surveillance and watchful waiting?
Active surveillance - have found a problem and monitor it before trying to cure it.
Watchful waiting - aim is not to cure - wait for it to cause Sx and then treat the Sx in a palliative approach.
What are the Rx options for renal cancer?
Radical nephrectomy
Partial nephrectomy
Ablation
Immunotherapy
Tyrosine Kinase Inhibitor therapy
Resection of mets
Most cancers = surgery + radio + chemo. However radiotherapy doesn’t work on the kidney and chemo isn’t great either. There surgery + immunotherapy is the best choice.
I.e. Surgery + Immunotherapy + TKIs
What is the peak age of incidence of kidney cancer?
85-89
What is the prognosis for kidney cancer?
95% 5 year survival
Where does transitional cell carcinoma arise from the in the bladder?
From the urothelium
What percentage of TCC of bladder and ureter will be muscle invasive and what percentage will not?
20% will be muscle invasive
80% will not
What percentage of TCC is found in the bladder and what percentage is in the ureter?
95% is bladder
5% is ureter
What are the risk factors for urothelial cancer?
Smoking
Petrochemicals
Hairdressers
Chronic bladder inflammation
Schistosomiasis (more SCC - lays eggs in the bladder)
What are the types of urothelial cancer?
TCC
SCC - 3%
Adenocarcinoma - 1%
What are the S&Sx of urothelial cancer?
Haematuria - 90%
Irritative LUTS
Pain with obstruction
Pelvic mass
What is the prognosis for urothelial cancer?
95% have 5 year survival if not muscle invasive
If muscle invasive - only 5% will be alive at 5 years
What investigations are done for urothelial cancer?
CT Urogram
Cytology
Flexible cystoscopy
Can do CT chest & Bone scan if worried about mets
What are the Rx options for urothelial cancer?
TURBT
Chemo
Radio
Cystectomy
What is painless haematuria assumed to be?
Assumed to be TCC unless proven otherwise
What does TURBT stand for?
Trans-uretheral Resection of Bladder Tumour
What intravesicle medication can be given to Ps with TCC?
Intravesicle BCG - thought to directly infect and kill cancer cells + has immunotherapy effect.
What was found to have an 8% improvement in 5YS for TCC?
Neoadjuvant chemotherapy
Treatment given as a first step to shrink a tumor before the main treatment, which is usually surgery, is given.
How are Ps with metastatic renal cancer treated?
Supportive care
Chemo
Palliative radiotherapy if needed
Which is the commonest cancer in men?
Prostate cancer
Where is the commonest and lowest incidence of prostate cancer?
Highest = Australia, USA, Western Europe
Lowest = Japan, Eastern Asia
What are the S&S of prostate cancer?
Asymptomatic in early stages
Haematuria
LUTS
Haematospermia
Bone pain if mets
Bladder outflow obstruction with AKI - rare
How is prostate cancer diagnosed?
Elevated PSA
DRE
Prostate biopsy
What is the 5YS rate of prostate cancer?
98%
Which grading system is used for prostate cancer?
Gleason grading system
What is PSA?
Enzyme involved in the liquification of semen - should be found in high levels in the semen and should be low in the blood
What do you look for on a DRE for prostate cancer?
Size
Induration
Asymmetry
Loss of median sulcus
Nodule
When should Ps with prostate cancer have a bone scan?
If their PSA >20 or Gleason score >4
Which is the best imaging for metastatic disease?
PET-CT - picks up v low grade metastatic disease
What can PSA be increased by apart from cancer?
BPH
Infection
Instrumentation
Ejactularion
Retention
Which medications can lower PSA?
Finasteride
Dutasteride
What happens to our PSA as we age naturally?
The prostate grows with age - therefore PSA should naturally increase incrementally with age.
How is prostate density linked to cancer risk?
Increased prostate density = inc risk of prostate cancer
What is doubling time?
How long it takes for the PSA to double - can be a good predictor of when Rx will be needed
Where does prostate cancer like to metastasise to?
Pelvis
Axial skeleton
Ribs
What is brachytherapy?
Internal radiation treatment - surgery puts seeds of radiation into the prostate = can use a higher dose and it decays over weeks
How is hormone therapy used with prostate cancer?
Can you androgen deprivation therapy = stops the prostate from gdowing
Can also use synthetic LHRH agonists (this causes a rise and then a fall by negative feedback mechanism in testosterone release) b- commonest!
Can use LHRH antagonist
Can also use antiandrogens (Biclutamide) which block the effect of testosterone directly
What is RALP?
Radio-assisted Laparotic Prostatectomy
How does prostate treatment differ with age?
Younger Ps = more surgery, brachytherapy, radio and chemo
Older Ps - no surgery or brachytherapy or chemo. More hormones & radiotherapy
What type of cancer is prostate cancer?
Adenocarcinoma
What are the RF for prostate cancer?
Alcohol
Smoking
FHx
AC
Vit D?
Metabolic syndrome
BRACA2
What investigations can be done for prostate cancer?
PSA
MRI
Biopsy
Bone scan
PET scan
What is testicular cancer divided into?
Seminomas
Spermatocytic Seminoma
Non-Seminomas Germ Cell Tumours (NSGCT) - aka teratomas
What is the age peak for testicular cancer?
NSGCT = 20-30
SGCT = 30-40
What are the RF for testicular cancer?
Cryptorchidism (undescended testes)
Testicular dysgenesis
FHx
Which hormonal markers can be used for NSGCTs?
α FP = Yolk sac tumours
β HCG = choriocarcinoma
What can high levels of αFP indicate?
Yolk sac NSGCT
also
Hepatocellular carcinoma
Pancreatic, Biliary, Gastric or Bronchial carcinomas
Pregnancy - 12-14w peak
What can high levels of β HCG indicate?
NSGCT
Breast, Kidney, Bladder, Stomach, Liver cancer
Also = Pregnancy - 12-14w peak
What do very high tumour markers in terms of prognosis in testicular cancer?
Not a good prognosis
What are the S&S of testicular cancer?
Scrotal mass
Pain
Nodular testical
Palpable abdominal lymph nodes
What is the prognosis of testicular cancer?
Very good prognosis
What are the investigations for testicular cancer?
Clinical exam
Tumour markers
Scrotal USSS
CT CAP to stage
What is the Rx for testicular cancer?
Inguinal orchidectomy
Check out LN - radio if needed
RPLND (Retroperitoneal lymph node dissection)
Chemo - BEP - 3 cycles
What is the most common type of penile cancer?
SCC
Most commonly from the epithelium of the inner prepuce or glans
What is the peak incidence of penile cancer?
75-90
What are the RFs for penile cancer?
HPV - 50%
Multiple sexual partners
Early age of intercourse
Phimosis (chronic infection)
Penile Intraepithelial Neoplasia
Smoking
Low economic status / rural area
When should you think about penile cancer?
If there are lesions which do not respond to a course of topical steroids or ABx
What are the S&S of penile cancer?
Penile mass
Pain
Groin mass
Skin changes
Ulceration
Palpable lymph nodes
What’s the prognosis of penile cancer?
80% cure rate
10YS = 68%
Nodal disease - 5YS = 27%
What investigations are done for penile cancer?
Biopsy
MRI
Staging CT
Sentinel LN excision
What is the Rx for penile cancer?
Local excision and reconstruction
ILND (Inguinal Lymph Node Dissection)
Radiotherapy
Chemotherapy
