1B urological cancers Flashcards
What types of kidney cancers are there and how common are each in %?
- 85% are renal cell carcinomas (adenocarcinomas)
- 10% are transitional cell carcinomas
- 5% are sarcoma/Wilms tumour/other types
What aetiological factors are there that cause kidney cancers?
- Smoking
- Hypertension
- Renal failure and dialysis
- Genetic predisposition with Von Hippel-Lindau syndrome (50% of individuals will develop RCC)
What clinical features can you find in kidney cancers?
- There may be a mass
- Loin pain
- Haemorrhage
- Palpable mass
- Metastatic disease symptoms like bone pain, haemoptysis, shortness of breath
- Commonest: painless haematuria (particularly if large tumour like transitional cell carcinoma) or persistent microscopic haematuria (red flag and can reflect urological malignancies)
What are the three types of RCC?
- Clear cell
- Papillary
- Chromophobe RCC
What investigations would we do on painless visible haematuria?
- CT urogram
- Flexible cystoscopy
- Renal function
What is a CT urogram used to look at?
- The top end of the urinary system- CT scan of kidneys which could reveal masses
- Can look down ureters too to look for pathology there e.g. ureteric filling defect which could indicate transitional cell carcinomas or stones (which also cause haematuria)
- Get a little idea of the bladder but we don’t look at it directly- if we see a large bladder mass causing haematuria we might see a filling defect or clot in the bladder
What is flexible cystoscopy and what are we looking for?
-
Bladder (under local anaesthetic):
- exophytic lesions (looking for tumours)
- bleeding from ureteric orifices which could mean bleed is higher (e.g. ureters) and its trickling down into bladder
- Red patches in bladder could indicate pre-cancer or carcinoma in-situ
- Urethra for TCC
- Can see strictures that cause haematuria or bleeding prostate
What investigations do we do on persistent non visible haematuria?
- Flexible cystoscopy
- US KUB (US of kidneys, ureter and bladder)
What is non-visible haematuria?
When you see RBCs in urine on microscopy or dipstick but not visually
How do we investigate a suspected renal cancer?
- CT renal triple phase
- Staging CT chest
- Bone scan if symptomatic
What staging system would we use for RCC?
TNM staging
What does T1 mean in kidney cancer?
Tumour ≤ 7cm
What does T2 mean in kidney cancer?
Tumour >7cm
What does T3 mean in kidney cancer?
Extends outside kidney but not beyond ipsilateral adrenal or perinephric fascia
What does T4 mean in kidney cancer?
Tumour beyond perinephric fascia into surrounding structures
What does N1 mean in kidney cancer?
Metastasis in single regional LN e.g. paraaortic
What does N2 mean in kidney cancer?
Mets in ≥2 regional LN
What does M1 mean in kidney cancer?
Distant metastasis
What grading system can we use for kidney cancer?
Fuhrman grade
- 1 = well differentiated
- 2 = moderately differentiated
- 3 + 4 = poorly differentiated
What is managementof kidney cancer dependent on?
Patient specific- depends on:
- ASA status (healthiness of patient)
- Comorbidities
- Classification of lesion
How do we manage kidney cancer in patients with small tumours who are unfit for surgery?
- Cryosurgery- freeze the lesion
- Can follow it up with serial scanning
What is the gold standard for management of kidney cancer?
Excision either via:
- Partial nephrectomy
- Radical nephrectomy (full kidney removal)
When is a partial nephrectomy done?
- single kidney
- bilateral tumour
- multifocal RCC in patients with VHL (multiple small lesions)
- T1 tumours (up to 7cm)
Describe the technique for radical nephrectomy
Can remove large tumours through loin or transperitoneal especially if there’s tumour thrombus in IVC to get control of blood vessels
What is the management for metastatic disease of kidney cancer?
- Receptor tyrosine kinase inhibitors
- Immunotherapy
What are we trying to avoid with these patients?
Taking out so much kidney that we have to put them on dialysis
What types of bladder cancers are there and how common are each in %?
- > 90% are transitional cell carcinoma
- 1-7% are squamous cell carcinoma
- 2% are adenocarcinoma
What problem could occur from transitional cell carcinoma in the bladder?
- TCC arises from transitional epithelium which also lines ureter and kidney
- If you have a bladder cancer you could get a field change where the cancer travels all the way up from urethra to kidney
This means patients need a CT scan to assess urothelium everywhere else.
What percentage of SCC occurs due to endemic schistosomiasis?
75%
What is schistosomiasis?
An infection caused by blood flukes (parasites)
What aetiological factors are there to bladder cancer?
- Smoking
- occupational exposure (aromatic hydrocarbons)
- chronic inflammation of bladder (bladder stones, schistosomiasis, long term catheter)
- drugs (cyclophosphamide)
- radiotherapy
How might patients present in bladder cancer?
- Visible/non-visible haematuria
- Retention of urine
- Clots
- Ureteric bleeding
- Lower urinary tract symptoms e.g. irritation (always wanting to go to the toilet)
- UTI e.g. in older patients, esp if they’re smokers, who have UTI you might want to think about bladder cancer
- Suprapubic pain
- Metastatic disease symptoms e.g. bone pain, lower limb swelling
What investigations do we do for painless visible haematuria?
- Flexible cystoscopy
- CT urogram
- Renal function
How can renal function be impaired due to TCC?
If you have a TCC in ureter or renal pelvis then it may cause ureteric dilatation due to causing an obstruction- leading to impaired renal function
This is aka hydronephrosis
What investigations do we do for persistent microscopic haematuria for bladder cancer?
- Flexible cystoscopy
- US KUB
If a biopsy has proven muscle invasion bladder cancer then how do we investigate further?
We do staging investigations
Depending on whether it’s invasive or not, how can we classify bladder cancer?
- Superficial bladder cancer
- Muscle invasive bladder cancer
When would an MRI be useful in bladder cancer?
If we have a TCC in bladder that is carcinoma in situ, it could cause a generalised field change leading to ureter and urethra getting cancer in it too
We can get MRI when we’re unsure if it’s invading the uterus, vagina, bowel or has caused a fistula
What does Ta mean?
Non invasive papillary carcinoma
What does Tis mean?
Carcinoma in situ (precancerous but can be aggressive and can progress)
What does T1 mean in bladder cancer?
Invades subepithelial connective tissue
What does T2 mean in bladder cancer?
Invades muscularis propria
What does T3 mean in bladder cancer?
Invades perivesical fat
What does T4 mean in bladder cancer?
Invades prostate, uterus, vagina, bowel, pelvic or abdominal wall
What does N1 mean in bladder cancer?
1 LN below common iliac bifurcation
What does N2 mean in bladder cancer?
> 1 LN below common iliac bifurcation
What does N3 mean in bladder cancer?
Mets in a common iliac LN
What does M1 mean in bladder cancer?
Distant mets
What does G1 mean in bladder cancer?
WHO classification for well differentiated
What does G2 mean in bladder cancer?
Moderate differentiated in WHO classification
What does G3 mean in bladder cancer?
Poorly differentiated in WHO classification
How does a cystoscopy work?
Look down the cystoscope down urethra into bladder
What technique can we do now along with a cystoscopy?
Transurethral resection of bladder lesion
- We use heat to cut out all visible bladder tumour
- This also provides histology and can be curative
If the tumour extends beyond the muscle, then we can’t complete the resection or else this could perforate the bladder causing peritoneal seeding
How do we manage non muscle invasive bladder cancer?
- If it’s low grade and no CIS (carcinoma in situ) then we can remove it and consider cystoscopic surveillance
- Can also have intravesicular chemo or BCG (immunotherapy)
- to reduce recurrence rate
- BCG usually done for carcinoma in situ
How do we manage muscle invasive bladder cancer?
- Cystectomy
- Radiotherapy
- +/- chemo
- Palliative treatment
What type of cancer causes prostate cancer mostly?
> 95% of prostate cancer is adenocarcinoma
What risk factors are there to prostate cancer?
- Increasing age
- Western nations (Scandinavian countries)
- Ethnicities (African Americans)
What are the clinical features of prostate cancer?
- Usually asymptomatic unless metastatic
- Some patients may present with:
- acute urinary retention
- hydronephrosis (need to decompress)
- renal failure
How do we detect prostate cancer through blood tests?
- Levels of PSA
- Need imaging/rectal exam as well as PSA to confirm prostate cancer
What else other than prostate cancer can cause higher PSA levels?
- In an enlarged prostate so it may be increased in UTI or increased volume of prostate
- Prostatitis
- BPH
PSA is made by prostate tissue so it’s prostate-specific but not prostate cancer-specific
What is PSA?
PSAis anenzyme(serine protease) normally produced by the glandular tissue of the prostate. It is produced at detectable levels only byprostate tissue.
What is the main way now of detecting prostate cancer?
MRI prior to biopsy testing
What were random prostate biopsies associated with historically?
Under-detection of high grade (clinically significant) prostate cancer and over-detection of low grade (clinically insignificant) prostate cancer
How have techniques investigating prostate cancer changed?
It’s proven now that multiparametric MRI before biopsy and MRI targeted biopsy is superior to the previous gold standard of transrectal ultrasonography-guided prostate biopsies
After MRI, what is the final stage of diagnosis of prostate cancer?
- Transperineal prostate biopsy- systematic template biopsies of the prostate
- Widely used in most centres over transrectal biopsies as less risk of infection and able to sample all areas of the prostate
What does T1 mean in prostate cancer?
Non palpable or visible on imaging
a: <5% of removed tissue; found in surgery
b: >5% of removed tissue; found in surgery
c: found in biopsy after raised PSA levels
What does T2 mean in prostate cancer?
Palpable tumour
a) less than half of one lobe
b) more than half of one lobe
c) both lobes but still within prostate gland
What does T3 mean in prostate cancer?
Beyond prostatic capsule into periprostatic fat
What does T4 mean in prostate cancer?
Tumour fixed onto adjacent structure/pelvic side wall
What does N1 mean in prostate cancer?
Regional LN (pelvis)
What does M1a mean in prostate cancer?
Non regional LN
What does M1b mean in prostate cancer?
Bone
What does M1x mean in prostate cancer?
Other sites
What system do we use to grade prostate cancer?
- Gleason score which goes from 1-10
- Since prostate cancer is multifocal we use 2 scores based on levels of differentiation
- 2-6 is well differentiated
- 7 is moderately differentiated
- 8 is poorly differentiated
How do we treat young and fit patients with high grade prostate cancer?
Radical prostatectomy/radiotherapy
What do we do post-prostatectomy?
- Monitor PSA (should be undetectable or <0.01ng/ml)
- If >0.2ng/ml then relapse- then might put them on hormone anti-androgen therapy and radiotherapy
How do we treat young and fit patients with low grade prostate cancer?
Active surveillance (regular PSA, MRI and Biopsy)
How do we treat old/unfit patients with high grade prostate cancer/metastatic disease?
Hormone therapy
How do we treat old/unfit patients with low grade prostate cancer?
Watchful waiting (regular PSA testing)
What side effects can prostatectomy/radical surgery have?
- Prostate contains proximal sphincter and through prostatectomy this removes the proximal urethral sphincter and changes urethral length
- Risk of damage to cavernous nerves (innervation to bladder and urethra)- can cause erectile dysfunction
