1b Urological Cancers and BPH Flashcards
What are the risk factors for kidney cancer?
Smoking, renal failure and dialysis, obesity, hypertension
Which condition leads to a genetic predisposition to kidney cancer?
Von Hippel-Lindau
What is the most common type of kidney cancer?
Adenocarcinoma - renal cell carcinoma
What is the most common symptom which might suggest Kidney Cancer?
Painless, visible Haematuria
Which investigations should be done if painless, non visible haematuria was present?
Flexible cystoscopy
CT urogram
Renal Function
What investigations should be done is persistent non-visible haematuria was present?
Flexible cystoscopy
US KUB
What investigations should be done if kidney cancer is suspected?
CT renal triple phase
Staging CT chest
Bone scan if symptomatic
What are the main clinical features of Kidney Cancer?
Painless haematuria/persistent microscopic haematuria can is a red flag symptom and can reflect any of these urological malignancies
What are some additional features of renal cell carcinoma?
Loin pain
Palpable mass
Metastatic disease symptoms –bone pain, haemoptysis
Palpable bladder lesions
Penile Mass – rectal exam to assess the size of the cancer
What is the grading system used for kidney cancer?
Fuhrman grade
1 = well differentiated
2 = moderate differentiated
3 + 4 = poorly differentiated
Describe the criteria for the TMN staging of RCC?
T1 – Tumour ≤ 7cm
T2 – Tumour >7cm
T3 – Extends outside kidney but not beyond ipsilateral adrenal or perinephric fascia
T4 – Tumour beyond perinephric fascia into surrounding structures
N1 – Met in single regional LN
N2 – met in ≥2 regional LN
M1- distant met
What is the gold standard for kidney cancer management?
Gold standard is excision either via:
Partial nephrectomy (single kidney, bilateral tumour, multifocal RCC in patients with VHL, T1 tumours (up to 7cm)
Radical Nephrectomy
What treatment is offered to patients with kidney cancer, but small tumours and unfit for surgery?
Cryosurgery - Freeze
What treatment can be given to patients with metastatic kidney cancer?
Receptor tyrosine Kinase Inhibitors
What are the risk factors for Bladder cancer?
Smoking, occupational exposure( aromatic hydrocarbons), chronic inflammation of bladder (bladder stones, schistosomiasis, long term catheter), drugs (cyclophosphamide), Radiotherapy
What is the most common type of bladder cancer?
Transitional cell carcinoma
Which parasite can cause bladder cancer?
schistosomiasis
What is the main clinical feature of bladder cancer?
Painless haematuria/persistent microscopic haematuria can is a red flag symptom and can reflect any of these urological malignancies
What are the additional features of bladder cancer?
Suprapubic pain
Lower urinary tract symptoms and UTI
Metastatic disease symptoms – bone pain, lower limb swelling
What investigations should be done if the patient has painless visible haematuria?
Flexible cystoscopy
CT urogram
Renal function
What investigations should be done if the patient has persistent visible haematuria?
Flexible cystoscopy
US KUB
At what point would you state staging investigations for bladder cancer?
If the biopsy has proven to invade the muscle - then start staging investigations
What classification system is used for bladder cancer?
WHO classification
G1 = well differentiated
G2 = moderate differentiated
G3 = poorly differentiated
Describe the TMN staging for bladder cancer?
TNM staging of Bladder cancer
Ta – non invasive papillary carcinoma
Tis – carcinoma in situ
T1 – invades subepithelial connective tissue
T2 – invades muscularis propria
T3 – invades perivesical fat
T4 – prostate, uterus, vagina, bowel, pelvic or abdominal wall
N1 – 1 LN below common iliac birufication
N2 - >1 LN below common iliac birufication
N3 – Mets in a common iliac LN
M1- distant mets
What technique is used to remove bladder tumours?
A transurethral resection of bladder lesion uses heat to cut out all visible bladder tumour.
What is the management protocol for bladder cancer if it is non muscle invasive?
Non Muscle Invasive
- If low grade and no CIS (carcinoma in situ) then consideration of cystoscopic surveillance +/- intravesicular chemotherapy/BCG
What is the management protocol for bladder cancer which is muscle invasive?
Cystectomy
Radiotherapy
+/- chemotherapy
Palliative treatment
What type of cancer is most prostate cancer?
Adenocarcinoma
What are the risk factors for prostate cancer?
Increasing age, western nations, ethnicity
In which other conditions is PSA raised in?
Inflammation eg UTI, Prostatitis and Benign Prostate Hyperplasia
What is PSA?
enzyme which liquefies the ejaculate, and is used as a marker for prostate cancer
If PSA is high, what is done to confirm next steps of treatment?
Multiparametric MRI before biopsy
What is the method of biopsy done for the prostate?
Trans perineal prostate biopsy
Why are trans perineal prostate biopsies prefered over transrectal?
less risk of infection and able to sample all areas of the prostate.
What is the benefit of the multiparametric MRI?
Allows density of the PSA to be established, as sometimes the Prostate might just be enlarged in which case the PSA would be raised regardless
What is the score used to grade prostate cancer?
Gleason score
What are the levels of gleason score?
Since multifocal two scores based on level of differentiation
2-6 = Well differentiated
7 = Moderately differentiated
8 – Poorly differentiated
What are the TNM stages for prostate cancer?
T1 – non palpable or visible on imaging
T2 – palpable tumour
T3 – beyond prostatic capsule into periprostatic fat
T4 – tumour fixed onto adjacent structure/pelvic side wall
N1 – regional LN (pelvis)
M1a- non regional LN
M1b- bone
M1x- other sites
What is the management of prostate cancer in patients who are young and fit, and have high grade cancer?
Radical prostatectomy/Radiotherapy
What is the management of patients who have low grade cancer and are young and fit?
Active surveillance (regular PSA, MRI and Bloods)
What should PSA levels be post prostectomy?
Post prostatectomy – monitor PSA ( should be undetectable or <0.01ng/ml). If >0.2ng/ml then relapse
What is the management plan in a patient with prostate cancer who is old / unfit, and has high grade cancer?
Hormone therapy - androgen replacement
What is the management of prostate cancer if old and unwell, with low grade cancer?
Watchful waiting with regular PSA testing
Why might bladder function be affected in a prostectomy?
The prostate contains the proximal sphincteric unit, which controls some degree of urinary continence. Prostatectomy removes the proximal urethral sphincter and there is a risk of inadvertent damage to the cavernous nerve to the prostate (which provides neural innervation to the bladder and urethra) resulting in bladder function being affected(3).
What happens to urethral length in a prostectomy?
Moreover, urethral length changes during the operation which can also affect continence
Damage to what structure causes erectile dysfunction in a prostectomy?
Cavernous nerve
Which muscle does a prostectomy remove?
proximal urethral sphincter
What does the cavernous nerve innervate?
Bladder and urethra
What are the three broad classifications of testicular tumours?
Germ cell tumour
Sex cord tumours
Miscellaneous
What are the three most common types of testicular tumours?
- Seminoma
- Spermatocytic seminoma
- Teratoma differentiated
What is the difference between stage 1A, 1B and 1S testicular cancers?
1A - patients have tumours limited to testis and epididymis, no vascular or lymphatic involvement and no signs of metastasis
1B - more locally invasive primary tumour, but no sign of metastatic disease
1S - persistently elevated serum tumour marker levels, indicating subclinical metastatic disease
What is AFP?
Alpha feto-protein - serum tumour marker
In which situations is AFP elevatd?
Elevated in patients with yolk sac component within a teratomatous germ cell tumour
Where is AFP usually synthesized?
normally synthesised by fetal yolk sac, liver , intestine
What are the three main serum tumour markers?
AFP
beta sub unit of HCG
lactate dehydrogenase (LDH)
What cells secrete HCG?
Secreted by placental syncitiotrophoblastic cells
What cancers produce HCG?
choriocarcinomas
What is LDH a marker for?
general tumour marker
Which investigations are done for testicular cancer?
Abdominopelvic CT
Chest CT
Bone Scan / MRI
What is radical Orchidectomy?
Removal of the testes through the abdominal wall
What are the pathological prognostic factors in stage 1 disease (testicular cancer)?
1.Seminoma
- tumour size (>4cm)
- rete invasion (stromal)
- Non-seminomatous tumours (NSGCT)
- lymphovascular invasion
- presence (and extent) of embryonal carcinoma
What are the symptoms of penile cancer?
Inability/ difficulty / pain on retracting foreskin (phimosis – partial/ complete)
Spraying of stream (meatal stenosis)
Obstructive LUTS (urethral stricture)
Association with penile cancer
What is important to examine for when considering penile cancer?
regional inguinal lymphadenopathy
