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Cancer care (Y4) > 6- Urological cancer 1/2 > Flashcards

6- Urological cancer 1/2 Flashcards

1
Q

prostate cancer

A

part of the big 4 (lung, bowel, breast and prostate)
Most common cancer in men

  • Most prostate cancers very slow growing and pt will outlive
  • Advanced prostate cancer spread to the lymph nodes and bones -> poorer prognosis
  • Adenocarcinomas that are androgen dependent (e.g. rely testosterone)
  • Grow in the peripheral zone of the prostate ->Cause change in urination late on
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2
Q

risk factors for prostate cancer

A

Risk factor
- Age
- Fx
- Black African or caribbean origin
- Tall stature
- Genetic mutations e.g. BRCA2 gene mutation
- Anabolic steroids

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3
Q

where does prostate cancer metastasise

A
  • Lymph nodes
  • Bones
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4
Q

red flags for prostate adenocarcinoma

A
  • Difficulty starting urination.
  • Weak or interrupted flow of urine.
  • Urinating often, especially at night.
  • Trouble emptying the bladder completely.
  • Pain or burning during urination.
  • Blood in the urine or semen.
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5
Q

presentation of prostate cancer

A

May be asymptomatic - PSA test

Lower Urinary Tract symptoms- late sign due to usually occurring in peripheral zone and not transitional like BPH
- Hesitancy
- Frequency
- Weak flow
- Terminal dribble
- Nocturia

Other symptoms: haematuria and erectile dysfunction

Symptoms of metastasis
- Weight loss
- Bone pain
- Cauda equina syndrome

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6
Q

investigations for prostate cancer

A
  • DRE- evidence of asymmetry, nodularity, craggy or fixed irregular mass
  • Prostate specific antigen (PSA)
  • Multiparametric MRI of prostate
  • Prostate biopsy (transrectal US or transperineal biopsy- increasinglty replacing TRUS)
  • Isotope bone scan
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7
Q

DRE for prostate

A
  • Benign prostate feels smooth, symmetrical and slightly soft, with maintained central sulcus
  • Infected- enlarged, tender and warm
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8
Q

refferal for prostate cancer

A

2- week wait if DRE suggestive

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9
Q

prostate specific antigen

A

Produced by both malignant and normal healthy cells in the prostate gland- not very specific

Can be raised due to:

  • Prostate cancer
  • BPH
  • Prostatitis
  • Vigorous exercise
  • Ejaculation
  • Recent DRE
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10
Q

screening for prostate cancer

A

Controversial since may cause distress to patient due to its lack of specificity i.e. just because its raised doesn’t mean its cancer and similarly just because its not raised doesn’t mean its not cancer

-> important to do PSA in context of DRE

  • False positives may lead to further investigations inc prostate biopsies- may be unnecessary
  • False negatives lead to false reassurance

10% raised in men over 50-70%

Key problems
* Over diagnasis
* Over treatment
* QoL
* cost-effectiveness

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11
Q

prostate biopsy

A

2 main types

  • Transperineal (Template) biopsy– this involves sampling prostatic tissue transperineally in a systematic manner, done as a day case under general anaesthetic. The transperineal approach allows better access to the anterior part of the prostate and also has a lower risk of infection (most common now- can get biopsy from more areas)
  • TransRectal UltraSound-guided (TRUS) biopsy – this involves sampling the prostate transrectally, usually under local anaesthetic. Generally 12 cores are taken bilaterally in equal distribution from base to apex. Transrectal biopsies are associated with a 1-2% risk of sepsis.
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12
Q

RISKS of prostate biopsy

A
  • Pain (particularly lower abdominal, rectal or perineal pain)
  • Bleeding (blood in the stools, urine or semen)
  • Infection
  • Urinary retention due to short term swelling of the prostate
  • Erectile dysfunction (rare)
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13
Q

Multiparametric MRI for prostate cancer

A

now the usual first-line investigation for suspected localised prostate cancer. The results are reported on a Likert scale, scored as:
* 1 – very low suspicion
* 2 – low suspicion
* 3 – equivocal
* 4 – probable cancer
* 5 – definite cancer

Patients with suspicious lesions on MRI (Likert 3 or more) will then go on to a biopsy (which can be several different forms).

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14
Q

Isotope bone scan (radionuclide scan or bone scintigraphy) for prostate cancer

A
  • Radioactive isotope given by IV injection, 2-3 h wait for bone to take up isotope
  • Gamma camera used to take pics of entire skeleton
  • Metastatic bone lesion take up more of the isotope- stand out on scan
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15
Q

grading system for prostate cancer

A

Gleasons grading system

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16
Q

staging for prostate cancer

A

The TNM staging system can be used for prostate cancer, rating the T (tumour), N (lymph nodes) and M (metastasis).

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17
Q

grading for prostate cancer

A

Gleason’s grading system
The greater the Gleason score, the more poorly differentiated the tumour is (the cells have mutated further from normal prostate tissue) and the worse the prognosis is. The tissue samples are graded 1 (closest to normal) to 5 (most abnormal).

The Gleason score will be made up of two numbers added together for the total score (for example, 3 + 4 = 7):
* The first number is the grade of the most prevalent pattern in the biopsy
* The second number is the grade of the second most prevalent pattern in the biopsy

A Gleason score of:
* 6 is considered low risk
* 7 is intermediate risk (3 + 4 is lower risk than 4 + 3)
* 8 or above is deemed to be high risk

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18
Q

factors influencing treatment decisions in prostate cancer

A

depends on the grade and stage and performance status of the cancer and patient
- Age
- DRE (T stage (T1 localised/ T4 advanced))
- PSA
- Biopsy (Gleason Grade)
- MRI scan (pelvis) and bone scan - N-stage and M-stage

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19
Q

metastatic prostate cancer

A
  • spreads to bones
  • sclerotic/ osteoblastic metastases (as opposed to lytic in breast and lung cancer)
  • hot spots on bone scan
  • highly unlikely if PSA <10
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20
Q

options for management of localised prostate cancer

A

Low grade
- Surveillance or watchful waiting in early prostate cancer (regular PSA, DRE, biopsies)

Medium- high grade
- Aim: cure
- Radical prostatectomy - robotic approach
- Radiotherapy

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21
Q

types of radiotherapy for prostate cancer

A
  • External beam radiotherapy directed at the prostate
  • Brachytherapy
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22
Q

External beam radiotherapy directed at the prostate

A

Complications:
- Proctitis – inflammation in the rectum
- Pain
- Altered bowel habits
- Rectal bleeding and discharge
- Prednisolone used to reduce inflammation

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23
Q

Brachytherapy (radiotherapy) for prostate

A
  • Involves implanting radioactive emtal ‘seeds’ in the prostate
  • Targeted, continuous radiotherapy to the prostate
  • Complication: radiation to bladder (cystitis) or rectum (prostatitis) and cancer, ED, incontinences
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24
Q

management of metastatic prostate cancer

A
  • Medical castration with hormones therapy
  • Surgical castration i.e. orchidectomy
  • Chemotherapy only used in metastatic e.g. steroids + docezatol (only if fit enough)
  • Palliation
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25
Q

Hormone therapy for metastatic prostate cancer- medical castration and surgical castration

A

Anti-Androgen therapy

Aim: reduce testosterone that stimulates cancer to grow (adenocarcinoma is often androgen dependent)

Two main type: GnRH agonists and Androgen- receptor blockers

LHRH agonists (GnRH agonists) e.g. Goserlin
- Aims to reduce testosterone that stimulates cancer to grow by increasing LH, increasing negative feedback on the pituitary, therefore reducing testosterone production by the testes
- Sometimes used with radiotherapy
- Or when cure isnt possible

Androgen-receptor blockers e.g. such as bicalutamide

Surgical castration
Bilateral orchidectomy to remove the testicles (rarely used)

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26
Q

side effects of hormone therapy in prostate cancer

A
  • Hot flushes
  • Sexual dysfunction
  • Gynaecomastia
  • Fatigue
  • Osteoporosis
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27
Q

complications of radical prostatectomy

A

ED and UI

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28
Q

palliative care in prostate cancer

A
  • Palliative- metastatic
    o Single dose radiotherapy
    o Bisphosphosphonates e.g. zoledronic acid
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29
Q

Common presentations of other urological malignancies

A
  • Haematuria
  • Testicular lump
  • Penile lump or ulcers
30
Q

haematuria

A

Presence of blood in the urine. It is never normal .

Types:
Visible (20% have cancer)
- ‘macroscopic’ or ‘gross’ haematuria
- Pink, red, dark brown

Non-visible (confirmed by urine dipstick or urine microscopy) (5% have cancer)
- ‘microscopic’ or ‘dipstick positive’
- Symptomatic non-visible haematuria (s-NVH): haematuria with associated symptoms e.g. suprapubic pain or renal colic
- Asymptomatic non-visible haematuria (a-NVH): haematuria with no associated symptoms

31
Q

DDx for haematuria

A

Urological
Upper tract
* Pyelonephritis
* Cystic kidneys
* Renal cell carcinoma
* Glomerulonephritis
* Kidney stone obstruction
* Idiopathic

Lower tract
* Urinary tract infection
* Bladder stone
* Bladder cancer
* Prostate cancer

Nephrological (Glomerular)
Persistent asymptomatic non visible haematuria, age <40 with associated proteinuria,
↑BP & ↓eGFR is most likely to be nephrological in origin.

32
Q

Urological referral for haematuria

A

2 week wait
- >45 with either: visible haematuria without UT,
visible haematuria that persists
- >60yrs with unexplained non-visible haematuria +
Dysuria or raised WCC

33
Q

Investigation for haematuria

A

Urinalysis
- Presence of nitrites and/or leukocyte- infection

Baseline bloods (FBC, U and Es and clotting)
- PSA in pt with prostatic pathology
- In pt with deranged renal function-spot albumin:creatinine ratio or protein:creatinine ratio

Specialist investigations
- Flexible cystoscopy (gold standard for assessing LUT) under local
- Urine cytology
- Upper urinary tract imaging
o US KUB imaging
o CT urogram

34
Q

Pseudohaematuria

A

is red or brown urine that is not secondary to the presence of haemoglobin.
Causes include:
- medication (such as rifampicin or methyldopa),
- hyperbilirubinuria or myoglobinuria
- certain foods (such as beetroot or rhubarb)

blood thinners e.g. DOAC can cause haematuria to be more likely

35
Q

testicular lump

A

Lump in body of testis (usually painless)
Suspect testis cancer!

  • Refer via 2 week wait to Urology
  • Urgent ultrasound of scrotum to confirm diagnosis
  • Check testis tumour markers if testicular mass on ultrasound (aFP, hCG, LDH)
36
Q

penile lump/ulcer

A
  • Suspect penile cancer if a sexually transmitted infection has been excluded or lump/ulcer/lesion is persistent despite treatment.
  • Beware the male with recurrent balanitis and phimosis
  • Examine!
37
Q

bladder cancer background

A
  • Most commonly transitional cell carcinoma (90%) or squamous cell carcinoma, adenocarcinoma (rare) or sarcoma (rare)
  • Most bladder cancers are superficial with a good prognosis.
38
Q

main types of bladder cancer

A

Transitional cell carcinoma most common

Squamous cell carcinoma - schistosomiases -> travel history

39
Q

Risk factors for bladder cancer

A
  • Schistosomiases (especially SCC)
  • Exposure to aniline dyes used in the industrial manufacture of dyes, rubber and plastics
  • Smoking
  • Older
  • Male to female ratio is 3:1
40
Q

bladder cancer metastasis

A

Metastasis
- Lymph nodes
- Bones
- Ling
- Liver
- Peritoneum

41
Q

Presentation of bladder cancer

A
  • Painless haematuria either visible or non-visible
  • Recurrent UTIs or LUTS (freq, urgency or feeling of incomplete voiding)
  • Locally advanced disease may present with localised symptoms e.g. pelvic pain
  • Metastatic disease may present with systemic symptoms- weight loss or lethargy
42
Q

investigations for bladder cancer

A

Urgent cystoscopy
- Flexible cystoscopy under local anaesthetic
- If suspicious lesion identified then a rigid cystoscopy will be required (under general)

Biopsy- Transurethral resection of bladder tumour (TURBT) can be used for diagnosis and resection

Imaging
- CT staging

Urine cytology- to identify cancerous cells in urine- poor sensitivity and specificity

43
Q

Transurethral Resection of Bladder Tumour

A

Transurethral Resection of Bladder Tumour (often termed TURBT) involves resection of bladder tissue by diathermy during rigid cystoscopy.
Typically, the procedure is performed under general or regional anaesthesia. The biopsy samples obtain can aid in assessing the stage of the disease.
Depending on the disease, intravesical treatments may be instilled into the bladder following the procedure.

44
Q

Bladder cancers can further be classified into:
y

A
  • Non-muscle-invasive bladder cancer – does not penetrate into the deeper layers of the bladder wall (around 70-80% cases)
  • Muscle-invasive bladder cancer – penetrates into the deeper layers of the bladder wall
  • Locally advanced or metastatic bladder cancer – spreading beyond the bladder and distall
45
Q

purpose of staging

A
  • determine prognosis
  • dictate management
46
Q

bladder cancer staging

A
47
Q

management of bladder cancer

A

determined by classification of cancer

48
Q

management: non-muscle invasive bladder cancer

A

Low risk
Carcinoma in-situ or T1 tumours can typically be resected via TURBT, the mainstay of management

Medium risk
- Cases with deemed higher risk disease, even in non-invasive, may require adjuvant intravesical therapy, such as:
- Bacille Calmette-Guerin (BCG)
- Mitomycin C.

High risk
- Radical cystectomy can also be offered to those with high-risk disease or limited response to initial treatments.

Prognosis
- Unfortunately, superficial bladder tumours have a high rate of recurrence, with around 70% recurring within 3 years, and these recurrences are more likely to be more invasive.
- Consequently, these patients require routine follow-up with regular surveillance via cytology and cystoscopy.

49
Q

managment of muscle invasive bladder cancer

A

1) Radical cystectomy- complete removal of the bladder
- Neoadjuvant chemo (cisplatin)
- If fit enough

2) Following radical cystectomy
- Illeal conduit formation with urine draining via a urostomy
- Bladder reconstruction – from a segment of small bowel (neobladder) and urine draining urethrally or via catheter

Prognosis: Require regular follow up with CT

50
Q

Types of urinary diversion

A
  • Ileal conduit formation with urine draining via a urostomy
  • Bladder reconstruction, from a segment of small bowel* (often termed a neobladder) and urine draining urethrally or via catheter
51
Q

Management of Locally advanced or metastatic bladder cancer

A
  • Chemotherapy (cisplatin-based regime or carboplatin + gemcitabine)
  • Immunotherapy e.g. checkpoint inhibitor Pembrolizumab
  • Any symptoms of the disease, such as pelvic pain, ongoing bleeding, or urinary frequency, should be also be managed appropriately with specialist advice and input through the MDT.
  • Palliative options should also be discussed with the patient when appropriate
52
Q

prognosis of bladder disease

A

Prognosis
- High risk of developing upper urinary tract tumours and urethral tumours
- Prognosis dependent on stage
o Superficial : 5 year survival of 80-90%
o Muscle invasive and metastatic- 30-60% / 10-15%

53
Q

Renal cancer
Types:

A

- Renal cell carcinoma- most common
- Transitional cell carcinoma (urothelial tumours)
- Nephroblastoma in children (Wilms tumour)
- Squamous cell carcinomas (chronic inflammation secondary to:
o Renal calculi
o Infection
o schistosomiasis

54
Q

Renal cell carcinoma
Background

A
  • Most common renal cancer.
  • Adenocarcinoma in parenchyma of the kidneys
    o Pyramids
    o Cortex
    o Medulla
  • Arises predominantly from proximal convoluted tubules- appearing most commonly in the upper pole of the kidney

Types of RCC
- Clear cell (80%)
- Papillary (15%)
- Chromophobe (5%)

55
Q

Metastasis RCC

A
  • Spread via direct invasion into perinephric tissues, adrenal gland, renal vein or inferior vena cava
  • Spread via lymphatic system to pre-aortic and hilar nodes
  • Haematogenous spread to bones, liver, brain, bones, lung
  • Cannonball metastates in lung are a classic feature of metastatic RCC
56
Q

referral for RCC

A

Referral
2-week wait for those: >45 with unexplained visible haematuria, either without a UTI or persisting after treatment for UTI

57
Q

Risk factors for RCC

A
  • Smoking - key
  • Men
  • Developed countries
  • Industrial exposure to carcinogens (cadium, lead or aromatic hydrocarbons)
  • Dialysis x30
  • Obesity
  • HTN
  • Anatomical abnormalities such as polycystic kidneys and horseshoe kidney
  • Genetic disorders: Hippel-Lindau disease, BAP1 mutant disease
58
Q

presentation of RCC

A
  • Haematuria (vis or non vis)
  • Flank/loin pain
  • Flank mass (more commonly a cyst)

Non specific: lethargy or weight loss

Paraneoplastic syndromes
- Polycythaemia due to parathyroid hormone
- Hypertension due to renin
- Pyrexia of unknown origin
- Clinical features of metastasis e.g. haemoptysis or pathological fractures

59
Q

histological findings of RCC

A
  • Composed of polyhedral clear cells
  • Dark staining nuclei and cytoplasm rich with lipid and glycogen granules
  • Can cause tumour thrombosis
60
Q

investigations for RCC

A

Investigations
- Bloods (FBC, urea, U&Es, calcium, liver function tests, CRP)
- Urinalysis- non-visible haematuria and cytology
- Imaging
o CT CAP pre and post IV contrast (gold standard)
o Chest for staging after
o US
o Biopsy of renal lesion

61
Q

staging of RCC

A
62
Q

management of localised RCC

A

CHEMO DOESNT WORK IN RCC

Surgical management
- Laparoscopic or open approaches
- Small tumours- partial nephrectomy
- Larger tumours- radical nephrectomy i.e. remove kidney, perinephric fat and local lymph nodes en bloc

For those not fit enough for surgical management
- Percutaneous radiofrequency ablation or laparoscopic/percutaneous cryotherapy
- Renal artery embolisation
- Surveillance of slow growing small renal passes in patients unfit for surgery
- Adrenal gland should be spared if possible

63
Q

Management of metastatic RCC

A

CHEMO DOESNT WORK IN RCC

Chemotherapy ineffective in pts with RCC
- In otherwise fit patients with metastatic disease, nephrectomy combined with immunotherapy (such as IFN-α or IL-2 agents) is often recommended.
- Biological agents that can be used in combination for metastatic disease include Sunitinib (a tyrosine kinase inhibitor) and Pazopanib (also a tyrosine kinase inhibitor)
- Metastasectomy (surgical resection of solitary metastases) is recommended where the disease is resectable and the patient is otherwise well.

64
Q

Metastasectomy

A

(surgical resection of solitary metastases) is recommended where the disease is resectable and the patient is otherwise well.

65
Q

prognosis of RCC

A
  • 25% have metastasis at presentation
  • Survival in patients who have undergone nephrectomy is around 70% at 3 years and 60% at 5 years
  • Worse stage = poorer prognosis
66
Q

Upper tract transitional cell carcinoma

Background

A
  • Can affect anywhere from the calyx to the bladder.
  • Upper tract specific to pelvis and ureter
  • transitional cell carcinoma
67
Q

RF for Upper tract transitional cell carcinoma (UTTCC)

A
  • Analgesic misuse
  • Exposure to aniline dyes used in the industrial manufacture of dyes, rubber and plastics
  • Smoking
  • Male to female ratio is 3:1
68
Q

UTTCC metastasis

A
  • Pelvic lymph nodes
  • Lungs
  • Liver
  • Bones
  • Adrenals
  • Brain
69
Q

presentation of UTTCC

A
  • Haematuria
  • Incidental finding on imaging (US or CT)
  • Weight loss
  • Back pain
  • Loss of appetite/ tiredness/ painful or frequent urination
  • Signs and symptoms of obstruction
70
Q

investigations for UTTCC

A
  • Abdominal examination and history
  • Bloods (FBC, U&Es, CRP, LFTs)
  • Urinalysis- protein, blood, bacteria
  • Urine cytology
  • Ureteroscopy
  • CT scan- CT urogram (test using a CT scan and contrast to look at the urinary system)
    –>Better than CT KUB
  • US
  • PET scan- malignancy
  • Bone scan
71
Q

management of UTTCC

A

1) Surgery
- Nephroureterectomy
- Segmental resection of the ureter
2) Chemotherapies

Cancer care (Y4) (30 decks)

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