6- Urological cancer (2/2) Flashcards
Testis cancer
Background
Most common cancer in males aged 20-40 yo
Categorisation
- Germ cell tumours (95%) (usually malignant)
- Non- germ cell tumours (5%) (usually benign)
germ cell tumours
seminomas
non-seminomatous -GCT
seminomas
germ cell tumour
* Remain localised until late and have good prognosis
non-seminomatous GCT
metastasise early and worse prognosis
* Yolk sac tumours
* Choriocarcinoma
* Embryonal carcinoma
* Teratomas (mostly)
where to testicular cancers metastasise
Metastasis
* Lymphatics
* Lungs
* Liver
* Brain
RF testicular cancer
Risk factors
* Undescended testes (cryptorchidism)
* Previous testicular malignancy
* Male infertility
* Family history
* Increased height
presentation of testciular cancer
- Unilateral painless lump (occasionally pain)
o Arising from testicle
o Hard
o Irregular
o Non fluctuant
o No transillumination - Rarely gynaecomastia- Leydig cell tumour
- Evidence of metastasis may present with weight loss, back pain (from retroperitoneal metastases), or dyspnoea (secondary to lung metastases).
*Lymphatic drainage of the testes is to the para-aortic nodes, therefore localised lymphadenopathy may not be present, even in cases of metastatic disease
investigations for testis cancer
- Scrotal US
- Tumour markers (diagnostic and prognostic)
- Staging CT CAP with contrast
- Trans-scrotal percutaneous bipsy should not be performed -> can cause seeding of cancer
tumour markers for testicular cancer
both diagnostic and prognostic
AFP (Alpha-fetoprotein)
- NSGCT e.g. teratomas
- Not in pure seminomas
BHCG (Beta-hCG)
- NSGCT e.g. teratomas and choriocarcinoma
- Seminomas (5)
LDH (Lactate dehydrogenase)
- Marker for tumour volume and necrosis
- Response to oncological treatment
AFP (Alpha-fetoprotein)
- NSGCT e.g. teratomas
- Not in pure seminomas
BHCG (Beta-hCG)
- NSGCT e.g. teratomas and choriocarcinoma
- Seminomas
LDH (Lactate dehydrogenase)
- Marker for tumour volume and necrosis
- Response to oncological treatment
Staging system of testicular cancer
R
Royal Marsden
* Stage 1 – isolated to the testicle
* Stage 2 – spread to the retroperitoneal lymph nodes
* Stage 3 – spread to the lymph nodes above the diaphragm
* Stage 4 – metastasised to other organs
management of testicular cancer
- Surgery to remove the affected testicle (inguinal radical orchidectomy) – a prosthesis can be inserted
- Chemotherapy
- Radiotherapy
- Sperm banking to save sperm for future use, as treatment may cause infertility
Long term side effects of testicular cancer treatment are
particularly significant, as most patients are young and expected to live many years after treatment of testicular cancer. Side effects include:
- Infertility
- Hypogonadism (testosterone replacement may be required)
- Peripheral neuropathy
- Hearing loss
- Lasting kidney, liver or heart damage
- Increased risk of cancer in the future
testicular cnacer prognosis
Prognosis
- Overall high rate of remission
management of Stage 1 NSGCTs
Will require orchidectomy , then further managed dependent on their risk score.
- Low risk patients without any evidence of vascular invasion can routinely enter just surveillance
- Whilst high risk patients (including embryonal cancer >50% or proliferation rate >70%) or those with vascular invasion require adjuvant chemotherapy, and then surveillance, including regular examination, surveillance CT imaging and plain film chest radiographs (CXRs), and tumour markers.
management of metastastic 1 NSGCTs
NSGCTs management is also dependent on risk scoring.
o Cases with intermediate prognosis should be treated with chemotherapy,
o whilst those with poor prognosis should be treated with one cycle of chemotherapy before reassessment (those with marker decline should have continued chemotherapy cycles,
o whilst those with unfavourable decline should have their chemotherapy intensified).
management stage 1 seminoma
often be managed with orchidectomy alone and surveillance monitoring.
- Patients with a high relapse risk are often considered for adjuvant chemotherapy.
- Histological factors which indicate higher risk for relapse are invasion of rete testis and tumour size >4cm.
- Surveillance for stage 1 seminoma includes twice yearly including regular examination, surveillance CT imaging, and tumour markers. Beyond 5 years, surveillance can be transferred to the GP, with regular examination and tumour markers alone.
management of metastatic seminoma
Stage IIA can be treated with either radiotherapy or chemotherapy, whilst higher stage disease will require chemotherapy alone and treated similar to metastatic NSGCTs (as above).
Penile cancer background
Most common is squamous cell carcinoma, arising from the epithelium of the inner prepuce or the glans- Rare
risk factors for penile cancer
Risk factors
- HPV 16,18
- Phimosis - smegma build up
- Smoking
- Lichen sclerosis
- Untreated HIV infection
Protective- circumcision
risk factors for penile cancer
Risk factors
- HPV 16,18
- Phimosis - smegma build up
- Smoking
- Lichen sclerosis
- Untreated HIV infection
Protective- circumcision
presentation of penile cancer
- Palpable/ ulcerating lesions on the penis usually located on the glans
- Painless
- May discharge or bleed
- Inguinal lymphadenopathy (30-60%)
- Distant mets uncommon
DD for penile cancer
- Herpes or syphilis
- Psoriasis
- Lichen planus
- Balanitis
- Premalignant -condyloma acuminatum (genital warts)
investigations for penile cancer
Investigations
- Penile biopsy to confirm diagnosis
- PET-CT imaging to determine inguinal involvement
o If inguinal involvement- CT CAP
staging for penile cancer
TNM
Aim of penile cancer management
complete tumour removal and oncological control and organ preservation
management of penile cancer
combination: surgery, radiotherapy, chemotherapy
penile cancer surgery
(2cm tumour-free margin for resection)
Organ sparing treatment
* Local excision
* Partial glansectomy
* Total glansectomy with reconstruction
* Radical circumcision if only foreskin tumours
Invasive penile cancer
* Partial amputation with reconstruction
* Total penectomy
If inguinal lymph node involvement- radical inguinal lymphadenectomy, neoadjuvant chemo or radio
Glands resurfacing after penile cancer surgery
consisting of complete removal of the glandular epithelium down to the corpus spongiosum, followed by reconstruction with a split skin or buccal mucosa graft
Vulval
Background
-
Very rare
- Pre malignant condition (VIN)
- Elderly patients
- Usually SCC
- Caused by HPV and chronic skin disease
Risk factors for vulval cancer
- HPV 16 and 18
- Herpes simples virus type 2
- Smoking
- Immunosuppression
- Chronic vulvar irritation
- Conditions such as Lichen sclerosis
Presentation of vulval cancer
Vulval cancer may present with symptoms of:
* Vulval lump
* Ulceration
* Bleeding
* Pain
* Itching
* Lymphadenopathy in the groin
Vulval cancer most frequently affects the labia majora, giving an appearance of:
* Irregular mass
* Fungating lesion
* Ulceration
* Bleeding
referral if suspected vulval cancer
- 2 week wait if suspected
Investigation for vulval cancer
- Biopsy of the lesion
- Sentinel node biopsy to demonstrate lymph node spread
- Further imaging for staging (e.g. CT abdomen and pelvis)
staging of vuval cancer
Staging
- FIGO
management of vulval cancer
- Surgery- vulvectomy (wide local excision)
- Lymph node dissection
- Radiotherapy
- Chemoradiotherapy
malignant condition related to vulval cancer
Vulval intraepithelial neoplasia (VIN)
- Pre malignant condition
- Involves squamous epithelium
- Can resolve spontaneously
- Can progress to vulval cancer
Vulval intraepithelial neoplasia (VIN)
types (2)
1) High grade squamous intraepithelial lesion
* HPV
2) Differentiated VIN
* Lichen sclerosis
presentation of VIN
- Can be asymptomatic
- Can present with itching/burning/pain
investigation for VIN
biopsy
management of VIN
- Conservative: Antihistamine
- Medical: Imiquimod
- Surgical: Wide local excision
