9.3 - Urological cancers Flashcards
What kind of haematuria is an alarm bell?
Visible/macroscopic haematuria
What are some epidemiological facts about kidney cancer? (3)
- 13,100 new kidney cancer cases in the UK every year
- kidney cancer is 7th most common cancer in the UK
- incidence and mortality rising
What types of kidney cancers are there and how common are each in %?
- 85% - renal cell carcinoma (adenocarcinoma) - RCC
- 10% - transitional cell carcinoma (epithelial)
- 5% - sarcoma/Wilms tumour/other types
What can cause kidney cancers? (5)
- smoking
- obesity
- hypertension
- renal failure and dialysis
- genetic causes (e.g. predisposition with Von Hippel-Lindau syndrome –> 50% develop RCC)
What clinical features can you find in kidney cancers? (1 + 3)
- painless haematuria/persistent microscopic haematuria is a red flag symptom and can reflect any of these urological malignancies
- additional features of RCCs include:
- loin pain
- palpable mass
- metastatic disease symptoms - bone pain, haemoptysis
What are the main types of renal cell carcinoma? (3)
- clear cell - 75%
- papillary - 15%
- chromophobe renal cell cancer - 5%
What are the risk factors for kidney cancer? (8 - just to be aware of)
- older age
- smoking
- obesity
- hypertension
- hepatitis C
- exposure to certain dyes, asbestos, cadmium, herbicides and solvents
- treatment for kidney failure
- certain inherited syndromes (Von Hippel-Lindau etc)
What are the symptoms of kidney cancer? (11 - just to be aware of)
- blood in urine (pink, red, cola-coloured)
- back pain just below the ribs that will not go away
- unexplained weight loss/loss of appetite
- fatigue
- intermittent fever
- a lump on your side, belly or lower back
- anaemic
- night sweats
- family history of kidney disease
- high levels of calcium in your blood
- high BP (EPO = increased viscosity)
Asymptomatic in early stages
What investigations are done on painless visible haematuria for kidney cancer?
- flexible cystoscopy
- CT urogram
- renal function
What investigations are done on persistent non-visible haematuria for kidney cancer?
- flexible cystoscopy
- US KUB (ultrasound of kidneys, ureter and bladder)
What investigations are done for suspected kidney cancer?
- CT renal triple phase
- staging CT chest
- bone scan if symptomatic
What are we looking for in flexible cystoscopy?
- looking at bladder (lower end of urinary system) under local anaesthetic - for exophytic lesions (tumours) or bleeding from ureteric orifices (higher bleed e.g. ureters)
- can look at urethra for transitional cell carcinoma
- can see strictures causing haematuria / bleeding prostate
What is CT urogram used to look at?
- top end of urinary system - CT scan of kidneys which could reveal masses
- can look down ureters to look for pathology e.g. ureteric filling defect could indicate transitional cell carcinomas / stones
- bladder not seen directly but large mass causing haematuria –> filling defect / clot in bladder
Which out of visible and non-visible haematuria are we more concerned about?
Visible since 50-60% of these cases have serious underlying pathology vs non-visible 1-3% chance
What staging system is used for renal cell carcinomas?
TNM staging
What do each of the different TNM staging parameters mean for renal cell carcinomas?
- 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 grading system do we use for kidney cancers?
Fuhrman grade:
- 1 = well differentiated
- 2 = moderate differentiated
- 3+4 = poorly differentiated
What is the management for kidney cancer dependent on? (3)
Patient specific:
- ASA status (healthiness of patient)
- comorbidities
- classification of lesion
What is the gold standard for management of kidney cancer?
Excision either via:
- partial nephrectomy (done when single kidney, bilateral tumour, multifocal RCC in patients with Von-Hippel Lindau, T1 tumours <7cm)
- radical nephrectomy (full kidney removal)
How do we manage kidney cancer in patients with small tumours who are unfit for surgery?
Cryosurgery (freeze tumour), can follow up with serial scanning/watchful waiting
How do we manage kidney cancer in those with metastatic disease? (2)
- receptor tyrosine kinase inhibitors
- immunotherapy
What are we trying to avoid when managing patients with kidney cancer?
Taking out so much kidney that we have to put them on dialysis
What are some epidemiological facts about bladder cancer? (3)
- 10,200 new bladder cancer cases in the UK every year
- bladder cancer is 11th most common cancer in the UK
- incidence and mortality declining (increased screening, decreased smoking)
What types of bladder cancers are there and how common are each in %? (3)
- > 90% - transitional cell carcinoma
- 1-7% - squamous cell carcinoma (75% SCC where schistosomiasis is endemic)
- 2% - adenocarcinoma
What can cause bladder cancer? (4)
- smoking
- radiation
- catheterisation
- schistosomiasis
What problem could occur from a transitional cell carcinoma of the bladder?
- TCC arises from transitional epithelium which also lines ureter and kidney
- if you have bladder cancer you could get a field change where cancer travels up from urethra to kidney (so patients also need CT scan to assess uroepithelium everywhere else)
What are the clinical features of bladder cancer? (1 + 3)
- painless haematuria / persistent microscopic haematuria is a red flag symptom and can reflect any of these urological malignancies
- additional features include:
- suprapubic pain
- lower urinary tract symptoms and UTIs
- metastatic disease symptoms - bone pain, lower limb swelling
What are some risk factors for bladder cancer? (7 - just to be aware of)
- behavioural e.g. smoking
- chemical exposure
- chronic infection/irritation
- genetics
- iatrogenic e.g. radiation, catheterisation
- medical conditions
- occupational exposures e.g. schistosomiasis
What are some types of signs/symptoms seen in bladder cancer? (4 - just to be aware of)
- haematuria (gross or microscopic)
- irritative symptoms (e.g. dysuria)
- obstructive symptoms (e.g. decreased force of stream)
- signs and symptoms of metastases/advanced disease
What investigations are done on painless visible haematuria for bladder cancer?
- flexible cystoscopy
- CT urogram
- renal function (TCC ureter/renal pelvis may cause ureteric dilatation –> impaired renal function - hydronephrosis)
What investigations are done for persistent microscopic haematuria for bladder cancer?
- flexible cystoscopy
- US KUB (kidney, ureter, bladder)
If a biopsy has proven muscle invasion how do we investigate bladder cancer further?
Staging investigations
How can we classify bladder cancer? (2)
- superficial bladder cancer (non-invasive)
- muscle-invasive bladder cancer
How do we stage bladder cancer?
TNM staging
What do each of the different TNM parameters mean for bladder cancer?
- Ta - non-invasive papillary carcinoma
- Tis - carcinoma in situ (precancer)
- T1 - invades subepithelial connective tissue
- T2 - invades muscularis propria
- T3 - invades perivesical fat
- T4 - prostate, uterus, vagina, bowel, pelvis or abdominal wall
- N1 - 1 LN below common iliac bifurcation
- N2 - >1 LN below common iliac bifurcation
- N3 - mets in a common iliac LN
- M1 - distant mets
What grading system is used for bladder cancers?
WHO classification:
- G1 = well-differentiated
- G2 = moderate differentiated
- G3 = poorly differentiated
How does a cystoscopy work?
Look down the cystoscope down the urethra into the bladder
How does cystoscopy + transurethral resection of bladder lesion work for bladder cancer?
- transurethral resection of bladder lesion uses heat to cut out all visible bladder tumour
- provides histology and can also be curative
When can cystoscopy + transurethral resection of bladder lesion not be done?
If bladder tumour extends beyond the muscle, resection cannot be completed or else this could perforate the bladder causing peritoneal bleeding
What can red patches on bladder/lining on flexible cystoscopy show?
Pre-cancer / carcinoma-in-situ
How do we manage non-muscle invasive bladder cancer?
If low grade and no carcinoma-in-situ then consideration of cystoscopic surveillance +/- intravesicular chemotherapy/BCG (immunotherapy to reduce recurrence rate for CIS)
How do we manage muscle-invasive bladder cancer? (4)
- cystectomy (remove bladder and join bowel to ureter)
- radiotherapy
- +/- chemotherapy
- palliative treatment
What is gold standard for ureteric transitional cell carcinoma (TCC)?
- gold standard - nephroureterectomy
- if patient older etc use flexible cystoscopy to ablate with laser
What are some epidemiological stats about prostate cancer? (3)
- 48,500 new prostate cancer cases in the UK every year
- prostate cancer is the most common cancer in men within the UK
- incidence rising but mortality rates declining (patients usually die WITH the disease rather than FROM it)
What is the most common type of prostate cancer (and what % of prostate cancer is this)?
> 95% of prostate cancer is adenocarcinoma
What are some risk factors for prostate cancer? (6)
- increasing age
- Western nations - Scandinavian countries
- ethnicity - African-Americans
- family history
- obesity (weak link)
- diet high in Ca2+ (weak link)
What are the clinical features of prostate cancer? (1 + 3)
- usually asymptomatic unless metastatic
- patients may present with:
- acute urinary retention
- hydronephrosis (need to decompress)
- renal failure
What is PSA?
Prostatic specific antigen - enzyme (serine protease) normally produced by the glandular tissue of the prostate
Why do PSA levels tend to increase with age?
PSA levels increase with prostatic enlargement (PSA can be normalised to total prostate volume using the index of PSA) which tends to occur with age
What are normal PSA levels at different age groups?
- men<50 = 0-2.5ng/ml
- men 50-59 = 0-3.5ng/ml
- men 60-69 = 0-4.5ng/ml
- men 70-79 = 0-6.5ng/ml
How do we detect prostate cancer through blood tests?
PSA levels: prostate-specific but not prostate-cancer specific
What can cause elevated PSA levels? (5)
- UTI / infection
- prostatitis
- benign prostatic hyperplasia
- prostate cancer
- trauma (after biopsy/cystoscopy)
Therefore elevated PSA is not always cancer
How is MRI used to diagnose prostate cancer?
Multiparametric MRI > MRI pelvis for prostate cancer
- management paradigm for suspected prostate cancer has shifted towards imaging prior to biopsy testing
- historically random biopsies of the prostate were associated with an under-detection of high grade (clinically significant) prostate cancer and over-detection of low grade (clinically insignificant) prostate cancer
- several studies have shown that the use of risk assessment with multiparametric MRI before biopsy and MRI-targeted biopsy is superior to the previous gold standard of transrectal ultrasonography-guided prostate biopsies
What is done after MRI to diagnose prostate cancer?
- trans-perineal prostate biopsy: systemic 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 staging system do we use for prostate cancer?
TNM staging
What do each of the different TNM parameters mean for prostate cancer?
- T1 - non palpable, not visible on imaging (localised)
- T2 - palpable tumour (localised)
- 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 system is used for grading prostate cancer?
Gleason score (since multifocal, two scores based on level of differentiation)
- Gleason score 2-6 = well-differentiated, low/very low risk, grade group 1
- Gleason score 7 = moderately-differentiated, intermediate risk
- 3 + 4 = grade group 2
- 4 + 3 = grade group 3
- Gleason score 8-10 = poor-differentiated, high/very high risk
- 8 = grade group 4
- 9-10 = grade group 5
What do Gleason scores of 1 to 5 mean (prostate cancer)?
- 1 = nearly normal cells
- 2 = some abnormal cells loosely packed
- 3 = many abnormal cells
- 4 = very few normal cells left
- 5 = completely abnormal cells
How do we treat young and fit patients with high grade prostate cancer?
Radical prostatectomy / radiotherapy / focal
What do we do post-prostatectomy (prostate cancer)?
- monitor PSA - should be undetectable or <0.01ng/ml
- if >0.2ng/ml then relapse - 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 (e.g. anti-androgen treatments to block testosterone and shrink prostate)
How do we treat old/unfit patients with low grade prostate cancer?
Watchful waiting (regular PSA testing)
What side effects can prostatectomy/radical prostate surgery have? (2)
- prostate contains proximal sphincter –> prostatectomy removes the proximal urethral sphincter and changes urethral length
- risk of damage to cavernous nerves (innervation to bladder and urethra) –> can cause erectile dysfunction
What should all patients with suspected prostate cancer undergo?
MRI imaging
