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Year 2 - BRS > 9.3 - Urological cancers > Flashcards

9.3 - Urological cancers Flashcards

1
Q

What kind of haematuria is an alarm bell?

A

Visible/macroscopic haematuria

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2
Q

What are some epidemiological facts about kidney cancer? (3)

A
  • 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
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3
Q

What types of kidney cancers are there and how common are each in %?

A
  • 85% - renal cell carcinoma (adenocarcinoma) - RCC
  • 10% - transitional cell carcinoma (epithelial)
  • 5% - sarcoma/Wilms tumour/other types
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4
Q

What can cause kidney cancers? (5)

A
  • smoking
  • obesity
  • hypertension
  • renal failure and dialysis
  • genetic causes (e.g. predisposition with Von Hippel-Lindau syndrome –> 50% develop RCC)
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5
Q

What clinical features can you find in kidney cancers? (1 + 3)

A
  • 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
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6
Q

What are the main types of renal cell carcinoma? (3)

A
  • clear cell - 75%
  • papillary - 15%
  • chromophobe renal cell cancer - 5%
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7
Q

What are the risk factors for kidney cancer? (8 - just to be aware of)

A
  • 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)
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8
Q

What are the symptoms of kidney cancer? (11 - just to be aware of)

A
  • 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

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9
Q

What investigations are done on painless visible haematuria for kidney cancer?

A
  • flexible cystoscopy
  • CT urogram
  • renal function
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10
Q

What investigations are done on persistent non-visible haematuria for kidney cancer?

A
  • flexible cystoscopy
  • US KUB (ultrasound of kidneys, ureter and bladder)
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11
Q

What investigations are done for suspected kidney cancer?

A
  • CT renal triple phase
  • staging CT chest
  • bone scan if symptomatic
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12
Q

What are we looking for in flexible cystoscopy?

A
  • 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
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13
Q

What is CT urogram used to look at?

A
  • 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
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14
Q

Which out of visible and non-visible haematuria are we more concerned about?

A

Visible since 50-60% of these cases have serious underlying pathology vs non-visible 1-3% chance

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15
Q

What staging system is used for renal cell carcinomas?

A

TNM staging

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16
Q

What do each of the different TNM staging parameters mean for renal cell carcinomas?

A
  • 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
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17
Q

What grading system do we use for kidney cancers?

A

Fuhrman grade:

  • 1 = well differentiated
  • 2 = moderate differentiated
  • 3+4 = poorly differentiated
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18
Q

What is the management for kidney cancer dependent on? (3)

A

Patient specific:

  • ASA status (healthiness of patient)
  • comorbidities
  • classification of lesion
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19
Q

What is the gold standard for management of kidney cancer?

A

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)
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20
Q

How do we manage kidney cancer in patients with small tumours who are unfit for surgery?

A

Cryosurgery (freeze tumour), can follow up with serial scanning/watchful waiting

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21
Q

How do we manage kidney cancer in those with metastatic disease? (2)

A
  • receptor tyrosine kinase inhibitors
  • immunotherapy
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21
Q

What are we trying to avoid when managing patients with kidney cancer?

A

Taking out so much kidney that we have to put them on dialysis

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21
Q

What are some epidemiological facts about bladder cancer? (3)

A
  • 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)
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22
Q

What types of bladder cancers are there and how common are each in %? (3)

A
  • > 90% - transitional cell carcinoma
  • 1-7% - squamous cell carcinoma (75% SCC where schistosomiasis is endemic)
  • 2% - adenocarcinoma
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23
Q

What can cause bladder cancer? (4)

A
  • smoking
  • radiation
  • catheterisation
  • schistosomiasis
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24
Q

What problem could occur from a transitional cell carcinoma of the bladder?

A
  • 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)
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25
Q

What are the clinical features of bladder cancer? (1 + 3)

A
  • 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
26
Q

What are some risk factors for bladder cancer? (7 - just to be aware of)

A
  • behavioural e.g. smoking
  • chemical exposure
  • chronic infection/irritation
  • genetics
  • iatrogenic e.g. radiation, catheterisation
  • medical conditions
  • occupational exposures e.g. schistosomiasis
27
Q

What are some types of signs/symptoms seen in bladder cancer? (4 - just to be aware of)

A
  • haematuria (gross or microscopic)
  • irritative symptoms (e.g. dysuria)
  • obstructive symptoms (e.g. decreased force of stream)
  • signs and symptoms of metastases/advanced disease
28
Q

What investigations are done on painless visible haematuria for bladder cancer?

A
  • flexible cystoscopy
  • CT urogram
  • renal function (TCC ureter/renal pelvis may cause ureteric dilatation –> impaired renal function - hydronephrosis)
29
Q

What investigations are done for persistent microscopic haematuria for bladder cancer?

A
  • flexible cystoscopy
  • US KUB (kidney, ureter, bladder)
30
Q

If a biopsy has proven muscle invasion how do we investigate bladder cancer further?

A

Staging investigations

31
Q

How can we classify bladder cancer? (2)

A
  • superficial bladder cancer (non-invasive)
  • muscle-invasive bladder cancer
32
Q

How do we stage bladder cancer?

A

TNM staging

33
Q

What do each of the different TNM parameters mean for bladder cancer?

A
  • 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
34
Q

What grading system is used for bladder cancers?

A

WHO classification:

  • G1 = well-differentiated
  • G2 = moderate differentiated
  • G3 = poorly differentiated
35
Q

How does a cystoscopy work?

A

Look down the cystoscope down the urethra into the bladder

36
Q

How does cystoscopy + transurethral resection of bladder lesion work for bladder cancer?

A
  • transurethral resection of bladder lesion uses heat to cut out all visible bladder tumour
  • provides histology and can also be curative
37
Q

When can cystoscopy + transurethral resection of bladder lesion not be done?

A

If bladder tumour extends beyond the muscle, resection cannot be completed or else this could perforate the bladder causing peritoneal bleeding

38
Q

What can red patches on bladder/lining on flexible cystoscopy show?

A

Pre-cancer / carcinoma-in-situ

39
Q

How do we manage non-muscle invasive bladder cancer?

A

If low grade and no carcinoma-in-situ then consideration of cystoscopic surveillance +/- intravesicular chemotherapy/BCG (immunotherapy to reduce recurrence rate for CIS)

40
Q

How do we manage muscle-invasive bladder cancer? (4)

A
  • cystectomy (remove bladder and join bowel to ureter)
  • radiotherapy
  • +/- chemotherapy
  • palliative treatment
41
Q

What is gold standard for ureteric transitional cell carcinoma (TCC)?

A
  • gold standard - nephroureterectomy
  • if patient older etc use flexible cystoscopy to ablate with laser
42
Q

What are some epidemiological stats about prostate cancer? (3)

A
  • 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)
43
Q

What is the most common type of prostate cancer (and what % of prostate cancer is this)?

A

> 95% of prostate cancer is adenocarcinoma

44
Q

What are some risk factors for prostate cancer? (6)

A
  • increasing age
  • Western nations - Scandinavian countries
  • ethnicity - African-Americans
  • family history
  • obesity (weak link)
  • diet high in Ca2+ (weak link)
45
Q

What are the clinical features of prostate cancer? (1 + 3)

A
  • usually asymptomatic unless metastatic
  • patients may present with:
    • acute urinary retention
    • hydronephrosis (need to decompress)
    • renal failure
46
Q

What is PSA?

A

Prostatic specific antigen - enzyme (serine protease) normally produced by the glandular tissue of the prostate

47
Q

Why do PSA levels tend to increase with age?

A

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

48
Q

What are normal PSA levels at different age groups?

A
  • 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
49
Q

How do we detect prostate cancer through blood tests?

A

PSA levels: prostate-specific but not prostate-cancer specific

50
Q

What can cause elevated PSA levels? (5)

A
  • UTI / infection
  • prostatitis
  • benign prostatic hyperplasia
  • prostate cancer
  • trauma (after biopsy/cystoscopy)

Therefore elevated PSA is not always cancer

51
Q

How is MRI used to diagnose prostate cancer?

Multiparametric MRI > MRI pelvis for prostate cancer

A
  • 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
52
Q

What is done after MRI to diagnose prostate cancer?

A
  • 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
53
Q

What staging system do we use for prostate cancer?

A

TNM staging

54
Q

What do each of the different TNM parameters mean for prostate cancer?

A
  • 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
55
Q

What system is used for grading prostate cancer?

A

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
56
Q

What do Gleason scores of 1 to 5 mean (prostate cancer)?

A
  • 1 = nearly normal cells
  • 2 = some abnormal cells loosely packed
  • 3 = many abnormal cells
  • 4 = very few normal cells left
  • 5 = completely abnormal cells
57
Q

How do we treat young and fit patients with high grade prostate cancer?

A

Radical prostatectomy / radiotherapy / focal

58
Q

What do we do post-prostatectomy (prostate cancer)?

A
  • 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
59
Q

How do we treat young and fit patients with low grade prostate cancer?

A

Active surveillance (regular PSA, MRI and biopsy)

60
Q

How do we treat old/unfit patients with high grade prostate cancer/metastatic disease?

A

Hormone therapy (e.g. anti-androgen treatments to block testosterone and shrink prostate)

61
Q

How do we treat old/unfit patients with low grade prostate cancer?

A

Watchful waiting (regular PSA testing)

62
Q

What side effects can prostatectomy/radical prostate surgery have? (2)

A
  • 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
63
Q

What should all patients with suspected prostate cancer undergo?

A

MRI imaging

Year 2 - BRS (84 decks)

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