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MK SR INDEX CASES CANCER CARE > Bladder and Prostate cancer > Flashcards

Bladder and Prostate cancer Flashcards

1
Q

Haematuria: What is normal?

A

Up to 20 Red Blood Cells per High Power Field

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2
Q

Types of Visible Haematuria

A
  • “Cola” - post strep GN
  • Initial / bloody discharge – urethral cause
  • Terminal – prostatic, trigonal, bladder
  • Throughout & without clots (urokinase) – renal
  • Clots – ? bladder cancer
  • Old / altered blood (& myoglobinuria ) is tea coloured
  • NB: remember beetrooturia, drugs (rifampicin, nitrofurantoin, phenytoin)
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3
Q

Investigations for haematuria

A
  • U & Es , FBC , ESR , Calcium , LFTs
  • Urine microscopy and culture
  • Urine cytology
  • Imaging – (historically IVU) U/S KUB, CT, MRI
  • Cystoscopy
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4
Q

What is the most likely cause of haematuria in patients less than 40 years old?

A

Nephrological causes

e.g. Glomerulonephritis ,
nephrotic syndrome

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5
Q

Renal Cell Cancer – Aetiology

A
  • Genetic
  • Obesity
  • Smoking
  • Dialysis ( cystic disease)
  • ? Hypertension
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6
Q

Genetic Causes of Renal Cell Cancer

A
  • Von Hippel Lindau Syndrome
  • Birt Hogg Dube Syndrome ( skin lesions)
  • Hereditary Papillary Syndrome
  • Fumarate Hydratase deficiency (HLRCC
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7
Q

What is Von Hippel Lindau Disease?

A 
Genetic condition causing Tumours of CNS, eye, kidney,
adrenal, pancreas
• Benign / malignant and cysts
• Renal Cell carcinoma
• Multiple lesions
• Chr 3p 25.3
• Inhibition of tumour suppressor
gene

Cryotherapy is increasingly being used to treat.

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8
Q

Presentation of Renal Cancer

A
  • Haematuria
  • Anaemia
  • Loin mass
  • Abdo Pain
  • Varicocoele
  • Thrombo-embolism
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9
Q

Presentation of Renal Cancer:: Investigation results

A
  • Polycythaemia
  • Hypertension
  • Hypercalcaemia
  • Abnormal LFTs
  • Elevated CRP / ESR
  • Gyneacomastia
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10
Q

Symptoms of renal cancer

A
  • Blood in urine
  • Constant loin / flank pain
  • “Clot colic”
  • Malaise
  • Sweats
  • Weight loss
  • Scrotal swelling
  • Bone pain / pathological fracture
  • Shortness of breath
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11
Q

Renal Cell Cancer – Paraneoplasia

A
  • Hypertension from increased Renin from JGA
  • Hypercalcaemia from increased PTH
  • Polycythaemia from increased EPO
  • Anaemia from decreased EPO (also blood loss )
  • Stauffer’s Syndrome – increased LFTs (cholestasis)
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12
Q

Signs of renal cancer

A
  • Haematuria
  • Loin / abdominal mass
  • Anaemia
  • Supraclavicular LN (Troisier’s sign)
  • Varicocoele – right side and persistent on lying down (grade 3)
  • Hypertension
  • multiple skin lesions - Birt Hogg Dube
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13
Q

Mechanism between renal cell cancer and hypertension

A

increased Renin from JGA

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14
Q

Mechanism between renal cell cancer and hypercalcaemia

A

increased PTH

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15
Q

Mechanism between renal cell cancer and polycythaemia

A

increased EPO

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16
Q

Spread pattern of renal cell cancer

A

• Direct to perinephric fat, adrenal
• Lymph to nodes at renal hilum, para-aortic area and
mediastinum (like most organs it follows arterial supply)
• Venous spread to renal vein / IVC / Right atrium
• Metastatic to lungs, liver, bone, brain, skin

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17
Q

Role of ultrasound in diagnosis of renal cell cancer

A
  • Harmless
  • Inexpensive
  • Operator-dependent
  • Solid and vascular
  • Doppler or Micro-bubble
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18
Q

Role of contrast CT in diagnosis of renal cell cancer

A
  • Ionizing radiation
  • Adequate renal function > eGFR 50mls/min
  • Solid, heterogenous & enhancing ( > 20 Hounsfield Units )
  • Triple phase: No contrast, renal parenchyma and then collecting system
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19
Q

Role of MRI in diagnosis of renal cell cancer

A 
• Non ionizing
• With or without contrast gadolinium
• Harmless ??
• Not in 1st trimester pregnancy
• Claustrophobic
(“open ”)
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20
Q

Role of renal biopsy in diagnosis of renal cell cancer

A
  • Increasing use
  • Risk of seeding – historical
  • Bilateral lesions
  • Single kidney
  • Benign ?
  • Co-axial needles
  • LA +/- sedation
  • U/S or CT guided
  • Histology
  • Immunohistochemistry
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21
Q

How is renal cell cancer staged?

A

• CT thorax , abdomen and pelvis
• Isotope Bone scan if bone pain or abnormal Alk Phos / Calcium
• No role for PET CT as 30% RCC are PET negative
• MAG 3 renogram for differential if eGFR < 60mls/min or bilateral
lesions

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22
Q

What is “Adult Wilms’ Tumour”?

A
  • Adult version of nephroblastoma
  • Very rare < 1% adult renal Ca
  • Discovered on histology after nephrectomy
  • Bilateral extremely rare ( cf paed Wilms’ 5% )
  • Chemo and radio-sensitive (cf RCC )
  • 80% 5 Yr survival with multi-modality treatment
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23
Q

Benign solid renal masses

A
  • Oncocytoma
  • Central scar
  • cf Oncocytic RCC / Chromophobe
  • Birt Hogg Dube
  • Angiomyolipoma
24
Q

Treatment of localised RCC

A
  • Radio and chemo-resistant
  • Surgical complete removal is often curative
  • Surveillance in elderly / unfit
  • Nephron-sparing ideally
  • Minimally invasive
  • Ablation (cryotherapy or radiofrequency )
25
Q

Definition of Radical Nephrectomy

A 
• Removal of entire kidney and
tumour and perinephric fat
within Gerota’s fascia
• The adrenal gland is only
removed if obviously involved
• No place for routine
lymphadectomy but give staging
information
26
Q

Treatment of Metastatic RCC

A
  • Palliative
  • Palliative nephrectomy or embolisation for symptoms
  • Metastatectomy for oligo disease
  • Tyrosine Kinase Inhibitors eg Sunitinib , sorafinib
27
Q

The majority of bladder cancers are which type?

A

95% Transitional Cell Carcinoma (in the West)

28
Q

Risk factors for bladder cancer

A

95% Transitional Cell Carcinoma

• Smoking related in 50%
• Stopping reduces the risk
• Occupations – rubber industry (napthylamines), gas workers,
hairdressers, taxi / HGV drivers / mechanics / painters &
decorators / leather workers . Aromatic amines
• Genetic – Lynch Syndrome .AD

29
Q

Spread pattern bladder cancer: Direct spread

A
  • Detrusor muscle
  • Ureteric orifices
  • Prostate
  • Urethra
  • Uterus / vagina
  • Bowel / pelvic sidewalls
30
Q

Spread pattern bladder cancer: lymphatic spread

A
  • Iliac nodes

* Para-aortic nodes

31
Q

Spread pattern bladder cancer: haematogenous spread

A
  • Liver (38%)
  • Lung (36%)
  • Adrenal gland (21%)
  • Bone (27%)
  • Any organ may be affected
32
Q

Pros and cons of Transurethral Resection of Bladder Tumour

TURBT

A

Pros:
• Diagnosis and treatment
• Obtain detrusor muscle
• Enables accurate staging

Risks:
• Bleeding
• Infection
• Bladder perforation

33
Q

Management of Non muscle-invasive bladder cancer

A
  • TURBT Then Surveillance with flexible cystoscopy
  • Intravesical treatment If high risk or recurrent, Mitomycin. BCG
  • Radical cystectomy (or radiotherapy), High risk / high volume disease
34
Q

Management of muscle-invasive bladder cancer

A
  • Requires radical treatment if the patient is fit enough
  • Radical cystectomy: With ileal conduit or neobladder
  • Pre-operative chemotherapy: improves survival by 5%
  • Radiotherapy if unfit
35
Q

Management of metastatic bladder cancer

A
  • Systemic chemotherapy
  • Complete response in 15%
  • BUT:
  • 20 % develop neutropaenia
  • 3% die of sepsis
  • Median survival 14 months

Palliative radiotherapy
• Metastatic pain
• Haematuria
• Spinal cord compression

36
Q

Risk factors of prostate cancer

A

• Age Very uncommon in men <50
• Family history (One first degree relative RRx 2 Two first degree relative RR x 4)
• Vitamin E alone may increase the risk of prostate cancer
• 17% relative increase in numbers of CaP (2011 SELECT data)
Folate is involved in multiple cellular processes including DNA methylation
• Folic acid supplementation may increase the risk of prostate cancer.
• Dairy and Calcium - High intake of calcium or protein from dairy products is associated with an increased risk of prostate cancer
• Hormones

37
Q

Pathology of prostate cancer

A
  • Adenocarcinoma >95%
  • Sarcomas or secondary deposits from other sites are rare
  • 75% located in peripheral zone • 20% anterior zone
  • 85% multifocal
  • Driven by TESTOSTERONE
38
Q

Common sites of metastasis in prostate cancer

A
  • Common sites of metastasis:
  • Bone
  • Pelvic lymph nodes
39
Q

Diagnosis of prostate cancer in primary care

A

• Urinary symptoms
• E.g. poor flow, nocturia, haematuria • Non-specific
• Advanced disease
• e.g. bone pain, weight loss, anaemia, spinal cord compression
• Abnormal prostate on rectal examination (DRE)
PSA

40
Q

Principles of Screening

A
  1. Condition sought should be an important health problem;
  2. Accepted treatment;
  3. Facilities for diagnosis / treatment available;
  4. Recognisable latent or early symptomatic stage;
  5. Sensitive and specific test;
  6. Test acceptable to population;
  7. Natural history of latent to declared disease understood; 8. Agreed policy on whom to treat;
  8. Cost balanced relative to total healthcare expenditure; 10. Continuing process - screening interval
41
Q

Grading – Outline Gleason Score for prostate cancer

A
  • Sum of two scores of 1-5 (due to multifocal nature) • E.g. Gleason 3+4=7
  • Reflects tumour tissue differentiation
  • Gleaon score 6 – low risk
  • Gleason score 7 – intermediate • Gleason 8-10 – high risk
42
Q

Management of prostate cancer in Organ confined disease

A
  • Active surveillance
  • Low risk, low volume disease
  • Requires regular MRI / biopsies / PSA checks / rectal examination
    • Radical prostatectomy • Robotic
  • Open
  • Radiotherapy / hormones • External Beam
  • Brachytherapy
43
Q

Side effects of treatment for prostate cancer

A

Side effects are important
Incontinence
Impotence
Bowel / bladder toxicity

44
Q

Management of prostate cancer – advanced disease

A
  • 5yr survival for metastatic disease 35%
  • Hormone therapy / androgen deprivation • LHRH agonists with Bicalutamide cover
  • Reduce circulating testosterone
  • Palliation for e.g. symptomatic bony mets
  • Cause hot flushes, reduced libido, osteoporosis • Bilateral orchidectomy is an alternative
  • Chemotherapy
  • E.g. Docetaxel
  • Patient needs to be fit enough
  • Newer agents
  • Abiraterone
  • Enzalutamide
  • Often given as part of CLINICAL TRIALS
45
Q

Epidemiology of testicular cancer

A
  • Most common cancer in men 20-45 years • Rare below 15 and above 60 years
  • 1-2% of all male cancers
  • Most curable cancer
  • Non-seminomatous germ cell tumours • Common at ages 20-35
  • Seminoma
  • Common at ages 35-45
46
Q

Risk factors for testicular cancer

A
  • Race: caucasians in Europe and USA most at risk
  • Previous testicular cancer
  • 12 fold risk of metachronus TC • TC is bilateral in 1-2%
  • Cryptorchidism (undescended testes)
  • 5-10% have history of cryptorchidism
  • Orchidopexy does not completely eliminate risk of TC
  • Intratubular germ cell neoplasia
  • Malignant change in spermatogonia
  • 50% develop germ cell TC within 5 years

HIV - • Higher risk of seminoma
• First degree relatives
• 4-9 fold increased risk of TC
•

47
Q

Staging of testicular cancer

A 
• T0–notumour
• Tis–Testicularintraepithelial
neoplasia
• T1-Tumourlimitedtotestis
• T2–Limitedtotestis
• Vascular/lymphatic/tunica vaginalis
invasion
• T3 – Invades spermatic cord
• T4–invadesscrotum
• N1-3
Nodalmetastasis 
• M1
• non regional node or distant metastasis
Staging
48
Q

Presentation of testicular cancer

A
  • Scrotal lump
  • Usually painless
  • Symptoms of advance disease in 10%
  • Patient factors – denial, fear, self-neglect, ignorance • Weight loss
  • Lumps in neck
  • Chest symptoms
  • Bone pain
49
Q

Signs on examination of testicular cancer

A
  • Bimanual palpation
  • Examine normal side first
  • Mass
  • Hard
  • Non-tenderin95%
  • Non-transilluminable
  • Assess epididymis and spermatic cord for involvement
  • General examination
  • Cahchexia,lymphadenopathy,chest signs, hepatomegaly, abdo mass, gynaecomastia
50
Q

DIFFERENTIAL DIAGNOSIS of testicular cancer

A
  • Hydrocele
  • Epididymal cyst
  • Inguinal hernia
  • TB
  • Varicocele
  • Spermgranuloma
  • Testicular torsion
  • Epdididymo-orchitis
51
Q

Investigations for testicular cancer

A 
• Ultrasoundscan
• Tumourmarkers
• Alphafetoprotein(AFP)
• Beta-HCG(BHCG)
Investigations
 • Lactate Dehydrogenase (LDH) • Not true tumour marker
• CT chest / abdomen / pelvis
52
Q

Treatment of testicular cancer

A
  • Radical inguinal orchidectomy
  • Testis, epididymis and spermatic cord excised through inguinal (groin) incision
  • Both diagnostic, and curative in 75% • Consider biopsy of contralateral testis
  • In patients at risk of Tis • Small testis <12ml
  • Undescended testis
  • Age <30
53
Q

Tumour markers for testicular cancer

A 
Alphafeto protein 
• 50-70% of teratomas and yolk sac tumours
• Human chorionic gonadotrophin (HCG) • Choriocarcinomas (100%)
• Teratomas (40%)
• Seminomas (10%)
• Lactate dehydrogenase
• Non-specific
• Elevated in up to 20% of seminomas
54
Q

Post op Treatment of testicular cancer

A 
• Localised disease
Treatment post op
• Surveillance
• though 30% relapse rate, salvage chemotherapy has 99% cure • Requires cooperative patient
• Adjuvant chemotherapy
• Occasionally radiotherapy
• Metastatic disease
• Chemotherapy
• Surgery (Retroperitoneal lymph node disection) • For residual or recurrent mass after chemotherapy
• Radiotherapy (in seminoma)
55
Q

Surveillance after treatment for testicular cancer

A
  • Clinic visits
  • Chest Xray
  • Abdominal CT
  • Tumour markers
  • Surveillance up to 10 years post treatment. • Relapse most common within 2 years

MK SR INDEX CASES CANCER CARE (16 decks)

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