Bladder and Prostate cancer Flashcards
1
Q
Haematuria: What is normal?
A
Up to 20 Red Blood Cells per High Power Field
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)
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
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
5
Q
Renal Cell Cancer – Aetiology
A
- Genetic
- Obesity
- Smoking
- Dialysis ( cystic disease)
- ? Hypertension
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
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.
8
Q
Presentation of Renal Cancer
A
- Haematuria
- Anaemia
- Loin mass
- Abdo Pain
- Varicocoele
- Thrombo-embolism
9
Q
Presentation of Renal Cancer:: Investigation results
A
- Polycythaemia
- Hypertension
- Hypercalcaemia
- Abnormal LFTs
- Elevated CRP / ESR
- Gyneacomastia
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
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)
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
13
Q
Mechanism between renal cell cancer and hypertension
A
increased Renin from JGA
14
Q
Mechanism between renal cell cancer and hypercalcaemia
A
increased PTH
15
Q
Mechanism between renal cell cancer and polycythaemia
A
increased EPO
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
17
Q
Role of ultrasound in diagnosis of renal cell cancer
A
- Harmless
- Inexpensive
- Operator-dependent
- Solid and vascular
- Doppler or Micro-bubble
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
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 ”)
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
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
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
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
Definition of Radical Nephrectomy
```
• 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
Treatment of Metastatic RCC
* Palliative
* Palliative nephrectomy or embolisation for symptoms
* Metastatectomy for oligo disease
* Tyrosine Kinase Inhibitors eg Sunitinib , sorafinib
27
The majority of bladder cancers are which type?
95% Transitional Cell Carcinoma (in the West)
28
Risk factors for bladder cancer
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
Spread pattern bladder cancer: Direct spread
* Detrusor muscle
* Ureteric orifices
* Prostate
* Urethra
* Uterus / vagina
* Bowel / pelvic sidewalls
30
Spread pattern bladder cancer: lymphatic spread
* Iliac nodes
| * Para-aortic nodes
31
Spread pattern bladder cancer: haematogenous spread
* Liver (38%)
* Lung (36%)
* Adrenal gland (21%)
* Bone (27%)
* Any organ may be affected
32
Pros and cons of Transurethral Resection of Bladder Tumour
| TURBT
Pros:
• Diagnosis and treatment
• Obtain detrusor muscle
• Enables accurate staging
Risks:
• Bleeding
• Infection
• Bladder perforation
33
Management of Non muscle-invasive bladder cancer
* 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
Management of muscle-invasive bladder cancer
* 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
Management of metastatic bladder cancer
* 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
Risk factors of prostate cancer
• 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
Pathology of prostate cancer
* 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
Common sites of metastasis in prostate cancer
* Common sites of metastasis:
* Bone
* Pelvic lymph nodes
39
Diagnosis of prostate cancer in primary care
• 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
Principles of Screening
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;
9. Cost balanced relative to total healthcare expenditure; 10. Continuing process - screening interval
41
Grading – Outline Gleason Score for prostate cancer
* 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
Management of prostate cancer in Organ confined disease
* 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
Side effects of treatment for prostate cancer
Side effects are important
Incontinence
Impotence
Bowel / bladder toxicity
44
Management of prostate cancer – advanced disease
* 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
Epidemiology of testicular cancer
* 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
Risk factors for testicular cancer
* 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
Staging of testicular cancer
```
• 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
Presentation of testicular cancer
* 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
Signs on examination of testicular cancer
* 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
DIFFERENTIAL DIAGNOSIS of testicular cancer
* Hydrocele
* Epididymal cyst
* Inguinal hernia
* TB
* Varicocele
* Spermgranuloma
* Testicular torsion
* Epdididymo-orchitis
51
Investigations for testicular cancer
```
• Ultrasoundscan
• Tumourmarkers
• Alphafetoprotein(AFP)
• Beta-HCG(BHCG)
Investigations
• Lactate Dehydrogenase (LDH) • Not true tumour marker
• CT chest / abdomen / pelvis
```
52
Treatment of testicular cancer
* 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
Tumour markers for testicular cancer
```
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
Post op Treatment of testicular cancer
```
• 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
Surveillance after treatment for testicular cancer
* Clinic visits
* Chest Xray
* Abdominal CT
* Tumour markers
* Surveillance up to 10 years post treatment. • Relapse most common within 2 years
