Breast, Renal & Urology Flashcards
Breast cancer
most common cancer in women, 2nd most common cause of cancer death in the UK
incidence ↑ with age
Risk factors fro breast cancer
↑age personal history of breast cancer family history of breast cancer obesity nulliparity 1st pregnancy age >30yrs early menarche / late menopause COCP HRT ionising radiation
Genetics:
- BRCA 1
- BRAC2
- p53 gene mutation
Types of breast cancer
Invasive ductal carcinoma
- most common
- may be quite aggressive
- usually unilateral & unifocal
Invasive lobular carcinoma
- less aggressive
- often multifocal
Ductal carcinoma in situ (DCIS)
Lobular carcinoma in situ (DCIS)
Medullary breast cancer
- most common type associated with BRCA1
- often triple +ve cancer
Mucinous carcinoma
Pagets disease of the nipple
-eczematous changes of the nipple associated with underlying malignancy
Presentation of breast cancer
palpable mass
-often non tender, firm
nipple discharge
-bloody discharge is associated strongly with ductal carcinoma
nipple retraction, scaling of the nipple
axillae lymphadenopathy, skin changes e.g. discolouration, dimpling, Peau d’orange, oedema of the arm
NB mastalgia (breast pain) is an uncommon presentation of breast cancer
Screening for breast cancer
NHS screening programme for women aged 50-70yrs, who are offered mammography every 3yrs, after age 70 pts are encouraged to make their own mammography appointments
if ↑ breast cancer risk due to FH screening may be offered at younger agre
-e.g. if one 1st degree relative diagnosed at <40y/o or 1st degree male relative diagnosed, or if one 1st degree relative with bilateral cancer at age <50yrs
NB first invitation should be sent to all women before age 53yrs
Investigations for breast cancer
mammography
- bilateral
- preferred if pt >30y/o
USS of breast + regional lymph nodes
- often with a biopsy
- preferred if <30y/o due to denser breast tissue in younger pts
Biopsy
- fine needle aspration
- core biopsy (preferred)
Human epithelial growth factor receptor 2 (HER2) status
Hormon receptor testing
-progesterone & oestrogen
genetic testing for BRCA1/BRCA2
-for all women <50y/o with triple -ve breast cancer
NB generally pts will have triple assessment of examination, imaging & biopsy at the breast clinic
Referral for breast cancer pathway
age ≥30yrs with unexplained breast lump ± pain
age ≥50yrs with discharge/retraction/other change of one nipple
consider referral if skin changes suggestive of breast cancer or age ≥30yrs with unexplained lump in axilla
NB if <30y/o with unexplained breast lump consider non urgent referral
Management of breast cancer
Surgical
- offered to majority of pts
- mastectomy ± axillary lymph node clearance
- if lymph spread suggested = sentinel node biopsy to asses spread during surgery
- usually also offered breast reconstruction
Radiotherapy
-whole breast radiotherapy is offered to most pts
Hormonal therapy
- offered as adjuvant therapy if hormone receptor +ve
- pre-menopause = tamoxifen
- post-menopause = anastrozole
Biologicals
- Trastuzumab for HER2 +ve cancer
- also known as herceptin
- contraindicated if pt has heart problems
chemotherapy
- used pre/post op
- FEC-D is used
Hormonal treatment of breast cancer
offered as adjuvant therapy if hormone receptor +ve
pre-menopause = tamoxifen
- ↑ risk of VTE
- ↑ risk of endometrial cancer
- NB also used in males
post-menopausal = aromatase inhibitors e.g. anastrozole
Fibroadenoma
a benign breast tumour typically seen in women aged <35 (peak incidence 25-35) accounts for ~10% of all breast masses
presents as highly mobile, firm, smooth & non-tender breast lump (also called a breast mouse)
no ↑ risk of malignancy
generally gets smaller over time, but if >3cm is usually excised
Breast cyst
usually seen in women aged 35-50yrs
presents as solitary cyst, usually a discrete small lump that may fluctuate in size
should be referred for imaging at breast clinic
may require aspiration
Fat necrosis
usually seen in larger, fatty breasts in overweight women
often after trauma
lump is painless, skin may be red/bruised/dimpled
may require biopsy to confirm diagnosis but then no further management is needed
Ductal papilloma
benign warty lesion usually located behind the areola that may cause sticky nipple discharge (discharge is usually from a single duct)
requires triple assessment to rule out cancer
Phyllodes tumour
rare tumour that is hard to distinguish from a fibroadenoma but usually occurs in older women
i.e. mobile, small, firm breast lump
treated with wide excision & follow-up
Sclerosis adenosis
sclerosis within the lobules causing a lump/pain
can be hard to distinguish from malignancy so biopsy is advised but no ↑ risk of malignancy
Cyclical mastalgia
common cause of benign breast pain in young females
breast pain that varies in intensity according to the phases of the menstrual cycle
- pain rapidly resolves with the start of menstruation
- pain generally diffuse & bilateral
management includes supportive bras, topical/oral analgesia (NSAIDs/paracetamol)
consider referral if no improvement after 3 months, specialists may consider danazol or bromocriptine
Puerperal mastitis
inflammation of the breast, often secondary to nipple fissures, affecting ~10% of breast feeding mothers
presents with ≥1 week postpartum in one breast with painful/tender, red, hot breast with pain during breastfeeding, fever and malaise
women should be encouraged to continue breast feeding
give Abx (flucloxacillin, 10-14days) if systemically unwell / nipple fissure / symptoms not improving 12-24h post effective milk removal
NB if untreated may cause breast abscess
Breast abscess
may be a consequence of untreated Puerperal mastitis or mammary duct ectasia
presents with purulent nipple discharge, a fluctuating mass, pain and fever
Non lactational mastitis
usually seen in smokers or those with nipple rings usually are of reproductive age
mammary duct ectasia
due to dilation of breast ducts, usually seen in perimenopausal women (age 40-50yrs)
presents as tender lump around areola with green nipple discharge ± blood
usually no treatment needed unless recurrent/persistent then may need surgical excision
may progress to breast abscess
Testicular cancer
most common malignancy in men aged 20-30yrs
95% are germ cell tumours e.g. seminomas or non seminomas (e.g. embryonal, teratoma)
Risk factors for testicular cancer
infertility cryptorchidism Fh of testicular cancer mumps orchitis Klinefelters syndrome
Presentation, investigations & management of testicular cancer
Presentation:
- painless testicular lump
- hydrocele
- gynaecomastia
- NB pain is a rare symptom
Investigations:
- testicular USS (1st line)
- Tumour markers
- Seminomas = ↑hCG
- non-seminomas = ↑AFP / beta-hCG
- germ cell tumours = ↑LDH
Management:
-orchidectomy ± chemo/radiotherapy
Hydrocele
presents as a fluctuating, painless transilluminating mass, usually possible to get above the mass on examination
investigated with USS in younger men to exclude cancer
Varicocele
abnormal enlargement of pampiniform plexus, most common cause of scrotal enlargement
generally presents as painless enlargement or with dull aching pain of hemiscortum
-most commonly left sided
feels like bag of worms on palpation, with negative transillumination
diagnosed with USS
management is generally conservative but surgery may be required if painful
NB there is an increased risk of subfertility/infertility
Bening prostatic hyperplasia (BPH)
a non-neoplastic glandular & stromal hyperplasia of the transition zone to the prostate
common enough to be considered normal with increasing age
~50% of 50y/o mean have evidence of BPH, but unusual before age 45
Presentation of Bening prostatic hyperplasia (BPH)
lower urinary tract symptoms (LUTS)
- urinary frequency
- urinary urgency
- hesitancy
- incomplete emptying
- weak/intermittent stream
- straining
- terminal dribble
- nocturia
PR examination
-symmetrically enlarged, smooth, firm, non tender prostate
Assessment of Bening prostatic hyperplasia (BPH)
International prostate symptom score (IPSS)
- used to assess the severity of LUTS
- assess impact on QoL
Investigations for Bening prostatic hyperplasia (BPH)
Prostate specific antigen (PSA)
- indicated if pt is worried about prostate cancer
- usually ↑
Prostate USS
-done pre surgery
Urinalysis (normal usually) post-void residual bladder scan urinary frequency - volume chart uroflowmetry U&Es, FBC, LFTs
Management of Bening prostatic hyperplasia (BPH)
Minimal symptoms
-watchful waiting
Pharmacological (trialed before surgery)
- Alpha-1 antagonist (1st line)
- e.g. Tamsulosin or alfuzosin
- improve symptoms in ~70% of men
- ↓ muscle tone of prostate & bladder
- side effects: dizziness, hypotension, dry mouth
- 5-alpha reductase inhibitors (2nd line)
- e.g. finasteride
- block conversion of testosterone→dihydrotestosterone
- ↓ prostate volume
- side effects: erectile/ejaculation dysfunction, ↓ libido
- can be combine with Alpha-1 antagonist if severe BPH
Surgery (2nd line)
- generally only after failed medical treatment
- transurethral resection of prostate (TURP) = procedure of choice
- may consider UroLift system
Prostatitis
an inflammation of the prostate gland that may be of infectious or non infectious
infectious causes are commonly due to E.coli (may also be STI causes e.g. Chlamydia/Gonorrhoea especially in <35y/o men, while non infectious may be inflammatory response post UTI
presents generally with fever, malaise, dysuria / frequency / urgency (due to bladder irritation, with pain radiating to lower back, perineum, rectum or penis
DRE may reveal a tender, boggy prostate gland
treatment includes STI screening and a 14day course of quinones if bacterial, and NSAIDs
Pharmacological treatment of Benign prostatic hyperplasia (BPH)
1st line = Alpha-1 antagonist
- e.g. Tamsulosin or alfuzosin
- improve symptoms in ~70% of men
- ↓ muscle tone of prostate & bladder
- side effects: dizziness, hypotension, dry mouth
2nd line = 5-alpha reductase inhibitors
- e.g. finasteride
- block conversion of testosterone→dihydrotestosterone
- ↓ prostate volume
- side effects: erectile/ejaculation dysfunction, ↓ libido
If severe symptoms then both drug types can be combined
Prostate cancer
a malignant tumour of glandular origin situated in the prostate, most commonly adenocarcinomas arising in the peripheral zone of the prostate
most common site of metastasis = bones & lymph nodes
most common cancer in men (~27% of all male cancer)
especially common in black males
usually seen at age >50yrs
Location of prostate lesions
Prostate cancer:
-peripheral zone
BPH
-transitional zone
Epidemiology & Risk factors for Prostate cancer
most common cancer in men (~27% of all male cancer)
especially common in black males
least common in asian men
usually seen at age >50yrs
2nd most common cause of cancer death in males
Risk factors:
- ↑ age
- afro-carribbean origin
- afro-american origin
- Family history
Presentation of prostate cancer
typically asymptomatic
LUTS (hesitancy, weak stream, incomplete emptying, frequency) haematuria flank pain weight loss ↓ appetite Bone pain (if metastasis)
PR examination
- may remain normal even in advanced disease
- hard irregular prostate with lobar asymmetry
DRE examination findings for prostate pathology
Prostate cancer
- may remain normal even in advanced disease
- hard irregular prostate with lobar asymmetry
BPH
-symmetrically enlarged, smooth, firm, non tender prostate
Prostatitis
-tender, boggy prostate gland
Investigations for prostate cancer
Prostate specific antigen (PSA) ↑
multi parametric MRI*
-1st line imagine now
transurethral ultrasound guided biopsy
- biopsy is grade with Gleason scale
- Gleason scale goes from 1-10
- used as prognostic indicator
Management of prostate cancer
Localised prostate cancer
- active monitoring
- watchful waiting
Locally advanced cancer
- radical prostatectomy
- commonly causes erectile dysfunction
- radiotherapy
- external beam & brachytherapy
Metastatic prostate cancer
- hormonal therapy with anti androgen therapy
- GnRH agonist e.g. goserelin*
- bicalutamide (non steroidal anti androgen)
- cryptoterone acetate, abiraterone
- enzalutamide (NICE recommended)
- bilateral orchidectomy
Bladder cancer
most common malignancy of the urinary tract
Types:
- transitional cell (urothelial) carcinoma (~90% of cases)
- squamous cell carcinoma (~8% of cases)
- adenocarcinoma (~2% of cases)
NB these can occur anywhere in the urinary tract but bladder is most common place
Risk factors for bladder cancer
smoking
exposure to aniline dyes e.g. 2-naphthylamine
rubber manufacturing
cyclophosphamide
Risk factor for squamous cell bladder cancer
Indwelling catheters
schistosomiasis**
Presentation of bladder cancer
painless macroscopic haematuria
dysuria
urinary frequency
other voiding symptoms
NB painless haematuria is cancer until proven otherwise
Investigations for bladder cancer
Urinalysis
- haematuria
- may show pyuria
cystoscopy ± biopsy
urine cytology
CT/MRI chest/abdo/pelvis
U&Es, FBC
NB incidental microscopic haematuria is still associated with bladder cancer and should be treated as such especially in those aged >60
Management of bladder cancer
Non-invasive
-transurethral resection of bladder tumour (TURBT)
Invasive cancer
- neo-adjuvant chemotherapy
- radical cystectomy
Metastatic disease
-treated with cisplatin based chemo
NB pts should be followed up post TURBT with cystoscopy every 3 months as superficial transitional cell carcinoma may recur in ~80% of pts
Renal cell carcinoma (RCC)
also known as hypernephroma
a renal malignancy arising from the renal parenchyma/cortex (usually proximal tubular epithelium) accounting for ~90% of renal cancers
Most common kidney cancer in adults (NB in children Wilm’s tumour is most common)
~85% are clear cell carcinomas
usually seen in males, aged 60-70yrs
Risk factors for Renal cell carcinoma (RCC)
smoking
obesity
HTN
also associated with von Hippel-Lindau syndrome & tuberous sclerosis
Presentation of Renal cell carcinoma (RCC)
Triad of
-haematuria
-loin pain
-loin/abdo mass
plus
fatigue, weight loss, varicocele (L sided usually), pyrexia of unknown origin, oedema
~25% of pts have metastatic disease
- haemoptysis
- bone pain
- pathological fractures
NB paraneoplastic features e.g. hepatic dysfunction or polycythaemia (↑EPO production) may be present
Investigations for Renal cell carcinoma (RCC)
FBC
-Hb ↓
urinalysis
-haematuria ± proteinuria
CT kidney with contrast MRI/USS kidney U&Es (usually normal) LFTs (may be abnormal) Urine MC&S CT/MRI chest/abdo/pelvis
Management of Renal cell carcinoma (RCC)
confined disease
-partial/total nephrectomy depending on tumour size
if <7cm = partial
advanced/metastatic disease
- receptor kinase inhibitors (1st line)
- e.g. surafenib / sutinib - alpha-interferon & interleukin 2
- help ↓ tumour size
Nephrolithiasis (renal stones)
encompasses te formation of all types of urinary calculi in the kidney / urinary system
- ~80% of stones are calcium containing - calcium oxalate stones are most common type
very common condition, usually age 40-60yrs
more common in men (3:1 male:female ratio)
most common in white people
