Cancer Flashcards
How does penile cancer present (6)
Palpable/ulcerating (fungating) lesion on the penis with rolled edge, mast commonly on the glans.
Usually painless but may discharge/bleed.
Not responding (4 weeks) to STD rx.
Early present as ulcer, later cauliflower appearance,late auto- amputation.
Long-standing phimosis with discharge+ palpable lump under foreskin
Inguinal lymphadenopathy in 30-60%
Diagnosis of penile cancer
Biopsy any suspicious lesion and send for histology.
Diagnosis of lump in scrotum
Testicular cancer until proven otherwise
Testicular cancer incidence in which populations (2)
Ages 20-40
White
Which lymph nodes associated with testicular cancer
Para- aortic lymph nodes
NOT inguinal unless invasion of tunica albuginea
What is a Neuroblastoma?
Non-cancerous flank mass
Name 6 possible etiologies penile cancer
- Presence foreskin → smegma → chronic irritation
- hpv 16, 18
- pre-malignant conditions: cis - red, velvety lesion on glans
- BXO / lichen sclerosis et atrophicus: White plaque
- leukoplakia
- condyloma acuminata
Most common type of penile cancer?
Squamous cell carcinoma > 90%
How does penile cancer spread? (3)
- Local spread: foreskin → glans → penile shaft → urethra → Buck’s fascia (barrier to corporeal invasion there low incidence haematogoneous metastasis)
- lymphatic:
- early spread to superficial and deep inguinal lymph nodes
- advanced disease to inguinal nodes: skin involvement (ulceration) or femoral vessels (haemorrhage)
- Iliac node involvement via Cloquet’s node (deep inguinal node in femoral canal)
• haematogenous: rare. Usually lung metastasis
Treatment of penile carcinoma in situ? (red, velvety lesion on glans) (2)
- 5-fluorouracil cream
* laser treatment
Treatment of BXO / lichen sclerosis et atrophicus? (3)
- Circumcision
- local excision of lesion on glans
- reconstructive surgery for urethral strictures
- steroid cream
At what age should prostate cancer be screened for routinely?
All men from 45
African men and men with first degree relatives from 40
Name 5 risk factors prostate cancer
• Genetic predisposition
- BRCA 1 and 2, HOX B1
-First degree relative 2x risk and earlier onset
• age: > 50, risk increase 1% per year after 65
• black Africans
• diet high in animal fat 2x risk
• androgens
Where does prostate cancer arise?
Peripheral zone
Where does BPH arise?
Transitional zone
Most common type prostate cancer?
Adenocarcinoma ( rarely urothelial cell carcinoma or sarcoma)
Which Gleason score and PSA is low risk mortality /well differentiated? Stage?
≤ 6
PSA <10
Stage t1-t2 a
Which Gleason score and PSA is intermediate risk / moderately differentiated? Stage?
Intermediate favourable: 7=3+4
Intermediate unfavourable: 7=4+3
PSA 10-20
Stage t2b-c
Which Gleason score and PSA is high-very high risk / poorly differentiated? Stage?
High risk: 8
Very high: 9-10
PSA >20
T3-4
Symptoms prostate cancer? (6)
- Mostly incidental, asymptomatic.
- LUTS
- complications of bladder outflow obstruction, kidney failure
- haematuria or haemospermia (uncommon)
- metastasis: bone pain , weight loss, anaemia, lymphoedema, paraplegia)
- ED
Rectal exam findings of organ-confined prostate cancer?
- Palpable normal prostate with increased psa- diagnosis made on multiple biopsies
- clinical BPH with nodule or hard area palpable in one or both lobes
Rectal exam findings of advanced non- organ-confined prostate cancer?
- Enlarged, hard, irregular
- edge poorly defined (indicate extracapsular spread )
- overlying rectal mucosa intact ( differentiate from rectal carcinoma)
How diagnose prostate cancer?
Biopsy!
• use TRUS probe to space biopsies evenly through prostate and biopsy suspicious hypo-echoic areas
• take at least 6 biopsy cores
• antibiotic cover to prevent bacteraemia and septicaemia after transrectal biopsy
• may have rectal bleed or haematuria after procedure
Staging prostate cancer?
TNM Tumour by rectal exam, TRUS • Tx: primary Tumour can't be assessed • To: no evidence • T1: clinically undetectable, normal DRE and TRUS. -A: incidental histologic finding in < 5% of tissue resected -B : > 5% - c: identified by needle biopsy due to elevated PSA • T2: palpable, confined to prostate - a: involve ≤ 1/2 of 1 lobe -B: > 1/2 of 1 lobe - c: both lobes • T3: extend through prostate capsule -A: extracapsular extension -B: invading seminal vesicles • T4: invades adjacent structures besides seminal vesicles
Iliac Nodes by CT (unreliable), or pelvic lymph node dissection
• Nx : not assessed
• No: no metastasis
• N1: regional lymph nodes
Metastasis by xray isotope bone scan
• Mo: no distant metastasis
• cM1: distant metastasis and pM1: distant metastasis microscopically confirmed
- a: nonregional lymph nodes
-B: bone
- c: other sites with or without bone disease
Where does prostate cancer metastasize?
Bone most commonly
Visceral less common, but often to liver, lung, adrenals
How does prostate cancer spread? (3)
- Local invasion
- lymph: obturator > iliac > presacral/para-aortic
- haematogenous dissemination occurs early
Management of t1-2 No Mo prostate cancer with PSA <10 and Gleason <7?
- Life expectancy >10 years
- active surveillance for Gleason < 6 young and healthy - patient more likely to die of other cause. Treatment of advancement and symptomatic
- watchful waiting for elderly or infirm
Management of t1-2 No Mo prostate cancer with PSA > 10 and Gleason ≥ 7?
• Life expectancy <10 years (intermediate to high risk)
• radical treatment indicated, potentially curative:
- radical prostatectomy and
- external beam or brachytherapy
Management of t3-4 or > No > Mo prostate cancer? (8)
• Patients not curable. High risk mortality. Palliation indicated
• ADT first line (80% hormone sensitive):
- GnRH lhrh analogues eg buserelin, goserelin, leuprorelin, triptorelin
- bilateral orchidectomy decrease testosterone production by 90%
-Oestrogens (not great options cardiovascular complications )
- anti-androgens eg flutamide, bicalutamide
- GnRH antagonist eg degarelix
• palliative TURP to relieve bladder outlet obstruction
• palliative radiotherapy for bone pain relapses
• for hormone refractory cancer:
-Chemotherapy: docetaxel, cabazitaxel
- novel antiandrogens : abiraterone, enzalutamide
- other novel agents: denosumab, sipuleucel T
Define watchful waiting
Done when short life expectancy < 5-10 years
Will likely only receive non - curative hormonal therapy if disease progresses
Define active surveillance
- Serial PSA, dre and biopsies done
- low grade disease
- curative treatment if disease progress
What is brachytherapy and how is it given?
• Radio- active seeds inserted through needles in perineum under TRUS control into prostate, single session
• Expensive, same efficacy as external beam
. Usually given to low volume, low PSA <10, low grade
Complication brachytherapy?
- Transient irritative voiding symptoms, may last months
* ED 50%
How is external beam radiotherapy administered for prostate cancer?
- Total dose given in small fractions over 6-7 weeks
* usually given to locally advanced disease, older pts
Name 3 complications external beam radiotherapy
- ED 50 %!
- radiation proctitis
- transient irritative bladder symptoms
- risk rectal cancer
Name 5 signs of spinal cord compression from prostate cancer
Emergency!
•Bone pain often precedes
• paraparesis → complete paraplegia
• sensory loss
• urinary retention late sign
• osteosclerotic metastases visible on xray
• MRI useful to determine level of spinal cord compression
Treatment spinal cord compression from prostate cancer? (3)
• High dose dexamethasone to reduce swelling
. Urgent castration: medical ketoconazole and oestrogens or bilateral orchidectomy
• radiation to spinal cord if previous hormone therapy
Where does renal cell carcinoma arise?
Proximal convoluted tubule epithelial cells in clear cell subtype most commonly
Name 8 risk factors RCC
- Smoking
- ht
- obesity!
- Acquired renal cystic disease esp on dialysis
- male
- Age 50-75
- end stage renal disease
- hereditary: Von hippel- Lindau disease (bilat) and hereditary papillary renal carcinoma
- horseshoe kidney
- possibly environmental exposures eg aromatic hydrocarbons
Spread of RCC? (4)
• Local: perinephric fat and fascia → adrenal → post abdominal wall → viscera
• lymphatic: hilar → para aortic → mediastinal → supra clavicular
. Haematogenous: lung, liver, bone, brain
. Grow along veins: Renal vein → IVC → right atrium (lause ascites, hepatic dysfunction, right atrial tumour, pulmonary emboli)
Clinical presentation RCC?
- asymptomatic or non-urological symptoms, > 50% diagnosed incidentally by US or CT
- urological “too late” triad in 10-15%: gross haematuria 50%, flank pain <50%, palpable mass <30%
- endocrine: hypercalcaemia, polycythaemia (high red cells)
- vascular: ht in 40%, DVT, varicocoele ! (venous drainage compression leading to dilatation veins), oedema of lower limbs (blocked IVC ), high output congestive cardiac failure (metastasis)
- “toxin “ production: anaemia, pyrexia, neuropathy/myopathy, non-metastatic hepatopathy (abnormal liver function)
- git: anorexia, weight loss, abdo pain non- specific
- metastases 30% at presentation: bone (pain), brain (neuro symptoms), lung (dyspnoea), liver.
(Paraneoplastic syndrome)
Investigations of suspect RCC? (7)
- FBC, ESR, LFT (metastasis), UCE
- Ultrasound mass: either simple cyst or renal tumour (solid mass)- irregular, poorly circumscribed border, internal echoes or variable echogenicity (hyper-echoic), no post wall signal enhancement
- CT for staging
- renal biopsy to confirm diagnosis if considering observation or other non-surgical therapy
- MRI for vascular extension in IVC can be done to plan surgery
- CXR for lung metastasis, isotope bone scan for mets
- can consider genetic testing if: family history Von hippel Lindau syndrome, bilat or multifocal tumour, onset ≤ 45, family history renal tumour, any renal tumour with history pneumothorax, childhood seizure disorder, dermatologic findings, associated tumours…
Treatment RCC? (6)
• Surgery = only effective rx
- Radical rephrectomy (kidney, adrenals, perinephric fat, para-aortic nodes) if no metastasis
- Heminephrectomy (nephron-sparing) if small <4cm incidental lesion, bilat tumours, poor total renal function or tumour in solitary kidney
- If heminephrectomy not possible, do unilateral or bilateral nephrectomy → dialysis → renal transplant
• immunotherapy for metastasis
- interleukin 2 (very toxic) or interferon alpha. Modest response.
- others for metastasis: tyrosine kinase inhibitors eg sunitinib, sorafenib; anti-angiogenesis / anti- VGF eg bevacizumab; MTOR inhibitors eg temsirolimus, everolimus
- renal unitary embolization in advanced disease and severe bleeding
Chemo and radiation ineffective!
Staging RCC?
Tumour • t1: < 7 cm, confined to renal parenchyma - a: <4cm - B: 4-7 cm • T2: > 7 cm, confined -A: 7-10cm - b: > 10cm • T3: extends into major veins or perinephric tissue, but not into ipsilateral adrenal or beyond gerotas fascia - a: into renal vein or sinus fat -B: into infra diaphragmatic IVC -C: supra-diaphragm IVC • T4: extend beyond Gerota's fascia including extension into ipsilateral adrenal
Nodes
. N1: single node, <2 cm
• N2: single node 2-5 cm or multiple <2cm
• n3: node >5cm
Metastasis
M1: distant metastasis
Classification bladder cancer? (4)
Epithelial tumours
. Transitional cell carcinoma 90%
• SCC 5%
• adenocarcínoma
Connective tissue
• rhabdomyosarcoma of bladder wall-rare
Second most common uro cancer?
Bladder
Name 7 risk factors urothelial bladder carcinoma
• Smoking! Most prevalent.
• industrial carcinogens: aromatic amines. Dry cleaning chemicals, rubber (naphthylamines), printing (benzidine), dye (naphthylamines), petroleum, leather
• drugs
- analgesic abuse
-Cyclophosphamide (chemo)
• pelvic irradiation pelvis
• schistosoma hematobium (bilharzia): SCC
• chronic irritation:cystitis, chronic catheterization, bladder stones (SCC)
• aristolochic acid herbal medication for gout, arthritis: Balkan nephropathy and Chinese herbal nephropathy
• male
• old age
Stages of urothelial carcinoma
Carcinoma in situ
• Flat, non-papillary erythematous lesion characterised by dysplasia confined to urothelium, may look normal on cystoscopy
• Highly malignant, high potential invasion and metastasis, worse prognosis, multi-focal
Papillary lesions non-muscle invasive 75%
• exophytic, papillary with narrow stalk confined to urothelium.
• often multiple because of “field of change”- predisposed to malignancy including prostatic urethra and upper tracts; progression rate 10-15%
• recurrence 50-75%
•. Good prognosis > 80% survival- malignant cells don’t come into contact with blood vessels or lymphatics
Non-papillary invasive sessile lesions 25%
• solid or ulcerated, may have necrosis
. usually high grade, poorly differentiated
•Most patients will develop overt metastasis in 1 year - lymph nodes (iliac → para-aortic), lung, peritoneum, liver (haematogenous)
Clinical presentation bladder cancer? (5)
- 20% asymptomatic
- painless haematuria = bladder cancer until proven otherwise
- irritative storage voiding symptoms: consider cis.
- 50% pain suggesting advanced disease
- metastasis : dyspnoea, bone pain
- clot retention
- palpable mass on bimanual exam - likely muscle invasion
- ureter obstruction → hydronephrosis, uremia (nausea, vomiting, diarrhea)
Special investigations bladder cancer? (5)
• FBC, ue, creatinine
• urine MCS, cytology : positive cytology usually high grade malignancies like cis. Non invasive tumours usually negative because well differentiated
• Ultrasound: mass, hydronephrosis
• cystoscope with biopsy! Gold standard
• CT with contrast: filling defects, lymph staging
. Bladder Tumour markers: nmp-22, BTA, immunocyt, fdp), EUG (filling defect, ureter obstruction)
Name 8 differentials for filling defect in bladder
•Bladder tumour, esp TCC • blood clot . Bladder stone esp uric acid • prostate (middle lobe) • foley catheter balloon • overlying bowel gas • foreign body • fungus ball (rare)
Treatment cis bladder?
Intravesical immunotherapy BCG TB weekly for 6 weeks
- if successful maintenance BCG every 3 months for 3 years
- unsuccessful: radical cystectomy
Treatment superficial papillary lesions of bladder (T1 invasion of lamina propria only)
- Complete TURBT or diathermy (fulguration) and BCG after each one → follow up cystoscope every 3 months and repeat TURBT
- cystectomy if extensive multiple recent tumours despite treatment or evidence of muscle invasion at follow-up
Treatment muscle invasive t2-3 bladder cancer?
- Radical cystectomy if no metastasis and pelvic lymph node dissection. Include prostatectomy in males and hysterectomy in females ; urinary diversion usually with ileal conduit bricker diversion
- if single tumour on dome: partial cystectomy (rarely met)
- radical radiotherapy “second best”
- post op adjuvant chemotherapy if advanced local disease or lymph involve
Staging bladder cancer?
Tumour
• ta: non-invasive papillary carcinoma, urothelium and on basement membrane
• Tis : carcinoma in situ, “flat tumour” in urothelium
• t1: invades subepithelial connective tissue into basement membrane
• T2 : invades muscularis lamina propria
-A : invade superficial inner half
-B : Deep outer half
• t3: invade perivesical tissue - Adventitia (fat)
- a: microscopic
-B : macroscopic extravesical mass
• t4: invades outside bladder
-A : prostatic stroma, uterus, vagina, seminal vesicles
-B : pelvic or abdominal wall
Nodes
• n 1: single regional lymph node in true pelvis (hypogastric, obturator, external iliac, presacral)
• n2: multiple in true pelvis
• n3: common iliac lymph nodes
Metastasis
• m 1
-A :. limited to lymph nodes beyond common iliac
- b: distant
Treatment muscle invasive advanced t4 or N1 or metastatic M1 disease? (4)
Palliative, treat symptoms
• haematuria: cystoscope and fulgaration (diathermy), intravesical alum or formalin, palliative radiotherapy
• severe irritative symptoms: anticholinergs eg oxybutinin, tolterodine; urinary diversion (bricker ileal conduit preferred)
• local pain: palliative radiotherapy
• uraemia due to bilat ureteric obstruction: percutaneous nephrostomy or double J stents if indicated
Etiology and causes SCC bladder? (5)
Chronic irritation → metaplasia urothelium → squamous cell epithelium
• schistosomiasis haematobium! (Bilharzia)
• bladder calculus
• recurrent UTI
• long term indwelling catheter or other foreign bodies
Treatment SCC bladder? (2)
• Radical cystectomy if operable ( most present late , poor prognosis )
. Palliative radiotherapy for bleeding
No effective chemo
Classification and causes bladder adenocarcinoma? (8)
Primary (rare)
• urachal (umbilicus) carcinoma
• secondary to cystitis cystica
• untreated bladder exstrophy
Secondary to adenocarcinoma elsewhere, bladder involved • prostate • sigmoid colon! • rectum • Uterus • stomach
Symptoms bladder adenocarcinoma? (3)
- Haematuria
- irritative symptoms
- mucus in urine
Treatment bladder adenocarcinoma?
Must exclude other adenocarcinoma - as most are secondary
If primary: radical cystectomy and excision urachus and umbilicus in cases of urachal carcinoma
How is intravesical bcg used?
- Solution: dissolve freeze dried powder with diluent in package
- further distill with saline, total volume 30ml
- use within 2-3h
- instill into bladder via small catheter by gravity, slow drip, not forced
- retain solution in bladder for 2h then void
- move position every 30-45 min
- repeat weekly for 6 weeks
- if successful, maintenance every 3 months for 3 years. If not, radical cystectomy
What is intravesical bcg used for?
(Bacille calmette guerin)
Primary therapy for urothelial cis Tis
Adjuvant therapy for recurrent high grade superficial papillary lesions t 1
Name 5 urological cancers that may metastasize to lungs
- RcC (most common)
- prostate
- testicular
- scc bladder
- scc penis
- malignant melanoma
- colorectal carcinoma
Second most common cancer genitourinary tract?
Urothelial carcinoma of the bladder
Name causes Virchow’s (left supraclavicular) node (7)
- Testicular cancer
- ovarian
- kidney
- pancreas
- prostate
- stomach
- gallbladder
