Cancer of the GU tract Flashcards
In which parts of the GU tract is cancer seen?
Kidney
Bladder
Prostate
Testis
Which is the most common type of kidney cancer?
Renal cell carcinoma (RCC)
Does renal cell carcinoma affect men or women more?
What age are people most affected?
Men more than women
Middle age, about age 55-60
Which part of the kidney do RCC arise from?
Proximal convoluted tubule epithelium
What do RCC tumours look like under a microscope?
Tumour made up of large cells with clear cytoplasms
What causes RCC?
Genetic susceptibility
Irradiation Hypertension Smoking Obesity Exposure to heavy metals Long term dialysis
How does long term dialysis increase the risk of getting RCC?
Long term dialysis results in cysts in the kidney
These cysts sometimes develop into malignancies
More cysts = more chance of malignancy developing
What genetic conditions increase the risk of RCC?
Von Hippel Lindau disease: development of many cysts in the kidney, some of these are likely to become malignant
Birt-Hogg-Dube Syndrome: 1/3 of patients get kidney cancer
What is the pathogenesis of Von-Hippel Lindau disease?
A mutation of the Von-Hippel Lindau (VHL) gene
VHL is a tumour suppressor gene
Without it you get overexpression of vascular endothelial growth factor (VEGF)- leading to angiogenesis
Tumours can grow bigger as they can generate their own blood supply
What are the clinical features of RCC?
Sometimes asymptomatic
Haematuria Loin pain Abdominal mass Anorexia, weight loss Nausea Hypertension
Signs of metastatic disease
How are kidney cancers often picked up?
Incidentally: often people are asymptomatic
Or they present with metastatic disease
How would a patient with metastatic kidney cancer present?
Mets in the bone, lung, liver
Anaemia or polycythaemia (excess Hb, high RBC count)
Hypercalcaemia
Why does RCC sometimes cause hypertension?
Damage to kidney results in increased renin secretion
More renin = raised BP
Investigations of RCC?
Blood:
- FBC to look for anaemia/polycythaemia
- LFT to check for liver mets
- Calcium levels
USS: to distinguish benign cyst from malignant
CT/MRI: look for mets
Bone scan: look for mets if raised Ca
Biopsy
What would a blood test looking at Ca levels help with when investigating RCC?
Low Ca = kidney damage
Raised Ca = bone mets/damage
How is RCC staged?
TNM staging
What is the link between a Varicocele and kidney cancer?
If you see a varicocele in men over 50 consider kidney cancer
In the under 20s they are usually benign
Management of localised kidney cancer?
Surgery:
- radical nephrectomy
- partial nephrectomy
Radiotherapy for people unable to tolerate surgery
Management of metastatic kidney cancer?
Targeted biological therapies that block VEGF (vascular endothelial growth factor)
- Sunitinib
Radiotherapy
Palliative care
What is a Wilm’s tumour?
A tumour of children
Nephroblastoma: cancer of primitive renal tubule and mesenchymal cells
How do patients with Wilm’s tumour present?
Haematuria
Abdominal mass
Where in the GU tract can transitional cell carcinomas (TCC) occur?
Which is the most common site?
Renal pelvis
Bladder (most common)
Ureters
They are lined with transitional cells
Which gender are most affected by TCC, and which age group?
Males
After age 40
What are the risk factors for TCC of the bladder?
Cigarette smoking Exposure to industrial chemicals Exposure to certain drugs Chronic inflammation Radiation
How do patients with bladder TCC present?
Painless haematuria
Symptoms suggestive of a UTI
- dysuria
- frequency
- urgency
Recurrent UTIs
Signs of metastatic disease
How do TCCs of the renal pelvis and ureters present?
Similarly to bladder TCC
Haematuria
Flank pain
Investigation of bladder TCC?
Cystoscopy + biopsy
Urine sample: may see sterile pyuria (WBCs)
CT scan: useful for staging
MRI: to look for any lymph involvement
What is pyuria?
Presence of white blood cells in urine
Can be sterile (cancer) or not (infection)
Management of bladder TCC?
Surgery:
- cystoscopic resection: removal of tumour
- bladder resection: removal of whole bladder
- local diathermy: heat/burning off tumour
Radiotherapy
Chemotherapy
Management of renal pelvis + ureter TCC?
Nephroureterectomy: removal of kidney + ureter
What type of cancer is prostatic cancer?
Adenocarcinoma
What region of the prostate does prostate cancer occur?
Peripheral zone
as opposed to central zone in BPH
Which age group is most often affected by prostate cancer?
Older men, mean age = 72
Incredibly rare to see it in under 40s
What are the risk factors of prostate cancer?
Family history
Having higher levels of testosterone
Age
Race: African American men are at a higher risk than Caucasians
Obesity
How do patients with prostate cancer present?
Asymptomatic sometimes
Problems with urination:
- Nocturia
- difficulty initiating
- poor stream
- dribbling after urination
Weight loss
Signs of metastatic disease, such as bone pain
Investigation of prostate cancer?
Blood:
- raised PSA
Digital rectal examination
Trans-rectal ultrasound
Biopsy
CT/MRI/X-ray: show up metastases
What would you feel in a DRE of a patient with prostate cancer?
Hard, irregular, enlarged prostates
Nodules
Does a raised PSA definitely mean cancer?
No!
Could be BPH, infection, trauma/surgery
Management of prostate cancer?
Very small tumours are managed with watchful waiting
Cancer confined to prostate:
- prostatectomy
- radiotherapy
Metastatic disease:
- Remove androgenic drive of tumour growth, i.e. remove testosterone using drugs or orchiectomy
What is orchiectomy?
Removal of the testicles
How come localised prostate cancer is not treated but managed with watchful waiting?
It is slow growing
Only 1 in 3 men progress from mild to advanced prostate cancer
Men are more likely to die WITH prostate cancer than OF it
What types of testicular cancer are there?
Which is most common?
Seminoma
Non-seminomatous (teratoma)
About a 50:50 split
What is a seminoma?
A tumour of the germ cells of seminiferous tubules of the testicle
What age group of males are most affected with seminomas?
Men aged 15-35
What are the clinical features of testicular tumour?
Painless lump on testis
Sometimes, no pain
Sometimes testicular atrophy
Haemospermia
Signs of metastasis
Where do testicular tumours metastasise to?
Retroperitoneum causing lower back pain
Lung causing dyspnoea
What is a teratoma?
Non-seminomatous germ cell tumour
Tumour is made up of healthy tissue but tissue that is not supposed to be found in that area
Which age group of males are most affected with teratoma?
Children and young men
What are the risk factors for testicular cancer?
Undescended testes, even after orchiopexy
Infant hernia
Infertility
What is undescended testes?
During development, the testis are formed within the abdomen
About 2 months before birth the testes move down the spermatic cord into the scrotum
If they don’t this is called undescended testes
What is orchiopexy?
Surgical procedure to move an undescended testicle into the scrotum and fix it there
Investigations of testicular tumour?
Pregnancy test: in some seminomas HCG levels are raised
Blood:
- tumour markers
CXR: look for lung mets
CT: staging of tumour
Biopsy
Treatment of testicular tumour?
Radical orchiectomy (removal of testicle) no affect on fertility + sexual function if only 1 is removed
Radiotherapy is effective
Chemotherapy
What is prognosis like for testicular cancer?
Very good
If caught before metastasis survival is 100%
