Cancer of the GU tract Flashcards by E Thomas

In which parts of the GU tract is cancer seen?

Kidney
Bladder
Prostate
Testis

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Which is the most common type of kidney cancer?

Renal cell carcinoma (RCC)

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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

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Which part of the kidney do RCC arise from?

Proximal convoluted tubule epithelium

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What do RCC tumours look like under a microscope?

Tumour made up of large cells with clear cytoplasms

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What causes RCC?

Genetic susceptibility

Irradiation
Hypertension
Smoking
Obesity
Exposure to heavy metals
Long term dialysis

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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

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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

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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

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What are the clinical features of RCC?

Sometimes asymptomatic

Haematuria
Loin pain
Abdominal mass
Anorexia, weight loss
Nausea
Hypertension

Signs of metastatic disease

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How are kidney cancers often picked up?

Incidentally: often people are asymptomatic

Or they present with metastatic disease

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How would a patient with metastatic kidney cancer present?

Mets in the bone, lung, liver

Anaemia or polycythaemia (excess Hb, high RBC count)

Hypercalcaemia

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Why does RCC sometimes cause hypertension?

Damage to kidney results in increased renin secretion

More renin = raised BP

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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

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What would a blood test looking at Ca levels help with when investigating RCC?

Low Ca = kidney damage

Raised Ca = bone mets/damage

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How is RCC staged?

TNM staging

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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

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Management of localised kidney cancer?

Surgery:

radical nephrectomy
partial nephrectomy

Radiotherapy for people unable to tolerate surgery

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Management of metastatic kidney cancer?

Targeted biological therapies that block VEGF (vascular endothelial growth factor)
- Sunitinib

Radiotherapy

Palliative care

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What is a Wilm’s tumour?

A tumour of children

Nephroblastoma: cancer of primitive renal tubule and mesenchymal cells

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How do patients with Wilm’s tumour present?

Haematuria

Abdominal mass

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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%