Cancers Flashcards
Definition of visible and non-visible haematuria
Visible = macroscopic or gross haematuria. Visible in urine, colouring it red/pink/brown.
Non-visible = microscopic. Blood is present on dipstick and urinalysis only.
what you look for on a dipstick and significant findings
Blood
Nitrites = specific for UTI. shows bacteria activity (infection)
Leukocytes = sensitive for UTI. shows inflammation
Protein = protein:creat ratio, signif proteinuria needs referal to nephrology
pH = signif in stones
glucose = signif in new diabetes eg. fungal balanitis
bilirubin
ketones
specific gravity
risk factors for urological malignancy
Bladder TCC =
smoking, occupational aromatic amine exposure
Bladder SCC =
long term catheters, recurrent UTI, bladder stones
Schistosomiasis (in endemic areas)
Common benign causes of haematuria
Infection eg. UTI Parasitic eg. schistosomiasis Trauma or recent surgery Renal calculi Nephrological causes eg. IgA nephropathy
Common malignant causes of haematuria
Kidney tumours (RCC, TCC) Ureter tumours (TCC) Bladder tumours (TCC, SCC, adenocarcinoma) Prostate tumours (Benign prostatic hyperplasia, adenocarcinoma)
How to take a history of haematuria
History = duration, where in stream, clots, associated symptoms (LUTS), past uro MHx, smoking, occupational exposure, foreign travel, recent trauma, anticoagulants?
Abdo, external genitalia, DRE exam
Pathophysiology of RCC
Adenocarcinoma tumour of the renal cortex.
Derived from the epithelium of prox. convoluted tubule.
Often appears in the upper pole of the kidney.
Can spread through direct invasion to perinephric tissues, adrenal gland, renal vein, inferior vena cava.
Can spread through lymphatic system to pre-aortic and hilar nodes.
Can spread by haematogenous spread to bones, liver, brain, lugns.
Risk factors and of RCC
SMOKING Obesity Genetic disorders (eg. von Hippel-Lindau disease) Industrial exposure to carcinogens (eg. cadmium, lead, aromatic hydrocarbons) Dialysis Hypertension Anatomical abnormalities (polycystic kidneys, horseshoe kdineys)
define a Paraneoplastic syndrome and list common ones associated with RCC
Rare clinical disorders triggered by an altered immune system response to a neoplasm.
Triggered by ectopic secretions of hormones by RCC =
Stauffer’s syndrome, hypercalcaemia (PTH), hypertension (renin), polycythaemia (due to erythropoetin), pyrexia, etc
Treatment options for RCC
TNM staging for treatment
Localised =
- partial nephrectomy if small
- radical nephrectomy if large (removes kidney, perinephric fat, local lymph nodes en bloc)
- Percutaneous radiofrequency ablation OR lap/percutaneous cryotherapy for those unsuitable for surgery.
- Renal artery embolisation for haemorrhaging disease.
- Surveillance
Metastatic
- Nephrectomy + immunotherapy (IFN-a or IL-2) for those fit for surgery
- Biological agents such as tyrosine kinase inhibitors (Sunitinib, Pazopanib)
- Metastasectomy (resection of mets)
N1 = regional lymph nodes
- Open nephrectomy and lymph node dissection
Define an Upper Tract Transitional Cell Carcinoma and how it presents
Uncommon
Presents with visible haematuria
What investigations would you do for a RCC
Routine blood tests
Urinalysis for non-visible haematuria and urine sent to cytology.
USS
abdo-pelvis CT with IV contrast to confirm
(+ additional chest for staging)
Bosniak classification to stage: 1 = benign, simple 2 = benign, mildly complex 2F = likely benign but need to follow up 3 = 60% chance of cancer 4 = definite RCC
how is a Upper Tract -TCC commonly treated
CT urogram then ureteroscopy + biopsy to confirm.
Small low grade tumours can be treated with laser ablation
Non metastatic cases can be treated with nephro-ureterectomy (laparoscopic if possible)
What is a Transurethral Resection of Bladder Tumour (TURBT) and how the histology is used to divide tumours into Ta/T1 and T2+
It involves resection of bladder tissue by diathermy during rigid cystoscopy.
Allows assessment of histological type (TCC or SCC), Grade (1,2,3) and Stage (Tis, ta, T1 or T2+)
If tumour is superficial (Ta/T1) then a single dose of intravesical mitomycin is given.
treatment of Non-Muscle-Invasive Bladder Cancer
Discuss at specialist MDT.
Carcinoma in-situ or T1 tumours
= resect via TURBT
Treat higher risk with adjunct intravesical therapy = BCG regimen.
- Live attenuated mycobacterium bovis is given IV and reduces progression
- BCG side effects = dysuria, freq, urgency, UTI, haematuria
Radical Cystectomy also offered for high risk, if initial treatments have failed.
Regular surveillance via cytology and cystoscopy
treatment of muscle-invasive bladder TCC
Radical cystectomy (complete removal of bladder)
Neoadjuvant chemo (typically cisplatin combination regimen)
Following radical cystectomy will require urinary diversion.
Regular follow-up with CT imaging
basic principles of the procedure of a radical cystectomy
Male = cystoprostatectomy
- removal of bladder and prostate
- urethra can be removed enbloc if needed
- pelvic lymph node dissection
Female = anterior exenteration
- remove bladder, uterus, tubes, ovaries, anterior vaginal wall
- pelvic lymph node dissection
How is prostate cancer usually diagnosed
Localised disease presents with LUTS, weak urinary stream, increased freq, urgency.
In advanced disease present with haematuria, dysuria, incontinence, haematospermia, suprapubic pain, loin pain, rectal tenesmus.
In metastatic disease, presents with bone pain and unexplained weight loss
Sometimes it is picked up incidentally when performing DRE.
