cancers and stones Flashcards
how are stones caused
increased saturation of urine with stone forming salts or
lack of inhibitors(citrate) to prevent crystal formation
radiopaque stones
calcium kidney stone(75-85%), struvite (10-15%)
unilateral backpain and renal colicky pain that waxes and wanes; may radiate to testes or uvula. N/V. They shift position frequently trying to get comfortable.
maybe fever, hematura, dysuria, urinary frequency
neprolithiasis symptoms
study of choice for nephrolithiasis
helical(spiral) CT (no contrast needed)
do ultrasound for children and pregnant patients
what drugs can help facilitate stone passage
alpha blocker or CCB
what do u do if pt has a large stone?
percutaneous nephrostomy is gold standard
admit to hospital if unable to maintain oral intake/need vigorous hydration
where are stones typically found
proximal tract and pass distally;
they lodge at the uteropelvic junction, uterovesicular junction, or ureter at the level of the iliac vessels
nephrolithiasis occurs when
and gender
3rd or 4th decade of life.
2 to 3 fold more common in males
most common stone
calcium (75-85%); they are radiopaque
uric acid stones
frequency
xray
form in who
assoc with what
urine and pH
tx
5-8%; radiolucent
radiolucent on xray but detectable on CT
form in pts with persistantly acidic urine with or w/out hyperuricemia
assoc with gout, xanthine oxidase def, high purine turnover states(chemo)
ACIDIC and decreased pH
tx: hydrate, alkalinize urine with CITRATE, restrict purine and allopurinol
radiolucent stones
uric acid and cystine
cystine stones
frequency
caused by what
xray
occur in what
pH
tx
microscope and testing
less than 1%
caused by impairment of cystine transport; defect in renal transport of certain amino acids
* radiolucent/radiopaque????
occur in autosomal recessive cystinuria
pH decreased
hydrate, Na restriction, alkalinization of urine, pencillamine
hexagonal crystals and + urinary cyanide nitroprusside test
struvite(made up of what)
frequency
organism
urine
common in who
pH
tx
10-15%; formed by combo of calcium, ammonium, magnesium
Proteus: staghorn calculi
ALKALINE urine
common in pts with abnormal urinary tract anatomy and urinary diversions and in those that require catherization
increased pH
tx: hydrate, treat UTI if present, surgical removal of staghorn calculi
frequency of recurrence of stones
30-50% in 5 years
+FH, low fluid intake, gout, meds(allopurinol, chemo, loop), postcolectomy/postileostomy, specific enzyme deficiencies, hyperPTH
risk factors for stones
location of stone symptoms
upper ureter
lower part of ureter
lodged in UVJ
upper ureter: pain radiates to ant abdomen
lower part of ureter: pain radiates to ipsilateral groin, testicle, labia
lodged in UVJ: urinary frequency and urgency noted with lower pelvic pain
neprolithiasis symptoms
unilateral backpain and renal colicky pain that waxes and wanes; may radiate to testes or uvula. N/V. They shift position frequently trying to get comfortable.
nephrolithiasis can mimic what other conditions
acute cholecystitis, acute appendicitis, acute cystitis, diverticultitis
Signs of neprolithiasis
tachycardia, tachypnea, diaphoresis, CVA tenderness, restlessness,
abdominal distention due to ileus
acute cholecystitis, acute appendicitis, acute cystitis, diverticultitis
nephrolithiasis can mimic what other conditions
tachycardia, tachypnea, diaphoresis, CVA tenderness, restlessness,
abdominal distention due to ileus
Signs of neprolithiasis
neprolithiasis
serum chemistries
UA
urine culture
renal ultrasonography
intravenous pyelogram
serum chemistries: nml or leukocytosis
UA: microscopic hematuria(85%), ~leukocytes and/or crystals
Do urine culture to R/O infection
renal ultrasonography: only find stones in kidney, proximal ureter, and UVJ
intravenous pyelogram: rarely indicated. must have nml renal function.
treatment for stones less than 5 mm
FLUIDS!, strain urine, analgesics, follow up weekly or biweekly
alpha blocker or CCB to facilitate passage
most stones pass within 2-4 weeks
treatment of stones 5-10 mm
less likely to pass spontaneously
increase fluids and analgesics
elective lithotripsy or ureteroscopy with a stone basket extraction
ESWL(extracorporal shockwave lithotripsy),
percutaneous nephrolithotomy, or
retrograde ureteroscopy
treat kidney stones 0.5-3 cm in diameter
ESWL for what size
renal stones less than 2 cm or
for ureteral stones less than 10 mm
ureteroscopy for who
more effective than ESWL for ureteral calculi
percutaneous nephrolithotomy
for stones greater than 2cm
pains meds for nephrolithiasis
combo of morphine and ketorolac
calcium stones
common causes
urinary pH
tx
common causes: idiopathic hypercalcuria and primary hyperPTH, fat malabsorption, ALKALINE urine
urinary pH: increase for calcium phosphate and decreased in calcium oxalate
tx: hydrate, Na and protein restriction, thiazide,
*do not decrease calcium intake because it can lead to hyperoxaluria and increase risk for osteoporosis
staghorn calculi
proteus organisum in struvite neprolithiasis
hexagonal crystals and + urinary cyanide nitroprusside test
cystine neprolithiasis
exposure to tobacco;
occupational carcinogens from rubber, dye, printing, chemical industries;
schistosomiasis
cyclophosphamide or aniline dye exposure
chronic infections
diets rich in meat and fat
causal factors in bladder cancer
2nd most common urologic cancer and
most frequent malignant tumor of urinary tract
usually transitional cell carcinoma/ bladder
they are uroepithelial tumors
1 risk factor
bladder cancer
gender
age
3 times as likely in men
40-70 years of age
smoking
bladder cancer presenting symptoms
painless gross hematuria
also bladder irritablility and infection
definitive diagnostic procedure for bladder cancer
cystoscopy then biopsy to confirm
bladder cancer treatment
1) carcinoma in situ
2) superficial lesions
3) large, high grade, recurrent or multiple lesions
1) intravesicular chemotherapy
2) endoscopic resection and fulgaration; then cystoscopy every 3 months
3) intravesical instillation of thiotepa, mitcomycin-C, or BCG
bladder cancer treatment
1) invasive cancers without mets; diffuse TCC in situ
2) invasive cancers with distant mets
1) radical cystectomy or radiation therapy for poor candidates for the radical cystectomy or those with unresectable local disease
2) chemo with or w/out radiation
RCC common in who
men,
older than 55
incidence is higher in american indian/alaskan native men
smoking
common symptom of RCC
gross or microscopic hematuria(usually), flank pain, palpable mass
fever common
maybe left sided varicocele
primary procedure for diagnosing RCC
CT scanning
3% of all adult cancers
RCC
RCC mets
spread along renal vein to IVC and can mets to lung and bone
von hippel-lindau disease and
hereditary papillary renal carcinoma
forms of hereditary RCC
internists’ tumor
RCC
RCC Tx
1) localized disease
2) advanced disease
3) avoid what
4) meds: interferon a and interleukin
1) radical nephrectomy(no benefit to add radiation)
2) radiation (little benefit of radical nephrectomy)
3) little benefit of chemo or hormonal therapy
4) interferon a and interleukin not successful
hypercalcemia, HTN, erythrocytosis, hepatic dysfunction in absence of hepatic mets
RCC assoc with paraneoplastic syndromes
primary study for RCC
CBC
CT with or w/out contrast.
confirm with histology or nephrectomy speciman
do an ultrasonography to rule out a stone in hematuria
CBC: polycythemia and anemia due to increased erythopoietin production in 5-10% of pts
most common malignancy in young men
highest cure rates of all cancers
related to what
testicular ca
cryptorchidism or previous cancer
testicular cancer symptoms
90% have PAINLESS, solid testicular swelling. maybe heaviness in arch
para-aortic lymphnode involvement or ureteral obstruction
maybe abdominal complaints or pulm symptoms from multiple nodules
painless scrotal swelling
look for testicular cancer
klinefelter syndrome
risk factor for testicular ca
what kind of tumor is a testicular cancer
90-95% are germ cell tumors and malignant
so LOOK FOR METS in lungs, pelvis, and abdomen
include seminomas and non-seminomas
diagnostic for non-seminomas
and seminomas
how common are these
alpha fetoprotein and beta HCG are elevated in non-seminomas
they are nml in seminomas
65% non seminoma
35% seminoma
mixed cell type(40%)
embryonal carcinoma(20%)
teratoma(5%)
choriocarcinoma(under 1%)
subtypes of non-seminomas in testicular cancers
testicular cancer dx
complete orchiectomy for dx; simple bx increases the risk of spreading cancer into scrotum
testicular cancer
which is radiosensitive and radioresistant
seminomatous tumors are radiosensitive
nonseminomatous tumors are radioresistant
non seminomatous tumors tx
stage 1, 2, and 3
1) limited to testis, nerve sparing retroperitoneal lymph node dissection or rigorous surveillance without surgery or chemo
2) can be treated with surgery or chemo
3) should be treated with surgery or chemo
seminomatous tumors tx for stage 1, 2, 3
stage 1 isolated to testis: do radiation of para-aortic and ipsilateral iliac nodal areas
stage IIa and IIb adds increased radiation to affected nodes
stage IIc and III is chemo
most common cancer in men
prostate
prostate cancer
1) pace of growth
2) kind of cell
3) can lead to what
1) slow growing
2) adenomatous cells
3) urinary obstruction and metastatic disease
prostate cancer
cause
risks
PSA level
cause unknown
risks: black, FH, high fat diet
PSA over 4.0
prostate cancer
initial test then what to confirm
transrectal ultrasonography reveals hypoechoic lesions in peripheral zone
bx confirms and allows histologic grading(gleason system)
6-12 biopsy samples are taken
prostate cancer tx
1) stage A and B
2) stage C
3) stage D
1) stage A and B(confined to the prostate): radical retropubic prostatectomy, [brachytherapy, or external beam radiation] radiation
2) stage C (tumor with local invasion): similar to above with reduced effectiveness.
3) stage D(distant mets): hormonal manipulation using orchiectomy, antiandrogens, LH releasing hormone agonists, androgen ablation, or estrogens. chemo for advanced disease
disadvantages of
radical prostatectomy and
radiation for prostate cancer
1) increased risk of incontinence and ED
2) radiation proctitis and GI symptoms
screening for prostate cancer
DRE and/or PSA at age 50;
begin earlier in blacks and FH
nephroblastoma
occur in who
mortality
wilms tumor
most often healthy kids; 10% in kids with recognized malformations
most curable; 5% have anaplasia and poor prognosis
incidence of anaplasia increases with age
painless abdominal mass in kids
wilms tumor
wilms presentation
anorexia, N/V, fever, abd pain, hematuria
HTN can occur with elevated renin levels
study of choice for a wilm’s tumor
ultrasonography
can order an MRI and CT to look at tumor extension and regional lymph nodes
CXR to look for pulm mets
wilms tx
multimodal approach:
surgery
chemo
in some: radiation
wilms
resectable vs unresectable tumor tx
radical nephrectomy with lymph node sampling for resectable tumors
preop biopsy then chemo for unresectable tumors
*the tumor is chemosensitive
wilms tumor
chemo vs radiation
the tumor is chemosensitive and responsive to
dactinomycin, vincristine, and doxorubicin
radiation is for higher stage tumors and for tumors with focal anaplasia
