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Metabolic and Endocrine > Haematuria and Renal Tract Tumours > Flashcards

Haematuria and Renal Tract Tumours Flashcards

1
Q

what are the common causes of haematuria?

A 
BPH (most common in men)
UTI (Most common in women
Acute pyelonephritis 
Alports syndrome
Bladder cancer
Prostate cancer 
Kidney stone
Menstruation
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2
Q

what is the most sinister type of heamaturia?

A

visible

need to rule out malignant causes first

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3
Q

describe the referral criteria for patients with haematuria?

A

Suspected cancer pathway referral (for appointment within 2 weeks) for bladder cancer if
-Over age 45 and have; Unexplained VH without UTI
or VH persisting or recurs after treatment of UTI
-Over age 60 and have
Unexplained NVH and either dysuria or raised WCC on blood test

Consider non urgent referral for bladder cancer in people age over 60 with recurrent or persistent unexplained UTI

Frank heamaturia- A&E

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4
Q

what should be considered when taking a history in a patient with haematuria?

A

Age
Gender
timing of blood in urine stream
LUTS
Pain
recent vigorous physical activity
exposures-smoking, industrial chemicals such as benzene and aromatic amines
periorbital and peripheral oedema– weight gain oliguria, dark urine, HTN suggest glomerular cause
recent pharyngitis or skin infection
joint pains, skin rashes, low grade fevers suggest collagen vascular disorder or SLE
family history of. Kidney stones, cancer, prostatic enlargement, sickle cell anaemia, collagen vascular disease, renal disease
recent urological interventions

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5
Q

what is important to consider on examination in a patient with haematuria?

A 
Vitals
Pallor of skin/conjunctiva
Oedema, cachexia
Abdominal mass/tenderness
DRE
Catheter/nephrostomy/stent
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6
Q

what investigations are important in a patient with haematuria?

A

Bloods: urea, electrolytes, eGFR, PSA (factors affecting PSA levels?), group and save
Urine tests; mid stream urine for microscopy, culture and sensitvity
Urine cytology – not routinely used
CT urogram/triple phase (non contrast for stones, arterial, venous phase contrast scan for lesions, delayed contrast look for filling defects)
Flexible cystoscopy

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7
Q

what is the management of haematuria in acute situation?

A
  • ABC (resuscitation)
  • Large IV access
  • Three way catheter (large), balloon, fluid into bladder, drain bladder)
  • Irrigation
  • Bladder wash (remove clot)
  • Blood transfusion if required
  • CT imaging and cystoscopy (could be renal cell carcinoma
  • Reverse anticoagulation if needed (higher incidence of renal cancer if patient is anticoagulated)
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8
Q

what are the types of bladder cancer?

A

transitional cell carcinoma 95%
squamous cell carcinoma
adenocarcinoma (rare unless metastatic from bowel)

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9
Q

what are the types of transitional cell carcinoma of the bladder?

A

non invasive

invasive

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10
Q

describe invasive transitional cell carcinoma of the bladder?

A

invades detrusor – resection not an option, neoadjuvant chemotherapy 3 cycles followed by cystectomy ureters joined and given bag (incontinent and continent diversion of ureters – in UK incontinent is more common), divert ureters into sigmoid (more common in developing countries). If not fit for surgery-chemotherapy

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11
Q

describe treatment of non invasive transitional cell carcinoma of the bladder?

A

can be high grade or low grade. Chemotherapy with BCG vaccine used inside bladder causing immune response in uroepitheliam and pre cancerous cells

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12
Q

what are the risk factors for transitional cell carcinoma of the bladder?

A

Smoking
Rubber industry (dyes, chemicals etc) with long term exposure
Haematuria more common than in squamous

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13
Q

what are the risk factors for squamous cell carcinoma?

A

Chronic irritation
Long term catheter
UTI
70-80% squamous cell in Egypt area due to parasite.

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14
Q

what is a risk factor for adenocarcinoma of the bladder?

A

bladder reconstruction

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15
Q

describe the incidence/prevelence of kidney cancer?

A

3% cancers in men, 2% in women
8th commonest cancer in men and 9th in women
Mortality 40%
Lifetime risk: 1 in 60 for men and 1 in 100 women

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16
Q

where do kidney cancers occur?

A

85% occur in renal parenchyma (renal cell carcinoma)
6% occur in renal pelvis (transitional cell carcinoma)
6% occur in ureter (transitional cell carcinoma)

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17
Q

what are the risk factors for kidney cancer?

A

Age
Male
Obesity 35% increased risk if overweight, 70% if obese
Smoking
Adult polycystic kidney disease X3-4
Renal dialysis risk X7 after 10 yrs
Radiotherapy for previous testicular/gynaecological cancer
Hypertension
Drugs- phenacetin (banned)-TCC
Diet
Family history (NB, von-Hippel lindau disease)

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18
Q

what are the 5 histological subgroups of renal cell carcinoma?

A 
Conventional (aka clear cell) RCC 75-80%
Papillary (aka chromophilic) RCC 10-15%
Chromophobic RCC 5%
Collecting duct RCC 1%
unclassified
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19
Q

describe conventional renal cell carcinoma?

A 
Graded histologically according to Fuhrman classification
Fuhrman 1 (well differentiated), furhman 4 (poorly differentiated
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20
Q

describe the presentation of kidney cancer?

A

Asymptomatic-incidental on imaging for other reason
Haematuria (visible or non visible)
Palpable mass
Weight loss/night sweats
Anaemia
Bone pain/fracture
Paraneoplastic syndromes-renal cancers can inappropriately secrete ectopic peptide hormones eg EPO, renin, PTH causing clinical effects

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21
Q

what is the treatment for kidney cancer that is localised?

A 
Surgery (nephrectomy)-partial or total (each can be open or laparoscopic surgery)
Radiofrequency ablation (RFA) or cryotherapy
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22
Q

what is the treatment for kidney cancer that is metastatic?

A

Nephrectomy can increase response to subsequent biological therapy

Biological therapy
Systemically-administered drugs which augment hosts immune response against tumour cells
Interferon alpha-15% partial response, 1% complete response
Tyrosine kinase inhibitors eg sunitinib- 35-40% partial response
Bevacizumab
temsirolimus

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23
Q

what is the mortality from kidney cancer?

A

10th highest cancer death in men and 12th in women
Depends on stage and grade
2% of all cancer related deaths per annum UK
1 year survivial = 67%
5 year survival = 50%
10 year survival = 43%
Depends on initial grade and stage of tumour
Average survival with metastatic disease = 18-24 months

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24
Q

describe the epidemiology of bladder cancer?

A

4th commonest cancer in men and 11th in women
Mortality = 50%
M:F = 5:2
Lifetime risk = 1 in 40 men, 1 in 100 women

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25
Q

what are the risk factors of bladder cancer?

A

Smoking risk x2-6
Occupation – aniline dyes (benzidine, alpha and beta naphthylamine) / paint, hair dyes, textile and pesticide industries
Hair dyes
Drugs – phenacetin, cyclophosphamide
Pelvicirridation
Social class
Race – higher in Caucasians
Diabetes
Dietary factors
Chronic urinary tract infection (squamous cell carcinoma)
Shistosomiasis in middle east (squamous cell carcinoma

26
Q

describe the histology of bladder cancer?

A 
90-95% - transitional cell carcinoma
3-4% squamous cell
1-2% - adenocarcinoma
Graded according to degree of cytological atypia (1=well differentialted, low grade to 3=poorly differentiated high grade)
Staging with TMN
27
Q

describe the presentation of local bladder cancer disease?

A

Haematuria
Irritative lower urinary tract symptoms (frequency and urgency)
Recurrent UTI

28
Q

describe the presentation of advanced/metastatic bladder cancer?

A

Weight loss/lethargy
Bone pain/fracture
Pelvic pain
Lower limb/genital oedema from pelvic lymphadenopathy

29
Q

what investigations are useful in a patient with bladder cancer?

A

cystoscopy

CT/MRI for staging

30
Q

describe the initial treatment of bladder cancer?

A

transurethral resection of bladder tumour (remove primary tumour and allows formal histological grade and stage
75% of initial tumours are superficial (non muscle invasive (80% recur over time, of these 80% remain superficial and 20% progress to muscle invasive disease
25% of tumours are muscle invasive from outset

31
Q

describe the treatment of low grade non muscle invasive bladder cancer?

A

cystoscopic surveillance for 5-10 years

32
Q

describe the treatment of moderate/high grade non muscle invasive bladder cancer treatment?

A

(including carcinoma in situ) – intravesical chemotherapy (mitomycin C) or intravesical immunotherapy (BCG) and cytoscopic surveillance

33
Q

describe the treatment of muscle invasive bladder cancer?

A

radical cystectomy or radiotherapy with or without neoadjucant cisplatin based systemic chemotherapy

34
Q

describe the treatment of metastatic disease bladder cancer?

A

palliative chemotherapy with or without palliative radiotherapy for local symptom control

35
Q

what is the survival for bladder cancer?

A

pTa/pT1 – 5 year survival 80-90%

pT2 + - 5 year survival <50%

36
Q

describe the epidemiology of prostate cancer?

A

Commonest cancer in men
25% of all newly diagnosed cancers in men
Mortality 25-30%
Lifetime risk is 1 in 6
Incidence is proportional to increasing age
Accounts for 12% cancer deaths in men
2nd commonest cause of cancer death in men (1 is lung cancer)
Increasing use of serum PSA has led to increase diagnosis and detection at earlier stage

37
Q

what are the risk factors for prostate cancer?

A

Age – 80% of 80year old men have histological evidence of prostate cancer
Family history-Genetic component in 5-10% (rising to 30-40% if patient <55 years old
Ethnic origin-Greater risk in African/caribbeans
Diet-Lycopenes and selenium protective

38
Q

describe the histology of prostate cancer?

A
  • 99% are adenocarcinomas
  • Graded using gleason scoring system (2 numbers
  • —2-4 = low grade
  • —5-7 moderate grade
  • —8-10 = high grade
39
Q

how is information on prostate cancer histology gained?

A
  • Histological material obtained via prostate biopsy
  • Transrectal prostate biopsy performed if clinical suspicion
  • Transrectal prostate biopsy has sensitivity of 65-70%
40
Q

describe the presentation of prostate cancer asymptomatically?

A

high PSA

41
Q

describe the presentation of local disease prostate cancer?

A

haematuria, lower tract symptoms like BPH

42
Q

describe the presentation of advanced/metastatic prostate cancer?

A

weight loss, lethargy, bone pain/fracture, pelvic pain, lower limb/genital oedema from pelvic lymphadenopathy

43
Q

what investigations are important for prostate cancer?

A

Pelvic MRI, isotope bone scan

44
Q

describe the T part of the TMN staging classification for prostate cancer?

A

T1 - organ confined, impalpable disease
T2 - organ confined, palpable disease
T3a - tumour extending into perioprostatic fat
T3b - tumour extending into seminal vesical
T4 - tumour extending into other viscera (T4a - bladder / T4b - rectum, pelvic sidewall)

45
Q

describe the N part of the TMN staging classification for prostate cancer?

A

N0 - no lymphadenopathy evident

N1-regional lymphadenopathy evident

46
Q

describe the M part of the TMN staging classification for prostate cancer?

A

M0 - no distant metastases

M1 - distant metastases

47
Q

what is localised prostate disease on the TMN staging system?

A

T1 or T2 N0M0

48
Q

what is locally advanced prostate disease on the TMN staging system?

A

T3 or T4 N0M0

49
Q

what is the treatment for low risk (PSA <10 and gleason <6 and T1/T2) prostate cancer?

A

active surveillance is preferred

50
Q

what is the treatment for medium risk (PSA 10-20 and gleason 7 and T2) prostate cancer?

A

radical prostetectomy is preferred

51
Q

what is the treatment for high risk (PSA <20 and gleason <8 and T3/T4) prostate cancer?

A

active surveilance and brachytherapy not recommended

radial prostatectomy and radical radiotherapy with neoadjuvant hormone therapy is preferred

52
Q

what is the treatment for metastatic prostate cancer?

A

Non curative
Hormone manipulation is palliative
Prostate cancer initially dependent of testosterone
Therapy aims at blocking testosterone production or testosterone metabolism by prostate cancer cell
Surgically-bilateral scrotal orchidectomy
Medically-anti-androgens, LMRH analogues, oestrogens
Average response to first line therapy=2-3 years

53
Q

what are the side effects involved in treatment of metastatic prostate cancer?

A

hot flushes,breast enlargement/tenderness, weight gain, osteoporosis, loss of libido, impotence

54
Q

describe prostate cancer that has eventually become castration resistant?

A 
Systemic chemotherapy (taxotere)
New agents (abiraterone, enzalutamide) appear promising and effective 
Palloatic vare
Media survivial 18-24 months
55
Q

describe the role of PSA testing?

A
  • must be interpreted with caution due to the natural increase in PSA with age, benign prostatic hypertrophy and with prostatitis.
  • The early results of screen- ing for prostate cancer have varied greatly from no benefit in a low-risk population to a halving of deaths from prostate cancer in a general population study but with no overall reduction in mortality.
  • Currently national screening pro- grammes are not recommended.
56
Q

describe the histology of germ cell tumours?

A 
seminoma
embryonal cancer
teratoma mature, immature or with malignant differentiation
choriocarcinoma
endodermal sinus tumour
mixed teratoma
57
Q

what are the signs and symptoms of testicular/germ cell cancers?

A

testicular mass often painful

para-aortic lymph nodes with back pain and gynaecomastia if hCG secreting

58
Q

what are the investigations and surgery for testicular/germ cell tumours?

A
  • ultrasound or MRI of testicle
  • assay of serum tumour markers (alpha fetoprotein, beta hCG, lactic dehydrogenase
  • urinary pregnancy test for hCG
  • CT or MRI for metastases
  • surgery for men is by inguinal approach to avoid spillage of highly metastatic tumour in scrotum
59
Q

describe the features of seminomas?

A

least common and are radiosensitive and chemosensitive

associated with raised LDH but only a mildly raised bete hCG and never a raised AFP

60
Q

what is the treatment for seminomas

A

Stage 1 disease limited to gonad with 30% 5 year risk or recurrence with surgery alone
adjuvant therapy with chemotherapy or radiotherapy to para-aortic lymph nodes leads to over 95% cure in early stage disease but chemotherapy with single agent cisplatin or carboplatin doesnt have long term risks of secondary malignancy associated with radiotherapy
intensive surveillance can be given with treatment for those who repalpe with equally high cure rate since combination chemotherapy will cure 90% of visible metastatic disease

61
Q

give examples of combination chemotherapy?

A

cisplatin
etoposide
bleomycin

62
Q

what is the treatment and features of teratomas?

A
  • adjuvant chemotherapy for those at moderate to high risk with cisplatin, etoposide and bleomycin leads to 95% cure rate
  • no vascular invasion may only require single cycle treatment instead of lymph node dissection
  • metastatic-usually involves para-aortic lymph and lyngs, spread rapidly and cause organ failure.
  • gynaecomastia and positive pregnancy test
  • 80% of teratomas express either beta hCG or AFP and all metastatic have elevated LDH
  • infertility in 20% due to azospermia

Metabolic and Endocrine (12 decks)

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