L27. Carcinoma of the Prostate, bladder and kidney

Question 1

What are the risks for prostate carcinoma and how is diagnosis made: clinical features

Answer 1

-Risks: Familial incidence, higher in african americans, western diet?
Clinical features: only obstructive symptoms later. On digital rectal exam there can be some firm areas/nodule but this is not specific. Trans rectal ultrasound and MRI can help but these tumours are diffuse so hard to distinguish.
-Biopsy is difficult.
-Serum Prostate specific antigen is elevated during to carcinoma but also in cases of inflammation and injury to the prostate as well as following a DRE, cystoscopy and ejaculation and older age. Very high levels are used to indicate metastatic cancer.

Question 2

What is the macroscopic and microscopic morphology of prostate carcinoma

Answer 2

Macro: indistinct, with some dense white areas
Micro: tumour glands lack basal cells which can be stained for and the glands themselves are smaller than normal.

Question 3

Compare the gleason grading system and ISUP grading

Answer 3

Gleason grades tumours using 5 levels of microscopic patterns (Going from regular, circumscribed region to necrosis inside a nodule and single file cells). The two most common patterns are added together for score eg. Total (primary + secondary pattern).
ISUP grading helps to differentiate between different prognosis from which number is the primary pattern and starts at Gscore of 6 as the lowest as scores 2-5 are no longer considered. eg Gscore 7 (3+4) = ISUP grade 2

Question 4

What is the progression of prostatic cancer

Answer 4

1. Local spread: extraprostatic fat, seminal vesicles, other pelvic organs (rare)
2. Lymph nodes- pelvic and aortic which may block of ureters
3. Distant metastasis- into vertebral bodies causing collapse and back pain.

Question 5

What is T1,2,3,4 TNM staging of prostatic tumour

Answer 5

T1; clinically inapparent tumour
T2: Palpable tumour confined within prostate
T3: tumour extends through prostatic capsule
T4: tumour is fixed or invades adjacent structures other than seminal vesicles

Question 6

How are Prostatic tumours treated

Answer 6

For small low grade tumours, there is no treatment but active surveillance- repeat exams over 6-12mo, PSA levels and biopsy for changes
For significant tumours there is treatment: prostatectomy - with nerve sparing for erectile and urinary control + radiotherapy which may cause rectal inflammation
For Advanced tumour: palliative care: Anti-androgen treatment w/wout castration + chemotherapy as well as palliative radiotherapy to control local and metastases effects.

Question 7

What are the risks for Bladder carcinoma and what cells does it arise from

Answer 7

Male, smoking, industrial chemicals/dyes used in printing which cause dysplasia within the urinary system.
Arises from urothelial cell carcinoma in situ and can be multifocal, affecting urothelium in the ureter and renal pelvis

Question 8

How is diagnosis made for Bladder carcinoma and what are the macroscopic and microscopic morphology

Answer 8

Clinical signs are haematuria from tumour that has broken off. These tumours are recurrent or new. Diagnosed from urine cytology and cystoscopy.

Macro: papillary tumours mostly, sometimes invasive
Micro: urothelial (transitional epithelium) or some adenocarcinoma (glandular).
Low grade tumours are flat and uniform, high grade have varied size, mitotic activity

Question 9

How is Bladder carcinoma treated

Answer 9

If tumour is insitu or only in the lamina propria then BCG : bacteria in the bladder causing a massive immune response which knocks out the cancer
If into the detrusor muscle then cystectomy which can be removal of the bladder as well as prostate usually.

Question 10

What are the risk factors for Renal clear cell carcinoma

Answer 10

Male, 60s, smoking, von hippel-lindau disease - sporadic cases also have 3p anomalies.

Question 11

what is the macroscopic appearance and microscopic appearance of renal clear cell carcinoma

Answer 11

Macro: well circumscribed, mottled red, yellow, brown, part cystic and invasion of the renal vein

Micro: adenocarcinoma, clear cytoplasm is low grade, big nuclei= high grade

Question 12

What are the clinical symptoms of Renal clear cell carcinoma and How does it spread

Answer 12

Clinical symptoms: late, showing haematuria, flank pain, palpable abdo mass, ectopic hormone production.
Spread: locally is uncommon, mainly blood metastases to lungs, bone, liver, adrenals, brain. Less spread to lymph nodes. This means that although 1’ tumour removed, it can easily come back