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Year 3 - Met3b > Oncological aspects of urological cancer > Flashcards

Oncological aspects of urological cancer Flashcards

1
Q

Name the types of urological cancer

A
  • prostate - most common
  • renal cancer
  • testicular
  • bladder
  • penile - least common
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2
Q

What is screening for

A
  • To detect cancer in its early stages
  • Often patient may be asymptomatic
  • Early detection leads to better cure rates
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3
Q

What is adjuvant therapy for

A
  • to remove as much of the tumour as possible
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4
Q

Name types of adjuvant therapy

A
  • chemotherapy
  • Endocrine treatments
  • biological therapy
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5
Q

What is the risk factors for prostate cancer

A
  • high fat diet
  • smoking
  • family history
  • high testosterone
  • afro-caribbean
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6
Q

What is the screening that is used in prostate cancer

A
  • PSA

- DRE in combination with PSA is more useful

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7
Q

why is PSA not necessarily a good screening test

A
  • not an adequate screening test as there are significant numbers of false negative and positives
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8
Q

What is PSA more useful in measuring

A
  • monitoring response to treatment
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9
Q

How do you confirm diagnosis in prostate cancer

A
  • TRUS - transurethral ultrasound biopsy which is used to confirm diagnosis
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10
Q

what are the symptoms of prostate cancer

A
  • majority are asymptomatic
  • LUTs - nocturia, frequency, poor stream, hesitancy, terminal dribbling
  • haematospermia
  • haematuria
  • perineal discomfort
  • leg oedema
  • anorexia and weight loss
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11
Q

What are the symptoms of metastatic prostate disease

A
  • bone pain and anaemia
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12
Q

what can locally advanced prostate cancer lead to

A
  • rectal symptoms and renal failure due to urinary tract outflow obstruction
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13
Q

What investigations would you use in prostate cancer

A
  • DRE
  • Blood
  • Biopsy
  • imaging
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14
Q

What does a DRE fill like in prostate cancer

A
  • hard

- irregular

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15
Q

What does bloods look like in prostate blood

A
  • raised PSA (normal in 30% of cancer cases)
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16
Q

What biopsy do you do in prostate cancer

A
  • transurethral ultrasound biopsy - this confirms diagnosis after raised PSA and abnormal DRE
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17
Q

What imaging do you use in prostate cancer

A
  • X rays
  • CT/MRI (used for staging)
  • bone scan (only in high risk of bony mets)
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18
Q

What type of cancer is prostate cancer

A
  • adrenocarcinoma - 95%
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19
Q

what area does prostate cancer tend to be in

A
  • peripheral zone - 75%
  • transition zone - 20%
  • central zone - 5%
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20
Q

Where do tumours spread in prostate cancer

A

Local

  • seminal vesicles
  • bladder
  • rectum

lymph or haematogenous
- sclerotic bony lesions

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21
Q

What do you need to warn patients of prior to treatment in prostate cancer

A
  • warn prior to radical treatment for potential of loss of sexual function as well as effects on urinary system
  • warn of potential loss of ejaculation and fertility
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22
Q

What score is used to grade prostate cancer

A

Gleason score

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23
Q

Describe how the Gleason score works

A

this is a score of the most common histological pattern seen + the highest grade of tumour histology seen
- a lower Gleason score is a better prognosis

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24
Q

What are the options for treatment of prostate cancer

A
  • Surgery - often a transurethral resection of the prostate (TURP)
  • Radiotherapy
  • cryotherapy
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25
Q

According to the Gleason score what is well differentiated versus a poor differentiated tumour

A

= 6-7 - well differentiated
= 7-8 - moderately differentiated
= 9-10 - poorly differentiated

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26
Q

what is the removal of the prostate gland called

A
  • Prostactomy
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27
Q

Who is a prostactomy considered in

A
  • considered with patients for a life expectancy of 15 years
  • PSA <15
  • under 75 years old
  • no co-morbidities
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28
Q

What are the types of radiotherapy that can be used in prostate cancer

A
  • External bean
  • Brachytherapy = implanting radioactive seeds into the prostate - causes LUTs and can make patients go into urinary obstruction (confined to small tumours)
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29
Q

most prostate cancer is responsible to the withdrawal….

A

most prostate cancer is responsible to the withdrawal of androgens

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30
Q

name the types of endocrine therapy that is used in prostate cancer

A
  • medical castration
  • androgen receptor antagonists in castrate resistant patients
  • inhibition of CYP12
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31
Q

How is medial castration achieved in prostate cancer

A
  • GNRH analogues such as goseralin
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32
Q

a rapid fall of PSA…

A
  • A rapid fall in PSA and a nadir of <1 suggests a good long term outcome
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33
Q

what happens in prostate cancer when the cancer is castrate resistant

A
  • it is named androgen independent
  • Blockade of adrenal androgens using a peripheral androgen receptor antagonist drug (eg bicalutamide) is effective in around 20% of these castrate resistant patients
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34
Q

Name the drugs that are used in castrate resistance prostate cancer

A
  • Androgen receptor antagonists – bicalutamide, enzalutamide
  • Corticosteroids – prednisolone and dexamethasone
  • Oestrogens – oestradiol
  • CYP 17 inhibitors – Abiraterone – very high response rate recorded but suggestion of lower response after corticosteroids
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35
Q

Describe what happens in the inhibition of CYP17 in prostate cancer

A
  • The enzyme complex blocks a hydroxylation of pregnenolone and removes the carbon chain on the steroid ring converting a C21 steroid to a C17 steroid – androgen precursors reduce and pregnenolone rises
  • If dexamethasone given as well then this suppresses ACTH and therefore pregnenolone will fall
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36
Q

What is enzalutaminde (prostate cancer treatment)

A
  •  Androgen receptor antagonist ( 5x affinity of bicalutamide)
  •  Also prevents androgen receptor binding DNA and co-activator proteins
  •  Able to overcome bicalutamide resistance
  •  67% response rate in chemo-naïve and 50% in chemotherapy treated patients
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37
Q

What type of chemotherapy drugs is used in prostate cancer

A

Taxanes

38
Q

name some example of taxanes that is used to treat prostate cancer

A
  • docetaxel

- cabazetaxel - modified taxane to overcome docetaxel resistance

39
Q

What are the side effects of docetaxel

A
  • infection
  • tiredness
  • hair loss
40
Q

What palliative care do you use in prostate cancer

A
  • Palliative radiotherapy
  • Bisphopshonates for bone disease – zoledronate
  • RANKL inhibitor for metastatic disease – denosumab
  • Analgesics
  • Blood transfusion for anaemia
41
Q

What is the management for localised prostate cancer

A

Low risk: active surveillance, if signs of disease progression opt for radical treatment

Moderate to high risk:

  • Offer active surveillance if moderate risk and they don’t want radical treatment
  • Radical prostatectomy or TURP OR radical radiotherapy (radical external beam ± brachytherapy)
  • Offer adjuvant hormonal therapy
42
Q

What is the management of locally advanced prostate cancer

A
  • pelvic radiotherapy
  • neoadjuvant hormonal and radiotherapy
  • radical prostatectomy
43
Q

What is the symptomatic management of metastatic disease

A
  • analgesia
  • management of hypercalcaemia and bone disease - bisphosphonates, RANKL inhibition (denosumab)
  • radiotherapy for bony mets and SC compression
  • blood transfusion for anaemia
44
Q

What are the risk factors for renal adenocarcinoma

A
  • Men>women (×1.5)
  • Smoking (×1.4-2.3)
  • Renal failure and dialysis (×30)
  • Hypertension (1.4-2.0)
  • Obesity
  • Genetic factors – von Hippel Lindau (VHL) syndrome (around 50% develop RCC)
45
Q

what is the classical triad of symptoms for renal adenocarcinoma

A
  • macroscopic haematuria
  • palpable mass
  • flank pain (<10%)
46
Q

What are the other presentations of renal adenocarcinoma

A
  • microscopic haematuria
  • abdominal pain
  • malaise, anorexia, weight loss
  • polycythaemia (5%) due to increased EPO by tumour
  • hypertension (30%) - due to increased renin by tumour
  • anaemia (30%) in case of decreased EPO
  • fever
  • varicocele with L sided tumours that have infiltrated the renal vein
  • paraneoplastic syndrome
47
Q

How does renal adenocarcinoma spread

A
  • via lymph, haematogenous or direct routes to bone, liver and lung
48
Q

What is the histology and genetics of renal adenocarcinoma

A
  • Clear cell carcinoma (80%) – Von-hippel lindau mutation
  • Papillary type 2 (10%) – fumarate/hydratase mutation
  • Papillary type 1 (5%) – C-met activation
  • Chromophobe (5%) – C-kit
49
Q

What are the investigation of renal cell carcinoma

A
  • BP - increased due to increased renin secretion
  • Blood - FBC (polycythaemia), ESR (usually increased), U&Es, LFTs, Calcium
  • urine - blood cells, cytology for malignant cells of no value
  • Imaging
50
Q

What imaging is used in renal adenocarcinoma

A
  • US renal and tract - may show solid lesion
  • CT abdomen with contrast - used to identify renal lesion and involvement of renal vein or IVC
  • MRI - better than CT for cancer staging

Looking for metastases

  • CT chest (lung)
  • Bone/DEXA scan (bone)
51
Q

What is the management of renal adenocarcinoma

  • localised
  • locally advanced
  • metastasis
A
  • Localised – radical or partial nephrectomy (open or laparoscopic)
  • Locally advanced – radical nephrectomy + adjuvant treatment
  • Metastasis – immunotherapy
52
Q

What is the surgical management of renal adenocarcinoma

A
  • radical nephrectomy - unless bilateral tumours are present or contralateral kidney functions poorly = partial nephrectomy
53
Q

What is the medical management for renal cell carcinoma

A
  • overreaction of various protein kinases is thought to be a major factor in many cancers
  • blocking these pathways may lead to reduced progression/cure
  • Tyrosine kinase inhibitors
  • immunotherapy
  • mTOR inhibitors
  • VEGF inhibitors
54
Q

Name some tyrosine kinase inhibitors in renal cell carcinoma

A

sunitinib, sorafenib, pazopanib

55
Q

Name some immunotherapy used in renal cell carcinoma

A

high-dose IL-2

56
Q

Name some mTOR inhibitor

A
  • Sirolimus

- Everolimus

57
Q

Name VEGF inhibitors

A
  • bevacizumab
58
Q

Describe when high dose IL2 is used in renal cell carcinoma treatment

A
  • For fit patients not anaemic, normal WBC and platelets
  • IL-2 response rate is 3-40%
  • 10% cure rate – often durable
  • Requires in patient admission – very toxic whilst being administered
59
Q

How does wills tumour present

A
  • seen within ages 1-3

- presents as abdominal mass

60
Q

How do you detect an Wlims tumour

A
  • US
  • CT
  • MRI
61
Q

What is the treatment of wilms tumour

A
  • nephrectomy
  • radiotherapy
  • chemotherapy
62
Q

What type of cancer is bladder cancer

A
  • Transitional cell carcinoma
63
Q

What is the second most common urological malignancy in the UK

A
  • bladder cancer
64
Q

where do transitional cell carcinoma arise

A
  • affect urothelium and may occur anywhere between renal pelvis and urethra
65
Q

any episode of haematuria should be…

A

Any episode of haematuria should be investigated to exclude bladder cancer

66
Q

where do transitional cell carcinoma eventually infect

A
  • tumours begin in the urothelium and become deeper eventually penetrating the muscle and getting fixed to other pelvic structures such s there ectum
67
Q

What are the two main risk factors for transitional cell carcinoma

A
  • aniline dyes

- smoking

68
Q

Name other risk factors for transitional cell carcinoma

A
  • Men>women (x2.5)
  • smoking
  • age
  • occupational - aniline dyes, rubber/paint
  • cyclophosphamide
  • chronic inflammation of bladder mucosa
69
Q

What are the risk factors for squamous cell carcinoma of the bladder

A
  • schistomiasis
  • BCG Treatment
  • smoking
70
Q

What is the presentation of bladder cancer

A
  • painless macroscopic haematuria = age >50: 34% have TCC bladder, age <50: 10% have TCC bladder
  • microscopic haematuria = age> 50: 7-13% have TCC, age<50: 5% have TCC
  • lower urinary tract symptoms
  • recurrent UTIs
  • pain
  • leg oedema
71
Q

What investigations should you carry out if you suspect bladder cancer

A

Persistent microscopic haematuria (2/3 dipstick tests) or macroscopic haematuria must be investigated:

  • Bloods – U&Es
  • Urine – MC&S, cytology

Imaging –

  • Renal USS
  • Intravenous urogram (IVU)
  • Flexible cystoscopy + biopsy – diagnostic
  • CT urogram – diagnostic + staging
  • CT/MRI – pelvic lymph node involvement
72
Q

What is the pathology of bladder cancer

A
  • Papillary – 70%
  • Mixed papillary and solid – 10%
  • Solid – 10%
  • Carcinoma in situ – 10%
    Grade 1 – differentiated
    Grade 2 – intermediate
    Grade 3 – poorly differentiated
73
Q

Where does bladder cancer spread to

A
  • local = pelvic structures
  • Lymphatic = para-aortic nodes
  • Haematogenous - liver + lungs + bone
74
Q

what is the management if bladder cancer is Tis/Ta/T1

A

Surgical

  • Diathermy via transurethral cystoscopy or
  • TURBT
  • consider intravesical chemotherapy for multiple small tumours or high grade tumours
  • mitomycin C, doxorubicin, cisplatin as maintenance
75
Q

What is the management of bladder cancer if it is T2-3

A

T2-3
Radical cystectomy – gold standard
- Radiotherapy preserves the bladder but gives worse survival rate
- “Salvage” cystectomy can be performed if radiotherapy fails (less effective than first-line surgery)

  • Post-op chemotherapy is effective but toxic – M-VAC (Methotrexate, Vinblastine, Adriamycin & Cisplatin)
  • Neoadjuvant chemotherapy of CMV (Cisplatin, Methotrexate, Vinblastine) ↑survival vs. stand-alone cystectomy or radiotherapy
  • If the bladder neck isn’t involved, reconstruction can de attempted, not at the cost of full tumour resection (vs. urostoma) – both use ~40cm of ileum (review with oncologist and urologist)
76
Q

What is the management of T4 bladder cancer

A
  • Palliative chemotherapy and/or radiotherapy

- chronic catheterisation and urinary diversions may ease pain

77
Q

what is the follow up for bladder cancer

A
  • Hx, examination and regular cystoscopy ± CT
  • High-risk tumour 🡪 every 3months for 2yrs; every 6months afterwards
  • Low-risk tumour 🡪 1st cystoscopy at 9 months; annually afterwards
78
Q

What is the complications of bladder cancer

A
  • sexual and urinary dysfunction

- bladder haemorrhage

79
Q

What is the prognosis of bladder cancer

A
  • median survival = 12-15 months

- 8% of those with metastatic disease will be cured

80
Q

what chemosensitive combinations are proposed for bladder cancer

A

o  gemcitabine and cisplatin

o  cisplatin and methotrexate

81
Q

What are the two types of germ cell tumours

A
  • seminomas

- non-seminomas

82
Q

What tumour markers do germ cell tumours produce

A
  • Alpha-fetoprotein (AFP)
  • Beta-human chorionic gonadotrophin (β-HCG)
  • Lactate dehydrogenase (LDH)
83
Q

Where do germ cell tumours arise

A
  • retroperitoneum

- mediastinum

84
Q

What are the risk factors for germ cell tumours

A
  • race (Caucasian x 3 compared to afro-caribbean)
  • undescended testicles
  • HIV
  • Infertility
  • first degree relative
85
Q

How does germ cell tumours present

A

Most commonly presents as stage 1

  • confined to testes
  • painless scrotal lump

delay seeking of help - metastasis (lymph nodes, lungs, liver and brain)

  • weight loss
  • bone pain
  • secondary hydrocele
  • SOB
  • abdominal masses
86
Q

What are the investigations of germ cell tumours

A
  • Blood – tumour markers (AFP, β-HCG, LDH), LFTs, bone profile, FBC

Imaging –

  • Testicular USS – hypoechoic region distorting normal architecture
  • CT abdo and chest (staging)
  • CXR
  • Excision biopsy
87
Q

Name the types of germ cell tumours

A

Germ cell tumours (90%)

  • Seminoma (SGCT)
  • Non-seminoma (NSGCT)

Non-germ cell tumours
Sex cord stromal tumours (3%)
- Leydig cell
- Sertoli cell

88
Q

What is the management of germ cells

  • non metastatic disease
  • metastatic disease
  • seminoma
  • non-seminoma
A
  • Non-metastatic disease: orchidectomy (+radiotherapy = ~95% cure)
  • Metastatic disease: orchidectomy + chemotherapy (3-4 cycles) of cisplatin+ etoposide +bleomycin (85-90% cure)
  • Seminoma – single-dose chemotherapy + resection of mets if needed
  • Non-seminoma – single-dose multidrug treatment
89
Q

What is the main risk factor for penile cancer

A

Human papilloma virus is the main risk factor

90
Q

if you are circumcised you do not get..

A

penile cancer

91
Q

What is the management of penile cancer

A
  • Surgical removal - including nodal block dissection
  • Radiotherapy - to draining inguinal nodes
  • Chemotherapy - cisplatin, fluorouracil, docetaxel

Year 3 - Met3b (26 decks)

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