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Renal > Renal and GU cancers and prostate cancers > Flashcards

Renal and GU cancers and prostate cancers Flashcards

1
Q

What is the most common renal cancer?

A

Renal cell carcinoma

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2
Q

What is Transitional Cell Carcinoma

A

From urothelium – transitional epithelium
Rare occurrence in renal pelvis or ureter, common in bladder

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3
Q

What is the commonest abdominal tumour of childhood?

A

Wilm’s Tumour – nephroblastoma

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4
Q

What is Angiomyolipoma?

A

Benign renal tumour
Mesenchymal tumour full of blood vessels, smooth muscle & fat

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5
Q

What is oncocytoma?

A

Benign renal mass (BRM)
Thought to arise from intercalated cells of collecting duct
Simultaneous with RCC in 7-32%
Surveillance if biopsy proven, partial nephrectomy if in doubt

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6
Q

What is renal cell carcinoma?

A

Adenocarcinoma

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7
Q

Histological subtypes of renal cell carcinoma

A

Clear cell, papillary, chromophobe, collecting duct

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8
Q

Metastasis of RCC

A

Local invasion
Invasion of renal vein (tumour thrombus as far as right atrium!)
Lung (cannonball), brain or bone mets

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9
Q

Which gender more likely to have renal cell carcinoma

A

Females more than males

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10
Q

Risk factors for RCC?

A
  • smoking
  • obesity
  • renal failure
  • HTN
  • social deprivation
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11
Q

Genetic causes of RCC

A

VHL syndrome – autosomal dominant

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12
Q

Paraneoplastic syndromes for RCC

A

Anaemia/polycythaemia 30%/5%
Hypertension 25%,
hypercalcaemia 20%,
Hypoglycaemia

Stauffer’s syndrome: hepatic dyfunction + fever + anorexia

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13
Q

Investigations for RCC

A

CT is gold standard imaging
FBC (polycythaemia/anaemia) U&E, LFT, Coag etc
Needle biopsy if diagnosis in doubt

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14
Q

classic triad of symptoms for renal cell carcinoma

A

flank pain
haematuria
abdo mass

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15
Q

Management of RCC?

A

Partial nephrectomy - Gold standard for small tumours confined to kidney
Radical nephrectomy
Palliative options
Adjuvant treatments

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16
Q

Presentation of Upper Tract Transitional Cell Carcinoma

A

Haematuria 80%, Loin pain 30% often “clot colic”

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17
Q

Management of Upper Tract Transitional Cell Carcinoma

A

Nephroureterectomy is gold standard curative treatment
Local treatment with ureteroscopy and laser of small lesions

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18
Q

General symptoms of kidney cancer

A
  • haematuria
  • loin pain
  • mass
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19
Q

Treatment for renal cancers such as RCC

A

Surgical
Does not respond to radiotherapy

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20
Q

Upper tract / kidney TCC has the same pathology as what?

A

Bladder cancer

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21
Q

Bladder cancer pathologies

A

Transitional Cell Carcinoma (90%): from transitional epithelium - the “urothelium”

Squamous Cell Carcinoma (5% in UK, 75% in Egypt): metaplasia - dysplasia process from irritation eg stones, schistosomiasis

Adenocarcinoma (2%): quite rare

Rarities: Spindle cell carcinoma, melanoma, lymphoma, sarcoma

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22
Q

TCC risk factors

A

Men 2.5x > Women
Age: >50
Carcinogens: tobacco smoke, rubber, diesel exhaust
Industrial exposure: hairdressers, chemical workers
Drugs eg Phenacetin, Cyclophosphamide, Pioglitazone

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23
Q

TCC grading and staging

A

Stage:
- Tis carcinoma in situ: superficial but very dangerous

  • Ta / T1 papillary non invasive / sub epithelial only: low risk
  • T2 muscle invasive
  • T3a/b through the muscle / invading perivesical fat
  • T4a/b invading prostate / pelvic side wall

Implantation: TCC can spread along incisions/tracts eg SPC tract

Lymph nodes: iliac or para-aortic nodes

Distant Mets: to liver / lung / bone / adrenal

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24
Q

What is Transurethral Resection of Bladder Tumour

A

Complete resection is adequate for 70% of superficial low risk disease
Controls haematuria in advanced disease

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25
Q

rf for bladder cancer

A
  • occupational exposure to dyes
    hairdresser, painter, nail artist
    -smoking
  • chemo and radiotherapy
    -male
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26
Q

presentation of bladder cancer

A

Painless haematuria

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27
Q

gold standard diagnostic test for bladder cancer

A

flexible cytoscopy

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28
Q

treatment for bladder cancer

A

conservative= support
medical= chemo or radiotherapy
surgery= TURBT

T1= transurethral resection or local diathermy
T2-3 = Radical cystectomy
T4 = palliative chemo and radiotherapy

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29
Q

What are the risk of Transurethral Resection of Bladder Tumour?

A

Pain, infection, bladder perforation
Need for 3 way catheter & irrigation for a day or so after big resection

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30
Q

IF a patient has schistosmiasis what would this indicate

A

more likely to have squamous cell carcinoma than transitional

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31
Q

Differential diagnosis for bladder cancer:

A

Infection: UTI, pyelonephritis, TB
Malignancy: anywhere in tract
Stones: bladder, kidney, ureteric
Trauma: penetrating Vs Blunt
Nephrological: diabetes, nephropathy (proteinuria)

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32
Q

When do you do a re-resection of of bladder tumour

A

If incomplete, high grade seemingly non invasive, or no muscle in sample
To be done within 6 weeks

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33
Q

What is mitomicin C

A

Chemotherapy
Reduces disease recurrence
Minimal side effects

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34
Q

What is BCG? - Vaccination

A

Reduces disease progression and recurrence
Significant side effects, risk of systemic BCGosis

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35
Q

What surgeries do we use for Muscle invasive bladder cancer?

A

Radical cystoprostatectomy / cystourethrectomy & lymphadenectomy
This is major surgery, 1% mortality, 33% morbidity

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36
Q

What is TCC commonly caused by?

A

Smoking and chemical exposure

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37
Q

How is haematuria investigated

A

flexi cystoscopy and upper tract imaging

38
Q

Mitomicin C or BCG can be used as what?

A

as instillations for bladder cancer

39
Q

What is muscle invasive disease treated by

A

Cystectomy - major surgery

40
Q

What is the most common urinary diversion?

A

Ileal conduit

41
Q

Mortality of testicular cancer

A

It is the most curable cancer, extremely sensitive to chemotherapy

42
Q

Epidemiology of testicular cancer

A

White caucasians have highest risk
Previous ca testis: 12x increased risk (bilateral in 1-2%)
Cryptorchidism: 6x increased risk
HIV: 33% increased risk of seminoma
Familial increased risk 4 - 8 fold

43
Q

Pathology of testicular cancer

A

90% are Germ Cell Tumours:
Seminoma (48%): spermatocytic, classical & anapaestic
Non seminoma (42%): teratoma, yolk sac tumour, choriocarcinoma, mixed
Mixed seminoma and non seminoma (10%): Leydig cell / Sertoli cell

44
Q

Symptoms of testicular cancer

A

painless lump in testicle which does not transilluminate

45
Q

OE for testicular cancer

A

hard mass arising from testis
Check lymph nodes, abdomen and lungs

46
Q

rf for testicular cancer

A

cryptorchidism , infertility, family history

47
Q

Investigations for testicular cancer

A

Scrotal USS to be done that day
Tumour markers: AFP, Beta-hCG, LDH
CXR & CTAP or CTCAP staging

48
Q

Definitive diagnosis and primary treatment of testicular cancer

A

Radical Inguinal Orchidectomy

49
Q

When do we Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks)?

A

Aged 45 and over and have:
Unexplained visible haematuria without urinary tract infection or
Visible haematuria that persists or recurs after successful treatment of urinary tract infection, or

Aged 60 and over and have unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test (new NICE recommendation for 2015).

50
Q

What is more likely non muscle invasive bladder cancer (NMIBC) Invasive MIBC

A

NMIBC

51
Q

MI requires what type of treatment if suitable

A

Cystectomy
Radiotherapy
+/- chemotherapy

52
Q

NMIBC

A

70% will recur
15% will progress to MI

So grade:
G1 – well differentiated
G2 - moderate
G3 – poorly differentiated
CIS – carcinoma in situ

53
Q

RF for NMIBC

A

Paraplegia
Smoking
Ocuupational
Drugs - phenacetin, aspirin
Bladder stones (Schistosomiasis)

54
Q

Prognosis of NMIBC

A

10yr survival 50%
Follow up depends on grade/
Stage.
Based mainly on cystoscopy

55
Q

Stage 1 renal cancer

A

Tumour <7cm in largest dimension
Limited to kidney
Management
Partual nephrectomy
Radical nephrectomy

56
Q

Stage 2 renal cancer

A

Tumour >7cm in largest dimension
Limited to kidney
Management options
Radical nephrectomy
Partial nephrectomyh

57
Q

Stage 3 renal cancer

A

Tumour in major veins or adrenal gland with inttact Gerota’s fascia
Regional lymph nodes involved

Management options
Radical nephrectomy plus adrenalectomy, tumour thrombus excision
Systemic treatment

58
Q

Stage 4 renal cancer

A

Tumour beyond Gerota’s fascia
Distant metastases
Management options
Systemic treatment
Elective cytoreductive nephrectomy

59
Q

Non specific constitutional symptoms

A

Weight Loss
Anorexia
Fever
Anaemia (normocytic)

60
Q

Prostate cancer epidemiology

A

Most commonly diagnosed cancer in men
A disease of the industrialised West.
Mean age at diagnosis 72
Family history in 5 – 10%
12- 16 % lifetime risk of diagnosis

67% of men in their 80s have prostate cancer on routine post mortem examination
3% of men die of prostate cancer

61
Q

Prostate cancer basics

A

Adenocarcinoma
Occurs in peripheral zone of prostate
85% of tumours are multifocal
Spreads locally through prostate capsule
Metastasises to lymph nodes and bone (sclerotic) and occasionally to lung, liver and brain

62
Q

What are the 3 zones of the prostate?

A

Peripheral
Central
Transitional

63
Q

What are the biomarkers for prostate cancer?

A

Tissue

Serum:
Prostate-specific Antigen (PSA)
Prostate-specific membrane antigen (PSMA)

Urine:
PCA3
Gene fusion products (TMPRSS2-ERG)

64
Q

What is PSA?

A

Prostate-specific antigen
Small amount of retrograde leakage
Detected in small quantities in the blood
Not cancer specific (prostate specific)
Elevated in benign prostate enlargement, urinary tract infection, prostatitis

65
Q

PSA stats

A

70% of men with an elevated PSA will not have prostate cancer
6% of men with prostate cancer will have a ‘normal’ PSA

66
Q

PSA levels

A

PSA 8.0 - 9.99 ng/Ml then you have 50% chance of prostate cancer - rises after this level

67
Q

What do we use to diagnose prostate cancer?

A

Lower urinary tract symptoms (LUTS)
Prostate specific antigen (PSA)
Transrectal ultrasound scan (TRUSS)
Prostate biopsy
Prostate cancer grading (Gleason grading)

68
Q

Grading of prostate cancer (Histological)

A

Gleason grading
Add the 2 most common types of cells in prostate together that you find histologically
Score e.g. 3+4
Higher score more aggressive

69
Q

What are the stages of prostate cancer diagnosis?

A

T stage
N stage
M satge

70
Q

What happens in T stage of prostate cancer staging

A

Tx - unable to assess size
T1 -no palpable tumour on DRE
T2 -palpable tumour, confined to prostate
T3 -palpable tumour extending beyond prostate
T4 - spread to nearby organs

71
Q

N stage for prostate cancer staging

A

NX – unable to assess nodes
N0 – no nodal spread
N1 – spread to lymph nodes

MRI scan, CT scan, (laparoscopy)

72
Q

M stage for prostate cancer staging

A

M0 – no metastasis
M1 – metastasis

Bone scan

73
Q

Prostatate cancer timeline

A

Presentation (symptoms/PSA) > Diagnosing (Biopsy) > Staging (DRE, MRI/CT & Bone scan) >
1. Localised
2. Locally advanced
3. Metastastic

74
Q

Localised prostate cancer

A

PSA detected disease

Occasionally detected during surgery for benign prostatic obstruction

Transrectal ultrasound and biopsy of prostate gland

No clinical evidence of metastatic disease

75
Q

What happens in localised prostate cancer

A

1.Curative >
a.Surgery - radical prostatectomy open, laparoscopic, robotic
b. radiotherapy - external beam, brachytherapy
c. adjuvant hormones
d. focal therapy
2. Observation

76
Q

What happens in local control of prostate cancer

A

Surgery
Radiotherapy + neoadjuvant hormone therapy

77
Q

Metastatic prostate cancer

A

Palliative > Hormone therapy

78
Q

Screening for prostate cancer

A

Before PSA, common presentation with advanced disease (>60%) (T3 or T4)
Commonest site of metastasis – bone (M1)
Currently majority of cases are T1c
Detected on PSA testing

79
Q

Reasons for screening for prostate cancer

A

Commonest cancer in men – lifetime risk c. 9%
Responsible for 10,000 deaths per annum in UK.
4th most common cause of cancer death.
3% of men will die of prostate cancer.

80
Q

Reasons against screening for prostate cancer

A

Uncertain natural history
Overtreatment
Morbidity of treatment

81
Q

Benefitst and risk of PSA testing

A

Benefits:
Early diagnosis of localised disease (cure)
Early treatment of advanced disease (effective palliation)

Risks:
Overdiagnosis of insignificant disease
Harm caused by investigation/ treatment

82
Q

Advanced disease of prostate cancer

A

Locally advanced
Radiotherapy
Radical prostatectomy

Metastatic disease

83
Q

Treatment for metastatic prostate cancer

A

Surgical castration:
Reduced pain due to bony metastases
Prolonged survival
Median survival 2.5 years

84
Q

Prognosis of advanced prostate cancer

A

Median survival 2.5 years but significant number of long-term ‘remission’ on androgen deprivation therapy
FAR BETTER PALLIATION THAN AVAILABLE FOR MOST METASTATIC SOLID TUMOURS
80% androgen-sensitive
Castration leads to remission of advanced disease (apoptosis of cancer cells)
Median response 2 years

Castration-resistant phase

85
Q

Castration-resistant prostate cancer

A

2nd line hormone therapy:
Abiraterone
Enzalutamide

Cytotoxic chemotherapy - Docetaxel, Carbazitaxel

86
Q

Key risk factors of prostate cancer

A

Increasing age
Family history
Black African or Caribbean origin
Tall stature
Anabolic steroids

87
Q

Presentation of prostate cancer

A

May be Asymptomatic
LUTS
Haematuria
Erectile dysfunction
Symptoms of advanced disease or metastasis

88
Q

What produces PSA

A

epithelial cells of the prostate
Glycoprotein secreted in semen - small amount in blood

89
Q

Why is PSA testing unreliable?

A

high rate of false positives (75%) and false negatives (15%).

90
Q

First line investigation used for suspected localised prostate cancer?

A

Multiparametric MRI

91
Q

Gleason score results

A

6 is considered low risk
7 is intermediate risk (3 + 4 is lower risk than 4 + 3)
8 or above is deemed to be high risk

Renal (15 decks)

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