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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
rf for bladder cancer
- occupational exposure to dyes hairdresser, painter, nail artist -smoking - chemo and radiotherapy -male
26
presentation of bladder cancer
Painless haematuria
27
gold standard diagnostic test for bladder cancer
flexible cytoscopy
28
treatment for bladder cancer
conservative= support medical= chemo or radiotherapy surgery= TURBT T1= transurethral resection or local diathermy T2-3 = Radical cystectomy T4 = palliative chemo and radiotherapy
29
What are the risk of Transurethral Resection of Bladder Tumour?
Pain, infection, bladder perforation Need for 3 way catheter & irrigation for a day or so after big resection
30
IF a patient has schistosmiasis what would this indicate
more likely to have squamous cell carcinoma than transitional
31
Differential diagnosis for bladder cancer:
Infection: UTI, pyelonephritis, TB Malignancy: anywhere in tract Stones: bladder, kidney, ureteric Trauma: penetrating Vs Blunt Nephrological: diabetes, nephropathy (proteinuria)
32
When do you do a re-resection of of bladder tumour
If incomplete, high grade seemingly non invasive, or no muscle in sample To be done within 6 weeks
33
What is mitomicin C
Chemotherapy Reduces disease recurrence Minimal side effects
34
What is BCG? - Vaccination
Reduces disease progression and recurrence Significant side effects, risk of systemic BCGosis
35
What surgeries do we use for Muscle invasive bladder cancer?
Radical cystoprostatectomy / cystourethrectomy & lymphadenectomy This is major surgery, 1% mortality, 33% morbidity
36
What is TCC commonly caused by?
Smoking and chemical exposure
37
How is haematuria investigated
flexi cystoscopy and upper tract imaging
38
Mitomicin C or BCG can be used as what?
as instillations for bladder cancer
39
What is muscle invasive disease treated by
Cystectomy - major surgery
40
What is the most common urinary diversion?
Ileal conduit
41
Mortality of testicular cancer
It is the most curable cancer, extremely sensitive to chemotherapy
42
Epidemiology of testicular cancer
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
Pathology of testicular cancer
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
Symptoms of testicular cancer
painless lump in testicle which does not transilluminate
45
OE for testicular cancer
hard mass arising from testis Check lymph nodes, abdomen and lungs
46
rf for testicular cancer
cryptorchidism , infertility, family history
47
Investigations for testicular cancer
Scrotal USS to be done that day Tumour markers: AFP, Beta-hCG, LDH CXR & CTAP or CTCAP staging
48
Definitive diagnosis and primary treatment of testicular cancer
Radical Inguinal Orchidectomy
49
When do we Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks)?
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
What is more likely non muscle invasive bladder cancer (NMIBC) Invasive MIBC
NMIBC
51
MI requires what type of treatment if suitable
Cystectomy Radiotherapy +/- chemotherapy
52
NMIBC
70% will recur 15% will progress to MI So grade: G1 – well differentiated G2 - moderate G3 – poorly differentiated CIS – carcinoma in situ
53
RF for NMIBC
Paraplegia Smoking Ocuupational Drugs - phenacetin, aspirin Bladder stones (Schistosomiasis)
54
Prognosis of NMIBC
10yr survival 50% Follow up depends on grade/ Stage. Based mainly on cystoscopy
55
Stage 1 renal cancer
Tumour <7cm in largest dimension Limited to kidney Management Partual nephrectomy Radical nephrectomy
56
Stage 2 renal cancer
Tumour >7cm in largest dimension Limited to kidney Management options Radical nephrectomy Partial nephrectomyh
57
Stage 3 renal cancer
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
Stage 4 renal cancer
Tumour beyond Gerota's fascia Distant metastases Management options Systemic treatment Elective cytoreductive nephrectomy
59
Non specific constitutional symptoms
Weight Loss Anorexia Fever Anaemia (normocytic)
60
Prostate cancer epidemiology
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
Prostate cancer basics
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
What are the 3 zones of the prostate?
Peripheral Central Transitional
63
What are the biomarkers for prostate cancer?
Tissue Serum: Prostate-specific Antigen (PSA) Prostate-specific membrane antigen (PSMA) Urine: PCA3 Gene fusion products (TMPRSS2-ERG)
64
What is PSA?
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
PSA stats
70% of men with an elevated PSA will not have prostate cancer 6% of men with prostate cancer will have a ‘normal’ PSA
66
PSA levels
PSA 8.0 - 9.99 ng/Ml then you have 50% chance of prostate cancer - rises after this level
67
What do we use to diagnose prostate cancer?
Lower urinary tract symptoms (LUTS) Prostate specific antigen (PSA) Transrectal ultrasound scan (TRUSS) Prostate biopsy Prostate cancer grading (Gleason grading)
68
Grading of prostate cancer (Histological)
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
What are the stages of prostate cancer diagnosis?
T stage N stage M satge
70
What happens in T stage of prostate cancer staging
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
N stage for prostate cancer staging
NX – unable to assess nodes N0 – no nodal spread N1 – spread to lymph nodes MRI scan, CT scan, (laparoscopy)
72
M stage for prostate cancer staging
M0 – no metastasis M1 – metastasis Bone scan
73
Prostatate cancer timeline
Presentation (symptoms/PSA) > Diagnosing (Biopsy) > Staging (DRE, MRI/CT & Bone scan) > 1. Localised 2. Locally advanced 3. Metastastic
74
Localised prostate cancer
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
What happens in localised prostate cancer
1.Curative > a.Surgery - radical prostatectomy open, laparoscopic, robotic b. radiotherapy - external beam, brachytherapy c. adjuvant hormones d. focal therapy 2. Observation
76
What happens in local control of prostate cancer
Surgery Radiotherapy + neoadjuvant hormone therapy
77
Metastatic prostate cancer
Palliative > Hormone therapy
78
Screening for prostate cancer
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
Reasons for screening for prostate cancer
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
Reasons against screening for prostate cancer
Uncertain natural history Overtreatment Morbidity of treatment
81
Benefitst and risk of PSA testing
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
Advanced disease of prostate cancer
Locally advanced Radiotherapy Radical prostatectomy Metastatic disease
83
Treatment for metastatic prostate cancer
Surgical castration: Reduced pain due to bony metastases Prolonged survival Median survival 2.5 years
84
Prognosis of advanced prostate cancer
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
Castration-resistant prostate cancer
2nd line hormone therapy: Abiraterone Enzalutamide Cytotoxic chemotherapy - Docetaxel, Carbazitaxel
86
Key risk factors of prostate cancer
Increasing age Family history Black African or Caribbean origin Tall stature Anabolic steroids
87
Presentation of prostate cancer
May be Asymptomatic LUTS Haematuria Erectile dysfunction Symptoms of advanced disease or metastasis
88
What produces PSA
epithelial cells of the prostate Glycoprotein secreted in semen - small amount in blood
89
Why is PSA testing unreliable?
high rate of false positives (75%) and false negatives (15%).
90
First line investigation used for suspected localised prostate cancer?
Multiparametric MRI
91
Gleason score results
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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