renal, bladder and testicular cancer Flashcards
what common feature do renal and bladder cancers present with?
haematuria
what feature of haematuria is very worrying and why?
clots - suggest active bleeding and can form a plug causing retention
fresh blood without any other symptoms eg loin pain or signs of infection as this can suggest a tumour
what should you ask about in the history with a pt with haematuria?
smoking associated symptoms (UTI, trauma, rash) - lees likely to be cancer instrumentation/catheters travel - schistosomiasis carcinogens - rubber and paint chemo eg cyclophosphamide FHx
what are the differentials for haematuria?
- infection: UTI, pylonephritis, TB
- trauma: penetrating vs blunt
- stones: KUB
- malignancy: anywhere in urinary tract
- nephrological: diabetes, nephropathy with proteinuria
name a surgical sieve and what it stands for
Congenital Vascular Infective Trauma Autoimmune Metabolic Inflammatory Neoplastic Neurological Degenerative Environmental Unknown
How else can the causes of haematuria be divided?
by anatomical location
kidneys, ureters, bladder, prostate, urethra, penis
and divide into malignancy, trauma, infection, stones for each area
which groups of people come under the suspected cancer referrals ie 2WW - 2 week wait to urology clinic
aged 45 or over and unexplained VISIBLE haematuria
aged 45 or over and have VISIBLE haematuria that persists or recurs after successful treatment of UTI
What group of people is offered a non-urgent referral to urology?
non visible haematuria recurrent or persistent unexplained UTI
what are the investigations for haematuria?
bloods:
- FBC
- U+E
- PSA + DRE
- glucose
MSU dip - microscopy, culture, sensitivity
cytology if available
imaging - USS/ CT,
flexible cystoscopy
why is a FBC done for haematuria?
to see how much blood they have lost - is it causing anaemia?
why is a PSA and DRE done for haematuria?
haematuria can be caused by an enlarged prostate
why is glucose done for haematuria?
recurrent UTIs and therefore haematuria can be the first presentation of diabebtes
when is USS done for haematuria?
if the pt has non-visible haematuria
If the pt has visible haematuria what imaging test is done?
CT urogram
also a flexible cystoscopy
Why is a flexible cystoscopy done?
imaging the bladder is not very good for looking at tumours in the bladder
How does bladder cancer present?
painless visible haematuria
irritative voiding/recurrent UTIs (CIS)
(but some people with non-visible haematuria may have bladder cancer)
what should be done before treatment is commenced for people with bladder cancer?
staging and MDT
What investigation is done to diagnose and stage bladder cancer?
Transuretheral Resection of Bladder Tumour
TURBT
what is the most common type of bladder cancer?
Transitional cell carcinoma 90%
What type of bladder cancer can Schistosomiasis and self catheterisation cause?
squamous cell carcinoma
What is bladder CIS?
bladder cancer in situ - it is poorly differentiated and mainly confined to the epithelium although 50% become muscle invasive
at what tumour stage do bladder cancers become muscle invasive?
T2
what treatments are offered for people with muscle invasive bladder cancer?
cystectomy - esp for younger pts
radiotherapy - instead of cystectomy for people who are not fit for surgery
chemo - also be used esp before surgery to shrink the size of the tumour
How are pts with Ta and T1 cancers treated?
cut away the tumour and keep them on regular flexible cystoscopies and can be done at 3 months, 9 months and 12 months and if it hasn’t come back at that time then you can discharge them
how is bladder cancer staged
Ta - just on the surface epithelium
T1 - gone through the lamina propria but hasn’t hit the muscle
T2 and above - muscle invasive
T3 - reached the pervescical fat
T4 - gone thorough the whole wall of the bladder
how is bladder cancer graded
G1 - well differentiated
G2- moderate
G3 - poorly differentiated
CIS - carcinoma in situ
what intervention do people with cis need
cystectomy
what are the risk factors for bladder cancer and why?
paraplegia - due to self catheterisation
smoking - as inhaled carcinogens are excreted in the urine
occupational carcinogens eg rubber, textiles, printing
drugs - aspirin and cyclophosphamide
bladder stones - cause irritation like schistosomiasis
what is the prognosis of bladder cancer
10 year survival is 50% - so not great
is renal cancer or bladder cancer more common?
renal cancer
what is your chance of dying from renal cancer?
1 in 3
how is renal cancer diagnosed?
picked up incidentally on scans for something else
some will have mets on presentation though:
- haematuria
flank pain
mass
weight loss
nodes
What is the most common type of renal cancer?
95% are a renal cell carcinoma (other percentage made of transitional cell carcinoma)
what are the stages of renal cancer ?
stage 1
stage 2
stage 3a,b,c
stage 4
what is stage 1 renal cancer?
tumour less than 7%
limited to kidney
what treatment would you offer sb with stage 1 renal cancer?
partial nephrectomy
radical nephrectomy
what may some people need a partial nephrectomy rather than a radical nephrectomy?
eg in diabetes to save nephrons
what is stage 2 renal cancer?
more than 7cm tumour
limited to the kidney
what is a stage 3 renal tumour?
tumour in the major veins (renal vein, IVC, right atrium) or adrenal gland with an intact Gerota’s fascia (fibrous tissue layer above the perinephric fat)
or regional lymph nodes involved
what are the management options for stage 3 cancer?
radical nephrectomy
adrenalectomy
lymph node dissection if needed
what is stage 4 renal cancer?
tumour is outside the kidney - gone through Gerota’s fascia and elsewhere - distant mets
what are the treatment options for stage 4 renal disease?
systemic treatment
cytoreductive nephrectomy
what are the principles for examining a mass?
look, feel, move
what is the sign of a true scrotal mass?
it is possible to get above it
what must be excluded if a pt presents with an acutely painful scrotum?
testicular torsion
what are the differentials of a testicular mass?
false scrotal reasons - inguinal hernia, varicocele
epididymitis hydrocele testicular torsion orchitis - inflammation of the testis appendix testis torsion spermatocele - epididymal cyst testicular rupture
do people with testicular cancer present with haematuria?
no - it is not connected to the bladder
in which scrotum is it more worrying to have a hydrocele and why?
right testicular vein drains directly into the IVC so there is no resistance there, but the left testicular vein drains into the the left renal vein at 90˚
a new varicocele on the left hand side that has come on really quick, could mean that they have a kidney tumour
who tends to get acute epidiymitis?
young males with STIs (gonorrheaandchlamydia) and UTIs
old men who self catheterise and may get STI that goes into the epididymis
how do STIs cause epidymitis?
retrograde spread from prostatic urethra to the seminal vesicle
what is hydrocele?
XS fluid in the tunica vaginalis (serous space surrounding the testis)
what is the cause of primary hydrocele?
processus vaginalis that hasn’t sealed up/ not obliterated
what is the cause of secondary hydrocele?
mainly not known but can be a reaction to testicular pathology eg testicular tumours, infections, torsion etc
name two types of testicular tumour
seminoma
non-seminoma - eg teratoma
what aged men get testicular cancer?
age 20-40
can women get prostate cancer?
no
is testicular cancer incidence increasing or decreasing and are most of the cancers benign or malignant?
malignant -92%
incidence is increasing
what are the risk factors for testicular cancer
Cryptorchidism = undescended testis
FHx
previous testicular tumour
What procedure is done if a pt has testicular cancer?
early inguinal orchidectomy - testis and spermatic cord excised
how does testicular cancer present?
painless lump in the testis
hard/craggy and can feel above it
does not transilluminate (as it is a solid mass - if it was a cyst it would transilluminate)
found incidentally
some may present with hydrocele, pain, mets in lung
how does testicular cancer present?
painless lump in the testis
hard/craggy and can feel above it
does not transilluminate (as it is a solid mass - if it was a cyst it would transilluminate)
found incidentally
some may present with hydrocele, pain, mets in lung or enlarged lymph nodes
if a young man comes in with cannonball mets in his lung what could it be?
testicular tumour that has metastasised
what investigations would be done for a testicular mass?
- ultrasound scan ON THE SAME DAY - as you want to operate on the on the same day
- tumour markers - Alpha Fetoprotein and beta-human chorionic gonadotropin, lactate dehydrogenase, measure tumour markers on the same day and then a day after the operation
- staging CT chest, abdo, pelvis
- CXR - only if the pt has respiratory symptoms, done on the same day
if someone has cannonball mets on XRAY what will they be offered before surgery?
chemo to reduce the size of the tumour
what is the half-life of AFP and B-hcg?
AFP - 5 days
B-hcg - 24-48 hours
What are seminomas very sensitive to?
radiotherapy
which of seminomas and teratomas spreads more easily?
teratomas
how is a teratoma treated and why?
chemo as less radiosensitive than seminomas
How is treatment for testicular cancers monitored?
sequential CT and tumour markers
from which cells in the testis do most testicular cancers come from?
germ cells - spermatogonia, spermatocytes ie the cells that go on to form the sperm
how fast do seminomas grow?
slowly
How fast do teratomas (or non-seminomas) grow
fast and can metastasise
What is the 5 year survival rate like for a seminoma or teratoma?
good - worst is 70%
