Renal, tubular and penile cancer Flashcards
How do you catergorise renal masses?
Beingin and Malignant (renal cell cancer - cortex: solid/ cyctic). transitional cell carcinoma, lymphoma (elderly pop.)
What are cycts?
simple fluid filled lesion
Oncocytoma
spherical
Radioloigcal
radiologically v diff to differentiate frm ohter cancers
main feature: Central scar
doent metastasise
Presentation of onco
loin pain, haematuria
What is the treatment fro oncocytoma?
ifsmal – partial nephrectomy
large - radical nephrectomy
Angiomiolipoma
sporadic in middle aged females
20% occurs in association with Tuberous sclerosis (autosomal dominant, mental retardtaion, epilepsy, hamartomas)
80% of TS develop AML
WHat is AML haemo?
blood vesserls, muscle and fat
How does CT of AML look like?
simply observe it, fatty tymour of low density
Presentation of AML
sometime s massive loin pain and haematuria, mass
Wunderlich syndrome - 10% (massive retroperitoneal bleed0
Investigation
US - bright echo pattern,
CT _ fatty tumour
Treatment
1-2 cm men - doesnt matter
<4 cm in pre-menopausal women –> need to be monitored as during pregnancy they can grow in size
Elective treatment for AML
Embolization(to decrease risk of bleeding), partial nephrectomy
Emergency treatment
Emvbolisation and emergency nephrectomy
Renal cell carcinoma
Adenocarcinoma of the renal cortex
Arises from the PCT of the nephron
tan coloured- solid and lobulated in gross appearance
10-25% contain cysts –> cyctsic strucutres
Histological classifical of RCC
- Conventional clear cell carcinoma (Gene of chromosome 3, loss of VHl –> they are predisposed to developing RCC)
- Papillary - 10-15% have it, can be found as a multifocal disease, can develop tumours on the toher side as well
3, Chromophobe - similar to benign but malignant, low risk of metastases, 5%
- collecting duct: rare, young patients, oin medulla and collectin gduct, very aggressive, they present with metastases
5.
Grading of RCC
grading - malignant potential of the tumour
1-4 (differentiation levels)
Staging of the RCC
size and extense of cancer
shorter renal vein on the right, hence more in the right side
What is the most lethal of urological cancers?
RCC
Who is RCC more common in?
Men
Modifiable risk factors in RCC
smoking,
obesity
hypertension
Non-modifiable risk factor in RCC
renal failure and dialysis
Which
loss of tumour suppressor gene in chromosome 3
PC of RCC
haematuria, loin pain and mass
pyrexia varicoceole (more so on the left side - left testicular vein goes directly into the renal vein, when the renal vein gets blocked by the tumour, it blocks the testicular vein as well -->
paraneoplastic syndrome- hormones and mass produced that can cause other symtpoms as well
How are RCC found first?
Incidental finding
Investigatio
US - CT - kidney, abdomen and pelvis, chest --> to check ofr metastases FBC Renal and liver functions Clotting
Polycythaemia
erythropoetin
What is stauffer syndrome?
abnormal liver function tests, they settle down once
Treatment of RCC depends on what?
size and location
Treamtment for RCC < 3cm
less than 3cm -
in old and frail –> just monitor them& and it is remains the same just leave it and keep checking 3-5 years
young - selected partial nephrectomy
old, healthy (either ablate with radiofrequency waves and burning the tumour, good cancer control in those < 3cm for 3-5 years )
radioablation in ppl fit elderly patient, selected younger apatients who are unfit
benign size
< 3cm
treatment >3cm
partial nephrectomy - more preferred in younger patients (40s - 50s), robotic technique
Radical nephrectomy - laparoscopically remove the whole kidney, low morbidity post-op
fit for surgery, 80 y/o, >3cm, healthy kidney - do radical nephrectomy
treatment for large tumours
radical nephrectomy
Risk in partial nephrectomy
bleeding
80 y/o, recent MI, tumour 2.5 cm
just monitor
but if keep on something done - ablation
45 y/o tumour 2.5 cm
younger patient
partial nephrectomy - gold standard,
ablation - optional
mass 7 cm
laparoscopic nephrectomy
tumour 15 cm
radical nephrectomy
How would you follow up in patients?
Risk categorise and chose accordingly, decrease radiation
FBCand renal and liver function
if it turns out t be a chromophobe –>
clear cell - grade 2 -
What is the most common solid cancer in men 20-45?
testicular cancer
Seminomatous cancer
35-45 (surgeons)
Non-seminomatous. teratomas
<35 (troops)
what is the porgnosis of testicular cancer?
good
Common in whom?
White caucasians in europe and USA
***very very rare in africana or asians
Risk factors
contralateral testicle - previous testicular cancer
crytpochordism
orchidopexy before 13 y/i - 2x risk
orcidopexy after 13 y/o - x% increased risk
HIV - higher risk of seminoma
Family history
Hisotological types of testicular
90% germ cells
PC of testicular cancer
scrotal lump in shower, delayed presentation can happen
5% acute pain - bleeding in the testis
10% - advacned disease including weihgt loss, neck lumps, chest symptoms or bone pain
On exam
always check the normal side first
abnormal - assymetry, non-tender hard testicle, irregular mass mostly intra-testicular
assymetry of slight scrota ldisclolouration
assess epidydmis, spermatic cord and scrotal skin
secondary hydrocoele
abdominal mass - advanced disease
Investigations
US for the testicle
CT chest abdomen for staging
blood tests:
serum tumour markers - AFP, B-HCG, LDH, raised in 50% cases
not raised in all cases, and mostly in metastatic diseases it is raised
FBC
LFT
Renal function tests
Treatment
Radical inguinal orchidectomy - inguinal approach, via inguinal canal, taking the testical out along as much length of the spermatic cord
not from the scrotum - dont want to expose another way for the cancer to take
On exam
always check the normal side first
abnormal - assymetry, non-tender hard testicle, irregular mass mostly intra-testicular
assymetry of slight scrota ldisclolouration
assess epidydmis, spermatic cord and scrotal skin
secondary hydrocoele
IMP**abdominal mass - advanced disease
Investigations
US for the testicle
CT chest abdomen for staging - done anyway regardless of the abdominal mass
blood tests:
serum tumour markers - AFP, B-HCG, LDH, raised in 50% cases
not raised in all cases, and mostly in metastatic diseases it is raised
FBC
LFT
Renal function tests
Treatment
Radical inguinal orchidectomy - inguinal approach, via inguinal canal, taking the testical out along as much length of the spermatic cord
not from the scrotum - dont want to expose another way for the cancer to take
re-check tumour markers 1 weeks post op, if they are not going down do CT, further follow up oncologist –> some form of chemotherapy in lower doses given to increase prognosis
Penile cancer
squamous cell cancer
95% - skin cancer
in the foreskin starts and then invades deeper into it
Kaposi’s sarcoma - HIV
BCC, malignant melanoma and sarcoma - rare
very rare
Risk factors in penile cancer
5th- 6 th decade phimosis - chronic imflammation geography - asia, africa, south america more commonly seen HPV - strongly associated type 16 and 18 Smoking Immunocompromised patient
protective risk factor in penile cancer
circumsicion
most common location
glans - 48%
prepuce
PC
hard painless lump
15-50% - hihgh incidence of delayed presentation for > 1 year due to embarassment
rare - urinalry retention or groin mass (inguinal lymphadenopathy)
Investigations
if small volume - not much done
MRI - if the glans skin involved and the corpora might be involved then do MR, tumour death
CT chest and abdomen - if advanced, if inguinal lymphadenopathy
Prognosis pof malignnay penile cancer in 5 years
0%
Treatment:
prepucial lesions
- circumcision
glans lesions - remove the skin over glans, put graft and let it take over, high risk that the undersurface of the foreskin in involved
deep - glasectomy
total penile amputation - supra-pubic catheter,
inguinal lymph present - inguinal lymphadenopathy, might have tiny metastases
