S11) Urological Cancers Flashcards
How does one assess haematuria?
- Visible changes
- Non visible changes: microscopy & urine dipstick
What is the differential diagnosis of haematuria?
- Urological
I. Cancer
II. Other – stones, infection, inflammation, BPH
- Nephrological (glomerular)
Describe the key components of the history of a patient presenting with haematuria
- Smoking
- Occupation
- Painful/painless
- Other LUTS
- Family history
How would one examine a patient presenting with haematuria?
- BP
- Abdominal mass
- Varicocele
- Leg swelling
- Assess prostate by DRE (males)
What investigations would one request for in a patient presenting with haematuria?
- Radiology: ultrasound, CT
- Endoscopy: flexible cystoscopy, up bladder and ureter and to kidney
- Urine: culture & sensitivity, cytology
- Bloods: FBC, U&E
What is Renal Cell Carcinoma?
RCC is a malignant tumour arising from the renal cells in the parenchyma of the kidney
How does RCC present?
- Haematuria - first sign
- it can be asymptomatic so symptoms may only appear once it has metastasised
- Incidental finding (on imaging)
- A palpable mass (rare)
How does RCC present if advanced?
- Large varicocele: compression of gonadal vein so it can’t drain (only to do with left)
- Pulmonary/tumour embolus
- Loss of weight/appetite (metastasis)
- Hypercalcaemia: small number can secrete PTH-rP
What are the risk factors for RCC?
- Smoking (2x↑)
- Obesity
- Dialysis
- male: female 3:1
Identify the three ways in which RCC can spread
worst case is it spreads up the renal vein to the IVC and up to the right atria
How can localised RCC be treated?
- Surveillance
- Excision: radical nephrectomy / partial nephrectomy
- Ablation: cryoablation / radiofrequency ablation
What does a radical nephrectomy involved?
Radical nephrectomy – removal of kidney, adrenal, surrounding fat, upper ureter
How can metastatic RCC be treated?
- Cannot be cured
- Palliative treatment – biological therapies (targeted)
- try and prevent angiogenesis surrounding the tumour to slow growth
What is clear renal cell carcinoma?
- CCRCC is a renal cortical tumour typically characterised by malignant epithelial cells
- The proximal convoluted tubule gives rise to this tumour
What is a Bladder Transitional Cell Carcinoma?
- TCC of the bladder is a malignant tumour arising from the transitional epithelial cells lining the bladder
- It is the most common primary neoplasm of the urinary bladder and the entire urinary system
How does TCC present?
- Haematuria
- Incidental finding (imaging, CT, US)
How does TCC present, if advanced?
- Loss of weight/appetite (metastasis)
- DVT
- Lymphoedema
- can be pale if they’re losing blood → anaemic
What are the risk factors for bladder TCC?
- Smoking (4x↑)
- Occupational exposure: rubber, plastics, handling of carbon, crude oil, combustion e.g. painters, mechanics, printers, hairdressers
- -* more likely in males
Describe five features seen in the urine cytology of a patient with bladder cancer
- Clusters of neoplastic cells
- High nuclear:cytoplasmic ratio
- Nuclear hyperchromasia
- Pleomorphism
- Coarse nuclear chromatin
What is the initial management of bladder TCC?
Transurethral removal of bladder tumour
Outline the treatment plan of muscle invasive bladder TCC
What is a squamous cell carcinoma of the bladder?
A squamous cell carcinoma of the bladder is a rare malignant neoplasm derived from bladder urothelium with pure squamous phenotype
Which conditions in a patient’s history would cause one to consider the possibility of a squamous cell carcinoma of the bladder?
Schistosomiasis – parasitic infection of the urinary tract/intestines by shistosomes (parasitic flatworms)
What is a Renal Transitional Cell Carcinoma?
Renal TCC is a malignant tumour arising from the transitional epithelial cells lining the urinary tract from the renal calyces to the ureteral orifice
presents with haematuria, obstruction occurs earlier
What are the risk factors for renal TCC?
- Smoking
- Phenacetin abuse
- Balkan’s nephropathy
What is the standard treatment of renal TCC?
Nephro-ureterectomy – kidney, fat, ureter, cuff of bladder as patients have a 40% chance of developing bladder cancer
- scan regularly to check for bladder cancer
*
What is the treatment for metastatic TCC (renal/bladder)?
- Systemic chemotherapy
- Biological therapies – immunotherapy
What is prostate cancer?
- Prostate cancer is the slow-growing development of cancer in the prostate gland of the male reproductive system
- It commonly forms in the peripheral zone of the prostate but benign tumours also form in the transitional zone
BPH → hypertrophy of prostate more central
What are the risk factors for prostate cancer?
- Age (increases)
- Family history e.g. BRCA2 gene mutation
- Ethnicity (Black > White > Asian)
What does screening for prostate cancer involve?
PSA testing – prostate specific antigen blood test
When should a doctor refer a patient for PSA screening?
- When they present with associated symptoms
- When they come to discuss a family member who has prostate cancer / because they have read about PSA
What are the issues with PSA testing results?
- You can’t rely on a PSA within 6 weeks of a urinary infection
- Having a normal PSA does not mean you do not have prostate cancer
- You can have a normal PSA but an abnormal feeling prostate on DRE
State four other causes of raised PSA
- Infection
- Inflammation
- Large prostate
- Urinary retention
(prostate cancer)
How do patients with prostate cancer present?
- Urinary symptoms
- Bone pain
- Abnormal DRE (digital rectal exam)
- Incidental finding (at transurethral resection of prostate)
Outline the diagnostic pathway for prostate cancer
- DRE + Serum PSA → transrectal ultrasound-guided biopsy of prostate
- Lower urinary tract symptoms → transurethral resection of prostate (TURP)
What are the 5 factors influencing treatment decisions for prostate cancer?
- Age
- DRE (localised, locally advanced, advanced)
- PSA level
- Biopsies (Gleason grade, extent)
- MRI / bone scan (metastases)
How is localised prostate cancer treated?
- Surveillance
- Robotic radical prostatectomy
- Radiotherapy
How is locally advanced prostate cancer treated?
- Surveillance
- Hormones
- Hormones & radiotherapy
Describe the treatement of metastatic prostate cancer
- Hormones(± chemotherapy):
I. Surgical castration
II. Medical castration: LHRH and GnRH antagonist (androgen blocker to stop testosterone)
- Palliative care:
I. Single-dose radiotherapy
II. Chemotherapy
Why is it possible to feel changes in the prostate during a digital rectal examination?
- Tumour normally occurs in peripheral zone of prostate gland
- Posterior side of the prostate is right next to the anterior wall of the rectum
Why do patients with prostate cancer present with urinary symptoms?
What are these symptoms?
Tumour compresses the prostatic urethra, hence producing LUT symptoms:
- Urinary retention
- Urinary frequency
- Dysuria
- Nocturia
Why do patients with prostate cancer present with lower back pain?
- Bone metastases (main)
- Lymphatic metastases to seminal vesicles (nerve compression)
staging of bladder TCC
75% are superficial so only within the inside of the bladder
T3 and T4 are all tumours that spread from inside to outside => more invasive
how do you diagnose and treat TCC
- Investigate with cystoscopy and biopsy
*
what are some investigations you could request and what to they suggest
how should the prostate feel normally and how does it feel during BPH and prostate cancer
normal: soft and spongy and should feel two lobes
BPH: larger and a little but firmer but still feel two different lobes
cancer: irregular, bumpy and hard and can’t feel the two lobes separately
pathology of prostate cancer
T1: unsuspected and can’t palpate
T2: tumour confined to prostate
T3: local extension of tumour beyond prostatic capsule
T4: tumour fixed onto other structures
describe this bone scan and how it has come about
- this occurs in advanced prostatic cancer
- patients can develop sclerotic bone lesions
- these are hot spot on bone scan
what is a possible mistake that can happen during surgery of the prostate
you can hit the pudendal nerve and it can effect the bladder and continence
what hormone causes prostatic cancer
testosterone
as you age it gets converted into dihydrotestosterone which is more potent and can promote tumour growth
side effects of castration
hot flashes
impotence
thinning of bones
diminished muscle mass
increase in breasts
weight gain
mood changes ;
what is polycystic kidney disease
- accounts for 8-10% of CKD
- most common inherited nephropathy
- cysts can develop anywhere and compress surrounding parenchyma and impair renal function
- cysts can develop in childhood but not cause problems till adulthood
what fills the cysts in Polycystic kidney disease
kidneys are large and filled with yellow fluid like cysts replacing parenchyma
haemorrhage in the cysts can occur
cysts are lined with cuboidal epithelium
what conditions can polycystic kidney disease cause
hyeprtension and a CKD
it is autosomal dominant condition
an be associated with valvular heart disease, diverticular disease and berry aneurysm
must avoid contact sports and it can cause the cysts to burst and cause lots of bleeding
when should family members of people with polycystic kidney disease be screened
- when there is a large number of family members with the disease available for linkage
- family members should screen on an annual basis for high BP to urine dipstick abnormalities
- late teens get US, if there are no cysts then its likely she does not have the disease
