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
- 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
- Incidental finding (on imaging)
- A palpable mass (rare)
How does RCC present if advanced?
- Large varicocele
- Pulmonary/tumour embolus
- Loss of weight/appetite (metastasis)
- Hypercalcaemia
What are the risk factors for RCC?
- Smoking (2x↑)
- Obesity
- Dialysis
Identify the three ways in which RCC can spread
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)
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)
How does TCC present, if advanced?
- Loss of weight/appetite (metastasis)
- DVT
- Lymphoedema
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
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
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
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
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
How do patients with prostate cancer present?
- Urinary symptoms
- Bone pain
- Abnormal DRE
- 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
- 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)
