Tumours of the Urinary System Flashcards
What is the most common cancer diagnosed in med?
Prostate cancer
In blood tests, what is looked at specifically regarding prostate cancer?
PSA
-> prostate specific antigen
Generally, what is the prognosis of prostate cancer like?
Very good
What are some of the risk factors for prostate cancer?
Increasing age
Family history
Race/ethnicity
Georgaphy
Obesity
Diet
Which race/ethnicity is most at risk of prostate cancer?
African/Afro-Caribbean have highest risk
Caucasian have moderate risk
East Asian have lowest risk
Family history of which syndrome increases risks of prostate cancer?
Lynch syndrome
What % of prostate cancers can be palpated via the rectum?
80%
Which zone of the prostate do most prostate cancers occur?
Peripheral zone
P=P
RECAP- name the four zones of the prostate
Transition zone
Central zone
Peripheral zone
Anterior fibromuscular stroma
What is important to note about the symptoms of prostate cancers?
Often asymptomatic and do not present with usual cancer symptoms e.g. weight loss
How is prostate cancer diagnosed?
Opportunistic ad hoc PSA testing
What is important to note about PSA elevation?
Whilst PSA is prostate specific, it is not cancer specific, so when raised, it’s not always cancer
When else may PSA be raised apart from prostate cancer?
BPE (benign prostate enlargement)
Infection
What are the symptoms of localised prostate cancer?
Trick question, if it’s localised, there will be no symptoms
What are some of the symptoms of distant metastases from metastatic prostate cancer?
Bone pain or sciatica
Paraplegia secondary to spinal cord compression
Lymph node enlargement
Loin pain or anuria due to obstruction of ureters by lymph nodes
What are some of the symptoms of widespread metastases from metastatic prostate cancer?
Lethargy
Weight loss
What is the commonest mode of presentation for prostate cancer?
Asymptomatic - incidentally noted
What is important to note about normal serum range for PSA?
It increases with age because of BPH
What is the normal PSA for those who are <50?
2.5 upper limit
What is the normal PSA for those who are 50-60?
3.5 upper limit
What is the normal PSA for those who are 60-70?
4.5 upper limit
What is the normal PSA for those who are >70?
6.5 upper limit
What can be done to differentiate between transient and persistent rise in PSA?
Recheck PSA in at least 3 weeks
How long is the half-life of PSA?
2.2 days
List some causes of transient causes of elevated PSA.
UTI
Chronic prostatitis
Instrumental e.g. catheterisation
Physiological e.g. ejaculation
Recent urological procedure
List some causes of persistent causes of elevated PSA.
BPH
Prostate cancer
Okay, so, if a GP checks bloods of a man and the PSA is elevated, what should they do?
Not worry and recheck in 3 weeks
If still raised, it’s a persistent rise
How is a diagnosis of prostate cancer most commonly made?
Usually due to a rise in age-specific PSA
Abnormal prostate on digital rectal examination
If prostate cancer is suspected, what is done to confirm?
Pre-biopsy prostate multiparametric MRI to identify the area of interest to biopsy
Biopsy then carried out
->important to note that MRI does not actually diagnosis but gives information relating to diagnosis. Can also be used for staging of prostate cancer
Basically just give a wee summary pf the steps of a prostate cancer diagnosis pls x
Serum PSA
Digital rectal examination
Pre-biopsy MRI
Biopsy
Additional staging for metastasis if required e.g. bone scan
What is meant by ad hoc PSA testing?
Testing PSA level in men who are worried about prostate cancer or who have family history, not testing every man once he reaches a certain age like breast screening
What is meant by the grading of cancer?
Assessment of the aggression of the cancer
What is meant by staging of cancer?
Assessment of the spread of cancer
What is grading of prostate cancer based on?
Gleason sum score
What is used for the staging of cancer?
TMN staging system
How is a Gleason Sum Score given?
Score of 3-5 given looking at the largest area
Score of 3-5 given looking at the second largest area
Two numbers added to give the total sum score
What is the commonest organ that prostate cancer spreads to?
Bone
For the purposes of treatment and prognosis, prostate cancer is divided into 4 clinical stages. What are they?
Localised stage
Locally advanced stage
Metastatic stage
Castrate-resistant/Hormone-refractory stage
What is the treatment for localised prostate cancer?
Watchful waiting
Radiotherapy
Radical prostatectomy
What is the treatment for locally advanced prostate cancer?
Watchful waiting
Hormone therapy followed by surgery
Hormone therapy followed by radiation
What does prostate cancer require to fuel it’s growth?
Testosterone
The following are reasonable treatment options for low-risk localised prostate cancer EXCEPT:
a. external beam radiotherapy
b. active surveillance
c. brachytherapy
d. radical prostatectomy
e. radical chemotherapy
E- radical chemotherapy
->this is for advanced disease
What is the presentation of testicular cancer?
Usually a painless lump
Can be tender, inflamed, swollen
What decade is the peak incidence of testicular cancer?
3rd decade
(20-30)
What are some of the risk factors for testicular cancer?
Undescended testis– 10 x risk
Infertility
Genetic abnormalities
Chromosomal abnormalities
Race- Caucasian
Which syndrome increases risks of testicular cancer?
Klinefelter syndrome
If there is a lump in the testis, it is considered to be a testicular tumour until proven otherwise. What are some differential diagnosis’?
Infection
Epidydimal cyst
Missed testicular torsion
What tests should be considered for someone with a lump in the testis?
MSSU
STI screen
Tumour markers
What is the most important imaging investigation in the diagnosis of testicular cancer?
Testicular ultrasound
What are the three main tumour markers indicative of testicular cancer?
AFP
HCG
LDH
-> in 70% of testicular cancers, at least one will be abnormal
For testicular cancer, the main lymphatic spread to regional lymph nodes occurs in which group of lymph nodes?
Para-aortic lymph nodes
What is the treatment for testicular cancer?
Radical orchidectomy using an inguinal incision
Why is biopsy of testicular mass not carried out?
Risk of tumour seedling across biopsy tract
What type of tumour makes up 95% of testicular cancers?
Germ cell tumour
->other 5% are non-germ cell tumours
What are the three ways testicular cancer can spread?
Local spread e.g. local invasion
Regional spread to para-aortic lymph nodes
Distant spread e.g. lungs, bone, liver
Stage 1 testicular cancer?
Disease confined to testes
Stage 2 testicular cancer?
Infra-diaphragmatic para-aortic lymph nodes involved
Stage 3 testicular cancer?
Supra-diaphragmatic para-aortic lymph nodes involved
Stage 4 testicular cancer?
Extra-lymphatic disease involving solid organs e.g. lungs, liver and bone
What is the treatment for metastatic testicular cancer?
Chemotherapy
What are urothelial tumours?
Malignant tumours of the lining transitional cell epithelium which can occur at any point in the urinary tract
Where is the most common site for urothelial tumours?
Bladder-90%
What is the usual tumour type of bladder cancer?
Transitional cell carcinoma
In countries where schistosomiasis is endemic, e.g. Sub-Saharan Africam what is the most common tumour of the bladder?
Squamous cell carcinoma
What are some risk factors for transitional cell carcinoma?
Smoking
Aromatic amines
Non-hereditary genetic abnormalities
What are some of the risks factors for squamous cell carcinoma?
Schistosomiasis
Chronic cystitis
Cyclophosphamide therapy
Pelvic radiotherapy
What is the most common presenting feature of bladder cancer?
Painless visible haematuria
What are some other presenting features of bladder cancer?
Recurrent UTI’s
Storage bladder symptoms e.g. dysuria, frequency, urgency, incontinence
Bladder pain
What is the first step if a patient presents with haematuria?
Urine culture to rule out infection
What other investigations are used to investigate haematuria?
Upper tract imaging e.g. ultrasound for kidneys, CT urogram for ureters
Urine cytology
BP, U&E’s
Above what age is frank haematuria suggestive of nalignancy?
> 50
If someone above 50 has frank haematuria, what should be done?
Flexible cystourethroscopy within two weeks
IVU and ultrasound
In a patient over 50 with microscopic haematuria, what should be done next?
Flexible cystourethroscopy within 4-6wks
Ultrasound
What is meant by carcinoma is situ?
Cells at the base of the membrane have changed their appearance but are not truly invading yet
If a bladder cancer was given the stage Ta, what does this mean?
Cancer is superficial and does not invade the lamina propria
If a bladder cancer was given the stage T1, what does this mean?
Cancer is through the lamina propria but not invading the detrusor muscle
If a bladder cancer was given the stage T2, what does this mean?
Cancer going into detrusor muscle
If a bladder cancer was given the stage T3, what does this mean?
Cancer spreading more though detrusor muscle
If a bladder cancer was given the stage T4, what does this mean?
Bladder cancer is spreading to other organs
What is the treatment for bladder cancer if it is low grade and non-muscle invasive?
Endoscopic resection followed by single instillation of chemotherapy
What is the treatment for bladder cancer if it is high grade and non-muscle invasive?
Intravesical BCG
->Endoscopic resection alone not sufficient
BCG is same as vaccine for TB as allows bladder to fight it’s own cancer
What is the treatment for muscle invasive bladder cancer?
Neoadjuvant chemotherapy followed by radical radiotherapy and/or radical cystoprostatectomy in men and hysterectomy in women
What is the prognosis like for:
a. non-invasive low-grade bladder cancer
b. invasive, high-grade bladder cancer
a. 90% 5yr survival
b. 50% 5yr survival
What are the symptoms of upper tract urothelial cancers?
Frank haematuria
Unilateral ureteric obstruction
Flank or loin pain
What are the diagnostic investigations for upper tract urothelial cancers?
CT-IVU or IVU
Urine cytology
Ureteroscopy and biopsy
Where is the commonest site for upper tract urothelial cancers?
Renal pelvis or collecting system
Name two types of benign renal cancers.
Oncocytoma
Angiomyolipoma
What is the most common malignant renal tumour
Renal carcinoma
Where do most renal adenocarcinomas arise from?
Proximal tubules
What are some of the risk factors for renal adenocarcinoma?
Family history
Smoking
Anti-hypertensive medication
Obesity
End-stage renal failure
Acquired renal cystic disease
What is the presentation of renal adenocarcinoma?
50% asymptomatic
10% classic triad of flank pain, mass and haematuria
How can renal adenocarcinomas spread?
Direct invasion through the renal capsule
Venous invasion to renal vein and vena cava
Where can hematogenous spread of renal adenocarcinoma spread to?
Lungs and bone most commonly
What investigations are used in renal adenocarcinomas?
CT scan of abdomen and chest mandatory
Bloods; U&E’s, FBC
What is the treatment of renal adenocarcinoma?
Surgery- radical nephrectomy
