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Urinary System > Tumours of the Urinary System > Flashcards

Tumours of the Urinary System Flashcards

1
Q

What are the potential sites of urothelial tumours?

A

Malignant tumours of the transitional cell epithelium lining (urothelium) can occur at any point from the renal calyces to the tip of the urethra
Most common site is the bladder

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2
Q

What percentage of urothelial tumours are of the bladder?

A

90%

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3
Q

What is the most common tumour type in bladder cancer?

A

Tumour type most often a transitional cell carcinoma

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4
Q

When is squamous cell carcinoma of the bladder common?

A

In areas where schistosomiasis is endemic

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5
Q

What are the risk factors for transitional cell carcinoma?

A

Smoking
Aromatic amines
Non-hereditary genetic abnormalities e.g. TSG, including p53 and Rb

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6
Q

What percentage of cases of transitional cell carcinoma does smoking account for?

A

40%

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7
Q

How does smoking affect the risk of recurrence of transitional cell carcinoma?

A

Tendency for TCC to recur, with higher recurrence risk in patients who continue to smoke

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8
Q

What are the risk factors for squamous cell carcinoma of the bladder?

A

Schistosomiasis - S. haematobium only
Chronic cystitis e.g. recurrent UTI, long-term catheter, bladder stone
Cyclophosphamide therapy
Pelvic radiotherapy

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9
Q

What is the presentation of bladder cancer?

A

Most frequent presenting symptom is painless visible haematuria
Occasionally, symptoms due to invasive or metastatic disease may be present
Haematuria may be frank or microscopic
Recurrent UTI
Storage bladder symptoms e.g. dysuria, nocturia, urgency +/- urge incontinence

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10
Q

What tumour type should be suspected if storage bladder symptoms are present?

A

Carcinoma in situ

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11
Q

What is the investigation of haematuria?

A

Urine culture (majority of painful haematuria will be UTI)
Cystourethroscopy
Upper tract imaging - intravenous urogram, US
Urine cytology
BP and U&Es

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12
Q

What is the risk of malignancy in > 50s with frank haematuria?

A

25-35%

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13
Q

What is the investigation of frank haematuria in over 50s?

A

Flexible cystourethroscopy within 2 weeks
IVU and USS (or CT-IVU)
Urine cytology - not very sensitive or specific so not routinely done

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14
Q

What is the risk of malignancy in > 50s with microscopic haematuria?

A

5-10%

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15
Q

What is the investigation of dipstix or microscopic haematuria in over 50s?

A

Flexible cystourethroscopy within 4-6 weeks

IVU and USS

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16
Q

What will IVU alone miss?

A

A proportion of renal cell tumours, especially those < 3cm

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17
Q

What will USS alone miss?

A

A proportion of urothelial tumours of the upper tract

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18
Q

How are urothelial tumours of the bladder assessed?

A

Grade and T stage
Cystoscopy and endoscopic resection
EUA to assess bladder mass thickening before and after TURBT

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19
Q

How are urothelial tumours of the bladder staged?

A

T, N and M stage
Cross sectional imaging - CT or MRI
Bone scan if symptomatic
IVU for upper tract TCC

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20
Q

What are the treatment options for urothelial tumours of the bladder?

A

Endoscopic or radical

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21
Q

How are bladder tumours classified?

A

Grade of tumour
Stage of tumour - TNM classification, T-stage; non-muscle invasive or muscle invasive
Combined to describe TCC e.g. G1pTa

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22
Q

What are the grades of TCC (WHO 1973)?

A

G1 - well differentiated, commonly non-invasive
G2 - moderately differentiated, often non-invasive
G3 - poorly differentiated, often invasive

Carcinoma in situ - non-muscle invasive but very aggressive

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23
Q

What does the treatment of bladder cancer depend on?

A

Site
Clinical stage
Histological grade of tumour
Patient age and co-morbidities

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24
Q

What is the treatment of low grade non-muscle invasive bladder cancer, e.g. Ta or T1?

A

Endoscopic resection followed by a single instillation of intravesical chemotherapy (mitomycin C) within 24 hours

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25
Q

What is the treatment for moderate grade bladder cancer?

A

Endoscopic resection followed by a single instillation of intravesical chemotherapy (mitomycin C) within 24 hours plus prolonged endoscopic follow-up

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26
Q

When should you consider a prolonged course of intravesical chemotherapy?

A

For repeated recurrences (6 weeks - 6 months)

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27
Q

What is the treatment of high grade non-muscle invasive cancer or CIS of the bladder?

A

Very aggressive treatment, endoscopic resection alone is not sufficient

Intravesical BCG therapy - maintenance course, weekly for 3 weeks, repeated 6 monthly over 3 weeks

Patients refractory to BCG need radical surgery

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28
Q

What is the risk of progression to muscle invasive stage of high grade non-muscle invasive cancer of the bladder?

A

50-80% risk of progression to muscle invasive stage

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29
Q

How does BCG work?

A

By inducing immunomodulatory tumour cell killing - mediated by natural killer cells and cytokines, especially IL-2

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30
Q

What is the risk of systemic BCG with BCG therapy?

A

1% risk - similar to TB, treated with anti-tuberculosis drugs

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31
Q

What is the treatment of muscle invasive bladder cancer e.g. T2-T3?

A

Neoadjuvant chemotherapy for local tumour - down-staging and systemic control
Followed by
Radical radiotherapy and/or radical cystoprostatectomy for men or anterior pelvic exenteration with urethrectomy in women, with extended lymphadenectomy

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32
Q

What is radical surgery for muscle invasive bladder cancer combined with?

A

Radical surgery is combined with incontinent urinary diversion i.e. ileal conduit, continent diversion e.g. bowel pouch with catheterisable stoma or othrotopic bladder substitution

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33
Q

What does the prognosis of bladder cancer depend on?

A 
Stage
Grade
Size
Multi-focality 
Presence of concurrent CIS 
Recurrence at 3 months
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34
Q

What is the 5-year survival of non-invasive low grade bladder TCC?

A

90%

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35
Q

What is the 5-year survival of invasive high grade bladder TCC?

A

50%

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36
Q

What is the presentation of upper urinary tract transitional cell carcinoma?

A

Frank haematuria
Unilateral ureteric obstruction
Flank or loin pain
Symptoms of nodal or metastatic disease e.g. bone pain, hyperclacaemia, lung/brain symptoms

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37
Q

What are the diagnostic investigations for upper urinary tract transitional cell carcinoma?

A

CT-ICU or IVU - shows filling defect in renal pelvis
Urine cytology
Ureteroscopy and biopsy and histology

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38
Q

What are the commonest sites of upper tract TCC?

A

Renal pelvis or collecting system commonest

Ureter less commonly

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39
Q

What are the typical characteristic of upper tract TCC?

A

Tumours are often high grade and multi-focal on one side

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40
Q

When is there a high risk of local recurrence of upper tract TCC?

A

If treated endoscopically or by segmental resection

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41
Q

Is the risk of contralateral disease low or high with upper tract TCC?

A

Low risk

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42
Q

When is upper tract TCC difficult to follow up?

A

If treated endoscopically

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43
Q

How are most upper tract TCCs treated?

A

Nephro-ureterectomy

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44
Q

What is the treatment of upper tract TCCs in patients unfit for nephro-ureterectomy or with bilateral disease?

A

Absolute indication for nephron-sparing endoscopic treatment e.g. ureteroscopic laser ablation
Need regular surveillance ureteroscopy

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45
Q

When is there a relative indication for endoscopic treatment of upper tract TCCs?

A

If unifocal and low-grade disease

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46
Q

What is there a high risk of in all cases of upper tract TCCs?

A

Synchronous and metachronous bladder TCC

Surveillance cystoscopy is needed

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47
Q

What is the risk of synchronous and metachronous bladder TCC in upper tract TCC?

A

40% over 10 years

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48
Q

What are the benign tumours in renal cancer?

A

Oncocytoma

Angiomyolipoma

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49
Q

What are the malignant tumours in renal cancer?

A

Renal adenocarcinoma - most common adult renal malignancy

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50
Q

What are the histological subtypes of renal cancer?

A

Clear cell 85%
Papillary 10%
Chromophobe 4%
Bellini type ductal carcinoma 1%

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51
Q

What are the risk factors for renal adenocarcinoma?

A 
Family history - autosomal dominant e.g. familial clear cell RCC, hereditary papillary RCC
Smoking 
Anti-hypertensive medication
Obesity 
End-stage renal failure 
Acquired renal cystic disease
52
Q

What is the presentation of renal adenocarcinoma?

A

Asymptomatic in 50%

Classic triad of flank pain, mass and haematuria in 10%

Paraneoplastic syndrome in 30%

  • anorexia, cachexia and pyrexia
  • hypertension, hypercalcaemia and abnormal LFTs
  • anaemia, polycythaemia and raised ESR

Metastatic disease in 30% - bone, brain, lungs, liver

53
Q

What are the modes of spread of renal adenocarcinoma?

A

Direct - through renal capsule
Venous - to renal vein and vena cava
Lymphatic - to nodes
Haematogenous - to bone and lungs

54
Q

What are the T stages of the TNM classification of renal cancer?

A

T1 - tumour < 7cm confined within renal capsule
T2 - tumour > 7cm confined within renal capsule
T3 - local extension outside capsule
T3a - into adrenal or peri-renal fat
T3b - into renal vein or IVC below diaphragm
T3c - tumour thrombus in IVC extends above diaphragm
T4 - tumour invades beyond Gerota’s fascia

55
Q

What is the investigation of renal adenocarcinoma?

A 
CT scan (triple phase) of abdomen and chest - mandatory, provides radiological diagnosis and complete TNM staging, and assesses contralateral kidney 
Bloods - U&amp;Es and FBC

Optional tests:
IVU - shows calyces distortion and soft tissue mass
Ultrasound - differentiated tumour from cyst
DMSA or MAG-3 renogram to assess split renal function if doubts about contralateral kidney

56
Q

What is the treatment of renal adenocarcinoma?

A

Surgical - radical nephrectomy
Laparoscopic radical nephrectomy is standard for T1 tumours or T2 tumours in laparoscopic centres
Worthwhile even with major venous invasion i.e. T3b or higher
Curative if T2 or lower

57
Q

What is the treatment of renal adenocarcinoma in patients with metastatic disease who have symptoms from the primary tumour?

A

Palliative cytoreductive nephrectomy is beneficial, prolongs median survival by 6 months

58
Q

What is the treatment of metastases in renal adenocarcinoma?

A

Little effective treatment since RCC is radio-resistant and chemo-resistant
Immunotherapy - interferon alpha, interleukin 2
Multi-targeted receptor tyrosine kinase inhibitors

Rare spontaneous regression of metastases may occur following nephrectomy

59
Q

What is the response rate to immunotherapy in treatment of metastases in renal cancer?

A

20% at most with either interferon alpha or interleukin 2

60
Q

Give an example of a multi-targeted receptor tyrosine kinase inhibitor?

A

Sunitinib
Sorafenib
Temsirolimus

Superior response rates than to immunotherapy but no improvement in survival

61
Q

What is the 5 year survival of stage T1 renal adenocarcinoma?

A

95%

62
Q

What is the 5 year survival of stage T2 renal adenocarcinoma?

A

90%

63
Q

What is the 5 year survival of stage T3 renal adenocarcinoma?

A

60%

64
Q

What is the 5 year survival of stage T4 renal adenocarcinoma?

A

20%

65
Q

What is the 5 year survival of stage N1 or N2 renal adenocarcinoma?

A

20%

66
Q

What is the survival of stage M1 renal adenocarcinoma?

A

12-18 months median survival

67
Q

How many new cases of prostate cancer are there per year in the UK?

A

41,000

68
Q

How many cases of prostate cancer are there per 100,000 men per year?

A

134 cases per 100,000 men/year

69
Q

What percentage of new cases of prostate cancer are in men aged > 65?

A

75%

70
Q

What percentage of new cases of prostate cancer are in men aged < 50?

A

1%

71
Q

What percentage of new cases of prostate cancer are in men aged < 70?

A

45%

72
Q

What are the risk factors for prostate cancer?

A 
Age
Race/ethnicity 
Geography 
Family history - HPC1, BRCA1 and 2 
Diet 
Drugs
73
Q

What is the increase in risk of prostate cancer in men with a first-degree relative with prostate cancer?

A

Relative 2x risk

74
Q

What foods/dietary components have an effect on prostate cancer risk?

A

Selenium
Lycopene
Vitamin E
Omega 3 fatty acid

75
Q

What effect does finasteride/dutasteride have on the risk of prostate cancer?

A

Relative risk reduction of 25-30% but higher risk of developing higher grade prostate cancer

76
Q

How is prostate cancer diagnosed?

A

Diagnostic triad of PSA, digital rectal examination and TRUS-guided prostate biopsies

(remember PSA is prostate-specific but not necessarily cancer-specific)

77
Q

What is the presentation of local disease prostate cancer?

A 
Weak stream 
Hesitancy 
Sensation of incomplete emptying 
Frequency 
Urgency 
Urge incontinence
UTI
78
Q

What percentage of newly diagnosed prostate cancers are localised?

A

80%

79
Q

What is the presentation of locally invasive prostate cancer?

A 
Haematuria
Perineal and suprapubic pain 
Impotence
Incontinence
Loin pain or anuria resulting from obstruction of the ureters
Symptoms of renal failure 
Haemospermia
Rectal symptoms, including tenesmus
80
Q

What is the presentation of metastatic prostate cancer, with distant metastases?

A

Bone pain or sciatica
Paraplegia secondary to spinal cord compression
Lymph node enlargement
Lymphoedema, particularly in the lower limbs
Loin pain or anuria due to obstruction of the ureters by lymph nodes

81
Q

What is the presentation of metastatic prostate cancer with widespread metastases?

A

Lethargy
Weight loss
Cachexia

82
Q

How is prostate cancer diagnosed in a symptomatic male?

A

PSA - prostate specific antigen
DRE
Transrectal ultrasound and needle biopsy
Incidental finding at TURP

83
Q

What produces PSA?

A

Glands of prostate

84
Q

What is the normal serum range of PSA?

A

0-4.0 ug/mL

85
Q

What is the serum range of PSA in < 50s?

A

2.5x upper limit

86
Q

What is the serum range of PSA in 50-60 years?

A

3.5x upper limit

87
Q

What is the serum range of PSA in 60-70 years?

A

4.5x upper limit

88
Q

What is the serum range of PSA in > 70s?

A

6.5x upper limit

89
Q

What are the causes of elevated PSA?

A 
UTI 
Chronic prostatitis 
Instrumentation 
Physiological 
Recent urological procedure 
BPH 
Prostate cancer
90
Q

What is the half-life of PSA?

A

2.2 days

91
Q

When should you re-check PSA if a repeat test is needed?

A

In 3 weeks

92
Q 
What is the probability of cancer based on PSA levels;
0-1.0
1.0-2.5
2.5-4.0
4.0-10
> 10?
A 
0-1.0 - 5%
1.0-2.5 - 15%
2.5-4.0 - 25%
4.0-10 - 40%
> 10 - 70%
93
Q

What is the risk of death from prostate cancer within 15 years according to the Gleason Score?

A 
Score 2-4 - risk 4-7% 
Score 5 - risk 6-11%
Score 6 - risk 18-30% 
Score 7 - risk 42-70% 
Score 8-10 - risk 60-87%
94
Q

For the purposes of treatment and prognosis, what 4 categories is prostate cancer divided into?

A

Localised stage
Locally advanced stage
Metastatic stage
Hormone refractory stage

95
Q

How is localised prostate cancer staged?

A 
DRE
PSA
Transrectal US guided biopsy
CT
MRI
96
Q

What is the treatment for localised prostate cancer?

A

Watchful waiting
Radiotherapy - external beam, brachytherapy
Radical prostatectomy - open, laparoscopic, robotic

Cryotherapy and thermotherapy treatments under investigation

97
Q

What is the treatment of locally advanced prostate cancer?

A

Watchful waiting
Hormone therapy alone
Hormone therapy followed by surgery or radiation
Intermittent hormone therapy

98
Q

What are the types of hormone therapy for prostate cancer?

A

Surgical castration - bilateral orchidectomy
Chemical castration - LHRH analogue
Anti-androgens
Oestrogens

99
Q

What are the potential complications of metastatic and hormone refractory prostate cancer?

A

Bone - pain, pathological fractures, anaemia, spinal cord compression
Rectal - constipation, bowel obstruction
Ureteric - obstruction resulting in renal failure
Pelvic lymphatic obstruction - lymphoedema, DVT
Lower urinary tract dysfunction - haematuria, acute retention

100
Q

What is the mainstay of treatment for metastatic and hormone refractory prostate cancer?

A

Immediate hormone therapy

Supportive treatment e.g. palliative radiotherapy to bony metastases, palliative care support may also be given

101
Q

When will the hormone refractory stage of prostate cancer be reached?

A

In 18-24 months of treatment

102
Q

What are the complications of diethylboestrol?

A

High risk of thromboembolic and cardiovascular complications

103
Q

What is the survival benefit of docetaxel?

A

3 months

104
Q

What is the presentation of testicular cancer?

A

Usually a painless lump
Tender inflamed swelling
History of trauma
Symptoms/signs from nodal or distant metastases

105
Q

When is the peak incidence of testicular cancer?

A

3rd decade

106
Q

When is there a higher risk of testicular cancer?

A

Testicular maldescent
Infertility
Atrophic testis
Previous cancer in contralateral testis

107
Q

What is a precursor lesion for testicular cancer?

A

Testicular germ cell neoplasia in situ

108
Q

What tumour markers might be present in testicular cancer?

A

Alpha fetoprotein - teratoma
Beta-HCG - seminoma
Lactase dehydrogenase - non-specific marker of tumour burden

109
Q

How is testicular cancer diagnosed?

A

Lump in testis is a testicular tumour until proven otherwise
MSSU
Testicular ultrasound and CXR
Tumour markers

110
Q

What are the differential diagnoses for a lump in the testis?

A

Infection
Epididymal cyst
Missed testicular torsion

111
Q

What is the treatment of testicular cancer?

A

Radical orchidectomy is essential
Occasionally may need biopsy of normal contralateral testis, if there is a high risk for another tumour
Further treatment depends on tumour type, stage and grade

112
Q

What percentage of testicular tumours are germ cell tumours?

A

95% germ cell

5% non-germ cell

113
Q

What are the types of germ cell tumours?

A

Seminomatous GCT - classical, spermatocytic or anapaestic

Non-seminomatous GCT - teratoma, yolk sac, choriocarcinoma, mixed GT

114
Q

What are the types of non-germ cell tumour?

A

Leydig
Sertoli
Lymphoma (rare)

115
Q

What age group does seminomatous mainly affect?

A

30-40 year olds

116
Q

What age group does non-seminomatous GCT mainly affect?

A

20-30 year olds

117
Q

How are testicular tumours graded?

A

Based on histological assessment of differentiation
Assessment of aggressiveness
Low grade - well differentiated
High grade - poorly differentiated

118
Q

How are testicular tumours staged?

A

Assessment of spread
Staged using TNM system

Local staging via pathological assessment of orchidectomy specimen
Nodal staging via CT
Distant staging via CT of chest, abdomen and pelvis

Tumour markers can also provide staging and prognostic information

119
Q

What are the ways in which testicular cancer can spread?

A

Local - to adjacent structures
Regional - lymphatic invasion
Distant - to bone, lungs, liver etc.

120
Q

What are the stages of testicular cancer?

A

Stage I - confined to the testis
Stage II - infra-diaphragmatic nodes involved
Stage III - supra-diaphragmatic nodes involved
Stage IV - extra-lymphatic disease

121
Q

What does further treatment for testicular cancer following orchidectomy depend on?

A

Tumour type, stage and grade

122
Q

What is the treatment for testicular cancer with low grade and negative markers?

A

Orchidectomy followed by one of;

  • surveillance
  • adjuvant radiotherapy (SGCT only)
  • prophylactic chemotherapy
123
Q

What is the treatment for testicular cancer with nodal disease, persistent markers or relapse on surveillance?

A

Orchidectomy

Combination chemotherapy or lymph node dissection (NSGCT only)

124
Q

What is the treatment for testicular cancer with metastases?

A

First and second line chemotherapy

125
Q

What is the 5 year survival of stage 1 testicular cancer?

A

99%

126
Q

What is the 5 year survival of stage 2/3 testicular cancer?

A

96^

127
Q

What is the 5 year survival of stage 4 testicular cancer?

A

73%

Urinary System (22 decks)

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