Tumours Of The Urinary System Flashcards
What are the common sites of urothelial tumours?
Most common site is bladder but can occur anywhere from renal calyces to the tip of the urethra
What are the types of bladder cancer?
90% transitional cell carcinoma
Squamous cell carcinoma can occur where schistosomiasis is endemic
What are the risk factors for transitional cell carcinoma of the bladder?
Smoking
Aromatic amines (present in paint and dark hair dyes)
Non-hereditary genetic abnormalities
What are the risk factors for squamous cell carcinoma of the bladder?
Schistosomiasis
Chronic cystitis
Cyclophosphamide therapy
Pelvic radiotherapy
What are the presenting symptoms of bladder cancer?
Most common presenting symptom is painless visible haematuria
Recurrent UTIs
Storage bladder problems- dysuria, frequency, bladder pain
How is haematuria investigates?
Urine culture
Upper tract imaging
Cystourethroscopy
Urine cytology
How is bladder cancer diagnosed?
Cystoscopy and endoscopic resection
Examination under anaesthetic to assess bladder mass/thickening before and after surgery
How is bladder cancer staging investigated?
Cross-sectional imaging (CT/MRI)
Bone scan if symptomatic
CTU for upper tract TCC
How is bladder cancer treated?
Endoscopic or radical
How is transitional cell carcinoma graded?
G1- well differentiated, non-invasive
G2- moderately differentiated, often non-invasive
G3- poorly differentiated, often invasive
Carcinoma in situ- non-muscle invasive but very aggressive
How is low grade non-muscle invasive bladder cancer treated?
Endoscopic resection followed by instillation of intravesical chemotherapy
Prolonged endoscopic follow up for moderate grade rumours
Consider prolonged course of intravesical chemotherapy
How is high grade non-muscle invasive bladder cancer treated?
CIS- consider intravesical BCG therapy
Radical surgery may be necessary
How is muscle invasive bladder cancer treated?
Neoadjuvant chemotherapy for local and systemic control, followed by:
Radical radiotherapy
Radical cystoprostatectomy
AND/OR
Radical surgery combined with urinary diversion
What is the prognosis of bladder cancer dependent on?
Stage Grade Size Multifocality Presence of concurrent CIS Recurrence at 3 months
What are the presenting factors of upper tract urothelial cancer?
Frank haematuria
Unilateral ureteric obstruction
Flank or loin pain
What are the symptoms of nodal or metastatic disease?
Bone pain
Hypercalcaemia
Lung symptoms
Brain symptoms
What are the diagnostic investigations for upper tract urothelial cancer?
CT-IVU or IVU- shows filling defect in renal pelvis
Urine cytology
Ureteroscopy and biopsy
Where is upper tract urothelial cancer most common?
In the renal pelvis or collecting system
How is upper tract urothelial cancer treated?
Most TCC’s treated with nephro-ureterectomy
If unfit or has bilateral disease, nephron sparing endoscopic treatment
If unifocal and low grade- relative indication for endoscopic treatment
What are the different kinds of renal tumour?
Benign- oncocytoma, angiomyolipoma
Malignant- renal adenocarcinoma
What are the risk factors for renal adenocarcinoma?
Family history Smoking Anti-hypertensive medication Obesity End-stage renal failure Acquired renal cystic disease
How does renal adenocarcinoma present?
~50% asymptomatic
Classic triad- flank pain, mass and haematuria
Paraneoplastic syndrome- anorexia, cachexia, pyrexia, hypertension, hypercalcemia, abnormal LFTs, anaemia, polycythaemia and raised ESR
Metastatic symptoms
Where are the common sites for metastases of renal adenocarcinoma?
Bone
Brain
Lungs
Liver
How is renal cancer staged?
T1- tumour <7cm and confined within renal capsule
T2- tumour >7cm and 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
What are the mechanisms for spread of renal adenocarcinoma?
Direct spread through the renal capsule
Venous invasion to renal vein and vena cava
Haematogenous spread to lungs and bone
Lymphatic spread to paracaval nodes
How is renal adenocarcinoma investigated?
CT scan of abdomen and Chest
Bloods- U&E, FBC
Optional:
- ultrasound can differentiate tumour from cyst
How is renal adenocarcinoma treated?
Surgically- radical nephrectomy
How can metastatic renal adenocarcinoma he managed?
Palliative cytoreductive nephrectomy
Little treatment as RCC is radioresistant and chemoresistant
Can give multitargeted receptor tyrosine kinase inhibitors or immunotherapy
What are the risk factors for prostate cancer?
Age Race/ethnicity Geography Family history (first degree relative 2x risk) HPC1, BRCA1 and BRCA2 genes
How does prostate cancer usually present?
Most newly diagnosed prostate cancers are localised and asymptomatic
Diagnosed through opportunistic PSA testing
What is the diagnostic triad for prostate cancer?
PSA
Abnormal digital rectal examination
TRUS-guided prostate biopsies
What are the symptoms of local prostate cancer?
Weak stream Hesitancy Sensation of incomplete emptying Frequency Urgency Urge incontinence UTI
What are the symptoms of locally invasive prostate cancer?
Haematuria Perineal and suprapubic pain Impotence Incontinence Loin pain or anuria Symptoms of renal failure Haemospermia Rectal symptoms
What are the symptoms of metastases in prostate cancer?
Bone pain or sciatica Paraplegia secondary to spinal cord compression Lymph node enlargement Lymphoedema, particularly in lower limbs Loin pain or anuria Lethargy Weight loss Cachexia
What are the potential causes of an increased PSA/
UTI Chronic prostatitis Instrumentation (eg catheterisation) Physiological (eg ejaculation) Recent urological procedure BPH Prostate cancer
How is prostate cancer graded?
Gleason sum score-
number of highest area added to number of second highest area are added together for a score
Changing to ISUP grade groups
What are the stages of prostate cancer?
Localised stage
Locally advanced stage
Metastatic stage
Hormone refractory stage
What investigations can be used to stage prostate cancer?
Digital rectal examination PSA Transrectal US guided biopsies CT MRI
How is localised prostate cancer staged?
T2a- <50% of one lobe T2b- >50% of one lobe T2c- affects both lobes T3- invades spermatic cord T4- invades surrounding structures
How is localised prostate cancer managed?
Watchful waiting
Radiotherapy- external beam or brachytherapy
Radical prostatectomy- robotic
How is locally advanced prostate cancer managed?
Watchful waiting
Hormone therapy than can be followed by surgery or radiation
What are the possible types of hormonal therapy for prostate cancer?
Surgical castration
Chemical castration- LHRH analogues
Anti-androgens
Oestrogens
How is metastatic and hormone refractory prostate cancer managed?
Immediate hormonal therapy
Supportive treatment can be palliative radiotherapy, colostomy, nephrostomy, zoledronic acid or palliative care support
How does testicular cancer present?
Most commonly- painless lump Less common: -Tender inflamed swelling -History of trauma causing excess pain -Symptoms/signs from nodal or distant metastases
What are the risk factors for testicular cancer?
Peak incidence in third decade
Higher risk in caucasians
Risk higher in infertility, atrophic testis and previous cancer in testis
What are the different tumour markers that can be present in testicular cancer?
AFP (alpfa-fetoprotein)- teratoma
BetaHCG (human chorionic gonadotrophin)- seminoma
LDH (lactate dehydrogenase)- non-specific marker of tumour
How is a lump in the testis managed?
Testicular tumour until proven otherwise Can also be: -Infection -Epididymal cyst -Missed testicular torsion
How should a testicular lump be investigated?
MSSU
Testicular ultrasound scan and chest X-ray
Tumour markers
How is testicular cancer managed?
Radical orchidectomy essential
May need biopsy of contralateral testis if high risk for tumour
Further treatment depends on tumour type, stage and grade
Which group of lymph nodes does the main lymphatic spread of testicular cancer spread to?
Para-aortic lymph nodes
Describe the pathology of testicular cancer
95% germ cell tumour
Seminoma mainly affects 30-40 year olds
Non-seminomas mainly affect 20-30 year olds
How is testicular cancer staged?
Stage I- disease is confined to the testis
Stage II- Infradiaphragmatic nodes involved
Stage III- supradiaphragmatic nodes involved
Stage IV- extralymphatic disease
How is testicular cancer treated post-orchidectomy?
Low stage, negative markers: -Surveillance -Adjuvant radiotherapy -Prophylactic chemotherapy Nodal disease, persistent tumour markers or relapse on surveillance: -Combination chemotherapy -Lymph node dissection Metastases: -First-line chemotherapy -Second-line chemotherapy
