Tumours of the Urinary Tract

Question 1

What are the risk factors for prostate cancer?

Answer 1

• Age,
• Familial and genetic factors - BRCA mutation and TP53.
• Hormones,
• Racial factors,
• Geographical

Question 2

What are the signs and symptoms of prostate cancer?

Answer 2

• Often asymptomatic,
• Painful or slow micturition,
• UTI,
• Haematuria,
• Urinary retention,
• Lymphoedema,
• Metastases can present with bone pain or renal failure
• Raised PSA

Question 3

What are the investigations for prostate cancer?

Answer 3

• Digital rectal examination,
• Prostate specific antigen (although not very specific)
• Trans-rectal ultrasound biopsy (guided needle biopsy)

Question 4

What is the pathology of prostate cancers?

Answer 4

• Majority are adenocarcinomas. They commonly arise in peripheral zones of prostate.
• Graded via Gleasons
  Staged via TNM

Question 5

Describe features of PSA

Answer 5

• It is serine protease which is secreted into seminal fluid. It is responsible for liquifaction of seminal coagulation.
• Small proportion leaks into circulation, however is very dependant on age, prostate size, inflammation, infection. PSA can be raised with stimulation or exercise

Question 6

What are the treatment options for prostate cancer

Answer 6

• Active surveillance,
• Radiotherapy (with or without a LHRH analogue),
• Radical prostatectomy,
• Cryotherapy
• TURP

Question 7

What are the metastatic complications of prostate cancer?

Answer 7

• Spinal cord compression (urological emergency which can present with severe pain, urinary retention or constipation. Required urgent MRI)
• Ureteric obstruction (causes anorexia, weight loss and raised creatinine)

Question 8

What are the treatment options for advanced prostate cancer?

Answer 8

• Androgen ablation therapy (medical castration with LHRH analogue)
• Orchidectomy (surgical castration)
• Chemotherapy
• TURP for symptom relief,
• Radiotherapy

Question 9

What are the risk factors for bladder cancer?

Answer 9

• Age,
• Race,
• Environmental carcinogens,
• Chronic inflammation,
• Drugs eg cyclophosphamide,
• Pelvic radiation,
• Hydrocarbons,
• Smoking (accounts for 50% of bladder cancers)

Question 10

What is the presentation and investigations for bladder cancer?

Answer 10

• Painless, frank haematuria. Although some may present with microscopic haematuria. UTIs and hydronephrosis
• Investigate via cystoscopy, renal ultrasound or KUB.

Question 11

What is the pathology of bladder cancer?

Answer 11

• Most commonly they are transitional cell carcinomas, others include squamous carcinoma or adenocarcinoma.
• Grade 1-3 depends on differentiation.
• Staging is TNM. Muscular invasion has poor prognosis

Question 12

What is the treatment of bladder cancer?

Answer 12

• Once diagnosed an urgent transurethral resection of the bladder tumour is booked,
• Low grade superficial TCC has low risk of progression so flexible cystoscopy in 3 months.
• High grade non muscle invasion bladder cancer: Treat with intravesical BCG immunotherapy and 6 weekly chemotherapy instillations into bladder. Cystectomy if treatment fails
• Muscular invasive bladder cancer requires radicle therapy. Either radicle cystectomy or radiotherapy and neo-adjuvant chemo.

Question 13

What is a radicle cystectomy?

Answer 13

• Bladder and prostate/uterus is removed.
• Urine is diverted into an ileal conduit or orthotopic neobladder (rare)

Question 14

What is the treatment for metastatic bladder cancer?

Answer 14

• Often pulmonary
• Treated with intensive chemo but is normally palliative. M-VAC chemo (methotrexate, vinblastine, doxorubicin and cisplatin)

Question 15

What are the risk factors for renal cancer?

Answer 15

• Smoking,
• Obesity,
• Hypertension,
• Acquired renal cystic disease,
• Haemodialysis,
• Genetics - VHL

Question 16

What is the presentation of renal cancer?

Answer 16

• Incidental,
• Systemic symptoms (night sweats, fever, fatigue, weight loss, haemoptysis).
• Classic triad is mass, pain and haematuria.
• Can present with varicocele, lower limb oedema or paraneoplastic syndrome

Question 17

What are the different paraneoplastic syndromes associated with renal cancer?

Answer 17

• Polycythaemia due to increased EPO production.
• Hypercalcaemia due to PTH like substance or osteolytic
• Hypertension due to excess renin secretion
• Deranged LFTs (Stauffer syndrome due to hepatotoxic tumour products)
• Rare - cushings syndrome,

Question 18

What is the diagnosis and pathology of renal cancers?

Answer 18

Initial diagnosis is via ultrasound, FBC, UEs, LFTs, CRP, bone profile and LDH. Then CT kidneys and renal biopsy and chest X ray.
- Most renal cancers are clear cell carcinomas, some are papillary. Rare cancers include chromophobe, collecting duct and medullary cell.

Question 19

What are the treatments for small and large renal masses?

Answer 19

Large renal mass - Radical nephrectomy (remove of kidney and gerota’s fascia but spares the adrenal gland) if no indication for nephron sparing surgery.
Small renal mass - Nephron sparing surgery (indicated in single kidney, CKD or CV disease), radical nephrectomy or surveillance.
Metastatic disease is treated with tyrosine kinase inhibitors

Question 20

Explain the presentation, investigations and treatment of testicular carcinoma

Answer 20

• Usually presents as a painless lump
• Investigations: scrotal ultrasound, tumour markers, alpha fetoprotein(teratoma and yolk sac tumourss), beta hCG (teratoma or seminoma), LDH.
• Treatment includes radical orchidectomy, chemotherapy, para-aortic nodal radiotherapy and retroperitoneal LN dissection

Question 21

Describe the presentation and treatment for penile cancer

Answer 21

• Rare cancer which is associated with HPV infections and smoking.
• Treatment is circumcision, topical treatments (5FU), lymphadenectomy or chemotherapy