Tumours Of The Urinary Tract Flashcards
What are the risk factors for prostate cancer?
Age - risk increases with age Hormones Racial factors - black Familial and genetic factors - abnormalities on chromosomes 1 and 8 - BRCA2 gene mutations - PTEN and TP53 - tumour suppressor genes Geographic variations - highest in western cultures
What are the signs and symptoms of prostate cancer?
Asymptomatic Painful/slow micturition UTI Haematuria Urinary retention Lymphoedema Metastatic - bone pain - renal failure (ureteric obstruction)
What investigations are used in the diagnosis of prostate cancer?
Digital rectal examination
PSA - prostate specific antigen
TRUS - needle guided biopsy
Where in the prostate do prostate cancers normally arise?
Peripheral zones
What is the Gleason grading system?
Based on the extent to which the tumour cells are arranged into recognisable glandular structures and describes and spectrum of histological malignancies
<4 - well differentiated
5-7 - moderately differentiated
>7 - poorly differentiated
Describe the T staging (in TNM staging) of the prostate.
T1 - tumour can’t be seen with imaging or felt on DRE (incidental finding by transrectal US)
T2 - can be felt by DRE or seen on TRUS, but confined to the prostate
T3 - cancer has grown outside the prostate, possibly into the seminal vesicles
Describe the N staging (in TNM staging) of the prostate.
N0 - not spread to any nearby lymph nodes
N1 - cancer has spread to one or more nearby lymph ndoes
Describe the M staging (in TNM staging) of the prostate.
M0 - cancer hasn’t spread beyond nearby lymph nodes
M1 - cancer has spread beyond nearby lymph nodes
How does the prostate specific antigen help assess the prostate?
Serine protease is secreted into seminal fluid
- responsible for the liquefaction of seminal coagulation Small proportional leaks into circulation
Tissue, not tumour specific
What is the normal level of PSA?
50-59 >3ng/ml
60-69 >4ng/ml
70-79 >5 ng/ml
What is the treatment for localised prostate cancer?
Waiting Radiotherapy - external beam - conformal - brachytherapy Radical prostatectomy Cryotherapy TURP if symptomatic
What are the metastatic complications of prostate cancer, and how are they treated?
Spinal cord compression - severe pain - retention - urgent MRI - radiotherapy vs spinal decompression surgery Ureteric obstruction - anorexia, weight loss, raised creatinine - nephrostomise or stenting
What are the treatment options for advanced prostate cancer?
Androgen ablation therapy - medical castration (LHRH analogue) Surgical castration TURP for symptom relief Chemotherapy Radiotherapy
What are the risk factors for bladder cancer?
Age - common in 80s Race - white Environmental carcinogens Chronic inflammation - stones, infection, long term catheters Drugs - phenacitin - cyclophsophamide Pelvic radiotherapy Smoking
How does bladder cancer present?
Painless frank haematuria Microscopic haematuria (5% of cases)
How is bladder cancer diagnosed?
Cystoscopy
Renal USS/KUB
Which types of bladder cancer are the most common?
Transitional cell carcinoma (90%) - superficial 75% - invasive - 25% Squamous carcinoma (5%) Adenocarcinoma (2%) Metastatic
What is the grading system for bladder cancer?
Grade 1 - well differentiated
Grade 2 - moderately differentiated
Grade 3 - poorly differentiated
Carcinoma in situ
Describe the tumour staging for bladder cancer.
Tis - carcinoma in situ
Ta - noninvasive papillary carcinoma
T1 - invasion of the lamina propria
T2 - invasion of the muscle layer of the bladder wall
T3 - tumour has spread into the perivesical tissue (fatty tissue surrounding the bladder)
T4 - tumours has spread to the (a) abdominal wall, pelvic wall or (b) prostate/seminal vesicles or uterus/vagina
What is the treatment for bladder cancer?
Urgent trans-urethral resection of bladder tumour
CT IVU
Bimanual examination carrier out
Intravesicle mitomycin reduces risk of recurrence
How is a low grade superficial (non-invasive papillary tumour) treated?
Low risk of progression
- flexible check cystoscopy every 3 months
6 weekly course of mitomycin treatments for persistent tumours
How is a high grade, non-muscle invasive bladder cancer treated?
50% chance of progression to muscle invasive disease
Cystoscopy and re-biopsy
Treat with intravesical BCG immunotherapy
- 6 weeks
- then further cystosopy and biopsy
Cystectomy if treatment fails
How is muscle invasive bladder cancer treated?
Requires radical therapy
- cystectomy or radiotherapy
Radiotheapy doesn’t work well if there is multifocal disease or widespread CIS
Neo-adjuvant chemotherapy
How is metastatic bladder cancer treated?
Often pulmonary Treated with chemotherapy - M-VAC - methotrexate, vinblastine, doxorubicin and cisplatin - highly toxic Gemicitobine and docetaxel
What are the different types of renal tumour?
Renal cell carcinoma (85%)
Transitional cell carcinoma
Sarcoma
Metastases
What are the risk factors for renal cell carcinoma?
Smoking Obesity Hypertension Acquired renal cystic disease Haemodialysis Genetics - VHL, HPRCC, tuberous sclerosis
How do renal carcinomas present?
80% incidental 25% systemic symptoms - night sweats - fever - fatigue - weight loss - haemoptysis 10% classic triad - mass, pain and haematuria Varicocele Lower limb oedema Paraneoplastic syndrome
Name the paraneoplastic syndomes.
Polycythaemia (from increased EPO) Hypercalcaemia (PTH like substance) Hypertension (renin secretion) Deranged LFTs ACTH, prolactin, insulin and gonadotrophins ( all rare)
How is the initial diagnosis of renal cell carcinoma made?
US FBC, UEs, LFTs, CRP, bone profile and LDH CT kidneys MRI Renal biopsy CT chest - mets
Describe the tumours staging of renal cell carcinomas.
T1 - <7cm
T2 - >7cm
T3 - enters the renal vein/IVC
T4 - extends beyond the Gerota fascia
How is a large renal mass treated?
Radical nephrectomy
- removal of kidney and Gerota’s fascia (sparing the adrenal gland)
How are small renal masses treated?
Biopsy Nephron sparing surgery (partial neprectomy or cryotherapy) - when it affects a single kidney - CKD - CV risk factors - T1a tumours Radical nephrectomy Surveillance
How are metastatic renal cell carincomas treated?
Tyrosine Kinase Inhibitor
What are the risk factors for testicular cancer?
Age 20-45
Cryptorchidism
HIV
Caucasian
How does testicular cancer present?
Painless lump
Often found after incidental trauma
What are the investigations for testicular cancer?
Scrotal US Tumour markers - alpha feroprotein - beta hCG - LDH
What are the different classifications of testicular cancers?
Germ cell - seminoma - teratoma - mixed - yolk sac Stromal tumours - leydig - sertoli Other - lymphoma - metastasis
What is the treatment for testicular cancer?
Radical orchidectomy
Chemotherapy
Para-aortic nodal radiotherapy
Retroperitoneal lymph node dissection
What is the treatment for penile cancer?
Circumcision Topical treatment CO2/5FU Penectomy and reconstruction Lymphadenectomy Chemo/radiotherapy
