Urinary: Cancer & APCKD Flashcards
How does renal cell carcinoma present?
- Localised or advanced
- Haematuria
- Incidental finding on imaging
- Palpable mass is rare
If advanced
- Large varicoele may be present
- Pulmonary/tumour embolus
- Loss of weight/loss of appetite
- Hypercalcaemia
How does a transitional cell carcinoma present?
- Localised
- Haematuria
- Incidental finding on imaging
If advanced
- Loss of weight/loss of apetite/symptom of metastasis
- DVT
- Lymphoedema
What is the percentage of patient with visible haematuria and over 45 that present with cancer?
20%
What is the history undertaken if cancer in urinary tract is suspected?
- Smoking history
- Occupation history
- Painful or painless – painless is more worrying from a cancer point of view. Painful is likely external
- Other LUTS – beginning of steream. Prostate cancer
- Family history
What is the examination undertaken if cancer in urinary tract is suspected?
- BP
- Abdominal mass – ulickly to be cancer
- Varicocele
- Leg swelling – lympadema (blockage of lymph node by cancer)
- Asses prostate by DRE (Size, Texture)
What are the types of test undertaken for haematuria?
- Radiology
- Endoscopy
- Urine
- Blood tests
What are the radiological test performed in haematuria?
- Ultrasound (can pick up bladder cancer but not the smallest of cancer)
- CT (need good kidney function to be able to inject contrast)
What is an example of an endoscopic test?
-Flexible cystoscopy to look inside the bladder
What are the Urine tests done?
- Culture and sensitivity
- Cytology
Describe the epidemiology of Renal Cell Carcinoma.
- 7th most common cancer in Uk
- 95% of all upper urinary tract tumours
- Rising incidence and mortality
- Common in men and whites
- 30% metastases on presentation
What is the aetiology of RCC?
- Smoking
- Obesity
- Dialysis
Where does renal cell carcinoma spread?
- Spread to the right atrium via IVC (can embolise to the lung to cause a pulmonary embolism)
- Perinephric spread
- Lymph node metastases
What is the treatment for localised renal cell carcinoma?
- Surveillance
- Excison via radical nephrectomy or partial nephrectomy
- Ablation (cyroablation, radiofrequency ablation)
What is the treatment for metastatic Renal Cell Carcinoma?
Palliative (Chemo- and radio- resistant)
- Biological therapies – act on the cell cycle, vaccine, monoclonal antibodies.
- Those targeting angiogenesis are now 1st choice. Tyrosine kinase inhibitors given
Describe epidemiology of Bladder
- In UK, 8th most common cancer in men and 14th in women.
- Incidence is decreasing
- Presentation is often more advanced in women
- 3X more in men
- More in White than non-white
What are risk factors of Bladder TCC?
- White
- Male
- Smoking
- Occupational exposure
What are some occupational exposure for bladder TCC?
- Dye more carcinogenic
- Handling of poly aromatic hydrocarbons
- Painters, mechanics, printers, hairdressers
What is the initial treatment for bladder TCC?
-TUR bladder tumour
What is the staging of bladder TCC?
Ta – rare chance of death T1 T2 -– low survival as muscle invasive from here T3 T4
What is the histological grading of TCC?
- Normal
- Grade 1
- Grade 2
- Grade 3
- Carcinoma in Situ (grade 3 tumour that has yet to invade)
What are further treatments for high risk and low risk non muscle-invasive TCC?
High-Risk
- Check cystoscopies
- Intravesical immunotherapy
Low-risk
- Check cystoscopies
- Intravesical immunotherapy or not
What is further treatment for muscle invasive TCC?
- Neoadjuvant chemotherapy
- Radical (Cystectomy or Radiotherapy)
If not curative, Palliative chemotherapy/radiotherapy
What is the aetiology for Upper Urinary Tract TCC?
- Smoking
- Phenacetin abuse
- Balkan’s Nephropathy
Describe the epidemiology of Upper urinary tract TCC
5% of all malignancies of upper urinary tract.
What are initial investigation for suspected Upper urinary tract TCC?
- Ultrasound
- CT Urogram (Filling defect, Ureteric stricture)
- Retrograde pyelogram
- Ureteroscopy (Biopsy, Washings for cytology)
What is the standard treatment for upper urinary tract TCC?
-Nephro-ureterectomy
What is the treatment for metastatic TCC?
-Systemic chemotherapy (Traditionally cisplatin-based but needs reasonable kidney function for this to happen
-Biological therapies
Immunotherapy (New)
Describe the biological therapy used in metastatic TCC.
Cancer cells employ a protective mechanism to avoid destruction by the immune system
- One anti-TCC strategy is to introduce antibodies to block this protective mechanism
- Targeting the Programmed Cell Death Receptor 1 (can be given in the presence of poor renal function
Describe the epidemiology of Prostate Cancer.
- Commonest cancer in men
- 2nd most common cause of death from cancer in men
- Rare in men lower than 50 years of age
What are risk factors for prostate cancer?
- Age
- Family history (BRCA2 gene mutation)
- Ethnicity (Black>white>Asian)
Describe screening for prostate cancer.
PSA screening
- Enzyme
- If it is higher doesn’t means prostate cancer
- If it is low/normal doesn’t mean you do not have prostate cancer
- Cant rely on PSA within 6 weeks of a urinary retention
- You need glands to make PSA. If they are replaced by the cancer then you can’t make it
What the issue with PSA screening
- Over diagnosis -
- Over treatment
- QOL (co-morbidities of established treatment. Our screening isn’t good enough)
- Cost-effectiveness
- Other causes of raised PSA (Infection, Inflammation, Large prostate, Urinary retention)
What is the presentation of prostate cancer?
- Urinary symptoms
- Bone pain – spread to bone
- Had their PSA check then biopsied
- DRE for another reason – change in bowel habit
- Incidental finding at transurethral resection of prostate (TURP) for retention/urinary symptoms
Why do patient with prostate cancer experience bone pain?
- Bone metastases
- Sclerotic as it is osteoblastic
- Hot spots on bone scan
- Highly unlikely if PSA <10 ng/ml)
What is the diagnostic pathway for prostatic cancer?
- DRE
- Serum PSA (If abnormal for the previous : Transrectal ultrasound guided bipsy of prostate)
- LUTS tract symptoms (Transurethreal resection of prostate)
What is the treatment for local prostate cancer?
- Established Rxs (Surveillance, Robotic radical prostatectomy)
- Radiotherapy (External beam, Brachytherapy)
What is the treatment for locally advanced prostate cancer?
- Surveillance (Rapid rise in PSA)
- Hormones
- Hormones and radiotherapy
What are the treatment types for hormones and palliation?
- Hormone (+-chemotherapy)
- Palliation
What are the types of hormonal treatments for metastatic prostate cancer?
- Surgical castration
- Medical castration using LHRH agonists to decrease testosterone
Describe the palliative treatment for metastatic prostate cancer?
- Single dose radiotherapy
- Bisphosphonates
- Zoledronic acid (Chemotherapy )
- New treatments (eg abiraterone, enzalutamide)
What are factors affecting treatment decisions for prostate cancer?
- Age
- DRE (Localised, Locally-advanced, Advanced)
- PSA level
- Biopsies (Gleason grade, Extent)
- MRI scan and bone scan (Nodal and visceral metastases)
What is acute polycystic kidney disease?
- Autosomal dominant (+new mutations)
- Mutation in PKD 1 gene and PKD 2 gene
- Cysts grow with age generally presents in adulthood
- Big kidneys
- Diagnosed with ultrasound and Genetic testing
What are secondary complications from cyst in APCKD?
- Pain
- Bleeding into cyst
- Infection
- Renal stones)
What is the clinical disease in APCKD?
- Cyst fluid filled
- Hypertension very common
- Increase incidence of intra-cranial aneurysms
- Increased incidence of heart valve abnormalities
