Urinary Malignancies

Question 1

Discuss some of the epidemiology of prostate cancer.

Answer 1

As men age the prostate tends to enlarge. This can be due to benign reasons or due to malignancy. Prostate cancer tends to be asymptomatic and although it is the largest killer of males by any cancer men are unlikely to die of it. This is because it is so common.

Question 2

What risk factors are there for prostate cancer?

Answer 2

• Increased age – post 80, 80% of men have a prostate cancer but it’s probably higher than this.
• Family history
• 4 x increased risk if one 1st degree relative diagnosed with prostate cancer before the age of 60 – BRCA2 gene mutation.
• Ethnicity – black>white>Asian

Question 3

What screening occurs for prostate cancer in the UK?

Answer 3

NHS does not recommend mass population screening but does support opportunistic screening if patients are counselled i.e. if the patient presents with urinary tract symptoms – so only if they have been told they are being tested.

Question 4

What issues are there for screening for the prostate specific antigen (PSA)

Answer 4

Issues for PSA (prostate specific antigen) screening – over diagnosis, over treatment, QoL – co-morbidities established treatment. Cost effectiveness, other causes of a raised PSA – infection, inflammation, large prostate.

Question 5

How does prostate cancer usually present?

Answer 5

Usually 
•Asymptomatic
•Benign enlargement of prostate, bladder over activity +/- CaP
•Bone pain in advanced metastatic
Unusual 
•Haematuria in advanced CaP

Question 6

How do we go about diagnosing prostate cancer?

Answer 6

• Digital rectal examination (DRE) – Must also do serum PSA, this decides whether a biopsy is needed
• Biopsy carried out by a TRUS transrectal ultrasound guided biopsy of prostate

Question 7

What factors influecne the treatment decisions for people with prostate cancer?

Answer 7

• Age - are they likely to die from prostate cancer
• DRE – localised T1/T2, locally advanced T3 and advanced T4
• PSA level
• Biopsies – Gleason grade
• MRI scan and bone scan – nodal and visceral metastases NM part of TNM

Question 8

How are localised prostate cancer treated?

Answer 8

Established CaP
Surveillance – if low grade may do more damage than good by treating – QoL.
Robotic radical prostatectomy
Radiotherapy – external beam, low dose rate brachytherapy (implanted beads)

Question 9

How are developmental prostate cancer treated?

Answer 9

High intensity focused ultrasound (HIFU)
Primary Cryotherapy – freeze the prostate
Brachytherapy – high dose

Question 10

How are metastatic prostate cancer treated?

Answer 10

Hormones +/- chemotherapy – surgical castration, medical castration – LHRH agonists.
Palliation – single dose radiotherapy, Bisphosphonates – zoledronic acid, chemotherapy (docetaxel), new treatments such as abiraterone and enzalutamide.

Question 11

Where does prostate most commonly metastasis to?

Answer 11

Bone metastases – sclerotic (osteoblastic), hot spots on bone scan, highly unlikely if PSA < 10ng/ml.

Question 12

How do we manage locally advanced prostate cancer (T3)

Answer 12

Surveillance, hormones and hormone radiotherapy.

Question 13

How do we treat the lower urinary tract symptoms of prostate cancers?

Answer 13

Lower urinary tract symptoms (LUTS) are treated with Transurethral resection of prostate TURP

Question 14

With visible haematuria what is the risk of malignancy?

Answer 14

Haematuria can be visible meaning on investigation there is a 20% chance of a malignancy.

Question 15

How is invisible haematuria detected?

Answer 15

If Non-visible this could be symptomatic or asymptomatic and is detected via microscopy or urine dipstick analysis.

Question 16

What differential diagnosis are there for haematuria?

Answer 16

• Cancer – renal cell carcinoma (RCC), Upper tract transitional carcinoma (TCC), bladder cancer, advanced prostate carcinoma.
• Other – stones, infection, inflammation, benign prostatic hyperplasia (large)
• Nephrological (glomerular)

Question 17

What investigations must be done with haematuria?

Answer 17

Endoscopy (cystoscopy)
Urine culture and cytology (abnormal cells)
Full Blood Count
Radiology 
Ultrasound

Question 18

What is important to find out in a history and on examination when presenting with haematuria?

Answer 18

History – smoking, occupation, painful or painless, other LUTS and family history.
Examination – BP, abdominal mass, varicocele (veins in the scrotum), leg swelling and assess prostate by DRE (male) – looking at the size and texture.

Question 19

Discuss some of the epidemiology of bladder cancer

Answer 19

4th most common cancer in men 11th in women in the UK. Incidence is decreasing, but presentation is often more advanced in women. M:F 2.5:1. 90% are transitional cell carcinoma.

Question 20

What are the risk factors for bladder cancer?

Answer 20

• Smoking
• Occupational exposure (rubber, plastics, carbon, crude oil, combustion, smeting, painters, mechanics, printers and (hairdressers).
• Schistosomiasis (infection caused by parasitic flatworms called schistosomes) most commonly found in water in Africa – usually get squamous cell carcinoma

Question 21

What immediate treatment is done after a diagnosis of bladder cancer?

Answer 21

After identifying the cancer, we do a transurethral resection of the bladder tumour (TURBT) and then give a localised chemical (chemotherapy) to the bladder. Not all chemotherapy has to be systemic.

Question 22

What are the most common stages that present with bladder cancer?

Answer 22

• 75% of Cancers are superficial (Ta/T1)
• 5% are Tis (In situ)
• 20% are muscle invasive

Question 23

What further treatment is done in different bladder cancers?

Answer 23

• High risk non-muscle invasive TCC (transitional cell carcinoma) – check cystoscopies and intravesical chemotherapy/immunotherapy
• Low risk – check cystoscopies periodically, +/- intravesical chemotherapy
• Muscle invasive TCC – potentially curative – neoadjuvant chemotherapy, radical cystectomy or radiotherapy. Not curative – palliative chemotherapy/radiotherapy.

Question 24

What is radical cystectomy?

Answer 24

The removal of the urinary bladder. A piece of Ileum may be used to make a conduit from the ureters to the abdomen, where urine can be collected in a bag. May also attempt to reconstruct the bladder from a piece of small intestine.

Question 25

Discuss the epidemiology of renal cell carcinomas

Answer 25

Renal Cell Carcinoma is the 7th most common cancer in the UK, making up 95% of all upper urinary tract tumours. The incidence and mortality are increasing. There is a Male to Female ratio of 3:2, and 30% of RCC have metastases on presentation.

Question 26

What are the risk factors for real cell carcinomas?

Answer 26

• Smoking doubles risk
• Obesity
• Dialysis

Question 27

Where are the common metastases for renal cell carcinomas?

Answer 27

Metastases of RCC can spread to lymph nodes, up the renal vein and vena cava into the right atrium and into the subscapular fat (Perinephric spread).

Question 28

What treatment is there for established renal cell carcinomas?

Answer 28

• Surveillance
• Radical nephrectomy – Removal of kidney, adrenal, surrounding fat, upper ureter
• Partial nephrectomy

Question 29

What treatments are there for developmental renal cell carcinomas?

Answer 29

• Ablation (removal of tumour from the surface of kidney via an erosive process)
• Palliative - Molecular therapies targeting angiogenesis and Immunotherapy

Question 30

Discuss the epidemiology of upper tract transitional cell carcinomas

Answer 30

Only 5% of all malignancies of upper urinary tract (Rest are RCC). 5% are due to the spread of cancer from the bladder up the ureter. 40% of cancers of the upper urinary tract spread to the bladder.

Question 31

What investigations are done for upper tract transitional cell carcinomas?

Answer 31

• Ultrasound – Hydronephrosis – Swelling of kidney due to backup of urine
• CT Urogram – looking for filling defect and Ureteric structure
• Retrograde pyelogram – Inject contrast into the ureter
• Ureteroscopy – Biopsy and Washings for cytology

Question 32

What treatments are there for upper tract transitional cell cracinomas?

Answer 32

Nephro-ureterectomy – Removal of the kidney, fat, ureter and cuff of bladder.