Urinary System Cancer Flashcards
What are some of the reasons why PSA mass screening is not recommended by NICE?
- overdiagnosis
- over-treatment
- quality of life (considering side-effects of treatment e.g. impotence, incontinence)
- cost-effectiveness
note: opportunistic screening (if patients are counselled) is OK e.g. patient request due to family history
Outline the aetiology of prostate cancer.
- increased incidence with age (but also increased incidence of benign prostatic hypertrophy & urinary symptoms)
- increased incidence in Australia, Western Europe, North America compared to Africa and Asia (but increased mortality in Africa and Asia)
- majority of patients with prostate cancer are asymptomatic, have localised disease, and die with prostate cancer (not because of it)
Risk factors:
- increasing age
- family history: e.g. if one 1st degree relative diagnosed before 60yrs this quadruples risk
- associated with BRCA2 mutation
- black > white > Asian
What are some of the causes of a raised PSA?
PSA = prostate screening antibody
- infection
- inflammation
- hypertrophy
- prostate cancer
note: prostate cancer does not always cause increased PSA, and vice versa a +ve biopsy could be due to sampling error
What are some of the typical and atypical way prostate cancer patients present?
Typical:
- asymptomatic
- urinary symptoms:
- > obstruction of urethra = hesitancy, dribbling, variability of stream force, sensation of incomplete emptying, acute retention (overflow incontinence)
- > irritation of urethra = nocturia, increased frequency, urgency (& urge incontinence)
(could also be due to benign prostatic hypertrophy or bladder overactivity)
- bone pain e.g. back pain
- weight loss (cancer)
- anaemia (cancer)
Atypical:
- haematuria (advanced prostate cancer - rupture of prostatic veins)
- severe chronic kidney disease (due to painless bladder distension causing hydronephrosis)
- tenesmus (rectal invasion)
- haematospermia (invasion)
- supra-pubic/perineal pain
How is prostate cancer diagnosed?
Digital rectal examination + serum PSA (4 ng/ml ) + transrectal ultrasound-guided biopsy (TRUS) of prostate
How is a prostate biopsy interpreted?
Gleason grade
Cancer staged according to microscopic appearance (how well it resembles normal prostatic tissue) and the two worst scores are added together
Score out of 10 (5 is worst grade)
What may an MRI/bone scan show which indicates prostate cancer?
Nodal & visceral metastases
note: bone metastases are sclerotic (osteoblastic) and appear as hot spots on bone scan
What is the treatment for prostate cancer?
Localised:
- surveillance (“watch and wait”)
- radical prostatectomy (open, laparoscopic, robotic)
- radiotherapy (external beam or low dose brachytherapy - radioactive “seeds” implanted)
Metastatic:
- surgical/medical castration (androgens drive prostate cancer)
e. g. LHRH agonists (LH releasing hormone) —> initial increase in testosterone (therefore given anti-androgen too) —> system exhausted (LHRH release usually pulsatile) —> reduction in testosterone
- palliation: single-dose radiotherapy, bisphosphonates, chemotherapy
How can haematuria present?
Visible or non-visible (haem peroxidated on dipstick causing colour change)
Symptomatic or asymptomatic
Episodic (may present late)
What are some non-nephrological causes of haematuria?
- renal calculi
- infection
- inflammation
- benign prostatic hypertrophy
- cancer: renal cell carcinoma, upper tract transitional cell carcinoma, bladder, advanced prostate
What investigations and examinations should be performed for haematuria?
HISTORY:
- ?smoking
- occupation (textile/dye industry)
- painful or painless
- other lower urinary tract symptoms
- family history
EXAMINATION:
- BP
- ?abdominal masses (more likely to be a polycystic kidney)
- ?varicocele (collection of veins in testicle - usually left)
- ?leg swelling
- DRE (size, texture)
INVESTIGATIONS:
- FBC
- UE
- urine culture & sensitivity
- cytology
- ultrasound (?enlarged kidney/liver)
- flexible cystoscopy
Outline the aetiology of bladder cancer.
- reducing in incidence
- more advanced presentation in females (frequent UTIs dismissed due to common occurrence in women?)
- 90% are transitional cell carcinomas
Risk factors:
- smoking (quadruples risk)
- occupational e.g. rubber/plastic manufacture, polyaromatic hydrocarbons
- schistosomiasis (Egypt)
What is schistosomiasis?
(bilharziasis)
Blood flukes lay eggs which can cause bladder irritation
-> squamous metaplasia -> bladder cancer
What is the treatment for bladder cancer?
- Surgical trans-urethral resection of tumour
- Separate deep trans-urethral resection of muscle
- Single intravesical instillation of mitomycin C (reduce recurrence)
Low risk, non-muscle invasive TCC —> check cytoscopies, +/-intravesical chemotherapy
High risk, non-muscle invasive TCC —> check cytoscopies, +/- intravesical immunotherapy
Muscle invasice TCC —-> neoadjuvant chemotherapy + radical cystectomy/radiotherapy (+ possibly of prostate/uterus)
note: after radical cystectomy either the ileum is used to create a stoma (urostomy) OR the intestines are used to reconstruct a bladder (self-catheterisation required)
Outline the aetiology of renal cell carcinoma.
- 95% of all upper urinary tract tumours (calcyces, renal pelvis)
- increasing in incidence in mortality
- 30% present with metastases
Risk factors:
- smoking doubles risk
- obesity
- dialysis
Tends to spread to:
- perinephric fat
- lymph nodes
- IVC —> right atrium (tumour thrombus)
