Urinary tract malignancies Flashcards
Give 3 causes of haematuria.
Infection - UTI; schistosomiasis
Malignancy - bladder
Metabolic - kidney stones; diabetes.
(lecture 19.2.18)
Describe the management of T1 bladder cancer
Tumour in lamina propria, not muscle. (NMIBC) Surveillance TURBT Transurethral cystoscopy and diathermy \+/- maintenance chemotherapy
Describe the management of T2/3 bladder cancer
Tumour has spread to muscle wall (MIBC)
Radical cystectomy
Post-operative/ neoadjuvant chemotherapy
Preserve bladder function eg urostomy/ reconstruction
Give 3 risk factors for bladder cancer
Occupation: Rubber, benzine dyes exposure
Family history
Older age
Unexplained visible haematuria without UTI
Paraplegia (-> wheelchair; long-term catheter)
Bladder stones
Infection - parasites eg schistosomiasis (squamous)
Chronic cystitis
Male
Smoking
(PTS, lecture)
What investigations would you do if you suspect someone has bladder cancer?
Testing for cancer: Flexible cystoscopy (more painful for younger people due to intact sphincters) CT urogram Biopsy Urine dipstick, cytology and microscopy Bimanual examination under anaesthesia (looking for masses either side of bladder) MRI/lymphangiography (PTS)
Describe the management of bladder cancer.
- Staging eg with TNM.
- MDT
- Diagnose using transurethral resection of bladder tumour (TURBT). Must include muscle to stage.
What are the complications of TURBT?
Hole in bladder, especially in women because a) women, especially older, have very thin bladder wall. b) hit the obturator nerve -> leg kick -> hole in bladder.
Describe the pathology of bladder cancers.
> 90% transitional cell carcinoma.
5% squamous cell carcinoma (long-term catheter)
1% carcinoma in situ
Describe the main presenting symptom/sign of bladder cancer.
Painless haematuria.
What is the most common stage of bladder cancer at presentation?
80% non-muscle invasive at presentation.
What is the recurrence rate of NMIBC? What percentage will become muscle invasive?
70%, 15% become muscle-invasive.
lecture 19.2.18
Describe the management of T4 bladder cancer
Palliative chemo/radiotherapy
PTS
Which is more common: renal cancer or bladder cancer?
Renal.
Give 3 risk factors of renal cancer
Smoking Obesity Hypertension CKD Renal abnormalities eg polycystic; horseshoe kidney. Haemodialysis
How is renal cancer usually diagnosed?
Incidental finding on scan (70%)
Describe the pathology of renal cancer
90% renal cell adenocarcinoma of the proximal tubule epithelium. Highly vascular.
5% TCC
Stage 1 renal cancer - definition and management?
<7cm
Nephrectomy
Stage 1 renal cancer - definition and management?
<7cm
Partial/radical nephrectomy
Stage 2 renal cancer - definition and management?
> 7cm, localised, below diaphragm
Partial/usually radical nephrectomy
Stage 3 renal cancer - definition and management?
Major veins or regional lymph nodes affected.
Radical nephrectomy and adrenolectomy, above diaphragm into right atrium. Usually metastasised by this point.
Biological therapies:
mTOR inhibitors eg Temsirolismus;
Tyrosine Kinase inhibitors eg sunitinib
MABs eg bevacizumab
Stage 4 renal cancer - definition and management?
Distant metastases, beyond Gerota’s fascia into adrenal glands.
Systemic treatment/ elective cytoreductive nephrectomy (allows TKIs to work better).
Give 3 signs of renal cancer
Abdominal mass
haematuria
obstruction LUTS
(PTS)
Give 3 signs of renal cancer
Abdominal mass
Haematuria
obstruction LUTS
(PTS)
Give 3 symptoms of renal cancer
Loin/flank pain
General cancer: weight loss, fatigue, loss of appetite, dyspnoea
Why is renal cell carcinoma not often treated with chemo/radiotherapy?
It is likely to be chemo/radiotherapy resistant.
What are the common sites of lymph node metastases of bladder cancer?
Para-aortic and iliac.
PTS
Describe the main 2 types of testicular cancer and give 3 differences.
Seminoma - slower-growing, radiosensitive, low-level tumour markers. Radiotherapy unless stage IV (chemo). Younger people.
Teratoma - faster-growing, less radiosensitive, treated with chemotherapy. Older people.
What would you consider in your differential diagnosis for acutely painful scrotum?
Testicular torsion unless proven otherwise!
What is a false scrotal mass?
Mass that looks like it is in scrotum but not - you can feel above it.
What could cause a testicular mass?
Hydrocele: excessive fluid in tunica vaginalis
Appendix testis torsion: twisted embryological remnant
Why is a cancerous testicle taken out via the groin?
To get all the cord out, and to avoid damaging the testicle during surgery causing tumour seeding.
What is tumour seeding and how can it be caused?
Releasing tumour cells into the surrounding area which can grow into further masses. Can be caused by biopsy, therefore biopsy not done, so high rate of unnecessary testicular removal.
Give 3 signs of testicular cancer.
Painless, hard, craggy true scrotal mass (can’t feel above it)
Haematospermia
Abdominal mass
What investigations should you do if you suspect testicular cancer?
Same-day scrotal ultrasound
Same-day tumour markers - AFP (alpha-feta protein), beta HCG
Lactate DeHydrogenase - important for radiographers to make prognosis
Chest abdo pelvis CT
CXR only if chest symtoms - cannonball metastases require chemotherapy BEFORE surgery.
What is the half life of AFP?
12 days. (Lecturer says half-lives come up in exams)
What is the half-life of beta HCG?
1-2 days
Give 3 risk factors for testicular cancer
Undescended testis (perhaps something inherently wrong with that testicle)
Infant hernia
Infertility
Describe stage 2 testicular cancer
Para-aortic metastases, infra-diaphragmatic
Describe stage 3 testicular cancer
supradiaphragmatic
Describe stage 4 testicular cancer
in the lungs
Describe stage 1 testicular cancer
no metastases
