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YEAR 4 CANCER CARE > Uro Can E > Flashcards

Uro Can E Flashcards

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1
Q

How can you class bladder cancer?
how common?

A
  • Transitional cell carcinoma (most common, 80-90% cases)
  • squamous cell carcinoma (SCC)
  • adenocarcinoma (rare)
  • sarcoma (rare).

Bladder cancer most common tumour of urinary system

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2
Q

Epidiemiology of bladder cancer?

A
  • Age >80 yrs
  • more common in men 3:1
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3
Q

Prognosis of bladder cancer?

A
  • most diagnosed bladder cancers are superficial (Ta, T1, or CIS)
  • have a GOOD prognosis.
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4
Q

Anatomy of the bladder

A

divided into four layers, which are important when classifying bladder malignancies:

  • Inner lining of the bladder is called the transitional epithelium (urothelium)
  • The second layer is a connective tissue layer called the lamina propria
  • The third layer is a muscular layer and is termed the muscularis propria
  • The four (outer) layer is the fatty connective tissues
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5
Q

RF for bladder cancer

A
  • Smoking
  • increasing age
  • exposure to aromatic hydrocarbons (e.g. industrial dyes or rubbers)- TCC
  • Schistosomiasis infection (SCC subtype)
  • previous radiation to the pelvis.

TOM TIP: Dye factory workers get transitional cell carcinoma of the bladder

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6
Q

Presenting features of bladder cancer

A
  • painless haematuria ( visible or non-visible)
  • recurrent UTIs / (LUTS), e.g. frequency, urgency, or feeling of incomplete voiding.
  • pelvic pain

Systemic features:
* Weight loss
* Night sweats

Other:
* invade adjacent structures e.g. obturator nerve- neuropathic pain on the medial thigh

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7
Q

What presentation is bladder cancer until proven otherwise?

A

Visible haematuria is bladder cancer until proven otherwise.

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8
Q

Revisison: causes of haematuria?

A
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9
Q

The NICE guidelines on recognising bladder cancer advises a 2 week wait referral for:

A
  • Aged >/=45 with unexplained visible haematuria, either without a UTI or persisting after treatment for a UTI
  • Aged >/= 60 with microscopic haematuria (positive on a urine dipstick) PLUS:
    Dysuria or;
    Raised white blood cells on a full blood count

The NICE guidelines also recommend considering a non-urgent referral in people over 60 with recurrent unexplained UTIs.

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10
Q

Clincial examination of pt with suspected bladder cancer?

A
  • unremarkable
  • ureteric obstruction may be present
  • signs of hydronephrosis e.g. ballotable
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11
Q

Bladder cancer staging

A

TNM

  1. Non-muscle-invasive bladder cancer
  2. Muscle-invasive bladder cancer

Non-muscle-invasive bladder cancer includes:
* Tis/carcinoma in situ: cancer cells only affect the urothelium and are flat
* Ta: cancer only affecting the urothelium and projecting into the bladder
* T1: cancer invading the connective tissue layer beyond the urothelium, but not the muscle layer
* Invasive bladder cancer includes T2 – 4 and any lymph node or metastatic spread.

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12
Q

Differencials for bladder cancer

A

All causes of haematuria should be evaluated for bladder cancer.

other causes of haematuria:
* UTI
* renal calculi
* prostate
* renal cancer

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13
Q

investigations for suspected bladder cancer?

(clue: procedure focused )

A
  • flexible cystoscopy under local anaethetic
  • Rigid cystoscopy (under GA) if suspcious lesion found with flexible
  • Biopsy and potential resection via transurethral resection of bladder tumour (TURBT), either on initial assessment (if appears superficial) or following biopsy results (if appears invasive).
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14
Q

Sites bladder cancer metastasies to?

A
  • Lungs
  • Liver
  • Bone
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15
Q

Treatment of non-muscle invasive bladder cancer

This includes stages CIS, Ta and T1

A

Surgery
* (TURBT)- cystoscope inserted into the bladder via the urethra and areas are resected. GOLD STANDARD
* Radical cystectomy can also be offered to those with high-risk disease or limited response to initial treatments.

Chemotherapy
* bladder instilled with agents such e.g. Mitomycin C, either at the time of a TURBT or at weekly intervals following a TURBT.

Immunotherapy
* BCG immunotherapy can be instilled into the bladders of patients with higher risk non muscle invasive cancers.

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16
Q

Why is follow up so important with superficial bladder cancers? What is done?

A
  • high rate of recurrence- 70% recurring within 3 years
  • recurrences are more likely to be more invasive.
  • Routine follow-up with regular surveillance via cytology and cystoscopy.
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17
Q

Treatment of Muscle invasice bladder cancer

what follow up needed?

A
  • any stage of bladder cancer from T2 and above.
  • If fit enough for surgery - radical cystectomy with urinary diversion = GOLD standard
  • Consider neoadjuvant chemotherapy, typically with a cisplatin combination regimen.
  • Regular follow-up with CT imaging to monitor for local and distant recurrence.

no significant co-morbidities, no metastatic disease- cystectomy.

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18
Q

Following radical cystectomy, patients will require urinary diversion; how is this done?

A
  • Ileal conduit formation with urine draining via a urostomy
    OR
  • Bladder reconstruction, from a segment of small bowel* (often termed a neobladder) and urine draining urethrally or via catheter

*Alongside routine bloods, B12 and folate levels should also be checked at least annually due to the resection of part of the ileum during the urinary diversion procedures.

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19
Q

Treatment for metastatic bladder cancer / locally advanced?

A
  • chemotherapy e.g. cisplatin‑based regimen
  • MDT input for symptom management i.e. pelvic pain, ongoing bleeding, or urinary frequency
  • Palliative options should also be discussed with the patient when appropriate.
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20
Q

Prognosis for bladder cancer?

A

higher risk of developing upper urinary tract tumours and urethral tumours.

5 year survival
* superficial disease - 80-90%
* muscle-invasive -30-60%
* metastatic disease - 10-15% respectively.

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21
Q

How common is prostate cancer in men in UK? what is the survival rate?

A
  • most common cancer in men
  • 1 in 8 men are diagnosed in their life
  • 10 year survival rate is 80% (but 10,000 men die each year in uK)
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22
Q

what age group gets prostate cancer?

A
  • majority in older men
  • 25% cases in men under 65
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23
Q

Pathophysiology of prostate cancer?

A
  • not fully understood
  • agreed that the growth of prostate cancer is influenced by androgens (testosterone and dihydrotestosterone (DHT)).
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24
Q

What type of cancer are most prostate cancers?

A

majority of prostate cancers (>95%) are adenocarcinomas.

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25
Q

Where in the prostate is cancer most often found?

A
  • 75% of prostate adenocarcinomas - peripheral zone
  • 20% - transitional zone
  • 5% in the central zone
  • Prostate cancers are often multifocal.
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26
Q

classification of Prostate adenocarcinomas ?

A
  • Acinar adenocarcinoma – originates in the glandular cells that line the prostate gland (most common form)
  • Ductal adenocarcinoma – originates in the cells that line the ducts of the prostate gland (grow and metastasise faster than acinar)
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27
Q

RF for developing prostate cancer?

A
  • Increasing age
  • Family history
  • Black African or Caribbean origin
  • Tall stature
  • Genetic predisposition plays a part, men with BRCA2 or BRCA1 gene are at greater risk.
  • Anabolic steroids

Less significant modifiable risk factors:
* obesity
* diabetes mellitus
* smoking (associated with increased risk of prostate cancer death) degree of exercise (considered protective).

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28
Q

Clinical features a pt with prostate cancer might present with?

A

Localised disease:
* LUTS- including weak urinary stream, increased urinary frequency, and urgency.

Advanced localised disease:
* haematuria
* erectile dysfunction
* dysuria
* incontinence
* haematospermia
* suprapubic pain
* loin pain
* rectal tenesmus.

metastatic disease:
* bone pain
* lethargy
* anorexia
* unexplained weight loss.

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29
Q

A DRE is done if diagnosis of prostate cancer is suspected.
Why?
What are you looking for?

A

why?
* most prostate adenocarcinomas arise from the posterior peripheral zone.

checking for:
* evidence of asymmetry
* nodularity
* a fixed irregular mass.

note: Tumours >0.2mL can be palpable

30
Q

Differencials for Prostate cancer?

A
  • Benign prostatic hyperplasia (BPH) – a non-cancerous enlargement of the prostate gland, will also cause LUTS symptoms initially
  • Prostatitis – inflammation of the prostate gland; patients usually present with perineal pain, with neutrophils seen on urinalysis
  • Other causes of haematuria – these may include bladder cancer, urinary stones, urinary tract infections, and pyelonephritis
31
Q

What is prostate-specific antigen (PSA)?

A
  • glycoprotein
  • secreted in the semen, with a small amount entering the blood.
  • Its enzymatic activity helps thin the thick semen into a liquid consistency after ejaculation.
  • It is specific to the prostate, meaning it is not produced anywhere else in the body.
  • A raised level can be an indicator of prostate cancer.
32
Q

Why treat PSA with caution?

A

PSA testing is unreliable, with a high rate of false positives (75%) and false negatives (15%).

False positives:
* lead to further investigations, invasive prostate biopsies, which have complications and may be unnecessary.
* Unnecessary diagnosis and treatment -(the patient would have died of other causes before experiencing any adverse effects of the prostate cancer).

False negatives:
* may lead to false reassurance.

TOM: Counselling a patient about whether to have a PSA test is a common OSCE scenario. Testing the concept and implications of false positives and false negatives. Explain to a patient to allow them to make an informed decision for themselves.

33
Q

Common causes of a raised PSA?

A
  • Prostate cancer
  • Benign prostatic hyperplasia
  • Prostatitis
  • Urinary tract infections
  • urinary retention
  • recent urological surgery
  • Vigorous exercise (notably cycling)
  • Recent ejaculation or prostate stimulation
34
Q

How might a benign prostate feel on examination? how might an infected inflammed prostate feel on examination?

A

benign prostate:
* smooth, symmetrical and slightly soft, with a maintained central sulcus (the dip in the middle between the right and left lobe).
* There may be generalised enlargement in prostatic hyperplasia.

An infected or inflamed prostate (prostatitis):
* enlarged
* tender
* warm.

35
Q

Investigations for Prostate cancer?

A

Bedside:
* DRE
* urine dip

Lab:
* PSA
* free:total PSA

Imaging:
* MRI scan of the prostate reported using Likert score.
* 3 or more Likert - biopsy
* MRI identifies abnormal areas of the prostate, which can then be targeted for biopsy.
* See locations (central / peripheral)
* local lymph node involvement

free:total PSA ratio, can be used to increase the accuracy of the test for men with PSA from 4-10; a low free:total ratio is associated with an increased chance of diagnosing prostate cancer.

36
Q

Diagnosis of prostate cancer?

A

Biops!

  1. Transperineal biopsy - more common
    * trend towards performing only transperineal due to the decreased risk of infection
    * needles inserted through the perineum. It is usually under local anaesthetic.
  2. TransRectal UltraSound-guided (TRUS) biopsy
    * usually used for a posterior lesion
37
Q

Risks of a prostate biopsy?

A
  • Pain (particularly lower abdominal, rectal or perineal pain)
  • Bleeding (blood in the stools, urine or semen)
  • Infection
  • Urinary retention due to short term swelling of the prostate
  • Erectile dysfunction (rare)
38
Q

Why would a CT or isotope bone scan be considered for a patient with suspected prostate cancer?

A
  • CT and bone isotope are further imaging techniques - used to look for bony metastasis.
  • A radioactive isotope is given by intravenous injection, followed by a short wait (2-3 hours) to allow the bones to take up the isotope. A gamma camera is used to take pictures of the entire skeleton.
  • Metastatic bone lesions take up more of the isotope, making them stand out on the scan.
39
Q

grading system for prostate cancer?

A

Gleason grading system

40
Q

Explain the gleason grading system for prostate cancer?

A
  • based on the histology from the prostate biopsies.
  • The greater the Gleason score, the more poorly differentiated the tumour is and the worse the prognosis is.
  • The tissue samples are graded 1 (closest to normal) to 5 (most abnormal).
  • The Gleason score will be made up of two numbers added together for the total score (for example, 3 + 4 = 7)
  • The first number is the grade of the most prevalent pattern in the biopsy
  • The second number is the grade of the second most prevalent pattern in the biopsy
41
Q

What is a gleason score for
low risk
intermediate risk
high risk

A
  • 6 is considered low risk
  • 7 is intermediate risk (3 + 4 is lower risk than 4 + 3)
  • 8 or above is deemed to be high risk
42
Q

Once diagnosis of prostate cancer is confirmed what needs to be done to stage the cancer?

what type of imaging?

A

Staging of prostate cancer is typically done for men with intermediate or high-risk disease

  • CT chest-abdomen-pelvis scan
  • PET-CT nuclear medicine scan.
43
Q

Management of prostate cancer:
where are all pts discussed?
management is based on what?

A

ALL pts discussed at specialist prostate cancer multidisciplinary team (MDT) meeting.

Management of localised cancer relates directly to risk stratification based on:
* PSA levels
* Gleason score
* T staging (from TNM).
NICE produced risk stratification for prostate cancer based on the following parameters:

44
Q

What aew the different management techniques for prostate cancer? (headings for now)

A
  • Surveillance or watchful waiting in early prostate cancer
  • External beam radiotherapy directed at the prostate
  • Brachytherapy
  • Hormone therapy
  • Surgery
45
Q

Who gets active surveillance of prostate cancer? what does that involve?

A
  • low grade prostate cancer
    Repeat investigations:
  • PSA (3 monthly)
  • DRE (6month)
  • biopsies (1-3 years)
  • If the cancers grade or stage increasestcan reassess their treatment options.
  • reduces the chances of over treating patients.
46
Q

Who gets radiotherapy for prostate cancer

A

Radiotherapy can be either curative or palliative.
In palliation it can help reduce the tumour bulk as well as reduce pain of bony metastasis.

47
Q

What are local and systemic effects of radiotherapy for prostate cancer?

A

Local effects:
* Bowel fibrosis
* Bladder fibrosis
* Radiation cystitis
* Diarrhoea

Systemic effects:
* Nausea
* Tiredness
* Loss of hair in treatment area

DR TOM: A key complication of external beam radiotherapy is proctitis (inflammation in the rectum) caused by radiation affecting the rectum. Proctitis can cause pain, altered bowel habit, rectal bleeding and discharge. Prednisolone suppositories can help reduce inflammation.

48
Q

Surgical management of prostate cancer : who gets it ? how is it done? Key complications?

A
  • remove prostate and affected organs
  • curative intent so cant do for people with mets
  • Robotically assisted laparoscopic prostatectomy (RALP) replacing open surgery
  • Key complications are erectile dysfunction and urinary incontinence.
49
Q

Benefits of modern robotically assisted laparoscopic prostatectomy (RALP) to traditional open surgery?

A

The benefits include a reduced frequency of post-operative complications such as:

  • Pain
  • Atelectasis
  • Pneumonia
  • Post operative ileus
  • Prolonged hospital stay
50
Q

Who gets hormonal management of prostate cancer?

A
  • Hormonal therapy for patients with metastatic disease.
  • Activity of prostate cancer depends on circulating levels of testosterone, so reducing testosterone levels can help reduce the symptoms of metastatic prostate cancer such as pain.
  • Used in combination with radiotherapy, or alone in advanced disease where cure is not possible
51
Q

What are hormonal options for treating protstate cancer ? how work?

A

Androgen-receptor blockers such as bicalutamide
* In addition to GnRH analogues to prevent an increase in disease activity following a transient surge in LH & FSH

GnRH agonists such as goserelin (Zoladex) or leuprorelin (Prostap)
* These paradoxically result LH & FSH blockade at the pituitary by causing over stimulation.

Bilateral orchidectomy to remove the testicles (rarely used)

52
Q

How to prevent transient increase in testosterone when treating prostate cancer ? why dangerous?

A
  • GnRH analogues cause a transient increase in testosterone before LH, FSH blockage is achieved which can increase the disease activity.
  • DaNGER of malignant cord compression if there is a disease in the spine.
  • GIVE an androgen receptor antagonist- prevents an increase in disease activity following a transient surge in LH & FSH.
53
Q

Side effects of hormone therapy for prostate cancer

A
  • Hot flushes
  • Sexual dysfunction
  • Gynaecomastia
  • Fatigue
  • Osteoporosis
    *
54
Q

What is bracytherapy for prostate cancer? side effects?

A
  • implanting radioactive metal “seeds” into the prostate
  • delivers continuous, targeted radiotherapy to the prostate.

Complications:
* radiation can cause inflammation in nearby organs i.e. bladder (cystitis) or rectum (proctitis).
* erectile dysfunction
* incontinence
* increased risk of bladder or rectal cancer.

55
Q

Definition of renal cell carcinoma?

A

Renal cell carcinoma (RCC) is the most common type of kidney tumour (85% of all renal malignancies).

It is a type of adenocarcinoma that arises from the renal tubules.

56
Q

Renal cell carcinoma (RCC) is the most common form of adult renal tumour. What are other renal malignancies?

A
  • transitional cell carcinoma (urothelial tumours)
  • nephroblastoma in children (Wilm’s tumour)
  • squamous cell carcinomas
57
Q

What are some cuases of squamous cell carcinoma of the kidney?

A

chronic inflammation secondary to renal calculi, infection and schistosomiasis.

58
Q

Epidiemiology of renal cell carcinoma?

A
  • higher incidence in developed countries
  • RCC is 1.5x more common in men
  • peak incidence 50-70yrs
59
Q

How can Renal cell carcinoma sprad?

A
  • direct invasion in to perinephric tissues within Gerota’s fascia, adrenal gland, renal vein or the inferior vena cava.
  • RCC can spread via the lymphatic system to pre-aortic and hilar nodes
  • haematogenous spread to the bones, liver, brain and lung.
60
Q

What is a classic CXR finding from metastatic renal cell carcinoma?

A
  • “Cannonball metastases” in the lungs
  • clearly-defined circular opacities scattered throughout the lung fields on a chest x-ray.
61
Q

Causes of renal cell carcinoma?

A
  • Smoking
  • Obesity
  • Hypertension
  • Industrial exposure to carcinogens (such as cadmium, lead, or aromatic hydrocarbons
  • dialysis / End-stage renal failure
  • Genetic: Von Hippel-Lindau Disease
  • Tuberous sclerosis
  • anatomical abnormalities such as polycystic kidneys and horseshoe kidneys.
62
Q

Presentation of renal cell carcinoma?

A

may be asymptomatic
* Haematuria
* Vague loin pain
* flank pain / mass
* Non-specific symptoms of cancer (e.g., weight loss, fatigue, anorexia, night sweats)
* Palpable renal mass on examination
* Left sided mass - left varicocoele, due to compression of the left testicular vein as it joins the left renal vein.

63
Q

Paraneoplastic syndromes in RCC can lead to what kind of presentations?

A
  • Polycythaemia – secretion of unregulated erythropoietin
  • Hypercalcaemia – secretion of PTrP- mimics the action of PTH
  • Hypertension – due to various factors, including increased renin secretion, polycythaemia and physical compression
  • Stauffer’s syndrome – abnormal liver function tests (raised ALT, AST, ALP and bilirubin) without liver metastasis
  • Hypercalcaemia can also be caused by bony metastases.
64
Q

clincial features of metastasis might see in renal cell carcinoma?

A

haemoptysis
pathological fractures

65
Q

The NICE guidelines on recognising renal cell cancer advises a two week wait referral for those:

A

Aged over 45 with unexplained visible haematuria, either without a UTI or persisting after treatment for a UTI

66
Q

differencials for renal cell carcinoma?

A

Other important differentials of haematuria to be considered:
* other urological malignancy
* renal stones
* UTI

67
Q

Bed and Lab tests for renal cancer?

A

Bedisde:
* Urinanalysis - non-visible haematuria and urine should be sent for cytology

Lab
* FBC
* U&E
* Ca
* LFT
* CRP

68
Q

Imaging and other investigations for renal cancer?

A
  • As for most cases of haematuria, initial imaging through US.

CT abdomen-pelvis pre and post IV contrast:
* gold standard for suspected cases
* additional chest for staging once the condition is confirmed.

Biopsy
* small renal masses when surveillance or minimally invasive ablative therapies are being considered.

69
Q

Staging of renal cancer?

A
  • A CT thorax, abdomen and pelvis are used to stage the cancer
  • TNM staging
  • also other staging eg. American Joint Committee on Cancer (AJCC) staging classification
70
Q

Management for renal cancer?

A
  • (MDT) meeting to decide the best course of action.

Surgery
* first-line
* Partial nephrectomy
* Radical nephrectomy (take kidney + surrounding tissue, lymph nodes and possibly adrenal gland)

Non surgical (pt not suitable) less invasive:
* Arterial embolisation- cutting off the blood supply
* Percutaneous cryotherapy- freeze / kill the tumour
* Radiofrequency ablation- electrical current to kill the tumour cells

71
Q

Treatment of metastatic renal cancer?

A
  • Chemotherapy generally ineffective in patients with RCC.

fit patients ;
* with metastatic disease, nephrectomy combined with immunotherapy (such as IFN-α or IL-2 agents)

  • Biological agents that can be used in combination e..g tyrosine kinase inhibitors
  • Metastasectomy (surgical resection of solitary metastases) is recommended where the disease is resectable and the patient is otherwise well.
72
Q

What chemo do you use for Bladder Cancer?

A

Mitomycin

immunotherapy- BCG- need to do a quantiferon test before

YEAR 4 CANCER CARE (22 decks)

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