Uro-oncology Flashcards
What are the risk factors of renal cell carcinoma (RCC)?
- HTN
- Tobacco
- Obesity
- PKD, Kidney Transplant, Hemodialysis
- 2-3% hereditary e.g. tuberous sclerosis
What are the modes of diagnosis for RCC?
- CT/MRI of abdomen
- US guided kidney biopsy or after nephrectomy
What are the clinical features of RCC?
- no early signs
- constitutional symptoms
- hematuria
- flank pain
- palpable renal mass
- atypical symptoms related to paraneoplastic syndromes e.g. hypecalcemia
- Paraneoplastic Syndromes -> polycythemia, hypercalcemia, stauffer syndrome (cholestasis in healthy liver)
- RCC triad: painless hematura, flank pain, abdominal mass (rare only 10%)
What is the TNM staging of RCC?
T1: up to 7cm tumour
T2: up to 10cm tumour
T3: tumour extension under Gerot’s fascia, including major veins e.g. IVC
T4: tumour penetrates Gerot’s fascia plus into ipsilateral adrenal
N0: no metastases in regional LN
N1: metastases in 1 regional LN
N2: > 1 LN
M0: no distant metastases
M1: distant metastases
RCC staging in localised disease?
- T category (T1-T4)
- Nodal involvement
- Tumour volume ( < 10cm or > 10cm)
- Nuclear grade (1-4)
- Tumour necrosis
What is the Mozzar Criteria?
- a method of risk assessment and staging for advanced RCC
Takes into consideration: each score 1
- Time from dx to tx (more than 1 year)
- Calcium levels (over upper limit of normal)
- Hb levels
- neutrophil
- platelet count
- performance status (Karnofsky Score)
Favourable risk: 0
Intermediate: 1-2
Unfavourable: 3-6
What is the ESMO- treatment for local and locally advanced RCC?
- Nephron sparring nephrectomy
- radical nephrectomy/nephrouretherectomy
Cytoreductive surgery in T3, T4 is an option
No recommendation on adjuvant tx
ESMO recommendation for first line treatment of clear cell RCC?
- depends on risk: good, intermediate or poor
- VEGF receptor inhibitors e.g. sunitinib (availablefor all risks)
Good risk: Sunitinib
Intermediate: Nivolumab and Ipilimumab
Poor: Nivolumab and Ipilimumab
- Anti- VEGF e.g. bevacizumab (Good & Inter)
- Sunitinib option for all types
ESMO recommendation for non clear cell Renal Cell Carcinoma?
- papillary (chromophilic)
- Chromophobe
- collecting duct/medullary
- predominant (sarcomatoid)
Sunitinib indicated for the above
Other options:
Everolimus for Chromopho/philic
Pazopanib for Coll and Sarco
What is urothelial carcinoma?
- carcinoma of upper urothelium - confined to pelvis and renal (usually occurs with lower)
- Bladder is the most common site
- often surgically treated - nephrouretherectomy
Graded 1-4 (low, low, high, high)
- lower urothelium - urinary bladder carcinoma
90% transitiocellular (TCC)
10% SCC, ADC etc
What are the risk factors of urothelial carcinoma?
- tobacco smoking
- polycyclic hydrocarbons
- aromatic amines
- aristolochia
- cyclophosphamide
What are the symptoms of urothelial carcinoma (UC)
- hematuria, painless
- rarely dysuric disturbances
Diagnosis of UC?
- US of urinary tract
- MSCT/MRI
- IV urography
- cystoscopy
- urine sediment cytology
TNM staging of urothelial cancer?
T1: invades epithelium
T2: invade muscles (superficial and deep)
T3: invades perivesical tissue
T4: tumour invades structures e.g. prostate, vagina etc
N1: 1 LN
N2: more LNs in perivesicular, obturator
N3: LNs in region of iliac communis
M0: no distant metastases
M1: distant metastases
ESMO tx for local TCC?
No invasion of muscle:
Low risk = intravesicle Cht after Transuretheral Resection of Bladder Tumour (TRBT)
according to risk, modes of surveillance via cystoscopy
*very high risk offer radical cystectomy
Invasion of muscle
Unfit for Cht = radical cystectomy
Fit for Cht = 3-4 cycles of cisplatin then cystectomy
then risk assessed FU
Metastatic Urothelial Cancer Tx?
- cisplatin and gemcitabine (GC) 4-6 cycles is the standard approach
- Younger Px: possible MVAC and HD MVAC
-50% are unfit for cisplatin -> ICI e.g. pembro nivolu are 1st line in these px
- further drugs may be used after GC e.g. Avelinmab to prolongue 0S
What is the follow up strategy for TCC?
- cystoscopy with urine sediment at 3 months with TUR biopsy at 6 months
*TCC high incidence of recurrence
What are the risk factors of prostate cancer?
- most common type of cancer in males
- old age
- smoking
- low fruit and veg intake, high refined meat intake
- afro-american
What are the symptoms of prostate cancer?
- no specific
- resemble BPH
- hematuria
- painful ejaculation
- hemospermia
- perineal pain
- bone metastases
Screening and diagnosis for prostate cancer?
- DRE
- PSA total (under 4 ng/ml is normal)
- free PSA/PSA ratio
PSA 4-10 is the grey zone
* perform fPSA/tPSA ration
- < 0.5 is malignant
- > 2.5 BHP
What type of cancer is prostate cancer?
90% adenocarcinoma
When is PSA screening indicated?
- male > 50 years
- FHx in > 45 years
- Afro-american > 45 years
- BRCA 1/2 carriers > 40 years
What is the gleason score?
Sum of 2 growth patterns:
- most frequent histology pattern
- highly aggressive or poor differentiation
1) nearly normal cells
2) some abnormal cells loosely packed
3) many abnormal cells
4) very few normal cell left
5) completely abnormal cells
What is the TNMm staging for Prostate Cancer?
T1: clinically undetectable PC
T2: tumour confined to prostate
T3: tumour breaks prostate capsule
T4: infiltrates surrounding tissue e.g. rectum, bladder (Excludes seminal vesicle)
N0: no LN
N1: > 1 LN
M0: no distant metastases
M1: distant metastases -> non regional LN, then bone, then visceral organs w or w/o bone
Risk profile according to PSA levels for PC?
LOW RISK: < 10
INTERMEDIATE RISK: 10-20
HIGH RISK: > 20
Risk profile in localised PC?
Low risk:
- T1a-c T2a
- gleason score 6
- PSA < 10
Intermediate risk:
- < T2b
- gleason score 7
- PSA 10-20
High risk:
- > T2c
- gleason score 8-10
- > 20
What is androgen deprivation therapy?
- therapy designed to decrease testosterone production by the testes
- locally advanced or metastatic PC
LHRH agonist e.g. goserelin, leuoproreline
Anti-androgen e.g:
Non-steroidal: enzalutamide, darolutamide
steroidal: spiranolactone, abirateron
Testosterone R blocker: non-steroidal AA
Testosterone synthesis Inhibitor: abirateron
Total Androgen Blockade: combined use of LHRH agonists and AA
Treatment of localised PC of low and intermediate risk?
Low risk: treatment range fro watchful waiting, active surveillance, radiotherapy or radical prostatectomy
Intermediate risk:
same as above, but may consider neoAdj Androgen Deprivation Test (ADT)
Treatment of localised and locally advanced PC of high risk?
Either radical prostatectomy plus pelvic LN dissection
or
ADT neoadj 4-6 months, then with radiotherapy + ADT and then adjuvant ADT for 2 years
Treatment of metastatic hormone sensitive PC?
If low hormone sensitive: ADT plus RT plus docetaxel
If high hormone sensitive: ADT plus docetaxel
What is the castration resistant PC? Types?
- progressive PC under ADT treatment accompanied with castration level of testosterone (< 0.5ng/ml)
- metastatic (mCRPC) or non-metastatic (nmCRPC)
- PC 90% are hormone sensitive initially
nmCRPC and mCRPC treatment?
nmCRPC M0:
- enzalutamide or darolutamide
mCRPC:
- enzalutamide or abiraterone
- Docetaxel may be recommended
Bone metastasis mCRPC:
- bisphosphonate
- Radon is bone metastasis w/o visceral metastasis
*Radon not to be used with abiraterone or prednisolone
What is testicular cancer?
- germ cell testicular tumour
- primarily affects younger men aged 15-40
- seminoma (45-55%) or non-seminoma (40-45%)
- 95% are confined with testicle and 5% extragonadal germ cell tumour e.g. cerebrum or mediastinum
What are the clinical features of Test. C?
- Painless enlargement of testicle
- enlarged inguinal LN
- compact lump in tissue
- rarely painful enlargement - intra-tumour hemorrhage or tumour infarct
What are the diagnostic tests of Test.C?
- LDH
- AFP
- Beta- HCG
- Ultrasound of testicle
- inguinal orchidectomy to internal inguinal ring (diagnostic & therapeutic)
What are the types of Test. C?
Germ Cell Tumour
- seminoma
- yolk sac
- choriocarinoma
Sex Cord Testicular Tumour
- leydig cell tumour
- sertoli tumour
Adnexeal Paratesticular tumour
- epididymal adenocarcinoma
Hematopoetic
- leukemia/lymphoma
Miscellaneous
- carcinoid, endometrial carcinoma
What is the TNM staging TC?
T1: confined to testis or epididymis
T2: penetration of tunica albuginea
T3: invasion of spermatic cord
T4: invasion of scrotal skin
N1: LN enlargement of 2cm
N2: Ln 2-5cm
N3: Ln > 5cm
M0: no distant metastases
M1a: in non-regional LN or lungs
M1b: in visceral organs outside lungs
What is S staging?
Staging taking into consideration levels of LDH, Beta-HCG and AFP
Sx
S0
S1
S2
S3
Poor outcome: S3 stage with non-seminoma tumour, mediastinal involvement and visceral non-pulmonary involvement
ESMO recommendation for seminoma?
Depends of staging
Stage 1
- Low risk : surveillance FU
- High risk: same as above or with carboplatin
Stage 2a
- Either RT, clinical trial or BEP (Bleomycin, Etoposide and Platinum)
- Then FU
Stage 2B-3
- BEP 3-4 cycles
- Biopsy
- FU
ESMO recommendations for Non-seminomas?
Stage 1
- ranges from surveillance and FU to using of BEP 1 cycle and FU
- depends if low or high risk
Stage 2B-3
- depends of good, intermediate or poor
- use of BEP and VIP (cisplatin, etoposide, ifosfamide)
- resection if > 1cm
- FU
Refractory tx of tc?
- Salvage chemo with Gemcitabin and oxaplatin
- If embryonic cancer relaps and is chemosensitive -> auto SCTx
Refractory cases are palliative
What is the cause of penile cancer?
- rare tumour
- mostly SCC
- HPV 16 (p16+ and warty)
- HPV negative (veruccus presentation)
How do you treat penile cancer?
operable: surgery with R0 resection
inoperable: for locally advanced or metastatic
- cisplatin based chemo and cemiplimab
