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Clinical Oncology > Uro-oncology > Flashcards

Uro-oncology Flashcards

1
Q

What are the risk factors of renal cell carcinoma (RCC)?

A
  • HTN
  • Tobacco
  • Obesity
  • PKD, Kidney Transplant, Hemodialysis
  • 2-3% hereditary e.g. tuberous sclerosis
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2
Q

What are the modes of diagnosis for RCC?

A
  • CT/MRI of abdomen
  • US guided kidney biopsy or after nephrectomy
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3
Q

What are the clinical features of RCC?

A
  • 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%)
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4
Q

What is the TNM staging of RCC?

A

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

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5
Q

RCC staging in localised disease?

A
  • T category (T1-T4)
  • Nodal involvement
  • Tumour volume ( < 10cm or > 10cm)
  • Nuclear grade (1-4)
  • Tumour necrosis
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6
Q

What is the Mozzar Criteria?

A
  • 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

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7
Q

What is the ESMO- treatment for local and locally advanced RCC?

A
  • Nephron sparring nephrectomy
  • radical nephrectomy/nephrouretherectomy

Cytoreductive surgery in T3, T4 is an option

No recommendation on adjuvant tx

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8
Q

ESMO recommendation for first line treatment of clear cell RCC?

A
  • 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
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9
Q

ESMO recommendation for non clear cell Renal Cell Carcinoma?

A
  • papillary (chromophilic)
  • Chromophobe
  • collecting duct/medullary
  • predominant (sarcomatoid)

Sunitinib indicated for the above

Other options:
Everolimus for Chromopho/philic
Pazopanib for Coll and Sarco

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10
Q

What is urothelial carcinoma?

A
  • 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

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11
Q

What are the risk factors of urothelial carcinoma?

A
  • tobacco smoking
  • polycyclic hydrocarbons
  • aromatic amines
  • aristolochia
  • cyclophosphamide
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12
Q

What are the symptoms of urothelial carcinoma (UC)

A
  • hematuria, painless
  • rarely dysuric disturbances
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13
Q

Diagnosis of UC?

A
  • US of urinary tract
  • MSCT/MRI
  • IV urography
  • cystoscopy
  • urine sediment cytology
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14
Q

TNM staging of urothelial cancer?

A

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

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15
Q

ESMO tx for local TCC?

A

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

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16
Q

Metastatic Urothelial Cancer Tx?

A
  • 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
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17
Q

What is the follow up strategy for TCC?

A
  • cystoscopy with urine sediment at 3 months with TUR biopsy at 6 months

*TCC high incidence of recurrence

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18
Q

What are the risk factors of prostate cancer?

A
  • most common type of cancer in males
  • old age
  • smoking
  • low fruit and veg intake, high refined meat intake
  • afro-american
19
Q

What are the symptoms of prostate cancer?

A
  • no specific
  • resemble BPH
  • hematuria
  • painful ejaculation
  • hemospermia
  • perineal pain
  • bone metastases
20
Q

Screening and diagnosis for prostate cancer?

A
  • 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

21
Q

What type of cancer is prostate cancer?

A

90% adenocarcinoma

22
Q

When is PSA screening indicated?

A
  • male > 50 years
    • FHx in > 45 years
  • Afro-american > 45 years
  • BRCA 1/2 carriers > 40 years
23
Q

What is the gleason score?

A

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

24
Q

What is the TNMm staging for Prostate Cancer?

A

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

25
Q

Risk profile according to PSA levels for PC?

A

LOW RISK: < 10

INTERMEDIATE RISK: 10-20

HIGH RISK: > 20

26
Q

Risk profile in localised PC?

A

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

27
Q

What is androgen deprivation therapy?

A
  • 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

28
Q

Treatment of localised PC of low and intermediate risk?

A

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)

29
Q

Treatment of localised and locally advanced PC of high risk?

A

Either radical prostatectomy plus pelvic LN dissection

or

ADT neoadj 4-6 months, then with radiotherapy + ADT and then adjuvant ADT for 2 years

30
Q

Treatment of metastatic hormone sensitive PC?

A

If low hormone sensitive: ADT plus RT plus docetaxel

If high hormone sensitive: ADT plus docetaxel

31
Q

What is the castration resistant PC? Types?

A
  • 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
32
Q

nmCRPC and mCRPC treatment?

A

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

33
Q

What is testicular cancer?

A
  • 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
34
Q

What are the clinical features of Test. C?

A
  • Painless enlargement of testicle
  • enlarged inguinal LN
  • compact lump in tissue
  • rarely painful enlargement - intra-tumour hemorrhage or tumour infarct
35
Q

What are the diagnostic tests of Test.C?

A
  • LDH
  • AFP
  • Beta- HCG
  • Ultrasound of testicle
  • inguinal orchidectomy to internal inguinal ring (diagnostic & therapeutic)
36
Q

What are the types of Test. C?

A

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

37
Q

What is the TNM staging TC?

A

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

38
Q

What is S staging?

A

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

39
Q

ESMO recommendation for seminoma?

A

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

40
Q

ESMO recommendations for Non-seminomas?

A

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

41
Q

Refractory tx of tc?

A
  • Salvage chemo with Gemcitabin and oxaplatin
  • If embryonic cancer relaps and is chemosensitive -> auto SCTx

Refractory cases are palliative

42
Q

What is the cause of penile cancer?

A
  • rare tumour
  • mostly SCC
  • HPV 16 (p16+ and warty)
  • HPV negative (veruccus presentation)
43
Q

How do you treat penile cancer?

A

operable: surgery with R0 resection

inoperable: for locally advanced or metastatic
- cisplatin based chemo and cemiplimab

Clinical Oncology (11 decks)

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