(uro-renal) urological cancers - REM Flashcards by Rasha Rashid

in the UK, how common is kidney cancer?

kidney cancer is the 7th most common cancer in the UK

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what are the types of kidney cancer and their prevalence?

85% = renal cell carcinoma (adenocarcinoma)
10% = transitional cell carcinoma, 
5% = sarcoma/Wilms tumour/other types

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what is Von Hippel-Lindau syndrome linked to?

genetic predisposition with Von Hippel-Lindau syndrome (approx 50% of individuals will develop RCC)

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what is a red flag symptom of kidney cancer?

painless haematuria OR persistent microscopic haematuria

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which investigations are carried out for painless visible haematuria?

flexible cystoscopy
CT urogram
renal function

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which investigations are carried out for persistent non-visible haematuria?

flexible cystoscopy

US KUB

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which investigations are carried out for suspected renal cancer?

CT renal triple phase scan
staging CT chest
bone scan if symptomatic (to assess presence of bony mets)

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what is a flexible cytoscopy?

a routine examination of your bladder which is carried out using a flexible telescope (cystoscope) passed into the urethra and into your bladder

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what is a CT urogram?

a CT scan and special dye (contrast medium) to look at the urinary system and kidneys

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what is a US KUB?

ultrasound of the kidneys, ureters and bladder

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what is a triple phase renal CT scan?

a delayed scan with contrast for improved characterisation and visualisaton of a lesion

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explain the TMN staging of renal cell carcinomas

staged based on tumour size, metastases, node involvement

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explain how renal cell carcinomas are staged based on size in TMN

T1 – tumour ≤ 7cm
T2 – tumour >7cm
T3 – extends outside kidney but not beyond ipsilateral adrenal or perinephric fascia
T4 – tumour beyond perinephric fascia into surrounding structures

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explain how renal cell carcinomas are stages based on metastases in TMN

M1 - distant metastasis/es

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explain how renal cell carcinomas are stages based on node involvement in TMN

N1 – met in single regional lymph node

N2 – met in ≥2 regional lymph node

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how are renal cell carcinomas graded based on differentiation?

Fuhrman grading = can inform prognosis and treatment plan

1 = well differentiated
2 = moderate differentiated
3 + 4 = poorly differentiated

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how is kidney cancer managed?

(is patient specific = comorbidities, lesion classification)
partial nephrectomy
radical nephrectomy
cryosurgery
receptor tyrosine kinase inhibitors

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what is a partial nephrectomy and when is it used?

excision of only the tumour, while leaving the organ intact and unaffected

single kidney
bilateral tumour
multifocal RCC in patients with VHL
T1 tumours (up to 7cm)

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what is a radical nephrectomy?

resection of the whole kidney

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what is a cryosurgery and when is it used?

freezing the excision

= in patents with small tumours + unfit for surgery

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when are receptor tyrosine kinase inhibitors the choice of treatment for kidney cancer?

metastatic kidney cancer

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what are the different types of bladder cancer?

> 90% = transitional cell carcinoma

1-7% = squamous cell carcinoma (75% SCC where schistosomiasis is endemic)

2% = adenocarcinoma

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what are the risk factors for bladder cancer?

smoking
(age > 55, male)
occupational exposure to chemicals

drugs (cyclophosphamides)
radiotherapy

chronic inflammation (bladder stones, schistosomiasis, long term catheter)

what investigations would you do for a patient with painless visible haematuria?

flexible cystoscopy
CT urogram
renal function

what investigations would you do for a patient with persistentmicroscopic haematuria?

flexible cystoscopy | US KUB

what are the two types of bladder cancer?

non-muscle invasive muscle invasice

what happens when a biopsy proves muscle-invasive bladder cancer?

staging investigations

explain the tumour staging in bladder TMN staging

Ta – non invasive papillary carcinoma Tis – carcinoma in situ T1 – invades subepithelial connective tissue T2 – invades muscularis propria T3 – invades perivesical fat T4 – prostate, uterus, vagina, bowel, pelvic or abdominal wall

explain the node staging in bladder TMN staging

N1 – 1 LN below common iliac birufication N2 - >1 LN below common iliac birufication N3 – Mets in a common iliac LN

explain the metastases staging in bladder TMN staging

M1 - distant mets

explain the WHO classification of bladder cancer

``` G1 = well differentiated G2 = moderate differentiated G3 = poorly differentiated ```

how is a bladder cancer usually treated?

cystoscopy + transurethral resection of bladder lesion = transurethral resection of bladder lesion uses heat to ablate all visible bladder tumour (provides histology and also can be curative)

when can a transurethral resection of a bladder lesion not occur?

if the tumour invasion extends beyond muscle then the resection is incomplete due to the risk of perforating the bladder

explain the management protocol for non-muscle invasive bladder cancer

if no CIS (carcinoma in situ) + low grade bladder tumour then = cystoscopic surveillance +/- intravesicular chemotherapy/BCG vaccine

explain the management protocol for muscle invasive bladder cancer

cystectomy radiotherapy +/- chemotherapy palliative treatment

what are the types of prostate cancer?

>95% of prostate cancer is adenocarcinoma

what are the risk factors for prostate cancer?

increasing age Western nations (Scandinavian countries) ethnicity (African Americans)

what are the clinical features of prostate cancer?

usually asymptomatic unless metastatic

which marker is elevated in prostate cancer?

PSA - prostate-specific antigen

why must PSA levels be interpreted cautiously?

while PSA is prostate-specific, it is not prostate-cancer specific = can be elevated in (UTI, prostatitis)

how is suspected prostate cancer now managed?

imaging prior to biopsy | = risk assessment with multiparametric MRI before biopsy

why are biopsies no longer immediately done following suspected prostate cancer?

random biopsies of the prostate were associated with an under detection of high grade (clinically significant) prostate cancer and over detection of low grade (clinically insignificant) prostate cancer

what type of biopsy is done of the prostate for suspected prostate cancer and why?

(following the multiparametric MRI) trasnperineal prostate biopsy = less risk of infection and able to sample all areas of the prostate

explain the tumour staging in prostate TMN staging

T1 – non palpable or visible on imaging - T1a = in less than 5% of removed tissue - T1b = in more than 5% of removed tissue - T1c = found by biopsy after e.g. raised PSA T2 – palpable tumour (completely inside the prostate gland) - T2a = half of one side - T2b = more than half of one side, not both - T2c = both sides T3 – beyond prostatic capsule into periprostatic fat - T3a = broken through prostatic capsule - T3b = spread to seminal vesicles T4 – tumour fixed onto adjacent structure/pelvic side wall (spread to other organs)

explain the node involvement in prostate TMN staging

N0 - has not spread to nearby LNs | N1 – regional LN (pelvis)

explain the tumour staging in prostate TMN staging

M0 - cancer has not spread M1 = cancer has spread to other body parts - M1a- non regional LN outside pelvis - M1b- bone - M1x- other sites

which grading scale is used to score prostate cancer?

Gleason score ``` 2-6 = well differentiated 7 = moderately differentiated 8 = poorly differentiated ```

what does prostate cancer management depend on?

highly dependent on patient age/comorbidities and stage and grade of prostate cancer

how is high grade prostate cancer in a young, fit male managed?

radical prostatectomy or radiotherapy

how is low grade prostate cancer in a young, fit male managed?

active surveillance (monitor PSA, MRI)

how is high grade prostate cancer in an old, unfit male managed?

hormone therapy

how is high grade prostate cancer in an old, unfit male managed?

watchful waiting (Regular PSA testing)

explain the possible complications of a prostatectomy

prostatectomy = removes the proximal urethral sphincter so 1) possible risk of inadvertent damage to the cavernous nerve to the prostate (which provides neural innervation to the bladder and urethra) + reduction in urethral length = urinary incontinence 2) damage to cavernous nerves = erectile dysfunction

what is the main treatment for urinary incontinence caused by a prostatectomy?

- pelvic floor muscle exercises | - artificial urinary sphincter device

what is the required follow-up after a prostatectomy?

monitor PSA levels every 6 months = should be undetectable or <0.01 ng/ml (a biochemical relapse is defined as a PSA >0.2ng/ml)

what should patients that present with haematuria undergo?

red flag symptom- all patients should undergo cystoscopy and imaging