Uro - Urological Cancers

Question 1

What are the different groups of urological cancers?

Answer 1

→ kidney
→ prostate
→ bladder
→ testicular + penile (much more rare)

Question 2

What is the epidemiology of kidney cancers like?

Answer 2

→ 13,100 new kidney cancer cases in the UK every year(1)
→ Kidney cancer is the 7th most common cancer in the UK(1)
→ Incidence and mortality rising (2)

Question 3

What are the different types of kidney cancers + their prevalence?

Answer 3

→ 85% = Renal Cell carcinoma (adenocarcinoma)
→ 10% = transitional cell carcinoma
→ 5% = Sarcoma/Wilms tumour/other types

Question 4

What are the risk factors for kidney cancers?

Answer 4

→ genetic factors
→ smoking
→ obesity
→ patients on renal dialysis
→ hypertension

Question 5

What are the usual clinical signs of kidney cancer?

Answer 5

→ Painless haematuria
→ persistent microscopic haematuria (red flag symptom and can reflect any of these urological malignancies)
→ Loin pain
→ Palpable mass
→ Metastatic disease symptoms –bone pain, haemoptysis

Question 6

What are the investigations done for kidney cancer if there is painless visible haematuria?

Answer 6

→ flexible cystoscopy
→ CT urogram
→ renal function

Question 7

What are the investigations done for kidney cancer if there is persistent non-visible haematuria?

Answer 7

→ Flexible cystoscopy

→ US KUB (ultrasound of the kidneys, ureters and bladder)

Question 8

What are the investigations if kidney cancer is suspected?

Answer 8

→ CT renal triple phase
→ staging CT chest
→ bone scan if symptomatic

Question 9

How do you stage RCC kidney cancers?

Answer 9

→ 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
→ N1 – Met in single regional lymph node
→ N2 – met in ≥2 regional lymph nodes
→ M1 - distant met

Question 10

How do you grade kidney cancers via Fuhrman grades?

Answer 10

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

Question 11

What does kidney cancer management depend on?

Answer 11

Patient specific, depends on:
→ the ASA status (ability to tolerate surgery and anaesthesia)
→ comorbidities
→ classification of lesion (TMN staging)

Question 12

How is kidney cancer managed?

Answer 12

Gold standard is excision either via:
→ Partial nephrectomy (single kidney, bilateral tumour, multifocal RCC in patients with VHL, T1 tumours (up to 7cm)
→ Radical Nephrectomy

Question 13

How do you treat patients with very small tumours who are unfit for surgery?

Answer 13

cryosurgery

→ tumours are frozen which destroys cancer cells and abnormal tissue

Question 14

How do you treat the metastatic disease of kidney cancers?

Answer 14

(RTKI) receptor tyrosine kinase inhibitors

Question 15

What is the prognosis like for kidney cancers?

Answer 15

once staging crosses T3/T4, prognosis gets much worse

Question 16

What are the consequences of radical nephrectomy?

Answer 16

with both kidneys removed, patient will need to be put on dialysis

Question 17

What is the epidemiology of bladder cancer?

Answer 17

→ 10,200 new bladder cancer cases in the UK every year
→ Bladder cancer is the 11th most common cancer in the UK
→ Incidence and mortality declining

Question 18

What are the different types of bladder cancer? What is their prevalence?

Answer 18

→ >90% = transitional cell carcinoma
→ 1-7% = squamous cell carcinoma (75% SCC where schistosomiasis is endemic),
→ 2% = Adenocarcinoma

Question 19

???? What are the risk factors for bladder cancer?

Answer 19

→ smoking
→ old age
→ UTIs

Question 20

What is the clinical presentation for bladder cancer?

Answer 20

→ Painless haematuria
→ persistent microscopic haematuria can is a red flag symptom and can reflect any of these urological malignancies
→ Suprapubic pain
→ Lower urinary tract symptoms
→ Metastatic disease symptoms –bone pain, lower limb swelling

Question 21

What investigation are done for bladder cancer for painless visible haematuria?

Answer 21

→ Flexible cystoscopy
→ CT urogram
→ Renal function

Question 22

What investigation are done for bladder cancer for persistent microscopic haematuria?

Answer 22

→ Flexible cystoscopy (often under general anaesthetic as you can do surgery at the same time)
→ transurethral resection of bladder lesion
→ US KUB (ultrasound for kidneys, ureters and bladder)

Question 23

What’s the next step if biopsy shows muscle invasive bladder cancer?

Answer 23

→ staging investigations need to be done

→ muscle invasive cancer is treated differently to superficial cancers

Question 24

How are bladder cancers staged?

Answer 24

→ 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
→ N1 – 1 Lymph Node below common iliac birufication
→ N2 – >1 LN below common iliac birufication
→ N3 – Mets in a common iliac LN
→ M1 – distant mets

Question 25

How are bladder cancers graded?

Answer 25

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

Question 26

*What is the process of a rigid cystoscopy or transurethral resection of a bladder lesion?

Answer 26

→ transurethral resection of bladder lesion uses heat to cut out all visible bladder tumour
→ provides histology and also can be curative

Question 27

What differentiates management protocol for bladder cancers?

Answer 27

→ non-muscle (superficial) invasive

→ muscle invasive

Question 28

What is the management protocol for non-muscle invasive bladder cancer?

Answer 28

→ If low grade and no CIS (carcinoma in situ), then consideration of cystoscopic surveillance +/- intravesicular chemotherapy/BCG

Question 29

What is the management protocol for muscle invasive bladder cancer?

Answer 29

→ Cystectomy = removal of bladder
→ Radiotherapy (makes it very hard to do surgery after, tissue becomes sticky)
→ +/- chemotherapy
→ Palliative treatment

Question 30

What is the epidemiology of prostate cancer?

Answer 30

→ 48,500 new prostate cancer cases in the UK every year
→ Prostate cancer is the most common cancer in men within the UK
→ Incidence rising but mortality rates declining

Question 31

What are the types of prostate cancer and their prevalence?

Answer 31

95% = adenocarcinoma

Question 32

What are the risk factor for prostate cancer?

Answer 32

→ Increasing age
→ Western nations (Scandinavian countries)
→ Ethnicity (African Americans)

Question 33

????? What are the main clinical features of prostatic cancer?

Answer 33

→ Usually asymptomatic unless metastatic
→ some may present with
urinary incompetence
hydro something something

Question 34

What are the blood tests that can be done to investigate prostatic cancer?

Answer 34

look for PSA levels
→ prostate specific antigen is prostate-specific but not prostate-cancer specific
→ Can be elevated in (UTI, prostatitis)

Question 35

What investigations can be done for prostate cancer?

Answer 35

MRI

Trans perineal prostate biopsy

Question 36

What is the staging of prostate cancers?

Answer 36

T1 – non palpable or visible on imaging
T2 – palpable tumour
T3 – beyond prostatic capsule into periprostatic fat
T4 – tumour fixed onto adjacent structure/pelvic side wall
N1 – regional LN (pelvis)
M1a -  non regional LN
M1b - bone
M1x - other sites

Question 37

What is the grading of prostate cancers?

Answer 37

→ Gleason score
→ Since multifocal two scores based on level of differentiation
→ 2-6 = Well differentiated
→ 7 = Moderately differentiated
→ 8 – Poorly differentiated

Question 38

What does prostate cancer management depend on?

Answer 38

→ patient age
→ comorbidities
→ stage and grade of prostate cancer

Question 39

What is the management for someone young + fit with a high grade prostate cancer?

Answer 39

Radical prostatectomy

Radiotherapy

Question 40

What is the management for someone young + fit with a low grade prostate cancer?

Answer 40

Active surveillance (Regular PSA, MRI and Bx)

Question 41

What is the management for someone old / unfit with a high grade prostate cancer + - metastatic disease?

Answer 41

hormone therapy

Question 42

What is the management for someone old + unfit with a low grade prostate cancer?

Answer 42

Watchful waiting (regular PSA testing)

Question 43

What should be done post-prostatectomy?

Answer 43

→ monitor PSA ( should be undetectable or <0.01ng/ml). → If >0.2ng/ml then relapse

Question 44

What are the side effects of prostatectomy? How?

Answer 44

erectile dysfunction:
→ prostate contains the proximal sphincter
→ Prostatectomy removes the proximal urethral sphincter and changes urethral length
→ Risk of damage to cavernous nerves (innervation to bladder and urethra)
→ Damage to cavernous nerves causes ED