Urological cancer Flashcards
Which age group is usually effected by prostate cancer? Are individuals with prostate cancer usually symptomatic?
70 years and above
Usually asymptomatic
Prostate cancer does not have a screening program, why?
If screening programme was to be present PSA test would used for screening but it is inadequate
Controversy over using Prostate Specific Antigen (PSA)
May not be an adequate screening test as significant numbers of false negatives and false
positives
PSA has age dependent cut offs
PSA is most useful in monitoring response to treatment
How is a diagnosis for prostate cancer confirmed?
Transurethral Ultrasound (TRUS) biopsy
What are the signs and symptoms of prostate cancer?
Lower urinary tract symptoms (LUTS)- give examples
Symptoms from metastatic disease - Bone pain (esp in back) spinal cord compression, anaemia
Locally advanced disease can lead to rectal symptoms and renal failure due to
urinary tract outflow obstruction
Which region of the prostate does prostate cancer most often present?
In the peripheral zone
In a digital rectal exam, how would prostate cancer differ for BPH?
Prostate cancer- Hard, irregular, asymmetrical, fixed
BPG- Enlarged, smooth, elastic
Prostate cancer is usually asymptomatic but when symptoms do present it is due to 3 main pathological events, what are these?
Enlarged prostate- leading to LUTS
Local invasion of cancer
Metastasis of cancer
What are the symptoms associated with the local invasion of prostate cancer?
Urinary obstruction and incontinence
Haematuria and haematospermia
Haematochezia
Erectile dysfunction
What are the symptoms associated with metastasis of prostate cancer?
Bone pain (esp back) Anaemia (lethargy) Unintentional Weight loss and anorexia Spinal cord compression Pelvic, testicular and lower back pain Pathological spontaneous pone fractures
Before a patient has a PSA test, what must happen first?
They must be counselled on what a PSA test is and the positive and negative aspects of having the test. They should be guided towards useful websites that provide the patient with reliable information.
Which other conditions can cause a raised PSA test?
BPH Acute urinary retention UTI Prostatitis Catheter Vigorous exercise Digital rectal exam Ejaculation
If a patient does choose to have a prostate screen which 2 tests/ examinations are offered?
PSA test
Digital rectal exam
When should a patient be referred to urological cancer specialists? (2 week wait pathway)
If there PSA levels are abnormal or rising - above age specific range
Prostate feels abnormal on DRE
In someone presenting with an abnormal PSA and DRE examination- which investigations would you conduct to further investigate prostate cancer?
FBC U and E LFT Bone profile Multiparametric MRI
Biopsy (transurethral ultrasound guided biopsy or transperineal)
Free: total PSA ratio
PSA density
Done if the biopsy shows signs of intermediate or high grade disease
Bone scan
Staging CT
Which 3 aspects are used in the staging of prostate cancer? Describe the results for each stage
PSA
Gleason
TNM (tumour size, nodes, metastasis)
Low risk = PSA <10, Gleason <6, TNM TI-T2a
Intermediate risk = PSA 10-20, Gleason 7, TNM T2b
High risk= PSA >20, Gleason 8-10, TNM >T2c
What is the Gleason score?
Prostate cells have distinct patterns as they change from normal cells to tumour cells.
These patters are assigned a number from 1 -5. 1= Prostate cells 5= highly mutated cells.
one Gleason grade to the most predominant pattern in the biopsy and a second Gleason grade to the second most predominant pattern.
The maximum Gleason grade is 10
When is localised therapy appropriate for prostate cancer patients? What are the available treatment options for localised therapy?
No extensive disease
PSA < 30
Low Gleason Score
Active surveillance (low risk patients)
Surgery (radical proctectomy or trans urethral resection)
Radiotherapy (Radical radiotherapy)
Cryotherapy- freezing and thawing of prostate cells to kill malignant
tissue
Adjuvant Androgen deprivation therapy may be combined with radical therapies, particularly those with intermediate or high risk disease receiving radiotherapy
Docetaxel chemotherapy may be used in patients with non-metastatic high risk disease
What is the specific criteria for cancer therapy?
Life expectancy > 15 years
(<75 years)
PSA < 15
No comorbidities- other diseases
Which types of radiotherapy treatment are available for prostate cancer patients?
External beam
Brachytherapy- implanting radioactive seeds into
prostate
They can be used together
Before a PSA test men should not have what?
Active or recent UTI (last 6 weeks)
Ejaculated for 48 hours
Engaged vigorous exercise for 48 hours
Had a urological intervention in the past 6 weeks
When should PSA test be offered in asymptomatic patients?
Men over 50
Which symptoms would require a PSA test?
Lower urinary tract symptoms (e.g. nocturia, frequency, hesitancy, urgency or retention)
Visible haematuria
Unexplained symptoms that may be explained by advanced prostate cancer (e.g lower back pain, bone pain, weight loss).
Erectile dysfunction.
If a patient has a normal DRE and a normal PSA does that exclude prostate camcer?
No - In this case clinical discretion must be used and the patient may require further clinical review
What is the first line investigation technique in those with suspected prostate cancer?
Multiparametric MRI
Which score is used in assessing the risk of prostate cancer using a Multiparametric MRI?
Likert score - a 5-point score based upon the radiologists impression of the scan
- Clinically significant cancer highly unlikely to be present
- Clinically significant cancer is unlikely to be present
- Chance of clinically significant cancer is equivocal
- Clinically significant cancer is likely to be present
- Clinically significant cancer is highly likely to be present
Following a Multiparametric MRI when is a prostate biopsy most likely going to be offered to the patient?
patients with a Likert score of 3 or greater
Which drugs are used in androgen deprivation therapy?
Gonadotrophin Releasing Hormone (GnRH) analogues e.g goserelin
Medical castration
In those taking androgen deprivation therapy which result is suggestive of a good long term outcome?
A rapid fall in PSA and a nadir of < 1 (absolute lowest level that the PSA drops after treatment)
How is locally advanced prostate cancer treated?
radical prostatectomy and radical radiotherapy. Docetaxel chemotherapy may be used
What is the What is the period of control for androgen deprivation therapy and what percentage of people are responsive to it?
1-3 years
80% responsive
If chemical castration- androgen deprivation therapy does not work what is the next course of action?
The disease is termed castrate resistant (or
androgen independent)
Other drugs are tried-
Androgen receptor antagonists - bicalutamide, enzalutamide
Corticosteroids - prednisone, dexamethasone
Oestrogens - oestradiol, diethylstilbestrol
Cyp 17 inhibitors - Abiraterone – very high response rate recorded; but suggestion of
lower response after corticosteroids/diethylstilbestrol
How is metastatic prostate cancer treated?
Docetaxel chemotherapy and androgen deprivation therapy are often used.
Bilateral orchidectomy can be offered as an alternative to androgen deprivation therapies.
Palliative care may be required
What are the palliative treatment options for prostate cancer?
Palliative radiotherapy
Bisphosphonates for bone disease – Alenronate, Zoledronic acid
RANKL inhibitor for metastatic disease –denosumab
Analgesics
Blood transfusion for anaemia
Palliative care team support
What is the most common type of kidney cancer?
Renal cell carcinoma
What are the signs and symptoms associated with renal cancer?
Abdominal pain Loin pain Loin mass Macro- / microscopic haematuria Fevers / pyrexia of unknown origin Night sweats Malaise Features of paraneoplastic syndromes Weight loss Anaemia or Polycythaemia (due to erythropoeitin production) Varicocele (classically left sided) (tumour effects venous return) Bone pain Hypercalcaemia
If local spread of renal cell cancer was to occur, where would it spread to?
renal vein and IVC
What is the most common location for the distant metastasis of renal cancer?
Lungs
What is a common X ray finding associated with metastasis of cancer to the lungs?
Cannon balls
What are the risk factors associated with renal cell cancer?
Overweight (obesity)
Smoking
Hypertension
Family history
Various rare inherited conditions
- Von Hippel-Lindau syndrome
- Hereditary papillary renal carcinoma
- Tuberous sclerosis
- Birt–Hogg–Dubé syndrome
There are 3 main types of renal cell cancer, what are they?
Clear cell
Papillary (type 1 and 2)
Chromophobe
Which mutations are associated with each type of renal cell carcinoma?
Clear cell- Von-Hippel Lindau mutation
Papillary type 1- C-met activation
Papillary type 2- Fumarate / Hydratase mutation
Chromophobe - C-kit
Varicoceles can be an indication of renal cell carcinoma. Under which circumstances should a patient with a varicocele be referred ?
older patients with unexplained new varicocele
urgent referral in those with varicocele which appear suddenly and are painful, do not drain when lying down or a solitary right-sided varicocele.
List 7 symptoms of paraneoplastic syndromes
Fever Hypercalcaemia Hypertension Neuromyopathies Polycythaemia Cushing’s syndrome
Which test should be conducted in someone suspected of having renal cell cancer?
Urine
Urine dip and MSU
Urine cytology
Blood FBC- rise in WCC UE - Hypercalcaemia LFT ESR- Rise Bone profile
Imaging-
CT- Main means of diagnosis
MRI- preferred in young patients, pregnant women or those with a contrast allergy. Also used where diagnosis is unclear
Bone scan- Used if bony metastasis are suspected
What are the treatment options for localised renal cell cancer?
those with lesions < 7cm (i.e. T1a and T1b) - partial nephrectomy is preferred where possible
T2 tumours radical nephrectomy is typically preferred.
How is metastatic renal cell cancer treated?
Tyrosine kinase inhibitors
sunitinib, sorafenib, pazopanib
Immunotherapy
high dose Interleukin 2
Mammalian target of rapamycin (mTOR) inhibitors
everolimus, sirolimus
What are the blood result requirements for someone to take High dose interleukin 2?
not anaemic, normal WBC and platelets
In which age groups does testicular cancer most often present?
20-40 years
What are the risk factors associated with testicular cancer?
Undescended tactical
Hypospadias - the opening of the urethra is on the underside of the penis instead of at the tip
Infertility
Klinefelter’s syndrome
Tall men
There are 3 main classifications for germ cell tumour, what are they?
Seminoma, Non - seminoma, Mixed
How does a testicular cancer usually present?
unilateral scrotal mass
Which clinical signs or symptoms are associated with testicular cancer?
Testicular lump Testicular pain/discomfort Back pain, flank pain (indicative of metastasis) Lymphadenopathy Gynaecomastia (more common in NSGCT)
When should a patient be referred urgently to urology via a two-week wait pathway?
non-painful testicular enlargement or change in size or change in texture
Additionally refer patients describing a dragging sensation, new varicocele or hydrocele.
Which method is used to diagnose testicular cancer?
Testicular ultrasound
How is a testicular cancer confined to the testicles treated?
orchidectomy followed by
Adjuvant therapy reduces risk of relapse but does not improve overall survival
Adjuvant therapy = In seminoma carboplatin chemotherapy or radiotherapy
Or
NSGCT / mixed seminoma= adjuvant bleomycin, etoposide and cisplatin (BEP) chemotherapy
What is the role of tumour markers in the management of testicular cancer?
Used to support the diagnosis and offer prognostic information
Which tumour markers are relevant to in testicular cancer?
Alpha-fetoprotein (AFP): may be produced by yolk sac components of tumours
Human chorionic gonadotrophin (hCG): may be produced by trophoblastic components of tumours
LDH: general marker of increased cell turnover
Where in the body does testicular cancer most often metastasize to?
lungs, lymph nodes, liver and brain
How is metastatic cancer treated in testicular cancer?
Seminoma = chemotherapy (e.g. cisplatin), radiotherapy or both
NSGCT = adjuvant bleomycin, etoposide and cisplatin (BEP) chemotherapy
What is the prognosis for testicular cancer
Cure rate is very high -99% for stage 1 tumours
85-90% for those with metastatic disease can expect to be cured
What should happen to tumour markers after treatment of testicular cancer?
they should normalise
After chemotherapy has been completed for testicular cancer, what should happen to residual masses?
They should be removed
Which 3 factors indicate poorer survival in testicular cancer?
Shorter initial remission time
Very high tumour markers
Extra-gonadal primary sites
What is the treatment strategy for a relapse in testicular cancer?
Cisplatin based therapy for first relapse
High dose chemotherapy with autologous stem cell rescue is often used on
second or subsequent relapse- Often high dose carboplatin and etoposide are used
What is the most common type of bladder cancer?
Transitional cell carcinoma
Where do tumours effecting the urothelium occure?
Anywhere between the renal pelvis and
the urethra
What are the main risk factors for bladder cancer?
aniline dyes smoking Chronic bladder infections/irritation Medications (e.g.cyclophosphamide) Family history Schistosoma haematobium (a significant risk factor in the development of bladder squamous cell carcinoma)
