Urological Cancer Flashcards
Outline the risk factors of kidney cancer
RISK FACTORS OF KIDNEY CANCER
• Smoking
• Renal failure and dialysis
• Obesity
• Hypertension
• Genetic predisposition with Von Hippel-lindau syndrome (50% of individuals will develop RCC) – more in notes
What are the clinical features of kidney cancer?
Painless haematuria/persistent microscopic haematuria = RED FLAG
(can reflect any urological malignancy)
Additional features of RCC include:
Loin pain
Palpable mass
Metastatic disease symptoms e.g. bone pain, haemoptysis
What investigations are conducted when a patient has painless visible haematuria?
cystoscopy, CT urogram, Renal function (prognostic to determine if kidneys can survive contrast insult)
What investigations are made when a patient has persistent non-visible haematuria?
Flexible cystoscopy, US KUB (non visible is less associated with cancer)
What investigations are made when a patient has suspected kidney cancer?
CT renal triple phase (longer scan, better visualisation), staging CT chest, bone scan if symptomatic
What is a CT urogram specifically good at viewing?
Ureters
Outline the TNM staging for kidney cancers?
TNM staging of RCC
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 LN
N2 – met in ≥2 regional LN
M1- distant met
Outline the Fuhrman grading system for describing kidney cancer
Fuhrman grade
1 = well differentiated
2 = moderate differentiated
3 = poorly differentiated
4 = presecence of sarcomatoid/rhabdoid differentation
What is the gold standard management plan for kidney cancer?
Gold standard is excision : partial nephrectomy (single kidney, bilateral tumour, multifocal RCC in patients with VHL, T1 tumours), radical nephrectomy
In patient with small kidney tumours unfit for surgery what is the first line management?
Cryosurgery
What is the management plan for patients with kidney cancer that have metastatic disease?
Receptor tyrosine kinase inhibitors, block cell signalling pathway and reduce angiogenesis -> reducing spread
Outline the risk factors for bladder cancer?
RISK FACTORS
Smoking
• Occupational exposure - dye industry (aromatic hydrocarbons)
• Chronic inflammation of bladder (bladder stones, schistosomiasis, long term catheter)
• Drugs (cyclophosphamide)
• Radiotherapy
What are the clinical features of bladder cancer?
• Painless haematuria/persistent microscopic haematuria can is a red flag symptom and can reflect any of these urological malignancies
• Additional Features of bladder cancer include
- Suprapubic pain
- Lower urinary tract symptoms
- Metastatic disease symptoms
> bone pain
> lower limb swelling (local lymph node involvement)
More than 90% of bladder cancer is _______
Transitional cell carcinoma
Outline the TNM staging of bladder cancer?
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 LN below common iliac birufication
N2 - >1 LN below common iliac birufication
N3 – Mets in a common iliac LN
M1- distant mets
When investigating for bladder cancer, what is the next step if biopsy is proven muscle invasive?
Staging investigations
What does the management protocol for bladder cancer depend on?
Wether it is muscle invasive or non-muscle invasive
What does a rigid cystoscopy in bladder cancer provide?
Histology but can also be curative
What is a rigid cystoscopy?
cystoscopy + transurethral resection of bladder lesion uses heat (cauterize) to cut out all visible bladder tumour
In a rigid cystoscopy what happens if the tumour extends beyond the muscle?
if the tumour extends beyond muscle then the resection is incomplete due to the risk of perforating the bladder
Outline the WHO classification of bladder cancer?
WHO classification of bladder cancer
G1 = well differentiated
G2 = moderate differentiated
G3 = poorly differentiated
Outline the management protocol for non muscle invasive bladder cancer?
Non Muscle Invasive
- If low grade and no CIS (carcinoma in situ) then consideration of cystoscopic surveillance +/- intravesicular chemotherapy/BCG
- TB vaccine in bladder, inflammatory response shown to reduce risk of progression of bladder lesion
Outline the management protocol for muscle invasive bladder cancer
Cystectomy
Radiotherapy
Chemotherapy
Palliative treatment
More than 95% of prostate cancers are______
Adenocarcinoma
Outline the risk factors for prostate cancer?
Risk factors for prostate cancer
Age >65
Race (black > native Americans > Asian)
Family history
Diet high in fat
Cadmium and rubber manufacturing
Androgen exposure
In general, is bladder cancer symptomatic or asymptomatic?
Usually asymptomatic unless metastatic
What markers are looked at in blood test for prostate cancer?
PSA is prostate-specific but not prostate-cancer specific
- can be elevated in (UTI, prostatitis)
- can be done in community
When investigating for prostate cancer, when is MRI imaging done?
Prior to biopsy
Other than prostate cancer, what else can cause high blood PSA levels?
Hyperplasia of prostate
Inflammation
Why are biopsies for prostate cancer conducted after MRI?
random biopsies associated with an under detection of high grade (clinically significant) prostate cancer and over detection of low grade (clinically insignificant) prostate cancer
Why are trans perineal prostate biopsies preferred to transrectal biopsies to investigate prostate cancer?
Less risk of infection and able to sample all areas of the prostate
Outline the TNM staging for prostate cancer
TNM staging of prostate cancer
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
Outline the Gleason score grading system for prostate cancer
Gleason score – grading
• Since multifocal two scores based on level of differentiation
• above grade 3 = cancer
• use most common grade and highest grade to calculate gleason score (eg. 4 + 3 = 7)
2-6 = Well differentiated (low-grade)
7 = Moderately differentiated (intermediate grade)
8 – Poorly differentiated (high-grade)
What is the management protocol for prostate cancer dependent on?
Patient age and comorbidities and stage and grade of the prostate cancer
If a patient is young and fit with high grade prostate cancer, what is the management plan?
Is a patient is young and fit but has low grade prostate cancer, what is the management plan?
Post prostatectomy, what is the management plan?
If a patient is old/unfit with high grade prostate cancer/ metastatic disease, what is the management protocol?
If a patient is old/unfit with low grade cancer, what is the management protocol?
What are the side effects of prostatectomy and treatment of prostate cancer?
Urinary incontinence and erectile dysfunction
What are the six types of germ cell testicular tumours as classified by WHO?
Seminoma
Spermatocytic seminoma
Teratoma differentiated
Embryonal carcinoma
Yolk sac tumour
Choriocarcinoma
What are the five types of sex cord/gonadal stromal testicular tumours as classified by WHO?
Leydig cell tumour
Sertoli cell tumour
Granulosa cell tumour
Tumours of thecoma/ fibroma group
Mixed tumours
What are the three principle serum tumour markers for germ cell testicular tumours?
Alpha-fetoprotein (AFP)
Beta subunit of HCG
Lactate dehydrogenase (LDH)
Where is AFP normally synthesised?
By foetal yolk sac, liver, intestine
What is the serum half life of AFP?
4.5 days
AFP is elevated in which patients?
Elevated in patients with yolk sac component within a teratomatous germ cell tumour
The beta subunit of HCG is secreted by which cells?
Secreted by placental syncitiotrophoblastic cells
What percentage of seminomas and all choriocarcinomas produce HCG?
10%
LDH is a specific tumour marker for?
General tumour marker
-Not specific for any particular type of GCT
-Elevation of LDH correlates with tumour burden
What are the pathological prognostic factors in stage 1 seminoma?
Tumoursize of >4cm
Rete invasion (stromal)
What are the pathological prognostic factors in stage 1 non-seminomatous tumours?
lymphovascular invasion
- presence (and extent) of embryonal carcinoma
What are the symptoms of penile cancer?
Inability/ difficulty / pain on retracting foreskin (phimosis – partial/ complete)
•Spraying of stream (meatal stenosis)
•Obstructive LUTS (urethral stricture)
•Association with penile cancer
