Urological Cancer

Question 1

How is haematuria classified

Answer 1

Visible - 20% of having tumour

Non-visible symptomatic - 5% of having tumour

Non-visible asymptomatic - 0.5% of having tumour

Question 2

Name some causes of haematuria

Answer 2

Urological cancer: RCC, bladder caner, upper urinary tract TCC, advanced prostate carcinoma

Other urological causes: infection, inflammation, benign prostatic hyperplasia

Nephrological/glomerular causes

Question 3

How is the cause of haematuria investigated and what is looked for at each stage

Answer 3

History - smoking, occupation, painful/painless, other LUTS, family history

Examination - BP, abdo mass, varicoele, leg swelling, prostate size

Radiology - USS, CT

Endoscopy - flexible cystoscopy to visualise urinary tract

Urine sample for culture and sensitivity

Question 4

Describe renal cell carcinomas

Answer 4

Occur in parenchyma of kidney body

Are malignant or benign - commonly malignant

Cells in the carcinoma are full of lgycogen -> clear cell carcinoma

Higher chance in males and white have higher chance than non-white

Affects all age groups

Question 5

What are the risk factors for RCC

Answer 5

Being white

Being male

Smoking

Obesity

Dialysis

Question 6

How does RCC present

Answer 6

Have haematuria and possible palpable mass if enlarged

May present as incidental finding on imaging

If advanced: large varicoele, pulmonary/tumour embolus, loss of weight, loss of appetite, symptoms of metastasis, hypercalcaemia

Question 7

How does RCC spread

Answer 7

Local/perinephric spread into local fat

Spread via lymphatics into lymph nodes

Spread into renal vein -> IVC -> spread to right atrium

Question 8

What is the treatment for RCC

Answer 8

Small RCC are put under surveillance - small tumours can be benign, malignant or have slow progression. Check on tumour to see progression

Excision - radical or partial nephrectomy

Ablation - eitehr cryoablation or radiofrequency ablation

Question 9

What is a transitional cell carcinoma and how does it present

Answer 9

TCC is a carcinoma of the transitional cell epithelium lining the respiratory tract

Presents with haematuria or incidental finding on imaging

If advanced, presents with: weight loss, loss of appetite, symptoms of metastasis, DVT, lymphoedema (if spread to lymph nodes)

Question 10

What are the risk factors for bladder TCC

Answer 10

Men at greater risk - though women often present later so is more advanced and greater mortality

Whites at greater risk

Smoking increases

Occupation exposure: rubber/plastic manufacture, handling of carbon/crude oil/combustion/smelting, painters, mechanics, printers, hairdressers

Question 11

What is the treatment for bladder TCC

Answer 11

Initially is superficial TUR bladder tumour - cut away tumour usuing electric current

Lower risk non-muscle-invasive TCC - check cystoscopies over next few years for growth

High risk non-muscle-invasive TCC - check cystoscopies and give intravesical immunotherapy or give BCG to increase number of TH1 cells which are affective against cancer

Muscle-invasive TCC - neoadjuvent chemo -> either radical radiotherapy or cystectomy

Question 12

Describe the risk factors for upper urinary tract TCC and its relationship with bladder TCC

Answer 12

Risk factors: smoking, phenacetin abuse, Balkan’s nephropathy

Patients with bladder cancer have 5% chance of developing upper tract TCC

Patients with upper tract TCC have 40% chance of developing bladder cancer

Question 13

What is the treatment for an upper urinary tract TCC and why is this procedure used

Answer 13

Treatment for upper urinary tract TCC is nephrouereterectomy to remove kidney, fat, ureter and cuff of bladder

This is done to decrease risk of cancer spreading from the ureter down into the bladder
Also it is difficult to look up ureter if kidney removed -> ureter also removed so don’t have to worry about cancers in ureter

Question 14

What is the treatment for metastatic TCC

Answer 14

Systemic chemotherapy - cisplatin-based treatment

Biological therapies - immunotherapy. Introduce antibodies that block the protective mechanism used by cancer cells to evade immune system destruction. This therapy targets programmed cell death receptor 1

Systemic chemo can only be used if kidney function reasonable

Question 15

What are the risk factors for prostate cancer

Answer 15

Increasing age

Family history - 4x risk if 1st degree relative diagnosed with prostate cancer before 60. BRCA2 gene mutation

Black have highest chance of developing aggressive prostate cancer

Question 16

What are the issues with using PSA screening for prostate cancer

Answer 16

Over-diagnosis

Over-treatment

Affects QoL - co-morbidities of treatment

Cost-effectiveness

Have other causes of a raised PSA level: infection, inflammation, large prostate, urinary retention

Can have normal PSA but still have prostate cancer

Question 17

How does prostate cancer present

Answer 17

Urinary symptoms

Bone pain - due to metastases

PSA checked -> biopsied

DRE for another reason, e.g. look for cause for change in bowel habit

Incidental finding at transurethral rescetion of prostate for retention/urinary symptoms

Question 18

How is prostate cancer staged using the DRE

Answer 18

Localised - normal or feeling some irregular nodules

Locally-advanced - highly irregular and hard

Advanced - smooth and hard feel

Prostate is usualyl smooth and soft

Question 19

What is the treatment for prostate cancer

Answer 19

Localised treatment: surveillence, robotic radical prostatectomy, radiotherapy (external beam or brachytherapy)

Locally advanced treatment: surveillence, hormones, hormones and radiotherapy

Question 20

What is the treatment for metastatic prostate cancer

Answer 20

Hormones +/- radiotherapy - decrease level of testosterone

• Surgical castration
• Chemical castration - give continuous LHRH agonist which results in decreased testosterone production over time

Palliation - single-dose radiotherapy, bisphosphonates, chemo