urological cancers Flashcards
what is the epidemiology of kidney cancer?
13,100 new kidney cancer cases in the UK every year
Kidney cancer is the 7th most common cancer in the UK
Incidence and mortality rising
85% of kidney cancer is Renal Cell carcinoma(adenocarcinoma)(RCC)
10% transitional cell carcinoma, Sarcoma/Wilms tumour/other types(5%)
Risk factors: Smoking, Renal failure and dialysis, obesity, hypertension
Genetic predisposition with Von Hippel-lindau syndrome (50% of individuals will develop RCC)(
what are the clinical features of kidney cancer?
Painless haematuria/persistent microscopic haematuria is a red flag symptom and can reflect any of these urological malignancies
Additional Features of RCC include:
Loin pain
Palpable mass
Metastatic disease symptoms: bone pain, haemoptysis
what investigations are done for kidney cancer?
Painless visible Haematuria – more worrying:
Flexible cystoscopy (Flexible cysyoscopy looks inside the bladder
Can find transitional cell carcinoma, kidney stones, carcinoma in situ)
CT urogram
Renal function
Persistent non visible haematuria:
Flexible cystoscopy
US KUB
Suspected kidney cancer:
CT renal triple phase
staging CT chest
bone scan if symptomatic
how is kidney cancer staged and graded?
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
Fuhrman grade:
1 = well differentiated
2 = moderate differentiated
3 + 4 = poorly differentiated
1-3 based on nuclear size , 4 = presecence of sarcomatoid/rhabdoid differentation
how is kidney cancer managed?
Management:
Patient specific ( depends on the ASA status, comorbidities, classification of lesion)
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
In patents with small tumours unfit for surgery – Cryosurgery
Metastatic disease- Receptor Tyrosine Kinase inhibitors
immunotherapy
what is the epidemiology of bladder cancer?
Epidemiology:
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
Types of cancer:
>90% of bladder cancer is transitional cell carcinoma, 1-7% squamous cell carcinoma (75% SCC where schistosomiasis is endemic), Adenocarcinoma(2%)(2)
causes:
Smoking, occupational exposure( 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 haematuriais 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
what investigations are done for bladder cancer?
Painless visible Haematuria:
Flexible cystoscopy
CT urogram
Renal function
Persistent microscopic haematuria:
Flexible cystoscopy
US KUB
If biopsy proven muscle invasive then staging investigations
how is bladder cancer staged and graded?
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
WHO classification:
G1 = well differentiated
G2 = moderate differentiated
G3 = poorly differentiated
what is Cystoscopy + transurethral resection of bladder lesion?
A transurethral resection of bladder lesion uses heat to cut out all visible bladder tumour.
This provides histology and also can be curative.
However, if the tumour extends beyond muscle then the resection is incomplete due to the risk of perforating the bladder
Might follow after a flexible cystoscopy if seen some changes suggestive of cancer
This scope is rigid (unlike flexible cystoscopy)
what is the management of bladder cancer?
Non Muscle Invasive:
-If low grade and no Carcinoma in situ then consideration of cystoscopic surveillance +/- intravesicular chemotherapy/BCG
Muscle Invasive: Cystectomy Radiotherapy \+/- chemotherapy Palliative treatment
what is the epidemiology of prostate cancer?
Epidemiology:
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
Types of cancer:
>95% of prostate cancer is adenocarcinoma
Risk factors: Increasing age, Western nations(Scandinavian countries), Ethnicity(African Americans)
Clinical Feature:
Usually asymptomatic unless metastatic
PSA screening, prostatic specific antigen – can be a biomarker for prostate cancer, especially in keeping with clinical findings
what investigations are done for prostate cancer?
Blood tests:
PSA is prostate-specific but not prostate-cancer specific
Can be elevated in (UTI, prostatitis)
MRI :
Management paradigm for suspected prostate cancer has shifted towards imaging prior to biopsy testing.
Historically 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.
Several large RCT’s have shown that the use of risk assessment with multiparametric MRI before biopsy and MRI targeted biopsy is superior to the previous gold standard of transrectal ultrasonography-guided prostate biopsies.
Trans perineal prostate biopsy:
Systematic template biopsies of the prostate
Widely used in most centres over transrectal biopsies as less risk of infection and able to sample all areas of the prostate.
how is prostate cancer staged and graded?
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
Gleason score:
Since multifocal two scores based on level of differentiation
2-6 = Well differentiated
7 = Moderately differentiated
8 – Poorly differentiated
how is prostate cancer managed?
Highly dependent on patient age/comorbidities and stage and grade of prostate cancer
If young and fit:
+ High grade cancer -> Radical prostatectomy/Radiotherapy
+ Low grade cancer -> Active surveillance ( Regular PSA, MRI and Bx)
Post prostatectomy – monitor PSA ( should be undetectable or <0.01ng/ml). If >0.2ng/ml then relapse
if old/unfit:
+ high grade cancer/Metastatic disease -> Hormone therapy
+ Low grade cancer -> Watchful waiting (regular PSA testing)
