Urological cancers Flashcards
How common I kidney cancer?
Incidence/ mortality trend?
- Kidney cancer is 7th most common cancer in UK
- Incidence and mortality rising
What types of kidney cancers are there and which is the most common?
Most are renal cell carcinomas (adenocarcinomas)
Transitional cell carcinomas
Sarcomas/Wilms tumor/ other types
What aetiological factors are there that cause kidney cancers?
Smoking
Hypertension
Renal failure and dialysis
Genetic predisposition with Von Hippel-Lindau syndrome (50% of individuals will develop RCC)
What clinical features can you find in kidney cancers?
-You may or may not feel a mass- if there is a mass there’s likely to be systemic symptoms too like weight loss or anaemic or polycythaemic (because of paraneoplastic syndromes), hypercalcaemia (again since tumour might secrete this)
- Loin pain
- Haemorrhage
-Varicocele
- Metastatic disease symptoms like bone pain, haemoptysis, shortness of breath
- Commonest- painless haematuria (particularly if large tumour like transitional cell carcinoma) or persistent microscopic haematuria- a red flag and can reflect urological malignancies
If you can’t find a mass how then do we often find kidney cancers?
A lot of them are incidentally found on scans
Where and why would you see varicocele in kidney cancer?
- left sided renal tumours
- You get compression of renal vein due to tumour thrombus
What investigations would we do on painless visible haematuria?
Ask a history about smoking, coagulation problems
CT urogram
Flexible cystoscopy
Renal function
What is CT urogram used for?
- The top end of the urinary system- CT scan of kidneys which could reveal masses
- Can look down ureters too to look for pathology there e.g. ureteric filling defect which could indicate transitional cell carcinomas or stones (which also cause haematuria)
- Get a little idea of the bladder but we don’t look at it directly- if we see a large bladder mass causing haematuria we might see a filling defect or clot in the bladder
What is flexible cystoscopy and what is it used to look for
- Looking at bladder under local anaesthetic- looking for exophytic lesions (looking for tumours) or bleeding from ureteric orifices which could mean bleed is higher (e.g. ureters) and its trickling down into bladder
- Can look at urethra for transitional cell carcinoma
- Can see strictures that cause haematuria or bleeding prostate
- Red patches in bladder could indicate pre-cancer or carcinoma in-situ
What investigations do we do on persistent non visible haematuria?
- Flexible cystoscopy
- US KUB (US of kidneys, ureter and bladder)
-((CT urogram))
What is non-visible haematuria?
When you see RBCs in urine on microscopy or dipstick but not visually
Which out of visible and non-visible haematuria are we more concerned about?
How would they present in clinic?
Other than bladder cancer what could this indicate?
- Visible because usually these cases have serious underlying pathology
- Often see them in clinic with large bladder and anaemic and have to wash out bladder because of clots
- Also have to check for visible haematuria to see if there’s a renal problem, esp if there’s proteinuria
How do we investigate a suspected renal cancer?
- CT renal triple phase
- Staging CT chest
- Bone scan if symptomatic
What staging system would we use for RCC?
TNM staging (see pic)
What grading system can we use for kidney cancer?
Fuhrman grade
- 1 = well differentiated
- 2 = moderately differentiated
- 3 + 4 = poorly differentiated
What is kidney cancer management dependent on?
Patient specific- depends on:
- ASA status (healthiness of patient)
- Comorbidities
- Classification of lesion
How do we manage kidney cancer in patients with small tumours who are unfit for surgery?
- Cryosurgery- freeze the lesion
- Can follow it up with serial scanning
What is the gold standard for management of kidney cancer?
Excision either via partial nephrectomy or radical nephrectomy (full kidney removal)
When would we do a partial nephrectomy?
- single kidney
- bilateral tumour
- multifocal RCC in patients with VHL (multiple small lesions)
- T1 tumours (up to 7cm)
How would we treat metastatic kidney disease?
- Receptor tyrosine kinase inhibitors
What do we want to avoid in resection of kidney cancer?
Taking out so much kidney that we have to put them on dialysis
Why is incidence and mortality of bladder cancer declining?
- more screening
- less patients are smoking
What types of bladder cancers are there?
> 90% are transitional cell carcinoma
squamous cell carcinoma
adenocarcinoma
complication of transitional cell carcinoma of the bladder?
- TCC arises from transitional epithelium which also lines ureter and kidney
- If you have a bladder cancer you could get a field change where the cancer travels all the way up from urethra to kidney
(therefore these patient need a CT scan to assess urothelium everywhere else)
Commonest cause of squamous cell carcinoma of the bladder?
schistosomiasis- an infection caused by blood flukes (parasites)
Aetiological causes of bladder cancer
- Smoking
- occupational exposure (aromatic hydrocarbons)
- chronic inflammation of bladder (bladder stones, schistosomiasis, long term catheter)
- drugs (cyclophosphamide)
- radiotherapy
How might bladder cancer patients present?
- Visible/non-visible haematuria
- Retention of urine
- Clots
- Ureteric bleeding
- Lower urinary tract symptoms e.g. irritation (always wanting to go to the toilet)
- UTI e.g. in older patients, esp if they’re smokers, who have UTI you might want to think about bladder cancer
- Suprapubic pain
- Metastatic disease symptoms e.g. bone pain, lower limb swelling
How can renal function be impaired due to transitional cell carcinoma of the bladder
If you have a TCC in ureter or renal pelvis then it may cause ureteric dilatation due to causing an obstruction- leading to impaired renal function
(hydronephrosis)
If a biopsy has proven muscle invasion then how do we investigate further?
Depending on whether it’s invasive or not, how can we classify bladder cancer?
We do staging investigations
- Superficial bladder cancer
- Muscle invasive bladder cancer
When would an MRI be useful in bladder cancer?
If we have a TCC in bladder that is carcinoma in situ, it could cause a generalised field change leading to ureter and urethra getting cancer in it too
We can get MRI when we’re unsure if it’s invading the uterus, vagina, bowel or has caused a fistula
TNM staging of bladder cancer
staging bladder cancer
How does bladder cystoscopy work?
Look down the cystoscope down urethra into bladder
What technique can we do now along with a cystoscopy in bladder?
Transurethral resection of bladder lesion
- We use heat to cut out all visible bladder tumour
- This also provides histology and can be curative
How do we manage non muscle invasive bladder cancer?
If it’s low grade and no CIS (carcinoma in situ) consider cystoscopic surveillance +/intravesicular chemo or BCG
How do we manage muscle invasive bladder cancer?
- Cystectomy
- Radiotherapy
- +/- chemo
- Palliative treatment
Most common cancer in men in the UK?
Prostate cancer
What is happening to incidence and mortality rates of prostate cancer?
Incidence rising but mortality rates declining
Most common type of prostate cancer?
> 95% of prostate cancer is adenocarcinoma
Prostate cancer risk factors?
- Increasing age
- Western nations (Scandinavian countries)
- Ethnicities (African Americans)
Prostate cancer clinical features
- Usually asymptomatic unless metastatic
- Some patients may present with:
- acute urinary retention
- hydronephrosis (need to decompress)
- renal failure
How do we detect prostate cancer through blood tests?
Levels of PSA
What else can cause higher PSA levels other than prostate cancer?
- In an enlarged prostate so it may be increased in UTI or increased volume of prostate
- Prostatitis
- BPH
Why can enlarged prostate cause high PSA?
PSA is made by prostate tissue so it’s prostate-specific but not prostate cancer-specific
What do we need in addition to PSA levels to diagnose prostate cancer?
Imaging/rectal exam
What is the main way now of detecting prostate cancer?
MRI prior to biopsy testing
What were random prostate biopsies associated with historically?
How have techniques changed?
Under-detection of high grade (clinically significant) prostate cancer and over-detection of low grade (clinically insignificant) prostate cancer
It’s proven now that multiparametric MRI before biopsy and MRI targeted biopsy is superior to the previous gold standard of transrectal ultrasonography-guided prostate biopsies
After MRI, what is the final stage of diagnosis of prostate cancer?
- Transperineal 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
TNM staging of prostate cancer
Image showing T1-4 grading of prostate cancer
What system do we use to grade prostate cancer?
How do we treat young and fit patients with high grade prostate cancer?
Radical prostatectomy/radiotherapy
What do we do post-prostatectomy?
- Monitor PSA (should be undetectable or <0.01ng/ml)
- If >0.2ng/ml then relapse- then might put them on hormone anti-androgen therapy and radiotherapy
How do we treat young and fit patients with low grade prostate cancer?
Active surveillance (regular PSA, MRI and Biopsy)
How do we treat old/unfit patients with high grade prostate cancer/metastatic disease?
Hormone therapy
How do we treat old/unfit patients with low grade prostate cancer?
Watchful waiting (regular PSA testing)
What side effects can prostatectomy/radical surgery have?
- Prostate contains proximal sphincter and through prostatectomy this removes the proximal urethral sphincter and changes urethral length
- Risk of damage to cavernous nerves (S2-S4 parasympathetic fibres (innervation to bladder and urethra)- can cause erectile dysfunction (parasympathetic causes erection)
