Urological Cancers Flashcards
What types of kidney cancers are there and how common are each in %?
- 85% are renal cell carcinomas (adenocarcinomas)
- 10% are transitional cell carcinomas
- 5% are sarcoma/Wilms tumour/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) (increases the risk of tumour and cyst production in different parts of organs)
Obesity
As well as age,having hepatitis c,exposure to certain dyes asbestos cadmium herbicides and solvents,birt hogg dube syndrome,tue tuberculosis sclerosis and familial papillary renal cell carcinoma
What clinical features can you find in kidney cancers? (7
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
- Palpable mass
-varicocele as you get compression of renal vein - 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? And what symptoms do we see in renal cancer
A lot of them are incidentally found on scans
Blood in urine,back pain below the ribs that doesn’t go away,unexplained weight loss or loss of appetite,fatigue,fever,lump in side belly or lower back,anaemia,night sweats,family history of kidney disease,high bp and high calcium in blood
Main types of renal cell carcinoma/cancers
Clear cell most common,appear as bright yellow due to high lipid content and associated with VHL
Papillary has a papillary growth pattern
Chromophobe renal cell cancer Origim from distal tubules and has better prognosis due to low metastasis
What investigations would we do on painless visible haematuria? (4)
Ask a history about smoking, coagulation problems
CT urogram
Flexible cystoscopy
Renal function
CT urogram- what is this used to look at?
- 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
Flexible cystoscopy- what is this and what are we looking for? (4)
- 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? (2)
- Flexible cystoscopy
- US KUB (US of kidneys, ureter and bladder)
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?
- Visible because 50-60% of 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
- Non visible has 1-3% chance
- 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? (3)
- CT renal triple phase
- Staging CT chest
- Bone scan if symptomatic
What staging system would we use for RCC?
TNM staging
- 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?Metastasis in single regional LN e.g. paraaortic
- N2?Mets in ≥2 regional LN
- M1?Distant metastasis
What grading system can we use for kidney cancer?
Fuhrman grade
- 1 = well differentiated
- 2 = moderately differentiated
- 3 + 4 = poorly differentiated
4 based in sarcomatoid/rhabdoid differentiation
1x3 on nuclear size
What is 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?
Excision either via:
- Partial nephrectomy- when do we do it? (4)
- single kidney
- bilateral tumour
- multifocal RCC in patients with VHL (multiple small lesions)
- T1 tumours (up to 7cm)
- Radical nephrectomy (full kidney removal)- describe the technique for thiscan remove large tumours through loin or transperitoneal esp if there’s tumour thrombus in IVC to get control of blood vessels
What about metastatic disease? (2)
- Receptor tyrosine kinase inhibitors
- Immunotherapy
What are we trying to avoid with these patients?
Taking out so much kidney that we have to put them on dialysis
What types of bladder cancers are there and how common are each in %?
- > 90% are transitional cell carcinoma- what problem could occur from one of these in 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
- What does this mean bladder cancer patients also have to get done?A CT scan to assess urothelium everywhere else
- 1-7% are squamous cell carcinoma- 75% SCC where schistosomiasis is endemic- what is this?An infection caused by blood flukes (parasites)
- 2% are adenocarcinoma
What aetiological factors are there for bladder cancer
- Smoking
- occupational exposure (aromatic hydrocarbons)
- chronic inflammation of bladder (bladder stones, schistosomiasis, long term catheter)
- drugs (cyclophosphamide)
- radiotherapy
How might patients present? (5) bladder cancer
- 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
What investigations do we do for painless visible haematuria? (3)
- Flexible cystoscopy
- CT urogram
- Renal function- how can it be impaired due to TCC?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 functionThis is aka hydronephrosis
What investigations do we do for persistent microscopic haematuria? (2)
- Flexible cystoscopy
- US KUB
If a biopsy has proven muscle invasion then how do we investigate further?
We do staging investigations
Depending on whether it’s invasive or not, how can we classify bladder cancer? (2)
- Superficial bladder cancer
- Muscle invasive bladder cancer
When would an MRI be useful
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
Outline the meaning of the following in the TNM staging of bladder cancer
- TaNon invasive papillary carcinoma
- TisCarcinoma in situ (precancerous but can be aggressive and can progess)
- T1Invades subepithelial connective tissue
- T2Invades muscularis propria
- T3Invades perivesical fat
- T4Invades prostate, uterus, vagina, bowel, pelvic or abdominal wall
- N11 LN below common iliac bifurcation
- N2> 1 LN below common iliac bifurcation
- N3Mets in a common iliac LN
- M1Distant mets
Describe the meaning of the following in the WHO classification for staging
- G1Well differentiated
- G2Moderate differentiated
- G3Poorly differentiated
How does a cystoscopy work?
Look down the cystoscope down urethra into bladder
What technique can we do now along with a cystoscopy
Transurethral resection of bladder lesion
- We use heat to cut out all visible bladder tumour
- This also provides histology and can be curative
If the tumour extends beyond the muscle then what do we do?
We can’t complete the resection or else this could perforate the bladder causing peritoneal seeding
Cystectomy
Radiotherapy
Chemotherapy?
Palliative care
How do we manage non muscle invasive bladder cancer?
If it’s low grade and no CIS (carcinoma in situ) then we can remove it and consider cystoscopic surveillance +- intravesicular chemotheraoy/bcg
Can also have intravesicular chemo or BCG (immunotherapy)- why?
To reduce recurrence rate
BCG usually done for carcinoma in situ
How do we manage muscle invasive bladder cancer? (4
- Cystectomy
- Radiotherapy
- +/- chemo
- Palliative treatment
What type of cancer causes prostate cancer mostly?
> 95% of prostate cancer is adenocarcinoma
What risk factors are there? (3) prostate cancer
- Increasing age
- Western nations (Scandinavian countries)
- Ethnicities (African Americans)
-family history
-obesity and diet
What clinical features are there? Prostate cancer (4)
- 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 which is an enzyme (serine protease) produced by glandular tissue of prostate
Can also be caused by - In an enlarged prostate so it may be increased in UTI or increased volume of prostate. Size increases with age
- Prostatitis
- BPH
This is because PSA is made by prostate tissue so it’s prostate-specific but not prostate cancer-specific
What is the main way now of detecting prostate cancer?
MRI prior to biopsy testing
What were random prostate biopsies associated with historically?
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?
- 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
Describe the meaning of the following in the TNM staging of prostate cancer
- T1Non palpable or visible on imaging
- T2Palpable tumour
- T3Beyond prostatic capsule into periprostatic fat
- T4Tumour fixed onto adjacent structure/pelvic side wall
- N1Regional LN (pelvis)
- M1aNon regional LN
- M1bBone
- M1xOther sites
What system do we use to grade prostate cancer?
- Gleason score which goes from 1-10
- Since prostate cancer is multifocal we use 2 scores based on levels of differentiation
- 2-6 is well differentiated
- 7 is moderately differentiated
- 8 is poorly differentiated
Low/very low risk group-grade group 1-Gleason score <6
Intermediate (favorable or unfavorable)-grade group 2/3- Gleason score 7 (3+4) or 4+3)
High/very high-grade group 4-score 8
Grade group 5 score 9-10
How do we treat young and fit patients with high grade cancer
Radical prostatectomy/radiotherapy
- 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 cancer?
Active surveillance (regular PSA, MRI and Biopsy)
How do we treat old/unfit patients with high grade cancer/metastatic disease?
Hormone therapy
How do we treat old/unfit patients with low grade cancer?
Watchful waiting (regular PSA testing)
What side effects can prostatectomy/radical surgery have? (2)
- Prostate contains proximal sphincter and through prostatectomy this removes the proximal urethral sphincter and changes urethral length. Proximal sphincter has some degree of control of urinary continence
- Risk of damage to cavernous nerves (innervation to bladder and urethra)- can cause erectile dysfunction
Tumour staging for prostate cancer in more detail
T1-too small to be seen in scan or felt. T1a means cancer is in less than 5% of tissue removed,T1b means it’s in more than 5%,T1c found by biopsy,latter found by accident for other surgery
T2. Eans cancer is completely inside prostate gland. T2a means it’s in half of the side,T2b means it’s in more than half of one side,T2c means cancer in both sides of prostate
T3 means cance has broken through the capsule of the prostate gland dividing into T3a and T3b,T3a means cancer has broken through the capsule,T3b means cancer has spread into tubes that carry semen
T4 means cancer has spread to other parts of the organs such as bladder or pelvic wall
N0 means no cancer in lymph nodes and N1 means there are cancer in lymphocytes nodes near prostate
Metastasis M0 means cancer hasn’t spread to other parts of the body,M1means cancer has spread, splits into M1a which means there are cancer cells in lymph nodes outside pelvis,M1b means ther are cancer cells in the bone
