Urological cancers Flashcards
What proportion of men with a raised PSA have cancer?
1/3
Non-cancer causes of raised PSA?
BPH Prostatitis and UTI Ejaculation Vigorous exercise Urinary retention Instrumentation of the urinary tract
PSA referral?
> 3.0 ng/ml in 50-69 y/o men
What is a chancre?
Genital ulcer usually formed in the primary stage of syphilis
Presenting sign of testicular cancer in young men?
Hydrocele - fluid around the testicle
Germ cell tumours can be divided into:
Seminomas
Non-seminomas
Examples of non-seminoma tumours:
Embryonal
Yolk sac
Teratoma
Choriocarcinoma
Non-germ cell tumours:
Leydig cell tumours
Sarcomas
Risk factors for seminomas and teratomas include:
Infertility Cryptorchidism Family history Klinefelter's syndrome Mumps orchitis
Germ cell tumour findings:
Elevated AFP in 60%
Elevated LDH in 40%
Seminoma findings:
hCG elevated in 20%
Presenting features of testicular cancer:
Painless (usually) lump
Hydrocele
Gynaecomastia
Risk factors for transitional cell carcinoma of the bladder:
Smoking
Exposure to aromatic amines - aniline dyes in the textile industry (e.g. 2-naphthylamine and benzidine)
Rubber manufacture
Cyclophosphamide
Risk factors for squamous cell carcinoma of the bladder:
Schistosamiosis (parasite)
Smoking
Which prostate cancer treatment causes an initial increase in the size of the tumour before shrinkage?
GnRH agonists such as buserelin
Function of GnRH antagonists?
Suppressed LH production and thus the release of DHT and suppresses tumour proliferation
Function of anti-androgens?
Directly block the effect of DHT and testosterone, preventing tumour proliferation
Often prescribed alongside GnRH agonists as can prevent the flare in growth
Function of 5-alpha-reductase blockers?
Shrink tumour by preventing formation of proliferative factor DHT from testosterone
Common complication of radical prostatectomy?
Erectile dysfunction
Localised prostate cancer management (T1/2)?
Watchful waiting
Radical prostatectomy
Radiotherapy: external beam and brachytherapy
Localised advanced prostate cancer management (T3/4)?
Hormonal therapy: GnRH agonist and anti-androgen
Radical prostatectomy
Radiotherapy: external beam and brachytherapy
Orchidectomy
Risks of radiotherapy for prostate cancer:
Bladder, colon and rectal cancer
Age range for teratoma of testicle?
Aged 20-30
Histology of seminoma?
Sheet like lobular patterns of cells
Fibrous septa with lymphocytic inclusions
Granulomas
Age of onset for non-seminomatous germ cell tumours:
Aged 20-30
Measure post chemo/for residual disease in non-seminomatous germ cell tumours?
Retroperitoneal lymph node dissection
Non-seminomatous germ cell tumour markers:
AFP elevated in 70% of cases
hCG elevated in 40% of cases
Seminoma markers:
AFP usually normal
hCG elevated in 10% of seminomas
LDH elevated in 10-20% of seminomas
What testicular cancer differential can be caused by chlamydia or gonorrhoea infections?
Epididymo-orchitis
Non-infective cause of epididymitis?
Amiodarone
Cause of hydrocele in children?
Patent processus vaginalis
Differentials for testicular cancer?
Epididymo-orchitis
Testicular torsion
Hydrocele
Why do you investigate visible haematuria?
Bladder/kidney cancer until proven otherwise
Immediate response to presentation of visible haematuria?
CT urogram and endoscopy
Where do transitional cell cancers form?
Collecting system
Ureter
Bladder
Urethra
What set of associated factors is met with the same response as a presentation of visible blood?
Over 50 years old
Non-visible haematuria
Smoker
Papillary cancer?
Flowery non-invasive cancer in the bladder lining
3 types of lower urinary tract symptoms (LUTs)
Voiding LUTS - Problems initiaiting
Storage LUTS - Frequency, nocturia, incontinence
Micturition LUTS - Dribble after finishing
Big risk factor for bladder cancer?
Smoking
Young person with non-visible blood non-smoker investigation?
Ultrasound of the kidneys
Endoscope
Common benign tumour of the kidney?
Angiomyolipoma
What is TURP?
Trans-urethral resection of the prostate
Investigations for microscopic haematuria:
BP
Proteinuria
GFR
Proportional of bladder cancers that are non-invasive?
70-75%
What percentage of non-visible haematurias are due to malignancy?
2%
What signifies a bladder is invasive?
Entry into the muscle layer through the mucosa and lamina propria (T2)
Tis bladder cancer?
Carcinoma in situ (will progress to invasive within 2 years if left in 50% of cases)
Ta bladder cancer?
Through urothelium (mucosa)
T1 bladder cancer?
Through urothelium not through lamina propria
T2 bladder cancer?
Through urotheloim and lamina propria and into muscle layer (invasive)
T3 bladder cancer?
Through urothelium, lamina propria, through the muscle layer and into the peri-visceral fat
T4 bladder cancer?
Through fat and out of the bladder
Treatment for non-invasive bladder cancer
Transurethral resection
Adjuvant intravesical therapy (chemo/BCG)
(BCG is an immunotherapy used in bladder cancer and to prevent TB)
Treatment for invasive bladder cancer
Radical cystectomy and urinary diversion
Radical radiotherapy
Stage I renal cancer?
<7cm
Stage II renal cancer?
> 7cm
Stage III renal cancer?
Has involvement of the renal vein (invading the vena cava potentially)
Stage IV renal cancer?
Spreading to other organs/lymph nodes
Treatment for stage I renal cancer?
Partial nephrectomy
Treatment for stage II renal cancer?
Radical nephrectomy
Classic renal cancer type?
Clear cell
Main three types of bladder cancer?
Transitional cell (urothelial) carcinoma (95%)
Squamous cell carcinoma
Adenocarcinoma
Visible difference between low and high grade tumours in the bladder?
Low grade are papillary and grow into the bladder cavity
High grade are either flat or in situ
Early symptoms or prostate cancer?
Asymptomatic
Late symptoms of prostate cancer?
Haematuria LUTS Bone pain - metastases Weight loss Reduced appetite
Treatment for advanced renal cell carcinoma metastatic disease?
1st line: Target molecular therapy Adjunct: surgery? Adjunct: chemotherapy? Adjunct: palliative RT Adjunct: bisphosphonates for bone metastases
Types of prostate cancer:
Acinar adenocarcinoma (most common)
Ductal adenocarcinoma (grows and spreads more quickly than acinar)
Transitional cell carcinoma (rarely can start in prostate)
Squamous cell carcinoma (grow and spread quicker than adenocarcinoma)
Small cell carcinoma (neuroendocrine)
Which lobe of the prostate becomes cancerous?
Posterior - will become hard and raggedy, loss of midline groove
Occasionally lateral lobe induration (fibrosis) with ablation of the lateral sulcus
Investigations for prostate cancer?
PR
mpMRI
PSA
Then - biopsy if worrying
Difference between staging and grading?
Staging represents spread of the cancer
Grading represents aggression of the cancer
Dont tend to offer radical solutions to prostate cancer over which age?
75
Side effects of radical prostate cancer treatment?
Erectile dysfunction
Micturition LUTS
5 things that can raise PSA?
Inflammation (prostatitis) Massive BPH Cancer (only thing that will make the PSA super high) Infection (UTI) Instrumentation (e.g. cystoscopy)
Does a PSA level of 5-20 create a clear diagnostic picture?
No, could be any of the 5 things that can raise PSA
Does a PSA level of >100 suggest cancer?
Yes, cancer is the only thing that will cause a huge increase in PSA
“At risk” group for testicular cancer?
Men aged 20-40
Important risk factors for testicular cancer:
Infertility/sub-fertility Undescended testis - corrective surgery when younger History of STIs HIV Smoking Klinefelter's (small) Contra-lateral testicular cancer
Paraneoplastic syndrome of testicular cancer?
Testicular cancer-associated paraneoplastic syndrome
What are the symptoms and cause of testicular cancer-associated paraneoplastic syndrome?
Progressive loss of control of limbs, eye movements and in some cases speech
Cancer causes an AI response to be mounted against the brain
Which lymph nodes does testicular cancer spread to?
Retroperitoneal lymph nodes (testes are retroperitoneal pre-descent)
Differential diagnoses of testicular cancer (VITMN):
V - Varicocele
I - Infection (epididymoorchitis/abscess)
T - Testicular rupture/torsion (very painful)
M - Small? - Klinefelter’s/FSH or LH or testosterone levels
N - Neoplasm
Where does testicular cancer metastasise to?
Commonly the lung, chest lymph nodes and lymph nodes at the base of the neck (check supraclavicular)
More advanced cancers spread to bone and liver
Appearance of testis and renal metastases on CXR?
Cannon-ball
Examination with testicular cancer suspected?
Bimanual palpitation
Abdominal exam
Lymph node exam (including supraclavicular node)
Ultrasound (100% sensitive in the scrotum)
Are tumour markers elevated in seminomas or non-seminomas?
Non-seminomas
What are the tumour markers measured in suspected testicular cancer?
alpha-beta-Protein
beta-hCG
LDH
Investigations for testicular cancer?
FBC and U+E
Tumour markers: alpha-beta-Protein, beta-hCG, LDH
FSH/LH and testosterone
Staging: CXR and CT
What does BRCA1 confer a 15% risk of in males?
Prostate cancer
