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Block 34 - Metabolic > Urological cancers > Flashcards

Urological cancers Flashcards

1
Q

1) What does the term ‘prostate cancer’ usually refer to?
2) What percentage of all cancers in men does ‘prostate cancer’ account for?
3) Are prostate cancers usually benign or malignant?

A

1) Prostate adenocarcinoma.
2) 7% (commonest male malignancy)
3) Malignant.

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2
Q

1) Where does prostate adenocarcinoma usually arise from?
2) Prostate adenocarcinoma is usually caused by a genetic mutation where?
3) What will the genetic mutation lead to?
4) What histological entity is most likely to be the precursor of invasive prostate cancer?

A

1) The peripheral zone of the prostate.
2) In a luminal cell or a basal cell within the prostate.
3) Uncontrolled cell division.
4) High grade prostatic intraepithelial neoplasia.

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3
Q

1) Give 2 identified causative mutations of prostate cancer.
2) In the early stages of prostate cancer, what do neoplastic cells require for replication?
3) In later stages of prostate cancer, what do neoplastic cells require for replication?
4) How quick is the rate of growth of prostate cancer?

A

1) BRCA1 and BRCA2.
2) Early on, they require androgens for replication.
3) Later on, the cancer cells can replicate without the need for androgens.
4) Prostate cancer cells have a relatively slow rate of growth.

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4
Q

As well as adenocarcinoma, name 2 other types of prostate cancer.

A

Transitional cell carcinoma and small cell prostate cancer (this arises from neuroendocrine cells).

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5
Q

State which blood tests you would order for a patient with suspected prostate cancer.

A 
FBC
U&Es
Creatinine
LFTs
PSA
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6
Q

Aside from bloods, what other investigations would you perform for a patient with suspected prostate cancer?

A

DRE
USS and biopsy
Urine dipstick, microscopy and culture
Plain Xray and pelvic CT scan

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7
Q

1) How would you locally stage a prostate tumour?
2) In high income countries, how does prostate cancer normally present?
3) Early on in the development of prostate cancer, why are there typically no symptoms?
4) What is the most common site of metastatic spread from prostate cancer?

A

1) An endorectal coil MRI is used.
2) As a result of screening.
3) As most tumours originate in the posterior peripheral zone far away from the urethra.
4) Bone, particularly the vertebrae and pelvis.

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8
Q

State 3 general symptoms of prostate cancer.

A

Difficulty urinating
Bleeding (haematuria)
Pain with urination and ejaculation.

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9
Q

Which 3 other categories of symptoms can be associated with prostate cancer?

A

1) Symptoms of BPH
2) Symptoms of BOO
3) Symptoms of metastatic disease

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10
Q

Give the 3 main symptoms of BPH.

A

Frequency
Urgency
Nocturia

**FUN

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11
Q

Give the 5 main symptoms of bladder outflow obstruction.

A 
Hesitancy
Intermittent flow
Terminal dribbling
Weak stream
Incomplete emptying
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12
Q

Give 4 signs or symptoms of metastatic disease associated with prostate cancer.

A

Elevated PSA
Abnormal PR examination
Bone pain
Palpable lymph nodes

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13
Q

1) What scoring system is used to grade prostate cancer?
2) How is a Gleason score determined?
3) According to the Gleason score, what scores correlate to low, intermediate and high grade tumours?

A

1) The Gleason score.
2) With a pathologist assigning scores to the most predominant histological patterns present on a biopsy. There are 2 scores given, one for the most predominant pattern and another for the second most predominant pattern.
3) =6 is low grade, 7 is intermediate grade and 8-10 is high grade.

**Pathologists rarely give out a Gleason score <6, so 6 is considered to be low grade.

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14
Q

Describe management of prostate cancer is the tumour is confined to the prostate with no metastases (i.e. low risk).

A

Active surveillance with routine tumour marker measurement and imaging.

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15
Q

Describe management of prostate cancer determined to have an intermediate risk.

A

Radical prostatectomy OR radical radiotherapy with 6 months of androgen deprivation therapy (before, during or after radiotherapy)

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16
Q

Describe management of prostate cancer determined to have a high risk.

A

Radical prostatectomy OR radical radiotherapy with 6 months of androgen deprivation therapy (before, during or after radiotherapy) if there is a realistic prospect of long term disease control.

Androgen deprivation therapy may be continued for up to 3 years.

**Active surveillance is not appropriate.

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17
Q

State other treatments that can be used for intermediate or high risk prostate cancers which aren’t first line.

A

High dose rate brachytherapy in combination with external beam radiotherapy.

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18
Q

Name 2 drugs which can be used as part of androgen deprivation therapy in those with prostate cancer.

A 
LHRH agonist (Goserelin - trade name Zoladex)
Antiandrogens (Cyproterone)
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19
Q

Give 3 adjuvant types of treatment which may be required for patients with prostate cancer.

A

Analgesia
Radiotherapy for bone metastases
Treatment for hypercalcaemia

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20
Q

1) Briefly describe the epidemiology of testicular cancer.
2) What percentage of testicular cancers arise from germ cells?
3) What other cells can testicular cancers arise from?

A

1) Most common cancer in young men (15-44).
2) >96%.
3) Stromal cells (Leydig and Sertoli).

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21
Q

1) What are the 2 classifications of testicular cancer arising from germ cells?
2) Name the 4 types of non-seminomas.

A

1) Seminoma and non-seminoma.

2) Embryonal, yolk sac, teratoma and choriocarcinoma.

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22
Q

Give 4 basic characteristics of seminomas.

A

Slow growing
Metastasise late
Good prognosis
secrete hCG

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23
Q

Give 3 basic characteristics of non-seminomas.

A

Aggressive
Fast growing
Metastasise early

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24
Q

Give a basic description of the following non-seminomas:

a) embryonal
b) yolk sac
c) choriocarcinoma
d) teratoma

A

a) most aggressive; secretes hCG and AFP
b) commonest in children; secretes AFP
c) aggressive, secretes hCG
d) usually benign; chemo-radio resistant; requires surgery.

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25
Q

1) Testicular cancers which produce hCG can cause a patient to present with which specific symptoms?
1a) Why is this?

A

1) Gynaecomastia or symptoms of hyperthyroidism.

1a) Because hCG is similar in structure to TSH and LH/FSH, so high levels of secretion of hCG can mimic these.

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26
Q

1) What does initial treatment of testicular cancer normally involve?
2) How would you treat metastatic teratoma?
3) What are the treatment options for stage 1 seminomas?

A

1) Radical orchidectomy.
2) Primary treatment is chemotherapy using BEP regimen (Bleomycin, Etoposide and a platinum agent such as cisplatin).
3) Surveillance, carboplatin chemotherapy or radiotherapy (in those who chemo is inappropriate).

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27
Q

1) What are the treatment options for stage 2 seminomas?
2) What are the treatment options for stage III/ IV seminomas?
3) What should be offered to a patient with testicular cancer before commencing treatment?

A

1) Radiotherapy may be appropriate if RT volume permits curative doses, if not, chemotherapy with cisplatin and etoposide.
2) 4 cycles of cisplatin and etoposide.
3) Sperm banking.

28
Q

1) What does initial treatment of testicular cancer normally involve?
2) How would you treat metastatic teratoma?
3) What are the treatment options for stage 1 seminomas?

A

1) Radical orchidectomy (retroperitoneal lymph node dissection may be needed post orchidectomy).
2) Primary treatment is chemotherapy using BEP regimen (Bleomycin, Etoposide and a platinum agent such as cisplatin).
3) Surveillance, carboplatin chemotherapy or radiotherapy (in those who chemo is inappropriate).

29
Q

1) What does initial treatment of testicular cancer normally involve?
2) How would you treat metastatic teratoma?
3) What are the treatment options for stage 1 seminomas?

A

1) Radical orchidectomy (retroperitoneal lymph node dissection may be needed post orchidectomy). Radical orchidectomy cures 95% stage 1 seminomas.
2) Primary treatment is chemotherapy using BEP regimen (Bleomycin, Etoposide and a platinum agent such as cisplatin).
3) Surveillance, carboplatin chemotherapy or radiotherapy (in those who chemo is inappropriate).

30
Q

1) What are the treatment options for stage 2 seminomas?
2) What are the treatment options for stage III/ IV seminomas?
3) What should be offered to a patient with testicular cancer before commencing treatment?
4) After treatment of testicular cancer, what should you encourage the patient to do?

A

1) Radiotherapy may be appropriate if RT volume permits curative doses, if not, chemotherapy with cisplatin and etoposide.
2) 4 cycles of cisplatin and etoposide.
3) Sperm banking.
4) Regularly self-examine for signs of recurrence.

31
Q

1) What is the most common form of kidney cancer in adults?
2) Generally, who is more affected by the most common form of kidney cancer?
3) Why is this renal cancer known as a ‘silent’ cancer?

A

1) Renal cell carcinoma
2) Older males.
3) Because symptoms do not often get noticed until the tumour has grown to be very large.

32
Q

1) Where does renal cell carcinoma form from?
2) What is the most common change seen in cells affected by renal cell carcinoma?
3) What are these abnormal cells filled with?
4) Renal cell carcinoma is linked with mutations located where?

A

1) Epithelial cells in the PCT in the cortex.
2) Cells become polygonal epithelial cells which are angular and often have 4 sides.
3) Clear cytoplasm, carbohydrates and lipids.
4) on the short arm of chromosome 3 (3p).

33
Q

1) What is the most commonly implicated gene in patients with renal cell carcinoma?
2) What does this gene normally code for?
3) What does the mutation of this gene cause?

A

1) Von-Hippel Lindau gene.
2) The Von-Hippel Lindau tumour suppressor protein.
3) Upregulation of the IGF-1 pathway.

34
Q

What are the 2 main effects which occur as a result of the Von-Hippel Lindau gene mutation causing an up regulation of the IGF-1 pathway?

A

1) Dysregulated cell growth.
2) Upregulation of hypoxia inducible factors which causes upregulation of production of VEGF and its receptor leading to angiogenesis.

35
Q

1) How does renal cell carcinoma caused by sporadic mutations often develop?
2) How do inherited renal cell carcinomas (caused by Von-Hippel Lindau mutation) often develop?

A

1) Often solitary tumours in the upper pole of the kidney, usually occurring in older men who smoke.
2) Tumours typically affect younger men and women and often involve both kidneys.

36
Q

1) What type of cancer is renal cell carcinoma?
2) What percentage of renal cancers are renal cell carcinomas?
3) What is the average age at presentation for renal cell carcinomas?

A

1) Adenocarcinoma.
2) 90%.
3) 55 years.

37
Q

1) What is the inheritance pattern of Von-Hippel Lindau disease?
2) What is the primary cause of death in patients with Von-Hippel Lindau disease?

A

1) Autosomal dominant.

2) RCC.

38
Q

Describe the areas of the body which can be affected by Von-Hippel Lindau disease.

A

Cysts, malignant and benign tumours develop in the CNS and eyes (often haemangioblastomas). Cysts and tumours can also develop in the pancreas, kidneys, ears, lungs and genital tract. Can also cause pheochromocytoma.

39
Q

1) What percentage of renal cell carcinomas are found incidentally?
2) What percentage of patients with RCC have metastases at presentation?
3) What is the classical triad of signs and/or symptoms associated with RCC?

A

1) 50% are found incidentally.
2) 25% have metastases at presentation.
3) Flank pain, haematuria and a palpable mass.

40
Q

1) What symptoms can be caused by inflammation in renal cell carcinoma?
2) How can haematogenous spread occur in patients with RCC?
3) Describe what can happen to the left testicle of some patients with RCC which does not commonly happen to the right.

A

1) Malaise, weight loss and fever.
2) If the tumour invades the renal vein, it can invade the IVC which increases the risk of haematogenous spread.
3) Varicocele formation can occur on the left testicle if a renal tumour impedes venous drainage by putting pressure on the left renal vein. This does not commonly happen to the right testicle.

41
Q

Name 4 hormones that can be produced as a result of paraneoplastic syndromes in patients with renal cell carcinoma and state what they can cause.

A

1) EPO > polycythaemia
2) Renin > HTN
3) PTH related proteins > hypercalcaemia
4) ACTH > increased cortisol > Cushing’s syndrome

42
Q

Give 5 risk factors for the development of RCC.

A 
Male
Age >55
Smoking history
Obesity
HTN
3p mutation
Pelvic radiation
Oestrogen exposure
Asbestos/ Cadmium/ petroleum exposure
43
Q

1) How is renal cell carcinoma staged?
2) What might an increased ALP level suggest in patients with RCC?
3) What might increased transaminases or poor LFTs suggest in a patient with RCC?
4) What is the most common histological finding on RCC biopsies?
5) Why would you perform a CXR in patients with RCC?

A

1) TMN staging
2) Bony mets
3) Liver metastases
4) Clear cell carcinoma
5) To look for cannonball metastases

44
Q

1) Name 4 blood tests which you would request for a patient with suspected renal cell carcinoma.
2) Name 3 other non-radiological investigations you would perform.
3) Name 3 radiological investigations you would perform for a patient with suspected or confirmed RCC.

A

1) FBC, ESR, U&Es, LFTs.
2) BP, Urinalysis, Biopsy.
3) USS, CT, MRI, CXR.

45
Q

1) Which treatments are RCCS resistant to?
2) What is the standard treatment for T1a and T1b tumours if possible?
3) What is the standard treatment for T2 RCC tumours?

A

1) Chemotherapy and radiotherapy.
2) Partial nephrectomy which is nephron sparing and is preferred for low stage tumours as it spares some renal function.
3) Laporascopic or open radical nephrectomy.

46
Q

1) Which types of patients with RCC might be treated with ablative techniques?
2) Name 2 ablative techniques which can be used for RCC.

A

1) Those who are unfit for or unwilling to have surgery.

2) Cryoablation and radio frequency ablation.

47
Q

1) Why is surgery not often used for metastatic RCC?
2) Why might radiotherapy be used in metastatic disease?
3) Name the 2 first line immunomodulatory agents which are used for systemic metastatic RCC.

A

1) Because it is rarely curative (there is some survival benefit seen with cytoreductive nephrectomy).
2) Because it can be effective for symptom control.
3) Sunitinib and Pazopanib (NICE approved standard first line therapies).

48
Q

1) What does Sunitinib do?

2) What is the only systemic treatment available which is capable of curing patients with metastatic RCC?

A

1) VEGF inhibitor

2) IL-2 cures patients with metastatic renal cell carcinoma in 20% of people.

49
Q

1) What is the 5 year survival for patients with RCC which is confined to the parenchyma?
2) What is the 5 year survival for patients with RCC with distant metastases?

A

1) 60-70%.

2) 5%.

50
Q

1) What is a transitional cell carcinoma?
2) Where can a transitional cell carcinoma arise?
3) Who are transitional cell carcinomas more common in?
4) What normally is the age of onset for transitional cell carcinomas?

A

1) A cancer arising from transitional urothelium.
2) In the bladder, ureters or renal pelvis.
3) Men.
4) >40 years.

51
Q

1) Name 4 risk factors for transitional cell carcinomas.
2) Name 4 signs or symptoms which can be associated with transitional cell carcinoma.
3) Name 4 investigations that you might do for a patient with suspected transitional cell carcinoma.

A

1) Cyclophosphamide, aniline dyes, phenacetin and smoking.
2) Painless haematuria, lower UTI symptoms, dysuria and urinary tract obstruction.
3) Urine cytology, cystoscopy, uteroscopy, biopsy, retrograde pyelography, CT, MRI.

52
Q

1) What is the non-eponymous name for a Wilm’s tumour?
2) What is a Wilm’s tumour?
3) How does a Wilm’s tumour often present?

A

1) Nephroblastoma.
2) A childhood tumour of primitive renal tubules and mesenchymal cells
3) Presents with an abdominal mass ± haematuria.

**A film’s tumour is the chief abdominal malignancy in children.

53
Q

1) What percentage of bladder cancers are transitional cell carcinomas?
2) What type of bladder cancer can follow infection with schistosomiasis?
3) Which types of bladder cancers are rare in the Western world?

A

1) 90%
2) Squamous cell carcinomas.
3) Adenocarcinomas and squamous cell carcinomas.

54
Q

Where are the common sites of metastases for the following mechanisms of spread:

a) Local tumour spread
b) Lymphatic spread
c) Haematogenous spread

A

a) to pelvic structures.
b) to iliac and para-aortic nodes
c) to the liver and lungs

55
Q

What are the 3 types of transitional cell carcinoma that can occur in the bladder?

A

1) Carcinoma in situ - confined to urothelial layer.
2) Sessile tumour - projects out of urothelium.
3) Papillary tumour - projects out of the urothelium.

56
Q

1) How are carcinogens such as nitrosamines removed from the body?
2) Why does this contribute towards the development of bladder cancer?
3) How is bladder cancer classified?
4) Why is it important to stage bladder cancers into low and high grades?

A

1) They are concentrated and excreted in the urine.
2) Because this means that cells in the urinary tract are exposed to these carcinogens. Exposure to these tends to be prolonged in the bladder but malignant transformation can occur anywhere in the urinary tract.
3) TMN staging.
4) As this will tailor the treatment.

57
Q

State 5 risk factors for the development of bladder cancer.

A 
Smoking 
Cyclophosphamide
Age >40
Aristolochic acid
Chronic cystitis (SCC)
Schistosomiasis (SCC)
Pelvic irradiation
Male sex
FHx
Certain chemicals: aromatic amines, rubber and dye industries, arsenic, benzidine.
58
Q

1) What is the gold standard diagnostic test for bladder cancer?
2) What other test can be diagnostic and also provides the cancer staging?
3) Why might you request an MRI or lymphangiography In a patient with bladder cancer?

A

1) Cystoscopy + biopsy
2) CT urogram
3) To identify any involved pelvic lymph nodes.

59
Q

1) Why might you carry out urinalysis on a patient with suspected bladder cancer?
2) Why might you carry out urine cytology on a patient with suspected bladder cancer.
3) What blood tests might you order if you suspect bladder cancer?

A

1) There may be sterile pyuria.
2) There may be RBC casts.
3) FBC, U&Es, Creatinine, CRP.

60
Q

Give 5 signs or symptoms which might suggest bladder cancer.

A 
Haematuria ± dysuria (normally painless, dysuria is associated with aggressive bladder cancer).
Renal colic
Blood clots in urine
Increased frequency and urgency
Urinary retention
Systemic signs of malignancy
Recurrent UTIs
Flank pain

**Presentation of haematuria in any patient >40 is a urothelial tumour until proven otherwise.

61
Q

1) Which bladder tumours have low malignancy potential?
2) Which bladder tumours are low grade?
3) Which bladder tumours are high grade?

A

1) Tumours in situ, Ta (including papillary and sessile tumours) = these are the majority of bladder tumours.
2) T1/T2a (tumour has grown to deeper layers)
3) T2b, T3, T4.

62
Q

What does management of bladder cancers often depend on?

A

Depends if the tumour has invaded the detrusor muscle or not.

63
Q

1) How is diagnosis of prostate cancer made?

2) Give 3 risk factors for the development of prostate cancer.

A

1) By USS, PSA and biopsy.
2) Old age, obesity, high fat diet, low fibre diet, Fox, African heritage, increased testosterone levels, North American/ NW European descent.

64
Q

According to NICE, how would you go about treating the following risk stratified non muscle invasive bladder cancers:

1) Low risk
2) Intermediate risk
3) High risk

A

1) TURBT and single dose of mitomycin C at the same time and a further TURBT within 6 weeks if biopsies do not show invasion of muscle.
2) 6 doses of intravesical mitomycin C after TURBT.
3) TURBT and a second TURBT no later than 6 weeks after the first with either a BCG procedure or radial cystectomy.

65
Q

How would you treat muscle invasive bladder cancer according to NICE?

A

Neoadjuvant chemotherapy regimen with a cisplatin combination therapy before radical cystectomy or radical radiotherapy.

** If neoadjuvant chemotherapy is not suitable, offer adjuvant chemotherapy using a cisplatin combination regimen.

66
Q

1) What is the first line chemotherapy regimen for muscle invasive bladder cancers?
2) What is the first line chemotherapy regimen for muscle invasive bladder cancers if cisplatin regimens are contraindicated?
3) What is the chemotherapy used for incurable locally advanced or metastatic urothelial bladder cancer for whom cisplatin‑based chemotherapy is not suitable

A

1) cisplatin in combination with gemcitabine, or accelerated [high‑dose] methotrexate, vinblastine, doxorubicin and cisplatin [MVAC] in combination with granulocyte‑colony stimulating factor [G‑CSF]
2) carboplatin in combination with gemcitabine.
3) carboplatin in combination with paclitaxel or gemcitabine in combination with paclitaxel.

67
Q

1) What management is often used for T4 stage bladder cancer?
2) When are follow ups required for high risk tumours?
3) When are follow ups required for intermediate risk tumours?
4) When are follow ups required for low risk tumours?

A

1) Palliative
2) every 3 months for 2 years then every 6 months for 2 years and then annually.
3) at 3, 9 and 18 months after and then annually.
4) 3 and 12 months after.

Block 34 - Metabolic (18 decks)

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