Urological Cancers Flashcards
What is the epidemiology of kidney cancer?
13,100 new kidney cancer cases in the UK every year
7th most common in the UK
Incidence and mortality rates are rising
What are the different types of kidney cancers?
Renal Cell Carcinoma (RCC / adenocarcinoma) = 85%
Transitional cell carcinoma = 10%
Sarcoma / Wilms tumour / other types = 5%
What are the risk factors for kidney cancer?
Smoking Renal failure and dialysis Obesity Hypertension Genetic predisposition with Von Hippel-lindau syndrome - (50% of individuals will develop RCC
How does kidney cancer present clinically?
Haematuria
Loin pain
Palpable mass
Matastatic disease symptoms - bone pain, haemoptysis
What is the red flag symptom clinically for kidney cancer?
Painless haematuria - esp. painless because if it is painful, it is also likely to be an infection etc.
OR
Persistent microscopic haematuria
What is the first line investigation with anyone presenting with the red flag symptoms of (painless OR persistent non-visible microscopic) haematuria?
Painless =
Flexible cystoscopy
CT urogram
Renal function
Persistent non-visible haematuria =
Flexible cystoscopy
USS KUB (ultrasound scan kidneys, ureters, and bladders)
What investigations are done next if the first line imaging shows suspected kidney cancer?
CT renal triple phase
Staging CT chest
Bone scan is symptomatic
How is kidney cancer staged using the TNM staging or Fuhrman grade system?
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
How is kidney cancer managed?
Patient specific - depends on
Classification of the lesion itself - staging and metastases
Gold standard = excision of partial or whole kidney (takes out ureter too)
AKA partial or radical nephrectomy
When is partial nephrectomy chosen over radical nephrectomy?
Partial = if they have a single functioning kidney, bilateral tumour, multifocal RCC in patients with VHL, a small tumour (T1 tumours up to 7cm) etc.
What is the management for patients with small tumours that are unfit for surgery?
What is the management for patients with metastatic disease?
In patients with small tumours unfit for surgery = cryosurgery (use of extreme cold to destroy abnormal tissues e.g. using liquid nitrogen)
Metastatic disease = Receptor Tyrosine Kinase inhibitors
What is the epidemiology for bladder cancer?
10,200 new bladder cancer cases in the UK every year
11th most common cancer in the UK
Incidence and mortality declining
What are the different types of bladder cancer?
Transitional cell carcinoma = >90%
Squamous Cell Carcinoma = 1-7% (75% SCC where schistosomiasis is endemic)
Adenocarcinoma = 2%
What are the main risk factors for bladder cancer?
Smoking
Occupational exposure e.g. aromatic hydrocarbons, dye industry etc., less of an issue now with better regulations
Radiotherapy - for other conditions
Chronic infections - e.g. long-term catheters, gallstones, schistosomiasis (parasitic flatworms)
How does bladder cancer present clinically?
Haematuria
Suprapubic pain
Lower urinary tract symptoms
Metastatic disease symptoms - bone pain, lower limb swelling
What is the main red flag sign clinically for bladder cancer?
Painless haematuria - esp. painless because if it is painful, it is also likely to be an infection etc.
OR
Persistent microscopic haematuria
What is the first line investigation with anyone presenting with the red flag symptoms of (painless OR persistent non-visible microscopic) haematuria?
Painless visible =
Flexible cystoscopy
CT urogram
Renal function
Persistent non-visible / microscopic =
Flexible cystoscopy
Ultrasound (USS) kidneys, ureters, and bladders (KUB)
What investigations are done next if the first line imaging shows suspected bladder cancer?
Cystoscopy = camera placed via erethra to look into bladder and biopsy of lesion
Biopsy - check for muscle invasion
How is bladder cancer staged using the TNM system and WHO classification?
TNM system =
Staged in terms of invasion into the bladder mucosa:
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 system =
G1 = well differentiated
G2 = moderate differentiated
G3 = poorly differentiated
What is the use of a cystoscopy and transuretheral resection of bladder lesion?
Use cystoscope to look at the bladder lesion
Then use heat to cut out all visible bladder tumour
Provides histology and can also be curative - but if the tumour extends beyond myscle then the resection is incomplete due to risk of perforating the bladder
What is the management protocol for bladder cancer?
Muscle invasive = Cystectomy Radiotherapy \+/- chemotherapy Palliative treatment
Non-muscle invasive =
If low grade and no concerns over carcinoma in situ (CIS), then consideration of cystoscopic surveillance
Then use heat and cauterise to excise lesion OR chemotherapy or BCG (immunological therapy) to limit progression of the lesion
What is the epidemiolgy of prostate cancer?
48,500 new prostate cancer cases in the UK every year
Most common cancer in men within the UK
Incidence rising but mortality rates declining
What are the different types of prostate cancer?
Adenocarcinoma = >95%
What are the risk factors for prostate cancer?
Increasing age
Western nations (Scandinavian countries)
Ethnicity - particularly African Americans
How does prostate cancer present clinically?
Often asymptomatic unless metastatic
So how is prostate cancer usually found?
Via routine prostate screening -
PSA blood test = looks for PSA in the blood
What is the issue with using PSA as a marker for prostate cancer?
PSA is prostate specific but not prostate cancer specific - it can be elevated in other conditions e.g. UTI, prostatitis
What is the next line of investigation if blood tests show elevated PSA?
MRI =
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 - now with imaging before biopsy = allows for more specific detection of high grade lesions - better idea of lesion locations
Multiparametric MRI before biopsy and MRI targeted biopsy is superior to the previous gold standard of transrectal ultrasonography-guided prostate biopsies
How are prostate biopsies taken?
Previously = trans rectal Now = trans perineal due to lower infection risk and perineal route gives access to all parts of the prostate
How is prostate cancer staged and graded using TNM staging and the gleason score?
TNM staging = 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 = compare prostate imaging to a normal prostate
Take 2 scores due to variability
Both scores are added together
Since multifocal two scores based on level of differentiation
2-6 = Well differentiated
7 = Moderately differentiated
8 = Poorly differentiated
How is prostate cancer managed?
If:
You and fit + high grade cancer –> radical prostatectomy / radiotherapy = although high curative rate, high risk of side effects due to structures surrounding many delicate structures e.g. erectile dysfunction, urinary incontinence
Therefore, for young and fit + low grade –> active surveillance via regular PSA testing, MRI and biopsy
Post prostatectomy - monitor PSA (should be undetectable / <0.01 ng/ml, if it rises above 0.2 ng/ml then relapse
Old and/or unfit + high grade / metastatic –> hormone therapy but many side effects, also only temporary so works as palliative care
Old and/or unfit + low grade –> watchful waiting via regular PSA testing as they are more likely to die from other co-morbidities than the prostate cancer so not worth treating
What are the treatment side effects?
High risk of urinary continence and erectile dysfunction
The prostate contains the proximal sphincter
Prostatectomy removes the proximal urethral sphincter and changes urethral length
Risk of damage to cavernous nerves (innervation to bladder and urethra)
Damage to cavernous nerves causes ED (erectile dysfunction)
How is UI fixed?
Pelvic floor exercises to strengthen the muscles around that area
Artificial urinary sphincter
How is ED fixed?
Hormone therapy
Prostaglandin injections into the penis
Penile prosthesis
