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Y4 Cancer care > Urological malignancies > Flashcards

Urological malignancies Flashcards

1
Q

What is the most common cancer in men?

A

Prostate cancer, then lung then bowel

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2
Q

What are risk factors for prostate cancer?

A
  • Increasing age (rare under the age of 50)
  • Close family history (2-3x risk)
  • Ethinicity- African heritage
  • Genetic conditions- BRAC1, BRAC2
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3
Q

How do patients with prostate cancer present?

A
  • Asymptomatic (had a PSA test)
  • Lower urinary tract symptoms (LUTS)- prostate feels malignant and/or raised PSA
  • Bone pain
  • Ejaculatory symptoms (blood in semen)
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4
Q

What is the diagnostic pathway of prostate cancer?

A
  • PSA
  • DRE
  • MRI of the prostate. Increasingly performed pre-biopsy, if no suspicous areas, no biopsy could be discussed with patient
  • Biopsies- transperineal biopsies
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5
Q

Common causes of raised PSA

A
  • Prostate cancer
  • Urinary infection
  • Prostatic inflammation (prostatitis)
  • Enlarged prostate (BPH)
  • Acute urinary retention
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6
Q

What is the PSA dilemma?

A
  • 1 in 7 men will have a normal PSA and will have prostate cancer. 1 in 50 will have a higher risk of prostate cancer

10% of men aged 50-70 will have a raised PSA
Most men where PCA is not detected, continue to have PSA checked (increases anxiety)

ERSPC screening trial
- 50% have clinically insignificant prostate cancer

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7
Q

What are factors that influence treatment decisions for prostate cancer?

A
  • Age
  • PSA
  • MRI T-stage and N-stage
    T1/T2 (localised)
    T3 (locally-advanced)
    T4 (advanced)
  • Gleason grade
  • Bone scan (PSMA-PET scan) M-stage
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8
Q

Gleason score

A
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9
Q

What type of bone metastases are seen in prostate cancer?

A

Sclerotic (osteoblastic)
Unlikely if PSA <20

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10
Q

How do you treat metastatic prostate cancer?

A

Treatment
Castration (hormone therapy)
LHRH agonist
- Need to cover the flare with 28 days of oral bicalutamide
Or LHRH antagonist (sometimes)- why not just use this? patients had allergies to medications
Or surgical castration (rarely)

If performance status <2 and hormone sensitive
- And chemotherapy (docetaxel) a novel androgen receptor inhibitor (darolutamide)
- And prostate radiotherapy if <4 bone metastases

Palliation
- Single-dose radiotherapy, bisphosphonates (widespread bone pain)

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11
Q

Difference in LHRH and GNRH??? treatment in prostate cancer and how it words

A
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12
Q

How do you treat localised prostate cancer? (<=T2 N0 M0, PSA <20) people do not have disease outside of the pelvic region

A

Curative intent
- Active surveillance/monitoring
- Robotic prostatectomy
- Radical radiotherapy (with hormone treatment)
External beam
High dose rate brachytherapy

Palliative intent
- Deferred hormone therapy (watchful waiting)

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13
Q

What factors determine treatment?

A

Stage, Gleason score and PSA level determine prognostic risk and treatment

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14
Q

What is the risk for a patient with <=T2 N0 M0, Gleason score 6, PSA <10

A

Low risk
Localised prostate cancer
Active surveillance is the treatment choice

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15
Q

What is the risk of a patient with <=T2 N0 M0, gleason 7 and/or PSA 10-20

A

Intermediate-risk, localised

The options are active surveillance, robotic prostatectomy or radical radiotherapy

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16
Q

What is the risk of a patient with T3/T4 N0 M0 and/or gleason score-8-10 and/pr PSA >20

A

This is high-risk, non-metastatic prostate cancer
The options are radical radiotherapy (with hormone treatment) or robotic prostatectomy (not if T4 or PSA >30)

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17
Q

What are issues with PSA screening?

A
  • Over-diagnosis
  • Over-treatment
  • QoL- co-morbidities of established treatments
  • Cost-effectiveness
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18
Q

What are differential diagnoses of haematuria?

A

Urological
Cancer
- Renal cell carcinoma
- Upper tract TCC
- Bladder carcinoma
- Advanced prostate carcinoma

Other
- Stones
- Infection
- Inflammation
- BPH

Nephrological- glomerular

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19
Q

What is lead time bias?

A

Lead time bias occurs when a diagnostic approach merely identifies the disease earlier and gives the impression that survival is prolonged

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20
Q

What is length time bias?

A

Length Bias: Diseases that progress slowly are more likely to be caught by screening, making it seem like screening helps more than it actually does.

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21
Q

How do you investigation haematuria in secondary care?

A
  • Flexible cystoscopy!!!!!
  • Cytology of the urine
  • Ultrasound urinary tract or CT urogram

Primary care will have usually have checked eGFR, albumin/creatinine ratio, MSU

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22
Q

How do you suspect and refer testicular cancer?

A

Lump in body of testis (usually painless)
- Suspect testis cancer

Refer via cancer pathway to Urology
- Urgent ultrasound of scrotum to confirm diagnosis
- Check testis tumour markers if testicular mass on ultrasound (aFP, hCG, LDH)

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23
Q

When should you suspect penile cancer?

A

Suspect penile cancer if a STI has been excluded or lump/ulcer/lesion is persistent despite treatment

Beware the male with recurrent balanitis and phimosis

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24
Q

What are risk factors for bladder TCC?

A
  • Smoking
  • Occupational exposure; rubber or plastics, handling or carbon, crude oil, combustion, smelting
  • Ionising radiation
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25
Q

How do you treat intermediate-risk nonmuscle-invasive bladder TCC?

A

Intravesical chemotherapy and check cystoscopies

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26
Q

How does bladder TCC present?

A

Haematuria
Recurrent UTIs

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27
Q

How do you treat low-risk nonmuscle-invasive bladder TCC?

A

Check cystoscopies

28
Q

How do you treat high-risk nonmuscle-invasive bladder TCC?

A
  • Intravesical BCG & check cystoscopies
  • Radical cystectomy
29
Q

How do you treat muscle-invasive bladder TCC?

A

Radical cystectomy or radiotherapy
Urostomy- ileal conduit- plumb into the intestine, out of a stoma
Not flushed to the skin
The ureters will stretch- too close to the skin so nee the intestine

30
Q

How do you treat metastatic TCC?

A

Palliative chemotherapy (improve QOL/symptoms) or immunotherapy

31
Q

What is the systemic chemotherapy (traditional) for metastatic TCC?

A

Cisplatin-based (need reasonable kidney function)

32
Q

What is the immunotherapy for treatment of metastatic TCC?

A

Immunotherapy (checkpoint inhibitors)
Atezolizumab/Nivolumab

33
Q

What is the standard treatment of upper urinary tract TCC?

A

Nephro-ureterectomy
(kidney, fat, ureter, cuff of bladder)

34
Q

What are the epidemiology and presentation of RCC?

A

95% of all upper urinary tract tumours

Increasing incidence
Increasing mortality
1/3 are preventable

Risk factors
- Obesity
- Smoking
- Inherited factors

Presentation
- Haematuria
- Incidental finding on imaging
- Palpable mass- rare!!

35
Q

What is the treatment for localised RCC?

A
  • Surveillance
  • Excision radical nephrectomy
    Open
    Laparoscopic

Partial nephrectomy
- Open
- Robotic

36
Q

How to treat metastatic RCC

A

Immunotherapy- Pembrolizumab

37
Q

What is the first line treatment for testicular cancer?

A

Inguinal orchidectomy

38
Q

What type of cancer is seen in penile cancer?

A

Squamous cell carcinoma

39
Q

What are some risk factors for penile cancer?

A

Phimosis, poor hygeine- smegma
HPV 16&18

40
Q

What is superficial bladder cancer?

A

Non-muscle invasive bladder cancer (NMIBC).
Confined to the urothelium (stages Ta, T1, CIS).
High recurrence rate, lower risk of progression.

41
Q

What is transitional cell carcinoma (TCC)?

A

Most common bladder cancer (90%).
Arises from urothelial cells.
Can be superficial or muscle-invasive.

42
Q

What defines muscle-invasive bladder cancer (MIBC)?

A

Cancer invades the muscle layer of the bladder wall (T2 or higher).
Higher risk of metastasis.
Requires aggressive treatment (radical cystectomy, radiotherapy).

43
Q

What are the layers of the bladder wall?

A

Urothelium.
Lamina propria.
Muscularis propria.
Serosa.

44
Q

Why does muscle-invasive bladder cancer have a worse prognosis?

A

Increased risk of metastasis.
Higher recurrence rate.
Requires more aggressive treatment.

45
Q

What is the difference between resection and radical cystectomy?

A

Resection (TURBT): Transurethral removal of non-invasive tumours.
Radical cystectomy: Complete bladder removal for muscle-invasive or high-risk cancers.

46
Q

Order of investigations for bladder cancer

A
  1. CT KUB no contrast
  2. Flexible cystopscopy
  3. Biopsy
  4. Resection
  5. CT chest
47
Q

What is flexible cystoscopy used for in bladder cancer?

A

Visualisation of the bladder.
Diagnostic tool for tumour detection.
Allows for biopsy and follow-up.

48
Q

What are the late side effects of bladder radiotherapy?

A

Chronic radiation cystitis.
Bladder fibrosis or shrinkage.
Risk of secondary malignancies (e.g., bowel, bladder).

49
Q

What secondary cancers can develop after bladder radiotherapy?

A

Bowel cancer.
Rectal cancer.
Urethral cancer.

50
Q

Why is re-do flexible cystoscopy performed every 6 months in NMIBC?

A

Surveillance for recurrence.
High recurrence rate in NMIBC.
Detects early relapse.

51
Q

Why is an annual CT scan performed in bladder cancer follow-up?

A

Surveillance for recurrence or metastasis.
Detects post-treatment complications.
Important for long-term management.

52
Q

What is the most common zone of the prostate for prostate cancer to develop in?

A

Transitional zone

53
Q

Risk factors for prostate cancer

A
  • Age >50
  • Black ethnicity
  • Family history of prostate cancer
  • Family history of breast/colorectal cancer
  • High levels of dietary fat
54
Q

Difference in presentation of LUTS in prostate cancer and BPH?

A

LUTS occur later on in prostate cancer compared to BPH

55
Q

What are some complications of radical treatment for prostate cancer?

A
  • Dysuria
  • Urinary frequency
  • Urinary incontinence
  • Rectal bleeding
  • Erectile dysfunction
56
Q

Where will lymphatic spread go to first in prostate cancer?

A

Obturator nodes

57
Q

Options for Localised prostate cancer (T1/T2)

A

Treatment depends on life expectancy and patient choice.

Options include:
conservative: active monitoring & watchful waiting
radical prostatectomy
radiotherapy: external beam and brachytherapy

58
Q

Options for Localised advanced prostate cancer (T3/T4)

A

Hormonal therapy: see below
radical prostatectomy: erectile dysfunction is a common complication
radiotherapy
external beam and brachytherapy
patients may develop proctitis and are also at increased risk of bladder, colon, and rectal cancer following radiotherapy for prostate cancer

59
Q

Explain how Gonadotropin-releasing hormone antagonists therapy works in prostate cancer?

A

Two different types!!

Agonsits: These stimulate the initial release of hormones but eventually reduce testosterone levels (e.g., leuprolide, goserelin).

Antagonsits: These block the action of GnRH right away, leading to a rapid decrease in testosterone levels (e.g., degarelix).

60
Q

What is the tumour flare and how would it manifest?

A

Initial stimulation of prostate cancer growth may result in bone pain, bladder obstruction and other symptoms

Seen in GnRH agonists

61
Q

What is the Cambridge prognostic group system?

A

Doctors look at the results of your tests and scans to give you a score from 1 to 5. They look at the:

Grade Group or Gleason score
prostate specific antigen (PSA) level
tumour stage. This is from the T stage from the TNM staging

It’s important to know that the CPG system does not apply if you have cancer that has already spread to other parts of the body. This is metastatic or advanced prostate cancer.

Mainly put into low, intermediate and high risk

62
Q

What do you give in conjunction with Goserelin to protect in a flare?

A

Bicalutamide- antiandrogen prevents the testosteone surge
Preventing exacerbation of symptoms and optimising treatment options

63
Q

What happens after a patient presents to the GP with suspected prostate cancer

A
  1. DRE
  2. PSA
  3. Referral to 2WW urology
  4. Multiparametric MRI
  5. Biopsy
  6. CT scan
  7. Bone scan (radionuclide, bone scintigraphy, nuclear medicine bone scan)
64
Q

What is involved in a multi-parametric MRI?

A
  • T2 weighted
  • Diffusion weighted imaging
  • Dynamic contrast enhanced imaging
65
Q

Causes of LUTS in prostate cancer treatment

A
  • Fibrosis of the bladder due to radiotherapy
  • Strictures of the urethra due to radiotherapy

Y4 Cancer care (15 decks)

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