Urological malignancies Flashcards
Where is the most common site for a transitional cell carcinoma and how does this present?
Trigone
Ureteric obstruction
What are some pre-malignant lesions that might indicate penile cancer?
Balanitis xerotica obliterans
Leukoplakia
What is balanitis xerotica obliterans?
Lichenus sclerosis and atrophy
White patches, fissuring, bleeding. scarring
What is the name given to squamous carcinoma-in-situ if it is located on the glans, prepuce or shaft of the penis?
Erythroplasia of Queyrat
What are the treatments avaliable for Erythroplasia of Queyrat or Bowen’s disease?
Circumcision (if prepuce alone)
Topical 5 fluorouracil
How does invasive squamous cell carcinoma of the penis present?
Red raised area penis
Fungating mass, foul smelling
Phimosis
Presentation delayed in up to 50% of cases
What is phimosis?
A condition of the penis where the foreskin cannot be fully retracted over the glans penis
How is carcinoma of the penis treated?
Surgery
Inguinal Nodes:
Prognosis, treatment options
Imaging, radionuclide sentinal node biopsy
Inguinal lymphadenectomy
Radiotherapy
What are some examples of germ-cell testicular tumour?
Seminoma
Teratoma
Embryonal
Yolk sac
Choriocarcinoma
Intra-tubular germ cell neoplasia (ITGCN)
What is the presentation of testicular tumours?
Painless, insensitive testicular swelling
How do metastatsis from testicular tumours present?
Neck nodes
Dyspneoa
What imaging is done in testicular tumours?
Ultrasound scanning
Also CXR, CT Abdomen/Thorax for staging
Which serum marker would indicate seminoma?
PLAP - placental alkaline phosphatase
Which serum marker is never raised in pure seminoma?
AFP - alpha fetoprotein
When might AFP be raised?
Hepatocellular carcinoma
Nonseminomatous germ cell tumors of the ovary and testis (eg, yolk sac and embryonal carcinoma)
When might HCG (human chorionic gonadotrophin) be raised?
In 5-10% of pure seminomas
Teratomas
Why are LDH levels measured with testicular tumours?
To assess tumour burden
How does seminoma spread usually?
Via lymphatics
What is a seminoma?
A germ-cell tumour of the testicle
Which lymph nodes become swollen with seminoma?
Para-aortic
Due to where testicles originally descend from
What is orchidectomy?
A procedure where one or both of the testicles are removed
What increases the risk of development of testicular tumour?
Undescended testicle
Which serum marker becomes raised with teratoma?
HCG
What is the verumontanum?
An elevation in the floor of the prostatic portion of the urethra where the seminal ducts enter
Which area of the prostate gives rise to BPH?
The transitional zone
Where is the transitonal zone of the prostate?
Surrounds the prostatic urethra proximal to the Veru
Where is the central zone of the prostate?
Cone shaped region that surround the ejaculatory ducts
Where is the peripheral zone of the prostate?
Posteriolateral prostate - this is the majority of prostatic tissue
Where is the origin of most prostate adenocarcinoma?
Peripheral zone
What is the peak age of developing a prostate cancer?
70-74
How does prostate cancer present?
Urinary frequency
Difficulty finishing
Nocturia
Haematuria
Bone pain
Anorexia
Weight loss
What abnormalities may be felt on PR exam in prostatic cancer?
Assymetry
Enlarged prostate
Nodule
Craggy
What is prostate specific antigen?
A glycoprotein (kallikrein-like serine protease) enzyme produced by the secretory epithelial cells of the prostate gland that is involved in the liquefication of semen
What things can raise a PSA?
Carcinoma of the prostate
Benign prostatic hyperplasia
Prostate drugs (alpha-blockers)
Riding bikes etc
Prostatitis / UTI’s
Retention Catheterization DRE
What investigations can be done following a raised PSA result?
Trans-rectal ultrasound biopsy
What are the disadvantages of a trans-rectal ultrasound biopsy?
Uncomfortable
1% risk of significant sepsis and bleeding May need repeat biopsy
When is a trans-rectal ultrasound biopsy indicated?
Men with an abnormal DRE, an elevated PSA
Previous normal biopsies but rising PSA trends
Previous biopsies showing prostatic interepithelial neoplasia or atypical small acinar proliferation
How is a sample obtained in trans-rectal ultrasound guided prostate biopsy?
Ultrasound probe passed through the rectum and prostate visualised in sagittal and transverse sections
5 biopsies taken from each lobe
What kind of cancer are most prostate cancers?
Multifocal adenocarcinomas
Where are the most common sites of metastasis from a prostate lesion?
Pelvic lymph nodes
Skeleton
What is characterstic of the bone metastasis from the prostate?
Sclerotic lesions
What scoring system is used to grade prostate cancers?
Gleason’s
What is unique about Gleason’s scoring system?
Gives a score based on the architectural appearance of the prostate glands rather than cytological features
How is Gleason’s score calculated?
Microscopically,CaP is graded from 1 to 5
The initial feature of malignancy is loss of the basement membrane and the Gleason score increases with loss of the glandular structure and replacement by a disorganised malignant cell growth pattern.
The two most abundant cell patterns are assessed and then added together to give a score between 2 to 10
Why is Gleasons score widely used to grade prostate carcinoma?
Gives a very good indication of prognosis
What imaging is used for TNM staging of prostate cancer?
MRI
Bone scan
CT
At which TNM staging is prostate cancer no longer confined to the prostate?
T3-4: at T3, it invades past the prostate capsule
What is the difference between watchful waiting/deferred treatment and active surveillance?
Watchful waiting is conservative management until local or systemic involvement which is then followed by palliative care
Active surveillance follows the patient until they reach a certain threshold e.g. degeneration on biopsy, followed by curative treatment
What surgical option is avaliable for prostate cancer?
Radical prostatectomy (open, laprascopic or robotic)
What are the complications associated with radical prostatectomy?
Erectile dysfunction
Bladder neck stenosis
Incontinence
What non-surgical treatment is there for prostatic cancer?
External-beam radiotherapy
Brachytherapy (internal radiotherapy)
What complications can arise from radiotherapy of the prostate?
Irritative lower urinary tract symptoms
Haematuria
GI symptoms
Erectile Dysfunction
Incontinence
What is the ideal treatment for locally invasive prostatic cancer?
Radiotherapy with neo-adjuvant hormonal therapy
For which patients is watchful waiting the ideal management of locally invasive prostatic cancer?
Asymptomatic patients with well and moderately differentiated tumours and a life expectancy < 10 years
Patients who do not accept treatment-related complications
In which patients is hormonal therapy the ideal treatment for prostatic carcinoma?
Symptomatic patients, who need palliation of symptoms, unfit for curative treatment
How is metastatic prostatic cancer treated?
Androgen Deprivation therapy:
Hormonal therapy (LHRH analogues and anti-androgens)
Bilateral Subcapsular Orchidectomy
Maximal Androgen blockade
Diethylstilbesterol/ Steroids
Cytotoxic chemotherapy
Why is androgen blockade used to treat prostatic cancer?
Prostate cell growth is under control of testosterone
Testosterone release is inhibited by circulating androgen, due to the negative feedback mechanism
If prostate cells are deprived of androgenic stimulation, they undergo apoptosis
What is the ‘testosterone surge’ or ‘flare up’ phenomenon associated with LHRH analogues
LHRH analogues initially stimulate pituitary LHRH receptors, inducing a transient rise in LH and FSH release, and consequently elevate testosterone production
20% of patients manifest with catastrophic spinal cord compression
How is the flare up or testosterone surge phenomenon associated with prostate cancer prevented?
To prevent this anti-androgen is given for cover 1 week before and 2 weeks after the first dose of LHRH injection
What are the side effects of LHRH antagonists?
Loss of libido
Hot flushes and sweats Weight gain Gynaecomastia Anaemia Cognitive changes Osteoporosis
How do anti-androgens have effect against prostate cancer?
Anti-androgens compete with testosterone and DHT for binding sites on their receptors in the prostate cell nucleus, thus promoting apoptosis and inhibiting CaP growth
What types of anti-androgen are there?
Steroidal: cyproterone acetate
Non-steroidal: nilutamide, flutamide and bicalutamide
What are the side effects of steroidal anti-androgens?
Loss of libido and erectile dysfunction
Gynaecomastia (rare)
Cardiovascular toxicity
Hepatotoxicity
What are the side effects of non-steroidal anti-androgens?
Gynaecomastia
Breast pain
Hot flashes
Hepatotoxicity
