Urological malignancies Flashcards
What are the clinical features of RCC?
- Haematuria
- Loin pain
- Loin/abdo mass
- <10% classic triad: haematuria, pain and abdo mass
- Signs of metastatic disease → bone pain, night sweats, fatigue, weight loss, dyspnoea and haemoptysis
- Less common features: pyrexia of unkown origin, VTE, acute varicocele, lower limb oedema
What are the risk factors for developing RCC?
- Environmental:
- cigarette, pipe, or cigar smoking
- tobacco chewing
- renal failure
- transplant recipients and dialysis
- BMI >25
- HTN
- occupation asbestos exposure
- asian migrants to western countries are at increased risk RCC - Anatomical:
- polycystic kidneys
- horseshoe kidneys - Genetic:
- von Hipple Lindau syndrome → around 50% develop RCC
What investigations should be carried out for RCC?
- Renal USS (entire renal tract)
- CT of abdomen with contrast (renal masses)
- CT chest
- Bone scan (DEXA)
- Bloods: FBC/U&Es/Calcium/LFT
What are the different management options for RCC?
- Localised:
- radical or partial nephrectomy (open or laparoscopic) - Locally advanced:
- radical nephrectomy ± adjuvant treatment - Metastatic:
- chemotherapy rarely successful
- tyrosine kinase inhibitors (sunitinib, sorafenib, pazopanib)
- immunotherapy (hgih dose IL-2)
- mammalian target of rapamycin (mTOR) inhibitors (everolimus, sirolimus)
What are the clinical features of bladder cancer?
- Painless macroscopic haematuria (85%)
- Age >50: 34% have TCC bladder
- Age <50: 10% have TCC bladder - Microscopic haematuria:
- Age >50: 7-13% have TCC
- Age <50: 5% have TCC - LUTS
- Recurrent UTIs
- Pain
- Lower limb swelling
What are the risk factors of bladder cancer?
- M:F = 2.5:1
- Increased age
- Smoking (x2-5)
- Occupation (rubber/paint and dye manufacture)
- Chronic inflammation of bladder mucosa
- Schistosomiasis (squamous cell carcinoma)
What are investigations should be carried out for bladder cancer?
- Persistent microscopic haematuria (2 of 3 dipstick tests) or macroscopic haematuria must be investigated:
- renal function, urine MC&S, glomerulonephritis screen
- IV urogram
- USS renal tract
- Flexible cystoscopy
- Urine cytology
- CT urogram more recently in place of IVU and USS
What are the different management options for bladder cancer?
- Superficial transurethral resection of bladder tumour - curative in 70%
- 30% recur (therefore check cystoscopy 3 months)
- adjuvant treatment:
(i) intravesical mitomycin (MMC): reduced recurrence rate
(ii) intravesical BCG: stimulates immune system in ballder wall which attack cancer cells - Muscle invasive TCC:
- radical cystectomy + urinary diversion
- radical external beam radiotherapy
- metastatic disease: chemotherapy combinations include gemcitabine + cisplatin or cisplatin + methotrexate
In what area of the prostate does cancer most often occur?
Peripheral zone (75%) - 95% adenocarcinoma
What are the clinical features of prostate cancer?
- majority are asymptomatic
- LUTS
- haematospermia/haematuria
- perineal discomfort
- lower limb swelling
- anorexia and weight loss
- bone pain/pathological fractures
What are the risk factors for prostate cancer?
- high fat diets
2. smoking
What investigations should be carried out for prostate cancer?
- PSA
2. Transrectal US guided biopsy
What is the gleason score? What score indicate the following:
(a) well differentiated
(b) moderately differentiated
(c) poorly differentiated
- most common histological pattern seen + the highest grade of tumour histology seen
(a) well differentiated: 2-4
(b) moderately differentiated: 5-7
(c) poorly differentiated: 8-10
What are the management options for prostate cancer?
- radical prostatectomy - open, laparoscopic, robot-assisted
- radical external beam radiotherapy
- brachytherapy - implanting and radioactive seeds into prostate
- cryotherapy - freezing and thawing of prostate cells to kill malignant tissue
- adjuvant hormonal therapy
- endocrine therapy:
(i) medical castration → GnRH analogues (goserelin)
(ii) Androgen receptor antagonists (bicalutamide, enzalutamide)
(iii) corticosteroids (prednisolone, dexamethasone)
(iv) oestrogen
(v) Cyp 17 inhibitors (Abiraterone) - Chemotherapy: taxanes (docetaxel, cabazetaxel)
What are the options in pallaitive treatment for prostate cancer?
- palliative radiotherapy
- bisphosphonates for bone disease (zoledronate)
- RANKL inhibitor for metastatic disease (denosumab)
- Analgesics
- Blood transfusion for anaemia
- Palliative care team support
What is the most common type of testicular tumour?
Germ cell tumour (90%)
What are the clinical features of testicular cancer?
- painless scrotal lump
- 5% acute scrotal pain (intra-tumoural haemorrhage)
- if delay in seeking help, sign of metastases (weight loss, lymphadenopathy, bone pain)_
What are the risk factors for testicular cancer?
- race: icnreased risk of caucasian compared ot Afro-Caribbean
- undescended tests (x3-14 risk)
- HIV infection
- first degree relatives
What investigations should be carried out for suspected testicular cancer?
- Testicular USS:
- hypoechoic region distorting normal architecture
- microlithiasis - CT abdomen and chest (staging purposes)
- Serum tumour markers:
- Alpha fetoprotein (AFP)
- B-hCG
- Lactate dehydrogenase (LDH)
What are the management options for non-seminoma germ cell tumour?
- Non-metastatic disease:
- surveillance (25% relapse rate of risk factors)
- adjuvant chemotherapy if risk factors for relapse → lymphatic/vascular invasion - Metastatic disease:
- chemotherapy (bleomycin + etoposide + cisplatin)
What are the management options for seminoma germ cell tumour?
- Non-metastatic disease:
- chemotherapy
- radiotherapy
(reduces risk of para-aortic nodal spread to <1%) - Metastatic disease:
- radiotherapy or chemotherapy
- retroperitoneal lymph node dissection
What are the management options for penile cancer?
- Surgical removal - including inguinal nodes
- Radiotherapy - to draining inguinal nodes
- Chemotherapy - cisplatin, fluorouracil, docetaxel
