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AKT - Lizzie Bain > Urological malignancies and testicular disease > Flashcards

Urological malignancies and testicular disease Flashcards

1
Q

What are the classical symptoms of renal cancer?

A

haematuria
loin pain
loin mass

new varicocele raises suspicion of ipsilateral cancer

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2
Q

What is the most significant risk factor for prostate cancer?

A

Age >50

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3
Q

What is the preferred treatment option for men with low prognostic risk prostate cancer who are suitable for radical Rx in the event of disease progression?

A
  • active surveillance
  • protocol of a baseline multiparametric MRI (mpMRI), PSA testing, DRE and prostate biopsy at specified intervals
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4
Q

What are the 2ww referral criteria for possible bladder cancer?

A
  • age >=45 with unexplained VH without UTI
  • age >=45 with VH that persists or recurs after successful treatment of UTI
  • age >=60 with unexplained NVH AND either dysuria or raised WCC on blood test.
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5
Q

When should a non-urgent referral for bladder cancer be considered?

A
  • age >=60 with recurrent or persistent unexplained UTI
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6
Q

What are the 2ww referral criteria for renal cancer?

A
  • age >=45 with unexplained VH without UTI
  • age >=45 with VH that persists or recurs after successful treatment of UTI
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7
Q

What are the 2ww referral criteria for prostate cancer?

A
  • prostate feels malignant on DRE (hard, nodules)
  • Consider a DRE and PSA test if:
  • LUTS (nocturia, urinary frequency, hesitancy, urgency,retention)
  • erectile dysfunction
  • visible haematuria
  • Then refer if PSA levels are above threshold for age (take patient preference into account)
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8
Q

What are the 2ww referral criteria for testicular cancer?

A
  • non-painful enlargement/change in shape/change in texture of the testis
  • unexplained or persistent testicular symptoms - consider direct access USS in primary care.
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9
Q

What are the 2ww criteria for penile cancer?

A
  • penile mass or ulcerated lesion, when an STI has been excluded.
  • persistent penile lesion after treatment for STI has been completed.
  • unexplained or persistent symptoms affecting the foreskin or glans.
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10
Q

Which ethnic group is highest risk for prostate cancer?

A

black caribbean

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11
Q

Why is an anti-androgen (e.g. cyproterone) prescribed alongside the gonadorelin analogue (e.g goserelin)? How long should it be given for?

A

To reduce the risk of ‘tumour flare’.

During the initial stage (one to two weeks) of using goserelin, increased production of testosterone can cause progression of prostate cancer.
This tumour ‘flare’ may cause spinal cord compression, ureteric obstruction or increased bone pain.
To reduce this risk, anti-androgen treatment should be started three days before the goserelin and continued for three weeks.

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12
Q

What effect do 5-ARIs (finasteride etc.) have on PSA level?

A

Typically halve the PSA levels after 9-12 months. (best to double the value to get the true result)

PSA levels may also be lower in obesity.

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13
Q

Which is the most common testicular tumour in men aged >50?

A

Non-Hodgkin’s lymphoma

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14
Q

Those treated with androgen deprivation therapy for prostate cancer can develop severe hot flushes. What is the first line treatment for the hot flushes?

A

Medroxyprogesterone for 10 weeks.

If not tolerated or ineffective - consider cyproterone acetate or megestrol acetate. There is no good quality evidence for the use of complementary therapies.

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15
Q

How do testicular malignancies present?

A
  • Usually painless
  • Can present with dull ache or dragging sensation.
  • Testicular lump - firm, non-tender, immobile, continuous with affected testis.
  • Usually no palpable lymphadenopathy (spread to paraortic nodes rather than inguinal nodes)
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16
Q

Almost all cancers of the prostate are which type of carcinoma?

A
  • 95% are adenocarcinomas
  • Prostate cancer is multifocal - the different foci may be caused by different mutations and so can differ in growth rate and ability to metastasise.
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17
Q

What are the three most common types of cancer in men in the UK? Listed 1-3.

A
  1. prostate cancer
  2. Lung
  3. Bowel
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18
Q

What are the three most common types of cancer in women in the UK? Listed 1-3.

A
  1. Breast
  2. lung
  3. bowel
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19
Q

What are the three leading causes of cancer death in men in the UK? Listed 1-3

A
  1. Lung
  2. Prostate
  3. Bowel
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20
Q

What are the three leading causes of cancer death in women in the UK? Listed 1-3

A
  1. Lung
  2. Breast
  3. Bowel
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21
Q

What are the risk factors for developing prostate cancer?

A
  • increasing age
  • black ethnicity
  • family history of prostate cancer
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22
Q

Which symptoms should lead prostate cancer to be suspected?

A

Any of the following symptoms that are unexplained:
* Lower back or bone pain.
* Lethargy.
* Erectile dysfunction.
* Haematuria.
* Anorexia/weight loss.
* Lower urinary tract symptoms (LUTS), such as frequency, urgency, hesitancy, terminal dribbling, and/or overactive bladder.

Early prostate cancer is usually asymptomatic. Locally advanced prostate cancer can cause obstructive LUTS.

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23
Q

If prostate cancer is suspected based on symptoms, how should they be assessed in primary care?

A
  • DRE - signs of prostate Cancer are a HARD gland, palpable nodules
  • but a gland that feels normal does not exclude a tumour
  • Consider PSA testing - after counselling.
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24
Q

Why does prostate cancer often cause a raised PSA?

A

PSA = a protein produced by the prostate gland. Secreted by the prostate epithelial cells into prostatic fluid. It liquifies semen to allow spermatozoa to move freely. Small amounts are present in the blood.

In prostate cancer - the altered prostate architecture causes PSA to leak out and increases the levels in the blood.

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25
Q

Why is PSA an inaccurate marker for prostate cancer?

A
  • False negatives: Cancer can be present without increased PSA levels (15% of men with a normal PSA will have cancer)
  • False positives: PSA levels can be increased by conditions other than cancer (3 in 4 men (75%) with a raised PSA will not have cancer - have a negative biopsy). This leads to unnecessary investigation e.g biopsy which has risks of bleeding and infection.
  • PSA levels increase naturally with age.
  • It does not distinguish between aggressive tumours and those which are not. This can lead to unnecessary treatment for slow growing tumours - associated anxiety, tests and treatments with adverse effects.
26
Q

What advice should be given to a patient before they have a PSA test?

A

people should not have:
* An active urinary infection or within previous 6 weeks.
* Ejaculated in previous 48 hours.
* Exercised vigorously, for example cycling, in the previous 48 hours.
* Had a urological intervention such as prostate biopsy in previous 6 weeks.

27
Q

How soon must the PSA blood specimen reach the lab?

A

specimen must reach the laboratory within 16 hours.

28
Q

Why is screening for prostate cancer currently not recommended in the UK?

A
  • PSA test is not appropriate as a screening tool - as not sensitive or specific for this purpose. Would generate too many false positives and false negatives.
  • There is no single treatment that is superior for patients with **early stage **prostate cancer
  • It is unclear if PSA screening would impact on deaths due to prostate cancer.
29
Q

How are those referred on 2ww investigated in secondary care?

A
  • multiparametric MRI first line for suspected localised prostate cancer.
  • Transrectal ultrasound-guided (TRUS) prostate biopsy
  • imaging to assess stage
30
Q

What are the treatment options in secondary care for prostate cancer?

A

Depend on prognostic risk - determined by staging (localised T1/T2, locally advanced T3/T4, metastatic), PSA result, Gleason score, age, comorbidities and preference:

  • Watchful waiting (conservative)
  • Active surveillance (conservative)
  • Radical treatments: radical prostatectomy, external beam radiotherapy, and brachytherapy.
  • Adjunctive and palliative treatments: hormone therapy, chemotherapy, or bisphosphonates.
31
Q

What is ‘watchful waiting’ for prostate cancer? Who is it suitable for?

A
  • It is a strategy for ‘controlling’ rather than ‘curing’ prostate cancer.
  • Avoids use of surgery or radiotherapy
  • If a patient requires treatment they would receive long term hormone therapy to control the cancer
  • Lots of men on watchful waiting require no treatment
  • Suitable for older men, men with significant comorbidities, or those with slowly progressive tumours that are likely to die of another cause.
  • An option for men in any prognostic group.
32
Q

What is ‘active surveillance’ for prostate cancer? Who is it suitable for?

A
  • part of a ‘curative’ strategy
  • for people with localised prostate cancer, in whom radical treatments are suitable.
  • PSA is repeated at intervals depending on age and the level - allows the prognostic risk to be reassessed.
  • DRE every 12 months
  • At 12-18 months: mpMRI
  • mpMRI and/or re-biopsy any time clinical/PSA concern
  • Treatment is offered when the risk increases
  • reduces the risk of overtreatment.
33
Q

What are the three radical treatments for prostate cancer?

A
  1. radical prostatectomy: surgery to remove the entire prostate gland and lymph nodes (open or lap)
  2. External beam radiotherapy: directed at the tumour from outside
  3. Bracytherapy: radiotherapy given internally directly into the prostate- either with permanently implanted radioactive seeds (low dose rate), or temporarily inserted radioactive sources (high dose rate).
34
Q

What are the three adjunctive and palliative treatments for prostate cancer?

A
  • hormonal treatments
  • chemotherapy
  • bisphosphonates
35
Q

What are the three stages of prostate cancer?

A
  • Localized prostate cancer is confined within the capsule and seldom causes symptoms.
  • Locally advanced prostate cancer extends beyond the capsule of the prostate and is often asymptomatic when diagnosed.
  • Metastatic prostate cancer most frequently affects the bones, where it causes pain and fragility fractures.
36
Q

What are the common complications of radial prostatectomy?

A
  • erectile dusfunction (50%)
  • incontinence (25%)
37
Q

What are the complications of prostate radiotherapy?

A
  • proctitis
  • increased risk of bladder, colon, rectal cancer
  • persistent cancer (30%)
38
Q

What are the two types of hormone treatment for prostate cancer and how do they work?

A
  1. Androgen deprivation- drugs that lower testosterone levels. Luteinizing hormone-releasing hormone (LHRH) agonists e.g. goserelin (zoladex), leuprorelin, triptorelin.
    * paradoxically result in lower LH levels long term by causing overstimulation -> disrupts hormonal feedback systems. The testosterone level will rise initially for around 2-3 weeks ‘tumour flare’ before falling to castration leves
    * LHRH antagonist e.g. degarelix - can suppress testosterone while avoiding flare.

Abiraterone - androgen synthesis inhibitor. For hormone relapsed metastatic prostate cancer (androgen deprivation therapy failed), with no/mild symptoms, before chemotherapy indicated.

  1. Androgen blockade (anti-androgens): drugs bind to and block the hormone receptors on cancer cells - prevents androgens from stimulating cancer growth. e.g. cyproterone acetate - used to prevent tumour flare (steroidal), bicalutamide - monotherapy (non-steroidal).
39
Q

When is chemotherapy used in prostate cancer? Which chemo?

A
  • Hormone-relapsed metastatic disease
  • Docetaxel with prednisolone
40
Q

When are bisphosphonates used in the treatment of prostate cancer?

A
  • inhibit bone resorption
  • Used to treat hypercalcaemia, osteoporosis, bone pain
  • should be offered to those on androgen deprivation therapy with osteoporosis.
  • can be used for pain relief in hormone-refractory prostate cancer, when analgesia and palliative radiotherapy have failed.
41
Q

What are the complications of TRUS biopsy?

A
  • sepsis: 1% of cases
  • pain: lasting >= 2 weeks in 15% and severe in 7%
  • fever: 5%
  • haematuria and rectal bleeding
42
Q

What is the Gleason score and what does a higher score indicate?

A
  • Predicts prognosis in prostate ca
  • Needle biopsy - then assessing the glandular architecture seen on histology
  • The most prevalent then second most prevalent pattern (grade) are added to give a score.
  • Gleason Grade range is 1-5
  • So Gleason score range is 2-10
  • The higher the score the worse the prognosis.
43
Q

How often should PSA be monitored after radical treatment?

A
  • 6 weeks
  • then every 6 months for 2 years
  • then once Yearly afterwards
44
Q

What are the adverse effects of hormonal treatment for prostate ca?

A
  • weight gain
  • tiredness
  • hot flushes
  • loss of libido
  • E.D
  • gynaecomastia
  • reduced bone density.
45
Q

How should the adverse effect of hormone therapy for prostate cancer - fatigue - be managed?

A
  • supervised resistance and aerobic exercise twice per week for 12 weeks
46
Q

How should the adverse effect of hormone therapy for prostate cancer - osteoporosis - be managed?

A
  • assess the fracture risk
  • offer bisphosphonates if they have osteoporosis
  • consider denosumab if bisphosphonates CI/not tolerated
47
Q

How should the adverse effect of hormone therapy for prostate cancer - gynaecomastia - be managed?

A
  • For men starting long-term bicalutamide monotherapy (longer than 6 months), offer referral to a specialist for prophylactic radiotherapy to both breast buds within the first month of treatment.
  • f radiotherapy is unsuccessful, consider weekly tamoxifen (off-label use).
48
Q

How should radiation-induced enteropahty be managed in a person with prostate cancer?

A
  • Symptoms may include diarrhoea, faecal urgency, steatorrhoea, or rectal pain.
  • refer for specialist assessment and care - sigmoidoscopy to check nature of radiation injury, exclude IBD and bowel cancer.
49
Q

How should I manage sexual dysfunction in a person with prostate cancer?

A
  • Offer a phosphodiesterase-5 (PDE-5) inhibitor, such as sildenafil, tadalafil, or vardenafil, to men who experience loss of erectile function.
  • If PDE-5 inhibitors are ineffective or contraindicated, offer a choice of:
  • Intraurethral inserts.
  • Penile injections.
  • Penile prostheses.
  • Vacuum devices.
  • Consider referring men (and their partner) for psychosexual counselling.
50
Q

How should I manage urinary incontinence or retention in a person with prostate cancer?

A
  • men with urinary symptoms after treatment should be referred to specialist continence service for assessment, diagnosis and conservative Mx
  • if intractable urinary incontinence despite the above - re-refer to surgeon for consideration of artificial urinary sphincter.
51
Q

What can cause transient or spurious NVH?

A
  • urinary tract infection
  • menstruation
  • vigorous exercise (this normally settles after around 3 days)
  • sexual intercourse
52
Q

What can cause persistent NVH? What tests should be done?

A
  • cancer (bladder, renal, prostate)
  • stones
  • benign prostatic hyperplasia
  • prostatitis
  • urethritis e.g. Chlamydia
  • renal causes: IgA nephropathy, thin basement membrane disease
  • urine dipstick: persistent non-visible haematuria is often defined as blood being present in 2 out of 3 samples tested 2-3 weeks apart
  • urine microscopy may be used but time to analysis significantly affects the number of red blood cells detected
  • U&E eGFR, albumin:creatinine (ACR) or protein:creatinine ratio (PCR) and blood pressure should also be checked
53
Q

What is the most common malignancy in men aged 20-30?

A

testicular cancer

54
Q

What is the most common type of testicular cancer?

A
  • 95% of cases are germ-cell tumours
  • Germ cell tumours can be divided into:
  • seminomas (60%)- peak age 35
  • non seminomas: embryonal, yolk sac, teratoma - peak age 25, choriocarcinoma.
55
Q

Give examples of the non-germ cell tumours?

A

leydig cell tumours
sarcomas

56
Q

How are testicular tumours diagnosed in secondary care?

A

Ultrasound is first line

57
Q

What are the presenting features of testicular torsion? Symptoms and signs.

A
  • severe sudden onset testicular pain
  • may be assoc RIF pain, nausea, vomiting
  • Exam: tender, hard testis, riding higher than contralateral testis
  • Pain not eased by elevation
  • Most common in adolescents and young males 15-30.
  • Emergency referral for surgery, contralateral testis should also be fixed.

Any acutely painful scrotum should be treated as torsion until proven otherwise.

58
Q

What is a hydrocele? What are the 2 types and what causes them?

A

An accumulation of fluid within the tunica vaginalis
Can be:
* Communicating: due to patency of the processus vaginalise - allowing peritoneal fluid to drain down into the scrotum. Common in newborn males - usually resolve within first few months. Refer urology if persists >1yr
* non-communicating: caused by excessive fluid production within the tunica vaginalis. A reaction to pathology in the testis or covering. e.g. infection (epididymo-orchitis), tumour, torsion.

59
Q

What are the features of a hydrocele on examination?

A
  • swelling in the scrotum
  • soft and non-tender
  • swelling confined to the scrotum - can ‘get above’ it on examination
  • smooth surface, transilluminates
  • testis is within the swelling
  • testis may be difficult to palpate if the hydrocele is large - requires USS if underlying testis cannot be palpated (consider an impalpable tumour!)
60
Q

How should hydroceles be managed in adults?

A
  • urgent USS of the scrotum needed if:
  • age 18-40 or
  • testis cannot be palpated
  • manage any underlying cause: torsion, epididymo-orchitis, trauma - admission/specialist referral. Refer a haematocele for emergency urological assessment.
  • if idiopathic - reassure , advise on scrotal support
  • if large and symptomatic - refer to urology for surgery.
61
Q

What is a varicocele, what are the features and how is it treated?

A
  • collection of varicose veins in the pampniform plexus of the cord and scrotum
  • can be due to obstruction of testicular veins in the abdo
  • More common on left side
  • Assoc with infertility
  • Presents with ‘bag of worms’ scrotal swelling
  • dull ache in the testis at the end of the day/after exercise
  • visible when pt stands
  • can’t get above the mass
  • Reassurance only.
  • If severe symptoms can refer urology
62
Q

What are epididymal cysts? what are the examination findings? how are they managed?

A
  • cysts in the epididymis
  • single or multiple cysts
  • May contain clear fluid or sperm (spermatoceles)
  • Middle aged-elderly males
  • painless lump in epididymis - above and behind testis
  • can usually ‘get above’ the lump
  • It is separate from the testis
  • refer for uSS if unsure of diagnosis
  • Reassurance only. If becomes painful - routine referral.

AKT - Lizzie Bain (55 decks)

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