Urological Malignancy Flashcards
How much does a positive family hx increase the risk of developing prostate cancer?
4x increased risk
Aside from FHx, what are the other risk factors for prostate cancer?
- Increasing age
- BRCA2 gene mutation
- Ethnicity (black>white>asian)
What is the most common type of bladder cancer?
Transitional cell carcinoma
Tell me about the demographics of bladder cancer.
4th most common cancer in men.
M:F 3:1
Incidence increases with age
Where do bladder cancers metastasise to?
Lymph nodes
Lung
Liver
Bone
Tell me about bladder carcinoma in situ.
Usually high grade but non invasive, multifocal, and tend to reoccur
What symptoms can prostate cancer present with?
- None
- bladder overactivity
- urgency
- incomplete voiding
- dribbling
- reduced stream power
- bone pain
- haematuria
Where are pts with unexplained haematuria referred to?
2WW haematuria clinic
What kind of cancer is prostate cancer usually?
Adenocarcinoma
What is the mean age and lifetime risk of diagnosis of prostate cancer?
72 years old
1 in 6 lifetime risk
Which ethnicity is most at risk of developing prostate cancer?
African-American
How does prostate cancer develop?
Slowly, often not causing symptoms until it is advanced
How is prostate cancer diagnosed?
- Hx and Ex including a DRE
- Raised PSA (although not diagnostic in itself)
- Transrectal needle biopsy
- CT
- Bone scan
What are the acceptable PSA ranges in the different age groups?
40-49 -> 0-2.5
50-59 -> 0-3.5
60-69 -> 0-4.5
70-79 -> 0-6.5
What are the elements of a prostate cancer diagnosis?
- DRE
- PSA
- Biopsy
How does a positive DRE affect the risk of having prostate cancer regardless of PSA?
Roughly doubles it compared to if DRE is negative
What are the other causes of raised PSA?
UTI Prostatitis BPH Acute urinary retention Trauma/sports e.g. long distance cycling
What factors influence treatment decisions in prostate cancer?
Age DRE outcome PSA Biopsies MRI and bone scan
How is prostate cancer graded?
Gleason grade
What kind of bone mets does prostate cancer cause?
Sclerotic aka Osteoblastic
What can we do for metastatic CaProstate?
-Treatment or palliation
What treatment can we do for metastatic CaProstate?
- Surgical castration
- Medical castration (LRH agonists)
What palliative care can we do for metastatic CaProstate?
Single dose radiotherapy
Bisphosphonates
Can metastatic CaProstate become resistant to treatment?
Yes -> CRPC
What can we do for castrate resistant prostate cancer?
- Add antiandrogen e.g. bicalutamide
- Consider prednisolone + docetaxel (chemo)
What are the treatment options for localised CaP?
- Watchful waiting
- Active surveillance
- Radical prostatecomy
- Radiotherapy
What are the treatment options for radiotherapy for CaP?
- External beam
- Brachytherapy
What are the issues associated with PSA screening for prostate cancer?
- Overdiagnosis
- Over-treatment
- QoL after treatment
- Cost-effectiveness
What is the difference between watchful waiting and active surveillance?
Watchful waiting is less intensive follow-up.
Active surveillance needs physical examination, PSA, and treatment.
Watchful waiting best for low/medium risk localised disease with co-morbidities.
What is thought to account for 40% of bladder cancer cases?
Smoking
Other than smoking, exposure to what is a major cause of TCC/bladder cancer?
Industrial chemical carcinogens e.g. benzidine or β-naphthylaminen
Where might a patient have had exposure to β-naphthylaminen or benzidine?
In their occupational hx - chemical, cable, rubber, leather, painting, or dye industries
A patient presents to the GP with recurrent painless haematuria. What other features would qualify them for a 2ww referal to urology?
- No evidence of current UTI
- If non-visible haematuria, dysuria or raised WBCs on blood test.
Basically, pretty much everyone over 45 with haematuria gets referred.
https://www.macmillan.org.uk/documents/aboutus/health_professionals/pccl/rapidreferralguidelines.pdf
Other than painless haematuria, what other symptoms might someone with TCC have? Why?
Localised pain - clot retention or local nerve involvement
-Flank pain - TCC spread to kidney or ureter -> outflow obstruction
How should painless haematuria -> ?TCC be investigated?
- Urinalysis for malignant cells
- Cystoscopy
- USS
- CT
How is staging of baldder cancer different to other cancers?
TNM is still used but as most tumours that do not invade the basement membrane will go on to become metastatic, the are classed as Ta instead of T1-4.
What % of ?TCCs are in fact papillomas?
30% - which is low, so manage them as if they are TCC.
How are pelvic and ureteric tumours managed?
By nephroureterectomy, followed up by regular cystoscopy as these can spread to become TCCs of the bladder.
How are Ta stage bladder tumours treated?
Transurethral recetion with cystoscopy follow up
What % of Ta stage TCCs will reoccur? What does this mean for the pt?
70% will recurr, so the pt with need repeat cystoscopy at regular intervals.
How are T1 stage bladder tumours treated?
Intravesical BCG
Tell me about intravesical BCG.
Vaccine given for TB is given as a form of immunotherapy which causes an immune response against the tumour. Usually given after main tumour has been resected. Left within the bladder for 2 hours.
What % of patients with stage T1 TCC will have disease recurrence within 5 years of initial treatment?
50%
How are T2 stage and above bladder tumours treated?
Under 70s - radical cystectomy.
Over 70 - radiotherapy
Why do we offer a radial cystectomy to pts under 70 with stage T2+ TCC?
Mortality risk increases with age, so can’t offer it to over 70s as risk is not worth the benefit.
Need to replace bladder with portion of bowel so pt needs to be able to recover from that as well.
Stoma formed for some pts which pt needs to be able to take care of.
What are the 5 year survival rates for TCC?
80-90% if lesions do not involve bladder muscle.
5% with metastatic disease.
What is the most common type of kidney tumour to occur in adults?
Renal cell carcinoma
What is the most common type of kidney tumour to occur in children?
Wilm’s tumour
Where do RCCs originate from?
Proximal renal tubular epithelium
What are the types of RCC that can occur?
Clear cell (most common)
Papillary
Chromophobe
Collecting duct carcinoma
Other than RCC and Wilm’s tumour, what renal tumour occur?
Transitional cell carcinoma Renal oncocytoma Angiomyolipoma Leiyomyosarcoma Sarcoma Adenoma
Tell me about the epidemiology of renal cancers.
2-3% of all malignancies
M:F 1.5:1
Highest rate between ages 60 and 70
2-3% of RCCs are hereditary
What are the risk factors for renal cancer?
Lifestyle - smoking and obesity mainly
HTN
Long term renal dialysis, tuberous sclerosis, renal transplant, and acquired renal cystic disease.
What is the classic triad associated with RCC?
Haematuria
Loin pain
Loin mass
Is the classic triad for RCC seen often? How does it usually present?
No - often RCC is asymptomatic, or presents with:
- Fatigue
- Weight loss
- Haematuria
- Palpable mass
- Varicocele
- Bilateral ankle oedema
- HTN
- Pyrexia of unknown origin
May present with signs of metastatic disease
What % of RCC pts get paraneoplastic symptoms, and what are these classically for RCC?
30%
Neuromyopathy Polycythaemia A,yloidosis Elevated ESR Hypercalcaemia Abnormal LFTs
Where does RCC tend to metastasise to?
Local structures - adrenals, liver, spleen, colon, pancreas, renal vein.
May spread to IVC from renal vein.
Lungs are the most common site.
Bone
How do RCC mets look on a CXR?
Cannon ball lesions - so classic it is almost diagnostic.
What kind of bone mets do RCCs produce?
Osteolytic lesions
What investigations can be done in primary care when suspecting RCC?
Urinalysis and M,C&S (rule out UTI)
Renal function tests (usually normal if one kidney is working well)
FBC (iron def anaemia or polycythaemia)
What are the 2ww referral guidelines for suspected RCC?
Urgently refer patients (appointment within two weeks) if they are: • Aged 45 years and over with either: – Unexplained visible haematuria without urinary tract infection – Visible haematuria that persists or recurs after successful treatment of urinary tract infection.
What is the best initial investigation for RCC in secondary care?
CT scan before and after IV contrast.
Cystoscopy should also be performed to rule our bladder cancers.
CXR for chest mets.
How is RCC staged?
Using TNM
T0-4
N0-2
M0-1
What are the different T stages of RCC?
TX - cannot be assesed
T0 - no primary tumour
T1 - less than 7cm greatest diameter, limited to kidney
T2 - over 7cm diameter, limited to kidney
T3 - extends into major veins or perinephric tissue
T4 - extends beyond Gerota’s fascia
What are the different N stages of RCC?
NX - cannot be assessed
N0 - no regional node mets
N1 - mets in a single regional lymph node
N2 - mets in more than 1 regional lymph node
How is RCC managed?
Local disease - surgery +- chemo/radiotherapy. Usually partial nephrectomy.
Adavanced/Metastatic - tumour nephrectomy in fit pts with interferon alfa. Specific immunotherapy used for different types of RCC.
Radiotherapy for brain mets and bone lesions for palliation
Bisphosphonates can reduce bone risk if known bone mets.
Which oncological emergency occurs with RCC most commonly?
Hypercalcaemia due to produciton of parathyroid-like hormone.
What is the 5 year survival for a pt with RCC confined to the kidney?
60-70%
What is the 5 year survival for a pt with RCC with lymph node spread?
15-35%
What is the 5 year survival for a pt with RCC with metastatic spread?
5%
What do 95% of testicular cancers arise from?
Germ cells
What are the 2 types of testicular germ cell tumours?
Seminoma
Teratoma
How common is testicular cancer?
1-2% of all tumours
Incidence is very low.
Lifetime risk for a man developing testicular cancer is about 1 in 200.
In which age group is testicular cancer most common?
Age 15-35
A man in his 20s present to the GP with a painful lump in his testes.
What are the 2ww guidelines for referral of ?testicular cancer?
Consider urgent referral (appointment within
two weeks) in men with any of the following changes
in the testis:
• Non-painful enlargement
• Change in shape
• Change in texture
A man in his 20s present to the GP with a painless lump in his testes. What other symptom might suggest para-aortic lymph node spread?
Back pain
How should a suspicious testicular lump be investigated?
USS
Bloods for tumour markers
Which tumour markers should be checked for in ?testicular cancer?
- Alpha fetoprotein
- Beta hCG
- Lactate dehydrogenase
To where does testicular cancer metastasise, and how can this be investigated?
Lungs
Liver
Retroperitoneal
CT/MRI
What are the risk factors for testicular cancer?
- Cryptorchidism or testicular maldescent
- Klinefelter’s
- FHx
- Male infertility
- Infantile hernia
- Malignancy in contralateral testis.
What pattern of tumour markers in seen with seminoma testicular cancer?
LDH raised
Mildly raised bHCG sometimes
AFP is never raised
Are seminomas chemo or radio sensitive?
Yes! Both :)
What is the 5 year survival for seminomatous testicular cancer?
Excellent - 90-95%
How are teratomas managed most frequently?
Inguinal orchiectomy i.e. remove testicle via inguinal route to minimise spread of malignant cells in the scrotum
Where do teratoma tetsicular cancers usually spread to?
Lungs and lymph nodes
Which tumour markers are expressed by teratomas?
80% will express AFP or HCG
Is the prognosis for teratomas better or worse then seminomas?
Worse, 5 year survival can be as low as 60% depending on tumour stage and metastatic spread.
What should be encouraged to aid diagnosis of testicular cancer?
Self-examination of the testicles for all men on a monthly basis.
Why is testicular cancer bad? Other than the fact it’s cancer obviously…
It affects many young men, and is the quickest progressing urological tumour.
How will a testicular cancer feel on examination?
Painless, palpable, hard irregular swelling - this is true of teratomas and seminomas.
If a man is experiencing testicular pain, what is the top differential until proven otherwise?
Testicular torsion
If testicular pain is torsion, how long do you have from onset to treat the condition?
4 hours
What is the main symptoms reported for testicular cancer, and what other symptoms can be seen?
Lump in the testes is most common.
Testicular/abdo pain Dragging sensation Recent hx of trauma (causes them to examine themselves) Hydrocele Gynaecomastia Back pain/resp symptoms (mets)
How does the levels of the sensation of the testes differ when it is:
a) normal
b) inflamed
c) malignant
a) delicate
b) very tender
c) lacks normal level of sensation
Will lymph nodes be palpable with testicular cancer?
Not usually - the testes drain deeper than the scrotum (which drains to inguinal nodes) so lymphatic spread from the testes is unlikely to be palpable
What can be done following a radial orchidectomy for testicular cancer?
A testicular prosthesis should be offered.
What should be offered to a man if radiotherapy or chemotherapy is needed to treat testicular cancer?
Sperm storage
What treatment do all testicular cancer pts with mets get?
Chemotherapy
What are the complications of testicular cancer and it’s treatment?
- Often normal QoL is regained :D
- Reduced fertility after chemo
- Recurrence (follow-up for 5-10 years)
- Local risks of radiotherapy and chemo
What kind of cancer is penile cancer?
Squamous cell carcinoma (95%)
How common is penile cancer?
Rare - less than 1 in 100,000 males in Europe are affected.
What is an important causative factor in developing penile cancer?
HPV infection
What are the risk factors for penile cancer?
- Phimosis
- HPV infection
- Genital warts
- Smoking
- HIV
- Penile injury
- Dermatological conditions and UV light treatment
What do men with penile cancer present with?
A penile lump, ulcer, or erythematous lesion, 50% of the time present on the glans.
What are the differentials for penile cancer?
Metastatic skin cancer or genital warts
STIs should also be ruled out before referral.
How should ?penile cancer be investigated?
Biopsy to confirm diagnosis
MRI to stage
Lymph node sampling
How is penile cancer staged?
TNM
What techniques are used to treat penile cancer?
Surgery is the mainstay of treatemnt. Chemo and radiotherapy may be used, depending on the lesion, but often efficacy is not great.
What is the prognosis like for penile cancer?
Cure rate is 80%, but it can be mutilating and have devistating psychological effects on the pts.
Why is presentation of penile cancer often delayed?
Embarrassment about the lesion
What is BPH?
Increase in size of prostate gland without malignancy present.
How common is BPH?
Very, especially with advancing age.
What does the prostate do?
Responds to testosterone, and secretes proteolytic enzymes into semen (keeps semen in fluid state)
Does BPH occur in castrated men?
No
What symptoms does BPH tend to present with?
- Urinary frequency passing small volumes each time
- Urinary urgency
- Hesitancy
- Incomplete bladder emptying
- Pushing or straining to urinate
- Dribbling of urine (flow rate decreased)
What should be examined following a hx suggesting BPH?
- Abdomen for palpable bladder
- Lower neurological function (exclude neurological cause of urinary symptoms)
- DRE to assess size of prostate
What should be investigated following a hx suggesting BPH?
- Urine for infection and blood
- Bloods for FBC, U+Es, LFTs.
- PSA.
Do PSA reference values change with age?
Yes
Once malignancy is excluded, how should BPH be managed?
- Watchful waiting if symptoms are minimal
- Alpha blockers e.g. tamsulosin (most selective for prostate)
- 5-alpha reductase inhibitors e.g. finasteride/dutasteride
- Surgery if very large prostate or failure to respond to medical therapy
What surgical procedures can be done for BPH?
- Open prostatectomy
- Transurethral resection of prostate is standard technique
What complications can arise from BPH?
- Urinary retention
- Recurrent UTIs
- Impaired kidney function
- Bladder calculi
- Haematuria
What red flags should prompt 2ww referral for someone with ?BPH?
- Visible haematuria
- Suspicion of prostate cancer (nodular prostate +/- raised PSA)
- Culture negative dysuria
What are the differentials for painful lumps in the groin?
- Tender lymph nodes
- Strangulated femoral hernia
- Psoas abscess
What are the differentials for painless lumps in the groin?
- Skin swellings
- Non-tender nodes
- Femoral hernia
- Undescended/maldescended/ectopic testes
- Femoral artery aneurysm
What are the differentials for painful lumps in the testes?
- Testicular torsion
- Epididymo-orchitis/orchitis
- Strangulated inguinal hernia
- Haematocele/haematoma
What are the differentials for painless lumps in the testes?
- Inguinal hernia
- Hydrocele
- Epididymal cyst
- Spermatocele
- Varicocele
- Testicular tumour
- Skin swellings
When taking a hx for a groin/testicualr swelling, what assocaited symptoms should you ask about?
- Urethral discharge
- Dysuria
- Abdominal pain
- N+V
- Back pain/weight loss/dyspnoea
- Parotid swelling (mumps orchitis)
What imaging is best to use for a testicular or groin lump?
Ultrasound
By what weeks gestation have the testes usually descended?
Can occur between 28 and 40 weeks gestation.
What is an undescended testicle?
A testicle that has not reached the scrotum
What is cryptorchidism?
Hidden testicle i.e. undescended testicle
What are retractile testis?
Testis retract out of the scrotum in the cold, on examination, on excitement, or on physical activity, and normally descend when relaxed or warm.
Are maldescended testis usually unilateral or bilateral?
Unilateral
What can go wrong in testicular descent?
Testicle can arrest i.e. incomplete descent, or become ectopic i.e. descent deviates from normal path.
How common is undescended testes?
1-6% of boys are affected. Most common birth defect amongst boys.
How are undescended testis managed?
If by age 1 it has not corrected spontaneously, it isn’t likely to at all. However most are still referred and operated on before age 1.
- Hormone Rx withhCG or GnRH (best for low testis)
- Surgery with orchiopexy
How much does hx of undescended testis increase risk of developing testicular cancer?
3 times more likely than background rate
When should undescended testes be checked for?
72 hours after birth (or at NIPE), and at the 6-8 week check.
