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Renal-Urology > Urological malignancy > Flashcards

Urological malignancy Flashcards

1
Q

What is the most common kidney cancer?

A

Renal call carcinoma - 90% of renal cancers

e.g. adenocarcinoma proximal renal tubular epithelium

  • M>F @ 2:1
  • ~55y/o
  • 15% haemodialysis patients
  • 50% incidental findings (e.g. on CT etc)

clear cell renal cell carcinoma is most commont type of RCC (

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2
Q

How does kidney cancer present?

A
  1. -haematuria, loin pain, abdominal mass,
  2. anorexia, malaise, weight loss, fever
    • varicocele (invasion of L renal vein compressing L testicular)
    • spread: bone, liver, lung
    • paraneoplastic syndromes e.g. EPO producing
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3
Q

What are the investigatons of kidney cancer?

A
  1. ↑BP (renin)
  2. Polycythaemia (EPO), ↑ALP (mets)
  3. Urine cytology
  4. USS/CT/MRI,
    • CT renal protocol,
  5. DMSA (nuclear med for renal morphology)
  6. CXR (cannon ball metastases)
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4
Q

What is the management of T1a (<4cm in kid), T2-3 (tumour inside kidney but 7cm+) and metastatic renal carcinoma?

(staging)

A

(T1a) Renal preservation if possible - active surveillance, cryotherapy, partial nephrectomy

Radical nephrectomy (T2-3)

Metastatic disease - tyrosine kinase inhibitors, cytoreductive nephrectomy (remove–>systemic Tx)

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5
Q

What is a nephrobalstoma/Wilms tumour?

A

Chief abdominal malignancy in children

(primitive renal tubules and mesenchymal cells)

Presents with (1) abdo mass and (2) haematuria - NO abdo pain

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6
Q

What are the cancers of the renal pelvis –> bladder called?

A

transitional cell carcinoma

  • 50% are in the bladder
  • of bladder cancers - 90% are transitional cell carcinoma
  • ~40y/o and M>F 4:1

squamous cell carcinoma is 2nd most common e.g. RD schistosomiasis & long term catherterisation

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7
Q

What is the presentation of transitional cell carcinoma aka urothelial e.g. renal pelvis-bladder cancers?

A
  • Painless haematuria, frequency, urgency, dysuria, urinary tract obstruction, recurrent UTIs
  • Hx:
    • smoking, aromatic amines (rubber industry), chronic cystitis, schistosomiasis (SCC), pelvis irradiation
  • Spread:
    • local, lymphatic, liver & lungs

Remeber RF = industrial dye/solvents/rubber/textile/plastic workers & cigarrete smoking

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8
Q

What Ix are done for transitional cell carcinoma/cancer of renal pelvis–>bladder?

A
  • USS or CT/MRI
  • urine cytology (urothelium readuly sheds)
  • flexible cystoscopy + biopsy,
  • Intravenous urography (IVU)
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9
Q

What is the management of Tis/Ta/T1 transitional cell carcinoma?

A

NB: Tis/Ta and T1 are 80% of all TCC patients; not invaded detrusor musc just mucosa

papillary architecture

high recurrence though

  • TURBT - diathermy
    • reg follow up w/cystoscope and urine cytology
    • Ta = surveillance
  • Intravesical chemotherapy (intermediate risk - multiple large, reccurenct)
  • Intravesical BCG immunotherapy (high risk eg T1 or CIS/Tis)
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10
Q

What is the management of T2-3 Transitional cell carcinoma?

A

e.g. spread to detrusor/renal parenchyma/ fat/msucle surrounding; look solid over papillary

  • Radical cystectomy
    • & urinary diversion
  • (chemo)Radiotherapy - worse survival but preserves bladder
  • Neoadjuvant chemo e.g. then surg
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11
Q

What is the management of T4 Transitional cell carcinoma?

A

NB: T4 = abdo/pelvic wall spread, prostate/vagina etc spread

  • Palliative chemo/radiotherapy,
  • chronic catheterisation & urinary diversions to help relieve pain
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12
Q

What is the name of prostate cancer?

A

Adenocarcinoma

  • most common male malignancy,
  • 80% in men >80yrs;
  • peripheral zone of the prostate
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13
Q

What is the presentation of prostate adenocarcinoma?

A
  • asymptomatic OR
    • nocturia, hesitancy, poor stream, terminal dribbling,
      • weight loss +/- bone pain suggests mets
  • -associated with family hx & ↑testosterone
  • -spread: locally or to bone
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14
Q

What investigations can be done for prostate cancer?

A
  1. DRE (hard, irregular),
  2. PSA↑ (+consider trend and age related e.g. over 4 is abnormal),
  3. transrectal USS & biopsy (prophylactic ciprofloxacin for infection),
  4. x-rays, bone scan,
  5. CT, MRI (staging)

Prognosis: PSA level, stage & grade

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15
Q

What is the treatment for prostate-confined disease?

(adenocarcinoma)

A
  • Radical prostatectomy (<70yrs)
  • Radical radiotherapy (+/- neoadjuvant hormonal therapy)
  • Hormone therapy (delays progression)
  • Active surveillance (>70yrs & low risk)
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16
Q

What is the treatment for metastatic disease (prostate adenocarcinoma)?

A
  • Hormonal drugs (benefit for 1-2yrs)
    • e.g. LRH agonists (stimulate then inhibit pituitary LH/FSH)
  • Symptomatic: analgesia,
    • bone mets:
      • treat hypercalcaemia (osteoclast activation relation to bone mets),
      • radiotherapy for bone mets
17
Q

What is the name of penis cancer?

and what is its presentation?

A

Squamous cell carcinoma (95%)

others e.g. Merkel cell carcinoma, small cell carcinoma, melanoma and other are generally rare

Px: chronic fungating ulcer, bloody/purulent discharge

18
Q

What is the treatment of penile cancer/ squamous cell carcinoma?

A

early: radiotherapy & irridium wires

or

late: amputation & lymph node dissection

19
Q

What is the name of testicular cancer?

A
  • 95% are Germ cell tumours
  • can have stromal tumours e.g. leydig/sertoli cells
  • lymphoma
20
Q

What is the presentation of testicular cancer?

A
  • commonest malignancy in males 15-44yrs;
  • 10% in undescended testes, even after orchidopexy;
    • contralateral tumour in 5%
  • RFs: undescended testis, infant hernia, infertility
  • Symptoms:
    • painless, hard testis lump, +/- haemospermia,
    • 2o hydrocele, pain,
    • dyspnoea (lung mets),
    • abdominal mass or effects of secreted hormones e.g. testosterone
21
Q

What are the investigations for testicular cancer?

A
  • CXR, (lung mets and nodes)
  • CT, excision biopsy,
  • alpha-FP (typical of yolk sac/embryonal tumours)
  • & beta-hCG (useful tumour markers, help monitor treatment) (found in non seminoma)
  • lactate dehydrogenase (LDH) - proportional to bulk of tumour

Staging:

  1. no mets,
  2. para-aortic /infra-diaphragmatic nodes,
  3. supra-diaphragamtic nodes,
  4. lungs
22
Q

What is the treatment for testicular cancer?

A

radical orchidectomy (inguinal approach due to LNs),

radiotherapy (seminomas very sensitive),

chemotherapy (useful for Non Seminomatous Germ Tumout)

23
Q

What are the risk factors for renal cell carcinoma / adenocarcinoma?

A

RFs: male, age, smoking, obesity, phenacetin (paintkiller and antipyrexial drug)

Familial syndromes e.g. von Hippel Lindau syndrome (rare AD genetic disease predisposing individual to tumours including RCC & phaeochromocytoma)

24
Q

What is the grading used for renal cell carcinoma?

& staging?

A

Grading = Fuhrman 1-4

  • 1 closely resemble normal;
  • 4 has large nuclei & pleomorphic etc.

[Staging (TNM): tumour, nodes, metastasis]

25
Q

How is the prognosis of renal cell carcinoma made?

A

SSIGN

  1. Stage
  2. Size
  3. Grade
  4. Necrosis
26
Q

What is CIS (Tis) of bladder cancer?

A

CIS a flat pre-cancer

lesion in which the urothelium contains cells that display the nuclear features associated with malignancy (pleomorphism, mitosis etc) but no invasion through basement membrane

  • BUT it has high risk progression (40%) to of muscle invasive urothelial carcinoma

(which can transition to extensive local invasion and mets –> death)

  • often picked up on urine cytology
  • use blue light cystoscopy (HAL dye)- as otherwise Don’t see much - only a darker region
27
Q

How do you treat CIS/Tis of bladder?

A

MANAGE MORE AGGRESSIVELY THAN SUPERFICIAL - tends to be field chance at lots of sites in

  • intravesicle!
    • Chemotherapy w/mitomycin
    • BCG therapy (immunotherapy)
  • Can do TURBT?
28
Q

What are the RFs for penile cancer?

A

RFs:

  • HPV,
  • warts,
  • smoking,
  • phimosis,
  • do penile preserving surgery if possible
29
Q

What is a seminoma?

A

a pure seminoma is a germ cell tumour

they are less aggressive testicular cancers

  • 40% cases
  • Peak incidence 30-40yrs
  • Less aggressive
  • Late spread, lymphatic to para-aortic nodes
  • Usually confined to testes at presentation
  • Rx: radical orchiectomy (sometimes chemo if metastatic)
30
Q

What does it mean if a testicular cancer is non-seminoma?

A

yolk sac tumour, choriocarcinoma, teratoma, embryonal carcinoma, seminoma in combination with the above - more aggressive, lymphoma

  • can use b-HCG, AFP as tumour markers
  • 60% cases
  • Peak incidence 20-30yrs
  • More aggressive
  • Earlier spread via blood, lung (also liver & brain) mets
  • Sometimes tumour is metastatic at presentation
  • Rx: radical orchiectomy + chemotherapy usually
31
Q

What are the different types of cystoscopy/ureteroscopy and how are they performed/what are their uses?

A

Flexible: examines urethra & bladder, performed using LA, limited potential for intervention

Rigid: under GA, permits biopsy & resectoscope allows resection of tissue

Ureteroscopy: provides access to the ureter & pelvicalyceal system, allows passage of instruments & laser fibres for the Rx stones & upper tract tumours

32
Q

What is TURBT vs TURP?

A

TURBT = Transurethral Resection of Bladder Tumor

used in TCC Tis/Ta/T1 (80% all patients)

  • TURBT - diathermy via transurethral resection of bladder tumour
  • Consider intravesical chemotherapy (mutliple tumours/high grade)
  • Maintenance - mitomycin C, doxorubicin, cisplatin (or intravesicular BCG immunotherapy)

While TURP = transurethral resection of prostate

  • is a BPH treatment (most common surgery for BPH);
  • considered for adenocarcinoma of prostate with
    • LOCALISED disease and
    • severe symptoms with features of obstruction

Renal-Urology (8 decks)

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