Urological malignancy Flashcards
What is the most common kidney cancer?
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 (
How does kidney cancer present?
- -haematuria, loin pain, abdominal mass,
- anorexia, malaise, weight loss, fever
- varicocele (invasion of L renal vein compressing L testicular)
- spread: bone, liver, lung
- paraneoplastic syndromes e.g. EPO producing
What are the investigatons of kidney cancer?
- ↑BP (renin)
- Polycythaemia (EPO), ↑ALP (mets)
- Urine cytology
- USS/CT/MRI,
- CT renal protocol,
- DMSA (nuclear med for renal morphology)
- CXR (cannon ball metastases)
What is the management of T1a (<4cm in kid), T2-3 (tumour inside kidney but 7cm+) and metastatic renal carcinoma?
(staging)
(T1a) Renal preservation if possible - active surveillance, cryotherapy, partial nephrectomy
Radical nephrectomy (T2-3)
Metastatic disease - tyrosine kinase inhibitors, cytoreductive nephrectomy (remove–>systemic Tx)
What is a nephrobalstoma/Wilms tumour?
Chief abdominal malignancy in children
(primitive renal tubules and mesenchymal cells)
Presents with (1) abdo mass and (2) haematuria - NO abdo pain
What are the cancers of the renal pelvis –> bladder called?
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
What is the presentation of transitional cell carcinoma aka urothelial e.g. renal pelvis-bladder cancers?
- 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
What Ix are done for transitional cell carcinoma/cancer of renal pelvis–>bladder?
- USS or CT/MRI
- urine cytology (urothelium readuly sheds)
- flexible cystoscopy + biopsy,
- Intravenous urography (IVU)
What is the management of Tis/Ta/T1 transitional cell carcinoma?
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)
What is the management of T2-3 Transitional cell carcinoma?
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
What is the management of T4 Transitional cell carcinoma?
NB: T4 = abdo/pelvic wall spread, prostate/vagina etc spread
- Palliative chemo/radiotherapy,
- chronic catheterisation & urinary diversions to help relieve pain
What is the name of prostate cancer?
Adenocarcinoma
- most common male malignancy,
- 80% in men >80yrs;
- peripheral zone of the prostate
What is the presentation of prostate adenocarcinoma?
- asymptomatic OR
- nocturia, hesitancy, poor stream, terminal dribbling,
- weight loss +/- bone pain suggests mets
- nocturia, hesitancy, poor stream, terminal dribbling,
- -associated with family hx & ↑testosterone
- -spread: locally or to bone
What investigations can be done for prostate cancer?
- DRE (hard, irregular),
- PSA↑ (+consider trend and age related e.g. over 4 is abnormal),
- transrectal USS & biopsy (prophylactic ciprofloxacin for infection),
- x-rays, bone scan,
- CT, MRI (staging)
Prognosis: PSA level, stage & grade
What is the treatment for prostate-confined disease?
(adenocarcinoma)
- Radical prostatectomy (<70yrs)
- Radical radiotherapy (+/- neoadjuvant hormonal therapy)
- Hormone therapy (delays progression)
- Active surveillance (>70yrs & low risk)
What is the treatment for metastatic disease (prostate adenocarcinoma)?
- 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
- bone mets:
What is the name of penis cancer?
and what is its presentation?
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
What is the treatment of penile cancer/ squamous cell carcinoma?
early: radiotherapy & irridium wires
or
late: amputation & lymph node dissection
What is the name of testicular cancer?
- 95% are Germ cell tumours
- can have stromal tumours e.g. leydig/sertoli cells
- lymphoma
What is the presentation of testicular cancer?
- 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
What are the investigations for testicular cancer?
- 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:
- no mets,
- para-aortic /infra-diaphragmatic nodes,
- supra-diaphragamtic nodes,
- lungs
What is the treatment for testicular cancer?
radical orchidectomy (inguinal approach due to LNs),
radiotherapy (seminomas very sensitive),
chemotherapy (useful for Non Seminomatous Germ Tumout)
What are the risk factors for renal cell carcinoma / adenocarcinoma?
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)
What is the grading used for renal cell carcinoma?
& staging?
Grading = Fuhrman 1-4
- 1 closely resemble normal;
- 4 has large nuclei & pleomorphic etc.
[Staging (TNM): tumour, nodes, metastasis]
How is the prognosis of renal cell carcinoma made?
SSIGN
- Stage
- Size
- Grade
- Necrosis
What is CIS (Tis) of bladder cancer?
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
How do you treat CIS/Tis of bladder?
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?
What are the RFs for penile cancer?
RFs:
- HPV,
- warts,
- smoking,
- phimosis,
- do penile preserving surgery if possible
What is a seminoma?
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)
What does it mean if a testicular cancer is non-seminoma?
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
What are the different types of cystoscopy/ureteroscopy and how are they performed/what are their uses?
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
What is TURBT vs TURP?
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
