Urologocial cancer Flashcards by Becky Mladenovic

Risk factors for prostrate cancer

Increasing age
Family history (4x higher risk if 1st degree relative <60)
BRCA2
Afro-Caribbean>Caucasian>Asian

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Presentation of prostate cancer

Asymptomatic
LUTS - nocturia, urgency, frequency, hesitancy, straining, post micturation dribble, intermittent/weak stream
Bone pain (lower back)
Ejaculatory symptoms (very rare) - haematospermia

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Diagnosis of prostate cancer

DRE + PSA (need both together!)
MRI pelvis can be performed pre-biopsy to decide if need a biopsy and which biopsy method is more appropriate
Prostate biopsy (transrectal or transperineal)

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Describe transrectal and transperineal prostate biopsies

Transrectal: done under LA, 3% risk of sepsis, given high dose antibiotics beforehand (metronidazole and ciprofloxacin)

Transperineal: done under GA, lower infection risk

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Causes of raised PSA

Prostate cancer
UTI
Prostatitis
BPH
Urinary retention

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If patient has a UTI, when should you redo the PSA level

4-6 weeks

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Percentage of men with a normal PSA who have prostate cancer

15%

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Treatment for metastatic prostate cancer

Surgical:
Orchidectomy

Hormone therapy:
LHRH agonist depot (gasorelin) with initial anti-androgen (bicalutamide) to prevent initial flare up

Add-ons:
Prednisolone
Docetaxel chemo

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Palliative management of metastatic prostate cancer

Single dose radiotherapy

Zoledronic acid

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Treatment of locally advanced prostate cancer

Radical radiotherapy + adjuvant hormone therapy

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Curative management of localised prostate cancer

Active Surveillance - PSA and DRE every 6 months
Radical prostatectomy (only <70)
Radiotherapy

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Palliative management of localised prostate cancer

‘Watch and wait’

Can give hormone therapy if progressing

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Candidates for robotic prostatectomy

Age <70
Intermediate/high risk localised prostate cancer
PSA <20
BMI <35

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Describe length time and lead time bias

Length time bias:
Screening programme is better at picking up slow growing tumours

Lead time bias:
Screening picks up cancer much earlier than it would have been detected clinically and therefore appears to improve survival

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Differential for haematuria

Urological cancer
Stones
UTI
Inflammation 
BPH
Glomerular disease

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3 key investigations for haematuria

Endoscopy: flexible cystoscopy
Radiology: ultrasound of kidneys and bladder
Urine: cytology

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Investigations usually performed by GP before get to urology investigations

EGFR
ACR
MSU

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Investigations for painless testicular lump

Refer via 2ww
Urgent USS of scrotum to diagnose
If USS confirms mass - tumour markers

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When to suspect penile cancer

Penile lump or ulcer which:
Persists despite treatment
OR
STI has been excluded

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Describe paraphimosis

Can’t replace foreskin
Leads to necrosis of glans penis due to venous congestion
More common in long term catheter use

Describe phimosis

Can’t retract phimosis

Occurs in recurrent balanitis e.g diabetic patients or poor hygiene

Risk factors for bladder cancer

Male x3
Caucasian>other
Smoking x4
Occupational exposure - rubber, plastics, printers, crude oil, combustion

What are the superficial and invasive bladder stages

Superficial: T1, Ta, Tis

Muscle invasive: T2-4

Risk factors for RCC

Male 1.5x
Caucasian>other
Smoking x2
Obesity
Dialysis

Treatment for localised RCC

Surveillance Radical nephrectomy Partial nephrectomy if renal hilum not involved

Treatment for metastatic RCC

Palliative: Targeted therapies - TKIs to target angiogenesis Nephrectomy + adjuvant chemo if few lung mets

Treatment for testicular cancer

Inguinal orchidectomy Single dose RT para-aortic LNs Freeze sperm if possible Can insert prosthesis during surgery for cosmetic reasons

Risk factors for testicular cancer

History of undescended testis | Kleinfelters syndrome

Risk factors for penile cancer

Phimosis | HPV 16+18 (condyloma acuminata)

Treatment for upper urinalysis tract TCC

Nephrourectomy | Kidney, surrounding fat, ureter, cuff of bladder

Treatment of metastatic bladder TCC

Systemic chemo - cisplatin | Immunotherapy - pembroluzimab

Curative treatment of muscle invasive bladder TCC

Neoadjuvant chemo | Radical cystectomy or RT

Palliative treatment of muscle invasive bladder TCC

Chemo or RT

Methods of cystectomy

Ileal conduit to make a urostomy (usually R side) | Reconstructed bladder from segment of bowel connected to patients urethra

Treatment of low risk superficial bladder TCC

TURBT Check cystoscopies Cystoscopic surveillance

Treatment for intermediate risk superficial bladder TCC

TURBT Check cystoscopies 6 doses of weekly intravesical mitomycin followed by cystoscopic surveillance

Treatment for high risk superficial bladder TCC

TURBT Check cystoscopies BCG regimen (mycobacterium bovis) or hyperthermic mitomycin If fails, need cystectomy

Long term effects of hormone therapy for prostate cancer and the clinical relevance of this

CVS events CVA Osteoporosis Decreased muscle bulk Can give long term hormones intermittently guided by PSA

Effectiveness of long term hormone therapy

80% response | >2 years responsive

What is low risk localised prostate cancer

T1-T2a PSA <10 Gleason <7

What is intermediate localised prostate cancer

T2b PSA 10-20 Gleason 7

What is high risk localised prostate cancer

T2c-T3c PSA >20 Gleason 8 or above

What is the difference between active surveillance and watchful waiting

AS: PSA and DRE surveillance with intention of radical curative treatment if cancer is progressing Watchful waiting: monitor PSA and if symptoms occur treat with palliative intent (deferred hormone therapy)

Types of testicular tumours and most common type

Germ - seminoma, teratoma, choriocarcinoma, yolk sac tumour Non germ - leydig, sertoli Most common is seminoma

Why can't you biopsy a testicular tumour

High risk of seeding

Features of a seminoma

``` Normal AFP levels Raised beta-HCG and LDH Late metastasises RT sensitive Histology: no haemorrhage, large cells in lobules have 'fried egg appearance' I.e large cytoplasm ```

Histological features of yolk sac tumour

Raised AFP | Schiller Duval bodies

Tumour marker levels in teratoma

None are raised

Tumour marker levels in choriocarcinoma

Very high beta-HCG