Urology 3: urological cancer Flashcards
what is the association between haematuria and urological cancer
microscopic: 5% risk
visible: 20% risk
how should the patient be referred if they have haematuria
2 week wait to urology
if there are clots (causing an obstruction) urgent admission
what can cause false results for haematuria on urinalysis
false + : exercise, menstruation, myoglobin
false - : vit C intake, heavy proteinuria
what travel related infection is linked to urological cancer
schistomiasis
linked to bladder squamous cell carcinoma
what imaging can be used to investigate haematuria
CT urogram with non-contrast and delayed post-contrast phase
USS
cystostomy +/- biopsy
if they have clots or active bleeding may need wash out in surgery before cystostomy
what medication should be stopped if a patient presents with haematuria
anticoagulants
what are the different types of cancer of the urinary tract
kidney- RCC, TCC
ureter - TCC
bladder - TCC, SCC, adenocarcinoma
prostate - BPH, adenocarcinoma
describe RCC
tumour of the renal parenchyma
clear cell is the most common type and is associated with von-hippel lindau syndrome
what are the types of RCC
clear - around 70% of cases
papillary
chromophobe - less aggressive
collecting duct -rare, aggressive
medullar - rare, associated with sickle cell disease, aggressive
presentation of RCC
majority are incidental findings
triad (only seen in around 10%): loin pain, palpable mass, haematuria
risk factors: heavy smoking, obesity, FHx
what are paraneoplastic syndromes
group of clinical disorders or syndromes associated with malignant disease but not directly linked to the physical effects of the primary or metastatic tumour
HTN, anaemia, polycythemia, pyrexia, hypercalcaemia, cushings, amenorrhoea, staufers syndrome (abnormal LFTs)
what classification is used for renal cysts
bosniak
1- benign, simple
2- midly complex (cyst with septation), benign
3 - very likely to be benign but needs follow up
4 - 60% chance of cancer, multiple septations and compartments
5 - definite RCC
what are the management options for RCC which hasn’t metastasised
T1a /b- in older or cormobid patients survalience
can also consider ablation, radical nephrectomy or partial nephrectomy
T2a and above: laparoscopic or open radical nephrectomy +/- lymph node dissection
how can RCC with metastatic disease be managed
nephrectomy and resection of mets if possible
tyrosine kinase inhibitor +/- cytoreductive nephrectomy (pallative treatment to reduce symptoms and improve chemos effectiveness)
targeted therapties to interfere with VEGF pathway
describe ureteric TCC
uncommon
visible haematuria
CT urogram best for imaging
to confirm ureteroscopy +/- biopsy
how would you manage non-metastatic ureteric TCC
small low grade tumour - ablation
majority are managed with laparoscopic nephro-ureterctomy
what are the different types of bladder cancers and their specific risk factors
TCC (80%) - smoking, rubber and dye exposure
SCC (20%) - long term catheters, recurrent UTI, bladder stones, schistosomiasis
adenocarcinoma -rare
how can you manage bladder cancers initially
TURBT - trans ureteral resection of bladder tumour (can be diagnostic or curative)
T1 can be fully resected but T2 cant due to muscular invasion
if superficial tumour single dose of intravesical mitomycin is given
for more advanced cancer they may be offered 6 weekly mitomycin intilations, cystectomy and BCG regimen
how can the BCG regime be used to manage bladder cancer
live attenuated mycobacterium bovis
given intravesically to stimulate type 4 hypersensitivity reaction that activates immune cells to tumour antigens
reduces progression
side effects of the BCG regime
dysuria, frequency, urgency
UTI
haematuria
bladder contracture / ureteric stenosis (rare)
systemic BCGosis (rare)
if it fails then cystectomy
side effects of the BCG regime
dysuria, frequency, urgency
UTI
haematuria
bladder contracture / ureteric stenosis (rare)
systemic BCGosis (rare)
if it fails then cystectomy
how generally are muscle invasive bladder cancers managed
RCC: organ confined - neoadjuvent chemo, and cystectomy, then chemoradiotherapy
if metastatic then palliative chemotherapy
SCC/adenoma: likely to be invasive so generally treated with cystectomy
what are the different types of radical cystectomy
male = cystoprostatectomy
female = anterior exenteration (bladder, uterus, tubes, ovaries and anterior vaginal wall)
both get pelvic lymph node dissection
what are some options for urinary diversion after cystectomy
ileal conduit - stoma (ureters connected to small bowel)
neobladder - new bladder made of small bowel
continent cutaneous diversion - catherterisable stoma, pouch fashioned from bowel, and patient passes catherter to empty pouch
when is a continent diversion contraindicated
renal impairment
hepatic impairment
inadequate small bowel
not able to catherterise
what are some complications of continent diversions
hyperchloraemic metabolic acidosis (small bowel can re-absorb urine)
incontinence
stones (stagnant urine)
mucous
perforation (dont have the sensation of full bladder)
needs emptying every three hours initially
risk factors for prostate cancer
age - peaks in 70s
family history
genetics (HPC1, BRCA)
ethnic origin (afro-caribbean)
how can prostate cancer present
often picked up when asymptomatic
can cause LUTS
in advanced disease - bone pain, weight loss
when should you do a PSA test
patients with LUTs - unless life expectancy <10yrs and benign DRE
avoid in retention/haematuria unless DRE is suggestive of malignancy
bone pain / weight loss and DRE concerning
how does PSA change with age
increases with age
there isnt a specific PSA value to exclude cancer
if >100 likely to have metastases but there are other causes to raise PSA
what is active surveillance and waitful watching for prostate cancer
used for low risk disease
monitor PSA/DRE 6 monthly
aim is to avoid unnesessary treatment if the disease doesnt progress
waitfull watching: for older or comorbid patients with non metastatic disease
aim is pallative treatment with hormones if metastatic or symptomatic
what are surgical options for prostate cancer
curative - radical prostectomy
palliative - billateral nephrostomy (prevents symptom of obstruction)
what treatment options are there for prostate cancer with metastatic disease
androgen deprivation therapy
- bicalutamide for 28 days
- LNRH analouge injection after 14 days then monthly or longer if stable
early docetaxel chemotherpay
describe testicular cancer
uncommon
men who are 15-45
majority are germ cell tumours
can also be lymphoma and leydig cell tumour (linked to klinefelters)
what are the different types of germ cell tumours
non-seminomatous germ cell tumours
seminoma
presentation of testicular tumours
noticable lump
solid mas inseperable from the testis on clinical exam
can have systemic symptoms if mets
USS to diagnose, CT CAP for staging
what are some testis tumour markers
AFP - specific for NSGCT
B-HCG - NSGCT
LDH
managment of testicular canceer
inguinal orchidecotmy with testicular prosthesis
if advanced mets then neoadjuvant chemo
retroperitoneal lymph node disection for NSGCT
describe penile cancer
very rare
SCC
Excision- circumcision, glansectomy, partial/total penectomy
may need inguinal node dissection
