W06: TUMOURS & NEPHRO-UROLITHIASIS Flashcards
Describe the aetiology, presentation, investigation of tumours of the urinary system.
age: >65y/o, <70y/o = trend changing w/ ⇧PSA testing
ethnicity: african living in west with vs east asian men living in western (less risk)
family hx: 1st degree relative 2x risk
majority occur in the PERIPHERAL ZONE and present LOCALISED; asymptomatic and incidental PSA testing
*METASTATIC SYMPTOMS: bone pain, paraplegia d/t SC compression, LN enlargement, lymphoedema, loin pain
+ wt loss and cachexia
- PSA, DRE, TRUS biopsies
- symptoms are not cancer specific but indicative of prostate enlargement
+ pre-biopsy prostate MRI
+ then TRUST biopsy
Explain the differences between grading and staging of cancers and why both are critically important in the management of cancers
stage of a cancer describes the size of a tumour and how far it has spread from where it originated. The grade describes the appearance of the cancerous cells
Describe the grading and staging systems of the commonest urinary system tumours (i.e. prostate and bladder cancer) and how they affect management and prognosis.
GLEASON GRADING SYSTEM: Grade 3 to Grade 5
most common and second most graded SUM
= score calculates risk of death within 15 years
2-4 4-7%
5 6-11%
6 18-30%
7 42-70%
8-10 60-87%
ISUP score: 6 = GRADE1 7 = GRADE 2 7 (4+3) = GRADE 3 8 = GRADE 4 9-10 = GRADE 5
STAGING: DRE, PSA, MRI, CT, Bone scan (distant)
Describe the definitions of localised, locally advanced and metastatic disease of urinary system tumours and link them to TNM staging system
Local staging (via pathological assessment of orchidectomy specimen)
Nodal staging (via CT scan)
Distant staging (chest, abdomen and pelvis) (via CT scan)
Tumour markers also provide staging and prognostic information
for testes:
Stage II - Infradiaphragmatic nodes involved
Stage III - Supradiaphragmatic nodes involved
Describe risk stratification system used in non-metastatic prostate cancer (i.e. D’Amico classification) based on clinical and histological (i.e. biopsy) features and serum PSA, and how it affects management and prognosis.
a
Describe the principles of management of tumours of the urinary system.
LOCALISED If life expectancy is less than 10 years = no radical tx = WATCHFUL WAITING - PSA checks, examinations
METASTATIC (confirmed by bone scan)
= HORMONE THERAPY
RADICAL Tx for life expectancy 10yr+ / intermed-high risk disease or localised low risk but high tumour volume and burden
- external-beam
- brachytherapy
RADICAL PROSTATECTOMY
- open
- lap.
- robotic
locally advanced prostate cancer
- neoadj hormone + surgery / RT (standard)
- hormone alone - unfit, can alleviate symptoms
+DOCETAXEL CHEMOTHERAPY + HORMONAL for metastatic
+Palliative RT for bone pain/mets ; nephrostomy
Refractory stage = adds chemotherapy drug that wasn’t added before already
What is the commonest mode of presentation for prostate cancer?
a. Frank haematuria
b. Asymptomatic (i.e. incidentally noted)
c. Acute urinary retention
d. Symptoms of benign prostatic enlargement and obstruction
e. Bone pain
Asymptomatic (i.e. incidentally noted)
The significance of ad-hoc PSA testing
As the Wilson-Junger criteria not met as screening would lead to over-dx and over-tx of harmless cancers, ad-hoc PSA testing can help avoid under-tx of aggressive cancers
< 50 years : 2.5 is upper limit
50-60 years : 3.5 is upper limit
60-70 years : 4.5 is upper limit
>70 years : 6.5 is upper limit
important to observe PSA testing over time as sudden spikes can be d/t many things. chronic elevations d/t BPH and prostate Ca.
Grading Vs Staging
GRADING - aggressiveness assessment via histology
STAGING - assessment of spread via clinical and radiological assessment
Mechanism of hormone rx / androgen deprivation
starving cancer cells of testosterone via
* surgical castration = bilateral orchidectomy
- chemical = LHRH analogue downregulate androgen receptors via negative feedback @ pituitary
+anti-androgen @ first week d/t flare
+ LHRH antagonist do not cause flare = inhibit androgen receptor - OESTEROGEN = inhibits LHRH and testosterone secretion, inactivates androgens and has direct cytotoxic effect on prostatic epithelial cells
The following are reasonable treatment options for low-risk localised prostate cancer except:
a. External beam radiotherapy b. Active surveillance c. Brachytherapy d. Radical prostatectomy e. Radical chemotherapy
Radical chemotherapy only for mets
The following statements about screening for prostate cancer are true except:
a. PSA is the best available screening test b. Compared with ad-hoc opportunistic PSA testing, screening for prostate cancer is beneficial because it saves lives c. If screening is advocated, it should be performed for men at risk of prostate cancer rather than the entire male population d. Screening for prostate cancer is not currently advocated e. For suspicious cases detected by screening, there is a need to undergo a definitive test to confirm or exclude presence of prostate cancer
Compared with ad-hoc opportunistic PSA testing, screening for prostate cancer is beneficial because it saves lives
= doesnt as it will only increase overdx and overtx
TESTICULAR CANCER
third decade, common young men, caucasian, maldescent infertility, atrophic testis, precursor of in-situ testicular germ cell neoplasia
painless lump common presentation, with less common: swelling, hx of trauma, nodal mets signs
detection/dx * markers: AFP (teratoma), ßHCG (seminoma), LDH (non-spec. tumour burden) * lump = tumour until proven otherwise ?infection, cyst, torsion * MSSU * USS and CXR * tum markers
- germ cell tumour most common
- seminoma = 30-40y/o mainly
- non-seminmatous = 20-30 y/o
Mgmt of Testicular Cancer
- radical orchidectomy
- biopsy of contralateral testis for surveillance
Nodal disease or relapse = combo chemoT or LN dissection
Mets only = 1st line chemoT, 2nd line chemoT
For testicular cancer, the main lymphatic spread to regional lymph nodes occurs in which group of lymph nodes?
a. Scrotal lymph nodes b. Inguinal lymph nodes c. Pelvic lymph nodes (i.e. internal iliac chain) d. Mediastinal lymph nodes e. Para-aortic lymph nodes
Para-aortic lymph nodes
- following major blood vessels, testicular artery origin = aorta
- inguinal LN would be relevant if spread to scrotal skin only
When performing radical inguinal orchidectomy for testicular cancer:
Where is the incision made?
Why is the incision made here?
i.
ii.
UROTHELIAL CANCERS types and common presentations, and investigations
malignancies of the transitional cell epithelium lining, spanning calyces to urethral tip, with BLADDER CANCER the most common
= TRANSITIONAL CELL CARCINOMA: smoking, aromatic amines, non-hereditary genetic abn.
= SQUAMOUS CELL CARCINOMA (Schistosomiasis endemic) - chronic cystisis (recurrent UTI, LT catheter)
*PAINLESS VISIBLE HAEMATURIA - frank/microscopic
+ invasive/mets symptoms
+ recurrent UTI, storage symptoms
• CULTURE
• cystourethroscopy
!urgent = upper tract imaging (COMBO OF CT & USS), urine cytology
STORAGE SYMPTOMS
dysuria, frequency, nocturia, urgency +/- urge incontinence
bladder pain
if present, suspect CIS
Staging of urothelial tumours
*bluelight cystoscopy
T - cystoscopy and endoscropic resection via TURBT
EUA assess mass/thickening
N,M - Ct/MRI imaging, bone scan (mets symptomatic), CTU for upper tract
Grades of TCC (WHO 1973): G1 = Well diff. - commonly non-invasive G2 = Mod. diff. - often non-invasive G3 = Poorly diff. - often invasive Carcinoma in situ (CIS) – non-muscle invasive but VERY aggressive (hence treated differently
MGMT OF UROTHELIAL TUMOURS
> endoscopic resection for low grade
+ CHEMOTHERAPY
+ follow up
> endoscopic resection for aggressive plus BCG therapy (stimulate immune response) for CIS plus high-grade
> NEOADJUVANT CHEMOT. + RT/CYSTOPROSTATECTOMY or EXENTERATION w/ URETHRECTOMY
for muscle invasivion
UPPER TRACT TCC: presentation, and dx approach
commonly presents w/ frank haem., unilateral obstruction, flank/loin pain, mets disease
- common involvement of collecting system, high risk recurrence and often high-grade and multifocal
- CT-IVU/ IVU identify filling defect thus tumour
- urine cytology
- biopsy
benign and malignant RENAL CANCERs
benign: oncocytoma, angiomyolipoma
malignant: RENAL ADENOCARCINOMA (very common) mostly arise from PROXIMAL TUBULES often CLEAR CELL
* FHx, smoking, anti-hypertensive meds, obesity, end-stge RFailure, acquired cystic disease
ADENOCAR. - often asymptomatic and incidentally found
- FLANK PAIN
- MASS
- HAEMATURIA
- Paraneoplastic syndrome = anorexia, cachexia, pyrexia
- HT, hypercalcaemia, abn LFT
- anemic, polycythaemia, raised ESR
METS = bone, brain lungs, liver
Spreading of renal adenoca.
DIRECT INVASION OF CAPSULE
VENOUS INVASION TO RENAL VEIN => VENA CAVA
Haematogenous spread to lungs and bone
LYMPH SPREAD = PARACAVAL NODES
Investigations of Rencal Adenoca.
CT SCAN - abdo, chest, contralat. kidney
BLOODS
+ USS differentiates tumour from cyst
+ MAG-3 assess split funct
Mgmt Renal AdenoCa.
> SURGICAL - radical nephrectomy (lap), ≤T2 = curative
*palliative cytoreductive nephrectomy is beneficial even w/ mets
- RCC often radioresistant/chemoresistant
+ tyrosine kinase inhibitors
+ IMMUNOTHERAPY
NEPHROUROLITHIASIS presentation & investigation
M>F, recurrence common, COLIC PRESENTATION COMMONEST
- renal pain, colic, dysuria/haematuria / testicular/vulval pain, UTI, loin tenderness, pyrexia
- FBC, UE, creatinine
- calcium, albumin, urate,
- parathormone
- urinalysis/culture; 24hr urine
- KUB XR, USS
- IVU, CT KUB
NEPHROUROLITHIASIS MGMT
immediate relief potentially achieved by stent insertion or nephrostomy followed by DEFINITE Tx:
> SURGERY: for obstruction, recurrent haematuria pain infection, progressive loss of functio
- open (least recurrence) - for non-functionning
- percutaneous - large stone burden, ESWL resistant; USS guided/ XR guided, risk of injury
! active UTI, untreated coagulopathy, obesity - endoscopic - severe obstruction, pain+++, persistent haemutia, failed ESWL,
!perforation, avulsion, ureteral necrosis, stricture formation - Extracorporeal shock wave lithotripsy (ESWL) = FIRST LINE FOR CALCULI
Bladder stone presentation, dx, tx
- groin/penile pain = STRANGURY (bladder spasm pushing stone out)
- dysuria, freq., haematuria
- persistent UTI
- sudden interruption to urinary stream
> Transurethral cystolitholapaxy
(commonest for adults)
> Percutaneous suprapubic cystolitholapaxy
(mainly for children)
What is the gold standard diagnostic tool for renal stones?
The gold standard for diagnosis of renal stones is a non-contrast CT scan of the renal tract (KUB). The benefit of the CT KUB (Fig. 3) as an imaging modality is the high sensitivity and specificity in identifying stone disease, as well as concurrent assessment of any alternative pathology.
