Week 10 Malignancy of the Urinary Tract Flashcards
what are some of the risk factors of Prostate cancer?
- increased age
- family history- increased 4x risk if a first degree relative diagnosed before age of 60, also BRCA2 gene mutation
- ethnicity- black > white > asian
Is mass screening of Prostate cancer a good idea- why?
not recommended to screen for PSA (prostate specific antigen)- due to possibility of:
- overdiagnosis
- over- treatment
- quality of life- co morbidities of established treatments
- cost effectiveness
- PSA may be raised due to- infection, inflammation or large prostate
how does prostate cancer usually present?
usual:
- asymptomatic
- urinary symptoms- benign enlargement of prostate/bladder, overactivity
- bone pain- most common metastatic site
unusual:
- haematuria- advanced cancer
how is prostate cancer usually diagnosed?
digital rectal examination (DRE)- TRUS- transrectal ultrasound- allows guided biopsy of prostate
- check serum PSA
lower urinary tract symptoms (LUTS)- transurethral resection of prostate (TURP)
what factors affect the treatment choice of prostate cancer?
age
DRE- localised (T1/2), locally advanced (T3), advanced (T4)
PSA level
biopsies- gleason grading, extent
MRI scan and bone scan- nodal and visceral metastasis?
how is localised (T1/2) prostate cancer treated- established and developmental options?
established treatments:
- surveillance- PSA every 6months
- radical protatectomy- open- laparoscopic- robotic
- radiotherapy- external beam, low dose rate brachytherapy- implant radioactive substance which releases it from within
developmental:
- HIFU- high intensity flourescent ultrasound
- primary cryotherapy- use of extreme cold
- high dose brachytherapy
how is locally advanced prostate cancer (T3) treated?
surveilance
hormones
hormones with radiotherapy
describe the epidemiology of Prostate cancer- who affected
correlation with increased age- urinary symptoms, benign enlargement of prostate
most pts diagnosed are- asymptomatic, have localised disease, unlikely to die from it
how is metastatic prostate cancer treated/ managed?
NO CURE- maintain quality of life only
Hormones:
- surgical castration- removal of testes
- medical castration- now more common- LHRH agonist (LH releasing hormone)- removal of testosterone
Palliation:
- single dose radiotherapy- for bone pain
- bisphosphonates- for widespread bone pain- zoledronic acid
- chemo
- new treatments
How can haematuria be classified on presentation and how is this associated with the likelihood of having a urological malignancy?
visible haematuria- 20% find urological malignancy
non visible:
- symptomatic- dipstick dont need microscope- 5% find malignancy
- asymptomatic- found microscopically- 0.5% find malignancy
what would be the possible differential diagnosis of haematuria?
urological:
- cancer- renal cell carcinoma (RCC), upper tract transitional cell carcinoma (TCC), bladder cancer, advanced prostate carcinoma
- other- stones, infection, inflammation, large benign prostate hyperplasia
nephrological (glomerular):
- more common in young people- if have proteinuria, high BP- early glomerular disease
what would you want to ask in a history and expect to see in an examination of a pt with haematuria?
history- smoker, occupation, painful/painless, other LUTS, family history
examination- BP, abdominal mass, varicocele (varicous veins on scrotum), leg swelling (lymphedema), assess prostate by DRE (male)- size and texture
what investigations would you perform on a pt presenting with haematuria?
bloods- FBC, U&E
radiology- ultrasound of urinary tract
urine- culture and sensitivity, cytology
endoscopy- flexibly cystoscopy- allows exam of bladder lining and urethra via camera- shows bladder cancer
describe the epidemiology of bladder cancer- incidence, M:F ratio, common type, risk factors?
- 4th most common cancer in males, 11th in females- presentation more advanced in females
- M:F 2.5:1
- decreasing incidence
- 90% transitional cell carcinoma (TCC)
- risk factors- smoking (X4), occupational exposure (rubber manufacture, painters, hairdressers etc), schistosomiasis (bilharzia)- chronic disease due to infection with blood flukes (squamous cell carcinoma (SCC)
what is the initial definitive treatment of bladder cancer?
trans urethral resection (TUR) bladder tumour (TURBT)
- superficial TURBT
- separate deep TUR of muscle
- single intravesical dose of mitomycin C (chemo) into bladder- dont loose hair
what is the staging of bladder cancer?
75% superficial- no muscle invasion just epithelium and subepithelium -Ta or T1
5% only affect epithelium TI
20% muscle invasive- T2,3,4 - even with treatment 50% die within 5yr
what further treatment options are there for different staged bladder cancer?
low risk non muscle invasive TCC (G1,G2, Ta)
- check bladder every few weeks- cystoscopies +/- intravesical chemo
high risk no muscle invasive TCC (G3, Tis, T1)
- check cystoscopies, intracesical immunotherapy
muscle invasive TCC
- potentially curative- neoadjuvant chemo (chemo before surgery) + radical cystectomy (remove bladder) or radiotherapy
- palliative- chemo/radiotherapy to reduce symptoms
describe options of radial cystectomy
can remove whole bladder- ileal conduit- insert piece of detached bowel which opens onto skin surface- sticks out so that urine doesnt irritate skin
can reconstruct bladder from bowel in small number of cases
what is the commonest type of renal parenchyma cancer?
renal cell carcinoma (RCC)
describe the epidemiology of renal cell carcinoma- how common, M:F ratio, presentation, aetiology (causes)?
8th most common cancer in UK- 95% of all upper urinary tract tumours incidence and mortality increasing M:F 3:2 30% metastatic on presentation causes- smoking (X2), obesity, dialysis
describe the possible spread of renal cell carcinoma
lymph node metastasis
perinephric spread- into surrounding fat
IVC spread to right atrium- tract up IVC to RA
what imaging is done to diagnose renal cell carcinoma?
ultrasound and CT to fully stage
how are localised RCC treated- established and developmental treatments?
established:
- surveillance- smaller tumours may be able to leave alone
- radical nephrectomy- remove kidney- sometimes adrenal, upper ureter and surrounding fat also
- partial nephrectomy- part of above
developmental:
- ablation
how is metastatic RCC treated?
palliative- molecular therapies targeting angiogenesis are now first choice
- chemo and radio resistant
describe the epidemiology of upper tract transitional cell carcinoma (TCC)- how common, aetiology (causes)
only 5% of all malignancies of upper urinary tract
causes- smoking, phenacetin abuse (painkiller), balkans nephropathy
what is the likelyhood of a pt with bladder cancer developing cancer in the upper urinary tract?
5%
what is the likelihood of a pt with upper urinary tract cancer developing bladder cancer?
40%
what initial investigations would you do if you suspected upper tract transitional cell carcinoma (TCC)?
- ultrasound- hydronephrosis- fluid buildup due to failed drainage
- CT urogram- filing defect, ureteric stricture
- retrograde pyelogram- contrast injected to show ureter and kidney - flows up in opposite direction to urine
- ureteroscopy- biopsy, washing for cytology
what is the standard treatment for upper tract transitional cell carcinoma (TCC)?
nephro- ureterectomy- kidney, fat, ureter, cuff of bladder
Describe the bone metastasis of prostate cancer- what found, how?
slcerotic (osteoblastic)
hot spots on bone scan shown up
unlikely if PSA
