14 - Urological Malignancy Flashcards by Charlotte Humphries

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How common in renal cancer?

3% of all cancers

3 in 10,000

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What are the RF for renal cancer?

Obesity
Smoking
DM
Asbestos / Cadmium / Lead
FHx

Von Hippel-Lindau gene (tumour suppressor gene)

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What are the protective factors for renal cancer?

Moderate alcohol
Exercise

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Which is the commonest renal cancer?

Clear Cell RCC - 75%
Chromophobe RCC
Type I Papillary

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How does renal cancer present?

Mass
Haematuria
Pain
Systemic effects

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What paraneoplastic effects can occur from renal cancer?

Malaise
Weight loss
Hypercalcaemia
Polycythaemia
Liver dysfunction

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What investigations can you do for renal cancer?

Bloods
USS
CT
MRI
Biopsy

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What do kidney cancer bone mets look like? How does this differ to prostate bone mets?

Kidney = Lytic lesions
Prostate = sclerotic lesions

Kidney mets - dont show up well on a bone scan
Prostate mets - show up well on a bone scan

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At what stage kidney cancer is the tumour no longer limited to the kidney?

Stage III

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What is the difference between active surveillance and watchful waiting?

Active surveillance - have found a problem and monitor it before trying to cure it.

Watchful waiting - aim is not to cure - wait for it to cause Sx and then treat the Sx in a palliative approach.

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What are the Rx options for renal cancer?

Radical nephrectomy
Partial nephrectomy
Ablation
Immunotherapy
Tyrosine Kinase Inhibitor therapy
Resection of mets

Most cancers = surgery + radio + chemo. However radiotherapy doesn’t work on the kidney and chemo isn’t great either. There surgery + immunotherapy is the best choice.

I.e. Surgery + Immunotherapy + TKIs

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What is the peak age of incidence of kidney cancer?

85-89

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What is the prognosis for kidney cancer?

95% 5 year survival

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Where does transitional cell carcinoma arise from the in the bladder?

From the urothelium

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What percentage of TCC of bladder and ureter will be muscle invasive and what percentage will not?

20% will be muscle invasive
80% will not

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What percentage of TCC is found in the bladder and what percentage is in the ureter?

95% is bladder
5% is ureter

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What are the risk factors for urothelial cancer?

Smoking
Petrochemicals
Hairdressers
Chronic bladder inflammation
Schistosomiasis (more SCC - lays eggs in the bladder)

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What are the types of urothelial cancer?

TCC
SCC - 3%
Adenocarcinoma - 1%

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What are the S&Sx of urothelial cancer?

Haematuria - 90%
Irritative LUTS
Pain with obstruction
Pelvic mass

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What is the prognosis for urothelial cancer?

95% have 5 year survival if not muscle invasive

If muscle invasive - only 5% will be alive at 5 years

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What investigations are done for urothelial cancer?

CT Urogram
Cytology
Flexible cystoscopy
Can do CT chest & Bone scan if worried about mets

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What are the Rx options for urothelial cancer?

TURBT
Chemo
Radio
Cystectomy

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What is painless haematuria assumed to be?

Assumed to be TCC unless proven otherwise

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What does TURBT stand for?

Trans-uretheral Resection of Bladder Tumour

What intravesicle medication can be given to Ps with TCC?

Intravesicle BCG - thought to directly infect and kill cancer cells + has immunotherapy effect.

What was found to have an 8% improvement in 5YS for TCC?

Neoadjuvant chemotherapy Treatment given as a first step to shrink a tumor before the main treatment, which is usually surgery, is given.

How are Ps with metastatic renal cancer treated?

Supportive care Chemo Palliative radiotherapy if needed

Which is the commonest cancer in men?

Prostate cancer

Where is the commonest and lowest incidence of prostate cancer?

Highest = Australia, USA, Western Europe Lowest = Japan, Eastern Asia

What are the S&S of prostate cancer?

Asymptomatic in early stages Haematuria LUTS Haematospermia Bone pain if mets Bladder outflow obstruction with AKI - rare

How is prostate cancer diagnosed?

Elevated PSA DRE Prostate biopsy

What is the 5YS rate of prostate cancer?

98%

Which grading system is used for prostate cancer?

Gleason grading system

What is PSA?

Enzyme involved in the liquification of semen - should be found in high levels in the semen and should be low in the blood

What do you look for on a DRE for prostate cancer?

Size Induration Asymmetry Loss of median sulcus Nodule

When should Ps with prostate cancer have a bone scan?

If their PSA >20 or Gleason score >4

Which is the best imaging for metastatic disease?

PET-CT - picks up v low grade metastatic disease

What can PSA be increased by apart from cancer?

BPH Infection Instrumentation Ejactularion Retention

Which medications can lower PSA?

Finasteride Dutasteride

What happens to our PSA as we age naturally?

The prostate grows with age - therefore PSA should naturally increase incrementally with age.

How is prostate density linked to cancer risk?

Increased prostate density = inc risk of prostate cancer

What is doubling time?

How long it takes for the PSA to double - can be a good predictor of when Rx will be needed

Where does prostate cancer like to metastasise to?

Pelvis Axial skeleton Ribs

What is brachytherapy?

Internal radiation treatment - surgery puts seeds of radiation into the prostate = can use a higher dose and it decays over weeks

How is hormone therapy used with prostate cancer?

Can you androgen deprivation therapy = stops the prostate from gdowing Can also use synthetic LHRH agonists (this causes a rise and then a fall by negative feedback mechanism in testosterone release) b- commonest! Can use LHRH antagonist Can also use antiandrogens (Biclutamide) which block the effect of testosterone directly

What is RALP?

Radio-assisted Laparotic Prostatectomy

How does prostate treatment differ with age?

Younger Ps = more surgery, brachytherapy, radio and chemo Older Ps - no surgery or brachytherapy or chemo. More hormones & radiotherapy

What type of cancer is prostate cancer?

Adenocarcinoma

What are the RF for prostate cancer?

Alcohol Smoking FHx AC Vit D? Metabolic syndrome BRACA2

What investigations can be done for prostate cancer?

PSA MRI Biopsy Bone scan PET scan

What is testicular cancer divided into?

Seminomas Spermatocytic Seminoma Non-Seminomas Germ Cell Tumours (NSGCT) - aka teratomas

What is the age peak for testicular cancer?

NSGCT = 20-30 SGCT = 30-40

What are the RF for testicular cancer?

Cryptorchidism (undescended testes) Testicular dysgenesis FHx

Which hormonal markers can be used for NSGCTs?

α FP = Yolk sac tumours β HCG = choriocarcinoma

What can high levels of αFP indicate?

Yolk sac NSGCT also Hepatocellular carcinoma Pancreatic, Biliary, Gastric or Bronchial carcinomas Pregnancy - 12-14w peak

What can high levels of β HCG indicate?

NSGCT Breast, Kidney, Bladder, Stomach, Liver cancer Also = Pregnancy - 12-14w peak

What do very high tumour markers in terms of prognosis in testicular cancer?

Not a good prognosis

What are the S&S of testicular cancer?

Scrotal mass Pain Nodular testical Palpable abdominal lymph nodes

What is the prognosis of testicular cancer?

Very good prognosis

What are the investigations for testicular cancer?

Clinical exam Tumour markers Scrotal USSS CT CAP to stage

What is the Rx for testicular cancer?

Inguinal orchidectomy Check out LN - radio if needed RPLND (Retroperitoneal lymph node dissection) Chemo - BEP - 3 cycles

What is the most common type of penile cancer?

SCC Most commonly from the epithelium of the inner prepuce or glans

What is the peak incidence of penile cancer?

75-90

What are the RFs for penile cancer?

HPV - 50% Multiple sexual partners Early age of intercourse Phimosis (chronic infection) Penile Intraepithelial Neoplasia Smoking Low economic status / rural area

When should you think about penile cancer?

If there are lesions which do not respond to a course of topical steroids or ABx

What are the S&S of penile cancer?

Penile mass Pain Groin mass Skin changes Ulceration Palpable lymph nodes

What's the prognosis of penile cancer?

80% cure rate 10YS = 68% Nodal disease - 5YS = 27%

What investigations are done for penile cancer?

Biopsy MRI Staging CT Sentinel LN excision

What is the Rx for penile cancer?

Local excision and reconstruction ILND (Inguinal Lymph Node Dissection) Radiotherapy Chemotherapy