17) Malignancy of Urinary Tract

Question 1

What is the most common cancer in men?

Answer 1

Prostate cancer

Question 2

Are those with prostate cancer likely to die form it?

Answer 2

No

Question 3

What are some risk factors for prostate cancer?

Answer 3

Increasing age
Family history
Ethnicity

Question 4

What ethnicities are more at risk of developing prostate cancer?

Answer 4

Black > White > Asian

Question 5

What is meant by a family history of prostate cancer?

Answer 5

If 1st degree relative diagnosed before 60

BRCA2 gene mutation

Question 6

What screening programmes are available for prostate cancer?

Answer 6

Opportunistic if patients are counselled and present with urinary symptoms

Question 7

What are some issues with screening?

Answer 7

Overdiagnosis
Overtreatment
Cost effectiveness
Serum PSA can be raised in infection, inflamm and hyperplasia of prostate

Question 8

How does prostate cancer present?

Answer 8

Asymptomatic (majority)
Enlargement of prostate, bladder overactivity
Bone pain - metastasis to bone and LN

Question 9

If prostate cancer is advanced what other symptom may be seen?

Answer 9

Haematuria

Question 10

In what ways can prostate cancer be diagnosed?

Answer 10

Digital rectal exam
Serum PSA (prostate specific antigen)
Lower urinary tract symptoms

Question 11

Why and how is a biopsy of the prostate carried out?

Answer 11

If needed after DRE or serum PSA

Transrectal ultrasound guided biopsy

Question 12

What is carried out if prostate cancer is suspected from lower urinary tract symptoms?

Answer 12

Transurethral resection of prostate - cutting away small bits of prostate to relive symptoms

Question 13

What factors affect treatment decisions of prostate cancer?

Answer 13

Age
T stage by DRE
PSA level
Gleason Grade - biopsy 
MRI and bone scan for metastasis

Question 14

Describe the T stages obtained by DRE:

Answer 14

T1/2 - Localised
T3 - Locally advanced, nodules
T4 - Advanced, hard with smooth surface due to nodules coalescing

Question 15

What treatment is there for localised prostate cancer?

Answer 15

Surveillance - treatment may do more damage
Radical prostatectomy
Radiotherapy

Question 16

What is a radical prostatectomy?

Answer 16

Removal of part of all of the prostate

Question 17

What treatment is there for locally advanced (T3) prostate cancer?

Answer 17

Surveillance

Hormones +/- radiotherapy

Question 18

What treatment is there for metastatic prostate cancer?

Answer 18

Surgical castration
Medical castration - LHRH agonists
Palliation - radio, chemo, bisphosphonates

Question 19

How do LHRH agonists work?

Answer 19

Firstly stimulate testosterone but after a week cause decrease in normal LHRH so decrease in LH and testosterone, therefore, slow growth of prostate and cancer cells

Question 20

Describe bone metastasis in prostate cancer and how they can be spotted:

Answer 20

They are sclerotic (osteoblastic)

Spotted as hot spots on bone scan

Question 21

What is non-visible haematuria?

Answer 21

Seen on dipstick or microscopy

Question 22

State some causes of haematuria:

Answer 22

Renal cell carcinoma
Bladder cancer 
Advanced prostate cancer
Stones
Infection
Inflamm
Glomerular diseases

Question 23

What examinations would you do if haematuria was present?

Answer 23

BP
Abdominal mass
Varicocele - veins in scrotum
Leg swelling 
DRE

Question 24

What tests and investigations would you carry out if haematuria was present?

Answer 24

FBC
Urine culture
Flexible cystoscopy
Ultrasound

Question 25

What type of cancer are most bladder cancers?

Answer 25

Transitional cell carcinoma

Question 26

What are some risk factors for bladder cancer?

Answer 26

Smoking Occupational exposure - rubber, plastic, hydrocarbons, paints and dyes (Schistosomiasis)

Question 27

What two stages of bladder cancer are there?

Answer 27

Superficial and muscle invasive

Question 28

What treatment is there for high risk non-muscle invasive bladder cancer?

Answer 28

Cystoscopy, intravesical chemotherapy

Question 29

What treatment is there for low risk non-muscle invasive bladder cancer?

Answer 29

Cystoscopy +/- intravesical chemotherapy

Question 30

What treatment is there for muscle invasive bladder cancer?

Answer 30

Neoadjuvant chemo + radical cystectomy or radiotherapy | or Palliative chemo/radiotherapy

Question 31

What is a radical cystectomy?

Answer 31

Removal of bladder (womb and ovaries). Ileum may be used to make a channel for ureters and urine collected in bag. May attempt to reconstruct bladder from intestine

Question 32

What cancer causes most upper urinary tract tumours?

Answer 32

Renal cell carcinoma

Question 33

What are risk factors for RCC?

Answer 33

Smoking, obesity, dialysis

Question 34

Where can RCC spread?

Answer 34

Perinephric fat Lymph node IVS to right atrium

Question 35

What treatment is there for localised RCC?

Answer 35

Surveillance Radical or partial nephrectomy Ablation - erosive process removing tumour

Question 36

What is a radical nephrectomy?

Answer 36

Removal of kidney, adrenal, surrounding fat and upper ureter

Question 37

What treatment is there for metastatic RCC?

Answer 37

Palliative - molecular therapies targeting angiogenesis

Question 38

What is the other causes of upper urinary tract malignancy?

Answer 38

Upper tract transitional cell carcinoma

Question 39

What are risk factors for upper tract TCC?

Answer 39

Smoking, phenacetin abuse, Balkan's nephropathy

Question 40

What percentage of UUT cancers spread up from bladder?

Answer 40

5%

Question 41

What percentage of UUT cancers spread to bladder?

Answer 41

40%

Question 42

What investigations can you use in upper tract TCC?

Answer 42

Ultrasound - hydronephrosis CT urogram Retrograde pyelogram Ureteroscopy - biopsy

Question 43

What treatment is there for upper tract TCC?

Answer 43

Nephro-ureterctomy - removal of kidney, fat, ureter and cuff of bladder

Question 44

What is hydronephrosis?

Answer 44

Swelling of kidney due to urine back up