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Urology > Cancer > Flashcards

Cancer Flashcards

1
Q

How does penile cancer present (6)

A

Palpable/ulcerating (fungating) lesion on the penis with rolled edge, mast commonly on the glans.

Usually painless but may discharge/bleed.

Not responding (4 weeks) to STD rx.

Early present as ulcer, later cauliflower appearance,late auto- amputation.

Long-standing phimosis with discharge+ palpable lump under foreskin

Inguinal lymphadenopathy in 30-60%

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2
Q

Diagnosis of penile cancer

A

Biopsy any suspicious lesion and send for histology.

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3
Q

Diagnosis of lump in scrotum

A

Testicular cancer until proven otherwise

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4
Q

Testicular cancer incidence in which populations (2)

A

Ages 20-40

White

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5
Q

Which lymph nodes associated with testicular cancer

A

Para- aortic lymph nodes

NOT inguinal unless invasion of tunica albuginea

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6
Q

What is a Neuroblastoma?

A

Non-cancerous flank mass

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7
Q

Name 6 possible etiologies penile cancer

A
  • Presence foreskin → smegma → chronic irritation
  • hpv 16, 18
  • pre-malignant conditions: cis - red, velvety lesion on glans
  • BXO / lichen sclerosis et atrophicus: White plaque
  • leukoplakia
  • condyloma acuminata
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8
Q

Most common type of penile cancer?

A

Squamous cell carcinoma > 90%

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9
Q

How does penile cancer spread? (3)

A
  • Local spread: foreskin → glans → penile shaft → urethra → Buck’s fascia (barrier to corporeal invasion there low incidence haematogoneous metastasis)
  • lymphatic:
  • early spread to superficial and deep inguinal lymph nodes
  • advanced disease to inguinal nodes: skin involvement (ulceration) or femoral vessels (haemorrhage)
  • Iliac node involvement via Cloquet’s node (deep inguinal node in femoral canal)

• haematogenous: rare. Usually lung metastasis

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10
Q

Treatment of penile carcinoma in situ? (red, velvety lesion on glans) (2)

A
  • 5-fluorouracil cream

* laser treatment

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11
Q

Treatment of BXO / lichen sclerosis et atrophicus? (3)

A
  • Circumcision
  • local excision of lesion on glans
  • reconstructive surgery for urethral strictures
  • steroid cream
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12
Q

At what age should prostate cancer be screened for routinely?

A

All men from 45

African men and men with first degree relatives from 40

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13
Q

Name 5 risk factors prostate cancer

A

• Genetic predisposition
- BRCA 1 and 2, HOX B1
-First degree relative 2x risk and earlier onset
• age: > 50, risk increase 1% per year after 65
• black Africans
• diet high in animal fat 2x risk
• androgens

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14
Q

Where does prostate cancer arise?

A

Peripheral zone

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15
Q

Where does BPH arise?

A

Transitional zone

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16
Q

Most common type prostate cancer?

A

Adenocarcinoma ( rarely urothelial cell carcinoma or sarcoma)

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17
Q

Which Gleason score and PSA is low risk mortality /well differentiated? Stage?

A

≤ 6

PSA <10

Stage t1-t2 a

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18
Q

Which Gleason score and PSA is intermediate risk / moderately differentiated? Stage?

A

Intermediate favourable: 7=3+4
Intermediate unfavourable: 7=4+3

PSA 10-20

Stage t2b-c

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19
Q

Which Gleason score and PSA is high-very high risk / poorly differentiated? Stage?

A

High risk: 8
Very high: 9-10

PSA >20

T3-4

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20
Q

Symptoms prostate cancer? (6)

A
  • Mostly incidental, asymptomatic.
  • LUTS
  • complications of bladder outflow obstruction, kidney failure
  • haematuria or haemospermia (uncommon)
  • metastasis: bone pain , weight loss, anaemia, lymphoedema, paraplegia)
  • ED
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21
Q

Rectal exam findings of organ-confined prostate cancer?

A
  • Palpable normal prostate with increased psa- diagnosis made on multiple biopsies
  • clinical BPH with nodule or hard area palpable in one or both lobes
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22
Q

Rectal exam findings of advanced non- organ-confined prostate cancer?

A
  • Enlarged, hard, irregular
  • edge poorly defined (indicate extracapsular spread )
  • overlying rectal mucosa intact ( differentiate from rectal carcinoma)
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23
Q

How diagnose prostate cancer?

A

Biopsy!
• use TRUS probe to space biopsies evenly through prostate and biopsy suspicious hypo-echoic areas
• take at least 6 biopsy cores
• antibiotic cover to prevent bacteraemia and septicaemia after transrectal biopsy
• may have rectal bleed or haematuria after procedure

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24
Q

Staging prostate cancer?

A 
TNM
Tumour by rectal exam, TRUS
• Tx: primary Tumour can't be assessed
• To: no evidence
• T1: clinically undetectable, normal DRE and TRUS.
-A: incidental histologic finding in < 5% of tissue resected
-B : > 5%
- c: identified by needle biopsy due to elevated PSA
• T2: palpable, confined to prostate
- a: involve ≤ 1/2 of 1 lobe
-B: > 1/2 of 1 lobe
- c: both lobes
• T3: extend through prostate capsule
-A: extracapsular extension
-B: invading seminal vesicles
• T4: invades adjacent structures besides seminal vesicles

Iliac Nodes by CT (unreliable), or pelvic lymph node dissection
• Nx : not assessed
• No: no metastasis
• N1: regional lymph nodes

Metastasis by xray isotope bone scan
• Mo: no distant metastasis
• cM1: distant metastasis and pM1: distant metastasis microscopically confirmed
- a: nonregional lymph nodes
-B: bone
- c: other sites with or without bone disease

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25
Q

Where does prostate cancer metastasize?

A

Bone most commonly

Visceral less common, but often to liver, lung, adrenals

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26
Q

How does prostate cancer spread? (3)

A
  • Local invasion
  • lymph: obturator > iliac > presacral/para-aortic
  • haematogenous dissemination occurs early
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27
Q

Management of t1-2 No Mo prostate cancer with PSA <10 and Gleason <7?

A
  • Life expectancy >10 years
  • active surveillance for Gleason < 6 young and healthy - patient more likely to die of other cause. Treatment of advancement and symptomatic
  • watchful waiting for elderly or infirm
28
Q

Management of t1-2 No Mo prostate cancer with PSA > 10 and Gleason ≥ 7?

A

• Life expectancy <10 years (intermediate to high risk)
• radical treatment indicated, potentially curative:
- radical prostatectomy and
- external beam or brachytherapy

29
Q

Management of t3-4 or > No > Mo prostate cancer? (8)

A

• Patients not curable. High risk mortality. Palliation indicated
• ADT first line (80% hormone sensitive):
- GnRH lhrh analogues eg buserelin, goserelin, leuprorelin, triptorelin
- bilateral orchidectomy decrease testosterone production by 90%
-Oestrogens (not great options cardiovascular complications )
- anti-androgens eg flutamide, bicalutamide
- GnRH antagonist eg degarelix
• palliative TURP to relieve bladder outlet obstruction
• palliative radiotherapy for bone pain relapses
• for hormone refractory cancer:
-Chemotherapy: docetaxel, cabazitaxel
- novel antiandrogens : abiraterone, enzalutamide
- other novel agents: denosumab, sipuleucel T

30
Q

Define watchful waiting

A

Done when short life expectancy < 5-10 years

Will likely only receive non - curative hormonal therapy if disease progresses

31
Q

Define active surveillance

A
  • Serial PSA, dre and biopsies done
  • low grade disease
  • curative treatment if disease progress
32
Q

What is brachytherapy and how is it given?

A

• Radio- active seeds inserted through needles in perineum under TRUS control into prostate, single session
• Expensive, same efficacy as external beam
. Usually given to low volume, low PSA <10, low grade

33
Q

Complication brachytherapy?

A
  • Transient irritative voiding symptoms, may last months

* ED 50%

34
Q

How is external beam radiotherapy administered for prostate cancer?

A
  • Total dose given in small fractions over 6-7 weeks

* usually given to locally advanced disease, older pts

35
Q

Name 3 complications external beam radiotherapy

A
  • ED 50 %!
  • radiation proctitis
  • transient irritative bladder symptoms
  • risk rectal cancer
36
Q

Name 5 signs of spinal cord compression from prostate cancer

A

Emergency!
•Bone pain often precedes
• paraparesis → complete paraplegia
• sensory loss
• urinary retention late sign
• osteosclerotic metastases visible on xray
• MRI useful to determine level of spinal cord compression

37
Q

Treatment spinal cord compression from prostate cancer? (3)

A

• High dose dexamethasone to reduce swelling
. Urgent castration: medical ketoconazole and oestrogens or bilateral orchidectomy
• radiation to spinal cord if previous hormone therapy

38
Q

Where does renal cell carcinoma arise?

A

Proximal convoluted tubule epithelial cells in clear cell subtype most commonly

39
Q

Name 8 risk factors RCC

A
  • Smoking
  • ht
  • obesity!
  • Acquired renal cystic disease esp on dialysis
  • male
  • Age 50-75
  • end stage renal disease
  • hereditary: Von hippel- Lindau disease (bilat) and hereditary papillary renal carcinoma
  • horseshoe kidney
  • possibly environmental exposures eg aromatic hydrocarbons
40
Q

Spread of RCC? (4)

A

• Local: perinephric fat and fascia → adrenal → post abdominal wall → viscera
• lymphatic: hilar → para aortic → mediastinal → supra clavicular
. Haematogenous: lung, liver, bone, brain
. Grow along veins: Renal vein → IVC → right atrium (lause ascites, hepatic dysfunction, right atrial tumour, pulmonary emboli)

41
Q

Clinical presentation RCC?

A
  • asymptomatic or non-urological symptoms, > 50% diagnosed incidentally by US or CT
  • urological “too late” triad in 10-15%: gross haematuria 50%, flank pain <50%, palpable mass <30%
  • endocrine: hypercalcaemia, polycythaemia (high red cells)
  • vascular: ht in 40%, DVT, varicocoele ! (venous drainage compression leading to dilatation veins), oedema of lower limbs (blocked IVC ), high output congestive cardiac failure (metastasis)
  • “toxin “ production: anaemia, pyrexia, neuropathy/myopathy, non-metastatic hepatopathy (abnormal liver function)
  • git: anorexia, weight loss, abdo pain non- specific
  • metastases 30% at presentation: bone (pain), brain (neuro symptoms), lung (dyspnoea), liver.

(Paraneoplastic syndrome)

42
Q

Investigations of suspect RCC? (7)

A
  • FBC, ESR, LFT (metastasis), UCE
  • Ultrasound mass: either simple cyst or renal tumour (solid mass)- irregular, poorly circumscribed border, internal echoes or variable echogenicity (hyper-echoic), no post wall signal enhancement
  • CT for staging
  • renal biopsy to confirm diagnosis if considering observation or other non-surgical therapy
  • MRI for vascular extension in IVC can be done to plan surgery
  • CXR for lung metastasis, isotope bone scan for mets
  • can consider genetic testing if: family history Von hippel Lindau syndrome, bilat or multifocal tumour, onset ≤ 45, family history renal tumour, any renal tumour with history pneumothorax, childhood seizure disorder, dermatologic findings, associated tumours…
43
Q

Treatment RCC? (6)

A

• Surgery = only effective rx

  • Radical rephrectomy (kidney, adrenals, perinephric fat, para-aortic nodes) if no metastasis
  • Heminephrectomy (nephron-sparing) if small <4cm incidental lesion, bilat tumours, poor total renal function or tumour in solitary kidney
  • If heminephrectomy not possible, do unilateral or bilateral nephrectomy → dialysis → renal transplant

• immunotherapy for metastasis
- interleukin 2 (very toxic) or interferon alpha. Modest response.

  • others for metastasis: tyrosine kinase inhibitors eg sunitinib, sorafenib; anti-angiogenesis / anti- VGF eg bevacizumab; MTOR inhibitors eg temsirolimus, everolimus
  • renal unitary embolization in advanced disease and severe bleeding

Chemo and radiation ineffective!

44
Q

Staging RCC?

A 
Tumour
• t1: < 7 cm, confined to renal parenchyma
- a: <4cm
- B: 4-7 cm
• T2: > 7 cm, confined
-A: 7-10cm
- b: > 10cm
• T3: extends into major veins or perinephric tissue, but not into ipsilateral adrenal or beyond gerotas fascia
- a: into renal vein or sinus fat
-B: into infra diaphragmatic IVC
-C: supra-diaphragm IVC
• T4: extend beyond Gerota's fascia including extension into ipsilateral adrenal

Nodes
. N1: single node, <2 cm
• N2: single node 2-5 cm or multiple <2cm
• n3: node >5cm

Metastasis
M1: distant metastasis

45
Q

Classification bladder cancer? (4)

A

Epithelial tumours
. Transitional cell carcinoma 90%
• SCC 5%
• adenocarcínoma

Connective tissue
• rhabdomyosarcoma of bladder wall-rare

46
Q

Second most common uro cancer?

A

Bladder

47
Q

Name 7 risk factors urothelial bladder carcinoma

A

• Smoking! Most prevalent.
• industrial carcinogens: aromatic amines. Dry cleaning chemicals, rubber (naphthylamines), printing (benzidine), dye (naphthylamines), petroleum, leather
• drugs
- analgesic abuse
-Cyclophosphamide (chemo)
• pelvic irradiation pelvis
• schistosoma hematobium (bilharzia): SCC
• chronic irritation:cystitis, chronic catheterization, bladder stones (SCC)
• aristolochic acid herbal medication for gout, arthritis: Balkan nephropathy and Chinese herbal nephropathy
• male
• old age

48
Q

Stages of urothelial carcinoma

A

Carcinoma in situ
• Flat, non-papillary erythematous lesion characterised by dysplasia confined to urothelium, may look normal on cystoscopy
• Highly malignant, high potential invasion and metastasis, worse prognosis, multi-focal

Papillary lesions non-muscle invasive 75%
• exophytic, papillary with narrow stalk confined to urothelium.
• often multiple because of “field of change”- predisposed to malignancy including prostatic urethra and upper tracts; progression rate 10-15%
• recurrence 50-75%
•. Good prognosis > 80% survival- malignant cells don’t come into contact with blood vessels or lymphatics

Non-papillary invasive sessile lesions 25%
• solid or ulcerated, may have necrosis
. usually high grade, poorly differentiated
•Most patients will develop overt metastasis in 1 year - lymph nodes (iliac → para-aortic), lung, peritoneum, liver (haematogenous)

49
Q

Clinical presentation bladder cancer? (5)

A
  • 20% asymptomatic
  • painless haematuria = bladder cancer until proven otherwise
  • irritative storage voiding symptoms: consider cis.
  • 50% pain suggesting advanced disease
  • metastasis : dyspnoea, bone pain
  • clot retention
  • palpable mass on bimanual exam - likely muscle invasion
  • ureter obstruction → hydronephrosis, uremia (nausea, vomiting, diarrhea)
50
Q

Special investigations bladder cancer? (5)

A

• FBC, ue, creatinine
• urine MCS, cytology : positive cytology usually high grade malignancies like cis. Non invasive tumours usually negative because well differentiated
• Ultrasound: mass, hydronephrosis
• cystoscope with biopsy! Gold standard
• CT with contrast: filling defects, lymph staging
. Bladder Tumour markers: nmp-22, BTA, immunocyt, fdp), EUG (filling defect, ureter obstruction)

51
Q

Name 8 differentials for filling defect in bladder

A 
•Bladder tumour, esp TCC
• blood clot
. Bladder stone esp uric acid 
• prostate (middle lobe)
• foley catheter balloon
• overlying bowel gas
• foreign body
• fungus ball (rare)
52
Q

Treatment cis bladder?

A

Intravesical immunotherapy BCG TB weekly for 6 weeks

  • if successful maintenance BCG every 3 months for 3 years
  • unsuccessful: radical cystectomy
53
Q

Treatment superficial papillary lesions of bladder (T1 invasion of lamina propria only)

A
  • Complete TURBT or diathermy (fulguration) and BCG after each one → follow up cystoscope every 3 months and repeat TURBT
  • cystectomy if extensive multiple recent tumours despite treatment or evidence of muscle invasion at follow-up
54
Q

Treatment muscle invasive t2-3 bladder cancer?

A
  • Radical cystectomy if no metastasis and pelvic lymph node dissection. Include prostatectomy in males and hysterectomy in females ; urinary diversion usually with ileal conduit bricker diversion
  • if single tumour on dome: partial cystectomy (rarely met)
  • radical radiotherapy “second best”
  • post op adjuvant chemotherapy if advanced local disease or lymph involve
55
Q

Staging bladder cancer?

A

Tumour
• ta: non-invasive papillary carcinoma, urothelium and on basement membrane
• Tis : carcinoma in situ, “flat tumour” in urothelium
• t1: invades subepithelial connective tissue into basement membrane
• T2 : invades muscularis lamina propria
-A : invade superficial inner half
-B : Deep outer half
• t3: invade perivesical tissue - Adventitia (fat)
- a: microscopic
-B : macroscopic extravesical mass
• t4: invades outside bladder
-A : prostatic stroma, uterus, vagina, seminal vesicles
-B : pelvic or abdominal wall

Nodes
• n 1: single regional lymph node in true pelvis (hypogastric, obturator, external iliac, presacral)
• n2: multiple in true pelvis
• n3: common iliac lymph nodes

Metastasis
• m 1
-A :. limited to lymph nodes beyond common iliac
- b: distant

56
Q

Treatment muscle invasive advanced t4 or N1 or metastatic M1 disease? (4)

A

Palliative, treat symptoms
• haematuria: cystoscope and fulgaration (diathermy), intravesical alum or formalin, palliative radiotherapy
• severe irritative symptoms: anticholinergs eg oxybutinin, tolterodine; urinary diversion (bricker ileal conduit preferred)
• local pain: palliative radiotherapy
• uraemia due to bilat ureteric obstruction: percutaneous nephrostomy or double J stents if indicated

57
Q

Etiology and causes SCC bladder? (5)

A

Chronic irritation → metaplasia urothelium → squamous cell epithelium
• schistosomiasis haematobium! (Bilharzia)
• bladder calculus
• recurrent UTI
• long term indwelling catheter or other foreign bodies

58
Q

Treatment SCC bladder? (2)

A

• Radical cystectomy if operable ( most present late , poor prognosis )
. Palliative radiotherapy for bleeding
No effective chemo

59
Q

Classification and causes bladder adenocarcinoma? (8)

A

Primary (rare)
• urachal (umbilicus) carcinoma
• secondary to cystitis cystica
• untreated bladder exstrophy

Secondary to adenocarcinoma elsewhere, bladder involved
• prostate
• sigmoid colon!
• rectum
• Uterus
• stomach
60
Q

Symptoms bladder adenocarcinoma? (3)

A
  • Haematuria
  • irritative symptoms
  • mucus in urine
61
Q

Treatment bladder adenocarcinoma?

A

Must exclude other adenocarcinoma - as most are secondary

If primary: radical cystectomy and excision urachus and umbilicus in cases of urachal carcinoma

62
Q

How is intravesical bcg used?

A
  • Solution: dissolve freeze dried powder with diluent in package
  • further distill with saline, total volume 30ml
  • use within 2-3h
  • instill into bladder via small catheter by gravity, slow drip, not forced
  • retain solution in bladder for 2h then void
  • move position every 30-45 min
  • repeat weekly for 6 weeks
  • if successful, maintenance every 3 months for 3 years. If not, radical cystectomy
63
Q

What is intravesical bcg used for?

A

(Bacille calmette guerin)
Primary therapy for urothelial cis Tis
Adjuvant therapy for recurrent high grade superficial papillary lesions t 1

64
Q

Name 5 urological cancers that may metastasize to lungs

A
  • RcC (most common)
  • prostate
  • testicular
  • scc bladder
  • scc penis
  • malignant melanoma
  • colorectal carcinoma
65
Q

Second most common cancer genitourinary tract?

A

Urothelial carcinoma of the bladder

66
Q

Name causes Virchow’s (left supraclavicular) node (7)

A
  • Testicular cancer
  • ovarian
  • kidney
  • pancreas
  • prostate
  • stomach
  • gallbladder

Urology (18 decks)

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