Cancer Flashcards
(66 cards)
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%
2
Q
Diagnosis of penile cancer
A
Biopsy any suspicious lesion and send for histology.
3
Q
Diagnosis of lump in scrotum
A
Testicular cancer until proven otherwise
4
Q
Testicular cancer incidence in which populations (2)
A
Ages 20-40
White
5
Q
Which lymph nodes associated with testicular cancer
A
Para- aortic lymph nodes
NOT inguinal unless invasion of tunica albuginea
6
Q
What is a Neuroblastoma?
A
Non-cancerous flank mass
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
8
Q
Most common type of penile cancer?
A
Squamous cell carcinoma > 90%
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
10
Q
Treatment of penile carcinoma in situ? (red, velvety lesion on glans) (2)
A
- 5-fluorouracil cream
* laser treatment
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
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
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
14
Q
Where does prostate cancer arise?
A
Peripheral zone
15
Q
Where does BPH arise?
A
Transitional zone
16
Q
Most common type prostate cancer?
A
Adenocarcinoma ( rarely urothelial cell carcinoma or sarcoma)
17
Q
Which Gleason score and PSA is low risk mortality /well differentiated? Stage?
A
≤ 6
PSA <10
Stage t1-t2 a
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
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
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
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
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)
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
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
25
Where does prostate cancer metastasize?
Bone most commonly
| Visceral less common, but often to liver, lung, adrenals
26
How does prostate cancer spread? (3)
* Local invasion
* lymph: obturator > iliac > presacral/para-aortic
* haematogenous dissemination occurs early
27
Management of t1-2 No Mo prostate cancer with PSA <10 and Gleason <7?
* 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
Management of t1-2 No Mo prostate cancer with PSA > 10 and Gleason ≥ 7?
• Life expectancy <10 years (intermediate to high risk)
• radical treatment indicated, potentially curative:
- radical prostatectomy and
- external beam or brachytherapy
29
Management of t3-4 or > No > Mo prostate cancer? (8)
• 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
Define watchful waiting
Done when short life expectancy < 5-10 years
| Will likely only receive non - curative hormonal therapy if disease progresses
31
Define active surveillance
* Serial PSA, dre and biopsies done
* low grade disease
* curative treatment if disease progress
32
What is brachytherapy and how is it given?
• 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
Complication brachytherapy?
* Transient irritative voiding symptoms, may last months
| * ED 50%
34
How is external beam radiotherapy administered for prostate cancer?
* Total dose given in small fractions over 6-7 weeks
| * usually given to locally advanced disease, older pts
35
Name 3 complications external beam radiotherapy
* ED 50 %!
* radiation proctitis
* transient irritative bladder symptoms
* risk rectal cancer
36
Name 5 signs of spinal cord compression from prostate cancer
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
Treatment spinal cord compression from prostate cancer? (3)
• High dose dexamethasone to reduce swelling
. Urgent castration: medical ketoconazole and oestrogens or bilateral orchidectomy
• radiation to spinal cord if previous hormone therapy
38
Where does renal cell carcinoma arise?
Proximal convoluted tubule epithelial cells in clear cell subtype most commonly
39
Name 8 risk factors RCC
* 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
Spread of RCC? (4)
• 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
Clinical presentation RCC?
* 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
Investigations of suspect RCC? (7)
* 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
Treatment RCC? (6)
• 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
Staging RCC?
```
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
Classification bladder cancer? (4)
Epithelial tumours
. Transitional cell carcinoma 90%
• SCC 5%
• adenocarcínoma
Connective tissue
• rhabdomyosarcoma of bladder wall-rare
46
Second most common uro cancer?
Bladder
47
Name 7 risk factors urothelial bladder carcinoma
• 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
Stages of urothelial carcinoma
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
Clinical presentation bladder cancer? (5)
* 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
Special investigations bladder cancer? (5)
• 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
Name 8 differentials for filling defect in bladder
```
•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
Treatment cis bladder?
Intravesical immunotherapy BCG TB weekly for 6 weeks
- if successful maintenance BCG every 3 months for 3 years
- unsuccessful: radical cystectomy
53
Treatment superficial papillary lesions of bladder (T1 invasion of lamina propria only)
* 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
Treatment muscle invasive t2-3 bladder cancer?
* 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
Staging bladder cancer?
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
Treatment muscle invasive advanced t4 or N1 or metastatic M1 disease? (4)
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
Etiology and causes SCC bladder? (5)
Chronic irritation → metaplasia urothelium → squamous cell epithelium
• schistosomiasis haematobium! (Bilharzia)
• bladder calculus
• recurrent UTI
• long term indwelling catheter or other foreign bodies
58
Treatment SCC bladder? (2)
• Radical cystectomy if operable ( most present late , poor prognosis )
. Palliative radiotherapy for bleeding
No effective chemo
59
Classification and causes bladder adenocarcinoma? (8)
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
Symptoms bladder adenocarcinoma? (3)
* Haematuria
* irritative symptoms
* mucus in urine
61
Treatment bladder adenocarcinoma?
Must exclude other adenocarcinoma - as most are secondary
| If primary: radical cystectomy and excision urachus and umbilicus in cases of urachal carcinoma
62
How is intravesical bcg used?
* 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
What is intravesical bcg used for?
(Bacille calmette guerin)
Primary therapy for urothelial cis Tis
Adjuvant therapy for recurrent high grade superficial papillary lesions t 1
64
Name 5 urological cancers that may metastasize to lungs
* RcC (most common)
* prostate
* testicular
* scc bladder
* scc penis
* malignant melanoma
* colorectal carcinoma
65
Second most common cancer genitourinary tract?
Urothelial carcinoma of the bladder
66
Name causes Virchow's (left supraclavicular) node (7)
* Testicular cancer
* ovarian
* kidney
* pancreas
* prostate
* stomach
* gallbladder
