Renal, Testicular and Penile Cancer

Question 1

what are the three main types of benign renal tumours

Answer 1

simple cysts
angiomyolipoma
oncocytoma

Question 2

who gets angiomylipoma

Answer 2

80% sporadic in middle aged females

20% associated with tuberous sclerosis

Question 3

what are the features of tuberous sclerosis

Answer 3

autosomal dominant 
mental retardation 
epilepsy 
adenoma sebaceum 
hamartomas 
80% develop angiomyolipoma

Question 4

what is the pathology of an angiomyolipoma

Answer 4

blood vessels, immature smooth muscle and fat

Question 5

what is the presentation of an angiomyolipoma

Answer 5

50% found incidentally 
loin pain 
haematuria 
mass 
10% wunderlichs syndrome= massive retroperitoneal bleed

Question 6

what investigations for an angiomyolipoma

Answer 6

USS (bright echo pattern)

CT (fatty tumour of low density)

Question 7

what is the treatment for an angiomyolipoma

Answer 7

> 4cm in considered to be removed as can spontaneously bleed when they reach this size
elective- embolisation/ partial nephrectomy
emergency- embolisation/ emergency nephrectomy

Question 8

what is the pathology of an oncocytoma

Answer 8

spherical, capsulation, brown/ tan colour, has central scar, not know to metastasise
difficult to differentiate radiologically from an RCC

Question 9

what is the histology of an oncocytoma

Answer 9

aggregates of eosinophils, similar to chromophobe RCC

Question 10

what is the presentation of an oncocytoma

Answer 10

95% incidental
loin pain
haematuria
CT scan- spoke wheel pattern

Question 11

what is the treatment for an oncocytoma

Answer 11

partial nephrectomy (doesn’t metastasise but hard to differentiate from RCC)

Question 12

what are the most common types of malignant renal cancers

Answer 12

renal cell carcinoma
transitional cell carcinoma
lymphoma

Question 13

what are the types of renal cell carcinomas

Answer 13

clear cell (80%)
papillary (10-15%)
chromophobe (5%)
collecting duct
meduallary

Question 14

what is a renal cell carcinoma

Answer 14

adenocarcinoma of the renal cortex- arises from the proximal convoluted tubules

can be solid/ complex cystic

Question 15

what do renal cell carcinomas look like

Answer 15

tan colours
lobulated
solid
10-25% contain cysts

Question 16

what gene predisposes you to clear cell carcinoma

Answer 16

loss of von hipple lindau (VHL) gene on chromosome 3

VHL syndrome (AD)- 50% get RCC, loss of both copies of a tumour suppressor gene at chromo 3p25

Question 17

what are 40%of papillary renal cancers

Answer 17

multifocal

Question 18

what are collecting duct renal cell carcinomas like

Answer 18

rare, affects young patients, poor prognosis

Question 19

what are medullary renal cell carcinomas like

Answer 19

rare, affects young sickle cell patients, very poor prognosis

Question 20

how do you grade and stage renal cell cancer

Answer 20

Grading 1-4

staging:
T1 upto 7cm
T2 >7cm confined to kidney T3 extends beyond kidney into renal vein, perinephric fat, renal sinus, IVC (more common on right as shorter renal vein)
T4 beyond gerotas fascia into surrounding fascia

Question 21

what is the most lethal of the urological cancers

Answer 21

renal cell carcinoma

Question 22

who gets renal cell carcinoma

Answer 22

M5:F1
smoking 
renal failure and dialysis 
obesity 
hypertension 
low SE status 
asbestos 
cadium exposure 
phenacetin 
VHL syndrome

Question 23

what is the presentation of renal cell carcinoma

Answer 23

haematuria 
loin pain 
mass 
(<10% have all three of these symptoms together) 
pryexia of unknown origin
varicocoele (dilates veins around the testes- more common on left testes, tumour blocks the left gonadal vein)
paraneoplastic syndrome in 30%
common to find tumours incidentally

Question 24

what paraneoplastic syndromes are seen in renal cancers

Answer 24

30% anaemia (haematuia, chronic disease)
5% polycythaemia (erythtopoetin)
25% hypertension (renin, renal artery compression)
hypoglycaemia (insulin)
cushings (ACTH)
10-20% hypercalcaemia (PTH like substance)
gynaecomastia, amenorrhoea, reduced libido, baldness (gonadotrophins)
stauffers syndrome (fever, anorexia, abnormal LFTs)

Question 25

what investigations for a renal carcinoma

Answer 25

USS CT chest abdo and pelvis for staging FBCs, renal and liver function tests

Question 26

what is the treatment for a renal cell carcinoma

Answer 26

small tumour <3cm- surveillance in elderly unfit patients ablation in fit elderly or young unfit >3cm- partial nephrectomy, robotic technique, radical nephrectomy if young and other kidney working well large tumours- radical nephrectomy, laparoscopic approach gold standard follow up= FBC, renal and liver function tests, imaging CT/USS + CSR for 5-10 years (different imaging each year to minimise radiation)

Question 27

who gets testicular cancer

Answer 27

(most common solid tumour in) men 20-45 white caucasians in europe and USA previous testicular cancer (increases risk for contralateral testes) cryptorchidism (orchidopexy before 13 years of age 2 fold increase, orchidoplexy after 13 5 fold increase) HIV FHx

Question 28

what are the types of testicular cancer

Answer 28

seminomatous 42% non seminomatous 48% mixed germ layer

Question 29

what is the presentation of tescticular cancer

Answer 29

scrotal lump delayed presentation occasionally seen 5% acute bleeding 10% symptoms of advanced disease (inc weight loss, neck lumps, chest symptoms, bone pain)

Question 30

what is seen on exam in testicular cancer

Answer 30

``` asymmetry slight scrotal discolouration examine normal side first hard non tender irregular mass mostly intratesticular assess involvement of the epididymis, spermatic chord and scortal skin secondary hydrocoele ``` abdo mass= advanced disease (mets to paraaortic lymph nodes)

Question 31

what investigations for testicular cancer

Answer 31

USS testical CT chest abdo and pelvis for staging bloods- serum tumour markers (alpha feto protein, B-HCG, LDH), FBCs, LFTs, renal function tests

Question 32

what is the treatment for renal cancer

Answer 32

radical inguinal orchidectomy (dont go scrotal route as will expose new path to cancer) offer sperm preservation and testicular prosthesis recheck tumour markers if raised pre op CT scan, oncology follow up (can have chemo as adjuvant treatment)

Question 33

what are the types of penile cancer

Answer 33

``` 95% squamous cell cancer kaposis sarcoma basal cell carcinoma MM sarcoma (in HIV) ``` (all skin cancers)

Question 34

who gets penile cancers

Answer 34

``` 5th - 6th decade 40% have pre malignant conditions (fibrosis) phimosis (chronic inflammation) asia, africa, south america HPV types 16 and 18 smoking immunocompromised patients ``` (circumcision has a protective effect)

Question 35

where go you get penile cancers

Answer 35

``` glans 48% prepuce 31% glans and prepuse 9% coronal sulcus 6% shaft 2% ```

Question 36

what is the presentation of penile cancer

Answer 36

hard painless lump 15-59% delayed presentation for >1 years (embarrassment, neglect, fear, ignorance) rarely urinary retention or groin mass (inguinal lymphadenopathy)

Question 37

what investigations into penile cancer

Answer 37

MRI to asses tumour | CT abdo chest and pelvis in advanced disease

Question 38

what is the treatment for penile cancer

Answer 38

``` prepucial lesions- circumscision glans lesions- superficial= glans resurfacing, deep= glansectomy advanced disease= total penile amputation with formation of a penile urethrostomy inguinal lymphadenectomy (if involved or high risk cancer) ```