Renal & Urology Cancer

Question 1

Renal cell cancer is also known as

Answer 1

hypernephroma

Question 2

Renal cell cancer accounts for 85% of primary renal neoplasms.

Answer 2

true

Question 3

Renal cell cancer arises from?

Answer 3

proximal renal tubular epithelium.

Question 4

Most common subtype of renal cell cancer?

Answer 4

clear cell (75 to 85 percent of tumours).

Question 5

Associations for renal cell cancer?

Answer 5

more common in middle-aged men
smoking
von Hippel-Lindau syndrome
tuberous sclerosis

Question 6

Classical triad of renal cell cancer?

Answer 6

haematuria, loin pain, abdominal mass

Question 7

Why might RCC present with left varicocele?

Answer 7

due to occlusion of left testicular vein

Question 8

RCC never presents with pyrexia

Answer 8

false

pyrexia of unknown origin

Question 9

endocrine effects of rcc?

Answer 9

may secrete erythropoietin (polycythaemia), parathyroid hormone (hypercalcaemia), renin, ACTH

Question 10

in rcc ?% have metastases at presentation

Answer 10

25%

Question 11

What is paraneoplastic hepatic dysfunction syndrome? why does it arise?

Answer 11

Typically presents as cholestasis/hepatosplenomegaly. It is thought to be secondary to increased levels of IL-6

Question 12

rcc is associated with Stauffer syndrome

Answer 12

true

another name for paraneoplastic hepatic dysfunction syndrome

Question 13

Outline management for rcc

Answer 13

for confined disease a partial or total nephrectomy depending on the tumour size

tyrosine kinase inhibitors (e.g. sorafenib, sunitinib) and interleukin-2 have been used to reduce tumour size and also treat patients with metatases

receptor tyrosine kinase inhibitors (e.g. sorafenib, sunitinib) have been shown to have superior efficacy compared to interferon-alpha

Question 14

Prostate cancer a common condition and up to 30,000 men are diagnosed with the condition each year.

Answer 14

true

Question 15

Up to 9,000 will die in the UK from prostate cancer per year.

Answer 15

true

Question 16

Early prostate cancers have few symptoms.

Answer 16

true

Locally advanced disease may present as pelvic pain or with urinary symptoms.

Question 17

prostate cancer mets may present as bone pain

Answer 17

true

Question 18

What tests would you do prostate cancer?

Answer 18

Prostate specific antigen measurement
Digital rectal examination
Trans rectal USS (+/- biopsy)
MRI/ CT and bone scan for staging.

Question 19

The normal upper limit for PSA is

Answer 19

4ng/ml

Question 20

Why might PSA be raised? What is an alternative?

Answer 20

False positives may be due to prostatitis, UTI, BPH, vigorous DRE.

The percentage of free: total PSA may help to distinguish benign disease from cancer.

Values of <20% are suggestive of cancer and biopsy is advised.

Question 21

risk factors for prostate canceR?

Answer 21

increasing age
obesity
Afro-Caribbean ethnicity
family history: around 5-10% of cases have a strong family history

Question 22

wHY is prostate cancer (localised) often asymptomatic?

Answer 22

partly because cancers tend to develop in the periphery of the prostate and hence don’t cause obstructive symptoms early on.

Question 23

Features of PC & DRE?

Answer 23

bladder outlet obstruction: hesitancy, urinary retention
haematuria, haematospermia
pain: back, perineal or testicular
digital rectal examination: asymmetrical, hard, nodular enlargement with loss of median sulcus

Question 24

Prostate cancer investigations - NICE have now advocated the increasing use of what first line?

Answer 24

multiparametric MRI as a first-line investigation.

replaced trus biopsy

Question 25

How are results of Multiparametric MRI reported? Outline what this means

Answer 25

5‑point Likert scale If the Likert scale is >=3 a multiparametric MRI-influenced prostate biopsy is offered If the Likert scale is 1-2 then NICE recommend discussing with the patient the pros and cons of having a biopsy.

Question 26

Complications of TRUS biopsy:

Answer 26

sepsis: 1% of cases pain: lasting >= 2 weeks in 15% and severe in 7% fever: 5% haematuria and rectal bleeding

Question 27

What is PSA?

Answer 27

serine protease enzyme produced by normal and malignant prostate epithelial cells. It has become an important tumour marker but much controversy still exists regarding its usefulness as a screening tool.

Question 28

When should men be referred in prostate cancer

Answer 28

men aged 50-69 years should be referred if the PSA is >= 3.0 ng/ml OR there is an abnormal DRE

Question 29

After prostatitis and urinary tract infection NICE recommend to postpone the PSA test for at least?

Answer 29

1 month after treatment

Question 30

Describe sensitivity & specificity of PSA?

Answer 30

PSA of 4-10 ng/ml 33% will be found to have prostate cancer. PSA of 10-20 ng/ml this rises to 60% around 20% with prostate cancer have a normal PSA various methods are used to try and add greater meaning to a PSA level including age-adjusted upper limits and monitoring change in PSA level with time (PSA velocity or PSA doubling time)

Question 31

*whether digital rectal examination actually causes a rise in PSA levels is a matter of debate

Answer 31

true

Question 32

Describe histopathology of PC?

Answer 32

95% adenocarcinoma. Often multifocal- 70% lie in the peripheral zone. In situ malignancy is sometimes found in areas adjacent to cancer. Multiple biopsies needed to call true in situ disease.

Question 33

How is PC graded? Describe

Answer 33

Graded using the Gleason grading system 2 is best prognosis and 10 the worst. Grades awarded for most dominant grade (on scale of 1-5) and also for second most dominant grade (scale 1-5). The two added together give the Gleason score.

Question 34

In PC lymphatic spread occurs where?

Answer 34

first to the obturator nodes spread to the seminal vesicles is associated with distant disease.

Question 35

In PC when would you watch and wait'?

Answer 35

Elderly, multiple co-morbidities, low Gleason score

Question 36

What stage is localised PC? How would you treat this?

Answer 36

t1/t2 Treatment depends on life expectancy and patient choice. Options include: conservative: active monitoring & watchful waiting radical prostatectomy radiotherapy: external beam and brachytherapy

Question 37

What stage is localised ADVANCED PC? How would you treat this?

Answer 37

T3/T4) hormonal therapy radical prostatectomy: erectile dysfunction is a common complication radiotherapy: external beam and brachytherapy. Patients are at increased risk of bladder, colon, and rectal cancer following radiotherapy for prostate cancer

Question 38

What hormonal therapy could you use in PC?

Answer 38

Synthetic GnRH agonist e.g. Goserelin (Zoladex) - cover initially with anti-androgen to prevent rise in testosterone Anti-androgen: Cyproterone Acetate prevents DHT binding from intracytoplasmic protein complexes Orchidectomy

Question 39

Why is hormonal therapy used in PC?

Answer 39

Testosterone stimulates prostate tissue and prostatic cancers usually show some degree of testosterone dependence. 95% of testosterone is derived from the testis and bilateral orchidectomy may be used for this reason. Pharmacological alternatives include LHRH analogues and anti androgens (which may be given in combination).

Question 40

In the UK the National Institute for Clinical Excellence (NICE) suggests that active surveillance is the preferred option for low risk men in PC. when is this suitable

Answer 40

clinical stage T1c Gleason score 3+3 PSA density < 0.15 ng/ml/ml Those who have cancer in less than 50% of their biopsy cores, with < 10 mm of any core involved.

Question 41

Candidates for active surveillance should (PC)

Answer 41

have had at least 10 biopsy cores taken | have at least one re-biopsy.

Question 42

If men on active surveillance show evidence of disease progression, offer ? (PC)

Answer 42

offer radical treatment. Treatment decisions should be made with the man, taking into account co-morbidities and life expectancy.

Question 43

Testicular cancer is the most common malignancy in men aged 20-30 years

Answer 43

true

Question 44

How do you categorise testicular cancer?

Answer 44

95% of cases of testicular cancer are germ-cell tumours. Germ cell tumours may essentially be divided into: 1. seminomas 2. non-seminomas: including embryonal, yolk sac, teratoma and choriocarcinoma Non-germ cell tumours include Leydig cell tumours and sarcomas.

Question 45

The peak incidence for teratomas is

Answer 45

25yrs

Question 46

The peak incidence for seminomas is

Answer 46

35yrs

Question 47

risk factors for testicular cancer

Answer 47

``` infertility (increases risk by a factor of 3) cryptorchidism family history Klinefelter's syndrome mumps orchitis ```

Question 48

Testicular cancer usually is a painless lump

Answer 48

yes a painless lump is the most common presenting symptom pain may also be present in a minority of men

Question 49

Other than painless lump, how else might testicular cancer present

Answer 49

hydrocele | gynaecomastia

Question 50

Why do you get gynaecomastia in testicular cancer?

Answer 50

this occurs due to an increased oestrogen:androgen ratio germ-cell tumours → hCG → Leydig cell dysfunction → increases in both oestradiol and testosterone production, but rise in oestradiol is relatively greater than testosterone leydig cell tumours → directly secrete more oestradiol and convert additional androgen precursors to oestrogens

Question 51

Describe bloods in germ cell tumours

Answer 51

AFP is elevated in around 60% of germ cell tumours | LDH is elevated in around 40% of germ cell tumours

Question 52

Describe bloods in seminomas

Answer 52

hCG may be elevated in around 20%

Question 53

Diagnosis testicular cancer?

Answer 53

US

Question 54

Management testicular cancer?

Answer 54

treatment depends on whether the tumour is a seminoma or a non-seminoma orchidectomy chemotherapy and radiotherapy may be given depending on staging and tumour type

Question 55

Prognosis testicular cancer?

Answer 55

5 year survival for seminomas is around 95% if Stage I | 5 year survival for teratomas is around 85% if Stage I

Question 56

Risk factors for transitional cell carcinoma of the bladder include:

Answer 56

Smoking Exposure to aniline dyes in the printing and textile industry: examples are 2-naphthylamine and benzidine Rubber manufacture Cyclophosphamide

Question 57

Risk factors for squamous cell carcinoma of the bladder include:

Answer 57

Schistosomiasis | Smoking

Question 58

Bladder cancer is the second most common urological cancer. It most commonly affects males aged between

Answer 58

50 and 80 years of age.

Question 59

Those who are current, or previous (within 20 years), smokers have a 2-5 fold increased risk of bladder cancer

Answer 59

true

Question 60

Exposure to hydrocarbons such as 2-Naphthylamine increases the risk of bladder cancer

Answer 60

true

Question 61

Although rare in the UK, chronic bladder inflammation arising from Schistosomiasis infection remains a common cause of squamous cell carcinomas, in those countries where the disease is endemic.

Answer 61

true

Question 62

Which lymph nodes are in the true pelvis

Answer 62

hypogastric, obturator, external iliac, or presacral lymph node

Question 63

What are the types of bladder cancer?

Answer 63

Transitional cell carcinoma (>90% of cases) Squamous cell carcinoma ( 1-7% -except in regions affected by schistosomiasis) Adenocarcinoma (2%)

Question 64

Describe the typical growth of TCC

Answer 64

may arise as solitary lesions, or may be multifocal, owing to the effect of 'field change' within the urothelium. Up to 70% of TCC's will have a papillary growth pattern. These tumours are usually superficial in location and accordingly have a better prognosis. The remaining tumours show either mixed papillary and solid growth or pure solid growths. These tumours are typically more prone to local invasion and may be of higher grade, the prognosis is therefore worse.

Question 65

Bladder cancer - describe T part of TNM

Answer 65

T0 No evidence of tumour Ta Non invasive papillary carcinoma T1 Tumour invades sub epithelial connective tissue T2a Tumor invades superficial muscularis propria (inner half) T2b Tumor invades deep muscularis propria (outer half) T3 Tumour extends to perivesical fat T4 Tumor invades any of the following: prostatic stroma, seminal vesicles, uterus, vagina T4a Invasion of uterus, prostate or bowel T4b Invasion of pelvic sidewall or abdominal wall

Question 66

Bladder cancer - describe N part of TNM

Answer 66

N0 No nodal disease N1 Single regional lymph node metastasis in the true pelvis N2 Multiple regional lymph node metastasis in the true pelvis N3 Lymph node metastasis to the common iliac lymph nodes Lymph nodes in true pelvis: hypogastric, obturator, external iliac, or presacral lymph node metastasis

Question 67

Bladder cancer - describe M part of TNM

Answer 67

M0 No distant metastasis | M1 Distant disease

Question 68

bladder cancer - Those with T3 disease or worse have a 30% (or higher) risk of regional or distant lymph node metastasis.

Answer 68

true

Question 69

Describe typical presentation of bladder cancer?

Answer 69

Most patients (85%) will present with painless, macroscopic haematuria. In those patients with incidental microscopic haematuria, up to 10% of females aged over 50 will be found to have a malignancy (once infection excluded).

Question 70

Describe how bladder cancer is investigated?

Answer 70

Most will undergo a cystoscopy and biopsies or TURBT, this provides histological diagnosis and information relating to depth of invasion. Locoregional spread is best determined using pelvic MRI and distant disease CT scanning. Nodes of uncertain significance may be investigated using PET CT.

Question 71

Describe treatment of bladder cancer?

Answer 71

Those with superficial lesions may be managed using TURBT in isolation. Those with recurrences or higher grade/ risk on histology may be offered intravesical chemotherapy. Those with T2 disease are usually offered either surgery (radical cystectomy and ileal conduit) or radical radiotherapy.

Question 72

Describe prognosis of bladder cancer

Answer 72

``` T1 90% T2 60% T3 35% T4a 10-25% Any T, N1-N2 30% ```

Question 73

Nephroblastoma (Wilm's tumours) | Usually present in

Answer 73

first 4 years of life

Question 74

Nephroblastoma presents

Answer 74

May often present as a mass associated with haematuria (pyrexia may occur in 50%) Often metastasise early (usually to lung)

Question 75

mx nephroblastoma

Answer 75

nephrectomy

Question 76

Prognosis nephroblastoma

Answer 76

Younger children have better prognosis (<1 year of age =80% overall 5 year survival)

Question 77

Tumour markes in seminoma

Answer 77

AFP usually normal HCG elevated in 10% seminomas Lactate dehydrogenase; elevated in 10-20% seminomas (but also in many other conditions)

Question 78

Pathology seminoma

Answer 78

Sheet like lobular patterns of cells with substantial fibrous component. Fibrous septa contain lymphocytic inclusions and granulomas may be seen.

Question 79

Non seminomatous germ cell tumours markers?

Answer 79

AFP elevated in up to 70% of cases HCG elevated in up to 40% of cases Other markers rarely helpful

Question 80

Pathology non eminomatous germ cell tumours?

Answer 80

Heterogenous texture with occasional ectopic tissue such as hair

Question 81

Tyoes of Non seminomatous germ cell tumours

Answer 81

``` Non seminomatous germ cell tumours (42%) Teratoma Yolk sac tumour Choriocarcinoma Mixed germ cell tumours (10%) ```

Question 82

seminoma is a type of germ cell tumour

Answer 82

true

Question 83

Key features of seminoma

Answer 83

``` Commonest subtype (50%) Average age at diagnosis = 40 Even advanced disease associated with 5 year survival of 73% ```

Question 84

Key features of Non seminomatous germ cell tumours

Answer 84

Younger age at presentation =20-30 years Advanced disease carries worse prognosis (48% at 5 years) Retroperitoneal lymph node dissection may be needed for residual disease after chemotherap