Tumours of the Urinary System 1 Flashcards Preview

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Flashcards in Tumours of the Urinary System 1 Deck (52):
1

What is the most common cancer in terms of new cases?

Prostate cancer

2

What is the epidemiology of prostate cancer?

75% of new cases aged >65 years
-However 45% of new cases

3

What are the risk factors for prostate cancer?

Age

Race/Ethnicity
-Niggas get it bad

Geography
-Northwest Europe, North america, Caribbean

Family History
-First degree relative 2x risk
-HPC1, BRCA1 and 2

Food (probable only)

Drugs
-Finasteride

4

What percentage of newly diagnosed prostate cancers are localised?

80%

5

How do most prostate cancers present?

Mostly asymptomatic

Diagnosed through apportunistic PSA testing

6

What is the diagnostic triad of Prostate cancer?

PSA

Digital rectal examination

TRUS-guided prostate biopsies


(may also be an incidental finding at TURP)

7

What are the presenting symptoms of localised (not invasive) prostate cancer?

Weak stream

Hesitancy

Dribly dribly

Sensation of incomplete emptying

Frequency

Urgency

Urge incontinence

Urinary tract infection

8

What are the presenting symptoms of locally invasive prostate cancer disease?

Haematuria

Perineal and suprapubic pain

Impotence

Incontinence

Loin pain or anuria resulting from obstrcution of the ureters

Symptoms of renal failure

Haemospermia

Rectal symptoms including tenesmus

9

What are the presenting symptoms of distant prostate metastases?

Bone pain or sciatica

Paraplegia secondary to spinal cord compression

Lymph node enlargement

Lymphoedema, particularly in the lower limbs

Loin pain or anuria due to obstruction of the ureters by lymph nodes

10

What are the presenting symptoms of widespread prostate metastases?

Lethargy (e.g. due to anaemia, uraemia)

Weight loss and cachexia

11

What is the commonest mode of presentation of prostate cancer?

Asymptomatic

12

What does the prostate do?

Produces kallikrein serine protease which liquifies semen

13

What is the half life of PSA?

2.2 days

(wait for 8 x t1/2 for levels to normalise = 3 weeks)

14

What is the normal serum range for PSA given by the lab?

Why does this need to be taken with a pinch of salt?

Normal serum range 0-4.0 ug/mL

Normal range however ranges with age
- 70: 6.5 upper limit

15

What can cause elevations in PSA?

Urinary Tract Infection

Chronic prostatitis

Instrumentation (e.g. catheterisation)

Physiological (e.g. ejactulation)

Recent urological procedure

BENIGN PROSTATIC HYPERPLASIA

PROSTATE CANCER

16

Give the posibility of cancer based on different levels of PSA

0-1.0: 5%
1.0-2.5: 15%
2.5-4.0: 25%
4.0-10: 40%
>10: 70%

17

What is the Gleason Pathological Grading System?

Pathologist classifies prostate cancer

Score 1-5 (well to poorly differentiated)

Most common score added to the second most common score

e.g. most of tissue grade 3 with a lot grade 2 also
- 3+2=5
-Gleason Score 5

Useful prognostically

18

What are the prognostic values of the gleason score?

Risk of death from CaP within 15 years given

2-4 = 4-7%
5 = 6-11%
6 = 18-30%
7 = 42-70%
8-10 = 60-87%

19

For the purpose of treatment and prognosis it is useful to divide prostate cancer into 4 stages.

What are they?

Localised stage

Locally advanced stage

Metastatic stage

Hormone refractory stage

20

How can you stage localised prostate cancer?

Digital rectal examination

PSA

Transrectal US guided biopsies

CT

MRI

21

How can you stage localised prostate cancer by digital rectal examination?

T1 = cannot feel

T2a = feel on one lobe

T2b = feel on both lobes

T3 = takes up most of prostate

T4 = Everywhere and spread into pelvis

22

What are the broad options for treatment of prostate cancer?

Watchful waiting

Radiotherapy

Radical prostatectomy

Others under investigation

23

What radiotherapy options are available for localised prostate cancer?

External-beam

Brachytherapy

24

What radical prostatectomy options are available for localised prostate cancer?

Open
Laparoscopic
ROBOTIC

25

What treatments for localised prostate cancer are under investigation?

Cryotherapy
Thermotherapy

26

What are the treatment options for locally advanced prostate cancer?

Watchful waiting

Hormone therapy followed by surgery

Hormone therapy followed by radiation

Hormone therapy alone

Intermitted hormone therapy (clinical research)

27

Give some types of hormonal therapy for prostate cancer

SURGICAL CASTRATION
-(i.e. bilateral orchidectomy)

Chemical castration

Anti-androgens

Oestrogens

28

Describe chemical castration

i.e. LHRH analogue
-Goserelin, leuprorelin

Eventually downregulates androgen receptors by negative feedback

Tumour flare in first week of therapy (hence need shitloads of beer during this period)

29

What are anti-androgens?

Inhibits androgen receptors

30

Describe the use of oestrogens for prostate cancer?

i.e. diethylstilboestrol

Inhibits LHRH and testosterone secretion, inactivates andogens and has direct cytotoxic effect on prostate epithelial cells

31

What are the areas metastatic and hormone refractory prostate cancer can have complications?

Bone

Rectal

Ureteric

Pelvic lymphatic obstruction

Lower urinary tract dysfunction

32

What bone complications occur in metastatic and hormone refractory prostate cancer?

Bone pain

Pathological fractures

Anaemia

Spinal cord compression

Itchy penis

33

What are the rectal complications of metastatic and hormone refractory prostate cancer?

Constipation

Bowel obstruction

34

What are the ureteric complications of metastatic and hormone refractory prostate cancer?

Obstruction resulting in renal failure

35

What is the treatment of metastatic and hormone refractory prostate cancer?

Mainstay:
-Immediate hormonal therapy

Supportive:
-Palliative radiotherapy to bone metastases
-Colostomy
-Nephrostomy
-Zoledronic acid
-Palliative care support

36

What is the treatment of hormone refractory stage of prostate cancer?

Reached in 18-24 months of treatment

Diethylstilboestrol can be tried (high risk of thromboembolic and cardiovascular complications); median response time 4 months

Docetaxel has survival benefit of 3 months

Median survival is 10 months

37

What is the best treatment option for low risk localised prostate cancer?

Active surveillance

(Extremely good prognosis so risk of over treatment)

38

What is the presentation of testicular cancer?

Usually
-Painless lump

Less often
-Tender inflamed swelling
-History of trauma
-Symptoms from metastasis

39

What is the epidaemiology of testicular cancer?

One of the commonest cancers of young men

Peak incidence in third decade

Higher risk in Caucasians

Risk higher in testicular maldescent

40

How do you diagnose testicular cancer?

Lump in testis = testicular tumour until proven otherwise

Ultrasound and CXR

Tumour markers

Orchidectomy through a groin incision

41

When is blood for tumour markers taken in testicular tumour?

Immediately before and serially after surgery

(markers should drop to zero)

42

What tumour markers are taken in testicular tumour?

AFP
-Alpha fetoprotein

HCG
-Human Chorionic Gonadotrophin

LDH
-Lactate dehydrogenase
-More global sign to indicate mets

43

What is the pathology of testicular cancer?

Germ cell (95%)

Non-germ cell (5%)
-Sex cord-stromal

44

What are the types of germ cell testicular cancer?

Seminomatous (mainly 30-40s)
-Spermatocytic,
-Classical,
-Anaplastic

Non-seminomatous (mainly 20-30s)
-Teratoma
-Yolk sac
-Choriocarcinoma
-Mixed (often)

45

What are the types of non-germ cell testicular cancer?

Leydig
Sertoli
Lymphoma rare

46

How does testicular cancer spread?

Spread by local invasion to adjacent structures

Lymphatic invasion to para-aortic lymph nodes

47

How do you stage testicular cancer?

Nodal staging

CT scanning, lymphangiography

48

What are the stages of testicular cancer?

Stage I
-Disease is confined to the testis

Stage II
-Infradiaphragmatic nodes involved

Stage III
-Supradiaphragmatic nodes involved

Stage IV
-Extralymphatic disease

49

How do you treat low stage, negative markers testicular cancer?

Orchidectomy and surveillance or

-Adjuvant radiotherapy
-Prophylactic chemotherapy

50

How do you treat nodal disease, peristent tumour markers or relapse on surveillance in testicular cancer?

Combination chemotherapy

51

How do you treat persistant nodes in testicular cancer?

Salvage node dissection

Repeat chemotherapy

52

What is the prognosis for testicular cancer?

Extremely good for early treated disease
-Seminoma Stage I - 95% 5-year survival
-Non-seminomatous Stage I - 90% 5-year survival

Much worse if nodal disease persists after combination chemotherapy