Tumours of the Urinary System 1 Flashcards by Andrew Hay

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

Prostate cancer

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What is the epidemiology of prostate cancer?

75% of new cases aged >65 years

-However 45% of new cases

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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

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What percentage of newly diagnosed prostate cancers are localised?

80%

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How do most prostate cancers present?

Mostly asymptomatic

Diagnosed through apportunistic PSA testing

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What is the diagnostic triad of Prostate cancer?

PSA

Digital rectal examination

TRUS-guided prostate biopsies

(may also be an incidental finding at TURP)

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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

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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

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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

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What are the presenting symptoms of widespread prostate metastases?

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

Weight loss and cachexia

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What is the commonest mode of presentation of prostate cancer?

Asymptomatic

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What does the prostate do?

Produces kallikrein serine protease which liquifies semen

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What is the half life of PSA?

2.2 days

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

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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

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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

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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%

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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

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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%

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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

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How can you stage localised prostate cancer?

Digital rectal examination

PSA

Transrectal US guided biopsies

MRI

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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

What are the broad options for treatment of prostate cancer?

Watchful waiting

Radiotherapy

Radical prostatectomy

Others under investigation

What radiotherapy options are available for localised prostate cancer?

External-beam

Brachytherapy

What radical prostatectomy options are available for localised prostate cancer?

Open
Laparoscopic
ROBOTIC

What treatments for localised prostate cancer are under investigation?

Cryotherapy | Thermotherapy

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)

Give some types of hormonal therapy for prostate cancer

SURGICAL CASTRATION -(i.e. bilateral orchidectomy) Chemical castration Anti-androgens Oestrogens

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)

What are anti-androgens?

Inhibits androgen receptors

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

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

Bone Rectal Ureteric Pelvic lymphatic obstruction Lower urinary tract dysfunction

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

Bone pain Pathological fractures Anaemia Spinal cord compression Itchy penis

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

Constipation Bowel obstruction

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

Obstruction resulting in renal failure

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

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

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

Active surveillance | Extremely good prognosis so risk of over treatment

What is the presentation of testicular cancer?

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

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

How do you diagnose testicular cancer?

Lump in testis = testicular tumour until proven otherwise Ultrasound and CXR Tumour markers Orchidectomy through a groin incision

When is blood for tumour markers taken in testicular tumour?

Immediately before and serially after surgery | markers should drop to zero

What tumour markers are taken in testicular tumour?

AFP -Alpha fetoprotein HCG -Human Chorionic Gonadotrophin LDH - Lactate dehydrogenase - More global sign to indicate mets

What is the pathology of testicular cancer?

Germ cell (95%) Non-germ cell (5%) -Sex cord-stromal

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)

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

Leydig Sertoli Lymphoma rare

How does testicular cancer spread?

Spread by local invasion to adjacent structures Lymphatic invasion to para-aortic lymph nodes

How do you stage testicular cancer?

Nodal staging CT scanning, lymphangiography

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

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

Orchidectomy and surveillance or - Adjuvant radiotherapy - Prophylactic chemotherapy

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

Combination chemotherapy

How do you treat persistant nodes in testicular cancer?

Salvage node dissection Repeat chemotherapy

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