Tumours of the Urinary System 1 Flashcards
What is the most common cancer in terms of new cases?
Prostate cancer
What is the epidemiology of prostate cancer?
75% of new cases aged >65 years
-However 45% of new cases
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
What percentage of newly diagnosed prostate cancers are localised?
80%
How do most prostate cancers present?
Mostly asymptomatic
Diagnosed through apportunistic PSA testing
What is the diagnostic triad of Prostate cancer?
PSA
Digital rectal examination
TRUS-guided prostate biopsies
(may also be an incidental finding at TURP)
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
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
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
What are the presenting symptoms of widespread prostate metastases?
Lethargy (e.g. due to anaemia, uraemia)
Weight loss and cachexia
What is the commonest mode of presentation of prostate cancer?
Asymptomatic
What does the prostate do?
Produces kallikrein serine protease which liquifies semen
What is the half life of PSA?
2.2 days
wait for 8 x t1/2 for levels to normalise = 3 weeks
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
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
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%
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
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%
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
How can you stage localised prostate cancer?
Digital rectal examination
PSA
Transrectal US guided biopsies
CT
MRI
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
