Tumours Of The Urinary Tract

Question 1

What are the risk factors for prostate cancer?

Answer 1

Age 
- risk increases with age 
Hormones
Racial factors
- black
Familial and genetic factors 
- abnormalities on chromosomes 1 and 8
- BRCA2 gene mutations 
- PTEN and TP53 - tumour suppressor genes
Geographic variations
- highest in western cultures

Question 2

What are the signs and symptoms of prostate cancer?

Answer 2

Asymptomatic 
Painful/slow micturition 
UTI
Haematuria
Urinary retention 
Lymphoedema 
Metastatic 
- bone pain
- renal failure (ureteric obstruction)

Question 3

What investigations are used in the diagnosis of prostate cancer?

Answer 3

Digital rectal examination
PSA - prostate specific antigen
TRUS - needle guided biopsy

Question 4

Where in the prostate do prostate cancers normally arise?

Answer 4

Peripheral zones

Question 5

What is the Gleason grading system?

Answer 5

Based on the extent to which the tumour cells are arranged into recognisable glandular structures and describes and spectrum of histological malignancies
<4 - well differentiated
5-7 - moderately differentiated
>7 - poorly differentiated

Question 6

Describe the T staging (in TNM staging) of the prostate.

Answer 6

T1 - tumour can’t be seen with imaging or felt on DRE (incidental finding by transrectal US)
T2 - can be felt by DRE or seen on TRUS, but confined to the prostate
T3 - cancer has grown outside the prostate, possibly into the seminal vesicles

Question 7

Describe the N staging (in TNM staging) of the prostate.

Answer 7

N0 - not spread to any nearby lymph nodes

N1 - cancer has spread to one or more nearby lymph ndoes

Question 8

Describe the M staging (in TNM staging) of the prostate.

Answer 8

M0 - cancer hasn’t spread beyond nearby lymph nodes

M1 - cancer has spread beyond nearby lymph nodes

Question 9

How does the prostate specific antigen help assess the prostate?

Answer 9

Serine protease is secreted into seminal fluid
- responsible for the liquefaction of seminal coagulation Small proportional leaks into circulation
Tissue, not tumour specific

Question 10

What is the normal level of PSA?

Answer 10

50-59 >3ng/ml
60-69 >4ng/ml
70-79 >5 ng/ml

Question 11

What is the treatment for localised prostate cancer?

Answer 11

Waiting 
Radiotherapy
- external beam
- conformal 
- brachytherapy 
Radical prostatectomy 
Cryotherapy 
TURP if symptomatic

Question 12

What are the metastatic complications of prostate cancer, and how are they treated?

Answer 12

Spinal cord compression 
- severe pain
- retention
- urgent MRI
- radiotherapy vs spinal decompression surgery
Ureteric obstruction
- anorexia, weight loss, raised creatinine
- nephrostomise or stenting

Question 13

What are the treatment options for advanced prostate cancer?

Answer 13

Androgen ablation therapy  
- medical castration (LHRH analogue)
Surgical castration
TURP for symptom relief 
Chemotherapy
Radiotherapy

Question 14

What are the risk factors for bladder cancer?

Answer 14

Age 
- common in 80s
Race
- white
Environmental carcinogens 
Chronic inflammation
- stones, infection, long term catheters 
Drugs
- phenacitin
- cyclophsophamide 
Pelvic radiotherapy 
Smoking

Question 15

How does bladder cancer present?

Answer 15

Painless frank haematuria 
Microscopic haematuria (5% of cases)

Question 16

How is bladder cancer diagnosed?

Answer 16

Cystoscopy

Renal USS/KUB

Question 17

Which types of bladder cancer are the most common?

Answer 17

Transitional cell carcinoma (90%)
- superficial 75%
- invasive - 25%
Squamous carcinoma (5%)
Adenocarcinoma (2%)
Metastatic

Question 18

What is the grading system for bladder cancer?

Answer 18

Grade 1 - well differentiated
Grade 2 - moderately differentiated
Grade 3 - poorly differentiated
Carcinoma in situ

Question 19

Describe the tumour staging for bladder cancer.

Answer 19

Tis - carcinoma in situ
Ta - noninvasive papillary carcinoma
T1 - invasion of the lamina propria
T2 - invasion of the muscle layer of the bladder wall
T3 - tumour has spread into the perivesical tissue (fatty tissue surrounding the bladder)
T4 - tumours has spread to the (a) abdominal wall, pelvic wall or (b) prostate/seminal vesicles or uterus/vagina

Question 20

What is the treatment for bladder cancer?

Answer 20

Urgent trans-urethral resection of bladder tumour
CT IVU
Bimanual examination carrier out
Intravesicle mitomycin reduces risk of recurrence

Question 21

How is a low grade superficial (non-invasive papillary tumour) treated?

Answer 21

Low risk of progression
- flexible check cystoscopy every 3 months
6 weekly course of mitomycin treatments for persistent tumours

Question 22

How is a high grade, non-muscle invasive bladder cancer treated?

Answer 22

50% chance of progression to muscle invasive disease
Cystoscopy and re-biopsy
Treat with intravesical BCG immunotherapy
- 6 weeks
- then further cystosopy and biopsy
Cystectomy if treatment fails

Question 23

How is muscle invasive bladder cancer treated?

Answer 23

Requires radical therapy
- cystectomy or radiotherapy
Radiotheapy doesn’t work well if there is multifocal disease or widespread CIS
Neo-adjuvant chemotherapy

Question 24

How is metastatic bladder cancer treated?

Answer 24

Often pulmonary
Treated with chemotherapy 
- M-VAC
- methotrexate, vinblastine, doxorubicin and cisplatin 
- highly toxic
Gemicitobine and docetaxel

Question 25

What are the different types of renal tumour?

Answer 25

Renal cell carcinoma (85%) Transitional cell carcinoma Sarcoma Metastases

Question 26

What are the risk factors for renal cell carcinoma?

Answer 26

``` Smoking Obesity Hypertension Acquired renal cystic disease Haemodialysis Genetics - VHL, HPRCC, tuberous sclerosis ```

Question 27

How do renal carcinomas present?

Answer 27

``` 80% incidental 25% systemic symptoms - night sweats - fever - fatigue - weight loss - haemoptysis 10% classic triad - mass, pain and haematuria Varicocele Lower limb oedema Paraneoplastic syndrome ```

Question 28

Name the paraneoplastic syndomes.

Answer 28

``` Polycythaemia (from increased EPO) Hypercalcaemia (PTH like substance) Hypertension (renin secretion) Deranged LFTs ACTH, prolactin, insulin and gonadotrophins ( all rare) ```

Question 29

How is the initial diagnosis of renal cell carcinoma made?

Answer 29

``` US FBC, UEs, LFTs, CRP, bone profile and LDH CT kidneys MRI Renal biopsy CT chest - mets ```

Question 30

Describe the tumours staging of renal cell carcinomas.

Answer 30

T1 - <7cm T2 - >7cm T3 - enters the renal vein/IVC T4 - extends beyond the Gerota fascia

Question 31

How is a large renal mass treated?

Answer 31

Radical nephrectomy | - removal of kidney and Gerota's fascia (sparing the adrenal gland)

Question 32

How are small renal masses treated?

Answer 32

``` Biopsy Nephron sparing surgery (partial neprectomy or cryotherapy) - when it affects a single kidney - CKD - CV risk factors - T1a tumours Radical nephrectomy Surveillance ```

Question 33

How are metastatic renal cell carincomas treated?

Answer 33

Tyrosine Kinase Inhibitor

Question 34

What are the risk factors for testicular cancer?

Answer 34

Age 20-45 Cryptorchidism HIV Caucasian

Question 35

How does testicular cancer present?

Answer 35

Painless lump | Often found after incidental trauma

Question 36

What are the investigations for testicular cancer?

Answer 36

``` Scrotal US Tumour markers - alpha feroprotein - beta hCG - LDH ```

Question 37

What are the different classifications of testicular cancers?

Answer 37

``` Germ cell - seminoma - teratoma - mixed - yolk sac Stromal tumours - leydig - sertoli Other - lymphoma - metastasis ```

Question 38

What is the treatment for testicular cancer?

Answer 38

Radical orchidectomy Chemotherapy Para-aortic nodal radiotherapy Retroperitoneal lymph node dissection

Question 39

What is the treatment for penile cancer?

Answer 39

``` Circumcision Topical treatment CO2/5FU Penectomy and reconstruction Lymphadenectomy Chemo/radiotherapy ```