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MET3B -Renal > Urological cancer > Flashcards

Urological cancer Flashcards

1
Q

Which age group is usually effected by prostate cancer? Are individuals with prostate cancer usually symptomatic?

A

70 years and above

Usually asymptomatic

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2
Q

Prostate cancer does not have a screening program, why?

A

If screening programme was to be present PSA test would used for screening but it is inadequate

Controversy over using Prostate Specific Antigen (PSA)

May not be an adequate screening test as significant numbers of false negatives and false
positives

PSA has age dependent cut offs

PSA is most useful in monitoring response to treatment

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3
Q

How is a diagnosis for prostate cancer confirmed?

A

Transurethral Ultrasound (TRUS) biopsy

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4
Q

What are the signs and symptoms of prostate cancer?

A

Lower urinary tract symptoms (LUTS)- give examples

Symptoms from metastatic disease - 
Bone pain (esp in back) spinal cord compression, anaemia

Locally advanced disease can lead to rectal symptoms and renal failure due to
urinary tract outflow obstruction

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5
Q

Which region of the prostate does prostate cancer most often present?

A

In the peripheral zone

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6
Q

In a digital rectal exam, how would prostate cancer differ for BPH?

A

Prostate cancer- Hard, irregular, asymmetrical, fixed

BPG- Enlarged, smooth, elastic

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7
Q

Prostate cancer is usually asymptomatic but when symptoms do present it is due to 3 main pathological events, what are these?

A

Enlarged prostate- leading to LUTS

Local invasion of cancer

Metastasis of cancer

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8
Q

What are the symptoms associated with the local invasion of prostate cancer?

A

Urinary obstruction and incontinence

Haematuria and haematospermia
Haematochezia
Erectile dysfunction

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9
Q

What are the symptoms associated with metastasis of prostate cancer?

A 
Bone pain (esp back)
Anaemia (lethargy)
Unintentional Weight loss and anorexia 
Spinal cord compression 
Pelvic, testicular and lower back pain
Pathological spontaneous pone fractures
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10
Q

Before a patient has a PSA test, what must happen first?

A

They must be counselled on what a PSA test is and the positive and negative aspects of having the test. They should be guided towards useful websites that provide the patient with reliable information.

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11
Q

Which other conditions can cause a raised PSA test?

A 
BPH
Acute urinary retention 
UTI
Prostatitis 
Catheter
Vigorous exercise 
Digital rectal exam 
Ejaculation
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12
Q

If a patient does choose to have a prostate screen which 2 tests/ examinations are offered?

A

PSA test

Digital rectal exam

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13
Q

When should a patient be referred to urological cancer specialists? (2 week wait pathway)

A

If there PSA levels are abnormal or rising - above age specific range

Prostate feels abnormal on DRE

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14
Q

In someone presenting with an abnormal PSA and DRE examination- which investigations would you conduct to further investigate prostate cancer?

A 
FBC
U and E
LFT
Bone profile 
Multiparametric MRI

Biopsy (transurethral ultrasound guided biopsy or transperineal)

Free: total PSA ratio
PSA density

Done if the biopsy shows signs of intermediate or high grade disease

Bone scan
Staging CT

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15
Q

Which 3 aspects are used in the staging of prostate cancer? Describe the results for each stage

A

PSA
Gleason
TNM (tumour size, nodes, metastasis)

Low risk = PSA <10, Gleason <6, TNM TI-T2a

Intermediate risk = PSA 10-20, Gleason 7, TNM T2b

High risk= PSA >20, Gleason 8-10, TNM >T2c

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16
Q

What is the Gleason score?

A

Prostate cells have distinct patterns as they change from normal cells to tumour cells.
These patters are assigned a number from 1 -5. 1= Prostate cells 5= highly mutated cells.

one Gleason grade to the most predominant pattern in the biopsy and a second Gleason grade to the second most predominant pattern.

The maximum Gleason grade is 10

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17
Q

When is localised therapy appropriate for prostate cancer patients? What are the available treatment options for localised therapy?

A

No extensive disease
PSA < 30
Low Gleason Score

Active surveillance (low risk patients)

Surgery (radical proctectomy or trans urethral resection)

Radiotherapy (Radical radiotherapy)

Cryotherapy- freezing and thawing of prostate cells to kill malignant
tissue

Adjuvant Androgen deprivation therapy may be combined with radical therapies, particularly those with intermediate or high risk disease receiving radiotherapy

Docetaxel chemotherapy may be used in patients with non-metastatic high risk disease

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18
Q

What is the specific criteria for cancer therapy?

A

Life expectancy > 15 years
(<75 years)
PSA < 15
No comorbidities- other diseases

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19
Q

Which types of radiotherapy treatment are available for prostate cancer patients?

A

External beam
Brachytherapy- implanting radioactive seeds into
prostate

They can be used together

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20
Q

Before a PSA test men should not have what?

A

Active or recent UTI (last 6 weeks)
Ejaculated for 48 hours
Engaged vigorous exercise for 48 hours
Had a urological intervention in the past 6 weeks

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21
Q

When should PSA test be offered in asymptomatic patients?

A

Men over 50

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22
Q

Which symptoms would require a PSA test?

A

Lower urinary tract symptoms (e.g. nocturia, frequency, hesitancy, urgency or retention)

Visible haematuria

Unexplained symptoms that may be explained by advanced prostate cancer (e.g lower back pain, bone pain, weight loss).

Erectile dysfunction.

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23
Q

If a patient has a normal DRE and a normal PSA does that exclude prostate camcer?

A

No - In this case clinical discretion must be used and the patient may require further clinical review

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24
Q

What is the first line investigation technique in those with suspected prostate cancer?

A

Multiparametric MRI

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25
Q

Which score is used in assessing the risk of prostate cancer using a Multiparametric MRI?

A

Likert score - a 5-point score based upon the radiologists impression of the scan

  1. Clinically significant cancer highly unlikely to be present
  2. Clinically significant cancer is unlikely to be present
  3. Chance of clinically significant cancer is equivocal
  4. Clinically significant cancer is likely to be present
  5. Clinically significant cancer is highly likely to be present
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26
Q

Following a Multiparametric MRI when is a prostate biopsy most likely going to be offered to the patient?

A

patients with a Likert score of 3 or greater

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27
Q

Which drugs are used in androgen deprivation therapy?

A

Gonadotrophin Releasing Hormone (GnRH) analogues e.g goserelin

Medical castration

28
Q

In those taking androgen deprivation therapy which result is suggestive of a good long term outcome?

A

A rapid fall in PSA and a nadir of < 1 (absolute lowest level that the PSA drops after treatment)

29
Q

How is locally advanced prostate cancer treated?

A

radical prostatectomy and radical radiotherapy. Docetaxel chemotherapy may be used

30
Q

What is the What is the period of control for androgen deprivation therapy and what percentage of people are responsive to it?

A

1-3 years

80% responsive

31
Q

If chemical castration- androgen deprivation therapy does not work what is the next course of action?

A

The disease is termed castrate resistant (or
androgen independent)

Other drugs are tried-

Androgen receptor antagonists - bicalutamide, enzalutamide

Corticosteroids - prednisone, dexamethasone

Oestrogens - oestradiol, diethylstilbestrol

Cyp 17 inhibitors - Abiraterone – very high response rate recorded; but suggestion of
lower response after corticosteroids/diethylstilbestrol

32
Q

How is metastatic prostate cancer treated?

A

Docetaxel chemotherapy and androgen deprivation therapy are often used.

Bilateral orchidectomy can be offered as an alternative to androgen deprivation therapies.

Palliative care may be required

33
Q

What are the palliative treatment options for prostate cancer?

A

Palliative radiotherapy

Bisphosphonates for bone disease – Alenronate, Zoledronic acid

RANKL inhibitor for metastatic disease –denosumab

Analgesics

Blood transfusion for anaemia

Palliative care team support

34
Q

What is the most common type of kidney cancer?

A

Renal cell carcinoma

35
Q

What are the signs and symptoms associated with renal cancer?

A 
Abdominal pain
Loin pain
Loin mass
Macro- / microscopic haematuria
Fevers / pyrexia of unknown origin
Night sweats
Malaise
Features of paraneoplastic syndromes
Weight loss
Anaemia or Polycythaemia (due to erythropoeitin production)
Varicocele (classically left sided) (tumour effects venous return)
Bone pain
Hypercalcaemia
36
Q

If local spread of renal cell cancer was to occur, where would it spread to?

A

renal vein and IVC

37
Q

What is the most common location for the distant metastasis of renal cancer?

A

Lungs

38
Q

What is a common X ray finding associated with metastasis of cancer to the lungs?

A

Cannon balls

39
Q

What are the risk factors associated with renal cell cancer?

A

Overweight (obesity)

Smoking

Hypertension

Family history

Various rare inherited conditions

  • Von Hippel-Lindau syndrome
  • Hereditary papillary renal carcinoma
  • Tuberous sclerosis
  • Birt–Hogg–Dubé syndrome
40
Q

There are 3 main types of renal cell cancer, what are they?

A

Clear cell
Papillary (type 1 and 2)
Chromophobe

41
Q

Which mutations are associated with each type of renal cell carcinoma?

A

Clear cell- Von-Hippel Lindau mutation

Papillary type 1- C-met activation

Papillary type 2- Fumarate / Hydratase mutation

Chromophobe - C-kit

42
Q

Varicoceles can be an indication of renal cell carcinoma. Under which circumstances should a patient with a varicocele be referred ?

A

older patients with unexplained new varicocele

urgent referral in those with varicocele which appear suddenly and are painful, do not drain when lying down or a solitary right-sided varicocele.

43
Q

List 7 symptoms of paraneoplastic syndromes

A 
Fever
Hypercalcaemia
Hypertension
Neuromyopathies 
Polycythaemia 
Cushing’s syndrome
44
Q

Which test should be conducted in someone suspected of having renal cell cancer?

A

Urine
Urine dip and MSU
Urine cytology

Blood 
FBC- rise in WCC
UE - Hypercalcaemia 
LFT
ESR- Rise 
Bone profile

Imaging-
CT- Main means of diagnosis

MRI- preferred in young patients, pregnant women or those with a contrast allergy. Also used where diagnosis is unclear

Bone scan- Used if bony metastasis are suspected

45
Q

What are the treatment options for localised renal cell cancer?

A

those with lesions < 7cm (i.e. T1a and T1b) - partial nephrectomy is preferred where possible

T2 tumours radical nephrectomy is typically preferred.

46
Q

How is metastatic renal cell cancer treated?

A

Tyrosine kinase inhibitors
sunitinib, sorafenib, pazopanib

Immunotherapy
high dose Interleukin 2

Mammalian target of rapamycin (mTOR) inhibitors
everolimus, sirolimus

47
Q

What are the blood result requirements for someone to take High dose interleukin 2?

A

not anaemic, normal WBC and platelets

48
Q

In which age groups does testicular cancer most often present?

A

20-40 years

49
Q

What are the risk factors associated with testicular cancer?

A

Undescended tactical

Hypospadias - the opening of the urethra is on the underside of the penis instead of at the tip

Infertility

Klinefelter’s syndrome

Tall men

50
Q

There are 3 main classifications for germ cell tumour, what are they?

A

Seminoma, Non - seminoma, Mixed

51
Q

How does a testicular cancer usually present?

A

unilateral scrotal mass

52
Q

Which clinical signs or symptoms are associated with testicular cancer?

A 
Testicular lump
Testicular pain/discomfort
Back pain, flank pain (indicative of metastasis)
Lymphadenopathy
Gynaecomastia (more common in NSGCT)
53
Q

When should a patient be referred urgently to urology via a two-week wait pathway?

A

non-painful testicular enlargement or change in size or change in texture

Additionally refer patients describing a dragging sensation, new varicocele or hydrocele.

54
Q

Which method is used to diagnose testicular cancer?

A

Testicular ultrasound

55
Q

How is a testicular cancer confined to the testicles treated?

A

orchidectomy followed by

Adjuvant therapy reduces risk of relapse but does not improve overall survival

Adjuvant therapy = In seminoma carboplatin chemotherapy or radiotherapy

Or

NSGCT / mixed seminoma= adjuvant bleomycin, etoposide and cisplatin (BEP) chemotherapy

56
Q

What is the role of tumour markers in the management of testicular cancer?

A

Used to support the diagnosis and offer prognostic information

57
Q

Which tumour markers are relevant to in testicular cancer?

A

Alpha-fetoprotein (AFP): may be produced by yolk sac components of tumours

Human chorionic gonadotrophin (hCG): may be produced by trophoblastic components of tumours

LDH: general marker of increased cell turnover

58
Q

Where in the body does testicular cancer most often metastasize to?

A

lungs, lymph nodes, liver and brain

59
Q

How is metastatic cancer treated in testicular cancer?

A

Seminoma = chemotherapy (e.g. cisplatin), radiotherapy or both

NSGCT = adjuvant bleomycin, etoposide and cisplatin (BEP) chemotherapy

60
Q

What is the prognosis for testicular cancer

A

Cure rate is very high -99% for stage 1 tumours

85-90% for those with metastatic disease can expect to be cured

61
Q

What should happen to tumour markers after treatment of testicular cancer?

A

they should normalise

62
Q

After chemotherapy has been completed for testicular cancer, what should happen to residual masses?

A

They should be removed

63
Q

Which 3 factors indicate poorer survival in testicular cancer?

A

Shorter initial remission time

Very high tumour markers

Extra-gonadal primary sites

64
Q

What is the treatment strategy for a relapse in testicular cancer?

A

Cisplatin based therapy for first relapse

High dose chemotherapy with autologous stem cell rescue is often used on
second or subsequent relapse- Often high dose carboplatin and etoposide are used

65
Q

What is the most common type of bladder cancer?

A

Transitional cell carcinoma

66
Q

Where do tumours effecting the urothelium occure?

A

Anywhere between the renal pelvis and

the urethra

67
Q

What are the main risk factors for bladder cancer?

A 
aniline dyes
 smoking
Chronic bladder infections/irritation
Medications (e.g.cyclophosphamide) 
Family history
Schistosoma haematobium (a significant risk factor in the development of bladder squamous cell carcinoma)

MET3B -Renal (5 decks)

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