Yr4: Cancer Care > Urological Cancers > Flashcards

Urological Cancers Flashcards

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1
Q

Prostate cancer is the ______ most common cancer in men

Prostate cancer is the _____ most common cause of cancer related death in men

A
  • Most common cancer in men
  • Second most common cause of cancer related death in men (lung if most common)
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2
Q

Remind yourself of the structure of the prostate

A
  • Main zones to be aware of: peripheral, central, transitional
  • Vas deferens pass through central zone
  • Urethra passes through transitional zone
  • 70% cancers are in the peripheral zone but tumours are often multifocal(in comparison to BPH which primarily affects the transition zone) b
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3
Q

What type of cancer are most prostate cancers?

A

Most (>95%) are adenocarcinomas and around 70-75% arise in the peripheral zone. Prostate adenocarcinomas can be divided into:

  • Acinar adenocarcinoma: glandular cells (most common)
  • Ductal adenocarcinoma: cells that line ducts of prostate gland
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4
Q

State some risk factors for prostate cancer- highlighting the most important

A
  • Advancing age
  • Family history (by FH referring to if they have 1st degree relative diagnosed before age 60yrs. 4x risk)
  • BRCA2 mutation (5-7x risk)
  • Black african ethnicity > white > asian

Other less significant risk factors: obesity, diabetes, smoking, lack of exercise

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5
Q

State some symptoms & signs of prostate cancer

A

May be symptomatic; alternatively may be asymptomatic but had abnormal DRE (hard, nodular, enlarged, loss of median sulcus) or raised PSA

  • Lower urinary tract symptoms (frequency, hesitancy, poor stream, terminal dribble, nocturia)
  • Haematuria
  • Haematospermia
  • Erectile dysfunction
  • Bone pain
  • General symptoms of malignancy: malaise, anorexia, weight loss
  • Ejaculatory problems (rare)
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6
Q

Discuss limitations of DRE

A

DRE can only detect tumours in posterior and lateral aspects of prostate hence must always also perform PSA; likewise, PSA should always be done with DRE (as can have normal PSA but abnormal prostate)

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7
Q

PSA can be raised due to a number of causes other than prostate cancer; state some

A
  • BPH
  • Urinary infection (always dipstick and if there is infection repeat PSA in 4-6 weeks)
  • Prostatitis
  • Acute urinary retention
  • Vigorous exercise (notably cycling)
  • Recent ejaculation or prostate stimulation
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8
Q

What investigations would you do if you suspect prostate cancer?

A
  • DRE
  • PSA
  • Multiparametric MRI prostate/pelvis (increasingly performed pre-biopsy as it helps decide appropriate biopsy technique since TRUS cannot access anterior whereas trasperineal allow you to access more of the prostate. Use Likert scale; if >/=3 then offer biopsy)
  • Biopsy
    • TRUS (transrectal ultrasound): local anaesthetic, put ultrasound in rectum to visualise prostate and take biopsy via the rectum)
    • Trasperineal/template biopsy: used to be under GA however now moving towards LA. Allows better access to anterior prostate and has less risk of infection. Put ultrasound in rectum but put needle through perineal region
  • Isotope bone scan: look for bony metastases. Radioactive isotope via IV injection, wait few hours then use gamma camera to take pictures.
  • PET scan: look for metastases
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9
Q

Compare advantages and disadvantages of TRUS biopsies and transperineal/template biopsies for prostate cancer

A

TRUS

  • Quicker
  • LA (although transperineal is increasingly being done under LA also as opposed to GA)

Transperineal/template

  • Allows better access to anterior portion of prostate
  • Lower infection risk
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10
Q

State some potential complications of a TRUS biopsy

A
  • Pain
  • Fever
  • Rectal bleeding
  • Haematuria
  • Sepsis (1%)
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11
Q

When should you refer a man via 2WW according to NICE?

A

Refer the man urgently using a suspected cancer pathway referral (for an appointment within 2 weeks) if:

  • Digital rectal examination (DRE) reveals a hard, nodular prostate (suggestive of cancer) or
  • PSA levels are above the age-specific reference range
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12
Q

What grading system do we use to score prostate cancer?

Briefly describe this grading system

A

Gleason Grading System

  • Based on the histology (level of differentiation) from the prostate biopsies
  • Score between 1 and 5 (greater the score, the more poorly differentiated the tissue is)
  • Gleason score is:
    • Most common differentiation/grade + second most common differentiation/grade seen (e.g. 3+4=6)
    • If there is also a small amount of a third differentiation this is often put in brackets after e.g. 3+4 (5)=7
  • We can use Gleason score to determine risk level:
    • >/=6 is low risk
    • 7 is intermediate risk
    • 8-10 is high risk
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13
Q

What staging is used for prostate cancer?

A

TNM

T for Tumour:

  • TX – unable to assess size
  • T1 – too small to be felt on examination or seen on scans
  • T2 – contained within the prostate
  • T3 – extends out of the prostate
  • T4 – spread to nearby organs

N for Nodes:

  • NX – unable to assess nodes
  • N0 – no nodal spread
  • N1 – spread to lymph nodes

M for Metastasis:

  • M0 – no metastasis
  • M1 – metastasis
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14
Q

State some common sites for metastases in prostate cancer

A
  • Bone- SCLEROTIC
  • Lymph nodes
  • Liver
  • Lungs
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15
Q

State some factors that influence treatment decisions for prostate cancer

A
  • Age (need to have 10yrs or more of life left for treatments such as radical prostatectomy)
  • DRE (DRE findings can correlate to T stage e.g. T1/T2 may have normal prostate, T3 have irregular/nodular prostate, T4 all nodules can merge so it feels smooth but it will be heard and there will be loss of gutters)
  • PSA
  • Biopsies (Gleason grade & extent)
  • MRI pelvis (N&M stage)
  • Bone scan (N&M stage)
    *
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16
Q

When deciding how to manage prostate cancer we can split in into three categories; state these

A
  • Localised prostate cancer (T1/T2= cancer not spread outside prostate)
  • Localised advanced prostate cancer (T3/T4= cancer spread to nearby sites/organs outside prostate but not to distant sites)
  • Metastatic prostate cancer
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17
Q

Discuss the management of localised prostate cancer

(T1/T2; PSA <20; N0; M0)

A

Curative Intent Options

  • Active surveillance (Sources vary but PSA every 3-4/6 months, DRE every 6-12 months, MRI scan/biopsy etc.. every 1-3yrs)
  • Radical prostatectomy (robotic approach is standard)
  • Radiotherapy
    • External beam
    • Brachytherapy (less commonly used now)

Palliative Intent Options

  • Watchful waiting and giving hormones for symptoms
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18
Q

Discuss the management of locally advanced prostate cancer

A

Various options which may be used in combination:

  • Radical prostatectomy
  • Radiotherapy (external beam or brachytherapy)
  • Hormonal therapy
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19
Q

Discuss the management of metastatic prostate cancer

A

Treatment (although inevitably all will relapse)

  • Hormone therapy
    • Surgical castration (bilateral orchidectomy)
    • Medical castration
      • GnRH agonists (+ anti-androgen at start)
  • Chemotherapy (docetaxel)- if good performance status

Palliative

  • Single dose radiotherapy
  • Bisphosphonates e.g. zoledronic acid
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20
Q

Explain how hormone therapy works for prostate cancer

Explain how hormone therapy works for prostate cancer

What must be give pts prior to starting GnRH agonists?

A
  • Growth of prostate is stimulated by androgens hence if decrease androgens we can decrease growth
  • GnRH is usually released in a pulsatile fashion; if we give GnRH agonists continually desensitisation occurs resulting in decreased LH and FSH production leading to decreased androgen production
  • Give pts bicalutamide (a non-steroidal anti-androgen) when starting an GnRH agonist to stop tumour flare (which is idea that when you initially give GnRH agonist it increases androgen production). Usually have a 10-14 days of bicalutamide prior to starting GnRH agonist and continue the bicalutamide for 4-6 weeks.
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21
Q

State some examples of hormone treatments used in prostate cancer

A
  • Goserelin (zoladex)
  • Leuprorelin (Prostap)
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22
Q

Discuss the management of metastatic castrate resistant prostate cancer

A
  • Add antiandrogen e.g. Bicalutamide
  • Consider prednisolone + docetaxel chemotherapy (if WHO performance status 0-2)
  • If docetaxel resistant and PS 0-2 consider:
    • Enzalutamide (androgen antagonist that is 5x stronger than bicalutamide)
    • Prednisolone + abiraterone (irreversibly blocks cytochrome P17 which is involved in production of testosterone)
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23
Q

State some common side effects of radical prostatectomy

A
  • Erectile dysfunction (sometimes nerve sparing techniques can be used)
  • Urinary incontinence
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24
Q

State a key side effect/complication of external beam radiotherapy for prostate cancer

A
  • Proctitis (inflammation of rectum) causing pain, altered bowel habit (frequency & urgency), rectal bleeding & discharge, altered bladder habits
    • ~⅓ experience long term minor increase in bowel frequency & rectal bleeding
  • Erectile dysfunction (40%)

*Can give prednisolone suppositories to help proctitis

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25
State some common side effects of brachytherapy for prostate cancer
* Cystitis *(dysuria, increased frequency)* * Proctitis *(pain, increased frequency, rectal bleeding & discharge)* * Erectile dysfunction * Incontinence * Increased risk of bladder cancer * Increased risk of rectal cancer
26
State some common side effects of hormone therapy
* Hot flushes * Gynaecomastia * Fatigue/lethargy * Osteoporosis * Sexual dysfunction * Reduced libido * Varying degrees of erectile dysfunction
27
Discuss whether PSA screening should be routinely done
* PSA is a protease enzyme produced by both normal and malignant prostate epithelial cells * 1 in 7 men with normal PSA have prostate cancer. 1 in 50 will have higher risk prostate cancer. * In men aged 50-70yrs 10% will have raised PSA. Around 25-30% men with PSA of 4-10ng/ml will have prostate cancer. Around 50-60% of men with PSA 10-20ng/ml will have prostate cancer. * However, just because they have prostate cancer it does not mean it would have caused a problem and required treatment before they die (of other causes). ERSPC (screening) trial found that 50% had clinically insignificant CaP. * Many men die with prostate cancer not from it * PSA testing and early diagnosis of cancer may lead to overdiagnosis and over-treatment * Many of treatments for prostate cancer decrease quality of life (see side effects of treatments cards) * Hence, routine screening is not done however you can do a PSA in men over 50yrs who request it and consider it in men with symptoms that might suggest prostate cancer. You must counsel men about PSA testing prior to testing. Can also guide to online resources e.g. NHS website, PHE patient sheet regarding PSA
28
Highlight issues/disadvantages of PSA screening
* Overdiagnosis * Over-treatment * QoL (many of treatments decrease QoL) * Not cost-effective to do mass screening
29
Discuss the prognosis of prostate cancer *(what is the 5yr survival?)*
5yr survival= \>85% 10yr survival= ~80% *\*\*Sources vary. Figures taken from Cancer Research UK*
30
See Yr3 Surgery: General Surgery for more on other types of urological cancer
31
State some differential diagnoses for haematuria
_Urological_ * Cancer * Renal cell carcinoma * Upper tract TCC * Bladder carcinoma * Advanced prostate carcinoma * Other * Stones * Infection * Inflammation * BPH * _Nephrological_ * Glomerulonephritis
32
State some potential causes of haematuria
_Urological_ * Cancer * Renal cell carcinoma *(most common histological subtype is clear cell)* * Upper tract TCC * Bladder carcinoma * Advanced prostate carcinoma * Other * UTI * Stones * Inflammation * BPH _Nephrological_ * Glomerulonephritis
33
Which pts with haematuria should be referred for further investigations via 2WW?
_Refer via 2WW if pt is_ **_\>/=45yrs_** _and has either_: * **Unexplained visible haematuria** without UTI * Or **visible haematuria** that **persists or recurs** after successful treatment of **UTI** _Refer via 2WW if pt is_ **_\>/=60yrs_** _with unexplained_ **_non-visible haematuria_** _and either:_ * **Dysuria** * Or **raised WCC** on blood test *\*NOTE: these show when to refer with haematuria. Image shows cancer specific referral*
34
What investigations should be done for haematuria when pt is referred to urology?
* Ultrasound renal tract * Flexible cystoscopy * Urine sample sent for cytology
35
Discuss the epidemiology of renal cell carcinoma, include: * Age of presentation * What is happening to incidence & mortality * Male:female ratio * % that have metastases on presentation
* 50-70yrs * Incidence & mortality increasing * Male: female is 3:1 * 30% have metastases on presentation
36
State some associations/risk factors for renal cell carcinoma
* Smoking * Industrial exposure to carcinogens (e.g. aromatic hydrocarbons) * Dialysis * Hypertension * Other disorders e.g. von Hippel-Lindau disease, tuberous sclerosis
37
State some clinical features of renal cell carcinoma
* Haematuria (visible or non-visible) * Flank pain * Flank mass * Left sided varicocele * Generic symptoms e.g. fatigue, anorexia, weight loss * Endocrine effects e.g. * Polycythaemia (secrete EPO) * Hypercalcaemia (secrete PTH) * Hypertension (renin) * Cushing's (ACTH)
38
Discuss the management of renal cell carcinoma
* _Localised disease:_ * Partial or total nephrectomy * If not suitable for surgery, percutaneous radiofrequency ablation or cryotherapy * _Metastatic_ * Immunotherapy (e.g. IFN-alpha or IL-2 agents) - *this may be combined with nephrectomy if pt otherwise fit and well* * Biological agents such as receptor tyrosine kinase inhibitors e.g. sunitinib *\*RENAL CELL CARCINOMA IS CHEMO AND RADIO RESISTANT*
39
Discuss the prognosis of renal cell carcinoma
* 25% have metastases at presentation * Prognosis dependent on stage when present * If localised and have nephrectomy then 5yr survival ~60% * Poorer prognosis with worse stage disease
40
Who should you refer via 2WW for testicular cancer?
If testicular cancer, or squamous cell carcinoma of the scrotum is suspected, the person should be referred for an urgent outpatient appointment with a urologist, to be seen within 2 weeks. *\*may present with non-painful enlargement, change in shape, change in texture*
41
For testicular cancer, discuss: * Age common in * Risk factors * What type of tumour most common
* **20-30yrs** * Risk factors: * **Cryptorchidism** * FH * Kleinfelter's syndrome * Mumps orchitis * **95% are germ cell tumour**s * Germ cells tumours can be divided into seminomas and non-seminomas (embryonal, yolk sac, teratoma, choriocarcinoma) * Non-germ cell tumours which include Leydig & Sertoli cell tumours
42
State some clinical features of testicular cancer
* Lump which is usually _PAINLESS_ * Hydrocele * Gynaecomastia *(occurs due to increased oestrogen: androgen ratio)*
43
Discuss epidemiology of bladder cancer. including: * Age of presentation * Male:female ratio * Ethnicity most common in * Types
* \>60yrs * Male:female is 3:1 * White \> non-white * Types: * Transitional cell carcinoma (80-90%) * Squamous cell carcinoma * Adenocarcinoma (rare) * Sarcoma (rare)
44
Explain why gynaecomastia can occur in testicular cancer
* **Increase in oestrogen: androgen ratio** * In germ cell tumours: hCG is released which leads to Leydig cell dysfunction causing increase in both oestradiol and testosterone (but oestradiol rise is greater) * In leydig cell tumours: secrete more oestradiol and convert additional androgen precursors into oestrogens
45
State what investigations would be done in suspected and/or confirmed testicular cancer
* **First line= ultrasound testes** * Tumour markers: * **hCG** (seminomas & non-seminomas) * **AFP** (non-seminomas) * **LDH** (40% germ cell tumours) * **Staging with CT chest-abdomen-pelvis** with contrast
46
What staging is used for bladder cancer?
TNM *\*don't need to learn specific TNM staging. Know that most are superficial upon presentation* T0- No evidence of tumour Ta- Non invasive papillary carcinoma T1- Tumour invades sub epithelial connective tissue T2a- Tumor invades superficial muscularis propria (inner half) T2b- Tumor invades deep muscularis propria (outer half) T3- Tumour extends to perivesical fat T4- Tumor invades any of the following: prostatic stroma, seminal vesicles, uterus, vagina T4a- Invasion of uterus, prostate or bowel T4b- Invasion of pelvic sidewall or abdominal wall N0- No nodal disease N1- Single regional lymph node metastasis in the true pelvis (hypogastric, obturator, external iliac, or presacral lymph node) N2- Multiple regional lymph node metastasis in the true pelvis (hypogastric, obturator, external iliac, or presacral lymph node metastasis) N3- Lymph node metastasis to the common iliac lymph nodes M0- No distant metastasis M1- Distant disease
47
Discuss the management of testicular cancer
Management depends on type and stage. Options include: * **Inguinal orchidectomy** *(inguinal approach limits lymphatic disruption)* * **Chemotherapy** * **Radiotherapy** * **Cryopreservation should be offered**
48
Discuss the prognosis of testicular cancer
98% 10yr survival
49
Discuss the epidemiology of bladder cancer, include: * Age of presentation * Male: female ratio * Which ethnicity more common in * What is happening to incidence and mortality?
* \>55/60yrs (AVERAGE AGE DIAGNOSIS ~73YRS) * Male:female is 3:1 * White \> non-white * Incidence decreasing, mortality decreasing but less so in women
50
State some risk factors for bladder cancer
* Smoking (x4) * Exposure to anile dyes/amylamines- commonly through rubber or plastics manufacture * Cyclophosphamide * Exposure to polyaromatic hydrocarbons- through handling of carbon, crude oil, combustion * Schistosomiasis (squamous cell carcinoma type)
51
State some symptoms & signs of bladder cancer
* Haematuria * Painless visible haematuria (most pts) * Non-visible haematuria * Recurrent UTIs * Pelvic pain * Systemic symptoms (weight loss, lethargy)
52
Discuss the 2WW referral criteria for bladder cancer
* **\>/=45yrs** and have: * Unexplained v**isible haematuria** without UTI * or **visible haematuria that persists or recurs** after successful treatment of urinary tract infection. * \>/=60yrs and have **unexplained non-visible haematuria** and **either dysuria or a raised white cell count on a blood test**
53
Discuss the management of intermediate/high risk non-muscle invasive bladder cancer
* Resection via TURBT * Adjuvant intravesical chemotherapy (BCG or mitomycin C)
54
What investigations will be done for bladder cancer?
* **Flexible cystoscopy** (under LA) * **Rigid cystoscopy** (if tumour identified) for biopsy *(may also potentially resect tumour, TURBT, if it appears superficial or may wait until after biopsy results)* * **Staging CT thorax, abdomen, pelvis**
55
Management of bladder cancer is determined by the classification; state 4 categories that are often used when deciding how to treat bladder cancer
* Low risk non-muscle invasive * Intermediate/high risk non-muscle invasive * Muscle invasive * Metastatic
56
Discuss the management of muscle invasive bladder cancer
Management can be **potentially curative or palliative** (see image) Pts having radical cystectomy will require urinary diversion either via: * **Ileal conduit** **formation** with urine draining via a urostomy * **Bladder reconstruction**, from a segment of small bowel\* (often termed a neobladder) and urine draining urethrally or via catheter Will then require **regular follow-up with CT imaging** to monitor for local and distant recurrence. **B12** should also be checked annually due to resection of part of ileum *\*Chemo is typically cis-platin based*
57
Discuss the management of low risk non-muscle invasive bladder cancer
* Resection via TURBT
58
Discuss the management of metastatic bladder cancer
* **Chemotherapy** *(cis platin based or* carboplatin plus gemcitabine-based regime) * **Immunotherapy** (e.g. antibodies to target the programmed cell death receptor 1 and block protective mechanism of cancer cells against destruction by immune system)
59
Image showing ileal conduit & neobladder
60
Discuss the management of upper urinary tract TCC
Nephro-urectomy (removal of kidney, fat, ureter, cuff of bladder)
61
Discuss the prognosis of bladder cancer
5yr survival ~50%
62
For penile cancer, discuss: * Age range most commonly affected * How common it is * Risk factors * What is protective? * Most common type
* Most commonly in men \>60yrs * Uncommon ~600 new cases/yr in UK * Risk factors: * HPV 16 & 18 * Phimosis (leading to issues with hygiene & smegma) * Smoking * Lichen sclerosis * Age * HIV * Previous UV light treatment for psoriasis * Circumcision is protective * Squamous cell carcinoma
63
Describe presentation of penile cancer
* Persisting growth or sore on penis * Rash * Bleeding from the penis or under the foreskin * Smelly discharge * Thickening of the skin of the penis or foreskin causing phimosis * Change in the colour of the skin of your penis or foreskin Other symptoms of penile cancer include: * Lump in the groin * Fatigue * Stomach pain * Weight loss
64
Discuss 2WW referral for penile cancer
Men with any of the following (after STI has been ruled out as a cause, or they have completed treatment for an STI): * Penile mass * Ulcerated lesion * Unexplained or persistent symptoms affecting the foreskin or glans
65
Discuss investigations for penile cancer
Would be referred to specialist regional centre * Penile biopsy * PET-CT imaging to determine if there is inguinal lymphadenopathy * Staging CT TAP if have positive inguinal lymph nodes
66
Discuss management of penile cancer
Management often requires combination of surgery, radiotherapy & chemotherapy. * Superficial may be offered topical chemotherapy & long term surveillance * Laser treatment to ablate tumour * Surgery to remove tumour *(whilst ensuring as much of penis is preserved as possible) \*\*MOST CASES REQUIRE SURGERY* * Neoadjuvant radiotherapy or chemotherapy may be required
67
Discuss the prognosis of penile cancer
* 5yr survival is 70%
Yr4: Cancer Care
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