Urological Cancers Flashcards
What is the epidemiology of kidney cancer?
13,100 new kidney cancer cases in the UK every year
7th most common in the UK
Incidence and mortality rates are rising
What are the different types of kidney cancers?
Renal Cell Carcinoma (RCC / adenocarcinoma) = 85%
Transitional cell carcinoma = 10%
Sarcoma / Wilms tumour / other types = 5%
What are the risk factors for kidney cancer?
Smoking Renal failure and dialysis Obesity Hypertension Genetic predisposition with Von Hippel-lindau syndrome - (50% of individuals will develop RCC
How does kidney cancer present clinically?
Haematuria
Loin pain
Palpable mass
Matastatic disease symptoms - bone pain, haemoptysis
What is the red flag symptom clinically for kidney cancer?
Painless haematuria - esp. painless because if it is painful, it is also likely to be an infection etc.
OR
Persistent microscopic haematuria
What is the first line investigation with anyone presenting with the red flag symptoms of (painless OR persistent non-visible microscopic) haematuria?
Painless = Flexible cystoscopy (looks at bladder and urethra) CT urogram (looks at kidneys and ureter- doesn't fully look at bladder) Renal function
Persistent non-visible haematuria =
Flexible cystoscopy
USS KUB (ultrasound scan kidneys, ureter, and bladders)
What investigations are done next if the first line imaging shows suspected kidney cancer?
CT renal triple phase (corticomedullary, nephrogenic and renal phase- allows you to see urinary tract at different times)
Staging CT chest
Bone scan if symptomatic
How is kidney cancer staged using the TNM staging or Fuhrman grade system?
TNM staging of RCC = T1 – Tumour ≤ 7cm T2 – Tumour >7cm T3 – Extends outside kidney but not beyond ipsilateral adrenal or perinephric fascia T4 – Tumour beyond perinephric fascia into surrounding structures N1 – Met in single regional LN N2 – met in ≥2 regional LN M1 – distant met
Fuhrman grade =
1 = well differentiated (not worrying)
2 = moderate differentiated
3 + 4 = poorly differentiated
How is kidney cancer managed?
Patient specific - depends on:
- ASA status (can they tolerate anasthsia and surgery)
- comorbidities
- classification of the lesion itself - staging and metastases
Gold standard = excision of partial or whole kidney (takes out ureter too)
AKA partial or radical (entire thing) nephrectomy
When is partial nephrectomy chosen over radical nephrectomy?
Partial = if they have a single functioning kidney, bilateral tumour, multifocal (multiple small lesions) RCC in patients with Von Hippel Lindau, a small tumour (T1 tumours up to 7cm) etc.
What is the management for patients with small tumours that are unfit for surgery?
What is the management for patients with metastatic disease?
In patients with small tumours unfit for surgery = cryosurgery (use of extreme cold to destroy abnormal tissues e.g. using liquid nitrogen)
Metastatic disease = Receptor Tyrosine Kinase inhibitors
What is the epidemiology for bladder cancer?
10,200 new bladder cancer cases in the UK every year
11th most common cancer in the UK
Incidence and mortality declining (more screening, less smokers)
What are the different types of bladder cancer?
Transitional cell carcinoma = >90%
Squamous Cell Carcinoma = 1-7% (75% SCC where schistosomiasis is endemic)
Adenocarcinoma = 2%
What are the main risk factors for bladder cancer?
Smoking
Occupational exposure e.g. aromatic hydrocarbons, dye industry etc., less of an issue now with better regulations
Radiotherapy - for other conditions
Chronic infections - e.g. long-term catheters, gallstones, schistosomiasis (parasitic flatworms)
How does bladder cancer present clinically?
Haematuria
Suprapubic pain
Lower urinary tract symptoms
Metastatic disease symptoms - bone pain, lower limb swelling
What is the main red flag sign clinically for bladder cancer?
Painless haematuria - esp. painless because if it is painful, it is also likely to be an infection etc.
OR
Persistent microscopic haematuria
What is the first line investigation with anyone presenting with the red flag symptoms of (painless OR persistent non-visible microscopic) haematuria?
Painless visible =
Flexible cystoscopy
CT urogram
Renal function
Persistent non-visible / microscopic =
Flexible cystoscopy
Ultrasound (USS) kidneys, ureters, and bladders (KUB)
What investigations are done next if the first line imaging shows suspected bladder cancer?
Cystoscopy = camera placed via urethra to look into bladder and biopsy of lesion
Biopsy - check for muscle invasion
How is bladder cancer staged using the TNM system and WHO classification?
TNM system =
Staged in terms of invasion into the bladder mucosa:
Ta – non invasive papillary carcinoma
Tis – carcinoma in situ
T1 – invades subepithelial connective tissue
T2 – invades muscularis propria
T3 – invades perivesical fat
T4 – prostate, uterus, vagina, bowel, pelvic or abdominal wall
N1 – 1 LN below common iliac birufication
N2 - >1 LN below common iliac birufication
N3 – Mets in a common iliac LN
M1- distant mets
WHO system =
G1 = well differentiated
G2 = moderate differentiated
G3 = poorly differentiated
What is one method of resecting a bladder lesion?
cystoscopy and transurethral resection
Use cystoscope to look at the bladder lesion
Then use heat to cut out all visible bladder tumour
Provides histology and can also be curative - but if the tumour extends beyond muscle then the resection is incomplete due to risk of perforating the bladder
What is the management protocol for bladder cancer?
Muscle invasive =
Cystectomy (removal of part or whole bladder)
Radiotherapy (sometimes neoadjuvant radio/chemo before therapy)
+/- chemotherapy
Palliative treatment
Non-muscle invasive =
If low grade and no concerns over carcinoma in situ (CIS), then consideration of cystoscopic surveillance
Then use heat and cauterise to excise lesion OR intravesical chemotherapy or BCG (immunological therapy) to limit progression of the lesion
What is the epidemiology of prostate cancer?
48,500 new prostate cancer cases in the UK every year
Most common cancer in men within the UK
Incidence rising but mortality rates declining (PSA screening)
What are the different types of prostate cancer?
Adenocarcinoma = >95%
What are the risk factors for prostate cancer?
Increasing age
Western nations (Scandinavian countries)
Ethnicity - particularly African Americans
