Urological cancers

Question 1

What is the most common type of kidney cancer?

Answer 1

Renal cell carcinoma (adenocarcinoma)

Question 2

What is the name of the cancer where malignant cells form in the renl pelvis (top part of the kidney) and ureter?

Answer 2

Transitional cell carcinoma

Question 3

What is a red flag symptom that can reflect any urological malignancy in the kidney, ureter, bladder or urethra?

Answer 3

Painless haematuria or Persistent microscopic haematuria (latter often in incidental scanning)

Question 4

What is the most common presentation in kidney cancer patients?

Answer 4

Haematuria

Question 5

What could you expect to find on physical examination of a kidney cancer patient?

Answer 5

Palpable mass

Question 6

If you suspect kidney cancer, what should be done?

Answer 6

CT renal triple phase - assessment of renal masses

Staging CT Chest

Bone scan if symptomatic

Question 7

What does the T1-4 mean in the TNM staging of RCC?

Answer 7

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

Question 8

Define the N1-2 in the TNM staging of RCC?

Answer 8

N1 - Metastasis in single regional lymph node

N2 - Metastasis in ≥2 regional lymph nodes

Question 9

What is meant by M1 in TNM staging of RCC?

Answer 9

Distant metastasis.

Question 10

What grading system do you use for kidney cancer and describe what the different grades mean

Answer 10

FUHRMANS GRADE
1 = well differentiated

2 = moderate differentiated

3 + 4 = poorly differentiated

Question 11

What is the gold standard for kidney cancer management?

Answer 11

Partial nephrectomy

Radical nephrectomy - especially for RCC

Question 12

When would you consider partial nephrectomy over a radical nephrectomy?

Answer 12

-Single kidney
-Bilateral tumour
-T1 tumours

Question 13

In patients with small tumours unfit for surgery, what management is considered?

Answer 13

Cryosurgery

Question 14

In metastatic disease, what management is considered?

Answer 14

Receptor Tyrsoine Kinase inhibitors

Question 15

What is the most common type of bladder cancer?

Answer 15

90% of bladder cancer is Transitional Cell Carcinoma

Question 16

Where shistosomiasis is endemic, what type of bladder cancer is most common?

Answer 16

Squamous cell carcinoma

Question 17

What are additional features of bladder cancer?

Answer 17

Suprapubic pain

Lower urinary tract symptoms - burning pee, bloody urine etc

Metastatic disease symptoms - bone pain, lower limb swelling

Irritative - going to the toilet a lot

Question 18

If a patient has painless visible haematuria but you suspect anaemia, what test might you order?

Answer 18

FBC

Question 19

What investigations would you carry out when there is painless visible haematuria?

Answer 19

-Flexible cytoscopy
-CT urogram
-Renal function

Question 20

What investigations should be carried out for persistent microscopic haematuria?

Answer 20

Flexible cystoscopy

US Kidneys and Urinary Bladder - does not look at ureters in males, this is only seen in females

Question 21

If biopsy is proven muscle invasive, then what investigation set should be done?

Answer 21

Staging investigations

Question 22

What is the difference between Ta and Tis in TNM staging of bladder cancer?

Answer 22

Ta - non invasive papillary carcinoma

Tis - carcinoma in situ

Question 23

What is the WHO classification grading system for bladder cancer?

Answer 23

G1 - Well differentiated

G2 - Moderate differentiated

G3 - Poorly differentiated

Question 24

If the cancer is multifocal, what is treatment is recommended?

Answer 24

Bladder chemotherapy

Question 25

What is MRI useful for in bladder cancers?

Answer 25

For fistula detection and investigation

Question 26

What is a fistula?

Answer 26

A fistula is an abnormal connection or passageway that forms between two organs or between an organ and the skin.

Question 27

When a patient acutely presents with haematuria, what investigation is performed?

Answer 27

Cystoscopy + Transuretheral resection of bladder lesion Uses heat to cut out all visible bladder tumour

Question 28

What is the management for non-muscle invasive bladder cancer?

Answer 28

If low grade and no carcinoma in situ: -cystoscopic surveillance +/- intravesicular chemotherapy/Bacillus Calmette-Guerin (intravesicular immunotherapy that triggers immune response of bladder)

Question 29

If the bladder cancer is muscle invasive, then what management should be carried out?

Answer 29

Cystectomy Radiotherapy - but may not be fit enough +/- chemotherapy as neo-adjuvant Palliative treatment

Question 30

What blood tests would you take whilst investigating prostate cancer?

Answer 30

PSA test (prostate specific antigen)

Question 31

Why should you not screen for PSA in a patient with a UTI?

Answer 31

UTI can cause the prostate to enlarge which increases PSA

Question 32

What investigation is superior to the previous gold standard of transrectal ultrasonography-guided prostate biopsies?

Answer 32

Multiparametric MRI before biopsy and then MRI targeted biopsy

Question 33

What is the preferred way of taking a biopsy of the prostate?

Answer 33

Trans perineal prostate biopsy

Question 34

What is meant by T1-4 in the TNM staging of prostate cancer?

Answer 34

T1 – non palpable or visible on imaging T2 – palpable tumour T3 – beyond prostatic capsule into periprostatic fat T4 – tumour fixed onto adjacent structure/pelvic side wall

Question 35

What is meant by T1a-T1c?

Answer 35

T1a means cancer is <5% of removed tissue T1b means cancer is ≥5% of removed tissue T1c cancers are found by biopsy, for example after raised PSA level

Question 36

What does T2a-T2c mean?

Answer 36

T2a - cancer only half on one side of prostate gland T2b - cancer in more than half a side of prostate gland but not on both sides T2c - cancer in both sides but still inside prostate gland

Question 37

What is meant by T3a-T3b?

Answer 37

T3a - cancer broken through capsule of prostate gland T3b - cancer spread into seminal vesicles

Question 38

What is meant by N1 in TNM staging of prostate cancer?

Answer 38

Regional lymph node involvement (pelvis)

Question 39

What is meant by M1a, M1b and M1x in TNM staging of prostate cancer?

Answer 39

M1a- non regional LN (outside the pelvis) M1b- bone M1x- other sites

Question 40

What do you use to report how differentiated a cancer cell is?

Answer 40

Gleason score.

Question 41

If the patient is young and fit, then how does the management change if they have high or low grade cancer?

Answer 41

High grade (7 or +) → Radical prostatectomy/Radiotherapy Low grade → Active surveillance (Regular PSA, MRI and Bx)

Question 42

What are the side effects of the prostatectomy?

Answer 42

Incontinence - due to removal of proximal sphincter and so there is increased urethral length Erectile Dysfunction - damage to cavernous nerves (innervation to bladder and urethra)