Urological Cancer Kieran Jefferson Consultant Urological Surgeon
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Transcript of Urological Cancer Kieran Jefferson Consultant Urological Surgeon
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Urological Cancer
Kieran JeffersonConsultant Urological SurgeonUniversity Hospital, Coventry
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Recommended Texts
• Urology – a handbook for medical students
– Brewster, Cranston et al
• Oxford Handbook of Urology
– Similar authors, more postgraduate
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Two-week wait urology
• Haematuria – – frank/microscopic over 50 years old
• Raised PSA/abnormal DRE• Mass in body of testis• Renal mass on imaging/palpation• Any suspicious penile lesion
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Haematuria
• Common, major challenge for urologists
• Visible haematuria 20% chance cancer
• Microscopic haematuria 5-10% chance
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Causes of haematuria
• Infection• Benign prostatic hypertrophy• Malignancy
– bladder, kidney, ureter, prostate
• Stone – bladder, ureter, kidney
• Glomerulonephritis– IgA nephropathy
• Trauma
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Management
• History and examination
• Investigations
• Treatment
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History
• Type, duration, associated LUTS or pain• Medication
– Anticoagulants– nephrotoxins
• Medical/surgical history– stone or previous surgery
• SHx– Smoking, chemical exposure, employment
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Examination
• Stigmata of renal disease– Hypertension– Oedema
• Abdomino-pelvic masses/scars
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Investigations• Ideally as part of ‘one-stop’ haematuria
clinic
• MSU dipstix, M,C&S, cytology• FBC, U&Es• Flexible cystoscopy• USS renal tract +/- or contrast CT
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Treatment
• As per aetiology
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Bladder cancer
• 4th commonest male/10th commonest female cancer
• Risk Factors– Age, sex– Smoking, exposure to benzene compounds– Drugs – phenacetin, cyclophosphamide
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Bladder cancer subtypes
• Primary– Transitional cell carcinoma– Squamous cell carcinoma– Adenocarcinoma– Sarcoma
• Secondary
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Presentation
• Symptoms/signs from primary or secondary tumours +/- paraneoplastic phenomena
• Haematuria, dysuria, frequency/urgency• Ureteric obstruction
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Ureteric obstruction
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Management• As for all cancers, dependent on stage
and grade of tumour and co-morbidities
• TCCs described as GxTy (grade/TNM stage)
• Can be either curative or palliative
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Diagnosis/staging
• Clinical diagnosis usually made at flexi cysto
• TURBT (including VE or DRE) to establish tissue diagnosis, then Mitomycin
• If tissue stage pT2 or greater, staging CT chest/abdo/pelvis
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Treatment
• Superficial TCC (pT<2)– TURBT followed by regular review flexi cystoscopy– Intravesical treatment with mitomycin or bCG if high grade or
multiply recurrent– Recurrent high grade disease merits consideration of
cystectomy
• Invasive TCC or other subtypes– Radical surgery or radiotherapy after neoadjuvant
chemotherapy if cure possible– Palliative surgery/radiotherapy/medical symptom control
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Prognosis
• Superficial TCC – excellent unless high-grade
• Invasive TCC – approx 50% overall 5y/s
• Metastatic – extremely poor
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Renal cell cancer
• UK 7000 cases; 3600 deaths/year • 3% all cancer• Mortality is NOT declining• >50% incidental findings on imaging• 30% present with metastases
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Clinical Features
• Asymptomatic (>50%)• Haematuria• Flank Pain• Mass
• Metastatic/paraneoplastic
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• Anaemia (>30%)• Erythrocytosis (3%)• Cachexia• Hepatic dysfunction• Hormonal abnormalities• Hypercalcaemia
Paraneoplastic Syndromes
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Metastases
• Lung• Bone• Liver• Brain
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Management
• Dependent on stage, grade & co-morbidity!• Curative vs palliative
• Only curative option is surgery– Laparoscopic radical nephrectomy– Lap/open partial nephrectomy
• Palliation with TKIs and mTOR antagonists
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Prognosis
• Good if resectable primary tumour
• Very poor for metastatic disease
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Prostate cancer
• Commonest solid tumour in UK males• 35000 cases & 10000 deaths per year
• Risk factors• Age, male sex
• Significantly less common in oriental races
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Pathology
• Adenocarcinoma is commonest form (95%+)
• Gleason Grading system• Sum of two commonest morphologies
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Presentation
• Asymptomatic • raised PSA/opportunistic DRE
• LUTS, lymphoedema, PE/DVT, ureteric obstruction/ARF, haematuria, impotence
• Bone pain, anaemia, sclerotic bone on XR
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Management• Dependent on stage, grade & co-morbidity!
• History & Examination
• PSA, U/Es, FBC• Truss-guided prostate biopsy• Isotope bone scan/MRI prostate
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Selecting treatment• Not all tumours warrant treatment (morbidity
of treatment outweighs potential benefit to patient)
• Whitmore’s conundrum– ‘Is it possible that no treatable prostate cancer
requires treatment, but that all those requiring treatment are untreatable?’
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Treatment options
• Curative (radical)– Radical prostatectomy (open, laparoscopic, robotic)– Radical external beam radiotherapy– Brachytherapy
• Palliative– Watchful waiting– Hormone ablation– Chemotherapy– Radiotherapy
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‘The Third Way’
• Active surveillance– Aims to select out patients who will do badly and defer radical
treatment until progression is imminent– Good evidence that rate of change of PSA correlates well with
aggressiveness of tumour– Only immediate side-effect is psychological
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Testicular cancer
• Commonest solid tumour of young men
• Commoner in European populations
• Exceptionally good prognosis due to effective platinum-based chemotherapy
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Pathology
• Germ cell tumours (95%)• Seminoma, teratoma
• Sertoli cell tumours• Leydig cell tumours• Lymphomas (older men)
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Presentation
• Painless testicular lump• Pain from infarction/infection/trauma
• Symptomatic metastases• Retroperitoneal lymph nodes (varicocoele)• Lungs, bones
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Management
• Dependent on stage, grade & co-morbidity!
• But• Almost all are potentially curable• Co-morbidity is uncommon in these men
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Assessment• History & Examination
• Serum Tumour Markers• Αlpha-foetoprotein (AFP)• ß-human chorionic gonadotrophin (hCG)• Lactate dehydrogenase (LDH)
• Radical orchidectomy for histology followed by CT chest/abdo/pelvis
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Oncological management• Most now get chemotherapy
• Platinum-based
• Some also radiotherapy and retroperitoneal lymph node dissection
• Vast majority are cured but need regular imaging and risk second Ca
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Penile cancer• Rare (in UK)• Association with HPV subtypes (cf cervical
cancer)• Any suspicious lesion on glans or prepuce
warrants early referral if fails to respond to steroids
• Squamous tumours usually treated surgically, some role for radiotherapy/chemo
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Any questions?