Urological Cancer
Kieran JeffersonConsultant Urological SurgeonUniversity Hospital, Coventry
Recommended Texts
Urology a handbook for medical studentsBrewster, Cranston et al
Oxford Handbook of UrologySimilar authors, more postgraduate
Two-week wait urology
Haematuria frank/microscopic over 50 years oldRaised PSA/abnormal DREMass in body of testisRenal mass on imaging/palpationAny suspicious penile lesion
Haematuria
Common, major challenge for urologists
Visible haematuria 20% chance cancer
Microscopic haematuria 5-10% chance
Causes of haematuriaInfectionBenign prostatic hypertrophyMalignancy bladder, kidney, ureter, prostateStone bladder, ureter, kidneyGlomerulonephritisIgA nephropathyTrauma
Management
History and examination
Investigations
Treatment
HistoryType, duration, associated LUTS or painMedicationAnticoagulantsnephrotoxinsMedical/surgical historystone or previous surgerySHxSmoking, chemical exposure, employment
Examination
Stigmata of renal diseaseHypertensionOedema
Abdomino-pelvic masses/scars
InvestigationsIdeally as part of one-stop haematuria clinic
MSU dipstix, M,C&S, cytologyFBC, U&EsFlexible cystoscopyUSS renal tract +/- or contrast CT
Treatment
As per aetiology
Bladder cancer
4th commonest male/10th commonest female cancer
Risk FactorsAge, sexSmoking, exposure to benzene compoundsDrugs phenacetin, cyclophosphamide
Bladder cancer subtypesPrimaryTransitional cell carcinomaSquamous cell carcinomaAdenocarcinomaSarcoma
Secondary
PresentationSymptoms/signs from primary or secondary tumours +/- paraneoplastic phenomena
Haematuria, dysuria, frequency/urgencyUreteric obstruction
Ureteric obstruction
ManagementAs 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
Diagnosis/staging
Clinical diagnosis usually made at flexi cystoTURBT (including VE or DRE) to establish tissue diagnosis, then MitomycinIf tissue stage pT2 or greater, staging CT chest/abdo/pelvis
Prognosis
Superficial TCC excellent unless high-grade
Invasive TCC approx 50% overall 5y/s
Metastatic extremely poor
Renal cell cancerUK 7000 cases; 3600 deaths/year 3% all cancerMortality is NOT declining>50% incidental findings on imaging30% present with metastases
Clinical FeaturesAsymptomatic (>50%)HaematuriaFlank PainMass
Metastatic/paraneoplastic
Anaemia (>30%)Erythrocytosis (3%)CachexiaHepatic dysfunctionHormonal abnormalitiesHypercalcaemiaParaneoplastic Syndromes
Metastases
LungBoneLiverBrain
ManagementDependent on stage, grade & co-morbidity!Curative vs palliative
Only curative option is surgeryLaparoscopic radical nephrectomyLap/open partial nephrectomyPalliation with TKIs and mTOR antagonists
Prognosis
Good if resectable primary tumour
Very poor for metastatic disease
Prostate cancerCommonest solid tumour in UK males35000 cases & 10000 deaths per year
Risk factorsAge, male sex
Significantly less common in oriental races
Pathology
Adenocarcinoma is commonest form (95%+)
Gleason Grading systemSum of two commonest morphologies
Presentation
Asymptomatic raised PSA/opportunistic DRE
LUTS, lymphoedema, PE/DVT, ureteric obstruction/ARF, haematuria, impotence
Bone pain, anaemia, sclerotic bone on XR
ManagementDependent on stage, grade & co-morbidity!
History & Examination
PSA, U/Es, FBCTruss-guided prostate biopsyIsotope bone scan/MRI prostate
Selecting treatmentNot all tumours warrant treatment (morbidity of treatment outweighs potential benefit to patient)
Whitmores conundrumIs it possible that no treatable prostate cancer requires treatment, but that all those requiring treatment are untreatable?
Treatment optionsCurative (radical)Radical prostatectomy (open, laparoscopic, robotic)Radical external beam radiotherapyBrachytherapy
PalliativeWatchful waitingHormone ablationChemotherapyRadiotherapy
The Third Way
Active surveillanceAims to select out patients who will do badly and defer radical treatment until progression is imminentGood evidence that rate of change of PSA correlates well with aggressiveness of tumourOnly immediate side-effect is psychological
Testicular cancer
Commonest solid tumour of young men
Commoner in European populations
Exceptionally good prognosis due to effective platinum-based chemotherapy
Pathology
Germ cell tumours (95%)Seminoma, teratoma
Sertoli cell tumoursLeydig cell tumoursLymphomas (older men)
Presentation
Painless testicular lumpPain from infarction/infection/trauma
Symptomatic metastasesRetroperitoneal lymph nodes (varicocoele)Lungs, bones
Management
Dependent on stage, grade & co-morbidity!
ButAlmost all are potentially curableCo-morbidity is uncommon in these men
AssessmentHistory & Examination
Serum Tumour Markerslpha-foetoprotein (AFP)-human chorionic gonadotrophin (hCG)Lactate dehydrogenase (LDH)
Radical orchidectomy for histology followed by CT chest/abdo/pelvis
Oncological managementMost now get chemotherapyPlatinum-based
Some also radiotherapy and retroperitoneal lymph node dissection
Vast majority are cured but need regular imaging and risk second Ca
Penile cancerRare (in UK)Association with HPV subtypes (cf cervical cancer)Any suspicious lesion on glans or prepuce warrants early referral if fails to respond to steroidsSquamous tumours usually treated surgically, some role for radiotherapy/chemo
Any questions?
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