Transcript Urology for Medical students

Urological Cancer
Kieran Jefferson
Consultant Urological Surgeon
University Hospital, Coventry
Recommended Texts
• Urology – a handbook
for medical students
– Brewster, Cranston et al
• Oxford Handbook of
Urology
– Similar authors, more
postgraduate
Two-week wait urology
• Haematuria –
– frank/microscopic over 50 years old
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Raised PSA/abnormal DRE
Mass in body of testis
Renal mass on imaging/palpation
Any suspicious penile lesion
Haematuria
• Common, major challenge for urologists
• Visible haematuria  20% chance cancer
• Microscopic haematuria  5-10% chance
Causes of haematuria
• Infection
• Benign prostatic hypertrophy
• Malignancy
– bladder, kidney, ureter, prostate
• Stone
– bladder, ureter, kidney
• Glomerulonephritis
– IgA nephropathy
• Trauma
Management
• History and examination
• Investigations
• Treatment
History
• Type, duration, associated LUTS or pain
• Medication
– Anticoagulants
– nephrotoxins
• Medical/surgical history
– stone or previous surgery
• SHx
– Smoking, chemical exposure, employment
Examination
• Stigmata of renal disease
– Hypertension
– Oedema
• Abdomino-pelvic masses/scars
Investigations
• Ideally as part of ‘one-stop’ haematuria
clinic
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MSU  dipstix, M,C&S, cytology
FBC, U&Es
Flexible cystoscopy
USS renal tract +/- or contrast CT
Treatment
• As per aetiology
Bladder cancer
• 4th commonest male/10th commonest female
cancer
• Risk Factors
– Age, sex
– Smoking, exposure to benzene compounds
– Drugs – phenacetin, cyclophosphamide
Bladder cancer subtypes
• Primary
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Transitional cell carcinoma
Squamous cell carcinoma
Adenocarcinoma
Sarcoma
• Secondary
Presentation
• Symptoms/signs from primary or secondary
tumours +/- paraneoplastic phenomena
• Haematuria, dysuria, frequency/urgency
• Ureteric obstruction
Ureteric obstruction
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
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
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
Prognosis
• Superficial TCC – excellent unless highgrade
• Invasive TCC – approx 50% overall 5y/s
• Metastatic – extremely poor
Renal cell cancer
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UK 7000 cases; 3600 deaths/year
3% all cancer
Mortality is NOT declining
>50% incidental findings on imaging
30% present with metastases
Clinical Features
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Asymptomatic (>50%)
Haematuria
Flank Pain
Mass
• Metastatic/paraneoplastic
Paraneoplastic Syndromes
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Anaemia (>30%)
Erythrocytosis (3%)
Cachexia
Hepatic dysfunction
Hormonal abnormalities
Hypercalcaemia
Metastases
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Lung
Bone
Liver
Brain
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
Prognosis
• Good if resectable primary tumour
• Very poor for metastatic disease
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
Pathology
• Adenocarcinoma is commonest form (95%+)
• Gleason Grading system
• Sum 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
Management
• Dependent on stage, grade & co-morbidity!
• History & Examination
• PSA, U/Es, FBC
• Truss-guided prostate biopsy
• Isotope bone scan/MRI prostate
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?’
Treatment options
• Curative (radical)
– Radical prostatectomy (open, laparoscopic, robotic)
– Radical external beam radiotherapy
– Brachytherapy
• Palliative
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Watchful waiting
Hormone ablation
Chemotherapy
Radiotherapy
‘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
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 tumours
• Leydig cell tumours
• Lymphomas (older men)
Presentation
• Painless testicular lump
• Pain from infarction/infection/trauma
• Symptomatic metastases
• Retroperitoneal lymph nodes (varicocoele)
• Lungs, bones
Management
• Dependent on stage, grade & co-morbidity!
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• Almost all are potentially curable
• Co-morbidity is uncommon in these men
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
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
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
Any questions?