Urological Cancer

Kieran JeffersonConsultant Urological SurgeonUniversity 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

• 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

• 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– 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 high-grade

• Invasive TCC – approx 50% overall 5y/s

• Metastatic – extremely poor

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

Clinical Features

• Asymptomatic (>50%)• Haematuria• Flank Pain• Mass

• Metastatic/paraneoplastic

• Anaemia (>30%)• Erythrocytosis (3%)• Cachexia• Hepatic dysfunction• Hormonal abnormalities• Hypercalcaemia

Paraneoplastic Syndromes

Metastases

• 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– 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!

• But• 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?