Urological Cancer

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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 – - PowerPoint PPT Presentation

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  • 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

  • TreatmentSuperficial TCC (pT
  • 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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