Part 12

What % of patients with visible haematuria have urinary tract cancer 

>45 y/o :

Unexplained Visible haematuria without UTI 

VH that persists or recurs after successful treatment of UTI 

> 60 y/o : 

Unexplained NVH and either dysuria or raised WBC 

Swelling of the kidney due to build-up of urine due to an obstruction or blockage 

Other causes for what apart from cancer? 

Infection:

Pyelonephritis 

TB 

Stones 

Foreign bodies 

Drugs (anti-coagulants, NSAIDs) 

Prostatic disease 

Nephritis, IgA 

Stages of what cancer? 

Tis = carcinoma insitu 'flat-tumour', only found on the surface. Non-muscle invasive muscle cancer. Often comes back after treatment 

Ta/T1 = non-invasive 

T2 = invaded detrusor muscle 

T3 = beyond detrusor 

T4 = Beyond detrusor, fat, the organ altogether

Non muscle invasive = 80% 

Transurethral resection 

Adjuvant intravesical therapy (chemo or anti-immune agent 'BCG') 

Muscle Invasive = 20% 

Radical cystectomy and urinary diversion 

Radical radiotherapy 

Stage 1 = <7cm 

Stage 2 = >7cm 

Stage 3 = invading renal vein / IVC 

Stage 4 = invading further up the IVC, even to the point of the RA (and / or invading lymph nodes) 

Stage 1 = partial nephrectomy 

Stage 2-4 = Radical nephrectomy 

Chemo and radiotherapy is not used in this type of cancer, only immunotherapy (VEGF inhibitors) 

What is the 5 year survival of prostate cancer? 

Symptoms

Often None 

Lower UTI 

Late symptoms = 

Haematuria 

Lower urinary tract symptoms 

Pain 

Weight loss 

T1 = too small to be seen on MRI or felt, diagnosed at TURP (Transurethreal resection of ...) or biopsy 

T2 = confined to ... 

T3 = Breached capsule and may invade seminal vesicles 

T4 = invasion to other organs 

Erectile dysfunction (80-90%) 

Urinary incontinence 

Rectal bleeding (proctitis) 

Urinary bleeding (cystitis) 

Where does prostate cancer often spread to first in metastatic disease 

What is the first line treatment in metastatic prostate disease 

Not curative but allows for palliation 

LHRH agonists (competitive with LH, down regulates LH via negative feedback and therefore reduces testosterone) 

LHRH antagonists 

Anti-androgens (at cellular level) 

All act to reduce the effects of testosterone 

Symptoms

Lump, skin changes 

Weight loss 

Back pain 

LUTS 

Hx

Undescended testes (big risk factor) 

Smoking 

First lymph nodes testicular cancer often spreads to 

V - Variocle 

I - Infection (epididimoorhcitis, abscess) 

T - Trauma 

M - morphology 

N - neoplasm 

VITMN 

Tumour markers for what cancer ?

LDH 

Alpha-foetoprotein 

Beta-HCG 

Why when performing a radical orchidectomy do we do so through the inguinal canal? 

Low risk = radical orchidectomy + monitoring (CT of chest, abdo, pelvis. Check tumour markers) 

High risk = radical orchidectomy + chemo + monitoring 

What percentage of testicular cancers are from germ cells? 

Seminoma = carboplatin, 1 cycle 

Non-seminoma = BEP (bleomycin, etoposide, platinum (cisplatin)) 2 cycles 

Metastatic = Systemic chemo - BEP (3-4 cycles) + retroperitoneal lymph node dissection for residual masses 

Risk factors for what cancer: 

Smoking - strongest 

Diet rich in animal fats and proteins 

Obesity 

FHx: > 3 first degree relatives = x20 

Hereditary symptoms: Lynch, Peutz-Jeghers 

Symptoms

70% dull peigastric pain (radiating to / or middle back - esp cancer of the tail) 

Jaundice (10%) painless - dark urine, pale stools, itching 

Weight loss (>10% body weight)

Sickness, steatorrhoea, blood clots, diabetes 

In the presence of a palpably enlarged gall bladder, which is non-tender with mild painless jaundice. - unlikely to be gall stones 

Gall stone = repeat infection, causing fibrosis of the gall bladder, not palpable 

Pancreatic tumour marker?

T1 = inside the organ <2cm in any direction 

1a = <0.5 

1b = <1cm 

1c < 2cm 

T2 = within organ but 2-4cm in any direction 

T3 = within organ but >4cm 

T4 = involvement of nearby blood vessels 

N1 = 1-3LN 

N2 = >4LNs 

Resectable if less than 3 cm and head of organ involved as presents with jaundice earlier 

Less likely to be resectable if body or tail involved as these tend to present later and nearby LN or major blood vessels involved 

What are the three types of surgery for pancreatic cancer? 

Most common type of pancreatic cancer 

>80% of ductal carcinomas 

Most are benign, have better prognosis than other exocrine pancreatic cancers 

Cancer of the acinar cells (end of ducts that make the juices) 

Presents at a younger age than adenocarcinomas 

Slower growing 

Aka islet cell tumours 

Mostly benign 

1/3 release hormones leading to symptoms 

2/3rds therefore are non-functioning (however non-functioning are more likely to be malignant) 

Better prognosis than adenocarcinomas of the pancreas 

Grading based on differentiation, Well differentiated = low and intermediation grade whereas poorly differentiated = high grade with rapid growth and spread 

Tumour marker in PNETs 

In high grade >20% 

Low grade < 20% 

cellular marker for proliferation