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?