URO ONCOLOGY for medical students on 28 January 2016

URO-ONCOLOGY     

Dr Clarence Lei Chang Moh, FRCS Urol, Consultant Urologist,  clarencelei@gmail.com

           

HAEMATURIA

Painless gross haematuria can be a symptom of kidney or bladder cancer.  Therefore, it is usually investigated with an Ultrasound scan and CTU (CT urogram) to see the upper tract and a cystoscopy to see the bladder.  Painful gross haematuria is commoner and may be caused by stones or infection.  Other sources of gross haematuria include BPH, benign prostatic hyperplasia (usually > 55 years of age), glomerulonephritis (usually young) and vascular malformations. Radiocontrast is contra-indicated  if there is renal failure or a strong history of allergy.

The main tumours of the urinary system are:

1)  Kidney:      adenocarcinoma, Wilm’s tumour (the later in children).

2)  Bladder:     transitional cell tumour, the commonest tumour of the urinary system.

3)  Prostate:    adenocarcinoma.

4)  Testis:        teratoma, seminoma.

5)  Penis:         squamous cell carcinoma.

KIDNEY:

Adenocarcinoma (or RCC, renal cell carcinoma, usu CCC, clear cell carcinoma)

Presentation:             Gross painless haematuria; renal mass.

Investigations:           CT shows a SOL.

Ultrasound to distinguish solid tumour from cyst, see IVC and renal vein invasion by tumour thrombus (feature of RCC).

CXR

CT scan to see para-aortic lymph nodes.

Management:            Surgical removal is currently the only hope of cure.  This is possible in locally confined disease; embolus present in the renal vein/IVC can be removed with the cardiac surgeon.  Chemotherapy and radiotherapy are not effective. Immunotherapy (e.g. interleukin-2) and kinase inhibitors (sorafenib, sunitinib) is promising  for metastatic disease.

In Wilm’s tumour, chemotherapy has important role and hence, important to manage with paediatric oncologist.

                       

BLADDER:

Clinically commoner then cancer prostate in Malaysia.  Usually TCC (transitional cell carcinoma). Almost ALL tumours in the bladder are TCCs.

Presentation:             Gross painless haematuria; suprapubic mass rarely (i.e. unusual to have clinical signs).

 

Aetiology:                  Smoking increases risk 4 x

                                    An ‘industrial disease’ where aromatic amines were used e.g. in rubber/dye industries.

Investigations:           (1)   CTU, to see upper tract

(2)     Ultrasound, to see any big tumour in bladder.

(3)     Cystoscopy – commonly a papillary growth.

(4)     EUA, to stage locally.

(5)     CT abdomen and pelvis, to stage

Management:                        Depends on stage and grade:

(a)     NMIBT, non muscle invasive bladder tumour – transurethral resection (TURBT, transurethral resection bladder tumour). May reduce recurrence with immediate intravesical Mitomycin C /BCG and cessation of smoking.

(b)     Bladder Muscle Invasive – radical surgery to remove bladder and urinary diversion.  Radiotherapy if not fit for surgery.  5-year survival: 50%. Grade 3 TCC especially if associated with CIS (carcinoma in situ) may be treated with radical surgery if the patient is agreeable.

(c)     Advanced (locally fixed, node positive or metastatic) – palliative chemotherapy.

Note:  T.C.C. may be found occasionally in other parts of the urothelium e.g. ureter and renal pelvis.

PROSTATE:

Radical differences in incidence (e.g. very low in Japanese) may be related to genetics and diet. 

Presentation:             If early, detected by blood test, PSA (prostatic specific antigen).  If advanced, urinary retention, bone pain from secondaries.

Investigation:                        Biopsies (transrectal ultrasound guided)

X-ray (pelvis) osteosclerotic lesions (Ca prostate is the commonest cause of such lesions).

CT Pelvis and/or laparoscopy to stage (lymph nodes)

Bone Scan.

Management:            (a)  Localised disease:  radical prostatectomy (or radiotherapy) if  life expectancy > 10 years as disease may be slow growing. Robot assisted laparoscopic radical prostatectomy (RALP) is the preferred treatment for localized disease. In low grade low volume disease with slow PSA doubling time, active surveillance may be an option.

(b)     Advanced disease (local invasion, node +ve, metastatic) palliation by androgen deprivation.  This may be surgical (orchidectomy) or medical (injection LHRH analogue 3 monthly). Localised bone pain can be treated with radiotherapy.

TESTIS:

Presentation:             Testicular mass – any SUCH MASS SHOULD BE CONSIDERED MALIGNANT UNLESS PROVEN OTHERWISE.

Aetiology:                  A maldescended testis has a higher incidence (5%), patients with such a history should do TSE (testicular self examination) monthly; usu. a cancer of young men.

Investigation:            Ultrasound – to determine that the swelling is actually testicular (and not, e.g. a hydrocele).

Tumour markers – alpha-fetoprotein, beta-HCG (raised in teratoma).

Management:            Radical orchidectomy as biopsy – inguinal route mandatory to control vascular pedicle to prevent tumour embolisation.  When diagnosis confirmed, to stage tumour with CXR, CT scan abdomen and chest.

CHEMOTHERAPY IS THE MAINSTAY OF TREATMENT AND OFTEN CURATIVE.

PENIS:

Presentation:             Penile ulcer and growth, often in an advanced state although the penis is an easily visible and often used organ.

Aetiology:                  Circumcision in infancy gives complete immunity.

Investigation:                        Biopsy (including inguinal lymph nodes if these are enlarged).

Management:            Surgery, chemo and radiotherapy.

23.10.01; updated 28.1.2016

Urolithiasis lecture at Unimas 2016