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 – Raised PSA/abnormal DRE 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 Abdomino-pelvic masses/scars 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) Invasive TCC or other subtypes 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

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

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) Palliative 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%) Sertoli cell tumours 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?