Oncology

Diagnosis, Therapy

Kidney Cancer Information

Cancers of the kidney may be referred to by many names, renal cell carcinoma (RCC), hypernephroma, Grawitz’s tumour and clear cell carcinoma. They make up 85% of all renal malignancies. Incidence continues to increase due to improvements in and increased access to Ultrasound and CT scanning.

They are more common in men than in women by a ratio of 2:1. The commonest age to present with the disease is between 60 and 80. People with a rare genetic condition called von Hippel Lindau disease develop tumours at an early age.

Presentation

The classical triad of a mass, pain and visible blood in the urine is now rarely seen, less than 10% of patients present this way. The majority are diagnosed incidentally during imaging for another condition, resulting in a less advanced cancer at diagnosis. In symptomatic RCC haematuria (50%) is the commonest symptom, 25% have symptoms of disease spread such as weight loss, night sweats, fever and fatigue. Lower limb swelling and acute left varicocoele occur secondary to venous obstruction. 10-40% of patients suffer from a paraneoplastic syndrome due to the ectopic secretion of hormones.

Histological subtypes

Conventional (70-80%), also known as clear cell due to the pathology process that removes the fat from the cells resulting in characteristic appearance.

Papillary(10-15%), multifocal in 40%.

Chromophobe (5%)

Collecting duct rare, poor prognosis, young patients.

Medulary cell rare, young, Afro-Caribbean, sickle cell disease, poor prognosis.

Treatment

The majority of kidney cancers are treated with surgery. Laproscopic (Key Hole) renal surgery is usually possible, but open radical nephrectomy (kidney removal)remains necessary in a number of cases. Treatment is dictated by a number of factors including age, other health problems, size of the tumour, number of tumours and the condition of the other kidney. Kidney sparing surgery (Partial Nephrectomy) or treatment is the preferred option, if appropriate.

Tumours not amenable to partial nephrectomy, with a normal contralateral kidney may be treated with a laparoscopic radical nephrectomy or open radical nephrectomy if not suitable for key hole surgery. Small tumours may be removed from the kidney . Partial nephrectomy can be performed with a key hole technique but may require open surgery.

Other options for small and occasionally multiple tumours, include cryotherapy (freezing of tumour) and radio frequency ablation (heating of tumour).

Often small incidentally found lesions in the elderly, may only require treatment if they become symptomatic. Blood in the urine can be dealt with by blocking the blood supply of the tumour, this is performed by radiologists.

Cancer spread is usually managed by the oncologists, single areas of spread may be resected from the relevant organ if possible, this includes brain disease. If chemotherapy is planned, oncologists often request the removal of the kidney to reduce tumour load. Immunotherapy with interferon alpha and interlukins was the commonest treatment. Newer tyrosine kinase inhibitors such as Sunitinib and Sorafenib are now being used clinically.

Benign Renal Masses

Renal cysts are present in >50% of the population over the age of 50, this was unknown until the advent of widespread renal tract USS. Simple cysts make up 70% of the benign renal masses and seldom require treatment.

Solid benign masses include oncocytomas and angiomyolipomas (AML). Oncocytomas are difficult to distinguish from malignant tumours and are therefore usually removed, if found no follow up is required. AML occur sporadically but 20% are associated with tuberosclerosis,  a rare genetic condition. They are composed of blood vessels, smooth muscle and fat. When they become greater than 4cm, due to the risk of haemorrhage, treatment is usually recommended with either embolization or resection.

Prostate Cancer

Prostate cancer is the most common male cancer in the UK with over 40 000 new diagnoses made yearly. It presents most commonly in older men. It is uncommon in men under the age of 50 years and may be suspected because of urinary symptoms or a raised prostate cancer blood test (Prostate Specific Antigen or PSA). Common urinary symptoms are a weak or hesitant urinary flow, daytime and night-time frequency of passing urine and post voiding dribble. However, these symptoms are the same for benign enlargement of the prostate. PSA is only produced by the prostate gland and is commonly raised in prostate cancer. It may also be raised in other non cancer related prostate conditions but if over the recommended age related level it represents a high risk of prostate cancer. The prostate is situated at the bladder neck and is in close proximity to the rectum. It can therefore be examined by placing a finger in the rectum. If the prostate feels firm or clearly nodular, a cancer may be suspected. Therefore either a raised PSA or abnormal rectal examination represents a high risk for prostate cancer. A biopsy of the prostate may be performed by placing an ultrasound probe into the rectum and directing a needle firstly to give local anaesthetic and secondly to take multiple biopsies of the prostate gland. This is then examined under a microscope by a pathologist to see if there is harmless benign enlargement of the prostate or cancerous enlargement.Once a prostate cancer is diagnosed various radiology tests may be performed depending on the PSA level and the biopsy results. These tests may include a Magnetic Resonance Scan (MRI) or bone scan. These look for the local extent of the disease, the presence of lymph node enlargement or distant bony spread.
Conventional management for localised prostate cancer include active surveillance, radical prostatectomy, external beam radiotherapy and brachytherapy (radioactive seed placement). West Sussex Urology offers all these options. All prostate cancer patients are discussed either within the local or specialist multi-disciplinary team (MDT) where all results are checked and treatment options discussed with surgeons, oncologists, radiologist and pathologist.Laparoscopic radical prostatectomy is a new service with West Sussex, performed by James Hicks and Simon Woodhams. Brachytherapy is provided by Paul Carter.Metastatic or spread prostate cancer is treated by switching off the male hormone, testosterone, thus removing the driver that makes prostate cancers grow. This most commonly, involves daily tablets or 3 monthly injections or a combination of both.Oncology support, including External Beam Radiotherapy (EBRT), for West Sussex Urology prostate cancer patients is provided by Dr Ghassan Khoury, at the Nuffield Health Chichester Hospital, and Dr Ashok Nikopota at Goring Hall Hospital.Multiparametric MRIMRI is increasingly being used in the assessment of Prostate cancer risk and prostate cancer assessment and management.

WSU has access to modern multi-parametric MRI through private services at Western Sussex Hospitals Foundation Trust, the Nuffield group and Goring Hall Hospitals.

The indications for prostate MRI are; The staging of prostate cancer in biopsy proven disease. The assessment of prostate cancer risk in patients with elevated PSA, prior to prostate biopsy The follow up of prostate cancer patients on an active surveillance treatment plan.

This gives the option for targeted biopsy of the prostate,if necessary, through the trans-rectal or perineal routes. Biopsy of the prostate can be avoided in low risk disease on MRI. The MRI scans are reported by our prostate specialist radiologists and where necessary reviewed in local and regional multi-disciplinary team meetings.

Learn more about prostate cancer with these helpful articles.
Prostate Cancer Awareness| Prostate Cancer – Article for Sussex

Bladder Cancer information

About 10,000 people a year in the UK get bladder cancer. It is more common in men than women and rare below the age of 50 years. Cigarette smoking is the biggest risk factor although often there does not appear to be any obvious cause. It is thought that cancer causing chemicals from the cigarettes are absorbed into the blood and then excreted in the urine where they are concentrated and lead to the cancer. Transitional cell carcinoma is the commonest type of bladder cancer and it starts in the waterproof lining on the inside of the bladder. Less common types include squamous cell carcinoma which can be associated with longstanding infection and adenocarcinoma.

Most of the cancers occur just in the lining on the inside of the bladder Sometimes they grow deeper into the muscle of the bladder wall and become invasive in which case their management is more complicated. Carcinoma-in-situ is an aggressive type of bladder cancer that again occurs just on the surface but has a much greater chance of becoming invasive.

What are the symptoms of bladder cancer?

The appearance of blood in the urine is called haematuria and this is the commonest way bladder cancer is found. This symptom should always be reported to a doctor. Sometimes the blood can’t be seen in which case it is picked up on a simple urine stick test as part of a screening test. Usually the haematuria is painless and it can be intermittent so if it stops it doesn’t mean the problem has gone away. Other causes of haematuria include infection, bladder or kidney stones or bleeding from veins over the prostate gland. Painful urination, voiding frequently and urinary urgency are usually symptoms of infection but if these symptoms don’t settle with antibiotics investigations will be necessary.

How is bladder cancer diagnosed?

Your GP will send you to see one of our specialists if there is an episode of unexplained haematuria or some other indication that there might be an underlying cancer. We will ask you questions about the bleeding and also about your general health and any medication you are taking. You will then require an examination including a prostate check in men. We can test your urine with a special NMP22 bladder check test immediately in the clinic- this test detects abnormal proteins in the urine and gives a good early indication that there might be a bladder cancer present. Usually blood tests are arranged including tests of kidney function and a PSA test. Scans of the kidneys are important and this can be either an ultrasound or CT scan. Finally we will schedule an appointment to look into the bladder with a flexible cystoscope. This is usually done under a local anaesthetic with a lubricant jelly that is gently squeezed into the urethra (at the tip of the penis or opening of the vagina) allowing the telescope to be easily passed into the bladder. The procedure takes just a few minutes but allows excellent views of the inside of the bladder and will diagnose most problems. Patients can normally go home a short while after the procedure.

How is bladder cancer treated?

If a bladder cancer is discovered during the initial tests the next step will be to arrange an admission to either Goring Hall Hospital or The Nuffield Hospital for an operation. Under a general anaesthetic ‘key hole’ techniques are used to pass an instrument through the urethra and scrape away the tumour with a hot wire loop. After the operation a catheter is required to drain the urine for one or two days until it clears. The catheter can then be removed and once voiding normally the patient can go home. Specimens obtained are sent away for histological analysis where they are examined under a microscope to determine what sort of tumour was present and how deeply it has spread into the bladder wall. Most tumours are just on the surface lining of the inside of the bladder so this initial operation will cure the problem although they have a tendency to recur so regular follow up bladder checks will be required. Often a solution called Mitomycin is instilled into the bladder for an hour after the surgery to try and prevent these recurrences in the future. Once the results of the histology are available the patients case will be discussed with a team of specialists called the Multidisciplinary Team who will determine the extent of the cancer and make a plan for any future treatment that may be required.

What if the cancer is more advanced?

Cancers that appear to be more aggressive but haven’t put down roots– so called high grade  G3pT1 or CIS- often require a course of  weekly bladder instillations with a substance called BCG. This is put into the bladder with a temporary catheter and again needs to be retained for about an hour. Tumours that are found to invade deeply into the wall of the bladder will require further treatment either in the form of radiotherapy or surgery (a cystectomy) to remove the bladder. A course of chemotherapy may be given first to shrink the tumour. If the bladder does have to be removed then the urine will be brought out into a bag that attaches to the skin of the abdomen (a urostomy). Alternatively we can fashion a new bladder using the patient’s bowel so that they can void the normal way after the operation (a bladder reconstruction or neobladder). We are fortunate that in our group we have a team of three surgeons who specialise in this complex operation so that two of us can operate at the same time on each case.

Summary

Luckily most tumours are just on the inner surface lining of the bladder and can be cured with simple keyhole surgery. For the more advanced cancers we are fortunate to have a team of specialists who can offer the very best treatment available. Further information can be found at http://www.macmillan.org.uk.