Uro-oncology: staging, risk stratification and treatment sequence
What the exam tests
Staging, risk stratification and treatment sequence for prostate, kidney, bladder, testis and penile cancer. The commonest format is a scenario asking which single next step changes survival.
Core rules
- Prostate cancer: PSA plus DRE, then multiparametric MRI before biopsy. Grade group 1 to 5 replaces Gleason sums in reporting. Metastatic hormone-sensitive disease is treated with androgen deprivation plus docetaxel or an androgen receptor pathway inhibitor; these improve survival and are not reserved for progression.
- Bladder cancer: TURBT must include muscle. High-risk non-muscle-invasive disease (T1, carcinoma in situ, multifocal recurrence) receives intravesical BCG. Muscle-invasive disease in a fit patient gets neoadjuvant cisplatin-based chemotherapy followed by radical cystectomy or radiotherapy.
- Renal cancer: partial nephrectomy is preferred for T1 tumours where technically feasible; small masses in frail patients can be surveilled. Clear cell, papillary and chromophobe are the main subtypes.
- Testis cancer: radical inguinal orchidectomy, tumour markers (AFP, beta-hCG, LDH) and staging CT. Never biopsy through the scrotum.
- Penile cancer: squamous cell carcinoma linked to phimosis and HPV; treat the primary and stage the groin, since nodal status drives survival.
Worked example
A 58-year-old has PSA 12, a PI-RADS 5 lesion, biopsy grade group 3, and PSMA PET showing no metastases. Reasoning: this is high-risk localised disease. The options are radical prostatectomy with extended pelvic lymph node dissection, or radical radiotherapy with two to three years of androgen deprivation. Both are curative-intent; androgen deprivation alone would be undertreatment.
Traps
Offering surveillance to grade group 3 disease; omitting neoadjuvant chemotherapy in muscle-invasive bladder cancer; trans-scrotal testicular biopsy; forgetting that pure seminoma does not raise AFP.