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a_GYNGU > 11/20- Malignant Diseases of the GU system > Flashcards

11/20- Malignant Diseases of the GU system Flashcards

1
Q

What is the most common urologic malignancies? Next?

A
  1. Prostate
  2. Bladder
  3. Kidney
  4. Testis
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2
Q

Among men, ___ cancer is the most common.

This cancer is the #__ cause of cancer deaths in men

A

Among men, prostate cancer is the most common.

This cancer is the #2 cause of cancer deaths in men (2nd to lung)

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3
Q

Bladder is the #__ most common and the #__ cause of cancer deaths (among men)

A

Bladder is the #4 most common and the #8 cause of cancer deaths (among men)

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4
Q

T/F: There is no GU cancer in the top 10 causes of cancer in women. What is the highest?

A
  • True; no GU cancer in top 10 women cancer cases
  • Kidney cancer is #8 (only 3% of new cases)
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5
Q

What are the risk factors for Prostate cancer?

  • Which is most important
  • What are modifiable risk factors
A
  • Advanced age
  • African American race (more common and earlier age/higher stage)
  • Family history (strongest!)
  • Modifiable risk factors
  • Obesity
  • Fat intake (mono-unsaturated fats)
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6
Q

Describe family history role in prostate cancer/risks

A
  • 2-3x increased risk of prostate cancer
  • BRCA link: female relatives with breast/ovarian cancer
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7
Q

What is involved in prostate cancer screening?

A
  • PSA: prostate-specific antigen
  • DRE: digital rectal exam
  • Palpation of posterior zone of prostate
  • Should be done annually for men > 50 yo BOTH are required
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8
Q

What is PSA? - What is it’s function? - Circulation

A

Serine protease that is unique to prostate

  • Lyses seminal coagulum
  • Circulates free or bound to a-1 antichymotrypsin
  • %free correlates with benign vs. malignant
  • >25%: more likely BPH
  • < 10%: at least 50% chance of being cancer
  • Only valid at total PSA values 4-10
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9
Q

Describe the expected values/diagnostic criteria levels of PSA

A

% free correlates with benign vs. malignant

  • >25%: more likely BPH
  • <10%: at least 50% chance of being cancer
  • Only valid at total PSA values 4-10
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10
Q

__% of prostate cancer occurs in the ____ zone

A

75% of prostate cancer occurs in the posterior zone

  • Habitus may make difficult; technical points
  • PSA testing has caused “stage migration” (finding earlier)
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11
Q

What has US Preventive Services Task Force (USPSTF) recommends what for prostate screening?

What does American Urological Association say?

A
  • Recommends against prostate specific antigen (PSA)-based screening for prostate cancer
  • American Urological Association disagrees: all men 55-69 yo should discuss PSA screening with provider and get screened every 2 yrs
  • Little benefit to men 70+ with life expectancy under 10-15 yrs
  • Screening with PSA has reduced prostate cancer mortality
  • Screening with PSA has led to diagnosis and treatment of many indolent cancers
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12
Q

What is the sensitivity and specificity of PSA screening?

How to improve?

A

Overall

  • Sensitivity: 35%
  • Specificity: 63%

If stratify for PSA > 4:

  • Sensitivity: 86%
  • Specificity: 33%
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13
Q

How should we manage screening of prostate cancer?

A

Need to focus on age-specific! recommendations and practices (and tx need to maximize cure and minimize ASEs)

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14
Q

How is prostate cancer diagnosed?

  • What is the most common stage?
A
  • Transrectal US-guided prostate biopsy
  • Histologic report: Gleason grading
  • DRE >> clinical stage
  • Most common = T1c
  • Risk stratification

Biopsy features + DRE = grade and stage then:

  • Staging: imaging in intermediate/high risk
  • Bone scan and CT of abdomen/pelvis
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15
Q

Describe the staging of prostate cancer

A
  • T1a, T1b by TURP
  • T1c: non-palpable
  • T2: palpable but organ confined
  • T3a: extra-capsular
  • T3b: SV invasion
  • T4: invades adjacent organs
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16
Q

What is the median age of diagnosis of prostate cancer?

  • Most common stage
  • Peak when and why
A
  • Median age of Dx: 66 yo
  • Most in cT1c stage (localized): 60-75%
  • Peak in 1992 due to PSA use
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17
Q

How are prostate cancer deaths changing?

A

Prostate cancer deaths are decreasing

  • PSA finding cancer earlier
  • Better treatments
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18
Q

What is the 5 year survival of prostate cancer:

  • Localized
  • Regional
  • Distant
  • All stages
A

Natural history of prostate cancer is very long:

  • Localized: 100%
  • Regional: 100%
  • Distant: 28%
  • All stages: 99%
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19
Q

What is management/treatment of prostate cancer?

A

Active surveillance

  • Risk features
  • Protocol for monitoring

Surgery

  • Radical prostatectomy + bilateral pelvic LND
  • Approaches and risks

Radiation

  • External beam therapy
  • Brachytherapy: radioactive seeds

Investigational

  • Focal therapies
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20
Q

Describe TMN staging of organ-confined prostate cancer

A

Organ-confined: not though to involve regional LN or any visceral organs

  • Clinical stage: cT1-3, N0, M0
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21
Q

Surgery is therapeutic and diagnostic for treating prostate cancer. What does it involve?

A
  • Excision of prostate, seminal vesicles
  • Excision of pelvic LNs
  • Anastomosis of bladder to urethra
  • Pathologic analysis > prognostic information
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22
Q

Describe TMN staging of advanced stage prostate cancer

A
  • Locally advanced stage: cT4
  • Nodal metastasis: N1
  • Distant metastasis: M1

This scan shows something at femoral head (not kidneys, those normally light up), and actually has a lot of vertebral mets

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23
Q

What is treatment for advanced stage prostate cancer treatment?

A

Systemic treatment

  • Androgen deprivation (ADT)
  • Chemotherapy
  • Other hormonal tx

Role for local therapy (Surgery, XRT) must be individualized

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24
Q

What are surgical and pharmacologic methods of androgen deprivation?

A

Surgical: orchiectomy

Pharmacologic:

  • LHRH agonists: Lupron, Zoladex, Eligard
  • Anti-androgens: Bicalutamide, Flutamide
  • Older but occasionally utilized:
  • Ketoconazole
  • Diethylstilbesterol
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25
Q

SUMMARY of prostate cancer

  • Screening
  • Staging
  • Treatment
A

Screening

  • PSA and stage migration
  • Long survival and low mortality make use of PSA controversial

Staging

  • Overwhelming majority low-stage
  • Most common stage

Treatment

  • Risk stratified
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26
Q

Testis cancer is a ___ ___ tumor

A

Testis cancer is a germ cell tumor

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27
Q

What is seen here?

A

Testis cancer

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28
Q

Describe epidemiology of testis cancer:

  • Most common malignancy in what population
  • __% of all cancers in men worldwide
  • Age of distribution is ____
  • Ethnicity
A
  • Most common malignancy in young men (15-34 yo)
  • 1% of all cancers in men worldwide
  • Age of distribution is bimodal
  • Whites 5-6x more than blacks
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29
Q

What are risk factors for testis cancer?

A
  • Undescended testicle (even if brought down)
  • Maternal estrogen exposure
  • Contralateral testis tumor
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30
Q

25% of men with testis cancer will present how? (important)

A

Subfertile semen parameters (in 25% of men with testis cancer)

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31
Q

What signs/symptoms contribute to diagnosis of testis cancer?

A
  • Palpable mass
  • Tender breasts (2%)
  • Rarely with back pain
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32
Q

What is seen here?

A
  • Left pic: irregular contour, heterogeneous echo
  • Right pic: normal; homogeneous echogenecity, spherical/round
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33
Q

What are serum tumor markers that can help diagnose/monitor testis cancer?

A

Serum tumor markers:

- AFP

- beta-HCG

- LDH

Stage not defined fully until nadir of markers

34
Q

How is the TNM stage of testis cancer established?

A
  • Radical orchiectomy for T
  • CT scan a/p for N/M
  • LNs of retroperitoneum! (due to vascular drainage; embryologically, testes start high and then descends. Only to inguinal LNs in late stages)
35
Q

Break down testis cancer staging for:

  • Localized presentation
  • Regional presentation
  • Distant metastatic presentation

What are the 5 yr survival rates?

A
  • Localized: 69% of cases
  • 5 yr survival: 99%
  • Regional: 18% of cases
  • 5 yr survival: 96%
  • Distant metastatic: 12% of cases
  • 74% 5 yr survival
36
Q

What are the testis cancer types?

  • What are products they make?
  • What are most tumors
A

They are GERM CELL tumors

  • Seminoma: 10-20%
  • Make B-hCG but never AFP
  • Non-seminoma
  • Embryonal: 60% make AFP, 65% make B-hCG
  • Choriocarcinoma: ALL, 100%!, make B-hCG
  • Yolk sac: 90% make AFP
  • Teratoma
  • Most are MIXED GCTs
37
Q

What is the treatment for testis cancer?

A
  • Treatment determined by stage + histology + risk category
  • Surgery: orchiectomy (nearly always step 1)
  • Observation
  • Surgery: Retroperitoneal LND (RPLND)
  • Chemotherapy
  • Radiation therapy
38
Q

Describe fertility preservation in testis cancer treatment

A
  • Chemo is toxic to spermatogenesis
  • RPLND can lead to retrograde ejaculation
  • Injury to ?
39
Q

What are some newer concepts of long-term toxicities of testis cancer treatment?

A
  • CV SE and metabolic synrome
  • Pulmonary toxicity of bleomycin
  • Secondary malignancy
  • Leukemia after chemo
  • Solid organ tumors after radiation
40
Q

SUMMARY: Testis cancer

  • Age
  • Staging
A
  • Young man’s disease
  • Staging
  • Primary tumor
  • Tumor markers (based on cell types present)
  • Imaging: to look at primary landing zone (retroperitoneal!)
41
Q

Describe cancer of the male genitalia

A

Penile cancer: squamous cell cancer

42
Q

What are risk factors for penile squamous cell cancer?

A
  • HPV (positive in 30-60% of cases)
  • Hygiene: circumcision
  • Smoking
43
Q

What is the incidence for penile squamous cancer?

A

.< 1% in US

44
Q

How is carcinoma in situ managed? Prognosis?

A
  • Topical treatment
  • Can progress to invasive
45
Q

Describe the staging and surgery for penile (squamous cell) cancer

A

Surgery:

  • Partial penectomy
  • Radical penectomy
  • Inguinal LND
  • Pelvic LND
46
Q

Describe urothelial cancer

  • Aka?
  • Where can it occur
A
  • Transitional cell carcinoma

Locations:

  • Bladder
  • Ureter
  • Renal pelvis
47
Q

What are risk factors for bladder cancer?

A
  • Males (3x)
  • Cigarette smoking ~ 50% of cases
  • Occupational/environmental exposure: 20% of cases
  • Aromatic amines: plastics, chemical, rubber processing (and tobacco)
  • Aluminum, dye, pesticides, arsenic, leather processing, printing industry
  • Infection
  • Schistosoma hematobium
48
Q

Describe the connection between bladder cancer and tobacco

A
  • Smokers of > 2 packs/day have ~7x the risk of nonsmokers
  • Risk in nonsmokers 1-2%
  • Risk in smokers 6-10%
  • Rationale for screening in firefighters
  • Smoking cessation, even at time of diagnosis, improves bladder cancer survival
49
Q

How is bladder cancer diagnosed?

A

Hematuria

  • Gross painless hematuria >> automatic workup
  • Microscopic hematuria >> more detail needed

Testing of microhematuria

  • Urinalysis with micro (dip inadequate)
  • Urine culture
  • If >= 3 rbc/hpf in absence of infection -> workup
50
Q

Describe the diagnostic workup of microhematuria in bladder cancer?

A

DDx:

  • Kidneys: stone, mass, infection
  • Ureters: stone, mass
  • Bladder: stone, mass, infection
  • Prostate: BPH
  • Anticoagulation effect
  • Trauma
  • Prior pelvic radiation
  • Atrophic vaginitis/urethritis

Prevalence of microhematuria: 1-20%

51
Q

What are risk factors for hematuria?

A
  • Age > 40 yo
  • Male
  • History of tobacco use
  • Chemical exposure
  • History of stones
  • Symptoms
52
Q

Workup for bladder cancer?

A
  • CT abdomen/pelvis (3-phase)
  • Cystoscopy
  • +/- Urine cytology
53
Q

What is the presentation of bladder cancer?

A
  • Other symptoms (with microhematuria)
  • Dysuria
  • Urgency/frequenc
  • Burning or suprapubic pain
  • Women frequently misdiagnosed and treated UTI even with gross hematuria
  • 10% present with symptoms related to metastasis or advanced disease
  • Bone pain
  • Constitutional symptoms
54
Q

How do you evaluate bladder cancer?

A
  • Urine cytology
  • Cystoscopy
  • Biopsy
  • Resection (TUR)
  • Bimanual exam
  • Imaging
  • Hydronephrosis
  • Lymphadenopathy
  • Visceral lesions
55
Q

Describe the staging of bladder cancer?

What is most common?

A

Stage [Tis -T4] + Grade [Low/High]

56
Q

Describe non-muscle invasive UC-bladder

  • Stages
  • Treatment
  • Surveillance
  • Management of recurrence
A
  • Stages: Tis, Ta, T1
  • Surgery: TUBT - Intravesical therapy:
  • Mitomycin
  • BCG: Bacillus Camille-Guerin
  • Surveillance:
  • Regular interval cystoscopy
  • Annual imaging
  • Urine cytology
  • Management of recurrence
  • Depending on presentation, some chance of progression to more invasive disease
57
Q

Describe muscle-invasive UC-bladder

  • Stages
  • Surgery
  • Surveillance
  • Management of recurrence
A
  • Stages T2-T4
  • Surgery:
  • Diagnostic TURBT + bimanual exam
  • Cystectomy/Cystoprostatectomy
    • Radical cystectomy: women (bladder, +/- uterus, +/- anterior wall of vagina), man (bladder, prostate, seminal vesicles)
    • Bilateral pelvic LND
  • Chemotherapy: neoadjuvant/ajuvant
  • CISPLATIN-based
  • Chemoradiation
  • Non-surgical candidates
  • Inferior survival vs. surgery
  • Urinary diversion:
  • Ileal conduit (incontinent stoma)
  • Neobladder (continent)
  • Continent cutaneous diversion
  • Surveillance
  • Urine cytology
  • Scheduled imaging - Management of recurrence
  • Urothelial: upper tracts
  • Distant
58
Q

What is shown here?

A

Urinary diversion

  • Bowel segment with bowel re-anastomosis
59
Q

Describe the pathology of bladder cancer (and percentages)

A
  • Urothelial cell carcinoma (UC): 90%
  • Squamous cell carcinoma (SCC): 7%
  • 85% of cases in Egypt secondary to Bilharzial infection (schistosomiasis)
  • Chronic irritation: long term catheter
  • Adenocarcinoma: 2%
60
Q

Describe urothelial cancer of the upper tracts

  • Location
  • Percnetages
A
  • Ureter or renal pelvis
  • 5-7% of all renal tumors
  • 5% of urothelial cancers
  • > 80% of those had prior bladder cancer
61
Q

Describe management/treatment for urothelial cancer in upper tracts

A

Surgery

  • Endoscopy: biopsy and fulguration
  • Resection: segmental, nephroureterectomy

Chemotherapy

62
Q

Describe the survival of urothelial cancer

A
  • Overall 77% alive and disease-free at 5 yrs
63
Q

SUMMARY: Urothelial cancer

  • Screening
  • Staging
  • Survival
A
  • Bladder cancer is uncommon

Screening

  • No routine or recommended screening
  • Microhematuria!
  • Target populations

Staging: bladder cancer:

- 80% are non-muscle-invasive at presentation

  • 90% are urothelial (transitional) cell cancer

Survival

  • Example of high cost of care
64
Q

What is the most common kidney cancer?

A

Renal Cell Carcinoma

65
Q

What are risk factors for kidney cancer (renal cell carcinoma)?

A
  • Obesity
  • Tobacco use
  • 20-40% of men with RCC
  • 10-20% of women
  • Hypertension
66
Q

Hereditary syndromes are responsible for __% of RCCs

A

Hereditary syndromes are responsible for 2-3% of RCCs

67
Q

What are hereditary syndromes/causes of kidney cancer?

A
  • Von Hippel-Lindau
  • Tubeous sclerosis
  • Hereditary papillary renal cell carcinoma
  • Hereditary leiomyomatosis and RCC (HLRCC)
68
Q

What is Von Hippel-Lindau syndrome?

  • Inheritance pattern
  • Locus
  • Gene
  • Cancer type
  • Associated manifestations
  • Age of onset
  • Uni or bilateral
A
  • Autosomal dominant
  • Chr 3p
  • VHL gene
  • Clear cell renal cell carcinoma (in 50%)
  • Associated manifestations: pheochromocytoma, retinal angiomas, hemangioblastomas of SC/brainstem, cysts of kidney/pancreas
  • Early onset: 20s-40s
  • Often bilateral, multiple
69
Q

What renal cancer is associated with tuberous sclerosis?

A
  • Clear cell renal cell carcinoma
  • Also angiomyolipoma
70
Q

What are the genetics/mechanism behind hereditary papillary renal cell carcinoma?

A
  • Met proto-oncogene mutations
  • chr 7q31-34
  • Encodes hepatocyte GF
71
Q

What cancers are associated with Hereditary Leiomyomatosis and RCC (HLRCC)?

  • Genetics
A
  • Cutaneous leiomyomas
  • Uterine fibroids
  • 20% have RCC
  • Chr1q: fumarate hydratase gene
72
Q

Describe the mechanisms for the following genes:

  • VHL
  • HIF
  • VHL (TSG)
A
  • VHL: codes for protein r/f degradation of HIF
  • HIF: induces angiogenesis in hypoxic environment via regulation of VEGF/PDGF

- VHL (TSG) mutn: constitutive activation of HIF in normoxic conditions >> urnegulated angiogenesis

73
Q

Describe the VEGF pathway and what gene is involved

A

VEGF pathway:

  • Neovascularity, proliferation
  • VHL: tumor suppressor gene
  • Involved in VHL and sporadic RCC

Can target alteration with new meds

  • Targeted therapy
74
Q

What is the diagnostic workup for a renal mass?

A
  • Imaging
  • Preferred: axial imaging (CT/MRI) pre and post-contrast phases
  • Alternative: renal US
  • Urinalysis
  • When considering malignancy in DDx:
  • Add chest x-ray
  • Labwork: renal function, CBC, livery function
75
Q

What is the presentation of kidney cancer?

  • Classic triad (TESTED)
  • Gende
  • Median age
  • Syndromes
A

Classic triad (observed in under 25%)

  • Hematuria: gross or microscpic
  • Flank pain
  • Palpable abdominal mass

Paraneoplastic syndromes common:

  • Hypercalcemia
  • Elevated LFTs

Epidemiology:

  • Males (2x)
  • Median age at dx = 64 yo
76
Q

Describe the class of renal cystic lesions. How are they classified?

  • Malignancy risk
A

Cystic lesions are classified on CT (Bosniak)

  • Class I: simple cyst (0% malignancy risk)
  • Class II: nonenhancing fine septum or Ca++ (minimal malignancy risk)
  • Class IIf: hyperdense, multiple septa, wall nodules (5-15% malignancy risk)
  • Class III: enhancing nodule or septa (50% malignancy risk)
  • Class IV: enhancing soft tissue component (90% malignancy risk)
77
Q

What is seen here?

A

Bosniak cysts

78
Q

What has improved the incidental finding of kidney cancer and caused a stage migration?

A

CT era

79
Q

Describe kidney cancer staging

A

- Stage I: confined to kidney, < 7 cm

- Stage II: confined to kidney, > 7 cm

- Stage III: outside capsule but within Gerota’s fascia; can go to vena cava

- Stage IV: outside Gerota’s fascia, to other organs, to LNs

80
Q

What are some kidney cancer mimics?

A

25% of resected masses are benign

  • Oncocytoma: along spectrum of chromophome
  • Angiomyolipoma: characteristic macroscopic FAT on imaging
  • Secondary malignancies: lymphoma, metastasis from other primary (breast)
81
Q

What is done to treat kidney cancer?

A
  • Active surveillance for small renal masses (< 4 cm)
  • Surgery
  • Nephron-sparing surgery: partial nephrectomy
  • Radical nephrectomy
  • +/- regional LN dissection
  • Mestastectomy in select cases
  • Ablative therapies: cryotherapy, radiofrequency ablation
  • Systemic therapy: “targeted” immunotherapy

- Molecular pathway modulators

  • VEGF inhibitors (anti-angiogenic): Bevacizumab (Avastin), Sunitinib (Sutent), SOrafenib, Pazopanib
  • mTOR inhibitors: GFs, Hif-1 regulation; Everolimus, Temsirolimus

- Cytokine therapy

  • Interferon, Interleukin-2
  • Much more toxic, only agent with any reported ‘complete response’
82
Q

SUMMARY: kidney cancer

A
  • The small renal mass is most common
  • Hereditary syndromes are rare
  • Think young, bilateral masses, other stigmata
  • Treatment
  • Surgery is mainstay
  • Role for targeted therapy

a_GYNGU (17 decks)

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