Genitourinary Cancer Flashcards
Objectives
Renal Cell Carcinoma Pathophysiology
- Most commonly originates in the epithelial lining of the proximal convoluted tubule
- Hereditary and nonhereditary forms
Renal Cell Carcinoma Incidence
- Approx 74,000 new cases per year
- Approx 15,000 deaths from RCC
- new cases inc by 1%/yr (2006-2015)
- Median age of diagnosis – 64 years old
- Men > Women
RCC risk factors
- Cigarette Smoking
- Obesity
- Hypertension
- Occupational exposure
- Cadmium, asbestos, petroleum by-products
- Long term renal dialysis
- Acquired renal cystic disease
- Genetic disorders
- Chronic hepatitis C infection
RCC classic triad of signs and symptoms
- Hematuria, microscopic or gross
- Flank pain
- Palpable mass, abdominal or flank
**Most asymptomatic and found incidentally on radiographic imaging
RCC Signs and Symptoms
- Weight loss
- Fever
- Hypertension
- Night sweats
- Malaise
- Varicocele in males
- Most commonly left sided due to obstruction of gonadal vein
- Paraneoplastic syndromes
- Erythrocytosis, hypercalcemia, hypertension, hepatic dysfunction
RCC Dx imaging
- Ultrasound
- CT
- MRI
**Becoming more commonly diagnosed with more frequent use of imaging
RCC Dx Via Tissue
- Biopsy
- Limited
- Concerns regarding sampling error, technical failure, procedure complications, and biopsy tract seeding
- Can be used to confirm diagnosis in patients who are not surgical candidates
- Preferable to biopsy a metastatic lesion
- Partial or Radical Nephrectomy
RCC subtypes
- Clear cell (75-85%)
- Papillary (10-15%)
- Chromophobe (5-10%)
- Oncocytic (3-7%)
- Collecting duct (Bellini’s duct, very rare)
RCC Stage 1 description
Tumor diameter of <7 cm, limited to the kidney. No lymph node involvement or distant metastases
RCC Stage 2 description
Tumor >7.0 cm but limited to the kidney. No lymph node involvement or distant metastases
RCC Stage 3 description
Tumor any size with the involvement of a nearby lymph node but no distant metastases, with or without spread to fatty tissue around the kidney, with or without spread into the large veins leading from the kidney to the heart.
OR
Tumor spread to fatty tissue around the kidney and/or spread into the large veins leading from the kidney to the heart, but distant metastasis
RCC stage 4 description
Tumor spread directly through the fatty tissue and the fascia ligament-like tissue surrounding the kidney.
OR
Involvement of >one lymph node near the kidney
OR
Involvement of any lymph node not near the kidney
OR
Distant metastases, such as in the lungs, bone, or brain.
RCC staging image
RCC Staging is done via…
- Abd/pel CT
- Bone scan
- Bone pain or elevated alkaline phosphatase
- Chest CT or CXR
- MRI if suspect invasion into vena cava or atrium
MC sites of RCC metastasis
- Neighboring lymph nodes
- Lungs
- Liver
- Bones
- Brain
RCC prognosis
- Clear cell considered most aggressive of the common histologies
- Papillary and chromophobe are generally more indolent
- Mixed renal tumors can occur in up to 5% of cases with prognosis dictated by more aggressive subtype.
Localized RCC Tx w/ surgery
- Isolated solid renal masses, resectable stage I, II, III
- both diagnostic and curative
- Radical or partial nephrectomy
Localized RCC Tx w/ active surveillance
- <2-3cm with repeat imaging q3-6 months
Localized RCC Tx w/ ablative procedures
- Cryotherapy
- Radiofrequency Ablation
Advanced RCC Tx
- Consider debulking nephrectomy
- Systemic Therapy
- Immunotherapy
- Can consider radiation therapy with disseminated disease
- Chemotherapy has shown little effect
RCC take-away points
- Linked to smoking
- Hematuria
- Paraneoplastic syndromes
- Common incidental finding of renal mass for imaging to evaluate another symptom
- Diagnose = Usually ultrasound first
- Treatment = nephrectomy
- Depends on stage
Prostate Cancer Description
- Adenocarcinoma (>95%)
- MC region is the peripheral zone 70%
- Outer portion palpable on DRE
- 10-20% transitional zone
- Portion surrounding urethra
- ~5% central zone
- portion of prostatic urethra with ejaculatory ducts
Prostate Cancer Incidence
- Estimated 174,650 new cases diagnosed in 2019
- Rarely diagnosed in men younger than 40 y/o
- 1 in 5 AA men diagnosed in their lifetime
- 1 in 6 Caucasian men diagnosed in their lifetime
Prostate Cancer Risk Factors
- Advanced age
- Disease of aging
- incidence peaks between 65-74 y/o
- Family history
- Diet, obesity
- Ethnicity
- AA>W
- Genetic Factors/mutations
Prostate Cancer Symptoms
- Rare for patients to present with symptoms, usually asymptomatic in early stages
- Nonspecific urinary symptoms, uncommon
- Hematuria, hematospermia
- Late stages
- Bone pain, weight loss, weakness, fatigue, urinary symptoms
- Presenting with elevated PSA
Prostate Cancer Signs
- PSA
- Protein made solely by prostate glands
- Not specific for malignancy
- Can be elevated in benign conditions
- PSA increase >0.75ng/DL in one year is concerning
- Digital Rectal Examination
- Prostate nodules, induration, asymmetry
Prostate Cancer Dx
- Prostate biopsy
- Elevated PSA or abnormal DRE
- 12 cores
- Continue to follow PSAs and DREs
- Transrectal Ultrasound, guiding prostate biopsy
- MRI prostate
Prostate Cancer Staging Work-up
- PSA > 10ng/ml
- Gleason score ≥7
- Physical findings that suggest T3 disease
- Nuclear bone scan
- CT A/P
Prostate Cancer Metastasis
- Bones
- Lymph nodes
- Brain
- Liver
- Lungs
staging prostate cancer
- TNM
- Gleason score
- Prostate biopsy
Gleason Pattern
Gleason Score
- Gleason score adds the pattern number of the primary pattern (MC pattern seen in the biopsy– at least 50%) plus the secondary pattern (next most common pattern)
- Ex: Gleason 4 + 3
- The significance of the Gleason score is as follows
- A score of 6 indicates a low-grade or well-differentiated tumor
- A score of 7 indicates a moderate-grade or moderately differentiated tumor
- A score of 8-10 indicates a high-grade or poorly differentiated tumor
Prostate Cancer Staging TNM
- Stage I
- Cancer found incidentally in small part of sample when prostate tissue removed for other reason, e.g. BPH; cells closely resemble nl cells and gland feels nl to the examining finger
- Stage II
- more of prostate involved, lump felt
- Stage III
- tumor spread through capsule
- Stage IV
- tumor invaded nearby structures, or spread to lymph nodes or other organs
Prostate Cancer Tx Active surveillance
- Most slow growing; 50-75% will die of something else
- Avoids overtreatment, side effects
prostate cancer tx choice?
- ~94% choose treatment because 90% are diagnosed in early stage where surgery curative
- Decision depends on
- expected life expectancy (i.e. age at diagnosis)
- comorbidities
- Gleason score
other prostate cancer tx
- Surgery = radical prostatectomy
- Urinary incontinence
- Erectile dysfunction
- Radiation
- Hormonal therapy
- If advanced
Prostate Cancer Takeaways….
- Very Common
- Slow Growing
- Elevated PSA
- GLEASON grading system
- Treatment = depends on staging
- Prostatectomy
- Radiation
- Hormones
Bladder cancer description
- Cancer of the cells lining the urinary bladder
- Most common - transitional cell carcinoma
- Squamous cell carcinoma
- adenocarcinoma
bladder cancer histopathology
- MC = transitional cell
- Papillary
- wart-like appearance
- attached to a stalk
- Nonpapillary (sessile)
- flat
- much less common
- more invasive, worse outcome
bladder cancer incidence
- 9th most common cancer in the world
- Approx 80,000 new cases and 18,000 deaths annually
- Median age of diagnosis:
- 69 y/o in men
- 71 y/o in women
- M > F
- White males > AA men and Hispanic men
bladder cancer risk factors
- Cigarette Smoking!!
- Extent of smoking related to aggressiveness of bladder cancer
- Exposure to secondhand smoke
- Occupations
- Metal workers, painters, rubber industry workers, leather workers, textile and electrical workers, miners, cement workers, manufacturing carpets, paints, plastics
- Chronic bladder infections or ongoing source of bladder inflammation (i.e. chronic foley)
- Upper urinary tract cancer
- Radiation
- Meds: Cyclophosphamide, glitazones
bladder cancer signs and symptoms
- Painless Gross Hematuria
- Can be microscopic
- Irritative Bladder symptoms
- Dysuria, frequency, urgency
- Abdominal pain, pelvic pain, flank pain
- Advanced disease
- Fatigue, weight loss, failure to thrive
- Advanced disease
- Could all be sx of other disorders e.g. UTI so must evaluate carefully, esp risk factor hx
bladder cancer dx
- Urinalysis with microscopic
- Urine Cytology
- Urine Culture to check for infection
- Cystoscopy
- Including TURBT, transurethral resection of bladder tumor
- Upper tract imaging
- CT Urogram
- Renal ultrasound + retrograde pyelograms
bladder cancer metastasis
- Lymph nodes in the pelvis
- Bones
- Liver
- Lungs
- Ureters – hydronephrosis
- Urethra – strictures
bladder cancer metastasis evaluated w/…
- Abdominal, pelvic CT scan
- Abdominal MRI scan
- CXR
- Bone scan
bladder cancer staging
- TNM system
- Grading
- Microscopic appearance
bladder cancer stage 0 and 1
- Partial cystectomy/TURBT
- Chemotherapy or immunotherapy (BCG, interferon) injected directly into bladder
bladder cancer stage 2 and 3
- Radical cystectomy + nearby nodes, preop chemo to shrink tumor with urinary diversion (e.g. urostomy bag)
- Partial cystectomy, then radiation and IV chemo
- Chemo IV + radiation (pts who opt not to/can’t have surg)
bladder cancer stage 4
- Surgery not appropriate
- Chemo is often considered
bladder cancer 5 year survival by stage
bladder cancer take-away points…
- Major Risk = Smoking
- Painless hematuria
- Diagnosis = cystoscopy
- Treatment = depends on stage
testicular cancer description
- Cancer of the germ cells (sperm-producing cells) of the testes (95% of testicular tumors are germ cell tumors)
testicular tumor types
germ cell tumors
~95% of testicular tumors insert picture here!!
- Seminoma
- Pure seminoma 50% of all GCTs
- Average age approx. 40 years old
- Tumors markers normal
- Embryonal Carcinoma
- Pure embryonal 2% of all GCTs
- Do not produce AFP
- ¨Yolk Sac Tumor
- Prepubertal children
- Increased AFP
- ¨Choriocarcinoma
- Most aggressive and least common type
- Very high serum beta-hCG
- Do not produce AFP
Seminoma histopathology
- slow-growing
- usually found in men in their 30s and 40s
- usually just in testes, but can spread to lymph nodes
- very sensitive to radiation therapy
Testicular cancer Incidence
- Most common cancer in men ages 15-35
- Secondary peak after age of 60
- About 9,000 new cases diagnosed annually
- 400 deaths occur annually
- W > B
Testicular cancer risk factors
- Abnormal testicle development
- History of undescended testicle (cryptorchidism)
- Hypospadias
- Contralateral testicular cancer
- Family History
- Hx of HIV
- Klinefelter syndrome (47XXY)
Testicular cancer signs and symptoms
- Discomfort or pain in the testicle
- Heavy feeling in the scrotum
- Enlargement/lump/swelling of a testicle or a change in the way it feels
- Gynecomastia
- Production of hcg
- If advanced…
- Neck mass
- Nausea/vomiting
- Pain in the back or lower abdomen
- BUT may be no symptoms
Testicular cancer DDx
- Torsion
- Epididymitis
- Epididymo-orchitis
- Hydrocele
- Varicocele
- Hernia
- Hematoma
- Spermatocele
- Any firm, fixed mass is cancer until proven otherwise
Testicular cancer dx PE
- Firm, hard, or fixed mass within scrotum is suspicious for cancer until proven otherwise
- Check nodes
Testicular cancer Dx .. blood tests for tumor markers
- AFP
- b HCG
- LDH
Testicular cancer Dx imaging
- Scrotal Ultrasound
- CT chest/abd/pelvis
Testicular cancer interventional Dx
- Radical inguinal orchiectomy – histologic evaluation
- Retroperitoneal lymph node dissection (RPLND)
- Identify nodal micromets
- Gold standard for providing accurate pathologic staging of retroperitoneum
Testicular cancer Metastasis
- Abdomen
- Lungs
- Retroperitoneum
- Spine
Testicular cancer Prognosis
- Overall cure rate >90%
- Advanced tumors have 5 year survival of >70%
staging of Testicular cancer
- lts of clinical and radiographic evaluation
- TNM and Serum tumor markers
Testicular cancer Tx
- Depends on stage and cell type
- Suspicious neoplasm = radical inguinal orchiectomy
- RPLND
- Radiation therapy only used for seminomas
- Metastatic, stage IIC or III - chemotherapy
- Cisplatin
- Bleomycin
- Etoposide
- Clinically advanced disease
- Radical orchiectomy prior to chemotherapy
testicular cancer take-aways
- Most common malignancy in young men
- Risk Factor = cryptorchidism
- Fixed, solid mass in scrotum = cancer until proven otherwise
- Scrotal US
- CT scans for staging
- Two types:
- Seminomatous
- Nonseminomatous
- Treatment = orchiectomy, chemotherapy
What is the chief symptom associated with bladder cancer?
Hematuria
Which of the following would be of most concern if found while examining a 26 year old healthy male patient?
Nontender mass on the testes
A 65 year old woman presents with a complaint of blood in her urine, intermittently for the last month. She denies fever, chills, flank pain, or dysuria. Social history positive for 45 pack year tobacco use, but she reports quitting last year. What is the most likely cause of her hematuria?
Bladder Cancer
A 54 year old woman presents with gross hematuria and flank pain. Physical exam is positive for a RUQ palpable mass and negative for CVA tenderness. Gross blood is observed in urine specimen. What is your most likely diagnosis?
Renal Cell Carcinoma
Which of the following radiographic studies is indicated for the initial evaluation of a questionable palpable mass in the area of the kidney, with no other complaints by the patient?
Renal Ultrasound
