Genitourinary Neoplasms Flashcards
Renal Cell Carcinoma etiology
● Unknown etiology in most cases
● Some genetic syndromes are associated
○ Von Hippel Landau, Birt-Hogg-Dube, tuberous sclerosis complex, familial
or hereditary syndromes
Renal Cell Carcinoma classic triad
○ Gross hematuria, flank pain, palpable flank mass
○ Full “Triad” occurs in only 10% of cases
■ Generally represents advanced disease
How is Renal Cell Carcinoma typically found?
● Usually found on CT scan during work up for one of the three symptoms of the triad
● Often asymptomatic
Renal Cell Carcinoma diagnostics
● Typically discovered incidentally
● Gold-standard imaging – CT Urogram (3 scans)
■ No biopsy is needed
■ Biopsy exists, in certain cases
● CXR or CT chest (secondary to Dx)
When to refer a potential Renal Cell Carcinoma to urology
● Renal mass seen on CT
● “Complex renal cyst”
Where is metastasis of Renal Cell Carcinoma most likely?
Metastasis most likely move to the lymph,
lungs, liver, bones
Renal Cell Carcinoma Management
● Cryotherapy
● Gold Standard – Surgical excision
○ Radical nephrectomy
○ Robotic partial nephrectomy
Surgical excision Techniques for Renal Cell Carcinoma
○ Radical nephrectomy
■ Large or hilar tumors
■ “Open” or “hand-assisted laparoscopic” approach
○ Robotic partial nephrectomy
■ Exophytic and solitary tumors
■ Effort to spare nephrons
Renal Cell Carcinoma complications
● Acute or chronic kidney disease, abdominal hematoma, infection, bleeding,
pneumonia
● Solitary kidney
Prevention of Renal Cell Carcinoma
Modifiable risk factors for RCC include
○ Smoking, obesity, poorly-controlled hypertension,
diet and alcohol, and occupational exposures
Prostate Cancer epidemiology
● Most common cancer in men (after skin cancer)
○ 1 in 9 men (11%)
● Mortality – Second leading cause of male cancer death after lung cancer
○ 1 in 41 (2.4%)
● Major Risk Factors
○ Family Hx
○ African American
■ 1 in 4 (25%)
■ 2-3 x higher mortality
Prostate Cancer etiology
● Relatively unknown causes
● Genetics
○ Higher association with Lynch syndrome and BRCA2
Clinical Presentation of Prostate Cancer
● Asymptomatic
○ Identified through screening
● May present with obstructive urinary symptoms
○ Can be confused with benign prostate enlargement
● Metastasis
○ Bone pain
○ Vertebral fracture
Diagnostic Evaluations for Prostate Cancer
● Prostate Specific Antigen (PSA)
● Digital Rectal Exam (DRE)
● Prostate Biopsy – definitive diagnosis
● CT ab/pelvis – Lymph involvement
● Bone scan – metastatic
What is Prostate Specific Antigen (PSA) testing?
○ Released from the prostate tissue (<4 ng/mL)
○ Elevation in PSA
■ Cancer, infection, inflammation,
enlargement, recent ejaculation
■ Significant saddle time
The introduction of PSA had correlated with
____
significant reduction of death from prostate cancer
Why is there controversy over Prostate Specific Antigen (PSA)?
● There has been a some controversy around
PSA testing since USPSTF recommendations in
2011 that recommended AGAINST PSA
screening, regardless of age, race, or risk factors
○ Over diagnosing and possibly unnecessary
treatment
● We need to be wise on how and when to use it
What can cause PSA to be falsely elevated?
Infection, inflammation, enlargement, recent ejaculation
What can cause PSA to be falsely lowered?
5-Alpha Reductase inhibitors (Finasteride and Dutasteride)
PSA velocity/doubling time
4 years (more accurate with PSA <6 ng/mL)
Digital Rectal Exam (DRE) use in prostate cancer
○ Low sensitivity when used only screening method
■ Some providers use this as an excuse to never do them
○ Useful as a baseline test in screening, but doesn’t need to be done annually
● Important in patients with suspected prostatitis or BPH
as a cause of the elevated PSA
Prostate Cancer Management
● Observation/active surveillance – older men with low grade disease
● Androgen deprivation – Shot every 3+ months, controls but does not cure
○ Often use with metastasis
● Surgical Excision: Open vs Laparoscopic
● Radiation: Brachytherapy (implanting radioactive seeds) vs External beam
Surgical and radiological complications of prostate cancer management
● Surgery
○ Incontinence – stress
○ Impotence
● Radiation
○ Incontinence – although less than surgery
○ Impotence
Bladder Cancer epidemiology
● 2nd most common genitourinary cancer
● Men 3-4 x more common than women
● Higher in caucasians
● Average age of diagnosis 65 years old (rare <40)
● 90% Transitional Cell Carcinoma
Bladder cancer etiology
● Cigarette smoking – 2-3x greater risk of bladder cancer
○ Smoking accounts for 65% of bladder cancer in men and 20-30% in women
● Environmental exposures – Textiles, hair dyes, rubbers
Bladder Cancer clinical presentation
● Painless GROSS hematuria (80-90%)
● May have irritative voiding symptoms (20%)
● Smoker (+/-)
Bladder Cancer diagnostic evaluations
● Physical exam – unremarkable
● Urine microscopy
○ >3 RBC/HPF – “TNTC” – too numerous to count
● Urine culture – would be negative
● CT Urogram: Rule out other cause of hematuria
● Cystoscopy for Biopsy
Bladder Cancer management
● Transurethral Resection (TUR) – surgical excision
● Intravesical Chemotherapy (BCG or Mitomycin C)
● Radiation: Significant complications, 33-68% recurrence
● Radical Cystectomy
○ Diversion of the ureters (urostomy)
○ NeoBladder – pouch made from the small
bowel
Bladder Cancer prevention
● Smoking cessation
● Increase oral hydration
Testicular Cancer epidemiology
● Most common cancer in men aged 18-35 (rare >45 years)
● 1 in 250 men in their lifetime
● Two general types
○ Seminomas (55%)
○ Non-seminomas (44%)
Testicular Cancer risk factors
○ History of cryptorchidism
○ Family history
○ Previous testicular cancer
Testicular Cancer clinical presentation
“Rock hard” nodule on the testile
○ Usually unilateral
○ Starts painless
Testicular Cancer diagnostic evaluations
● Careful exam
● Scrotal Ultrasound – Gold Standard
● Biopsy – NO!!! can spread/seed
● CT abdomen/pelvis/chest
Tumor markers for testicular cancer
pre and post surgery
○ Alpha fetoprotein (aFP)
○ Beta human chorionic gonadotropin
(bHCG)
○ Lactate dehydrogenase (LDH)
Testicular Cancer management
● Radical orchiectomy – excision
● Radiation
Testicular Cancer metastasis
● Metastasis through lymph nodes
○ Ascending from the testicles up through the abdomen toward the chest
