GU Cancers Flashcards
What is the most common noncutaneous cancer in American men?
Prostate cancer
What are the risk factors for prostate cancer?
- African American
- FH
A. 2 X greater risk w/ 1st degree relative
B. Shared familial risk for breast CA and prostate CA (BRCA2 and BRCA1 mutations) - High fat diet
What is the function of a normal BRCA1 and BRCA2 gene?
Genes that produce tumor suppressor proteins that help repair damaged DNA & maintain stability of the cell’s genetic material
Mutated BRCA1 and BRCA2 genes do what?
DNA damage may not be repaired properly & cells are likely to develop additional genetic alterations that can lead to cancer
What is the most common type of prostate cancer?
Adenocarcinoma
Where do most tumors originate in prostate cancer?
Peripheral zone of middle lobe
What is the pathophys of prostate adencarcinoma?
Prostate lesion growth: prostate gland → prostate capsule → along ejaculatory duct
What is prostatic intraepithelial neoplasia (PIN)
Premalignant change
What are the less common types of prostate cancer? What is their prognosis?
Sarcoma
Squamous cell
Ductal transitional carcinoma
Poor prognosis
Define PSA and describe what it’s used for
- Prostate Specific Antigen
A. Glycoprotein produced only by prostate cells
B. Used in detecting, staging and monitoring prostate cancer
What are the US preventative services task force recommendations for ending PSA screening?
All men 75 and older
Who should be screened annually for PSA at 40 yrs?
- African American male
2. 2 or more 1st degree relatives with prostate CA
What tests are indicated if PSA is elevated?
Requires histology specimen (Biopsy)
Transrectal needle Bx guided by transrectal U/S (TRUS)
What are some benign causes of elevated PSA?
- BPH
- Acute prostatitis
- Subclinical inflammation
- prostate biopsy
- cystoscopy
- TURP
- Urinary retention
- ejaculation
- perineal trauma
- prostatic infarction
What are the sxs of early prostate cancer?
- Asymptomatic
- Prostate nodules are detected on DRE
- Nodularity
- Asymmetry
- Induration
- Change in texture - Symmetric enlargement and firmness is more likely BPH
- Rise in PSA
What are the sxs of late prostate cancer?
1. Obstructive voiding sx’s A. Large or locally extensive disease 2. Bone pain A. Pelvis B. Ribs C. Vertebral bodies 3. Other metastatic sx’s A. Weight loss B. Loss of appetite C. LE edema secondary to venous or lymphatic obstruction
How many sites are necessary for a prostate biopsy?
10-12
What are the risks of Bx?
- Rectal or perineal pain
- Hematuria
- Hematospermia
- Minor rectal bleeding
- Potential for prostatitis and UTI
What are the indications for prostate biopsy?
- Abnormality on DRE
- Elevated PSA
- Normal (0-4.0 ng/mL) - Both
What other imaging studies are indicated in prostate cancer?
- Abd/pelvis CT scan
- Radionuclide Bone Scan
- Used for staging disease
What is the Gleasson Score used for?
- System of grading prostate cancer tissue, indicates aggressiveness of the tumor
- Similar to normal prostate tissue→ less likely to spread
- Very different from normal → more likely to spread
What is the equation for gleason scores?
Most common tumor pattern + second most common tumor pattern = Gleason Score
What high results on a gleason score indicative of?
- Combined scores of 8 or higher are the most aggressive cancers
- <6 = better prognosis
What is a gleason score of 2-4 indicative of?
- Cells look very much like normal cells
2. Low risk of metastasis
What is a gleason score of 5-7 indicative of?
Intermediate risk of mets
What is a gleason score of 8-10 indicative of?
- Cells have very few features of a normal cell
2. Likely to be aggressive (mets)
What are the stages of prostate cancer?
- Stage I (T1)
Tumor cells < than 5% of prostate tissue & low-grade - Stage II (T2)
More extensive or aggressive cells that are confined to the prostate - Stage III (T3)
Tumor has grown through the prostate capsule - Stage IV (T4)
Cancer has spread beyond the prostate to other organs
What is the median survival for metastatic prostate disease?
1-3 years
When is the risk of metastasis of prostate cancer considered low?
- Cancer confined to prostate capsule (Stage I-II)
- Gleason score ≤ to 6
- PSA ≤ 10
What is the treatment for stage i-ii prostate cancer?
1. Definitive treatment: Aimed to cure A. Radical prostatectomy -Open Laparotomy: Midline incision in lower abdomen -Minimally invasive: Robotic Prostatectomy via laparoscopy
What are the complications of treatment in stage i-ii?
Urine incontinence
ED
What are the radiation therapy options for prostate cancer stage i-ii?
- Radiation Therapy (RT) +/- Androgen Deprivation Tx
A. External Beam (EBRT)
-Pelvic radiation 5 days per week x 5-8 weeks
B. Brachytherapy
C. Low-Dose Rate
-Permanent rice-size “seeds” into prostate→ emit radiation
-Lose radioactivity over time
D. High-Dose Rate
-Temporary implant of radioactive source into prostate x 1-2 days
-In-pt. and usually combined with EBRT
What are the complications of EBRT?
- Urinary frequency
- Bladder pain
- ED
- Proctitis
What are the complications of Brachytherapy?
- Prostate Hypertrophy
- Increased Urine frequency
- Increased Urgency
- Dysuria
- Urine retention (temp. cath)
- Less proctitis
What is the active surveillance for stage i-ii prostate cancer?
Monitor q 3-6 mo
PSA, DRE
Possible additional Bx
What is androgen deprivation therapy and its SE?
- Used w/ EBRT in Intermediate - High Risk (Gl 7-10)
- S/E
↓ Libido
ED
Hot flashes
↓ Muscle mass
↑ Body fat
Osteoporosis
Gynecomastia
Increased risk of cardiovascular disease
What are ex of the drugs used in androgen deprivation? How long is it used?
- Treatment for two - three years is standard of care
A. goserelin (Zoladex)
B. flutamide
C. leuprolide (Lupron)
What is the life expectancy for intermediate to high risk prostate CA?
<10 yrs
What are common treatments for intermediate to high risk prostate ca?
- No one “best” treatment
- Combination Tx
- Radiation Tx w/ lifelong ADT
- Total prostatectomy
What are the palliative therapy options for prostate cancer?
ADT may be useful
Surveillance
When is palliative tx indicated?
Stage III-IV and age or comorbidity precludes definitive therapy
What is the prevalence of renal cell carcinoma?
2.6% of adult cancer
What demographic does renal cell carcinoma affect?
M>F
What are the risk factors for RCC?
- Smoking
- Obesity
- Hypertension
- S/P Hysterectomy
- Heredity
- Polycystic Kidneys
What is the pathophys for RCC?
- Renal cancers arise from proximal convoluted tubule epithelium
- Can occur anywhere in kidney
- Tumors can include areas of ischemia, necrosis and focal hemorrhage
What are the histological classifications for RCC?
- Clear cell : most common
- Papillary
- Granular
- Spindle like cell tumors
What is the classic triad for RCC?
- Flank pain, Palpable renal mass, Hematuria
- Occurs in only 10-15% of cases
- When present strongly suggests locally advanced disease
What are other symptoms of RCC?
- Weight loss
- Fever
- HTN
- Night sweats
- Malaise
What are the DS used in RCC?
- U/A w/ micro
- +/- anemia
- Abd/Renal U/S
- CT Abd
What is the most valuable imaging tool for RCC?
CT Abd
Solid lesion of kidney is RCC until proven otherwise
What is CT Abd used for?
- Identifies mass as well as staging disease
- Presence of lymph nodes, renal vein involvement, hepatic involvement
- Solid lesion of kidney → RCC until proven otherwise
Where does RCC commonly metastasize to?
- Lymph nodes
- Lungs
- Liver
- Adrenal glands
- Brain
- Skeleton
What test is used to determine if mets are present?
CT w/ bone scan
When is radical nephrectomy indicated in RCC?
- Primary treatment for localized disease
2. Can be laproscopic
When is partial nephrectomy indicated in RCC?
1. Reserved for pts with: A. Single kidney B. Bilateral lesions C. Tumor < 4 cm D. Significant renal disease
Define radio frequency ablation
A. Electrode probe inserted, sending radio frequencies to tissue, generating heat through the friction of water molecules to 50 degrees C.
Define Cryoablation
A. Probe cooled with chemical fluids, freezing temp causes tumor cell death by causing osmotic dehydration
What immunotherapy agents are used in RCC? What is the MOA?
Axitinib Bevacizumab Carfilzomib Everolimus Interferon-α Interleukin-2 Inhibits growth factor preventing tumors from forming
What is the prognosis for RCC?
- 25-30% of people have this metastatic spread by the time they are diagnosed with renal cell carcinoma
- If cancer is encapsulated, which is about 60% of cases, it can be cured roughly 90% w/surgery
What is the epidemiology of bladder cancer
- Males > females
2. 9th leading cause of cancer
What are the risk factors for bladder cancer?
- Cigarette smoking: number 1 risk factor
- Exposure to industrial dyes or solvents
- Hairdressers
- Petroleum workers
- Spray painters
- Leather finishers
- Bus drivers
- Motor mechanics
- Machine setters
Transitional cell carcinoma makes up what percent of bladder cancer?
90%
What types of cancers makes up the remainding 10% of bladder cancer?
- Squamous cell carcinoma
- Adenocarcinoma
- Sarcoma
- Small cell carcinoma
What is the pathophys of bladder cancer?
Carcinogen exposure or chronic inflammation cause epithelial cellular changes
Bladder tumors can develop on surface or inside bladder wall and invade surrounding muscle
What are the sxs of bladder cancer?
- Asymptomatic in early stages
- Common symptoms
-Hematuria: 85-90% of patients
+/- irritative voiding sx’s
-Dysuria, frequency - In advanced disease
-Pelvic pain
-Lower-extremity edema
-Flank pain
What DS are indicated in bladder cancer?
1. U/A w/micro A. +RBC’s 2. CBC A. +/- anemia 3. Urine cytology 4. BLadder U/S 5. CT or MRI 6. Cytoscopy and biopsy
What is the sensitivity of urine cytology?
- 80-90% sensitive for high grade lesions
2. 50% sensitive for superficial lesions
What is the bladder U/S used for in bladder cancer?
- Detects mass
2. Filling/emptying defect
What is the bladder CT/MRI used for in bladder cancer?
- Evaluate upper urinary tract
- R/O mets
CT done more often than MRI
What is the cytoscopy and biopsy used for in bladder cancer?
Gold Standard for Dx
What is the staging of bladder disease based on?
Extent of bladder wall penetration
Presence of regional or distant metastases
What is the tx for superficial bladder cancer?
- Complete transurethral resection (TURBT) and selective use of intravesical chemotherapy (Q week for 6-12 wks)
- Partial cystectomy
What is the tx for invasive disease?
- Radical cystectomy, irradiation or combination of chemo/surgery or chemo/irradiation
- Radical cystectomy is mainstay of tx for muscle-invasive bladder cancer
- Urinary diversion various choices
Define resectoscope and its uses
Electrocautery device attached to a cystoscope
Serves primarily for pathological staging
In non-muscle invasive bladder cancer, TUR is the treatment
What are the chemotherapy agents used for bladder cancer?
- Bacillus Calmette–Guérin (BCG)
A. Used to treat and prevent the recurrence of superficial tumors
B. Effective in up to 2/3 of in-situ cases - valrubicin (Valstar)
What is the 5 year survival rate for superficial bladder cancer?
81%`
What is the 5 yr survival rate for advanced bladder cancer after radial cystectomy?
50-75%
What is the most common solid tumor in men?
Testicular cancer
What is the pathophys of testicular cancer?
- Primary etiology unknown
- Most originate from germ cell tumors
- Testicular cancer may metastasize to lungs, liver, viscera or bone
- Spreads via lymphatics to iliac, para-aorta and mediastinal lymph nodes
What percentage of testicular cancers are seminomas? Describe them.
- Approximately 35% are Seminomas
A. Uniform undifferentiated cells resembling primitive gonadal cells
B. Less aggressive
What percentage of testicular cancers are seminomas? Describe them.
- 65% are nonseminomas
A. Tumor cells with varying degrees of differentiation
B. More aggressive
Which type of testicular cancer has the highest risk of mets?
Nonseminomas: Choriocarcinomas
Hematogenous spread to liver, bone and brain
What are the risk factors for testicular cancer?
Cryptorchidism
Even if surgically corrected
Previous Hx testicular cancer
Maternal use of diethylstibestrol (DES) during pregnancy
What are the sxs of testicular cancer?
- Scrotal mass
A. PAINLESS enlargement of testis
B. Solid mass
-May have hydrocele also
C. 10% present with acute pain
D. Dull ache or heavy sensation: usually due to secondary hydrocele - Ureteral obstruction
A. Secondary to para-aortic lymph node involvement
B. Systemic manifestations of germ cell tumors- gynecomastia
What are the sxs of testicular cancer mets?
- Supraclavicular neck mass
- Anorexia, nausea, other GI sx’s
- Back pain
- Cough, SOB, Hemoptysis, CP
A. With mediastinal adenopathy
B. With metastatic lung disease
What are the Ds for testicular cancer?What are their results?
1. First Test to Order A. Serum tumor markers: -Beta-hCG: Elevated with seminomas -Alpha fetoprotein: Elevated with nonseminomas -LDH: Elevated with both types of tumors B. High resolution CT scan of abd/pelvis C. CXR: If abnl, order Chest CT
What is the definitive diagnosis for testicular cancer?
Diagnosis confirmed by radical inguinal orchiectomy
How is clinical staging determined in testicular cancer?
Chest, abdominal and pelvic CT scans
When is semen cryopreservation indicated in testicular cancer?
Prior to surgery for testicular cancer
How is the staging for nonseminoma tumors determined?
1. Stage I disease limited to testes Cured by orchiectomy alone 2. Stage II disease Orchiectomy or chemotherapy 3. Stage III disease Orchiectomy and chemotherapy
How is the staging for seminoma tumors determined?
- Stage I & IIa seminomas (retroperitoneal disease < 10 cm in diameter)
Radical orchiectomy & retroperitoneal irradiation - Stage IIb seminomas with > 10 cm retroperitoneal involvement
Primary chemotherapy - Stage III
Primary chemotherapy
What is “surveillance” in the context of testicular cancer?
Patients are followed monthly for first 2 years and bimonthly for year 3
Tumor markers are obtained at each visit
CXR and CT scans are obtained q 3 months
Follow up continues beyond 3 years
80% of relapses will occur within first 2 years
If relapse occurs, chemo or surgery
What is the prognosis of testicular tumors for nonseminomas?
- 5 year disease free survival rate range from 96-100%
2. For low volume Stage B disease, 5 year disease free survival rate is 90%
What is the prognosis of testicular tumors for seminomas?
5 year disease free survival rate 92-98% (orchiectomy and retroperitoneal irradiation)
What is the prognosis of stage iii testicular tumors?
Stage III disease with primary chemo followed by surgery have a 5 year disease free survival rate of 55-80%
