GU Malignancies Flashcards
Prostate cancer risk factors
o Age >45 years o African American race o Obesity (high BMI) o High testosterone level o Genetic factors -BRCA1/2 gene mutations -Chromosome 1 abnormalities o Chronic Infection o Diet -High animal fat -Increased calcium / Vitamin D deficiency -Low vegetable intake -Low omega-3-fatty acids
prostate cancer clinical presentation
o Most patients asymptomatic at presentation
o Symptoms may include urinary urgency, frequency, hesitancy, and nocturia
o New onset erectile dysfunction
o Hematuria or hematospermia in older men and is a more advanced disease
o First sign of metastatic disease is pain in the sacrum (commonly)
o Also likes to metastasize to lung, liver, and brain
prostate cancer epidemiology
o Prostate cancer is most common tumor in males in the US
o Prostate cancer is the 2nd most common cause of cancer death in men
o American males have 18% risk of developing prostate cancer, but only 3% risk of death
o 10-year survival rates
-With localized disease = 75%
-With regional disease = 55%
-With distant metastases = 15%
prostate cancer screening: risks vs. benefits
o Anxiety/psychological distress
o False negative and false positive results
o Rare but possible complications of biopsy
o Overdiagnosis of cancer that would never become clinically significant
o Risks of treatment
prostate cancer screening: informed consent
o Prostate cancer is an important health problem
o The benefits of screening and aggressive treatment have not been proven
o DRE and PSA can have false positive and false negative results
o The probability of further invasive evaluation as a result of screening is high
o Aggressive therapy is necessary to realize any benefit from finding a tumor
o A small but real risk of serious side effects, including chronic sexual and urinary problems, and early death may result from treatment
o Early detection may save lives
o Early detection and treatment may avert future cancer-related illness
Prostate cancer screening: general recommendations
o When to discuss prostate cancer screening -Average risk men at age 50-55 years -High risk men at 40-45 yrs -AA, FH, BRCA mutation o How often to consider screening -Serum PSA q 2-4 yrs -Recommend against DRE o When to stop screening -Comorbidities/life expectancy <10 yrs -Age >69 yrs; Age >65 yrs if PSA <1.0
prostate cancer screening: other recommendations
o ACS
-Screen avg risk men age 50 with PSA +/- DRE; if PSA >2.5 screen annually, o/w screen q 2 yrs; refer PSA >4
o AUA
-Screening with informed consent age 55-69 with PSA, no DRE, q 2 yrs
o USPSTF
-Recommends against screening
o Others available as well
prostate cancer screening: prostate specific antigen
o PSA is a glycoprotein produced by the prostate epithelial cells
o PSA liquefies seminal fluid
o Elevations in PSA may precede clinical disease by 5-10 years or longer
o In prostate cancer, PSA production is increased and tissue barriers between prostate gland lumen and capillary are disrupted → increased serum PSA
prostate cancer: digital rectal examination
o Nodules, asymmetry, or induration of the prostate gland
o Can detect tumors in the posterior and lateral aspects
o Most cancers detected by DRE are too advanced to improve mortality
prostate cancer: screening/biopsy techniques
o Combination PSA + DRE
-Minimal improvement in detecting prostate cancer than either method alone
o Transrectal US
-Used to guide prostate biopsy
o Prostate biopsy
-Used for suspicious lesions or areas only
-Too expensive, complicated for routine screening
prostate cancer: race and age specific reference ranges
o 40 to 49 years-old - 0 to 2.0 ng/mL (blacks); 0 to 2.5 (whites)
o 50 to 59 years-old - 0 to 4.0 ng/mL (blacks); 0 to 3.5 (whites)
o 60 to 69 years-old - 0 to 4.5 ng/mL (blacks); 0 to 3.5 (whites)
o 70 to 79 years-old - 0 to 5.5 ng/mL (blacks); 0 to 3.5 (whites)
Prostate cancer: positive screening results
o Abnormal DRE (if performed)
-Refer to Urology for transrectal US (TRUS) guided prostate biopsy
o High PSA
-PSA 4-7: Repeat in a few weeks to confirm
-Repeat PSA >4, refer to Urology
-PSA >7: Refer to Urology for TRUS-guided biopsy
-PSA increasing >0.75 ng/mL/year, refer to Urology
o A lot of providers will treat with Cipro (not supported by evidence, but common clinical practice for PSA 4-7)
prostate cancer: prostate biopsy
o Gold standard for diagnosis of prostate cancer
o TRUS-guided biopsy (extended protocol preferred over sextant protocol)
-Biopsy of any suspicious areas
-At least 6 core samples from base, midzone, and apical areas of right and left lobes
-Lateral samples may also be taken for better results
-Samples sent to pathology for stains and histology
prostate cancer staging
o Clinical stage -DRE and/or TRUS results o Pathological stage -Based on Gleason Score o TNM staging and Gleason grade scores used to determine therapy
prostate cancer: gleason grade
o Analysis of tumor histology
o Provides some index of prognosis
o Tumors graded from 1 to 5 based on degree of glandular differentiation and structural architecture
o Add primary and secondary scores to form the Gleason score (Range from 2-10, increasing # correlates with increasing tumor aggressiveness )
prostate cancer: clinical staging
o Provides means for determining prognosis and choosing treatment options
o Radionuclide bone scan
-Positive scan indicates disease outside the gland
-Eliminates potential for curative surgery
o MRI or CT scan of abdomen/pelvis
-Used to design treatment protocols for men undergoing external beam radiation, PSA >10 ng/mL, or Gleason score >6 (increased likelihood of lymphatic metastases)
prostate cancer: treatment (early detection)
o Watchful waiting o Radical prostatectomy o Radiation therapy -External beam radiation -Interstitial implantation (brachytherapy) o Androgen deprivation therapy -Definitive therapy or as adjunct
prostate cancer: treatment (advanced)
o Androgen deprivation therapy
-LHRH Agonist (Lupron, Zoladex)
-Anti-androgens (Flutamide, Casadex) prevent testosterone flare
o Palliative care for metastatic bone disease
o Local therapy for advancing disease may be used
-Radiation, surgery, medications
o This is palliative care, not curative
testicular cancer
o Most common malignancy in males ages 15-35 yrs
o 95% are germ cell tumors
-50% seminoma
-45% non-seminoma, including teratocarcinoma, embryonal ca, choriocarcinoma, and yolk sac tumors
o 5-year survival rate >95%
testicular cancer: risk factors
o Cryptorchidism í undescended testicle; increased risk for testicular cancer
o Cancer of the contralateral testicle
o HIV infection
o Carcinoma in situ or testicular intraepithelial neoplasia
o Family history of testicular cancer
o Extragonadal germ cell tumor
o Klinefelter and Down syndromes
o Race (rare in African American population)
o Marijuana use
testicular cancer: clinical presentation
o Painless mass discovered by patient or partner, or by clinician on physical exam
o Rapidly dividing tumor cells may cause pain
o Testicular swelling or enlargement
o Aching in the scrotum or lower abdomen
o On PE: firm, nontender mass, does not transilluminate; some patients may have gynecomastia
o 20% present with mets: back pain, abdominal mass, pulmonary symptoms
testicular cancer: diagnostic evaluation
o Diagnosis by scrotum US o If US suggestive of testicular cancer, follow with CT scan of abdomen/pelvis and CXR o Serum tumor markers: Pre- and Post- orchiectomy -AFP elevated above 10,000 ng/mL -β-hCG elevated above 10,000 mIU/mL -LDH elevated (nonspecific) o Radical inguinal orchiectomy -Provide histological diagnosis -Local tumor control o Retroperitoneal lymph node dissection -Gold standard for staging -Number and size of nodes are important o TMN staging with serum tumor markers
testicular cancer: prognosis and tx
o Good risk -Any primary site -No nonpulmonary visceral metastases -Normal or low serum tumor markers o Intermediate risk -Testicular or retroperitoneal primary -No nonpulmonary visceral metastases -Low to moderate increase in serum tumor markers o Poor risk -Mediastinal primary site -Nonpulmonary visceral metastases -Significant elevation of serum tumor markers o Treatment based on histologic type of cancer -Surgical treatment -Radiation -Chemotherapy
testicular cancer: therapy summary
o Radical Orchiectomy for diagnosis and treatment of primary tumor
o Treatment based on tumor type and stage
-Seminoma: surveillance, radiation, or chemo and radiation
-Non-seminoma: surveillance, RPLND, chemo alone or in conjunction with RPLND
testicular cancer: fertility and sperm banking
o Semen cryopreservation should be made available to every patient diagnosed with testicular cancer prior to starting therapy if he wishes to preserve fertility
renal cell carcinoma
o Primary tumor of the kidney
o 2.6% of all adult cancers
o Peak incidence in the 6th decade of life
o Male to female ratio is 2:1
o Cigarette smoking is only known significant risk factor
o 4% familial, 10-20% higher in AA population
renal cell carcinoma: histology
o Originates from different parts of the nephron
o Various cell types
-Clear, granular, spindle
o Various histologic patterns
-Acinar, papillary, solid
o Cell type and histologic pattern do not affect treatment
renal cell carcinoma: clinical presentation
o >50% detected incidentally on US or CT scans done for other reasons
o Hematuria most common finding
o “Too Late Triad:” flank pain, hematuria, palpable mass
o 20-30% present with symptoms of metastatic disease (cough, bone pain)
o Anorexia, malaise, weight loss, night sweats may be present in paraneoplastic syndrome
o Kidney cancer likes to go to the lungs and bones
renal cell carcinoma: laboratory findings
o Hematuria (gross or microscopic) in 60% o Anemia is common o Hypercalcemia in up to 10% of patients o Paraneoplastic syndrome not uncommon -Gonadotropin excess -Erythrocytosis, thrombocytosis, coagulopathy -Fever -55% have elevated ESR -14% have elevated LFT's without mets -13% have elevated serum calcium
renal cell carcinoma: imaging studies
o CT scan (with and w/o contrast) most valuable for assessing tumor
-Confirm character of the mass
-Helps in staging the tumor
-Look at contralateral kidney
o CXR to r/o pulmonary metastases
o Bone scan for pts with bone pain or elevated serum alkaline phosphatase
o MRI and Doppler US if suspected renal vein or vena cava thrombosis
renal cell carcinoma: diagnosis
o Solid mass on imaging studies is assumed to be cancer until proven otherwise
o Biopsy of mass for definitive diagnosis and staging (rarely done because of false negatives, hemorrhage, and tumor seeding)
renal cell carcinoma: staging
o Stage 1 and 2 are within the capsule
o Stage 3 and 4 outside of the capsule
renal cell carcinoma: tx
o Partial or radical nephrectomy is the primary treatment
o Radiofrequency or cryosurgical ablation is being studied
o No effective chemotherapy
-Some agents are used systemically after surgery with partial response
-Vaccines under investigation
renal cell carcinoma: prognosis
o 5-year survival rates:
- 90-100% in T1-T2 tumors confined to the renal capsule - 50-60% in T3-T4 tumors extending beyond the renal capsule - 0-15% in node positive tumors
bladder cancer
o Second most common urologic cancer
o Male to female ratio is almost 3:1
o Mean age at diagnosis is 65 years
o Cigarette smoking accounts for 60% of cases
o Exposure to industrial dyes or solvents accounts for about 15% of new cases
o 90% are transitional cell carcinomas
o 60ish yo man with hematuria with smoking hx, its either kidney or bladder cancer
bladder cancer: clinical presentation
o Hematuria (gross or microscopic) in 85-90%
o Irritative voiding symptoms in some patients
-Urinary frequency and urgency
o Palpable masses and symptoms of metastatic disease may present late
-Mass in the suprapubic region
-HSM, supraclavicular LAD, lymphedema of the LE if extending to pelvic nodes
o Because of chronic hematuria, they have anemia as well
bladder cancer: laboratory findings
o Hematuria; occasionally pyuria
-Painless hematuria is bladder cancer until proven otherwise
o Azotemia if ureteral obstruction present
o Anemia
o Urine cytology is usually positive
bladder cancer imaging studies and diagnosis
o May be detected using IVP, US, CT, MRI
-Filling defects within the bladder
-Staging of advanced lesions
o Confirmed by cystoscopy and biopsy by transurethral resection
-Random bladder and prostate biopsies also for staging
bladder cancer tx: surgical
o Transurethral resection as initial treatment in all patients; 70% are noninvasive superficial tumors
o Indications: T2-T3 cancers
o Partial cystectomy for some patients
o Radical cystectomy with pelvic node dissection for more extensive disease
-Men - bladder, prostate, seminal vesicles, surrounding fat and peritoneal attachments
-Women - bladder, uterus, cervix, urethra, anterior vaginal vault, ovaries
-Urinary diversion required in both male and female
bladder cancer tx: radiotherapy
o External beam radiation delivered in fractions over a 6-8 week period
o About 10-15% of patients develop bladder, bowel, or rectal complications
o Local recurrence occurs in 30-70% with radiotherapy alone
o More often used in combination with chemotherapy to prevent relapse
o Indications: T2-T3 cancers
bladder cancer tx: intravesical chemotherapy
o Immunotherapeutic or chemotherapeutic agents delivered directly into the bladder by urethral catheter
-Immuotherapy: BCG/interferon
-Chemotherapy: mitomycin C at time of bladder tumor resection or cyclical if BCG fails
o Eradicate existing disease or prevent or delay recurrence after transurethral resection
o Administered weekly for 6-12 weeks x 2 hrs
o Indications: superficial or localized cancers
o Side effects: irritative voiding symptoms, hemorrhagic cystitis
bladder cancer treatment: chemotherapy
o Combination chemotherapy has been used to decreased the rate of recurrence
o Indications: T2-T3 or more distant cancers
o May also be combined with surgery and/or radiotherapy
o Moderate responses have been seen in patients with using chemotherapy
-15-45% depending on studies and comorbidities
bladder cancer prognosis
o 50-80% of bladder cancers are superficial at presentation
-Excellent survival rates at 81%
-50% have low grade recurrences
o Survival rates decrease with increased tumor grade or stage
