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Medicine I: Module 3 > GU Malignancies > Flashcards

GU Malignancies Flashcards

1
Q

Prostate cancer risk factors

A 
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
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2
Q

prostate cancer clinical presentation

A

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

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3
Q

prostate cancer epidemiology

A

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%

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4
Q

prostate cancer screening: risks vs. benefits

A

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

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5
Q

prostate cancer screening: informed consent

A

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

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6
Q

Prostate cancer screening: general recommendations

A 
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
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7
Q

prostate cancer screening: other recommendations

A

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

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8
Q

prostate cancer screening: prostate specific antigen

A

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

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9
Q

prostate cancer: digital rectal examination

A

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

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10
Q

prostate cancer: screening/biopsy techniques

A

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

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11
Q

prostate cancer: race and age specific reference ranges

A

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)

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12
Q

Prostate cancer: positive screening results

A

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)

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13
Q

prostate cancer: prostate biopsy

A

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

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14
Q

prostate cancer staging

A 
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
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15
Q

prostate cancer: gleason grade

A

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 )

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16
Q

prostate cancer: clinical staging

A

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)

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17
Q

prostate cancer: treatment (early detection)

A 
o	Watchful waiting
o	Radical prostatectomy
o	Radiation therapy
	-External beam radiation
	-Interstitial implantation (brachytherapy)
o	Androgen deprivation therapy
	-Definitive therapy or as adjunct
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18
Q

prostate cancer: treatment (advanced)

A

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

19
Q

testicular cancer

A

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%

20
Q

testicular cancer: risk factors

A

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

21
Q

testicular cancer: clinical presentation

A

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

22
Q

testicular cancer: diagnostic evaluation

A 
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
23
Q

testicular cancer: prognosis and tx

A 
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
24
Q

testicular cancer: therapy summary

A

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

25
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
26
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
27
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
28
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
29
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 ```
30
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
31
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)
32
renal cell carcinoma: staging
o Stage 1 and 2 are within the capsule | o Stage 3 and 4 outside of the capsule
33
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
34
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
35
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
36
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
37
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
38
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
39
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
40
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
41
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
42
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
43
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

Medicine I: Module 3 (6 decks)

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