Lecture 11: Prostate and Kidney Cancer

Question 1

What are the risk factors for prostate cancer?

Answer 1

1) age/sex- increases with age especially for over 50
2) diet-high fat diet association
3) family history-3-5x if relative has it
4) race-BLACKS! get it more and have higher rate of aggressive disease

Question 2

IF age 55-69–>+family history and black—>DRE/PSA—>If DRE + and PSA + (age specific, >4, % freeTransrectal ultrasound/biopsy

Answer 2

If DRE-/PSA- then do annual DRE/PSA until either one is positive

Question 3

How do you diagnose ze prostate cancer?

Answer 3

1) Digital rectal exam-nodules, firmness
2) Serum Prostate-Specific Antigen (PSA)
- serine protease
- liquefies ejaculate
- prostate specific but NOT cancer specific
- varies with age and benign conditions
- LOW PSA=HIGH CANCER CHANCE (free PSA=amount NOT bound to albumin)
- only validated in PSA 4-10

Question 4

How do you stage the prostate cancer?

Answer 4

1) cT1-NOT clinically apparent by palpation or imaging
2) cT2-papable confined to prostate
3) cT3-extended outside prostate and/or into seminal vesicles
4) cT4-fixed or involving adjacent organs (rectum, bladder)

Question 5

How do you treat local prostate cancer?

Answer 5

If localized cancer:

1) active surveillance
2) radical prostatectomy-remove all or part of prostate
3) external beam radiation
4) brachytherapy-radioactive seeds radiate the tumor

Question 6

What are signs and symptoms of early prostate cancer?

Answer 6

none

Question 7

What are signs and symptoms of progressive prostate cancer?

Answer 7

1) hesitancy, decreased stream, nocturia
2) hematospermia-blood in semen
3) impotence

Question 8

What are signs of advanced prostate cancer?

Answer 8

bone pain

Question 9

What do all of the following have in common?

1) cytoscopy (endoscopy of the bladder)/catherization
2) biopsy
3) benign prostatic hyperplasia
4) prostatitis/urinary infection
5) recent ejaculation
6) bike riding
7) NOT DRE (digital rectal exam)

Answer 9

Factors that can give you FALSELY POSITIVE PSA Elevations

Question 10

What do you use to stage prostate cancer?

Answer 10

1) pelvic CT or MRI (lymph nodes)
2) bone scan (bone mets)
3) PSA level
4) palpation of prostate cancer extent

Question 11

How do you treat metastatic prostate cancer?

Answer 11

1) NO CURE
2) androgen deprivation therapy (castration)
- GnRH agonists and antagonists (medical castration)
- orchiectomy (surgical castration)
3) chemotherapy after becoming castration resistant
4) newer therapy: immunotherapy, novel anti-androgens, adrenal androgen synthesis inhibitors

Question 12

How do you screen prostate cancer? (controversial)

Answer 12

1) prostate specific antigens

2) digital rectal exams

Question 13

How do you diagnose prostate cancer?

Answer 13

transultrasound guided prostate biopsy

Question 14

What’s on the differential for a solid renal mass?

Answer 14

1) RENAL CELL CARCINOMA-until proven otherwise, 90%, enhancing spherical mass
2) Oncocytomas-indistinguishable from RCC on imaging
3) Angiomyolipomas-fat density by CT, tuberous sclerosis
4) Urothelial carcinoma-renal pelvis

Question 15

What are some risk factors for Renal Cancer?

Answer 15

1) smoking dem cigarettes
2) obesity
3) hypertension
4) Von-Hippel Lindau
5) Tuberous Sclerosis
6) Acquired renal cystic disease in patients with end-stage renal disease

Question 16

What risk factor for renal cancer am I describing?

1) Cerebellar hemangio-blastoma
2) Retinal angiomas
3) Renal cysts
4) Clear renal cell cancer
5) Epididymal cystadenoma
6) Pancreatic cysts
7) Pheochromocytoma

Answer 16

Von-Hippel Lindau

Question 17

What are the less common differentials for solid renal mass?

Answer 17

1) adrenal tumors
2) renal abscesses
3) xanthogranulomatous pyelonephritis
4) metastases to the kidney (breast, lung primary)
5) lymphoma

Question 18

What is malignant renal cancer pathology?

Answer 18

1) Clear cell (conventional)
- 85% renal cell carcinoma
- proximal tubules

2) papillary-multifocal and bilateral
3) chromophobe

Question 19

What is benign renal cancer pathology?

Answer 19

1) Oncocytoma-cannot differentiate from malignant tumor on imaging
2) angiomyolipoma-fat seen on CT is diagnostic

Question 20

What is the ‘classic triad’ of symptoms seen in renal masses?

Answer 20

1) flank pain
2) palpable mass
3) hematuria

• only 10% have the triad at presentation, usually advanced stage
• 25% of Renal Cell Cancer present with mets

Question 21

What disease am I describing AND what u gonna do about it?

1) reversible syndrome of hepatic dysfunction (high LFTs)
2) NO mets

Answer 21

Hepatopathy-Stauffer’s Syndrome (signs and symptoms renal cell carcinoma)-paraneoplastic syndrome

Work-Up

1) Cross-Sectional Imaging-CT SCAN preferred or ultrasound
2) If Mets-chest x-ray, bone scan if high alk phos, LFTs, serum Ca, CBC, head CT/MRI if wide mets
3) Renal Biopsy- unnecessary if big, helpful if small tumors

Question 22

How do you stage kidney tumors?

Answer 22

T1-confined to kidney, 7cm
T3- into major veins or perinephritic tissue
T4-beyond gerona’s fascia

Question 23

How do you treat kidney tumors?

Answer 23

1) Partial Nephrectomy-PREFERRED
- efficacious and safe
- preserves kidney function
- lowers long term morbidity/mortality

2) Radical Nephrectomy
- previous standard of care
- now ONLY for masses not treatable with partial nephrectomy

3) laprascopic cryotherapy-freeze the tumor
4) percutaneous cryotherapy
5) percutaneous radio frequency ablation (burn it off)/microwave

Question 24

How do you treat renal cancer with mets?

Answer 24

1) CYTOREDUCTIVE NEPHRECTOMY (kidney removal) FOLLOWED BY IMMUNOTHERAPY IMPROVES SURVIVAL for good surgical candidates

2) poor prognosis
3) resistant to chemo/radiation
4) old treatment immunotherapy with interferon and interleukin