Urologic Cancers- Brian Miller Flashcards
Penile Cancer:
accounts for ___% of all cancer in men in the US
1%
-More common in less developed countries
Africa, parts of Asia, South America
–Can be 10-20% of male cancer cases in these regions
Penile CA:
-MC demographic?
Hispanic, Asian/Pacific Islander men
-Mean age of dx = 60 yo
Penile CA:
-list risk factors
- HPV infection
- Phimosis
- uncircumsized men
- HIV infection
- smoking
Penile CA:
___% of cases are squamous cell carcinoma (SCC)
95%
-Less common: Basal cell carcinoma, Kaposi sarcoma, malignant melanoma, extramammary Paget disease, urethral carcinoma, metastases
Penile CA:
Sx?
- ALMOST ALWAYS 2/2 Pt noticing a lump, mass, or ulceration on penis, MC on glans
- 30-60% will have inguinal lymphadenopathy on exam
Penile CA:
-If infection is suspected (ie erythema/swelling/drainage) can attempt–> ?
trial of antibiotics and/or antifungal meds BUT…
-If there is a palpable mass and LAD–> biopsy is needed
Penile CA:
IF dx is clear on exam, Pt will be taken to _____
OR, quickly for excision of lesion if possible
Penile CA: tx for tumors w low risk of recurrence (Tis, Ta lesions of glans and T1a/T1b of glans) =
- consider organ-preserving strategies
- Partial penectomy –> Goal is 1-2 cm of negative margins
- Radiation
- Laser ablation, glans resurfacing (Tis)
- Mohs micrographic surgery
Topical tx – fluorouracil, imiquimod
Penile CA:
-tx of tumors w/ high risk of recurrence (ie bulky, T2-T4 tumors) ?
- **penectomy
- Interstitial brachytherapy can be considered for those refusing surgery
Bladder CA:
-how common?
- MC malignancy of urinary system
- Urothelial (transitional cell) carcinoma, MC histologic type
- -can also be found in the ureter and kidney
Blaader Ca:
-divided into 3 categories (list)
Non-muscle invasive
Muscle invasive
Metastatic
Bladder CA:
Sx**
- **painless hematuria
- with gross hematuria there is higher chance of bladder CA
- Microscopic hematuria= >3 RBC/hpf
- **Irritative voiding Sx: frequency, urgency, hesitancy
- pain
Hematuria present only at beginning of urination=
urethral source**
Terminal hematuria=
bladder neck source
-often seen in dysfunctional voiding
If hematuria is present throughout voiding–> ?
kidney, ureter, and bladder affected
Bladder CA: work-up
H&P
Office cystoscopy
Consider cytology –>** +/- transitional cells
- CT a/p (abdomen/pelvis)
- Imaging of upper tract collecting system
Bladder CA:
tx?
If tumor visualized on office cystoscopy and/or positive cytology…
- Exam under anesthesia
- ***TURBT – transurethral resection of bladder tumor
Pathologic evaluation will help differential muscle invasive vs noninvasive
Non-muscle invasive bladder CA tx?
After tissue evaluation, patients are risk stratified
Low – 1 dose of intravesical chemotherapy
Intermediate – extended course of intravesical chemo
High – extended course of intravesical chemo, +/- systemic chemo, consider cystectomy
Muscle-invasive bladder CA: tx?
Radical cystectomy
Bladder CA w/ mets disease?
Platinum based chemotherapy
Prostate Cancer:
-how common?
- VERY common
- 60% of 80yo will have it on autopsy
- second only to melanoma and lung CA as a leading cause of CA deaths
Prostate eval:
what is included?
- PSA
- DRE: normal= symmetric/smooth, abnormal= asymmetric/nodules/masses
- Sx: usually none
If Pt has abnormal PSA and/or abnormal DRE, what is the next step?
prostate biopsy
***TRUS – transrectal ultrasound guided biopsy
Describe TRUS:
-how many cores are typically taken?
-12
-Tissue sent for pathologic evaluation
–>If positive= consider tx
–>If negative = observation
-If PSA still high or rising?
18 – 24 core biopsy
Prep:
Enema
–2 days of abx prophylaxis
Why: cuz of Increased UTI/sepsis risk
Prostate CA:
MC mets to ______
BONE
- Consider bone scan if symptomatic and/or high grade disease
- histologic grade- gleason score
- PSA level
Gleason score:
-ranges from?
2-5
–combines 2 of most prevalent tissue types from bx
(2 scores added together= gleason score)
-Ranges from 6-10 (lower numbers are usually not diagnostic for cancer
Gleason score and TNM staging are used to guide treatment
Prostate CA:
-Localized dz: tx?
-very low risk–> PSA <10, normal DRE, low Gleason <6, < 3 positive cores
Active surveillance
Prostate CA:
Localized, low risk: tx?
PSA<10, normal DRE, low Gleason <6, ***>3 positive cores
–>Surveillance, radiation, radical prostatectomy
Prostate CA:
Localized, intermediate risk
tx?
PSA >10, Gleason 7, larger and/or in both lobes
-RT, radical prostatectomy
Prostate CA:
localized high risk? tx
PSA >20, Gleason 8+
-RT, radical prostatectomy
Prostate CA:
stage 4 tx?
=Lymph node involvement/distant mets
tx=RT +/- ADT (chemotherapy)
After prostate CA tx:
f/u w/?
serial PSA to assess for recurrence
-Follow with serial CT scans (depending on risk level)
Primary Testicular Tumors :
list the 2 types?**-
- Germ Cell tumors (95%)
- Stromal tumors (5%)
Describe serum tumor markers associated w/ Germ cell tumors** (which lab markers?**)
- AFP**
- bHCG**
KNOW
2 types of germ cell tumors
Seminoma – originate from seminiferous tubules
Non-Seminoma – originate from sperm/ova cells
- -Yolk Sac Tumor
- -Embryonal Carcinoma
- -Choriocarcinoma
- -Teratoma
Labs associated w/ stromal tumors
**inhibin
Ex’s of subtypes of stromal tumors
Leydig Cell Tumors (Testosterone)
Sertoli Cell Tumors (Estradiol)
Granulosa Cell Tumors
Mixed/Undifferentiated
Seminoma vs NSGCT (non-seminoma germ cell tumor)
- Seminoma: more likely to be local dz (limited to testicle)
- -stage 1 dz, 15% w stage 2 , generally DO NOT have elevated b-hcg and AFP, generally sensitive to radiation tx
-NSGCT: MORE likely to present w/ mets, will have elevated b-hcg and AFP, LESS sensitive to radiation tx
Testicular CA:
demographic
- younger, 15-35 yo
- prognosis= very good
- **Testicular tumors account for 21.4% of all neoplasms in male adolescents and young adults in the U.S.
- MC** solid tumor in this age group.
Risk factors for testicular tumors
A prior personal history of cryptorchidism
A family history of testicular cancer
A prior personal history of testicular cancer
Intra-tubular Germ Cell Neoplasia (ITGCN)
Testicular CA: MOST Pts–70% present with:
an incidentally discovered painless, unilateral mass in the scrotum.
-20% of cases the first symptom is scrotal pain.
DDx of testicular mass:
- Epididymo-orchitis, Torsion, Hematoma, or Para-testicular tumors.
- Other potential etiologies include hernia, hydrocele, varicocele, or spermatocele,
testicular tumor:
-First steps of the work-up:
- ** GET A Scrotal US**
- **Serum Tumor Markers: bHCG, AFP, LDH
- -if those are negative and concern for a stromal tumor: Inhibin, Testosterone, Estradiol
- staging imaging: Pre op CXR for orchiectomy to R/O pumonary mets
- Recommend sperm banking
Testicular tumor:
-Dx?
=*Inguinal surgical approach
–In post pubertal male, radical orchiectomy is indicated
-If markers are negative, <2cm mass, and suspect benign disease or a stromal tumor:
–Testis sparing surgery may be reasonable
–Must have pathology available for immediate frozen section analysis
–If markers are positive or concern on frozen section=
Inguinal radical orchiectomy
Testicular tumor:
staging?
- **Serum Markers (based on levels AFTER orchiectomy)
- TNM staging and Group staging 1 2 3
**AFP half life =
5-7 days
AFP may be elevated in: Yolk Sac Tumor, Embryonal Carcinoma (EC)
Physiologic elevation of AFP: Infants, Liver disease
bHCG half life =
24-36hrs**
bHCG may be elevated in ______
- *Seminoma, Choriocarcinoma, EC
- May see elevation with Marijuana use or elevated LH (hypogonadism)
testicular tumor: tx?
-**Orchiectomy
Exception:
Patient with massive pulmonary metastatic disease with fatal potential
-Chemotherapy and RT based on clinical/pathologic staging
Renal cell carcinoma:
-MC subtype?
transitional cell carcinoma
- Others include: oncocytomas, collecting duct tumors and renal sarcomas
- Wilms’ Tumor and nephroblastoma seen in children
Renal cell carcinoma:
demographic?
- M>F
- 50-70 yo
- 3rd MC GU cancer after prostate and bladder cancer
- 7th MC cancer over all for men, 9th for women
- -Over 50% are discovered incidentally
Renal cell carcinoma:
risk factors?
- -Tobacco smoking contributes to 24-30% of RCC cases
- -Tobacco results in a 2-fold increased risk
Occupational:
Leather tanners, shoe workers, asbestos workers.
-Obesity, HTN
____% of those on long term dialysis develop acquired polycystic kidney disease, out of which 5.8% develop RCC.
33-50%
_______ is a key determinant in the pathophysiology of RCC
*Pseudo-hypoxia driving angiogenesis
RCCs are the most _______ of all solid tumors
vascularized
RCC: presentation?
Presentation
- -45% present with localized disease (T1-2)
- -25% with locally advanced disease (T3-4)
- -30% with metastatic disease (N1 or M1)
Distant metastases
Lung (75%), soft tissue (36%),
RCC: classic triad that occurs in 5-10% of Pts?
-other Sx?
KNOW!!!
**Flank pain, hematuria, and palpable abdominal mass
-*Hematuria present 40% of Pts
-Systemic symptoms
Fatigue, Weight Loss, Hypercalcemia, Hepatic Dysfunction
RCC: workup?
-labs?
-CBC, BMP, LFT’s, alkaline phosphatase, urinalysis
- CT or MRI of Abd/Pel
- *CT Chest once confirmed RCC
Localized RCC Treatment
**Surgery is the only curative therapy for stage I-III
- 20-30% of patients relapse within 2-3 years
- -Metastases to the lung most common 50%
RCC: chemo?
RCC has intrinsic resistance to conventional chemotherapy
–so it’s rarely used
Risk factors for anal CA:
HPV HIV Multiple partners Receptive anal intercourse Smoking
Most common histologic type of anal cancer?
-Squamous cell carcinoma**
Anal CA:
-is uncommon, and is NOT related to _____
Hemorrhoids, fissures, fistulas
Anal CA:
sx?
**Rectal bleeding – 45%
-Bleeding thought to be secondary to hemorrhoids/ fissure often delay diagnosis
Anorectal pain – 30%
Sensation of mass/fullness – 30%
No symptoms – 20%
Anal Cancer: work-up?
DRE Inguinal lymph node evaluation Biopsy CT chest, abdomen and pelvis Anoscopy HIV testing GYN evaluation
Anal CA: primary tx?
=Combination therapy of radiation and chemotherapy
-May achieve cure w/o surgery
Preservation of anal sphincter
Anal CA: Following RT and chemo–> tx?
- Restage and proceed with surgical resection if needed
- APR (abdominoperineal resection) – less common recently
- Removal of anus – colostomy required
- Local excision – more common of late
If metastatic disease is present
Focus will remain on RT and chemo
