48: Prostate and Kidney Cancer – Flashcards
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What are the risk factors for prostate cancer?
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Age (>50) Diet (high % fat) Family history (3-5x if close relativel) Race (higher incidence in African Americans, higher rates of aggressive disease)
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Urologic malignancies make up what % of all new male cancers?
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40%
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What is the prevalence of prostate cancer?
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1/6 risk of detectable cancer 1/34 lifetime risk of dying
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When did we see a big increase in prostate cancer incidence? Why?
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1992 Advent of PSA screening
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What are the possible causes of mortality changes we have seen in prostate cancer?
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Earlier diagnosis from screening Improved management Change in competing cause of death Change in reporting deaths Lead-time bias
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What is lead time bias?
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Picking the cancer up at an earlier stage
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What are signs and symptoms of early disease?
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None
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What are signs and symptoms of progressive disease?
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Hesitancy Decreased stream Nocturia Hematospermia impotence
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What are signs and symptoms of advanced disease?
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Bone pain
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How can we detect prostate cancer?
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Digital rectal exam (DRE) Serum Prostate-Specific Antigen (PSA)
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What are indications on DRE that a man may have prostate cancer?
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Nodules Firmness
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What is PSA?
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Serine protease that liquifies ejaculate
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What is important to note about PSA?
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Prostate specific but NOT cancer-specific - varies with age and benign conditions
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How can we enhance the specificity of PSA?
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Age-referenced PSA velocity PSA density % free PSA
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Describe how we use PSA velocity to diagnose prostate cancer
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How quickly it goes up .75 ng/ml/yr rise
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Describe how % free PSA works
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Amount not bound to albumin Inversely proportional to risk of malignancy Decreased % free PSA = higher risk of cancer
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In what population does % free PSA work?
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Men with PSA 4-10
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What can cause false-positive PSA elevation?
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Cytoscopy/catheterization Biopsy BPH Prostatitis/urinary infection Bike riding
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What does NOT cause an increase in PSA?
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Digital Rectal Exam
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Why is there so much controversy over PSA screening?
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Many patients die with prostate cancer vs from prostate cancer False positives and false negatives Morbidity of treatment Lack of proof of efficacy Over-diagnosis, over-treatment COST
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What did the PLCO prostate cancer screening trial find?
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No significant difference between deaths from prostate cancer between screened and control groups at 13 years
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What were the problems with the PLCO trial?
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Published before meeting statistical power Participants allowed 1 prior PSA (44% did) - those men had a 25% lower Pa mortality Sextant biopsy (PSA >4, abnormal DRE) Regional physicians made final decision on whether to biopsy Contamination (52% got PSA outside randomization)
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What did the ERSPC screening trial for prostate cancer show?
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Screened every 4 years, cut point PSA >3 21% reduction in CaP deaths To prevent 1 death, 37 cancers need to be diagnosed
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What were the problems with the ERSPC screening trial?
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Men screened every 4 years 6 core biopsies Various triggers for biopsy (PSA, DRE, TRUS, PSA density) between countries Compliance with biopsy 2X higher than with PLCO
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What are the benefits of screening for CaP?
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Detects significant cancers when curable Decreased mortality rate
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Describe how screening of CaP changed the detection rates
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Stage migration: >85% clinical stage T1c Incidence of clinically organ-confined CaP increased from 61% to >90% + LNs decreased from 25% to <1%
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How much did the mortality rate decrease with the advent of screening for CaP?
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50%
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What are the risks of PSA screening?
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Over-detection Overtreatment Morbidity - anxiety, biopsy complications, surgery/XRT complication Cost ($447 million medicare)
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Who do you not screen for prostate cancer with PSA?
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Patients 70 unless excellent health
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What is considered average risk for prostate cancer?
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No family history Not African American
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In what group do you screen/shared decision making when thinking about getting a PSA?
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Age 55-69 - group with greatest likelihood of benefit Consider screening every 2 years vs annual
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What kinds of patients should have their PSA checked?
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Lower urinary tract symptoms
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What is used to diagnose/stage prostate cancer?
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Trans-rectal ultrasound-guided biopsy (TRUS)
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Describe the pathology of prostate cancer
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95% adenocarcinoma 70% arise from acinar cells in the peripheral zone 10% from the transition zone
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Describe the Gleason grading scale (how it works)
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Most prominent grade + next most prominent grade, 6-10
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What are the classifications for the Gleason grading scale?
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6 - low risk 7 - moderate risk 8-10 - high risk
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For the Gleason grading scale, is 4+3 or 3+4 worse?
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4+3
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Describe local invasion for prostate cancer
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Pelvic side wall Seminal vesicles Bladder base
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Describe metastases for prostate cancer
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Lymph nodes - obturator/hypogastric Bones - osteoblastic (can spread anywhere)
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Which cancers the metastasize to bone are osteoblastic?
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Breast Thyroid Prostate
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Describe the staging of prostate cancer
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cT1: not clinically apparent by palpation or imaging (identified by PSA only) cT2: palpable, confined to prostate cT3: extended outside prostate and/or into seminal vesicle cT4: fixed or involving adjacent organs (rectum, bladder)
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When staging, what imaging can you use? When would you use them?
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Pelvic CT or MRI (lymph nodes) Bone scan (bone mets) Certain high risk individuals
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What are the treatment options for localized prostate cancer?
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Active surveillance Radical prostatectomy External beam radiation Brachytherapy
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What is the goal of active surveillance? What fraction of new diagnoses are eligible?
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Avoid therapy with low risk prostate cancer 2/3 new diagnoses are eligible
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What is the protocol for active surveillance?
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Periodic monitoring with PSA, DRE, and prostate biopsy Treat those who progress on monitoring
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Is active surveillance the same as watchful waiting? If no, explain
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No Watchful waiting doesn't involve biopsies or PSAs - it's when you have prostate cancer but will die of something else
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What's the difference when comparing patients who underwent radical prostatectomy versus watchful waiting?
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Surgical excision reduces the risk of metastases and death from prostate cancer significantly
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What are the two options for external beam radiation therapy?
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3D conformational radiation therapy (CRT) Intensity modulated radiation therapy (IMRT)
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What are the treatment options for metastatic prostate cancer?
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No curative treatments Androgen deprivation therapy Chemotherapy after becoming castration resistant Newer therapies
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What are your options for androgen deprivation therapy?
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GnRH agonists and antagonists (medical castration) Orchiectomy (surgical castration)
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What are newer therapies used for metastatic prostate cancer?
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Immunotherapy Novel anti-androgens Adrenal androgen synthesis inhibitors
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What is the best way to stage prostate cancer?
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PSA level Palpation of prostate cancer extent Pelvic CT/MRI Bone scan
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Of those who have cancer, what percent die from renal cancer?
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3%
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What is the M:F ratio of renal cancer?
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2:1
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At diagnosis, what percent of patients with renal cancer have metastases?
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1/4
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A solid renal mass is
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renal cell carcinoma until proven otherwise
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What is your differential diagnosis for a solid renal mass?
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Renal Cell Carcinoma Oncocytomas Angiomyolipomas Urothelial carcinoma
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How do you distinguish the different renal cancers on imaging?
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Can't tell the difference between RCC and oncocytoma Angiomyolipomas - you can see fat density by CT
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Renal cell carcinoma account for what percent of primary renal neoplasms?
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85-90%
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What does a renal cell carcinoma typically look like on imaging?
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Enhancing, typically spherical mass
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What are risk factors for renal cancer?
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Cigarette smoking Obesity, HTN Von-Hippel Lindau, Tuberous Sclerosis Acquired renal cystic dz in patients w/ end stage renal disease
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What do you see in Von-Hippel Lindau disease?
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Cerebellar hemangio-blastoma Retinal angiomas Renal cysts, clear renal cell cancer Epindymal cystadenoma Pancreatic cysts Pheochromocytoma
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What are less common differential diagnoses for a solid renal mass?
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Adrenal tumors Renal abscess Xanthogranulomatous pyelonephritis Mets to the kidney (breast, lung primary) Lymphoma
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What are the malignant pathologies possible for a renal mass?
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Clear cell (conventional) Papillary Chromophobe
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What are the pathologies for a benign renal mass?
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Oncocytoma Angiomyolipoma
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Describe clear cell renal carcinoma
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Malignant 85% of RCC Proximal tubule
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Describe papillary renal cell carcinoma
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Can be multifocal and bilateral
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What are the three clinical presentations discussed for renal cancer?
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Incidentaloma Classic Triad 25% present with metastatic disease
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Why do we have more incidentalomas now than before?
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Increased detection of incidental renal mass (>50%) due to routine use of abdominal imaging (stage migration)
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What is the classic triad for renal cancer?
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Flank pain Palpable mass Hematuria
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How often do you see the classic triad for renal cancer?
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10% of patients have it at presentation Usually advanced stage
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Why are renal tumors known as the 'internist's tumor'?
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Paraneoplastic syndromes
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What paraneoplastic syndromes are renal masses associated with?
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10% - hypercalcemia (PTHrP) 5% - Erythrocytosis (Epo) HTN, Fever, Anemia Cachexia, Neuromyopathy Hepatopathy
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Describe Stauffer's syndrome
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Hepatopathy - renal paraneoplastic syndrome Reversible syndrome of hepatic dysfunction (elevated LFTs) Absence of metastatic disease
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What is the best workup for a renal mass?
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Cross-sectional imaging: CT preferred, abdominal MRI if it can't be done, ultrasound is less sensitive Renal biopsy
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Why is a CT scan preferred for imaging of a renal mass?
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Least cost, highly sensitive Contrast-enhanced - want to know if mass has blood flow
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When would you use an ultrasound to image a renal mass?
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Should not be used alone May help determine if it's cystic
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How do you work up a metastatic primary kidney cancer?
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CXR (most common met spot) Bone scan if alk phos elevated LFTs, serum calcium, CBC Head CT/MRI if symptoms or widely metastatic disease
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When is a renal biopsy unnecessary?
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Large (>4cm) renal tumors
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When is a renal biopsy helpful?
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Small tumors <4cm Other known primary (metastatic disease) Suspected lymphoma High surgical risk (co-morbidities, solitary kidney, etc) - don't want to perform surgery
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Describe the staging for kidney cancer
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T1 - confined to kidney, 7cm T3 - Into major veins or perinephric tissue T4 - beyond Gerota's fascia (loves blood vessels)
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How do you treat kidney cancer?
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Surgical cancer Local: Surgical resection (radical vs partial nephrectomy) Open vs. laproscopic
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When would you use a radical nephrectomy?
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Previous standard of care Now reserved for masses 'not amenable to partial nephrectomy'
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Why would you use a partial nephrectomy?
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Efficacious and safe Preserves renal function - decreases long term morbidity/mortality
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What are some other minimally invasive treatments for renal masses?
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Laproscopic cryotherapy (freeze) Percutaneous cryotherapy Percutaneous radiofrequency ablation/microwave
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How do you treat metastatic renal cancer?
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Cytoreductive nephrectomy followed by immunothearpy
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What are the difficulties with treating metastatic renal cancer?
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Poor prognosis Resistant to chemotherapy and radiotherapy
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What is the preferred treatment for localized kidney cancer?
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Laproscopic nephrectomy Partial nephrectomy for select patients
