GU Cancer – Flashcard
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testicular cancer etiology
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congenital and acquired factors; strong correlation w/ cryptorchid testicles (seminoma is most common), exogenous estrogen to pregnant women increases risk in fetus, trauma, testicular atrophy d/t infection
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development and testicular cancer
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totipotent germ cells may deviate from developmental pathway --> leads to seminomatous or embryonal tumors
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seminoma
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grossly presents as firm nodular testicle
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testicular cancer pathology
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seminoma, embryonal, teratoma, choriocarcinoma, mixed (usually includes seminoma)
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lymphatic metastasis
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nodes from L4 to T1 (concentrate at hilum), spread from right testes, spread from left testes, right to left crossover, retroperitoneal masses
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testicular cancer s/s
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nodular firm enlarged testicular mass, inguinal supraclavicular scalene lymphadenopathy, palpable retroperitoneal disease, painless testicular enlargement, back pain, cough/ dyspnea, bone pain, lower extremity swelling
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testicular cancer imaging
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US, CT chest abdomen and pelvis (assess lungs and retroperitoneum)
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testicular cancer PE
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testicular mass (differentiate from spermatocele or hydrocele), palpate for lymphadenopathy -- don't mistake for benign lesions (order TSON)
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testicular cancer labs
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TSON, hCG, AFP (usually not elevated in classic seminoma), lactate dehydrogenase (nonspecific - d/t increased cell turnover)
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testicular cancer tx
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inguinal exploration and radical orchiectomy (gold standard), retroperitoneal radiation (stage I and IIa), chemo, RPLND
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testicular cancer prognosis
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seminoma w/ orchiectomy - 98% 5yr survival at stage I and 92-94% at stage II; NSGCT - stage I 96-100% w/ orchiectomy and RPLND, stage II 90% (w/ above +chemo)
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non-germ cell testicular cancer
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leydig cell, sertoli cell, gonadoblastoma, lymphoma (secondary, most common tumor >50)
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penile cancer epidemiology
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most common in 6th decade; poor hygiene is common risk factor; virtually unheard of in circumcised
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penile cancer etiology
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thought to be d/t smegma accumulation under foreskin leads to chronic inflammation -- possible viral cause (similar to cervical cancer and HPV)
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precancerous penile lesions
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leukoplakia, balanitis xerotica obliterans, giant condyloma acuminata
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leukoplakia
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most common in diabetics, white plaque involving meatus, may precede or be concomitant w/ other penile cancers
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balanitis xerotica obliterans
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white patch originating on prepuce or glans; usually involves meatus; common among middle aged diabetics
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giant condyloma acuminata
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cauliflower like lesions, glans and prepuce, HPV
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penile squamous cell
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bowens disease - usually involving shaft, red plaque w/ encrustations
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penile erythroplasia of queyrat
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velvety red lesion w/ ulcerations - usually involve glans
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carcinoma in situ of penis
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squamous cell and erythroplasia of queyrat
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invasive carcinoma of penis
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squamous cell - commonly on glans then prepuse then shaft; papillary or ulcerative in nature
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penis spread
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may involve entire glans or shaft; bucks fascia prevents invasion into corporal bodies and hematogenous spread; mostly spread through lymphatics - femoral or iliac, inguinal, bilateral drainage
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distant penis metastases
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lung, liver, bone, brain, <10%
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penile cancer s/s
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typical lesions; enlarged inguinal lymph nodes (may be d/t inflammation or metastatic spread), phimosis, pain, discharge, irritave voiding symptoms, bleeding from lesion
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penile cancer imaging
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CXR, bone scan, CT a/p w/wo contrast
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penile dx
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biopsy of primary lesion
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CIS tx
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may be treated conservatively in reliable patients - 5-flurouracil, neodymium, laser treatments
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invasive carcinoma tx
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complete excision w/ negative margins, simple circumcision, wedge resection, partial penectomy, total penectomy w/ perineal urethrostomy; -- may include regional lymph node dissection
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penile cancer systemic dz tx
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chemo
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penile cancer prognosis
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correlates w/ presence of nodal dz; node negative - 65-90%, +nodes - inguinal (30-50%), iliac <20%; bone/ soft tissue mets - 0%
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prognosis after penectomy
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high rate of depression, suicides high
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ureothelial cell carcinoma
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neoplastic disease of bladder ureter and renal pelvis
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bladder cancer risk factors
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cigarrete smoking (2-fold increased risk), occupational exposure (benzidine, beta-napthylamine, 4-aminobiphenyl (chemical, dye, rubber, petroleum, leather, printing)), patients receiving cyclophsphamide, aritifical sweetners, trauma (chronic infection, instrumentation, bladder calculi)
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cyclophosphamide
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cytotoxic treatment malignancies
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papilloma bladder
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fine tumor w/ stalk (normal cytology), rare and benign
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CIS bladder
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flat anaplastic lesions
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TCC bladder
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90% of neoplasms - papillary and exophytic; when more sessile - usually more invasive
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s/s of bladder cancer
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hematuria, vesicular irritability (frequency, urgency, dysuria, most common among wide spread CIS), bone pain from mets, flank pain (retroperitoneal mass, ureteral orifice obstruction -> hydronephroureter), bladder wall thickening, palpable mass (suprapubic or non-mobile bladder), hepatomegaly, supraclaviculary lymphadenopathy, ower lymphedema
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bladder cancer UA
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hematuria (gross or micro), pyuria (absence of infection)
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urine cytology UA
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neoplastic cells - usually finds high grade or CIS, less useful for low/mid grade papillary carcinomas
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other bladder cancer dx
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FISH analysis - genetic assay, other antigen tests
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bladder cancer CT
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not routinely ordered, most tumors difficult, thickened bladder wall nonspecific, may be useful for retroperitoneal masses and lymphadenopathy
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cytoscopy and biopsy bladder cancer
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gold standard dx; direct visualization - picks up CIS or smaller tumors, dependent on practitioner, differentiate between cystitis and CIS
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IVP bladder cancer
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look for filling defect, not widely used
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transurethral resection of bladder tumor
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uses cystocope, effective in Tis, Ta, T1 and subtypes, occasional superficial T2
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ADR of transurethral resection of bladder tumor
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gross hematuria, clot retention, infection, bladder perforation, anesthesia risks
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intravesicle chemo bladder cancer
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used in Ta, T1, small CIS (may be used immediately following TURBT)
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mitomycin C
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inhibits DNA synthesis, 1 instillation qweek x 6, significant irritative symtpoms, rash on palms and genitilia
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Bacillus Calmette-Guerin (BCG)
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strain of mycobacteriaum bovus - live attenuated vaccine aganst Tb, induces immune response against tumor (most effective against CIS, often more effective than chemo), given 3 instillations/ week every 3-6months for 3 years after TURBT
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ADR BCG
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irritative voiding symptoms, gross hematuria, BCG sepsis (treated w/ isoniazid, rifampin, ethambutol)
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TURVT
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initial therapy for most bladder cancer, gives grading and type
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partial cystecomy
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robotic or open or laparoscopic, cystotomy followed by multilayer closure, useful for localized high grade tumors
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radical cystecomy
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removal of bladder and surrounding adipose, prostate, seminal vesicles, peritoneal attachments in men; take cervix, uterus, anterior vaginal wall, urethra (including meatus), and ovaries in women, used in muscle invasive or wide spread high grade disease, leads to neobladder, illeostomy conduit, continent urinary diversion, take extensive bilateral pelvic lymphadenectomy
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radiation and bladder cacner
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alt. to cystecomy, common local recurrence, 5-8weeks of tx, often offered to poor surgical candidates, 18-41% 5yr survival rate
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chemo and bladder cancer
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most active agent - cisplatin, response improves w/ combo therapy, most common: MVAC (methotraxate, vinblastine, doxorubiin, cisplastin) --death from toxicity - 3-4%; long-term sruvivability - 20-25%; median survival time from start of therapy - 1 year
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upper tract carcinoma epidemiology
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avg 65 yrs; male 2-4:1; similar risk factors to bladder cancer
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upper tract
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comprised of urothelium (transitional cells)
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s/s of upper tract
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hematuria, irritative voiding symptoms; constitutional sympsoms: weight loss, fatigue, anemia, anorexia; CVA tenderness (d/t hydronephrosis from tumor obstruction)
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uper tract UCC imaging
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IVP - filling defect, CT w/wo contrast - delayed images show defect; MRI - less frequently
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upper tract UCC tx
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surgical, limited role of radiation
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ureteral tx
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papillary and suggestive of local diseae - uretroscopy and resection - difficult d/t thin ureter, often spreads; distal - distal ureterectomy and reimplantation
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renal pelvis, proximal ureter or multiple lesions tx
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nephroureterectomy w/ bladder cuff - open or robotic
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renal cancer etiology
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thought to be d/t occupational exposures, chromosomal abbertions, cigarrette smoking (only definitive link, 2-fold increase in riks)
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RRC occurence types
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sporadic - de novo RCC; inherited - chromosomal abnormalities of chromosome 3p, von hippel-lindau dz - familial cancer syndrome, hereditary papillary renal carcinoma
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RCC associations
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acquired cystic dz of the kidneys, pts undergoing dialysis, long-term renal insufficiency
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RCC
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originates from proximal renal tubular epithelium, grow in renal cortex then distribute to perinephric dz - may cause mass effect (vericocele, IVC compression)
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RCC spread
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direct invasion through renal capsule; lung most common also liver, bone, ipsilateral lympatics and adrenal gland, brain, contralateral kidney
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classic triad of RCC
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gross hematuria (most detected by microscopic hematuria eval), flank pain, palpable mass
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s/s of RCC
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triad, asymptomatic, paraneoplastic syndromes (erythrocytosis, HTN, hypercalcemia)
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RCC labs
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hematuria, anemia, elevated ESR, erythrocytosis
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CT RCC
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w/ IV contrast -- may have calcifcation, honsfiled units, allows for staging
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honsfield units
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more dense than simple cysts, less dense than renal parenchyma
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MRI RCC
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equivalent to CT; primary advantage: no radiaition, no iodinated dye, better vascular eval - caval thrombus
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US RCC
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noninvasive, inexpensive, good for those unable to tolerated dye
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RCC tx localized
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surgical removal /tx - partial nephrectomy, total nephrectomy, cryoablation, high-intensity focused US
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RCC tx disseminated dz
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met disease aggresive <10% 5yrs, surgery - palliative, tx of resectable metastatic foci; radiation, biological response modifiers (interleukin, interferon)
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RCC survival
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T1-T2 dz - 80-100%; T3- 50-60% mets - 16-32%
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nephroblastoma
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most common solid renal tumor kids; peaks in 3rd year of life
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nephroblastmoa etiology
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sporadic - post-zygotic mutations; familial - pre/post zygotic mutations
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nephroblastoma s/s
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usually found by family or PCP, abdominal pain/ distention, anorexia, n/v, fever, hematuria
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nephroblastoma labs
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anemia, hematuria, altered liver enzymes and chemistries in mets
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nephroblastoma imaging
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initial US followed by CT; CXR or CT for lung mets; MRI - no radiation, identifies caval thrombus and cardiac extension
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nephroblastoma tx
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provided highest possible cure rate w/ lowest tx morbidity
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unilateral nephroblastoma tx
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radical nephrectomy - transabdominal incision - RPLND not recommended
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bilatera nephroblastoma tx
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chemo, partial nephrectomy, radiation
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radiation nephroblastoma
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radiosensitve tumor; post-op radiation - for sage II and IV
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chemo nephroblastoma
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chemosensitive, I-II w/ favorable resection
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prostate schreening
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do not screen w/ PSA according to USPSTF; DRE - not enough evidence
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harms of prostate detection
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most dz clinically insignficant; dx tests - TRUS w/ biopsy is invasive and has complciations; tx invasive, post-tx lifestyle
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prostate PE
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DRE -> assymetry, induration
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prostate labs
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PSA (high, rapid velocity, PSA density, free vs. total); PCA3 assay - genetic assay - mRNA
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s/s of prostate
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asymptomatic, occasionally LUTS - same as BPH, mets -weight loss, bone pain, lymphedema, path features
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PSA
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glycoprotein specific to prsotate - increased in serum by cell death; normal range 0-4ng/mL
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free PSA
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most bound to proteins - %free increased in CaP
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PSA density
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tPSA/ prostate volume - 0.15 PSA/ CC prostate or greater
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normal DRE
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walnut, soft but gives w/ pressure, symmetrical, anodular
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abnormal DRE
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induration, nodularity, asymmetry, boggy, irregularity
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prostate dx
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TRUS w/ biopsy -> FNB (12 samples, bilateral - base, mid, apex); ASAP (atypical small acinar proliferation-- rebiopsy in 6 mo), PIN - prostatic intraepithelial neoplasia (premalignant lesion)
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prostate staging
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gleason score - sum of 2 #s (5 is worst) X- most prevalent grade, Y 2nd most prevalent grade, Z- sum
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prostate mets
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follow lymph chains (obturator most common), axial skeleton, occasioanl (proximal femur, pelvis, T spine, ribs, sternum, skull, humerus); spinal mets - may cause cord compression
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prostate Tx
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many options but most effect lifestyle, cause ED, some cause incontinence, invasive/ expensive, radiation
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active surveillance in prostate
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use in gleason 2-6;younger men w/ low grade, older men w/o curative option -- involves repeat PSA and DRE, biopsy q6mo-1yr
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risk of disease progression prostate
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low w/ gleason 6 or less, significant increase at 7
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radical prostatectomy
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surgical removal of prostate seminal vesicles and part of Vas - may involve BPLND
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risks of prostatectomy
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blood loss, infection, hernia, obturator injury, incontinence, ED, cardio events, rectal injury, ureteral injury
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prostate radiation
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slightly less effective than prostatectomy; external beam, cyberknife, brachytherapy, proton therapy
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risks of radiation w/ prostate
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ED, incontinence, LUTS, hematuria, hematochezia, chronic diarrhea, radiation cystitis, radiation coliitis
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met dz prostate tx
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testosterone, chemo (no good outcomes), androgen deprivation (bilateral orchiectomy, GnRH agonist, GnRH antagonist)
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docetexal
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promising chemo, not curative, less SE - prostate
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ketoconazole
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suppresses adrenal androgens, very quick action, useful w/ symptomatic metastatic dz (spinal cord compression)
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GnRH agonsit
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leuprolide, goserelin (binds to receptors in pituitary - chronic stimulation desensitzes pituitary and leads to decreased FSH/ LH)
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GnRH antagonist
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bind to GnRH receptors, blocking GnRH activity; degarelix- prevents initial gonadotropin surge of agonist; quick action (3days)
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provenge
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therapuetic vaccine against CaP - extends life by 4-7mo; better than chemo at metastatic stage of dz (less ADR)
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harvesting WBC
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incubated w/ prostatic acid phosphatase; incubated w/ granulocyte-macrophage colony stimulating factor (mature WBCs) -> immune attack on CaP cells
