Urinary System and Male Genitourinary Cancers – Flashcards
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Which zone of the prostate is most susceptible to cancer?
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The Peripheral zone
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What are some aspects of the prostate's anatomy that make surgical treatment of prostatic malignancies difficult?
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It is located closely to the bladder, rectum, and seminal vesicles, and it also has a closely associated neurovascular bundle (if you remove the prostate, it is highy likely you damage the NV bundle and lose the ability to generate erections)
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Risk factors for prostate cancer
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Age (older=higher risk) African American > Caucasian Diet Obesity Family history: risk proportional to number of 1st degree relatives with prostate cancer Genetic alterations Inflammation
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What signs and symptoms are associated with early prostate cancer?
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No symptoms
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What signs and symptoms are associated with advanced prostate cancer?
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Urinary issues Hematuria Urinary retention Back pain Ureteral obstruction (basically, the urine flow is being blocked by the mass, and there is inflammation in the retroperitoneum)
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Screening for prostate cancer
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Prostate-specific antigen (PSA) and digital rectal exam (DRE) at intervals
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PSA screening recommendations
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No screening men <40 Screen high risk men between 40-54 Screen men 55-69 after discussion of risks, benefits Increase screening interval to 2 years in low risk men Don't screen men in poor health over age 70 or men with less than 10-15 year life expectancy
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What type of lab values/test results would you need to see to indicate a prostate biopsy?
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Abnormal rectal exam Elevated PSA Rapidly increasing PSA
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How does the Gleason system of prostate cancer grading work?
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Under a low-powered microscope, five specific patters of prostate cancer cells have been identified ("grades"). They are #1-5. Basically, you add the most common and second most common cancer cell patters together and get a number. The most common pattern is more important than the second in terms of prognosis (a Gleason score of 4+3=7 has a worse prognosis of 3+4=7)
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Prostate cancer staging system T categories
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TX: Primary tumor cannot be assessed T1: Clinically inapparent tumor neither palpable nor visible by imaging T1a: Tumor incidental histologic finding in 5% or less of tissue resected T1b: Tumor incidental histologic finding in more than 5% of tissue resected T1c: Tumor identified by needle biopsy T2: Tumor confined within prostate T2a: Tumor involves ≤50% of one lobe T2b: Tumor involves >50% of one lobe but not both lobes T2c: TUmor involves both lobes T3: Tumor extends through the prostate capsule T3a: Extracapsular extension (unilateral or bilateral) T3b: TUmor invades seminal vesicle(s) T4: Tumor is fixed or invades adjacent structures other than seminal vesicles
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Prostate cancer staging system N Categoreis
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NX: Regional lymph nodes were not assessed N0: The cancer has not spread to lymph nodes N1: the cancer has spread to lymph nodes
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Prostate cancer staging system M Categories
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MX: Distant metastasis cannot be assessed M0: No distant metastasis M1: Distant metastasis M1a: The cancer has spread to distant lymph nodes M1b: The cancer has spread to bone(s) M1c: The cancer has spread to other organs (e.g., lungs, liver, brain)
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Low risk Prostate cancer
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Diagnostic PSA <10.0ng/mL AND highest biopsy Gleason score ≤6 AND clinical stage T1c or T2a
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Intermediate risk Prostate cancer
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Diagnostic PSA ≥10 but <20 ng/mL OR highest biopsy Gleason score = 7 OR clinical stage T2b
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High risk
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Diagnostic PSA ≥20 ng/mL or highest Gleason score ≥8 OR clinical stage T2c/T3
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Imaging for prostate cancer
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No further workup for low risk disease CT scan: Evaluate for lymph node metastases Bone scan: Evaluate for bone metastases -Obtain if the PSA> 20, Gleason ≥8, T3 or T4, or the patient is exhibiting symptoms
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Active surveillance
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Traditionally for low risk disease (pts with limited life expectancy or comorbidities), but it's now being used with younger pts Relies on serial monitoring (repeated PSA and DRE, repeat prostate biopsies, prostate MRI) ~1/3 men go on to treatment and very few men have died from cancer while on active surveillance
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Radial prostatectomy
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Gold standard for clinically localized disease Open and Robotic Can result in incontinence and erectile dysfunction
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Robotic prostatectomy
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Use the Da Vinci machine!!! Benefits include magnified 3D vision, wristed instruments, reduced blood loss, smaller incisions, and potentially small improvements in urinary and sexual side effects
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External Beam Radiation
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Most common type is intensity modulated radiation therapy (IMRT)-- precision application of radiation therapy to prostate, avoiding surrounding structures Benefits: Slower onset of side effects
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Brachytherapy
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Radioactive pellets (iodine/palladium isotopes) are implanted into the prostate to treat the prostate gland over time Side effects include irritative voiding, dysuria, late and slow onset erectile dysfunction, and pts have to avoid children and pregnant women for 2 months
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Prton Beam Therapy
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Peak dose occurs near the source and dissipates over distance Photons interact differently in tissue and maximal energy occurs as the movement slows (we call this the Bragg Peak) Hope to decrease local side effects from treatment Improves outcomes
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Crytherapy
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Freezing tissue causes coagulative necrosis Results in cell rupture, apoptosis, and ischemia Minor surgical procedure Resutls in loss of erections Option for men who are poor candidates or who want to avoid surgery and radiation
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How does one go about treating metastatic prostate cancer?
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The big thing is that you need to get the testosterone OUT. So you castrate the patient either by orchiectomy or by hormone ablating drugs
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Medical castration
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Luteinizing/Gonadotropin releasing hormone agonists (LHRHA/GnRHA) stop the pulsatile release of GnRH and subsequently LH, which renders the pituitary unresponsive These drugs are Leuprolide, Goserelin-- major issue is Tumor flare (initial stimulation of testosterone with LHRHA-- this is a major no-no with critical metastases because it gets more power for a hot second) Abarelix (LHRH antagonist)- no tumor flare
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LHRA/GnRHA drugs
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Leuprolide Goserelin
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LHRH antagonist
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Abarelix
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Docetaxel
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Taxane based chemotherapy
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Abiraterone
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CYP 17 inhibitor, prevents androgen production
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Enzalutamide
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Anti-androgen
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Provenge
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Novel immunotherapy
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Radium 223
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Bone-specific agent
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Bone Health in prostate cancer
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Denosumab and zolendronic acid
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Bladder Cancer Risk Factors
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Smoking Chemical exposures: aromatic amines, aniline dye (occupations incl. petroleum, textile, rubber workers, hair dressers, dry cleaners) Chronic cystitis: due to indwelling catheter, Schistosoma haematobium, and bladder stones Radiation exposure Cyclophosphamide Lynch Syndrome (leads to upper tract urothelial carcinoma)
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Presentation of Bladder Cancer
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Painless hematuria (gross or microscopic) Irritative voiding symptoms: Frequency of urination, urgency of urination, dysuria) Positive dipstick urine analysis
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CT Urogram
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CT of abdomen and pelvis with unenhanced, nephrographic, and pyelographic phases
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Unenhanced CT urogram
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Used to evaluate for stone disease
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Nephrographic CT urogram
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Used to identify enhancing renal masses
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Pyelographic CT urogram
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Evaluates the urothelial lining
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Bladder Cancer Stage
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Ta: noninvasic papillary carcinoma Tis: carcinoma in situ (CIS) T1: Tumor that invades subepithelial connective tissue (lamina propria) T2: Muscle invasive (muscularis propria) T3: perivesical fat invasion T4: Invades adjacent organs
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Treatment for state Ta bladder cancer
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Transurethral resection Intravesical therapy (chemotherapy or BCG)
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Treatment for GIS bladder cancer
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Transurethral resection Intravesical BCG
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Treatment for Stage T1
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Transurethral resection Intravesical therapy (usually BCG) Cystectomy is optional
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Treatment for muscle invasive bladder cancer
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T2 or greater Cystectomy with or without chemotherapy
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Intravesical Immunotherapy for Bladder Cancer
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Bacillus Calmette-Guerin--Live attenuated strain of Mycobacterium bovis Promotes lymphocytic response to bladder cancer Indicated for CIS and non-muscle invasive disease 58%-64% complete response rates Side effects include dysuria, hematuria, flu-like symptoms BCG sepsis is really rare but it is life threatening (treat this with STEROIDS and antibiotics)
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Radical cystectomy
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Indicated for muscle invasive disease and refractory non-invasive disease This is a pretty high risk surgery (40% complications in 30 days, 5-8% risk of 90 day mortality, 10 year survival rate 45-87% for node negative, 34% 10 yr survival rate for node positive)
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Adjuvant chemotherapy
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Hey! If you give the patient cisplatin chemotherapy before a cystectomy, patients tend to have better survival rates
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Urinary diversion
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Ileal conduit (ostomy bag, least amount of perioperative complication) Ileal neobladder (no bag, willing to catheterize but no necessary, nocturnal incontinence) Continent colon pouch (good for urethra involvement or females with a posterior tumor) Patients will be hypokalemic and experience hyperchloremic metabolic acidosis, B12 deficiency
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Risk factors for testicular cancer
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Cryptorchidism Family history Infertility Personal history (5% risk in contralateral testicle) Intratubular germ cell neoplasia Marijuana abuse Sports supplements
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Presentation of testicular cancer
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Painless testicular mass Exam: firm mass Pain in only about 10% of pts May have a history of trauma which prompts evaluation but is not related to cancer development Gynecomastia is more common with stromal tumors Delay in diagnosis is really common, often treated as epididymitis
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Work up for testicular cancer suspicion
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History and Physical Exam Scrotal Ultrasound Serum tumor markers Chest X-ray
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Testiculat Cancer Tumor Markers
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Important for diagnosis and staging Beta-Human Chorionic Gonadotropin (HCG): Produced by syncytiotrophoblasts; marijuana can cause false elevation Alpha-Fetoprotein (AFP): can be falsely elevated in liver disease Lactate Dehydrogenase (LDH): Can be elevated in seminoma or nonseminoma
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Seminoma
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Most common testicular tumor in adults Tumor markers: LDH elevated in advanved disease, may have mild hCG elevation, no produciton of AFP Both radiosensitive and chemosensitive
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Spermatocytic Seminoma
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Variant occurring in older men Not aggressive No HCG or AFP production
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Nonseminomatous Germ Cell Tumors (NSGCT)
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Can be pure or mixed with Seminoma Pure NSGCT: Embryonal Carcinoma, Yolk Sac Carcinoma, Choriocarcinoma, Teratoma
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Embryonal Carcinoma
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Usually 25-35 yr old May secrete HCG and/or AFP most undifferentiated Highest risk of micrometastasis
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Yolk Sac tumors
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Most present at <2 years of age Almost always secrete AFP
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Choriocarcinoma
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Elevated HCG Early hematogenous spread
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Teratomas
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Usually normal markers but can have mild elevations of AFP Resistant to chemotherapy and radiation Bone, teeth, hair Grow locally, but can also transform into somatic malignancies
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Leydig Cell Tumors
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Most common Stromal tumor Most often adult males 20-60 yr old, but 25% in children Adults may present with gynecomastia, impotence, and decreased libido due to androgen excess and peripheral conversion to estrogen Children: presents as precocious puberty 90% are benign
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Sertoli Cell Tumor
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Very rare Occur at any age 1/3 have gynecomastia 90% are benign Unlike Leydig cell tumors, you can't determine the malignancy of this stromal tumor at the cellular level-- you just have to look for evidence of spread within the body
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Testicular Cancer Staging
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Similar to prostate (I really don't want to write this out) pTx= can't be assessed pT0= no primary tumor pTis- carcinoma in situ pT1= localized to testicle pT3= invades spermatic cord pT4= invades the scrotum N-- lymph nodes (kinda the same sequence) M-- distance metastasis S- serum tumor markers (can't figure these out until AFTER the testicles are removed)
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Treatment Options for Stage 1 Seminoma
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(pT1-4 N0 M0 SX) 98% survival Radiation (infertility, skin, nausea/vomiting; 5% risk of recurrence) Observation (compliant patients; 80% cured with radical orchiectomy) Chemotherapy (non-inferior to radiation therapy; less side effects)
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Treatment options for Stage one NSGCT
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(pT1-4 N0 M0 SX) >98% survival Chemotherapy (relpase 2-3%) Surgery (RPLND; therapeutic in 50-90%, 90% cured with chemo for relapse) Radiation is NOT used okay!
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Treatment for advanced seminoma
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Surgery reserved for PET active disease following treatment
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Treatment for advanced NSGCT
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Chemotherapy Post-chemotherapy is needed if there is disease in the retroperitoneum after the removal
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Risk factors for Penile Cancer
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Uncircumcised Poor hygiene HPV infection (16!!, 18, 31, 33) Tobacco
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Premalignant penile lesions
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CIS: 10% of men development penile squamous cell carcinoma Red, velvety papules or plaques Diagnosed on biopsy (Erythroplasia of Queyrat on glans, Bowen's Disease on shaft) TreatmentL 5-fluorouracil, surgery, laser ablation
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Penile Cancer Work-Up
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Biopsy is initial step Staging done by lymph node exam MRI may aid in local staging and surgical planning CT can assess pelvic metastasis
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Penile Cancer Treatment
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Local excision: Mohs, laser Distal vs total penectomy Lymph node dissection for palpable disease Radiation Chemotherapy
