Uro- Urologic Cancers

What are RFs for bladder cancer?

Cigarette smoking, industrial dye/solvent exposures, schistosomiasis (developing countries)

What is the MC type of bladder cancer?

Transitional (urothelial) cell carcinoma

Which type of BC is associated with Schistosomiasis?

squamous cell carcinoma

What is the MC symptom of bladder cancer?

Painless gross hematuria

What abnormal results may be seen on BMP/LFTs in a patient with bladder cancer?

Azotemia

What is needed to make the diagnosis/check for recurrence of bladder cancer?

urine cytology

Which test is better at assessing locations of tumors in BC?

CT urogram

If a CT urogram cannot be obtained what is the next best step?

CT abd/pelvis w/ contrast or IV pyelogram

*if CT CI → MRI

What is the gold standard for diagnosing BC?

Cystoscopy -can perform biopsy at the same time

What is a NMP22 BladderChek test?

point-of-care assay that can detect elevated levels of abnormal urinary protein seen with bladder cancer; used to screen high risk pts

What urinary protein is seen in small amounts in healthy individuals, but often elevated in bladder cancer?

NMP22

What types of BC are non-muscle invasive?

CIS, Ta, T1

What types of BC are muscle invasive?

T2 and greater

Are the majority of BC non-muscle invasive or muscle invasive?

NMIBC

What staging system does bladder CA use?

TNM

What stage of bladder cancer:

High-grade dysplasia, confined to epithelium

Carcinoma in situ (CIS)

What stage of bladder cancer:

Papillary tumor confined to the epithelium

Ta

What stage of bladder cancer:

Tumor invasion into the lamina propria

T1

What stage of bladder cancer:

Tumor invasion into the muscularis propria

T2

What stage of bladder cancer:

Tumor involvement of the perivesical fat

T3

What stage of bladder cancer:

Tumor involvement of adjacent organs such as the prostate, rectum, or pelvic side wall

T4

What is the tx for non-invasive bladder cancer?

TURBT ± intravesical BCG or gemcitabine

What is the tx for invasive bladder cancer?

radical cystectomy

When is a radical cystectomy indicated to tx bladder cancer?

tumor is too bulky to undergo TURBT, prostatic urethra involvement, CIS or T1 high-grade tumor refractory to conservative management

What is the tx for stage II-III BC?

combined Cisplatin + Radical cystectomy or TURBT + chemo

What is the tx for Stage IV w/ metastasis?

chemo

What is intravesical therapy?

immunotherapy or chemo agents delivered directly into bladder via catheter; performed 6-12 wks post TURBT

What stages of invasive bladder cancer warrant radical cystoprostatectomy for men and anterior exenteration for women?

Stage T2-T4

When is a partial cystectomy indicated?

pts w/ solitary lesions

What is removed in a radical cystectomy?

M: bladder, prostate, seminal vesicles, surrounding fat, peritoneal attachments, bilateral pelvic lymph nodes

W: bladder, uterus, cervix, ovaries, ant. vagina

What type of urinary diversion procedure:

Segment of the ileum directs urine through a stoma into an external collecting bag

Ileal conduit urinary diversion

What type of urinary diversion procedure:

A pouch made out of portions of colon stores urine until it is drained via a catheter inserted through a stoma

Indiana pouch reservoir

What type of urinary diversion procedure:

Intestine is made into a reservoir and connected to the urethra

Neobladder to urethra diversion

What is the first line chemo tx for bladder cancer?

MVAC -MTX, Vinblastine, Dosorubicin, Cisplatin

GC: Gemcitabine, Cisplatin

What is the MC neoplasm in men 20-35 y/o?

Testicular cancer

What is the MC type of testicular cancer?

Germ cell tumors (seminoma > nonseminoma)

What is the MC testicular tumor in males > 50 yo?

lymphoma

*MC secondary neoplasm of the testis

How does testicular cancer present?

painless unilateral lump or swelling with sensation of "heaviness" or dull pain

What is the preferred imaging modality for testicular cancer?

scrotal US

*can differentiate intratesicular vs extratesticular masses

Why are MRI abd/pelvis/scrotum and PET scans not recommended to evaluate testicular cancer?

risk of false negative; add little benefit

How is AFP affected in pure seminomas?

Normal

How is AFP affected in non-seminomas?

Elevated

What lab value may be elevated in both non-seminomas and pure seminomas?

LDH

*maybe B-Hcg (more common in non-seminomas tho)

What do higher levels of LDH represent?

higher tumor burden, growth rate, and cellular proliferation

What is the tx for testicular cancer?

Radical inguinal orchiectomy

When is radiotherapy and chemo recommended for testicular cancer?

Stage 2+ post-orchiectomy

What is the MC primary site of secondary tumor of the testis?

Prostate

What is the MC type of penile cancer?

squamous cell carcinoma

What are RFs for penile cancer?

poor hygiene, phimosis, HPV, smoking, penile trauma

How does penile cancer present?

small, flat, ulcerative lesion on the glans penis that won't heal; may have inguinal LAD

What is Bowen disease?

rare penile cancer: lesions are red, velvety plaques

What is required to diagnose penile cancer?

tissue biopsy

What staging system does penile CA use?

TNM

What stage of penile cancer:

Tumor confined to glans or prepuce

Stage 1

What stage of penile cancer:

Involves penile shaft

Stage 2

What stage of penile cancer:

Operable inguinal node mets

Stage 3

What stage of penile cancer:

Tumor extends beyond shaft, with inoperable inguinal or distal mets

Stage 4

When diagnosing penile cancer, what conditions must be ruled out with a biopsy?

Syphilis, chancroid, condylomata

What is the gold standard tx for penile cancer?

surgical removal of the primary tumor

What is the tx for penile cancer if it involves the shaft?

complete penectomy

When is chemo necessary for penile cancer?

mets beyond pelvic/inguinal lymph nodes and unresectable tumor

What is the tx for Bowen disease?

Fluorouracil cream or laser therapy

What is the MC malignancy and 6th leading cause of cancer death in men, worldwide?

Prostate cancer

What are RF for prostate cancer?

older age, FMH, obesity, HTN, agent orange exposure, persistent elevated testosterone, AA ethnicity

How does prostate cancer present?

obstructive sx from growth of tumor, DRE → induration, nodules, or “normal” prostate, regional LAD if advanced

What is the MC site of distant mets from prostate cancer?

Axial skeleton

What is useful in detecting and staging prostatic cancer, and monitoring its response to tx?

PSA

What is PSA?

glycoprotein produced only in the cytoplasm of benign and malignant prostate cells

What PSA value is high?

> 4 ng/mL

What PSA velocity level suggests potential cancer?

inc > 0.75 ng/ml

What lab value can help differentiate elevated PSA d/t BPH vs cancer?

free PSA

*>25% less cancer risk; < 10% cancer risk ~50%

Why might BUN and SrCr be elevated in a pt with prostatic cancer?

If pt has urinary retention or urethral obstruction

What lab values will be elevated in prostate cancer if there are bony mets?

elevated alkaline phosphatase or hypercalcemia

What imaging can detect suspicious areas for biopsy in prostate cancer?

Transrectal US-guided biopsy (TRUS)

What imaging has a high degree of accuracy and reliability when detecting prostate cancer?

*preferred over TRUS

prostate MRI

What is the gold standard for diagnosing prostate cancer?

prostate biopsy

What is a PSA velocity test?

shows the changes in PSA over period of time (18-24 mos)

What ages should PSA testing be done in?

55-69 yo

When should men NOT be screened for prostate cancer?

> 70 yo

What is the MC type of prostatic cancer?

Adenocarcinoma

*most arise in periphery

What is the grading system used to determine prognosis in prostate cancer?

Gleason grading system

What is Gleason grading system based on?

architecture and cellular arrangement rather than histological criteria

What Gleason pattern:

cancerous prostate closely resembles normal prostate tissue, glands are small, well-formed, and closely packed; uniform

Pattern 1

What Gleason pattern:

tissue still has well-formed glands, but they are larger and have more (stroma) tissue between them

Pattern 2

What Gleason pattern:

tissue still has recognizable glands, but the cells are darker, some of these cells have left the glands and are beginning to invade surrounding tissue → distinctly infiltrative margins

Pattern 3

What Gleason pattern:

tissue has few recognizable glands, many cells are invading surrounding tissue; irregular masses of neoplastic glands

Pattern 4

What Gleason pattern:

tissue does not have recognizable glands, often just sheets of cells throughout the surrounding tissue; only occasional gland formation

Pattern 5

What Gleason score is highly aggressive?

8-10

What Gleason score is moderately aggressive?

7

What Gleason score is mildly aggressive?

5-6

What Gleason score is very low aggression?

2-4

What grades are small and well-differentiated cancers and are usually confined w/in the prostate?

T1 & T2

What grades of prostate cancer are large-volume or poorly differentiated cancers that are more commonly locally extensive or metastatic?

T3 & T4

What stage of prostate cancer is ideal for radical prostatectomy?

T1 and T2

What is removed in a radical prostatectomy?

Seminal vesicles, prostate, and ampulla of vas deferens

How often should patients with localized prostate cancer have PSA checks? Biopsies?

PSA every 6 months, Bx every 1-3 years

What hormone therapy can be given for localized prostate cancer?

anti-androgen first: Bicalutamide

GnRH: leuprolide

If pts are at an inc risk of prostate cancer, when should they begin PSA screenings?

age 40

How often should a PSA be checked?

every 2-4 yrs until 70 yo

If PSA > 10ng/mL which is the likelihood they will have prostate cancer?

50-70%