GU Cancers

Bladder Cancer

The second most common urologic cancer (usually epithelial cells) that usually affects older white males

Smoking 🥇. occupational exposures, aging, recurrent UTIs, chemo, XRT, schistosomiasis (squamous or adenocarcinoma)

Risk factors for bladder cancers

constant irritation of the epithelium

Patho for bladder cancer

Cystoscopy with transurethral biopsy (random bladder and prostate biopsy); imaging-wise we are getting U/S, chest/abd/pelvic CT/MRI, CBC

71 y/o male presents to the clinic for his yearly physical. He really has no complaints other than it sometimes burns when he pees but nothing crazy. On physical exam you note a pelvic mass and BLE edema. UA shows RBCs and WBCs and the other labs are as follows elevated BUN/creat, low Hgb, Hct, and RBCs. What can you use to confirm your diagnosis?

Any GU infection, renal/bladder stone

DDX for bladder cancer

based on pathology, wall invasion, regional metastasis, distant metastasis

What are the stages of bladder cancer - determined by transurethral resection of bladder tumors

Transurethral surgery, single dose intravesical chemo/immunotherapy (6 weeks if high risk)

Treatment plan for Non-Muscle involvement bladder cancer (Tis, Ta, T1)

Bacillus Calmette-Gue’rin

What is the standard of bladder cancer care that prevents progression?

irritative voiding, hemorrhagic cysts

ADRs for Bacillus Calmette-Gue’rin

radical cystectomy, chemo, XRT

Treatment plan for High Grade T1 Bladder Cancer

Neoadjuvant Chemo → Radical Cystectomy (partial is optional) 🏆, trimodal bladder preservation (TURBT resection, Chemo, EBRT)

Treatment plan for Muscle Invasive but localized (T2-T3) bladder cancer

Neoadjuvant Chemo → Radical Cystectomy → chemo, immunotherapy, XRT

Treatment plan for metastatic bladder cancer - refer to oncology

NO routine screening in this house

Screening recommendation for bladder cancer

Prostate cancer

What is the most common non-skin cancer and the 2nd leading cause of cancer death in men?

Over 50, black, FHx, fatty diet, tobacco, obesity, high T, EtOH (4-5 drinks/day), inactivity

Risk factors for Prostate cancer

posterior/peripheral zones (can be central/transitional)

What is the most common site for Prostate cancer

obstructive/irritative symptoms, elevated PSA, Nodularity on DRE, night sweats, anorexia, weight loss, fever, back/rib/hip pain (mets to spine and pathological fracture), neurological symptoms (spinal cord compression)

Signs and Symptoms for Prostate cancer

If early normal exam; DRE findings include asymmetric, indurated, nodular on the posterior and lateral aspects

Physical exam findings for Prostate cancer

UA, CBC, CMP, ALP, Ca2+, PSA (detect and stage, monitor treatment, track recurrence)

Work-Up for Prostate cancer

4.1-10 (localized), 40+ (metastasis), rate of increased over 1 year over 0.35 (velocity), low free PSA (under 10%, above 25% is a good sign)

Red Flag PSA scores

Transrectal US-guided biopsy OR trans-perineal approach

For bros with an abnormal DRE or labs what is the next step?

Gleason grading based on architecture of the 2 largest sites of tumor (Big number BAD)

How is Prostate cancer scored?

PSA, gleason grade, TMN

Prostate cancer is staged base on…

(those with high grade tumors should consider genetic testing)

Watchful waiting (PSA only)

What is the preferred treatment plan for Prostate cancer in patients with a limited life expectancy

Active Surveillance (PSA q 3 months, DRE q 6 months, mpMRI, Yearly TRUS biopsy, stop at 70 y/o or decline)

What is the preferred treatment plan for Prostate cancer in patients with favorable stages, older men with small/well differentiated tumors, or a 10-15 year life expectancy?

Radical Prostatectomy with RXT/ADT/Chemo (removes seminele vesicles, prostate, vas deferens)

What is the preferred treatment plan for Prostate cancer in patients with localized T1, T2, T3 and w/o mets

External beam radiotherapy/brachytherapy

What is the preferred treatment plan for Prostate cancer in patients with T1, T2, and selected T3?

Cryosurgery/ablation, US ablation, lasers

What are some examples of focal therapy in Prostate cancer

Androgen Deprivation Therapy (Leuprolide/goserelin (LHRH agonist), degarelix (LHRH antagonist))

Gameplan for metastatic hormone dependent Prostate cancer

Hot flashes, gynecomastia, ED, testosterone flare (spinal met homies)

ADRs for Leuprolide/goserelin (LHRH agonist)

Hot flashes, ED, weight gain, increased LFTs, NO test flare

ADRs for degarelix (LHRH antagonist)

Ketoconazole, prednisone, abiraterone (complete androgen blockade)

Medications for adrenal gland blockage of Prostate cancers (reserved for homies with severe metastasis or castrate resistant)

Kattan Nomogram

What predicts the likelihood that a patient will be disease free after a radial prostatectomy and radiation therapy based on staging, gleason score, and PSA level?

CAPRA nomogram

What predicts the rate of PSA recurrence, metastasis, and survival after prostatectomy and radiation based on PSA, Gleason score, clinical stage, % positive biopsies and age?

Shared decision making between 55-59 and no screening over 70 (USPSTF)

Recommendations for Prostate Cancer Screening?

Germ Cell Tumor (testicular cancer)

The most common solid malignant tumor in young men (15-35), usually right sided?

Germ cell (Seminomas (35%) or Non-seminomas (65%)), malignant tumors (most common bilateral)

What are the types of testicular cancer?

Cryptorchidism (UDT), ectopic testicle, FHx, trauma, Down’s, Klinefelter’s, Mumps orchitis, HIV, infertility

Risk factors for testicular cancer

CBC, CMP, LFT, UA, STI, Sperm Count, AFP (nonseminomas), Beta-hCG (5000+ with nonseminomas), LDH (with seminomas), U/S, CT chest/abd/pelvis post orchiectomy

21 y/o male with a hx of Cryptorchidism presents to the clinic for painless enlargement of the testis and a feeling of heaviness. On physical exam you note gynecomastia, cough, and a hydrocele. What do you want to order?

Radical Orchiectomy (establishes staging)

Treatment plan for testicular cancer

Active surveillance with single agent and adjuvant XT (stage 1), Orhiectomy + retroperitoneal XRT/chemo (IIa and IIb), Chemo and surgical resection of lymph noeds(IIIc)

Treatment plan for Seminoma

Orchiectomy (stage 1 - 75% cure rate), Chemo/radiation/adjuvant chemo then salvage/palliative chemo and surgical resection of node for other stages

Treatment plan for Non-Seminoma

NONE

Screening recommendations for testicular cancer

Penile Cancer

A rare epithelial squamous cell carcinoma of older men that originates in the coronal sulcus of the glans or under the foreskin, infiltrating the corpus cavernosum

phimosis, paraphimosis, late circumcision, urethral strictures, penile tears, poor hygiene, HIV, HPV 16 and 18, recurrent UTIs, 60+, smoking

Risk factors for Penile Cancer

Penile Amputation, metastasis

Complications of Penile Cancer

Biopsy of penis and regional nodes 🏆, MRI (assess depth), CT Abd/pelvis to evaluate metastatic disease, cystoscopy

67 y/o male presents to the clinic for a painless lumpy ulcer on the surface of his penis. On physical exam you note a rash-like ulcer on the glans with a foul smelling discharge, as well as inguinal adenopathy. What do you want to order?

Topical Chemo (fluorouracil 5%, Imiquimod 5%), Mohs surgery, wide local excision, laser surgery, radiation therapy,

Gameplan for Penile Cancer less than T2 (noninvasive = 100% cure rate)

Glansectomy vs penectomy or complete amputation; Dissection, adjuvant chemo or radiation therapy (if regional nodes are affected)

Gameplan for Penile Cancer T2-T4 (50-70% cure rate with 1 node, 20-40 with 2)