Genito-Urinary Malignancies Flashcards
Prostate Cancer
Etiology
Risk Factors
Symptoms
Etiology
- 1 in 8 men will get it; 2nd leading cause of death but most men will die WITH the cancer not because of it
Risk Factors
- older age (peak 70)
- AA or caribbean (SES or genetic?)
- family history: 1st degree relative
- BRCA2 gene increases risk of getting intesne cancer
- high fat diet
- obestiy smoking
- vasectomy!!
Symptoms
- most asymptomatic
- if LUTS: more commonly due to BPH
- if late stage catch: more intense symptoms, obstructive voiding issues, boney pain: METS, LE edema
Prostate Cancer
Screening
PSA (normal, free, density)
when to screen
how often
Screening
PSA: prostate specific antigen (made by ALL prostate cells- not just cancer thus mehhh about usefulness in detecting)
- Grade D rec to screen > 70 years old
- Grade C rec to screen from 55-69 (shared decision making)
in general: PSA > 4 is abnormal
but the PSA will rise with age anyway, so higher in younger is suspcicious but not necessary in an older person unless very high
always also consider the DRE and its findings
Additonal Tests
Free PSA
- high Free PSA = more likely to be ok
- low free PSA = cancer risk
PSA Density : based on volume
PSAD > .15 = abnormal
Blood tests can be done too
Prostate MRI : good r/o if negative
urine based testing with mRNA
- exoDx: best negative predictive value
- select MDX: need DRE along with
stop screenign after < 10 years of life expectancy
When to Screen
- symptoms? screen
- under 40 = no
- 40-54: base on risk
- 55-69: converse with pt.
- 70+: no
How often
- PSA < 1 = 2-4 years
- PSA 1-3: 1-2 years
- PSA > 3: biposy now
Prostate Cancer
you get an elevated PSA… now you need to biopsy
what can you do
- refer to urolgoy to do this
Biopsy (MRI > US)
- transrectal (risk of urosepsis)
- transperineal
- fusion guided
Prostate Cancer
pathology
biopsy score: Gleason Score
majority of prostate cancer is in the peripheral zone (70%)
Gleason Score: the top 2 scores given to the cells when biopsied to identify how abnormal they are (gleason is alwasy added 2 score together)
- Gleason 6 (3+3) is the lowest
- Gleaseon 10 (5+5) is the highest
- gleason under 6 (1 or 2) isnt suspicious for cancer
pattern 4 = cribiform, & glomerual formations; poorly formed glands on microscope
pattern 5 = really bad, just sheets of cancer cell within the sample
each gleason score is given a group
- Gleason SCORE of 6 = gleason GROup = 1
- *must be in gleason group > 2 to treat & be considered clinically significant cancer
gleason score indicated the need for a US + MRI fusion biospy to see exactly where the tumor is and map it
Prostate Cancer
Treatment
- QOL impact
- when to check for METS
- categories of disease and treatment type
significant QOL side effects (urinary and sexual)
- stress urinary incontinence, urge incontinence (radiation)
- erectile dysfunction (radiation and surgery)
if pt. has intermediate unfavorable risk (group 3 grade) = risk for METS = do bone and soft tissue imaging
- bone and lymph are first sites of spread
- use CT, MRI or technetium bone scan, or PSMA PET scan
Treatment: based on category
- low risk: active surveillance
- Intermediate Risk: active treatment v surveillance – discuss
- unfavorable risk: active treatment
Prostate Cancer- Treatments
- types of therapy for LOCAL cancer
- what is biochemical recurrance
- watchful waiting
- active surveillance
- Focal therapy ( HIFU, IRE, cryotherapy)
- Radiation thearpy (beam, brachytherapy)
- Radical Prostatectomy
radiation and surgery are equlivent in prostate treatment
Biochemical recurrance: the disease process returning (as noted by PSA levels) post- surgery or post-radiation
- after surgery– PSA is undetectable
- after radiation – PSA is the lowest it will be
considered recurrance…
- surgery: PSA comes back to 0.2
- radiation: ** PSA is 2+ whatever it was at lowest**
- not alwasy cancer but need to be suspicious
Prostate Cancer
Metastatic Disease
where
types
treatments
PSA level
- PSA: normally very hig –> > 50
- commonly: lymph and bone spread
- assess testosterone level: assess ability to respond to testosterone lowering medications (if the level is high)
Hormone Sensitive Metastatic Prosatate Cancer: responds to medical treatment of dropping testosterone levels
Hormone Refractory/Castraction Resistanat Prostate Cancer: elevated or rising PSA levels despite meds and radiation
Treatments
- systemic therapy is mainstay treatment
- androgen deprivation:pills, injections or bilat. orchiectomy
- newer antiandrogens: enzalutamide, abiraterone (given with steriods) apalutamide, darolutamide
- chemo (‘taxels)
- immunotherapy (T cells)
- radium for bones
Treated local prostate cancer: 90-95% survival
biochemical reuccrance rate - increases with increased gleason score
Renal Cell Carcinoma
etiology
Risk Factors
Genetic Syndromes with inc. risk
Etiology
- men > women
- cancer of the clear cells majority in the proximal conveluted tubual
Risk Factors
- men
- obesity
- older age (55-75 years)
- smoker
- family history
- acquired cystic kidney disease (those on hemodialysis)
Genetic Syndromes for Increased RIsk
- von Hippel Lindau (ccRCC)
- Birt Hog Dube
- Tuberous Sclerosis
- hereditary Papillary RCC: the ONLY manifestation is RCC
- Hereditary leoimyomatosis & RCC (HLRCC)
- Succinate Dehydrongease
- MiT Family Kidney Cancer
Renal Cell Carcinoma
Symptoms and Signs
Diagnosis
(classes of cysts which you should consider CA)
Symptoms & Signs
- most are asymptomatic
- classic triad: palpable flank mass, hematuria & flank pain
- large tumors: early satiety, flank pain, hematuria
- metastatic disease: souch, unintentional weight loss
Diagnosis
CT or MRI
- CT (or urogram) does timed contrast to see the flow of the contrats through the kidneys to get a picture of the physiology as well
(majority of masses that are seen on CT are cancerous masses – some may be benign but unlikely)
to ensure you’re seeing a masses, the amount of contrast for the image determines what you see
- strong enhancement will pick up massess of cancerous material
Cyst Classifications
- stage IIF: regularlly follow
- stage III and IV : more likley to be cancer – excise
Follow Up imaging: assess via TNM cancer spread scale
- suspect pulmonary spread: get chest xray or CT
- brain is suspected malignancy to there
Renal Cell Carcinoma
Treatment
levels (4)
metastisis to where
treatmet for METS
Treatment Levels
- watchful waiting
- active surveillance: watch and follow – at 3cm you act
- thermal ablation (cryotherapy, microwave/radio frequency)
- surgical removal (partial or total/radial nephrectomy) totacl nephrectopy (keeps the adrenal gland)
METS RCC
- most commonly to the lungs, lymph, bone, liver, adrenals & brain
- normal chemo not used; targeted VEGFI, TKI are used & new immunotherapy
- none can cure: IL-2 is new and may but very risky
Prognosis
- local disease: good (90% survival)
- more invasive or METs: 15%
Urothelial Cancer
Etiology
Risk Factors
Symptoms and Signs
Etiology
- bladder and upper tract cancer
- majority are non-muscle invasive (CIS, Ta, T1)
- CIS: still dangerous!! 90% can die within 2 years
- most common: urothelial cell carcinoma
Risk Factors
- older age (>65)
- males
- tobacco use
- textile industry exposure
- childhood chemo exposure
- indwelling cath.
- pioglitozone usage (a DM med)
Symptoms and Signs
- painless hematuria is most common (micro (foudn in lab) or gross (1ml naked to eye))
- timing of the blood: initial (think lower UT), mid (bladder), terminal (upper/kidneys)
- color of urine cna give a good description never dx. microscopic hematuria on a dip stick alone!!!
- irritative voiding symptoms (not common)
urothelial cancer
diagnosis
treatment
METS disease
Diagnosis
- hematuria: get a urine microscopy and urinalysis dip (micro to confirm)
then get.. (depending on risk factors)
- cystoscopy
- CT urogram/Renal US
- gross hematuria: immedaite urine cytology
Treatment
- for NMIBC: TURBT and intravescial therapies & low-dose chemo 1x post -op
- agents: BCG vax., mitomycin C, valrubuin is the only FDA approved one
- for MIBC: gold standard: meoadjuvant chemo AND radial cysectomy, lymph node dissection and diversion of urine
there are bladder sparing options for surgery avalible
- tri-modal thearpy
- max TURBT
- radio chemo
- radiation
follow up with routine surveillence
METS
- most commong to lymph, bonel, lung, liver, peritoneum
- cisplatin is standard of care to inc. survival
- immunotherapy with PD1 and PD-L1
Upper Tract Urothelial Cancer
Etiology
Symptoms
Diagnosis
Treatment
Etiology
- rare: men > women
- commonly in the renal pelvis
- risk: exposure to the balkan and chinese herb (aristolochic acid) or genetic
Symptoms
- asymptomatic
- hematuria
- no bladder findings –> need CT urogram, cystoscopy, uteroscopy, cytolgies
Treatment
- can do nephron sparing laser, segmental ureterectomy
- if high grade: nephroureterctomy with bladder cuff
Testicular Cancer
Etiology
Symptoms
Diagnosis
Treatment
Etiology
- MC solid malignancy in 15-34
- if undecended testicles: fix early!! increased risk
- can be seminomas, or non-seminomas from germ line most commonly
- seminomas: simple, no AFP, slow growing
Symptoms
- painless testicular mass
- metastaitc disease: back pain, cough, edema
Diagnosis
- solid marble like mass on exam —> send to urology
- Labs: pure seminomas do not produce AFP
- scrotal US
- CXR or CT abd/pelvis to check for METS
Treatment
- Radical Inguinal Orchiectomy (the whoel testicle and contents of scrotum to the inguinal ring)
- sperm banking!!!
- removal: then stage cancer & monitor with tumor markers (AFP, bHCG, LDH)
- seminonas: are chemo and radio sensitive!!
- radical lymphnode dissection, chemo (BEC)
- stage 1: can surveillance and then consider chemo and LNdissection
- stage 2: chem & radiation
Penile Cancer
Etiology
Symptoms
Diagnosis
Treatment
Etiology
- rare: africa, asia and South america where circumscion is not common
- risk factors: older age, smoking, phimosis, inflammatory conditions, HPV!!!!, obesity, HIV, phototherapy for other conditions
- most commonly a squamous cell carcinoma
- most a result of HPV!!
Symptoms
- lesion, rash, ulceration on penis (glans, foreskin, sulcus)
- delayed presention to office due to embarrassemtn or awareness
- inguinal lymph involvment common & metatasis common by the time of presentation
Diagnosis
- get exam
- imaging from all angles
Treatment
- priamry tumor: topical treatment, laser, escision
- lymph involved: depends on priamry tumor
- T1 tumor: excise
- T2: partial or total penectomy
- nodes: low risk surveillence, high risk (dissection bilateral)
- palpable LN: chemo or surgery
