Bladder cancer / testicular cancer (one lecture)

Question 1

Epidemiology of bladder cancer (urothelial carcinoma)

Answer 1

bladder cancer = #5 most common cancer overall, #8 cause of cancer deaths

• more MALE than female (4:1)
• peak incidence at age 70-80 - disease of old ppl.
• low death rate (lots of pt’s on surveillance)- most pt’s don’t die

Question 2

risk factors for bladder cancer

Answer 2

smoking! =responsible for 50% of cases in males, 30% of cases in females!! quitting smoking reduces risk but does not eliminate it. dose dependent relationship.
others
-environmental / occupational exposures (20% of cases)
- chemicals
-pelvic radiation
-cyclophosphamide
-schistosomiasis exposure

Question 3

clinical presentation of bladder cancer

Answer 3

• *Gross hematuria which is intermittent and painless** = key! (gross hematuria is rare even in severe UTI’s)
• happens in 80-90% of patients.
• bladder cancer is the most common cause of gross hematuria in patients over age 50.

**irritative voiding symptoms (dysuria, urgency) present in 20-30% of cases - often confuses practitioners.

Question 4

general staging for bladder cancer

Answer 4

T2 = muscle invasive bladder cancer

Everything else = non-muscle invasive bladder cancer.
T1 = lamina propria
Ta = non invasive
CIS - carcinoma in situ

Question 5

general methods of treating bladder cancer

Answer 5

most common = transurethral resection of bladder tumor

• *everyone gets a single dose of intravesical chemotherapy, immediately after surgery - unless T2 or above
• *T1 stage or lower - also get BCG a month after surgery.

Question 6

which lymph nodes does bladder cancer go to?

Answer 6

pelvic and retroperitoneal lymph nodes.

Question 7

when is bladder removal indicated for bladder cancer?

Answer 7

-if cancer has invaded the muscle.

Question 8

What are the criteria for asymptomatic microscopic hematuria?

Answer 8

• 3 RBC per high power field on microscopy on ONE specimen!.
• positive heme on dipstick is NOT sufficient!!

Question 9

T/F a thorough physical exam is vital to the diagnosis of bladder cancer

Answer 9

False. not very important because the lymph nodes are not palpable.

Question 10

urine cytology utility in bladder cancer

Answer 10

modest sensitivity but excellent specificity

Question 11

person says she’s had some gross hematuria but not today. Her urine is positive for heme. next step?

Answer 11

-look at the piss under the microscope - looking for RBCs

Question 12

imaging for bladder cancer

Answer 12

CT of abdomen and pelvis.

Question 13

gold standard for bladder cancer diagnosis

Answer 13

-cystoscopy

Question 14

what’s the rule regarding re-resection of a tumor/

Answer 14

if there is lamina propria invasion, REDO the resection no matter what! (even if there is muscle present, but ESPECIALLY if there is no muscle present.)

Question 15

surveillance for bladder cancer

Answer 15

Lifelong Surveillance is crucial for bladder cancer patients!! 70% recurrence rate.
-cystoscopy, cytology, and upper tract imaging - every 3 months for 2 years, then every 6 mo for the next 2 years, then yearly after 4 years.

Question 16

recurrence rate for bladder cancer

Answer 16

-70% within 3 years.

Question 17

who gets testicular cancer

Answer 17

young men

Question 18

When should you do a scrotal exam?

Answer 18

On any man who presents with abdominal pain.

Question 19

2 categories of testicular tumors.

Answer 19

• Seminoma (30-60% of cancers)
  vs.
• Non-seminoma germ cell tumors

Question 20

prognosis for testicular cancer

Answer 20

good- cure rates are high due to early recognition and effective treatment.

Question 21

testicular cancer biopsy - syncytiotrophoblasts present

Answer 21

-think seminoma - syncytiotrophoblasts are always present in seminomas.

Question 22

testicular cancer biopsy - AFP elevated

Answer 22

some component must be non-seminoma.

Seminomas NEVER make AFP! if AFP is present, then SOME PORTION of the tumor must be non-seminoma.

Question 23

treatment for teratoma

Answer 23

surgery - it is not chemosensitive.

Question 24

most common testicular tumor type in children

Answer 24

yolk sac tumor.

Question 25

lymphatic spread from testicular cancer

Answer 25

retroperitoneal nodes.

Question 26

clinical presentation of testicular cancer

Answer 26

UNILATERAL, painless, hard, enlargement of the testicle.

Question 27

which 2 situations should you always have testicular cancer on the differential?

Answer 27

• abdominal pain (vs. appendicitis)

- retroperitoneal mass (vs. lymphoma)

Question 28

testicular mass. you suspect cancer (since it’s unilateral, painless, and firm). Next step?

Answer 28

1- order tumor markers (AFP, hCG, LDH - also CBC)

AFP = yolk sac or embryonal, NEVER elevated in seminoma!!

Question 29

Testicular mass - with high AFP. Next step?

Answer 29

get an ultrasound of the scrotum to confirm the mass!

-then remove the tumor.

Question 30

When should CT and chest xray be tone for testicular cancer workup?

Answer 30

before or after the orchiectomy - doesn’t matter (everyone gets an orchiectomy no matter what.)

Question 31

T/F - a testicular biopsy should never be done

Answer 31

True!! take it out man.

Question 32

When is radiation used for testicular cancer?

Answer 32

for seminomas - never for non-seminomas.

26 gray dose does the job, without causing second cancers.

Question 33

treatment for seminoma

Answer 33

-orchiectomy then radiation.

For high stage (IIB and above), do chemotherapy.

Question 34

treatment of non-seminoma

Answer 34

-orchiectomy + surveillance or chemo - depends on stage.