Genitourinary Neoplasms

Question 1

Renal Cell Carcinoma etiology

Answer 1

● Unknown etiology in most cases
● Some genetic syndromes are associated
○ Von Hippel Landau, Birt-Hogg-Dube, tuberous sclerosis complex, familial
or hereditary syndromes

Question 2

Renal Cell Carcinoma classic triad

Answer 2

○ Gross hematuria, flank pain, palpable flank mass
○ Full “Triad” occurs in only 10% of cases
■ Generally represents advanced disease

Question 3

How is Renal Cell Carcinoma typically found?

Answer 3

● Usually found on CT scan during work up for one of the three symptoms of the triad
● Often asymptomatic

Question 4

Renal Cell Carcinoma diagnostics

Answer 4

● Typically discovered incidentally
● Gold-standard imaging – CT Urogram (3 scans)
■ No biopsy is needed
■ Biopsy exists, in certain cases
● CXR or CT chest (secondary to Dx)

Question 5

When to refer a potential Renal Cell Carcinoma to urology

Answer 5

● Renal mass seen on CT
● “Complex renal cyst”

Question 6

Where is metastasis of Renal Cell Carcinoma most likely?

Answer 6

Metastasis most likely move to the lymph,
lungs, liver, bones

Question 7

Renal Cell Carcinoma Management

Answer 7

● Cryotherapy
● Gold Standard – Surgical excision
○ Radical nephrectomy
○ Robotic partial nephrectomy

Question 8

Surgical excision Techniques for Renal Cell Carcinoma

Answer 8

○ Radical nephrectomy
■ Large or hilar tumors
■ “Open” or “hand-assisted laparoscopic” approach
○ Robotic partial nephrectomy
■ Exophytic and solitary tumors
■ Effort to spare nephrons

Question 9

Renal Cell Carcinoma complications

Answer 9

● Acute or chronic kidney disease, abdominal hematoma, infection, bleeding,
pneumonia
● Solitary kidney

Question 10

Prevention of Renal Cell Carcinoma

Answer 10

Modifiable risk factors for RCC include
○ Smoking, obesity, poorly-controlled hypertension,
diet and alcohol, and occupational exposures

Question 11

Prostate Cancer epidemiology

Answer 11

● Most common cancer in men (after skin cancer)
○ 1 in 9 men (11%)
● Mortality – Second leading cause of male cancer death after lung cancer
○ 1 in 41 (2.4%)
● Major Risk Factors
○ Family Hx
○ African American
■ 1 in 4 (25%)
■ 2-3 x higher mortality

Question 12

Prostate Cancer etiology

Answer 12

● Relatively unknown causes
● Genetics
○ Higher association with Lynch syndrome and BRCA2

Question 13

Clinical Presentation of Prostate Cancer

Answer 13

● Asymptomatic
○ Identified through screening
● May present with obstructive urinary symptoms
○ Can be confused with benign prostate enlargement
● Metastasis
○ Bone pain
○ Vertebral fracture

Question 14

Diagnostic Evaluations for Prostate Cancer

Answer 14

● Prostate Specific Antigen (PSA)
● Digital Rectal Exam (DRE)
● Prostate Biopsy – definitive diagnosis
● CT ab/pelvis – Lymph involvement
● Bone scan – metastatic

Question 15

What is Prostate Specific Antigen (PSA) testing?

Answer 15

○ Released from the prostate tissue (<4 ng/mL)
○ Elevation in PSA
■ Cancer, infection, inflammation,
enlargement, recent ejaculation
■ Significant saddle time

Question 16

The introduction of PSA had correlated with
____

Answer 16

significant reduction of death from prostate cancer

Question 17

Why is there controversy over Prostate Specific Antigen (PSA)?

Answer 17

● There has been a some controversy around
PSA testing since USPSTF recommendations in
2011 that recommended AGAINST PSA
screening, regardless of age, race, or risk factors
○ Over diagnosing and possibly unnecessary
treatment
● We need to be wise on how and when to use it

Question 18

What can cause PSA to be falsely elevated?

Answer 18

Infection, inflammation, enlargement, recent ejaculation

Question 19

What can cause PSA to be falsely lowered?

Answer 19

5-Alpha Reductase inhibitors (Finasteride and Dutasteride)

Question 20

PSA velocity/doubling time

Answer 20

4 years (more accurate with PSA <6 ng/mL)

Question 21

Digital Rectal Exam (DRE) use in prostate cancer

Answer 21

○ Low sensitivity when used only screening method
■ Some providers use this as an excuse to never do them
○ Useful as a baseline test in screening, but doesn’t need to be done annually
● Important in patients with suspected prostatitis or BPH
as a cause of the elevated PSA

Question 22

Prostate Cancer Management

Answer 22

● Observation/active surveillance – older men with low grade disease
● Androgen deprivation – Shot every 3+ months, controls but does not cure
○ Often use with metastasis
● Surgical Excision: Open vs Laparoscopic
● Radiation: Brachytherapy (implanting radioactive seeds) vs External beam

Question 23

Surgical and radiological complications of prostate cancer management

Answer 23

● Surgery
○ Incontinence – stress
○ Impotence
● Radiation
○ Incontinence – although less than surgery
○ Impotence

Question 24

Bladder Cancer epidemiology

Answer 24

● 2nd most common genitourinary cancer
● Men 3-4 x more common than women
● Higher in caucasians
● Average age of diagnosis 65 years old (rare <40)
● 90% Transitional Cell Carcinoma

Question 25

Bladder cancer etiology

Answer 25

● Cigarette smoking – 2-3x greater risk of bladder cancer
○ Smoking accounts for 65% of bladder cancer in men and 20-30% in women
● Environmental exposures – Textiles, hair dyes, rubbers

Question 26

Bladder Cancer clinical presentation

Answer 26

● Painless GROSS hematuria (80-90%)
● May have irritative voiding symptoms (20%)
● Smoker (+/-)

Question 27

Bladder Cancer diagnostic evaluations

Answer 27

● Physical exam – unremarkable
● Urine microscopy
○ >3 RBC/HPF – “TNTC” – too numerous to count
● Urine culture – would be negative
● CT Urogram: Rule out other cause of hematuria
● Cystoscopy for Biopsy

Question 28

Bladder Cancer management

Answer 28

● Transurethral Resection (TUR) – surgical excision
● Intravesical Chemotherapy (BCG or Mitomycin C)
● Radiation: Significant complications, 33-68% recurrence
● Radical Cystectomy
○ Diversion of the ureters (urostomy)
○ NeoBladder – pouch made from the small
bowel

Question 29

Bladder Cancer prevention

Answer 29

● Smoking cessation
● Increase oral hydration

Question 30

Testicular Cancer epidemiology

Answer 30

● Most common cancer in men aged 18-35 (rare >45 years)
● 1 in 250 men in their lifetime
● Two general types
○ Seminomas (55%)
○ Non-seminomas (44%)

Question 31

Testicular Cancer risk factors

Answer 31

○ History of cryptorchidism
○ Family history
○ Previous testicular cancer

Question 32

Testicular Cancer clinical presentation

Answer 32

“Rock hard” nodule on the testile
○ Usually unilateral
○ Starts painless

Question 33

Testicular Cancer diagnostic evaluations

Answer 33

● Careful exam
● Scrotal Ultrasound – Gold Standard
● Biopsy – NO!!! can spread/seed
● CT abdomen/pelvis/chest

Question 34

Tumor markers for testicular cancer

Answer 34

pre and post surgery
○ Alpha fetoprotein (aFP)
○ Beta human chorionic gonadotropin
(bHCG)
○ Lactate dehydrogenase (LDH)

Question 35

Testicular Cancer management

Answer 35

● Radical orchiectomy – excision
● Radiation

Question 36

Testicular Cancer metastasis

Answer 36

● Metastasis through lymph nodes
○ Ascending from the testicles up through the abdomen toward the chest