Urologic Oncology

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Urologic Oncology

• Raj S. Pruthi, M.D.
• Division of Urologic Surgery
• The University of North Carolina at Chapel Hill

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Question 1

• Which of the following is true regarding prostate
  ca.?
• Common cancer with high mortality
• Common cancer with low mortality
• Uncommon cancer with high mortality
• Uncommon cancer with low mortality

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Question 2

• What is the most common symptom of localized
  prostate ca.?
• Hematuria
• Urinary sxs -- frequency,nocturia
• Bony pain
• No symptoms

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Question 3

• Prostate ca. screening should begin at age
• 80
• 65
• 50
• 30

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Question 4

• The following are common treatments of prostate
  ca. except
• surgery
• radiation
• chemotherapy
• castration

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Question 5

• The following groups have an increased relative
  risk of prostate ca. Development, except.
• family history
• Americans
• African-Americans
• h/o STDs

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Question 6

• The most common factor associated with bladder
  cancer develoment in the U.S. is
• family history
• h/o STDs
• industrial exposure -- aniline dyes/aromatic
  amines
• smoking

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Question 7

• The most symptom of bladder cancer is
• no symptoms
• hematuria
• recurrent UTIs
• bony pain

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Question 8

• Bladder cancer is most commonly
• adenocarcinoma
• squamous cell ca.
• transitional cell ca.
• clear cell ca.

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Question 9

• Renal cell carcinoma
• is a transitional cell ca cell type
• has a very benign course / does not typically
  require any treatment
• typically requires a nephrectomy for localized
  disease
• is very responsive to radiation therapy

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Question 10

• Testicular cancer.
• is rarely curable
• is resistant to chemotherapy
• commonly presents a painless testicular lump
• is most common in men over age 40

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Prostate Cancer

• 200,000 new cases per year -- 1st
• 40,000 deaths per year -- 2nd
• Lifetime risk 1 in 8

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Presentation

• 1950
• 28 localized
• 72 locally-extensive / metastatic
• 2000
• 80 localized (no symptoms)
• 20 locally-extensive / metastatic

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Prostate CancerSymptoms

• Localized (curable) NONE!
• Locally-extensive voiding symptoms
• Metastatic bony pain
• spine, pelvis, ribs, skull, long bones
• (prostate cancer patients may have BPH)

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Risk Factors

• Age
• Ethnicity
• Family History
• Geographic Variation

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Age

• 95 occur ages 45 - 90
• exponential increase after age 50
• age risk
• lt40 1 in 10,000
• 40-59 1 in 100
• 60-79 1 in 8

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Ethnicity

• Relative risk ( / 100,000)
• African Americans 90
• White Americans 50
• Japanese Americans 20
• Native Japanese 5

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Geographic Variation
HIGH
MEDIUM
LOW
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Family History

• 10 are familial
• Most occur in patients lt age 55
• Those with family hx have higher risk
• 1 relative 2X
• 2 relatives 5X
• 3 relatives 11X

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Detection

• PSA (prostate specific antigen)
• DRE (digital rectal exam)

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DetectionPSA

• serine protease
• bound and free forms
• produced by prostate tissue only
• produced by benign and malignant cells
• not cancer specific
• cancer produces higher levels PSA

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PSAElevation

• CANCER
• Enlarged prostate (BPH)
• Prostatitis
• Prostate infarct
• DRE
• Bicycle riding, sexual activity, etc.

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Screening

• YEARLY AFTER AGE 50
• YEARLY AFTER AGE 40
• African-Americans
• Family History

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Detection

• Abnormal DRE
• OR
• Abnormal PSA

BIOPSY
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TRUS / PNBx
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Pathology

• Adenocarcinoma
• Spread by direct extension, perineural invasion,
  lymphatics
• Found in peripheral zone
• Spread to
• seminal vesicles
• lymph nodes
• bones

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PathologyGrade

• Gleason score ( 2-10)
• 2-6 low grade
• 7 intermediate
• 8-10 high grade
• Important prognostic info.
• High grades aggressive cancers

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PathologyStage

• A PSA or TURP detected T1
• B Nodule on Prostate T2
• C Extends beyond Prostate T3,T4
• D1 Spread to LNs N
• D2 Distant Spread (bones) M

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Treatment

• Nothing - Watchful Waiting
• Surgery - Radical Prostatectomy
• Radiation -
• External Beam Radiation
• Brachytherapy
• Hormone - Androgen Ablation

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Treatment Options

• T1, T2 surgery, radiation (ebRT, brachy),
  watchful waiting
• T3, T4 radiation (ebRT), hormones
• N, M hormones

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Radical Prostatectomy
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Radical Prostatectomy
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Radical Prostatectomy
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Puboprostatic Ligs. / DVC
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Apical / Urethral Dissection
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Lateral Pedicles
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Seminal Vesicles
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Bladder Neck
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Bladder Neck Preservation
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Urethral-Bladder Anastamosis
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Prostate Specimen
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Radical Prostatectomy
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Bladder Cancer

• 40,000 cases per year
• 10,000 deaths per year
• 2nd most common urologic malignancy
• malesfemales 31

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Pathology

• Transitional cell ca. 90
• Squamous cell ca. 8
• Adenoca. 2

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Etiology

• Enviromental factors
• cigarettes
• carcinogenic aromatic amines
• cyclophosphamide
• pelvic irradiation
• schistosomiasis

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Stage

• A confined to epithelium Ta
• A invade submucosa T1
• B invade muscle T2, 3a
• C Extends perivesicle fat T3bc,4
• D Spread to LNs, Distant NM

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Signs / Symptoms

• Hematuria
• Irritative voiding sxs

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Diagnosis

• Cystoscopy
• Urine Cytology
• IVP / CT
• TURBT

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Treatment

• Superficial (Ta,T1)
• TURBT /- intravesical therapy
• Muscle-invasive (T2,3a)
• cystectomy
• Metastatic
• chemotherapy

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Treatment - Cystectomy
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Upper tract TCCa

• Renal pelvis / ureter
• Dx IVP, cytology, ureteroscopy
• Rx
• Nephroureterectomy
• partial (distal) ureterctomy
• laser ablation
• F/U Bladder surveillence

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Renal Cell Carcinoma

• 20,000 new cases per year
• 10,000 deaths per year
• malesfemales 21

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Pathology

• Adenocarcinoma
• arise from proximal tubule
• spread via direct extension, lymphatics,
  hematogenous
• Spread to
• LNs, lung, bone, liver

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Signs / Symptoms

• Hematuria
• Flank pain
• Flank mass
• Incidentally discovered

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Diagnosis

• CT scan with / without contrast
• heterogeneous, enhancing mass
• Renal ultrasound
• MRI
• IVP

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Stage

• I confined to kidney T1,T2
• II confined to Gerotas T3a
• III renal vein, v. cava , LNs T3bc,N
• IV Adj.orgs, distant met T4, M

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Treatment

• T1, T2, T3
• radical nephrectomy
• cavotomy/extract tumor thrombus for T3b,c
• T4,N,M
• immunotherapy (/- nephrectomy)

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Tumor Thrombus
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Tumor Thrombus
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Radical Nephrectomy
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Patient positioningFlank
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Radical Nephrectomy
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Partial nephrectomy
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Incisions
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Radical Nephrectomy
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Radical Nephrectomy
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Partial nephrectomy
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Hilar Vessels
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Renal Vein
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Renal Artery
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Incisions
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Renal Tumors

• RCCa
• Angiomyolipoma
• Oncocytoma
• Renal pelvic TCCa
• Complex renal cysts

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Survival (5-year)

• I 75
• II 65
• III 40
• IV 10

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Testicular Carcinoma

• 5,000 new cases per year
• 1,000 deaths per year
• Most common solid tumor of young adult men (age
  20-40)

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Pathology

• 95 germ cell tumors
• seminoma
• embryonal cell ca.
• choriocarcinoma
• teratocarcinoma
• yolk sac tumors
• 5 interstitial cell tumors (Sertoli, Leydig)

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Pathology

• Rapidly growing tumors
• Metastasize early
• retroperitoneal, mediastinal LNs
• lungs,liver,brain,bones
• Tumor markers
• beta-HCG
• alpha-fetoprotein

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Staging

• Ttumor
• T1 confined to testis
• T2 invades tunica alb.
• T3 invades cord / scrotum
• Nlymph nodes
• N1 lt 2cm
• N2 2 - 5 cm
• N3 gt 5 cm
• M distant metastasis

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Signs / Symptoms

• Painless testicular mass
• considered malignant
• virilization, gynecomastia
• secondary hydrocele
• retroperitoneal mass

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Treatment

• Radical orchiectomy
• Retroperitoneal lymph node dissection
• Radiation
• Chemotherapy
• All treatments highly effective

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Survival

• Seminoma 98
• Non-seminoma 95

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Penile cancer

• Uncommon in U.S.
• Rare in circumcised (at birth) men

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Pathology

• Squamous cell ca.
• CIS
• Erythroplasia of Queyrat / Bowens disease
• Chronic inflammation, phimosis

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Signs / Symptoms

• Penile lesion / mass / ulcer on glans, foreskin,
  shaft
• Secondary infection may co-exist
• May be hidden by phimosis
• Inguinal lymph nodes

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Treatment

• Excisional bx
• Partial vs. total penectomy
• Inguinal lymph node dissection
• Radiation and chemotherapy have limited efficacy
  / palliative

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Survival

• Localized (confined to penis) 80
• Inguinal lymph nodes 30
• Distant metastasis lt 5

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Adrenal tumors

• Cysts
• Adenomas
• Myolipomas
• Adenocarcinomas
• Pheochromocytomas
• Aldosteronoma

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Adrenocortical Ca.

• gt 6 cm in size
• gt 50 functional
• Highly malignant
• Dx CT, MRI, serum/urine chemistries
• Rx
• adrenalectomy
• mitotane

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Pheochromocytoma

• Hypersecretion of E, NE
• htn, palpitations, diaphoresis
• 10 are
• malignant, bilateral, extra-adrenal
• Dx CT, MRI, serum/urine chemistries
• Rx surgical excision

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