9 urinary and male genital

7/29/2019 9 Urinary and Male Genital

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Bladder cancer


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Urothelial tumors

-90% in bladder

-8% renal pelvis

-2% ureters and urethra


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Histology of bladder cancer

Urothelial-more than 90% of bladder cancer

Squamous cell carcinoma-5% of bladder cancer

-worldwide, this is the most common form, accounting

for 75% of bladder cancer in underdeveloped

nations.

-In the industrialized countries SCC is associated with

persistent inflammation from long-term indwelling

Foley catheters and bladder stones.-In underdeveloped nations, SCC is associated with

bladder infestation by Schistosoma haematobium.


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Etiology-Urothelial tumors

I. Environmental factors-implicated in more

than 80% of bladder cancer

-50% caused by tobacco use (increases the risk

3x)

-aromatic amines, aniline dyes, nitrites and

nitrates

-industrial contact to chemicals, plastics, coal,

tar and asphalt

-cyclophosphamide

II. Genetic factors


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Etiology-SCC1. Schistosoma haematobium

Parasitic trematode=flatworm

found in large parts of Africa, parts of the

Arabia, the Middle East, Iran, Madagascar

and Mauritius.

Infection occurs through contact with

fresh water that contains infective

cercariae released from an intermediate

host snail.

Male worms are longer and thicker. They

possess a structure known as agynecophoral canal running the length of

the body in which the female remains

during much of the life cycle.

The thinner female separates from her

mate to migrate to the venules bordering

the intestine or bladder in order to

deposit eggs.


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Etiology-SCC2. Irritative risk factors:

long-term indwelling Foley catheters

bladder stones


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Symptoms 80-90% of patients with bladder cancer present with painless

gross hematuria

Consider all patients with gross hematuria to have bladder

cancer until proven otherwise.

Suspect bladder cancer if any patient presents with

unexplained microscopic hematuria.

20-30% present irritative bladder symptoms such as dysuria,

urgency or frequency of urination that are related to

a) more advanced muscle-invasive disease or

b) CIS

Patients with advanced disease can present with pelvic or

bony pain, lower-extremity edema from iliac vessel

compression or flank pain from ureteral obstruction


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Diagnosis Cystoscopy with TUR-V (transurethral

resection) Clinical examination for inguinal lymph nodes

CT/MRI/PET-CT of pelvis and abdomen

Chest radiography


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TUR-V (click on the video)


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Treatment

Non-muscle invasive bladder cancer:

TUR-V

+/- intravesical chemotherapy instillation or

intravesical BCG (Bacillus Calmette-Guerin)


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Treatment

Muscle invasive bladder cancer:

1. Bladder conserving therapy: maximal TUR-V

or segmental cystectomy followed by

chemoradiation

2. Cystectomy plus pelvic lymphadenectomy


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Questions

What are the two main types of bladder

cancer and what risk factors do they have?

What is the treatment for non-muscle

invading bladder cancer?

What are the treatment choices for muscle-

invading bladder cancer?


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Prostate cancer

(prostate adenocarcinoma)


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Epidemiology

USA: surpassed lung cancer in known

incidence around 1990 due to PSA screening

One project that analyzed autopsy studies from around the

world came to the following conclusion regarding the actual

rate of prostate cancer in men of different ages:

20 to 30 years, 2% to 8%

31 to 40 years: 9% to 31%

41 to 50 years: 3% to 43%

51 to 60 years: 5% to 46% 61 to 70 years: 14% to 70%

71 to 80 years: 31% to 83%

81 to 90 years: 40% to 73%


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Risk factors

I. Genetic

- e.g. BRCA1/2 mutations

- black race

II. Environmental-high fat and red meat plus low fruits +

vegetables diet

-cause not exactly known


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Extension

Local: through the prostatic capsule,

through the seminal vesicles

Regional lymph nodes: lymph nodes

from the true pelvis

Metastases: most frequent-bone


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Symptoms

Bladder Outlet Obstruction (BOO): weak urinary

stream, frequent (nocturnal) and voiding incomplete

emptying of the bladder The two most probable causes

BOO are a weakly contracting bladder muscle or

Benign Prostatic Hyperplasia (BPH) followed by

prostate cancer

More advanced stages:

-lumbar pain due to para-aortic metastases/bone meta

-other bone pain


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Diagnosis

Digital rectal examination (prostatic nodule)

PSA

US guided prostate biopsy


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Age-specific upper limits of

normal for PSA

Age (years) PSA in blood (ng/mL)

40-49 2.5

50-59 3.5

60-69 4.5

70-79 6.5

PSA is not a perfect test:

-men with a PSA level below the age-specific limit of normal can have

cancer

-PSA is not cancer-specific and is produced by both cancerous and non-

cancerous prostate cells [increased PSA can occur is benign prostatichyperplasia (BPH, i.e. prostate enlargement) or prostatitis (infection of the

prostate]


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Diagnosis (2)


Examinations for extension:

-rectal US

-pelvine MRI

-scintigraphy with anti-PSMA (prostate specific

membrane antigen) antibodies (prostascint)

-bone scintigraphy


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Prostascint

Abnormal ProstaScint accumulation is

demonstrated in the seminal vesicles (red

arrows on image A) and right pelvic lymph

nodes (yellow arrow on image B).


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Scintigraphy with PET and Technetium


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Treatment

Life expectancy is important in the decision to

treat or not a certain patient


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Treatment

1. Watchful waiting-for patients with a life expectancy of less than 5

years because of comorbidities plus have to

be asymptomatic2. (Nerve sparing) radical prostatectomy plus

pelvic lymphadenectomy

-side effects: 40-90% impotence, 10%incontinence

T


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Treatment

3. Prostate brachytherapy-mainly for cancer

localized to the prostate

a) LDR (low dose rate;

seed implant)

b) HDR (high dose rate;

treatment through catheters)

T


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Treatment

4. External beam radiotherapy

-for cancer limited to the prostate

-for cancer spread to the seminal vesicles

and/or lymph nodes

T t t


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Treatment

5. Hormonal treatment

-associated to surgery/radiotherapy

-alone in metastatic disease

-consists ofandrogen deprivation therapy

through LHRH agonist or orchiectomy

6. Chemotherapy

-in metastatic disease


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Screening

After discussing potential benefits and harms of

screening

From 50 yrs in normal risk men with DRE and

PSA

From 40 yrs in men with increased risk (first

degree relative with prostate cancer, black

race)


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Questions

What are the treatment modalities in prostate

cancer?

How is screening done in prostate cancer?

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