urologic oncology raj s. pruthi, m.d. division of urologic surgery the university of north carolina...

Urologic OncologyUrologic Oncology

Raj S. Pruthi, M.D.Division of Urologic Surgery

The University of North Carolina at Chapel Hill

Question 1Question 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

Question 2Question 2

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

Question 3Question 3

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

Question 4Question 4

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

Question 5Question 5

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

Question 6Question 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

Question 7Question 7

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

Question 8Question 8

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

Question 9Question 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

Question 10Question 10

• Testicular cancer….– is rarely curable– is resistant to chemotherapy– commonly presents a painless testicular

lump– is most common in men over age 40

Prostate CancerProstate Cancer

• 200,000 new cases per year -- 1st

• 40,000 deaths per year -- 2nd

• Lifetime risk = 1 in 8

PresentationPresentation

• 1950– 28% localized– 72% locally-extensive / metastatic

• 2000– 80% localized (no symptoms)– 20% locally-extensive / metastatic

Prostate Cancer:Symptoms

Prostate Cancer:Symptoms

• Localized (curable) = NONE!

• Locally-extensive = voiding symptoms

• Metastatic = bony pain– spine, pelvis, ribs, skull, long bones

(prostate cancer patients may have BPH)

Risk FactorsRisk Factors

• Age

• Ethnicity

• Family History

• Geographic Variation

AgeAge

• 95% occur ages 45 - 90

• exponential increase after age 50

age risk

<40 1 in 10,000

40-59 1 in 100

60-79 1 in 8

EthnicityEthnicity

Relative risk (# / 100,000)

• African Americans 90

• White Americans 50

• Japanese Americans 20

• Native Japanese 5

Geographic Variation

HIGH

MEDIUM

LOW

Family HistoryFamily History

• 10 % are familial

• Most occur in patients < age 55

• Those with family hx have higher risk:– 1 relative 2X– 2 relatives 5X– 3 relatives 11X

DetectionDetection

» PSA (prostate specific antigen)

» DRE (digital rectal exam)

Detection:PSA

Detection:PSA

• 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

PSA:Elevation

PSA:Elevation

» CANCER

» Enlarged prostate (BPH)

» Prostatitis

» Prostate infarct

ØDRE

ØBicycle riding, sexual activity, etc.

ScreeningScreening

• YEARLY AFTER AGE 50

• YEARLY AFTER AGE 40– African-Americans

– Family History

DetectionDetection

• Abnormal DRE

OR

• Abnormal PSABIOPSY

TRUS / PNBx

PathologyPathology

• Adenocarcinoma • Spread by direct extension, perineural

invasion, lymphatics• Found in peripheral zone• Spread to

– seminal vesicles

– lymph nodes

– bones

Pathology:Grade

Pathology:Grade

• Gleason score ( 2-10)– 2-6 = low grade– 7 = intermediate– 8-10 = high grade

• Important prognostic info.

• High grades = aggressive cancers

Pathology:Stage

Pathology:Stage

A PSA or TURP detected T1

B Nodule on Prostate T2

C Extends beyond ProstateT3,T4

D1 Spread to LNs N+

D2 Distant Spread (bones) M+

TreatmentTreatment

• Nothing - “Watchful Waiting”

• Surgery - “Radical Prostatectomy”

• Radiation - – “External Beam Radiation”– “Brachytherapy”

• Hormone - “Androgen Ablation”

Treatment OptionsTreatment Options

• T1, T2 surgery, radiation (ebRT, brachy), watchful waiting

• T3, T4 radiation (ebRT), hormones

• N+, M+ hormones

Radical Prostatectomy

Radical Prostatectomy

Radical ProstatectomyRadical Prostatectomy

Puboprostatic Ligs. / DVCPuboprostatic Ligs. / DVC

Apical / Urethral DissectionApical / Urethral Dissection

Lateral PediclesLateral Pedicles

Seminal VesiclesSeminal Vesicles

Bladder NeckBladder Neck

Bladder Neck PreservationBladder Neck Preservation

Urethral-Bladder AnastamosisUrethral-Bladder Anastamosis

Prostate SpecimenProstate Specimen

Radical Prostatectomy

Bladder CancerBladder Cancer

• 40,000 cases per year

• 10,000 deaths per year

• 2nd most common urologic malignancy

• males:females = 3:1

PathologyPathology

• Transitional cell ca. = 90%

• Squamous cell ca. = 8%

• Adenoca. = 2%

EtiologyEtiology

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

StageStage

A confined to epithelium Ta

A invade submucosa T1

B invade muscle T2, 3a

C Extends perivesicle fatT3bc,4

D Spread to LNs, Distant N+M+

Signs / SymptomsSigns / Symptoms

• Hematuria

• Irritative voiding sx’s

DiagnosisDiagnosis

• Cystoscopy

• Urine Cytology

• IVP / CT

• TURBT

TreatmentTreatment

• Superficial (Ta,T1)– TURBT +/-

intravesical therapy

• Muscle-invasive (T2,3a)– cystectomy

• Metastatic– chemotherapy

Treatment - CystectomyTreatment - Cystectomy

Upper tract TCCaUpper tract TCCa

• Renal pelvis / ureter

• Dx: IVP, cytology, ureteroscopy

• Rx: – Nephroureterectomy– partial (distal) ureterctomy– laser ablation

• F/U: Bladder surveillence

Renal Cell CarcinomaRenal Cell Carcinoma

• 20,000 new cases per year

• 10,000 deaths per year

• males:females = 2:1

PathologyPathology

• Adenocarcinoma

• arise from proximal tubule

• spread via direct extension, lymphatics, hematogenous

• Spread to:– LNs, lung, bone, liver

Signs / SymptomsSigns / Symptoms

• Hematuria

• Flank pain

• Flank mass

• Incidentally discovered

DiagnosisDiagnosis

• CT scan with / without contrast– heterogeneous, enhancing mass

• Renal ultrasound

• MRI

• IVP

StageStage

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+

TreatmentTreatment

• T1, T2, T3– radical nephrectomy– cavotomy/extract tumor thrombus for T3b,c

• T4,N+,M+– immunotherapy (+/- nephrectomy)

Tumor ThrombusTumor Thrombus

Tumor ThrombusTumor Thrombus

Radical NephrectomyRadical Nephrectomy

Patient positioning:Flank

Patient positioning:Flank

Radical NephrectomyRadical Nephrectomy

Partial nephrectomyPartial nephrectomy

IncisionsIncisions

Radical NephrectomyRadical Nephrectomy

Radical NephrectomyRadical Nephrectomy

Partial nephrectomyPartial nephrectomy

Hilar VesselsHilar Vessels

Renal VeinRenal Vein

Renal ArteryRenal Artery

IncisionsIncisions

Renal TumorsRenal Tumors

• RCCa

• Angiomyolipoma

• Oncocytoma

• Renal pelvic TCCa

• Complex renal cysts

Survival (5-year)

Survival (5-year)

• I = 75%

• II = 65%

• III = 40%

• IV = 10%

Testicular CarcinomaTesticular Carcinoma

• 5,000 new cases per year

• 1,000 deaths per year• Most common solid

tumor of young adult men (age 20-40)

PathologyPathology

• 95% germ cell tumors– seminoma– embryonal cell ca.– choriocarcinoma– teratocarcinoma– yolk sac tumors

• 5% interstitial cell tumors (Sertoli, Leydig)

PathologyPathology

• Rapidly growing tumors

• Metastasize early– retroperitoneal, mediastinal LNs– lungs,liver,brain,bones

• Tumor markers– beta-HCG– alpha-fetoprotein

StagingStaging

• T=tumor• T1 = confined to testis

• T2 = invades tunica alb.

• T3 = invades cord / scrotum

• N=lymph nodes• N1 = < 2cm

• N2 = 2 - 5 cm

• N3 = > 5 cm

• M = distant metastasis

Signs / SymptomsSigns / Symptoms

• Painless testicular mass– considered malignant

• virilization, gynecomastia

• secondary hydrocele

• retroperitoneal mass

TreatmentTreatment

• Radical orchiectomy

• Retroperitoneal lymph node dissection

• Radiation

• Chemotherapy

All treatments highly effective

SurvivalSurvival

• Seminoma = 98%

• Non-seminoma = 95%

Penile cancerPenile cancer

• Uncommon in U.S.

• Rare in circumcised (at birth) men

PathologyPathology

• Squamous cell ca.

• CIS– Erythroplasia of Queyrat / Bowens disease

• Chronic inflammation, phimosis

Signs / SymptomsSigns / Symptoms

• Penile lesion / mass / ulcer on glans, foreskin, shaft

• Secondary infection may co-exist

• May be hidden by phimosis

• Inguinal lymph nodes

TreatmentTreatment

• Excisional bx

• Partial vs. total penectomy

• Inguinal lymph node dissection

• Radiation and chemotherapy have limited efficacy / palliative

SurvivalSurvival

• Localized (confined to penis) = 80%

• Inguinal lymph nodes = 30%

• Distant metastasis < 5%

Adrenal tumorsAdrenal tumors

• Cysts

• Adenomas

• Myolipomas

• Adenocarcinomas

• Pheochromocytomas

• Aldosteronoma

Adrenocortical Ca.Adrenocortical Ca.

• > 6 cm in size

• > 50% functional

• Highly malignant

• Dx = CT, MRI, serum/urine chemistries

• Rx– adrenalectomy– mitotane

PheochromocytomaPheochromocytoma

• Hypersecretion of E, NE– htn, palpitations, diaphoresis

• 10% are:– malignant, bilateral, extra-adrenal

• Dx: CT, MRI, serum/urine chemistries

• Rx = surgical excision