dr. frank papanikolaou · dr. frank papanikolaou . urologist, trillium health partners . medical...
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Urologic Oncology Update
Dr. Frank Papanikolaou
Urologist, Trillium Health Partners Medical Director of Ambulatory Care, Credit Valley Hospital Tariff Chair, Section of Urology of the OMA Delegate, Credit Valley Medical Society Executive Member at Large of the Canadian Urological Association
Introduction
• Urologic cancers are common and clinically significant
• Family doctors have an integral role in diagnosis, counselling and support for our patients going through cancer treatment
• We value this partnership
Risk Factors for Prostate Cancer Age (median age of 71 years) Family History Geographic location (Northern climates) Race
Caucasians: 16.6% of the men get prostate cancer and 3.5% die African americans: 18.1% get prostate cancer and 4.3 % die
Canadian Guidelines for Prostate Cancer Screening
• Prostate cancer screening should be offered to all men 50 years of age with at least a 10-year life expectancy
• If there is a family history of prostate cancer or if the patient is of African descent, screening should be offered at age 40 years
• Initial screening should include DRE and PSA • Informed consent regarding the harms and benefits
of PCa screening must be explained to each patient
Canadian Guidelines for Prostate Cancer Screening
• There is no strict PSA screening threshold that should be used for all patients
• It is important to consider PSA velocity, PSA density, and age specific PSA ranges
• The lowest PSA threshold demonstrating a benefit to screening was 2.5 ng/ml
Histologic Grading
• Gleason Score– Tumors are graded
from 1-5– A higher number
indicates a moreaggressive tumor
– Two most predominantpatterns addedtogether for a scorefrom 2-10
Stage I(A) : low grade, low volume localized
Stage II (B) : localized
Stage III (C) : locally advanced
Stage IV(D) : metastatic
Triaging Treatment
• Patients with a life expectancy of less than 10 years and low grade/ low stage lesions may be candidates for Active Surveillance
• Eradication of the cancer is the goal of therapy in patients with a life expectancy greater than 10 years – Surgery – Radiation
Active Surveillance
The chance of dying of
prostate cancer decreases with:
Lower Gleason score Older age (more competing causes of mortality)
Treatment
• Eradication of the cancer is the goal of therapy in patients with a life expectancy greater than 10 years – Radical Prostatectomy – External-beam Radiation – Brachytherapy
• Decision of treatment modality depends on patient preference, age, and patient comorbidities
Radical Prostatectomy • Surgical removal of the prostate
• Most common side effects are impotence andincontinence
open laparoscopic robotic
External-Beam Radiation • Radiation to the prostate (and pelvis) from
outside the body• Most common side effects are impotence and
rectal irritation• Risks include secondary malignancy
Brachytherapy
HDR – High dose radiation delivered to the prostate through rods implanted temporarily for the procedure
LDR – Low dose radioactive seeds implanted into the prostate permanently which decay over 12 months
Metastatic Prostate Cancer
• Prostate Cancer tends to spread to bone and lymphnodes
• Less commonly, metastatic lesions have been foundin brain, liver and lungs.
• 1941 Charles Huggins showed that advancedprostate cancer was inhibited by decreasingTestosterone (castration or estrogen) andactivated by adding Testosterone.
• 1966 Nobel Prize in Medicine
Treatment of Metastatic Prostate Cancer
Hormone Physiology
• Most androgens areproduced in thetesticles
• Androgens fuel thegrowth of prostate cells,including prostatecancer cells
• Hormone therapy“androgen-deprivationtherapy” cuts off thefuel supply
Hormone Therapies
LHRH agonists (Lupron, Zoladex)
The GnRH antagonists (Degarelix)
Orchiectomy
Anti-androgens (casodex)
Side Effects of ADT (that you might see in your patients)
• Sexual effects: decreased libido and erectile dysfunction
• Physical effects: hot flashes, fatigue, weight gain, hair changes, breast pain, decreased muscle mass, bone mineral density
• Metabolic changes: lipid changes, anemia and diabetes mellitus
• Mental changes: lack of initiative, emotional lability, and decreased memory and cognitive function
Risk Factors for Bladder Cancer • Cigarette smoking: 2-4 fold increased risk
4-Aminobiphenyl O-toluidine
• Industrial dyes – Arylamine exposure
• Chemotherapy – cyclophosphamide
• Pelvic radiation therapy
Pathology of Bladder Cancer
• 90% Transitional Cell Carcinoma (TCC)
• 5% Squamous cell Carcinoma- more common in Middle East (schistosomiasis, also seen in chronic catheterization
• 0.5%-2% Adenocarcinoma – urachal origin
Muscle Invasive Bladder Cancer (Stage T2)
• Radical Cystectomy and Lymph nodedissection-AND:– Males: prostate– Females: anterior exenteration
• Reconstruction:– Ileal conduit– Neobladder– Catheterizable Pouch
Conclusions
• Median survival of cystectomy alone was 46months compared with 77 months forcombination therapy
Kidney Cancer
• Risk Factors – Smoking – Obesity – Exposure to chemicals (asbestos, cadmium,
herbicides, benzene) – HTN – Male – Genetic Risk Factors…
Criteria for referring patients with renal tumours for genetic assessment
Patients with any renal tumour (benign or malignant) AND any one of the following: Bilaterality or multifocality Early age of onset (≤45 years of age) 1st or 2nd degree relative with any renal tumour Skin leiomyomas*, fibrofolliculomas/trichodisomas*
Criteria for referring patients with renal tumours for genetic assessment
One of the following associated tumours: Pheochromocytoma/paraganglioma* Hemangioblastoma of the retina, brainstem, cerebellum or spinal cord* Early onset of multiple uterine fibroids (<30 years of age)* Lymphangiomyomatosis* Childhood seizure disorder*(*or 1st degree relative with same)
Criteria for referring patients with renal tumours for genetic assessment
Patients, with or without RCC, who report a family member (any) with a known clinical or genetic diagnosis of any one of the following:
Von Hippel-Lindau syndrome Birt-Hogg-Dubé syndrome Hereditary leiomyomatosis and renal cell cancer Hereditary papillary renal cell cancer Hereditary paraganglioma/pheochromocytoma Tuberous sclerosis
Types of Kidney Cancer • Clear cell is the type of cell that is found in about 70% of
kidney cancers
• Papillary kidney cancer, which develops in 10% to 15% of
patients, is divided into two different subtypes, called type 1
and type 2
• Sarcomatoid is the type of cell that grows the fastest
• Collecting duct is a rare type that behaves in a similar way to
transitional cell carcinoma
• Chromophobe is rare