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