Urologic Oncology
Raj S. Pruthi, M.D.
Division of Urologic Surgery
The University of North Carolina at Chapel Hill
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
Question 2
• What is the most common symptom of
localized prostate ca.?
–
–
–
–
Hematuria
Urinary sx’s -- frequency,nocturia
Bony pain
No symptoms
Question 3
• Prostate ca. screening should begin at
age…
–
–
–
–
80
65
50
30
Question 4
• The following are common treatments of
prostate ca. except
–
–
–
–
surgery
radiation
chemotherapy
castration
Question 5
• The following groups have an increased
relative risk of prostate ca. Development,
except….
–
–
–
–
family history
Americans
African-Americans
h/o STDs
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
Question 7
• The most symptom of bladder cancer is…
–
–
–
–
no symptoms
hematuria
recurrent UTIs
bony pain
Question 8
• Bladder cancer is most commonly…
–
–
–
–
adenocarcinoma
squamous cell ca.
transitional cell ca.
clear cell ca.
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
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
Prostate Cancer
• 200,000 new cases per year -- 1st
• 40,000 deaths per year -- 2nd
• Lifetime risk = 1 in 8
Presentation
• 1950
– 28% localized
– 72% locally-extensive / metastatic
• 2000
– 80% localized (no symptoms)
– 20% locally-extensive / metastatic
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 Factors
•
•
•
•
Age
Ethnicity
Family History
Geographic Variation
Age
• 95% occur ages 45 - 90
• exponential increase after age 50
age
<40
40-59
60-79
risk
1 in 10,000
1 in 100
1 in 8
Ethnicity
Relative risk
(# / 100,000)
• African Americans
• White Americans
• Japanese Americans
90
50
20
• Native Japanese
5
Geographic Variation
HIGH
MEDIUM
LOW
Family History
• 10 % are familial
• Most occur in patients < age 55
• Those with family hx have higher risk:
– 1 relative
– 2 relatives
– 3 relatives
2X
5X
11X
Detection
» PSA (prostate specific antigen)
» DRE (digital rectal exam)
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
»
»
»
»
CANCER
Enlarged prostate (BPH)
Prostatitis
Prostate infarct
Ø DRE
Ø Bicycle riding, sexual activity, etc.
Screening
• YEARLY AFTER AGE 50
• YEARLY AFTER AGE 40
– African-Americans
– Family History
Detection
• Abnormal DRE
OR
• Abnormal PSA
BIOPSY
TRUS / PNBx
Pathology
• Adenocarcinoma
• Spread by direct extension, perineural
invasion, lymphatics
• Found in peripheral zone
• Spread to
– seminal vesicles
– lymph nodes
– bones
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
A
B
C
D1
D2
PSA or TURP detected
Nodule on Prostate
Extends beyond Prostate
Spread to LNs
Distant Spread (bones)
T1
T2
T3,T4
N+
M+
Treatment
• Nothing - “Watchful Waiting”
• Surgery - “Radical Prostatectomy”
• Radiation – “External Beam Radiation”
– “Brachytherapy”
• Hormone - “Androgen Ablation”
Treatment Options
• T1, T2
surgery, radiation (ebRT,
brachy), watchful waiting
• T3, T4
radiation (ebRT), hormones
• N+, M+
hormones
Radical Prostatectomy
Radical Prostatectomy
Radical Prostatectomy
Puboprostatic Ligs. / DVC
Apical / Urethral Dissection
Lateral Pedicles
Seminal Vesicles
Bladder Neck
Bladder Neck Preservation
Urethral-Bladder Anastamosis
Prostate Specimen
Radical Prostatectomy
Bladder Cancer
•
•
•
•
40,000 cases per year
10,000 deaths per year
2nd most common urologic malignancy
males:females = 3:1
Pathology
• Transitional cell ca. = 90%
• Squamous cell ca. = 8%
• Adenoca. = 2%
Etiology
• Enviromental factors
–
–
–
–
–
cigarettes
carcinogenic aromatic amines
cyclophosphamide
pelvic irradiation
schistosomiasis
Stage
A
A
B
C
D
confined to epithelium
invade submucosa
invade muscle
Extends perivesicle fat
Spread to LNs, Distant
Ta
T1
T2, 3a
T3bc,4
N+M+
Signs / Symptoms
• Hematuria
• Irritative voiding sx’s
Diagnosis
•
•
•
•
Cystoscopy
Urine Cytology
IVP / CT
TURBT
Treatment
• Superficial (Ta,T1)
– TURBT +/intravesical therapy
• Muscle-invasive
(T2,3a)
– cystectomy
• Metastatic
– chemotherapy
Treatment - Cystectomy
Upper tract TCCa
• Renal pelvis / ureter
• Dx: IVP, cytology, ureteroscopy
• Rx:
– Nephroureterectomy
– partial (distal) ureterctomy
– laser ablation
• F/U: Bladder surveillence
Renal Cell Carcinoma
• 20,000 new cases per
year
• 10,000 deaths per
year
• males:females = 2:1
Pathology
• Adenocarcinoma
• arise from proximal tubule
• spread via direct extension, lymphatics,
hematogenous
• Spread to:
– LNs, lung, bone, liver
Signs / Symptoms
• Hematuria
• Flank pain
• Flank mass
• Incidentally discovered
Diagnosis
• CT scan with / without contrast
– heterogeneous, enhancing mass
• Renal ultrasound
• MRI
• IVP
Stage
I
II
III
IV
confined to kidney
confined to Gerotas
renal vein, v. cava , LNs
Adj.orgs, distant met
T1,T2
T3a
T3bc,N+
T4, M+
Treatment
• T1, T2, T3
– radical nephrectomy
– cavotomy/extract tumor thrombus for T3b,c
• T4,N+,M+
– immunotherapy (+/- nephrectomy)
Tumor Thrombus
Tumor Thrombus
Radical Nephrectomy
Patient positioning:
Flank
Radical Nephrectomy
Partial nephrectomy
Incisions
Radical Nephrectomy
Radical Nephrectomy
Partial nephrectomy
Hilar Vessels
Renal Vein
Renal Artery
Incisions
Renal Tumors
•
•
•
•
•
RCCa
Angiomyolipoma
Oncocytoma
Renal pelvic TCCa
Complex renal cysts
Survival
(5-year)
•
•
•
•
I = 75%
II = 65%
III = 40%
IV = 10%
Testicular Carcinoma
• 5,000 new cases per
year
• 1,000 deaths per year
• Most common solid
tumor of young adult
men (age 20-40)
Pathology
• 95% germ cell tumors
–
–
–
–
–
seminoma
embryonal cell ca.
choriocarcinoma
teratocarcinoma
yolk sac tumors
• 5% interstitial cell tumors (Sertoli,
Leydig)
Pathology
• Rapidly growing tumors
• Metastasize early
– retroperitoneal, mediastinal LNs
– lungs,liver,brain,bones
• Tumor markers
– beta-HCG
– alpha-fetoprotein
Staging
• 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 / Symptoms
• Painless testicular mass
– considered malignant
• virilization, gynecomastia
• secondary hydrocele
• retroperitoneal mass
Treatment
•
•
•
•
Radical orchiectomy
Retroperitoneal lymph node dissection
Radiation
Chemotherapy
All treatments highly effective
Survival
• Seminoma = 98%
• Non-seminoma = 95%
Penile cancer
• Uncommon in U.S.
• Rare in circumcised (at birth) men
Pathology
• Squamous cell ca.
• CIS
– Erythroplasia of Queyrat / Bowens disease
• Chronic inflammation, phimosis
Signs / Symptoms
• Penile lesion / mass / ulcer on glans,
foreskin, shaft
• Secondary infection may co-exist
• May be hidden by phimosis
• Inguinal lymph nodes
Treatment
• Excisional bx
• Partial vs. total penectomy
• Inguinal lymph node dissection
• Radiation and chemotherapy have
limited efficacy / palliative
Survival
• Localized (confined to penis) = 80%
• Inguinal lymph nodes = 30%
• Distant metastasis < 5%
Adrenal tumors
•
•
•
•
•
•
Cysts
Adenomas
Myolipomas
Adenocarcinomas
Pheochromocytomas
Aldosteronoma
Adrenocortical Ca.
•
•
•
•
•
> 6 cm in size
> 50% functional
Highly malignant
Dx = CT, MRI, serum/urine chemistries
Rx
– adrenalectomy
– mitotane
Pheochromocytoma
• Hypersecretion of E, NE
– htn, palpitations, diaphoresis
• 10% are:
– malignant, bilateral, extra-adrenal
• Dx: CT, MRI, serum/urine chemistries
• Rx = surgical excision