Mr Rahul Mistry
Urology Special Registrar
Mersey Deanery
 Prostate cancer
 Testicular cancer
 Bladder cancer
 Commonest malignancy of male urogenital tract
 There are about 10,000 cases per year in the United
Kingdom
 Rare befor...
 Adenocarcinomas
 Arise in the posterior / periphery
 Spread through capsule into perineural
spaces, bladder neck, pelv...
 Not well known
 First-line relative - risk is at least doubled
 If two or more first-line relatives - the risk increas...
 60% symptoms of bladder outflow
obstruction
 10% incidental findings atTURP
 Bone pain, cord compression or leuco-
ery...
 DRE:
 Hard nodule
 Loss of central sulcus
 Transrectal biopsy
 Pelvic MRI - staging
 Bone scans – metastasis
 Unli...
 Prostate specific antigen
 Kallikrein-like protein produced by prostatic epithelial cells
 Age matched:
 40-50:2.5
 ...
PPV = positive predictive value
PSA ng/mL PPV for cancer
0 - 1 2.8-5%
1 - 2.5 10.5-14%
2.5 - 4 22-30%
4 - 10 41%
> 10 69%
Gleason score Risk of cancer death Cancer-specific
mortality
2 – 4 4 – 7% 8%
5 6 – 11% 14%
6 18 – 30% 44%
7 42 – 70% 76%
8...
 Grading score
 Score: 2 – 10
 2 - least aggressive
 10 -most aggressive.
 Total score = the sum of the two most comm...
 TX Primary tumour cannot be assessed
 T0 No evidence of primary tumour
 T1 Clinically inapparent tumour not palpable o...
 More men die with than from prostate cancer
 Treatment depends on stage of disease, patient's age
and general fitness
...
 80% of prostate cancers are androgen dependent for growth
 Hormonal therapy involves androgen depletion
 Produces good...
 Regulated by the hypothalamic-pituitary-gonadal axis.
 LHRH stimulates the anterior pituitary to release LH and FSH
 L...
 Commonest solid malignancy in young men
 1% - 1.5% of male neoplasms
 5% of urological tumours
 3-6 new cases occurri...
 History of cryptorchidism
 x4-13 increased risk
 7-10% tumours in undecended testis
 Klinefelter’s syndrome
 FHx
 F...
 Unilateral testicular mass
 20% scrotal pain
 27% local pain
 Trauma
 Reduction in testis size
 Gynaecomastia 7% (b...
 Staging and response to treatment
 Alpha-fetoprotein
 Produced by yolk sac elements
 Not produced by seminomas
 Beta...
 Ultrasound
 Sensitivity almost 100%: intra- or extratesticular
 Inexpensive test
 Screening test of the contralateral...
Radical Orchidectomy
 Seminomas are radiosensitive
 Teratomas are not radiosensitive
 Surgery: Inguinal orchidectomy
 Radiotherapy
 Chemot...
 95% transitional cell carcinomas
 4% squamous / adenocarcinoma
 Superficial tumours are usually low grade and
associat...
 TCCs should be regarded a 'field change' disease
with a spectrum of aggression
 80% ofTCCs are superficial and well dif...
 Occupational exposure
 20% ofTCC are believed to result from occupational
factors
 Chemical implicated - aniline dyes,...
 Requires
bladder
muscle to be
included in
specimen
 Staged
according to
depth of
tumour
invasion
 Grade of
tumour
diff...
 80% present with painless haematuria
 Also present with treatment-resistant infection or bladder
irritability and steri...
 RequiresTURT follow-up
 Consider prophylactic chemotherapy (mitomycin-C)
if risk factor for recurrence or invasion (e.g...
 Carcinoma-in-situ is an aggressive disease
 Often associated with positive cytology
 50% patients progress to muscle i...
 Choices are between radical cystectomy and radiotherapy
 Radical cystectomy has an operative mortality of about 5%
 Ur...
 Prostate_Exam.pps
Prostate cancer is a disease that can affect men as they
older. The sooner it’s detected, the better t...
Urological Malignancies
Urological Malignancies
Urological Malignancies
Urological Malignancies
Urological Malignancies
Urological Malignancies
Urological Malignancies
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Urological Malignancies

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Lecture given by Mr Mistry on 26 Oct 2010.

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Urological Malignancies

  1. 1. Mr Rahul Mistry Urology Special Registrar Mersey Deanery
  2. 2.  Prostate cancer  Testicular cancer  Bladder cancer
  3. 3.  Commonest malignancy of male urogenital tract  There are about 10,000 cases per year in the United Kingdom  Rare before the age of 50 years  Found at post-mortem in 80% of men older than 80 years  5-10% of operation for benign disease reveal unsuspected prostate cancer
  4. 4.  Adenocarcinomas  Arise in the posterior / periphery  Spread through capsule into perineural spaces, bladder neck, pelvic wall and rectum  Lymphatic spread - common  Haematogenous spread occurs to axial skeleton  Graded by Gleason classification
  5. 5.  Not well known  First-line relative - risk is at least doubled  If two or more first-line relatives - the risk increases 5- to 11-fold  Incidence high in the USA and Northern Europe and low in South- East Asia  However, if Japanese men move from Japan to Hawaii, their risk of CaP increases, and if they move to California their risk increases even more and approaches that of American men  High content of animal fat in the diet may be important in increasing the risk of developing CaP  Low intakes of vitamin E, selenium, lignans and isoflavenoids (soybeans)  Sunlight might be protective againstCaP due to an increase in vitamin D levels
  6. 6.  60% symptoms of bladder outflow obstruction  10% incidental findings atTURP  Bone pain, cord compression or leuco- erythroblastic anaemia  Renal failure can occur due to bilateral ureteric obstruction
  7. 7.  DRE:  Hard nodule  Loss of central sulcus  Transrectal biopsy  Pelvic MRI - staging  Bone scans – metastasis  Unlikely to be abnormal if asymptomatic and PSA < 10 ng/ml
  8. 8.  Prostate specific antigen  Kallikrein-like protein produced by prostatic epithelial cells  Age matched:  40-50:2.5  50-60: 3.5  60-70: 4.5  70-80: 6.5  >10 ng/ml is highly suggestive of prostatic carcinoma  Can be significantly raised in BPH, UTI’s or secondary to retention  Monitoring response to treatment
  9. 9. PPV = positive predictive value PSA ng/mL PPV for cancer 0 - 1 2.8-5% 1 - 2.5 10.5-14% 2.5 - 4 22-30% 4 - 10 41% > 10 69%
  10. 10. Gleason score Risk of cancer death Cancer-specific mortality 2 – 4 4 – 7% 8% 5 6 – 11% 14% 6 18 – 30% 44% 7 42 – 70% 76% 8 – 10 60 – 87% 93%
  11. 11.  Grading score  Score: 2 – 10  2 - least aggressive  10 -most aggressive.  Total score = the sum of the two most common patterns (grades 1-5) of tumour growth found  TRUS prostate biopsy  TURP
  12. 12.  TX Primary tumour cannot be assessed  T0 No evidence of primary tumour  T1 Clinically inapparent tumour not palpable or visible by imaging  T1a Incidental histological finding in 5% or less of tissue resected  T1b Incidental histological finding in more than 5% of tissue resected  T1c Tumour identified by needle biopsy (e.g., because of elevated PSA)  T2 Tumour confined within the prostate  T2a Tumour involves one half of one lobe or less  T2b Tumour involves more than half of one lobe, but not both lobes  T2c Tumour involves both lobes  T3 Tumour extends through the prostatic capsule  T3a Extracapsular extension (unilateral or bilateral)  T3b Tumour invades seminal vesicle(s)  T4 Tumour is fixed or invades adjacent structures other than seminal vesicles: bladder neck, external sphincter, rectum, levator muscles, or pelvic wall
  13. 13.  More men die with than from prostate cancer  Treatment depends on stage of disease, patient's age and general fitness  Local disease –  Observation  Radical radiotherapy / brachythrapy  Radical prostatectomy  Locally advanced disease  Radical radiotherapy  Hormonal therapy  Metastatic disease  Hormonal therapy
  14. 14.  80% of prostate cancers are androgen dependent for growth  Hormonal therapy involves androgen depletion  Produces good palliation until tumours 'escape' from hormonal control  Androgen depletion can be achieved by:  Bilateral subcapsular orchidectomy  LHRH agonists - goseraline (Zoladex)  Anti-androgens - cyproterone acetate, bicalutamide  Complete androgen blockade  Oestrogens - stilbeostrol
  15. 15.  Regulated by the hypothalamic-pituitary-gonadal axis.  LHRH stimulates the anterior pituitary to release LH and FSH  LH stimulates the Leydig cells of the testes to secrete testosterone  In Prostate cells, testosterone is converted by the enzyme 5-α -reductase into 5-α -dihydrotestosterone (DHT), which is an androgenic stimulant approximately 10 times more powerful than the parent molecule  Circulating testosterone is peripherally aromatized and converted into oestrogens which, together with the circulating androgens, exert a negative feedback control on the hypothalamic LH secretion  If prostate cells are deprived of androgenic stimulation, they undergo apoptosis (programmed cell death)  Any treatment ultimately resulting in the suppression of androgen activity is referred to as androgen deprivation therapy
  16. 16.  Commonest solid malignancy in young men  1% - 1.5% of male neoplasms  5% of urological tumours  3-6 new cases occurring per 100,000 males per year inWestern society  Only 1-2% of cases are bilateral  Incidence high in caucasians in northern Europe and USA  1400 new cases per year in UK  95% 5 year survival testis localised disease  Peak incidence  Third decade of life for non-seminoma  Fourth decade for pure seminoma
  17. 17.  History of cryptorchidism  x4-13 increased risk  7-10% tumours in undecended testis  Klinefelter’s syndrome  FHx  Father/brother: x6-8 increased risk  Presence of a contralateral tumour  5-10% risk  HIV  seminoma
  18. 18.  Unilateral testicular mass  20% scrotal pain  27% local pain  Trauma  Reduction in testis size  Gynaecomastia 7% (beta HCG) more common in non- seminomatous tumours  Symptoms of metastatic disease  Seminomas metastasize to para-aortic nodes back pain – 11%  Teratomas – spread to para-aortic nodes, liver, lung, bone and brain  10% of cases can mimic an epididymo-orchitis  Supraclavicular / distant metastases  Palpable abdominal mass
  19. 19.  Staging and response to treatment  Alpha-fetoprotein  Produced by yolk sac elements  Not produced by seminomas  Beta-human chorionic gonadotrophin  Produced by trophoblastic elements  Elevated levels seen in both teratomas and seminoma  Lactate Dehydrogenase  Less specific marker  Concentration is proportional to tumour volume  Elevated in 80% of patients with advanced testicular cancer  It should be noted that negative markers levels do not exclude the diagnosis of a germ cell tumour
  20. 20.  Ultrasound  Sensitivity almost 100%: intra- or extratesticular  Inexpensive test  Screening test of the contralateral testis in the follow-up  Elevated serum beta-hCG or AFP  MRI  Higher sensitivity and specificity than ultrasound  May differentiate seminomatous from non-seminomatous tumours  Sensitivity of 100% and a specificity of 95-100%  High cost  Thoraco-abdominalCT scanning for staging
  21. 21. Radical Orchidectomy
  22. 22.  Seminomas are radiosensitive  Teratomas are not radiosensitive  Surgery: Inguinal orchidectomy  Radiotherapy  Chemotherapy
  23. 23.  95% transitional cell carcinomas  4% squamous / adenocarcinoma  Superficial tumours are usually low grade and associated with a good prognosis  Muscle invasive tumours are of higher grade and have a poorer prognosis
  24. 24.  TCCs should be regarded a 'field change' disease with a spectrum of aggression  80% ofTCCs are superficial and well differentiated  Only 20% progress to muscle invasion  Associated with good prognosis  20% ofTCCs are high-grade and muscle invasive  50% have muscle invasion at time of presentation  Associated with poor prognosis
  25. 25.  Occupational exposure  20% ofTCC are believed to result from occupational factors  Chemical implicated - aniline dyes, chlorinated hydrocarbons  Cigarette smoking  Pelvic irradiation - for carcinoma of the cervix  Schistosoma haematobium associated with increased risk of squamous carcinoma
  26. 26.  Requires bladder muscle to be included in specimen  Staged according to depth of tumour invasion  Grade of tumour differentiation Tis In-situ disease Ta Epithelium only T1 Lamina propria invasion T2 Superficial muscle invasion T3a Deep muscle invasion T3b Perivesical fat invasion T4 Prostate or contiguous muscle G1 Well differentiated G2 Moderately well differentiated G3 Poorly differentiated
  27. 27.  80% present with painless haematuria  Also present with treatment-resistant infection or bladder irritability and sterile pyuria Haematuria clinic involves:  Urinalysis  Mid stream urine  Serum urea and creatinine  Ultrasound - bladder and kidneys  KUB xray - to exclude urinary tract calcification  Flexible cystoscopy  Consider IVU / CT urography if no pathology identified
  28. 28.  RequiresTURT follow-up  Consider prophylactic chemotherapy (mitomycin-C) if risk factor for recurrence or invasion (e.g. high grade)  Consider immunotherapy  BCG = attenuated strain of Mycobacterium bovis  Reduces risk of recurrence and progression  50-70% response rate recorded  Occasionally associated with development of systemic mycobacterial infection
  29. 29.  Carcinoma-in-situ is an aggressive disease  Often associated with positive cytology  50% patients progress to muscle invasion  Consider immunotherapy - BCG  If fails patient may need radical cystectomy
  30. 30.  Choices are between radical cystectomy and radiotherapy  Radical cystectomy has an operative mortality of about 5%  Urinary diversion achieved by:  Ileal conduit  Neo-bladder  Local recurrence rates after surgery are approximately 15% and after radiotherapy alone 50%  Pre-operative radiotherapy is no better than surgery alone  Adjuvant chemotherapy may have a role
  31. 31.  Prostate_Exam.pps Prostate cancer is a disease that can affect men as they older. The sooner it’s detected, the better the prognosis. Urologia O n l i n e
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