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GENITOURINARY TUMORS (Prostate cancer (Treatment (hormonal therapy…
GENITOURINARY TUMORS
Prostate cancer
-
etiology
- genetic predispositions:
family history: relative <50 years – 3x increase risk
African (black) origin
- hormonal factors – androgens
- age, obesity and diet
symptoms
- Early Disease:
Peripheral zone: none.
Transition zone:Urinary frequency, urgency, Decreased urine stream, Nycturia
- Progressive Disease: Hematospermia, Impotence, Decreased ejaculate volume
- Advanced Disease: Bone pain
screening
Advantages
- Early disease highly curable; advanced disease generally incurable
- Screening relatively simple: Routine PSA and DRE
Disadvantages
- Value not proven
- Suboptimal sensitivity, specificity, predictive value of tests (DRE, PSA, TRUS)
- Psychological and economic burden of diagnosis
- Morbidity of potentially unnecessary treatment
pathology
- adenocarcinoma - >95%
- Gleason score:
each fragment graded 1-5
result: sum of 2 most prevalent scores
-<6 – good prognosis
-7 – intermediate prognosis
->8 – poor prognosis
Diagnostic procedures
-
-
- Transrectal ultrasound (TRUS)
- Biopsy
- Magnetic resonance imaging
- Bone scan
progression
- lymph node metastases: hypogastric, external iliac, obturator, lingual
- distant metastases: bone, liver, brain, lungs
prognostic factors
- Early disease: PSA, Gleason score, TNM stage
Treatment
- T1: prostatectomy, radiotherapy, watchful waiting
- T2: prostatectomy, radiotherapy, watchful waiting
- T3: prostatectomy ?, radiotherapy, watchful waiting
- T4: radiotherapy?, watchful waiting, hormonal therapy
- N+: prostatectomy?, radiotherapy?, watchful waiting?, hormonal therapy
- M+: watchful waiting?, hormonal therapy
-
Postoperative RT
- indications:
(+) margin, pT3 (capsular invasion, seminal vesicle invasion), N (+), PSA>0 after 3 weeks following surgery (if M+ excluded)
hormonal therapy
- combined with local therapy
- palliative
- Methods: estrogens, orchidectomy, androgen receptor antagonists, LHRH agonists (medical castration), „maximal androgen blockade”
COMPLICATIONS
- androgen deprivation:
increase body fat, increase risk of coronary disease
decrease insulin sensitivity, decrease bone mineral density
-
URINARY BLADDER CANCER
-
etiology
- smoking
- schistosome infection (Ca planoepitheliale)
- dye industry, transport (aromatic amines, combustion gases)
- phenacetine
- low fluid intake
- chemotherapy (cyclophosphamide)
- chronic irritation (Ca planoepitheliale)
urolithiasis, neurogenic bladder
symptoms
- hematuria, recurrent infections, dysuria, pelvic pain, lumbar pain, leg edema, bone pain
pathology
- 90% - Ca transitiocellulare +/- Ca planoepitheliale +/- Adenoca
- 10%- other
Ca planoepitheliale (Mediterranean) – 6-8%
Adenoca – 2%
Ca microcellulare anapasticum – <1%
Sarcoma, Melanoma, metastases (colorectal, ovary, cervix, lung, lymphomas)
staging
- superficial tumor: 80%
Mucosa Ta, Tis
Lamina propria T1
- muscle-invasive tumor 20%
Muscle superficial T2a, deep T2b
Perivesical tissue micro- T3a, macro- scopically T3b
Prostate, uterus, vagina T4a
Pelvic, abdominal wall T4b
diagnosis
- physical exam: ? metastases (lymph nodes, liver, bones, CNS)
- bi-manual exam
- urine test: dipstick, cytology
- CBC, liver, renal function tests
- cystoscopy + biopsy/ TURB
- chest X-ray
- IV pyelography (classical, CT- or MRI-based)
- ultrasound (assessment of bladder and kidneys)
- CT: abdomen + pelvis
- MRI (particluarly in impaired renal function)
- bone scan, PET
superficial tumor
- 50-80% – risk of progression
10-25% - progression to muscle-invasive disease
- Tis – risk of local progression and dissemination
- multifocality
- treatment: TURB + BCG/ChT, cystectomy – in high-risk groups
muscle-invasive tumor
- cystectomy + lymph node dissection
- RT +/- ChT + salvage cystectomy
- TURB + partial cystectomy +/- RT
Testicular Tumors
- most common cancer between 20-44 y (25%)
-
pathology
- Germinal Tumors:
seminoma 25%
non-seminoma 75% (embryonal carcinoma, teratoma, yolk sac tumor, chorioncarcinoma)
mixed tumors
- Other tumors:
stromal and sex cord tumors (Sertolioma, Leydigioma, Sarcoma)
lymphomas
diagnosis
- ultrasound, tumor markers (α–FP, β-HCG, LDH), biopsy=inguinal orchidectomy, abdominal CT, chest x-ray/CT
staging
- Royal Marsden Hospital classification:
st.I - limited to testis
st.II-subdiaphragmatic nodes
st. III-supradiaphragmatic nodes
st. IV-hematogenous nodes
treatment
Seminoma
st. I (>95% cure rate)
- radical inguinal orchidectomy
+surveillance (15% recurrence rate, monitoring: CT, markers, chest X-ray no impact on survival)
or chemotherapy (1-2 x CBDCA)
or RT (paraaortic nodes, 20 Gy)
-
Non-seminoma
st. I (>95% cure rate)
- radical inguinal orchidectomy
+surveillance (monitoring: CT, markers, chest X-ray no impact on survival)
or chemotherapy (2 x BEP)
st. II (~90% cure rate)
- radical inguinal orchidectomy
+chemotherapy + resection of residual mass
Seminoma, non-seminoma – st. III, IV
- radical inguinal orchidectomy
+chemotherapy + resection or irradiation (seminoma) of residual mass
complications
- infertility- 2nd tumors: stomach, bladder, colon, pancreas
RENAL CANCER
-
etiology
- genetic predisposition
von Hippel-Lindau disease, tuberous sclerosis
- smoking
symptoms
- pain, hematuria, lumbar tumor, left varicocele, paraneoplasmatic syndromes ( hiperkalcemia, policytemia, fever)
treatment
- nephrectomy
- nephron sparing surgery
- radiotherapy – only palliative
- chemotherapy – low efficacy
- hormonal therapy – historical value
- cytokines (IFN, IL-2) – some activity
- targeted therapy – inhibitors of VEGFR TK, mTOR inhibitors
Types
- clear cell: 75-85%, VHL mutation
- papillary I: 12-14%, c-MET mutation
- papillary II: 12-14%, FH mutation
- chromophobic: 4-6, BHD mutation
- oncocytic: 2-4, BHD
- collecting duct