Transcript Bladder cancer

Bladder cancer
Urothelial tumors
-90% in bladder
-8% renal pelvis
-2% ureters and urethra
Histology of bladder cancer
• Urothelial-more than 90% of bladder cancer
• Squamous cell carcinoma-5% of bladder cancer
-worldwide, this is the most common form, accounting
for 75% of bladder cancer in underdeveloped
nations.
-In the industrialized countries SCC is associated with
persistent inflammation from long-term indwelling
Foley catheters and bladder stones.
-In underdeveloped nations, SCC is associated with
bladder infestation by Schistosoma haematobium.
Etiology-Urothelial tumors
I. Environmental factors-implicated in more
than 80% of bladder cancer
-50% caused by tobacco use (increases the risk
3x)
-aromatic amines, aniline dyes, nitrites and
nitrates
-industrial contact to chemicals, plastics, coal,
tar and asphalt
-cyclophosphamide
II. Genetic factors
Etiology-SCC
1. Schistosoma haematobium
• Parasitic trematode=flatworm
• found in large parts of Africa, parts of the
Arabia, the Middle East, Iran, Madagascar
and Mauritius.
• Infection occurs through contact with
fresh water that contains infective
cercariae released from an intermediate
host snail.
Male worms are longer and thicker. They
possess a structure known as a
gynecophoral canal running the length of
the body in which the female remains
during much of the life cycle.
The thinner female separates from her
mate to migrate to the venules bordering
the intestine or bladder in order to
deposit eggs.
Etiology-SCC
2. Irritative risk factors:
• long-term indwelling Foley catheters
• bladder stones
Symptoms
• 80-90% of patients with bladder cancer present with painless
gross hematuria
Consider all patients with gross hematuria to have bladder
cancer until proven otherwise.
Suspect bladder cancer if any patient presents with
unexplained microscopic hematuria.
• 20-30% present irritative bladder symptoms such as dysuria,
urgency or frequency of urination that are related to
a) more advanced muscle-invasive disease or
b) CIS
• Patients with advanced disease can present with pelvic or
bony pain, lower-extremity edema from iliac vessel
compression or flank pain from ureteral obstruction
Diagnosis
• Cystoscopy with TUR-V (transurethral
resection)
• Clinical examination for inguinal lymph nodes
• CT/MRI/PET-CT of pelvis and abdomen
• Chest radiography
TUR-V (click on the video)
Treatment
• Non-muscle invasive bladder cancer:
TUR-V
+/- intravesical chemotherapy instillation or
intravesical BCG (Bacillus Calmette-Guerin)
Treatment
• Muscle invasive bladder cancer:
1. Bladder conserving therapy: maximal TUR-V
or segmental cystectomy followed by
chemoradiation
2. Cystectomy plus pelvic lymphadenectomy
Questions
• What are the two main types of bladder
cancer and what risk factors do they have?
• What is the treatment for non-muscle
invading bladder cancer?
• What are the treatment choices for muscleinvading bladder cancer?
Prostate cancer
(prostate adenocarcinoma)
Epidemiology
• USA: surpassed lung cancer in known
incidence around 1990 due to PSA screening
• One project that analyzed autopsy studies from around the
world came to the following conclusion regarding the actual
rate of prostate cancer in men of different ages:
• 20 to 30 years, 2% to 8%
• 31 to 40 years: 9% to 31%
• 41 to 50 years: 3% to 43%
• 51 to 60 years: 5% to 46%
• 61 to 70 years: 14% to 70%
• 71 to 80 years: 31% to 83%
• 81 to 90 years: 40% to 73%
Risk factors
I. Genetic
- e.g. BRCA1/2 mutations
- black race
II. Environmental
-high fat and red meat plus low fruits +
vegetables diet
-cause not exactly known
Extension
• Local: through the prostatic capsule,
through the seminal vesicles
• Regional lymph nodes: lymph nodes
from the true pelvis
• Metastases: most frequent-bone
Symptoms
• Bladder Outlet Obstruction (BOO): weak urinary
stream, frequent (nocturnal) and voiding incomplete
emptying of the bladder The two most probable causes
BOO are a weakly contracting bladder muscle or
Benign Prostatic Hyperplasia (BPH) followed by
prostate cancer
• More advanced stages:
-lumbar pain due to para-aortic metastases/bone meta
-other bone pain
Diagnosis
• Digital rectal examination (prostatic nodule)
• PSA
• US guided prostate biopsy
Age-specific upper limits of
normal for PSA
Age (years)
PSA in blood (ng/mL)
40-49
2.5
50-59
3.5
60-69
4.5
70-79
6.5
PSA is not a perfect test:
-men with a PSA level below the age-specific limit of normal can have
cancer
-PSA is not cancer-specific and is produced by both cancerous and noncancerous prostate cells [increased PSA can occur is benign prostatic
hyperplasia (BPH, i.e. prostate enlargement) or prostatitis (infection of the
prostate]
US guided prostate biopsy
Diagnosis (2)
• US guided prostate biopsy
• Examinations for extension:
-rectal US
-pelvine MRI
-scintigraphy with anti-PSMA (prostate specific
membrane antigen) antibodies (“prostascint”)
-bone scintigraphy
Prostascint
Abnormal ProstaScint accumulation is
demonstrated in the seminal vesicles (red
arrows on image A) and right pelvic lymph
nodes (yellow arrow on image B).
Scintigraphy with PET and Technetium
Treatment
• Life expectancy is important in the decision to
treat or not a certain patient
Treatment
1. Watchful waiting
-for patients with a life expectancy of less than 5
years because of comorbidities plus have to
be asymptomatic
2. (Nerve sparing) radical prostatectomy plus
pelvic lymphadenectomy
-side effects: 40-90% impotence, 10%
incontinence
Treatment
3. Prostate brachytherapy-mainly for cancer
localized to the prostate
a) LDR (low dose rate;
seed implant)
b) HDR (high dose rate;
treatment through catheters)
Treatment
4. External beam radiotherapy
-for cancer limited to the prostate
-for cancer spread to the seminal vesicles
and/or lymph nodes
Treatment
5. Hormonal treatment
-associated to surgery/radiotherapy
-alone in metastatic disease
-consists of androgen deprivation therapy
through LHRH agonist or orchiectomy
6. Chemotherapy
-in metastatic disease
Screening
After discussing potential benefits and harms of
screening
• From 50 yrs in normal risk men with DRE and
PSA
• From 40 yrs in men with increased risk (first
degree relative with prostate cancer, black
race)
Questions
• What are the treatment modalities in prostate
cancer?
• How is screening done in prostate cancer?