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Urologic Malignancies Scope • Anatomy •Urologic Malignancies • Trauma • Emergencies • Infections • Lower Urinary Tract Obstruction • Upper Urinary Tract Obstruction • Pediatric Urology • Key Points Emmanuel L. Barcenas Urologist/Urologic Surgeon Urology Specialty Group and Associates • Doctor of Medicine, SWU • Diplomate, Philippine Board of Surgery and the Philippine Board of Urology • Fellow, Philippine Urological Association • Fellow, Philippine College of Surgeons • Member, Philippine Endourological Society • Member, Phillippine Society of Urooncologists Urologic Malignancies Urologic Malignancies •Bladder Cancer •Testicular Cancer •Kidney Cancer •Prostate Cancer Urothelial Tumors of the UB •Transitional cell epithelium lines the urinary tract from the renal pelvis, ureter, urinary bladder, and the proximal two-thirds of the urethra •Tobacco use is the most frequent risk factor (50% in men and 40% in women), followed by occupational exposure to various carcinogenic materials such as automobile exhaust or industrial solvents. Detection of Urothelial Cancer •Painless gross hematuria occurs in 85% of patients & requires a complete evaluation that includes cystoscopy, urine cytology, CT scan, & a PSA. •Recurrent or significant hematuria (>3 RBC’s/HPF on 3 urinalysis, a single urinalysis with >100 RBCs, or gross Hematuria) is associated with significant renal or urologic lesion in 9.1% Detection of Urothelial Cancer • Patients with microscopic hematuria require a full evaluation, but low-risk patients do not require repeat evaluations. • High-risk individuals primarily are those with a smoking history & should be evaluated every 6 months. • The level of suspicion for urogenital neoplasms in patients with isolated painless hematuria and nondysmorphic RBCs increases with age. • White light cystoscopy with random bladder biopsies is the gold standard for tumor detection History & Staging •Low-grade papillary lesions are likely to recur in up to 60% of patients but invade in less than 10% of cases. •High-grade lesions also recur; invasion & subsequent stage progression can occur in 50% of tumors. •Muscle-invasive bladder cancer leads to death in a significant proportion of patients despite aggressive therapy. Pathology •Malignant tumors are classified as low grade or high grade. •The most important risk factor for progression is grade. •Urothelial tumors exhibit polychronotropism, which is the tendency to recur over time in new locations in the urothelial tract. •As long as urothelium is present, continuous monitoring is required. •In the presence of a known bladder tumor, unilateral or bilateral hydronephrosis is an ominous sign of locally advanced disease (at least muscle-invasive bladder cancer) •Patients who have disease invading into bladder muscle (T2), immediate (within 3 months of diagnosis) cystectomy with extended lymph node dissection offers the best chance of survival Non Muscle Invasive Bladder Ca •Patients with non–muscle-invasive bladder cancer (confined to the bladder mucosa or submucosa) can be managed with TUR alone and adjuvant intravesical (instilled into the bladder) chemotherapy/immunotherapy •Intravesical treatments are advised for patients with diffuse ClS，recurrent disease ，>40% involvement of the bladder surface by tumor，or T1 disease Endoscopic Surgical Management •TURBT is performed both to remove all visible tumors & to provide specimens for pathologic examination to determine stage & grade. •Repeat resection within 1 to 6 weeks is usually indicated in patients with high-grade disease. • Single-dose intravesical chemotherapy administered within 6 hours of resection reduces recurrence of low-risk tumors. •All suspicious lesions should be sampled, but “random” biopsies are not required in low-risk patients. Immunotherapy •Intravesical BCG has higher efficacy than intravesical chemotherapy. •BCG is the only agent shown to delay or reduce high-grade tumor progression. •Standard therapy, is Bacillus Calmette- Guérin (BCG) in six weekly instillations, followed by maintenance administrations for > 1 year •BCG is contraindicated in the setting of a disrupted urothelium because of the risk of intravasation & septic death. Intravesical Chemotherapy •Intravesical chemotherapy has a clear impact on tumor recurrence when immediately instilled after TURBT & in the adjuvant setting •In general, side effects of chemotherapy tend to be less common & less severe than those for BCG, but BCG is more efficacious. •Because upper tract recurrence is fairly common (up to 17% of patients with carcinoma in situ), surveillance must be performed with RGPs or CT urograms. •Patients are monitored for recurrence at 3 month intervals during the first year. Surveillance & Prevention •Cystoscopy is the hallmark of surveillance. Usually every 3 months. •Increased fluids, smoking cessation, & a low-fat diet are recommended. Prevention •Stopping or never starting smoking is the best prevention for bladder cancer. •There are no clear dietary or micronutrient programs to prevent primary bladder cancer. •BCG plus high-dose vitamins may prevent recurrent bladder cancer. Muscle Invasive Bladder Cancers Neoadjuvant Chemotherapy •Presurgical (or neoadjuvant) chemotherapy increases the cure rate by 5–15%, •In patients receiving three cycles of neoadjuvant MVAC followed by cystectomy had a significantly better median (6.2 yea rs) and 5-year surviva l (57%) compared to cystectomy alone (median survival 3.8 years; 5-year survival 42%). •In men, the prostate is removed with the bladder (Radical Cysto Prostatectomy). •In women, the uterus, ovaries, and anterior wall of the vagina are removed with the bladder (Anterior Pelvic Exenteration). Partial Cystectomy •Limited to patients with a solitary lesion in which radical cystectomy is otherwise contraindicated & a sufficient margin can be obtained. •Partial cystectomy can be curative in other tumor types including squamous cell carcinoma & adenocarcinoma. Partial Cystectomy •Restricted to primary solitary lesions unsuitable for removal by transurethral resection and to residual tumor at repeat resection 2 months later. •The tumor must also lie at a site that allows 2 cm of normal tissue around it to be removed. •Bladder must have adequate capacity and compliance to be functional after removal of part of its wall. Radical Cystectomy •Designed to remove the bladder, pelvic peritoneum, prostate, and seminal vesicles in men and the urethra, uterus, broad ligaments, and anterior third of the vaginal wall in women. •In both sexes, pelvic lymphadenectomy is an integral part of the operation. •Some form of urinary diversion must be created. Radical Cystectomy •The boundaries of dissection of a standard pelvic lymph node dissection are the genitofemoral nerve laterally, the internal iliac artery medially, Cooper ligament caudally, & the crossing of the ureter at the common iliac artery cranially. •Female patients with stage T1 or T2 bladder tumors that are distal to the bladder trigone are candidates for orthotopic neobladder construction. •Orthotopic neobladder has emerged as a popular urinary diversion for patients without urethral involvement. •Most common diversion is noncontinent, the ileal conduit Metastatic Disease •Overall response rates of >50% have been reported using combinations such as methotrexate， vinblastine ， doxorubicin， and cisplatin (MVAC); gemcitabine and cisplatin (GC); or gemcitabine，paclitaxel， and cisplatin (GPC) MANAGEMENT OF BLADDER CANCER Nature of Lesion Management Approach Non-muscle-invasive disease Endoscopic removal usually with intravesical therapy Muscle-invasive disease Cystectomy 士 systemic chemotherapy (before or after surgery) Metastatic disease Curative or palliative chemotherapy (based on prognostic factors) 士su rgery Testicular Tumors •Primary germ cell tumors (GCTs) of the testis arising by the malignant transformation of primordial germ cells constitute 95% of all testicular neoplasms •Testicular cancer is the most common solid malignancy in men age 15 to 35 years. •A painless testicular mass is pathognomonic for a testicular malignancy •A major risk for the development of testicular cancer is cryptorchidism. •Cryptorchidism is associated with a several- fold higher risk of GCT. •Abdominal cryptorchid testes are at a higher risk than inguinal cryptorchid testes. •An isochromosome of the short arm of chromosome 12 [i( 1 2p)] is pathognomonic for GCT Demographics •Testicular cancer is the most common solid tumor in men between the ages of 20 and 35 years. •Careful history, physical examination, and serum tumor markers (hCG, AFP, and LDH) are helpful in establishing the correct diagnosis. •Scrotal ultrasonography is extremely accurate in identifying solid intratesticular lesions, with greater than 95% sensitivity and specificity. Tumor Markers •Initial studies must include tumor markers, including α-fetoprotein (AFP), β-human chorionic gonadotropin (BHCG), and lactate dehydrogenase (LDH). •Elevated tumor markers are found almost exclusively in non-seminomatous germ cell tumors •10% of patients with localized seminomas and 25% with metastatic seminomas will have a modest rise in β-human chorionic gonadotropin. Tumor Markers •AFP concentration is increased only in patients with nonseminoma GCT. •The presence of an increased AFP level in a patient whose tumor shows only seminoma, the patient should be treated for nonseminomatous GCT •LDH levels are less specific than AFP or hCG but are increased in 50-60% patients with metastatic nonseminoma and in up to 80% of patients with advanced seminoma.
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