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 tumorsI. 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-cyclophosphamideII. Genetic factors

Etiology-SCC1. 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-SCC2. 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 muscle-

invading 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 factorsI. Genetic- e.g. BRCA1/2 mutations- black raceII. 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 non-cancerous 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

Treatment3. Prostate brachytherapy-mainly for cancer

localized to the prostatea) LDR (low dose rate; seed implant)

b) HDR (high dose rate; treatment through catheters)

Treatment4. External beam radiotherapy-for cancer limited to the prostate-for cancer spread to the seminal vesicles

and/or lymph nodes

Treatment5. 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?