How common is prostate cancer? What helps dx prostate cancer? MC type?
- 2nd most common cancer in men in America - 2nd greatest cause of mortality in men
- PSA helps dx in 1/6 men w/ prostate cancer
- clinical incidence doesn’t match prevalence at autopsy - over 40% of men over 50 are found to have cancer
- MC type: adenocarcinoma
- other types:
sarcomas
SCC
transitional cell carcinoma
neuroendocrine tumors
RFs for prostate cancer?
- age: rare in men younger than 40, develops in 40s
- race: higher rates in African American men (higher PSAs), lower rate in Asian-American/Hispanic latino men
- family hx:
2 fold greater risk w/ 1st degree relative - genetic:
mutations especially on BRCA 2 increase risk in men, men w/ lynch syndrome (HNPCC) - enviro carcinogens: agent orange
Clinical presentation of prostate cancer?
- men w/ early stage cancer usually have no sxs: urinary frequency/urgency nocturia hesitancy - hematuria/hematospermia - bone pain (pathological fracture)
Dx of prostate cancer?
PE:
- DRE: nodules, induration, asymmetry
- TRUS: MRI guided
- MRI
- bone scan
Pathology of prostate CA? MC zones of prostate that are affected?
- acinar cells of prostate will develp into adenocarcinoma
- zones:
peripheral zone - majority (70%)
central: 2-5%
transition: 10-20%
Gleason grading scale?
- scoring system using numbers 1-5
- grade 1: cancerous tissue looks like normal prostate tissue
- grade 5: cancer cells and growth patterns look very abnormal
- diff areas of prostate ahve diff cancer grades - gleason grade (sum) adds 2 grades together:
primary tumor
secondary tumor (minority of the tumor) - ex:
majority: 3 (primary)
less: 4 (secondary) - total gleason grade = 7
TMN staging system?
- stage T1: cancer is found in prostate only, can’t be felt by DRE or seen on imaging
- T2a and T2b: tumor that is too small to be felt or seen on image (2a) or slightly larger tumor that can be felt on DRE (2b)
- stage T3: cancer has spread beyond outer layers of prostate into nearby tissues, and may have spread to seminal vesicles
- stage T4: any tumor that has spread to other parts of the body
- stage N+ or M+: spread to lymph nodes or met to other areas of body
Risk classificaiton of prostate cancer stages?
guidelines from ESMO
- low risk: T1-T2a and gleason score 6 or less and PSA 10 or less
- intermediate risk: T2b and/or Gleason score 7 and/or PSA 10-20 (usually go on to tx: prostatectomy)
- high risk:
T2c and greater or Gleason score 8-10 or PSA greater than 20 (get mets workup)
Diff tx options for prostate cancer?
- active surveillance: Gleason 6 (slow growing)
- open radical prostatectomy vs MIRP (gleason 6 and up)
- radiation:
external beam, high dose radiation (HDR), brachytherapy - HIFU (High intensity focused US)
- hormone therapy:
orchiectomy
androgen deprivation LHRH (for older pts that can’t undergo surgery) - this suppresses testosterone
Advantages and disadvantages of external beam radiation therapy? CI?
advantages:
-effective long-term cancer control w/ high-dose txs, very low risk of urinary incontinence, available for cure of pts over wide range of ages and in those w/ significant comorbidity
disadvantages:
- sig risk of impotence, lack of lymph node removed, late rectal sxs more common than w/ brachytherapy or radical prostatectomy, up to half of pts have some temp. bowel and bladder sxs during tx
**Usually tx of choice if want to preserve continence and erection
CI:
previous pelvic irradiation
active inflammatory disease of rectum
very low bladder capacity
chronic moderate or severe diarrhea from any cause
Advantages and disadvantages of brachytherapy? CI?
advantages:
- cancer control rates appear equal to surgery and EBRT for organ confined tumors
- quicker than EBRT (single tx)
- available for cure over wide range of ages and in those w/ some comorbidity
disadvantages:
- sig risk of impotence
- lack of lymph node removed
- up to half may have some temp. bladder or bowel sxs with tx
CI:
- previous pelvic irradiation
- large volume gland
- marked voiding sxs
- large or high grade tumors
- chronic moderate or severe diarrhea
- active inflammatory disease of rectum
Advantages and disadvantages of radical prostatectomy? CI?
advantages:
- effective long term cancer control
- predictions of prognosis can be more precise based on pathologic features in specimen
- pelvic lymph node dissection is possible through same incision, PSA failure is easy to detect
disadvantages:
- sig risk of impotence
- risk of operative morbidity
- low risk of long term incontinence
CI: higher medical operative risk, neurogenic bladder
Advantages and disadvantages of active survellience? CI?
advantages:
- reduces overtx
- avoids or postpones tx assoc complications
disadvantages:
tumor may progress past possibilty of cure
- later tx may result in more SEs
- living w/ untx cancer may cause anxiety
CI: high grade tumors (higher than gleason 6), not stage T1c
- prolonged expected survival
What pop group is testicular cancer most common?
Curable or not? MC types of cancers?
- MC cancer in men b/t 15-35
- accounts for 1% of all tumors in males
- tumor spreads by lymphatics and blood
- highly curable if discovered early
- 90-95% of all primary tumors arise from germ cells
- germ cell tumors:
seminomas (50%)
nonseminomas (more aggressive - non germ cell tumors (5%):
leydig cell
sertoli cell
Characteristics of seminomas?
- germ cell tumor
- slow growing
- found in men in 30s and 40s
- very sensitive to radiation
Characteristics of nonseminomas?
- germ cell tumor
- more common and quicker growing
- 4 subtypes:
embryonal carcinoma
yolk sac carcinoma
choricarcinoma
teratoma - occur in teen yrs and early 40s
- more sensitive to chemo
Causes of testicular cancer?
- cyrptorchidism
- family hx
- klinefelter syndrome
- previous hx of testicular cancer
- caucasian
Presenation of testicular cancer?
- painless testicular lump**
- enlarging testicle
- accum around testicle
- accumulation around testicle (hydrocele)
- mets:
swelling of lower extremities
back pain
cough
gynecomastia
Dx of testicular cancer?
- scrotal US
- CXR
- CT
- tumor markers:
beta-hCG
AFP
LDH - if you find mass in testicle: it is cancer until proven otherwise
Staging of testicular cancer?
- stage 1: confined to testicle
- stage 2: mets to retroperitoneal nodes
- stage 3: mets above diaphragm or to visceral organs
Tx of testicular cancer?
- radical orchiectomy
- depending on stage:
seminoma: radiation, chemo or both
nonseminoma: RPLND or survellience, chemo
**encourage self-testicular exams
How common is penile cancer? RFs?
rare type of cancer making up less than 1% of all cancers dx in men - occurs mainly in uncircumcised men - SCC (95%) - RFs: HPV age: older than 50 smegma: poor hygiene phimosis: uncircumcision
Presentation and dx of penile cancer?
- growth or sore on penis
- skin thickening on penis
- d/c w/ foul odor from under the foreskin
- pain in penis
- swollen lymph nodes in groin
- irregular swelling at end of penis
-dx: bx
Staging of penile cancer?
- O: cancer hasn’t grown below surface of layer of the skin
- 1: cancer has grown just below the surface layer of the skin
- 2: invasion into the shaft or corpora: no nodes or mets
- 3: tumor confined to penis, operable inguinal nodes mets
- 4: tumor involves adjacent structures, inoperable inguinal lymph nodes and distant mets
